Rekapitulasi Pasien Dept.

Orthopaedi RSUP HAM

Hari/Tgl: Minggu / 12 Agustus 2018

Tgl Masuk Ruanga Diagnosis Terapi Rencana Keterangan

No Identitas
n

1 Ariel Saputra 8/8/2018 RB3 Primary Bone Tumor O/T ( R) - IVFD RL 20gtt/i R/ Konsul anak 8/8/2018
Pratama/L/12th IGD 3.2.3 Proximal Tibia -Parasetamol 500mg 3x1 hb/ht/l/trom
75.23.43 - MST 5mg 2x1 11.2/33/10460/360000
-Amitriptilin 1,25 mg 1x1 PT/Aptt
-Inj. ketorolac30 mg/8j 15,2/31,1
Albumin 3,4
NA/k/cl : 133/4,2/100

2 Suriani/P/42th 8/8/2018 RB3 Post ORIF Clavicle union fx + -IVFD RL 20gtt/i R/ 8/8/2018
66.69.09 POLI 3.2.2 Union ( r) carpal bone + Union -Inj. Ceftriaxone 1g/12j -susul hasil kultur HB/HT/L/Trom
(R ) Distal femur + osteomyelitis -Inj. Gentamicin 20mg/8j mikrobiologi 14,7/45/11.140/51200
+ malunion ( R ) 1/3 proximal -Inj. Ranitidine 25mg/12j aPTT: 29,4
shaft tibia -Inj. metoclopramid / 8j BUN/Ur/Cr : 6/13/0,53
- Inj. ketorolac30 mg/8j Na/k/cl : 138/3,8/105

3 Nehemia 8/8/2018 Rb3 Multiple lacarated wound o/t -IVFD RL 20gtt/i R/ 8/8/2018
Sitompul/L/28 IGD 3.4.1 bilateral pedis -Inj. Ceftriaxone 1g/12j -Konsul B.Plastik HB/HT/L/Trom
tahun/ -Inj. Gentamicin 20mg/8j rawat bersama 13,4/37/13.100/230000
75.24.21 -Inj. Ranitidine 25mg/12j Na/k/cl : 135/2,6/87
-Inj. metoclopramid / 8j KGDs : 79 mg/dl
- Inj. ketorolac30 mg/8j

4 DelonHajrio/L/13 5/8/2018 RB3 Susp. Spondylitis TB IVFD RL 20gtt/i R/ Operasi 07/08/2018

th/ 2.3.2. Inj. Ceftriaxone 1g/12j (15/08/2018) ALP : 74
75.19.15 Inj. Gentamicin 20mg/8j SGOT/SGPT: 13/23
Inj. Ranitidine 25mg/12j 04/8/2018
Hb/Ht/L/Plt:
9.6/30/7.140/29.200
PT/INR/APTT/TT:
13.2/0.86/28.2/15.5
KGDs: 97
pH/pCO2/pO2/HCO3/TCO2/BE
/SaO2 :
7.47/28.6/178/20.7/21.6/-
1.4/99.3
Alb: 2.7
BUN/Ur/Cr: 10/21/0.55
Na/K/Cl: 130/4.3/99
 5 YayukSartini/P/3 2/7/2018 RB3 Post Debridement + VAC + -IVFD RL 20gtt/i Post Debridement + 08/08/2018
5th Konsul Uro 3.2.1. Symphisis diastasis pelvic APC II -Inj. Ceftriaxone 1g/12j VAC (07/08/2018) Hb/Ht/L/T: 8.9/27/9920/396.000
74.90.06 Sacroiliac joint (R) widening -Inj. Gentamicin 20mg/8j Albumin : 2,6
Closed (R) shaft Femur fx -Inj. Ranitidine 25mg/12j CRP kuantitatif : 1,4
Open (R) tibia imminens type -Inj. Ketorolac 30mg/8j 16/07/2018:
IIIA -Tramadol drip 1 amp/12 KGDs: 102
Post sistostomi d/t rupture uretra jam BUN/Ur/Cr: 17/36/0.59
Na/K/Cl: 132/4,2/102

6 Natanael/L/5th 26/07/2018 RB3 Primary bone tumor (L) proximal -Parasetamol syr 3x cth1 Post MRI 01/08/18
67.80.23 IGD 3.3.3 femur sugg. Benign -IVFD RL 20gtt/i ALP: 197
LDH: 141
26/07/2018
Hb/Ht/L/Plt:13,1/38/9420/43700
0
KGDS: 119
BUN/Ur/Cr: 10/21/0,55
Na/K/Cl: 134/43/103

7 Maya 01/08/2018 RB3 Septic Arthritis -IVFD Rl 20 gtt/i R/ Cek DL post 06/8/2018
Sihombing/P/15th/ IGD 3.6.2 -Inj.ceftriaxone 500 mg/12j transfusi Hb/Ht/L/T:
75.14.75 -Inj ranitidine 25mg/12 j 9.9/29/10.380/773.000
-Parasetamol 500mg 3x1 31/7/2018
PT/INR/APTT/TT:
17,6/1,17/25,6/14,7
KGDs: 124
BUN/Ur/Cr: 14/30/0,61
Na/K/Cl: 133/4,9/98

8 Nurtho/L/13th 10/07/2018 RB3 Open (L) distal Tibia fibula Fx -IVFD Rl 20 gtt/i R/Pertahankan VAC 02/08/18
74.89.31 IGD 3.7.3 type III B + Post debridement -Inj.ceftriaxone 500 mg/12j Hb/Ht/L/T:
-Inj ranitidine 25mg/12 j 10.1/31/11.740/320.000
-Inj. Ketorolac 15mg/8j GDS: 191
-Inj. Gentamicin 40mg/8j BUN/Ur/Cr: 21/45/0.72
Na/K/Cl: 131/4.5/95
27/7/18
Hb/Ht/L/T:
12.7/38/9640/558000
KGDs: 95
BUN/Ur/Cr: 14/30/0,64
Na/K/Cl: 133/4,5/101
9 Jontri 07/08/2018 RB3 Non union (R) clavicle + post -IVFD RL 20gtt/i R/ 9/8/2018
Betuel/L/27th/ Poli 2.4.1 ORIF -Inj. Ceftriaxone 1g/12j -Mobilisasi duduk Hb/Ht/L/Plt:
71.34.15 -Inj. Ranitidine 25mg/12j -GV 15,4/44/13.470/336.000
- Inj. ketorolac30 mg/8j 3/8/2018
PT/APTT/TT/INR:
13,9/36,7/17,2/0,96
Alb :4.5
KGDS:64
Na/K/Cl: 137/4,2/103

10 Onedo Noel 10/08/2018 RB3 Open fracture (L) Tibia -IVFD RL 20gtt/i R/- 10/8/2018
Marpaung/L/4th/7 IGD 3.1.1 -Inj. Gentamicin 40 mg/8j Hb/Ht/Leu/Tro:
52705 -Inj. Ranitidine 25mg/12j 8,9/27/12.810/416.000
- Inj. ketorolac30 mg/8j PT/APTT/TT/INR:
20,1/34/18,4/1,4
KGDs: 89 mg/dL
BUN/Ur/Cr: 6/13/0,43
Na/K/Cl: 135/3,8/105

11. Yaumi 11/8/2018 RB3 Susp. Cervical HNP R/- 11/8/2018

alfitri/p/27/ IGD 1.1.1. Hb/Ht/Leu/Tro:
75.28.27

12 Ariston 24/07/2018 RB2A Pathological (L) Humerus -IVFD RL 20gtt/i R/ 08/08/18

Purba/L/58thn 1.5.1 fracture + post ORIF humerus -Inj. Ketorolac 30 mg/8 jam - GV Hb/Ht/L/T:
75.04.65 -Inj. Ranitidine 25mg/12j 9.1/28/10.030/159.000
-Inj.ceftriaxone 1g/12j Bun/Ur/Cr : 33/71/2.63
-Inj Gentamsin 80 mg/8jm Na/K/Cl: 132/5.5/105
31/07/2018
PT/APTT/TT: 15,2/26/16
ALP/SGPT/SGOT/LDH:
80/56/27/136
KGDS: 107BUN/Ur/Cr:
20/43/2,25
Na/K/Cl: 137/5/106
T3 Total/T4 Total/TSH:
0,61/6,27/2,35
Tumor Marker CEA/PSA/CA-
19-9/Cyfra 21-1:
1,08/0,99/3,6/7,43

13 Jumiro/P/70th/ 07/08/2018 RB2A LBP -IVFD RL 20gtt/i R/ 06/8/2018

75.19.68 IGD 2.2.1 -Parasetamol 500mg 3x2 -MRI lumbal Hb/Ht/L/Plt:
-amitriptilin 25 mg 1x1 14/08/2018 dengan 11,4/35/8.300/413.000
-Inj. Tramadol 1 amp/12jam pendampingan Alb :3,0
anestesi KGDS: 95
Na/K/Cl: 135/3,3/106
BUN/Ur/Cr: 20/43/0,74
14 Dwi Perwita Sari/ 08/08/2018 RB2A Necrotic Wound o/t right leg -IVFD Rl 20 gtt/i R/ 08/8/2018
P/ 25th/ IGD 1.4.3 -Inj.ceftriaxone 500 mg/12j -Konsul bedah plastik Hb/Ht/Leu/Trom :
75.22.45 -Inj ranitidine 25mg/12 j rawat bersama 6.2/20/3590/674.000
-Inj. Ketorolac 15mg/8j Na/K/Cl : 132/4.1/98
Bun/Ur/Cr : 9/19/0.81

15 Mardongan/L/55th 02/08/18 RB2B Susp. metastatic spine desease -Bisakodil supp k/p R/ 02/08/18
/75.16.42 3.5.6 fr.A -laxadine syr 1x cth1 -Mobilisasi miring Hb/Ht/L/T:
(sebelum tidur) kanan dan kiri/2jam 14.1/41/14.990/455.000
-Ranitidine 50mg/12j -pertahankan kateter pH/pCO2/pO2/HCO3/BE:
-Na. diklofenac 2x1 7.453/34.4/147.5/23.5/0.2
GDS: 119
BUN/Ur/Cr: 23/49/1.17
Na/K/Cl: 134/4.8/98

16 Adnen/P/50th/ 1/8/2018 RB2B Closed bilateral fracture pubic -parasetamol 500mg 3x1 R/ 08/08/18
75.14.97 IGD 2.4.2 superior dan inferior+ closed (L) - ranitidine 150mg 2x1 -CT Scan pelvic GDP: 273
shaft femur fx + closed (L) -terapi sesuai TS Interna 10/08/2018 √ Gula darah 2 jam PP: 325
humerus fx + DM tipe 2 07/08/18
pH/pCO2/pO2/HCO3/BE:
7.469/28,0/141.1/19,9/-2,3
05/08/2018
Hb/Ht/L/Tr :12.5/37/10.700/111
RaberInterna endocrine
02/08/18
HbA1c: 11.0
Kol Total: 146
Tri: 260
HDL: 24
LDL: 113
01/8/2018
BUN/Ur/Cr: 28/60/1.1
Na/K/Cl:
129/4.6/100
Alb ; 2.6

17 Berlian 07/08/2018 RB2B Phatological (L) Proximal femur -IVFD RL 20 gtt/i R/ 08/8/2018
Nauli/P/56th/ IGD 2.6.2 + Primary bone tumor (L) femur -Inj. Ketorolac 30 mg/8jam -Susul hasil AGDA Hb/Ht/L/Plt:
74.87.76 proximal post core biopsy -Inj. Ranitidine 50mg/12 - Cek darah post 10,8/34/8.580/314.000
jam transfusi 6/8/2018
PT/APTT/TT/INR:
16,5/26,7/13,6/1,15
Alb :3,2
KGDS:117
Na/K/Cl: 134/3.1/99
23/07/2018
BUN/Ur/Cr: 14/30/0,72
Procalcitonine :0.10
18 Ricky 31/07/2018 RB2B Abses o/t back fr.D -IVFD Rl 20 gtt/i R/ 09/8/2018
MuliadiSinaga/L/ Konsul 3.5.1 -Inj.ceftriaxone 500 mg/12j -GV Hb/Ht/L/Plt:
17th/ anak -Inj ranitidine 25mg/12 j -Pertahankan kateter 9,7/29/25.940/352.000
75.10.58 -Inj. Ketorolac 15mg/8j (evaluasi ulang) PT/APTT/TT/INR:
-Parasetamol 500mg 3x2 -mobilisasi miring 16.5/32.9/17.2/1.15
-MST 10 mg 2x1 kanan dan kiri/2jam ALP/SGOT/SGPT:
-Amitriptilin 25 mg 1x1 121/22/72
Albumin :2.4
KGDS: 74
Na/K/Cl: 124/4.1/90
Kalsium : 7.90
BUN/Ur/Cr: 19/41/0.6

19 Rusdiansyah/L/23 9/8/2018 RB2B Burst fracture L3 Fr.C -MST 10 mg 2x1 R/ CT-Scan lumbal 9/8/2018
th/ IGD 3.4.5 -Amitriptilin 25 mg 1x1 10/08/2018 √ Hb/Ht/Leu/Trom :
75.24.46 -Parasetamol 500mg 3x2 11.8/34/10710/215000
PT/APTT/TT/INR :
21.6/31.8/13.5/1.46
KGDS : 78
BUN/Ur/Cr : 9/19/0.63
Na/K/Cl : 134/4.1/106

20 Sakti Br 07/08/2018 RB2B Cervical injury fr.C + ulcus -IVFD RL 20 gtt/i R/ 06/8/2018
Karo/P/57th/ IGD 3.6.1 decubitus o/t back -Parasetamol 500mg 3x2 -MRI 10/08/2018 √ Hb/Ht/L/Plt:
75.21.08 -Gabapentin 300 mg 1x1 - mobilisasi miring 10,7/31/11.900/399.000
kanan dan kiri/2jam PT/APTT/TT/INR:
-pertahankan ulkus 15,5/24,5/20,5/1,07
dekubitus Alb: 2,8
KGDS: 149
Na/K/Cl: 128/4,2/94
BUN/Ur/Cr: 26/56/0,93

21 Nursiah/P/59th/ 05/08/2018 RB1 Closed (R) 1/3 shaft radius -IVFD RL 20 gtt/i R/ 07/08/18
75.18.91 3.3.5 fracture -siprofloksasin 500 mg 2x1 - ORIF radius ulna Hb/Ht/L/T:
Post ORIF bilateral femur - Na diklofenak 50mg 2x1 (13/08/2018) 6,7/29/7.350/280.000
-Ranitidine 150mg 2x1 4/8/2018
PT/APTT/TT/INR:
16,7/24,8/14,5/1.11
BUN/Ur/Cr: 17/36/0,53
Na/K/Cl: 139/4,0/106
22 Rahmi/P/18 3/8/2018 Rb1 Post debridement ( R) d/t open -IVFD RL 20 gtt/i R/ 04/08/2018
tahun/75.18.62 3.3.4 (R ) Ankle fx dislocation tipe III- -Ijeksi ceftriaxon 1gr/12 -GV Hb/Ht/l/Tr
B jam - mobilisasi duduk 9,7/30/13.300/292000
-Inj Gentamsin 80 mg/8jm dan berjalan Bun/Ur/Cr
-Inj Metronidazole 500 5/11/0,62
mg/8jm Na/K/Cl
-Parasetamol 500mg 3x1 136/4,5/101
-Inj randitidin 50 mg/12
jam

23 RisnawatiHaraha RA3 Perispiosthetic (R) femur post Terapi sesuai TS interna R/ ROI + 09/08/18
p/F/68th/ 1.3.2 hemiothoplo (R)+ surgical site Debridement jika KU Hb/Ht/L/T:
75.08.68 infection (R) femur membaik 7.8/25/15.270/272.000
Rawat Luka KGDS : 114
-Koreksi albumin Albumin : 1.9
06/8/2018
PT/APTT/TT/INR:
23,0/27,3/19,6/1,62
Alb: 2,1
KGDS: 77
Na/K/Cl: 133/2,9/98
CRP Kuantitatif : <0,7
03/08/18
pH/pCO2/pO2/HCO3/BE:
7.530/30.0/179.0/25.1/3.00

24 Harunuddin/L/ 1/8/2018 RA4 Primary bone tumor (L) proximal -IVFD RL 20gtt/i R/ 03/08/18
10th/ 3.1.3 tibia -Ringer laktat 20 gtt/i -GV Hb/Ht/L/T:
75.15.72 -Ketorolac 30 mg/8jam 14,5/41/8090/410.000
-Parasetamol 500mg 3x1 PT/APTT/TT/INR:
15.2/34.9/1.00
BUN/Ur/Cr: 10/21/0,50
Na/K/Cl: 137/4,1/103

25 Juari/L/36thn 25/07/18 RA4 Primary bone tumor o/t (R) -Siprofloksasin 500mg 2x1 R/ 06/08/2018
75.08.39 IGD 2.3.3 Proximal Tibia + Post close knee -Parasetamol 500mg 3x1 -PBJ (11/08/2018) Hb/Ht/L/T:
-Ranitidine 150mg 2x1 11.8/36/14.740/464.000
04/08/18
HbsAg: non reaktif
Anti HCV: non reaktif
Anti HIV(rapid 1): non reaktif
30/07/2018
SGOT/SGPT: 50/27
GDS: 94
BUN/Ur/Cr: 6/13/0.77
Ca/Na/K/Cl: 8.3/131/4.4/96
T3/T4/TSH: 0.89/9.33/2.35
 CEA: 1.17
Ca 19-9: 2.0
Cyfra 21-1: 0.70

26 Muhammad 26/07/2018 RA4 Susp. Pathological (L) humerus -NatriumDiclofenat 2x1 R/ 9/8/2018
AdilPanjaitan/L/6 KONSUL 2.32 fracture -Ranitidine 2x1 -mobilisasi miring KGDS : 232
3 th AdenoCaParu + Post ORIF(R) -Spiro moderate kanan dan kiri / 2jam pH/pCO2/pO2/HCO3/BE:
69.83.81 humerus - aff kateter dan NGT 7,354/47,2/108,4/25,7/-0,4
07/08/18
Hb/Ht/L/T:
11,6/34/13.480/168.000
PT/APTT/TT/INR:
15,7/37,6/18,8/1.08
BUN/Ur/Cr: 18/39/0,71
Na/K/Cl: 132/3,8/100
Alb : 2,5
SGOT/SGPT : 116/276

27 Khadijah/P/78/ 30/07/2018 Paviliun post revisi ORIF d/t Prosthetic -IVFD RL 20 gtt/i R/ 09/8/2018
73.07.07 IGD lt 5 faktur (R)proximal femur -Inj ranitidine 50mg/12j -GV HB/Ht/Leu/Trom :
5.2.2 -Ketorolac 30 mg/8jam -mobilisasi duduk 9.8/28/9160/464.000
-Inj.ceftriaxone 1g/12j Fibrinogen / D-dimer : 442/347
Albumin :2.0
07/8/2018
KgdPuasa: 100
KGD 2 Jam PP: Bahan belum
3/8/2018
Hb/Ht/L/T:
10,3/29/11840/510.000
Kolesterol total/TG/HDL/LDL:
101/60/37/78
02/08/18
pH/pCO2/pO2/HCO3/BE:
7.495/20.9/156.9/21.8/-0.2
Alb: 2.5
Na/K/Cl: 134/2.7/100
31/07/18
PT/APTT/TT/INR:
13.9/31,7/23,2/0.96
GDS/Alb: 211/1,7
BUN/Ur/Cr: 11/24/0.69
Na/K/Cl: 127/4,0/95
23/7/2018
CEA: 6.39
28. Yanita 9/8/2018 VIP Post stabilisasi posterior d/t - R/ 24/7/2018
sitorus/P/53th/ POLI Lantai 5 Spondilitis L4-5 Stabilisasi posterior √ Hb/Ht/Leu/Trom :
39.02.20 5.3.1 12.9/38/6240/277000
PT/APTT/TT/INR :
13.9/29/4/15.4/1.00
Albumin :4.6
KGDS : 116
BUN/Ur/Cr : 7/15/0.88
Na/K/Cl : 137/4.0/106

29 Jonsen 9/8/2018 RIC Chronic osteomyelitis (R) Femur -IVFD RL 20gtt/i R/ 30/7/2018
Simorangkir/L/52 POLI 404 Post ORIF(R) femur -Inj. ketorolac 30 mg/8j - ROI + Debridement HB/Ht/Leu/ TRom
th/ -Inj. Ranitidine 50mg/12j squestrectomi √ :12.6/38/8160/315.000
75.12.52 PT/ APTT/TT/INR :
14.6/32.5/16.9/0.96
Albumin : 4.6
KGDS :105

9/8/2018
BUN/UR/CR : 11/24/0.82