Koran Diges 02 Feb

KORAN BEDAH DIGESTIF SABTU, 2 FEBRUARI 2013

NO. IDENTITAS DIAGNOSIS PEMERIKSAAN PENUNJANG Ket/PJLONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 1

1. Debora Lisu’ Bua P/61thn/589557MRS 17/1/2013

BED 1

Aff infuse

Pondok asri 3 sudinag08321642992

D/ Susp. perforasi gaster

Boleh pulang

Foto Thorax AP 21/1/2013Susp. Hernia diafragmatika dextra ( Morgagni )Dilatatio aortae

CT Scan Abdomen 18/1/2013Hernia diafragmatika kanan berisi usus halus

Lab 18/1/2013RBC 4,02 HGB 11,01 HCT 34,6 MCHC 31,9 WBC 7,6 Monosit 1,18

Lab 17/1/2013WBC 11,2 RBC 3,17 HB 8,4 MCHC 31,5 HCT 26,6 PLT 349 CT/BT 7’00/2’30 PT/APTT 11,1/23 GDS 106 UR/CR 32/0,6 GOT/GPT 46/28 PROT.TOT 7,4 ALB 2,7 HBSAG (+) Anti HCV (-)

FOTO BNO 17/1/2013Gambaran meteorismus

USG abdomen 17/1/2013Over distended gasterMeteorismus

2 Kadek RosmiatiP/22thn/588577MRS19/01/2013

BED 2

Desa Tinading Cab Toli-toli

085299287429

D/ POH 7 Laparotomy Explorasi + Jejunostomy ec tu. rectosigmoid+colon transversum

Lab 25/1/2013Na 128 K 4,0 Cl 97 GDS 86 Ur/Cr 22/0,4 GOT 79 GPT 49 Albumin 2,1

Lab 21/1/2013Na:139 K:4,4 Cl:105 AFP:1,04 CEA:38,87 Ca-125:75,08 Alkali fosfatase:71 LDH:367 Alb 3,0

PA 16/10/2012Adenocarsinoma Colon Musinosum

Lab 12/01/2013CT/BT 8’30’’/2’’ PT/APTT 13/21,7 GDS 84 UR/CR 20/0,6 GOT/GPT 25/18 Na 146 Cl 112 K 4,4 WBC 6,8 RBC 4,31 Hb 11,9 HCT 36,91 PLT 325

Thorax PA 14/01/2013Tidak tampak tanda-tanda metastasis pada foto thorax ini

CT – Scan Abd. Upper Tanpa kontras 15/01/2013- Tidak tampak densitas massa colon pada CT Scan Abdomen ini- Susp. Metastasis tumor ke hepar - Ascites- Cholelith

3 RahelP/46thn/549708MRS17/01/2013

BED 3

Rencana tutup colostomy tunggu jadwalpro tutup colostomy

Pampang 2 lorong 8082188269654

D/ Ca Recti 1/3 prox. Post Hartman procedurePro tutup colostomy

Rencana parade

Lab 29/1/2013OCA 3,01 GDS 109 Ur/Cr 25/0,6 GOT/GPT 26/29 Prot.total 7.0 Albumin 3,1 CT/BT 8’00/2’00 PT/INR 10,6/1,07 APTT 25,3 Na/K/Cl 141/3,2/104 WBC 3,48 RBC 3,73 Hb 10,0 HCT 29,1 PLT 198 MCHC 34,4 MCV 78,0 MCHC 26,8

PA : Adenocarsinoma recti

Lab 26/11/2012CT 2’00” BT 8’00” PT 12,1 APTT 22,0 GDS 94 UR/CR 18/0,6 GOT/GPT 30/29 ALB 4,1 NA 145 CL 108 K 3,8 WBC 2,4 RBC 3,48 HB 10,2 HCT 29,4 PLT 147 HbsAg (-) CEA 2,95

CT – Scan 26/11/2013Tu. Colon Ascendens, susp metastasis ke hepar

Lab 18/01/2013GDS 253 UR/CR 22/0,6 GOT/GPT 30/16 ALB 3,7 NA 139 CL 105 K 3,8 RBC 3,6 HB 10,1 HCT 28,8 PLT 122

CT – Scan Abd. Tanpa kontras 18/01/2013Defect dan penonjolan loop usus ke dinding anterior abdomen sisi kiri (post colostomy)

1


4 JuventinaP/42thn/588490 MRS 17/1/2013

Bed 4

Anj : aff cateter epiduralAff infus

Desa mekar sari, konawe085241641198

D/POH 4, colostomy ec. Tumor Colorectal

Jawaban Konsul Obgyn ( 23/1/2013) Suspek massa intraabdomen + Ascites pro evaluasiSaran : Periksa ulang pemeriksaan MSCT Abdomen + kontras , sitology cairan asites. Bila ada hasil dapat dikonsul ulang ke bagian obgyn divisi onkology

Lab 21/1/2013AFP 3,68 CEA 6,00 Ca-125 10,89 LDH 600

Colon In loop 21/1/2013Kesan : Massa daerah distal rectosigmoid

Thorax PA (18/01/13)Elevasi diafragma kananTidak tampak tanda tanda metastases pada foto thorax ini

USG Abdomen 18/01/13)Tanda tanda sirosis hepatis. Asitess

Lab17/1/2013WBC 8,59 RBC 4,76 HB 12,8 HCT 40,5 PLT 425 CT/BT 8’00/2’00 PT/APTT 11,3/25,5 GDS 88 UR/CR 33/1,1 GOT/GPT 21/10 ALB 3,5 HBsAg (-) Anti HCV (-) Lab 11/1/2013GDS 86 UR/CR 24/0,7 GOT/GPT 21/12 CT/BT 8’00’’/2’00 PT 10 APTT 19,6 INR 0,8 NA 147 K 3,4 Cl 109 RBC 4,61 HGB 12,9 HCT 39,71 WBC 6,9

Foto Thorax AP (Kurang Inspirasi) 11/1/2013 Tidak tampak kelainan radiologik pada thorax ini

USG Abdomen 11/1/2013-Sesuai gambaran massa rectum

CT Scan 11/1/2013Tidak ada Expertise

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR ISOLASI5 Elisabeth

P/ 60 thn /588823/ MRS 23-01-2013

Bed 1

Griya Alam PermaiNo.telp 082199963622

D/ susp. tumor caecum

Rencana endoskopi 1/2/2013

CT Scan Abdomen 10/01/2013Tumor caecum annular type denga nodul kelenjar limfe di sekitarnya

Colon in Loop (17/1/13)Tidak tampak kelainan radiologic kecuali Redundancy colon descendens

Foto Thorax (17/1/13)Elongatio et atherosclerosis aortae

Lab 17/01/13GDS 76 Ur 42 Cr 0,5 GOT 20 GPY 18 Alk.Fos 89 Prot.total 7,9 Albumin 3,6 PT 10,5/10,6 APTT 28,9 / 26,7 Na 140 K 4,5 Cl 103 CEA 0,767

Urin Rutin 17/1/13Warna kuning, pH 5 BJ 1,025 keton ++/50 sed.leukosit 1 sed.eritrosit 3 sed.epittel 6

RL

6 Nurhayati P/ thn/ 585290MRS 15/01/13

Bed 2

DSN IV Wasidongi SidrapNo.telp 081342249726

D/ Tu. Gaster

POH 1 Laparatomy explorasi (30/1/2013)

(HbsAg +)

LAB 29/1/2013GDS 94 Albumin 3,1 WBC 6,41 RBC 4,90 Hb 10,8 HCT 35,8 MCV 73,1 MCH/MCHC 22,0/30,2 PLT 361

Lab 23/1/2013GDS 85 UR/CR 19/0,4 Albumin 2,8 NA 141 K 3,7 Cl 111 CT 8” BT 3” PT 10,8 APTT23 INR 0,9 WBC 7,87 RBC 4,48 HB 10,5 HCT 33,7 PLT 342

Lab 19/01/13RBC 3,44 HGB 7,6 HCT 25,4 PLT 395 WBC 5,5

Echocardiography 03/01/13Kesan : normal echo

OMD 28/12/12Kesan : obstruksi parsial 1/3 distal duodenum pars descendens oleh massa extraluminer dengan kalsifikasi didalamnya

2


CT-abdomen upper (dengan kontras) 28/12/12Kesan : susp. Teratoma mesenterium, Tu. Metastasis ke hepar, Splenomegaly

USG abdomen 26/12/12Kesan : metastasis Tu. Ke hepar, Splenomegaly, Ascites

Lab 26/12/12WBC 7,6 RBC 3,96 HGB 8,5 HCT 27,1 PLT 424 CT/BT 8’00/3’00 PT/APTT 10,9/23 GDS 112 UR/CR 14/0,4 GOT/GPT 17/17 ALP 208 ALB 2,7 Na 142 K 4,4 Cl 109 HbsAg reaktif, Anti HCV non reaktif

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 27. Ayyu

L/23thn/581726MRS 10/1/13

Bed 1

Jl. Jambu P.Kemerdekaan 12No.telp 082191699120

D/ Tu. Recti 1/3 distal

Tunggu hasil PA tgl 1/2/13

PA 17/1/2013Sediaan jaringan tidak ada sel-sel maligna

Foto thorax (8/1/13)Tidak tampak kelanan radiologik pada foto thorax ini

Colon in loop (7/1/13)Foto polos abdomen :

- Udara usu terdistribusi sampai ke distal colon- Tidak tampak dilatasi loop-loop usus, herring bone

appearane dan air fluid level- Kedua psoas line intak- Kedua preperitoneal fat line tidak tervisualisasi- Tulang-tulang intak

Lopografi :- Kontras dimasukkan sebanyak 100 cc melalui stoma

menggunakan catheter yang mengarah ke distal lalu mengisi colon desendens, colon sigmoid, hingga ke rktum

- Tidak tampak filling defek maupun additional shadow- Kaliber lumen rektum sedikit menyempit, mucosa dan

haustra dalam batas normal- Mucosa, kaliber lumen dan haustra colon lainnya dalam

batas normal

Lab (4/1/13)WBC 7,93 RBC 4,95 HB 15 HCT 44,4 PLT 294 BT/CT 3’00/8’00 PT/APTT 10,0 23,5 INR ,83 Na/K/Cl 138/3,8/100 GDS 87 Ur/Cr 19/0,8 GOT/GPT 24/51 Alb 3,9 HbSAg (-) anti HCV(-)

IL

8 JampiL/47thn/590883MRS 26/01/13

Bed 2

Km 12 masuk kota SorongNo.telp 085254671943

Hematokhezia + hemoroid externa grad II.

Tunggu jadwal colon in loop

Colonoscopy 1/2/2013

Lab 28/01/13CT/BT 7/2 PT 11,3 INR 0,90 APTT 24,5 Alb 4,7 HbsAg (-)

Lab 26/01/13WBC 8,08 RBC 4,84 HB 14,1 HCT 42,6 PLT 267 CT/BT 9’00”/3’00” PT/APTT 13,1/24,8 GDS 101 Ur/Cr 13/0,8 GOT/GPT 24/29 Na/K/Cl 145/3,84/107

USG Abd 26/01/13Kesan: kista hepar & kista ginjal bilateral

9 Ansar dg.HasengL/47thn/582237 MRS 14/1/2013

Bed 3

Jl.Barawaju II Panakukkang MKSNo.telp 082347757174

D/ Massa duodenum + cholesistisis

Rencana parade

Lab 29/1/2013WBC 9,43 RBC 3,90 Hb 10,5 HCT 33,1 MCV 84,9 MCH/MCHC 26,9/31,7 PLT 803

Lab 25/01/2013CEA 0,638

Lab 24/01/2013Bil. Total: 0,17 Bil. Direk: 0,14

Lab 23/01/2013WBC:7,11 RBC:3,41 HGB: 9,5 HCT:29,2 PLT:335

Lab 21/1/2013WBC:6,77 RBC:2,1 HGB:6,1 HCT:19,0 PLT:142

3


Lab 18/1/2013WBC 18,67 RBC 1,63 HGB 4,1 PLT 267 CA 19-9 312,5 CT/BT 8’00’’/3’00’’ PT/APTT 17,9/39,1

Lab 14/1/2013WBC 8,05 RBC 3,81 HB 9,6 HCT 30,7 PLT 527 CL 98 NA 137 K 3,7 LDL 68 TG 66 AS.URAT 7,6 PT 15,4 APTT31,2 GDS 96 UR/CR 13/0,8 GOT/GPT 18/10 ALB 2,8 KOL.TOTAL 109 HDL 28

MSCT Whole Abdomen non kontras 13/12/2012Massa pada duodenum pars transversum Tanda-tanda colekthasis ringan

USG ABDOMEN 28/12/2012Massa duodenum Cholekth

Thorax AP 02/01/2013KP Duplex lama aktif

BNO dan Esofagus maag duodenum 02/01/13Massa duodenum

10 SalangL/35thn/572718MRS10/01/2013

Bed 4

Jl. Laupa SersangNo.telp 082190675320

D/ Achalasia Esofagus, hipokalemi

operasi hari kamis 31/1/2013

Lab 30/1/2013Na/K/Cl 148/2,5/108

Lab 29/1/2013Na/K/Cl 141/2,4/103

Lab 26/01/2013WBC 5,52 RBC: 3,75 HGB: 11,9 HCT: 36,0 PLT: 237 CT/BT: 9’00”/3’00” PT/APTT: 12,7/25,5 INR: 1,0

Lab 16/01/13WBC 10,06 RBC 3,53 HGB 11,2 HCT 32,1 PLT 309 CT/ BT 7’00/ 2’00 PT/ APTT 10,6/ 21,8 GOT/ GPT 37/ 26 GDS 32 Ur/ Cr 14/ 0,8 Alb 3,1 Prot. Total 7,4 Na/ K/ Cl 141/ 2,0/ 13

Lab 10/1/13CT/BT 8”00/3”00, PT/APTT 12.3/26.6, GDS 95, Ur/Cr 14/0.8, GOT/GPT 24/21, Alb 2.7, Na/K/Cl 138/1.9/98, WBC 10.1, RBC 3.22, Hb 10.2, HCT 31.7, PLT 335

Foto Thorax AP 10/1/2013Kesan: Double density sepanjang aorta ascendens dan batas kanan jantung sangat curiga merupakan densitas dari esophagus yang melebar

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 3

11 Hugo DonaldL/40th/582008/MRS 13/01/13

JAMKESMAS

Bed 1

Sillanan Gadang Batu, Toraja081355011213

D/ Tu Hepar Susp HCC

dd/ klatskin tumor

LAB 28/1/2013AFP 31,45

Foto Thorax 25/01/2013Tidak tampak tanda-tanda metastasis + dilatatio et elongatio aortae

MSCT Abdomen 25/01/2013Cholestatis intrahepatik susp. Klatskin tumorCholelith Distended colon

Lab 24/01/2013WBC:9,22 RBC:3,67 HGB:9,0 HCT:24,5 PLT:391 GDS:114 Ur:18 Cr:0,4 Bil.total:21,40 Bil.direk:19,22 GOT:96 GPT:93 Albumin:2,6

Lab 17/01/2013Na 124 K 4,2 Cl 90

Lab 14/01/2013WBC 9,88, RBC 3,82 HGB 11,1 PLT 430, HCT 30,7, PT/APTT

RL

4


10,7/29,0, CT/BT 8’00”/5’00”, GDS 99, Ur/Cr 23/0,6, GOT/GPT 65/133, Alb 3,1, Na/K/Cl 123/3,9/91 HbsAg (-)

Lab 11/12/12:AFP:28,49

CT Scan Abd 4/12/12:Kesan: Massa terutama pada lobus kiri hepar(Hepatoma)

MSCT Whole Abdomen dengan kontras 11/12/12Kesan: Sesuai gambar hepatoma

USG Abdomen 4/12/12Kesan: Massa pada lobus kiri hepar susp abscess dd/HepatomaThorax 4/12/12Kesan Pulmo normal, elongation aorta

12 BasriL/40thn/582034MRS20/12/2012

JAMKESMASBED 2

Rampunan, Enrekang085399364967

D/ POH XVII Mile’s Procedure ec. Ca Recti

Lab (15/01/2013)RBC 4,63 HGB 9,1 HCT 30,4 PLT 217 WBC 19,4 GDS 149 Ur 37 Cr 1,0 GOT/GPT 22/14 Alb 2,6

Lab 13/01/2013RBC 4.63 HGB 9.1 HCT 30.4 PLT 217 WBC 19.4 GDS 149 Ur 37 Cr 1.0 GOT 22 GPT 14 Albumin 2.6

USG abdomen 10/1/2013Kesan: Tidak ada kelainan pada usg abdomen

Lab 07/1/13WBC : 7,69, RBC : 5,93, HB : 10,4, HCT : 34,7, PLT : 271, PT : 11,2, APTT : 22,0 GDS 190 Albumin : 3,6 SGOT 16 SGPT 13 Na 134, K : 3,9, Cl : 111

PA 18/01/2013Adenomacarcinoma recti (differensiasi sedang) dengan bagian 2 cm dan 5 cm arah distal tumor bebas dari sel-sel epitel maligna

Lab 26/12/2012CEA : 44,46

PA 02/01/2012Adenocarsinoma differensiasi sedang pada anus dan rectum

Lab 22/12/2012WBC 8,77, RBC 6,68, HGB 11,7, PLT 327, HCT 38,9, PT/APTT 11,3/21,6, CT/BT 7’00”/2’30”, GDP 103, GD2PP 215, TTGO 103, Ur/Cr 27/0,7, GOT/GPT 13/11, Alb 3,7, CEA 124, Na/K/Cl 142/3,8/106

Foto Colon In Loop 14/12/2012Kesan : Tu. recti 1/3 distal susp. malignancy

CT Scan Abdomen Tanpa kontras 14/12/2012Kesan : Tu. rectum tanpa pembesaran KGB (DUKES A/ T2 NxMx)

Foto Thoraks AP 14/12/2012Kesan : Tidak tampak tanda-tanda metastasis pada foto thoraks ini

13 Tajuddin / L / 48 tahun/ 591678

MRS 30-01-2013

Bed 3

Lampa Timur, Pinrang

D/ post op Laparatomi explorasi hr ke-XVII e.c. perforasi appendicitis ?

Lab 30 /01/2013 CT 9’30’’ BT 3’30” PT 9.3 APTT 33 GDS 97 Ur 16 Cr 0.8 GOT 59 GPT 25 Albumin 2.5 HBsAg (-) WBC 8.73 RBC 4.85 HGB 13.7 HCT 42 PLT 325

5


082347265485

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 1016. Katanang

P/45thn /585557MRS 07/01/13

Bed 1

Splenomegali (kista lien)

POH 4 laparatomi/ splenectomy

Lab 31/1-2013RBC 2.79 hgb 7.1 HCT 23.1 PLT 242 WBC 6.6Lab 29/1/2013WBC 68,47 RBC 3,34 HGB 6,5 HCT 22,3 MCV 66,8 MCH 19,5 MCHC 29,1 PLT 351

Lab 30/1/2013Hb 7,3 leukosit 63.400 trombosit 3900

Lab 28/01/13WBC 9,97 RBC 5,14 Hb 9,8 HCT 31,8 PLT 281Lab 27/01/13WBC 11,6 HB 9,4 HCT 31,4 PLT 359Lab 24/01/13CT/BT 7”/2” PT/APTT 14,2/25,3 INR 1,19 Na 144 K 3,7 Cl 110 HBSag non reactive anti hcv non reactive. UR/CR 31/0,4 GOT/GPT 22/12 GDP 84 GD2PP 116 WBC 8,76 RBC 4,17 Hgb 7,1 HCT 24,4 PLT 319Lab 21/01/13FE:3 TIBC:289 Feritine:5,96Lab 17/01/13CT/BT 8’00”/3’00”, PT 13, UR/CR 25/0,4, GDS 177, GOT/GPT 21/14, Alb 3,6 Na/K/Cl 138/3,9/105HbsAg (-) anti HCV (-) Malaria (-)

Lab 09/01/2013WBC : 10,41 RBC : 4,46 HGB : 7,4 PLT 337

Lab 28/12/2012WBC : 12,59 HGB : 8 PLT : 225 CT/BT : 8’00/3’00 PT/APTT : 13,1/25 CEA : 2,75 Na : 137 K : 4,7 Cl : 107

USG Abdomen 26/12/12Kesan: Hepatosplenomegaly

Foto BNO 26/12/12Kesan: Fecal impacted susp metastasis Tu ke tulangCT Abdomen lower pelvis 27/12/12Kesan Splenomegaly dengan kista

17. JunuhatiP/81 thn/582241MRS 6/12/2012

JKM

Bed 2

POH 30 Laparotomy e.c.Tumor rectosigmoid Stadium IV susp. Malignancy (3/1/13)

Lab 29/1/2013GDS 172 WBC 16,71 RBC 3,44 HGB 9,1 HCT 27,3 MCV 79,4 MCH 26,5 MCHC 33,3 PLT 280

Lab 27/1/2013Albumin 2,6 WBC 13,7 RBC 1,9 Hb 5,1 HCT 15,9 PLT 297Lab 16/01/13WBC 7,45 RBC 2,78 HGB 7,5 HCT 23,4 PLT 281Alb 2,1 GDS 75

PA 4/1/2013Jaringan omentum dan peritoneum yang mengandung sel-sel tumor dengan gambaran adenocarsinoma musinosum

Lab 3/1/13Na 143 K 9,9 Cl 105

Lab 2/1/2013Na 136, K 2.3, Cl 100, Alb 2.7

Lab 1/1/2013GDS 97, Ur 14, Cr 0.3, Na 134, K 2.1, Cl 98, Alb 2,7

Lab 30/12/2012

6


WBC 7,38 RBC 4,52 HGB 11,6 HCT 34,8 PLT 232 MCH 25,7 MCHC 33,3

Lab 28/12/2012WBC 25 RBC 4.09 HBG 10.9 HCT 33.3 MCV 81 MCH 26.6 PLT 286 PT/APTT 12.3/29.4 GDS 123 Ur/Cr 6/0.3 GOT/GPT 38/12 Alb 2.3 Na 137 K 2.1 Cl 102

Echocardiography 19/12/2012Kesimpulan:

Fungsi sistolik LV baik, EF 63% Dimensi ruang jantung normal Fungsi ventrikel kanan baik Katup-katup fungsi dan pergerakan baik Disfungsi diastolik

Lab 11/12/2012CEA 82,45

CT Scan Abdomen Upper 7/12/2012• Sesuai gambaran Tu. Sigmoid• Fatty liver

USG Abdomen 6/12/2012Tidak tampak kelainan radiologik

Foto Thoraks 6/12/2012Kesan: Pulmo normal. Dilatatio aortae

18 Sri WinarsiP/48 thn/586868 MRS 03-1-2013

bed 3

D/Tumor colon ascendenDivertikulosis Caecum

Post op 5 hemicolectomy dekstra

Lab 25/01/2013WBC 8,46 RBC 5,25 HGB 11,7 HCT 38,3 PLT 384

Lab 23/01/2013GDS 133 Ur/CR 12/0,6 GOT 16 GPT 9 Prot.total 6,1 Alb. 3,2 Na 137 k 3,9 Cl 105 CT 8’00’’ BT 2’ PT 10,3 APTT 19 HBsAg No reaktiv Anti HCV Non reaktiv WBC 8,65 RBC 4,39 MCV 72,7 PLT 380 HB 9,3 HCT 31,9

Lab 14/1/2013WBC 12,02 RBC 5,17 HGB 11 HCT 36,6 PLT 503UR/CR 12/0,7 GDS 66 GOT/GPT 17/7 CT/BT 7’0/2’0 PT/APTT 5,8/20,5

COLON IN LOOP (10/1/2013)Tumor colon ascendensDiverticulosis caecum

Lab (7/1/2013)CEA 2,2

Lab (5/1/2013)RBC 4,94 HGB 10,2 HCT 34,7 MCH 20,6 MCHC 29,3 PLT 338

IL

19 Marlian B. P / 50 tahun/ 588574MRS 12-01-2013

Bed 4

D/Tumor recti 1/3 distal

Colon in Loop 29/01/2013Sesuai dengan gambaran Ca. Recti 1/3 distal Lab 25/01/2013CEA 59,85 Ca-125 436,8

Lab 24/01/2013WBC 10,41 RBC 4,46 HGB 7,4 HCT 26,3 PLT 337Lab 12/01/2013CT 8’30’’ BT 2’ PT 10,4 APTT 21,9 GDS 101 UR 25 CR 1,3 Bil.total 0,37 Bil,Direct 0,17 GOT 64 GPT 33 Prot.total 6,2 Alb. 3,0 Globulin 3,2 Na 136 K 4,3 Cl 99 HBsAG (-) Anti HCV (-) WBC 6,8 RBC 3,82 HCT 31,7 MCV 83 PLT 368Lab 17/01/2013CEA 46,13 CA 19-9 530,2Lab 23/01/2013CEA 54,57CT Scan Abdomen 29/12/2012Massa ekstra lumen suspek limfoma Cholestatis intrahepatik e.c kista caput pancreas

7


Hydronefrosis sinistra e.c suspek. Kinking ureterAscitesUSG Abdomen ( 15/12/12)Massa hypocondrium dextra, suspek Tu. Extraluminer (Mesenterium)Slight HepatomegalyHydronephrosis sinistra ec. Susp Obstruksi di level ureterTanda tanda inflames region adnexa DextraAscitesMSCT Abdomen Tanpa Kontras ( 18/01/13)Massa rectumHydronephrosis sinistraAscitesFoto Thorax PA ( 16/12/13)Pulmo normalElongatio AortaePleural reaction Dextra

20 InadiaP/44 thn/579356MRS 19/11/2012

JKM

Bed 5

D/ Tumor gaster susp. Malignancy

Lab 27/01/13WBC 12,79 RBC 4,05 Hb 10 HCT 33 PLT 531Lab 24/01/13WBC 9,66 RBC 3,61 HGB 9,1 HCT 30,0 PLT 558

LAB 21/01/2013WBC 8,66 RBC 2,40 HGB 5,9 HCT 20,3 PLT 638

LAB 17/01/13WBC 10,36 RBC 1,76 HGB 4,6 HCT 15,4 PLT 401

Lab 17/01/2013Alb 2,9


Lab 9/1/2013WBC 11.98, RBC 1.35, HGB 3.4, HCT 11.8, PLT 453

Lab 29/12/2012WBC 8.3 PLT 476 MCHC 31.9 MCV 82 HCT 32.5 HGB 10.3 RBC 3.97 Ur/Cr 6/0.4 Alb 2.9 Na138 K 4.1 Cl 102

Lab 25/12/2012GDS 86, Alb 2,2, Na/K/Cl 135/3,5/100

Foto OMD 11/12/2012Kesan : Tu. gaster susp. malignancy

Lab 29/11/2012HBsAg (-), Anti HCV (-), CEA 4,35

Echocardiography 27/11/2012Kesimpulan : Kontraktilitas LV baik, EF 58%

Foto Thoraks 27/11/2012Kesan: Susp. efusi pleura kiri. Elevasi diafragma kiri (proses intraabdominal?)

USG Abdomen 22/11/2012Kesan : Massa hipokondrium kiri susp. massa intraluminer colon flexura lienalis-colon descendens. Ascites dan efusi pleura kiri

CT Scan Abdomen Lower Non Kontras 21/11/2012Kesan : Tu. Gaster. Atelektasis paru kiri. Efusi pleura kiri

Foto Thoraks 19/11/2012Kesan : Efusi pleura sinistra. Cardiomegaly

21 Sitti M. KotenP/48 thn/581478

D/ POH 31 Hartman Prosedur ec. Tu. Retrosigmoid

Lab 27/1/2013HGB 10,3 WBC 11,34 RBC 4,03 Hb 10,3 HCT 32,2 PLT 298Lab 24/01/2013

8


MRS 1/12/2012

JKM

Bed 6

(02/01/2013) Albumin 2,6

LAB 21/01/13Albumin 2,4 (hipoalbuminemia)

Lab 16/01/13 WBC 15,19 RBC 4,45 HGB 11,5 HCT 34,5 PLT 274 Alb 1,7 Ur/ Cr 10/ 0,4 GOT/ GPT 24/ 16 As. Urat 2,2 GDS 52

Lab (07/01/2013)Alb 2.0, Prot.total 7.9

Lab (03/01/2013)WBC 17.33, RBC 3.81, HB 9.3, HCT 28.3, PLT 252,

Lab 1/1/13CT 7’30” BT 2’30” PT 14,6 INR 1,1 APTT 25,7 HBsAg (+), Anti HCV Negatif GDS 72 Ur 11 Cr 0,4 GOT 48 GPT 21 Alb 2,5

Lab 2/1/13 WBC 7,96 RBC 4,40 Hb 10,6 HCT 33,2 PLT 314

Lab 31/12/12Albumin 2,6

Foto Colon In Loop 13/12/2012Kesan: Tu. rectosigmoid susp. malignancy

Echocardiography 12/12/2012Kesimpulan:

Fungsi sistolik LV & RV baik, EF 67% LVH Disfungsi diastolik Efusi pericard minimal

MSCT Whole Abdomen Non Kontras 7/12/2012Kesan: Massa para iliaca susp. limfoma

Lab 5/12/2012GDS 72, CEA 4,07

USG Abdomen 1/12/2012Kesan:

Susp. massa adneksa Ascites

Foto Thoraks 1/12/2012Kesan:

Cardiomegaly disertai dilatatio et elongatio aortae Tidak tampak tanda-tanda metastasis pada foto thoraks

iniLONTARA ATAS DEPAN (BEDAH DIGESTIF) KAMAR 11

22 MappangenreL/51 thn/588899/ MRS 24/1/2013

JKMBed 1

D/ Tu Recti 1/3 tengah

Lab 15/1/2013Gds 85 ur/cr 25/0,8 GOT/GPT 22/27 HBsAg (-) Na 141 K 4,5 Cl 105 CT 8’00” CT 3’00” PT 10,4/11,2 APTT 24,5/25,4 WBC 13,57 HB 9,1 HCT 28,5 PLT 563

Echocardiografi 17/1/2013Normal echocardiogram

CT-Abd Upper (tanpa kontras) 16/01/13Kesan: massa rectum (DUKES A)

USG Abdomen 15/1/2013Tidak tampak metastasis pada USG abdomen iniMassa rectumMultiple renal cyst bilateral disertai hidronefrosis dan hidraureter sinistra

9


23 Coang dg. SeseL/59thn/580059MRS 3/12/2012

JKM

Bed 2

D/ Post Laparatomi ec. Peritonitis generalisata ec. Perforasi jejunum dan colon transversum hari 9 (21/1/2013)

Lab 28/1/2013Na/K/Cl 128/3,6/97 WBC 5,34 RBC 3,66 HCB9,3 HCT 28,7 MCV 78,4 MCH 25,4 MCHC 32,4 PLT 102

Lab 23/01/2013GDS 103 Alb 2,30 WBC 7,96 RBC 3,27 HB 8,4 HCT 26,6 PLT 180

Lab 22/01/2013PT/APTT 12,8/31,5 GDS 150 Ur/Cr 22/0,30 GOT/GPT 18/9 Alb 2,0 Na/K/Cl 138/3,86/109 WBC 12,06 RBC 3,25 HB 8,0 HCT 25,7 PLT 256

Lab 21/01/2013Na/K/Cl 130/3,9/99

Lab 20/1/2013WBC 4,01 RBC 3,13 HgB 8,4 PLT 300 CT/BT 3’,00’’/12,2’ APTT 27,3 GDS 159 Ur/Cr 18/0,5 Bil.total 0,78 Bil.Direct 0,47 GOT/GPT 17/7 Albumin 2,4 HBsAg (+) Anti HCV (-)

PA (27/12/2012):Kesimpulan: mesenchymal tumor kemungkinan suatu embrional rhabdomyosarcoma.

Lab (15/1/13)WBC 4,56 RBC 3,27 HGB 8,8 HCT 27,7 PLT 285

Lab (10/1/2013)Prot. Total : 5,3. Alb 2,0. WBC 3,85. Hb 8,1. PLT 291.

Foto MD 7/12/2012Kesan: Tu. gaster daerah antrum pyloric disertai ulcus susp. Malignancy

24 WariL/67thn/590187MRS 21/1/2013

Bed 3

D/ Tumor Abdomen

Rencana colon in loop dan CT scan

Lab 31/1/2013PH 7,48 PCO2 31,4 SO2 93,8 HCO3 24,1 C+O2 14,4 C+O2 20,6 BE -0,3Kesan alkalosis respiratorikLab 28/1/2013GDS 83 Albumin 2,5

Lab 21/1/2013CT:8’00” BT:2’00” PT:15,0 APTT:35,4 GDS:44 Ur:86 Cr:1,30 GOT:179 GPT:19 Pro.tot:3,56 Albumin:2,40 As.Urat:12,2 Na:140 K:4,24 Cl:108 HbSAg:- WBC:10,90 RBC:3,92 HGB:10,6 PLT:312

USG Abdomen 21/1/2013Kesan : Ascites. Efusi Pleura D

25 Andi JahidingL/50 thn/558167MRS 16/01/2013

Bed 4

D/ Post colostomy e.c Ca Colon (Hartman Procedure)

Lab 28/1/2013CEA 4263

Foto BNO 3 posisi 30/1/2013Tanda-tanda localized ileus regio abdomen kiri bawahTanda

Lab PA12/07/2012Adenocarcinoma rescti diferensiasi sedang yang telah infasi hingga lemak serosa dan metastasis ke kelenjar regionaldengan kedua ujung dengan kedua ujung reseksi dan jaringan 3 cm dari distal bebas tumor

Foto thorax AP 16/01/2013- Dilatatio et elongation aorta - Elevasi kedua diafragma (proses intra abdominal DD/Inspirasi Kurang ) Lab 16/01/2013CT/BT 8’,00’’/2’,00’’ PT/APTT 13,5/31,2 INR !,09 GDS 76 Ur/Cr 57/1,4 GOT/GPT 119/39 Protein Total 7,9 Albumin 3,0 Hep.B negatif RBC 5,76 Hb 14,1 HCT 45,0 PLT 243 WBC 16,5

WS

10


26 B. Dg Sija58thn/L/583112MRS 30/1/2013Jamkesmas

D/ HIL (S) Echo Cardiography 11/12/12Fungsi sistolik LV baik, EF 71% disfungsi diastolikLab 10/12/2012CT/BT 8’00’’/3’00’’ PT/APTT 10,8/28,4 GDS 98 Ur/Cr 17/1,3 GOT/GPT 18/7 HBSAg (-) Anti-HCV (-) WBC 6,34 RBC 4,43 HGB 13,1 PLT 259

27 Dg. Baco/L/68 thn/578218

MRS 27/01/2013

Bed 6

D/ Tu. Recti 1/3 proximal

Lab 30/1/2013CEA 4,40

Lab 08/01/2013CT 8’00 BT 3’00” PT/APTT 11/24,5 GDS 126 Ur/Cr 29/1 GOT 21 GPT 26 albumin 3,7 HbsAg (ICT) nonreactive, anti HCV (ICT) nonreactive Na/K/Cl 138/4,2/102 WBC 7,0 RBC 3,97 HGB 12,3 HCT 36,1 MCV 91 MCH 31,0 MCHC 34,1 PLT 421

Foto BNO 8/1/2013Suspek vesicolith

Foto thorax 8/1/2013KP sinistra lama aktifElongatio aortae

Foto colon in loop 18/12/2012Suspek massa rectum proximal

Lab 11/12/2012Ur/Cr 34/1,0 GOT/GPT 27/28 Na/K/Cl 140/4,9/103 CT/BT 7’00/2’00 PT 10,0control 10,0 INR 0,83 APTT 23,9 control 25,5 WBC 8,6 RBC 4,27 HGB 13,2 HCT 37,7 MCV 88 MCH 30,9 MCHC 34,9 PLT 327

PALEM ATAS28 M. Arifuddin

L/60thn/588326MRS:11/01/13

Kmr B2/2 Bed 1

JL. Pelita 2 No.144 MKS

D/ Tu Colon Ascendens POH 2 hernikolektomi dextra ec. Tumor flexura dextra

Lab 30/01/2013GDS 512 kolesterol total 201 kolesterol HDL 46 kolesterol LDL 67 trigliserida 239

Lab 27/01/2013WBC 9,74 RBC 4,79 HGB 12,8 HCT 40,9 PLT 380 ALB. 3,9 Na/K/Cl 141/3,92/102 HBSaG (-) Anti HCV (-) BT/CT 6’30’’/2,’00’’ PT/APTT 11,2/26,6 GDS 377 Ur/Cr 20/0,8 GOT/GPT 21/29 Ptotein total 6,5

CT Abdomen Full Tanpa Kontras 23/01/2013Tu. Colon Ascendens

Lab 11-1-2013RBC 4,38, HGB 12,1, HCT 38.1, PLT 399, CT/BP 6/2 PT 10,2 APTT 27,3 GDS 201, Ur/Cr 19/0,8.,, HbsAg (-), Anti HCV (-), GOT/GPT 18/10, Na/K/Cl 143/4.4/107

USG Abdomen (11/01/13) :Kesan: -Appendicitis susp Perforasi -Massa paraumbilicalis kanan susp. Lipoma DD/ penebalan otot Hipertrofi prostat -Pelvocalyrctasis dextra

Urinalisa (11/01/13) :Kesan: Tidak ada kelainan

Colon in loop (17/01/13) :Sesuai gambaran tumor colon ascendens

IL

29 Siti NurbayaP/68thn/589769

B2 Kamar 5 Bed 1

D/ Post Hartman procedure + Colostomy hari 11 (19/1/2013)

Lab 22/1/2013GDS:76 Ur:42 Cr:0,7 GOT:25 GPT:12 Albumin:2,4 WBC:15,35 RBC:3,82 HGB:9,4 HCT:30,2 PLT:388

Lab 20/1/2013CT:8’00” BT:2’00” PT:12,2 APTT:22,5

MR

11


MRS 19/01/2013

Kariango DS pananrang pinrang/ jl. Berua raya graha amalia blok C no. 8 MKS085242675884

USG Abdomen 19/1/2013Kesan: Ileus Obstruktif

30 KristianL/55/584662MRS 18-01-13

B2/6 Bed 1

Jl. Kancil 3 No. 62 C palu

081340354111

D/Cholelithiasis Cholecystitis

Post op 5 open cholecystectomy

Lab 18/01/2013WBC 7,73 RBC 5,58 HGB 16,3 HCT 49,1 PLT 308 BT/CT 7’00’’/3’00’’ PT/APTT 9,8/24,5 Na/K/Cl 143/3,9/107 GOT/GPT 13/25 Prot.tot 7,3 Alb. 4,3 kolestrol.tot 288 GDS 94 Ur/Cr 29/0,1 BiL.total/direk 0,6/0,4Foto Thorax 18-01-2013Tidak tampak kelainan

CT Scan Abdomen Lower/Elvis 18-01-2013Cholecystitis disertai cholelithiasis

Lab 18-10-2013GDS 94 Ur/Cr 29/1.0 Bil. Total 0.6 Bil. Direk 0.14 GOT/GPT 13/25 Protein Total 7.3 Albumin 4.3 Kolesterol Total 285 Na 143 K 3.9 Cl 107 CT 7’00” BT 3’00” PT 9.8 INR 0.82 APTT 24.5 WBC 7.73 RBC 5.58 HGB 16.3 HCT 49.1 PLT 308

RL

31 Boimin L/52 thn/590452Konsul 28/01/13

B2/K 10

Jl. Prof.Abd rauf tarimana kendari085280379563

CKD stg V ec nefropati DM post CAPD

Lab 30/1/2013GDP 214 GD2PP 322

Lab 27/01/2013Ur/Cr168/8,4 WBC 6,49 RBC 2,58 Hb 7,6 HCT 22,5 PLT 135

Lab 26/01/13GDS 275 GD2PP 469

Lab 25/01/13Fernitine 705,1

WS

32 NurmiahP/41 th/ 587934Konsul 27/01/13

B2/K1 Bed 2

CKD stg V ec nefropati DM POH 2 CAPD

Lab 26/01/13PT/APTT 10,3/18,4

Lab 26/01/2013CT/BT 7’30”/2’30” PT 10,5 APTT 23,2 GDS 253 Ur/Cr 57/4,7 GOT/GPT 15/20Prot. Total 6,5 Alb 3,2 Na/K/Cl 130/3,57/98 WBC 6,45 RBC 2,9 Hb 7,8 HCT 23 PLT 345

WS

33 Yulianus julius 27thn/590048MRS 31/01/2013

B2/9 Bed 1

DSN sabbang loang sassa baebunta luwu utara085242426612

D/ Fistel perianal

Foto fistulografi 28/01/2013Kesan : blind fistel

Foto thorax 25/01/2013Kesan tidak tampak kelainan radiologik pada foto thorax ini

Lab25/01/2013WBC 5,65 RBC 5,39 HGB 15,8 HCT 47,4 PLT 283 BT/CT 8’00’’/3’00’’ PT/APTT 11,2/27,3 Na/K/Cl 142/5,0/106 GDS 95 Ur/Cr 27/0,9 GOT/GPT 27/18 kolesterol tot. 164 trigliserida 66 as.urat 7,7

34 Yusuf Reli / L/43thn/ 561927

MRS 01/2/2013

D/ appendicitis infiltrat

12


B2 km 12

Jl. DG. Hayo No. 100 MKS/08134400712

35 Ir. Abdul Hafid L/53/383654MRS 31/1/2013

B1 km 7

Jl. Lamumpatue lalabata soppeng

D/Susp Tu.Colon Lab 31/1/2013HbsAg (-) AntiHCV(-) CEA 0,395 Na/K/Cl 135/3,9/108 GDS 119 Ur/Cr 19/1,1 GOT/GPT 15/11 Alb 4,4 CT 6’00 BT 3’00 PT/APTT 10,6/23,1 WBC 10,63 RBC 4,53 HB 13,6 HCT 41,2 MCV 90,9 MCH 30,0 MCHC 33,0 PLT 304

MR

PALEM BAWAH 36 Belthia Bura

P/64 thn/589570MRS:18-01-13

Kmr B1/9

Jl. H. Kalla II campa gaya MKS

081342233636

D/cholecystolithiasis + splenomegaly + efusi pleura sinistra post chest tube hari 12 + Suspek Tu Colon

Lab 30/01/2013WBC 5,6 RBC 3,91 HGB 11,1 HCT 34,6 PLT 91 GDS 120 Na/K/Cl 143/3,5/11,3 Alb. 2,6

Lab 28/01/13WBC 3,12 RBC 3,2 Hb 8,7 HCT 27,8 PLT 72

PA 23/01/13Mesotel proliferaktif + lesi inflamasi

Lab (26/01/13)WBC 2,45 RBC 3,43 HB 9,2 HCT 29,7 PLT 81

Colon In Loop 25/01/2013Tu. Colon Ascendens

Foto Thorax 19-01-2013Kesan : - Efusi pleura massif sinistra - KP dextra lama tenang

Lab 18-01-13WBC 3,0 RBC 3,37 HGB 9,2, HCT 29,0 PLT 77 CT/BT 7’00’’/2’30’’ PT/APTT 12,8/28,9 INR 1,0 GDS 143 Ur/Cr 19/0,7 Bil.total 0,8 Bil.Direct 0,3 GOT/GPT 25/13 Albumin 2,7 Kol.total 135 HDL 33 LDL 85 TG 85

Lab 15-1-2013WBC 3,87 RBC 2,76, HGB 7,3, HCT 23,2, PLT 86, CT/BP 8/4 PT 15,0 APTT 36,3

Lab 09-01-13CEA 7,15 Fe 11,2 TIBC 128,6

Foto MSCT abdomen axial dengan rekontruksi multiplanar tanpa kontras:Kesan: -Efusi pleura kiri-Cholethiasis-Splenomegali

IL

37 Yohana Labi65 thn/P/590943MRS 27/1/2013

Kmr B1/1

Kel. Lemo tator komp.keuangan blok.G no.135 MKS

D/Cholelithiasis CT- Abdomen tanpa kontras 01/2/2013- cholestasis ec. Batu pada ductus choledocus- Hepatomegaly & kista hepar- Sludge galbleder- Susp. Massa portio uteri- Efusi pleura bilateral

Lab 30/01/2013WBC 18,1 RBC 2,83 HGB 7,0 HCT 23,3 PLT 466 Alb. 2,2Lab 27/1/2013WBC 22,33 RBC 2,13 HGB 5,1 HCT 17,6 PLT 373 BT 8”00 CT 3”00 PT/APTT 15,5/31,5 GDS 105 Ur/Cr 11/0,6 Bil..tot 0,85 Bil.direct 0,60 GOT/GPT 19/11

13


085298450464

Prot.tot 4,65 Alb 1,6 HbsAg (-) Anti HCV (-) Na/K/Cl 135/3,1/102 as.urat 1,5

USG Abdomen Choleliths dan choledocolithMassa bawah rahim dd/prolaps uteri

38 Yohanis lalang/60thn/L/ 587959

MRS 25/1/2013

Komp.SDN endtrop/bumi sudiang jraja blok E No. 11/ 085254021106

D/cholelithiasis + duble system + batu ureter 1/3 proximal D/ disertai hedronefrosis

Lab 09/01/2013WBC 5,9 RBC 4,5 HGB 14,2 HCT 42,1 PLT 186 GDS 80 Ur/Cr 31/1,5 GOT/GPT 17/14 as.urat 75 BT/CT 3’00’’/8’00’’ PT/APTT 24,1 Na/K/Cl 140/4,1/109

Foto thorax 09/01/2013-soft tissue density susp.Tu. paru sinistra DD/ pneumonia-bronchopneumonia

BNO-IVP 14/01/2013Kesan nefrolith

CT-Abdomen upper tanpa kontras 19/01/2013Hidronefrosis D/ ec.ureterolithKista ginjalCholelith

MR

39 Muhammad Yusuf/L/33 tahun/ 383892/ MRS 25-01-2013

B1/8

BTN kodam III Blok D3/13 sudiang makassar

D/ Trauma tumpul abdomen + ruptur lienPost Laparotomy + Splenoctomy VII

Lab 31/01/2013PH 7,31 pCO2 51,7 SO2 53,1 PO2 36,7 HCO3 23,4 ctO2 8,3 ctCO2 24,3 BE -0,8

Lab 30/01/2013WBC 13,03 RBC 13,89 HGB 10,4 HCT 33,4 PLT 58 GDS 133 Ur/Cr 58/0,9 GOT/GPT 53/60 Alb. 3,8 Laktat darah 20 CRP kuantitatif 59 PT/APTT 11,1/19,0

FOTO THORAX 30/1/2013Tanda-tanda edema paru sinistra Fraktur costa IV-IX sinistra belakang

Thorax AP 28/01/13Fraktur costa IV –IX kiri belakang

Lab 28/1/2013AGD: Alkalosis metabolik terkompensasi sempurna

Lab 27/01/13WBC 12,6 RBC 3,93 Hb 10,8 HCT 34,3 PLT 87 Na/ K/Cl 144/3,92/108CT/BT 7’30”/2’30” PT/APTT 12/29,6 GDS 120 Ur/Cr 34/0,9 GOT/GPT 102/90Alb 3,1 AGD : alkalosis metabolik

Thorax AP 26/01/13Pneumonia dekstraEdema paru + efusi pleura bilateralFr. Costa V-VIII kiri belakang

Lab 26/01/13CT/BT 8/2 PT/APTT 15/25,4 Na/K/Cl 144/4,3/112AGD:Asidosis metabolic GDS 117 Ur/Cr 28/1,2 GOT/GPT 86/73 Alb 2,2WBC 10,83 RBC 2,02 Hb 5,7 PLT 50

USG Abdomen 25/01/2013Kesan: Cairan bebas cavum peritoneum (hematoperitonium**)

CT Abdomen Lower/ Elvis (tanpa kontras) 25/01/2013Kesan: Fraktur kosta posterior kiri disertai laserasi lienEfusi pleura bilateral

Lab 25/01/13WBC 25,54 RBC 2,47 Hb 7 PLT 100 GDS 246 Ur/Cr 29/1,8 GOT/GPT 296/287Prot Total 7,1

MP

14


LONTARA 1 ATAS DEPAN40 Mardawiah

P/39 th/ 588801 MRS 16/01/2013

POH 2 laparotomy explorasi CBD +T-tube(op 30/1/2013)

Lab 28/1/2013WBC 9,60 RBC 4,22 Hb 12,4 HCT 37,3 PLT 523 Bil.tot14,6 Bil.Dir 13,0 CT 7,00 BT 3,00 PT 10,3 APTT 20,3

Thorax 23/01/2013Tidak ada kelainan

CT Scan Abdomen Upper 23/01/2013Cholestatic intra dan ekstra hepatik e.c batu proximal CBDCholelithiasis

Lab 18/01/2013RBC 3,20 HB 11,7 HCT 35,4 PLT 406 WBC 7,8

Lab 16/01/2013 GDS 90 UR/Cr 27/0,4 GOT/GPT 116/197 Hep.B (-) PT 9,8 INR 0,8 APTT 22,7 Bil.tot 13,8 Bil,Direk 11,01 Prot,total 6,4 Alb 3,6 Globulin 2,8 RBC 3,98 HB 12,5 HCT 38,1 PLT 428 WBC 10,7

USG Abdomen 16/01/2013Cholelith / Cholestatik intra dan ekstra hepatic e.c choledocolithiasis

Lab 15/01/2013HBsAg (-) Anti HCV (-) GDS 106 UR/CR 22/0,5 Bil. Total 9,3 Bil. Direk 8,9 GOT/GPT 123/126 AFP 167 Pro.total 6,3 Alb 4 Globuli 2,3 Kolesterol tot. 3,4 LDL 296 As.urat 4,2 WBC 7,56 RBC 4,35 HB 13,2 HCT 39,3 PLT 454

LONTARA I ATAS BELAKANG41 Syamsuddin

L/56 th/ 588709 MRS14/01/2013

K1/IIIBed 3

Tu.Rectosigmoid dan Tu. Colon Ascendens + cholelithiasis + nephrolithiasis

Lab 30/1/2013WBC 5,50 RBC 3,72 Hb 9,7 HCT 30,3 PLT 414 Alb 2,3 MCV 81,5 MCH 26,1 MCHC 32,0 PLT 414

Lab 25/01/2013WBC 5.02; RBC 3.09;Hb 7.9; HCT 25.2; PLT 405; CT 8’00”; BT 3’00”; PT 11.5; INR 0.96; APTT 27.8; CEA 68.42; Albumin 2.2

CT Abdomen Lower/Elvis 23/01/2013 Tu. Sigmoid dan Tu. Colon Ascendens Cholelith Splenomegaly

Foto Thorax 23/01/2013 Suspek Tumor mediastinum superior kanan DD/ pelebaran vena

cava superior Cardiomegaly disertai dilatation et elongation aortae Bronchopneumonia bilateral Tidak tampak tanda-tanda metastase pada foto thoraks ini

Colon in Loop 23/01/2013Sesuai dengan gambaran Tu. Rectosigmoid dan Tu. Colon AscendensNephrolith

Lab 17/01/2013RBC 3,95 HgB 10,8 HCT 33,0 PLT 380 WBC 3,1

Lab 16/01/2013RBC 3,62 HgB 9,6 HCT 30,5 PLT 365 WBC 3,6

Lab 14/01/2013Na/K/Cl 136/4,6/105 PT/APTT 12,0/24,1 HBsAg : (-) HCV (-) BT/CT 2/8 GDS 58 Ur/Cr 61/1,5 GOT/GPT 18/13 Alb 2,4 WBC 4,88 Hb 9,7

RL

15


PLT 412LONTARA 1 BAWAH BELAKANG

42 HariatiP/42thn/ 587036

Konsul 4/01/2013

Kmr12 Bed 2

D/ POH 16 laparotomy + eksplorasi CBD ec. Choledocolithiasis + T-Tube (16/01/13)Cholegografi

PA 21/1/2013kesimpulan : Cholecystitis Kronik

Lab 25/01/2013DHF (IgG dan IgM) Negatif; WBC 7.25; RBC 4.25; Hb 10.7; HCT 33.9; PLT 290

Cholangiografi 23/01/2013Ductus choledocus paten

Lab 23/01/2013WBC 6.45; RBC 3.30; HB 9.6; HCT 29.3; PLT 344; Na 136; K 2.5; Cl 106; PT 12.1; INR 1.01; APTT 23.0; GDS 85; Ur 9.5; Cr 0.3; Bil. Tot 7.0; Bil. Direk 5.2; GOT 57 GPT 45; Alb 3.3

Lab 17/01/2013GDS 115 Ur/Cr 14/0,4 GOT/GPT 156/166 Na 143 K 2,7 Cl 108 WBC 10,55 RBC 3,08 HgB 9,1 HCT 27,9 PLT 410

Lab 16/01/2013Ct 7’,00’’ BT 3’,00’’ PT 11,2 APTT 25,0 INR 0,93 GDS 77 GOT/GPT 97/100 WBC 7,9 RBC 3,0 HgB 8,9 HCT 26 PLT 462

MSCT abdomen non kontras (8/1/13)Kolestasis intra/ekstrahepatik susp.kista caput pankreas

Lab 04/01/2013Alkali fosfatase : 281 protein tot. : 6,2 Alb :3,1 Gamma GT : 268CA 19-9 : 2,2

USG abdomen 03/01/2013Cholelith

Urinalisa 03/01/2013Protein : 75/+++ Bilirubin : 6/+++ urobilinogen 4/++ nitrit (+) blood : 25/++ lekosit : 25/+

Lab 03/01/2013Bil. Total : 12,1 Bil. Direk : 11,7RBC : 3,72 HGB : 11,2 PLT : 212 WBC : 8,6

PAKISLontara II Bedah Urologi

43 Sakka72Thn/588876

Kmr 12 bed 5

MRS 14/01/2013Konsul 24/01/2013

D/ Tu. Recti 1/3 distal, susp. malignancy- Metastatic hepar

Optimalisasi dari T.S. Interna

Tunggu hasil PA rectum

Lab 27/01/2013PT/APTT 11,4/24,3 Ur/Cr 16,3/0,9 WBC 7,08 RBC 4,34 Hb 11,2 HCT 35,7 PLT 289


Foto Thorax 21/01/2013 KP Dupleks lama aktif Atherosclerosis aorta

USG Abdomen 21/01/2013 Hipertrofi prostat Cystisis

Lab 19/01/2013RBC 3.51; HB 9.4; HCT 29.6; PLT 281

Lab 16/01/2013WBC 7.48; RBC 2.53; HB 6.0; HCT 21.1; PLT 119; CEA 2946; PSA 7.70

MSCT Whole AbdomenTu. Recti dengan metastasis ke hepar (DUKES D)

44 Tn Abd Malik D/HIM (D) Lab 16/1/2013

16


L/67thn/589124MRS 27/1/2013

K2/ Bed 4

WBC 7,8 RBC 5,57 Hb 17,1 HCT 49,6 PLT 247 CT 7’00 BT 3’00 PT/APTT 9,2/26,2 GDS 131 Ur/Cr 15/1,0 GOT/GPT 28/25 Na/K/Cl 140/3,8/101 HbsAg (-) Anti HCV (-)

BNO IVP 23/1/2013Kesan: Hidronefrosis (D) grade III-IV ec batu staghorn

45 Siti Kumiati Konsul interna (29/01/2013) 46tahun/P589819MRS 20/1/2013

K11/ Bed 5

D/cholecystolithiasis

BNO abdomen polos 28/1/2013tidak tampak kelainan

CT Abdomen upper tanpa kontras 23/1/2013 Kesan : massa ginjal kanan susp RCC tumor metastasis ke tulang Nephrolith (D) Choelith

USG Abd 19/1/2013Kesan choelith Hydronephrosis dan nephrolith (D)

Thorax 19/1/2013Kesan : Cardiomegaly dengan dilatatio et athelosclerotic aortae

Lab 29/1/2013Na/K/Cl 139/3,8/109 CT 8’00 BT 3’00 PT 13’00 APTT 24,5 Ur/Cr 30/1,4 Bil.Tot 0,2 Bil.Dir 0,1 Alkali fosfatase 82 As.urt 10,5 HCT 25,5 PLT 682 WBC 13,85 RBC 3,42 Hb 7,7

Lab 20/1/2013GDS 109 Ur/Cr 30/2,0 GOT/GPT 15/9 Cal.Tot 150 HDL 25 LDL 118 TG 94

46 Markus kirinL/46Th/588126

K12 B3

Konsul 13/1/2013

D/ POH 13 Laparotomi Eksplorasi ec. peritonitis + drainase abses hepar generralisata e.c Ruptur Abses Hepar W VIII


Lab 22/1/2013WBC:12,98 RBC:2,47 HGB:7,4 HCT:22,9 PLT:287

Lab 21/1/2013GDS:118 Bil.tot:1,8 Bil.direk:1,5 GOT:666 GPT:280 Pro.tot:4,2 Albumin:1,6 Na:134 K:5,0 Cl:111 RBC 1,74 HGB 5,1 HCT 15,9 WBC 22,64 PLT 36

Lab 19/01/2013RBC 1.83 HGB 5.9 HCT 18.6 PLT 600 WBC 61.2 GDS 60 Bil.tots 3,1 bil direct 2,6

CT- SCAN 17/01/2013Hidronefrosis grade 4 ec nefrolith , Abses Hepar

Lab tgl 14/01/2013Bilirubin Total 5 Bilirubin Direk 4,9 AFP 0,7

Hasil Lab Tgl 10/01/13Alb 2,5 pt/apt 17,6/30,1 Na/K/Cl 133/4,6/102 Ur/Cr 37/0,8 wbc 36190 plt 166 Hb 13,5

USG 10/01/2013Susp Hepatoma, Meteorismus, Nefrolith Bilateral +Pelvicaliectasis D

Lontara II Ortopedi

Lontara II Bedah Onkologi

Lontara III THTLontara III Kulit

47 RinaP/45 thn/589259MRS 19/01/13

Kmr 1 Bed 1

D/ Ca. Recti 1/3 distal, POH 8 biopsi dalam narkose

PA 29/01/2013Kesimpulan : adenocarcinoma musinomum (adenocarcinoma diperensiasi sedang)Lab 28/1/2013CEA < 0,200

Lab 16/01/13CT 7” BT 3” PT 9,8 INR 0,82 APTT26,2 NA 139 K 3,2 CL 106 GDS

WS

17


96 UR 27 CR0,7 GOT 16 GPT 20 WBC 5,86 RBC 4,23 HGB 12,6 HCT 37,8 PLT 260S

CT Scan (17/01/13)Tidak tampak gambaran tumor colon

Thorax PA (16/01/13) Tidak ada kelainans

Lontara III MataLontara IV Obgyn

48 Fitriani/p/32thn/590200MRS 22/1/2013

Km 1 bed 5

D/POH 2 laparatomi Dikonsul dgn D/ appendicitis infiltrat

Lab 30/1/13RBC 3,89 HGB 9,4 HCT 29,3 PLT 426 WBC 11,9

USG 22/1/13Kesan slight hepatomegaly

RSP49 Chaeruddin

L/49th/586254MRS 29-12-12

419 B

D/ Wound dehisersi Post Op appendectomy

Lab 15/01/13Salmonella typhi : O : 1/ 80 H : 1/160 Paratyphi : AO : 1/160 AH : 1/320 BO : 1/320 BH : 1/80 CO : 1/320 CH : 1/80

Lab 29/12/2012WBC 15.12, RBC 3.92, HGB 10.9, HCT 34, PLT 567, CT/BT 7’00”/2’30”, PT/APTT 11.3/26.1, Ur/Cr 19/0,8, GOT/GPT 23/13, GDS 134, Na/K/Cl 131/4.7/96, Alb 2,7 HbsAg(-), Anti HCV (-)

Lab 31/12/2012WBC 11,23 RBC 3,84 HGB 10,8 HCT 32,4 MCV 84,5 MCH 28,1 MCHC 33,3 PLT 512

MSCT Abdomen 10/01/2013Cholelithiasis Multiple + Efusi DNefrolithiasis bilateral (batu kecil)Defek subcutis di abdomen kiri bawah (Mc Burney)tidakberhubungan dengan usus di sekitar defect, abses subcutis

IL

50 KristiantoL/36 thn/6052MRS 04/01/2013

Kamar 411 B

D/ Fistel perianal Post Colostomy Pro tutup colostomyBusinesi P/SPOH1 Fistelectomy (30/1/2013)

Lab 14/1/2013WBC 7,53 RBC 5,06 HGB 13,9 HCT 40,1 PLT 242 BT/CT 3’0/8’0 GOT/GPT 43,1/44,0 UR/CR 20,9/0,8

WS

51 Sri Wahyuni P/33thn/7298MRS 02/01/2013

Kamar 401

D/ Ikterus Obstruktif e.c tu. Caput pancreas

POH 9 Gastrojejunostomy + Cholesistectomy ec. Ca Caput pankreas whipple prosedur

Lab 21/12013Wbc : 18,68 RBC 3,43 hb : 10,7 HCT : 30,3 PLT : 148 Na:130 K:20 Cl:99 SGOT :78,2 SGPT:61,6 ur:12,8 cr:0,3 Bil.tot : 18,8 bil.direk : 15,3Urin : 500cc/12 jam, BAB (+) warna kehijauan

EKG14/1/2013Tidak inverse

Imunoserologi 02/01/2013HbsAg (-)

Tumor Marker 03/01/2013CA 19-9 : 357,5

ADT 03/01/2013Kesan : Anemia normositik normokrom susp. e.c penyakit kronik dengan leukositosis tanda inflamasi

CT Scan Abdomen 04/01/2013Kesan : - Kolestatik intra & ekstra hepatic e.c massa caput pancreas. Susp. Ileus

Lab 04/01/2013

IL

18


Alkali fosfatase : 590MRCP tanpa & dengan kontras 08/01/2013Kesan : -Stenosis distal CBD, Susp. Massa caput pancreas-Hepatosplenomegaly

52 Salmawati P/45 thn/004262Kmr 306

D/ Post op ec. Tumor colonPost kemotherapi siklus ke V

Lab 31/1/2013WBC 5,47 RBC 3,67 Hb 10,1 HCT 30,7 MCV 83,7 MCH 83,7 MCHC 32,9 PLT 116 PCT 0,14 Na/K/Cl 138/4,0/104 GOT/GPT 37/21 GDS 128 Ur/Cr 15/0,5

WS

53 Tandi/L/48 tahun/7365

MRS 25- 01-2013

Kmr 433

D/ Dyspepsia + ileus obstruktif parsial susp tumor gaster

Foto OMD 29/1/2013Tidak tampak kelainan radiologi pada foto omd ini

Lab 2 6 /01/2013 WBC 8,39 RBC 4,22 HGB 10,9 HCT 32,1 PLT 188

Lab 25/01/2013WBC 7,97 RBC 3,82 HGB 9,9 HCT 29,3 PLT 166 Na 132 K 3,2 Cl 105 GOT 10,1 GPT 9,5 Prot.total 4,9 Albumin 2,45 Ur 18,4 Cr 0,44

MSCT Abdomen 09/01/2013Kesan : efusi pleura bilateral

Thorax 07/01/2013 Kesan: normal

USG Abdomen 05/01/2013Kesan : gambaran ileus obstruktif

RL

PCC54 Salmin

L/46thn/589553MRS17/01/2013

Kamar 218

D/ Cholesistolith + cholelithiasis

Tunggu jadwal operasi

CT Abdomen lower/elvis (tanpa kontras) 23-01-13Kesan: -Distended GB dengan cholelyth ujung distal-Tanda-tanda cholecystitisUrin Rutin 18/1/2013Warna kuning, Ph 8s,0 Sedimen Leukosit 0-1, Sedimen eritrosit 0-1, sedimen epitel sel 1-2

Lab 17/1/2013PT/APTT 11,0/31,9 GDS 79 Ur/Cr 21/1,1 Bil.total 0,3 Bil.direk 0,1 GOT/GPT 19/35 Prot.total 4,2 Albumin 3,0 Kol.total 148 HDL 27 LDL 119 TG 81 WBC 14,0 RBC 4,28 HGB 12,8 HCT 39,0 PLT 417 HBsAg (-), anti HCV (-)

USG Abdomen 17/1/2013Over distended GB dengan choleliths

IL

55 Ny. Asrin L/591378

Kamar 219

D/susp. Colelithiasis+ nefrolithiasis (D)

Lab 31/1/2013WBC 5,6 RBC 3,47 Hb9,6 HCT 29,4 MCV 85 MCH 27,8 MCHC 32,8 PLT 371 PCT 0,242

Urin rutin 31/1/2013warna : kuningPH : 5,5BJ : 1,016Protein : negatifBilirubin : negatifLeukosit : ++++/500Blood :+-/5

Lab 30/1/2013WBC 4,8 RBC 3,27 Hb 8,0 HCT 27,5 MCV 84 MCH 24,6 MCHC 29,3 PLT 450 PCT 0,277 GDS 122 Ur/Cr 18/1,0 Bil.total 0,53 Bil.direct 0,16 GOT/GPT 36/19 Albumin 3,8 Na/K/Cl 144/3,3/109

Foto Thorax PA 29/1/2013Pulmo cor dalam batas normalDilatatio aortae, susp atherosclerosis

55 Muh. NizamL/35thn/563041

D/ POH 21 Laparotomi eksplorasi e.c

PA 10/1/2013Fistel dengan peradangan non spesifik

IL

19


MRS11/12/2012

Umum/Tunai

Kamar 222

fistel enterocutaneus


Lab 13/1/2013WBC 4,0 RBC 3,02 HGB 8,6 HCT 26,3 PLT 151 ALB 2,33

Lab 10/1/2013WBC 12.52, RBC 2.90, HGB 7.8, HCT 24.8, PLT 237 CT/BT 8’00”/3’00”, PT/APTT 13.1/27.1, INR 1,09 Ur/Cr 76/1,2 GOT/GPT 48/25,

Lab 3/1/2013WBC 11,3, RBC 4,52, HGB 12,1, HCT 37,2, PLT 580 CT/BT 7’00”/3’00”, PT/APTT 12,2/26,2, INR 1,0 GDS 174, Ur/Cr 79/1,1 GOT/GPT 13/22, Prot. Tot 6,9, Bil.tot 1,07, Bil.direct 0,27 Alb 4,5, Na/K/Cl 145/4,4/94,

UGIE 18/12/2012Kesan : Esofagitis candidiasis grade 2

Foto OMD 13/12/2012Kesan : Fistel enterocutaneus

Lab 12/12/2012CT/BT 9’30”/3’30”, PT/APTT 12,5/30,4, GDS 97, Ur/Cr 91/1,5, GOT/GPT 28/21, Prot. Tot 6,2, Alb 4,5, Na/K/Cl 145/4,8/93, HbsAg (-), Anti HCV (-)

57 Margarina KaromaP/56thn/587889MRS 8/1/13

Askes Wajib

Kamar 303

D/Tu. Retro peritoneum

POH 3 Laparotomi explorasi + ileostomi + biopsi

Lab 23-01-13CT/BT 7’30/3’30 PT/APTT 12,6/23,5 GDS 99 UR/CR 13/0,3 GOT/GPT 18/7 Alb 3,1 Na/K/Cl 137/2,8/107 WBC 8,4 RBC 3,62 HGB 10,5 HCT 31,6 PLT 529Foto Thorax PA 21/01/2013Foto thorax PA (kurang inspirasi). Kesan : -

Lab 18/1/2013Prot.total 6,4 Albumin 3,2 Na 132 K 3,2 Cl 104 WBC 6,5 RBC 3,65 HgB 10,5 HCT 31,9 PLT 392

PA 18/1/2013 Peradangan kronis tidak spesifik tidak ada sel-sel ganas

CT scan Abdomen 14-1-2013Kesan: Massa pada daerah rectosigmoid disertai tanda-tanda ileus obstruksi


Lab( 10 /1/13) WBC 27.2, RBC 3.45, HB 10.1, HCT 31.2 PLT 349, Alb 2.6

Lab(10/1/13)Alb. 2,6Lab(8/1/13)WBC 9,42, RBC 3,20, HB 8,9, HCT 29,2 PLT 41,9 Ur 30 Kr 0,5, GOT 20 GPT 21 Na 127CL93 K 3,6CT 8’’ BT 2’’ PT 12, APTT 24 GDS 68 alb 2,9 HbsAg (-), Anti HCV (-) BNO 3 Posisi Kesan : massa pelvis, Ileus paralitikThorax 8/1/2013Kesan: aspek bronchitis

RL

58 Damaris Kamaro P/85thn/557346MRS 4/1/2013

Askes Wajib

Kamar 321

D/ Tumor Colon ascendens POH 7 Hemicollectomy Dextra

Thorax PA 30/1/2013Kesan Bronchopneumonia bilateral Kardiomegali dengan dilatasi aortaeLab 27/1/2013WBC 3,59 RBC 3,43 Hb 10,2 HCT 31,0 MCV 90,4 MCH 29,7 MCHC 32,9 PLT 202 PCT 0,19 Ur/Cr 40/0,7Lab 25/01/2013CEA 3,16Lab 23/01/2013

WS

20


WBC 19.2; RBC 4.03; HB 12.3; HCT 37.3; PLT 347

Lab 19/1/2013WBC 8,1 RBC 4,2 HgB 12,4 HCT 37,9 PLT 251

LAB (17-1-2013)PT 11,4 APTT 29,1 CT 8’00 BT 2’30\ Lab 15-1-2013 Alb 3,0

Foto thorax PA 18/1/2013- CVC terpasang baik- Bronkpneumoni- Cardiomegaly dengan dilatio aorta serta atherocschlerosis

aorta

Foto thorax PA (11-1-2013)Kesan: Bronkopneumoni bilateral cardiomegaly dengan dilatasi aortae dan atherosclerosis aortae

Lab 10/1/2013WBC 4.6, RBC 2.83, HGB 9.1, HCT 27.6 PLT 271 HbsAg (-), Anti HCV (-), CT/BT 8”00/2”00, PT/APTT 11.1/32.6, GDS 105, Ur/Cr 26/0.7, GOT/GPT 15/9, Alb 2.1

Lab 5/1/2013WBC 8.8, RBC 3.61, HGB 11.4, HCT 35.2, PLT 435 GDS 114, Ur/Cr 39/0.8, GOT/GPT 15/17, Alb 2.79, Na/K/Cl 140/4.5/109.

Kolonoscopi RS Medistra 4/10/2012Kesimpulan: polip sigmoid dan tu.caecum

59 Tn DjamadingL/57thn/ 591239Kmr 306

D/HIL (D) Rencana operasiJumat 1/2/2013

Lab 29/1/2013WBC 8,7 RBC 5,46 Hb 15,7 HCT 47,0 MCV 86 MCH 28,7 MCHC 33,4 PLT 307 PCT 0,244 CT 8’00 BT 3’00 PT/APTT 9,8/25,4 GDS 96 Ur/Cr 28/1,1 GOT/GPT 20/26 Alk.Fosfatase 105 kol.total 202 as.urat 6,7 Foto Thorax PA 29/1/2013Kesan DBN

60 Tarpin AdamL/52thn/587906MRS 8/1/2013

Askes Wajib

Kmr 410

D/ ileus obstruktif parsial+ cholesistolith + cholesistitis

POH 3 kolesistektomi

Lab 19/1/2013Kol.total 149 HDL 21 LDL 105 TG 117

Lab (17/1/2013)WBC 11,5 RBC 4,47 HGB 13,8 HCT 42,4 PLT 505 PT 11,9 APTT 28,9 GDP 108

CT scan abdomen (14/1/2013):Kesan: Efusi pleura bilateral, cholecystolith akut, meteorismus

Foto Thorax 9/1/2013Tidak tampak kelainan

Foto polos abdomen 3 posisi 9/1/2013Kesan: ileus paralitik

Lab 9 /1/2013 WBC 20.30, RBC 4.87, HGB 14.8, HCT 43.4, PLT 228 GDS 125, Ur/Cr 31/0.9, GOT/GPT 28/38, Alb 3.4, Na/K/Cl 133/4.0/99, HbsAg (-) Anti HCV (-)

IL

61 Ernawaty / 48 tahun / P /326MRS 28/01/2013

D/ Polip Recti POH 2 Polipektomi

Lab 28/1/2013WBC 8,4 RBC 4,32 HGB 11,9 HCT 36,0 PLT 377 BT/CT 3’00/7’00 PT 9,7 INR 0,8 APTT 21,3 GDS 169 Ur/Cr 14/0,7 GOT/GPT 28/42 Prot.Total 6,9 Alb 3,8 Na/K/Cl 141/2,9/104 HbsAg non reactive

Lab 17/1/2013CEA 2,19Foto Thorax 29/1/2013kesan DBN

RL

62 Tn. Rachmat D/susp Tu. Lab 31/1/2013

21


Muchtar L/27thn/006464MRS 31/1/2013

Kmr 403

Abdomen CT 8’00 BT 3’00 PT 16,3 APTT 31,15 Ur/Cr 17/0,91

USG Abdomen 31/1/2013Kesan : tanda-tanda invaginasi disertai cairan disertai cairan bebas pada cavum peritoneum

Foto BNO 31/1/2013Kesan soft tissue mass rongga abdomen kanan

foto thorax PA 31/1/2013kesan : KP duplex lama aktif disertai pleural reaction bilateral

UGD63 Massetang

L/43thn/ 591637MRS 30/1/2013

Soppeng08114135810 (Nadia)

D/ Tu Recti 1/3 distal Rencana colon in loop Senin 4/2/2013

Lab 30/1/2013PT/APTT 11,8/23,2 CT/BT 7’00/2’00 GDS 103 Ur/Cr 15/0,7 GOT/GPT 23/17 Alb 4 Na/K/CL 144/4,76,107 HbsAg(-) RBC 4,4 HB 13,6 HCT 41,4 PLT 437 WBC 7,6USG abdomen 30/1/2013Tidak tampak tanda-tanda metastasis Tidak tampak tanda-tanda dilatasi loop-loop ususMassa rectum sulit dievaluasi

64 Julius RonaldoL/50thn/591667MRS 30/1/2013JKD

Jl. Siratal Mustakim No.9, Pare-pareYuli(081242728658)Ambo(081343662986)

D/Tu.Anorectal Lab 30/1/2013CT/BT 9’30/8’30 PT 9,3 APTT 33 GDS 97 Ur/Cr 16/0,8 GOT/GPT 59/25 Alb 2,5 Na/K/Cl 135/4,5/107 HbsAg (-) WBC 8,73 RBC 4,85 HB 13,7 HCT 42 PLT 325

65 SenahatiP/38th/591916MRS1/2/13Desa AmbapaHasna(085229346190)

D/ Tu Abdomen Lab 1/2/13CT/BT 8/3 PT 11,6 APTT 21,6 GDS 101 Ur/Cr 12/0,6 GOT/GPT 50/39 Alb 3,1Na/K/Cl 141/3,7/102 HbsAg (-) RBC 3,36 Hb 9,8 HCT 30,5 PLT 452 WBC 11,3

ICU66 Gede Putra

AstamanL/590280MRS 23/1/2013

ICU VIP 1

Kayu Calla MamujuNi Wayan E 085349982689

D/ Post Debridement Trauma Tumpul Abdomen + Trauma tumpul thoraks hari 10 (23-01-2013) Vulnus Excoriatum Regio Flank Sinistra

Lab 30/1/2013PT 12,1 APTT 23,5 INR 1,01 Na/K/Cl 132/4,8/99 Ur/Cr 43/0,6 Alb 3 WBC 14,55 RBC 3,62 Hb 10,2 HCT 31,7 PLT 304

Lab 28/1/2013AGD : Alkalis metabolik terkompensasi sempurna

Lab 27/1/2013GDS 109 Ur/Cr 33/0,8 GOT/GPT 51/34 Alb 2,2 Na/K/Cl 142/3,87/103 WBC 16,33 RBC 381 Hb 11,2 HCT 35 PLT 253

Foto Thorax AP (25/01/2013)Kesan: contusio paru bilateral + old fract. 1/3 middleLab (25/01/2013)AGD: asidosis respiratorik GDS 105 Ur/Cr 48/0,8 GOT/GPT 89/41 Alb 2,5 Na/K/Cl 145/3,9/109 WBC 11,13 RBC 3,98 HB 11,5 HCT 34,7 PLT 154

Lab 23/01/2013 CT/BT 8’/3’ PT /APTT 14,3/30,8 GDS 89 Ur/Cr 49/1,2 GOT/GPT 115/43 Prot Total 5,9 Alb 2,4 Na 140 K 3,4 Cl 109 Wbc 12,6 RBC 3,53 HB 10,2 HCT 30,8 PLT 146USG ABDOMEN 23/01/2013Tidak tampak tanda tanda laserasi organ intraabdomen

22


Efusi pleura dextra 67 Sabella

P/19thn/589900

JKD

ICU Bed 9

Bulurokeng081342400493

D/ Post reseksi anastomose ileum ec. Valvulus ileum hari 12 (21/1/2013)


Lab 31/1/2013AGD Alkalosis metabolik dan respiratorik (mixed vein)WBC 2,34 RBC 3,5 HB 9,2 HCT 30,7 PLT 57

PA 23/1/2013Peradangan kronik nonspesifik (sesuai perforasi)

Lab 30/1/2013AGD DBN

Lab 27/1/2013PT/APTT 183/38,2 INR 1,42 GDS 136 Bil.tot 2,04 GOT/GPT 1459/266 Alb 2,4 Na/K/Cl 153/4,19/115 WBC 5,96 RBC 2,73 Hb 7,2 PLT 39Thorax 27/1/2013Pulmo normalCardiomegali

Lab 29/1/2013WBC 6,77 RBC 3,72 Hb 10,3 HCT 32,1 PLT 66Lab (26/01/2013)Jam 08.59 HB 5,7 transfusi WB 2 bag HB 8,2 transfusi PRC 2 bag HB 11,3WBC 10,57 RBC 4,04 HCT 35 PLT 101 CT/BT 7’00”/3’00” PT/APTT 12,7/29,2 GDS 106 Bil.tot 0,41 Bil.direk 0,19 GOT/GPT 101/83 Alb 1,8 Na/K/Cl 143/6,5/15Foto Thorax AP (26/01/2013)Kesan: pneumonia (D), edema paru + efusi pleura bilateral, fr.coastae V-VIII kiri belakangLab 22/1/2013WBC:11,8 RBC:4,29 HGB:11,9 HCT:36,3 PLT:490 GDS:114 Ur:50 Cr:1,0 GOT:30 GPT:17 Albumin:1,7 Na:136 K:3,6 Cl:100Lab 21/1/2013CT:7’00” BT:3’00” PT:11,9 APTT:19,0BNO 3 posisi 21/1/2013Kesan : Dilatasi loop-loop usus disertai tanda- tanda ileus obstruktif. Fecal mass pada level colon ascendensUSG Abdomen 20/1/2013Kesan : Cairan bebas minimal intraperitonium. Dilatasi loop loop usus dengan peristaltic yang meningkat. Apendicitis belum dapat disingkirkan.

68 Marawiah/P/55 tahun/ 596065ICU bed 10Konsul 25/1/2013

Lekoboddong, Pangkep085397898384

D/ POH5 laparotomy explorasi ec perforasi sigmoid +tumor rectosigmoid

Lab 30/1/2013GDS 135 Ur/Cr 39/0,6 GOT/GPT 19/7 Alb 2,7 Na/K/Cl 148/3,2/106WBC 22,87 RBC 3,12 Hb 9 HCT 28,1 PLT 327Lab 28/1/2013AGD : asidosis respiratoriklab 24/1/2013 WBC 24,03 RBC 3,77 Hb 11,3 HCT 33,4 PLT 291 Ur/Cr 38/1,3 GOT/GPT 24/4 Na/K/Cl 140/3,4/104 HbsAg (-)BNO 3 posisi 24/1/2013Sesuai gambaran ileus paralitikLab 25/1/2013CT/BT 8/2 PT/APTT 14,6/27,6 GDS 110 Alb 3,0Thorax AP 25/1/2013PneumoperitoneumPneumonia D/Cardiomegaly +dilatatio aortaeLab 26/1/2013WBC 7,52 RBC 3,37 Hb 9,6 HCT 30,3 PLT 253 GDS 153 Ur/Cr 35/0,9 GOT/GPT 15/5 Alb 1,5 Na/K/Cl 142/3,1/115Thorax AP 27/1/2013Cardiomegaly + tanda-tanda bendungan paruDilatatio et Elongatio AortaeElevasi diafrgama kanan Lab 27/1/2013AGD asidosis metabolik

23


WBC 7,52 RBC 3,37 Hb 9,6 HCT 30,3 PLT 25369 Pattaungang/

L/42 tahun

ICU Bed 3

D/ POH 8 hemicolectomy ec Tu colon ascendens

Thorax AP 30/1/13Kesan : Pneumonia D/Lab 31/1/13AGD : dbnLab 29/1/13GDS 99 Ur/Cr 36/0,6 GOT/GPT 33/16 Alb 2,3 Na/K/Cl 144/ 3,7/110WBC 10,56 RBC 3,61 Hb 9,3 HCT 27,9 PLT 183Lab 27/1/13GDS 156 Ur/Cr 37/0,7 GOT/GPT 41/27 Alb 2,2 Na/K/Cl 147/4,5/116WBC 19,44 RBC 5,21 Hb 13,3 HCT 39,6 PLT 224Lab 23/1/13CEA 1,32Lab 23/1/2013CT/BT 8’00/2’30 PT/APTT 14,8/27,7 INR 1,19 Na 129 K3,8 Cl 103 CEA Menyusul GDS 129 UR/CR 40/0,8 GOT/GPT 11/10 Prot Tot 5,6 Albumin 2,4 Globulin 3,2 WBC 9,60 RBC 3,48 HGB 8,3 HCT 25,3 PLT 574Foto Thorax (23/01/2013)Dalam batas normalUSG Abdomen (21/01/2013)Suspect massa pada colon ascenden DD/ Appendicitis KronikCT Scan Abdomen Lower/Elvis (Tanpa kontras)(21/01/2013) Massa colon ascenden denga suspek metastases ke hepar LAB (22/01/2013)GDS 109, Prot Tot 5,78 Albumin 2,68 Globulin 3,10LAB (21/01/2013)GDS 130 UR/CR 36/0,9 GOT/GPT 11/10 WBC 9,9 RBC 4,01 HGB 9,4 HCT 30,2 PLT 901

69 Husain/L/70thn590926MRS 26/01/13

HCU Bed 3

Jl. Kapasaraya No. 25 B Mks081392478839Husmawati

POH3 laparotomy explorasi ec tu. Sigmoid dukes A

Lab 30/1/2013GDS 100 Ur/Cr 24/0,6 GOT/GPT 29/17 Alb 2,1 Bil. Total 1,21 Na/K/Cl 136/4,6/107 Bil.direk 0,69 WBC 10,35 RBC 4,45 HB 12,3 HCT 37 PLT 331Thorax 30/1/2013Pleural reaction dekstraElevasi diafragma dekstraLab 29/1/2013CT/BT 8/4 PT/APTT 10,5/24,3 Alb 3,4 Na/K/Cl 13,8/4,75/102 RBC 4,36 HB 11,5 HCT 37,3 PLT 527 WBC 6,8Thoraks 27/01/2013Kesan : Pleural reaction dextra, dilatatio et elongatio aortae, elevasi diafragma kanan (proses intraabdominal)BNO 3 posisi 27/01/2013Kesan : Gambaran ileus paralitikLab 26/01/2013WBC 7,11 RBC 4,48 Hb 11,7 Hct 37,2 PLT 520 CT 8’00 BT 3’00 PT 11,1 APTT 23,4 GDS 99 Ur/Cr 44/0,9 GOT 34 GPT 25 Prot.tot 6,4 Alb 3,5 Glob 2,9 Na 136 K 4,0 Cl 102 HbsAg (-) Anti HCV (-)

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Koran Diges 02 Feb

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