N Identitas Tanggal Ruanga Diagnosis Tanggal Rencana Lab

o Masuk n Operasi
1 Reza Angga 04/06/201 ULB Flame Burn injury Debridemen Evaluasi STSG 25/6/2019
Lk/ 21 tahun 9 Bed 1 mid dermal to deep t (25/06/2019) PCT 53,96
78.11.17 dermal TBSA 18% 06/06/2019 Diet TKTP 4 butir
+ post STSG o/t telur + 2 gelas susu 21/6/2019
DPJP: dr. (L) arm Fisioterapi + ROM
Hb/Ht/Leu/Plt: 10,1/30/20340/196.000
Utama Abdi exercise
Tarigan,Sp.BP Oral hygiene Albumin: 2,3
-RE Cek ulang BUN/Ur/Cr: 13/28/0,5
procalcitonin Na/K/Cl: 132/3,8/100

18/06/2019
Hb/Ht/Leu/Plt:
12,1/36/20.370/318.000
Albumin: 2,7
BUN/Ur/Cr: 10/21/0,68
Na/K/Cl: 132/4,4/97

14/06/2019
Hb/Ht/Leu//Plt:
12,9/38/18.150/425.000
Albumin: 2,5
Na/Ka/Cl: 130/4,2/96
07/06/2019
Hb/Ht/leu/Trom:
13,8/41/7.730/312.000
Albumin: 3,0
PT Pasien/kontrol/INR:18,6/14,9/1,27
APTT Pasien/kontrol: 47,5/33,2
 KGDS: 101
BUN/Ur/Cr: 13/28/0,59
Na/K/Cl: 133/3,9/95
2 Jainudin 29/05/201 ULB Electrical Burn Debridemen Evaluasi STSG ke- 18/06/2019
Sembiring 9 Bed 2 40% t 2 (25/06/2019) Hb/Ht/Leu/Plt: 9,4/28/11.110/421000
L/ 24 tahun 04/06/2019 ROM exercise Albumin: 2,6
78.08.60 Oral hygiene Na/K/Cl: 133/3,8/96
KGDS: 162

14/06/2019
Hb/Ht/Leu/Plt:
10,1/29/12.080/299.000
Albumin 2,9
GDS: 101
Ur/Cr: 21/0,57
Na/K/Cl: 135/3,7/99
11/06/2019
Hb/Ht/Leu/Tromb:
9.7/27/18.840/190.000
Albumin: 2,3
KGDS: 146
Na/K/Cl: 133/3,3/99
3. R.A. Linarsih Pavi lt5 Ulkus decubitus Rawat luka per 2 22/06/2019
Pr/ 83 thn 1.5-12 grade + DM tipe 2 hari KGDS/2PP: 110/113
78.24.62 Fisioterapi Albumin: 2.3
ROM exercise
21/06/2019
Hb/Ht/Leu/Plt: 10,5/32/7860/228000
KGDS: 159
 BUN/Ur/Cr: 37/79/0,69
Na/K/Cl: 127/3,8/98
4. Lamenta 19/06/201 RA2 Ulkus decubitus Gv lakset + 19/06/2019
Menda 9 3.3.2 grade II – III o/t duoderm 2-3 hari Hb/Ht/Leu/Plt: 8,9/27/9.970/320.000
Ginting sacrum PT/INR: 13,9(14)/1,01
62 thn/ Pr aPTT/TT: 31,7(32)/18,4(17,5)
77.85.98 Fibrinogen/D-dimer: 399/2.645
Albumin: 1,9
KGDS: 104
BUN/Ur/Cr: 7/15/0,48
Na/K/Cl: 129/2,6/100
5. Jason 19/06/201 RB2B post ORIF 19/06/2019
Pebruanto L 9 3.7.5 Mandibula Hb/Ht/Leu/Plt: 16.9/50/.7.290/215.000
Lk/24 tahun PT pasien/control/INR: 15.2/14/1.11
754589 APTT pasien/control: 31.7/32
TT pasien/control: 17.4/17.5
KGDS: 80
BUN/Ur/Cr: 9/19/0.81
Na/K/Cl: 136/4.2/102

6. Sugiat 10/06/201 RB2B Post debridement Debridemen 23/06/2019

Panggabean 9 2.5.1 d/t electrical burn t Hb/Ht/Leu/Plt: 11,1/34/9.210/367.000
Lk/ 28 Th injury 38% 08/06/2019 Albumin: 3,1
77.92.85 Na/K/Cl: 129/4,2/100
Debridemen
t 21/05/2019
24/06/2019 pH/pCO2/pO2/HCO3/TCO2/BE/SaO
2: 7,48/29/176/21,6/22,5/-1,3/100

17/06/2019
Hb/Ht/Leu/Plt:
11,4/34/12.180/211.000
PT/INR: 15,1(13,9)/1,04
aPTT: 28,5/31,9
Albumin: 2,4
BUN/Ur/Cr: 4/9/0,4
KGDS: 123
Na/K/Cl: 125/3,9/93

13/06/2019
Na/K/Cl: 129/3,4/95
12/06/2019:
Na/K/Cl: 129/3,4/95
12/06/2019:
Na/K/Cl: 124/3.3/92

11/06/2019
Hb/Ht/Leu/Plt: 9.5/29/5.18/135.000
PT pasien/control/INR: 15.2/14/1.08
APTT pasien/control: 32.9/32.8
TTpasien/control: 12.4/16.5
Albumin: 2.2
KGDS: 133
BUN/Ur/Cr: 9/0.42:
Na/K/Cl: 123/2.4/92
pH/pCO2/pO2/HCO3/TCO2/BE/SaO
2:
7.43/38/83/25.2/6.4/1/96
PCT: 3.65

29/05/2019
Hb/Ht/Leu/Tromb:
11/32/19.000/413.000
 Albumin: 2,4
Na/K/Cl: 130/4,3/9
7. Ridan Tarigan 11/06/201 RB2B SCC penis post Wide 14/06/2019
Lk/36thn 9 3.7.1 Wide excision Hb/Ht/Leu/Plt: 11.4/34/7.090/413.000
778951 Eksisi+STSG+loca 12/06/2019 Albumin: 2.6
l flap+Permanent KGDS: 94
oystostomi BUN/Ur/Cr: 10/21/0.49
Na/K/Cl:136/5.2/103

14/06/2019
Hb/Ht/Leu/Plt: 11,7/35/8540/211.000
Albumin: 2,4
KGDS: 134
BUN/Ur/Cr: 3/6/0.56
Na/K/Cl:132/3.2/103
Procalcitonin: 0.55

12/06/2019
Hb/Ht/Leu/Plt: 12.2/37/10660/286.000
Albumin: 2.8
KGDS: 74
BUN/Ur/Cr: 7/15/0.55
Na/K/Cl: 136/3.3/105
8. Jalinuddin 11/05/201 RB2B Ulkus decubitus Necrotomi+perawata 11/06/2019
Lk/53thn 9 3.8.4 o/t sacrum n luka Hb/Ht/Leu/Plt: 8.6/27/17630/538.000
781540 PT pasien/control/INR: 15.7/14/1.13
APTT pasien/control: 32.6/32.8
Albumin: 2.4
KGDS: 157
BUN/Ur/Cr: 12/260/62
Na/K/Cl: 126/4.5/98
9. Muhammad 17/06/201 RB2B Ulkus Dekubitus 23/06/2019
Arman 9 3.7.3 o/t Sacrum grade 1 Hb/Ht/Leu/Plt: 9.6/27/36.180/25.000
L/25 thn Ferritin/Besi/TIBC: > 200.000/12/48
78.19.55 KGDS: 43

23/06/2019
Hb/Ht/Leu/Plt: 9.3/28/38.630/31.000
Albumin: 1.5
KGDS: 40
BUN/Ur/Cr: 19/41/0.43
Na/K/Cl: 131/2/103
22/06/2019
Hb/Ht/Leu/Plt: 11,1/32/38.060/23.000
PT/INR: 24,6(13,80)/1,75

19/06/2019
LDH: 224
AFP: 0,61
Beta-HCG darah:683,06

17/06/2019
Hb/Ht/Leu/Plt: 5,1/17/63.620/72.000
PT/INR: 58,1(13,9)/4,66
aPTT: 77,7/31,9
pH/pCO2/pO2/HCO3/TCO2/BE/SpO2:
7,39/24/131/14,5/15,2/-8,7/99,0
Albumin: 1,0
KGDS: 79
BUN/Ur/Cr: 24/51/0,6
Na/K/Cl: 120/4,9/90
PCT: 87,52
HBsAg : -
 antiHCV: -
anti HIV
10 Nopati Lase 23/06/201 RB2B Bilateral ear Debridemen 23/06/2019
. 28 thn/ L 9 3.10.1 avulsion post t + Hb/Ht/Leu/Plt:
78.25.30 debridement Rekontruksi 15.1/45/24.310/201.000
daun telinga PT pasien/control/INR: 17.2/14/1.25
DPJP: dr.Arya + Primary APTT pasien/control: 34.7/32.5
Tjipta, SpBP- suture TT pasien/control: 15.5./17.5
RE (23/06/2019 KGDS: 100
) BUN/Ur/Cr: 10/21/0.73
Na/K/Cl: 138/3.3/105
11 Wahyu Satria 25/06/201 RB2B Post orif maxilla 26/06/2019 17/06/2019
. Harahap 9 1.4.2 dan mandibulla Rekontruksi Hb/Ht/Leu/Plt: 13.3/42/8.540/345.000
Lk/25 thn dan aff
implant
PT: 13.3(13.9)
738673 APTT: 26,4/31.9
DPJP:Dr.
TT: 12.7(18.2)
Frank Birtra
Buchari, Sp. INR: 0,96
BP-RE GDS: 92
BUN/Ur/Cr: 8/17/0,92
Na/K/Cl: 138/4,6/104

12 Yama Egalit 23/06/201 RB2B Open skin Debridemen Perawatan luka 23/06/2019
. Ginting 9 3.10.3 degloving cruris t + Primary post op Hb/Ht/Leu/Plt:
27 thn/ L (R) +post suture 13,5/39/29.090/275.000
78.25.29 debridement + (23/06/2019 PT/INR: 19,2(14,0)/1,4
marginal eksisi ) aPTT: 25/32,5
DPJP: dr.Arya pH/pCO2/pO2/HCO3/TCO2/BE/SpO
Tjipta, SpBP- 2: 7,38/24,0/189,0/14,2/14,9/9,5/100
 RE Albumin: 3,7
BUN/Ur/Cr: 9/19/0,85
Na/K/Cl: 136/3,9/106
KGDS: 126
13 Rifky Aditya 18/06/201 RB3 Open (R) proximal Perawatan luka 23/06/2019
. Lk/17 tahun 9 3.6.3 phalanx 2nd 3rd 4th Terapi sesuai RM 8.1 Hb/Ht/Leu/Trom :
78.20.91 sinistra S1 joint Pro assesment
11.7/34/7.430/235.000
widening crush
DPJP: injury (R) foot+
Orthopedi open degolving o/t
dorsal pedis
dextra+ post h-2
debridement + orif
(k-wire) digiti
2,3,4,5
14 Riski Pramana 22/06/201 RB3 Traumatic Perawatan luka 22/06/2019:
Tampubolon 9 3.4.1 amputation 4th 5th Terapi sesuai RM 8.1 Hb/Ht/Leu/Plt:
metatarsal open 14.2/41/14.850/197.000
fraktur proximal PT pasien/control/INR: 15.3/13,8/1.05
phalanx 3rd digiti APTT pasien/control: 27.7/32.0
cuboid fr (l) foot BUN/Ur/Cr: 10/21/0,857
+post Na/K/Cl: 134/4,3/102
derbridement GDS: 154
23/06/2019:
Hb/Ht/Leu/Plt:
11.8/34/9.420/293.000

15 Dedek 03/06/201 RB1 Gangrene vulva + Perawatan luka 22/06/2019

. Marianti 9 3.6.2 Cellulitis + DM dengan duoderm Hb/Ht/Leu/Plt: 8.7/25/19.160/427.000
Pr/41 thn tipe II Antibiotik sesuai
kultur
BUN/Ur/Cr: 21/45/0.98
781055 Na/K/Cl: 121/2.8/99
KGDS: 487

20/06/2019
KGD puasa: 92
KGD2pp: 54
HbA1c: 10,6
Kolesterol total : 123
Trigliserida/HDL : 171/17

19/06/2019
Hb/Ht/Leu/Plt: 9,1/26/16.430/804.000
pH/pCO2/pO2/HCO3/TCO2/BE/SpO2:
7,3/17/190/9,2/9,7/-14,2/100%
Albumin: 2,1
BUN/Ur/Cr: 5/11/0,42
Na/K/Cl: 129/2,4/106
PT/INR: 16,5(14,0)/1,14
aPTT/TT: 30,5(32)/15,5(17,5)
KGDS: 51

18/06/2019
PT: 15,2(14)
APTT: 29,4/32
INR: 1,1
pH/pCO2/pO2/HCO3/TCp2/BE/SaO2
: 7,4/14/172/8,7/9,1/-13,3/100
Albumin: 2,1
KGDS: 96
BUN/Ur/Cr: 8/17/0,48
Na/K/Cl: 127/2,8/95

17/06/2019
GDS: 152

13/06/2019
GDS: 448

12/06/2019
Hb/Ht/Leu/Plt:
10.6/30/23.650/884.000
KGDS: 332

10/06/2019
KGD puasa: 230
Kolestrol total: 117
Trigliserida: 159
Kolestrol HDL: 19
Kolestrol LDL: 71
07/06/2019
Hb/Ht/Leu/Plt: 6,6/19/25.490/758.000