KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

NO
RUANGAN
IDENTITAS & DIAGNOSIS
HASIL PEMERIKSAAN PENUNJANG
PALEM BAWAH

1.
B2/5
SUDIRMAN
57 tahun (31/12/1955)
RM: 618168
Tgl MRS/Konsul : 30/7/2013

BED 2

D/
-Post VATS
-Pneumothotaks D
R/
Terapi sesuai TS Pulmo
Fisioterapi paru
Lab 10/10/2013
Urine rutin: kuning, pH 7, Bj 1,015, sedimen leukosit 20, sedimen eritrosit penuh
Thoraks 8/10/2013
Kesan: Hydropneumothorax D
Bronkopneumonia bilateral
Emfisema pulmonum
Emfisema pulmonum
Emfisema subkutis
Lab 2/10/2013
GDS 129, Ur 15 Cr 0,4 GOT 30 GPT 20 Alb 2,8
Foto thoraks PA/AP (23/9/2013)
Kesan :bronchopneumonia duplex suspek spesifik, susp. Hydropneumothoraks, emphysema pulmonum
kiri, emphysema subcutis
Lab 1/10/2013
WBC : 9.400 RBC : 3,54 Hb : 10,5 HCT: 31,3% PLT: 547.000 GDS:116 Ur/Cr: 14/1,0 GPT/GPT: 22/17
Alb : 2,8
Lab 22/8/2013
GDS: 70Na 137 K 4,77 Cl 109 HGB 12,5
HCT 35.8 PLT 441 WBC 15.18 RBC 4,13
Ur/Cr 20/0,7 GOT/GPT 25/19 Alb 2,4
2.

3.
<

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

4.

5.
B2/11
Bed 2

B2/12
Bed 1

B2/3
Bed 2

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

LINTONG TANGKEBATU
47 tahun (3/3/2013)
RM 624144
Tgl MRS :29-9-2013
-

B2/5
Bed 2

D/
CKD stage V on HD regular
Post AV shunt hari 12
R/
GV+Rawat luka
Terapi lanjut sesuai TS Interna
Latihan tangan
Nadine Saifanah
11/4/2010 (3 thn)
RM: 430904
MRS: 19/9/2013
D/ PJB Sianotik
Tunggu jadwal OK

Happe
31-12-1954
RM:631380
MRS: 7/10/2013
D/ CKD Stage V on HD regular
Post op AV shunt Tunggu jadwal operasi
Pong Sampe
10-12-1937
RM: 617060
MRS: 16-10-2013
D/ Tumor Mediastinum
Tunggu jadwal operasi
Konsul Perioperatif
Lab 1/10/2013
WBC 116, RBC 3,05, HGB 8,7, HCT 25,7, PLT 184, Fe 11, TIBC 185, GDS 231, asam urat 10,6
Lab 3/10/2013
GDS 283, uc/cr 104/8,3
Lab 4/10/2013

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
WBc 8,24, RBC 3,4, HGB 8,7, HCT 26,8, PLT 185, BT/CT 3/7, PT/APTT 10,2/22,7, GDS 111, ur/cr 58/5,3,
Na/k/Cl 138/3,6/105

Lab 09/10/2013
CT/BT 8/2 PT/APTT 12,2/34,5 GDS 97 ur/kr 17/6,6
GOT/GPT 32/15 Alb 4,7
Lab 29/8/2013
WBC 8,89 HGB 18,4 HCT 57,2 PLT 142 Na 131 K 3,0 Cl 108
Lab 24/9/2013
GDS 129 Ur 15 Cr 0,4 GOT 38 GPT 20 CT 700 BT 300 PT 10,7 (13,1) APTT 26,7 (24,4) WBC 9,08 RBC
9,31 Hb 21,5 HCT 65,3 PLT 161

Lab 16/10/2013
WBC: 7.1 RBC: 3.56 HGB: 10.4 HCT: 33.6 PLT: 142
PT: 10.7, APTT: 37.7, Ur: 104 Cr:9 Na:127 K:3,6 Cl:95
CT Scan Kepala (16/10/2013)
Kesan: Perdarahan Intraserebri kiri
Infark serebri kiri
Atrofi serebri
Lab (16-10-2013)
WBC: 8.0 RBC: 4.8 HGB: 13.8 HCT: 41.1 PLT: 208
PT: 9.0, APTT: 35.1, Ur: 32 Cr:1.1 Na: 146 K: 3.6 Cl: 112
GDS: 102, SGOT: 14, SGPT: 12

PALEM ATAS
Nn.Indah dwi Aulia
Lab 8/10/2013
8/8/1996
WBC 6,02 RBC 4,79
HGB 14,3 HCT 41,5 PLT 311 CT 800 BT
RM 628480
200 INR 0,864
PT/APTT 9,7/27,3 GDS 98 ur/cr 15/0,5
D/ Emphyema hemi thorax S DD/ Tumor paru
SGOT 20 SGPT 10,
albumin 4,4 Na/K/Cl 141/4,4/107
post chest tube
Thorax PA 10/10/2013
Post VAST hari 2
Kesan: Efusi massif pleura S
Terapi sesuai TS pulmo
Lab 9/10/2013
Analisa gas darah
PH 7,48 pCO2 35, SO2 96,6 PO2 78,5 HCO3 26,6
Lab 30/9/2013
WBC 4,68, RBC 4,81,
HGB 14,1, HCT 43,2, PLT 300,
GOT/GPT 16/11, Na/K/Cl
132/4,4/104, ur/cr 14/0,5 CEA 1,56
6.

B1/3

LONTARA 1 INTERNA (ATAS DEPAN)

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
7.

K6/B2

SANATIA
50 thn
630371
MRS : 27/9/2013
D/Diabetic foot wagner IV (D)
R/ GV per hari
Lab10/10/2013
WBC: 9,9 RBC 3,16 HGB: 9 HCT: 27 PLT: 704
CT/BT: 8/3 PT/APTT:12,8/26,6 Na/K/Cl: 133/5,1/102 GDS: 268 ur/kr: 29/0,7 GOT/GPT: 25/10 prot tot: 7,0
alb: 2,5
USG 03/10/2013
Cholecystitis
Lab 29/9/2013
WBC 20.86 RBC 3,22 HGB 9,5 HCT 27,8 PLT 248 Na 139
K 3,3 Cl 110
-Ulkus : jaringan nekrotik, granulasi (-), pus (+), slough (+)
Foto Pedis AP + Obliq D/S 28/09/2013
Gas gangren pedis dextra setinggi distal cruris
Osteofit pada calcaneus D
Disuse osteoporosis
Foto Thoraks PA/AP 27/09/2013
Pulmo normal
Dilatatio aortae

8.

LONTARA I INTERNA (ATAS BELAKANG)

ISO B1
Tn Harun
16 thn
629937
MRS:26/9/2013
D/POH 2 amputasi above knee ec
Gangren below knee (S) ec rupture A. Poplitea
R/ Ketorolac amp/8 j
Lab 16/10/2013
WBC: 9,25RBC:3,45 HGB:9,6 HCT:29,0 PLT:603 GDS:85 Ur/Cr:18/0,4 SGOT/SGPT: 25/27 Na/K/Cl:
134/4,9/106
Lab 09/10/2013
Alb : 2,2
Lab 03/10/2013
WBC 19,61 RBC 3,34 HGB 6,0 HCT 18,3 PLT 548
Lab 30/9/2013
WBC 14,08 RBC 2,23 HGB 6,0 HCT 18,3 PLT 323
USG abdomen 26/9/2013
Kesan Ascites minimal
Tidak tampak tanda laserasi
9.

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

10.

K4/B2

K4/B4
MATIUS RABA
1/1/1963
RM 625262
Konsul 7/10/2013
D/ POH 2 AV Shunt Brachia Cephalica

Tn. Abdillah
TTL : 18/10/1989
TGL KONSUL : 7/10/2013
RM 630661
D/ CKD Stage V on HD Reguler
R/ rencana AV Shunt
LAB 15/10/2013
WBC 5,45 RBC 3,04 HGB 9 HCT 27,4 PLT 210
PT/APTT 11/29,2 ur/kr 67/3,6 Na/K/Cl 141/3,1/110
LAB 13/10/2013
WBC 5,9 RBC 3,08 HGB 9,3 HCT 28,6 PLT 242
Ur/kr 91/4,4
LAB 7/10/2013
Ur/Cr : 215/7,8 Na 141 K 4,5 Cl 105 WBC 9,7 RBC 2,31 Hb 68,9 HCT 20,8 PLT 387 alb 3,3
LAB 13/10/2013
WBC 9,5 RBC 3,25 HGB 9,4 HCT 28,5 PLT 327
PT/APTT 9,1/26 ur/kr 80/8,1 Na/K/Cl 139/4,7/107
LAB 7/10/2013
Ur/Cr : 254/24,1 Na 125 K 5,3 Cl 95 WBC 16,64 RBC 2,11 Hb 6,0 HCT 17,2 PLT 157
11.

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

12.

13.

14.
K5/B2

K4/B6

K1/B5

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

K6/B4

Tn. Darwis Dahlang

TTL : 01/09/1971
MRS : 9/10/2013
RM 632188
D/ Post op Graft Arteri Poplitea (D) ec rupture
Total arteri poplitea
Tn. Supriadi
TTL : 8/8/1995
MRS : 13/10/2013
RM : 632594
D/ Post Thoracotomi H 3 anterior ec v.ictum penetrans+pneumothorax

Petrus Liri
16/04/1976
RM: 632413
MRS:11/10/2013
D/Corpus alienum intraparenkim dextra
Hemathorax dextra post chest tube +WSD hri 7
R/takar produksi WSD/24jam
Awasi retensi chest tube
Sukirman
5/6/1988
RM:632855
MRS: 16/10/2013
D/ Pneumothorax Spontan (D) + Post op WSD Hari II
R/ Awasi patensi chest tube
Diet Biasa
Foto thorax kontrol
LAB 10/10/2013
WBC 16,64 RBC 2,11 Hb 8,4 HCT 17,2 PLT 157
Lab 09/10/2013
Ur/Cr : 23/1,2 Na 139 K 4,26 Cl 110, GDS 115, GOT/GPT 28/24

Lab 13/10/13
WBC 12,51 RBC 4,53 HGB 13,9 HCT 40,8 PLT 191 CT 800 BT 200 PT 10,1 APTT 25,1 GDS 99 UR 22

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
CR 0,8 SGOT 22 SGPT 12 ALB 4,1 as.urat 4,9 Na 144 K 4,0 Cl 107

Lab: 12/10/2013
WBC: 7,27 RBC: 3,35 HGB: 10,6 HCT:30,8 PLT: 129
Lab 11/10/2013
WBC: 7,2 RBC 3,01 HGB:9,6 HCT: 29,2 PLT: 55 GDS: 99 Ur/Cr: 25/0,8 SGOT/SGPT: 17/11 Na/K/Cl:
141/3,8/10 CT/BT: 8/2 PT: 10,1 APTT: 23,4

Lab: 16/10/2013
WBC: 12.5 RBC 4.74 HGB:14.7 HCT: 44.6 PLT: 259 GDS: 77 Ur/Cr: 14/0,7 SGOT/SGPT: 19/24 Prot total
4.4, Alb: 3.5 Na/K/Cl: 144/4.02/111 CT/BT: 7/2 PT: 9.7 0,1 APTT: 28.2
HbsAg: Non Reactive, Anti HCV: Non Reactive

LONTARA 1 INTERNA (BAWAH BELAKANG)

15.

K7/III B 2

Gusri
629905
23 thn
Konsul 5/10/2013
D/ CKD stage V rencana post AV shunt
Hari 1

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

Lab 13/10/2013
RBC 3,20 WBC 11,43 Hb 9,4. HCT 26,6 PLT 106 PT/APTT 10,1/29,1 INR 0,804 Ur 64 Cr 7,1 Na/K/Cl
136/3,2/109
Lab 7/10/2013
RBC2,19 WBC 8, Hb 6,6. HCT 19,2. PLT 183 CT/BT 800/300 PT/APTT 11,2/28,1
Lab 4/10/2013
Bil.tot 0,6 bil.direct 0,16 Alp 56 kol.tot 131 HDL 19 LDL72 TG179 Na/K/CL 132/3,4/102 AFP<0,05
LONTARA 1 INTERNA (BAWAH DEPAN)
16.

KMR 1
BED 2
22,7 PLT 441

Mince
57 tahun

Lab 12/10/2013
WBC 6,01 RBC 2,99 HGB 7,9 HCT

RM : 631794
Na/K/Cl 138/5,6/110
Tgl Konsul: 15/10/2013

PT/APTT 10,3/25,4 ur/kr 112/6,5

Lab 10/10/2013
WBC 7,49 RBC 3,09 HGB 6,1

HCT 23,1 PLT 423

ur/kr 135/6,1 Na/K/Cl 130/5,0/108

Lab 09/10/2013
GD2PP 110 HbA1c 5,0
Lab 08/10/2013
Na/K/Cl 128/5,0/104
PT/APTT 10,8/20,3

D/ CKD stg V
Rencana AV-shunt
GDS 215 ur/kr 129/6,3 GOT/GPT 17/13

Foto Thoraks 07/10/2013

Cardiomegaly dengan dilatation elongation et
atherosclerosis aorta disertai edema paru
Efusi pleura bilateral

PAKIS
LONTARA 2 ORTHOPEDI (BAWAH BELAKANG)
LONTARA 2 BEDAH UROLOGI (BAWAH DEPAN)
17.

18.
KMR 3
BED 3

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

KMR 3
BED 4
Noni
1/7/1961
RM: 632378
MRS: 16/10/2013
D/ Ulkus Kaki Diabetik Wagner III-IV pedis (D)
R/ Gv tiap hari
Foto pedis (D) AP/Obliq
Erna
5/5/1991
RM: 628993
MRS: 16/10/2013
D/ Tumor Ginjal (D) Pro Pemasangan CVC
Lab 14/10/2013
WBC 6.1; RBC 3.12; HB 8.6 ; HCT 26.9; PLT 575
GDS 296; UR 12; CR 0.4; SGOT 95; SGPT 54; ALB 2.2
NA 126; K 3.66; CL 98

Lab 16/10/2013
WBC 6.4; RBC 3.53; HB 8.8 ; HCT 18.2; PLT 536
GDS 132; UR 25; CR 0.6; SGOT 87; SGPT 18; ALB 3.0
NA 137; K 3.2; CL 102
LONTARA 2 BEDAH DIGESTIF (ATAS DEPAN)
19.
KMR 11
BED 3
Herianto Parimata
18 th
RM: 627930
MRS: 14/9/2013
CVC insitu baik Nyeri (-)
D/ Post pemasangan CVC
Gv/2 hari
Rawat CVC

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
Lab 1/10/2013
GDS 97 Ur/Cr 27/0.4 GOT 54 GPT 76 CT 800 BT 300 WBC 11,6 RBC 3,44 Hb 9,9 HCT 29,7 PLT 514
Lab 20/9/2013
WBC 18,9; HGB 9,5; HCT 29,0; PLT 598; ALB 2,6; NA 137; K 4,2; CL 107; RBC 3,22
Lab 14/9/2013
CT 800 BT 200 PT 12,9; APTT 34,1; Ur/Cr 39/0,5; GOT 31 GPT 17

LONTARA 2 BEDAH ONKOLOGI ( ATAS BELAKANG)

20.

21.

KMR 8
BED 5

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

Nurul Hikmah Humaerah

11-7-1992 (21thn)
RM: 626423
Tgl konsul: 12/09/2013
CVC insitu
D/ post CVC
Osteosarkoma femur D
Gv / 2hr

KMR 4
BED 1

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

Afifah
7 tahun
Tanggal MRS/konsul: 28/8/2013
D/PJB Asianotik ec VSD
Rencana Operasi repair VSD
Sabtu 19/10/2013
Lab 14/10/2013
WBC 11,2 RBC 3,52 HGB 9,9 HCT 30,9 PLT 435
Lab 11/10/2013
WBC 8,9 RBC 2,84 HGB 7,9 HCT 24 PLT 522 CT/BT 6/3
PT/APTT 14,8/20,9 alb 2,2
Lab 09/10/2013
WBC 8,4, RBC 3,36, Hgb 9,3, HCT 28,3, PLT 555 Na 132, K 4,4, Cl 107, CT/BT 8/3
Lab 2/10/2013
WBC 11,4 RBC 3,04 HGB 8,4 HCT 25,5 PLT 721
Lab 27/9/2013
Na/K/Cl 124/3,6/124 WBC 9,4 RBC 3,32 hb 9,2 HCT 28,6 PLT 574
Lab 24/9/2013
Na/K/Cl 124/3,6/99 WBC 9,4 RBC 3,32 hb 9,2 HCT 28,6 PLT 574
Lab 24/9/2013
Na/K/Cl 133/2,9/111 WBC 10,9 RBC 3,64 hb 10 HCT 30,7 PLT 386
USG 19/9/2013
Ascites
PNC ginjal kiri
Lab 16/9
WBC 28.52 RBC 2.82 Hb 2,6 PLT 533 HCT 23.3

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
CT/BT 8/2 PT 13.5 APTT 27.1 Na 132 K 4.2 Cl 108
Ur 13 Cr 8.2 GOT 13 GPT 5 Alb 1.64 Asam urat 2.4
Lab 14/9
Na/K/Cl: 130/4,03/110
Lab(11/9/2013)
Prot tot: 3,4 alb: 1,4 globulin: 2,0 As urat: 5,1 GDS 63 Ur/Cr: 40/0,3 GOT/GPT: 13/8 Na/K/Cl: 130/4,1/107
WBC: 23,3 RBC: 3,8 HB: 10,3 HCT: 84 PLT: 358.000
Lab(15/2/2013)
HbsAg: non reaktif
Foto femur D AP/lat(15/--/2013)
Susp. Osteosarcoma 1/3 distal femur dextra
Foto thorax AP(15/2/2013)
Tidak tampak kelainan radiologi pada foto thorax ini
MSCT scan tulang(18/2/2013)
Gambaran osteosarcoma os femur dextra
Lab 23/08/2013
WBC 14,33 RBC 4,13 HGB 12,1 HCT 34,1 PLT 437 GDS 120
Ur/kr 27/0,4 GOT/GPT 32/10 Na/K/Cl 141/4,0/105
CT/BT 8/3
PT/APTT 11,6/29,1
Foto Thoraks 23/08/2013
Sesuai gambaran L-R shunt
Lab 16/10/2013
WBC 10,45 RBC 4,04 HGB 11,6 HCT 33,2 PLT 410 GDS 73
Ur/kr 25/0,4 GOT/GPT 25/10 Na/K/Cl 144/4,1/110 Alb 4.0
HbsAg: Non Reactive CT/BT 730/200 PT/APTT 9.7/29,1
Foto Thorax 23-08-2013
Kesan: Sesuai Gambaran LR Shunt
Echocardiography 3-7-2013
Kesan: VSD PMO Sedang, PH ringan, Kontraksi myokard normal,
Saran: VSD Closure >> CCATH
LONTARA 3 MATA (ATAS BELAKANG)
.
LONTARA 3 KULKEL (ATAS BELAKANG)
LONTARA 3 THT/KULKEL (ATAS DEPAN)
22.

LONTARA 3 BEDAH SARAF (BAWAH DEPAN)

Kamar 4 Muspirah
PA 10/10/2013
Bed37 tahun (01/08/1976)
Kesan : Suspek Malignant Epithelial Tumor
2
RM 629722
Foto Thorax 7/10/2013
MRS 25/09/2013
Susp. Tumor metastasis ke pulmo
Cardiomegaly
dengan
dilatation
et
D/
tumor
regio
frontal
susp.atherosclerosis aortae disertai edema paru
Metastas
Efusi pleura bilateral
Efusi pleura D ec malignancy
Lab 4/10/2013
POH 21 chest tube
Cairan pleura : transudat
30/9/2013
R/ GV + rawat chest tube
WBC 9,5 RBC 3,84 HGB 10,4 HCT 31,6 PLT 182
GOT 32 GPT 22 Alb 2,8
USG abdomen (23/09/2013)
-organ-organ
intraabdominal
dalam
batas
normal
-efusi pleura dextra
Lab 24/09/2013
WBC 18,77 Hb 12i HCV non reakt,2 RBC 4,38

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
HCT 36,4 PLT 224 CT 8 BT 3 PT 11,4 c 11,0 INR
0,9 APTT 36,6 c 26,1 HbsAg & anti HCV non
reaktif GDS 115 Ur/Cr 21/0,5 GOT/GPT 33/45 Alb
3,0 Na/K/Cl 134/4,36/103

LONTARA 3 SARAF (BAWAH BELAKANG)

LONTARA 4 OBGYN (BAWAH DEPAN)
23.

24.
K5 B3

K6B3

Sariani
13/08/1982
632162
MRS 10/10/2013
D/ Efusi pleura D + post chest tube hri 7 +
NOK susp.ganas

Aisa Yusuf
4/01/1961 (52 tahun)
631695
MRS: 10/10/2013
D/ efusi pleura D
NOK susp. Ganas
Post chest tube hari ke-5

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
R/ rawat chest tube
Takar produksi
VIP albumin 3 x 1
Lab 9/10/2013
WBC 131 RBC 4,91 HGB 11,5 HCT 35,5 PLT 485 GDS 112 ur/cr 23/0,7 SGOT/SGPT 25/9 Na/K 135/4,3
LDH 1042 As.urat 5,9
Foto thorax 9/10/2013
Efusi masif pleura dextra
Elevasi diafragma kiri

LAB 7/10/2013
WBC 10,7 RBC 4,65 HGB 13,1 HCT 38,3 PLT 358 CT 800 BT 300 PT/APTT 11,8 control 12,0 INR 0,97
APTT 24,4 control 24,6 GDS 133 ur/cr 32/0,9 SGOT/SGPT 21/12 Na/K/Cl 140/4,4/104 Alb 3,5 LDH 482
As.urat 5,2
25.
K2B6
Arifa
03/03/1963
MRS 02/10/2013
D/Efusi pleura D + post chest tube hari ke-8+
NOK susp. Malignancy
Lab 2/10/2013
WBC 17,33 RBC 3,46 HGB 9,9 HCT 29,5 PLT 482 GDS 130 ur/cr 26/0,6 SGOT/SGPT 16/16 Alb 2,70
Lab 2/10/2013
LDH 370 AFP 0,70 CEA 130 Ca 125: 293,04 Beta HCG < 2,00
Foto Thorax 04/10/2013
Kesan : Efusi pleura dextra
LONTARA 4 OBGYN (BAWAH BELAKANG)
LONTARA 4 ANAK (ATAS DEPAN)
LONTARA 4 ANAK (ATAS BELAKANG)
INFECTION CENTER
26.
LA SUMAI
62thn
RM :599256
Tgl MRS/Konsul : 15/3/2013

LT 1
KMR 2

D/ Efusi pleura (D) NSCLC D

R/ Rencana VATS jika setuju
Terapi Sesuai TS Pulmonologi dan Gizi Klinik
Awasi dan Takar prod drain WSD/24 jam
08/10/2013
PT/APTT 12,5/34,3, GDS 98, Ur/Cr 26/0,7, SGOT/SGPT 12/11, Alb 3,4, WBC 5,49, RBC 3,26, HGB 10,2,
HCT 29,9, PLT 181

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
Foto Thorax PA 25/9/13
Kesan: Hydropneumothorax dextra
USG Abdomen bawah 4-6-13
- Congestive liver
- Cholelithiasis
- Splenomegaly
- Ascites
- Efusi Pleura bilateral (susp empyema thoracic kanan)
FNA 23/5/2013
Kesan : Non small cell carcinoma
FOTO THORAX PA
-Hydropneumothorax disertai kolaps pulmo dekstra dibandingkan dengan foto 1/7/2013
LAB 23/9/2013
Ur/Cr 31/0,1 Na 136 K 3,6 Cl 97
Gambaran Darah Tepi 11/09/2013
Anemia normositik normokrom suspek kausa penyakit kronik
27.
LT 1
KMR 4
Ayub Danari
27/7/1938/75 tahun
RM 629136 / JKM
MRS 21/9/2013
D/ Efusi Pleura (D)
R/ Awasi dan Takar prod WSD/ 24 j
Terapi lain sesuai TS Pulmo
Lab 15/10/2013
Alb 2.6
Lab 11/10/2013
WBC 4,49 RBC 3,46 HGB 9,9 PLT 240 HCT 29,8 ur/cr 14/0,7 prot. Total 4,3 albumin 2,1 globulin 2,2
HbsAg/Anti HCV non reaktif GDS 163
Sitologi cairan pleura 10/10/2013
Lesi hemorragik , tidak mengandung sel epitel maligna
Lab 07/10/2013
HBA1c 4,6, Alb 2,2
Lab ADT (1/10/2013)
Anemia normositik normokrom susp. Kausa penyakit kronik
Disertai neutropenia
DD/ susp. MDS
Lab 1/10/2013
GDS : 95 as. Urat : 11,2 Na/K/Cl 131/3,97/107
SGOT/SGPT : 28/29, PT 13,7 Albumin 2
APTT 25,7 ur/cr : 115/2,5
Lab 3/10/2013
WBC 7,64 RBC 2,31 Hb 6,6 HCT 19,9 PLT 356
Lab 27/9/13
GDP 57
Lab 26/9/2013
WBC 5,93 RBC 2,52 HGB 7,6 HCT 21,9 PLT 117
MSCT Thorax 24/9/2013
Efusi pleura massif (D)
Tidak tampak densitas massa pada kedua paru
USG Abdomen 24/92013
Efusi pleura (D)
Hipertrofi prostat

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
Foto thoraks 21/9/2013
Efusi pleura (D)
Kardiomegali disertai dilatation et atherosclerosis aortae
27/9/2013
Sitologi cairan pleura : sediaan apusan tanpa sel epitel maligna
30/9/2013
Sitologi (cairan pleura) : apusan tidak terdapat sel epitel maligna
28.
LT 1
KMR 6
Rudy Hasyim
25/5/1975/ 38thn
RM 632652
MRS. 14.10.2013
D/ Efusi pleura (S) + Tumor Paru (S)
R/Takar dan awasi prod WSD/24 jam
Terapi lain sesuai TS Pulmo
LAB 14/10/2013
WBC 14,18 HGB 15,1 HCT 42,1 PLT 375, ur/cr 16/0,7 Na/Cl/K 138/4.6/107 GOT/GPT Prot Total 3.49 Alb
2,3 GDS 104
Foto Thorax 14/10/2013
Kesan: Soft Tissue Mass Pulmo Sinistra
Efusi Pleura Sinistra
29.
LT 1
Harmawaty
40 thn
RM 632197
MRS. 14.10.2013
D/ Hidropneumothorax (S) Post Op Chest Tube WSD
R/Terapi lain sesuai TS Pulmo
LAB 12/10/2013
WBC 8.6 RBC 3.29 HGB 9.6 HCT 29.5 PLT 295, ur/cr 30/1.1
LAB 11/10/2013
WBC 4.5 RBC 3.33 HGB 9.5 HCT 28.8 PLT 284
Na/Cl/K 127/2.3/101
USG Abdomen (13/10/2013)
Pelvocalyectasis kiri
Efusi Pleura Bilateral dan ascites
Foto Thorax 10/10/2013
Kesan: Emfisema Subkutis
Hydropneumothorax sinistra
30.
LT 2
KMR 4
Bed 3

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013
Paruru Dg. Taje
4/1/1966/ 47thn
RM 628437
MRS. 17.9.2013
D/ Efusi pleura (D) + Empiema (D)
R/GV + Rawat Chest Tube
Awasi & Takar prod WSD/24 jam
Terapi lain sesuai TS Pulmo
Rencana VATS jika setuju
Sputum BTA 3x 20/9/13
Kesan: gambaran visual sputum sampel A: nanah lender sampel B nanah lendir sampel C nanah lendir
LAB 12/10/2013
WBC 10,5 RBC 4,36 HGB 12,4 HCT 37,5 PLT 314, ur/cr 10/0,6 K/Na/Cl 3,8/141/109 GOT/GPT 114/10 Alb
2,6 GDS 107, HbSAg non reaktif, Anti HCV non reaktif CT 800 BT 2 PT/APTT 9,2/26,6
LAB 20/9/2013:
WBC 7,7 RBC 3,84 HB 11 HCt 33,5 PLT 305 GDP 68 Ur 6 Cr 0,6 GOT 23 GPT 24 Kol Total 158 HDL 42 LDL
110 TGD 112
LED: I : 67; II : 100
LAB 27/9/2013:
GDP 67 HbA1c 3,8
30/9/2013
GOT : 14, GPT : 17
31.

LT 2
KMR 4
Bed 4

Taba
31/8/1966 / 47 thn
RM 679512
MRS 24/9/13
D/ Emphyema (D)
Atelektasis paru (D)
R/ Follow up CT/WSD
LAB 13/10/2013
RBC 2,90 HGB 9,9 HCT 30,0 PLT 226 WBC 7,2 CT 80 BT 30
LAB 12/10/2013
WBC 6,53 RBC 3,18 HGB 10,7 HCT 32,8 PLT 187, ur/cr 9/0,6 K/Na/Cl 3,6/135/106 GOT/GPT 121/46 Alb
1,6 GDS 94
Lab sputum BTA 3X (2/10/2013)
Pewarnaan BTA 1 : 3+
Pewarnaan BTA 2 : Pewarnaan BTA 3 : BTA
Kesan : gambaran visual sputum/dahak
Lab 23/9/13
GDS 105 Ur 40 Cr 0,9 GOT 61 GPT 47 Na 134 K 4,5 Cl 104
Hb 13,7 RBC 4,31 HCT 41,5 PLT 206 WBC 13,2
Foto thoraks PA 23/9/13
Kesan : hidropneumothoraks kanan disertai kolaps paru
KP sinistra aktif

32. VIP 1

ICU

AGD 14/10/2013
Alkalosis metabolik
AGD 13/10/2013
Alkalosis metabolik
AGD 18/9/2013
Asidosis respiratorik terkompensasi
sebagian
Lab 12/10/2013
GDS 111 UR 23 CR 0,5 SGOT 39,
SGPT 111, Na 139 K 4,4 Cl 105 CT
800 BT 200 PT 12,0/10,0 APTT
24,3/24,8 INR 1,00 WBC 8,81 RBC
3,38 HB 9,1 HCT 28,3 PLT 442
Foto thoraks 13/10/2013
Efusi pleura dextra
Lab 1/10/2013
GDS 112 UR 20 CR 0,4 BIL.TOT 1,7
SGOT 52, SGPT 110, ALB 3,3
Prokalsitonin 0,47 Na 133 K 4,5 Cl
100 WBC 16 RBC 3,51 HB 9,1 HCT
27,8 PLT 332
AGD 18/9/2013
PH 7,44, PCO2 42,7 SO2 98,9 PO2
121,8 HCO3 279 H02 14,5 HCO2
14,5 BE 4,3
LAB 17/9/13
WBC 20,7 RBC 3,63 HB 9,6 HCT
30,4 PLT 146 Na/K/CL 121/4,4/92
GDS 117 UR/CR 43/0,3 SGOT/SGPT
78/117 ALB 3 AS URAT 2
LAB 24/9/13
Ur/Cr:
38/0,4;
Bil.
Total:1,0;
SGOT/SGPT: 27/110; Prot.total: 5,6;
Alb: 2,3; WBC 20,62; RBC 3,73; Hb
10,2; PLT 315; HCT 30,5;
LAB 25/9/2013
RBC 3,17, HGB 8,9, HCT 26,7, PLT
262, WBC 14,2, GDS 79, Alb. 3,0,
CRP 62, Na 135, K 3,9, Cl 111
AGD(15/9/2013)
Kesan : Alkalosis Metabolik
LAB(11/9/2013)
WBC 19,52 RBC 3,7 HGB 10.2 HCT
30.5 PLT 131 Alb 3,9 GDS 94 Ur/Cr:
29/0,4 GOT/GPT: 31/29 As. Urat 3,4
Laktat darah 43
LAB 10/9/13
WBC 9,2 RBC 3,21 HGB 9,1 HCT
26,9 PLT 77 Alb 2,3 Na 134 K 3,7 Cl
106 GDS 91 Ur/Cr: 44/0,7 GOT/GPT:
156/64 biltot: 1,1 bil direct: 0,9
AGD 12/9/13
pH: 7,446 pCO2 48,4 SO2 99 pO2
126,2 HCO3 32,6
Foto Thorax :
contusio
regio
hemithorax
dextra disertai fraktur costa 34-5
Foto Thorax 12/9/2013 :
Edema paru DD/ kontusio paru
Foto Thorax 7/9/2013
efusi pleura dekstra dan atelektasis
pulmo dekstra
Lab 8/9/2013 :
AGD : PH 7,38 PCO2 79,4 SO2 95,2
PO2 79,4 HCOS 23,2 CtO2 19,2 BE 1,3
GDS 95 Ur 28 Cr 0,5 SGOT 113 GPT
44 Na 137 K 4,16 Cl 1,09 Bil Tot
0,56 WBC 4,62 RBC 3,57 HGB 10,1

KORAN BEDAH
THORAKS KARDIOVASKULAR
Muh Adnan
1/1/1996
JUMAT,
18 OKTOBER 2013
RM : 626404
Tgl MRS : 5/9/2013
D/ Post thoracotomi + chest
tube
WSD ec efusi pleura dextra
GV+ rawat luka
Rencana rawat ICU

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

CVCU
PICU
NICU
RSUH
PCC
33.

Lt 4
Hermin Sangka Lambe
Kmr 432 RM: 617616
Tgl MRS: 15/8/2013

Lab 8/10/2013
Ur/cr 93/5 Alb 2,1 Na/K/Cl 124/3,6/87
Lab 13/10/2013
WBC 4,5 RBC 2,55 HGB 7,9 HCT 22,3 PLT 116
D/ CKD stage V on HD reguler POH 2 Lab 4/10/2013
AV shunt (cimino)
Alb 2,5
R/ rawat luka/GV
Terapi sesuai TS interna

Lab 3/10/2013
WBC 4,7. RBC 3,08. Hb 9,2. PLT 169. GDS 153
Lab 1/10/2013
WBC 4,8, RBC 2,80, Hb 8,6, HCT 25, PLT 159, Na
132, K 4, Cl 100, PT/APTT 11,3/31,1, ur/cr 96/5
Lab 26/9/2013
Alkali fosfatse 60 PT 12,7 APTT 30,3 Bil.total
0,59 Bil direk 0,31 Albumin 2,2 Gamma GT 22
Sitologi 29/9/2013
Apusan cairan pleura umunya terdiri dari sel-sel
limfosit matang, beberapa sel masotel, terdapat
beberapa kelompok sel-sel yang lebih besar dari
limfosit dengan mebmran inti yang irregular, inti
hiperkromatik
Lab 26/9/2013
PT 12,7APTT 30,3 BIL.TOT 0,59 BIL.DIRECT 0,31
ALKALI FOSFOTASE 60 ALB 2,2 GAMMA GT 22
SITOLOGI 21/9/2013
Hapusan cairan pleura pleura umumnya terdiri
dari sel-sel limfosit matang, beberapa sel-sel
mesothel
Cairan Pleura 21/9/2013
Warna kuning kemerahan
Volume 23 cc pH 8 Glu 208 Prot 2,9 PMN 24 MN
76
BJ 1,010
Lab (14/9/2013)
CT/BT 8/2,3 PT/APTT 11,1/26,5 GDP 151 Ur/Cr
50/3,67 GOT/GPT 22/10 Prot total 4,6 alb 2,3
as.urat 4,2 na 134 K 3,7 Cl 104 WBC 3,3 RBC
2,13 HB 7,1 HCT 20,3 PLT 185\
Foto thorax(10/9/2013)
Efusi pleura kiri
Edema pulmo bilateral
Suspek pneumothorax kanan
Rencana av shunt jika pasien tidak sesak
Lab 24/9/2013
RBC 2,16 Hb 6,7 HCT 19,8 PLT 195 WBC 4,5 GDS
193 Ur 79 Cr 4,6 GOT 29 GPT 28 Na 129 K 3,7 Cl
100

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 18 OKTOBER 2013

IRD
34

Alimuddin Hamid
27/5/1975/ 38 thn
RM: 632959
MRS: 17/10/2013
D/ Efusi Pleura (S)

Lab 17/10/2013
WBC 12,0 RBC 3,73 HGB 9,5 HCT 29,5 PLT 416,
ur/cr 35/1,1 Na/K/Cl 134/4.48/101 GOT/GPT
21/22 GDS 107, HbSAg non reaktif, Anti HCV
non reaktif CT 730 BT 30 PT/APTT 12,7 c
11,3/26,6 c 25,4
LAIN LAIN