LIST PASIEN DIVISI ORTHOPEDISenin, 05 Oktober 2015

IRINA A ATAS : 6 PASIEN

No Kamar

Identitas Diagnosis PemeriksaanPenunjang

Terapi Ket

1. A10Bed 3

PJ:

patris

Rendy Tubuon/L/ 24th/44.45.65

MRS 22/7/2015Perawatan harike-70

Dr. Tommy. S, Sp.OT

- Post amputasi above knee dekstra ec neglectal fraktur tibia-fibula dekstra 1/3 tengah terbuka gr.IIIB- Osteomyelitis

2 8/0 9 /201 5Leu 10860Eri 4,36Hb 11,7Ht 36,2Tro 819MCH 27MCHC 32MCV 83LED 84

GDS 88Cl 93,8K 4,04Na 135Alb 3,48Glob 3,75SGOT 33SGPT 82 Prot.t 7,23Ur 13Cr 0,5

-IVFD RL : NaCl : 1:2 -Gentamicin 2x80mg(iv)-Ranitidin 2x1 amp-Ketorolac 3x1 amp-Metonidazol 3x500mg (iv)-Meropenem 3x1 gr IV (ST)-Vip Albumin 1x1 sach-Rawat luka 2x/hari (betadine+h2O2+Cuka belanda)

2, A10Bed 4

Momel

Billy Mewengkang/L/20th/

45.59.49

MRS 1/10/2015Perawatan Hari ke-5

Dr. Andre L, Sp.OT

Post debridement ec fraktur femur dextra 1/3 tengah terbuka grade III A

30 /0 9 /201 5Leu 26700Eri 5,39Hb 16,1Ht 45,2Tro 263MCH 30MCHC 36MCV 84

GDS 96Cl 108,0K 4,20Na 142SGOT 61SGPT 49Ur 18Cr 1,0

IVFD RL 20 gtt/mntCeftriaxone 2x1 gr ivRanitidin 2x1 amp ivKetorolac 3x1 amp ivPertahankan skin traksiRawat luka

3. A1Bed 2

Rully

Victor Sondakh/L/58th/

23.08.95

MRS 2/10/2015Perawatan hari ke-4

Dr. Djarot, Sp.OT

SCI frankle C susp. fraktur V thorakal IV-V+multiple vulnus ekskoriasi

0 4/ 1 0/201 5Leu 13110Eri 3,89Hb 12,5Ht 36,7Tro 127MCH 32MCHC 34MCV 94

GDP 252Cl 106K 4,50Na 135

O2 2-4 L/mntIVFD RL: NaCl 0,9%→ 10gtt/mntOmeprazole 2x 40mg ivTramadol 3x1 mg ivBed rest pada kasur rata & kerasDiet lunakRawat luka /hari

4. A7 Najoan Juin/L/ Post debridement ec. 2 8 /09/201 -IVFD RL 20 gtt/m

No Kamar

Identitas Diagnosis PemeriksaanPenunjang

Terapi Ket

Bed 2

PJ :

Denny

17thn/45.57.83

MRS 29/09/2015Perawatanharike-7

Dr. Haryanto, Sp.OT

Fr. Femur dextra 1/3 tengah terbuka gr IIIA fr. Cruris dextra 1/3 tengah tertutup + Hemartrosis regio Genu dextra

5Leu 29200Eri 6,57Hb 18,6Ht 58,1Tro 267MCH 28MCHC 32MCV 88

Ur 32Cr 1,2GDS 100Cl 103K 4,2Na 135

-Ciprofloksasin 2x400mg-Ranitidin inj 2x1 amp-Ketorolac inj k/p-Rawat luka-Pertahankan skin traksiPro ORIF

5. A6Bed 5

PJ:

Niar

Stela Abdjul/P10thn/45.51.80

MRS 19/09/2015Hari perawatan ke

16

Dr. Andre Lengkong, SpOT

Post debridement + osteotomy fibula sinistra ec. osteomyelitis

2 8/09/201 5Leu: 9292Eri: 4,09Hb: 11,5Ht: 35,4Tro: 353MCH: 28MCHC: 33MCV: 80LED 80PT 12,2”APTT 29,5”

GDS: 95Cl: 96,4K: 3,50Na:: 139SGOT: 20SGPT: 14Prot.T 7,41Alb 3,25Glob 4,16Ur 13Cr 0,4

IVFD RL 20tpmGentamicin 2x80mg(iv)Ceftriaxone inj 2x1Ranitidin inj 2x1Ketorolac 3x1Rawat luka 2x/hari

6. A7Bed

PJ:

Wondal Risky/L21 thn/45.61.26

MRS 03/10/2015Hari perawatan ke-3

Dr. Tommy S.,SpOT

Fr. Femur dextra 1/3 tengah tertutup

03/10/15Leu: 10620Eri: 3,56Hb: 10,5Ht: 31,9Tro: 171MCH: 29MCHC: 33MCV: 90

Cl: lisisK: lisisNa:: lisisSGOT: lisisSGPT: lisisUr 42Cr 1,0

IVFD RLRanitidin in 2x1 IVKetorolax 3x1 IV

Irina A Bawah : 4 pasien

No Kamar

Identitas Diagnosis Pemeriksaan Penunjang

Terapi Ket

1 B11Bed 1

PJ:Nota

Agus MarufL/46thn/35.43.31

MRS 14/09/2015Hari perawatan ke-

20

Dr.Djarot, Sp.OT

Post ORIF ec. Metal failure femur dextra

29/09/2015Leu: 7085Eri: 2,55Hb: 7,2Ht: 22,3Tro: 317MCH: 28MCHC: 32MCV: 88

-IVFD NaCl 0,9% 12 gtt/m-Meropenem 3x1gr-Ranitidin 2x1 amp-Rawat luka 2x/hari

2. B 9Bed 3

Patris

Rinaldy Prasetyo /L/16th/45.53.67

MRS 2/10/2015Perawatan hari 4

Dr. Andre L , Sp.OT

Fraktur radius ulna dextra 1/3 distal tertutupHematopneumothorax dengan perbaikanEDH Regio Temporal SinistraFr. Linier Os Temporal Sinistra

29 /0 9 /201 5Leu 8854Eri 2,11Hb 6,2Ht 19,1Tro 267MCH 29MCHC 32MCV 90

-Rawat luka-Tx lain sesuai TS Thovask dan NS

3. B7Bed 1

PJ:

Momel

Lumendek Fergio/L/18thn/45..57.08

MRS 29/09/2015Hariperawatanke-6

Dr.Djarot, Sp.OT

-Fr femur sinistra 1/3 tengah terbuka grIII A

28/09/2015Leu: 11910Eri: 4,57Hb: 13,5Ht: 41,2Tro: 286MCH: 30MCHC: 33MCV: 90

Ur 23Cr 0,7GDS 128Na 140K 3,7Cl 109

-IVFD Asering 14 gtt/m-Inj. Ceftriaxone 2x1gr (iv)-Inj.Ranitidin 2x1 (iv)-Inj.Ketorolac k/p-Rawat luka

4.. B4Bed 1

PJ:Denny

Toha DandongL/43thn/45.53.16

MRS 22/09/2015Hari perawatan ke-

12

Dr. Tommy. S, Sp.OT

Post ORIF tibia dextra (intramedullary tibia nail)

1 / 10 /2015 Leu:16200Eri: 3,56Hb: 11,6Ht: 33,6Tro: 850MCH: 33MCHC: 35MCV: 94Ur 34Cr 0,8

Na 137K 4,40Cl 108

30/09/15X-Foto Thorax: kesan normal

- IVFD NaCl 0,9%-Ceftriaxone inj 2x1-Ranitidin 2x1 amp-Ketorolac 3x1 amp -Rawat luka

sudah ada hasil x foto kontrol cruris dextra AP/Lat tanpa ekspertisi

hasil : Kesan

No Kamar

Identitas Diagnosis Pemeriksaan Penunjang

Terapi Ket

Normal

Anggrek 2

No Kamar

Identitas Diagnosis PemeriksaanPenunjang

Terapi Ket

1 K.207

PJ:

Nota

Rogi BenyaminP/90thn/45.51.04

MRS 18/09/2015Hari perawatan ke-

19

Dr. Andre. L, Sp.OT

-Fraktur Colum Femur Sinistra terpasang skin traksi-Hiperurisemia (8,2)-Electrolit Imbalance

25 /0 9 /201 5Leu 5293Eri 3,39Hb 9,9Ht 29,9Tro 158MCH 29MCHC 33MCV 88

GDS 82Cl 97K 3,34Na 140SGOT 19SGPT 8Ur 28Cr 10,7As urat 8,2PT 14,6”APTT 30,1”

-Asam mefenamat 3x500 mg (k/p)-Pertahankan skin traksi-Terapi lain sesuai TS Interna

Nyiur Melambai : 1 pasien

No Kamar

Identitas Diagnosis PemeriksaanPenunjang

Terapi Ket

1. K.10

Pj:

Winfried WalukowP/77thn/18.60.96

MRS 15/09/2015Hari perawatan ke-

20

Dr. Djarot, Sp.OT

-Diabetic foot + nekrosis-DM tipe 2-Electrolit imbalance-DM tipe II

2 8/0 9 /201 5Leu 9048Eri 3,55Hb 9,7Ht 29,7Tro 211MCH 27MCHC 33MCV 84

Ur 38Cr 2,8Prot.t 6,11Alb 2,05Glob 4,06

-Rencana amputasi above knee-Terapi lain sesuai TS interna dan TS Kardiologi