Jumat, 8 Maret 2019 BEDAH THORAX KARDIO VASKULER ARV/DNT/ALF/MMA/THD/SIW/MEL/ERA

RUAN PJ BED NAMA U RM MRS/BYR DIAGNOSIS PLAN STATUS DPJP PENUNJANG

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ALF 1 Fandi A 29 01316998 Igd 28/2 N stemi brugada tipe !, ensefalopati, stroke konvulsi, Pasang PDT jumat dg guiding prop DI 6/3 na 136/ k 4.0, ca 1.14, prot tot 5,3, alb 3.2, ph 7.43, be 0.9, pco2 38, po2
efusi pleura minimal, venilatot associated pneumonia, bronkhoskopi di icu 122, hco3 25.3, tot co2 26.5, o2 saturasi 99
post ROSC,
ALF 5 Rusniah
ICU ALF 8 Rohmadi 49 01452004 Igd 1/3,/ UMUM Fr costae 2,6,7 (S) post simole, fr costae 4,5(S) sequal Post ORIF postop SO 2/3 agd: ph 7.450 be 1.3 pco2 36.0 po2 113 ht 45 hco3 25 tot co2 26.1 sat 02 99
postlat , hiperglikemi laktat a. 2.6 , 1/3 hb 17.5 ht 46 al 12.3 at 270 gol a pt12 aptt 22.9 inr 0.900 gds
357 cr 1.1 ur 22 na 133 k 3.5 cl 98 hbsag nr
1/3 thorax: contusio pulmonum, efusi pleura (s), emfisema subkutis dinding
dada lateral s, dan supraclavicula s, fr.complete costae 2,6,7 dan post kiri, fr.
segmental costa 4,5 postrolateral kiri
RGB MMA H Juningsih 32 01452073 Igd 2/3 BPJS PAD ekstremitas inferior (D/S), Iskemi Anterolat), DM , Heparinisasi 10 IU/kgbb/jam, co Pre op PH 3/3 ct angio: trombus oklusi subtotal di sepanjang aorta abdominalis setingi VL
interna, co jantung, lapor DPJP 3 a. Femoralis komunis bilateral, stenosis setinggi apoplitea bilateral, cutt off di
A,tibialis Ant, post, 3/3 pt 12.2, aptt 22.5, 1/3 hb 13.5 ht 37 al 12.5 at 331 ur 52
cr 1.07
MMA J Djumiyati 67 01452063 Interna/bpjs ALI manus (S) post trombektomi, DM II, HT Post trombektomi, pro amputasi manus Post op, PH 6/3 hb 8.5, ht 25, al 19.8, at 128, ae 2.73, alb 2.6, na 135, k 3.5, ca 1.01, pt
HCU
preop 16.9, aptt 31.7, inr 1.430, USG dopler: NoFlow pada A.radialis & Ulnaris 1/3
mel1
Distalm(S)
HCU THD 4E Paras 10 01437280 Pediatri/ BPJS Anuria, SLE, febris ec pneumonia Post WSD, awasi patensi wsd Post op SO 2/3 Hb10.2 Ht 33 Al 4.2 At 245 Ae 3.13 Na 136 K 3.0 Cl 1.13
mel 2 4/3
ERA 601c Qori 17 01449144 Pediatri/BPJS Post chesttube ai Efusi pleura post traumatika Tunggu hasil RO toraks kontrol, evaluasi postop DI 19/2 hb 11.2, ht 33, Al 19.5=3, at 1110, ae 3,95, crp 13.75Torax pa: pneumonia,
Tta ruptur lien wsd 50cc/hr 26/2 efusi pleura (S), 12/2 hb 11.5, ht 33, al 17.7, at 520,
ERA 606C febriyanto 39 01452325 Igd 5/5, BPJS Fr costa 3-6 post (S), COR, fr maxilla (S) Orif elektif ro kontrol 24 jam prop SO 5/3 hb 15.5, ht 44, al 18.6, at 246, ae 4.69, pt 12.2, aptt 24.3, gds 184, cr 1.3, ur
19, na 1.39, k 3.5, hbsag NR
ERA 609A Yussri 57 01435276 Poli 25/2, BPJS Post torakotomi + sternotomi+ rekontruksi dinding dada Perawatan post op, ICU bed 2 Post op DI 5/3 hb 12.8, ht 36, al 8.7, at 206, gds 219, alb 3.7, na 136, k 3.8 25/2 pt 13.4,
a.i adeno ca paru metastase dinding dada post 5/3 aptt 25.4, sgot/pt 18/18, alb 4.2, ur/cr 19/0.7, na 136, k 3.8, k 0.80, hbsag NR,
radioterapi DPH 1 5/3 Thorax : tak tampak pulmonal metastasis
ERA 609C Aini Nur 42 01450983 Poli 5/3, BPJS Pseudoaneuresma R. Brachialis (S) Pro repair aneurisma Preop DI 5/3 Thorax: Cardiomegaly, terpasang HD Cath TIP setinggi costae 11 post D. 5/3
hb 10.4 ht 30 AL 4.8 AT 168 Ae 3.48 PT 15.5 APTT 28 INR 1.280 GDS 88 OT 25 PT
FL6
15 Ur 56 Alb 4.1 Cr 7.1 Na 138 K 3.7 Cl 110 HbsAg REACTIVE
6/2 hb 9.4 Alb 3.8 5/1 TIBC 187 BESI 73
ERA 611A Tri Setyo 44 01452023 Igd 1/3 BPJS Fr costae II, IV, V, VI, VII, VIII post (D), F ros temporal pars ORIF Elektif Preop SO 2/3 gds 94 ur 46 cr 1.3 Na 125 K 3.2 Cl 91, 1/3 hb 13.6 ht 42 al 5.2 at 112 ae
Utomo petrosa (D) Tunggu ts jantung dan bedah saraf 4.58 PT 14.8 APTT 26.9 INR 1.180 Gol B HbsAg NR, 1/3 Thorax: Cardomegaly,
old fr.costae 3-5,7dan 8 post (D)
ERA 611b Hartati 58 01444629 Poli 4/3, BPJS Pseudoaneuresma A. Brachialis (S) Pro repair vaskuler A brachialis (S), Preop PH 5/3 hb 8 ht 27 al 7.8 at 339 PT 14.2 APTT 26.2 INR 1.150 Gol O+ gds 132 ot 12 pt
perbaikan ku,Hb 8 ur 55 alb 3.8 cr 2.4 Na 1138 K 4.7 Cl 112 HbsAg NR
ERA 614C Sudarsih 70 01218533 Poli 28/2, BPJS Ulkus DM tipe 2 pedis (D), post amputasi digiti ?, critical Post DSA jumat, raber interna, cek lab ppostop DI 1/3 hb 12.3, ht 36, al 21.4, at 524, ae 4.36, pt 14.1, aptt 28.6, gds 173, sgot/pt
iskemik limb bilateral 32/17, ur/cr31/0.9, alb 2.4, na 122, k 2.9, cl 86, hbsag NR
FL8 SIW 804A Indah K 41 01452301 Interna/ bpjs DM II wagner 3, ulkus DM pedis (S) Pro debridement preop PH 4/3 alb 3, ur/cr 74/1, na 125, k 5.1, hbsag NR,h 8.9, ht 27, al 25.8, at 853, ae
3.34, gds 69, sgot/pt 32/21
FL 9 SIW 902B Lilia R 16 01053812 Igd 27/2 bpjs Hemangioma R. Temporo Lat (S) Tunggu hasil Usg dopler+ preop DI 4/3 usg dopler: gbran slow flow hemangioma R.temporalis S
SIW 904C Sukirman 76 01450574 Poli 5/3, BPJS Empyema, Hemitorax D+WSD Pro Chest tube thoracostomy, alirkan Pre op DI 5/3 Thorax: efusi pleura D + kolaps paru D. WSD tube dg tip setinggi ICS 5 post
WSD D, Cor tak valid dinilai 5/3 hb 12.4 ht 39 al 10.6 at 298 PT 13 APTT 28.7 INR
1.000 GOL A, GDS 87 OT 20 PT 18 UR 37 CR 1 ALB 2.6 Na 130 K 3.4 Cl 98
1/3 MSCT thorax: Empyema
MEL 905 C Lugiyem 54 01452469 igd 6/3 BPJS Hematotoraks (S), COR, Commotio cerebri, CF Post chettube Poetop PH 6/3 hb 10.3, ht 29, al 13.9, at 223, ae 3.12, 5/3 pt 13.3, aptt 24, gds 166, cr 0.6,
claviculla(D( 6/3 ur 35, na 136, k 3.6, hbsag NR
SIW 907A Wartono 01452039 Igd 2/3, bpjs FR costa 2-6 lat (S) COR GCS E4V5M6, OF metatarsal APost ORIF Post op SO 3/3 hb 8.2, ht 24, al 11.1, at 121,
1,2,3,4 pedis (D), OF phalang proksimal 5 pedis (D), OF 2/3, pt 13.8, aptt 27.4, na 136, k 3.5, cl 103, hbsag Reaktif,
phalang distal manus (S), Susp. Ruptur Tendon 2/3 agd: ph 7.430 be 2.5 pco2 41.0 po2 114 ht 29 hco3 27.2 tot co2 28.5 sat 02
99 laktat a. 1.10
SIW 912C Nita Asian 33 01451608 Igd 27/2, BPJS Efusi pleura (S), tumor mediastinum (S) Kemo 2 regimen (cisplatin 75mg, Postop PH 6/3 sgot/pt 67/24, ur/cr 19/0.3 , 2/3 agd: PH 7.395, BE 1.0, PCO2 42.2, PO2
etopusid 100mg) 28/2 99.7, HCO3 26.1, Total CO2 27.4, O2 saturasi 97.3, 26/2 torax : efusi pleura (S),
massa mediastinum, 21/2 TTB susp tymoma
MEL 913A Sulistyani 39 01451825 Poli 3/3 bpjs CKD + hipertensi Total Rekontruksi vaskuler dg graft di GA, prop SO 5/3 hb 11.3 ht 32, al 11.2 at 238, ae 3.93, cr 6.3, ur 80, na 135, k 3.7, cl 101
rencana jumat.
MEL 913E Saji 53 01452436 Igd 5/3, Bpjds Fr. Costae 2,3,4,5,6 (D) Dr. PH Sp BTKV: Pre op PH 5/3 Thorax: fr.komplite costae 2 psteron kanan, fr. Komplit costae 3456 kanan.
COR GCS E4V5M6 Pro ORIF Elektif jk TS Neurosergery acc Kardiomegaly. 5/3 hb 12.3 ht 34 al 15 at 402 gds 90 ur 31 cr 0.9
Flb 10 MEL 1002A Koeswand 50 01442656 igd 22/2, BPJS Wound dehisence post thoracotomy, alergi As.Mef medikasi dg allevyn+acticoat, preop PH 21/2 hb 11.4, ht 33, al 12.1, at 560, pt 13, aptt 27.8, gds 139, alb 3.4, cr 0.7, ur
ono 25, na 128, k 4.2, cl 91, hbsag NR, Thorax: Hidropneumothorax kiri diserti
kolaps paru kiri.kultur: AB kombinsi gentamycin+ceftaziddin

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 MEL 1012C Mulyadi 52 01452449 Igd 5/3, BPJS Fr costa 3,4,5 (S) posterior simple Dr. FE BS: preop PH 5/3 CT Scan SAH Frontal dan parietal S, ICH Frontal S, Hematosinus ethmoidalis
Cor gcs E3V5M6 Mrs bangsal, Awasi ku,vs,gcs bilateral, sphenoidalis bilateral, maksilaris S. Fr os frontal S,temporralis S, rima
Comotio cerebri Dr.PH SP BTKV: orbita superior S, os maxila S, Sinus ethmoidalis dan spenoidalis bilateral, brain
ORIF elektif edema, sinus maxila D.
5/3 hb 13.2 ht 37 al 11.5 at 188 PT 13.7 APTT 25.6 INR 1.060 GOL B GDS 132 UR
57 CR 1 Na 138 K 3.3 cl 104 HbsAg NR
akbar
IGD ngatiah
MMA: ROI+RGB, THD Aster, mel2,3, ERA:Anggrek+FL6, SIW: fl7,8, MEL: ,9,10