Koran Digestif Tgl 9 September 2013

Koran Bedah DigestifSenin, 09/09/2013

PALEM ATASNo Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi1 Atas B1/7 Baharuddin / 61 tahun

31-12-1951625488MRS 31/8/13

DPJP : Dr.dr.Ibrahim Labeda,Sp.B-KBD

D/Cholesistolithiasis POH 4 laparoskopi cholesitektomi ec. cholelitiasis

CT Abdomen Atas/Bawah (tanpa kontras) 3/9/13Kesan : cholelittisLab 3/9/13RBC 3,95 WBC 5,3 HGB 12 HCT 36,5 PLT 159 GDP 79 Kol.total 187 HDL 20 LDL 109 TGL 224Lab 31/8/13Na 135 K 4,3 Cl 105 CT 6’30” BT 2’00” GDS 83 PT 10,8 (11,3) APTT 27 (26,1) Ur 55 Cr 1,4 GOT 37 GPT 54 USG Abdomen 31/8/13Kesan : cholelithFoto thorax PA 4/9/13Kesan: kardiomegali dengan dilatation et elongation aortae + atherosclerosis aortae

Terapi post operasiIVFD RL 28 tpmCeftriaxone 1g/12j.ivMetronidazole 0,5 gr/8j/IVKetorolac amp/8 jam/IVRanitidin amp/ 8 j/ IV

2 Atas B2/5 Bed 1 Azis Taba 10/11/1959 / 53 thnASKES 623925MRS 23/8/2013

DPJP : Dr.dr.Warsinggih, Sp.B-KBD

D/Tumor Abdomen ec susp lymphoma UGIE (8-8-2013)- Gastropati hipertensi portal derajat sedang- Varises fundus derajat ringan

CT abd 13/8/2013Massa paraaorta abdominalis susp lymphomaSplenomegaly

USG abd 13/8/2013Massa paraaorta abdominalis susp lymphoma Splenomegaly

Lab 23/8/13WBC 9,52 RBC 3,45 HGB 10,4 HCT 33,2 PLT 177 CT/BT 8/3 PT/APTT 13,2(13,2)/22,6(26,5) GOT/GPT 116/47 Bil. Tot 1,94 Bildirek 1,38 Alb 3,1 GDS 109 Ur/CR 31/0,8 HbsAg + HCV – CEA 10,85 CAIg-g <3,00, Na: 138 , K : 4,6, Cl: 99, Asamurat:5,6Hasil PA 2/9/13Kesan: radang kroik aktif dengan helicobacter pillory (-)Hasil echo (27/8/13Kesan : disfungsi sistolik LV baik, ef 66 %, disfungsi diastlik

IVFD RL 28 tpmOmeprazole inj/12j/IVKetoroloc amp/8jam/ivSukralfat 3x1 cth

3 Atas B2/1 bed 2 PaiminTTL : 29-02-1960/ 52 tahun/LRM : 625761MRS : 6/09/2013ASKESDPJP : Dr.dr.Ibrahim Labeda,Sp.B-KBD

D/ Cholelitiasis Lab 5/09/2013BT/CT : 2’/8’, PT 10.3 C 10.6, APTT : 25.6 C 23.6CT Abdomen 4/09/2013Kesan : Chilaiditis Diseases, Hepatomegali, Tdk tampak cholelith opakLab 3/09/2013

Rencana Operasi Senin 9/9/2013Laparoscopy Cholesistektomi

1


GDP : 133, Ur/Cr : 35/0.85, As.Urat : 8.0, SGOT/SGPT : 18/46, Kol. Total : 276, HDL direk : 46, LDL direk : 219, TGL : 71, RBC 5.66, hb : 10,1, PLT : 342

4 Atas B2/3 bed 1 Ny. Elisabeth B / P/ 54 thn24/06/1959 (542518)MRS : 25/08/2013ASKES

DPJP : Dr.dr.Ronald E. Lusikooy,Sp.B-KBD

D/ Abses HeparPOH 6 open laparotomy ec. Abses hepar

Lab 25/8/13WBC 9,42 RBC 4,11 HGB 12,2 HCT 35,9 PLT 371 CT/BT 7.30/2.00 PT/APTT 11,1(11,9)/23,8(26,6) GOT/GPT 51/72 Bil. Tot 0,8 Bildirek 0,4 Alb 2,9 GDS 109 Ur/CR 7/0,6, Na: 142 , K : 3,6, Cl: 111,

CT Abdomen (whole) 28/8/13Kesan : lesi kistik sesuai gambaran miomaUSG 25/8/13Kesan: massa lobus kanan hepar susp.absesHasil PA 12/8/13Kesan : colecystitis chronic

IVFD RL: D5 28 tpmCeftriaxone 1g/12jivMetronidazole 0,5 gr/8 j /dripsKetorolac amp/8j/ivRanitidin Amp/8j/IVBalance cairan

5Atas B2/K7

bed 2Maemuna Djawasa/P/ 52(13-6-1961) 591443 ASKESMRS tgl 16-8-2013

DPJP : Dr.dr.Ronald E. Lusikooy,Sp.B-KBD

D/ POH 6 explorasi CBD MSCT scan abdomen21/8/2013- Cholestatik intra dan ekstra hepatic ec.

Susp.massa distal CBD DD/ luscent stone

- Cholelith

Lab (19/8/2013)WBC 11,16 RBC 3,28 Hgb 11,9 Hct 33,4 Plt 371 GPT 39 Alb 3,4 HbsAg non reactive CT 2’00 BT 8’00 PT 15,7 vontrol 10,8 APTT 30,01 cntrol 24,3 GDS 118 ureum 19 kreatinin 0,4 bil total 21,5 bil direct 18,6 GOT 46Echo 30/8/13Kesan : kontraktilitas LV baik , ef 63% +LVH disfungsi diastolic

Lab 06/09/13Bil. Total: 13,59Bil.diret 12,64Ab 2,5

IVFD Rl:D5 28 tpmCeftriaxone 1g/12j.ivMetilprednisolon 3x4

6Atas/B2/8 Tn. Sultan /L/

MRS 18/8/2013569915ASKES

DPJP : Dr.dr.Warsinggih, Sp.B-KBD

D/ post op H 20 Laparotomy eksplorasi +reseksi anastomis

Lab 26-8-13GDS 97, ur/cr 18/0,8 got/gpt 21/14, alb 219, ct/bt 7’/3’, Lab 20/08/2013 :Alb : 2,3, Na : 139, K : 4,15 , Cl: 106Lab16/08.2013WBC 24,7 RBC 4,3 HGB 13,01 HCT 40,0 PLT 199 CT 7’00 Bt 1,30 PT 10,9 APTT 26,7 Hbsag non reactive, antiHCV non reavtive GDS 89 Ureum 13 ,Kreatini 0,8 SGOT 22 SGPT 19 Protein total 6,1 Alb 3,9 Globulin 2,2 Na 136 Ka 3,9 Cl 105Lab 6/9/2013WBC 13,2 RBC 3,5 Hgb 10 Hct 30,5 Plt 306 GDS

Vip Albumin cap 3x2Durogesic patch 25 mg Makan dan minum biasaJus Buah

2


112 albumin 3 na/k/cl 130/3,6/102PA 20/08/13Kesan : adenocarcinoma difertiasi sedang dan kedua ujung reseski bebas tumor.

7 Atas B2/13 Najmi (286728) 31-12-1958MRS 28-08-13ASKES


D/POH 6 Laparoskopi Lab 19-8-13WBC 7,2 RBC 4,65 HGB 13, HCT 39,5 PLT 307 PTAPTT 11,9/24,8 Ur/Cr 24/0,6 CT/BT 6’/3’

IVFD RL:D5 28 tpmCeftriaxone 1g/12j.ivKetorolac amp/8 jam/IVRanitidin amp/ 8 j/ IVDiet bubur

PALEM BAWAH8 Bawah B2/14

bed 2J. Pamrorongan07/5/1948622932MRS 27-8-13Askes


D/Tu. Abdomen ec. RhabdomiosarkomaCKDHidronefdrosis Bilateral

Lab 31-08-2013PT : 11.2 C 11,3. APTT : 23.3 C 26.1. GDP : 76 Ur/Cr : 171/11,6. SGOT/SGPT : 55/17. Albumin : 3,9. Kol. Tot : 187. HDL : 187. HDL : 17. LDL : 140. Na/K/Cl : 130/58/101. HbsAg : -. Anti HCV : -. RBC ; 3,79. WBC : 6,28. Hb : 11,6. HCT : 32,3. PLT : 247USG Doopler vaskuler Ext Inf (D) 30-8-2013Kesan : deep vein thrombosis setinggi V.femoralis profundaedema intestinalDopper vaskuler: DVT susp. Setinggi vena plmonalis profunda+edema interstitial

Lab 15-8-13CT/BT 8/3, PT/APTT 10,4/21,6 GDS 126, ur/cr 79/2,9 GOT/GPT 32/19, HGB 13,5. PLT 388

USG (15-8-13)Fatty liver, hydronefrosis bilateral massa reg. inguinal (d)

R/ cipro 2x500Ranitidine 3x1Valium 2 mg 0-0-1Neurodex 2x1

9 B1/ 9 Nursiah rachman1/1/1947RM 317211MRS 24/8/13


POH 5 Laparoscopy Cholecystectomy CT scan 29-8-2013Kesan:

- cholecystilithiasis- myoma uteri

LAB 30/8/13Wbc 9,13 rbc 3,78 hgb 10,9 hct 32,3 plt 258

Lab 28/8/2013PT/APTT 10,7/ 27,9 HbA1C 5,1 Bil.total 0,54 Bil Direc 0,13 Alb 3,2

USG : Multiple cholelith dan tanda congenetive liver

Aff catheterCephadroxl 2x1Asam afenamat 3x1Omeprazole 1x1

LONTARA INo Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi10 L1 AD/K4/B1 Ny. Lina 17-3-1985 D/ ileus obstruksi Lab 3/9/13 IVFD RL:D5% 1:1 = 28 tpm

3


625101JKM


WBC 4,9 RBC 5,75 HGB 9,7 HCT 32,9 PLT 337 Alb 1,7 BT 3 CT 8Lab 29-8-13WBC 7,38 RBC 4,59 HB 11,8 HCT 33,5 PLT 471HBsAg (+)

Abdomen 3 posisi 29/7/2013Large Bowel Obstruction

Ceftriaxon 1 gr/8 jam/ivMetrinidazol 0,5 gr/ivRanitidine amp/8 jam/iv

11 L1 AD/RPK Bed 1

Tn. Mappe/L/7/5/1952625395JKM


D/Peritonitis generalisata e.c susp perforasi gaster

Lab4-09-2013WBC 5.6 RBC 4.11 HGB 10.8 PLT 155 HCT 34.1 Na/K/Cl 147/4.1/123SGOT/SGPT 33/28

Lab 30/8/2013RBC 5,15 HGB 14 HCT 43,1 PLT 226 Ur 50 Cr 1,4 SGOT 16 SGPT 12 GDS 118 Na 141 K 4,73 Cl 108

Foto thoraks AP (kurang inspirasi) 30/8/13Kesan :

- atelektasis lobus superior paru kanan- Pneumonia dextra- Cardiomegali dengan dilatatio aortae

Keluarga menolak pemasangan CVC

12 AB/K3B2 Mansyur dg.. Limpo9/1/1973625396JKM


D/ Tumor abdomen Lab 3/9/13WBC 8,55 RBC 3,94 HGB 9 HCT 28,4 PLT 495 Lab 30/8/13GDS 83 Ur 21 Cr 0,4 GOT 6 GPT 4 Alb 1,7 na 131 k 4,3 Cl 103FOTO thorax PA 30/9/13Kesan: tidak tampak kelainanCT whole bodyKesan: massa intraluminer area bulbus duodenum dengan distensi gaster sugestive trichobezom

VIP albumin 3x2Ceftriaxon 1 gr/12j/ivKetorolac amp/8j/ivRanitidin amp/8j/iv

13 AB/K7B2 Sahabuddin111/10/1969/613004JKM


D/HIL (S) Lab 4/9/13WBC 3,07 RBC 4,53 HGB 13,3 HCT 38,3 PLT 50.000Lab 3/9/13WBC 3,0 RBC 4,4 HGB 12,4 HCT 38,8 PLT 39.000 CT/BT 8’00”/3’00” PT/APTT 12,4 (13,5)/27,5(26,4) Na/k/Cl 140/3,1/106GDS 142 Ur/Cr 18/1,0 GOT/GPT 15/9 Alb 4,7 As.urat 7,3

Rencana operasi

14 AD/K3 B1 Sahari 1/11/1969624660JKM


D/ Tumor Colon Sigmoid CT whole body 28/8/13Kesan:-massa colon transversum yang meluas ke mesentrica

- nephrolith dextra

Transfuse PRC

15 RPK bawah bed Nurmawaddah/625469/25-11-1995 D/ Ileus paralitik susp. Peritonitis Lab 2/9/13 Instruksi post op :

4


3 Konsul tgl 1/9/2013Jamkesda


POH 1 Laparotomy ec peritonitis WBC 4,5 HGB 12,9 HCT 39,4 PLT 513 Na 137 K 2,82 Cl 105Lab 31/8/2013Hb 12,7 PLT 346 WBC 9,65 Alb 3 PT 12,4 APTT 27,7 SGOT 19 SGPT 9 Ur 10 Cr 0,6Lab 5/9/13WBC 3,71 HGB 12,9 HCT 32,9 PLT391 Na 133 K 3,4 Cl 105

USG abdomen 31/8/2013Dilatasi loop-loop usus halus sesuai tanda-tanda ileus

Foto abdomen 3 posisi 31/8/2013Sesuai dengan parsial small bowel obstruction

IVFD RL:D5 28 tpmCeftriaxone 1g/12j.ivMetronidazole 0,5 gr/8j/IVKetorolac amp/8 jam/IVRanitidin amp/ 8 j/ IV

LONTARA 2 DIGESTIVEISO

No Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi16 1 Andarias Ruruk/L/57 thn

(1/7/1956) 617461JKDMRS tgl 16/8/2013

Dr.dr.Ronald E.L,Sp.B-KBD

D/ - Burst Abdomen

- POH 13 Miles Procedure e.c Ca. anorectal

Lab 3/9/2013CT/BT 7’30”/3’00” PT/APTT 11,8(11,5)/29,4(24,6) Na/K/Cl 130/3,3/107 GDS 78 Ur/Cr 14/0,5 GOT/GPT 19/10 Alb 2,3 WBC 11,86 RBC 3,42 HGB 10,2 HCT 38,5 PLT 457

Lab 27/8/2013WBC 10,5; RBC 3,57; HCT 32,2; HB 10,1; PLT 341

Lab 16/8/2013Wbc 6,6 Rbc 3,96 Hgb 11,6 Hct 36,6 Plt 412 HBsAg (-) anti HCV (-) AFP 2,5 CEA 6,9 CA 19-9 45,34 CT 8’00 BT 3’00 PT 10,8 (10,7) APTT 24,6 (24,6) Na 134 K 4,4 Cl 100 GDS 100 Ur 16 Cr 0.9 GOT 18 GPT 15 Prot.total 6,2 Alb3,5 Asam urat 3,8

LGIE 18/7/2013Tumor recti susp. Maligna

FOTO THORAX (12/7/2013)Kesan : Bronchitis emphysematousTidak tampak tanda-tanda metastasis pada foto thorax

FOTO BNO/FOTO COLON INLOOP (11/7/2013)Kesan : -Usul : MSCT Scan lower abdomen

RL 28 tpmCeftriaxone 1gr/12 j/ivKetorolac 30 mg/12 j/ivRanitidine 1 amp/8 jam/ivPeriksa albuminKalbamin per drips

17 ISO bed 2 Ansar /L/38 tahun D/fistula perianal Lab 1/9/13 RL 28 tpm

5


1-7-1975609871JamkesmasMRS tgl 1-9-2013Dr.dr.Ronald E.L,Sp.B-KBD

WBC 21,7 RBC 3,61 HGB 9,4 HCT 29,8 PLT 599 CT 7’00” BT 2’30” PT 11,4 APTT 24,3 GDS 140 Ur 16 Cr 0,7 Alb 3 Na/k/Cl 137/3,8/111

Ceftriaxone 1gr/12 j/ivMteronidazole 0,5 g/8j/ivKetorolac 30 mg/12 j/ivRanitidine 1 amp/8 jam/ivMRI (tunggu hasil 9/9/2013)

LONTARA 2 DIGESTIVEKAMAR 1

No Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi18 KMR1/B1 Niswan /P/36 THN (624004)

23-2-1977ASKES


D/ POH 4 Laparoscopy Cholesistectomy

Lab 29-8-2013Bil.total 0,64; Bil.direk 0,14; GOT/GPT 19/17; Na/K/Cl 139/3,2/104WBC 9,3; RBC 4,81; HB 13; HCT 38,4; PLT 311CT abdo. Tanpa kontras 23/8/2013Kesan : cholelithLab 22/8/2013WBC 10,7; RBC 4,87; HB 12,6; HCT 394; PLT 285; SGOT/SGPT 18/35; GDS 122; Ur/Cr 17/0,6; CT/BT 8’00/3’00;PT/APTT 11,2(12,5)/25,2(26,1)

RL 28 tpmCeftriaxone 1gr/12 j/ivKetorolac 30 mg/12 j/ivRanitidine 1 amp/8 jam/ivDiet makan lunak

19 KMR1/B2 Iswari Dg Puji/P/22 thn(27/9/1990) 618534JKM

MRS 19/8/2013

Dr.dr.Ibrahim Labeda,Sp.B-KBD

D/ POH 3 laparoscopy ekplorasi + eksisi tumor

30/8/2013CEA 0,72 Ca-125 21,53Lab 12/7/2013

24/8/2013WBC 23,27 RBC 4,92 HCT 39,4 Hb 14,9 PLT 355 Alb 3,9 Na/K/Cl 144/2,8/113 CT/BT 8/2 PT/APTT 10,2(10,6)/26,1(24,9) GDS 125 Ur/Cr 23/0,7 GOT/GPT 13/13 prot.tot 6,3

Wbc 15 Rbc 4,58 Hct 42,5 Plt 314 Hgb 13,3 Na 136 K 3,2 Cl 113 CT 7’00 BT 2’00 PT 11,4 (12,2) APTT 22,9 (24) HBsAg (-) Anti HCV (-) GDS 97 Ur 15 Cr 0,6 GOT 15 GPT 17 Kol. Tot 171FOTO THORAX PA (12/7/2013)NormalUSG ABD (12/7/2013)-massa regio lumbal kanan dengan kalsifikasi didalamnyaSugestif teratomaHydronephrosis dextraAscites minimal

Ganti obat oralCefadroxil 2x500mgRanitidine 3x150mgAsam mefenamat 3x500mg

20 KMR 1/Bed 3 Hj. Saleha/ 58 th/ 31/12/1954622918MRS 31/8/2013

Dr.dr.Warsinggih,Sp.B-KBD

D/ Cholecystithiasis + hepatomegaly susp.HCC

Lab 5/9/2013WBC 8,2 RBC 5,01 Hb 13,4 HCT 41,2 PLT 312 CT 6’30” BT 3’00” PT 10,2 c 10,8 APTT 23,2 c 23,6 INR 0,805 Na 146 K 4,10 Cl 110 GDS 123 Ur 8 Cr 0,6 Bil. Total 0,62 Bil. Direct 0,21 GOT 28 GPT 21Albumin:4,4

Periksa UGIE (9/9/2013)Curcuma 3x1Ranitidin 2x1As. Mefenamat 3x1Rencana operasi rabu (11/9/2013)tunggu jadwal biopsi + lap colocystectomy

6


Lab 2/9/2013gamma GT: 62, AFP:1,01 CEA 0.83

Lab 29/8/2013WBC 8,49 RBC 5,25 Hb 13,8 HCT 41,9 PLT 338 CT 7’30” BT 2’00” PT 10 c 11,1 APTT 22,5 c 23,9 INR 0,8 Na 145 K 3,72 Cl 108 GDS 113 Ur 8 Cr 0,6 Bil. Total 0,62 Bil. Direct 0,21 GOT 28 GPT 21

CT abdomen 19/8/2013HepatomaCholelith

Foto thorax 19/8/2013Dilatation et elangatio

USG abdomen 19/8/2013Hepatoma Cholelithiasis

21 KMR 1 bed 4 Subaedah /622957/30-12-1959 (54 thn)JKMMRS 3-9-2013


D/ Hernia incisional RT 8/9/2013Spincther mencekik,mukosa licin, ampula berisis feses, tidak teraba massa tumorLab 27/8/13GDS 111 ur/cr 13/0,7 bil total /direct 0,52/0,16 GOT/GPT 28/5 Pro.total 6,7 albumin 3,5 Kol.total 189 HDL 35 LDL 91 TGT 128 Na/k/cl 142/3,7/103 CT/BT 7’00” /2’00” PT/APTT 11,1 (12,5)/23,7(25,8) WBC 7,7 RBC 4,65 HGB 9,9 HCT 32,4 PLT 595Lab 16/8/13BT/CT 8’30”/3’00” PT/APTT 11,2 (11,8)/23,9 (24,6) GDS 139 Ur/Cr 35,0,8 GOT/GPT 24/4 Alb 4,3 Na/K/Cl 137/4/107 WBC 8 RBC 4,83 HGB 10,2 HCT 33,4 PLT 806USG Whole AbdomenMassa intraabdominal extraabdominalMassa soliter lobus kiri hepar susp. MetastasisEchocardiogram 27/8/13Fungsi sistolik baikDisfungsi diastolik MSCT scan Abdomen non kontrasSusp.limfoma dengan gambaran extranodal di heparHernia incisional PA 28/1/13Fibromyxoid sarcoma, moderate grade

Tunggu jadwal operasi-foto colon in loop-periksa CEA


7


22 1 Abbas Suppu / L / 55 tahun / 624893 / 1.7.1958MRS 27/8/2013JamkesdaDPJP : Dr.dr. Ibrahim Labeda,Sp.B-KBD

D/ Tumor colon descendensSupek metastase hepar

Lab tgl 27/8/2013CT 8’00” Bt 3’00” PT 14,1 c 11,9 APTT 22,3 c 26,4 GDS 89 Ur 47 Cr 1,9 SGOT 629 SGPT 191 Alb 2,3 Na 133 K 5,09 Cl 103 HBsAg (-) Anti-HCV (-)

Lab 29/8/29013WBC 9,65 RBC 3,07 Hb 8,2 HCT 25,3 PLT 284

Lab 2/9/2013CEA 2,09 WBC 13,4 RBC 1,08 Hb 3,1 HCT 9,6 PLT 173

Lab tgl 5/9/2013WBC 24,87 RBC 2,06 Hb 6 HCT 18,4 PLT 104

Rencana colon in loop dan CT-scan abdomen ditundaKontrol HbTransfusi PRC 4 bagKonsul HOMVip albumin 3x4 tabIVRD RL 28 tpmCeftriaxone 1 gr/12j/IVKetorolac 1 amp/8j/IVRanitidine 1 amp/8j/IVTransfuse PRC

23 2 Hudri /L/ 40 tahun(31-012-1927) 527343JamkesdaMRS tgl 26-8-2013

DPJP : Dr.dr.Ronald E.Lusikooy,Sp.B-KBD

D/ HIL D residif (POH 4 herniatomy + herniography 5/9/2013)

LAB 26/8/13WBC 17,06 RBC 6,79 PLT 311HGB 19,8 HCT 55,5 CT 7’30” BT 2’00” PT 10,7(11,4) APTT 28,8 (27,4) GDS 161 Ur 24 Cr 0,6 SGOT 30 SGPT 14 Alb 4 Na 142 K 4,3 Cl 106 HbsAg (-) Anti HCV (-)

Harnioraphy 5/9/2013Instruksi post operasi

- Awasi TV dan akut abdomen- IVFD RL 28 tpm - Inj ceftriaxone 1 gr/12j/iv- Inj ranitidine amp 8j/iv- Inj ketorolac 30 mg/8j/ivMobilisi aktif

24 3 Nahao/L/ 77 thn/ 20/08/1936MRS 31/08/1964625425Jamkesda


D/ tu Abdomen Lab 6/ 9/2013WBC 14,8 RBC 3,7Hb 9,3HCT 29,9PLT 415

Lab 1/9/2013RBC 3,91 HB 9,4 HCT 30,1 PLT 809 WBC 26,5

IVFD RL 28 tpmInjeksi ceftriaxone 1 gr/12j/ivInjeksi ranitidin 1 gr/8j/ivKetorolac 1gr/8j/ivIP albumin 3x4

25 4 Hasanuddin (1/2/1966) 47 tahun625543MRS 1/9/2013JamkesdaDPJP : Dr.dr. Ibrahim Labeda,Sp.B-KBD

D/ POH 7 appendectomy 1/9/2013 Lab 1/9/13PT 12,8 (11,8) APTT 28,1(26,2) Na 137 K3,4 Cl 103 GDS 118 Ur 23 Cr 0,9 SGOT 21 SGPT 17 Alb 4,1 RBC 5,41 Hb 4,6 HCT 43,9 PLT 189 WBC 10,9 LED Jam 1 = 23 jam II=49

USG Abdomen 1/9/2013 Sesuai gambaran appendisitis

Ranitidin 2x1As. Mefenamat 3x1Cefadroxyl 2x1Mobilisasi aktifDiet lunakBesok boleh pulang


26 1 Tn. Agustinus Rurug / L/ 49 thn10-08-1964 (6244440)MRS 26 – 08-2013Jamkesmas


D/ Tumor abdomen suspek limfoma malignancy

Lab 6/9/2013WBC:40,5 RBC:2,65HB:7,8HCT:24,5 PLT:369Lab 26/08/2013WBC:30,4 RBC:1,98 HB:5,6 HCT:18,1 PLT:660 GDS:115 Ur: 43 Cr:0,5 GOT:41 GPT:20 Na:134 K:3,8 Cl:109 CT:7’30 BT:2’30 PT:16,6(11,9)

IVFD RL 28 tpmInjeksi ceftriaxone 1 gr/12j/ivInjeksi ranitidin 1 gr/8j/ivInjeksi ketorolac 30 mg/8j/ivDulcolax supp 2Transfuse PRC 2 bag

8


APPT:35,3(26,6), Alb 1,8 , HBS ag (-), Anti HCV (-)

USG 26/08/2013 : kesan : Loop-loop usus sulit dievaluasi massa abdomen supspek limfoma para aorta abdominalis, slight hepatomegali

Lab 31/08/2013Alb 2 WBC 37,59 RBC 2,79 Hb 8 HCT 24,1 PLT 375

MSCT Upper abdomen dengan kontras (2/9/13)Sesuai gambaran limfoma mesenteriumHepatomegali

Lab 2/9/2013WBC 32,6 RBC 3 HB 8,7 HCT 25,9 PLT 443

Lab 5/9/2013GDS 51 Ur 45 Cr 0,5 Alb 1,7

Farmadol 1 gr/8j/IVVip albumin 3x3

27 2 Jufri Dg. Ronrong/ L/ (12/8/1988) 618397JKM

MRS 27/7/13

DPJP : Dr.dr. Ibrahim Labeda,Sp.B-KBD

D/ POH 5 bypass ileocaecum side to side + colostomy transversa (3/9/2013)

Lab 09/08/2013WBC:10,1 RBC:1,73 HB:4,3 HCT:14,4 PLT:410 GDS:106 Ur:22 Cr:1 GOT:7 GPT:8 Na:138 K:3,6 Cl:109 CT:8’00 BT:2’00 PT:10,8(10,5) APPT:23,9(23,4)


Lab 16/8/2013CT 7’00 BT 2’00 PT 11,8 (12,6) APTT 23,5 (26,6)

Colon in loop(16/8/2013)Kesan; tumor rectum susp malignancyUsul CT Scan abdomen

LGIE (19/8/2013)Kesimpulan : Tu. Rectosigmoid polipoid ulseratif sirkuler

MSCT abdomen non kontras (19/8/2013)Kesan : massa rectosigmoid (Dukes B) + hidronephrosis sinistra

Lab 21/8/2013CEA 74,03

Diet bubur saring Minum bebasIVFD Clinimix : Dext 5% 1:1 : 28 tpmCeftriaxone 1 gr/12j/IVKetorolac 1 amp/8j/IVRanitidine 1 amp/8j/IVMetronidazole 0,5 gr/8j/IVRawat colostomy

9


PA 22/08/2013 :Kesan adenokarsinoma rekti (diff baik)

Lab (26/8/2013)WBC 9,3 RBC 3,66 HB 9,7 HCT 29,7 PLT 515 Na 139 K 4,8 Cl 103 CT 7’00 BT 3’00 PT 11,3(11,5) APTT 26,5(24,6) GOT 10 GPT 7 Protein total 6,4 Albumin 3,2 GDS 70 Ur 24 Cr 0,8 Bilirubin total 0,12 Bilirubin direk 0,07 H

Lab ( 2/9/2013)WBC 10,32 RBC 4,5 Hb 12,1 HCT 37 PLT 398

Lab 4/9/2013GDS 99 Alb 2,7 Prot total 6,3 WBC 8,79 RBC 4,32 Hb 11,9 HCT 35,7 PLT 277

28 3 Mathius Patantan/L/47thn(1/9/1965) 623122JKMMRS 16/8/2013


D/ POH 12 bypass ileocolica ec ileus obstruksi ec adhesi (24/8/2013)

Lab (29/8/2013)Na 137 K 3,4 Cl 104 WBC 13,9 RBC 2,42 Hb 7,4 HCT 21,1 PLT 373

Lab (28/8/2013)WBC 11,02 RBC 3,43 Hb 9,7 HCT 28,8 PLT 510

Lab 26/08/2013Alb 3,6 Na 132 K 3,8 Cl 95 CT 7’00 BT 3’00 PT 11,2 (11,5) APTT 26,5 (24,6) GDS 100 Ur 29 Cr 0,7 GOT 22 prot total 5,7, bil tot 0,74 bil direct 0,29 , Lab (25/8/2013)RBC 3,35 Hgb 9,5 HCT 27,1 PLT 395 WBC 6,62

Lab 23/8/2013CEA 0,83CT-SCAN whole body (tanpa kontras) 22/08/2013:Tanda-tanda peritonitis disertai perlengketan loop-loop usus dan congestive liver

Lab 4/9/2013Alb 2,1 Prot. Tot 4,3 WBC 7,56 RBC 3,87 Hb 10,8 HCT 31,3 PLT 120

IVFD RL 500 NaCl 500 Clinimix 1000Ceftriaxon 1gr/12j/ivRanitidine amp/8j/ivKetorolac amp/8j/ivMetronidazole 0,5 gr/8j/ivDrips farmadol 500 mg/24j/ivDiet bubur saringMobilisasi jalanTetap pasang colostomy bagGanti verban

LONTARA 2KAMAR 10

29 1 Amaniah /P/ 59 th(31-12-1954) 623589JKM

MRS 20/8/2013


D/ PAI CKDDD/ Abses abdomenSpondylolistesis

USG abdomen 20/8/2013Sesuai gambaran periapendicular cholelithSlight splenomegaly

Lab 20/8/2013CT 7’30’’ BT 3’0’’ PT 14,2(11,0) APTT 32,5(24,0) GDS 73 Ur 161 Cr 7,3 Bil tot 0,53 SGOT 34 SGPT

IVFD RL 28 tpm Ceftriaxon 1gr/12j/ivRanitidine 1 amp/ivKetorolac 1 amp/8j/IVVIP albumin 3x2Kontol Hb post transfuse, PT, APTT

10


26

21/8/2013MSCT scan abdomenKesan : abses/empyema periappendicular, hepatosplenomegaly, efusi pleura kanan, spondylolisthesis L4 terhadap L5

Lab 22/8/103Urin rutin : warna kuning, pH 6,0 BJ 1,02 Prot 25+ glu (-), bil (-) blood 10+ leu 25+

LAB 27/8/2013WBC 12,9 RBC 3,63 HGB 9,2 CT 27,9 PLT 165 NA 151 K 4,7 Cl 121 GOT 58 GPT 22 Protein total 6,5 Albumin 2,3 Au 9,7 GDS 92 Ur 140 Cr 2,1 Bilirubin total 0,53 CT 8’30’’ BT 3’00’ PT 16,3(12,5) APTT 27,1(25,8)

Lab 31/8/2013Alb 2,6 Na 142 K 3,72 Cl 110 Ur 31 Cr 0,7 WBC 12 RBC 3,04 Hb 7,5 HCT 24,4 PLT 139 PT 13,3 C 11,3 APTT 20,7 C 26,1

Lab 5/9/2013Ur 14 Cr 0,5 Alb 2,3 WBC 6,2 RBC 2,63 Hb 6,4 HCT 20,6 PLT 375Lab 6/9/2013WBC: 7,3 RBC:3,56 HB:96HCT: 29,8 PLT:357

30 2 Yohana dape /P/ 57 thn(7-4-1956) 620300JKMMRS tgl 16-8-2013


D/ POH 11 hemi kolektomi dextra (27/8/2013)

MSCT WHOLE ABDOMEN NON KONTRAS 2/8/2013Massa caecum Lab 28/8/2013Na 135 K 4,2 Cl 108 WBC 15,1 RBC 3,71 Hb 8,2 HCT 27,2 PLT 249Lab 20/8/2013WBC; 4,2 RBC: 4,99 HGB : 14,5 HCT: 40,3 P LT: 286LAB (19/8/2013)WBC 4,2 RBC 4,38 HGB 9,9 HCT 31,9 PLT 379 GDS 74 ALB 3,2 CEA 1,01 CT 7’00” BT 3’00” PT 11,4 (11,9) APTT 26,2 (24,8)LAB (14/8/2013)WBC 7,03 RBC3,78 HB 7,9 HCT 26,9 PLT 472 GDS 90 UR 12,4 CR 0,6 HBSAG/ANTI HCV (-) GOT 14 GPT 5 ALBUMIN 3,6 As urat 3,0 Na 135, K 3,8, Cl 105 CEA (-) AFP (-) Ca 19-9 13,79USG ABDOMEN (30/7/2013)Kesan : massa daerah inguinal kanan

Asam mefenamat 3x1Ranitidin 2x1Vip albumin 3x1CefadroxilDiet buburRencana kemoterapi bila luka baik

11


Tidak tampak tanda-tanda metastasis pada USG abdomen iniFOTO THORAX (29/7/2013)Kesan : pulmonormalCardiomegaly dengan dilatation, elongation, et atherosclerosis aortae (HHD)COLON INLOOP (29/7/2013)Kesan : susp. Massa caecum

Biopsi 30/8/2013Adenocarcinoma caecum differensiasi sedang yang tumbuh invasive hingga lapisan muskularis dengan kedua ujung reseksi bebas tumor

31 3 Nurjannah/P/22 tahun25/12/1990MRS 31/9/2013JamkesdaDr. dr. Ibrahim L, Sp.B, K-BD

V. Ictum regio iliaca sinistra susp. Penetrans + GIP0A0 usia kehamilan 24-26 minggu

USG Abdomen atas-bawah (whole abdomen) 31/8/2013 Gravid, tunggal, hidup, usia kehamilan sekitar 24-25 minggu

USG Abdomen atas-bawah (whole abdomen) 31/8/2013Organ yang terscan dalam batas normalTidak tampak cairan bebas intraperitoneal

Lab 31/8/2013CT 7’30” BT 3’00” PT 10,4 c 11,3 APTT 22,3 c 22,3 GDS 99 Ur 8 Cr 0,5 SGOT 13 SGPT 7 Kolesterol 130 Asam urat 3,7 Na 139 K 3,7 Cl 112 HBsAg (-) Anti HCV (-) WBC 19,4 RBC 3,55 Hb 11 HCT 31,6 PLT 228

Aff infuseAff catheterCefadroxil 2x1Ranitidine 3x1Asam mefenamatDiet bubur saring

32 4 Muliyani/P/54 tahun20/11/1958MRS 5/9/2013Jamkesmas

Susp CholelithiasisEchocardiography 27 Agustus 2013

- Fungsi sistolik LV baik, EF 75%- LVH (+)- Disfungsi diastolik

Foto thorax 23/8/2013- Pulmo normal- Cardiomegaly disertai dilatatio et

elongatio aortae

USG Abdomen Atas + Bawah (whole abdomen) 23/8/2013

• Cholelitiasis

Curcuma 2x1Omeprazole 2x1Pct 3x1Rencana laparoscopy cholecyctectomy hari Senin (9/9/2013)

5 Hawila/ P/ 26 tahun(01/09/1987) 619618

D/ Fistel Enterocutaneus high output Lab 7/9/2013WBC:6,15RBC:3,99 HB:11,6 HCT:34,5 PLT: 272\

RL: D5 1:1 28 tpmNutrisi parenteral sesiai GK

12


JAMKESMAS

MRS 21/07/2013


CT: 8’00” BT 3’00”PT: 11,2 c 10,8APTT 28,7 c 25,4 INR 0,90 GDS 98Alb 4,4, Na 142 K 4,0 Cl 112Lab 24/08/2013WBC 7,16 RBC 4,32 HGB 12,5 HCT 37,1 PLT 251 Na/K/CL 144/4.4/109 Ur/cr 18/0,4 GOT/GPT 32/54 Protein total 6,5 albumin 3,8 kolesterol total 122 HDL 42 LDL 69 TG 133Lab (15/8/2013)AFP 3,18 CEA ,0,50 CA 199 10,51Foto fistulografi 14/8/13Kesan; fistulaileocutenausLab 06/08/13WBC 8,3 RBC 3,41 HGB 9,7 HCT 30,3 PLT 301 GDS 100 Prot Tot 6 Alb 3,7 Na 142 K 3,7 Cl 107 Kol.tot 90 HDL 21 LDL 60 TG 80Lab 23/07/2013Alb 2,9

Rawat luka/fistel p-sTunggu hasil kultur dan sensitivitasRencana Laparotomy eksplorasi + reseksi usus ileustomy tgl 5/9/2013

LONTARA 2KAMAR 11

33 1 Abidin dg Ngintung/L/42tahun31/12/1970/ 625986JamkesdaMRS: 3/9/2013


D/POH 4 laparatomy explorasi ec ileus obstruktif


Foto thoraxPneumonal S

USG abdomenGambaran ileus obstruksi

Foto polos abdomen 3 posisiGambaran small bune obstruksi

IVFD RL:D5 2:1Ceftriaxone 1 gr/12 j/IVRanitidinKetorolacNovalgin amp/iv

34 2 Sirajuddin, L/52tahun14/5/1961/ 588885Jamkesmas MRS: 4/9/2013DPJP : Dr.dr. Ibrahim Labeda,Sp.B-KBD

D/ Post colostomy pro close colostomy Lab 3/9/2013WBC 10,1 RBC 4,43 Hb 13,7 HCT 41,1 PLT 296CT 8’00”BT 2’00” PT 11,7 c 11,5 INR 1,00 APTT 28,9 c 24,6 GDS 88 Ur/Cr 15/05 SGOT/SGPT 66/38 Na/K/Cl 135/4,3 / 103 HbsAG/Anti HCV non reactive

USG Abdomen 4/9/2013Susp. Nodul metastasis heparAscites minimal

IVFD Rl 28 tts/iCeftriaxon 1 gr /12 j/ivKetorolac 1 amp/ 8j/ivRanitidine 1 amp/8j/iv

35 3 Tn. Annggaria / L / 35 tahun /1.1.1978 / 625211 D/ POH 5 drainase Abses intra Lab 3/9/2013 Terapi lanjut

13


MRS 29/8/2013


abdomen WBC 32,66 RBC 3,55 HGB 10,7 HCT 32,1 PLT 574Lab 29/8/2013 WBC 10,32 RBC 3,99 Hb 12,1 HCT 36,8 PLT 506 CT 8’00” BT 3’00” PT 13,5 (11,7) INR 1,09 APTT 27,6 (25,8) Foto thoraks 29/8/2013Cor dan pulmo normalElevasi kedua diafragma

IVFD RL:D5 28 tts/iCeftriaxon 1 gr /12 j/ivKetorolac 1 amp/ 8j/ivRanitidine 1 amp/8j/ivMetronidazole 0,5 gr/8j/iv

36 4 Usman/L/52 thn(31/12/1968)/622388/MRS: 13/8/2013


D/ POH 4 Cholecsistotomy terbuka Foto colon inloop 21/8/2013Kesan: tidak tampak kelainan

MSCT abdomen 21/8/2013Kesan: tampak cholelith, tidak tampak tanda-tanda massa colon.

Lab13/08/2013GDS;105 UR/CR: 36/0,9 GOT/GPT:51/80 PROT.TOTAL:62 ALB.;3,3 CT: 7`00 BT:2`00 PT:11,9(10,7)APTT: 27,2 (24,6) Na; 146 K:3,9 Cl; 114WBC: 9,14 RBC4,32 HCT:37,4 PLT:252 HGB:13,0

USG 13/8/2013Tidak Tampak Kelainan

Lab 24/8/2013WBC 5,6 RBC 4,00 Hb 12,2 HCT 35,7 PLT 287 GPT/GOT 46/34 Alb 2,9 Na/K/Cl 41/4,8/108 CT/BT 8/2 PT/APTT 11,0(10,6) /26,7(24,9) GDS 166 Ur/Cr 23/1,0 Bil.Tot 0,3 Bil.direk 0,13

IVFD RL : Dext 5% : 1:1 28 tpmCeftriaxone 1 gr/12j/IVKetorolac 1 amp/8j/IVRanitidine 1 amp/8j/IVMetronidazole 500 mg/8j/IVUntuk sementara puasaAwasi TTV dan tanda-tanda akut abdomenTakar drain / hari

37 5 Hamja/L/63 tahun5-8-1950344424MRS tgl 30-8-2013Dr.dr.Ronald E.L,Sp.B-KBDUmum

D/abses hepar

Lab 30/8/2013WBC 20,5 RBC 5,13 HGB 15,7 HCT 42,4 PLT 322 CT 7’30” BT 2’00” PT 14,8 (12,1) APTT 31,9 (28,0)GDS 81 Ur 82 Cr 1,3 GOT 30 GPT 18 Alb 2,2 Na 125 K 4,23 Cl 100CT abdomen 31/8/13Hepatomegaly dengan abses hepar DD/massa heparKista heparAtherosclerosis aortaeUSG Abdomen 30/8/13Massa hipoechoic pada lobus kanan hepar suspek abses DD/hepatoma

IVFD RL 28 tpmCeftriaxone 1 gr/ 12 j/ivRanitidine/ 1 amp/ 12 j/ ivMetronidazole 0,5 gram/8jam/ivTransfusi VIP albumin 1 botol/hari selama 2 hari

38 6 Tn. A. Haruna/ L/ 58 thn(01-01-1955) 619909 JKMMRS tgl 23/7/2013

D/ POH 19 choledocoyeyenostomy +icterus obstructif e.c batu CBD

Tes sensitifitas Ab (2/9/2013)Sensitif : ceftazidine Meropenem28/8/2013Bil total 8,6 Bil direct 6,51 Alb 2,4 RBC 3,7 HGB

Ciprofloxacin 500 mg/8j/dripsRanitidin 1 amp/8j/IVFoto thoraks

14


12,6 HCT 38,7 PLT 172 WBC 16Lab 21/8/2013WBC 16; RBC 3,7; HB 12,6; HCT 38,7; PLT 172Lab 04/08/13PT: 10,2 APTT: 23,7 Bil.tot : 12,38 Bil.direk : 11,24Lab 13-08-2013WBC: 6,9 RBC: 3,81 HGB: 11 HCT: 34,3 PLT: 483 PT: 11,4 APTT: 29,0 INR 0,904Lab 06-08-2013WBC: 6,6 RBC: 3,42 HGB: 11,7 HCT: 36 PLT: 222 SGOT: 51 SGPT: 52 Bil.tot: 12,38 bil.direk:11,24

30/07/2013Ca 19-9: 229,5

Lab 5/9/2013Bil. Total 13,9 Bil. Direck 11,92 Na 129 K 3,2 Cl 104 WBC 10 RBC 2,23 Hb 7,4 HCT 22,4 PLT 131

LONTARA 2 BEDAH URO (TITIPAN)39 KMR11/B2 I Kupe/P/57 tahun

31/12/1955618812MRS 19/8/2013Umum

Hidronefrosis S + Post URS + PJ stent S + cholelithiasis

Usg Abdomen (18/8/2013)Hidronefrosis sinistraTerpasang PJ stent pada gnjal kiriCholelithiasisSplenomegaly

Lab 29/8/13WBC 7,6 RBC 3,42 HGB 10,4 HCT 29,8 PLT 384Na/k./cl 138/4,2/101

Rencana laparoskopi CholesitektomyB.Comb 2x1Cefadroxil 2x500 mgInterhistin 3x1Rencana laparoscopy cholecystectomy Senin (9/9/2013)

LONTARA 3 KULIT

No Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi

40 K1B1

Kasdin 4-10-1990625375MRS 30/8/13UMUM


D/Post op appendictomy hari 8 (30/8/2013)

Lab 2/9/13WBC 15,97 RBC 3,96 HGB 11,5 HCT 34,3 PLT 305USG Abdomen 30/8/13Kesan : tidak tampak kelainan pada USG abdomen iniLab 30/8/13CT 8’00” BT 2’00” PT 12,6 (12,1) APTT 26,8 (26,1) GDS 103 Ur 17 Cr 0,6 GOT 17 GPT 24 Na 142 K 3,7 Cl 107 RBC 4,73 HGB 14 HCT 42,2 PLT 455 WBC 16,5

IVFD RL:D5 28 tpm Ceftriaxon 1gr/12j/IVKetorolac 30 mg/8j/IVRanitidin 1 gr/8j/ IVMetronidazole 0,5 mg/8j/IVFarmadol 1 gr/8j/dripsMinum susuAff kateter

41 K1B4 Supardi31/12/1991 (21 tahun)626450

D/ Appendisitis akut post op appendectomyec. Appendicitis gangrenosa day 2

Lab 5/9/2013WBC 17,9 RBC 5,13 HGB 40,4 HCT 40 PLT 283 CT 7’30” BT 3’00” PT 13,1(12,1) APTT 35,4 (28,0)

R/RL 28tpmCeftriakson 1gr/8 j/iv

15


Mrs:5-9-12Jamkesmas


GDS 98 Ur 29 Cr 0,9 GOT 17 GPT 12 Alb 3,9 Na 140 K 3,9 Cl 112HCV: non reactiveUSGKesan: app. akur

KetorolacMetrodinazole 0,5 gr

LONTARA 3 MATA

No Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi42 L3 Ayupsulle (1-12-1948)

MRS 28-8-13624008JKMDr.dr.Warsinggih ,Sp.B-KBD

D/ Cholelithiasis Lab 28-8-13WBC 6,97 RBC 4,45 HGB 13,8 HCT 38,5 PLT 174 PT/APTT 13,2/26,5 Ur/Cr 24/0,8USG 22-8-2013Kesan : Cholelith

Rencana Operasi Cholesitektomy senin 9/9/2013

LONTARA 4 (GINEKOLOGI)

No Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi

43 K1/B3 Jenne/P/55tahun1-7-1958/622762UMUMMRS tgl 15-8-2013


D/ POH 3 Repair abdomen Lab 1/9/2013RBC 3,92 HGB 11,1 HCT 34,5 PLT 317La23/8/2013GDS 117 SGOT 9 SGPT 9 Alb 2,1Lab 22/8/2013RBC 3,50 Hb 9,8 HCT 31,0 PLT 561 WBC 24,0Ur/Cr 14/0,6 Na/K/Cl 138/3,7/108 CT/BT 7’30’’/2’30’’ Alb 2,1

Th sesuai ts. Obgin : Ceftriaxon 1gr/12j/IVKetorolac 30 mg/8j/IVRanitidin 1 gr/8j/ IVMetronidazole 0,5 mg/8j/IVRawat luka dan GV/hrAff drainMobilisasi jalanDiet bubur

CVCU44 B3 Lantia/p/44th

31/12/1970UMUMMRS: 6/9/13Konsul: 7/9/13626604

d/ ileus obstruktif parsial Lab 6/9/13Rbc 3,9 hgb 11,6 hct 35,4 plt 206 wbc 11,9 albumin 3,9 ck/ckmb 2687/62, troponin T 0,11 GDS 152 as.urat: 11,8 prot total 5,8 na/k/cl: 112/4,8/80 ct/bt 8/3 u/k:116/30

koreksi elektrolit

ICU45 B5 Ny Bena

6258281/7/1978Mrs 2/9/13

D/ POH-1 laparotomy eksplorasi Lab 8/9/13Wbc 10,54 Rbc 3,35 hgb 10 hct 28,,0 plt 361 wbc 11,9 albumin 2,0 GDS 131 asna/k/cl: 137/42,65/108 got/gpt 17/7 ur/cr 9/0,4

R/ lanjut sesuai TS anastesi

46 VIP III Ny. Hj kartika60422229/8/1958MRS 25/08/13

D/ POH 3 laparotomi ekplorasi+ by pass ileum colon transversum

R/ lanjut sesuai TS anastesiRawat kolestomi

47 B3 Marhuni62645912/12/1941MRS 25/08/13

D/POH laparotomi ekspolrasi Wbc 14,64 rbc 4,46 hgb 13,1 plt 469 hct 7,1 gds 33,3 ur/cr 121/1,7 sgot/sgpt 19/11 albumin 2,3

R/ lanjut sesuai TS anastesi

PCCNo Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi

16


48 Lt. 2/K 205 Menni /P/ 47 tahun(17-4-1966) 619035ASKESMRS tgl 2/8/2013

Dr.dr.Ronald E.L., Sp.B-KBD

D/ POH 19 Laparatomy + colostomy PA 21/8/2013Adenokarsinoma recti, deferensiasi jelek

Lab 19/8/2013RBC 3,64 Hgb 11,5 Plt 203 WBC 13,4 ur/cr 100/1,2Lab 09/08/2013Prot tot 8,7 Alb 2,7 Na 148 K 2,6 Cl 106CT: 9” BT: 2” PT:10,2/11,3 APTT: 27,3/27,0

5/8/13 : Ca 19-9 9,08

Lab 2/08/2013RBC 4,31 Hgb:12,4 HCT 37,3 PLT 315 WBC 11,5 GDS: 200 Ur 15 Cr 0,6 GOT 8 GPT 11 Pro.tot: 6,7 Alb 3,6 Na:142 K:3,7 Cl :102

Cefadroxil 2x500 mgRanitidin 3x1Mobilisasi jalanTh/ lanjutAnalgetik: Th/ sesuai TS anestesi bag manajemen nyeri

49 Lt. 2/K 207 Misbakhul Munif (626292) 15/9/1986 (26 tahun)MRS 5/9/2013dr. Mappincara, Sp.B-KBD.

D/ POH 3 Appendectomy ec App Phiegmonosa

Lab 5/9/2013WBC 20,4 RBC 5,10 Hb 14,9 HCT 44,8 PLT 246 CT/BT 7’00”/2’00” PT/APTT 11,2/28,2 GDS 124 Ur/Cr 21/0,8 SGOT/SGPT 21/38 Na 141 K 3,6 Cl 108

USG abdomenSesuai gambaran appendicitis akut

IVFD RL:D5 1:1 28 tpmInj. Ceftriaxone 1gr/12j/IVInj metronidazole 0,5gr/8j/IVInj ranitidine amp/8j/IVInj ketorolac amp/8j/IVInj as. Traneksamat amp/8j/IVPuasa

50 Lt.2 /K216 Tn. Rustam Effendi16/12/1959 5332428MRS 15/08/2013


D/ POH 10 Laparoscopy eksplorasi e.c Ca Rectosigmoid unresectable

Lab 28/8/2013WBC 17.9 HB 10.9 RBC 4.34 HCT 34.2 PLT 609Foto Thorax 27/8/2013Kesan: dbn

Lab 23/8/2013GDS 305 Na/K/Cl 135/3.2/98 Alb 2.5 Prot tot 6.7

Lab 15/8/2013CT/BT 7’30/3’00 PT/APTT 13.3/31.0 CEA 22.57 GOT/GPT 13/8 Ur/Cr 18/0.8

Lab 7/9/13Rbc 4,05 hgb 9,9 hct 31,5 plt 584 wbc 13,5 albumin 2,05 gdp 127

Cefadroxil 2x500 mgRanitidin 3x1

51 Lt 3/ K303 Ny. Hasnah Mahmud24/12/194331063831/8/2013


D/ POH 4 Ca Pankreas Lab 1/9/2013WBC : 27,9 RBC 4,16 Hb 11,9 HCT : 37,8 PLT : 420 GOT/GPT : 93/59 Ur/Cr : 172/135 Na/K/Cl : 129/ 6,4/91

Foto Thorax 31/8/2013Susp. Soft tissue mass dengan kalsifikasi didalamnya pada mediastinum superior kiri minimal.

R/ IVFD RL 24 tpmCefotaxim inj/12 j/IVKetorolac inj/8 j/IVRanitidin inj/8 j/IVAlirkan Ascites 100 cc/jam hingga produksi Buang cairan drainase

17


Lab 5/9/2013WBC 23,4 RBC 3,24 Hb 9,4 HCT 29,3 PLT 163 Alb 2,2 GDP 375

52 Lt 3 / K311 Lilies Listiawaty (620412)4-2-1961/ 52 tahunMRS 2-9-2013


D/ hemiparese (S) + ulkus peptikum / melena

Lab 2/9/13A1b 3 CT/BT 8’30”/3’30” GDS 108 Ur/Cr 17/0,3 SGOT/SGPT 55/45 Na 141 K 3,4 Cl 112 WBC 16,5 RBC 3,07 HGB 8,5 HCT 27,6 PLT 312

53 Lt. 2/K 205 Menni /P/ 47 tahun(17-4-1966) 619035ASKESMRS tgl 2/8/2013


D/ POH 19 Laparatomy + colostomy PA 21/8/2013Adenokarsinoma recti, deferensiasi jelek

Lab 19/8/2013RBC 3,64 Hgb 11,5 Plt 203 WBC 13,4 ur/cr 100/1,2Lab 09/08/2013Prot tot 8,7 Alb 2,7 Na 148 K 2,6 Cl 106CT: 9” BT: 2” PT:10,2/11,3 APTT: 27,3/27,0

5/8/13 : Ca 19-9 9,08

Lab 7/08/2013RBC 4,21 Hgb:11,8 HCT 37,2 PLT 389 WBC 7,6 GDS: 87 Ur 64 Cr 0,29 GOT 31 GPT 38 Pro.tot: 7,3 Alb 3,2 Na:14 K:4,3 Cl :102

Cefadroxil 2x500 mgRanitidin 3x1Mobilisasi jalanTh/ lanjutAnalgetik: Th/ sesuai TS anestesi bag manajemen nyeri

404 a.mustafal bakri/L5—5-1935 (78 thn)AskesMrs 6/9/13


Tu caecum Lab 2/9/13Rbc 4,25 hb 11,2 hct 34,9 wbc 8,7 plt 372

Lab 3/8/13Gds 147 ur/cr 53/1,7 sgot/sgpt 21/18 prot.total5,8 albumin 3,4 3/9/13Ct scan abdomenKesan:tu caecumLab 7/9/13Na/k/cl 136/4,4/102

RSUHNo Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi54 RSUH 308 A Hj. Heriati /P/ 45 tahun

(1-4-1968) 007296

MRS tgl 10/07/2013


D/ Post Nekrotomi Ca cervix std IV Lab 27/08/2013WBC 19.62 RBC 3.63 HGB 10.0 HCT 31.4 PLT 693 CT/BT 8/2 GDS 85 GOT/GPT 9/5 Alb 2.5 Ur/Cr 26/0.6PA 22/7/2013Squamous sel karsinoma dgn keratinisingLab 17/8/2013WBC 16790 RBC 3510000 Hgb 10,1 Plt 360000 HCT 30,8 Na/K/Cl 134/4,0/106 GOT/GPT 36,9/10,8 Alb 2,72

R/ IVFD RL 24 tpmCefotaxim inj/12 j/IVKetorolac inj/8 j/IVRanitidin inj/8 j/IV Makan minum biasaMakan biasa

18


16/8/2013Alb 3,1

55 RSUH 401 B Ny Rosmiati10/06/1966 RM 012462MRS 19/08/2013

dr. Mappincara, Sp.B-KBD

D/ Wound delusensi Post laporotomi explorasi ec Ca ovarium Stad IV

Lab 2/9/2013Elektrolit : Na/K/Cl : 134/4,2/99GDS : 81Lab 1/9/2013Albumin 2,9

Lab 30/8/2013WBC 9,78 RBC 3,45 Hb 9,9 HCT 30,5 PLT 609 Alb 2,8 Prot. Total 6,1

Lab 24/8/2013Alb 2,53

Lab 19-08-2013WBC 8,36 RTBC 3,82, HGB 10,4 PLT 696 GDS 74 GOT/GPT 14/11 Alb 1,7 PT/APTT 14,3-1,23/35,7 CT/BT 8/2 Na/K/Cl 131/4,5/99

Lab 22/8/2013Fe 0,18 TIBC 79,2 kol.total 99 HDL 18,9 LDL 63,1TG 95 As.Urat 2,43

IVFD RL 28 tpmCeftriaxone 1gr/12j/ivRanitidin 1 amp/8j/ivKetorolac amp/8j/ivVIP Albumin 3x3 capsDiet lunakGV/hari

56 RSUH 301 Tn. Kadir Alis17/07/1949 (64 th) 013684MRS 28/08/2013

D/ Abses perianal Lab 28/8/2013WBC 17,03 RBC 4,82 Hb 12,8 HCT 38,1 PLT 252 Alb 75

Lab 31/8/2013Ur 48,1 Cr 244

Lab 4/9/2013GDP 195 GDS 152 WBC 10,59 RBC 4,34 Hb 11,4 HCT 34,1 PLT 386 Na 134 K 4,2 Cl 103 CT/BT 8/3 Ur/Cr 53/2,1 SGOT/SGPT 17/13

Colon in Loop 2/9/2013Dalam batas normal (tidak tampak kelainan)

IVFD RL 28 tpmInj. Ceftriaxone 1 gr/12j/IVInj. Ketorolac amp/8j/IVInj. Ranitidin amp/8j/IVMetronidazole 0,5 gr/12j/IVGV/hari

57 RSUH 319 M. Fadli Agus / 29.11.1991 / 013228 / Askes

MRS 10/8/2013

dr. Mappincara, Sp.B-KBD

D/ POH 18 nephrectomy anastomosis usus halus

PA 21/8/2013 Abses renalis + fistel limfadenitis kronikLab 3/9/2013WBC 13,04 RBC 3,64 HCT 32 PLT 477 HGB 10,7 Na 136 K 4,2 Cl 101 Alb 3,7 SGOT 53 SGPT 72 Ur 32 cr 0,826.8.2013WBC 13,33 RBC 4,01 Hb 11,6 HCT 35,1 PLT 425 SGOT 21,8 SGPT 22,6 Ur 61 Cr 0,5 Alb 0,9 PT

R/ IVFD RL 24 tpmCefotaxim inj/12 j/IVKetorolac inj/8 j/IVRanitidin inj/8 j/IV Diet nasi lunak

19


14,7 APTT 39,258 RSUH 402 Tn.Sofyan (004148)

10-2-1959AskesMRS 20/8/13dr. Mappincara, Sp.B-KBD

D/ POH 8 Herniokolektomi (D) cholesistektomi

Lab 31/8/2013Na 131 K 4,1 Cl 99 Alb 2,7 GDS 11,6Lab 30/8/2013WBC 12,49 RBC 4,06 HGB 10,4 HCT 33,3 PLT 495

Terapi lanjut GVInj.cernevit/24 jamDiet susu 4x200ccRencana diet bubur saring

59 414 B Mince sumbung17/12/1953AskesTgl msk 13/8/13

Ca gaster 31/8/13Wbc ,66 rbc 4,3 hb 10,6hct 32,3 plt 381 na/k/cl 129,4,1,96 ur/cr15/0,6 got/gpt 24/22 lb 3,51

Ptv 2x1Neurosanbe 2x1Lnsoprazole2x1Clorytromicin 2x1Tamoliv 1gr/8j/dripsFentanyl 2,5cc/jam

60 421 Olcha29/10/1972012801Askes


Tumor rekti Wbc 10,5 rbc 4,93 hgb 12,8 hct 38,8 plt 506 na/k/cl 135/4,2/102 got/gpt18,6/1 gds 123,2 ur/cr 23/0,80

As.met500 mg

UGD

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Ny. Bena1/7/1978625828

2/9/2013

D/ prolaps Recti Lab 1/9/2013WBC : 13,9 RBC : 3,38 HGB : 10,3 HCT 30,8 PLT 347 SGOT/SGPT : 12/7 Na/K/Cl : 138/3,1/106

IVFD RL 28 tpmCeftriaxone 1gr/12j/ivRanitidin 1 amp/8j/ivKetorolac amp/8j/iv

62

Nurjannah25/12/1990

62547431/8/2013

D/ POH 3 laparotomy explorasi ec V. Ictum penetraus reg. Lumbalis sinistra

Lab 31/8/2013WBC : 19,40 RBC 3,38 Hb 10,3 HCT 31,6 PLT 347 SGOT/SGPT : 13/7 Ur/cr : 8/0,5 GDS : 99 Na/K/Cl : 139/3,7/112

R/ IVFD RL 24 tpmCefotaxim inj/12 j/IVKetorolac inj/8 j/IVRanitidin inj/8 j/IVAwasi TTV

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Sirajuddin (588885)14-5-1961

MRS 3/9/2013

D/post op colostomy Lab 3/9/12CT/BT 8/2 GDS 88 Ur/cr 15/0,15 Na 135 K 4,3 Cl 103 RBc 4,43 HGB 13,7 HCT 41,1 PLT 296 WBC 10,1

ICU64 VIP 3 Ika Kartika (24-8-1958) 55 tahun

MRS 25-8-2013Pindah ICU 4-9-2013

ASKES dr.Warsinggih,Sp.B-KBD

D/Ileus obstruksi parsial Lab 5/9/2013Na/K/Cl 143/3,0/111 WBC 5,63 RBC 3,47 HGB 10,4 HCT 31,5 PLT 215Lab 3/9/2013GDS 86 Ur/Cr 31/0,58 GOT/GPT 25/25 Alb 2,3 Na/K/Cl 141/3,2/109 BT/CT 3’00”/6’30” PT 12,0 (10,3) APTT 24,2(24,3) INR 1,0 RBC 2,15 HGB 6,9 HCT 21,3 PLT 155.000 WBC 3,9Abdomen 3 posisi 3/9/13Gambaran small bowel obstructionLab 29/8/13

Transfusi albumin 20% 1 botol/hariKoreksi kalium Rencana laparotomi eksplorasi + colostomy Sementara puasa

Terapi lain sesuai terapi TS Anestesi: O2 2 lpmHead up 300

Ceftriaxone 1 gr/12j?IVPanzo 40 mg/24j/IVMetronidazole 500 mg/8j/IV

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Na/k/Cl 151/3,2/121CT scan abdomen 26/8/13Ascites + ileus paralitikAbdomen 3 posisi 26/8/13Ileus paralitikUSG abdomenAscites + tak tampak nodul metastase di organ intrabdominal

Farmadol 1 gr/8j/IVCek hasil DR dan elektrolit post transfusi 2 bag PRC

IC

65 Lantai 3 kamar 1

Tn. Darpan Syarif/ L/ 38 thn(4-4-1975) 572326

UmumMRS tgl 31/7/13

Tgl pindah IC 5/9/2013


D/ Tumor anorectal susp malignancy + depresi sedang + B20 + Candidiasis oral

Lab 31/8/2013Anti HIV (ICT) Reaktive

PA 30/8/2013Squamous cell carcinoma keratinizing differensiasi sedang

MSCT Whole abdomen non kontras 28/8/2013Kesan: sesuai Tu.anorectal dengan tanda-tanda stasis fecal mass

Colon in loop : 28-8-13Kesan : Tu. Distal rectum

Lab 23/8/2013WBC 4,2 RBC 3,21 Hb 10,1 HCT 31,3 PLT 367 Na/K/Cl 143/3,5/106 CT/BT 8/3 PT/APTT 12,1 (13,2)/29,3 (26,5) INR 1,02 HbsAg – anti HCV – CEA 1,75 GDS 105 Ur/Cr 20/0,6 Bil.tot 0,4 bil.direk 0,16 GOT/GPT 15/10 Albumin 3,5 As.urat 4,2

Lab 31/7/13Wbc : 6,05. Rbc : 2,96. Hct : 29,4 . plt : 224. Hb: 9,6. GDs : 101. Ur : 20. Cr: 0,6 GOT : 36 GPt: 14 . Na: 147 K: 4,56 Cl: 112. HBsag -. Antihcv –

Terapi lain sesuai terapi TS Psikiatri:Kalxetin 20 mg 1-0-0Alprazolam 0,5 mg 0-1/2-1Psikoterapi supportif

Terapi lain sesuai terapi TS Infeksi Tropis:IVFD NaCl 9,0% : Dext 5% : 1:1 28 tpmKotrimoxazole 480 mg 2x2Bystatin drops 3x2 cc

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Koran Digestif Tgl 9 September 2013

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