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12 NOVEMBER 2018
A TERATAI
3. K1 BED 4A Legoh Stacy Appendisitis infiltrat + Lab 9/11/2018 EKG + xpertisi terlampir Laparoskopik
Meiva/P/28thn G5P4A1 hamil 17-18 Leu 17.700, 4.70, Hb 14.2, Ht 39.3%, (11/11/2018) Appendektomi
minggu. Trombo 311.000, MCH 30.2, MCHC 13/11/2018
39.62.49 36.1, MCV 83.6. SGOT 10, SGPT 9,
MRS 9/11/18 Ur 11, Cr 0.5, GDS 84, Clorida 104.9,
Kalium 3.89, Natrium 137.
DPJP : dr. Ferdinand
Tjandra Sp. B-KBD Urinalisis : Terlampir
4. K2 BED 8 Makawewe Fentje/L/51 Tumor Colon Sigmoid Lab 11/11/2018 EKG tanpa xpertisi CT Scan abdomen +
thn Leu 20.100, Eri 3.70, Hb 9.9, Ht 28%, (11/11/18) kontras
RM: 55.05.02 Trombo 334.000, MCH 26.8, MCHC
MRS: 11/11/2018 35.4, MCV 75.7. SGOT 30, SGPT 12, Foto polos abdomen 3 posisi
DPJP: dr. Ferdinand Ur 117, Cr 1.4, GDS 103, Clorida
Tjandra, Sp.B-KBD 97.9, Kalium 3.32, Natrium 137, PT X-Foto thoraks tanpa
12.8/14.8 det, APTT 39.0/37.4 det, xpertisi (11/11/18)
INR 0.93/1.13 det.
A ATAS
4. A7B6 Olii Mauda/L/69th Tumor Kolon Lab 6/11/2018 CT-Scan Abdomen: Rencana IBS
RM:54.80.98 Kanan+anemia+Hiponatr L 9.600, Hb 8, Tr 332.000 Tumor kolon kanan 12/11/18
HIJAU MRS: 6/11/18 emia Ur/Cr 26/0,7, Na 133, K 3,7, Cl 101,
DPJP: dr.Toar CEA 11,03, CA 19.9 300,1 EKG: terlampir
Mambu,SpB-KBD Lab 10/11/2018 X-foto thorax: terlampir
Albumin : 2.59
5. A6B1 Siu Hasana Ikterus obstruksi ec susp Lab 9/11/2018 CT Scan abdomen +
RM: 550391 choledocolithiasis dd/ Leu 8700, Eri 2.85, Hb 8.2, Ht 22.4%, kontras
MERAH MRS: 9/11/2018 tumor caput pankreas + Trombo 483.000, MCH 28.8, MCHC
DPJP: dr. Ferdinand DMT2 + Electrolite 36.6, MCV 78.6. SGOT 58, SGPT 53,
Tjandra, Sp.B-KBD imbalance. Ur 20, Cr 0.3, GDS 183, Clorida 81.5,
Kalium 3.03, Natrium 119, INR
5.04/1.00 det, APTT 66.6/33.8 det.
6. A6B4 Mahmud Ratna/P/46 Post ileostomi ec Lab 31/10/2018 X Foto thoraks +ekspertisi Cek hasil
thn perforasi ileum terminal Leu 6900, Eri 4.45, Hb 13.4, Ht 40%, (3/10/2018) SGOT/SGPT
RM: 53.79.02 Tumor ovarium distal Trombo 309.000, MCH 30.1, MCHC
MRS: 11/11/2018 33.5, MCV 89.9. SGOT 50, SGPT 31, Foto polos abdomen +
DPJP: dr. Toar Mambu, Ur 32, Cr 0.8, GDS 89, Clorida 104.7, xpertisi (28/9/2018)
Sp.B-KBD Kalium 4.17, Natrium 140, PT 12/13.4
det, APTT 28.4/33.1 det, INR EKG + xpertisi (31/10/18)
0.86/0.99 det.
Toleransi operasi kardiologi
(11/11/18)
7. A3 Yuliance General weakness + Ca
Tamaroba/P/46 thn mammae dextra post
HIJAU RM: 51.91.11 MRM on kemoterapi
MRS: 11/11/2018
DPJP: dr. Marselus
Merung, Sp.B(K)Onk
A BAWAH
1. B9 bed 3 BoyohDominicus/L/62 th -Stress ulcer Lab 3/11/18 X-foto thorax : terlampir Lab. Lengkap, AGD
Obstruksiususmekanikpars Leu 15.4, Eri 4.28, Hb 11.9, Ht 36.7,
DPJP : dr. W. SumantiSp ialec -tumor intraabdomen Ur 82, GDS 170, Cl 110 Abdomen 3 posisi : Kultur darah
B-KBD -Elektrolit imbalance terlampir
Lab 7/11/18 Ceftriaxone 2x2
Leu 17.7, Eri 3.56, Hb 10.9, Ht 32.0, EKG : terlampir gram iv
Trombo 273, MCH 30.6, MCHC 34.1,
MCV 89.9, Ur 48, Cr 1.2, GDS 205,
Amylase 17.6, Alb 2.72, Cl 112.4, K Tungguhasil CT-
4.29, Na 146, PT 15.1, INR 1.15, scan abdomen
APPT 42.9
Menunggubalasanko
Lab 8/11/18 nsul PPRA
Leu 15.4, Eri 4.28, Hb 11.9, Ht 36.7,
Ur 82, GDS 170, Clorida 110. Amilase
dan lipase dalam batas normal
2. B8 BED 1 Manongko Jhoni/L/57 Generall weakness ec Ca Lab 9/11/2018
thn Recti Leu 8.7, Eri 2.85, Hb 8.2, Ht 22.4,
RM: 36.66.51 Trombo 483.000, MCH 28.8, MCHC
MRS: 11/11/2018 36.6, C181.5, K 3.03, Na 119, INR
DPJP: dr. Ferdinand 5.04/1.00, APPT 66.6/33.8.
Tjandra, Sp.B-KBD
Lab 11/11/2018
Leu 6.2, Eri 3.42, Hb 9.9, Ht 28.1,
Trombo 218.000, MCH 28.9, MCHC
35.2, MCV 82.2, Ur 35, Cr 0.8, GDS
105, C1102.7, K 3.29, Na 133,SGOT
22, SGPT 14.
3. B8 Bed 5 PangkeyYulio/L/18 th Post Lab 21/10/2018 EKG: terlampir Rawat luka /12 jam
relaparotomydebridemante Urinalisis(makroskopis)
RM 548387 c burst abdomen Warna : kuning, kekeruhan : keruh, X-Foto Thorax: terlampir antibiotik
TTL 17-09-2000 (mikroskopis)
Post laparotomy Eri 10-12, Leu 1-5, Epitel 7-8, bakteri Hasilpemeriksaankepekaa Diet tktp
DPJP: dr. ToarMambu, appendectomy (-), jamur nantibiotik:
Sp.B-KBD (-), amoeba (-), terlampir Tunggu hasil kultur
(kimia) darah
beratjenis 1020, pH 6, Leukosit 1+,
Nitrit +, protein 2+, glukosa -, keton Mobilisasi
1+, urobilinogen 1+, bilirubin 2+,
darah/eritrosit 4+, silinder -, kristal –
Lab 3/11/2018
Leu 11700, Hb 12.4, Tro 243
Lab 7/11/2018
Leu 22.9, eri3.70, Hb 11.1, Ht 31,
Trombo 497, MCH 30, MCHC 35.8,
MCV 83.8
Lab 8/11/2018
CL 92.1, K 3.77, Na 134
4. B7 bed 8 Umar Bohang/L/ 42 th Stress ulcer Lab 1/11/2018 X-foto thorax: -menunggujadwalct-
Fistula Entero Na 153 K 2.97 Cl 101.7 Terlampir scan 14/11/18
RM 477710 Electrolite imbalance Leu 8000 Hb 4,6 Tro 545 -Tx lain lanjut
Tgl: 29/01/79 USG abdomen: -PPI
MRS 28/10/18 Lab 8/11/2018 Terlampir -Pasang NGT
Leu 7.2, Eri 3.19, Hb 8.4, Ht 26.2, -diet TKTP
DPJP : drToarMambu, Trombo 163, MCH 163, MCHC 32.1, EKG:
SpB-KBD MCV 82.1, Ur 39, Cr 0.8, Cl 106, K terlampir
3.9, NA 142
5. B5 Bed 3 Nurfid /L /55 th Squamous cell carcinoma Lab 11/10/18 X-Foto Thorax: terlampir -Menunggu jawaban
esofagus T4bN2M1 Leu 3.3, eri 3.09, hb 7.9, ht 26.9, tro konsul interna divisi
No. RM: 534805 275, mch 25.5, mchc 29.3, mcv 86.9 Hasil PA: terlampir hemato-onkologi
MRS:11/10/2018 Temporomandibular joint untuk chemopaliatif
TTL:08/03/1963 stiffness Lab 15/10/18 Hasil - TPN
Leu 4000 eri 4.49 hb 11.8 ht 40.1% Esofagogastroduodenokopi -rehab medic
DPJP: dr. Ferdinand trombo 253 mch 26.3 mchc 29.4 mcv : terlampir -tx lain lanjut
Tjandra, SpB-KBD 89.5
Lab 20/10/2018
Leu 5.7 Eri 4.95 Hb 13.2 Ht 41.5 Trom
245 MCH 26.6 MCHC 31.7, MCV
83.9 Ur 27 Cr 0.8 GDS 91 Cl 100 K
3.2 Na 133
Lab 6/11/2018
Leu 6, Eri 3.28, Hb 9.6, Ht 26.6,
Trombo 308, MCH 29.3, MCHC 36.1,
MCV 81.1, Ur 31, Cr 0.7, GDS 81, Alb
2.09, Cl 93.2, K 3.74, Na 129
Lab 8/11/2018
Fosfor 3.6, Mg 2.02, Ca 7.39
7. B7 bed 1 Jonny Stress ulcer Lab 3/11/2018 X-Foto Thorax: terlampir -Puasa
StevanusMaindoka/L/78t Leu 5.3 Eri 3.79 Hb 12.9 Ht 36.2% -NGT,
h Peritonitis ecperforasiusus Trom 261 MCH 34.0 MCHC 35.6 CT-Scan: Perforasi Gaster kateterpertahankan
MCV 95.5 Ur 93 Cr 2.1 GDS 115 Cl -TPN
102.8 K 4.46 Na 136 X-foto abdomen 3 -OMZ 2x40mg
DPJP : dr. Ferdinand posisi:terlampir -As.tranek
TjandraSpBKBD Lab 6/11/2018 -Sucralfat
Leu 5.9 Eri 3.33 Hb 10.8 Ht 31.8% -Terapi lain lanjut
Trom 153 MCH 32.4 MCHC 34 MCV
95.5 Ur 132 Cr 2.8 GDS 85 Cl 114.2
K 4.72 Na 142
9. B10 bed 1 Sumarni Gobel/P/61 th ILO post miles procedure Lab 6/11/2018 -Rawat luka/12 jam
ec adenocarcinnoma recti Leu 8.4 Eri 4.59 Hb 13.4 Ht 38.7% -Mobilisasi
No. RM: 495824 Trom 301 MCH 29.2 MCHC 34.6 -tunggujawabn konsul
MRS:6/11/2018 MCV 84.3 SGOT 20, SGPT 7, Cl 100 rehab medik
TTL:02/06/1957 Ulkus dekubitus gr 1-2 K 3.3 Na 136 -antibiotik
-atasinyeri
DPJP: dr Ferdinand Lab 8/11/2018
Tjandra SpB-KBD Protein tot 5.97, GDS 123, Alb 2.68,
Globulin 3.29, CEA 2.71
10. B8 bed 4 Fredrik Pondag, L, 70 th Tumor paru sinistrasusp Lab 06/11/2018 - Transfuse PRC
RM: 547440 malignancy Leu 12.9, Eri 3.39, Hb 9.6, Ht 29.6, - Tetusus:aminoflui
MRS:7/11/2018 Trombo 46.7, Na 134, K 3.40, Cl 104, d:nacl
TTL:24/04/1948 Tumor kolonsinistrasusp MCH 87.3, MCHC 32.4, MCV 87.3, - Rencanakolonosko
DPJP: dr Ferdinand malignancy GDS 87, Cr 1, Ur 41, SGOT 42, SGPT pi
Tjandra, SpB-KBD 11
12. Bopeng Roslin, P, 63 th Obstruksi usus mekanik Lab 9/11/2018 X-Foto abdomen 3 posisi :
RM ; 279375 parsial ec scibala Leu 9.8, Eri 2.06, Hb 6.8, Ht 18.9, Terlampir
MRS ; 9/11/2018 Trombo 165, MCH 33.0, MCHC 36.0,
TTL : 21/06/1955 MCV 91.7, SGOT 15, SGPT 6, Ur X-Foto Thoraks :
DPJP : dr. Ferdinand 229, Cr 7, GDS 110, Cl 105.6, K 4.8, Terlampir
Tjandra, SpB-KBD Na 134
X-Foto Femur : Terlampir
ICU
1. ICU lantai 1 Corry Pangkey/P/74thn Hematokezia pro evaluasi Lab 5/11/18 X-Foto Thorax Perbaiki KU
Bed 5 Leu 6.6, Eri 3.16,Hb 9.6, Ht 27.4%, Terlampir Rencana kolonoskopi
RM :54.56.84 Gagal nafas on ventilator Trombo 337 Ekg jika KU
DPJP: dr. Toar Mambu, Sepsis ec HAP dd Terlampir Memungkinkan
Sp.B KBD urosepsis Lab 9/11/18
Leu 8.0, eri 3.05, Hb 8.5, Ht 26.1,
HPT Trombo 247, MCH 27.9, MCHC 32.6,
Eos 1, Baso 0, Net batang 1, Net seg 78,
DMT2 Limf 14, Mon 6, MCV 85.6
Post Stoke
Lab 11/11/2018
Diff count 1/0/0/18/6, Na 133,K 3.10,
Cl 94.3.
IGD lt.4
1 Kamar 3a Tulengkey Novi/L/41 PankreatitisAkutddCa Lab 02/11/2018 X-Foto Thoraks: - Observasitanda -
caput Pankreas Leu 18.9, Eri 4.44,Hb 11.9, Ht 35,6 Terlampir tanda Peritonitis
31.58.01 Trombosit 213,MCH 26.7,MCHC 33.4
MRS:27/10/2018 MCV 80.2,Eosinofil 2%,Basofil - Rencana lain sesuai
0%,Netrofil batang 5%,Netrofil segmen EKG: terlampir TS Interna
DPJP: 78%,Limfosit 4%,Monosit
dr.Toar.Mambu,SpB-KBD 11%,Amilase 56,fosfor 1.7,Magnesium
1.91,Cl 93.1,kalium 2.70, Na
136,Calsium 7,19
Lab 04/11/2018
Ca 99,Kalium 3.3, Na132
Lab 6/11/18
Leu 19.9, Eri 4.07, Hb 11.6, Ht 33.7,
kolestrol 121, HDL 18, Alb 2.85, Cl
93.7
Lab 9/11/18
Leu 18.1, eri 4.54, Hb 12.0, Ht 36,
Trombo 529, ALb 3.4, Cl 91.4, K 4.91,
Na 132
IRINA B
Lab 11/11/2018
Leu 15.1, Eri 3.64, Hb
10.6,Ht 30.0, Tro 660.000,
MCH 29.1, MCHC 35.3,
MCV 82.4.
2 K1 KaniDecky/L/ 60 - Post Laparatomi Lab 6/11/18 X-foto thorax : IVFD NaCl: Aminofluid
th - Segmental paralitikec IBD terlampir
- Post hematemesis melena Leu 13.7, Eri 4.26, Hb 12.2, Ceftriaxone, OMZ, PCT,
54 99 02 - Elektrolit imbalance Ht 35.1, Tro 491, MCH Abd 3 posisi: Sucralfat, As.
28.6, MCHC 34.8, MCV terlampir Tranexamat
MRS 5/11/18 82.4
DPJP: dr. Cek Lab lengkap
ToarMambu, SpB-
KBD Lab 11/11/2018 Mobilisasi
Leu7.0, Eri 4.17, Hb 11.9,
Ht 34.7%, Tro 291.000, Rawat Luka
MCH 28.5, MCHC 34.3,
MCV 83.2. Diet: DL 1
IRINA C
1. C4 DeitjeTatuil/P/6 Massa Intrapelvic dan Lab 5/11/18 X-foto thorax : Konferensi bedah, interna,
7 th/ 54 85 46 peritoneum dd tumor adnexa Leu 12.5, Eri 4.06, Hb 11.5, terlampir obsgin, radiologi
111 Ht 24, Tro 584, Cl 93.5, K
bed 3 MRS 23/10/18 Asites 3.02, Na 134
Ct-scan abdomen :
DPJP : dr. Lab 10/11/18 terlampir
Ferdinand Leu 10.2, Eri 3.66, Hb 10.0,
Tjandra, Sp. B Ht 30.6, Trombo 357, MCH
KBD 27.3, MCHC 32.7, MCV
83.6, SGOT 17, SGPT 7, Ur
26, Cr 0.3, Albumin 1.99, Cl
88.6, K 3.89, Na 130.
ANGGREK 1
1. A1 Hammed Post laparotomikolesistektomi Lab 5/11/18 EKG : terlampir Cek Bilirubin 12/11/18
Husein/L/36 th Choledocojejunostomieksplorasi SGOT 45, SGPT 44, Bil tot Mobilisasi
CBD 26.80, Bildirek 26.86, Pro tot X-foto thorax : terlampir Terapisesuai TS interna
19.80.68 6.02, Fos 4.6, Glob 2.49
MRS : 27/10/18
Lab 2/11/18
SGOT 57, SGPT 45, Bil tot
26.54, Bildirek 23.45, Cl
93.1
DPJP : dr.
ToarMambu, SpB- Lab 8/11/18
KBD SGOT 48, SGPT 42, Bil tot
27.39, Bildirek 22.43, Prot
Total 6.66, Fosfor 4.3, Albu
3.81, Globulin 2.85
ANGGREK 2
Lab 10/11/18
Leu 8.5, Eri 4.73, Hb 13.7,
Ht 38.8, Trombo 213,
MCH 29.0, MCHC 35.3,
MCV 82.0, Ur 115, Cr 4.6,
Albumin 2.59, Cl 92.6, K
3.35, Na 131.
NYIUR
CVBC lt.3
Lab 7/11/2018
GDS 89, Asamurat
10.9, kolesterol 177,
HDL 38, LDL 105,
TG 170, Hba1c 5.4