LIST PASIEN DIVISI ORTHOPEDIRabu, 07 Oktober 2015IRINA A ATAS : 8 PASIENNoKamarIdentitasDiagnosisPemeriksaanPenunjangTerapiKet

1.A10Bed 3PJ:

patrisRendy Tubuon/L/ 24th/44.45.65MRS 22/7/2015

Perawatan harike-72Dr. Tommy. S, Sp.OT

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

28/09/2015Leu 10860Eri 4,36Hb 11,7Ht 36,2Tro 819MCH 27MCHC 32MCV 83LED 84GDS 88Cl 93,8K 4,04Na 135Alb 3,48Glob 3,75

SGOT 33

SGPT 82

Prot.t 7,23

Ur 13

Cr 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,A10

Bed 4

MomelBilly Mewengkang/L/20th/ 45.59.49

MRS 1/10/2015

Perawatan Hari ke-7Dr. Andre L, Sp.OT Post debridement ec fraktur femur dextra 1/3 tengah terbuka grade III A30/09/2015Leu 26700Eri 5,39Hb 16,1Ht 45,2Tro 263MCH 30MCHC 36MCV 84GDS 96Cl 108,0K 4,20Na 142SGOT 61SGPT 49Ur 18Cr 1,0

IVFD RL 20 gtt/mntCiprofloxacin 2x400 mg iv

Ranitidin 2x1 amp iv

Ketorolac 3x1 amp ivRawat lukaDiet TKTP

3.A1

Bed 2

RullyVictor Sondakh/L/58th/ 23.08.95

MRS 2/10/2015

Perawatan hari ke-6Dr. Djarot, Sp.OT SCI frankle C susp. Fraktur V thorakal IV-V+multiple vulnus ekskoriasi Fraktur femur dextra 1/3 tengah terbuka grade IIIA04/10/2015Leu 13110Eri 3,89Hb 12,5Ht 36,7Tro 127MCH 32MCHC 34MCV 94GDP 252Cl 106K 4,50Na 135

IVFD RL: NaCl 0,9% 10gtt/mnt

Omeprazole 2x 40mg ivKetorolacl 3x1 mg iv

Bed rest pada kasur rata & kerasDiet lunak

Rawat luka /hari

4.A7

Bed 2

PJ :

DennyNajoan Juin/L/

17thn/45.57.83

MRS 29/09/2015

Perawatanharike-9Dr. Haryanto, Sp.OT

Fr. Femur dextra 1/3 tengah terbuka gr IIIA fr. Cruris dextra 1/3 tengah tertutup + 28/09/2015

Leu 29200

Eri 6,57

Hb 18,6

Ht 58,1

Tro 267

MCH 28

MCHC 32

MCV 88Ur 32

Cr 1,2

GDS 100

Cl 103

K 4,2

Na 135-IVFD RL 20 gtt/m

-Ciprofloksasin 2x500mg

-Ranitidin inj 2x1 amp

-Ketorolac inj k/p-evaluasi skin traksi-Ganti back slab

5.A6

Bed 5

PJ:

NiarStela Abdjul/P

10thn/45.51.80

MRS 19/09/2015

Hari perawatan ke 18Dr. Andre Lengkong, SpOT Post debridement + osteotomy fibula sinistra ec. Osteomyelitis

06/10/2015

Leu: 13580Eri: 4,64Hb: 12,5Ht: 40,4Tro: 451MCH: 27MCHC: 31MCV: 87LED 77Alb 3,91IVFD RL 0,5% 10 gtt/mntCiprofloxacin 2x400 g/iv

Ketorolac 3x1 ampRawat luka 2x/hari

6.A7

Bed 3PJ:

Wondal Risky/L

21 thn/45.61.26

MRS 03/10/2015

Hari perawatan ke-5Dr. Tommy S.,SpOT Fr. Femur dextra 1/3 tengah tertutup03/10/15

Leu: 10620Eri: 3,56

Hb: 10,5

Ht: 31,9

Tro: 171

MCH: 29

MCHC: 33

MCV: 90Cl: lisis

K: lisis

Na:: lisis

SGOT: lisis

SGPT: lisis

Ur 42

Cr 1,0IVFD NaCl 0,9% 12 gtt/mRanitidin inj 2x1 amp IV

Ketorolac 3x1 amp IVPertahankan skin traksi

Persiapan ORIF

7.A2Bed

PJ:Kimbal haritje gertruida L/82 th/37.65.77MRS 5/10/2015Perawatan hari ke-2

Dr. Andre Lengkong, SpOT

Fr. Intertrochanter femur dextra 04/10/2015

Leu 7589

Eri 3,70

Hb 12,3

Ht 36,4

Trom 104

MCH 33

MCHC 34

MCV 98

Ur 16

Cr 0,5

GDS 239

Cl 103.0

K 3,9

Na 134

-Pertahankan skin traksi-Pro arthoplasty bila setuju-IVFD RL 20 gtt/mnt

-Ketorolac inj 3x1

8.A9

Bed

PJ:Elan Potale/P

45/45.61.19

MRS 6/10/2015

Perawatan hari ke-1

Dr. Tommy S,SpOT

-SCI Frankle E

-Fr. Cervical corpus 5

-Fr. Burst L 2,3

-Fr. Metatarsal 1,2,3,4

-Fr. Dislokasi metatarsal I pedis sinistra03/10/2015

Leu 8738Eri 3,86Hb 12,1Ht 35,5Trom 257MCH 31MCHC 34

MCV 92

Ur 29Cr 0,7GDS 108Cl 109.0

K 3,8Na 136

-IVFD NaCl 0,9%-Ceftriaxone inj.2x1 IV

-Ranitidin inj.2x1 IV

-Ketorolac inj.3x1 IV

-Pertahankan backslab & cervical collar

-Alas keras

Irina A Bawah : 7 pasienNoKamarIdentitasDiagnosisPemeriksaan PenunjangTerapiKet

1.B11

Bed 3Christo roring /L/13 th/45.60.77MRS 3/10/2015 hari perawatan ke 4Dr. Haryanto, Sp.OT

Fraktur radius ulna sinistra 1/3 distal terbuka gr. IIIA

Fraktur radius ulna dextra 1/3 distal tertutup

Multiple vulnus ekskoriasi, multiple vulnus laceratum

Leu 18580

Eri 4,06

Hb 11,1

Ht 32,9

Trom 204

MCH 27,3

MCHC 33,7

MCV 81

Pertahankan casting

Terapi sesuai TS NS

Pro op elektif

Ciprofloxacin 2x400 g/iv (2)

Ketorolac 3x1 amp

Ranitidine 2x1 amp

2.B 9

Bed 3

PatrisRinaldy Prasetyo /L/16th/45.53.67

MRS 2/10/2015

Perawatan hari 6Dr. Andre L , Sp.OTFraktur radius ulna dextra 1/3 distal tertutup

Hematopneumothorax dengan perbaikan

EDH Regio Temporal Sinistra

Fr. Linier Os Temporal Sinistra29/09/2015Leu 8854Eri 2,11

Hb 6,2

Ht 19,1

Tro 267

MCH 29

MCHC 32

MCV 90

-Rawat luka

-Tx lain sesuai TS Thovask dan NS-ciprofloxacin 2x400 mg/iv

3.B8 bed 6

Sarayar Frangky /L/26 th/ 45.61.36MRS 5/10/2015 hari perawatan ke 3

ICH Frontal sinistra

SAH parietal sinistra

Fraktur clavicula dextra 1/3 tengah

Fraktur costa 1 dextra anterior

Fraktur costa V dextra posterior

Anc kontusio paru

3/10/2015Leu 25790

Eri 5,27

Hb 15,1

Ht 48,3

Trom 237

MCH 29

MCHC 31

MCV 92

IVFD asering

Ceftriaxone 2x1

Ranitidine 2x1

Antrain 3x1

Brain act 3x1

ATS profilaksis

4.B7

Bed 1

PJ:

MomelLumendek Fergio/L/

18thn/45..57.08

MRS 29/09/2015

Hariperawatanke-8Dr.Djarot, Sp.OT-Fr femur sinistra 1/3 tengah terbuka grIII A28/09/2015

Leu: 11910

Eri: 4,57

Hb: 13,5

Ht: 41,2

Tro: 286

MCH: 30

MCHC: 33

MCV: 90Ur 23

Cr 0,7

GDS 128

Na 140

K 3,7

Cl 109

-AB lanjut oralAnalgetik lanjut oral

-Rawat luka

5.B4

Bed 1

PJ:

DennyToha Dandong

L/43thn/45.53.16

MRS 22/09/2015

Hari perawatan ke-14Dr. Tommy. S, Sp.OT

Post ORIF tibia dextra (intramedullary tibia nail)

1/10/2015

Leu:16200

Eri: 3,56

Hb: 11,6

Ht: 33,6

Tro: 850

MCH: 33

MCHC: 35

MCV: 94Ur 34

Cr 0,8

Na 137

K 4,40

Cl 10830/09/15X-Foto Thorax: kesan normal- IVFD NaCl 0,9%-Ciprofloxacin inj 2x1

-Ranitidin 2x1 amp

-Ketorolac 3x1 amp -Rawat lukasudah ada hasil x foto ontrol cruris dextra AP/Lat tanpa ekspertisi

hasil : Kesan Normal

6.B3 bed 3

Fike sangari P/39th/28.31.30

MRS 06/09/2015

SCI fleksibel B.E.C. potts disease

15/09/2015

Leu: 9600Eri: 5,12

Hb: 14,5

Ht: 40,2

Tro: 494

MCH: 28

MCHC: 36

MCV: 79Na 137

K 4,11

Cl 96,0

08/09/2015SGOT 19

SGPT 9

Ur 8

Cr 0,5

GDS 97

Alb 3,67O2 4-6 L/m

IVFD RL 14 gtt/mnt

Metilcoleramin inj 3x1

Omeprazole 2x1

Laxadin syr 2x1

Ketorolac 3x1

OAT lanjut

7.B5

Bed

PJ:Rondoy Debby

P/27 thn/45.61.34

MRS 3/10/2015

Hari perawatan ke-4

Dr. Tommy. S, Sp.OTContusio Serebri + susp. Fr. Cervical + susp. Fr. Manus dextra3/10/2015

Leu: 31380Eri: 4,48Hb: 13,4Ht: 41Tro: 211MCH: 30MCHC: 33MCV: 92GDS 173

Na 140K 4,1Cl 110

Advis dr. Tommy, SpOT:

-force slab

-hands ball

ICU: 1 pasienNoKamarIdentitasDiagnosisPemeriksaan

PenunjangTerapiKet

1Bed PJ:

NotaRogi BenyaminP/90thn/45.51.04

MRS 18/09/2015

Hari perawatan ke-20Dr. Andre. L, Sp.OT-Post raktur Colum Femur Sinistra terpasang skin traksi-Hiperurisemia (8,2)-Electrolit Imbalance25/09/2015Leu 5293Eri 3,39Hb 9,9Ht 29,9Tro 158MCH 29MCHC 33MCV 88

GDS 82

Cl 97

K 3,34

Na 140

SGOT 19

SGPT 8

Ur 28

Cr 10,7As urat 8,2

PT 14,6

APTT 30,1-Asam mefenamat 3x500 mg (k/p)-Terapi lain sesuai TS Interna

Nyiur Melambai : 1 pasien

NoKamarIdentitasDiagnosisPemeriksaan

PenunjangTerapiKet

1.K.10

Pj:

Winfried Walukow

P/77thn/18.60.96MRS 15/09/2015

Hari perawatan ke-21Dr. Djarot, Sp.OT

-Diabetic foot + nekrosis-DM tipe 2

-Electrolit imbalance

-DM tipe II28/09/2015Leu 9048Eri 3,55Hb 9,7Ht 29,7Tro 211MCH 27MCHC 33MCV 84

Ur 38Cr 2,8

Prot.t 6,11

Alb 2,05

Glob 4,06

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