BED 1
Ny. AW /P/55thnDIAGNOSApost tobectomy pulmo dextra lobus
sup/apex ec TBC pulmo dextraDPJPdr. Eka.
Lantang,Sp,ANcoassstephanusHARI PERAWATAN 28 november (Hari
Perwatan ke 1)
TANDA VITALTD Sistolik78-160TD
Diastolik40-110N130-150S33-37,5P18-24saturasi92-100KesadaranE4 M6
V5
MataKonj. Anemis -/-, Sklera ikterik -/-JantungSI-II n regular,
bising -ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+),
Pal: lemas /per : timpaniVENTILASIO2 Via nasal canul 3 l/mMOVAGDpH
: 7,123, Pco2 : 45,9, Po2 : 60,2, So2% : 80,0, Hct : 27, Hb : 9,0,
pHtc : 7,155, Pco2tc : 41,2, Po2tc : 50,7, Hco3- : 15,2, Tco2 :
16,6, BEecf : -14,3, Beb : -12,7, SBC : 14,2, O2ct : 101,5, O2cap
:124,6, A : 638,7, A-aDo2 : 588,0, a/A : 0,1, Ri : 9,8, Pso : 32,5,
Po2/f1o2 : 63,4 Mixed VeinBALANS CAIRANCM2546CKUrine320Uo
(cc/kg/jam)BalansBalans kumulatifPEMERIK.
PENUNJANGLABORATORIUM-Hb/Hct/Leu/Tr-Na/K/ClUreum/CreatininSGOT/SGPTGDPBilirubin
T/D/IPT/APTTProtein
T/A/GCK/CK-MBCa/MgFibD-dimer/FibrinogenAlbuminKulturLaktatCD3
(%/absolut)/CD4 (%/absolut)INRLEDPCTPx Penunjang lainCxrEchoCtscan
thoraxMRIanalisa cairan asitesHbA1c/Beta hidroksi butirat
(Keton)KulturCT Scan KepalaUSGMASALAH
TERAPIceftriaxone 3x25 ivRl 500 ccNS + RoculaxNS + VasconNS +
Heparinmidazolam + NS NS + morphin injNacl 0,9%
BED 2Tn. S/L/43 thnDIAGNOSADPJPdr. Eka Lantang,
Sp,AncoassStephanusHARI PERAWATAN 28 november (Hari Perwatan ke
1)
TANDA VITALTD Sistolik100/133TD
Diastolik60/100N90-110S34,8-38P18-20saturasi99-100KesadaranE1 M1
V1PEMERIK. FISIKMataKonj. Anemis -/-, Sklera ikterik
-/-JantungSI-II n regular, bising -ParuSp. Vesikuler, Rh-/-,
Wh-/-AbdomenI : datar, A : BU(+), Pal: lemas /per :
timpaniVENTILASIO2 Via mask 4 l/mMOVAGDpH : 7,497, Pco2 : 31,5, Po2
: 471,6, So2% : 99,6, Hct : 30, Hb : 9,9, pHtc : 7,479, Pco2tc :
33,2, Po2tc : 479,3, Hco3- : 24,6, BEecf : 1,2, Beb : 2,4, SBC :
26,6, O2ct : 151,0, O2cap :137,0, A : 674,0,7, A-aDo2 : 144,7,0,
a/A : 0,7, Ri : 0,4, Po2/f1o2 : 471,6Mixed VeinBALANS
CAIRANCMCKUrineUo (cc/kg/jam)BalansBalans kumulatifPEMERIK.
PENUNJANGLABORATORIUM-Hb/Hct/Leu/Tr-Na/K/ClUreum/CreatininSGOT/SGPTGDPBilirubin
T/D/IPT/APTTProtein
T/A/GCK/CK-MBCa/MgFibD-dimer/FibrinogenAlbuminKulturLaktatCD3
(%/absolut)/CD4 (%/absolut)INRLEDPCTPx Penunjang lainCxrEchoCtscan
thoraxMRIanalisa cairan asitesHbA1c/Beta hidroksi butirat
(Keton)KulturCT Scan KepalaUSG MASALAH
TERAPIceftriaxone 4x1Ranitidine 3x50 mgAntrain 3x50 mgBrain act
3x500 mgRl 500ccNacl 0,9% 500ccRl 500cc
BED 5PWNy LS/P/57 ThnDIAGNOSAGeneral Weeknes ec sepsis pneomoni
DIAGNOSAParaparesis UMN ec spondititis TBDPJPdr. Hendrik, Abraham.
SP.AnDPJPdr. Eka Lantang. SP.AncoasscoassStephanusHARI PERAWATAN20
Oktober 2014 (hari perawatan 1)HARI PERAWATAN28 november 2014 (hari
ke 2)TANDA VITALTANDA VITALTD Sistolik120-200TD Sistolik100-150TD
Diastolik70-120TD
Diastolik60-80N90-130N108-120S36,0-38,5S36-37,5P24-31P18-22saturasisaturasi97-100KesadaranCompos
MentisKesadaranE4M6V5PEMERIK. FISIKPEMERIK. FISIKMataKonjungtiva
anemis +/+ Sklera ikterik -/-kepalaKonjungtiva anemis -/- Sklera
ikterik -/-JantungSI-II Reguler, bising(-)JantungSI-II Reguler,
bising(-)ParuSimetris, Sp. Vesikuler Rh-/- Wh-/-ParuSimetris, Sp.
Vesikuler Rh-/- Wh-/-AbdomenI : datar lemas A : bu(+)n Pa : lemas,
Nyeri tekan (+) bekas operasi AbdomenI : datar lemas A : bu(+)n Pa
: lemas, Nyeri tekan (-)VENTILASIO2 via Nasal Canul
VENTILASIMOVMOVAGDAGDMixed VeinMixed VeinBALANS CAIRANBALANS
CAIRANCM1025CM1150CK350CK430Urine500Urine1500Uo (cc/kg/jam)0.7Uo
(cc/kg/jam)BalansBalansBalans kumulatifBalans kumulatifPEMERIK.
PENUNJANGPEMERIK. PENUNJANGLABORATORIUMLABORATORIUMHb/Hct/Leu/TrHct
35Hb/Hct/Leu/TrNa/K/Cl122/3.52/109.2Na/K/ClUreum/CreatininUreum/CreatininSGOT/SGPTSGOT/SGPTGDPGDPBilirubin
T/D/IBilirubin T/D/IPT/APTTPT/APTTProtein T/A/GProtein
T/A/GCK/CK-MBCK/CK-MBCa/MgCa/MgFibFibD-dimer/FibrinogenD-dimer/FibrinogenAlbuminAlbuminKulturKulturLaktatLaktatCD3
(%/absolut)/CD4 (%/absolut)CD3 (%/absolut)/CD4
(%/absolut)INRINRLEDLEDPCTPCTPx Penunjang lainPx Penunjang
lainCxrCxrEchoEchoCtscan thoraxCtscan thoraxMRIMRIanalisa cairan
asitesanalisa cairan asitesHbA1c/Beta hidroksi butirat
(Keton)HbA1c/Beta hidroksi butirat (Keton)KulturKulturCT Scan
KepalaCT Scan KepalaUSGUSGMASALAHMASALAH
TERAPIceftriaxone 2x1 gramTERAPIRimstar 4x1Ranitidin 2x1Ala 600
1x1Tramadol 3x1Focincyn 2x2 grHytiobac 2x1 Ranitidin 2x1Ketorolac
3x1Nacl 0,9% Rl 500 cc
BED 6Ny. AS/P/22th
DIAGNOSAFr.pelvic, susp trauma tumpulDPJPdr. Eka Lantang.
Sp.AncoassStephanusHARI PERAWATAN28 November 2014 (Hari perawatan
ke-8)TANDA VITALTD Sistolik110-140TD
Diastolik60-83N100-150S36,5-38,2P18-22saturasi98-99%KesadaranE4M6V5PEMERIK.
FISIKMataKonj. Anemis -/-, Sklera ikterik -/-JantungSI-II n
regular, bising -ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A
: BU(+), Pal: lemas VENTILASIO2 Via ventilator 3l/mMOVAGDpH :
7,468, Pco2 : 29,0, Po2 : 29,0, So2% : 98,1, Hct : 30, Hb : 10,0,
pHtc : 7,464, Pco2tc : 29,4, Po2tc : 107,9, Hco3- : 21,2, Tco2 :
22,1, BEecf : -2,7, Beb : -1,1, SBC : 23,5, O2ct : 139,0, O2cap
:138,3, A : 537,8, A-aDo2 : 429,9, a/A : 0,2, Ri : 4,1, Po2/f1o2 :
132,6Mixed VeinBALANS CAIRANCM1500CK660Urine1240Uo
(cc/kg/jam)BalansBalans kumulatifPEMERIK.
PENUNJANGLABORATORIUMHb/Hct/Leu/TrNa/K/ClUreum/CreatininSGOT/SGPTGDPBilirubin
T/D/IPT/APTTProtein
T/A/GCK/CK-MBCa/MgFibD-dimer/FibrinogenAlbuminKulturLaktatCD3
(%/absolut)/CD4 (%/absolut)INRLEDPCTPx Penunjang lainCxrEchoCtscan
thoraxMRIanalisa cairan asitesHbA1c/Beta hidroksi butirat
(Keton)KulturCT Scan KepalaUSGMASALAH
TERAPIcefriaxone 2x1grRanitidin 2x50 mgTramadol 3x100 mgasam
tranexamat 3x100 mgNacl 0,9%SanmolRl 500 cc
BED 4RS/P/81THNDIAGNOSAfr. Collum (s)??? + post
hermioorthoplastyDPJPdr. Lucky Kumaat. SP.AncoassDianaHARI
PERAWATAN12 november 2014 (hari ke 1)TANDA VITALTD Sistolik90-130TD
Diastolik40-80N90-100S35,5-37,5P20-24saturasi98-99KesadaranE4M6V5PEMERIK.
FISIKMataKonjungtiva anemis -/- Sklera ikterik -/-JantungSI-II
Reguler, bising(-)ParuSimetris, Sp. Vesikuler Rh-/- Wh-/-AbdomenI :
datar lemas A : bu(+)n Pa : lemas, Nyeri tekan
(-)VENTILASIMOVAGDMixed VeinBALANS CAIRANCM900CK450Urine450Uo
(cc/kg/jam)BalansBalans kumulatifPEMERIK.
PENUNJANGLABORATORIUMHb/Hct/Leu/TrNa/K/ClUreum/CreatininSGOT/SGPTGDPBilirubin
T/D/IPT/APTTProtein
T/A/GCK/CK-MBCa/MgFibD-dimer/FibrinogenAlbuminKulturLaktatCD3
(%/absolut)/CD4 (%/absolut)INRLEDPCTPx Penunjang lainCxrEchoCtscan
thoraxMRIanalisa cairan asitesHbA1c/Beta hidroksi butirat
(Keton)KulturCT Scan KepalaUSGMASALAH
TERAPIceftriaxone 3x1 gr
gentamisin 2x80mg (IM)ketorolac 3 x3mgranitdin 2x50mg
