LIST PASIEN THOVASK

Rabu 4 Januari 2017

Irina A bawah
1.

B9
Bed 2

Frans Pakiding /L/62 thn

Jln. Martadinata/04-04-1954
/swasta/kr.protestan

BPJS
Kelas
III

CM 48 81 85
MRS : 19-11-2016
HP: 45
dr. Adrian Tangkilisan, SpB,
SpBTKV
Rabe rInterna : dr. Efata Polii, SpPD
Raber Rehab medic : dr. Elfrida
Marpaung, SpKFR

Post repair WSD ec efusi

pleura ec malignancy

3/1/16
Leu 12420
Eri 3,53
Hb 10,0
Ht 30,5
Trom 433
MCH 28,2
MCHC 32,7
MCV 86,4
SGOT 33
SGPT 24
Ur 20
Cr 0,6
GDS 128
Alb 3,07
Cl 88,0
K 3,86
Na 138
23/12/16
Leu 10680
Eri 3,55
Hb 10,0
Ht 30,8
Trom 435
MCH 28,2
MCHC 32,5
MCV 86,7
SGOT 47
SGPT 39
Ur 18
Cr 0,6
Cl 100,0
K 4,10
Na 131
21/12/16
Leu 12240
Eri 3.52
Hb 9.8
Ht 30.1
Tromb 448
MCH 28.0

Alb2,84
LDH 1299
Cl 85,9
K 5,69
Na 128
Kal 8,78
GDS 109
Imunolog:
CEA 188,7
PT
@Detik
Pasien 13,6
Kontrol 12.9
@INR
Pasien 1,11
Kontrol 1.03
APTT
Pasien 33,3
Kontrol 29.7
14/12/16
Leu 16150
Eri 3.63
Hb11,4
Ht33.6
Trom 36,8
MCH 31.4
MCHC 33.8
MCV 92,7
Ur 12
Cr 0.4
Amilase 231,0
Lipase 351,4
LDH 718
GDS 126
Alb 2.27
Cl 80,0
K 3.28
Na 124
Anti hcv : non
reaktif
HbsAg non reaktif
Anti HIV : non

EKG (5-12-16)
Sinus rhytm + PAC
Saran: print out hasilct-scan
yang lama
90
HASIL CT SCAN
(9/12/16)
-Menyokong suatu masa pada
media stinum posterior , susp
lesi / masa pada paru kiri dd
proses metastase ?
-Efusi pleura kana
-Peradangan paru dd reaksi
pneumoni?
-Obstruksibilierec ?
Jawaban Anestesi
Saat ini pasien dengan
orthopneu ec massive efusi
pleura.
-Untuk assist breathing saat CT
scan sangat sulit dilakukan
sehubungan dg posisi peralatan
CT scan yang menghalangi
tindakan assist breathing
kecuali dilakukan pemasangan
ETT
-Untuk pemasangan ETT
mohon dipertimbangkan risk
and benefit dengan tindakan
diagnostic CT scan
Saran:
-X-foto thoraks ulang
-Mengurangi level efusi pleura
sambil melatih toleransi pasien
untuk breathing

Aminofluid : D5% 20 gtt/mnt

Methamizole 3x1 IV
Terapi lain sesuai TS interna &
rehab
p/ Rawat WSD + luka WSD

MCHC 3.7
MCV 85.6
19/12/16
Leu 11090
Eri 3,09
Hb 9,1
Ht 26,1
Trom 496
MCH 29,5
MCHC 34,9
MCV 84,6
SGOT 89
SGPT 52
Ur 23
Cr 0,5
Fosfor 4,5
Mg 1,92

B8 bed 1 Adrianus Didi Kapantow/L/59 th

Pakadoo dan ling 1
49.11.05
MRS;1/1/2017
HP: 5
DPJP: dr. Adrian T, SpBTKV
Raber NS & Ortho

Commotio cerebri
Susp fr. Femur
Fr. Clavicula 1/3 tengah
dextra tertutup
Fr. Costae 3 posterior dextra

4/1/2017
Leu 8753
Eri 4.52
Hb 13.8
Ht 40.9
Tromb 229
MCH 30.5
MCHC 33.7
MCV 90.5
Ur /Cr 36/0.5
As. Urat 9,6
Prot. Total 6,25
Alb 3,20
PT
@Detik
Pasien 13,0
Kontrol 12.9
@INR
Pasien 1,04
Kontrol 1.03
APTT
Pasien 26,2
Kontrol 29.7

reaktif
10/12/16
Leu 10480
Eri 3.54
Hb10.0
Ht30.6
Tromb 435
MCH 28.2
MCHC 32.5
MCV 86.7
Ur 17
Cr 0.6
SGOP 63
SGPT 41
GDS 126
Alb 2.27
Cl 87.4
K 2.80
Na 134
31/12/2016
Leu 15320
Eri 4.2
Hb 13.1
Ht 39.6
Tromb 240
MCH 31.0
MCHC 33.0
MCV 93.8
Ur /Cr 29/1.1
SGOP 39
SGPT 18
GDS 123
Cl 101.0
K 3.5
Na 139

EKG 2/1/17 : normal sinus

rhythm 70x/m

Methamizole 3x1 amp IV

Bisolvon 3x1 amp IV
Ts lain sesuai TS NS & ortho

Irina A Atas
1.

A2
Bed 3

Lili Minibar/P/53th/18-316/IRT/Islam/Kel Lawangirung

CM: 48.97.39
MRS: 10-12-2016
HP: 22
RABER
dr. Adrian Tangkilisan, SpB-TKV

Efusi pleura bilateral (D) et

(S) ec susp malignancy
Post MRM camammae
sinistra
Cardiomiopathy ec
druginduced

4/1/17
Leu 8753
Eri 4,52
Hb 13,8
Ht 40,9
Trom 229
MCH 30,5
MCHC 33,7
Eos 0%
Bas 0%
NetBat 1%
NetSeg 67%
Lim 25%
Mon 7%
MCV 90,5
Ur 36
Cr 0,5
Uric Ac 9,6
Protol 6,25
29/12/16
Leu7331
Eri4,52
Hb13,6
Ht41,0
Trom289
MCH 30,1
MCHC 33,1
Eos 1%
Bas 1%
NetBat 2%
NetSeg 61%
Lim 27%
Mon 8%
MCV 90,7
Ur 23
Cr 0,5
Fosfor 4,5
Uric Ac 11,5
Protol 6,81
Fos 3,2
Mg 1,46
Alb 3,40
Glo 3,41
Chlo 93,2

17/12/2016
Leu 7904
Eri4,11
Hb12,7
Ht 39,3
Trom 260
Ur/Cr 24/0,6
GDS 125
Alb3,11
Glob 2,68
Cl 96,4
K 3,5
Na 133
SGOT 40
SGPT 39
Ur 24
Cr 39
Protol 5,79
GDS 125
Mg 1,55
Alb 3,11
Glo 2,68
Chlo 99,0
Kal 3,50
Na 133
Cals 9,78
K 4,1

Foto thorax 5/1/17

Minimal pleura effusion
bilateral
Foto thorax (24/12/2016)
Efusi pleura D/S
EKG (15-12-2-16):
Sinus takikardia
Foto thorax 13/12/16
Efusi pleura D/S

Pro Echo
Tx lain sesuai TS.Onkologi dan
Cardiologi

K 2,91
Na 145
Ca10,22
C3

Rivaldo Maniku/L/17th
6/11/1999
Madidir Unet
491016
MRS:30/12/2016

Empiema sinistra ec susp

TB paru

Kamar
7

Givenly M Robot/L/4th
10/7/2012
49.11.54
Langowan

Efusi pleura s
Empiema s
Post WSD

Raber Pediatri

p/ Rawat WSD + luka WSD

IVFD NaCl 0.9% 20 tpm
Ketorolac 3x1 amp IV

1/1/2017
Leu 30710
Eri 4.39
Hb10.4
Ht 32.8
Tromb 570
MCH 23.7
MCHC 31.8
MCV 74.6
Ur 22
Cr 0.2
SGOP 59
SGPT 64
GDS 95
Cl 98.0
K 4.9
Na 127
Ca 8.96

p/ Rawat WSD + luka WSD

IVFD NaCl 0.9% : D5 20 tpm
Tunggu hasil kultur
R/Konsul Rehab