Koran Digestif Lontara 2 Kamar 10
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LONTARA 2 DIGESTIF Kamar 10 No Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi K10/B1 MADDE 01.07.1942 736885 Mrs : 15.12.15 DPJP : dr. Samuel Sampetoding, Sp.B KBD Tumor Intra AdomenTumor adnexa (NOK) LAB 22.12.15 Alb 2.5 Lab 20.12.15 Wbc :12.7 Hb :10.7 Ur/Cr :66/1.95 Hct :32Sgot/Sgpt:48/74 Alb :2.5 Na/Kal/Klo: 140/3.7/113 Lab 20.12.15 Wbc :14.1 Hb :8.8 Hct :26 PLT : 649 RBC : 2.85 Lab 17.12.15 CEA : 2.41 Ca-125 : 28.88 Lab 15.12.15 Wbc :18.0 Gds :113 Hb :7.6 Ur/Cr :121/3.02 Hct :23 Sgot/Sgpt:48/74 Pt/Aptt :9.8/27.2 Inr :0.92 Alb :3.1 HbsAg :Non reaktiv Na/Kal/Klo: 141/5.8/117 FotoThoraks PA/AP (15.12.15) - Cardiomegaly dengan dilatation et elongation aortae - Elevasidiafragmadextra (proses intra abdomen ?) - Tidaktampak tanda2 metastasepadafotothoraksini USG Abdomen Atas + Bawah (Whole Abdomen) (15.12.15) -Suspekmassakompleksadneksa - PNC bilateral IVFD RL 28 tpm Ranitidin amp/8 jam/iv Obgyn Acc rawat sama Tunggu jawaban konsul perioperatif
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Transcript of Koran Digestif Lontara 2 Kamar 10
LONTARA 2 DIGESTIFKamar 10
No Identitas Pasien Diagnosa Pemeriksaan Penunjang InstruksiK10/B1MADDE01.07.1942736885Mrs : 15.12.15
DPJP : dr. Samuel Sampetoding, Sp.B KBD
Tumor Intra AdomenTumor adnexa (NOK)
LAB 22.12.15Alb 2.5Lab 20.12.15 Wbc :12.7Hb :10.7 Ur/Cr :66/1.95Hct :32Sgot/Sgpt:48/74Alb :2.5Na/Kal/Klo: 140/3.7/113Lab 20.12.15 Wbc :14.1 Hb :8.8 Hct :26 PLT : 649RBC : 2.85
Lab 17.12.15CEA : 2.41Ca-125 : 28.88
Lab 15.12.15 Wbc :18.0 Gds :113Hb :7.6 Ur/Cr :121/3.02Hct :23 Sgot/Sgpt:48/74Pt/Aptt :9.8/27.2Inr :0.92Alb :3.1HbsAg :Non reaktivNa/Kal/Klo: 141/5.8/117
FotoThoraks PA/AP(15.12.15)- Cardiomegaly dengan dilatation et elongation aortae- Elevasidiafragmadextra (proses intra abdomen ?)- Tidaktampak tanda2 metastasepadafotothoraksini
USG Abdomen Atas + Bawah (Whole Abdomen)(15.12.15)-Suspekmassakompleksadneksa- PNC bilateralSimple renal cyst dextra-Ascites
CT Whole Abdomen (TanpaKontras)(15.12.15)- Massa region pelvis yang meluaske abdomen sugestifmassakompleks adnexa- Slight hepatomegaly
IVFD RL 28 tpm Ranitidin amp/8 jam/iv Obgyn Acc rawat sama Tunggu jawaban konsul perioperatif
K10B2NAIDAH
POH 10 laparatomi eksplorasi ec biopsi hepar ec adenocarsinoma recti 1/3
Lab 13/12/2015Wbc : 10.1 Plt : 493
IVFD RL 28tpm Ceftazidine 1gr/12jam/iv
31/12/1971 (40thn)665537Mrs : 30/10/2015
DPJP: Dr.warsinggih ,Sp B-K BD
medial + Burst abdomen Hb : 10.2 Pt/Aptt : 10.0/27.2Hct : 30 Gds : 200Ur/Cr : 49/1.43Sgot/Sgpt : 61/9Alb : 2.7As. Urat : 4.3Na/k/cl : 130/5.1/107
Lab 20/12/2015Gds 121
Lab 21/12/2015WBC 21.8RBC 3.78HGB 11.3HCT 33PLT 68PT 16.2INR 1.53APTT 31.6Albumin 3.1Natrium 147Kalium 4.2Klorida 115
26/12/2015WBC 12.7RBC 3.62HGB 11.2PLT 70GDS 145UR/Cr 68/0.52Protein total/alb 4.8/2.5SGOT 32Na/K/Cl 39/3.8/118
MSCT whole abdmen non kontras:Massa rectumAscitesTumor meta keheparLymphadenopathy paraaortaabdominalisEfusi pleura
30/10/2015USG ABDOMEN: lesiheterogenrongga pelvis suspekmassa rectumNodul metastasis heparHidronephrosissinistra
Colon in loop Tumor colon sigmoid sugestifmalignitas Usg abdomen:31/8/2015 Massa adnexa Tumor metastasis hepar Ascites Splenomegaly
Ketorolac 30mg/8jam/iv Ranitidin 50mg/8jam//iv Diet lunak Ambroxol 3x1 Transfusi trombosit 2 bag Infus albumin 25% Cek darah
Foto Thorax (18/12/2015)- CVC terpasang- CordanPulmo normal- Elevasidiafragmakanan
3. BED 3Sumarni1/7/1973722706MRS23/12/2015DPJP dr Samuel SAmpetoding, SpB-KBD
Adenocarcinoma gasterStd 4 Pro kemo S1
15/12/2015WBC 5.2RBC 4.05HGB 11PLT 318PT/APTT 13/30.5CT/BT 7.3/3Ur/Cr 43/0.8GDS 82SGOT/SGPT 52/44Albumin 2.9As. Urat 5.3Na/K/Cl 144/4.3/112CEA 16.76
PA 25/9/2015Adenocarcinoma diff jeleklambung yang sudahmengenai esophagus dengansatuujungreseksilambungbebas tumor
RL 28 tpmRanitidin 1 amp/8J/IVPro kemoharisenin 28/12/2015VIP albumin 3x2
4 BED 4Haratuo14/5/1964737280MRS18/12/2015DPJP Dr. dr Ronald Lusikooy SP.B-KBD
Tumor recti 1/3 distal 21/12/2015WBC 6RBC 4.51HGB 10.7PLT 447CEA 188.88
RL:D5 1:1 28tpmNeurobion 1 amp/24j/ivRencana colon in loop 28/12/2015Tunggu hasil biopsi anal kanal
5 BED 5ISA1/7/1961738070MRS24/12/2015DrdrWArsinggihSp.B-KBD
Tumor recti 1/3 distalPost colostomy
24/12/2015WBC 6.2RBC 4.27HGB 12.3PLT 265PT/APTT 9.7/25.2GDS 104Ur/Cr 46/0.71SGOT/SGPT 28/26Protein total/Alb/Glb 4.7/2.5/2.2NA/K/CL 140/1.6/100
Foto ThoraxTidakadatandatanda metastasis
RL 28 tpmRAnitidin 1 amp/8JKetorolac 1 amp/8JBilaselesaikoreksi AlbuminTungguhasil CT-ScanVip albumin 3x2 capsKCl 500meq dalam NaCl 0,9% 500ccInfus albumin 25%Cek CEA, elektrolit dan albumin post transfusi
6 BED 6Idesseng31/12/1959733820MRS21/11/2015SS
POH 11 drainase ascites + Bile 26/12/2015WBC 9.8RBC 4.05HGB 11.9PLT 193GDS 125Ur/Cr 25/0.56SGOT/SGPT 27/14Alb 2.5As. Urat 2.5
Cefadroxyl 2x1Ranitidine 2x1As. Mefenamat 2x1Udafalk 2x1VIP albumin 3x2Takar drain/12 JamRencanaOperasiselasa 24/12/2015Infus albumin 25%
NA/K/CL 136/3.8/112
23/12/2015Gama GT 78Tu. Marker AFP 0.82Bilirubin tot/dir 10.43/9.46
MRI 27/12/2015CholangiopancreatografidengankontrasKesan hepatomegaly dengan cholestasis intra danekstra hepatic ecsugestifmassa caput pancreas disertai stenosis CBDSplenomegalyAscites
MSCT whole Abddengankontras 27/12/2015Cholestatik intra et ekstra hepatic ecmassa caput pancreasAscitesEfusi pleura bilateralHepatosplenomegaly
USG whole abd 20/12/2015Hepatosplenomegalidilatasibilier intra hepaticCholesistitisAscites
Foto thorax 20/12/2015KardiomegaliTandatanda edema parudisertai dilatation aorta suspefusipneuma pleura dextraElevasi diaphragm kanan (proses inta hepatic?)
