Bed 1IDENTITASLO/P/44 thnDIAGNOSAEfusi pleura + sternotomiDPJPdr Lucky Kumaat,SpAncoassBilly, RintoHARI PERAWATAN16 Februari 2015 (Hari Perawatan ke 21)

TANDA VITALTD Sistolik130-150TD Diastolik75-100N90-120S36-37P18-30SPO296-99%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,518/pCO2 48/pO2 84,9/HCO3 39,4/BEecf 16,3/SO2 95,3/Hb 11,1/Hct 33 PO2/FIO2 84,9

16/02/2015BALANS CAIRANCMCKUrine1000Uo (cc/kg/jam)BalansBalans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/16/15Hb/Hct/Leu/TrNa/K/Cl127,8 / 3,07 / 100,8Ureum/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

TERAPISildemafil 3 x 12,5Captopril 2 x 12,5Cefixime 3 x 100 mgRanitidin 2 x 50 mgAsam mefenamat 3x1 tab

Bed 2IDENTITASPS/L/41 thnDIAGNOSATumor Parotis SinistraDPJPdr. Lucky Kumaat, SpAncoassBilly, RintoHARI PERAWATAN16 Februari 2015 (hari perawatan 0)

TANDA VITALTD Sistolik120-150TD Diastolik80-100N65-80S35,5-36P22-26SPO2100%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-Abdomendatar lemas, BU (+) NVENTILASIMOVAGDpH 7,448 /pCO2 37,7 /pO2 219,5 /HCO3 25,4/BEecf 1,0/SO2 98,47%/Hb 12,2,3 /Hct 37 % PO2/FIO2 548.9

12/02/2015BALANS CAIRANCM1100CKUrine800Uo (cc/kg/jam)Balans300Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/16/15Hb/Hct/Leu/TrNa/K/Cl140/ 3,25 / 102,9Ureum/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

TERAPICefozoline 2x1 gRanitidin 2x50 mgKetorolac 3x1 g

Bed 3IDENTITASFM/P/50 thnDIAGNOSAPost HTSOB, Mioma UteriDPJPdr. Lucky Kumaat, SpAncoassBilly, RintoHARI PERAWATAN16 Februari 2015 (Hari perawatan 0)

TANDA VITALTD Sistolik130-155TD Diastolik70-90N90-110S38-38,5P14-18SPO299-100%KesadaranE4M6V5

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,520/pCO2 30,4 /pO2 156/HCO3 25/Beecf 2,0/SO2 96,9%/Hb 7,9/Hct 24 %PO2/FIO2 487,4

12/02/2015BALANS CAIRANCM1200CKUrine1450Uo (cc/kg/jam)Balans-250Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/16/15Hb/Hct/Leu/TrNa/K/Cl136,7/ 2,95 / 103,5 Ureum/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 grAsam Traneksamat Ketorolac 3x2mg

bed 4IDENTITASOL/P/44thnDIAGNOSAEfusi Pleura post StenotomiDPJPdr. Iddo Posangi, Sp.AncoassYurike, RintoHARI PERAWATAN18 Februari 2015 (Hari perawatan ke 23)

TANDA VITALTD Sistolik130-160TD Diastolik70 - 90N86-120S36,4-37,2P22-34SPO294-97%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,515/pCO2 40,5/pO2 85,0/BEecf 9,8/SO2 96,1%/Hb 10,9/Hct 33 PO2/FIO2 236,1

12/02/2015BALANS CAIRANCM800CKUrine710Uo (cc/kg/jam)0.6Balans90Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM17&18/02/2015Hb/Hct/Leu/Tr10,4/35,7/9.900/445.000Na/K/Cl126,8/3,15/99,0Ureum/CreatininSGOT/SGPTGDPBilirubin T/D/IPT/APTT16,0/47,0Protein T/A/GCK/CK-MBCa/MgFibD-dimer/FibrinogenAlbuminKulturLaktatCD3 (%/absolut)/CD4 (%/absolut)INRLEDPCTPx Penunjang lainCxrEchoCtscan thoraxMRIanalisa cairan asitesHbA1c/Beta hidroksi butirat (Keton)KulturCT Scan KepalaUSGMASALAH

TERAPISildemafil 3x12,5 mgCaptopril 2x12,5 mgRanitidine 2x150 mgCefixime 3x100 mgKalne tab 3 x 500 mgAsam mefenamat (kp)

IDENTITASMP/L/44thnDIAGNOSAPenurunan Kesadaran ec CVD SH + Status EpileptikusDPJPdr. Iddo Posangi, Sp.AncoassYurike, RintoHARI PERAWATAN18 Februari 2015 (Hari perawatan ke 2)

TANDA VITALTD Sistolik90-145TD Diastolik50 - 90N90-140S39,5-41,8P32-44SPO252-97%KesadaranE1V1M1

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,462/pCO2 31,5/pO2 140,8/BEecf -1,3/SO2 93,8%/Hb 15,4/Hct 46 PO2/FIO2 234,6

12/02/2015BALANS CAIRANCM2448CKUrine700Uo (cc/kg/jam)0.58Balans1,748Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM15&18/02/2015Hb/Hct/Leu/Tr14,2/43,2/11.800/360.000Na/K/Cl145,3/3,97/115,2Ureum/Creatinin84,5/2,31SGOT/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 03.40 : pasien meninggal, TD 100/70 N 90 Sp 52 %.

TERAPISucralfat 4 x Ceftriaxone 2x1grAsam Tranexamat 3x500 mgCiticoline 2x500 mgOMZ 3 x 1Paracetamol drips 3x1mg

IDENTITASPD/P/68thnDIAGNOSAContucio Paru + Episema Subkutis Regio HematotoraksDPJPdr. Iddo Posangi, Sp.AncoassYurike, RintoHARI PERAWATAN18 Februari 2015

TANDA VITALTD Sistolik140-180TD Diastolik70 - 90N80-100S37-38P18-24SPO297-99%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,458/pCO2 32,8/pO2 106,7/BEecf -0,6/SO2 95,4%/Hb 5,7Hct 17 PO2/FIO2 296,4

12/02/2015BALANS CAIRANCM1650CKUrine1550Uo (cc/kg/jam)1.3Balans100Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM14&18/02/2015Hb/Hct/Leu/Tr10,4/30,8/23.900/203.000Na/K/Cl121,3/3,77/107,8Ureum/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

TERAPISucralfat 4 x Ceftriaxone 2x1grAsam Tranexamat 3x500 mgCiticoline 2x500 mgOMZ 3 x 1Paracetamol drips 3x1mg

IDENTITASEG/P/61thnDIAGNOSAPost HTSOB ec Torsi Kista Ovarium Dextra DPJPdr. Iddo Posangi, Sp.AncoassYurike, RintoHARI PERAWATAN18 Februari 2015

TANDA VITALTD Sistolik100-150TD Diastolik70 - 90N64-80S36,4-37,8P14-22SPO297-100%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH /pCO2 /pO2 /BEecf /SO2 /Hb Hct PO2/FIO2

12/02/2015BALANS CAIRANCM1000CKUrine550Uo (cc/kg/jam)0.45Balans-450Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/18/15Hb/Hct/Leu/TrNa/K/Cl121,3/3,77/107,8Ureum/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

TERAPIMetronidazol 2x0,5 gr Ceftriaxone 2x1grAsam Tranexamat 3x500 mgKetorolax 3x1 ampRanitidin 2x1 amp

IDENTITASPJ/P/42thnDIAGNOSAPost HTSOB ec Kista Ovarium DPJPdr. Iddo Posangi, Sp.AncoassYurike, RintoHARI PERAWATAN18 Februari 2015

TANDA VITALTD Sistolik140-200TD Diastolik60 - 100N70-80S36-36,4P16-22SPO298-100%KesadaranE4V5M6

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,458/pCO2 32,8/pO2 106,7/BEecf -0,6/SO2 95,4%/Hb 5,7Hct 17 PO2/FIO2 296,4

12/02/2015BALANS CAIRANCM1400CKUrine3700Uo (cc/kg/jam)3.08Balans-2300Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/18/15Hb/Hct/Leu/Tr13,5/38,5/19500/230000Na/K/Cl121,3/3,77/107,8Ureum/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

TERAPIMetronidazol 2x500 mg Ceftriaxone 3x1grVit C 3x100 mgKalnex 3x500 mgKaktrofen supp 1x1 ampTramadol

Bed 5IDENTITASEL/L/27 thnDIAGNOSAStatus epileptikusDPJPdr. Lucky Kumaat, Sp.AncoassBilly, RintoHARI PERAWATAN16 Februari 2015 (Hari Perawatan 2)

TANDA VITALTD Sistolik125-140TD Diastolik75-95N83-95S36,4-37,5P16-26SPO299%KesadaranE4V3M4

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH 7,465/pO2 81/HCO3 28,3 /Po2tc139/SO2 95,4/Hb 13,2/Hct 40/pHtc7,465PO2/FIO2 202,4

08/02/2015BALANS CAIRANCM1950CKUrine1550Uo (cc/kg/jam) cc/kg/jamBalans400Balans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/16/15Hb/Hct/Leu/TrNa/K/Cl133,2/3,33/103,6Ureum/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

TERAPIAs. Folat 2x1 tabICSR 2x1 tabDepakole 2x1 tabCefadroxil 3x1Fenitoin 3x 100 mgDiazepam 1 amp k/p

bed 6IDENTITASJL/L/44ThnDIAGNOSAcontusio cerebri + hemiparese (s) + S4H + ICH DPJPdr. Lucky Kumaat. Sp.AncoassRoy , YusniaHARI PERAWATAN16 Februari 2015 (hari perawatan ke 0)

TANDA VITALTD Sistolik105- 162TD Diastolik73 - 92N110 - 133S38 - 39.8 P18-48SPO293- 100%KesadaranE1V1M4

MataKonj. Anemis -/- Sklera ikterik -/-JantungSI-II n regular, bising -, murmur - ParuSp. Vesikuler, Rh-/-, Wh-/-AbdomenI : datar, A : BU(+), Pal: lemasVENTILASIMOVAGDpH7,520/pCO2 37,1/pO2 76,9 /HCO3 30,5/BEecf 7,5/SO2 94,9/Hb 9,4/Hct 28 PO2/FIO2 712,7

27/01/2015BALANS CAIRANCMCK UrineUo (cc/kg/jam)BalansBalans kumulatifPEMERIK. PENUNJANGLABORATORIUM2/16/15Hb/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

TERAPI