BEDAH THORAKS KARDIO VASKULAR

Kamis 4 Oktober 2018 MRT/JRM/YES/GAN/API

RUANG PJ BED NAMA AGE RM MRS DIAGNOSIS PLAN STATUS DPJP PENUNJANG
ICU GAN 908A Andik 27 01434281 IGD Post other repair of chest wall exploratory Perawatan post op Post Op PH 30/9 Hb 14,1 Ht 41 AL 11,6 AT 152 AE 4,32 PT 13,4 APTT 29,7 INR 1,040 GDS 89 Alb 4,3 Cr 0,9 Ur 48 Na
29/9 thoracotomy ai multiple fr. Of ribs + 3/10 139 K 3,7 Cl 107 HBsAg NR
hematothoraks Ro Thorax 30/9: 1. Fraktur komplit di media costa 6,7, 8 dan 9 posterior kanan, multiple fraktur linear di os
Post ORIF Clavicula D/S ai CF clavicula D/S scapula kanan dan Fraktur 1/3 media os clavicula bilateral; 2. Contusio Pulmonum

RGB GAN F Sutrisno 44 01434255 IGD Post rekonst. Dinding dada ai Fr. Costae 2-8 (S) Perawatan post op Post op PH 3/10 Hb 11.3 ht 34 al 11.1 at 253 ae 3,71 alb 3.2 na 130 k 5.2
29/9 displaced posterior + Hematotoraks (S) 2/10 1/10 GDS 116 SGOT 66 SGPT 107 Alb 3,5 Cr 0,7 Ur 51
Post ORIF Clavicula ai CF. Clavicula (S) 1/3 29/9: Hb 12.0 Ht 36 AL 12.4 AT 233 AE 3.93 Goldar B PT 12.9 APTT 25.4 INR 0.990 HBsAg NR
Tengah Allman Group I
GAN G Suparlan 47 01434111 IGD COS GCS E3V4M6 BTKV : ro thoraks 1/2 duduk 2 sendi Post Op SO 2/10 hb 10.9 ht 32 al 11 at 237 ae 3.49 pt 14.1 aptt 29.2 inr 1.100 gds 80 alb 3.3 ur 25 cr 0.9 na 139 k 4.9 cl
28/9 Post ORIF Costae ai Fr. Costae 5-8 (D) BS : poliklinis 3/10 110
Post ORIF humerus ai CF humerus D CF 1/3 28/9 hb 12.9 ht 37 al 16 at 131 pt 13.9 aptt 27.4 inr 1.080 gds 125 cr 0.8 ur 25 na 140 k 3.4 kalsium 1.07
distal Humerus type \ hbsag NR
28/9 thoraks PA : 1. Contusion pulmonum 2. Fr komplit costae 4 post kanan cost 6 dan 7 lateral kanan

Mlt 2 GAN 1B Fitriana 14 01434075 Anak Post chest tube thoracostomy (D) ai Obs emfisema subkutis Post op PH 1/10 Hb 10,5 Ht 36 AL 9,8 AT 397 AE 4,34
Hidropneumothorax (D) Elastic bandage Ro Thorax 27/9: 1. Hidropneumotoraks kanan disertai gambaran kolaps paru kanan; 2. TB paru milier lesi luas
Emfisema subkutis aktif; 3. Efusi pleura kiri
TB Milier 27/9: Hb 12.7 Ht 43 HL 12.3 HT 483 GDS 117 SGOT 57 SGPT 31 Alb 3.6 Cr 0.2 Ur 10 Na 132 K 3.6 Cl 90 Ca
1.27
HCU GAN C M. Ali 12 01432468 Anak Post chest tube thoracostomy (D) ai Efusi pleura Advis dr. PH KU PH 3/10 hb 11.1 ht 39 al 17.6 at 734 ae 4.42 na 128 k 6.4 cl 94
21/9 (S) susp tumor mediastinum FNAB 1/10 Hb 9,7 Ht 30 AL 17,3 AT 590 AE 3,76 Cr 1,2 Ur 178 Na 126 K 6,1 Cl 101 Ca 0,96
Mlt 2
Hiperkalemia Paru : bronkoskopi hari ini 29/9: Hb 8.2 Ht 28 AL 13.2 AT 678 PT 14.8 APTT 31.3 INR 1.170MSCT Thorax 26/9: 1. Massa mediastinum
TTNA usg guiding tunggu jadwal anterior yang menempel pada cor, aorta ascenden, aorta descenden, arcus aorta, a. pulmonalis dekstra sinistra,
vena cava superior, trakea, dinding anterior toraks dan diafragma (19/9) Hb 8,2 Ht 25 Al 15,8 At 529 LED 113
Alb 3,1 Ur 32 Cr 0,5 Au 6 CRP 29 Na 138 K 3,7 Cl 101
HCU GAN F Suwarno 65 01354382 Interna Post HD Cath ai CKD St V Perawatan post op Post op DI 2/10 hb 10.1 ht 30 al 24.3 at 324 ae 3.28 ur 200 cr 13.5 na 140 k 5.5 cl 102 1/10 gds 65 sgit 36 sgot 13
2/10 3/10
Agr 2
VIP
Mel 3 API 14C Syifa 12 01434261 Anak Efusi pleura massif (S) + susp TB paru dd massa Perawatan post chest tube Post op PH 1/10 Hb 10,3 Ht 32 AL 13,6 AT 409 AE 4,12
maulida 29/9 mediastinum ct scan thoraks kontras hari inia (10/9) mProtein total 7,0 LDH 1610 HBsAg NR
29/9 Hb 9,8 Ht 33 AL 11 At 491 cr 0,3 Ur 7
Flb 6 API 604B Anton 58 01426415 B. Onko Susp tumor susp malignansi R. Colli Advis dr. PH Pre Op PH 1/10 hb 14.5 ht 44 al 4 at 222 ae 4.85, ur 26 cr 1 alb 4.2 na 137k 4.1 cl 113 ca ion 1.05
2/10 dd ca thyroid Acc joint op 23/7 hbsag NR TSH 1.39 freeT4 11.88
Pro Subtotal thyroidectomy + MSCT Colli tanpa kontras : 1. Massa thyroid bilateral yang meluas hingga mendiastinum dan menyempitkan
sternotohomy airway setinggi c7-Th1
Flb 7 API 704E Rahma 20 01428306 TS. Tumor thyroid susp malginansi t4cn1Mo Advis dr. PH : Pre op PH 2/10 hb 12.6 ht 40 al 3.8 at 231 ae 4.54 gds 52 sgot 38 sgpt 54 ur 16 cr 0.7 ma 138 k 3.9 cl 114 tsh 1.18 gree
Onko Acc joint op t4
2/10 Pro total thyroidectomy 30/8 msct colli tanpa kontras : 1. Massa region colli hingga ke mediastinum yang hipervascularized
20/9 MRI cervical kontras :massa thyroid colli bilateral
API 705C Joko 50 01410293 TS. Ca thyroid Advis dr PH : 30/9 hb 13 ht 42 al 12.7 at 511 ae 4.93 gds 129 sgot 26 sgpt alb 4.1 ur 39 cr 0.6 na 136 k 5.0 cl 106
Sumpeno Onkologi Hydropneumothoraks Dibahas di weekly 30/9 thorak PA : 1. Hidropneumothoraks dapat merupakan subpleuraltype pulmonal meta 2. Atelektasis paru
2/10 Atelektasis (D) kanan
Flb 8 YES 802C Sukiyem 55 01433541 Interna Post DSA ai Ulkus DM Cruris Pedis (D) wagner V Advis dr. PH : Op PH 1/10 hb 9.5 ht 30 al 19.9 a ae 3.44 gdp 406 ur 21 cr 1.2 na 128 k 3.6 cl 1.09
26/9 Amputasi Below Knee Ro Toraks 24/9: Cardiomegaly disertai oedem pulmo
CT Angiografi 4/10 Pedis AP dan Obl 24/9: Pneumatisasi soft tissue regio pedis dekstra mengarah gambaran ulkus
24/9 hb 9.6 ht 28 al 24.7 at 680 ae 3.19 gds 452 sgot 19 sgpt 1 ur 25 cr 1.3 na 126 k 3,3 ca 1.11 hbsag NR
Flb 9 YES 901B Sarjimin 53 01433172 IGD Ulkus pedis (S) + selulitis cruris (D/S) + old fr Perawatan post op Post op SO 1/10 Hb 5,3 Ht 15 AL 16,4 AT 593 AE 2,08 Bilirubin Total 0,32 Bilirubin Direk 0,20 Bilirubin Indirek 0,12 Alb
20/9 tibia fibula (S) 2,2 Cr 0,6 Ur 13 29/9 GDS 66 Alb 2.0 Na 131 K 5.1 Cl 103 20/9 PT 17,5 APTT 33 HBSAg NR
Hipoalbumin + Anemia inkompatible
YES 902A Nurul 55 01348887 Poli Tumor paru dextra susp benign Pro vats k/p thoracotomy Pre op DI 1/10 hb 13.9 ht 44 al 7.7 at 267 ae 5.38 pt 13.9 aptt 29.5 inr 1.110 gds 113 sgot 18 sgpt 17 na 139 k 4.4 cl 107
3/10 ur 38 cr 0.8 hbsag NR
Msct thoraks : 1/ lesi heterodens di paru dekstra lobus inf segmen latero basal cenderung massa benign 2.
Lymphadenopaty mediastinum station 2R,4R,7 dan axilla bilateral 3. Multiple kistik hepar 4. cholelitiasi
YES 902C Fathurrohm 23 01434100 IGD Pneumothorax (S) ec susp fistel bronkopleura Pro CT scan thorax dgn kontras Obs SO 28/9: Hb 15.1 Ht 43 AL 9.0 AT 233 AE 4.66 Goldar B PT 13.0 APTT 29.9 INR 1.000 SGOT 26 SGPT 23 Cr 0.9
an 28/9 Hari ini Ur 20 Na 134 K 4.3 Cl 101 HBsAg NR
YES 908B Joko 44 01276892 IGD Rupture av shunt Perbaikan KU KU SO 1/10 SGOT 41 SGPT 17 Alb 3,5 30/9 hb 6.6 ht 21 al 7 at 311 ae 2.47 pt 15.6 aptt 30.5 inr 1.260 gds 70 ur 176
Prasetyo 30/9 CKD + Anemia pro repair av shunt cr 12.5 na 137 k5.1 cl 103 hbsag NR