Senin, 3 Juni 2019

PJT Lantai 6 (Wisnumurti)

Ruang Nama Usia DPJP Diagnosis Tanggal Masuk PH

613

614

Edi Darsono 01.89.20.68 50 dr. MTI/ STEMI inferior posterior onset 2,5 jam Killip I TR 1/14 GS 86 post successful fibrinolisis, 02/06/2019 2+1
Hipertensi Stage I

615
STEMI anterior ekstensif posterior Killip I TR 3/14 GS 95 post successful trombolisis,
Sapta Anggara 01.89.18.41 36 dr. PRG/ normokoroner, Hipoalbuminemia (Alb 2,55), CKD st V (Cr 5,68->8,38->5,47->6,67) ec obstruktif 31/05/2019 1+3
uropati dengan anemia renal (Hb 8,1->9,0->10,7), ISK, Obs Hematuria

616

UAP Subtype Angina First Onset TR3/7 GS 159, Riwayat ADHF Forester II (HT Emergency dan
Desaturasi), CHF CF II ec DA Kardiomegali DE HHD, Paroxysmal AF, AKI dd Akut on CRF (Cr 2,12-
Dalinem 01.89.19.00 77 dr. HPB/Lambang 30/05/2019 4
>1,53), CAP CURB 65, Problem : Leukositosis membaik(AL 25,85->13,25), Hipoalbumin (Alb 2,21-
617 >2,05), Gout Arthritis akut (AU 8,0)

618 Definite IE, CHF CF II ec DA : MR severe DE : VHD, problem : Anemia membaik (Hb 6,6 -> 9,3 ->
Pariyem 01.88.90.84 53 dr VYA/Agi 11,7 -> 11,5), Trombositopenia membaik (AT 94 -> 148 -> 160 -> 144), Hipoalbuminemia (Alb 20/05/2019 14
2,47 -> 2,83 -> 2,8), Hiponatremia membaik (Na 123 -> 137 -> 135), AKI dd Acute on CRF (Cr
1,12 -> 1,57 -> 1,36 -> 1,29 -> 1,4) Hipokalemia (2,97)

CAD2VD PPCI 1 DES di RCA dan 1 DES di LCX a/i, STEMI inferior onset 12 jam Killip IV TR 8/14 GS
Suyadi 01.89.16.31 58 dr. HPB/ 178, TAVB -> AV block grade I, DM2NO, CAP membaik, AKI membaik (2,58->0,99->0,87) 01/06/2019 4+2

620 CAD1VD early PCI 2 DES di LAD (overlapped) a/i UAP subtipe angina progresif (intermediate
Tinggal S 01.89.19.30 53 dr. FH/ risk), DM2NO, HHD, HT St I, CKD ec nefropathy DM dengan pemberatan CIN pro HD inisiasi (Cr 01/06/2019 1+2
4,89->4,63->5,68), Hipoalbuminemia (2,47->2,73), hiponatremia (128)

CHF CF III ec DA Dilatasi Semua Ruang Jantung, RWMA, MR Mod-Severe, TR Moderate DE IHD,
Post PPM VVIR ai AF-TAVB ec Degeneratif, DM Tipe II Obese, HT Stage I on Terapi, AKI dd Akut
Sumarni 01.89.04.43 72 dr. HPB/Abi on CRF (Cr 2,00-> 1,65), Dyspepsia tipe mixed dd Related Retraksi Kapsular Hepar, Hipokalemia 30/05/2019 1+4
(3,05)

CHF CF III ec DA RA RV LV Dilatasi, PR Moderate, TR Severe, AR Moderate, LV thrombus dd

Dissecting Intra Myocard Hematom DE : Susp DCM, Bifasicular block (LAFB, RBBB), PPOK dgn
infeksi sekunder, ISK, Susp. Cardiac Cirrhosis, Perdarahan saluran cerna bagian atas ec non
variceal dd variceal, Hiponatremia hipoosmolar membaik, Problem : Hipoalbuminemia (Alb2,75
Wasiyem 01.89.07.54 75 Prof. BYS/Abi -> 2,62 ->2,45), Pemanjangan diastase perdarahan (INR 1,48 -> 1,29 ->1,55), Hiperbilirubinemia 19/05/2019 16
(Bil. D 5,36 -> 4,67 ->5,0 Bil.T 7,73 -> 5,57 -> 6,89 -> 5,17 -> 6,35), Trombositopenia ec susp.
related cardiac sirosis membaik (AT 112 -> 130 ->108), Riw. Hipoglikemia teratasi, AKI dd acute
622 on CRF (0,68->1,21), Hiperkalemia (5,27)

Sri Tamtini 01.61.13.57
Syok Septik membaik, Post Amputasi above knee Sinistra H8 a/i Phlegmasia Cerulean Dolens
pada Trombus total di Osteal V. iliaca communis sinistra failed PTA, DVT V.Femoralis et popliteal
Bilateral. Ca cervix residif post chemotherapy dan brachytherapy, AKI dd Acute on CRF (Cr 4,99
54 dr. HPB/Falah -> 4,17 -> 2,59 -> 1,21), HAP, Post nefrostomy a/i Hidronefrosis Sinistra Grade 4, Nefrolithiasis 20/05/2019 13
Sinistra , Problem: Anemia membaik (Hb 6,6 -> 9,5 -> 9,9-> 10,1), Leukositosis membaik (AL
22,98 -> 24,88->20,68), Trombositopenia teratasi, Hipoalbuminemia (Alb 2,76 -> 1,98->2,98),
Hiponatremia membaik, Hiperkalemia teratasi

PJT Lantai 7 (Kesawamurti)

Post MVR mekanik a/i MS Severe ec RHD H7, CHF CF II ec DA MS Severe, MR Moderate, TR
Ardita Kusuma 01.88.05.70 46 Prof. BYS/ 02/06/2019 3+2+1
715 Severe DE RHD, AFNVR, AR moderate, DMT2, Normokoroner

Subtotal stenosis pada V. subclavia dan cephalica sinistra post successfull PTA a/i Edema
716 Giyarto Sudarmo/Tumiyah unilateral sinistra ec related stenosis v.subclavia sinistra dd limfadenopaty, CKD st V on HD rutin,
01.81.53.82 70 dr. MTI/Monika HT, DM, Problem: anemia renal (Hb 9,5), hipoalbuminemia (Alb 2,97), hipokalemia (K 3,29 -> 27/05/2019 7
2,73 -> 2,99), SNH

717 Post ASD closure + de vega H10 a/i ASD sekundum HFHR non reactive O2 test, TR severe, PH,
Ria Astuti 00.68.40.13 58 dr. LKD/ efusi perikard mild, AFNVR, DM2O, HT 02/06/2019 2+8+1

718 NSTEMI Killip I TR 2/7 GS 115, Status asmatikus dengan infeksi sekunder membaik, Gagal
Sujudi 01.89.18.71 63 dr. FH/ napas tipe 2 membaik, Sepsis membaik, Asidosis respiratorik membaik, Hipertensi stage II, 02/06/2019 1+1
DM2NO, AKI

719

720
Senin, 3 Juni 2019
Anggrek, Unit Stroke, Bougenville, Cendana, Dahlia, IMC2
A1
A2

Somnolen cum lateralisasi dextra cum parese N VII & XII ec stroke recurrent, CKD stage V on HD
VIP Sariman 36 Neuro/dr. EM rutin, DM2NO, CAD2VD PPCI 1 DES di LAD ai STEMI anterior (Januari 2019), OMI anterior, CHF cf 31/05/2019
II ec DA LVH Eksentrik, RWMA, DE IHD, HT terkontrol, Paroxysmal AF
US
ICH onset H6, CKD st V on HD rutin, DM2O, CHF ec HHD, HT emergensi dengan target organ
VIP Clara Titik Winarno 56 Neuro/dr. EM 31/05/2019
cerebral

2 Hiszkia 64 Neuro/dr. EM Hemiparese sinistra cum PN VII et XII (S) UMN ec Susp recurrent stroke (SNH & SH), HHD 02/06/2019

Neuro Somnolen cum communication disturbance acute onset cum lateralisasi (D) ec SH onset hari-19,
Restoras 1 Ahmad M 80 Neuro/dr. EM HHD, AFNVR, hipokalemia (K 2,57->2,3->2,6->2,43->2,9->3,34), AKI dd acute on CRF (Cr 1,4- 15/05/2019
i >1,3), hipomagnesemia (Mg 1,6), hipoalbuminemia (Alb 3,27)
B1
B2
B3
B4
B5
C1
8 Rodiah 69 Bedah/dr. FH Obstruksi parsial ec suspect malignancy dd adhesi usus, HT Stage II, HHD 30/05/2019
Pathological burst fracture VC VII post laminectomy, Ca ductal mammae S post ACCF H-8, HAP,
8 Wasirem 60 Bedah/dr. FH HHD 31/05/2019
C2
9 Agus Saputra 42 B. Digesti/dr. FH Post laparoskopi a/I Massa VU susp malignancy, Ascites related malignancy, AKI dd acute in CRF 28/05/2019
(Cr 2,73), Nefrolithiasis Dekstra, Stress Ulcer, thrombus katub v.iliaca bilateral, High Prob of PE

Post op VP shunt a/i hidrosefalus obstruktif ec meningioma H5, hipoalbuminemia (2,78) Operasi
C3 8 Dasiyem 64 B. Saraf/dr. FH fraktur femur dekstra (Des 18) 25/05/2019
C4
Close pathological fracture of the left femoral neck , ca mammae st IV on kemoterapi, metastase
C5 2 Dwi Purwanti 39 B. Orthopedi/dr. FH paru, VPC frequent RVOT type, HT 27/05/2019

Multiple Myeloma, Paraplegi ec fraktur kompresi vertebra post stabilisasi, Infeksi Saluran Kemih
2 Sutinarsih 52 UPD/dr. HM Komplikata, Erupsi makulopapuler ec suspect drug induced,Ulkus Decubitus grade III, HHD, APB 29/05/2019
freuquent ec related imbalance elektrolit, Problem : hiponatremia hipoosmolar euvolemik berat
(Na 112->114->116->126), hipokalemia (K 5,44->5,0->5,0->4,01->3,09)

Anemia et HiperLeukositosis ec Keganasan hematologi, Efusi Pleura Dekstra Masif on WSD ec

8 Paridi 74 UPD/dr. HM Suspect Malignancy dd Infeksi, CAP CURB 65-2, AKI dd Akut on CRF (Cr 1,42), VES Infrequent ec 30/05/2019
D1 Related Elevated Sympathetic Tone, Problem : Hipoalbuminemia (Alb 2,66)
 D1

Acute Confusional State, AKI dd Akut on CRF, Suspect CAP CR III, CHF CF II ec DA Kardiomegali
9 Paikem 75 UPD/dr. HM DE IHD, Riwayat NSTEMI (Agustus 2014) tanpa revaskularisasi, Problem : Anemia N-N ec Related 30/05/2019
Chronic Disease (Hb 9,2->10,2), Hiperkalemia (K 6,18->5,20->6,2)

CKD stage V, DM2 obese on therapy, CHF cf II ec DA: LVH konsentrik, DE: HHD, Hipertensi on
3 Titi Urian 65 UPD/dr. HM terapi, ISK 01/06/2019

Susp. IADP, CKD stg V on HD rutin, CHF cf II (HFpEF) ec DA LA LV Dilatasi, AR moderate DE HHD,
10 Ngatiyem/Gito K 71 UPD/dr. HM HT terkontrol, Ulkus regio mamae S 31/05/2019
D2
CLL dengan problem Anemia mikrositik hipokromik (Hb 6,4->7,7->6,0), Trombositopenia (AT 95-
8 Fadhil Mustafa 62 UPD/dr. HM >79->63->93), HFpEF, CAP 24/05/2019
D3
Muscle weekness ec Hipocalsemia (1,38->1,79->1,76), hipotiroid, hipoparatiroid sekunder,
10 Innette Risna 45 UPD/dr. VYA hipokalemia membaik, Prolonged QTc ec related hipocalcemia 31/05/2019

Sepsis, HAP, Hiponatremia membaik, AKI dd acute on CRF (1,22->1,59), Hipokalemia (2,17-
2 Sarmiyati 70 UPD/dr. VYA >2,32), HHD, Anemia normo-normo (Hb 9,9) ec OCD, Post stroke, Riw perdarahan saluran cerna 31/05/2019
D4 ec ulkus antrum, APB

Bisitopenia (Anemia dan thrombositopenia ec leukostasis related hematologic malignancy (AML

12 Matoyah 55 UPD/dr. VYA dengan Blast 82%) dengan problem gum bleeding, Bilateral pleural effusion, Problem : Anemia 27/05/2019
microcytic hypochromic (Hb 8,1->7,8), High Output state

D6
IMC2
IMP, ICU, M5, Yudistira 2,BU, PACU, Teratai
IMP
ARDS ec HAP dd pneumonitis lupus, asidosis metabolik, Sepsis, SLE serangan berat dengan
manifestasi anemia hemolitik, leukopenia, serositis dan nefritisCHF CF III ec DA MR severe DE
A Aidha Astri 19 Anest/dr. FH RHD, AKI dd Acute on CRF (Cr 1,68), Hipoalbuminemia (Alb 1,91-> 2,08->2,72), Pansitopenia (Hb 27/05/2019
7,2 -> 6,2 -> 5,2->9,1, AL 3,37 -> 3,75 -> 23,12->19,62, AT 80 -> 64 -> 121->81), hiperkalemia
(5,16)

ICU Post Amputatum Above Knee Ekstremitas Inferior Dextra ai ALI Rutherford III Ekstremitas
A Sudi Arjo 82 Anest/dr. FH Inferior Dekstra, AFRVR, CP Decompensata, Afasia Global cum Lateralisasi Dekstra Sub Akut non 30/05/2019
Progresif ec Suspect post SNH dd SH, Hipoalbuminemia berat (Alb 1,96->2,46->2,18),
Hipoglikemia, TB Paru Rontgen (+) dengan Infeksi Sekunder, PPOK
Sepsis ec CAP, Post VBAC pada P4A0 H10, Riwayat SC 3 tahun yll, PEB, CKD St V on HD rutin ec
B Riska Setyowati 31 Anest/dr. FH Stenosis Ureter Bilateral post DJ Stent dengan HN grade III-IV bilateral, HHD, Efusi pleura 21/05/2019
dekstra related CKD
M5
Mid dermal burn injury 28,5% ec listrik, Full thickness burn injury 0,5% ec listrik, Edema cerebri,
ISO-1 Acmad Macruf 46 B.Plastik/dr.DAK parasystole, hipoalbuminemia (2,76->3,08), hipomagnesemia (1,54->1,7), hipocalcemia (1,93- 28/05/2019
>2,08)
BU
Mid dermal burn injury 17.5% ec listrik, Deep dermal burn injury 12.5% ec listrik, Sindroma
A Dwi Susanto 26 B.Plastik/dr.DAK 25/05/2019
kompartemen regio antebrachii dan manus bilateral, early repolarization pattern, HT

PACU
Teratai