KORAN BEDAH THORAKS KARDIOVASKULAR AHAD 14 APRIL 2013

KORAN BEDAH THORAX KARDIOVASKULAR SELASA, 2 APRIL 2013[KORAN BEDAH THORAKS KARDIOVASKULAR MINGGU 5 MEI 2013]6

NORUANGANIDENTITAS & DIAGNOSISHASIL PEMERIKSAAN PENUNJANG

PALEM BAWAH

1.B2/5/Bed 1Armiani/P/34 tahun/577430

D/ CKD on HD reguler stage VPOH 8 AV shuntLab 27 /4/2013GDS 88 Ur/Cr 49/3,8 SGOT/PT 50/58 Lab 25/4/2013WBC 13,79 RBC 3,40 Hb 8,8 Hct 28,1 PLT 421 Na/K/Cl 139/4,5/103 CT/BT 800/230 PT/APTT 12,9/27 INR 1,09 Ur/Cr 117/5,9 SGOT/PT 29/52USG Abdomen (11/4/2013)Kesan : -PNC Bilateral -Ascites

2. B2/6 Bed 1Agustan/ 46 thn/ 602520

MRS 4/4/2013

D/ CKD Stage V ec Nefropati HT pro cimminoUSG Abdomen (11/4/2013) PNC Bilateral disertai ascites + efusi pleura dextra Kista hepar

Lab 25/4/2013WBC 17,09 RBC 3,66 Hb 10,2 Hct 29,6 PLT 145 GDS 97 Na/K/Cl 137/3,2/102 CT/BT 700/300 PT/APTT 9,1/29,7 INR 0,76 Ur/Cr 112/5,0 SGOT/PT 80/58 Alb 145

Lab 16/4/2013CT/BT 830/300 , PT 10,7, INR 0,904, APTT 27,4WBC 8,88, RBC 2,68, Hb 7,3, HCT 22,8, PLT 238

Lab 15/4/2013Kalsium 5,0, Ferritin 1477

Lab 15/4/2013Fe 124, TiBc 184, Ur/Cr 136/4,7, As. Urat 7,4, Calsium 5,0Na/K/Cl 133/3,3/104

Doppler 18/4/2013Kesan : Arteri vena radialis dan brachial kesan normalMarker spidol pada kedua lengan.

Lab 20/4/2013Wb 31.35 rb 3.30 hb 9.2 plt 82 ur 147 cr 5.3

3.B2/6 Bed 2

Mursalim/53 th/570156

MRS 23/3/2013

D/ CKD Stage V ec PC bilateralPro ciminoLab 25/4/2013WBC 12,25 RBC 2,88 Hb 8,4 Hct 25,8 PLT 251 Ur/Kr 212/5,7 Na/K/Cl 129/5,0/99Lab 21/4/2013WBC 17,64 RBC 2,79 HGB 8,4 HCT 25 PLT 206Lab 20/4/2013Ur 432 Cr 7,7Lab 19/4/2013Prot Tot 4,4 Alb 2,5 Na 129 K 8,2 Cl 99Lab 22/4/2013Wb 14.55 rb 3.28 hb 9.7 plt 256 troponin T 0.03 na 130 k 6.1 cl 103 ur 298 cr 6.3 albumin 2.6 ck-mb 21

4.B2/8 Bed 1Tamzil /L/53 tahun/277859

MTS 27-2-2013

D/ CKD stage 5 ec Nefropati DMOn HD reguler

Rencana : Pro cimino jika KU baikLab 27/4/2013RBC 2,35 WBC 3,5 Hb 7,5 Hct 23,0 PLT 170Lab 21/4/2013Ur 50 WBC 6,22 RBC 2,79 HGB 8,5 HCT 25,5 PLT 195Lab 14/04/2013WBC 12.72 RBC 3.05 Hb 9.3 HCT 28.0 PLT 203 Na/K/Cl 138/3,9/105 LAB 4-4-2013Ur/Cr 64/5.5 GOT/GPT 117/97 Prot.Total 8.0 Alb 3.4 Na/K/Cl 136/4.0/10.5 Lab 30/3/13Ur/kr 82/5,6 Prot.total 8,4 Alb 3,3 Na/K/Cl 141/4,0/107 WBC 7,04 RBC 3,32 Hb 0,9 HCT 30,7 PLT 155 Lab 26/3/13WBC 5,96 RBC 2,48 Hb 7,4 HCT 23,4 PLT 214 Na/K/Cl 146/4,8/112 GOT/GPT 87/64 GDS 75 Ur 60 Prot.total 5,9 Alb 3,2Lab 19/3/2013WBC 6,82 RBC 2,27 Hb 6,1 GDS 112 Fe 51 Ur/Cr 59/4,7 GOT/GPT 54/46 Na/K/Cl 135/3,9/104Foto thorax PA 14/3/2013Efusi pleura bilateralLab 16/3/2013WBC 6,79, RBC 2,48, HGB 7,3, PLT 190, HCT 22,6, Ur 41,2, Cr 4,3, Na 147, K 4,1, Cl 110Lab 9/3/2013WBC 6.79, RBC 2.48, HGB 7.3, HCT 22.6, PLT 190, Ur 41, Cr 4.3, Na 147, K 4.1, Cl 110Lab 9/3/2013CT/BT 800/400 PT/APTT 11,3/28,1Lab 8/3/2013WBC 4,87 RBC 2,44 Hb 7,1 HCT 22,2 PLT 176 CT/BT 800/400 PT/APTT 11,3/28,1Lab 4/3/2013Fe 200 TibC 137 Ur/Cr 84/6,1 GOT/GPT 38/25 Prot. Total 6.0 alb 2,8 HCT 21,1 PLT 156lab 27/2/2013WBC 8,7 RBC 2,61 bh 7,6 HCT 23,1 PLT 140Foto thorax PA 28/2/2013Kesan:efusi pleura bilateralUSG abdomen 23/4/2013PNC bilateralKista ginjal kiriEfusi pleura bilateral Ascites

5, B2/10 Bed 1Sardin Wijaya/ 24 tahun/605747

MRS 23/4/2013

D/ POH ke-6 Pemasangan CVCLab 1/5/2013WBC 13,56 RBC 2, 83 HBG 8,1 HCT 24,5 PLT 169 PT 10,3 APTT 28,0 IR 0. 86Foto thorax 2/4/2013Kesan: kardiomegaliLab 26/4/2013Ur/Cr 27,3/24 Prot.tot 5,8 Alb 3,2 CT/BT 700 PT/APTT 10,4/30,9 INR 0,87 Na/K/Cl 131/5,1/97 WBC 11,08 RBC3,54 HGB 10,6 PLT 90Lab 24/4/2013HbsAg (-) Anti HCV (-) Ferritine 138,2 WBC 11,35 RBC 1,83 HGB 5,3 PLT 167 PT/APTT 14,3/37,2 INR 1,1 Ur/Cr 321/14,9 GPT 16

6.B2/kmr 2Asni/P/57 thn/ 605899

D/ DM tipe II NonobeseKaki diabetik wagner III POH 7 debridementLab 25/4/2013GDP 192 G2PP 32 HbA1c 5,2 Kol. Total 112 HDL 17 LDL 70 Trigliserida 145Lab 23/4/2013Wb 15,31 rb 3,45 hb 9,4 Hct 29,2 mcv 84,6 plt 388Foto pedis dextra AP/LatDestruksi dan lesi-lesi litik pada caput metatarsal I-V, basis metatarsal V dan Phalanges II-V disertai tanda-tanda osteomielitis pedis dextraFoto pedis dextraFascitis plantarisDefect pada jaringan disekitar pedis dengan soft tissue swelling

PALEM ATAS

7.B2/9/Bed 2Yunus Aziz/56thn/L547374

MRS 5-3-2013

D/CKD stage V ec nefropati DM/HT + HD regulerPOH 14 Ekplorasi v.cephalicaLab 22/04/2013GDS 92 Ur 60 Cr 4,2 Na 126 K 3,1 Cl 99Lab 18/4/2013CT 630BT 2 PT 11,8 APTT 23,2 Ur 58 Cr 2,3 Na 136 K 3,26 Cl 103Lab 10/4/2013WBC 14.70 RBC 2,21 Hb 6.9 HCT 20,9 PLT 186LAB 10-4-2013GDS 162 Ur/Cr 85/3.9 Prot.Total 4.5 Alb 2.7 As.Urat 4.9 Ca/Na/K/Cl 6.9/127/4.0/103 WBC 2.94 RBC 1.63 HB 5.1 HCT 15.4 PLT 279Lab 1/4/2013D Dimer 2,6 WBC 7,67 RBC 7,26 Hb 9,6 PLT 180 HCT 24,2 Lab300313WBC 7,06 RBC 1,94 HB 5,7 HCT 17,3 PLT 309 Naa 127 K 3,9 Cl 98 CT 800 BT 200 PT11,7 APTT 25,9 Ur/Cr 110/5,0 GOT/GPT 33/51 Alb.2,7

Lab 20/3/2013GDP 827GD2PP 898

Lab 17/4/2013Na/K/Cl 126/3,0/98, Ur 98, Albumin 2,5, Ca 7,6WBC 11,75, RBC 3,23, Hb 9,2, HCT 28,4, PLT 16,1

Lab 18/4/2013Ct 830 bt 200 pt 11.8 inr 1,00 aptt 23.2 ur 58 cr 2.30 na 136 k 3.26 cl 103

Lab 22/4/2013Wb 10.7 rb 2.88 hb 8.8 plt 217

8.B2/6 Bed 2Nuehaenah/61th/597886

MRS 7/3/13

D/ CKD Stage V Post Cimino H-17HT Grade IIDM Type 2 non-obeseLab 25/4/2013WBC 50,31 RBC 2,81 HGB 8,0 HCT 24,7 PLT 206 Ur/Cr 95/5,3 Na/K/Cl 126/4,4/98Lab 24/4/2013CK 210 CKMB 20,7 Trop T 0,17Lab 11/4/13GDS 154 Ur 104 Cr 5,8 SGOT 19 SGPT 21 Alb 3,5 AU 5,5 WBC 20,50 RBC 4,01 HGB 11,5 HCT 33,7 PLT 464Lab 8/4/13Na 140 K 4,4 Cl 104

LONTARA 1 INTERNA (ATAS DEPAN)

9.Kmr 3 Kelas II Bed 1Marming/P/67th/605366

D/ Ulkus diabetik pedis dextra Wagner IIIDM tipe II non obese Lab 29/4/2013HbA1c 7,6 WBC 9,6 RBC 3,9 HGB 10,7 HCT 33,4 PLT 4,76Lab 26/4/2013HbA1c 8,1 Ur/Cr 15/0,6Lab 24/4/2013WBC 9,68 RBC 4,18 Hb 10,7 Hct 31,4 PLT 746Lab 22/04/2013GDP 241 Prot.Tot 6,7 Alb 2,69 Kol.Tot 155HDL 22 LDL 50 Tg 130 Na 136 K 4,3 Cl 106 GD2PP 417 GOT 11 GPT 7 As.Urat 2,1 Trop T 0,02 FT4 1,09 TSHs 0,855 HBsAg (-) WBC 18,39 RBC 4,32 Hb 11,9 HCT 37,4 PLT 343 Foto Pedis (D) AP / Obliq-fraktur patologis 1/3 medial basis phalanx distal digiti I pedis (D) -Destruksi lesi tititk caput metatarsal,phalanx proximal & phalanx distal digitali I pedis (D) dengan tanda-tanda osteomyelitis-soft tissue swelling regio phalanx digiti I dan plantaris pedis (D)

LONTARA 1 INTERNA (ATAS BELAKANG)

10.L1 Kelas 3 Kamar 7Bed 2Muh. Nuryadin/42 thn/L/605459

Susp. Tumor paru D + Efusi pleura D + Post Chest tube + WSD HR 14Lab 01/05/2013WBC14,27 RBC 419 HBG 12,1 PLT 670 HCT 36,9 Na 143 K 4,2 Cl 101 Kol.total 206 HDL 25 LDL 110 TGT 123 As.urat 4,6 GDS 64 Ur 29 Cr 0.9 GOT 23 GPT 1921/04/2013WBC 28,40 RBC 4,80 HGB 12,0 HCT 36,8 PLT 613 BT 700 CT 300 PT 14,7 APTT 28,3 INR 1,19 Na 142 K 4,3 Cl 103 GOT 43 GPT 50 GDS 134 Ur 43 HBsAg (-)

11.Kmr 5/IIIBed 2Muh. Wahyudin/36 thn/L/605468

Konsul 21/4/2013

D/ Post Chest Tube HR 13 ec effuse pleura (S)CT scan 29/4/2013Susp. Massa paru kiri DD/ empyema thoracic kiriEfusi pleura kiriSplenomegalyLab 21/4/2013 WBC 9,65 RBC 4,6 Hb 13,5 HCT 41,2 PLT 180, BT 8,00, CT 3,00 PT 13,6, APTT 22,7, GDS 87, GOT 33, GPT 15, ALB 3,9, HbsAg (+)

12. Kmr 5/IIIBed 1Yusman/38 thn/L/ 602790 Konsul 3/5/2013

D/ CKD stage V ec Nefropati HT + Gastropati UremikumLab 1/5/2013Na/K/Cl 134/2,8/103 Ur/Cr 43/6,4 Lab 29/4/2013Ur/Cr 57/8,3 Na/K/Cl 137/2,0/106 WBC 6,22 RBC 3,16 HGB 9,0 PLT 143Foto Thorax 26/4/2013Kesan : -Kardiomegali dengan tanda tanda bendungan paru-Dilatatio Aortae

13.Kmr 4 bed 4Arifin/49 thn/ L/ 605694Konsul : 2/5/2013

D/ Aneurisma aorta abdominalLab 22/4/2013GDS 77 Ur/Cr 61/1,5 SGOT/SGPT 48/31 Albumin 3,8 WBC 8,32 RBC 4,16 HGB 11,7 Pt/aPTT 13,4/25,9 Na/K/Cl 145/4,6/112 HBsAg (-) PLT 216

CT-Scan Abdomen tanpa kontras 23/4/2013Kesan ; -Aneurisma aortae abdominal setinggi CV L3-L4 disertai discection -Colelith-PNC sinistra

LONTARA 1 INTERNA (BAWAH DEPAN)

14L1 Kelas 3 KMR 2 Bed 1Faisal/40 tahun/

Konsul dari interna : 8/4/2013

D/ CKD Stg V on HD reg post cimino HR 13Lab 30/04/2013WBC 6,52 RBC 3,15 Hb , HCT 26,7 PLT 290 PT 10,2 APTT 22,0 CT 530 BT 230 Ur 39 Cr 5,1Lab 26/4/13Na 135 K 34,1 Cl 102 WBC 698 RBC 3,25 HGB 9,2 HCt 28,1 PLT 211 Ur/Cr 125/8,2 Prot.tot 6,8 Alb 3,6Lab 18/4/13CT 700 BT 200 PT 10,3 INR 0,90 APTT 26,3 Ur 123 Cr 6,3 Na 144 K 3,95 Cl 109 WBC 6,49 RBC 3,18 HGB 9,0 HCt 28,2 PLT 253

Lab 5/4/2013Ur 71 Cr 1,3 WBC 6500 RBC 2,8 Hb 8,0 HCT 25,3 PLT 261Lab 8/4/2013Na 136, K 4,1 Cl 103 Fe 27,6 TIBC 242 Ur 110 Cr 7,9 WBC 7,43 RBC 2,74 Hb 7,7 HVT 24,2 PLT 302USG 2/3/2013PNC bilateral dengan kista ginjal kanan

15.L1 Kelas 2 Kmr 4 Bed 2Syamsuddin/56thn/L/605724

Pemasangan CVC (Hr ke-5)D/CKD stage V on HD regulerLab 29/4/2013WBC 16,02 RBC 2,26 HGB 6,6 HCt 18,5 PLT 137

Lab 28/4/2013WBC 12,87 RBC 2,53 HGB 7,3 HCt 20,6 PLT 128

Lab 27/4/2013PT/APTT 10,8/31,9 INR 0,9

Lab 26/4/2013Ur/Cr 290/28 Alb 3,0 Na/K/Cl 113/6,0/6,8 WBC 9,83 RBC 2,79 HGB 8,2 HCT 22,3 PLT 135

LONTARA1 INTERNA (BAWAH BELAKANG)

16.Kmr 7/III/Bed 6Amiruddin/32tahun/604773/ MRS 16/4/2013

D/ CKD stage V + Pro cimino + efusi pleura (D) + post chest tube HR 5Lab 27/4/2013GDS 172 Ur/Cr 33/3,0 Prot.Tot : 5,4 Alb 2,2 Na 140 K 3,5 Cl 104 RBC 2,61 HGB 7,7 PLT 180 WBC 9,8

Lab 26/4/2013CT/BT 700/300 PT/APTT 10,1/28,7 INR 0,84

Lab 20/4/2013Ur/Cr 193/9,5 Na 139 K 9,4 Cl 102 WBC 14,86 RBC 3,51 HGB 10,0 PLT 2,57

17.Kmr 6/III/Bed 6Abd Wahid/20thn/ 559821

D/ Pseudoaneurisma antecubiti (S)Lab 22/4/2013Ur/Cr 84/9,2

Lab 20/4/2013Ur/Cr 112/10,0 Na/K/Cl 143/4,3/106

USG Doppler/Duplex Extremitas Atas kiriKesan : Aneurisma arteri pada area fossa cubiti kiri

Lab 15/4/2013HbsAg (-) Ct/BT 6/3 PT/APTT 11,6/25,4 Na/K/Cl 138/4,1/103 GDS 91 Ur 87 GOT/GPT 15/23 WBC 4,5 RBC 3,01 Hb 9,1 PLT 3,6

Foto Thorax PA 15/4/2013Kesan : Pulmo Normal, Cardiomegaly

18.Kmr 6/IIIBed 5Andarias Tato/L/ 595378/46 thn

MRS 21/2/2013Konsul interna 30/3/13

D/ CKD stage V ec PNC Bilateral onHD regulerPOH 24 ciminoLab 1/5/2013WBC 9,44 RBC 2,67 HBG 7,9 PLT 206 Ur 57 Cr 5,7 Kol. Total 96 HDL 23 LDL 44 TGT 83 Na 139 K 4,1 Cl 107Lb 22/4/13Analisa cairan pleuraWarna : kuning muda, Volume 10, bekuan : positif, BJ : 1,015, PH 8, Rivlta : positif, Glucosa :112, Prot 1,52, sel 250Hitung jenis sel MN 80%, PMN 20%

Lab 22/4/13CT 800 BT 300 PT 12,00 INR 1,00 APTT 28,4 WBC 8,12 RBC 3,04 HGB 8,9 HCT 27,3 PLT 156

Lab 19/4/13GDS 106 Ur 87 Cr 6,7 Prot tot 6,0 Alb 2,5

Foto thoraks PA 18/4/13HHD dengan tanda-tanda hipertensi pulmonalSusp. Efudi pleura S.Lab 2/4/2013Eristrosit: normositik, normokrom, giant cell, benda inklusi -, normoblast Leukosit: jumlah cukup, PMN>limfosit, granulasi -, hipersegmentasi+, vakuolisasi +, sel muda Trombosit: jumlah cukup, aggregasi trombosit +Kesan: Anemia normositik normokrom disertai tanda penurunan fungsi ginjal disertai leukosit tanda infeksiSaran: Tes Fungsi ginjal

19.Kmr 4/IIIBed 4Mardilah/P/42 thn/598795

MRS 16/3/13Konsul interna

D/ CKD stage V on HD reg ,, Efusi Pleura Dextra susp. Tu paru dextra post chest tube

Post repair chest tubeLab 29/4/2013Ur 64 Cr 16, 8 A1b 2,4 Ca 6,9 Na 137 K 3,9 Cl 105Lab 22/4/13Ur 64 Cr 6,8 Na 137 K 3,7 Cl 105 Alb 2,4 Calsium 105

PA 19/4/2013Kesimpulan: lesi inflamasi

Lab (11/4/2013)WBC: 16,50, RBC: 2,86, HGB: 7,7, HCT: 24,0, PLT: 333 Na 139 K 3,4 Cl 104 GDS 132 Ur 27 Cr 1,3 SGOT 15 SGPT 10 PT 12,3 INR 1,0 APTT 26,1

Lab 22/4/13Ur 93 Cr 7,1 Na 136 K 3,5 Cl 103

Lab 16/4/13WBC 22,77 RBC 4,08 HB 11,3 HCT 33,4 PLT 308Foto Thorax AP (16/4/2013)Kesan: efusi pleura massif D

Foto thoraks PA (22/4/13)Efusi pleura D

PA sitologi 19/4/13Lesi inflamasi

Lab 2/4/2013PT/APTT 12,4/37,3, CT 600, BT 200, INR 1,0, GDS 73, UR 54, CR 4,7, GOT 42, GPT 57, Na 139, K 3,2, Cl 106, WBC 7,54, RBC 2,71, Hb 7,8, HCT 24,1, PLT 147 Lab 1/4/2013CT/BT 630/200 GDS 140 Ur/Kr 56/6,7 Na/K/Cl 144/3,7/106Lab 27/3/13Ur 50 na 143 K 3,7 Cl 108 WBC 12,06 RBC 3,28 Hb 8,6 HCT 27,3 PLT 286Lab 22/3/13GDP 81 GD2PP 76 Ur 43 Cr 4,6 SGOT 22 SGPT 28 ProtTotal 6,1 Alb 3,1 Globulin 3,0 Lab 13/3/13HbsAG (-) ferritin 733.6Foto toraks 15/3/13

20.Kmr 4 bed 2 KELAS IIIKristina Satu/50 thn/601098

MRS 26-3-2013

D/ CKD stage V ec nefropati HT on HD regular A-V shuntPOH 3 ciminoLab 1/5/2013WBC 10.51 RBC 2,76 HBG 7,9 PLT 22 HCT 24 PT 18,1 control 11,9 APTT 92,3 control 23,7 IRN 1,29 Ur 41 Cr 24Lab 17/4/13UR 53 WBC 10,7 RBC 3,53 HB 10,4 HCT 32,2 PLT 231 Na 133 cl 104 k 3,4HbsAg +Lab 12/04/2013Ur 42 Cr 4,3 WBC 5,76 RBC 3,87 Hb 11,5 HCT 35,2 PLT 185

PAKIS

LONTARA 2 BEDAH UROLOGI

LONTARA 2 ORTHOPEDI

LONTARA 2 BEDAH DIGESTIF

LONTARA 2 BEDAH ONKOLOGI

LONTARA 3 THT

21.Kamar 1 bed 4Suriady/22thn/L/MRS 26-4-2013

D/ Pneumothorax Sinistra + aff chest tube+WSD hari ke-3

LONTARA 3 KULIT

LONTARA 3 MATA

22.Lt 3 Mata Kmr 4 bed 4Yaha/52thn/L/604094

MRS : 12/04/2013

D/ : Empiema thorax (D)Abses heparAff chest tube+WSD hari ke-315/4/2013MSCT scan Thorax (axial) Kesan : abses hepar disertai erosi dan perluasan ke ekstrathoracal dextra, pleuropneumonia dextra, athelosklerosis aortaLab 12-04-2013WBC 31,11 RBC 3,75 HGB 9,7 HCT 29,0 PLT 755SGOT 32 SGPT 20 Albumin 2,0 Na/K/Cl 112/5,1/82 HbsAg non reactive Anti HCV non reactive CT 90 BT 30 PT 15.1 control 9.9 INR 1.20 APTT 30,3 control 28,6 GDS 56 Ur 16 Cr 0,3Lab 22/4/2013Got 160 GPT 68 WB 4,71 RB 2,94 HB 7,5 PLT 258

LONTARA 3 BEDAH SARAF

LONTARA 4 OBGYN (BAWAH DEPAN)

LONTARA 4 OBGYN (BAWAH BELAKANG)

LONTARA 4 ANAK (ATAS DEPAN)

LONTARA 4 ANAK (ATAS BELAKANG)

INFECTION CENTER

23.Lt 1 kmr 2La Sumai/62 thn/ L/ 599256

MRS 15/3/2013

D/ POH 28 chest tube + WSD ec efusi pleura

Post Pleurodesis hari-4CT Thorax 2/4/2013Tumor pulmo dexttra (T3N1Mx)Efusi pleura bilateralPneumothorax dextrPA 1/3/2013Lesi inflamasi tidak ada sel epitel malignaMSCT dengan kontras 1/4/2013Dilatasi aorta ascendensCEA 270313 283Lab 270313RBC 3,72 HB 10,6 HCT 31,5 PLT172 WBC 13,9 GOT/GPT 17/30 Alb 2,5 Ur/Cr 43/0,7FNA 19/3/2013Efusi pleura Dextra klinis TB, DD/ MalignancyUSG ABDOMEN 18/3/2013Tidak tampak tanda-tanda metastase pada organ intraabdominalAsites susp massa kistik abdmen ekstralumenCT-SCAN TORAKS 18/3/13Tampak kontras potongan aksialEfusi pleura massif (D), asitesLab 15/3/2013PT/APTT 0,3/28,7 GDS 140 Ur/Cr 65/1,0 GOT/GPT 70/126 Na 141 K 3,98 Cl 107 PLT 197 WBC 18,38 RBC 5,33 HGB 14,5 HCT 43,4

24.Lt 1 Kmr 1 bed 1Salahuddin/L/66 thn/ 606512/ MRS 27-4-2103

D/ Efusi pleura masif (D) Lab 27/04/2013 WBC 8,5 RBC 5,41 HB 15,9 HCT 48,7 PLT 331 PT/aPTT 10,8/25,9 Na/K/Cl 143/3,6/106 GDS 102 Ur/Cr 15/0,9 GOT/GPT 24/18 CK/CKMB 122/18 CT-Scan Thorax dengan kontras (30/4/2013)Efusi Pleura Masif (S) dengan colaps pasru kiri

25.Lt 2 kmr 4 bed 1Rusdi/20 thn/L/604218

MRS 14/4/2013

D/ Hidropneumothorax S + Post chest tube HR ke 7Lab 15/4/2013Pewarnaan BTA 1, 2, 3 +3Lab 14/4/2013WBC 15,45 RBC 4,79 HGB 11,8 PLT 371, GOT/GPT 101/140 Ur/Cr 17/0,4 LED I 83, LED II 83

26, Lt 2 kmr 4 bed 2Syarifuddin dg Tiro/ L/52 thn/ 606919MRS 29/04/2013

D/ Hydropneumothorax (D) + emfisema subkutis Lab 29/04/2013WBC 19,3 RBC 3,71 HB 10, HCT 31,4 PLT 554 GDS 232 Ur/Cr 28/0,6 GPT 20, Na/K/Cl 133/4,5/99

27.Lt 1 kmr 4Hakim/20 thn/LMRS 20/4/2013

D/ Post Chest Tube + WSD hari ke-11Efusi Pleura Sinistra

Lab 22/4/2013As. Urat 5,6 RBC 3,67 WBC 16,34 Hb 10,0 HCT 30,1 PLT 431Lab 20/4/2013WBC 13,09 RBC 3,56 Hb 9,3 HCT 29,1 PLT 400 GDS 125 Ur/Cr 15/0,5 SGOT/PT 21/14 CT/BT 800/300 PT/APTT 14,3/31,3 PrOT. TOT 5,6 Alb 3,5 Glob 2,1 Na/K/Cl 136/4,4/100

28.Lt 2 kmr 7 bed 3Dahlia/44thn/P/MRS 16-4-2013/604531

D/ Pneumothorax sinistra post chest tube + WSD hari ke-13Foto Thorax 26-4-2013 TB Paru dextra lama aktif Pleuritis Dextra Hidropneumothorax sinistra disertai tanda-tanda atelektasi paru sinistraLab 23/4/2013WBC : 11,18 RBC 3,13 Hb 7,8 PLT 369 HCT 25,7

29.Lt.1.Kmr 4Abd Hamid/57thn/L/605385MRS 20/4

Post Chest Tube hari k-3D/ Efusi Pleura Dextra masif ec TB Extra paruLab 20/4/2013RBC 5,00 WBC 15,97 Hb 15,9 HCT 47,3 PLT 468

USG ABDOMEN 20-4-2013Kesan : simplerenal cyst Sinistra, Efusi Pleura Dextra

30.Lt.1 Kmr 3

Ket : ada konsul tapi belum di jawabRais Banda/605951/47tahun/L

MRS 24/4/2013

D/ Susp Ec Tu. Mediastinum anterior bagian ThynomaCT SCAN Thorax Tanpa Kontras 24/4/2013Kesan : massa mediastinum anterior suspek thynoma DD/ Lymphoma

Lab 24/4/2013WBC 16,22 RBC 3,96 Hb 11,4 HCT 34,3 PLT 578 PT/APTT 13,5/26,4 Na/K/Cl 135/3,9/98 GDS 112 Ur/Cr 26,0,5 GOT/GPT 52/30 Albumin 3,5

ICU

PICU

NICU

CVCU

31.Bed 2Tn.Musman/604228/JKM/ PH hari ke-30/ 1-7-1942

Diagnosa : TAVB

Rencana: Pemasangan PPM

RS UH

32.RSUH Lt.2 ICU Bed 4Ny.Pancai/80 tahun/P009936Lab 29/4/2013WBC 14,16 RBC 5,10 HBG 14, 8 HCT 45,7 PLT 262 LED I 8 LED II 16Lab 24/4/2013Na 134 K 3,3 Cl 99Analisa gas darah:PH 7,44 PCO2 44 SO2 98,7 PO2 124,2 HCO3 27,4

Lab 29/4/2013WBC 14,16 RBC 5,10 HGB 14,8 HCT 45,7 PLT 262 LED 1: 8 LED II: 16

LAB 26/4/2013Albumin 2,1

33RSUH Lt.3Kmr 317Tn. Nuralim/22 tahun/L/ 010318

Dikonsul tanggal 1/5/2013

Post CVC HR 2Hasil pemeriksaan mikrobiologis: 20/4/2013Kultur bakteri negative (tidak ada pertumbuhan)

Lab 18/4/2013:AFP 2,17Lab 17/4/2013:Ur 11 Cr 1,1

Lab 17/4/2013:CT 8 BT 3 PT 13,3 APTT 33,1 GDS 99 SGOT 23 SGPT 17 Na 146 K 3,8 Cl 108WBC 8,45 RBC 4,35 HGB 12,0 HCT 36,7 PLT 289

PCC

34Lt. 2 kmr 210Tn. Linto D /L/65 tahun

MRS 9/4/2013

D/ CKD stage V ec Nefropati DM pro ciminoLab (30/4/2013)RBC 2,81 WBC 3,6 Hb 8,7 Hct 26,3 PLT 263 CT/BT 830/300Foto Thorax (26/4/2013)masih tampak gambaran efusi pleura dextra bila dibandingkan dengan foto lama (15/4/2013) tampak sedikit perbaikanDopler vaskuler (26/4/2013)Arteri & v. radialis & brachialis kesan normal. Marker spidol pada lengan.Foto polos abdomen (15/4/2013)Tidak ada kelainan

35Lt. 2 kmr 216

Ket : Konsul belum di jawabTn. Abubakar /L/66 tahun/590732

D/ CKD stage V on HD reg pro ciminoLab 19/4/2013 WBC 4,9 RBC 3,58 HB 10,2 HCT 31,2 PLT 244 Ur/Cr 54/0,8 Lab 29/4/2013 Ur/Cr 63/3,0 Lab 01/05/2013WBC 50,9 RBC 3,16 HB 9,6 HCT 29,3 PLT 335 Lab 2/5/2013Ur/Cr 125/7,4 Na/K/Cl 132/5,2/95 PT/aPTT 13,4/31,5 USG Abdomen-PNC Bilateral-Ascites-Efusi Pleura (D)

36.Lt. 3 VIP B 309Hj. Abd. Bahaking/L/72 thn/ 607452

MRS 2/5/2013

D/ Acute Limb Ischemic + DMLab 3/5/2013WBC 10,0 RBC 4,14 HB 11,9 PLT 219 HCT 36,2 Kol.total 116 Kol.HDL 15 kol.LDL 106 GDP 105 GD2PP 134 HbA1c 6,36 Ur/Cr 28/0,6 SGOT/SGPT 60/68 Tg 83 Na/K/Cl 138/3,6/106

IRD

6