NOTES COASS PASIEN DIVISI THOVASK

Sabtu, 10 Januari 2015

Irina A Atas 1 Pasien
No
Identitas Pasien
1.
JacobusRosi/P/67 thn
A6
36.48.74
Bed 6
MRS 13/12/2014

Diagnosis
Selulitis R
brachii
antebrachii S

Terapi
-IVFD D5% + NaCl
0,9% = 1:1 20 gtt/m
-Ciprofloxacin 3x1gr
drips IV
-Gentamisin 2x1 IM

Lab
06/01/2015
Leu 11.500
Hb 15
Ht 45
Trom 237

dr.Richard Sumangkut, SpB-BTKV

Irina A bawah 2 Pasien

No
Identitas Pasien
1.
Maghfud Christian
B7
Saiful/L/48thn
Bed 8
43.12.59
MRS 4/12/2014

Diagnosis
Ulkus decubitus S+
Reg lumbal sacral+
genu sinistra

dr.Richard
Sumangkut,SpB(K)V
2.
B5
Bed 4

Roni Fredy
Kumbea/L/31thn
43.20.66
MRS 16/12/2014

Hematothorax

Terapi
-Rawat luka 2x1
dengan madu
-Cefixime 2x200
mg
-Metronidazole
3x500 mg
Cek DL, Na, K, Cl,
GDS, Ur, Cr
-Vip albumin 3x
1V caps
-IVFD NaCl : RL
1:1
- Ceftriaxone 2x1
gr
- CT Scan kontras
-Rawat luka
-WSD Terpasang

Lab
23/12/14
Leu: 5500
Eri: 2,1
Hb 5,7
Ht 19,1
Trom 706

Cr 0,6
Ur 16
K 2,98
Cl 99,7
Alb 1,7

9/01/15
Leu 9.300
Eri 4,43
Hb 10,6
Ht 35,5
Trombo 459

ICU - 1 Pasien
No
Bed 1

Identitas Pasien
Simson Mutiah/L/35 thn
43.30.95
MRS 26/12/2014

Irina B - 1 Pasien
No
Identitas Pasien
1.
Paula Sumayouw/p/51 thn
Kam
41.37.90
ar
MRS 19/12/2014
12 A

Irina C - 1 Pasien
No
Identitas Pasien
1.
Angkow Hendrik/L/62 thn
C2
29.51.47
MRS 9/1/2015
dr.Richard Sumangkut,SpB(K)V

Diangnosis
Post
Laparotomiresusif
ungsi
flepatoraphy+tam
pon v.cava
lafeurun
v.retum
teracoabdomen

DIagnosis
Post pasang WSD
Ec efusi (D) ec ca
Mamae (D)

Diagnosis
Ulkus DM regio
pedis sinistra

Terapi
- AS.tranexamat
3x500mg IV
- Vit C 1x 1 amp IV
-Vit K 1x1
-Ranitidin 2x1 IV
- Tramadol 1x50mg IV
Ceftracon 2x1 gram
IV

Terapi
-Terapi lanjut sesuai
TS interna
- Sedot indwelling
kateter: keluar 16ml
serohemoragik

Terapi
-Ceftriaxone
2x1 gr IV
-Metronidazole
3x500mg
drips
- Rawat Luka
- Terapi lain

Lab
27/12/2014
Leu 15.900
eri 2,06
Hb 6,5
Ht 18,9
Trom 174

Lab
28/12/14
Leu
10000
Eri 3,51
Hb 11,8
Ht 34,1
Trom 108
Lab
9/1/15
Leu
22.900
Eri 4,16
Hb 11,4
Ht 35,6
Trom 548

Cr 0,4
Ur 26
Na
130
K 3,1
CL 102

sesuai TS
Interna
Nyiur - 2 Pasien
No
Identitas pasien
1.
Ny. Jenny A. Mangundap/57
k.19
tahun
43. 34. 93
MRS 05/01/2015

Diagnosis
Selulitis cruris
dextra
hipertensi
terkontrol

Terapi
-IVFD NaCL
0.9%:RL = 20
gtt/m
-Ampicilin inj
4x1gr IV
-Clindamycin
4x300mg cap
-Micardis 40mg
1x1
-Sumagesic 3x1
tab (k/p)
-Mefinol 3x1 tab

Lab
9/1/15
Leu 14.100
Eri 3,74
Ht 35,3
Hb 11,9

CKD stage V pro

HD
Post
pemasangan
double-lumen

-IVFD Nacl
0.9%=10 gtt/m
-Metoklopiramid
inj 3x1 amp
-Ranitidine inj 2x1
amp IV
-As.folat 3x1
-Transfusi PRC 1
bag (tggl 7/1/15)
-Bicnat 3x1
-Fuson (ekstra)

6/1/2015
MCH 28
MCHC 33
MCV 85
Leu 8300
Eri 3
Hb 7
Ht 22
Trombo 331

Dr. Richard Sumangkut,

SpB(K)V

2.
k.12

Ny. Herodina Kamagi/64 thn

43. 38. 05
Masuk Nyiur 5/01/2015 jam
12.30
dr.AdrianTangkilisan,SpBBTKV

GDS 107
Kreatinin
10.9
Ur 159
Alb 3
Glob 2.8
Na 129
Kalium 4.35
Chl 97.5
Serum iron
30
Total
cholesterol
206