LAPORAN JAGA RUANGAN

11 - 24 MAY 2019

RSUD KOTA TANJUNGPINANG

DR. ANDRIANA KIRANA P
ICU
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

1. Tn. Siswandi 7/5/2019 dr. Guptaja, BP (HCAP), Syok sepsis e.c BP Pindah ruang
49 th Sp. PD CKD stage V e.c PGD (HCAP) Perbaikan, Teratai
on HD, Infeksi Saluran Kencing 14/5/2019
DM Type 2 Uncontrolled CKD stage V e.c PGD on
CAD, HD,
Anemia ringan e.c Hipoglikemia
penyakit kronik DM Type 2 Uncontrolled
CAD,
Anemia ringan e.c
penyakit kronik
Dislipidemia
Imobilisasi
2. Tn. Hartono 11/5/2019 dr. Augustin, STEMI Anteroseptal STEMI Anteroseptal Rujuk ke RS
55 th Sp PD Otorita Batam
13/5/19

STEMI : ST-Elevation Myocardial Infarction BP : Bronchopneumonia CKD : Chronic Kidney Disease

CAD : Coronary Artery Disease HCAP : Health Care Associated Pneumonia PGD : Penyakit Ginjal Diabetes
ICU
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

3. Ny. Ngasiati 14/5/2019 dr. Augustine, Susp. ICH Stroke e.c SDH Meninggal tgl
54 th Sp. PD CKD on HD CKD on HD 25/5/2019

4. Ny. Rosita 15/5/2019 dr. Isep, Sp P Susp. Pneumonia dd TB Susp. Pneumonia dd TB Pindah KU tgl
35 th Paru Paru 17/5/2019

5. Ny. Karsi 18/5/2019 dr. Guptaja, Hipertensi Emergensi Hipertensi Emergensi Pindah KU tgl
54 th Sp.PD HHD HHD 20/5/2019
Dislipidemia Dislipidemia
6. Ny. Nelly Evita 18/5/2019 dr. Guptaja, UAP e.c STEMI UAP e.c STEMI Pindah
53 th Sp.PD DM Tipe II DM Tipe II Bugenvile tgl
CAD OMI Septal CAD OMI Septal 20/5/2019
Bekas TB Paru Bekas TB Paru
7. Tn. Janu 22/5/2019 dr. Augustine, SVT SVT Unstable
25 th Sp.PD Obs. vomitus

STEMI : ST-Elevation Myocardial Infarction SDH : Subdural Hematoma CKD : Chronic Kidney Disease UAP: Unstable Angina Pectoris
CAD : Coronary Artery Disease ICH : Intra Cranial Hemorrhage HHD : Hypertensive Heart Disease OMI: Old Myocardial Infarction
ICU
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

8. Ny. Riri K 17/5/2019 dr. Muhibah, Inpartu + Prev.SC 2x + Post SC a.i bekas SC Pindah
32 th Sp. OG G3P2A0 Histerektomi a.i atonia Cempaka tgl
uteri 19/5/2019
9. Tn. Juanda 21/5/2019 dr. Augustine, Demam hari ke 3 Viral Infection Pindah Dahlia
21 th Sp PD dengan viral infection tgl 22/5/2019
Susp. DHF grade I
Tonsilitis Akut
10. Ny. Zahara 22/5/2019 dr. Augustine, NSTEMI antero extensiv Syok kardiogenik Meninggal tgl
69 th Sp.PD DM Tipe II eps. NSTEMI antero extensiv 23/5/2019
hipoglikemia DM Tipe II eps.
CAD hipoglikemia
Trigeminal Neuralgia CAD
Trigeminal Neuralgia

SC : Sectio Caesarean DHF : Dengue Hemorrhagic Fever NSTEMI : Non ST-Elevation Myocardial Infarction
CAD : Coronary Artery Disease DM : Diabetes Mellitus
ICU
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

11. Ny. Wasti 20/5/2019 dr. Muhibah, HELLP Syndrome + HELLP Syndrome +
Sp. OG G4P3A0 25-26 minggu G4P3A0 25-26 minggu
Anemia ringan e.c ?
Trombositopenia e.c ?
Gangguan faal hepar
Hipertensi urgensi
Gross hematuria
ISK Komplikata
12. Tn. Yul Erwin 19/5/2019 dr. Robert A, Ruptur a.ulnaris et Syok hipovolemik Meninggal tgl
40 th Sp B medialis dextra Anemia berat e.c 20/5/2019
perdarahan akut
Sirosis hepatis nekrotik
stadium dekompensata
Ensefalopati hepatikum
gr. II
Leukositosis e.c ?
AKI synd. hepatorenal
AKI : Acute Kidney Injury
ANGGREK
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

1. Muh. Fauzan 11/5/2019 dr. Rosalyn, GEA Dehidrasi Ringan Diare Akut Dehidrasi Perbaikan. Pulang
1,6 th Sp. A Sedang Rngan Sedang 13/05/2019
2. Omar Al Gala 11/5/2019 dr. Rosalyn, Obs. Vomitus, Viral infection, APS tgl
1,1 th Sp. A Febris hari ke-3 Sindrom Dyspepsia 12/05/2019
Dehidrasi Ringan
Sedang
3. By. Noviyanti 11/5/2019 dr. Rosalyn, Asfiksia Neonatorum Pneumonia Neonatal Perbaikan. Pulang
0 hr Sp. A 14/05/2019
4. Josia 12/5/2019 dr. Rosalyn, Epilepsi, Viral infection, Perbaikan. Pulang
3 th 11 bln Sp. A Obs. Febris hr ke3 Epilepsi 15/05/2019
5. Aliza Azahra 13/5/2019 dr. Kristina, Kejang Demam Kejang Demam APS tgl
10 bl Sp.A Kompleks, Kompleks, 14/05/2019
DD/ TB Paru, Bronkopneumonia,
Bronkopneumonia,
Bronkitis
ANGGREK
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

6. By. Dede Heni 16/05/19 dr. Kristina, Neonatus Cukup Bulan Pneumonia Neonatal, Perbaikan. Pulang
3 hr Sp. A Sesuai Masa Neonatus Cukup Bulan 19/05/2019
Kehamilan post SC a.i Sesuai Masa
CPD+Prev. SC 1x, Kehamilan post SC a.i
Pneumonia Neonatal CPD+Prev. SC 1x

7. Aryndra 16/05/19 dr. Rosalyn, Urtikaria Urtikaria Perbaikan. Pulang

Benedictus/ 2 th Sp.A 19/05/2019
8. Ricky Tan Jaya 16/05/19 dr. Kristina, Sindroma Steven Sindroma Steven Masih dalam
2 th Sp.A Johnson e.c susp Johnson e.c susp perawatan
carbamazepine, carbamazepine,
Epilepsi Epilepsi
Konjunctivitis ODS
9. By. Elfiyana 17/05/19 dr. Kristina, Neonatal Jaundice, Neonatal Jaundice, Perbaikan. Pulang
3 hari Sp.A BBLR, Neonatal Cukup BBLR, Neonatal Cukup 19/05/2019
Bulan Sesuai Masa Bulan Sesuai Masa
Kehamilan post SC a.i Kehamilan post SC a.i
prev. SC prev. SC
ANGGREK
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

10. Ressy Jayanti 17/05/19 dr. Rosalyn, Thalassemia Thalassemia Perbaikan. Pulang
18 th Sp.A 21/05/2019
11. Putri Aisyah 17/05/19 dr. Kristina, Anemia + Thalassemia Anemia + Thalassemia APS tgl
8 th Sp. A Minor Minor 17/05/2019
12. Shiddiq 18/05/19 dr. Kristina, TB Paru + Infeksi TB Paru + Infeksi Perbaikan. Pulang
1,2 th Sp.A sekunder sekunder 22/05/2019
13. Susilawati 18/05/19 dr. Kristina, DD/ Kejang demam Tonsilofaringitis akut + Perbaikan. Pulang
8 th Sp.A kompleks, Epilepsi + Kejang demam 21/05/2019
Tonsilofaringitis akut kompleks

14. Yoernni 20/05/19 dr. Kristina, Demam Dengue Demam Dengue Masih dalam
14,8 th Sp.A perawatan
15. Ega Alif 22/05/19 dr. Kristina, Asma bronkiale Asma bronkiale Perbaikan. Pulang
7 thn Sp. A intermittent, serangan intermittent, serangan 22/05/2019
ringan sedang ringan sedang
ANGGREK
NO Identitas Tgl Masuk DPJP Diagnosis Awal Diagnosis Kerja Perkembangan

16. Davri Nurshafiq 20/05/19 dr. Kristina, Demam Dengue Gastroenteritis Akut Perbaikan. Pulang
1 th 5 bln Sp.A 25/05/2019
17. By. Dwi Febrianti 22/05/19 dr. Rosalyn, Asfiksia Neonatorum Pneumonia Neonatal
2 th Sp.A e.c susp. TTN dd/
Pneumonia Neonatal
18. Dewi 23/05/19 dr. Rosalyn, Bronkopneumonia Bronkopneumonia APS tgl 24/05/19
2 th Sp.A
19. Dimas Andrean 22/05/19 dr. Rosalyn, Infeksi Bakterial Akut Infeksi Bakterial Akut Perbaikan. Pulang
9 th Sp.A 24/05/2019
20. Ria Sofiyanti 23/05/19 dr. Rosalyn, Dengue Shock Dengue Shock Masih dalam
13 th Sp.A Syndrome Syndrome perawatan
21. Muhammad 24/05/19 dr. Kristina, Abses colli Abses colli Masih dalam
Pandji Sp.A submandibular submandibular sinistra perawatan
11 th sinistra
 PASIEN MENINGGAL
N Tgl Penyebab
Identitas Ruang Diagnosis Awal Diagnosis Kerja Tgl † DPJP
O Masuk Kematian
1. Tn. Thai 12/5/19 ICU - Syok hipovolemik - Syok sepsis e.c ? 14/5/19 Gagal Dr.
Jua - Retensi urin - Hematemesis e.c Nafas Guptaja,
50 th - Anemia berat e.c stress ulcer Sp.PD
perdarahan - Anemia berat e.c
kronik perdarahan akut
- DM Tipe 2 + - DM Tipe 2 terkontrol
ulkus pedis dextra diet
- Hipoalbuminemia - Hipoalbuminemia
- Gangguan faal
hepar e.c ?
- Ileus paralitik
 PASIEN MENINGGAL
N Tgl Penyebab
Identitas Ruang Diagnosis Awal Diagnosis Kerja Tgl † DPJP
O Masuk Kematian
2. Tn. Yul 19/5/19 ICU - Ruptur a. ulnaris et - Syok hipovolemik 20/5/19 Syok Dr.
Erwin medialis dextra - Anemia berat e.c hipovolemik Robert,
40 th perdarahan akut + Sp.B
- Sirosis hepatis Ensefalopat
nekrotik std. i hepatikum
dekompensata
- Ensefalopati
hepatikum gr.2
- Leukositosis e.c ?
- AKI synd. hepatorenal
3. Ny. 11/5/19 ICU Susp. ICH Stroke e.c SDH 25/5/19 Cardiac Dr.
Ngasiati CKD on HD CKD on HD arrest Augustine
59 th , Sp.PD

AKI : Acute Kidney Injury ICH : Intracranial Hemorrhage SDH: Subdural hematoma
 PASIEN MENINGGAL
N Tgl Penyebab
Identitas Ruang Diagnosis Awal Diagnosis Kerja Tgl † DPJP
O Masuk Kematian
4. Ny. 22/5/19 ICU NSTEMI antero Syok kardiogenik 23/5/19 Syok Dr.
Zahara extensiv NSTEMI antero extensiv kardiogenik Augustine
69 th DM Tipe II eps. DM Tipe II eps. , Sp.PD
hipoglikemia hipoglikemia
CAD CAD
Trigeminal Neuralgia Trigeminal Neuralgia
5. Ny. 22/5/19 Dahlia Penurunan kesadaran Penurunan kesadaran e.c 24/5/19 Cardiac Dr.
Salmah e.c syok sepsis syok sepsis arrest Augustine
75 th CKD on HD CKD on HD , Sp.PD
DM Tipe 2 + DM Tipe 2
Hipoglikemia Pneumonia (CAP)
Pneumonia (CAP) CAD
CAD

NSTEMI : Non ST Elevation Myocardial Infarction CAD : Coronary Artery Disease CAP : Community Acquired Pneumonia
 PASIEN RUJUK
No Identitas Tgl masuk Tgl Rujuk DPJP Diagnosis Alasan Rujuk
1. Tn. Hartono 11/5/2019 13/5/2019 dr. Augustine, STEMI Anteroseptal Rujuk RSOB
55 th Sp.PD Alasan: PCI
2. Tn. Siswandi 11/5/2019 16/5/2019 dr. Guptaja, Syok sepsis Rujuk RS Ahmad
49 th Sp.PD Infeksi saluran kencing Tabib
CKD st. V e.c PGD on HD Alasan: Tidak ada
Hiperkalemia perbaikan klinis dan
DM Tipe 2 rencana kultur darah
CAD
Anemia
Dislipidemia
Hiperurisemia
Imobilisasi
Ulkus decubitus
STEMI : ST Elevation Myocardial Infarction CKD : Chronic Kidney Disease PGD : Penyakit Ginjal Diabetes
CAD: Coronary Artery Disease
 PASIEN PAPS
No Identitas Tgl masuk Tgl PAPS DPJP Diagnosis Alasan PAPS

1. Tn. Yasmin 2/5/2019 11/5/2019 dr. Eddy Sobri, DM Tipe 2 Terkontrol Ingin merawat pasien
68 th Sp. PD Abses plantar pedis dirumah
sinistra
2. Omar Al Gala 11/5/2019 12/5/2019 dr. Rosalyn, Sp. Viral infection, Ingin merawat pasien
1,1 th A Sindrom Dyspepsia dirumah
3. Aliza Azahra 13/5/2019 14/5/2019 dr. Kristina, Kejang Demam Ingin merawat pasien
10 bl Sp.A Kompleks, dirumah
Bronkopneumonia,
4. Diajeng Rahma 12/5/2019 14/5/2019 dr. Robert, Sp. B Cedera kepala ringan, Ingin berobat ke sinse
19 th Susp. Fraktur kompresi
lumbal V
5. Kurniawan 28/4/2019 17/5/2019 dr. Hendrik, Post debridement ulkus Ingin istirahat di rumah
49 th Sp.B diabetik h-17
Post amputasi digiti 4
pedis dextra h-5
 PASIEN PAPS
No Identitas Tgl masuk Tgl PAPS DPJP Diagnosis Alasan PAPS

6. Savira Andini 18/5/2019 20/5/2019 dr. Robert, Sp. B Appendisitis akut Ingin berobat jalan
19 th
7. Putri Aisyah 17/05/19 17/05/19 dr. Kristina, Sp. Anemia + Thalassemia Darah tidak bisa
8 th A Minor diambil dari RSUP
8. Sabian 19/5/2019 20/5/2019 dr. Robert, Sp.B Abses Orang tua pasien
9 th limphadenopathy merasa anaknya sudah
inguinal sinistra, membaik
Bronchopneumonia
dextra
9. Dewi 23/5/2019 24/5/2019 dr. Rosalyn, Bronkopneumonia Pasien umum,
2 th Sp.A keterbatasan biaya
PASIEN OK

Operasi Jumlah

Obgyn 36

Bedah 38

Mata 2

THT 6

Total 82
TERIMA KASIH