koran digest senin 30 des
TRANSCRIPT
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
PALEM ATAS (Indah085242057423)
No BedIdentitas Diagnosis Pemeriksaan Penunjang Terapi
1 B1/1 Laode halim12/5/199419 tahun MRS : 15/12/13RM : 606587
Askes
DR. dr. Ronald E. Lusikooy, Sp.B, KBD
POH 15 laparatomy ekplorasi + splenoctomy ec Trauma tumpul abdomen
Lab 26/12/13WBC 17,82 RBC 3,59 HGB 9,9 HCT 30,7 PLT 914Lab 18/12/13 :CRP : 45,0, GDS : 90, UR/CR : 31/0,80, BIL total : 0,58, bili direk : 0,21, GOT/GPT :64/31, Alkali fosfat : 57, protein total : 5,6, albumin : 3,2, CT/BT : 7/3, PT/APTT : 13,4/24,4, INR : 1,12, Na/K/Cl : 134/3,5/100
Lab 16/12/13 :WBC : 12,49, RBC : 3,13, HGB : 9,3, HCT : 26,8, PLT : 151, PT/APTT : 13,6/25,6, Na/K/Cl : 134/5,9/108,GDS : 153, UR/CR : 31/1,1, GOT/GPT : 53/26, ALB : 2,5
USG Abdomen : (15/12/13)Hematoma lien disertai cairan bebas intraperitonium
Terapi sesuai TS ortopediMobilisasi dudukDiet bebas
2 B2/4 Bed 2
Ny Sallama31/12/196646 Tahun636819MRS 12/11/2013KONSUL 14/11/13Askes Wajib
Dr.dr Ibrahim Labeda, Sp.B KBD
POH 17Drainage ascitesAdenocarsinoma Colon Ascendens Residif
Lab 27/12/13GDP 226Lab 24/12/13WBC 16,8 RBC 3,49 HGB 9,7 HCT 26,9 PLT 675 Ur/Cr 65/0,61Lab 21/12/13SGOT/SGPT 94/89Lab 0 6 /12/2013 WBC 10,9, RBC 3,73, Hb 10 HCT 29,7 PLT 591, Prot.total 5,6, albumin 2,7, globulin 2,9, Na/K/Cl 129/4,1/100GDP: 104, Chol.tot: 112, HDL direk: 13, LDL direk:69, TG: 107.Lab 3/12/2013 Globulin : 3,7, GDS : 250, Ur/Cr : 11/0,59, SGOT/SGPT : 28/26, Prot.total 6,1, Albumin 2,4, CT/BT : 9’00/4’00 PT : 15,4 control 12,4, INR : 1,24, APTT : 25,0 control 24,0, Na/K/Cl : 124/3,9/97Lab 02/12/2013 WBC 13,77, RBC 3,45, Hb 9,3 HCT 27,0 PLT 632, GDS 250, Ur/Cr : 11/0,59, SGOT/SGPT : 28/26, Prot.total 6,1, albumin 2,4, globulin 3,7, PT/APTT : 15,0/25,0, INR : 1,24, CT/BT : 9,00/4,00 Na/K/Cl 124/3,9/9,7Lab 30//11/2013WBC 15,45, RBC 4,1, Hb 10,6, HCT 31,4 PLT 598, Na/K/Cl 131/3,6/113
- IVFD NaCl 0,9% 28 tts/menit
- Vip Albumin 3x2 caps
- Takar produksi ascites/hari
- Cefotaxime 1gr/12j/IV
- Susu 5 x 200 cc- Cek elektrolit- Terapi TS gizi
klinik & interna lanjut
1
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Lab 27/11/13GDS 150, Na/K/Cl 128/4,0/104Lab 26/11/13WBC 13,4, RBC 3,78 Hb 9,8, HCT 29,4 PLT 525Lab 22/11 /13 WBC : 16,2. HGB : 7,8. RBC : 3,13. HCT : 24,8. PLT : 6,58. (Anemia mikrositik hipokrom, trombositosis,leukositosis)Colon In Loop 21/11/2013Tidak tampakcolon ascendens dan 1/3 proximal colon transversumLab 19/11/13WBC:9,5,HGB:11,0,HCT:30,6,PLT:553Lab 18/11/13CEA : 1,8, CA 19-9 : 9,99Lab 16/11/13WBC:14,37,HGB:9,11,HCT:27,7,PLT:507Hasil PA 10/06/13Adenocarsinoma colon , moderatelu differentiated dengan kedua ujung reseksi bebas tumorFoto thoraks PA 13/11/13Tidak tampak tanda tanda metastasis pada foto thorak iniMSCT scan abdomen 13/11/13:Massa colon ascendenas dengan tanda tanda obstruksi usus di proximalnya Hepatospenomegali, tidak tampak tanda tanda metastasis ke hepar.Lab 13/11/13 :Na/K/Cl 135/4,2/108, Bilirubin total : 0,1, Bilirubin direk : 0,1, Alkali fosfatase : 69, Gamma GT : 18
3 B2/6Bed 1
Ny. Thalha Kasim 12/10/195756 thnMRS: 7/12/2013RM :640024
ASKES
Dr.dr Ibrahim Labeda, Sp.B KBD
Tumor rectum 1/3 tengah
LAB (21/12/2013):WBC 9.64, RBC 3.38, HGB 9.3, HCT 26.6 PLT, HBsAg non reactive, PT 11.7 kontrol 10.9, APTT 24.4 kontrol 23.9, GS 145, Ur/Cr 39/ 0.7, GOT/GPT 41/45, Na 142, K 4.3, Cl 11.6, Albumin 3.6ECHO (18/12/13) :Disfungsi Diastolik EF 73%LAB 18/12/13 :GDS : 171, Protein total : 6,2, Albumin : 3,5, CEA : 2,57Foto polos abdomen + colon in loop : (10/12/13)Tumor rectum proximalCT-Scan Abdomen (16/12/13) :Massa recti 1/3 distal (dukes B ) Thorax PA 9/12/2014Kesan: cor & pulmo normal. Tidak tampak tanda-tanda metastasis pada foto ini.
- HP Pro 3x1 tab- Rencana operasi
selasa 31/12/2013 oleh Dr.dr.Ibrahim labeda Sp.B-KBD
- Colon skema hari I (Ahad, 29/12/13)
2
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Lab 7/12/2013WBC 7.51, RBC 3,62, HB 10.1, HCT 28.2, PLT 241, GDS 151, Ur/Cr : 31/0.7, SGOT/SGPT : 201/198, PT/APTT : 12.6/25.8, INR : 1.00, CT/BT : 8’/2.30’,Na/K/Cl: 145/4.10/112
PALEM BAWAH (Indah 085242057423)4 B1/K3 Ny.elva hendarsin
12-04-197142 thnMRS : 16/12/13RM :640406
Askes
DR. dr. Ronald E. Lusikooy, Sp.B, KBD
POH 10 Laparatomy +unroofing kista hepar
Lab 17/12/13CT/BT 8/3’30” PT/APTT 14,2/27,1 INR 1,19 GDS 69 SGOT/SGPT 20/14 WBC 8 RBC 4,39 HGB 12,2 HCT 35,0 PLT 279Lab 06/12/13 :RBC ; 4,78, WBC : 13,1, HGB : 13,1, HCT : 38,1, PLT : 304, GDS : 102, UR/CR : 19/0,65, Bilirubin total : 0,68, bilirubin direk : 0,23, GOT/GPT : 18/13, Protein total : 7,2, albumin : 4,5, tumor marker CA 125 : 36,69CT-Scan abdomen :05/12/13Multiple kista heparMassa padat ovarium kanan DD/Mioma uteri
- IVFD RL 28 tts/mnt
- ceftriaxone 1 gr./24jm/iv
- Ranitidine 1 amp/8jm/iv
- Diet bebas- Susu 5x200cc- Mobilisasi
duduk- Takar produksi
dran/hari
5 B2/4Bed 1
Tn. Pither Tandipayung28/2/195855 tahunRM 384339MRS 23/12/2013
ASKES
Dr.dr. Warsinggih Sp.B-KBD
CKD stg V on HD regular post CAPD H3
Lab 27/12/13PT/APTT 12,3/24,6 INR 1,00 Ur/Cr 76/4,7 Na/K/Cl 133/4,4/109 WBC 24,87 RBC 3,54 HGB 10,3 HCT 29,7 PLT 260LAB(24/12/2013):HBsAg non reactive, Na 136, K 5.1, Cl 101, BT 2, CT 8, PT 14,6 kontrol 12.1, INR 1.22, APTT 33.4 kontrol 26.7, GDS 64, GOT 37, GPT 62, Protein Total 5.9, Albmin 3.66, WBC 15.6, RBC 3.71, HGB 11, HCT 30.7, PLT 299USG Abdomen (11/11/2013):PNC bilterl kist ginjal kiri + ascites
IVFD RL 20 tpmCeftriaxon 1gr/12jam/IVRanitidin 1amp/8jam/IVKetorolac 1amp/8jam/IVTerapi lanjut TS interna
7. B2/9Bed 2
Tn/ Budimawan Aris23/9/199023 tahunMRS : 18/12/13RM : 603878
AskesDr.dr.Ibrahim Labeda, Sp.B (KBD)
Haemorroid grade II-III
LAB 20/12/2013:BT 3, CT 8, PT 11.9 kontrol 12.1, INR 0.99, APTT 26.3 kontrol 25.5, GDS 97, Ur/Cr 23/1.1, GOT/GPT 18/ 31, WBC 3.2, RBC 5.15, HGB 16, PLT 274, HCT 45.6ECHO 17/12/13 :Fungsi sistolik dan diastolik LV Baik , ef 63%Normal echocardiogramLAB 26/11/13WBC : 3,7, RBC : 5,28, HCT ; 46,4, PLT : 293, CT/BT : 8/3, PT/APTT : 13,0/27,2, na/k/cl : 140/4,0/105
Venosemil 3 x 200 mgCiprofloxacin 2x 500 mgNeurodex 1 x 1 tabTunggu hasil colon in loopRencana op hemorroidektomi dgn staplerTunggu jadwal op
LONTARA I Rezky Astarini (082393647334)
8 L1AD RPK B3
Tato Lando1/7/1945641206MRS 9/12/13Konsul dari interna : 11/12/13
Ileus obstruksi parsial e.c susp. Ca recti 1/3 tengahPOH 4Colostomi
25/12/2013Wbc 5.98 Rbc 2.49 Hb 7.4 Hct 21.6 Plt 136 ur/cr 55/0.8 got/gpt 117/82 alb. 1.423/12/2013WBC 3.4 RBC 292 HGB 8,9 HCT 24,7 PLT 102 Na/K/Cl 129?2.4/100 GDS 122 Ur/Kr
- IVFD RL 28tpm- Omeprazole vial/12j- Inpepsa 3x2 cth- Antasida syr 3x2 cth- Coctail drip/12j
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KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
JKS 24/0.84 Alb 1.613/12/2013Gol. Darah AB+WBC:11,62 RBC:4,87 HGB:14,5 HCT:43,2 PLT:222 GDS:140 ur/cr:40/0.8 GOT/GPT:27/41 Albumin:2,6 PT/APTT:13,8/22 INR:1,09Na:150 K:3,2 Cl:117Laboratorium 10/12/13CT : 7’30 BT: 3’00 PT : 13,1 APTT : 34,6 GDS : 93 Ureum : 59 kreatinin 0,9 GOT : 33 GPT : 31 protein total : 4,4 albumin : 2,6 Na : 144 K: 3,7 Cl : 112 WBC : 7,31 RBC : 4,55 HGB : 13,7 HCT : 38,9 PLT : 160
9 L1ADK3B3
Dg. Ngintang31/12/1957640694Konsul dari interna 9/12/2013
dr. Murny Rauf, Sp.B-KBD
Ikterus Obstruktif e.c batu CBD mutlak
23/12/2013Ur/Kr 28/0.63 Bil tot 1.35 Bil direct 0,81 SGOT/SGPT 25/15 Cholesterol tot 208 HDL 28 LDL 87 Trigerilserida 213 CT/BT 7.30/2.00 PT/APTT 12.5/26.0 Na/K/CL 132/3,9/104Foto Thorax 23/12/2013Cor dan pulmo dalam batas normal1 3 /12/2013 Bil. Total : 2,48 Bil. Direct : 1,09Lab 10/12/2013CT/BT 8/3; PT/APTT 12,2/24,5; Na/K/Cl 130/3.8/95; AFD 4.92; GDS 342 ; Bil tot 1.55;Bil Direct 0.78Lab 9/12/2013RBC : 3,75 WBC : 12,1 HGB : 10,5 HCT : 30,9 PLT : 4967/12/2013WBC : 15,33 RBC : 3,95 HGB : 11,4 HCT : 31,8 PLT : 300 GDP : 231 Kol Tot : 215 HDL : 3 LDL : 151 Tg : 3066/12/2013PPT : 13,0 APTT 24,1 GDS : 241 Ur : 12 Cr : 0,5 GOT : 31 GPT : 16 Na : 140 K : 2,8 Cl : 1035/12/2013WBC : 16,77 RBC : 4,16 HGB : 11,9 HCT : 32,9 PLT : 202USG Abdomen 6/12/2013- Cholestatis intra hepatic dan ekstrahepatik
e.c multiple choledocolith disertai pneumobilier- cholelith disertai cholesistitis- ascites- efusi pleura bilateral
- Terapi sesuai TS interna- Penjadwalan operasi
CBC
10 L1AB K1 III B5
Arifin 641720 21/5/2013MRS 12/12/13Konsul dari
Ikterus obstruksi e.c Ca caput pancreas
Lab 23/12/2013Wbc 11.50 Rbc 2.76 Hb 9.5 Plt 445 Lab 19/12/2013CT/BT 3/8 ; PT/APTT 13.3/50.2
-tunggu jadwal operasi -optimalisasi KU
4
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
interna 14/12/13Jamkesda
Lab 16/12/13CT/BT 8’/3’ PT:12,9 APTT:36,5 INR:1,08Laboratorium 13 / 12/13 CT : 9’00 BT : 4’00 PT: 28,1 APTT 60,2 Na : 134 K : 4,0 Cl : 104 GDS: 98 Ur : 20 Cr : 0,54 Bil. Tot : 15,13 Bilirubin direct : 13,34 GOT : 177 GPT : 207 Alkali fosfatase : 2111 Gamma GT : 939 albumin :3,0 Ca :7,1 TIBC :303 AFP : 1,08 Ca 19-9 :>5000Foto Thoraks:Kesan : Pulmo normal, elongation aortaUSG Abdomen 5/12/13-cholestatic intra dan extra hepatic e.c tumor caput pancreas
11 L1BBK6 II B2
Mardiah5/5/197064.1539MRS : 12/12/13 konsul dari interna : 14/12/13
Dr. Samuel, Sp.B KBD
Ikterus ostruksi e.c Baru CBD + gallstones
Lab 23/12/2013Wbc 5.0 Rbc 4.42 Hb 10.9 Hct 32.5 Plt 236 Pt/aptt 14.9/33.2Lab 20/12/2013PT/APTT 15.3/33.3 ; WBC 3.8;RBC 3.76; HGB 9.3; HCT 27,5; PLT 218Bil tot 19,34, Bil direct 16,38 SGOT/SGPT 84/22; Alb 2,6, Na/K/cl 137/3.32/115Lab 19/12/13Ca 125 : 216; CEA : 0,79 : Ca 19.9 <3.00Lab 14/12/13WBC:4,25 RBC:4,14 HGB:9,2 HCT:19,2 PLT:323 Kol.Total:215 LDL:191 HDL:4 Trigliserida:148 As.Urat:3,1Laboratorium 12/12/2013WBC : 5,18 RBC : 2,64 HGB: 4,3 HCT : 15,8 PLT : 412 PT : 18,3 APTT : 38,9 GDS : 87 ureum : 14 kreatinin : 0,5 bilirubin total : 18,5 bilirubin direct : 15,97 GOT : 89 GPT : 22 protein total : 6,5 albumin 2,0 globulin : 44 Na : 136 K : 3,1 Cl : 106CT Abdomen 12/12/2013 - Choleliyh dan choledocholith
menyebabkan dilatasi bile duct intra/extra hepatic
- Ascites
Rencana operasi senin
12 L1ABK1 III B1
Tonda3/4/194964.15.78MRS : 13/12/2013Konsul dari interna :14/12 St/2013
-Cholecyslithiasis-DM tipe 2 non obese
Lab 19/12/2013Bil tot 0,35 : Bil dirct 0,09; Alb 3,2; HbsAg Non reactiveColon in loop 18/12/13Tidak Nampak massa intraluminair kecuali diverticulosis colonSputum BTA (-)CT abdomen 19/12/13Hepatomegaly dgn cholesistisis intra dan extrahepatic, cholecystisis dgn cholelitiasisLab Urine rutin 16/12/13pH:6,0 BJ:1,030 Glukosa:+++/500 protein:- Leukosit:- Blood:-
- Tunggu jadwal operasi
5
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
WBC:6,2 RBC:4,15 HGB:10,5 HCT:30,5 PLT:420 GDP:159 Gamma-GT:174 Bil.Total:0,32 Alkali phosphate:163 HbA1c:10 Ur:18 Cr:0,7 Na:133 K:4,4 Cl:105Lab 14/12/2013GDP:141 Ur:19 Cr:0,7 GOT:27 GPT:74 Alb:3,1 Kol.Tot: 199 HDL:28 LDL:164 Trigliserida:110 As. Urat:3 WBC:11,1 RBC:4,6 HGB:11,7 HCT:35,5 MCV:77,2 MCH:25,4 PLT:489USG 12/12/2013Colelith disertai cholecystitis
13 L1 BBK6 III B6
Ny Maya1/07/1967
Cholelitiasis 24/12/2013Wbc 16.7 Rbc 7.75 Hb 20.3 Plt 239 Hct 58.7LAB:WBC 47.84, RBC 4.53, HGB 12.2, HCT 37.1, PLT 10.3Lab 16/12/13WBC 13,72; RBC 3,64; HGB 11,5;HCT 33,5;PLT 288; CEA 2.27Lab 18/12/13Urine rutin PH 6; BJ 1020 Prot(-) Glukosa(-) Bilirubin(-) keton(-)EchocardiographiFungsi diastolic LV baik EF 75%,Disfungsi diastolicFoto thorax 29/11/13,Tidak tampak kelainan pada fotoCT whole Abd 6/12/13 Cholelitiasis,asites minimalUSG 29/11/13Cholelith
- Cek Alp/GGp, Ca 19.9- Vit K/24 jam
14 L1ABK2B5
Jenne01/07/1932642425Konsul dari interna 22/12/13
Hemoroid grade IV
27/12/2013Wbc 35.6 Rbc 4.14 Hb 11.5 Hct 33.2 gds 85 as.urat 7.8 alb.3.0 pt/aptt 13.2/30.9USG Abdomen 27/12/2013Nefrolith bilateralEfusi pleura bilateralKista ginjal kiriLab 26/12/13Ur/Cr 27/1.0Lab 21/12/13CT/BT 7/2.3 ; Ur/Kr 35/1.1 ; alb 3.3Na/K/Cl 142/3.3/116 ; PT/APTT 11.8/21.4WBC 29.56 : RBC 4.12; HGB 11; HCT 33.5;PLT 86CT Abd atas/vawah 18/12/13Cholestatik intra/ekstrahepatik dgn pancreatitis akut DD/ Massa caput pancreas, Susp Tu. Metastasis, Splenomegaly, Hidroureter
- IVFD RL: D5 28tpm- Ceftriaxon 1 gr/12
jm- Ardium tab 2-2-2
6
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
LONTARA 2 DIGESTIVE KAMAR 1 (Eka Novryanti 085341171040)
19 Bed 1 Muh. Alwi KadirTL. 6/6/1977( 36 tahun )MRS.9/12/2013RM. 639544JAMKESMAS
Dr.dr.Ibrahim Labeda,SpB-KBD
Fistel peritoneal cutaneus + susp tumor paru
Hasil kultur dan sensitivitasResisten gram (+) dan gram (-) = BenzylpenisilinResisten gram (+)= oxacylinLab 29/12/2013WBC: 8,5 RBC:5,43 HGB:16,1 HCT:47,3 PLT: 323 LED jam I:11 jam II:27 CT/BT:9’00/3’00 PT/APTT:11,1/29,6 Na/Ca/Cl: 136/4,3/111 GDS:101 Ur/Cr:26/1,04 SGOT/SGPT: 39/35 Albumin:4,0 INR:0,93Foto thorax 29/12/2013Kesan: tuberculoma DD/ tumor paru dextraEchocardiogram 29/12/2013Kesan: -fungsi sistolik LV baik, EF 73% -Disfungsi diastolicCT thorax 25/12/2013Kesan: -nodul soliter paru kanan suspek tumor paru primer DD/tuberculoma -Fistel peritoneal cutaneus
-Ciprofloxacin (2x500)-Metronidazole (3x500)
20 K1B2 JupriRM 641439Tgl lahir 01/12/1971
Tu. Abdomen USG Abdomen 11/12/2013-Massa paraumbilikal sugestif mesenterial- Hepatoma lobus kanan DD/ metastasis hepar- Pelvocalyectasis DCT-scan 17/12/2013- Massa hepar susp hepatoma dengan
lesi satelitColon in loop 16/12/2013- Colon in loop normal- Sesuai gambaran extraluminerKimia darahGDS 166, ur/cr 14/1,9, alb 3,9, prot tot 8,5, WBC 8,6, RBC 4,38, HGB 13,9, PLT 203
As. Mefenamat 500 mg 3x1
21 K1B3 Ongky Arianto28/10/1990JamkesmasMRS 25/12/2013RM: 643482Dr.dr.Ronald E.L Sp.B;KBD
Anemia, Hematemesis + melena ec ca recti
Lab ( 28 -12-13) WBC13.73 Rbc 3.21 Hb 8.7 HCT 26.4 PLT 465
Lab 25/12/2013WBC 19,46; RBC 2,35; HGB 6,6; HCT 19,7; PLT 338; CT 7’30”; BT 3’; PT 10,7; INR 0,90; apt <15 control 23,3; GDS 76; UR/CR 76/27; GOT/GPT 24/29; Na 123; K 3,1; Cl 87Usg Abdomen 24/12/2013
IVFD RL 28 tpmCeftriaxone/12j/ivRanitidin/8j/ivOMZ/12j/ivCoctail drips/12jTransfusi PRC 2 bag
7
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Tidak tampak kelainan pada organ solid intraabdominal kecuali loop-loop usus yang dilatasi.
22 K1B4 Tn. SukriTL=31/12/1958 (54 thn)RM 64 19 57MRS 14/12/13UMUMDr.dr.Ronald.L.E.Sp.B-KBD
POH 6 Drainage billier ec susp tumor caput pankreas
- Lab ( 21 -12-13) CT 7.0 BT 2.0 PT 12.1 APTT 34.4 GDS 205 Ur/Kr 23/0.5 Bil.total 26.3 Bil. Direct 18.6 SGOT 56 SGPT 65 Alb 2.6 Na/K/Cl 134/3.5/114
- Imunoserologi Ca 19-9: 1211.62
CT Abdomen tanpa kontras (16-12-13)Kolestatik intra dan ekstrahepatik ec suspek stenosis distal CBDSludge GBEfusi pleura bilateral
- Lab (14-12-13) CT/BT 3’30”/8’30”, PT/APTT 27.5/54.9 GDS 98 Ur/Cr 30/0.5 Bil total 24.09 Bil direk 18.80 GOT/GPT60/60 prot.total 6.1 Albumin 2.9 Na/K/Cl 130/3.8/112 HbsAg dan Anti HCV non reaktif
- Lab (17-12-13) WBC 9.89 RBC 3.73 HGB 11.1 HCT 31.1 PLT 210
- USG Abdomen (14-12-13) - Cholestatik intra dan ekstrahepatik
dengan pankreatitis akut- Hypertrophy prostat
- IVFD NaCl:Aminofluid 1000:1000 28 tpm
- Ceftriaxone 1gr/12jam
- Metronidazole 0,5gr/8j/iv
- Ranitidin 1 amp/8jam/iv
- Ketorolac 1 amp/8jm/iv
- Vip albumin 3x2- Diet biasa- Mobilisasi duduk
ISOLASI (Kasma 085244846649)
23 Iso Bed 1
Ny.Asni09/05/1978RM 642270MRS 16/12/2013
Ikterus obstruksi susp choledocholithiasis + cholangitis
Tumor marker 23/12/2013CEA 3,51Ca 19.9 <3.00 (WNL)GDS 94, UR/CR 14/0,3, bil tot 16,2; bil direk 11,9; GoT/GPT 73/107; prot tot 4,3; Alb 2,7; Na 135; K 3,9; Cl 105; Darah rutin 19/12/2013WBC 19,65; RBC 3,75; HGB 10,4; PLT 248;PT 12,1 control 10,7INR 1,00; apt 19,1 control 23,5; CT 7’00”;
USG abd (27/12/13)- Kolestatik intrahepatik e.c susp.batu
pd duktus hepatikus comunis DD/batu pd proximal CBC
- IVFD clinimix: RL:NaCl 1:1:1 28 tpm
- Levofloxacin 500mg/12j/ iv
- Metronidazole 0.5 mg/8j/ iv
- Vip alb 3x2 caps- Vit K amp/24jam- OMZ vial/24j/iv- CT-Scan abdomen
24 IsoBed 2
Ny. Kadek Sugiarti01-07-1976
Fistel enterocutaneus
Lab 26/12/2013CT 7’30”; BT 3; PT 12,2 control 10,2; INR 1,00; APTT 21,7 control 26,2; GDS
- Takar produksi fistel/24 j
- IVFD RL 28 tpm
8
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
RM 643556MRS 27/12/2013Dr.dr.Ibrahim Labeda Sp.B-KBD
105; ur/cr 5/0,2; prot total 4,4; Alb 2,4; Globulin 2.0; Na 143; K 3,66; Cl 104; WBC 6,67; RBC 4,92; HGB 12,0; HCT 35,9; PLT 818
- Ceftriaxone 1 gr/12j/iv
- Ranitidin amp/8j/iv
- Ketorolac amp/8j/iv
LONTARA 2 DIGESTIVE KAMAR 2 (Nila (089666366277) )
25 Kamar 2 bed 1
a. Nama :Rosmiatib. pahec. 32 Tahund. Medis : 639238e. MRS : 4-12-2013
dr. Ronal R Sp.B KBD
POH 16 Eksplorasi CBD
Lab tanggal 16/12/13WBC 9,13 RBC 4,51 HGB 13,4 HCT 38,5 PLT 270 CT/BT 8’00”/3’00” GOT/GPT 15/10 Bilirubin total 0,65, bil.direct 0,29, albumin 3,5, Na/K/Cl 138/3,68/108Lab tgl 03/12/13SGOT 23SGPT 44 gamma 166 Lab tgl 28/11/13Bilirubin total 1,16, bil.direct 0,74, alk phosphatase 796,albumin 4,1, ur/cr 11/0,79,Na/K/Cl 137/4,0/101Lab tanggal 26/11/13WBC 5,4 RBC 4,69 HGB 14,1 HCT 40,8 PLT 348 CT/BT 8’00”/3’00” GOT/GPT 368/322USG tgl 26/11/13Kolestatik intra dan ekstra hepatik ec batu CBD ,CholelithCT Scan tgl 28/11/13 Cholestatic intra dan ekstrahepatic ec batu distal CBDpneumobiliaCholelith dengan cholecystitisFoto Thorax AP/PA tgl 29/11/2013Tidak Tampak kelainan radiologic pada foto thorax ini.
Cefadroxyl 2x500Pct 3x500Diet lunakGV+Rawat LukaAff hecting
26 Kamar 2 Bed 2
Ny. Wa Saku64001301/07/1958MRS 09/12/13JKM
dr. Warsinggih, Sp.B-KBD
Tu. Abdomensusp. Tumor Lien.
MSCT Scan Abdomen dengan kontras 5/12/2013- Massa di lien yang kesan mendesak
dan menyempitkan lumen gaster disertai perlengketan
- Abses hepar- Kista adneksa kiriEcho 5/12/2013- Fungsi sistolik LV cukup, EF 59%- LVH (+)- MR mild, AR moderateFoto polos abdomen 2/12/2013Soft tissue mass region hipochondrium kiriUSG abdomen bawah 2/12/2013Massa hypochondrium kiri susp tumor gaster mesenkimal DD/ LimfomaLab 2/12/2013
Asam mefenamat 3x500Ranitidin 2x150Terapi sesuai Ts. GH. Operasi Senin 30/12/2013
9
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
WBC 13,49; RBC 4,24; HGB 11,7; HCT 34,6; PLT 403; PT/APTT 14,5/26; INR 1,2; CT/BT 8’/3’; Na/K/Cl 139/4,0/105; GDS 140; Bil. Tot 0,90; Bil. Direk 0,24; As. Urat 4,7; GOT/GPT 22/12; Alb 3,7; prot. total 7,6; alkali phospat 80; Ur/Cr 33/0,79;HbsAg non reactive
27 Kamar 2 bed 3
Ny. Isapiah01-11-2013RM 638585JamkesdaMRS 21-12-2013Dr.dr. Ibrahim Labeda Sp.B KBD
Ca Recti 1/3 distal Pem. LGIE 01-11-2013Hemoroid eksternaTumor rectum susp. MalignaEchocardiogram Report Fungsi sistolik & diastolik LV baik, EF 68%USG abdomen tgl 22-11-2013Sesuai massa rectumTidak tampak tanda kelainan radiologik pada foto thotax ini.CT-Scan Abdomen tgl 25-11-2013Massa RectiLab tgl 22-11-2013WBC= 4,5 RBC= 3,71 HGB= 10.5 HCT= 30,9 PLT= 338. CT/BT= 8‘00/3’00 PT= 13,2 control 10,5. APTT= 23,3 control 22,9 INR= 1.10 GDS= 99 Ur/Cr= 20/0,9 SGOT/SGPT= 16/22 Alb= 4,1 Na/K/Cl= 124/3,8/105 CEA = 0,59 HbsAg= (-) Anti HCV= (-).
IVFD RL :D5% 1:1 28 TpmRanitidine amp/8j/ivKetorolac 30mg kp/8j/ivOBH Syrr 3x1 cthBisolvon Syr 3x1 cthRencana Colon In Loop
28 Kamar 2 bed 4
Husniati4o thn640683Mrs 10/12/13Dr. Ronald, Sp.B KBD
Tumor abdomen susp lymphoma
Lab 10/12/13Wbc 12,37 RBc 5,21 HB 13 HCT 39,2 PLT 385 USG abdomen 10/12/13Massa regio umbilical yang meluas ke inguinal kiri dengan gambaran lymphomaHydronephoris S
Tramadol amp/8j/ivDiet biasa
H. Parade : Rencana Laparotomi + Biopsi
LONTARA 2 DIGESTIVE KAMAR 3( Rahma 085218205466)
29 Bed 1 M. sarif 01/01/88613562Mrs 17/12/13Dr. dr. Ibrahim Sp.B KBD
Post colostomy X-ray 12/12/13BNOTidak tampak kelainan pada foto iniLopografiTidak tampak kelainan pada foto iniColon inLoopKaliber lumen kolon descendens sigmoid tampak mengecil
Diet biasaSpooling NaCL 0,9% pagi-soreKlisma yall/HariTunggu Status LamaH. Parade : Pro tutup colostomy
30 Bed 2 Rezky01-05-1982RM 642973MRS 21-12-2013JKMDr.dr.Ibrahim L SpB
D/ Post Laparatomi e.c Perforasi Gaster
Lab. Tgl 21-12-2013WBC= 14,54 RBC= 3,73 HGB= 8,8 HCT= 27,0 PLT= 560CT/BT= 7’00”/2’00” PT= 13,4 control 10,9. APTT= 225 control 23,9 INR= 1.095 GDS= 11,6 Ur/Cr=
IVFD RL:D5%:Climmix= 1:1:1Ceftriaxone 1 gr/8j/ivMinum Bebas+ makan Bubur
10
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
KBD 52/1,0 SGOT/SGPT= 78/53 Prot.total= 6,7 Alb= 2,2. Na/K/Cl= 152/4,1/122. HbsAg= (-), Anti HCV=(-).USG Abdomen atas tgl 21-12-2013Tidak tampak kelainan pada organ-organ abdomen yang terscan.
Omeprazole Vial/24J/IVUsul Aff cupCek Lab Kultur & sensitivitas Pus Luka OPMobilisasi dudukGV + Rawat LukaBoleh Rawat Jalan
31 Bed 3 La Madong31-12-1954RM: 643477MRS: 25-12-2013
D/ Splenomegaly
Lab tgl 25-12-2013WBC= 6,26 RBC= 3,25 HGB= 7,6 HCT= 26,1. PLT= 62. Prot.Total= 3,4 Globulin= 0,3 Bil.Total= 0,61 Bil.Direk= 0,25 CT/BT= 7’00”/3’00” PT= 15,1 control 10,3 APTT= 37,5 control 23,3 INR= 1,283 GDS= 92 Ur/Cr= 52/1,3 SGOT/SGPT= 33/33. Na/K/Cl= 136/3,7/136. Alb=2,2 HbsAg= (-) Anti HCV= (-)USG Abdomen tgl 25-12-2013Splenomegaly
IVFD RL 28 tpmCeftriaxone 1 gr/12j/ivRanitidine 50 mg/8j/ivMetronidazole 0,5gr/8j/ivTunggu hsil CT-scan Abdomen, evaluasi ADT.
32 Bed 4 Mardan1/12/1986642249MRS: 22/12-2013
Dr.dr.Ronald. E. Lusikooy Sp.B. B-KBD
Hematochecia e.c Colitis Ulseratif
Lab. 16-12-2013WBC= 9,19. RBC= 3,92. HGB= 7,7. HCT= 25,5 PLT= 435. CT/BT= 8’00”/3’00”. PT= 14,7 control 10,7. APTT= 30,1 control23,5. INR= 1,1 GDS= 64. Ur/Cr= 14/2,0. SGOT/SGPT= 27/27 Prot.total= 4,07. Alb= 1,7 Na/K/Cl= 135/4,42/116. HBsAG= (-). Anti HCV=(-) Lab tgl 18-12-2013WBC= 9,49 RBC= 4,43 HGB= 10,2 HCT= 31,7 PLT= 361. USG Abdomen Atas+Bawah tgl 18-12-2013Hepatomegaly
IVFD RL : Aminofluid 1000 1;1 28 tpmCeftriaxone 1 gr/12j/ivKetorolac amp/8j/ivRanitidine amp/8j/ivMetronidazole 0,5gr/8j/ivOBH Syr 3x1 cthTunggu Jadwal Kolonoskopi dan Endoskopi dari TS GEH
LONTARA 2 Bedah Digestif KAMAR 10(Ryan Kanzul Arasy 082369420682)
33 L2 diges K10Bed 1
Ny. Hadiah1/10/1960MRS: 18/11/2013 638001Jamkesmas
Dr. dr. Ibrahim Labeda, Sp.B-KBD
Tumor hepar +post op hari 6 laparatomy eksplorasi + debulking tumor
Lab 26/12/2013WBC 13,19; RBC 2,38; HB 6,4; HCT 20,1; PLT 341; Na/K/Cl 136/3,77/113; GDS 98; Ur/Kr 27/0,6; GOT/GPT 6/5; Alb 2,0; prot total 4,3Lab 23/12/2013WBC 8,8; RBC 4,37; HB 12,1; HCT 34,2; PLT 411; Alb 2,5; prot total 5,7Lab 19/12/2013WBC 8,25; RBC 3,69; HB 9,8; HCT 30,3; PLT 259; C/BT 8’/3’ PT/APTT
IVFD RL : D5: NaCl 0,9% = 28 TpmCeftriakson 1gr/12 jRanitidin 1amp/8 jam/ivFarmadol botol/iv/drips (jika demam)Transfusi PRC 2 bag premedikasi transfusi : Dexamethasone 1 amp/IV
11
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
11,7/30,1; INR 1,0; Na/K/Cl 140/3,3/110; GDS 125; Ur/Kr 24/0,7; GOT/GPT 15/8; Alb 2,7;Lab 16/12/2013WBC 8,49; RBC 3,52; HB 9,3; HCT 28,3; PLT 210Lab 12/12/13WBC 5,7; RBC 2,66; HGB 6,9; HCT 20,6; PLT 296; Na/K/Cl 141/3,2/108;CT/BT 8’/3’; PT/APTT 14,1/316; GDS 74; Ur/Kr 20/0,85 GOT/GPT 30/16 Prot. tot 5,0; albumin 2,3Lab 9/12/2013RBC 2,87; HGB 7,6; HCT 23,9; WBC 9,4; PLT 308;Lab 8/12/2013GOT/GPT 15/8; Albumin 1,8Na/K/Cl 137/3,5/115; CT /BT 8’/3’PT/APTT 13,7/31,1; GDS 108Ur/Kr 20/0,9;Lab 29 / 11 / 2013 WBC 6,4; RBC 2,95; HB 8,0; HCT 24,8; PLT 147;Lab 27/11/2013WBC 4,3; RBC 3,04; HGB 7,7; HCT 24,8; PLT 216USG Abd 26/11/2013Massa mesenterium berseptal disertai ascitesCholelithLab 23/11/2013WBC 4,90; RBC 3,35; HGB 8,6; HCT 26,4; PLT 349;Lab 21/11/2013RBC 2,26; HGB 6,3; HCT 20,4; PLT 268; WBC 5,0;Lab 20/11/2013RBC 1,96; HGB 4,3; HCT 34,7; PLT 260; WBC 4,3;Lab 18/11/2013WBC 4,36; RBC 1,46; HGB 2,6; HCT 10,3; PLT 213; CT/BT 8’/3’; PT/APTT 12,5/21,9; GDS 120; Ur/Cr 18/0,7; GOT/GPT 17/9; Na/K/Cl 140/4,0/113;PA 3/10/2013Cairan Kista:Mesotel Proliferatif dengan inflamasi (Cairan Peritonium)Kista Hemoragik (Cairan Kista)
Difhenidramin 1 amp/IMMobilisasi duduk
L2 diges Kamar10Bed 2
Hj. Jipa 1/1/1933 (80 thn)MRS 30/11/2013639479
Tumor Adnexa + ascites
Analisa cairan pleura 20-12-2013Warna:kuning; pH:8,0; rivalta:positif; LDH;411CT Scan Kepala 18/12/2013
IVFD RL : D5% : NaCl 0,9%=1:1:1= 28 tpmRanitidin 1amp/8jam/ivKetorolac jika nyeri
12
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Jamkesmas
Dr. dr. Ronald E. Lusikooy, Sp.B-KBD
Infark cerebri bilateralLab 18/12/2013AFP 0,67; CEA 1,35; CA 125 2211,36; Beta HCG kuantitatif <2,00;Foto thorax AP 4/12/2013- Cardiomegaly- Atherosclerosis aorta- Bulging diafragma kanan (proses
intrahepatik?)USG Abd 2/12/2013- Massa kompleks adneksa- Efusi pleura bilateralLab 2/12/2013 RBC 4,90; HGB 13,5; HCT 42,1; PLT 250;Lab 30/11/2013SGPT 45; protein total 5,3; albumin 3,1; globulin 2,2; Na/K/Cl 136/4,0/112;CT Scan 29/11/2013- Massa kompleks adneksa- Efusi pleura bilateralLab 29/11/2013GDP 67;Lab 28/11/2013CT/BT 8’3’; PT/APTT 12,9/27; GDS 275; Ur/Kr 21/0,9; SGOT/SGPT 168/45; Alb 3,1; Prot tot 5,3; Glo 2,2; Na/K/Cl 136/4,0/112; HBsAg non reactiveUrine Rutin 28/11/2013Warna Kuning agak keruh, protein +3/>300 glukosa +2/250 blood +2/80
Terapi lain sesuai TS bag GH, Neuro, dan obgynTakar dan alirkan drain ascites/24jam
35 L2 diges K 10 bed 3
Asnat Hagemur 5/2/1959 (54 th)64290120-12-2013Jamkesmas
Dr. dr. Ronald E. Lusikooy, Sp.B-KBD
Tumor abdomen USG kandungan 21-12-2013Massa kompleks dominan kistik kesan massa adneksa kananLab 20-12-2013WBC 10,50; RBC 4,75; HGB 7,5; HCT 28,2; PLT 231; CT/BT 7’/3’; PT/APTT 13,7/23,8; GDS 126; Ur/Cr 26/0,6; GOT/GPT 17/14; Na/K/Cl 142/3,4/112; albumin 3,1USG abdomen Whole abdomen 20-12-2013Tidak jelas tampak tanda-tanda pneumoperitoneumSplenomegalyMassa adnexa kanan
AFF infus.Ganti obat oralNeurodex tablet 3x1Cefixim 2 x 100 mgLansoprazole 1 x 1
36 L2 diges K 10 bed 4
Ny. A. Nurleny11-10-1970RM: 606115jamkesda
POH 10 laparatomy eksplorasi ec Tumor Recti 1/3 distal
Lab tgl 20-12-2013WBC 23,05; RBC 4,83; HGB 11,1; HCT 34,9; PLT 481; PT/APTT 14,6/33,0; GDS 45; Ur/Cr 7/0,4; GOT/GPT 103/103; Na/K/Cl 130/4,1/107; albumin 2,3
RL :D5% :NaCl 0.9% :Aminofluid 1 :1 :1 :1 28 tpmMakan bebasMobilisasi dudukInj. Imepronem 1 gr/12
13
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Lab tgl 20-12-2013CT/BT 8’/4’; PT/APTT 16,6/25,8; GDS 111; GOT/GPT 181/80; albumin 2,5Lab tgl 10-12-2013Feritin 1,60CEA 1659,61TIBC 30,7Lab tgl 07-12-2013GDP= 90Lab tgl 20-12-2013WBC= 8,7 RBC= 4.10 HGB= 9,7 HCT= 28,7 PLT= 411. GDS= 111 Ur/Cr= /0,41 SGOT/SGPT= 182/80 Alb= 2,5 As. Laktat= 55,5. CT/BT= 8’00”/4’00” PT= 16,6 control 12,1 APTT= 25,8 control 25,9 INR= 1,39 Na/K/Cl= 131/4,9/103. HBsAg= (-).
jam/IVKetorolac amp/8 jamPanzoprazol 40mg/24jam
37 L2 diges K 10Bed 5
Haramia1/7/1975 (38 thn)641950MRS 15/12/2013Jamkesmas
dr. Samuel Sampetoding, Sp.B-KBD, MARS
Cholestasis intrahepatik
Lab 28/12/2013GDS : 121; Bil. Total:15.3;Bil. Direk:13; Albumin: 1.6; Na: 144; K: 2.5; Cl:114Pem. Pre transfusi 19/12/2013Kesimpulan: incompatible pada minor dan autocontrolKesan : Ditemukan adanya antibodi yang couted pada sel darah merah pasien itu sendiri secara invivoSaran : tunda transfusi Lab 1 8 /12/2013 Ca 19-9 26,56; alkali phospat 114; CT Scan abdomen 18/12/2013- Splenomegaly- Meteorismus- Ascites Lab 14/12/2013WBC 9,82; RBC 2,09; HB 7,6; HCT 22,5; PLT 94;CT/BT 8’30”/3’30”; PT/APTT 22,6/51,6; INR 1,840; GDS 94; Ur/Kr 11/0,5; Bil. Total 11,38; Bil. Direk 9,33; GOT/GPT 107/42; Prot. total 9,3; Alb 1,3; Globulin 8,0; Na/K/Cl 134/3,1/117HBsAg/Anti HCV non reactive
IVFD NaCl 0,9%:RL28tpmInjeksi vit K 1amp/24jm/ivVip albumin 3x2 tabDrips Albumin 25 1 kolf/IV
Visite dr. Tantowi:Koreksi KaliumKonsul HOM
38 L2 digesK10 bed 6
Hj Jumriah1-7-1955 (58 th)642969MRS 21-12-2013Jamkesmas
Dr. dr. Ibrahim Labeda, Sp.B-KBD
Ca recti 1/3 distal +P.O. Mile’s procedure + prokemoterapi siklus V
BNO 3 PosisiSmall Bowell Obstruction
Lab 17-12-2013WBC 7,0 ; RBC 4,23; Hb:14,1; HCT 41,1; PLT 208; Na/K/Cl: 131/4,4/87; BT/CT: 3,00/8,00; PT 12,5 control 12,7; APTT 22,5 control 28,9
IVFD RL 20 tpmRanitidin 1 amp/8jam/IVCeftriakson 1gr/12jam/ivKetorolac amp/8j/ivMobilisasi dudukDiet Bubur
LONTARA 2 KAMAR 11 (Steven 085255536675)
14
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
39 Bed 1 Tn. Juhering1/7/1961640533MRS: 4/11/2013JKM
Dr. dr. Ibrahim Labeda, Sp.B KBD
POH 23drainage abcess scrotum+ Nekrotomi
POH 5Necrotomy + debridement
Lab 9/12/2013WBC 7.6 RBC 3.86 HGB 10.4 HCT 30.8 PLT 323 GDP 124 Alb 2.1 Kol. Total 103 HDL 17Lab 7/12/2013WBC:5,96 RBC:3,91 HGB:10,9 HCT:31,3 PLT:294 Ur/Cr:17/0,5 Alb:1,80 Globulin:4,15 CT/BT:9’30/3’30 PT/APTT:13,3/28,4 INR:1,095 GDS:183 SGOT/SGOT:57/33 Prot total:5,95Lab 4/12/2013WBC: 17,91 RBC: 4,05 HB: 11,2 PLT: 439 prot.total: 4,1 Alb: 1,9 Globulin: 1,9 CT/BT: 7’30/3’00 Ur/Cr: 22/0,6 GOT/GPT: 24/21 Na/K/Cl: 131/3,6/107 GDS: 110Foto thorax PA 4/12/2013Kesan:
- Bronchopneumonia bilateral- Cardiomegali- Limfadenopati DD/massa
mediastinum superior
- IVFD RL 24 tpm- Ceftriaxon
1gr/12jam/IV- Ketorolac
1amp/8jam/IV- Ranitidin
1amp/8jam/IV- Metronidazol
500mg/12jam/IV
40 Bed 2 Sujiono/ L/63 tahun01/07/1950(631732)MRS : 06/11/2013Penagihan
Dr. dr. Ronald E. L, Sp.B-KBD
D/ POH 23 laparatomi biopsyLimfoma maligna non Hodgkin
Lab 14/12/2013WBC 5.4 HGB 10.3 RBC 3.52 HCT 30.7 PLT 438Lab 12/12/2013WBC 3.7 RBC 3.52 HGB 10.3 HCT 29.8 PLT 3.58 Na/ K/Cl 140/ 3.5/ 100 GDS 93 Ur/ Cr 20/0.79 SGOT/SGPT 29/12 Alb 2.9Hasil PA 11/12/13Limfoma maligna non hodgkinLab 2/12/2013Albumin:3,4Lab 26/11/2013 WBC: 10,27 , HGB: 11,4 , PLT: 619, RBC: 3,92Lab 20/11/2013 CT 8, BT 3, PT 13,4, INR 1,11 APTT 33,2 Na 130 K 3,6, Cl 103 HbsAg non reactive Anti HCV non reactive, GDS 80, Ur 27 Cr 0,97, GOT 56, GPT 32, Albumin 2,5Lab 12/11/2013WBC 3,7 RBC 3,51 HGB 10,4 HCT 29,4 PLT 305 Na 134 K 3,8 Cl 105 GDS 84 Ur/Cr 15/0,8 SGOT/SGPT 20/5 Protein total 6,2 Alb 2,9 As.Urat 6,4 CT 8’ BT3’ PT/APTT12,8/26,4Lab 7/10/2013WBC 5,6 RBC 3,90 HB 10,9 HCT 32,6 PLT 379 CT 8’00” BT 3’00” PT 11,0
Alih rawat HOMNeurodex 2x1
15
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
APTT 27,6 CEA 1,01 GDS 90 ur 21 cr 0,9 GOT 21 GPT 6 Na/K/Cl 131/3,9/108Kolonoskopi 17/10/2013Massa tumor extraluminer infiltratif proktitis derajat sedangBiopsi 21/10/2013Epitel dengan displasia ringan dan radang kronik aktifUSG Abdomen (09/10/2013)Kesan : massa extraluminer dengan pembesaran KGB villi usus Colon Inloop (09/10/2013)Kesan : Tumor rectosigmoid dengan tanda-tanda obstruksi infiltratif CT-Scan Abdomen (09/10/2013)Kesan : Massa rectosigmoid yang infiltrasi ke jaringan di sekitarnya (DUKES C)Foto ThoraxCOR & Pulmo dalam batas normalOld Fracture 1/3 medial os clavicula dextra
41 Bed 3 Syarifuddin Rola31/12/1964639670MRS : 28/11/2013Konsul dari interna : 11/12/13
Dr. dr. Ronald Lusikoy Sp.B KBD
POH 11laparascopy drainase abses konversi laparatomi
PA 19/12/2013Kesimpulan : Jaringan nekrotik dengan peradangan supuratif (sesuai untuk abses)Foto thorax PA 15/12/2013- Efusi pleura dextra- Dilatatio et elongatio aortae- Atherosclerosis aortae- Emphysema subcutisLab 11/12/13Bilirubin total : 0,63 bilirubin direk : 0,08 albumin : 2,3 WBC : 10,33 RBC : 3,97 HGB : 11,2 HCT : 32,6 PLT : 512Lab 4/12/13AFP : 1,83 CEA : 1,62 alkali fosfatase : 426 gamma GT : 202Lab 2/12/13GDS : 60Lab 30/11/13CT : 7’00 BT: 3’00 PT : 15,7 APTT : 34,1 Albumin : 2,4 Na : 144 K : 3,6 Cl : 114Lab 29/11/13Ureum : 39 kreatinin : 0,7 GOT : 83 GPT : 88 protein total : 5,4USG Abdomen 3/12/2013-Hepatomegali dengan massa hepar susp. HCC dd/ abses hepar-multikistik ginjal bilateralCT Scan Abdomen 3/12/13- Multiple abses hepar
- Cefadroxyl 2x500mg- Metronidazol 500mg
3x1- Ranitidin 3x1- Asam mefenamat
3x500mg- GV luka/hari
16
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
- Kista ginjal kiriEfusi pleura
42 Bed 4 Hasjun Laki-lakiRM 633836Tgl.lahir 1-6-1970 33 thnMRS 23/10/2013JAMKESMAS
Dr. dr. Ibrahim Labeda, SpB-KBD
POH 25laparatomi eksplorasi miles’ procedure ec karsinoma anorektal
POH 5 rekonstruksi anus
Lab 23/12/2013GDS:85 Ur/Cr:17/0,55 As.urat:4,8 SGOT/SGPT:14/18 Alb:3,0 PT/APTT:12,9/11,9 Na/K/Cl:131/3,6/96 CT/BT:8’30/2’30Tumor marker 23/12/2013CEA:1,99Lab 12/12/2013WBC 6.4 RBC 3.37 HGB 9.7 HCT 28.3 PLT 432Lab 2/12/2013GDS: 93 Ur/Cr: 21/0,7 GOT/GPT: 18/12 Na/K/Cl: 135/3,7/106 HBsAg non reactive WBC: 6,17 RBC:4,29 HB: 12,8 PLT: 250Lab 18/11/2013WBC 15,91 RBC 4,15 HGB 12,4 HCT 34,5 PLT 433Lab 16/11/2013Ureum 13 kreatinin 0,5 GOT/GPT 19/17 Prot.total 4,9 Albumin 2,9 Globulin 2,0 Na/K/Cl 132/3,7/98 CT/BT 8”/2’30” PT/APTT 10,9/27,0 GDS 116Lab 16/11/2013WBC 14,12 RBC 4,03 HGB 11,8 HCT 32,7 PLT 400Lab 8/11/2013Na 136 K 4,0 Cl 96 GDS 120 Ur 10 Cr 0,5 GOT 26 GPT 23 WBC 12,38 RBC 4,40 HGB 12,9 PLT 390Lab 4/11/2013CEA : 1,95Lab 31/10/2013WBC 9,2 RBC 4,48 HB 13 HCT 38,2 PLT 404PA 1/11/2013Adenocarcinoma differensiasi sedangLab 23/10/2013WBC : 7,03,RBC;4,35 HB:12,7 HCT :36,0 PLT;423+ CT;7’00 BT; 2’30 PT;9,7 APTT:26,2 GDS:96 UR; 17 CR; 0,5 Na; 139 k; 3,6 cl;100HBsAg non reactive, anti HCV non reactiveFoto thorax PA/AP 23/10/2013KP dextra aktifTidak tampak tanda-tanda metastasis pada foto thorax ini
Cefadroxyl 500mg 2x1Ranitidin 3x1Asam mefenamat 3x500mg
43 Bed 5 Tn. Herman Romady25/4/1987641907
-Laserasi colon descenden
-Suspek trauma
CT Scan Abdomen 17/12/2013Kesan:
- Organ intraabdominal yang
Aff infuseCefadroxyl 2x500mgMetronidazol 3x500mg
17
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
14/12/2013Umum
Dr. dr. Ronald E. L, Sp.B-KBD
ureter (S) POH 22 laparotomi eksplorasi
terscan dalam batas normal- Efusi pleura bilateral
Lab 14/12/2013WBC 11.59 RBC 3.83 HGB 11.3 HCT 32.7 PLT 264 GDS 80 Ur/Cr 24/0.6 SGOT SGPT 65/46 Alb 2.2 USG Abdomen (14/12/2013)Efusi pleura minimal bilateral
Ranitidin 3x1Asam mefenamat 3x500mg
44 Bed 6 Tn. Abdul RahmanL: 1/7/1971MRS: 14/12/2013RM: 641892JKM
Dr. dr. Ronald E. L, Sp.B-KBD
Ileus obstruktif totalPost op10 laparotomy+ colostomy
Tumor marker 23/12/2013CEA: 19,17PA 18/12/2013Kesimpulan:
- Signet ring cell carcinoma recti- Kelenjar getah bening
mesentrium dengan sinus histiositosis
Lab 13/12/2013WBC 13.97 RBC 4.64 HGB 12.2 HCT 35.7 PLT 455 SGOT/SGPT 12/9 Alb 3.3 Na/K/Cl 140/3.8/108 CT/BT 8/3 PT/APTT 11.6/20/7 GDS 111 Ur/Cr 69/1.2
Cefadroxyl 2x500mgRanitidin 2x1Asam mefenamat 3x500mgXeloda 2x2
LONTARA 2 ONKOLOGI (Yaya Soraya Irnanda 085239795504)
LONTARA 2 UROLOGI (Yaya Soraya Irnanda 085239795504)
45 L2 uro Km 10 bed 3
Tiro Tompo14/9/1990 (23 th)641845MRS 13/12/2013Umum
LP: 116 cm
Tumor abdomen + seminoma testis
Lab 17/12/2013LDH 438; AFP 1,02; beta HCG kuantitatif <2,00Foto thorax PA 14/12/2013Efusi pleura sinistraUSG Abdomen 14/12/13-Susp tumor metastasis ke hepar-Lymphadenopathy-Ascites dan efusi pleura sinistraLab 13/12/2013RBC 4,65; HB 12,5; HCT 38,6; PLT 362; WBC 14,7;CT/BT 6’/2’30”; PT/APTT 12,7/25,7; INR 1,095; GDS 121; Ur/Kr 12/0,8; GOT/GPT 27/10; Protein tot 6,3; Alb 3,1; Na/K/Cl 142/3,9/106;
Terapi sesuai TS urologi Laxadine syr 3x1 cthDiet tinggi seratAwasi tanda – tanda akut abdomen
46 L2 uroKamar 12 bed 3
Rais Rahim,Ir9-2-1969 (44 th)642981MRS 21-12-2013JKD
-Melena ec susp gastritis erosiva-cholesistholithiasis-nefrolithiasis bilateral
Lab 23/12/2013RBC 2,94; HB 8,0; HCT 24,4; PLT 442; WBC 17,46CT/BT 7’30’’/2’30”; PT/APTT 11,3/25,8; INR 0,905; GDS 91; Ur/Kr 31/1,6; GOT/GPT 13/15; Protein tot 6,1; Alb 3,6; bil total 0,52 ; bil direct0,11 ; Na/K/Cl 142/3,7/110; hBsAg/antiHCV non reaktiv
Konsul ke bagian GEHEvaluasi tukak pepticR/gastritis kronikCek DR, Bil Direk, Indirek
18
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
LONTARA 2 ORTHOPEDY(Yaya Soraya Irnanda 085239795504)
LONTARA 3 MATA (Steven 085255536675)
LONTARA 3 BEDAH THT(Steven 085255536675)
LONTARA 3 SARAF(Steven 085255536675)
LONTARA 3 KUL-KEL(Steven 085255536675)47 L3
K1B4SemangMRS:27/12/2013RM:642453TL:1/12/2013Jamkesmas
Tumor anal CT scan abdomen tanpa kontras 23/12/2013Kesan:
- Tidak tampak massa pada lumen rectum
- Lyhmphadenophaty bilateralColon In Loop 23/12/2013Kesan: Suspek pendesakan hemorrhoid externa DD/massa rectum distalFoto thorax PA 18/12/2013Kesan:
- Bronchitis kronik- Bronchiectasis
Lab 18/12/2013CEA:15,63 WBC:5,0 RBC:4,48 HGB:11,6 HCT:33,3 PLT:416 PT/APTT:12,6/25,7 INR:1,05 Prot total:7,6 Alb:3,7 Glob:3,9 SGOT/SGPT:29/22 Alkali phospat:77 Bil.total:0,31 Bil.direk:0,10 GDS:98 Na/K/Cl:136/4,2/110 Ur/Cr:29/0,95
48. L3K3B1
Herlina BoriMRS: 21/12/2013TL:6/10/1972RM:217534Askes
Hernia InsisionalLab 22/12/2013WBC:13,82 RBC:4,58 HGB:13,9 HCT:38,5 PLT:259 CT/BT:8’00/3’00 PT/APTT:11,3/21,4 INR:0,9 Na/K/Cl:142/4,1/113 GDS:106 Ur/Cr:29/0,7 SGOT/SGPT:24/43 Alb:4,1USG Lower Abdomen 22/12/2013Kesan:
- Defek dinding abdomen region suprailiaka kanan dengan herniasi loop-loop usus
- Organ-organ abdomen lain yang terscan dalam batas normal
Thorax AP 22/12/2013Kesan:
- Pulmo normal- Cardiomegaly dengan dilatation
aortae
Aff infuseGanti oralNeurodex tab 2x1Asam mefenamat tab (kp)
LONTARA 4 GINEKOLOGI (Eka Novryanti 085341171040)
19
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
50 Kamar 3 Bed 6
PoliatiP/01-02-1963(50 tahun)RM 632917MRS 07/11/2013Jamkesmas
Post op drainase ascites
KholelithiasisKista heparKista MesenteriumPost drainage asites
POH 6 unroofing kista
Lab 16/12/13PT/APTT 13.1/25.0INR 1.095 GDS 97 Ur/Cr13/0,7 GOT/GPT 23/5 WBC 8.28 RBC4.50 HB 11.4 HCT 36.0 PLT 495MSCT Whole Abdomen Non-Kontras (12/12/13)Kista mesenteriumKista heparCholelithAscites dan efusi pleura blateralFoto thorax (111/12/13)Efusi pleura bilateral (dibandingkan foto lama tanggal 19/12/13 ada perbaikan)USG (09/12/13)Massa kompleks ovarium kiri dengan ascites dan pleura bilateralKista lobus kiri heparCholelithiasisMassa kistik berseptasi ekstra luminal region hipocondriumkiri.Lab 02/12/2013 Albumin 2,029/11/2013WBC 7,29 RBC 3,67 HGB 9,0 HCT 28,6 PLT 39224/11/2013Albumin 7,0 WBC 7,29 RBC 3,67 HGB 9,0 HCT 28,6 PLT 392Lab 15/11/2013WBC 5,92 RBC 3,24 HGB 7,7 HCT 24,1 PLT 413 CT/BT 8’00/3’00 Ur/Cr 22/0,9 GOT/GPT 23/14 Albumin 2,2Lab 23/10/2013CA125 3581.99CT AbdomenMassa ovarium kiriKista MesenteriumKista heparCholelithAsitesEfusi pleura dextraLab 17/10/2013WBC 5,4 RBC 4,76 HB 10,9 PLT 557 Na 141 K 3,9 Cl 109 GDS 111 Ur 21 Cr 1,0 GOT 19 GPT 6 Alb 3,3 CT 8 BT 3 PT 12,4 APTT 33USG Abdomen 18/10/2013Massa kompleks ovarium kiriKista heparCholelithAsites dan efusi pleura kanan
IVFD RL ; D5=2:1Cefotaxim/12 jamMetronidazole 0,5 mg/8jKetorolac amp/8jRanitidine amp/8jAs.traneksamat /8jTerapi sesuai TS obginTunggu jadwal operasi
20
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
51 Kamar 1 bed 2
Muhaira01/01/1976639683Tgl konsul 8/12/2013JKM
Tumor abdomen extraluminer
Lab ( 27 -12-13) WBC10.61 Rbc 4.47 Hb 11.7 HCT 36.5 PLT 532 Na/K/Cl 139/3.43/115
CT-scan Abdomen 05/12/2013Massa mesenterium dd/ massa
USG abdomenMassa kompleks adneksa yang menginfiltrasi diniding anteriorbuli-buli pelvocalyceal ginjal bilateral
Rencana operasi laparatomi eksplorasi + colostomy pada hari senin 30 Des 2013
52 Kamar 1 bed 3
Rahmatia5/12/1972638788JPSTggal konsul 8/12/2013
Post drainase ascites day 17
Lab ( 25 /12/13) Alb 2.2Lab (17/12/13)CT/BT 8’/2’30” PT/APTT 11.9/27.8 GDS 66 Ur/Cr 15/0.5 GOT/GPT 16/12 Albumin 1.9Hasil PA (11/12/13)Cervitis kronik non spesifikLab 06/12/2013GOT/GPT 19/7 ALB 3,4 WBC 5,9 RBC 5,30 HCT 41,1 PLT 458 HGB 13,6 PT/APTT 10,7/22,8 GDS Ur/Cr 44/0,8 CT/BT 8’00”/3’00”CT-scan abdomenKesan:-susp.massa periappendicular
Appendicolith-susp.massa adnexa kiri-asites dan efusi pleura dextra minimal
IVFD Nacl 0,9% 28 TPM-GV/2 hari-alirkan darah 100cc/jam
53 Kamar 5 bed 2
Nambi25/10/1969641178Tgl 11-12-2013JKM
Post drainase ascites day 14
Lab (17/12/13)Alb 2.1Lab (1 9 /12/13) WBC 6.28 RBC 4.42 Hb 10.8 PLT 439 HCT 34.1Foto thorax (16/12/13)Cardiomegaly dengan dilatation et elongatio disertai tanda-tanda bendungan paruUSG lower (16/12/13)Massa adnexa suspek malignancyAcites, Polib GBLab 1 0 /1 2 /2013 ALB 2, PT/APTT 11,0/21,2
GV/2 hari+rawat lukaTerapi lanjut sesuai Ts Obgin
54 Kmr 4 bed 4
Manusiwa Marthira16/21/51 (61 th)MRS 12/12/13RM 641625ASKES
POH 15drainase ascites
Lab (17/12/13)Alb 2.1Lab (1 9 /12/13) WBC 6.28 RBC 4.42 Hb 10.8 PLT 439 HCT 34.1Foto thorax AP (16/12/13)Cardiomegaly dg dilatation et elangatio disertai tanda2 mlignancyBendungan paru
Alirkan drain 100cc/jamGV/hari
21
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
Elevasi kedua diafragmaMSCT (16/12/13)Massa complex adnexa dg ascites suspek malignancyLab(14/12/13)Albumin 3.0 WBC 6.02 RBC 3.32 Hb 9.2 HCT 29.2 PLT 413Lab (12/12/13)CT/BT=8’30”/2’30” GDS 107 Ur/Cr=44/0.8GOT/GPT=46/23
55 Kmr 5 bed 3
Kasmira10-11-1996 (17 th)MRS 3/12/2013RM 641882JKD
POH 9drainase ascites
Usg AbdomenHidronefrosis dextra, ascites, komponen massa tidak dapat dievaluasiLDH 700 U/LAFP ,0,50 Ca 125 22,60Darah RutinWBC 5,26, RBC 5,11, HGB 10,8, PLT 272 Alb 3.3
R/ IVFD NaCl0.9% 28 tpmCeftriaxone 1gr/12jm/ivRanitidin /8j/ivKetorolac amp/8j/ivMetronidazole 0,5 gr/8j/ivBisolvon syr 3x1 cthAlirkan drain 100cc/jamGv/hari
56 Kmr 2 bed 4
Rita31-12-1968MRSTgl konsul 22/12/2013RM 642740Umum
NOK susp ganas + ascites
Darah RutinWBC 5,78, RBC 4,61, HGB 12,8, PLT 281Kimia darahNa 139, K 4,9, Cl 110UR/CR 28/0,4, GOT/GPT 22/6
TIA 24 cmH2O
IC (Eka Novryanti 085341171040)
ICU (NILA 089666366277)
58 ICU bed 3
Bentar 10-12-1989643311MRS: 25-12-2013Jamkesda
D/ post op hr 1Relaparatomi explorasi ec pertitonitis generalisata ec ruptur buli-buli Intraperitoneal+ruptur hepar 5,6-8
USG ABDOMEN 25-12-2013Ruptur Buli-Buli dengan hemoperitoneumUretrografiEkstravasasi kontras ke intraperitoneum suspek ruptur buli-buliFraktur ramus superior et ramus inferior os pubis bilateral.Lab tgl 26-12-2013WBC= 9,17 RBC= 2.86 HGB= 8,3 HCT= 24,2 PLT= 61 PT= 14,6 control 10,2 APTT= 32,3 control 28,2 GDS= 110 Ur/Cr= 42/1,2 SGOT/SGPT= 245/317 Alb= 2,2 Na/K/Cl= 136/4,47/115 ALKALOSIS METABOLIK
Awasi TTV & Tanda Akut AbdomenInfus RL 2000/24jImipenem 1 gr/8j/ivMetronidazole 500mg kp/8j/ivAs. Traneksamat 500mg/8J/IVTerapi sesuai di ICU
22
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
59 ICUVIP 4
Tn. UsengRM 6438271/7/1935JAMKESMAS
Dr. Murny A. Rauf, Sp.B KBD
POH 1 Laparotomi eksplorasi ec. Perforasi Gaster (rupture Antrum Piloric)
28/12/2013AGDPh 7.42Lab. LengkapWBC 11.49 RBC 3.33 Hb 10.1 HCT 30.3 PLT 89 Ur/Cr 94/3.1 GOT/GPT 61/33PROT. Total 3.1HBsAG Reactive, Anti HCV non ReactiveCT 9’30” BT 3’30” PT 18.7/9.9 INR 1.5 APTT 33.6/29.0 GDS 50
IVFD RL 2000cc/hrMeropenem 1gr/8j/ivPantoprazole 40mg/24J/ivFarmadol 0.5gr/8J/IVAs. Traneksamat 500mg/8J/IVBalance CairanAwasi TTVTerapi lain sesuai TS Anestesi
PCC (Taufiq 087840568100)
60 Lt 3330
Tn Benito AbbasMRS: 24/11/13Ttl:29/11/1957Umum
Dr Mappincara, SpB-KBD
Post Ielostomy + RCC (D) Residif Hematemesis melena ec susp metastase usus
Lab 11/12/13WBC:14,7 RBC:3,55 Hb:10,2 HCT:30,0 PLT:291Lab 4/12/13WBC:10,2 RBC:2,53 Hb:7,6 HCT:22,5 PLT:408Lab (29/11/13)WBC:13,1 RBC:1,57 HB:4,8 HCT:14,6 PLT:344 PT/APTT:12,5/25,6 Alb:3,3 Na/K/Cl:137/4,0/115USG (25/11/13)Massa hipokondrium sinistraSplenomegalyKista ginjal kananThoraxCardiomegali dan dilatatio + atherosclerosis aorta
Terapi sesuai TS Urologi + InternaSpooling Colostomy
61 Lt 4411
Hasanuddin ArfahTtl:9/4/1974RM:633470MRS:29/11/13
Dr Ibrahim Labeda, SpB-KBD
Tumor esofagus 1/3 distal
MD 9/12/13Susp tu esofagus 1/3 distalMSCT ThoraxMassa esofagus 1/3 distalEndoskopi 2/12/13Mucositis ec jamur pada hipofaringLab 30/11/13CT/BT 2/6’30’’ PT/APTT:10,9/28 GDS:102 Ur/Cr:30/10,3 GOT/GPT:26/36 Protot:7,9 Alb:5,1 Na/K/Cl:146/4,3/106 WBC:7,5 RBC:5,1 Hb:15,8 HCT:45,2 PLT:276PA 18-12-13Peradangan kronik non-spesifik pada antrium
RL 24 tpmCefttriaxone 1gr/12jRanitidne amp/8jEndoscopy Lepper + Biopsi
62 Lt 3312
Tn. A. SafriTtl : 31/12/63)RM : 618938
Dr.dr. Ronald Lusikooy, Sp.B-KBD
Tumor Abdomen susp. Aneurisma aorta + efusi pleura (s)
LAB 18-12-13RBC 3,5 HCT 28,4 PLT 469 WBC 11,7
Terapi lanjut sesai TS BTKV
23
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
63 Lt 4407
AnniTtl:31/12/1923RM614827MRS:10/12/13
Cholecistitis LabCT/BT:2/8 PT/APTT:12,9/20,8 GDS:131 Ur/Cr:31/1,1 GOT/GPT:30/24 AFP:1,18 CEA: 81,3 Ca 19-9 >500Na 132 K 3,5 Cl 102 As. Urat 3,3 Colesterol Tot 139, HDL 5 LDL 87 Tgd 233 as.urat 3.3Foto ThoraxLesi nodul soliter pada parabronchial dextra suspek Tu.paru DCardiomegali + dilatatio aortaeAtherosclerosis aorta
Terapi lanjut sesuai TS interna
RSUH (Taufiq Akbar 087840568100)
64 RSUH lt4 412
Tb AsriMRS: 22/11/13Ttl: RM: 016130
Dr dr Warsinggih, SpB K-BD
Ikterus Ob sec susp Ca Pankreas
Lab (7/12/13)WBC: 16,48 RBC:3,79 Hb:9,9 HCT:30,9 PLT:544Lab (2/12/13)GOT/GPT:59/40; Gamma GT:63,7 ALP:258,4 Bil Dir: 18,25; Biltot:42,7 GDS:92; Ur/Cr:28/0,6Lab (29/11/13)Na/k/Cl: 143/3,3/112MSCT Abd (26/11/13)Kolestatik intrahepatic dan ekstrahepatik disertai distended GB ec sugestif massa caput pancreasAscites dan efusi pleura bilateral
Optimalisasi KUInjeksi vit k 1 amp/12 jam/iv
65 RSUH lt4404
Hj MarthinaTtl:5/3/1959RM:016632MRS:10/12/13ASKESDr.dr. Warsinggih, SpB-KBD
POH VII CholisistekomiSusp batu CBD
Lab (17/12/13)WBC:13,98 RBC:3,81 Hb:10,5 HCT:32,2 PLT:480 Na/K/Cl:136/4,0/102 CT/BT 8/2 PT/APTT 12,9/33,4 GOT/GPT:72/92 ALP:535 Biltot:10,31 Bildir:6,24 Alb:2,9 GDS:146 Ur/Cr:24/0,5USG Abd (5/12/13) KolelitiasisBatu CBD menyebabkan kolestatik ductus biliaris intra dan ekstra hepatikMSCT abd (7/12/13)Choledocholithiasis distal disertai intra ekstra hepatik bile ectasisCholelithiasisNefrolith kiri pada pole bawahLab (8/12/13)GOT/GPT:98/107
- IVFD RL 28 tpm- Cefotaxim 1gr/12j- Metronidazole
500m/12j- Ranitidine amp/8j- Diet lunak- GV/hari
66 RSUHLt 4421
Zainal arifinTtl 5-9-1968010072
Post eksisi anorectum residif
Lab 21-12-13WBC : 7,4 RBC 4,37 HB 11,4 PLT 291
-ceftriaxon amp/12 jamMetronodazole 0,5 gram/12jamKetorolac amp/8jamRanitidine qmp/8jam
24
KORAN BEDAH DIGESTIFSENIN, 30DESEMBER 2013
67 RSUHLt 4423
Abdul HapidTtl:31/12/1959RM: 016701MRS:12/12/13Umum
Abses perianalDM tipe 2Trombositopeni pro evaluasi
Lab 13/12/13WBC:4,28 RBC:3,97 Hb:12,2 HCT:34,8 PLT:70 Na/K/Cl:132/4,4/100 CT/BT:7/2 PT/APTT:16,3/31,8 GOT/GPT:32/29 GDS:430 Ur/Cr:11/0,7Lab 21-12-13WBC : 3,5 PLT : 64 RBC : 3,53
- Broadced 1gr/8j/iv- Ranitidne amp/8j- Ketorolac amp/8j- Rawat luka
Konfirmasi interna trombosit 64ribu
68 RSUHLt 4403
Beddu AbbasTtl:10/10/1940Rm:016552MRS:08/12/13AskesDr.Warsinggih, SpB-KBD
Hipertrofi prostatHIL (s) irreponobilisHemoroid interna gr IIIPOH V
Lab 12/12/13WBC: 5,59 RBC:4,33 Hb:10,5 HCT:34,0 PLT:140 GOT/GPT: 238/262 Na/K/Cl:135/4,2/105 CT/BT:7/4 PT/APTT:21,1/34,5 GDS:110 Ur/Cr:80,5/1,5
- Perbaiki KU- Tunggu hasil HB
69 RSUH lt4422
Tn. SayogiTtl: 13/12/63Rm: 016737Mrs: 15/12/13Dr. Warsinggih, SpB-KBD
POH III Tu. Recti 1/3 Distal.
WBC 11,82 RBC 5,19 HB 15,7 HCT 45,8 PLT 414 Na 137 K 4,8 Cl 102 Sgot/Sgpt 66/45 Alb 4,1 Gds 79 Ur 21 Cr 0,8 HBSag (-) Anti Hcv (-)
Foto ThoraxKP Duplex lama aktif
- Optimalisasi KU- As. Mefenamat 3 x
500 mg- Ceftriaxone 1 gr/12
jam- Metronidazole 1 amp/
8 jam- Ketorolac 1 amp /
8jam- Ranitidin 1 amp / 8
jam
70 RSUH LT 4315
A.SafriTtl: 02/11/46Rm: 016870Mrs 19/12/13
Dr. warsinggih. Sp.B-KBD
Ikterus Obstruktif e.c susp. Batu CBD
LAB18-12-13WBC 12,77 RBC : 3,97 HB 11,1 PLT :265Tumor marker CA 19-9 >500u/mL
- Operasi hari ini
71 RSUHLT 4424
NurhayatiTtl: 01/01/70Rm: 016810Dr.dr Ibrahim Labeda, SpB-KBD
Tu. Abdomen e.c tu. mescenterium
Tgl 18/12/13WBC 36,74 RBC 2,45 HGB 7,5 HCT 23,1 Na 120, K 2,3 Cl 95 SGOT 36 SGPT 11 Alb 3,1 GDS 79 Ur 50 Cre 2,2 CT 9’00 BT 2’00 PT 12,8 APTT 36,1
CT Scan AbdomenMassa pada regio lumbalis dextra disertai pembesaran kelenjar paraaorta sugestive suatu Tu. Mescenterium
- Koreksi Kalium dalam 1 flacon dalam Nacl 100cc 12 tpm
72 RSUHLT 4425
RosnaTtl: 1-12-43Rm: 016904
Suspek Appendisitis akut
- Ranitidin 1g/8jam- Ceftriaxon 1gr/12jam- Metronodszloe
500mg/8jam
73 ICU Hj RosmiatiTtl : 31-12-1946RM : 016941Dr.dr Ibrahim Labeda, SpB-KBD
Tumur colon transversum suspek malignansi
Lab 20-12-13WBC:7,5 RBC:4,60 HB:11,3 PLT:296 Na:141 Cl:103 CT:6 BT:3 PT:14,7 APTT:35,1 GOT:21 GPT:15 GDS:109 Ur:39 Cr:0,8 HbsAg (-)
- Ranitidin 1g/8jam- Ceftriaxon 1gr/12jam
Metronodszloe 500mg/8jam
25