1

LIST PASIEN ORTHOPEDI

Jumat , 18 SEPTEMBER 2015
IRINA A ATAS: 5 pasien
No
.
1

Kamar

Identitas

Diagnosis

A10
Bed 3

Rendy Tubuon
L/ 24thn/
44.45.65

- Neglected
Fractur
tibia
fibula
1/3
tengah
comunitif
terbuka gr. IIIB +
osteomyelitis

MRS 22/7/2015
H-57
Dr. Tommy S,
SpOT

A2
Bed 2

Youke Pontoh
P/55 thn
45.39.09

SCI frankle E e.c

fraktur kompresi
vertebra Th 12

MRS 1/9/2015
H-17
Dr. Harry, SpOT

A1
B1

Moh Ismail
Montolagi
L/15/45.41.36
MRS 14/09/2015
H-4
Dr. Djarot, SpOT

post aff implant

Lab
15/9/2015
Leu 6200
Eri 3,73
Hb 8,7
Ht 27,4
Trombo
630
MCH 23
MCHC 32
MCV 73
Ur 17
Cr 0,7
GDS 123
Cl 97,1
K 4,51
Na 137
Alb 3,24
Glob 3,24
SGOT 30
SGPT 45
PT 14.8
INR 1.24
APPT 28.0
19/8/2015
EKG:
Dalam
batas
normal
08/09/15
X foto
thorax
Dalam
batas
normal
31/8/2015
Leu10700
Eri4,53
Hb 14,7
Ht 43,3
Trom308
MCH 30
MCHC 34
MCV 88

Lab
04/09/201
5
Leu 11700
Eri 5.44
Hb 13.6
Ht 41.5

8/9/2015
Leu 9500
Eri 4,07
Hb 9,4
Ht 30,2
Tro 680
MCH 23
MCHC 31
MCV 74
Ur 17
Cr 0,6
GDS 81
Cl 99,6
K 4,08
Na 137
SGOT 12
SGPT 8
PT 12,8
INR 1,02
APPT 20,6

Terapi
-

Rawat luka 2x sehari

IVFD RL 29 gtt/mnt
Cefotaxim 2x1 gr iv
Gentamicin 2x80 mg iv
Ranitidine 2x1gr iv
Ketorolac 3x1 gr iv
Paracetamol drips
2x1000 mg iv k/p
- Transfuse PRC 1
bag/hari sd Hb10g/dL
- Cek ekspertisi EKG
- R/ amputasi kaki kanan

21/7/2015
Foto Thorax:
Cor + pulmo
normal
Hemidiaphragm
a kanan letak
tinggi

SGOT 24
SGPT22
Ur25
Cr0,7
GDS 109
Cl 104
K 4,4
Na 139
12/09/2015
MRI spinal
thoracal :
Fraktur
kompresi very
TH12
(biconcave)
dengan
retropulsi
fragmen ke
posterior
menyebabkan
indentasi thecal
sac. Belum
sebabkan cord
kompresi
SGOT 18
SGPT 11
Ur 12
Cr 0.6
GDS 81
Cl 99.6
K 4.29

- Terapi lain sesuai

TS rehab medic

- Neurobion
1x500mg

- Metilcobalamin
2x500mg

- Penangana dari
bedah sudah tidak
ada

- IVFD nacl 0.9% :

RL 15 tpm

- Cefotaxime 2x1 inj

- Ketorolac 3x1
- Ranitidine 2x1

2
Trom 401
MCH 25
MCHC 33
MCV 76

16/09/201
5
Leu 10500
Eri 5.08
Hb 12.5
Ht 38.8
Trom 358
MCH 25
MCHC 32
MCV 76
4

A9
Bed 3

Andup Moh
TRisakti
L/6thn/45.36.67

Dislokasi cavum artic

coxae sinistra

MRS 16/09/2015
H-2
Dr. Djarot, SpOT

A6
Bed 1

Julian Elvita Lydia

P/40 Thn/
44.78.95
MRS 02/06/2015
H-107

SCI FrankleAe.c Fr. C5C6

Ulkus decubitus regio
sacrum gr. IV

dr.HaryantoS,SpO
T

16/09/201
5
Leu 7400
Eri 510
Hb 12.1
Ht 37.3
Trombo
429
Mch 24
Mchc 32
Mcv 73
Sgot 22
SGPT 7
Ur 14
Cr 0,3
GDS 107
Lab
1/9/2015
Leu 6700
Eri 3,06
Hb 8
Ht 25,3
Trom 558
MCH 26
MCHC 32
MCV 83
SGOT11
SGPT6
Ur 20
Cr0,4
GDS 184
Alb 3.09
Cl3.09
K3.6
Na132

Na 136
X foto thoraks
05/09/2015
Cor-pulmo tidak
ada kelainan
EKG
04/09/15
Dalam batas
normal

Cl 101,1
K 4,09
Na 138
PT 13.1
INR 1.05
APTT 31.2

- Rencana operasi
reposisi terbuka

31/8/2015
Foto thorax :
Cor dan pulmo
normal
02/09/15
Echo dalam
batas normal
PT 14,6
INR 1,22
APTT 32,3
Lab
16/09/2015
Leu 8300
Eri 3,24
Hb 8.3
Ht 26.6
Trom 563
MCH 26
MCHC 31
MCV 82

- SF 3x1 tab
- Metilcobalamin
2x500mg

- Terapi lain sesuai

TST KV & Rehab
medic

- Rencana pulang

27/06/2015
FotoToraks
:fotodanpulmo
normal.
Hemidiafragmal
etaktinggi
30/6/2015
EKG :
T inverted V1
V2 : gel II V3-V5
ec Sups
Elektrolitimbala
nce

IRINA A BAWAH: 15 Pasien

NO.

Kama
r

Nama

Diagnosis

Lab

Terapi

3
1

B11
B1

Agus Maruf
L/46 thn/
35.43.31
MRS 14/09/2015
H4

Post debridemen +
sequestrektomi + aff
implant ec metal
failure ec fraktur
dextra

Dr. Djarot, SpOT

03/09.2015
lab
Leu 7100
Eri 4,58
Hb 13,3
Ht 39,6
Trombo 410
MCH 29
MCHC 34
MCV 87
PT 12,2
Aptt 28,7
EKG
dalam batas
normal

SGOT 23
SGPT 11
Ur 23
Cr 0,8
Prot tot 7,72
GDS 81
Cl 101
Alb 3,76
Glob 3,98
K 4,19
Na 138

- IVFD RL 20 tts/m
makro

- Inj cefotaxim 2x1gr

iv

- Inj ranitidine 2x1gr

iv

- Inj ketorolac 2x1 iv

- Pertahankan irigasi
nacl 0,9% selama
5-7 hari -> 10 tpm

- Pertahankan
bacslab

- Diet bebas
- Cek hasil lab post
op

B10
Bed 1

Erni Sasembohe
P/80 thn/45.30.94

Fr. Femur dextra 1/3

proksimaltertutup

MRS 20/08/2015
H-28
Dr. Harry , Sp.OT

B10
Bed 4

Dila pangaIneng
P/54 th/42.29.67

- Post open biopsy ec

tumor femur dextra

MRS 14/8/2015
H-34
dr. Andre, SpOT

B9
Bed 1

Muhammad
Yunud
L/53thn/45.43.04
MRS 7/9/2015
H-10
Dr. Andre L, SpOT

ICH frontal dextra +

fraktur antebbrachii
dextra et sinistra
tertutup

Lab
28/8/2015
Leu4900
Eri 3,97
Hb12,7
Ht 37.7
Trom285
MCH 32
MCHC 34
MCV 95
Ur 27
Cr 0.8
GDS 140
08/09/2015
Leu 8400
Eri 4,33
Hb 13,3
Ht 41,5
Trom 279
MCH 31
MCHC 32
MCV 96
SGOT 19
SGPT 21
Ur 25
Cr 0.7
GDS 151
31/8/2015
Leu 5000
Eri 4,37
Hb12,1
Ht 37,7
Trom 277
MCH 28
MCHC 32
MCV 86
Ur 24
Cr 0,5
GDS 113
Na 138
K 3,89
Cl 100,9
PT 12,8
INR 1,02
APPT 28,1
6/9/2015
Leu 7600
Hb 13,5
Ht 41,3
Tro 213
MCH 31
MCHC 33
MCV 94
GDS 127
Eri 4,38
Cl 104,0
K 3,40

Cl 100.3
K 3.32
Na 139
PT 12.3
INR 0.97
APPT 21.9
24/8/2015
X-foto
Thorax:
Cardiomegal
i

- X foto kontrol
- As. Mefenamat 3x1
- Ranitidine 2x1
- Pertahankan skin
traksi

- Cek hasil CEA

- X foto skull,
thorax, vertebra,
pelvis

Cl 100.4
K 3,14
Na 139
PT 12.2
INR 0.96
APPT 21.1
Alb 4,10
CA 125
12.92
CA 19.9
10,6
8/9/2015
Leu 6000
Eri 4,00
Hb 11,2
Ht 34,5
Tro 392
MCH 28
MCHC 33
MCV 86
SGOT 16
SGPT 11
Ur 24
Cr 0,5
GDS 113
Na 138
K 3,89
Cl 100,9

- Cefixime 2 x 1
- Ranitidine 2 x 1
- Asam mefenamat
3x1

- Hasil foto femur

dextra & pelvis AP
ada pada pasien

- Pertahankan
bacsklab

- Terapi lain sesuai

TS NS

4
Na 139

B9
Bed 3

Ahmad Djailani
L/23 thn/45.44.88
MRS 10/9/2015
H-7
Dr. Tommy S,
SpOT

B9
Bed 4

Sadie Benny
L/52 thn/08.32.03

- Fr. tibia-fibula
sinistra 1/3 distal
terbuka gr. IIIA +
Avulsi jaringan
region dorsum pedis
sinistra

- Abses iliopsoas
Dextra

MRS 25/7/2015
H-54
Dr
. Tommy, Sp.OT

9/9/2015
Leu 16,51
10^3
Eri 5,22
Hb 14,3
Ht 41,3
MCV 79,1
MCH 27,4
MCHC 34,6
7/9/2015
Leu 11000
Eri 3,83
Hb 10,5
Ht 32,3
Tro 456
MCH 27
MCHC 33
MCV 84
Ur 15
Cr 0,6
Uric acid 7,1
GDS 116
Alb 3,13
Cl 95,7
K 3,87
Na 129
Lab
16/09/2015
Leuko 15300
Eri 4.03
Hb 10.7
Ht 34
Trombo 417

B9
Bed 6

Ridwan Mbuinga
L/59/454941

Fraktur tibia-fibula
dextra segmental
tertutup

MRS
16/09/15
H-2
Dr Djarot, SpOT

B9
Bed 8

ChristofelPolii
L/22 thn/04.01.58
MRS 06/7/2015
H-73
dr.Harry S, SpOT

- Post rekonstruksi
acetabulum +
reposisi terbuka +
plate & screw

- Dislokasi caput

femoris dextra
posterior + fraktur
acetabulum dextra

- IVFD RL 20gtt/m
- Cefotaxime 2x1g
- Gentamicin 2x1
- Ketorolac 3x1 amp
- Ranitidine 2x1amp
- Pertahankan
backslab
CT scan
Abdomen
(02/06/201
5):
Soft tissue
dinding
abdomen
baik
EKG
(8/9/2015):
Dalam batas
normal

08/9/2015
Leu 7000
Eri 5,40
Hb 15,7
Ht 46,8
Tro 251
MCH 29

lumbostomi

- Cefixime 2x200 mg
- Clindamycin 2x300
mg

- PCT 3x1 k/p

- Cetirizine 2x 5mg
- Rawat luka
- Tunggu hasil lab
PT, APTT

8/9/2015
X foto
thorax :
Foto thorax
normal

MCH 27
MCHC 32
MCV 84
LED 108
CRP 84

Lab
15/09/2015
Leuko 12800
Eri 4,38
Hb 13,1
Ht 39.8
Trom 186
MCH 30
MCHC 33
MCV 91
Ur 28
Cr 1,1
GDS 142
Na 133
K 3.9
Cl 100,9
SGOT 40
SGPT 41
CT-Scan
Pelvis:
Fr.
Acetabulum
Dextra

- Rencana vhreniko

- IVFD RL
- Cefotaxim 2x1 g iv
- Ranitidine 2x1 iv
- Ketorolac 3x1 iv
- Pertahankan gips

Foto
Thorax
(29/07/201
5):
Corbentukd
anukuran
normal,
pulmo
vascular
marking
normal.
Foto thorax

- IVFD RL 20 gtt/m
- Cefotaxime 3x1 gr
iv
- ketorolac 3x1 ap iv
- ranitidine 2x1 ap iv
- x foto pelvis AP
- rawat luka
- inj arixton 30
mg/0,5 cc selama 7
hari

B8
Bed 3

Ida Bagus Putu

Armada
L/24/45.47.41
MRS 14/09/15
H-4
Dr. Harry SpOT

10

B8
Bed 4

Kasim Jumadil
L/22 thn/45.16.18
MRS 8/9/2015
H-9

Trauma tumul toraks +

fraktur patel dextra +
vulnus laseratum
region digiti III manus
dextra + multiple
vulnus laseratum

Post rekonstruksi orif

ec Metal failure fraktur
femur dextra 1/3
proksimal

Dr. Djarot, SpOT

MCHC 34
MCV 87
GDS113
Cl 101,4
Ur 12
Cr 0,7
K 4,14
Na 138
PT 11,9
APTT 22,5
INR 0,93

7/9/2015
Cor pulmo
tidak ada
kelainan

13/09.2015
Leu 16.000
Eri 4,91
Hb 15,1
Ht 41,6
Trombo 210
MCH 31
MCHC 36
MCV 85

GDS 73
Cl 108
K 3,60
Na 143

1/9/2015
Leu 8800
Eri 6,89
Hb 16,9
Ht 50,9
Tro 385
MCH 25
MCHC 33
MCV 74
Ur 24
Cr 0,9
GDS 112
Cl 95,8

K 3,52
Na 137
PT 12,5
INR 0,99
APTT 20,2

15/09/015
Leu 20400
Eri 3.58
Hb 9.1
Ht 27.7
Tro 429
MCH 25
MCHC 33
MCV 78
11

B8
Bed 6

Stevanus
Kaaruan/ 24thn/
45.43.01
MRS 6/09/2015
H-11
Dr. Andre L,
SpOT

Fr. Calcanus sinistra

terbuka + vulnus
laceratum regio pedis
sinistra

6/9/2015
Leu 11300
Eri 5,23
Hb 14,0
Ht 42,6
Trom 233
MCH 27
MCHC 33
MCV 81
SGOT 30
SGPT 20
Ur 21
Cr 0,9
GDS 116
Cl 101,0
K 4,80
Na 136

EKG
8/9/2015
Dalam batas
normal
Lab
14/09/15
Leuko
11400
Eri 4.55
Hb 12,9
Ht 39,4
Trombo 229
MCH 28
MCHC 33
MCV 87

- iVFD RL 18 gtt/m
- ceftriaxone 2x1 iv
- ranitidine 2x1 iv
- ketorolac 3x1 iv
- pertahankan elastic
perban

- rawat luka

3/9/2015
EKG
:dalambatas
normal
1/9/2015
X foto
thorax :
cord an pul
normal

8/9/2015
Leu 12000
Eri 5,33
Hb 13,7
Ht 41,4
Tro 613
MCH 26
MCHC 32
MCV 85
Ur 14
Cr 0,7
Cl 98,1
K 4,09
Na 131

- IVFD RL 20 gtt/m
- Cefotaxime 2x1 iv
- Ketorolac 3x1 iv
- Ranitidine 2x1 iv
- Metilprednisolon
3x125 iv

- Kalnex 3x1 iv
- Transfuse PRC 1

bag /hari sampai

Hb>10g/dl

- Cek hasil lab

16/09/15

- IVFD NaCl 0,9%

- Cefotaxime 2x1 gr
iv

- Ketorolac 3x1 iv
- Ranitidin 2x1 iv
- Rawat luka
- Pertahankan back
slab

- CT scan ankle+
rekon 3D

6
12

B8
Bed 7

Indra Minggu
L/ 23/454823
MRS 15/09/15
H-3

SCI Frankle C ec fr
vertebra L I-II + vulnus
laceratum pedis
dextra

Dr Andre L, SpOT

13

B7
Bed 4

Johanis Lontoh
L/61/454708

SCI Frankle C ec susp

metastase ca buli

MRS 13/09/15
H-5
Dr. Tommy, SpOT

14/9/2015
Leu 23700
Eri 5,66
Hb 16.1
Ht 47.3
Tro 248
MCH 28
MCHC 34
MCV 84
Ur 32
Cr 1
GDS 165
12/9/2015
Leu 12300
Eri 4,94
Hb 14,1
Ht 43
Tro 308
MCH 29
MCHC 33
MCV 87
Ur 19
Cr 0.5
GDS 292

SGOT 135
SGPT 51
Cl 106
K 3.3
Na 138

- IVFD RL 14 gtt/m
- Cefotaxime 2x1 inj
- Omeprazole
2x40mg inj

- Ketorolac 3x1 iv
- Metilprednisolon
5,4/kgbb/24jam

SGOT 20
SGPT 11
Cl 97
K 4.3
Na 129
Ca 9.23

- IVFD Nacl 0,9 % 14

gtt/m

- Cefotaxime 2x1 iv
- Ketorolac 3x1 iv
- Ranitidine 2x1 iv
- Neurobion 1x 500
mg

- Metilcobalamin
2x500

- Cek MRI Vertebra

LII-III

14

B4
bed 3

Ris Bau
L/64/189690

MBD vertebra VI VII

VIII ec Ca prostat

MRS 15/09/15
H-3
Dr Tommy S,
SpOT

15

B5
Bed 4

SangariFike
P/39thn/28.31.30

SCI frankle C e.cpotts

disease

MRS 6/9/2015
H-12
Dr. Tommy S,
SpOT

14/9/2015
Leu 12600
Eri 3.60
Hb 10.1
Ht 31.5
Tro 526
MCH 28
MCHC 32
MCV 88
Ur 16
Cr 0.5
GDS 109
5/9/2015
Leu 6000
Eri 5,65
Hb 14,5
Ht 44,4
Trombo 612
MCH 26
MCHC 33
MCV 79
8/9/2015
Leu 5700
Eri 5,33
Hb 13,7
Ht 41,4
Trombo 613
MCH 26
MCHC 33
MCV 78

SGOT 18
SGPT 10
Cl 106
K 4,10
Na 131

- Cek LEA, PSA

- IVFD RL 20gtt/m
- Cefotaxime 2x1 iv
- Ranitidine 2x1 iv
- Ketorolac 3x1 iv
- Neurobion 1x 500
mg

- Metilcobalamin
2x500 mg

- Kapsul garam 3x1

Ur 13
Cr 0,6
GDS 61
Cl 103,0
K 3,70
Na 139

- IVFD RL 14 gtt/m
- Ranitidine 2x1gr IV
- Metilcobalamin
2x500mg

- Tramadol 3x1 IV
- R/ MRI
thorakolumbal

SGOT 19
SGPT 9
Ur 8
Cr 0,5
GDS 97
Alb 3,67
Cl 98,6
K 3,15
Na 137

Nyiur : 1pasien

K 20

Agnes Djarkasi
P/ 66thn
25.42.08
MRS
24/8/2015
H-24
Dr. Tommy
SpOT

Post hemiarthoplasty
e.c
Fr. Collum femur
sinistra

2/9/2015
Leu 11200
Eri 4.41
Hb 13,0
Ht 40,7
Trom 202
MCH 30
MCHC 32
LED 14

7/9/2015
Leu 10400
Eri 2,80
Hb 8,3
Ht 42,5
Tro 368
MCH 30
MCHC 32
LED 92
Ur 45
Cr 0,7
GDS 141
Fosfor 2,8

- IVFD NaCl 20
gtt/m

- Cefotaxime
2x1gr iv

- Ranitidin 2x1
amp iv

- Ketorolac 3%
3x1amp k/p

- Rawat luka
- Mobilisasi

7
Mg 1,88
Cl 94,4
K 3,85
Na 128
Ca 8,39

Anggrek : 2 Pasien
1

109

Nora Poluan
P/39/12.13.84
MRS 9/9/2015
H-9
Dr. Tommy S Sp
OT

Post repair tendon

(teknik krecho)
+pemasangan
backslab
Rupture total tendon
achiles dextra

14/9/2015
Leu 7600
Eri 4.95
Hb 14,2
Ht 42,9
Tro 313
MCH 29
MCHC 33
MCV 87

- IVFD RL 20 gtt/m
- Cefotaxime 3x1 gr
iv bila skin test
tidak alergi

- InjRanitidin 2x1
amp iv

- InjKetoroac 3x1
amp iv

- Pertahankan
backslab

Kumsuma Ria
P/61/45.31.81
MRS 20/08/2015
H-28
Dr. Tommy S Sp
OT

Post Hermiartroplasty
(7/9/2015)

7/9/2015
Leu 8800
Eri 3,74
Hb 10,4
Ht 32,8
Tro 610
MCH 28
MCHC 32
MCV 88
GDS 71
Alb 2,66
Cl 108,0
K 4,20
Na 139

27/8/2015
EKG :
Left atrial
hipertrofi
PUC trigeminis

- IVFD RL 20 gtt/m
- Cefotaxime 3x1 gr
iv bila skin test
tidak alergi

- InjRanitidin 2x1
amp iv

- InjKetoroac 2x1
amp iv

- Konsul rehab medic

untuk mobilisasi

- X foto pelvis AP
- Posisi tungkai kiri
abduksi