LIST PASIEN TKV

22 FEBRUARI 2019

A ATAS

1. A6 Bed 1 Ezter Jaya Ratu/P/48 th/ 14.00.67 - Post Lab 10/02/2019 EKG : sinus takikardia 115 bpm - Rawat luka
Orange TL : 29/07/1970 thoracotomy+open Leu 8.8, Eri 3.13, Hb 8.6, Ht 29, Trombo 365, MCH 27.5, MCHC 29.7, Eos 0, Baso dengan left axis deviasi - Rencana rawat jalan
DPJP :dr. Adrian Sp.B, window ec 0, Net batang 10, Net segmen 71, Limfo 11, Mono 8, MCV 92.7, Na 139, K 4.08, Cl Hasil MSCT dd/ giant bullae
Sp.BTKV empiema paru 88.8 sinistra disertai secondary
sinistra Lab 11/02/19 spontaneous pneumothorax
Leu 7.1 Eri 3.34 Hb 9.1 Ht 31.0 Trom 252 MCH 27.2 MCHC 29.4 MCV 92.8 sinistra
Batang 7 Segmen 70 Limf 14 Mono 9 SGOT 17 SGPT 12 Bil. Total 0.34 Bil. Direct Bronchopneumonia
0.16 Ur 21 Cr 0.5 GDS 97 Cl 85.5 K 4.31 Na 141 dextradisertai adenopathy hilar
Lab 12/02/2019 kanan
Leu 9.2 Eri 3,44 Hb 9.4 Ht 31.4 Trom 124 MCH 27.3 MCHC 29.9 MCV 91.3 FotoThorax : TB paru + pleuro
Lab 20/2/2019 pneumonia sinistra
Leu 8.6 Eri 3.34 Hb 9 Ht 30.7 Tro 402 MCH 26.9 MCHC 29.3 MCH 91.9

2 A8 bed 5 Kalimpoti Roni/L/26 th/56.15.49 - Ruptur lien gr V Lab 15/2/2019 X foto thorax (13/2/2019): - Pasang WSD
Pink TL: 12/6/1992 - Delayed Leu 20.2 Eri 2.20 Hb 9 Ht 20.1 Tro 612 MCH 40.9 MCHC 44.8 MCV 91.4 Efusi pleura sinistra - Antibiotik adekuat
DPJP :dr. Wega Sukanto, hematothorax Lab 20/2/2019 X foto thorax (20/2/2019:
Sp.BTKV sinistra Leu 12.7 Eri 2.92 Hb 11.1 Ht 26.6 Tro 680 MCH 38 MCHC 41.7 MCV 91.1 Efusi pleura kirir _
nronkopneumonia bilateral
non spesifik
MSCT abdomen : Ruptur lien
gr V disertai ascites dan
subileus, sugestif
hemoperitoneus dengan tanda
peritonitis
Efusi pleura bilateral dgn
colaps paru kiri

3 A7 bed 8 Dessaro Amir/L/51th/31.94.32 - Efusi pleura Lab 15/2/2019 EKG : sinus rhythm, HR 75, - Tunggu hasil x foto thorax AP
Hitam TL: 24/31967 sinistra Leu 19.3 Eri 5.57 Hb 15.2 Tro 240 MCH 27.3 MCHC 33.1 MCV 82.4 SGOT 71 normoaxis tegak
DPJP :dr. Wega Sukanto, - Acute pankreatitis SGPT 221 - Observasi jika jika terdapat
Sp.BTKV Lab 20/2/2019 MSCT : efusi pleura sinistra sesak napas
Leu 11.7 Eri 4.49 Hb 12.3 Ht 36 Tro 281 MCH 27.4 MCHC24.2 MCV 80.2 SGOT dgn komponen atelektasis
34 SGPT 40 Ur 27 Cr 0.9 GDS 90 Cl 98.5 K 3.64 Na 137 lobus inferior kiri

Foto thorax: Normal

A BAWAH
1 B10 bed 4 Altje Yultje Waani/P/45th/52.80.39 Efusi pleura sinistra on Lab 31/01/2019 EKG : Sinus rhytm. HR 100x/m - Rawat WSD
TL : 28/05/1964 WSD H9 Leu 11.5 , Eri 4.03 , Hb 11.7 , Ht 34.9 , Trom 361 , MCH 29.1 FotoThoraks :terlampir, belumekspertisi - Tunggu sitologi, kultur
MRS : 0202/19 Efusi perikardium , MCHC 33.6, MCV 86.7 , SGOT 16, SGPT 11, Ur 13, Cr MSCT Thoraks: - cairan pleura dan analisa
DPJP :dr. Wega Sukanto, Sp.BTKV Tumor paru dextra et 0.4, GDS 89, Cl 99.7, Na 136, K 3.72, PT 15, APTT 32.3 suspekmassadengankarakteristikmaligna central paru - Nebulizer
sinistra Lab 06/02/2019 sinistra - Menunggu hasil foto
Leu 9.7 , Eri 3.98 , Hb 11, Ht 33.5 , Trom 263 , MCH 27.6, - Limfadenopathy multiple karakteristik maligna di kontrol
MCHC 32.8, MCV 84.2 , SGOT 19, SGPT 11, Ur 13, Cr 0.4, mediastinum
GDS 94, Alb 3.27, Cl 98.7, Na 140, K 98.7, PT 14.9/13/1, - Efusi pleura masif sinistra dan efusi pericardium
APPT 25/30.8 - Multipel nodul paru dextra DD/ metastasis
 Lab 16/02/2019 - Lesilitik samar di korpus vertebra L1, suspeklesi
Leu 11.3 Eri 4.39 Hb 12.0 Ht 35.9 Trom 266 MCH 27.3 metastasis
MCHC 33.4 MCV 81.4 Cl 90.8 K 3.68 Na 129

A TERATAI

1 Kelas 2 Astono/L/55th/56.07.34 - Tumor paru kanan post TTB Lab 18/2/2019 - Oksigenasi
Bed 6 TL: 1/3/1963 - Efusi pleura dextra L:eu 10.8 Eri 5.28 Hb 14.1 Ht 42 Tro 310 MCH 26.7 MCHC 33.6 - Observasi sesak
DPJP: dr. Wega Sukanto, MCV 79 SGOT 16 SGPT 14.4 Ur 16 Cr 32 GDS 373 Cl 876 K - Rencana rawat jalan jika
Sp.BTKV 4.49 Na 130 memungkinkan

2 Kelas 2 Ngantung Nicolas/L/56 th/ 35.47.30 Multiple fraktur costae (3,4,5 lateral) Lab 18/02/2019 CT scan kepala terlampir - Analgetik adekuat
Bed 11 TL: 10/08/1992 sinistra Leu 24.7 Eri 3.09 Hb 9.6 Ht 26.9 Tro 260 MCH 31.1 MCHC 35.7 X foto skull terlampir - Transfusi PRC 1 kantong/hari
MRS: 10/02/2019 Old fraktur costae dextra MCV 87.1 SGOT 236 SGPT 206 Ur 47 Cr 1.5 GDS 519 Cl 102.2 K X foto cervical terlampir - AGD
DPJP :dr. Wega Sukanto, Post amputasi above knee ec crush 5.57 Na 136 PT 17.2/14.9 INR 1.37/1/25 APTT 33.3/34.1 X foto pelvic terlampir
Sp.BTKV injury pedis dextra, fraktur segmental Lab 19/02/2019 X foto genu terlampir
tibia fibula terbuka gr III Leu 9.1 Eri 2.07 Hb 6 Ht 18 Tro 107 MCH 29 MCHC 33.3 MCV 87 X foto thorax terlampir
X foto lumboscral terlampir
X foto cruris terlampir
X foto pedis terlampir

ICU
1. Bed 20 Banti Apniel/L/26 th/ 54.50.75 Delayed ekstubasi Lab 15/02/2019 X-foto thorax: - Rawat luka tiap hari
Lantai 2 TL: 10/08/1992 Post op sternotomi mediana Leu 12.3 Eri 2.26 Hb 6.7 Ht 20.2 Trom 132 MCH 29.3 MCHC 33.2 - Gambaran metastase paru, - Rawat WSD
MRS: 10/02/2019 Biopsi Tumor MCV89.4 GDS 117 Fosfor 4.7 Mg 1.53 Alb 2.66 Cl 5.63 K 105.6 penebalan jaringanlunak di - Transfusi PRC hingga ≥ 10
DPJP: dr. Adrian Sp.B, Sp.BTKV Efusi pericardium Ca papiler tiroid Na 141 Calsium 7.14 PT 15.9/13.7 INR 1.36/1.12 APTT 30.3/33.4 region colli terutama sisi kiri - Koreksi albumin
Tumor Mediastinum anterior Lab 17/02/2017 DD/ massa - Tx Lain sesuai TS bedah
Post op debulking tumor Leu 11.3, Eri 2.80, Hb 8.0, Ht 25.0, Tr 131, MCH 28.6, MCHC - Massa mediastinum superior onkologi dan anestesi
Eksisi Biopsi KGB 32.0, Eosinofil 3%, Basofil 0%, Netrofil Btng 0%, Netrofil sgmnt DD/ perluasan
77%, Limfosit 9%, Monosit 11%, MCV 89.3, Fos 4.8, Mg 1.94, Al lymphadenopathy paratrakea
3.09, Ch 104.5, Kl 4.59, Na 143, Cl 7.36 EKG: Normal
Lab 19/02/2017
Leu 10 Eri 3.18 Hb 8.9 Ht 28.9 Tro 133 MCH 28 MCHC 30.8 MCV
90.9 Ur 27 Cr 0.7 Cl 98 K 3.85 Na 141

IRINA E ATAS

1 Isolasi Rivaldo Hutapea/L/16 th/ 55.50.11 Tumor mediastinum Lab 29/01/2019 Foto thoraks Kontrol tanggal - Aff IPC
Bed 2 TL : 14/09/2002 Efusi pericardium Leu 8.0, eri 2.82, hb 7.8, ht 22.7%, tr 98.000, MCH 27.7, 06/02/2019 terlampir - Rawat luka
DPJP :dr. Wega Sukanto, MCHC 34.4, LED 53mm, MCV 80.5, SGOT 73, SGPT 16, Ur - Terapi lain sesuaipediatri
Sp.BTKV 28, Cr 0.6, Cholesterol 154, HDL 27, LDL 74, Trigliserida Echocardigrafi 28/01/2019
266, Protein total 6.15, Albumin 3.25, Na 133, K 3.00, CL Kesan :EfusiPericard, Efusi Pleura
97.3, Ca 8.25 CRP <6, ASTO 200IU
Hasil PA Cairan Pleura
Lab 13/02/2019 Radang kronik supurativa
Leu 13.2, Eri 2.52, Hb 7.2, Ht 20.7, Trombo72, MCH 28.6,
 MCHC 34.8, Eos 0, Baso 0, Net Batang 0, Net segmen52,
Limfo36, Mono 12, MCV 82.1, Cholestrol 166, HDL 26, LDL
73, TGA 337, Protein total 6.44, Alb 3.24, Cl 92.3, K 2.91, Na
136, Ca 8.76, CRP 24

IRINA B

K8 Dalegi Wilem/L/49 /45.12.61 Gangren pedis sinistra Lab 10/02/2019 X foto thorax terlampir Pro amputasi
TL: 10/11/1969 Elektrolit imbalance Leu 60.4 eri 3.49 Hb 9.9 Ht 27.5 Tro 352 MCH 28.4 X foto pedis terlampir Pro pasang DLC
MRS: 10/02/19 Acute on CKD MCHC 36.0 MCV 78.8 SGOT 8 SGPT 7 Ur 210 Cr EKG terlampir Terapi lain sesuai Interna
DPJP: dr. WegaSukanto, Sp.BTKV DM tipe 2 9.1 GDS 350 CK 286 CKMB 48 Cl 78.0 K 3.40 Na
Hipoalbuminemia 116 Anti HCV (-) HbsAg (-) Anti HIV (-)
Lab 11/02/2019
Leu 48.8eri 3.1 Hb 8.6Ht 24.6Tro 311 MCH 27.7
MCHC 35 MCV 79.4
Lab 19/2/2019
Leu 17.2 Eri 4.41 Hb 11.8 Ht 34 Tro 106 MCH 26.8
MCHC 24.7 MCV 77.1 Na 129 K 2.60 Cl 100

ANGGREK 2 bawah

Kamar 111 Purba Lemanus/ L /79thn/553312 - Adeno ca paru dengan Lab 09/02/2019 FotoThoraks (25/01/2019) terlampir - Rawat luka tiap hari
TL: 26/11/1939 metastase otak Leu 14.4 eri 3.94 Hb 12.8 Ht 37.9 Tro 142 MCH 32.5 - Terapi lain sesuai TS interna,
MRS: 16/01/2019 - Pneumonia MCHC 33.8 MCV 9.2 ur 33 Cr 0.7 Ca 7.06 Fosfor 2.8 Foto thorax kontrol terlampir - X foto thorax AP tegak
DPJP: dr. Adrian Sp.B, Sp.BTKV - Hiponatremia Mg 1.79 Na 141 K 3.49 Cl 103 eos 0 baso 0 net.batang kontrol
- Ulkus dekubitus 1 limf 7 mono 4 Hasil pemeriksaanCairan
Lab 15/02/2019 (Asites, Kista,urine, pleura) : Radang kronis
Leu 8.6 Eri 3.18 Hb 10.6 Ht 29.8 Trom 146 MCH 32.4 dengan sel – sel atipik mengarah adeno
MCHC 34.6 Eos 0 Baso 0 Net Btg 10 Net Seg 85 Lim karsinoma.
5 Mono 0 MCV 93.7 F 2.4 Mg 1.76 Alb 2.17 Cal 6.19
Lab 20/2/2019
Ur 29 Cr 0.5 Fosfor 4.3 Mg 1.49 Alb 2.21 Cl 102.7 K
5.46 Na 157 Ca 5.29

Kamar 101 Rambi Elne Vieke/P/27.01.12 - Multiple fraktur costae Lab 18/2/2019 EKG : sinus rhythm, HR 100x/m, normoaxis - Analgetik
TL : 9/8/1971 hemithorax dextra Leu 23 Eri 3.86 Hb 10.8 Ht 31.7 Tro 221 Na 137 K - Terapi lain sesua TS
MRS : 18/2/2019 5.80 Cl 100.5 MCH 28 MCHC 34.1 MCV 82.1 GDS orthopedi
DPJP :dr. Wega Sukanto, Sp.BTKV 204 Ur 53 Cr 1.4 SGOT 916 SGPT 1027
 CVBC Lantai 1

Kamar anak Manggiwu M Miracle/L/8th/56.09.76 Temponade jantung Lab 18/2/2019 X foto Thorax terlampir - Rencana pericardial window
Bed 2 TL : 11/03/2010 Efusi pleura bilateral Leu 17.2 Eri 4.14 Hb 8.1 Ht 27.7 Tro 353 MCH 19.6 MCHC 29.2 EKG Terlampir ke pleura kanan
MRS : 15/02/2019 MCV 66.9 Alb 2.95 Echo: tampak cardiac
DPJP :dr. Wega Sukanto, Sp.BTKV temponade