Jumat, 8 Februari 2019 BEDAH THORAX KARDIO VARKULER AFF/ATH/RAN/ARV/SYA/SIW/AGA

RUANG PJ BED NAMA U RM MRS DIAGNOSIS PLAN STATUS DPJP PENUNJANG

ICU ATH 11 Ali anwr 22 01449106 Igd 7/2 COR GCS E3V5M6, OF Tibia-Fibula (D) 1/3 Proximal GA tipe IIIC, CF shaft Amputasi setinggi demarkasi, transfemoral preop PH 6/2 hb 7., ht 20, al 12.2, at 199, pt 13.5, aptt 24.8, gds 98, cr0.7, ur 42, alb 2.9, na 126, k 4.1, cl
Femur (D), Trauma occuli (S), Anemia, susp ruptur A.poplitea amptation 93, hbsag NR
ATH 10 Sri hastuti 46 01448522 IGD Hematotorak fr costae 2,3,4,5 (d) Post chesttube thoracostomy, pro orif costa Post Op PH Hb 10,5 Ht 29 Al 26,9 at 219 At 3,26 Darah A PT 13,8 APTT25,8 GDS 186 OT/PT 142 / 99 Ur/Cr
31/1 Preop 27/0.7 Na 135 k 3.1 Cl 103
½ ro: contusio pulmonum, efusi pleura (D), fr costa 2,3,4,5,7 post, fr segmental costa 6,
terpassang wsd setinggi sic 8, emgisem subkutis reg supraclaviculaar bilaterl
ATH 15 Suratmi 60 01398320 Paru 30/1 Aspergilloma DD Tubercel tumor paru kanan Konsul tunggu konfrensi preop 28/1 HB 11.7 HT 36 AL 4.3 AT 260 AE 4.14 GDS 138 SGOT 14
RGB ATH L Cicilia nunuk 52 01448714 Igd 3/2 Hematothoraks, hemoperitoneum, ruptur hepar Post chestube thorachostomy postop PH 3/2 hb 15.2, ht 45, al 10.3, at 305, pt 12.2, aptt 26.7, gds 143, ur 39, alb 4.3, cr 0.9, na 140, k
Ro torax kontrol jika bagus aff wsd poliklinis 4.2, cl 103
ATH F Siti hapsah 32 01446609 Igd 3/2 Post pseudoaneurisma A.iliaca eks (S) Tranfusi, preop PH 3/2 hb 8, ht 23., al 5.6. at 308, pt 13.9, aptt 26.8, gds 80, ur 13, cr 0.4, na 133, k 4, cl 97
SYA 7d Himawan 38 01447441 22/1 INTERNA Hidropneumothoraks (D), TB pru aktif, lesi lua CKD st 5 Konsul pro trombektomi dekortikasi Pre Op 31/1 HB 12,9 Ht 38 Al 8,2 At 340 Ae 4,7Pt/aptt 13,6/ 31,2 gds 197 Alb 3,7 ur/r 24/0,8 Na 136 k
3,5 cl 106, 25/1 Ro hidropneumotoraks (D),
HCU SYA E Margono 63 01447087 neuro BTKV : Akut limb iskemia , Neuro: Stroke emboli Pro disartikulasi knee + trombektomi Preop DI 6/2 Hb 12 hct 41 Al 17 At 549
anggrek 2 Sub endo : DM tipe 2 , Cardio: IHD , NYHA II
Mel 2 Sya 11 H Iqbal 2 01350590 Pediatri 6/2 PJB asianotik PMO IR Mild Pro cath lab Preop pH 7/2 hb 11.8, ht 35, al 12.5, at 389, pt 11.6, aptt 31.9, Sgot 23, sgpt 12, alb 4.8, cr 0.5, ur 41, na
139, k 4.3, ca 1.07, hbsag NR
Sya 11 ext Andhika 3 01376756 Pediatri PJB asianotik, VSD Pro Cathlab Preop PH
Sya 11a Citra ratna 3 01349605 Pediatri 6/2 PDA Pro cathlab Preop PH 7/2 hb10.4, ht 34, al 12.1, at 139, pt 13.2, aptt 33.7,na 131, k3.6, ca 1.11, hbsag NR
SYA 1A Taufan Dinar 7 01441353 Poli 29/1 AVM R. Antebrachii (S) post repair vaskuler eksisi bertahap Perawatan post op Postop PH 29/1 (-)
MEL 3 SYA 17C Sukarna 54 01405829 Interna Burger Disease post vats simpatectomi + disartikulasi Perawatan post op postop DI 2/2 hb 10.7, ht 32, al 4,9, at 244, pt 12.4, aptt 27.3, alb 4.1
30/1 29/1 . GDS 169 SGOT 42 SGPT 36 ALB 3.3 CR 3.4 UR 145 NA 134 K 5.0 CA 1.03
FL6 AGA 607D Bambang S 36 01435873 Poli 6/2 Stenosis VCS Oklusi Total Bypass V.subclavia (D) Preop SO 7/2 hb 9.6, ht 32, al 4.5, at 289, pt 14.9, aptt 28.9, gds 138, sgot 8, sgpt 19, alb 3.8, na 132, k
5.1, ca 1.11, hbsag NR
AGA 608B Paryono 52 01286449 ½ Poli cardio Mild CAD, cSevere Aorta Stenosis Pro open heart (AVR 7/2 stop trombo aspilet preop SO Hb 10.4, ht 30, al 7.5, at 170, pt 13.1, aptt 30.7, gds 74sgot 27, sgpt 14, ur 39, cr 1.7, na 135m k
5hr preop 3.7, cl 106, hbsag NR
AGA 610B Dyah hastuti 34 01448973 Igd 5/2 DVT cruris ((S) Pro trombektomi elektif preop so 5/2 hb 10.7, ht 31, al 10.9, at 345, pt 16.1, aptt 27, gds 75, alb 3.2, cr 0.5, ur 15, hbsag NR
AGA 611b Sudarmi 74 01449271 IGD 7/2 Susp DVT R ext Inf (S) Heparinisasai 20 iu/kgBB/jam, USG doppler workup PH 6/2 hb 12,9 Al 17 At 213 hct 39
vaskuler , Elastic bandage, Konsul interna
AGA 614 A Abd Rochim 79 01448682 iGD PAD pedis (D) Ct angiografi Pre OP SO 2/2 Hb 1,1 ht 35 Al 15,7 At 419 Ae 5.07 Darah B PT 14,7 aPTT 28,4 GDS 87 alb 3.2 ur/cr 24/0.6
2/2 Na 129 K 5,3 Cl 99 HbsAg Nr
Cardio
HHD , NYHA II AFNVR
FL 8 AGA 802c darsini 60 01448822 Interna Ulkus dm pedis (S) Post op debridemen Post op PH 4/2 hb 9.4, ht 27, al 42.2, gds 61, sgot 13, sgpt 2, ur 134, cr 2.9, alb 2.2, na 127, k 3, ca 1.07
AGA 802B haryono 73 01426839 interna Ulkus DM cruris D , ulkus manus dextra Konsulan
AGA 804 B Sutarti 53 th 01448516 interna Ulkus DM pedis (S) Wagner III Post dsa Post OP DI 31/1 hb 7.9 Ht 22 Al 19,2 At 331 Ae 2,70 Pt 14,1 Aptt 27,8 INR 1,1GDs 189 Alb 2 Ur/Cr 63/ 1,9
Na 124 K 2,7 Cl 90
AGA 804C Purwato 45 th 01448395 interna Ulkus dm pedis (S) Post dsa Post Op DI 30/1 Hb 9.7 Ht 29 Al 25.8 At 680 Ae 3,5 GDS 176 ur/Cr 45/2,3 Alb 2,7 Na 132 k 3,9 Cl 1,12
AGA 804E Samiyati 63 01448628 Interna 1/2 Ulkus femur (D), cruRis (D), DM II, CKD on HD Pro debridement Preop SO 6/2 gds 50, as urat 9.5, TG 295, 5/3 hb 9.0, ht 26, al 9.5, at 85, cr 4.2, ur 117, ba 123, k 5.5,
cl97, 24/1 MRV: Trombus V Axilla (D) disertai tortous sistema vaskuler disekitar lesi
Flb 9 SIW 901c Yuniati 32 01336051 Poli 6/1 PAD dg rwyt ALI distal phalanx digiti2 manus [D] Pro Amputasi + konsul interna Preop PH 6/2 hb 12.7, ht 38, al 5, at 324,pt 14, aptt 32.4, gds91, cr 0.6, ur 17, hbsag NR
SIW 901B Iwan s 34 01448461 Poli 4/2 Ulkus PAD cruris (D) Pro pasang NPWT, pro dsa rabu depan preop DI 5/2 hb 7.9, ht 24, al 4.9, at 123, pt 15.4, aptt 36
5, sgot 15, sgpt 14, alb 2.6, ur 30, cr 0.7, na 131, k 2.8, cl 97-
SIW 903B Kasinah 76 th 01448623 IGD Selulitis Cruris(D) + pedis (D) Post debridement , BLPL Jumat 8/2 Post OP DI 1/2 Hb 10,7 Ht 31 Al 16,6 at 282 AE 3,5 darah O PT 13,7 APTT 26,6 INR 1,07 GDS 126 Ur/Cr
1/2 269/2.2 Na 131 K 4,1 Cl 99 HbsAg NR
Ro Pedis AP : Soft tissue swelling dan emphysema subkutis r. Padis (D) mengarah gambaran
selulitis r. Pedis kanan, RO thorax : Cardiomegali
SIW 905D Masruchin 48 th 01448655 IGD Tumor paru (D) Ct scan thorax kontrast (8/2) , konsul Pre OP DI 2/2 hb 10,5 Ht 35 AL 16,6 AT 486 Ae 4,15 OT/PT 57/22 Ur/cr 21/0.5 Na 131 K 3,2 Cl 92 HbsAg
2/2 Reaktif
Tim nyeri : MST 2 x 20mg , PCT 1g / 8 jm , morfin 6 x 20 mg
SIW 907D Agus 30 th 01448372 IGD Hematopneumothorax (d)+ CF costae IV,V (D) lokal simple +Contusio Post chest tube thoracostomy, post oris costae Post op SO 30/1 Hb 15,8 Ht 43 Al 13,6 AT 221 AE 4,53 darah B Na 136 K 2,9 Cl 102 HbsAg NR
supriyanto 30/1 pulmo (D) Postop 6/2 ½ contusio pulmonum (D), fr costa 4,5 post (D),
SIW 908D Sukardi 50 01448204 IGD Fr. Costae 5,6 (D) lateral simple Post ORIF elektif Post op 6/2 DI 29/1 HB 15.8 HT 44 AL 13.4 AT 230 AE 4.87 GOLDAR A PT 12.6 APTT 22.7 INR 0.960 GDS 138 CR
29/1 1.2 UR 32 NA 135 K 3.1 CL 99 HBSAG NR, susp hemangioma
SIW 908E Is Setyani 42 01448748 Igd 4/1 Fr kosta 5 lat (S), 6-8 post (S), kontusio pulmonum Pro orif preop PH 4/2 hb 11.7, ht 36, al 9.2, at 287, hbasg NR, RO: Fr kosta 5 lat (S), 6-8 post (S), kontusio
pulmonum
SIIW 911D Jawita 13 01447045 IGD Post amputasi ai post rekonstruksi vaskular dengan bypass ai Ruptur a. Pro konsul plastik untuk graft exposed Post op PH 30/1 hb 8.4, ht 24, al 11 at 343, pt 15.4, aptt 21.5, alb 3.1, na 134, k 5.2, cl 1.19
bulan 19/1 femoralis 20/1 19/1 Cut off pada a. femoralis profunda kiri; Stenosis a. femoralis superficialis kiri hingga ke
23/1 distalnya; Fr. komplit 1/3 distal os femur kiri (Salter-Harris tipe 2) dan fraktur 1/3 proksimal os
25/1 femur kiri (Salter-Harris type 1); Soft tissue sweeling mulai setinggi 1/3 proksimal femur kiri
disertai pneumatisasi soft tissue.
SIW 912A Darto 70 01448876 7/2 Bone tumor sternum suspek GCT sternum Pro rekontruksi dinding dada dengan eksisi Preop PH 6/2 hb 8,7 Hct 27 Al 4,1 At 273 Pt 14 Aptt 32 Gds 99 Na 137 K 3,9 Ca 1,23
tumor
siw 913E sapar 68 01448913 Igd 4/1 Pneumothorax (D), fr. Costae3,4(D), lat simple, emfisema subkutis Pro orif costa, chesttube thoracotomy preop SO 4/2 fr komplit kosta 3,4,5,6,7, fr inkomplit kosta 8,9-
hemithoraks (D), CF subtrochanter femur (D)
Fl 10 SIW 1001C istatik 40 01447927 Igd 5/2 Post amputasi below knee ai dead limb pedis (D) post OREf tibia fibula (D) Perawatan post op Postop SO 5/2 Hb 12 Hct 38 Al 27 At 426 Pt 13 Aptt 22,6 Gds 147 Alb 4,1 Na 128 k 5 Cl 87-