LIST PASIEN BEDAH THOVASK

Kamis, 25 Agustus 2017

A Bawah
B7 Bed 1 Budiman Edison/ L/ 16thn/ 16-07- Hematopneumothoraks dextra 13-08-2017 GDS 169 Rawat luka
2001/Tumumpa Dua Lk IV Ec vulnus ictum Leu 12200 Cl 101,0 Ceftriaxone 1gr 2x1 IV
TKV Eri 3,85 K 3,6 Ketorolac 3x1 IV
Hb 11,3 Na 137 Ranitidin 2x1 IV
MRS: 12-8-2017 Ht 32,2 PT 19,0 Asam tranexamat 3x1 IV
RM: 50.87.09 Tro 359 INR 1,73 Vit k 3x1iv
MCH 29,4 APPT 41,5 Vit c 3x1 iv
MCHC 35,1 N-ACE 3x1 tab
DPJP: dr. Adrian Tangkilisan, Sp.B- MCV 83,6 Foto thoraks Nebu/8jam pulmicort 1cc,ventolin 1 amp,
BTKV (22-08-2017) NaCl 1 cc
Hematopneumo Rawat WSD
thoraks dextra CEK LAB: DL, Na, K, Cl
TAMBAH KPO

B5 bed III Tuju R Stenly Vulnus sclopectorum region parasternal sinistra 22-08-2017 SGOT 76 ADT elektif
TN/L/23/08/1976/Tuminting Leu 15000 SGPT 69 IVFD 0,9 %
TKV Lingkungan III Eri 5.45 Ur 17 Ranitidin 2x1
Hb 16.5 Cr 1.2 Extraksi corpus alienum tanggal 25-08-2017
MRS :22-08-2017 Ht 45.9 Cl 99
RM : 37.95.68 Tro 286 K 3.8
MCH 30.3 Na 127
DPJP : dr. Adrian Tangkilisan, MCHC 35.9
Sp.B-BTKV MCV 84.2

B4 bed II Tarondek Revda Abses region thorax dextra 21-08-2017 Cefixime 2x100 mg
Linda/P/22/05/1962/SInisir Jaga V CKD 5 on HD Leu 12900 Paracetamol 3x500 mg
V Post DLC Eri 2.03
RM : 24.64.13 Hb 6.7 Rawat luka
Ht 18.9
DPJP : dr Djony Tjandra Sp.B (K)V Tro 313
MCH 33
MCHC 35.4
MCV 93.1

B4 bed III Tambun Lydia /P/64th/12-07- CKD on HD Pro DLC tgl 25-08-2017
1953/kotamobagu lingkungan II
V

RM : 495969
MRS 24-08-2017

DPJP : dr Djony Tjandra Sp.B (K)V

1
 A Atas
A7.7 Amir Zakaria/L/48th/15/08/1969/ Dx Bedah : AGD 15-08-2017 22-08-2017 EKG 18/8/17 IVFD NaCl 0,9% 20gtt/m
Dusun Selamat Pangadaa Kab Trauma tumpul thorax + hemotorax (S) on USD pH 7.508 Leu 17200 Leu 4500 DBN Ceftriaxone 2x1 gr(iv)
TKV Gorontalo dengan malposisi PCO2 38.2 Eri 4,34 Eri 4.12 Human albumin 100cc IV
Fraktur femur intratrokanter Dj tertutup PO2 116.8 Hb 13,6 Hb 12.9 Foto Thorax 21/8/17 Nebu ventolin 1 amp + NaCl 0,9 % 1cc +
SO2 97.5 Ht 38,7 Ht 36.7 Terpasang chest pulmicort 1 cc /8 jam 3x1
RM: 50.85.49 HCT 20% Trom 417 Trom 547 tube pada Rawat WSD
MRS: 11/08/2017 H B 6.5 MCH 31,3 MCH 31.3 Cek konsul rehab
hemithorax kanan
MCHC 35.1 MCHC 35.1
Efusi pleura susp.
MCV 89,2 MCV 89.1
DPJP: dr. Adrian Tangkilisan, SGOT 16 Hemothorax
Sp.B-TKV SGPT 30 Contusio paru
Ur 21 bilateral dd
Cr 0.7 pneumonia non
GDS 106 spesifik
Albumin 2.46 Multiple fraktur
Na 132 costa 2,3,4 kanan
K 4.61 dan 3,4,5,6, kiri
Cl 94.1

A7 Bed 8 Reydi tulong/ L/ 61thn/ 20-09- Susp aneurisma aorta abdominal Jawaban konsul Menunggu hasil CT-Scan angiografi
1966/ Malalayang II lk. 5 internal (15-8-
V 2017): terlampir
RM: 50.87.72
MRS: 14-08-2017 EKG18/8/17 : kesan
sinus bradikardi (HR
DPJP: dr. Richard Sumangkut Sp.B 55x/m)
(K)V
A Bed 3 Selviani Moha/ P/33thn/1-10-1983 Ca mammae sinistra T4 No Mx on Kemoterapi 21-08-2017 N-asetil sistein 3x caps
Leu 7800 Loratadine 2x10 mg
V RM : 50.61.03 Eri 4.69 Post kemoport
MRS : 15-08-2017 Hb 11.7
Ht 36.3
DPJP : dr Djony Tjandra Sp.B (K)V Trom 499
MCH 24.9
MCHC 32.2
MCV 77.4

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 A.TERATAI
R1 Bed 7 Melkior Lumunon/ L/ 52thn/19-05- Giant pseudoaneurisma Pro DLC jugular dextra 24/8/2017
1965 antebrachii dextra
Vask
RM: 00.45.01
MRS: 22-8-2017

DPJP: dr Djony Tjandra Sp.B (K)V

R1 Bed 6 Nimot J. Erikson/L/30th/29-6- Tumor suprarenal 11/8/17 15/8/2017 18/8/2017 23/8/17 Terapi lain sesuai TS bedah urologis dan
1987/Bitung Elektrolit imbalance Leu 19300 Leu 16570 Leu 14410 leu 14690 interna
TKV Hiponatremia Eri 5.80 Eri 5.82 Eri 5.63 eri 6.07
RM: 50.32.27 Hipoalbumin Hb 15.7 Hb 15.0 Hb 14.5 hb 15.9 Cek konsul rehab
MRS: 11-8-2017 Ht 44.8 Ht 43.3 Ht 42.5 ht 45.9 Tanya bagian urologi
Trombo 321 Tro 381 Tro 331 trombo 285 TKV jumat
DPJP: dr. Adrian Tangkilisan, MCH 27.1 MCH 25.8 MCH 25.8 MCH 26.2
Sp.B-TKV MCHC 35.0 MCHC 34.6 MCHC34.1 MCHC 34.6
MCV 77.2 Eos 0 MCV 75.5 MCV 75.6
SGOT 52 Baso0 SGOT 54 SGOT 83
SGPT 16 Net B 2 SGPT 15 SGPT 21
Ur 16 Net S 80 Ur 14 Ur 15
Cr 0.5 Lim 13 Cr 0.5 Cr 0.4
GDS 72 Mon 5 GDS 99 Alb 3.14
Alb 3.36 MCV 74.4 Alb 2.95 Cl 75.6
Chl 86.0 Cl 75.5 Chl 81.9 K 5.52
K 2.0 K 2.33 K 3.32 Na 115
Na 119 Na 119 Na 125
PT 17.5 Foto thorax
APPT 25.2 (5/8/2017): tidak
INR 1.55 tampak metastase
pada kedua paru.

Ekg 4/8/17
DBN

3
 Boarding
C1 Bed Manorek Heitty/P/41th/1-4- A: 20/07/17 27/07/17 CT-scan Thorax + Foto thoraks: Rawat WSD dan Rawat luka
1 1976/Lowian Ateletaksis paru dextra terpasang WSD Leu 6200 Leu 6200 kontras : terlampir tanpa Terapi lain sesusai Interna
DM Eri 3,58 Eri 3,20 Gambaran inflamasi ekspertisi Levofloxasin 1x250 mg i.v
RM 50.58.96 Pneumonia Hb 9,6 Hb 8,7 posterior paracardial Cek resep
Ht 29,3 Ht 26,4 paru kiri + CT-Scan thoraks Rx mau rpair ke Ok
TKV
DPJP:dr. Adrian Tangkilisan, Post repair WSD Trombo 277 Trombo 448 pneumothorax dextra (20/07/2017): Siapkan berkas
SpB(K)TKV MCH 26,8 MCH 27,2 disertai collaps paru gambaran
MCHC 32,8 MCHC 33,0 dextra + efusi pleura inflamasi
MCV 81,8 MCV 82,5 dextra minimal posterior parakar,
Chl 95,0 Chl 88,5 medial paru kiri
K 3,0 K 4,56 14/08/17 disertai colaps
Na 123 Na 133 Leu 7000 paru dextra dan
Eri 3,14
10/08/2017 Hb 9.6
Leu 12500 Ht 9.6 efusi paru dextra
Eri 2,5 Trombo 534 minimal
Hb 7,3 MCH 30.6
Ht 21,7 MCHC 33.9
Trombo 609 MCV 90.1
MCH 29.2 SGOT 29
MCHC 33,6 SGPT 8
MCV 86,8 Alb 2.43
Ur 10 Chl 100
Cr 0,4 K 4,60
Chlor 86,1 Na 134
K 3,72
Na 128
A1 Leidy mentu/P/29 tahun/4-01- Abses Regio mammae Dextra 23/8/2017 IVFD NaCL
1988 Leu 10000 Ceftriaxone 2cx1
B1 Eri 3,7 Raitidin 2x1
RM : 50.91.96 Hb 10,7 Ketorolac 3x1
DPJP : dr Richard Sumangkut Ht 29,3 Rawat luka
Sp.B KV Trombo 15
MCH 28,8
MCHC 36,8
MCV 79,2
Chl 102
K 4.01
Na 137

Anggrek 1
B2 Sumeisey Godfriet/L/66 thn/08-01- Dx Pro cimino tgl 24/08
1981/Kolongan jaga II CKD 5 on HD

RM : 50.53.16
DPJP: dr Djony Tjandra Sp.B (K)V

4
B5 Taysam Egam/L/75thn/18-08- Dx 19/08 Ur 206
1942/Manado CKD 5 ND Leu 6600 Cr 5,0
V Anemia ec renal dd GIT Bleeding Eri 2,93 GDS 107
RM : 00.15.92 Ob. Melena Hb 8,1 CL 10
Ht 23,8 K 5,3
Trombo 219 Na 134
DPJP: dr Djony Tjandra Sp.B (K)V MCH 27,6
MCHC 33,9 20/08/17
MCV 81,6 Na 127
SGOT 24
SGPT 18 K 5.10

Cl 112,0
B10 Ramli Botutihe

Anggrek 2
K 118 Jetje Ruindungan/ P/ 65thn/ 24- Dx Bedah: 12/8/2017 14/8/2017 15/8/2017 19/8/2017 EKG (14-8-2017) irama sinu, Pro amputasi digiti I pedis
V 07-1952 PAD Leu 10170 Leu 12100 GDS 94 PT 18.0/12.9 HR 120x/m. Poor R V2-V3 dextra
Gangren digiti I pedis dextra Eri 4.16 Eri 3.90 PT 16,4/13,1 INR 1.61/1.03 elevan J/poin V2-V3. OMI Perbaiki KU
RM: 17.38.45 DM II Hb 11.4 Hb 11.2 INR APPT 29.4/30.1 anteroseptal Rawat luka
HPT Ht 36.0 Ht 35.1 1,42/1,05 Terapi lain sesuai TS interna
DPJP: dr Djony Tjandra Sp.B (K)V CHF Tro 311 Tro 284 APTT 19/8/2017 CR pedis (26-7-2017) gas
MCH 27,4 MCH 28,7 32,9/30,0 Leu 6010 froming (+) daerah soft tissue
MCHC 31.7 MCHC 31.9 Eri 3.81 digiti 1 pedis dextra.
Eos 2 MCV 90.0 17/8/2017 Hb 10.4 Calcaneus Spru (early stage)
Bas 0 GDS 186 PT 16.7/12.8 Ht 33.0
Net B 3 Cl 88,6 INR Tro 253 Foto thoraks (26-7-2017)
Net S 70 K 3,54 1.45/1.02 MCH 27.3 keradangan paru pneumoni?
Lim 18 Na 134 APPT MCHC 31.5
Mon 7 PT18,7 25.0/29.7 MCV 86.6
MCV 86.5 INR 1,69 GDS 193
Chol 122 APPT 42,7 Eos 8
HDL 18 Bas 0
LDL 58 Net B 0
Trigli 229 Net S 50
Pro T 7.66 Lim 35
Hb A1C 7.5 Mon 7
Alb 2.92
Glo 4.74 21/8/2017
Leu 5790
Eri 3.96
Hb 11.5
Ht 34.4
Tro 355
MCH 25.0
MCHC 33.4
MCV 86.9

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K. 207 Patritrisya Kaawoan/ P/ 44 thn/ Pneumothorax dextra 17/8/2017 SGOT 14 Foto thoraks terlampir Tx sesuai TS interna
23-08-1972/girian indah bitung WSD H3 Leu 11300 SGPT 6 Menunggu CT scan thorax + kontras
TKV Atelektasis sinistra Eri 4.60 Ur 14
RM: 50.90.54 Hb 13.8 Cr 0.6
Ht 40.3 GDS 131
MRS : 17/8/2017 Tro 403 Cl 105.0
MCH 30.0 K 4.30
DPJP: dr. Adrian Tangkilisan,
MCHC 34.2 Na 139
SpB-TKV
MCV 87.6

21/8/2017
Leu 5790
Eri 3.96
Hb 11.5
Ht 34.4
Trombo 355
MCH 29.0
MCHC 33.4
MCV 86.9
K. 115 Johan Wowor/L/72 Post gagal nafas onventilator 20-08-2017
V CKD CVD Stroke Iskemik lewat fase akut Leu 2500
RM : 16.61.30 + hidrosefalus obstruktif post pasang VP Eri 3,78
MRS : 14-07-2017 shunt + DM Tipe II + Hipoalbuminemia + Hb : 11,5
Hipokalemia Ht 31,9
DPJP :dr. Richard Sumangkut, Thro 189
Sp.B
Mch 30,4
MCHC 36,1
NCT 84,4
UR 81
CR 3,5

K. 206 Oga fatmawati /P/55thn/14-04- Efusi pleura ec. Malignancy 21-08-2017 22-08-2017 Menunggu hasil foto thorax
1962/ Mogolaing jln anggrek Leu 21400 leu 18400
Eri 3.83 eri 3.41
RM : 48.36.40 Hb 9.6 hb 10.4
MRS : 21/08/2017 Ht 29.1 ht 28,6
Trombo 338 trombo 86
DPJP : dr. Adrian Tangkilisan,
MCH 2.51 MCH 30.5
SpB-TKV
MCHC 33 MCHC 36.4
MCV 76 MCV 83.9
SGOT 27 Ur 82
SGPT 10 Cr 3.4
Ur 27 P 5.0
Cr 0.8 Mg 1.55
GDS 115 Alb 3.03
Cl 103 Cl 99
K 4.3 K 2.2
Na 139 Na 129

PROT 7,78

6
 DDS 165
P4
Mg 1,7
Alb 3,06
Cl 99
K 3,2
Na 135
Ca 8,14

Irina B
K. 10 Tumurang Nesye/ P/ 58 thn/ 28-02- Ulkus DM + selulitis sinistra, PAD, DM tipe 2, 08/8/2017 12/8/2017 16/8/2017 ECHO : Terapi rawat ulkus
1959 chronic venous disease Leu 24000 Leu 30400 Leu 33400 PAD ekstremitas Medical gradual komprusi CCL1 uk. M
V Eri 3,65 Eri 3,67 Eri 3,7 inferior sinistra di bawah lutut
RM: 35.87.92 Hb 10.5 Hb 10.6 Hb 10.5 CVI severe ekstremitas Adrium 2x1 tab
Ht 30.6 Ht 31.0 Ht 31.6 inferior sinistra Cek D-dimer, fibrinogen, PT, APTT
MRS : 09/8/2017 Tro 309 Tro 321 Tro 341 Rawat bersama vaskuler
Terapi lain sesuai teman sejawat
MCH 28.8 MCH 28.9 MCH 28.4
DPJP: dr Djony Tjandra Sp.B (K)V interna
MCHC 34.3 MCHC 34.2 MCHC 33.2
MCV 83.8 MCV 84.5 MCV 84.4
Asam urat 7.7 Ureum 50 Clorida 95
Cholesterol 176 Kreatinin 1.2 Kalium 4
HDL 31 Clorida 98.8 Natrium 136
LDL 119 Kalium 4.05
Trig 129 Natrium 136
HBa1C 5.9%
PT 18.2 s
IMR 1.63 s
APPT 32.2 s
K5 Lexi Pono

V DPJP: dr Djony Tjandra Sp.B (K)V

Irina C1
105 Esther Natalia/ P/ 45 thn/ 15-02- Efusi pleura dextra et sinistra ec susp. malignancy 14/8/2017 18/8/2017 21/8/2017 EKG : sinus takikardi, Terapi sesuai TS interna
Bed 3 1971 Leu 19420 Leu 22480 Leu 19400 susp iskemik miocard CT scan thorax (+)
TKV Eri 5.55 Eri 5,54 Eri 6.05 lateral
RM: 50.82.50 Hb 13.8 Hb 13,8 Hb 15.7 PA:Susp
Ht 44.2 Ht 45 Ht 49.5 adenicarsinoma
MRS : /8/2017 Tro 351 Tro 350 Tro 386
MCH 24.9 MCH 24.9 MCH 26.0
DPJP: dr. Adrian Tangkilisan, SpB-
MCHC 31.2 MCHC 30.7 MCHC 31.7
TKV
Eos 1 Eos 1 Eos 1
Bas 0 Bas 0 Bas 0
Net B 0 Net B 0 Net B 1
Net S 85 Net S 80 Lim 8
Lim 10 Lim 16 Mon 4
Mon 4 Mon 3 MCV 81.8
MCV 79.6 MCV 81 Na 137
7
 GDS 172 Na 142 K 5.20
K 4,26 Cl 98.0
Cl 8.81 Fos 3.1
Fos 3.1 Ur 14
Ur Ac 2.5 Cr 0.3
Pro to 5,93
Mag 2.24
Alb 3.0
Glo 2.85
100 Andri Kastilong/L/44thn/20-08- Efusi pleura ec. Susp TB Paru dd/ malignancy 19-08-2017 X-Foto thorax : massive Menolak sementara WSD
Bed 5 1972/Lopana I Jg 5 Leu 12400 pleural effusion Dextra
Eri 5.27
RM : 50.53.02 Hb 15.9
Ht 44.1
DPJP: dr. Adrian Tangkilisan, SpB- Trom 376
TKV
MCH 30.2
MCHC 36.1
MCV 83.7
Ur 22
Cr 0.7
GDS 62

101 Cinta Kaunang/P/38thn/01-07- Efusi pleura dex massive ec. Suspec malignancy 21-08-2017 MCV 85.8 Na 142
Bed 3 1979/Motoling Barat Leu 14300 SGPT 25 K 3.49
Eri 3.65 Ur 14 Cl 97.2
RM : 50.53.58 Hb 10.6 Cr 0.5
Ht 31.3 GDS 117
DPJP: dr. Adrian Tangkilisan, SpB- Trom 499 Uric Acid Darah
TKV
MCH 29.0 2.8
MCHC 33.9 Albumin 3.18

103 Ate nusi/L/50thn/18-04-1967 CKD ec. Obstruktif nefropathy 21-08-2017

Bed 1 Na 130
RM : 50.93.05 K 6.00
MRS : 20-08-2017 Cl 96.0

DPJP: dr Djony Tjandra Sp.B (K)V

100 M. Jacob/L/62 thn/18/11/1954/62 Abses DM Pedis dex. 21-08-2017 MCV 84..2 K 5.60
Bed 3 thn/2522.67 PAD Leu 20200 Ur 185 Cl 103.0
Eri 2.59 Cr 4.8 Calsium 7.57
DPJP: dr Djony Tjandra Sp.B (K)V Hb 7.8 GDS 107
Ht 21.8 Fos 6.7
Trom 506 Mag 1.84
MCH 30.1 Alb 1.85
MCHC 35.8 Na 130

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 Irina C2
213 Fatima Abdul/ P/ 63thn/ 4-2-1954/ Post amputasi below knee ec gangrene pedis 10-08-2017 Glo 3,74 16/8/2017 EKG (14/08/07) : Sinus Rawat luka setiap hari
Bed 2 Kel Singkil II Ling.I sinistra Leu 21000 Sat. Transferin 47 Leu 13500 takikardi (110x/menit), Ceftriaxone 2x1
V Eri 2,95 Cl 93,5 Eri 3.25 old myocard infarct Ketorolac 3x1
RM: 50.80.59 Hb 5,9 K 3,06 Hb 9.8 anterioseptal, PAC Ranitidine 2x1konsul rehab
MRS: 6-8-2017 Ht 16,9 Na 124 Ht 28.0 occasional Menunggu hasil lab
Trom 405 Cal 6,99 Tro 419
DPJP : dr Djony Tjandra Sp.B (K)V
MCH 28,8 PT 25,7 MCH 30.2
MCHC 34,9 MCHC 35.0
MCV 82,4 14/8/2017 MCV 86.2c
SGOT 9 Leu ada bekuan
SGPT 3 Ur 77 21-08-2017
Ur 119 Cr 2.6 Leu 12380
Cr 2,5 As.urat 7.4 Eri 4.10
UA 9,6 P 3.3Mg 1.28 Hb 11.9
Kol 91 Alb 1.97 Ht 35.2
HDL 14 Cl 96.7 Trom 320
LDL 51 K 3.88 MCH 29.0
Tg 132 Na 128 MCHC 33.8
Prot tot 5,89 Cal 7.03 MCV 85.9
GDS 130 PT 17.3
HbA1C 4,8 INR 1.52 SGOT 12
SI 35 APPT 32.4 SGPT 5
TIBC 74 Ur 47
Fos 4,0 Cr 2.0
Mag 1,41 Uric acid
Alb 2,15 darah 5.9
Prot total 5.80
Na 139
K 3.70
Cl 101.6
Albumin 2.20
Mag 1.29
Fosfor 3.1

Irina C3

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203. B4 Supit Veronica/P/57th/12-04-1960/ Dx : Sepsis ec IADD dd Urosepsis dd 17/08/2017 21/08/2017 Albumin 2.13 DLC Jugular hari ini
V Pneumonia (HHP) Leu 13200 Leu 15700 Mag 2.25 USG abdomen
RM : 50.70.52 Urosepsis ec susp PNA Eri 2,26 Eri 2.43 Glob 4.49
MRS : 18-08-2017 Pneumonia (HAP) Hb 6,9 Hb 7.4 Fosfor 3.9
Anemia renal dd occult bleeding Ht 18,4 Ht 20.5 Hb A1C 5.6
DPJP : dr Djony Tjandra Sp.B (K)V DM tipe 2 + episode hipoglikemia Tro 553 Tro 472 Prot total 6.62
Hipertensi Gr. II MCH 30,5 MCH 30.5 PT 15.0
CKD 5 on HD MCHC 37,5 MCHC 36.1 APPT 39.3
MCV 81,4 MCV 84.4
Ur 54 GDS 82
Cr 5,3 SGOT 15
GDS 90 SGPT 5
Cl 104 Ur 78
Kal 3,60 Cr 8.4
Nat 136 Uric Acid Darah
6.7
Malaria Negatif Na 135
K 3.90
Cl 96.6

Irina C5
501 Bed Yanje Bawendu /L /63thn /01-02-1954 Pneumothorax dex ec. TB Paru Aktif 18/08/2017 CT-Scan Thoraxdenga kontras
1 /malalayang Leu 11900 Pasang WSD
TKV Hb 10.5
RM : 48.08.40 Tho 408
MRS : 18-08-2017 SGOT 3.5
SGPT 2.5
DPJP: dr. Adrian Tangkilisan, SpB-TKV
K 5.40

ICU
Lt 2 Sheren Kaligis / P /23 thn/ 12-10-1993 Dx : Vulnus ictum penetrans thorax abdominal 23/08/2017 VATS tanggal 23-08-2017
Leu 16900
RM: 50.84.18 Eri 4.0
DPJP : dr. Adrian Tangkilisan, SpB-TKV Hb 11.3
Ht33.9
Tro 570
MCH 28.3
MCHC 33.3
MCV 84.8
GDS 98
SGOT 35
SGPT 142
Alb 2.97

10
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