LIST PASIEN ORTHOPEDI

Jumat, 2 Juni 2017

IRINA A ATAS
1 A1B2 Budiman Jacobus/ L/ 56 th/ 28-01- - ICH Frontal Dextra 15/05/2017 15/5/2017 29/05/2017 Pro jam operasidenganThovask
1961/manente tahuna - Fr. Costa IV,V,VI,VII Leu 8900 EKG: ST-T Leu 5066 Terapi sesuai TS Thovask
posteriordextra Eri 4,06 change ec anemiaEri 3.92
RM: 50.12.95 - Fr. Claviculadextra 1/3 Hb 14,4 ddelektrolit Hb 12.9 R/ ORIF
MRS: 16/5/17 tengahtertutup Ht 39,8 imbalance dd MI Ht 37.9
Trom 59 Trom 135
DPJP: dr. Djarot, SpOT SGOT 57 Konsul rehab SGOT 18
SGPT 53 medic terlampir SGPT 15
Ur 22 Ur 24
Cr 0,7 EKG 28/05/2017 Cr 0,9
GDS 194 dbn GDS 307
Chlo 102 Alb 2.92
K 3,5 Chlo 100.1
Na 137 K 4.17
Na 134

2 A6 B5 Salam Sahara Abdul/P/70thn/16-01- Fr. Kompresi Tho 7,9,10,12, dan Lumbal 15/05/2017 X-foto thorax 15- IVFD NaCl 0,9% 28 gtt/m R/ Stabilisasi fraktur
1947/Seki Galael Selatan Halmahera 1 Leu 5100 05-2017 : As. Tranexamat 3x1 iv
Erit 4,68 ObsCardiomegali Vit. K 1x1 im
RM: 493676 Hb 13,7 hediafragmakiril Vit. C 3x1 iv
MRS: 28/05/2017 Ht 39,9 etaktinggi
Trom 179
DPJP: dr. Tomy S, SpOT MCH 29,3 EKG 28-05-2017
MCHC 34,3 : dbn
MCV 85,3
SGOT 31
SGPT 24
Ureum 15
Krea 0,7
GDS 86
Albu 3,84
Chlor 107,2
Kal 3,65
Nat 143
PT 13,3 dan 12,9
INR 1,07 dan 1,02
APPT 30,6 dan
28,7
4 A7B8 TethoolChristovel/L/ 43 thn/ 05-06-1973/kel. - Fr. Pelvis ramus superior 23/5/17 29/5/17 IVFD RL:Aminofluid 2:1 Menunggu jawaban konsul

1
 Pandu link I - Anemia Leu 14640 Leu 22280 Ketrorolac 3 x 1 iv k/p rehab
Eri 3,19 Eri 3,55 Ranitidin 2x50mg iv
RM: 50.12.27 Hb 9,4 Hb 10.0
MRS : 14-05-2017
Ht 28,1 Ht 31.3
DPJP: dr. Andriessanto L, SpOT
Trombo 421 Trombo 565
MCH 29,5 MCH 28.3
MCHC 33,6 MCHC 32.0
MCV 88 MCV 88.2
SGOT 29 Alb 3.28
SGPT 32 Na 133
Ur 0,4 K 3.97
Cr 30 Cl 96.6
GDS 139
Na 136
K 4,13
Cl 98,9
5 A6B2 Thetool I R/P/13 th/ 23-03-2004/Pandu ling II- - fr. Shaft femur dextra terttutup 22/05/2017 28/05/2017 EKG : Sinus takikardia ORIF jumat tgl 2-6-17 R/ Orifelektif
- - fr. Tibia fibula dextra Leu 9100 Leu 6768 Hasil CT Scan IVFD RL % 28gtt/m Acc anestesi
RM : 50.13.31 - - fr. Shaft fibula dextra Eri 53,13 Eri 5,73 dipegangkeluargapasien Ketorolax 3x 1 amp iv (k/p)
MRS :15-05-2017 - Hb 7,5 Hb 14,0
Ht 23% Ht 46,2 Foto thorak 23-517
Tr 538 Trom 470 Dbn
DPJP : dr. Djarot N, SpOT MCH 24,0 MCH 24,4
MCHC 32,6 MCHC 30,2
MCV 73,5 MCV 80,7
Alb 3,42 SGOT 15
Cl 106,0 SGPT 9
K 4,0 Ureum 21
Na 136 Crea 0,4
PT 14,7 GDS 86
INR 1,23 Albumin 4,08
APPT 27,9 Chlor 103
Kal 4,2
Nat 137
6 A1 Bed 1 Poluakan Emil/L/68 thn/ 10-04-1949/ Desa Frakturcollum femur sinistratertutup 22/5/17 Konsul rehab Konsulneuro EKG 26/5/2017: R/ Arthroplasty
Sea Tumpengan Post stroke Leu 8851 medik 26/05/2017 28/05/2017 terlampir Iskemi inferior saran echo Ketorolac 3x30 MG IV
Eri 4,71 terlampir
RM: 34.75.24 Hb 13,9 Hasil Echo
MRS : 22/5/17 Ht 42,3 dipegangkeluargapasien
Trombo 170
DPJP : dr. AndriessantoLengkong, SpOT MCH 29,6
MCHC 33
MCV 89,7
SGOT 15
SGPT 13
Ur 36
Cr 1,3
As urat 8,8
Na 138
K 3,69
Cl 104

2
7 A3 bed 4 MamahaniMeisy/P/20thn/21-11-1996/Leleko SCI Frankle E IVFD NaCl 0,9% 14 gtt
Fraktur corpus anterior vertebra lumbal V InjKetorolak 3x1 amp
RM : 46.19.44 Ceftriaxone 2x1 iv
MRS : 28-05-2017 Ranitidin 2x1 iv

DPJP: dr. Tommy S, SpOT

8 A6 Bed 1 AyuniCiciliaTatulus/P/15thn/20-06- Fraktur tibia fibula Sinistra 1/3 distal 29/5/17 PULANG ATAS IVFD NaCl 0,9% 500cc
2001/Tandurusa terbuka grade IIIA Leu 14930 PERMINTAAN SENDIRI /24 jam
Post debridement Eri 3.88 Ceftriaxone 2x1 iv
RM : 50.17.67 Hb 10.0 Ketorolak 3x1 iv
MRS : 30-05-2017 Ht 32 Ranitidin 2x1 iv
Trombo 611
DPJP : dr. Tommy S, SpOT MCH 25.8
MCHC 31.2
MCV 82.4
SGOT 22
SGPT 36
Ur 28
Cr 0.5
GDS 80
Na 131
K 4.4
Cl 98
9 A7 Bed 1 Woy Petrus/L/50thn/23-08-1966 Fr. Humerusdextra gr. IIIA 24/5/17 Pro ORIF elektif
Fr. Costae VI lateral dextra Leu 14330 Terarpi lain sesuai TKV
RM : 50.20.43 Contosio paru dextra Eri 3.49
MRS :24-05-2017 Hb 10.8 Menunggu jawaban
Ht 31.8 konsulrehab
DPJP : dr. Haryanto S, SpOT Trombo 116
SGOT 82
SGPT 34
Ur 31
Cr 1.5
GDS 127
Na 134
K 3.7
Cl 106

3
IRINA A BAWAH
1 B8 bed 2 Lukar Evan/14 thn/L/22-07-2002/Ranoyapo - Dislokasi posterior elbow 29/5/17 EKG Ceftriaxone inj 2x1 gr iv
- Post reposisi hip joint sinistraecdislokasi Leu 9032 Sinus takikardi Ranitidininj 2x1 iv
RM : 50.22.95 posterior hip joint sinistra Eri 2.82 Ketorolakinj 3x1 iv
MRS : 27-5-2017] - Multiple vulnus laceratum Hb 7.7 27-5-17 IVFD RL 20 gtt/mnt
\DPJP : dr. Tommy S, SpOT. Spine Ht 23.7 UL terlampir Rawatluka
Trombo 124
MCH 27.2
MCHC 32.3
MCV 84.3
SGOT 64
SGPT 37
GDS 88
Na 132
K 4.08
Cl 98

2 B10B4 Sompie Diana/P/50th/01/12/1966/ Kokole I - Fr. Shaft tibia sinistra tertutup 19/5/17 Cefixime 2x100mg R/ rawatjalan
jaga 1 - Fr.Shaft fibula sinistra tertutup Leuko13320 As. Mefenamat 3x500 mg (Pasienbelumpulang,
- Fr. Zygoma Sinistra Eri 5,15 Ranitidin 2x150 mg tunggujasaraharja)
RM: 50.16.55 Hb 13.7
MRS: 19/5/17 Ht 41,7
Trombo300
DPJP : dr.A. Lengkong, Sp.OT MCH 26.5
MCHC 32,7
Raber Ortopedi MCV 81,0
SGOT 25
SGPT 18
Ur 35
Cr 0.6
GDS 319
Na 134
K 3,80
Cl 101

4
3 B9B3 RumondorYoresDrise/L/34 thn/15-08-1982/ Fr. radius ulna sinistratebuka gr III A 20/5/17 20/5/17 1-06-17 IVFD NaCl 0,9% 20 gtt Rawatluka
Warukapas Fr. Fibula 1/3 proximal sinistra Leu 17640 Leu 24770 Ceftriaxone 2x1 gr iv Konsulparu/interna
Post repair arteri tibialis anterior ec vulnus Eri 2.29 Eri 4,46 Leu 6200 Ranitidin 2x1 amp iv Lab control
RM: 50.17.47 scisum regio cruris sinistra Hb 6.7 Hb 13,4 Eri 4,21 Ketorolac 3x1 amp
MRS :21-05-17 Post repair tendon ekstensor ec vulnus Ht 20.9 Ht 41,4 Hb 12,3 Konsul interna Paru tgl 1-
scissum regio antebrachii sinistra Trombo 179 Trombo 331 Ht 36,8 6-17
DPJP : dr. Djarot N, SpOT Ur 25 MCH 30,1 Trombo 416 TERLAMPIR
Cr 1.3 MCHC 32,4 MCH 29,2
GDS 94 MCV 92,9 MCHC 33,4
Na 141 MCV 87,4
K 3.90 25/5/17 SGOT 22
Cl 105 Leu 6204 SGPT 50
Eri 2,12 Ur 30
Hb 5,9 Cr 0,9
Ht 19,4 GDS 48
Trombo 229 Alb 3,02
MCH 27,9 Na 131
MCHC 30,5 K 4,20
MCV 91,3 Cl 107,0
SGOT 36 APPT 22,3
SGPT 51
Ur 18
Cr 0,8
GDS 102
Alb 2,46
Na 152
K 2,9
Cl 106
INR 2,41

26/5/2017
Leu 10360
Eri 2,50
Hb 7.3
Ht 22.8
Trombo 330000
MCH 29.3
MCHC 32.2
MCV 91,0
PT 12.9
APPT 27.7
INR 1.03

EKG 28/05/2017
DBN

Foto Thoraks 29-5-27

Susp TB paru aktif
5
 (minimal lesion)

5 B10 Bed 7 Natasya Sambeka/P/14thn/28-10- Fraktur palangs proksimal digiti 2 pedis Lab 29-5-17 IVFD RL 20 gtt/m Rawat Luka
2002/wolaang dextra Leu12650 Ceftriaxone 2 x 1gr iv ORIF Elektif
Eri 4,72 Ketorolac 3 x 1 amp iv
Hb 12,4 Ranitidin 2 x 1 amp iv
MRS 30-5-17 Ht38,8
DPJP : dr. Tommy S, SpOT Fraktur metatarsal digiti 2-4 pedis dextra Tromb 254
MCH 26,3
MCHC 32,0
MCV 82,2
SGOT 20
SGPT 23
Ureum20
Crea 0,6
Chlor 104
Kal3,70
Nat 132

6
TERATAI
1 KLS I KawengianSantje/P/85 thn/29-12-1931 OA Genu Bilateral 27/5/2017 EKG 20-5-17 Meloxicam 1x7,5mg k/p Konsul Rehab terlampir
Kleak CHF Leu 7015 Omeprazole 2x1 caps PO
Eri 4.87 Terlampir RaberKardiologi
RM : 38.68.68 Hb 12.1
MRS :26-05-2017 Ht 39.7 Hasil Foto Tgu jadwal MRI selasa
Tromb170000 29-5-27 6/6/17
DPJP : dr. Tommy S., SpOT MCH 24.8 Kesan:
MCHC 30.5 Kardiomegali
MCV 81.5
SGOT 15
SGPT 10
Ur 36
Cr 1,1
Uric Acid 5.6
Cholest 154
HDL 42
LDL 91
GDS 137
Alb 3.48
Na 139
K 3,91
Cl 105.2
2 R2B9 Ria Kurniawati HNP vertebra lumbal 2-5 EKG danfoto Lab 1-06-17 Pro Stabilisasi posterior
thorax : dbn Leu 9800 Tidak ada terapi
Eri 4.11
Hb 12.8
Ht 34,4
Tromb 363
MCH 31,1
MCHC 37,2
MCV 83,7
SGOT 20
SGPT 25
Ur 20
Cr 0,4
GDS 79
Alb 4,60
Na 139
K 4,30
Cl 104.0
APPT 20,0

7
 Lab 17-05-2017
Hb 14
leu 10790
Eri 470
Ht 39.2
Tromb 362
MCV 83.4
MCH 29.8
MCHC 35.7
SGOT 20
SGPT 33

3 R1 BED 3 NeltjeKojo/L/75 thn/18-01-1942 Post stabilisasi posterior ec 25/5/2017 26/05/2017 29/5/2017 IVFD RL 20 gtt/m RaberInterna (DMT2,
Kleak Fraktur Vertebra Lumbal IV Leu 6286 Leu 6046 Leu 12560 Ketorolak 3x1 iv Hipertensiterkontrol)
Eri 3,56 Eri 3,68 Eri 3,30 Cefazolin 3x1 gr iv Aff drain
RM : 00.12.79 Hb 10,6 Hb 11,2 Hb 9.70 As traneksamat 3 x 1 iv Affkateter
MRS :25-05-2017 Ht 33,5 Ht 34,5 Ht 31,3 Miacalcic 1x1 amp IM
Tromb 278o Tromb 256 Tromb 218 Esomeprzol 1x1 vial Konsul rehab 30-5-17
DPJP : dr. Tommy S., SpOT MCH 29,7 MCH 30,5 MCH 29,5 Diet biasa Terlampir
MCHC 31,7 MCHC 32,5 MCHC 31,1
MCV 93,9 MCV 94,0 MCV 94.8 Tunggu hasil foto kontrol
Ur 23 SGOT 20 Ur 35
Cr 1,3 SGPT 17 Cr 0.9
GDS 179 GDS 124 GDS 294
Na 136 Albu 4,18 Na 136
K 3,9 K 4.2
Cl 136 Cl 104
X-foto : Fos 4.8
kesansusp Mg 1.65
cardiomegaly Alb 3.35
Scoliosis Ca 8.60
thoracalisdengan Pt 17.1
konveksitaskeka INR 1.50
nan Aptt 36.8

Spirometri :
Obstruksiringan

8
4 R1 Bed 1 Rumondor Yuliana/P/78 thn/21-06-1938 FrakturCollumn Femur Dextra Kaltrofen supp EKG ulang
RanotanaWeruLk IX R/ Herniathroplasty Menunggu ekspertisi foto toraks
Ekspertisi foto thorax

RM : 31.50.24
MRS : 31-05-2017

DPJP : dr. Tommy S, SpOT

5 R2 Bed 6 SefanyaLiando/P/14 thn/ 23-09-2002 Fraktur shaft tibia proximal dextra ttp As mefenamat 3x1 tab k/p R/ rawat jalan tgl 2 juni 17
MaumbiJaga VII

RM : 50.25.64
MRS : 31-05-2017

DPJP: dr Djarot SpOT

9
ICU
1 Bed 17 ValenTumuju/L/23th/11-12-1993/Tikala - Post open amputasi above knee 25/5/17 26/5/2017 29/05/2017 1-06-27 IVFD DL : D5 : Rawat Luka
dextra Leu 18340 Leu 18710 Leu 18310 Leu 6300 Aminofluid 2:1:1 =
RM : 50.18.45 - Sepsis ecfrakturterbuka + Eri 4,16 Tro 73.000 Eri 3,26 Eri 1,41 28 gtt/m
MRS :23/05/2017 frcrurisdextra post amputasi SGOT 131 Hb 9.6 Hb 4,5
Hb 12,2
DPJP : dr. Tommy S, SpOT - Susp DIC SGPT 431 Ht 30,1 Ht 12,3 Pro disarticulasi of
Ht 36,7 Trom 214 Trom 500 hip bilakel. Setuju
- Melena ecsusp DIC
Trombo 48 27/05/2017 MCH 29,5 MCH 31,9
Post amputasi below knee dextra MCH 29,3 Leu 18760 MCHC 31,9 MCHC 36,6 Meropenem 3x1 gr
MCHC 33,2 Eri 3,42 MCV 92.3 001 eosinofil 1% IV
Eosin 0% Hb 10,1 SGOT 43 002 basofil 0%
Baso 0% Ht 30,7 SGPT 138 003 netrofil batang Metronidazole
Trom 99 Bil tot 6.87 12% 3x500 mg IV drips
NetroBatang 9%
MCH 29,4 Bil direct 6.41 004 netfrofil segmen
NetroSegmen 75% MCHC 32,8 Ureum 18 74% Esomeprazole
Limfo 12% MCV 89,8 Crea 0,4 005 limfosit 9% drips
Mono 4% Ureum 27 GDS 70 006 monosit 4%
MCV 88,3 Crea 0,4 Alb 2.45 MCV 87,2
SGOT 267 Albu 1,99 Chlor 92.6 Ureum 78
SGPT 686 Chlor 101,5 Kal 4.55 Crea 0,8
Kal 3,87 Nat 127 Fosfor 3,5
Ur 102 Nat 134 Magnesium 1,61
Cr 0,6 Chlor 101,0
Prot Tot 4,26 Kal 5,30
GDS 56 Nat 123
P 1,8 Kalsium6,86
Mg 2,03 PT 16,3
Alb 1,92 APPT 39,4
Glb 110 INR 1,41
Na 135
K3,5
Cl 110
Ca 7,46
CRP 24
PT 18,9
APPT 34,8

30/05/2017
Leu 17230
Eri 2.93
Hb 8.8
Ht 27.3
Trom 314
MCH 29,9
MCHC 32,2
MCV 92.9

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ANGGREK
1 Anggrek II WoranDientjeTaroreh/81 tahun/P/Paal 2 - Fraktur trochanter Femur Dextra 23/05/17 25/05/17 29/05/17 1-06-17 EKG 29-05-2017 : DBN KoreksiKaliumsesuai TS Interna
Bawah RM :00.49.75.23 Leu 5582 Ur 19 Leu 6040 Leu 8500 ekspertisifoto thorax : dbn R/Hemiarthoplastudextra
Bed112 MRS : 18/05/17 Eri 3,77 Cr 0,6 Eri 3,67 Eri 3.78 Total hip replacement jikakeluar
terapi sesuai interna
Hb 11,0 GDS 81 Hb 10.8 Hb 11,8
DPJP : dr Tommy S, SpOT
Ht 34,1 Alb 3,63 Ht 34,0 Ht 34,7
Trom 274 Na 138 Trom 293 Tro 270
MCH 29,2 K 2,8 Cl 105 MCH 31.2
MCHC 32,3 Cl 102 K 3.00 MCHC 34,0
MCV 90,4 Na 135 MCV 91,8
SGOT 15 SGOT 18
SGPT 9 SGPT 10
Ur 21
Cr 0.6
GDS 81
ALB 3,41
CL 104,0
K 3,60
Nat 136
PT 15,9
INR1,36
APPT 36,3

11
 31/05/17
Leu 10700
Eri 4,13
Hb 12,8
Ht 37,7
Trom 91
Cl 99
K 3.97
Na 140

NYIUR
1 VIP 8 Marie Wajong/80thn/P/Bahu/28-03-1937 - Fr collum femur sinistra 30/5/2017 1-06-17 PCT tab 500mg k/p
Leu 8645 Ur 41 Terapi lain ssi interna
RM :50.24.37 Eri 3,83 Cr 0,8
MRS : 29-05-2017 Fosfor 2,9 Menunggu hasil foto
Hb 11,4
Magnesium 1,66
Ht 36,3% Albumin 2,91
Trom 419000 Calsium 8,20
MCH 29,7
MCHC 31.1
MCV 94,7
SGOT 18
EKG :
SGPT 20
Dalambatas normal
Ur 82
Cr 1,1
GDS 70
Alb 3,37
Cl 104
K4
Na 137

12
NYIUR

2. Edison Wolok/73 Post stabilisasi 25/5/2017 26/5/2017 EKG 25/5/2017 Lab 30-5-17 IVFD RL 20 GTT Menungguhasil MRI
tahun/L/Gorontalo/16- posterior ec Fr Leu 4972 Alb 3.29 Poor R wave di III, Leu 16350 Fosfomycin 3x 1 iv lumbal
8-1943 Vertebra-Lumbal 1- Eri 5.33 IgE 631.3 avF, susp OMI Eri 4,37 As traneksamat3x1
2 Hb 12,9 iv
Hb 15.5 PT 15.4 inferior
RM :50.21.77 Ht 39,6 Vit k 1x1 ap IM
MRS : 25/05/17 Ht 49.7 APTT 35.5 Tro352 Vit c 3x1 ap iv
Trom 319000 INR 1.31 Hasil foto 26-5-17 MCH29,4 Omeprazole 2x1
DPJP : dr. Tommy S, MCH 29,0 Pulmo: tak MCHC 32,5 vial iv
Sp.OT MCHC 31.1 Pelebaran Eosinofil 0% Meetylprednisolon
MCV 93.3 mediastinum Basofil 0% 2x125mg iv
SGOT 16 superior Netrofil batang7 Mia calcic 1x1 ap
Netfofil segmen 78 IM
SGPT 11
Limfosit 10 Terapi lain ssi TS
Ur 13 Ekspertisi foto 26- Monosit 5 anestesi
Cr 0.7 5-17: MCV 90,5
GDS 89 Kesan : fr kompresi SGOT 19
Cl 103 cv th 5 dan th 12 SGPT 11
K 4.40 Spon. lumbal Bilirubin total 0,24
Na 135 Bilirubin direct
0,10
Ur 23
Cr 1,3
GDS 180
Fosfor 5,7
Magnesium 1,51
Alb 2,52
Clorida 104,0
K 5,30
Nat 130
Calsium 7,78
PT 20,5
INR 1,91
APPT 27,5

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Irina B
1 Kamar 4 Robin Catrina/P/80th/30-10-1936 Fr subtrochanter femur dextratertutup 26/5/2017 KonsulNeuro 1-06-17 lab IVFD Nacl 0,9%+ KSR 25 meq :
HPT Leu 12770 29-05-2017 : Ur 18 14 gtt/m
RM:502232 Hipokalemi Eri 3.25 terlampir Cr 0,4
MRS: hipoNa Cefixim 2x200mg PO
Hb 10.1 Foto Thorax GDS 91
DPJP: dr.Djarot N SpOT hipo cl
Ht 30.1 terlampir Clor 75,0 Terapi lain ssi TS Interna
Trom 404000 K 2,70
MCH 31.2 Nat 108 EKG
SGOT lisis 27-50-17
SGPT lisis Leu 16520 R/ herniarthroplasty dextra
Ur 20 Eri 3.32
Cr 0.6 Hb 10.4
GDS 112 Ht 31,0
Cllisis Trom 352
K lisis MCH 31,4
Na lisis MCHC 33,7
MCV 93,2
SGOT 20
SGPT 10
Ur 18
Cr 0.6
GDS 156
CL 85,3
K 2,37
Nat 130
PT 13,8
INR1,13
APPT 34,4

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