list pasien divisi orthopedi 04 oktober 2015
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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