KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013

NO

RUANG
AN

1.

B2/5
BED 2

2.

B1/7

3.

B1/8

4.

B2/1
BED 2

5.

B1/1

6.

KMR
I/II
Bed 2

7.

KMR
V/III
BED 4

IDENTITAS & DIAGNOSIS

HASIL PEMERIKSAAN PENUNJANG

PALEM BAWAH
SUDIRMAN, 57 tahun (31/12/1955)
Radiologi
RM: 618168
KP duplex lama tenang, pleural reaction bilateral,
Tgl MRS/Konsul : 30/7/2013
emfisema subkutis
D/ Post Thorakotomi Hr 17 ec reccurent
TGL 2/9/2013
WBC : 9.400 RBC : 3,54 Hb : 10,5 HCT: 31,3% PLT:
pneumothoraks + Multiple black
547.000 GDS:116 Ur/Cr: 14/1,0 GPT/GPT: 22/17
Post multiple insisi Hr 13 ec emfisema
Alb : 2,8
subcutis
TGL 22/8/2013
GDS: 70 Na 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
NURAENI, 54 tahun (31/12/1958)
Lab tgl 27/8/2013
RM : 616941
WBC 13.4 RBC 3,30 PLT 134 HB 9,0 HCT 28,3 Ur 70
Tgl MRS : 1/7/2013
Cr 1,9 Alb 2,8 GOT 27 GPT 20 Na 119 K 2,6 Cl 91
TGl Konsul : 30/8/2013
Lab tgl 22/8/13
Fe 35 TIBC 156 GDS 94 GOT 21 GPT 33 CT 800 BT
D/ CKD Stg V e.c PNC Bilateral (Pro HD
300 PT 12,0 ct 12,5 APTT 27,2 ct 26,1
Reguler) + Pro Cimino
YOSEFINA, 57 tahun (18/2/1956)
Foto Thorax AP tgl 27/8/2013
RM: 107931
KP milier kanan, efusi pleura kiri masif
Tgl MRS : 27/8/13
Tgl konsul : 28/8/13
Lab Tgl 27/8/2013
WBC 12.4 RBC 4,48 PLT 255 HB 13,1 HCT 40,8 GDS
D/ POH 7 Chest Tube e.c Efusi Pleura(s) e.c
174 Ur 12 Cr 0,6 GOT 27 GPT 20 Na 136 K 3,4 Cl 102
susp. TB Paru DD/ Malignancy POH 8
CT 800 BT 300 PT 9,3 ct 11,9 APTT 19,7 ct 26,4
HbsAg Non Reactive Anti-HCV (-)
Lab 02/9/13
WBC 8,4 RBC 4,41 HGB 12,7 HCT 38,6 PLT 278
TN. HARRY LAHAR, 48tahun
Lab 31/8/13
RM: 625269
GD2PP 409 RBC 5 WBC 19,8 Hb 11,5 PLT 431
MRS 29/8/2013
Lab 29/8/13
BT/CT 8/2 PT/APTT 10.7/33.6 GDS 596 Cr/Kr 16/0.3
D/PAD
Na/K/Cl 126/4.32/97 As urat 7.4 GOT/GPT 7/8 Alb 3.1
Munawar/41 thn/31-12-1971
Foto thorax (2/9/13) : efusi pleura masif dextra
RM : 622737
Lab 31/8/2013
MRS : 30/8/2013
WBC 8,6 RBC 5,11 Hb 13,4 PLT 147 HCT 41,9 Na
D/ Efusi Pleura dextra masif ec malignancy
142 K 3,99 Cl 109 CT 700 BT 300 PT 10,6 APTT
(adenoma)
25,5 HbsAg non-reactive
Lab 14/8/2013
GDS 75 UR/Cr 13/0,6 SGOT/SGPT 9/18
PALEM ATAS
LONTARA 1 INTERNA (ATAS DEPAN)
HJ. ST. ASNAH, 61 tahun(31/12/1952)
Lab 2/09/13
RM 427540
CT:800, Bt:200, PT:9,6ct11,0, APTT: 22,4ct24,5,
Tgl MRS : 20/8/13
SGOT: 14, SGPT:8, WBC 7,79 RBC 2,59 Hb 7,0 HCT
Tgl Konsul : 31/8/13
21,3 PLT 362000, Ur 69 Cr 6,2
D/ CKD Stg V e.c Nefropati DM pro AV
Lab 31/08/13
WBC 6,9 RBC 2,91 Hb 7,5 HCT 24,5 PLT 416 Ur 149 Cr
shunt
8,1 Na 152 K 3,9 Cl 101
Echocardiografi 26/8/13
Kontraktilitas LV menurun, EF 48%
LVH (+)
Disfungsi diastolik, global hipokinetik
Ny. Haniah, 40 tahun (25/1/1973)
Foto thorax AP 31/8/13
RM 621827
Kardiomegali
Tgl Mrs : 7/8/13
Lab 30/08/13
Tgl Konsul :
WBC 8,4 RBC 2,83 Hb 8 HCT 24,9 PLT 222 CT 700 BT
230 PT 9,9 ct 13,1 APTT 25,5 ct 25,2
D/ CKD stg V e.c PNC Bilateral Post AV
shunt Hr 6
Echocardiografi 27/8/13

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
Fungsi sistolik LV cukup, EF 51%
LVH (+) LV dilatasi, global hipokinetik, MR moderate,
Disfungsi diastolik
Lab 27/8/13
Na 136 K 4,5 Cl 99
Lab 3/9/13
WBC 7,4, RBC 2,75, Hb 7,5, HCT 24,2, PLT 275, Na 135
K 4,2 CI 104 Ur 77 Cr 8,4
LONTARA I INTERNA (ATAS BELAKANG)
SUNTA 46 th (31/12/1967)
Tgl 27/8/2013
RM : 621946
WBC: 27,0 RBC:2,64 HGB: 7,2 HCT:21,7 PLT:354
Tgl MRS/Konsul : 09/08/2013 / 28/08/2013
Ur:155 Cr:12,5 Na:132 K:5,4 Cl:97 GDS 80. Asam urat
10,2,
D/ CKD stg.V e.c PNC bilateral on HD
reguler + CHF
Tgl 09/08/2013
SGOT 26 SGPT 23
Tgl 20/08/2013
CT/BT = 800/300, PT 12,7 APTT 33,7
Foto Thoraks
KP Duplex lama aktif ( 16/08/2013)
USG Abdomen ( 16/08/2013)
PNC Bilateral

8.

KMR
1/III
BED 6

9.

KMR
2/III
BED 1

ABD RAHMAN, 59 tahun (1/7/1954)

RM : 623489
Tgl MRS/Konsul :31/7/2013,27/8/2013
D/ CKD stage V on HD regular

10.

KMR
4/III
BED 3

MASHAR, 39 tahun (23.03.1974)

RM: 622573
Tgl MRS/Konsul: 14.08.2013/ 21.08.2013
D/post chest tube hr 6
CKD Stage V ec. PNC bilateral

11.

KMR
7/II
BED 4

Husen Dg. Ngeppe, 32 tahun (1/1/1981)

RM : 652471
Tgl MRS : 31/08/2013
D/ Tumor Paru Dextra + Efusi Pleura Post
Chest Tube

12.

Kmar
7/II
Bed 4

Ardian, (0/0/0)
RM : 625845
Tgl MRS : 3/8/2013
D/ Pneumothoraks (D) post chest tube

13.

KMR

Hasma, 33 tahun

Pro Cimino
Lab tgl 2/9/2013
CT/BT : 8/3, PT: 12,1/12,6, APTT:30,4/26,4,
Ur/Cr:92/6,3, Na:131, K:3,6
Lab TgL22/8/2013
HbsAg: reactive
Lab Tgl 28/8/2013
WBC: 18,9 RBC:2,09 HGB: 5,9 HCT:19,1 PLT:349,PT/
APTT:12,5/27,7 GDS: Na/K/Cl:133/3,6/101
Ur/Cr:170/7,0 got/gpt 74/31 alb 2,7
Foto Thorax AP(21/8/2013)
Kesan: cardiomegaly dengan dilatatio et elongatio aortae
disertai tanda-tanda bendungan paru dini
Pro cimino
Foto thorax tgl 14/08/2013
Kesan: Cardiomegaly dengan edema paru
USG Abdomen Atas + Bawah (Whole Abdomen)
Kesan: PNC bilateral dengan ascites minimal
Lab tgl 28/08/2013
Ur/Cr: 143/13,2 RBC: 3,57 HGB: 9,4 PLT: 175 WBC: 7,4
Ct/bt 700/300
Pro cimino ( Kamis, 29/08/13 )
Lab 31/08/2013
WBC 9,42 RBC 3,42 Hb 10,5 HCT 31,8 PLT 443 CT 800
BT 300 PT 14,4 ct 11,3 APTT 31,4 ct 26,1 GDS 88 Ur 15
Cr 0,5 GOT 22 GPT 14 Alb 2,5 HBsAG (-) AntiHCV (-)
Na 93 K 3,6 Cl 108

Lab 3/09/2013
WBC 25,4 RBC 4,85 Hb 12,3 HCT 37,1 PLT 16 GDS 104
Ur/Cr 17/0,6 GOT/GPT 68/47

LONTARA 1 INTERNA (BAWAH BELAKANG)

Lab 3/9/2013

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
ISO
BED 2
JKD

RM :623770
Tgl MRS/Konsul :21/8/2013
D/ POH debridement + Ketonuria+ulkus
Diabetik Dekstra+gas ganggren

WBC 9,2 RBC 3,88 Hb 9,9 HCT 30,5 PLT 384 Alb 2,0
Kultu 2/9/103
Biakan anaerob E.Coli Acinetobacter baumanni
Tes sensitivitas antibiotik : Amoxicillin, Amikasin,
fosfomycin, gentamicin
Hasil gram : basil gram (-)
Tgl 25/8/2013
GDP:122 GDS:154

Tgl 29/8/2013
WBC

14.

KMR
ISO
BED 1
JKM

Murkeni, 57 tahun
RM :623843
Tgl MRS/Konsul :21/8/2013
D/ post debridement +ulkus wagner V
Diabetik Dekstra+gas ganggren+non obese
-POH 10 amputasi digiti minimi 2,3,4+
debridement.

Lab 3/9/2013
Wbc 20,3 RBC 4,02 HB 11,2 HCT 33,9 PLT 334 PT
18,3 APTT 32,8 UR 6 Cr 0,4 GOT/GPT 27/12 Alb 2,9
Kol tot 111 HDL 10 TG 156 LDL 72 As urat 1,4 Na
134 K 2,0 Cl 90
ADT : anemia normositik normokrom +leukositosis
Tgl 25/8/2013
GDP:154 GDS:88
Tgl 29/8/2013
WBC 26,5 RBC 2,31 HGB 6,6 PLT 550 Ur/Cr 61/28 Alb
2,4
Tgl 3/9/2013
GDP = 112 mg/dl

15.

KMR
4/III
BED 2

ERNA, 30 tahun (22/2/1983)

RM : 470540
Tgl MRS/Konsul : 24/7/2013
D/ POH 8 AV Shunt + CKD stg.V

16.

KMR
5/III
BED 4

ANDRIANI, 25 tahun (22/7/1988)

RM : 620240
Tgl MRS/Konsul : 25/7/2013
D/ POH 8 AV Shunt + CKD Stage V on
HD reguler

Lab (20/08/2013)
Ur:37 Cr:2,0 Alb:2,0
Lab (23/08/2013)
WBC:7,2 RBC:4,04 HGB:10,8 HCT:32,6 PLT:79
Lab (2/09/2013)
WBC:7,2 RBC:3,33 HGB:8,8 HCT:26,83PLT:158 Ur/Cr
61/2,8 Alb 2,4
Tgl 3/9/2013
WBC:30.9 RBC:2,27 HGB:19,2 PLT:502 Ur:49 Cr:4,5
Na:132 K:3,50 Cl:99 SGOT: 23 SGPT:11 As urat 4,4 PT
13,7 APTT 29,6
Tgl 5/8/2013
WBC:6,5 RBC:2,20 HGB:6,4 HCT:20,7 PLT:114 Ur:85
Cr:7,2 Na:133 K:3,30 Cl:104 SGOT: 26 SGPT:64
Tgl 18/8/2013
WBC:15.8x103 RBC:3x106 HGB:8.8 HCT:28.1
PLT:273x103 Ur:39 Cr:4.9 SGOT: 29 SGPT:35 Alb: 2.7
Tgl 21/8/2013
Ur:55 Cr:6,2 SGOT: 27 SGPT:31 GDS:96 Na:135 K:3,5
Cl:103
Tgl 29/8/2013
WBC:29 RBC:2,91 HGB:8,2 HCT:24,9PLT:396 Ur:82
Cr:6,2 Na:130 K:3,5 Cl:101 SGOT: 26 SGOT:19 SGPT 17
Alb 2,4 GDS 72 PT 11,5/12,9 APTT 37,6/26,7

17.

KMR
5/II BED
2

TAMSIR Kaluku, 56 tahun

RM : 622363
Tgl MRS/Konsul :15/8/2013
D/ Ulcus DM pedis dextra Wagner II

Tgl 2/9/2013
WBC 33,2 RBC 1,89 HGB 5,7 HCT 16,7 Na/K./Cl
129/4/103 PLT 579CT/BT: 8/3, Pt: 14,5/12,6, APTT:
28,9/26,4, Ur/Cr: 8,7/0,8, GOT/GPT: 25/8 Anti HbS
reactive

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013

18.

KMR
10/III
BED 5

19.

KMR
10/III
BED 6

24.

KMR 8
Bed 6

25.

KMR 9
Bed 1

KMR 4
Bed 5

26.

KMR 2
Bed 2

Tgl 12/8/2013
WBC: 19,18 RBC:3,46 HGB: 10,6 HCT:32,3 PLT:220
Ur:35 Cr:1,0 GDS:80 Na:148 K:3,3 Cl.103
Tgl 19/8/2013
WBC: 13,38 RBC:2.35 HGB: 7.2 HCT:21,4 PLT:263
GDS:84 Na:134 K:2.8 Cl.106 Fe: 15 TiBC: 55
Tgl 19/8/2013
GDP:138 GDS:139
LONTARA 1 INTERNA (BAWAH DEPAN)
PAKIS
LONTARA 2 ORTHOPEDI (BAWAH BELAKANG)
LONTARA 2 BEDAH UROLOGI (BAWAH DEPAN)
LONTARA 2 BEDAH DIGESTIF (ATAS DEPAN)
HAWILA, (01-09-1987) 26 thn
Lab 24/8/2013
RM : 619618
WBC 7,16; RBC 4,32; HB 12,5; HCT 37,1; PLT 251;
Tgl MRS : 21/07/2013
Na 144; K 4,4; CL 109; Ur 18; Cr 0,4; SGOT 32; SGPT
54; Prot.total 122; HDL 42; LDL 69; TG 133.
D/ Post pemasangan cvc + Fistel
Enterocutaneus high out
Foto Polos Abdomen (14/08/2013)
Fistula ileocutaneus
Lab 15/8/2013
AFP 3,18 CEA < 0,50 CA 19-9 10,51
LAB 24/08/2013
GDS 104;Ur 13; Cr 0,3; SGOT 63; SGPT 21; Prot.total
5,7; Albumin 1,8; kolesterol total 166; HDl 11; LDL118;
Tg 150; WBC 11,02; RBC 3,09; Hb 8,4; Hct 26,5; Plt 264;
Na 135; K 3,6;Cl 106.
Lab 29/8/13
Alb 2,3 WBC 11,45 RBC 3,98 Hb 11,8 HCT 34,9 PLT 286
LONTARA 2 BEDAH ONKOLOGI ( ATAS BELAKANG)
Ummu Kalsum, 42 tahun,
Lab 4/9/2013
RM 624596
Bil tot 0,2 bil direk 0,12 alk fosfatase 168
Tgl MRS : 26/8/13
Foto Thorax tgl 28/8/13
Tgl Konsul : 29/8/13
Hidropneumothorax dextra
D/ Efusi Pleura (D) e.c Post Chest Tube USG Abdomen
Efusi Pleura Dextra
Ulcus Ca Mammae (D)
Lab 26/8/13
WBC 8,1 RBC 5,0 Hb 12,1 PLT 456 CT 800 BT 200 PT
9,5 APTT 23,7 Na 138 K 3,9 Cl 112 GDS 159 Ur 23 Cr 0,4
GOT 522 GPT 372 Alb 2,8
Saiful, 17 tahun
Foto thorax PA tgl 27/8/13
RM
Dalam batas normal
Tgl MRS : 20/8/13
Lab 26/8/13
D/Post Stripping vein hari 1 ec Varises WBC 6,7 RBC 5,97 Hb 16,4 PLT 264 CT 720 BT 200 PT
11,7 APTT 30 Na 142 K 4,3 Cl 104 GDS 90 Ur 18 Cr 0,9
Bilateral gr III
GOT 24 GPT 25
LONTARA 3 MATA (ATAS BELAKANG)
.
LONTARA 3 KULKEL (ATAS BELAKANG)
LONTARA 3 THT (ATAS DEPAN)
LONTARA 3 BEDAH SARAF (BAWAH DEPAN)
Maiwati (megawati), 45 thn
Lab 1/9/13
WBC 9,1 RBC 2,83 Hb 8,7 PLT 95 HCT 26 GDS 105 Ur
RM ;625435
D/ Post Chest tube hari ke-6 ec contusio 23 Cr 0,6 GOT 50 GPT 17 Alb 2,5
paru sinistra + open depressed fraktur CT-scan 31/8/2013 : fr. Os frontal dan os nasal disertai
hemato sinus ,maxillaris bilateral
frontal+ nasal
LONTARA 3 SARAF (BAWAH BELAKANG)
Ludia Rinding, 66 tahun (26/2/1947)
Lab 4/9/2013
RM: 317689
GDS 164 ur/cr 31/1,7 GOT/GPT 44/38 CK 97 CKMB
Hj. Nori (31/12/1964) 48 tahun
RM : 613463
TGL MRS ; 21/08/2013
D/ Efusi Pleura e.c Malignancy + CVC
insitu
Chest tube : 4/8/2013

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
Tgl Konsul : 30/82013
D/ Ulkus Diabetik Wagner 1

27.

KMR
1/III
Bed 4

28.

KMR 5
BED 4

JKM

29.

30.

KMR
5
Bed 2

LT 1
KMR 2

11WBC 10,1 RBC 3,17 HB 9,1 HCT 28,6% PLT 268

Lab 28/8/13
WBC 12,81 RBC 3,52 Hb 10,6 HCT 29,7 PLT 182
Lab 21/8/13
GOT 212 GPT 126 Kol.tot 177 HDL 14 LDL 141 TG 201
GDS 256 Ur 14 Cr 0,5
LONTARA 4 OBGYN (BAWAH DEPAN)
Tukinem 55 tahun
Foto thoraks 29/8/13 : tidak tampak tanda metastasis,
RM : 622582 JKD
efusi pleura sinistra, elevasi diafragma bilateral (susp
TGL MRS/TGL Konsul :
ascites), emfisema subkutis
21/8/2013/25/8/2013
Foto thoraks PA 24/8/2013: Efusi pleura bilateral dan
D/ POH 11 chest tube ec efusi pleura
dilatasi aorta
bilateral
CT abd 19/8/13 Ascites massa adneksa kanan ,ascites,
efusi pleura bilateral, batu staghorn kanan serta
nefrolit kiri
IVP : 19/8/2013
Nefrolit disertai hidronefrosis dekstra grade 1 dan 2,
kingking 1/3 proximal, seduai gambaran tumor
ginekologi
Lab 14/8/2013
HCG(-),HbsAg(-), Na/K/cl:1,4/4,3/103,CT/BT:
8/3,pt/aptt:12/26,9,GDS:106,Ur?cr:27/0,7,GOT/GPT:17/8,
As.Urat:4,2
Ny. Halmina 51 thn
Foto thoraks (1/9/13)
RM: 619320
Efusi pleura Dextra
Tgl MRS 26/08/2013
Pleural reaction sinistra
Elevasi Diafragma kiri (proses intra abdominal)
D/ POH 9 chest tube e.c efusi pleura
bilateral
Foto thoraks (28/08/2013):
Efusi pleura dextra
Foto thoraks (26/08/2013):
Elevasi kedua diafragma
Tidak tampak tanda-tanda metastasis
Lab 26-08-2013
WBC 7,30 RBC 4,9 Hb 11,7 PLT 636
CT/BT 800/200 PT/APTT 13,4/32,6
Na/K/Cl 133/4,6/97
GDS 94 Ur/Cr 40/0,8 GOT/GPT 522/372 alb 3,2
Lab 02/9/13
CT/BT 8/3 PT 13 APT 35,7 Na/K/CI 13/4,7/98 GDS 109
Ur/Cr 42/1,1 GOT/GPT 30/8 Acb 2,7

LONTARA 4 OBGYN (BAWAH BELAKANG)

LONTARA 4 ANAK (ATAS DEPAN)
AFIFA WIDYASTUTI , 8thn
Lab 23-8-13
RM :616538
Ur/Cr 32/0,5 SGOT/SGPT 32/10 Prot.tot 11,6 Alb.3,1
Tgl MRS/Konsul : 26/8/3/2013,27/8/2013
Na/K/Cl 141/4,0/105 WBC 14,33 RBC 4,13 HGB 12,1
HCT 34,1 PLT 437 NEUT 62,4
D/ VSD
FOTO THORAX PA
-Sesuai gambaran L-R shunt
Lab 31/8/13
Hasil AGD : WNL
LONTARA 4 ANAK (ATAS BELAKANG)
INFECTION CENTER
LA SUMAI , 62thn
Lab 28-6-13
RM :599256
Ur/Cr 32/0,5 SGOT/SGPT 14/13 Prot.tot 4,9 Alb.3,1
Tgl MRS/Konsul : 15/3/2013
Na/K/Cl 134/3,1/96 WBC 5,0 RBC 3,50 HGB 9,4 HCT
30,4 PLT 191 NEUT 62,4
D/ Tumor NSCLC (Non Small Cell Lung
Cancer) + post chest tube + WSD
Lab 19-6-13
GOT/GPT: 31/24 Prot total: 5.6 Alb: 3.0 Koles tot: 105

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
HDL: 32 LDL: 65 Triglerida: 86
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 23/8/2013
Ur/Cr:39/0,6 GOT/GPT: 18/19 Alb: 3,6 Prot Total: 13,6
INR: 1,27 APTT: 38,6
WBC:3,9 RBC: 3,81 PLT: 159 HB: 11,4 HCT: 34,3
ICU
PICU
.
NICU
RSUH
31.

RSUH
419B
Bed 4

32.

RSUH
426
ASK

33.

RSUH
ICU
Bed 3

34.

RSUH
ICU
Bed 4

An. NADINE SAISANAH, 4tahun

(11/04/2010)
RM :
Tgl MRS/ Konsul: 29/082013
D/ PJB Sianotik (VSD+ASD+Atresia
Trikuspid)
SYAFRUDDIN, 50 tahun (5/9/1963)
RM : 013200
Tgl MRS/ Konsul: 7/8/2013
D/ Ulkus Diabetik

Tgl 29/8/2013
WBC: 8,89 RBC:8,10 HGB: 18,4 HCT:57,2 PLT:142
Na: 131 K: 3,0 Cl: 108

Tgl 28/8/13
GDS pagi 180 siang 218
Lab (21/082013)
Wbc: 6,33 RBC:3,22 Hb:8,2 HCT:26,4 PLT: 439
Na:127 K:3,7 Cl: 95
Lab (26/08/2013)
GDs pagi 275
Lab (27/08/2013)
GDs pagi 164
GDS siang 228
GDS malam223
Lab tgl 1/9/13
WBC 23 RBC 3,82 HGB 11,3 HCT 39,7 PLT 169 Alb 3,0

Tn. Yohanes R. 76 tahun

RM 013501
Tgl mrs/konsul: 27/08/2013
D/ Post CVC hari 8
TAMUGAU, (26/10/1957)
RM: 013258
Tgl MRS: 12/08/2013
D/ Post pemasangan WSD hr-13

Lab 30/8/13
WBC 20,07 RBC 4,19 Alb 3,1 HB 12,4 PLT 337 Prot.tot.
4,9
Echokardiografi (21/08/2013)
Fungsi sistolik global & segmental LVH baik; PE mild,
Disfungsi diastolik LV
Lab (22/082013)
WBC:18,83 RBC:4,18 Hb:12, 3 PLT:295
Ur/Cr:40/0,5 GOT/GPT:56/110 GDS:137
Lab (25/08/2013)
Na:135 K:3,5 Cl:95 Alb:2,45
PCC

35.

Lt 4
421

Hj. Pamajang 70 thn

RM: 62 5069
Tgl MRS: 28/08/2013
D/ Post Chest tube + WSD ec. Efusi pleura
(D)

Lab (28/08/2013)
AGD: Asidosis Respiratorik terkompensasi sempurna
GDS: 118
Ur/cr: 92/2,1
GOT/GPT: 41/31
Pt/aptt 12,4/24,1
HbsAg : REAKTIVE

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
AntiHCV (-)
Wbc 13,02 rbc 5,17 hb 12,4 plt 216
Thorax AP (28/08/2013)
Efusi pleura massif (D)
Pleuropneumoni (s)
Atherosclerosis aortae
CT Thoraks (21/082013)
Efusi Pleura (D) massive, Lymphadenophaty Hilar (s)
Lab (21/082013)
WBC:14,1 RBC:4,87 Hb:15,4 HCT:46,6 PLT:399
BT/CT:230/800 PT/APTT:24,8/208
GOT/GPT:46/50
Endoskopi (21/08/2013)
Faringitis kronik + unilateral adductor paralisis plica
vokalis (S)

36.

Lt 3
324

MUHAMMAD ASKAR / 39 tahun

(7/10/73)
RM: 572939
Tgl MRS/Konsul: 21/8/2013
D/ POH 11 chest tube e.c efusi
pleura(D)+TB Paru on treatment

37

Lt 3
306

SIRI RASYID, 65thn (31/12/1938)

RM: 622920
Tgl Mrs/konsul: 27/08/2013
D/ Tumor Sinonasal + Tumor Mediastinum
Rencana biopsi di kamar operasi
Kamis (30/08/2013)evaluasidanrawat
sama

38.

Lt 2
213

BAHARUDDIN ISMAIL (21/11/1955)

RM: 623277
Tgl Mrs/konsul: 26/08/2013
D/ CKD stage V on HD + POH 1 cimino

39.

Lt.2
224

Ny. Elis Toding (7/1/1937)

RM : 451775
Tgl Mrs/konsul: 30/08/2013
D/ CKD stg V on HD pro Cimino

40

Lt.2
203

Ny. Lintong (47 tahun)

(624144)
Tgl MRS/konsul : 22/ 08/ 2013-04/09/13
D/ CKD stg V + pro cimino

IRD

Lab (19/08/2013)
HBsAgreactive
AntiHCV nonreactive
WBC:9,98 RBC:3,65 HB:10,9 HCT:31,9 PLT:385
GDS:120 ur/cr:46/1,1 GOT/GPT:36/31 Prot Total: 6,7
Alb:3,5 Na:132, K:4.0 Cl:101
BT:3,00 CT:800 PT:12,5 APTT:21,6
CT Scan Thoraks(22/8/2013)
-massa mediastinum posterior yang meluas ke
mediastinum superior.
-tidak tampak tanda2 metastasis pada MSCT scan thoraks
ini.
Thoraks AP (23/8/2013)
- tampak pelebaran mediastinum sup pada sisi kanan
- COR CTI dalam batas normal,aorta dilatasi & kalsifikasi
- kedua sinus & diafragma baik
-tulang-tulang intak
Foto Oesophagography (23/8/2013)
Tumor mediastinum post yang mendesak oesophagus
keanterolateral dextra
Lab (18/08/2013)
WBC:21,8 RBC:3,57 HB:9,3 HCT:28,9 PLT:175
BT:3,00 CT:930 PT:12,4 APTT:20,5
Lab 29/8/13
Ur 126 , cr 5,1 Na 135 K 4,4 CI 101
Pro Cimino
Lab 01/9/13
N 12,4 C 12,1 ADTT 27,8 C 26,1 Ur 41 Kr 4,30 RBC
2,98 Hb 9,2 HCT 239 PLT 42 WBC 3,4
Lab 1/9/13
Ur 41 , cr 4,30 WBC 3,4 RBC 2,98 Hb 9,2 HCT 27,9
Lab
N 135 K4,4 Cl 101 Ur 180 cr 9,97 RBC 3,13 Hb 9,2
HCT 28,8% PLT 133 WBC 8,7 SGOT 10 SGPT 6
BNO :
Kesan : tampak gambaran radiopaque batu pada
daerah paravertebra L2-L3 kanan dan paravertebra
L1-2
CT-scan abdomen : nefrolith + hidronefrosis grade III
+ ureterolith prox kanan cystitis, cholesistolith, efusi
pleura bilateral
USG Abdomen : nefrolitiasis bilateral

KORAN BEDAH THORAKS KARDIOVASKULAR

JUMAT, 6 SEPTEMBER 2013
42

IRD

43

IRD

43.

CVCU
Bed 7

44.

Vip 2

Agus salim (24/8/93)

RM : 626204
Tgl MRS : 4/9/2013
D/POH 2 explorasi ec Penetrating Neck
Injury suspek ruptur arteri carotis dan
Vena jugularis dextra
Muh adnan/1/1/96
RM : 626404
Tgl MRS : 5/9/2013
D/Trauma Thorax suspek flail chest
TCB GCS 5x E1M4Vx
Vulnus Laserasis Regio axilla dextra
CVCU
Siti Ramlah, 45 tahun (29/11/1972)
RM : 187581
Tgl MRS : 18/08/2013
Tgl Konsul : 8/8/2013
D/Post recurrent Syncope e.c Bradiaritmia
on TPM POH 3 PPM + hyperthyroid

Lab (4/9/2013)
RBC 3,05 HB 9,0 HCT 27,4 PlT 79000 WBC 8,5
CT 730 BT 300 PT 12,2 APTT 36,2 HbsAg nonreactive Anti HCV non-reactive GDS 98 Ur/Cr 21/0,7
GOT/GPT 129/114 As Urat 3,5 Na 139 K 3,9 Cl 110
Foto Thorax : contusio regio hemithorax dextra
disertai fraktur costa 3-4-5

Lab 26/8/13
GOT 27 GPT 30 Pt 10,4 ct 11,5 APTT 21,9 ct 24,6
WBC 9,44 RBC 5, 17 Hb 16,9 HCT 45,5 PLT 29,4
Lab tgl 16/8/13
GDS 150 Ur 26,4 Cr 0,7 Na 143 K 0,21 CL 108 Bil tot
0,46 Bil direk 0,12 Prot.tot 6 Alb 3,6 Glo 2,4 Kol.tot 191
HDL 61 LDL 118 Tg 79 CK 148 CK-MB 23,5 AS.ur 7,4
Lab 2/9/2013
PT 14,1 APTT 26,0 WBC 6,5 RBC 2,79 Hb 7,9 PLT 376
HCT 24,7%
LAB
PT 12,6 APTT 38,2 WBC 6,7 RBC 3,13 Hb 8,6 PLT 422

Haniah, 69tahun (4/3/1954)

RM : 620020
Tgl MRS : 28/7/2013
D/ Luka Diabetik + DVT + DM type II +
CHF
NYHA
III
ec
CAD
+
Hypoalbuminemia
LAIN LAIN