koran subdivisi btkv 27 februari 2013-updatedxx

KORAN SUBDIVISI BEDAH THORAKS KARDIOVASKULAR RABU/ 27 FEBRUARI 2013

NO. RUANGAN

IDENTITAS & DIAGNOSIS

HASIL PEMERIKSAAN PENUNJANG

PALEM BAWAH1. B2/10 Mukhtar /L/57

thn585 947

MRS 27/1/2013

D/ CKD Stage V on post

cimino

Lab 25/02/2013RBC 3.03 HGB 8,7 HCT 27,3 PLT 110 Fe 28 TIBC 172 Ferritine 545.6Lab 23 /02/2013 GDS 110 Ur/Cr 730/4,1 Na 135 K ,5 Cl 102 Lab 18 /02/2013 Alb 2,8CT scan kepala 31 / 1 /2013 Tidak tampak kelainan

2. B2/3Bed 1

Sri Ismawati/P/ 58 thn/ 595

476MRS

22/2/2013

D/ CKD stage V ec

nephrophatic diabetik

Lab 23/2/2013PT 10,1 ApTT 18,6 INR 0,80 Lab 21/2/2013 GDS 160 HB1AC 6,8 Ur/Cr 4,9/6,9 GOT/GPT 10/11 As. Urat 7,9 Na/K/Cl 131/ 5,2/ 9,9 WBC 8,06 RBC 3,21 HGB 8,8 HCT 24,6 PLT 394Foto Thorax( 21/2/2013)TB paru duplex aktifDilatio et atherosclerosis aortaeUSG(21/2/2013)Tidak tampak kelainan

PALEM ATAS3. B2/2

Bed 2Rizal/L/20 thn

564283MRS

21/2/2013

D/ Post amputasi

Below knee(S) + Kontraktur

knee joint(S)

Lab 21 /02/2013 GDS 83 Ur/Cr 10/0,5 GOT/GPT 26/37 Na 147 K 4,05 Cl 107 HGB 15,7 RBC 5,71 PLT 436 WBC 11,04 HBSAG (-) CT 9’00 BT 3’00 PT 11,3 APTT 27,1 INR 0,90

4. B2/7 Bed 2

Alprida Patandianan/

P/28 thn588532

Konsul dari Interna

21/2/2013

D/ CKD Stage V on HD Reguler

Lab 23/2/2013Na/K/Cl 137/3,6/ 102 Lab 22 /02/2013 WBC 6,98 RBC 4,35 HGB 12,0 PLT 268 HCT 352 FE 42 TiBC 142 Ur/Kr 70/ 5,1 ferritin > 2000Lab 21 /02/2013 (Urin Rutin) Sedimen leukosit 4 Sedimen eritrosit 1 sedimen epitel sel 2Lab 20 /02/2013 Na 135 K 3,3 Cl 106 HGB 8,5 RBC 3,09 PLT 308 WBC 8,27Lab 22 /02/2013 GDS 83 Ur/Cr 10/0,5 GOT/GPT 26/37 Na 147 K 4,05 Cl 107 HGB 15,7 RBC 5,71 PLT 436 WBC 11,04 HBSAG (-) CT 7’00 BT 2’00 PT 11,3 APTT 22,2 INR 0,88

LONTARA 1 INTERNA (ATAS DEPAN)5. Kmr Isiba/P/35 thn Lab 25/02/2013

5/3Bed 2

419474

MRS 18/2/13

D/ CKD Stg V ec. PNC

Bilateral + HD on treatment efusi pleura (D) + post

chest tube H-7

WBC 6.92 HCT 26.0 RBC 2.85 HGB 8.2 PLT 184FNA 11/2/2013Suspek adenokarsinoma mamaeLab 18/2/2013ASM URAT 2.5 Na/K/Cl 144/4.15/107 hbsag (-) ANTI HCV (+) CT 6’30’’ BT 2’ PT 10.1 INR 0.8 APTT 26 GDS 105 UR/CR 37/3.7 GOT 18 GPT 16 ALB 3.8 Lab 21/02/2013Wbc 5,15 RBC 2,58 HGB 7,8 PLT 139Foto thorax 18/2/2013Efusi pleura dextraDilatatio et aterosklerosis aortaeFoto thorax 21/02/2013Cardiomegaly dengan tanda-tanda bendungan paru (CHF)Dilatatio et atherosclerosis aortaeEfusi plera dextraCitologi (cairan pleura) 7/2/2013Sediaan apusan tanpa adanya sel-sel maligna

LONTARA 1 INTERNA (ATAS BELAKANG)

6. Iso bed 2

M.Yusuf Rafi/L/31 thn

594693MRS

17/2/2013

D/ POH 68debrideme

nt + amputasi digiti I, V pedis (S)

ec.Buerger’s disease

Lab 17/02/2013GDS 131 Ur/Cr 9/0,5 GOT/GPT 35/100 Na 135 K 3,5 Cl 100 HGB 11,2 HCT 34,7 PLT 468 WBC15,74 HBSAG (-)

FotoPedis 16/2/2013Osteomyelitis disertai gas gangrene setinggi 2/3 tengah metatarsal pedis (s)

LONTARA 1 INTERNA (BAWAH DEPAN)

7.Km r 2/II

Bed 1

Supardi/L/47 thn/ 587047

MRs 3/1/2013

D/ Diabetic foot(D)

wegner 2

Lab 23/2/2013GDS strip 231 WBC 6,18 RBC 2,51 HGN 6,8 HCT 21,8 PLT 23Lab 21/2/ 2013WBC 6,27 HGB 6,6 RBC 2,53 HCT 21.9 PLT 236 Ur/Cr 32/ 3,4 GOT/GPT 28/ 22 Prot tot 5,2 Alb 2,4 Globulin 2,8 Na/K/Cl 133/ 3,5/102FOto thorax AP(3/1/2013)Cardiomegaly Efusi Pleura bilatearal

LONTARA1 INTERNA (BAWAH BELAKANG)

8. Kmr 5/ kelas

Syarifuddin/L/56 thn

Lab 22/02/2013WBC 31,62 RBC 3,11 HGB 8,5 PLT 413 BT’ 8’00 CT 2’00

1


II Bed 2

595081MRS 19/02/2013D/ Abses Scapularis (S)

POH 4 debridement

PT 14,1 INR 1,18 APTT 29,2Lab 21 /02/2013 GDP 41 GD2PP 171 HBA1c 12,6 GOT/GPT 31/40 HGB 12,7 HCT 38,1 PLT 622 WBC 22,44 Kol. Total 104 HDL 14 LDL 61 TG 146

Lab 1 9 /02/2013 GDS 87 Ur/Cr 29/0,7 GOT/GPT 36/53 Alb 2,3 Na 128 K 5,1 Cl 92 HGB 13,2 HCT 41,3 PLT 339 HBSAG (-) Anti HCV (-)

LONTARA 2 BEDAH UROLOGILONTARA 2 ORTHOPEDI

LONTARA 2 BEDAH DIGESTIF

9. Kmr

2 Bed 2

Takwi/L/ 53 thn595164MRS 19/2/2013

D/ Trauma Tumpul Thorax + EmfisemaSubkutisPost Insisi H-

4 e.c. Emfisema subkutis

Lab 19/2/2013CT/BT 8’00”/3’00” PT/APTT 12,4/31,0 INR 1,0 GDS 122 Ur/Cr 26/0,8 GOT/GPT 27/27 Prot.Total 4,9 RBC 3,47

WBC 8,3 HGB 12,7 PLT 224

LONTARA 2 BEDAH ONKOLOGI 10. Kmr 7

Bed 5Rabaji Dg.LinoP/52 thn/585142/JKM

MRS 22/12/2012

D/ POH 28 Chest tube e.c. Efusi pleura (s) + Ulkus ca mammae S

Rencanapleurodesis

Lab 22/2/13Wbc 4,62 RBC 4,44 HGB 12,3 HCT 38,6 LT 417Lab 15/02/2013CT/BT 8”/3” PT 10,9 INR 0,91 APTT 26,7 Na/K/Cl 134/4,2/101 GDS 78 Ur/Cr 18/0,5 GOT/GPT 44/21 Alb 2,2 Au 5,2 WBC 3,14 RBC 3,24 HB 8,8 HCT 28,5 PLT 179Lab 06/02/13WBC 5,02 RBC 3,19 PLT 33,9 HB 8,8 HCT 28,3 Alb 2,6 ER(-) PR (-) HER -2/NEU (-) Lab 25/01/2013Na 139 K 4,2 Cl 102 GDS 91 Ur/Cr 36/0,6 GOT/GPT 75/18 Alb 2,9 As.Urat 5,5 WBC 12,38 RBC 4,34 Hb 12,1 HCT 38,1 PLT 525USG 22/01/2013Kesan : hepato splenomegaly dengan fatty liverFoto Thorax 21/1/2013- Efusi pleura kiri- tidaktampaktanda-tandametastasepadafotothoraksini.Lab 19/1/2013WCB 8,26, RBC 3,68, HGB 10,4, HCT 32,8, PLT 426, GDS 86, Ur/Cr 15/0,5, GOT/GPT 84/24, Alb 2,6, As. urat 4,7, Na/K/Cl 135/4,2/105Echocardiogram 18/1/2013Kesimpulan:

- Fungsisistolik LV baik , 37%- DisfungsidiastolikLab 16/1/2013Alb 3,0PA 15/1/2013Kesimpulan; Invasive ductal karsinoma mamma (moderate grade malignancy)Lab 11/1/2013CEA 3,61, Ca 15-3 >300PA 31/12/2012Kesimpulan: Invasif duktal karsinoma mamma (moderate grade malignancy) yg metastase ke KGBLab 27/12/ 20 12 WBC 9,8 RBC 3,52 HB 10,2 HCT 31,8 PLT 239 Alb 2,1Lab 22/12/ 20 12 CT/BT 8’00”/4’00”, PT/APTT 10,7/24,7, GDS 72, Ur/Cr 30/0,6, GOT/GPT 60/19, Na 139, HBsAg (-), Anti HCV (-)USG Abdomen 22/12/ 20 12 Kesan: Hepatosplenomegaly dengan fatty liver

11. Kamar 6 bed 3

Ny.Ramlia /52 thn/592136 D/ post chest tube H-15 e.c. efusi pleura dextra + ulcus ca.mammae

Rencanapleurodesis

Lab 13/2/2013Kol. Total 116 Prot.total 5,1 Alb 2,7 Na 134 K 4,0 Cl 103 CT/BT 8/3 APTT 25,8 C.25,8 PT 11,8 C 108 INR 10,98WBC 14,49 RBC 4,52 HGB 10,8 PLT 693 HCT 35,3 Foto Thorax 09/02/13Efusi pleura bilateral terutama kanan, kardiomegali dengan atherosclerosis aortaUSG Abdomen

Tidak tampak nodul metastasis pada hepar Klasivitemyoma sub serosa Efusi pleura bilateral

Lab 06/02/13Wbc 15.7 Rbc 4.69 Hgb 12.2 Plt 955 hct 39.5 ur 16 cr 0.6 got/gpt 44/27 alb 1.2 gds 124 na 124 k 4.1 cl 99

LONTARA 3 THTLONTARA 3 KULITLONTARA 3 MATA

LONTARA 3 BEDAH SARAFLONTARA 3 SARAF

LONTARA 4 OBGYN (BAWAH DEPAN)LONTARA 4 OBGYN (BAWAH BELAKANG)

LONTARA 4 ANAK (ATAS DEPAN)LONTARA 4 ANAK (ATAS BELAKANG)

12.Lt.4 isolasi bed 1

An. Yusran/L/13/ 595774MRS 23/02/2013JKD

D/ efusi pleura susp. TB

Foto thorax AP/lateral 23/02/2013Efusi pleura masif dextraLab 24/02/2013WBC 15,9 RBC 4,07 HGB 9,6 PLT 508Lab 23/02/2013GDS 115 Ur 20 Cr 0,6 SGOT 49 GPT 11 Prot total 6,5 Alb 3,1 Kol total 109 Na/K/Cl 142/4.4/106

2


INFECTION CENTER13. Lt. 2

Kmr2Bed 3

PatahhuddinUsmanL/50 thn/589877

MRS 20/1/2013

D/ Post Chest Tube hari 32 dextra efusi pleura (S),Hidropneumotoraks (D)

Foto thorax 7/02/2013Hidropneumothorax D + Efusi pleura S + Aterosklerosis aortae

Post plurodesisWSD 18/02/2013D 50 cc, S minimal

Lab 23/1/2013WBC 5,23, RBC 4,53, HgB 13,7, HCT 41,6, PLT 164, GDS 96, Ur/Cr 25/0,5, SGOT/SGPT 39/36Foto Thorax 20/1/2013Kesan:- Hidropneumothoraxdextra- TB parudupleks lama aktif

ICU14. VIP 1 Aslau /L/49

thn /596028

MRS 23/2/2013

D/ Trauma Tumpul Thorax + Emfisema Subkutis + Fraktur costa III, IV, V, VI lateral sinistra + Contusio Paru Sinistra

Post chest tube H-4POH 1 ORIF

Lab 25/2/2013GDS 136 UR 18 CR 0,71 SGOT 183 SGPT 121 Na 132 K 3,7Klorida 102 WBC 8,98 RBC 2,88 HGB 8,7 HCT 25,8 PLT 156

Lab 23 /2/2013 CT/BT 8’00”/3’00” RBC 2,84 WBC 14,2 HGB 9,4 HCT 28,2 PLT 207 HbsAg (-)

15. HCU Bed 1

Rani/L/25 thn/594587Bed 2

MRS 15/2/2013

D/ Hematopmeumotoraks (d) pneumotorak

Foto thorax 24/02/2013Fraktur costa VI kanan ke lateral & fraktur kompresi CV Th 9-10Laterolisthesis CV Th 9 terhadap Th10Lab 16/2/2013RBC 3,10 HGB 8,8 WBC 12,4 GDS 192 Ur/Cr 29/1,10 HCT 27,2 PLT 202, GOT/GPT 266/298 Na/K/Cl 142/3,4/107USG 16/2/2013-Efusi pleura (d) -tidaktampaktanda-tandalacerasipada organ intra abdominal yang terscan.

s (s) + Fr. Vertebra torakal IX, X

post chest tube 9Bilateral

Lab 15/2/2013 RBC 9,36 HGB 21,1 HCT 38,3 Ur/Cr 29/1,10, GOT/GPT 266/296,Na/K/Cl 142/3,44/107, HBsAg (-)Urin 16/2/2013PH 6,0 BJ 1,015 BLOOD +5/250 ERITROSIT 10-15

16. Bed 6 Muslimin/L/29 THN/594394Bed 6MRS 15/2/2013

D/ Susp. Hematotoraks Dextra + fr. Vertebra cervical V, VI, VII

AGD 26/02/2013pH 7,42 pCO2 44,2 SO2 88,1 pO2 57,7 HCO3 27,3Lab 25/2/2013GDS 95 Ur/Cr 44/0,8 GOT/GPT 141/ 4,31 ALB 2,45 Na/K/Cl 129/4,49/95 CO2 45,5 SO2 98 PO2 101,8 BE 4,8AGD 18/2/2013pH7.361 pCO2 59 SO2 98.1 Po2 59 SO2 98.1 PO2 111.3 HCO3 29.1 Lab 18/2/2013WBC 11,4 RBC 3,8 HGB 11,0 HCT 34,4 PLT 123 GDS 138 Ur/Cr 62/0,9 GOT/GPT 54/43 Na/K/Cl 145/5,4/111Lab 15/2/2013GDS 107, UR/CR 31/110, GOT/GPT 40/30, Na/K/Cl 140/4,58/109, CT/BT 8/2, PT 12.0, INR 1,0, APTT 28.9, HBSAG (-) RBC 4.39 HB 12.7 HCT 39.7 PLT 22.3Lab 23/02/2013GDS 98, UR/CR 42/0,8, GOT/GPT 200/393, Na/K/Cl 135/4,7/100, PT 1,7, APTT 24,5, RBC 3,38 HB 9,5 WBC 11,60 PLT 216, ALB 2,4, GLOB 3,6

PICU

17. BED 8

An. Julian Ardiansyah/L

6 thn/ 581718

MRS 22/03/2013

D/ Efusi pleura (D) + diare akut dehidrasi berat + Hirsprug

disease post Duhamael

prosedure + Fistel

enterokutaneus

Post chest tube H 4

Lab 14/02/2013GDS 92, UR 14, CR 0,3, GOT 172 GPT 20, PROT TOT 5,9, ALB 2,3, GLOB 3,6, Na 131, K 4,6, Cl 97, WBC 12,02, RBC ,6, HB 9,8, HCT 30,1, PLT 488Foto Thorax 22/02/2013Efusi pleura masif (D)Lab 23/ 02/2013GDS 87, ALB 1,6, Na 117, K 4,77, Cl 94 WBC 116,06 RBC 3,17 HB 8,5 PLT 150

3


18. BED 11

Nn. Mildayanti

P/ 14 thn 595660

Konsul 23/03/13

D/ AKI + efusi pericardDD/ anemia defisieniAnemia penyakit kronik

Post chest tube bilateral H-3

Lab 25/02/2013GDS 98 Alb 2,3 Ca 3,9 CRP kuantitatif 89,8 ASTO (-)WBC 9,58 RBC 2,82 HGB 7,3 HCT 22,1 PLT 221 Lab 25/2/2013pH 7,33 pCO2 17,3 SO2 97,9 pO2 125,3 HCO3 11.9 αO2 -156 Alb 21Lab 22/03/2013Analisa gas darah : asidosis metabolit terkompensasi sebagianNa 133, K 4,9, Cl 107Retikulosit 2,4, GDS 11,5, UR 346, CR 3,7, SGOT 11, GPT 9, Protein Tot 4,88, ALB 2,5, GLOB 2,38, KOLEST 121, WBC 9,78,RBC 2,85, HB 6,6, HCT 20,5, PLT 239Foto Thorax AP lateral 22/03/2013- Cardiomegaly dengan edema paru (CHF)- Efusi pleura bilateral

NICUCVCURS UHPCC

19. 215 Tn. Linto DjodjuL/66thn/591235

Konsul 2/2/13

D/CKD Stage V on HDPost AV Shunt (Cimino) H-19

Lab 25/2/2013RBC 3,31 HGB 9,9 HCT 28,9 WBC 10,9 PLT 324 GDS 83 PT 14,2 INR 1,1 APTT 31,5 c 26,9 Lab 23/02/13RBC 3,40 HGB 9,8 HCT 29,6 WBC 11,2 PLT 278 Ur 68 Cr 5,7Lab 1 9 /02/2013 Ur/Cr 107/6,99 Alb 2,75 RBC 3,55 HGB 10,3 HCT 30,5 PLT Alb 2,75Lab 14/02/2013Na/K/Cl 134/3,5/101 Ur/Cr 70/4,9 RBC 3,65 HGB 10,5 HCT 31,4 WBC 10,4 PLT 249 Lym 16,5 Mono 9,7 Eos 8,1

Lab 10/2/13RBC 3,57 HGB 10,2 HCT 30,6 CT/BT 9’00”/3’00” PT/APTT 12,4/30,9 GDS 96 Ur/Cr 72/54 GOT/GPT 71/52 Alb 2,6 Lab 2/02/2013WBC 7,0 RBC 2,83 HgB 8,02 HCT 23,9 PLT 258CT 8;00 BT 3’00 PT 10,8 APTT 26,1 INR 0,90 GDS 176Ur 79 Cr 7,1 prot total 4,4 albumin 2,9 Na 131 K 2,7 Cl 97, D-Dimer 1,2

CT- Scan Hidronefrosis (s) denganureterolith (s)Echocardiogram 04/02/2013- MR moderate, TR moderate, AR trivial, disfungsi

diastolic

Echo vascular Doppler 04/02/2013- Marker di kedualenganFoto thorax 1/2/2013- Cardiomegaly- CVC terpasangbaik

20. 220 Ny. NuraeniP/Umur 65 thn,R M :000916

D/CKD stage V on HDPro AV-Shunt

Lab 23/02/13Ur 119 Cr 8,8 HGB 6,6 RBC 2,15 WBC 3,8 HCT 20,1 PLT 231Thorax AP 16/02/2013Cardiomegaly dengan dilataio et atherosclerosis aortae (HHD)USG : PNC bilateral,kista heparLab 14-02-2013PT/APTT ,9,8/21,3,GDS : 152,GOT/GPT:19/14,Albumin : 3,4,Asam Urat 10,0,HbsAg (-),Anti HCV (-),Rbc :1,99,HGB :6,0,HCT : 18,3,PLT :237,WBC 3,5Echocardioraphy 19/02/2013Hasil Echo Vascular DopplerTampakpembuluhdaraharteriradialiskanandengan 0,27 mmTampakpembuluhdaraharteriradialiskiridengan 0,32Diberi marker hypafixLab 19/02/2013GDS strip 117 Na/k/cl : 131 /4,2/104

ADT 14/2/2013Eritrosit- anisopoikilositosis, normosistik normokrom, burr cell(+) polikromasis (+) fragmented(+) ovalosit (+) sel pensil(-) bevda induksi (-) normoblast(-) Leukosit- jumlah menurun, PMN > limfosit , granulasi (+) hiperpigmentasi (+) vakuolisasi (+) sel muda (-) Trombosit- jumlah cukup giant trombositb (+)

21. Lt.3304/ VIP B

Tn. Amir/L/ 47 tahun/570786MRS 20/2/2013

D/BronkopneumoniaEmfisema subkutis

Pemeriksaan patologi anatomi 25/02/2013Lesi inflamasi suppuratifLab 25/2/2013Ur/ Kr 43/0.6 RBC 4,09 WBC 25,6 HGB 12,7 HCT 39,8 Na 129 k 4,2 Cl 105 Foto Thorax AP control (25/2/2013)Massih tampak gambaran pneumothorax (S) bila dibandingkan foto lama(20/2/2013) . Tampak banyak perbaikanBronchopneumonia spesifik blateralEmfiema subkuitis

Analisa Cairan PleuraWarna: merah keruh Bekuan: tidak ada Volume: 6 cc BJ: 1.015 Ph: 7,5 Rivalta (+) Glukosa: 1,2 Protein: 2,0 LDH: >36-- Sell 13.100/mm Hit.jenis sel: PMN : 60% MN:40%Thorax PA 20/2/2013Pneumothorax (S) (Tension pneumothorax)

4


Bronchopneumonia (D) susp.spesifik

Lab 20/2/2013Rbc :4,25,Hgb :13,7,PLT :361,Wbc :35,7,BT :3,CT :6”30,PT 11,4,INR 0,9,APTT 25,GDS 146,Ur/cr :67/1.0,GOT 15,GPT 37

IRD

5

koran subdivisi btkv 27 februari 2013-updatedxx

Documents