koran bedah wanita 200713.docx

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KORAN BEDAH WANITA SABTU, 20 JULI 2013 NO KMR/ BED MRS/ JAMINAN NAMA/ JK/UMUR/ RM DPJP DIAGNOSIS KET 1. Bed 13 16/07/2013 JKM Ny. Maulany P/28 th /175611 HN D/ Hemoroid grade IV pada G1P0A0 TD : 90/80 N : 80x/menit P : 20x/menit S : 36,5°C Ivfd RL 20 tpm Ceftriaxone 1x1gr/iv Anti hemoroid Supp 2x1 Paracetamol 3x1 Rendam PK pagi dan sore 2. Bed 11 19/07/2013 JKM Ny. Yoke Kastanya P/45 th JT D/ Appendisitis Akut TD : 110/70 N : 80x/menit P : 20x/menit S : 36,5°C Lab ( 19 /07/2013 ) RBC: 3.47,Hb:10.0,HCT: 29,1 USG Ivfd RL 20 tpm Ceftriaxone 1x1gr/iv Ranitidine 2x1/iv Ketoorolac 3x30mg/iv 3. Kamar 8 08/07/2013 ASK Ny. Hanijary Levina P/46/043342 AT D/ Post Laparatomi hari ke IV TD : 100/60 N : 80x/menit P : 20x/menit S : 36,5°C Lab (0 9 /07/2013 ) RBC: 4,4 Hb: 9,8 HCT: 30,7 PLT: 373 WBC: 9,5 golda: A Aff infuse Rawat jalan Ganti oral Cefadroxil 2x500 Asam mefenamat 3x500 Sohobion 2x1 tab 4. Bed 7 19/07/2013 ASK Ny. Wehelmina Mainake P/58 th /176119 AT D/ Ulcus Ca Mamma (D) TD : 110/50 N : 80x/menit P : 20x/menit S : 36,5°C Lab (0 9 /07/2013 ) RBC: 1.73, Hgb 4.3, Hct 13.4, Mcv 78, Wbc 22.8 Foto rontgen Ekg Ivfd RL 20 tpm Ceftriaxone 2x1/iv Ketorolac 3x30mg/iv Transamin/8 jam/ IV 5. Bed 15 08/07/2013 ASK Ny. Regina Sirken P/29 AT D/ Tumor 1/3 cruris tengah (D) TD: 100/60 N : 80x/menit P : 20x/menit S : 36,5°C Lab ( 13 /07/2013 ) HCT: 34,4, PLT: 510 WBC: 18,3 IVFD RL 20 tpm Ciprofloxacin 12 jam/ IV Ketorolac 3 x 30 mg/ IV Ranitidine 2 x 1 amp/iv Sohobion drip/iv Metronidazole /8 jam/iv Ondancetron 2x1/iv 6. TT 17 09/07/2013 JKM Nn. Tince Takaria P/27/032485 AT D/ Post Apendektomi hari ke IV Ivfd RL 24 tpm Tramadol 100mg

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KORAN BEDAH WANITASABTU, 20 JULI 2013

NOKMR/BEDMRS/JAMINANNAMA/JK/UMUR/RMDPJPDIAGNOSISKET

1.Bed 1316/07/2013JKMNy. Maulany P/28th/175611HND/ Hemoroid grade IV pada G1P0A0TD : 90/80N : 80x/menitP : 20x/menitS : 36,5CIvfd RL 20 tpmCeftriaxone 1x1gr/ivAnti hemoroid Supp 2x1Paracetamol 3x1Rendam PK pagi dan sore

2.Bed 1119/07/2013JKMNy. Yoke KastanyaP/45thJTD/ Appendisitis AkutTD : 110/70N : 80x/menitP : 20x/menitS : 36,5C

Lab (19/07/2013)RBC: 3.47,Hb:10.0,HCT: 29,1USGIvfd RL 20 tpmCeftriaxone 1x1gr/ivRanitidine 2x1/ivKetoorolac 3x30mg/iv

3.Kamar 808/07/2013ASKNy. Hanijary LevinaP/46/043342ATD/ Post Laparatomi hari ke IVTD : 100/60N : 80x/menitP : 20x/menitS : 36,5C

Lab (09/07/2013)RBC: 4,4 Hb: 9,8 HCT: 30,7 PLT: 373 WBC: 9,5 golda: AAff infuseRawat jalanGanti oralCefadroxil 2x500Asam mefenamat 3x500Sohobion 2x1 tab

4.Bed 719/07/2013ASKNy. Wehelmina MainakeP/58th/176119ATD/ Ulcus Ca Mamma (D)TD : 110/50N : 80x/menitP : 20x/menitS : 36,5C

Lab (09/07/2013)RBC: 1.73, Hgb 4.3, Hct 13.4, Mcv 78, Wbc 22.8Foto rontgen EkgIvfd RL 20 tpmCeftriaxone 2x1/ivKetorolac 3x30mg/ivTransamin/8 jam/ IV

5.Bed 1508/07/2013ASKNy. Regina SirkenP/29ATD/ Tumor 1/3 cruris tengah (D)TD: 100/60N : 80x/menitP : 20x/menitS : 36,5C

Lab (13/07/2013)HCT: 34,4, PLT: 510 WBC: 18,3IVFD RL 20 tpmCiprofloxacin 12 jam/ IVKetorolac 3 x 30 mg/ IVRanitidine 2 x 1 amp/ivSohobion drip/ivMetronidazole /8 jam/ivOndancetron 2x1/iv

6.TT 1709/07/2013JKMNn. Tince TakariaP/27/032485ATD/ Post Apendektomi hari ke IVTD : 100/60N : 80x/menitP : 20x/menitS : 36,5C

Lab (05/07/2013)RBC: 3,95 Hb: 11,3 HCT: 33,1 PLT: 304 WBC 10,1 Ivfd RL 24 tpmTramadol 100mg dalam RL 500mlCefadroxil 2 x 1 gr/ IVMetronidazole 0,5 gr/ 12 jamRanitidine 2 x 1 amp/ IV

7.TT 712/07/2013Umum Ny. MaryamP/48/175909HND/ Tumor Rectum 1/3 tengahTD : 130/70N : 80x/menitP : 20x/menitS : 36,5C

Aff infuseRaway jalanCiprofloxacin 2x1Paracetamol 3x1 kp

8.Kamar 113/07/2013UmumNy. Ita WahyunitaP/48thATD/ Post Ulcus Ca Mamma (D), Sepsis, Metastasis ke TulangTD : 80/50N : 120x/menitP : 20x/menitS : 36,5C

Lab (12/07/2013)Hb 10.2, Wbc 30.000, Eos 21-51, Trombosit 315.000, SGOT/PT 37/45, Ureum 25, Creatinin 0,7, Cholesterol 136, Bil T/I/D 0,4/0,7/0,1, Gdp 78MENINGGAL Pukul 01.48 am WIT

9.Bed 908/07/2013JKDNy. Yosina DiseraP/62/175810ATD/ Fraktur tibia fibula (S) grade IITD : 100/70N : 80x/menitP : 20x/menitS : 36,5CCefadroxil 2 x 500 mgAsam mefenamat 3 x 500 mgSohobion 2 x 1 tab

10.Bed 615/07/2013UNy. RumlawangP/38/043245ATD/ Post isthmus lubektomi tiroid hari ke IVTD : 90/70 N : 80x/menitP : 20x/menitS : 36,5C

Lab (08/07/2013)FT4 0.970, TSH 0.640, SGOT/PT 37/29, Ureum 26, Creatinin 0.77, GDP 81, CT/BT 2/4Aff infuse karena bengkak Ketorolac 3x30mg/ivRanitidine 2x1/ivCeftriaxone 2gr/24jam/ivKalnex 1gr/8 jam/iv

11.Kamar 616/07/2013ASKNy. Barbalin OrlapeanP/29th 043556JTD/ Post Apendektomi hari ke IIITD : 110/60 N : 80x/menitP : 20x/menitS : 36,5C

Lab (08/07/2013)Ureum 18, Creatinin 0.8, GDP 74, CT/BT 6/2Diet LunakCefadroxil 2x500Asam mefenamat 3x500Ranitidine 2x1 tab

12.Kamar 218/07/2013ASKNy. Theresia UrsulaP/042240ATD/ Post Excisi tumor hari ke ITD : 100/60 N : 80x/menitP : 20x/menitS : 36,5CAff infuseTerapi ganti oralcefadroxil 2x500As. Mefenaat 3x500Sohobion 2x1 tab

13.Kamar 318/07/2013ASKNy. MarlaATD/ Post excisi tumor hari ke ITD : 100/70 N : 80x/menitP : 20x/menitS : 36,5CAff infuseRawat jalanTerapi ganti oralcefadroxil 2x500As. Mefenaat 3x500Sohobion 2x1 tab

14.Kamar 718/07/2013ASKNy. Susana UbroP/40th/043450ATD/ Post appendektomi hari ke ITD : 110/70 N : 80x/menitP : 20x/menitS : 36,5C

Ivfd RL 24tpmTramadol 100 mg dalam RL 500 mlCefotaxim 2x1/ivMetronidazol 0,5gr/12 jam/drips

15.Bed 418/07/2013JKMNn. Prety SimbohP/17th/025839ATD/ Post debridementTD : 120/70 N : 80x/menitP : 20x/menitS : 36,5CAff infuseTerapi ganti oralcefadroxil 2x500As. Mefenaat 3x500Sohobion 2x1 tab

16.Bed 1618/07/2013JKMNn. Feronika MansoniP/17th/025839JTD/ Ca Mamma (D) post mastektomiTD : 110/70 N : 80x/menitP : 20x/menitS : 36,5CIvfd RL 20tpmCeftriaxone 2x1/ivNovalgin 3x1/ivParacetamol infuseGV pagi dan soreKonsul dr.saraf