KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

PALEM ATAS N o Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi Lab 17/03/2014 WBC 7,34; RBC 4,66; HGB 11,8; HCT 33,8; PLT 400; GDS 65 CT/BT 7,00/3,00 PT/APTT 12,3/30,3;INR 1,03 Ur/cr 43/0,80 Bil tot 0,53 Bil. Direk 0,28 GOT/GPT 48/31 Alb 3,0 HbsAg non reactive Anti HCV non reactive CEA 122,66 CT Abdomen atas bawah Tumor mesenterium 15/03/2014 Tidak tampak densitas massa pada abdomen dan ascites Lab 14/03/2014 RBC 3,89; WBC 6,4; HGB 9,7; PLT 348 CT/BT 800/300 Cernevit 1g/24j Farmadol (k/p)

B1/7

Kurniawati TL 01/03/1969 RM 656111 MRS 22/3/2014 JKN

D/Tumor Abdomen Post OP Laparotomi Kista Hepar

-IVFD Asering 28tpm -Ketorolac 1amp/12j -Ranitidin 1amp/8j/iv -Cek hasil lab -cek hasil foto Usman Daulasi 54 tahun 29-10-1959 Laki-laki JKN 615660 Dr. Samuel S, Sp. BKBD

Lab (15/3/2014) RBC 4,54 WBC 9,3 Hb 10,6 HCT 32,7 MCV 72 MCH 23,4 PLT 419 Lab (17/3/2014) PT 11,9 APTT 24,7 INR 0,99 GDS 102 Ur 22 Cr 0,63 GOT 22 GPT 21 Endoskopi (19/3/2014) -Hemoroid externa -polips recti & sigmoid -Tu. Recti curiga malignancy Lab (21/3/14) CEA 1,73

B2/11 SS

B2/4 RL

Ny. Nimrah 20-10-1980 Perempuan MRS 14/3/2014 Dr. dr. Ronald EL, Sp.B-KBD

Polips Recti + Hemoroid grade III

Tunggu hasil biopsi USG abdomen

PT/APTT13,1/34,3 INR 1,10GDS 89 Ur/cr 38/0,80 GOT/GPT 35/23 Nat 140; kal 3,5; Cl 107 Hasil PA 14/11/2013

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

Metastase Adenokarsinoma Musinosum pada Mesenterium Syamsuddi n Lipi 31/12/1938 653893 Dr. dr. Ronald EL, Sp.B-KBD PA 18/2/14 Adenocarcinoma colon difrensiasisedang, dengankeduaujungi nsdsbebas tumor Ardium 3x1 Lab 3/3/14 RBC 4,29 Hb 8,8 HCT 28,2 PLT 397 WBC 9,7 Ur 34 Cr 0,8 GDS 76 LAB 3/3/14 Ph 7,59 pCO2 20,1 pO2 104,1 SO2 98,6 Eecf -7 HCO3 16,2 O2Ct 13,8 As laktat 7 LAB 19/3/14 WBC 12.3 RBC 4.35 HGB 11.4 HCT 36.1 PLT 287 LAB 18/3/14 WBC 7.5 RBC 4.53 HGB 12.2 HCT 37.4 PLT 355 GDS 136 Ur/Cr 19/0.65 GOT/GPT 23/26 Alb 3.5 Na/K/Cl 137/4.0/98 PT 11.7 INR 0.97 APTT 28.9 PA (13/1/14) Kolesistitis kronik CT (5/3/14) Pneumobilier Pankreatitis kronis Lab (08/03/2014) WBC 8,7 RBC 3,49 HGB 10,9 HCT 32 GDS :96 Ur/Cr : 34/0,5;

B2/11 RL

Haemorrhoid rectum Gr.IV

Lab 20/03/2014 GDS 120 Na 131 K 3,7 Cl 100

B1/7 644804 Jkn WS

Rafael LT 04/08/1983 Laki-laki MRS 12/03/2014 Dr. dr. Warsinggih , Sp.B.KBD

B1/4 SS

Tn. JK Samban 10/9/1940 650884 Dr. Samuel S. Sp. B. KBD

LAB 12/3/2014 WBC 6.3 RBC 2.85 Hb 8.2 HCT 25.0 PLT 261 Ur/Cr 65/7.80 Alb 3.7 Na/K/Cl 135/4.9/108 PT/APTT 12.6/22/3 INR 1.10 PALEM BAWAH LAB 2/3/2014 WBC 12,66 RBC 4,31 HGB 8,8 HCT 28,1 PLT 700 Alb 2,5 Na/K/Cl 127/3.2/101 POH 27Hemicolectomy 17/2/14 dextra ec. Tu. GDS : 61Pro. Total Colon acendence : 4,8 Albumin : 2,2 WBC : 11,45 RBC : 4,449 HB : 9,4 HCT : 29,7 MCV : 66,1 MCH : 20,9 PLT : 223

POH-8 post CAPD

LAB 15/3/2014 WBC 8.4 RBC 3.07 Hb 8.9 HCT 26.6 PLT 269 Ur/Cr 89/10.10 As. Urat 8.9 Na/K/Cl 135/4.8/105 CT/BT 7/230 PT/APTT 12.4/25.0 INR 1.10 Ciprofloxacin 2x500 mg

B2/6 Bed 1 SS

Safri Laki-laki 12-12-69 645747 JKN Dr. Samuel S, Sp. BKBD

POH-6 post laparotomi eksplorasi e.c. hernia interna

RL:D5%:Aminofluid=5 00:500:1000 / 24 jam Ceftriaxon 1 gr/12 j/iv Ranitidin 50 mg/8j/iv Takar drain/24 jam Boleh minum 2 sdm/jam Balans cairan Aff NGT

Ciprofloxacin 2x500mg VIP Alb 3x2 Neurodex 1x1 GV B 2/13 Bed 2 RL Nurbaety Perempuan 31-12-77 647967 MRS 8-32014 Wound rehisensi postileostomi

Levofloxacin 2x1 tab GV/hari Mobilisasi jalan Diet biasa

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

Dr. dr. Ronald EL, Sp.B-KBD SGOT/SGPT : 15/14; prot total : 5,8; alb : 3,5; Lab (17/3/2014) RBC 3.53 HB 9.8 HCT 29.2 PLT 198 WBC 4.72 CT 7.00 BT 3.00 PT 13.0 INR 1.08 APTT 28.9 Na 135 K 4.5 Cl 99 Ur/Cr : 111/11.7 CKD stg V POH 12 CAPD Jadwal HD : selasa -jumat Lab (4/3/14) WBC 5.02 RBC 2.86 HB 7.7 HCT 24.0 PLT 408 UR/CR : 92/12.3 Na 130 K 4.4 Cl 96 USG Abd (25/2/14) - PNC bilateral -Ascites & efusi pleura bilateral Lab (12/03/2014) RBC : 4,16; WBC : 10,0; HGB : 14,0; HCT 42,8; PLT :212; Ur/Cr : 25/0,92; Albumin : 3,8; Na/K/Cl : 130/4,0/103; GDS : 112; bil.total : 12,21; bil. Direk : 9,61; CT/BT :7,00/3,00; PT/APTT : 14,7/28,6; INR: 1,23 Lab (12/3/2014) WBC 7,4 RBC 3,79 HB 10,7 HCT 32,4 PLT 312 PT/APTT 11,9/22,4 INR 1,00 Ciprofloxacin 2x500 mg GV/3 hari Diet biasa Warsinggih , Sp.B.KBD GDS 222 Ur/Cr 59/2,60 GOT/GPT 28/18 Na/K/Cl 139/3,3/109 Lab (07/03/2014) Ur/Cr : 96/3,89; Albumin : 2,2; Na/K/Cl : 139/3,9/104; RBC : 4,38; WBC : 8,70; HGB : 12,4; HCT 37,0; PLT : 229; Tn. Nataniel 05/11/1958 648648 Dr. Samuel S, Sp. BKBD

10

B2/4 bed 1 WS

Sulaeman 5/5/1967 651234 JKN MRS 15/2/2014 Dr. Warsinggih , Sp.B.KBD

13

B2/1 2 SS

Tu. Sigmoid

Tunggu hasil lab Fenitoin Alprazolam 0,5 mg 1x1

11

B2/10 IL

Akhmad Nasrul 31/12/1963 Laki-laki JKN 14/03/2014 Dr. Ibrahim Labeda, SP.B-KBD

POH-6 post eksplorasi CBD e.c. Batu CBD + GB Stone

IVFD RL:D5%: Aminofluid 500:500:1000 / 24 jam Ceftriaxon 1 gr/12 jam/iv Metronidazole 0,5 gr/8 jam/iv Ranitidin 50 mg/12 jam/iv Ketorolac 30 mg/8 jam/iv

14

B1/2 RL

Asriadi Abbas 28/6/1983 RM 655757 MRS 19/3/2014

Kolesistolithiasis dan kolesistitis

Lab rutin (19/3/2014) RBC : 4,73; HB : 14; WBC : 8.1; HCT : 40.7; PLT 182 CT : 800; BT : 200; PT : 12.2; APTT : 27.5; INR : 1.10; GDS : 77; Ur/cr : 14/1.0; SGOT/SGPT : 25/44; Na/K/Cl: 139/3.6/111; Bil total : 0.56; Bil direct : 0.14

IVFD RL 28 tpm Ketorolac 30mg/8j/iv Ranitidin 50mg/12j/iv Diet lunak Rencana operasi laparoskopi cholecystectomi hari Senin, 23-3-2014

Lontara 1 Johanis Toding 9/11/1954 654912 JKN HBSAG(+) BNO 3 POSISI 13/3/14 KESAN: gambaran ileus obstruktif Lab 15/3/2014 Diet bubur Rawat stoma Ceftriaxone 1gr/12j/iv Metronidazole 0.5 gr/8j/ iv Ketorolac /8 jam Ranitidine /8 jam KoreksiKalium 25 cc

12

B2/5 Bed 1 WS

I Bunga 01/12/1930 JKN 639124 Perempuan Dr. dr.

CKD Stage V POH 12 CAPD

Terapi sesuai TS interna GV Ciprofloxacin 2x500 PCT (KP)

13

L1AB K1/Bed1 MP

POH 7 Hortman Procedure ec Tumor Colon Sigmoid

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

RBC 5.57, WBC 9.5, HB 15, HCT 45.8, PLT 214, BT 330, CT 800, PT 15,8(11,8), APTT 36.3 (25.2), GDS 169, Ur 78, Cr 1.30, GOT 21, GPT 30, Na 137, K 3.1, Cl 112 Lab 20/3/2014 RBC 4.79, WBC 9.54, HB 13, HCT 37.8, PLT 125, Ur 61, Cr 2.08, Protein Tot. 5.1, Albumin 2.6 Foto Thorax 11/3/14 KESAN: cardiomegaly dengan dilatatio et elongatio aortae Usman 10/7/81 JKN 654140 Laki-laki CT Scan Abdomen 17/3/14 KESAN: Massa colon ascendensdisertai ascites Dilatasi loop-loop usus Efusi Pleura bilateral Thoraks AP 14/3/14 Efusi pleura bilateral 20/3/14 HGB/HCT 12.2/37.4 WBC 10.1 PLT 267 BT 3 CT 8 PT 13.2/11.3 APTT 26.1/24.6 INR 1.10 Alb 3.3 Ur 15 Kr 0.4 SGOT/SGPT 106/158 Bil tot 14.98 BilDirek 12.24 HBSAG (-) 22/3/14 WBC 13.9 RBC 3.2 HGB/HCT 10.5/31.3 PLT 452 CT 3 BT 8 PT dalamNaCl 28 tpm GV 20/3/2014 Massa colon ascendensdengant anda-tanda ileus obstruktif 23/3/14 WBC 3.5 RBC 3.04 HGB/HCT 8.3/25 PLT 79 PT 13.1/8.7 APTT 22.4/23.9 INR 1.1

L1BD RPK Bed 4

Tumor Colon Ascendens

Perbaikan KU Tunggu hasil Hb post Transfusi

14

L1AB K4/Bed3

Hambali 31/12/1960 654053 JKN

Tumor Colon Ascendens

LGIE 11/3/14 Tumor Colon Ascendens Curiga Malignancy Lab 15/3/2014 RBC 2.82, WBC 17.90, HB 7.1, HCT 22.2, PLT 411, BT 300, CT 800, PT 14.4(11.5), APTT 30.8 (23.8), GDS 68, CEA 3.06 CT Scan Abdomen

Tunggu hasil kolonoskopi

L1BB K5(III) Bed 1

Husna 8/2/47 JKN 655782 Perempuan

Ikterusobstruktifec suspbatu CBD dd. Ca caput pankreas

Tunggu hasil CEA

LIAD KI Bed I

Darwati 15/06/1970

Batu Distal CBD

Rencana Op kamis Perbaiki KU Koreksi albumin Diet rendah lemak

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

13.0/11.5 APTT 28.8/25.0 Bil tot 22.7 Alb 2.4 MRI Cholangio Pancreatografi (kontras) Cholestatik sistem bilier ec batu pada distal CBD LONTARA 2 DIGESTIVE KAMAR 1 Lab(19/3/2014) RBC 4.15 HGB 11.8 HCT 34.8 PLT 80 WBC 18.1 CT 6.00 BT 2.00 GDS 149 Ur 49 Cr 1.20 SGOT 36 SGPT 41 Na 138 K 3.7 Cl 110 Saleng Tumor abdomen 1/7/1941 suspek tumor Foto thorax 655759 mesenterium PA/AP MRS Leukositosis (19/3/2014) 19/3/2014 trombositopenia Kesan : cardiomegaly dengan dilatatio et elongatio aortae Elevasi diafragma dextra (proses intrahepatik) CT Whole Body (20/3/2014) Kesan : massa mesenterium Ileus obstruktif Efusi pleura bilateral Usul : MSCT scan abdomen dengan kontras USG abdomen (20/3/2014) Kesan : suspek massa colon sigmoid dengan tanda-tanda infiltrasi buli-buli Usul : MSCT scan abdomen dengan kontras POH-1 laparatomi ekspolarsi e.c laserasi lien grade II TCG GCS 10 perbaikan GCS15 Contusion paretal Dextra Pneumocephale Fraktur linear temporobasal

16

Kamar 1 Bed 4 IL

Agus 1/7/1988 RM 656210 MRS 23/3/2014 JKN

Lab (16/3/2014) WBC 12,3 RBC 2,53 HB 8,0 RBC 2,53 PLT 124

IVFDS Nacl : DS% : Aminofluid Ceftriaxone 1gr/12j/iv Ketorolac /8j/ iv Ranitidine /8 jam Diet lunak

15

Kamar 1 Bed 1 RL

IVFD RL : DS % 1:1 28 tpm Ceftriaxone 1gr/12j/iv Metronidazole 0.5 gr/8j/ iv Ranitidine /8 jam Awasi tanda vital dan akut abdomen Pindahkan iv line

17

Kamar 1 Bed 3 SS

Azis karim 31/12/1940 RM 649168 MRS 21/03/2014 JKN

Lab (16/3/2014) WBC15,7 RBC 2,63 HB 7,4 RBC 2,63 PLT 281 Ca recti 1/3 distal Rawat kolostomi GV/3 hari VIP albumin 3x2 cap

Na/K/Cl 156/3,8/126 HbsAg non reactive

18

kAmar 1 bed 2 IL

Judin matili 3/6/1959 RM 655980 MRS 21/3/2014 JKN

Tumor esofagus

hasil endoskopi (11/3/2014) hasil : tampak mukosa dan sisa makanan skope masuk 35cm tampak mukosa

IVFD RL:DS % : clinimix 500:500= 1000/24jam

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

berbenjol, merah dan mudah berdarah dengan lumen hampir tertutup total LONTARA 2 DIGESTIVE KAMAR ISOLASI Lab Rutin 12-03-2014 LED 42/71 WBC 16,9 RBC 4,99 HB 15,4 HCT 44,8 PLT 270 CT/BT 800/330 PT/APTT 15,6/30,2 GDS 80 Ur/Cr 18/0.80 GOT/GPT 19/21 Na/K/Cl 136/3,5/109 HbsAg (-) Anti HCV (-) perforasi caecum Hasil Foto Thorax 17/03/2014 -Cor dan pulmo tidak tampak kelainan Pneumoperitoniu m Hasil Foto Abdomen 17/03/2014 Gambaran ileus obstruktif dengan pneumoperitonium Hasil foto thorax PA/AP post pemasangan CVC Kesan : cardiomegaly

17

KAMAR ISO Bed 2 WS

Midon 10-02-1988 RM 654738 MRS 12-03-2014 JKN

Post Appendectomy Perawatan hari ke 3

-IVFD RL:DS 1:1 28 tpm Ceftriaxone 1gr/12j/iv Metronidazole 0.5 gr/8j/ iv Ranitidin 150 mg/8j/iv Ketorolac /8 jam/iv Diet lunak Mobilisasi duduk Rawat luka/GV

Kamar iso bed 1 SS

Johan tiranda 4/7/1968 MRS 26/3/2014

Adenocarsinoma sigmoid, siklus kemoterapi

Kemoterapi

Lab rutin (20/3/2014) WBC : 11.18; RBC : 3.91; HB : 10.6; HCT : 31.4; PLT : 539 Ny. Jumriah 8/08/1974 RM 653118 MRS 12/03/14 Lab Tanggal 17/03/2014 WBC 11,7; RBC3,36; HGB 8,9; HCT 27; PLT 634 PT/APTT 11,4/24,0 INR 0,95 Lab tgl 24/3/2014 HGB 7,7 RBC 2,82 MCV 83 MCHC 32,9 Rencana transfusi PRC 2 unit Rencana operasi explorasi CBD+IOC SF 1x1 Vipalbumin 3x2 cap Diet bebas

Kamar 2 bed 1 RL

LONTARA 2 DIGESTIVE KAMAR 2 Mainan 31/12/1930 Ca recti 1/3 distal, MRS kemoterpai 25/3/2014 JKN A.Zaenab Dg. Sanginging 11/12/1956 RM 655412 MRS 17/03/2014 -POH 5 Post laparatomy eksplorasi e.c ileus obstruksi -reseksi anastomose e.c tumor colon transversum -ileostomi e.c LAB 20/03/2014 WBC: 13,2 RBC: 5.08 HB: 11,2, PLT: 316, GDS: 117, Na/K/Cl : 138/3.2/104, Albumin 2,4

Kemoterapi siklus IV

22

Kamar 2 bed 4 IL

Ikterus Obstruktif ec. batu distal CBD

20

Kamar 2 bed 2 IL

Aff infus, ganti obat oral Cevofloxacin 2x500mg Ranitidin 2x150 mg Diet bebas Mobilisasi duduk Rawat luka/GV Aff kateter, aff drainase Rawat luka/stoma

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

PLT 628 WBC 13,0 MRI Cholangio Pancreatografi 13/03/14 Kesan : Cholestatik ductus biliaris ec. Batu distal CBD Foto Thorax PA -pulmo normal -cardiomegaly dengan dilatatio et elongatio aorta EKG Sinus rhytme dengan ICRBBB Echocardiograph y -fungsi sistolik LV baik, EF 68% -fungsi diastolik LV -WH (+) CT-Scan -Massa caput pankreas disertai tanda-tanda cholestatik intra maupun extrahepatik -Sludge pada GB Foto Thorax 18/03/2014 -Pulmo normal -Cardiomegaly MSCT Scan Abdomen (1-32014) Kesan : - Kolestatik ec Batu di Pangkal CBD - Choleliths - Splenomegaly Echocardiograph -Fungsi sistolik LV baik, EF 66% -Global normokinetik -Fungsi sistolik RV baik

Kamar 2 bed 3 IL

Hasil Lab 17/3/2014 WBC: 23,3, RBC: 3.90, HB: 10,1, PLT: 501, HCT: Sri ana 32,1, 23/6/1982 Adenocarsinoma Na 133, K 3,8, RM recti diferensiasi Cl:98 654137 moderat Hasil biopsy tgl MRS Fistel rectovagina 20/3/2014 10/3/2014 Gambaran adenocarsinoma diferensiasi sedang pada kedua sediaan LONTARA 2 DIGESTIVE KAMAR 3 LONTARA 2 BEDAH DIGESTIV KAMAR 10 LAB 21/03/2014 Protein total: 6.3, Albumin: 3.4 Saheriah 1-7-1958 RM 653470 MRS 17/03/2014 LAB WBC: 6.9, Hb: 11,7, PLT: 190, GDS: 128, Ur/Cr: 7/0,56, GOT:165, GPT: 248 ALP: 599, GGT: 267, Bil.tot: 8,18, Bil.dir: 6,25, prot.tot: 6,2

IVFD RL 28 tpm Ceftriaxone 1gr/12j/iv Ranitidin 150 mg/8j/iv Ketorolac /8 jam/iv VIP albumin 3x2 cap

25 Rencana op. double bypass

Bed 4 RL

24

Bed 3 SM

Ikterus Obstruktif e.c Tu. Caput Pankreas

Ainia Taraju 7-10-1968 RM 649435 MRS 19/03/2014

POH 3 eksplorasi CBD + cholelithiasis

Instruksi post op IVFD RL:D5% = 1:1 28 tpm Inj. Ceftriaxone 1 gr/12jam/iv Inj. Ketorolac /8jam/iv Inj. Ranitidin / 8jam/iv Diet bubur saring

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

24/3/2014 WBC 7,68, RBC 3,76, HB 8,9, HCT 28,9, PLT 569 20/3/2014 : Darah rutin : Hb : 6,8 HCT : 21,3 PLT : 739 BT : 3,00 CT 8,00 RBC:2,88 PT: 13,2 Tumor Abdomen APTT: 26,3 GDS:117 SGOT 25 SGPT : 15 Protein total :6,3 Albumin 3,1 Na; 136 cl 107 Kalium 5,0 Ur:7,4 Cr : 1,00 Polos abdomen 3 posisi 20/3/14: Gambaran ileus obstruktif Lab 17/3/2014 WBC 4,7 RBC 3,49 HB 10,1 Hct 31,9 Adenocarsinoma GDS 97 colon UR/CR 22/0,7 SGOT/SGPT 42/26 Na 142 K 4,1 Cl 106 LONTARA 2 KAMAR 11 Lab 22/3/2014 RBC 4,23 WBC 10,3 HGB 15,6 HCT 36,8 PLT 172 albumin 3,1 Lab 19/3/2014 RBC 5,4 WBC 5,9 HGB 15,6 HCT 44,7 PLT 259 CT 2 BT 7 GDS 77 Ur 15 Cr 0,80 SGOT 36 SGPT 73 Prot.total 7,1 Albumin 4,5 Na 142 K 3,5 Cl 108 CT-scan Abdomen(030320 14) Tidak tampak kelainan pada CTscan abdomen ini kecuali masih terlihat sisa kontras Foto Thorax PA (05032014) Efusi pleura dextra 23/3/2014 : Darah rutin : Hb : 9,8 HCT : 27,5 PLT : 460 BT : 3,00 CT 8,00 RBC:3.13 PT: 17,1 APTT: 26,3 GDS:101 SGOT 701 SGPT : 270 Na; 127 cl 96 Kalium 4,6 Ur:35cr:0,5 POH 9 laparatomi + hemikolektomi kanan ec Tumor Colon Ascendens

26

K 10 SS

Marliana 15-1-1963 RM 617634 MRS 20/3/2014

Rencana kemoterapi Transfusi PRC 2 bag

K10 Bed 5

Elizabeth 1/11/1963 50 tahun 647514 MRS 26/3/2014

Rencana kemoterapi

K11 IL Mirtodi 43 tahun 1/1/1971 RM 633372 MRS 23/3/2014

Tu. Abdomen DD/Tu.Hep ar

Mirtodi 43 tahun 1/1/1971 RM 633372 MRS 23/3/2014

Tu. Abdomen DD/Tu.Hepar

27

Bed 1 (SS)

Jefry Foster 27 tahun 01-01-1987 JKN MR 610341

POH 6 tutup ileostomi Post ileostomi ec appendicitis perforasi

IVFD RL : Dext5% : aminofluid 500:500:1000/24 jam Ceftriaxone 1gr/12j/iv Ketorolak/8j/iv Ranitidin/8 j/iv Puasa Balance cairan

28

Bed 3 (MP)

Haruna Dg Ngempo, 42 tahun 1/12/1971 Laki-laki 652564

Thorax (12/3/14) Cor & pulmo normal, tidak tampak tanda-tanda metastase pada foto thorax ini

IVFD RL 28 tpm Ceftriaxon 19/12j/iv Pct 3x500mg Ranitidine 1amp/8j/iv Rawat luka per 2 hari Mebilisasi duduk/jam

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

Diet bubur saring JKN MRS 26/2/2014 CT abd (11/3/14) Sesuai gambaran massa colonascendens, efusi pleura minimal bilateral Colonoskopi (7/3/14) IBD (proktitis) derajat sedang tumor kolon (ascenden/saekum) curiga malignancy Lab 4/3/2014. RBC:4.48, WBC:6.6, HBG:11.2, HCT:34.9. Lab 21/3/2014 INR 1,06 GDS 90 Ur 9 Cr 0,5 SGOT 17 SGPT 9 Prot. Total 5,9 Albumin 2,2 Na 138 K 4,0 Cl 98 101 Lab 20/3/2014 WBC 20,3 RBC 4,73 HGB 12,7 HCT 40 PLT 298 CT 730 BT 2 PT 12,7 APTT 30,6 INR 1,06 GDS 41 Ur 9 Cr 0,5 SGOT 17 SGPT 9 Prot. Total 5,9 Albumin 2,8 Na 138 K 4,0 Cl 98

Hasil PA (18/3/2014) Adenocarcinoma differensiasi sedang

Lab 12/3/2014 Ur/cr: 15/0.66, protein total: 4.2, Albumin: 2.1, Na:134, K: K: 3.3, Cl: 98

CT Scan 26/2/14 Kesan: massa proksimal colon ascenden Lab 22/3/2014 WBC 19,94 RBC 4,68 HGB 12,7 HCT 39,60 PLT 644 GDS 66 Ur 17 Cr 0,58 SGOT 21 SGPT 13 Albumin 2,5 Na 138, K 5,3 Cl

29

Bed 4 IL

Abd. Samad Suhaeb 54 tahun 13/3/1959 JKN MRS 5/3/2014

Echo 11/314 -fungsi sistolik dan diastolic LV baik, EF 67% -Global normokinetik IVFD RL 28 tpm Ceftriaxon 1g/12j/iv Ranitidine 1amp/8j/iv Terapi lain sesuai TS Gizi Klinik operasi

Adenocarcinoma Rektosigmoid

30

Bed 5 RL

Ace Lunrang 3/4/1953 655146 MRS 20/3/2014

Haemoroid grade IV

Lab (21/3/2014) WBC 6,36 RBC 4,64 HGB 13,2 HCT 37,9 PLT 265 CT 8 BT 2 PT 12,6 APTT

IVFD RL 28 tpm Ceftriaxone 1 gr/12j/iv ardium 3x1 Ketorolac 30mg/8j/iv Ranitidin amp /8j/iv Kompres hemoroid dengan Nacl

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

26,2 INR 1,05 GDS 96 Ur 24 Cr 0,80 SGOT 27 SGPT 38 Prot.total 5,9 Albumin 3,5 Na 144 K 3,7 Cl 104 32 USG abdomen (17/3/2014) Hipertrofi prostat Cystitis Pelviocalyectasis bilateral dan hidroureter kanan 22/3/14WBC 20,3 RBC 4,02 HGB 11,7 HCT 40 PLT 217 Lab. 19/3/14 RBC 4,63 HGB 13,1 HCT 39,4 PLT 344 WBC 7,64 Zainuddin 1/1/1953 618032 MRS 17/3/14 CT 730 BT 200 PT 10,7 INR 0,89 APTT 24,43 GDS 98 UR 30 CR 1,38 GOT/GPT 18/12 Albumin 4,2 Na 142 K 4,3 Cl 101 HbsAg nonreactive Anti HCV (-) CEA 4,66 PA 07/03/14 Adenocarcinoma differensiasi IVFD RL 28 tpm pantat 10 cc Ceftriaxone 1gr/12j/iv ranitidin 30mg/8j/iv ketorolak 30 mg/8j/iv diet bubur biasa mobilisasi duduk GV+rawat luka Aspirasi drain dari anus 5 ml/hari sedang LONTARA 2 ONKOLOGI Lab 25/3/2014 Ureum 66 Kreatinin 0,90 Asam urat 7,9 POH 2 Drainase SGOT 41 Ascites SGPT 12 NA 134 KALIUM 4,5 CL 98 LONTARA 2 UROLOGI Lab 26/3/2014 HB 14,0 RBC 5,01 Hemorroid externa HCT 42,1 PLT 232 WBC 7,8 LONTARA 2 ORTHOPEDI LONTARA 3 MATA LONTARA 3 BEDAH THT LONTARA 3 BEDAH SARAF LONTARA 3 KULKEL LONTARA 4 NIFAS HCU Lab rutin (20/3) RBC : 3.48; HB : 10.1; HCT : 31.4; PLT : 264; WBC : 7.3; BT:300; CT : 730; PT 13.2 c Fistel 11.3; INR : 1.10; enterocutaneus low APTT : 27.5 c output 24.6; GDS:104; Ur/cr : 15/0.5; GOT/GPT: 17/12; Prot total : 6.9; Albumin 3.4; Na/K/Cl: 137/3.9/102 CT Scan abdomen (17/3) -Massa kompleks Abses Subkutan adneksa kiri region abdomen disertai ascites sugestif malignancy

Lontara 2 onkologi Kamar 6 bed 1

Nanik suwarni 5/3/1970 Rm 619929

33

Lontara 2 Urologi Kamar 12 Bed 6

Kasman 5/1/1977 656672 MRS : 26/3/2014

31

Bed 6 SS

POH -7 Miles Procedure Tu. Recti 1/3 distal

34

Lontara IV Ginekologi Kamar 1 SS

Sitti Mauliah 18/6/1990 RM 644729 MRS 20/3/2014

Terapi lanjut dari TS Obgyn Rawat luka+gv konek kolostomy bag Takar produksi colostomy/24jam

34

Lontara IV Ginekologi Kamar 4 SS

St. Nurbaya 15/9/1972 652558

Terapi lanjut dari TS Obgyn Rawat luka 2 x sehari Rencana joint operasai untuk debridement bila Ts. Obgyn merencanakan untuk

10

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

-Susp abses subcutan dinding anterior abdomen Lab rutin (9/3) RBC : 3.09, Hb : 10.1, HCT : 30,3, PLT : 440, WBC : 26.6, CT : 300, VT : 800, GDS : 45, Ur/Cr : 56/0.7, GOT/GPT : 35/18 IC 35 Tn. Ambo Tang 4/1/1954 POH-5 eksisi+biopsi Soft tissue tumor gluteus D Efusi pleura susp. TB Paru CHF NYHA Grade 2 Empyema Foto thoraks PA (12/3) -Efusi pleura snistra massif Perdarahan (12/3) BT : 300, CT 700, PT : 12.1 c 11.7, APTT 26 c 25.2 -IVFD RL 28 tpm -Ceftriaxone 1 gr/12j/iv -Ranitidin amp/8j/iv -Pemeriksaan PA pengantar (+) -Diet bebas operasi Ur 60, cr 0,2 SGOT 44, SGPT 103, albumin 1,7 Na 140 K 2,8 Cl 101 ICU Lab(12/3/14) Protein total 3.9 albumin 2.1 CEA 2.26 USG Abdomen (4/3/14) Kesan : ascites MSCT abd (12/3/14) Kesan : Massa recti (DUKES B) Risal HN 26 tahun 10-1-1988 Laki-laki 622305 JKN MRS 24/2/2014 Colonoskopi 7/3/2014 Kesan:-hemorroid externa -hemorroid interna gr 2 -tumor rectum curiga malignancy Lab 18/3/2014 WBC 9.2, RBC 3.21x106, HGB 9.8, HCT 29.3, PLT 555 Lab 14/3/2014 GOT 14, GPT 8, Albumin 2.7 Urin rutin17/3/2014 Protein : trace, blood ++/80, lekosit ++/125, Mikroskopik : IVFD RL28 tpm Ceftriaxon 1g/12j/iv Pct 3x500 mg Ranitidine 3x1 Vip. Albumin 3x3 tab Periksa lab Rencana operasi 25/3/2014 Diet cair Persiapa operasi Informed consent + persiapan bedah Lapor OK Lapor anestesi puasa 8 jam pre op Berikan antibiotic ceftriaxon 1g pre op Siapkan 4 unit darah Cukur bulu pubis Klisma Pukul 17.00= Fleet enema Pukul 18.00= fleet phosfusida Pukul 19.30= flit phosfusida botol 05.00= flit enema

Lantai 1 kamar 3 MP

Lab rutin (5/3) WBC : 9.85, RBC : 4.61, HB : 11.8, HCT : 36.3, PLT : 191 Foto polos abdomen -ileus obstruktif (SBO) pneumoperitoneu m Foto thorax -TB paru duplex aktif Lab rutin (24/3/2014) RBC 3,19, WBC 16,42, HGB 8,8, HCT 27,5, PLT 91x103. -IVFD RL:Nacl 0,9%:aminofluid 500:500=100 cc/24 jam -inj.levofluxacin 0,5 gr/12jam/iv -inj.ceftriaxone 1 gr/12 jam/iv -inj.metronidazole 0,5 gr/8 jam/iv -inj.omeprazole 1 gr/24 jam/iv Takar produksi urine /24 jam -balance cairan -awasi TTV -lab control : DR.elektrolit, albumin

37

Bed 2 (MP)

POH 3 Miles Procedure ec Adenocarcinoma Recti 1/3 Distal + Fistel perianal

36

ICU IC Dr.Murni Rauf ,Sp.BKBD

Rahmi Rasyid 21/05/1992

POH 1 laparatomi eksplorasi

11

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

lekosit 10, eritrosit 7 Feses 17/3/2014 Warna coklat, konsistensi cair, lendir (+) Lab (23/3/14) GDS 67 Ureum 21 Kreatinin 0,40 Asam urat 1,5 SGOT 17 SGPT 23 RBC 3,04 HB 9,4 PLT 387 WBC 15,6 Natrium 119 Kalium 8,4 Clorida 91 Lab (9/3/14) GDS 66 UR 49 CR 1.0 SGOT 21 SGPT 98 ALB 2.4 Na 128 K 2.1 Cl 104 WBC 9.3 RBC 3.47 HB 10.6 HCT 31.4 PLT 167 Thorax (23/3/14) Efusi pleura bilateral Susp. Atelektasis Lobus superior paru dextra Thorax (9/3/14) CVC terpasang pada hemithorax kanandengan ujung tip setinggi CH Th 6 Lab (8/3/14) CT 8.00 BT 3.00 PT 14.7 INR 1.30 APTT 25.2 RBC 5.33 HB 16.2 HCT 48.1 PLT 224 WBC 18.7 Lab 24/3/2014 VIP 2 656168 JKN 31-12-1966 MRS : 23/3/2014 Volvulus Jejunum GDS 152 PT 11,3 APTT 23,3 Ureun 110 Kreatinin SGOT 21 SGPT 14 Albumin 2,7 Na 137, K 5,6 cl 108 PLT 3,87 RBC 4,05 Hb 11,6 Hct 35,1 Wb 10,6 Mobilisasi duduk Fisioterapi napas Puasa Ceftriaxon 1gr/12j/iv Metronidazole gr/j Ranitidine amp/8j/iv

40

ICU Bed 8

Martinus Payung 22/11/1979 MR 654119 JKN

POH 19 ec. Laparotomi explorasi v. ictum Lab 22/3/2014 RBC 5,91 HB 18,6 HCT 55,5 PLT 104 BT 3,00 CT 6,00 PT 15,4 APTT 28,7 Natrium 132 Kalium 4,3 CLorida 109 SGOT 30 SGPT 12 Allbumin 2,6 GDS 146

Terapi injeksi lanjut Lanjut terapi thoraks dan ICU GV dan Aff Hecting BNO 3 posisi

38

ICU Bed 5 SS

Hermanto 3/08/1980 RM 654066 JKN

- POH 18 laparatomi ec. Hernia diafragmatika - POH 9 Reposisi hernia diafragmatika, repair diafragmatika

Pertahankan dekompresi Diet TKTP NGT 25 cc/jam GV Neurobion /24jam Koreksi albumin Terapi lanjut ICU

41

ICU BED 2

HERMAN `31/12/198 9 656091 jkn

POH 8 laparotomi explorasi ec. Pancreatitis hemoragik

Pasang drain hisap di sebelah kiri Pasang drain biasa disebelah kanan Puasa Nutrisi parenteral Injeksi lanjut ICU Koreksi albumin

RSUH Lab tanggal 26/3/2014 WBC: 8140 hgb: 9.8 HCT: 28.6 plt: 71000 Na/K/Cl: 128/3.5/97 Meropenem 1gr/12jam/IV farmadol drips 0.5gr bila demam GV dan rawat luka Mobilisasi duduk

42

426 MP

Raehang (64thn) MRS: 15/3/14

Ileus obstruktif partial

39

ICU

Amir K

POH 5 ec

Takar produksi NGT

12

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

Lab tanggal 22/3/2014 WBC: 6360, PLT: 74000, Hb: 10.7, HcT: 31.1 tanggal 19/3/2014 Na/K/Cl: 135/3.3/100 hbsAg positive Lab tanggal 20/3/2014 WBC: 5320, HB: 10.4, HcT: 30.7, PLT: 64000 Lab 14/3/2014 Kolesterol tot 118 Kolesterol HDL 36 Kolesterol LDL 63 TG 99 Albumin 3,3 Lab tanggal 22/3/2014 WBC: 6360, PLT: 74000, Hb: 10.7, HcT: 31.1 Lab tanggal 19/3/2014 Na/K/Cl: 133/3.5/95 CEA: 0.81, Ca 125; 135.98 lab tanggal 20/3/2014 PT/aPTT: 16.9/29.3 SGOT/SGPT: 19/12 protein total; 4.9 albumin: 2.4 ur/cr: 30/0.5 WBC: 21830 HGB: 12.3 HCT: 35.9 PLT: 282000 CT Scan Abdomen tanggal 15/3/2014 kesan: small bowel obstruction disertai adanya soft tissuemass pada rongga pelvis susp. Loop-loop usus yang adhesi dd/ abses

USG Abdomen14/3/201 4 Kesan: hepatomegaly dengan ascites Lab 13/3/2014 WBC 26 RBC 4,020 HGB 11,4 HCT 33,9 PLT 364 Bil direct7,9 Bil> indirect 0,9 HbsAg (-) Lab tanggal 27/3/2014 WBC: 10780 HB: 17.8 PLT: 196000 HcT: 50.1 Suprianto 15/3/14 27/12/1966 54 Ikterus obstruktif Post op hari III eksplorasi CBD Lab tanggal 19/3/2014 AFP: 5.96 bilirubin direk: 19.4 bilirubin total: 21.4 gdp: 119 colestrol total: 169 20/3/2014 WBC: 20530

IVFD asering: D5: aminofluid metrodinazole 0.5gr/12jam/iv omeprazole amp/12jam/iv ketorolac amp/8jam/iv Balance cairan diet minum + bubur saring mobilisasi duduk GV hari ini

43

406 IL

Yunike(45) MRS 14/3/14 MR: 019765

POH-IV laparotomi eksplorasi e.c. multiple abses intraabdominal

44

Kamar 423 WS

IVFD asering : D5% 1;1 28 tpm Inj. Ranitidin 1 amp/8 jam /IV Inj. ketorolac 30 mg/8 jam Inj. Ceftriaxone 1amp/ 12jam diet bubur lunak minum bebas Awasi tanda-tanda akut abdomen

13

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

HGB: 15.7, HCT: 43.7 PLT: 190000 Lab 16/3/2014 PT 15,.6 APTT 32,1 HbsAg (+) Anti HCV (-) SGOT 55 Foto radiologi Cholelith Curiga batu pada duodenum Lab 22/3/2014 SGOT: 91 SGPT:59 Na/K/Cl: 134/2.1/103 BT/CT: 7/3 gamma GT: 159 protein total: 6.0, albumin:2.7 Lab 15-3-14 WBC 7,48 RBC 3,94hgb 11,8 hct 30,6 plt 369 CT 10,BT 3,PT 31,7 INR 3,38 APTT 52,8 SGOT/PT 104/61 Bil direct 38,4 bil. Tot 50,9 GDS 90 Kolestrol tot 184 Ur/cr 39/0,9 HbsAg (-), anti HCV (-) Foto radiologi 15/3/14 kesan:cor dan pulmo normal Tidak tampa tandatanda metastasis pada foto thorax ini USG Abdomen15/3/14:k olestatik intra dan extra hepatic, lesi mixechoic pada area caput pancreas susp massa caput pancreas, distended GB diserta sludge di dalamnya MSCT 17 maret 2014: massa pancreas dengan dilatasi duktus bilier serta distended GB, nodul soliter hepar, ascites Ct scan thorax tanggal 18/3/2014 penebalan dinding esophagus secara sirkuler pada 1/3 distal yang menyempitkan lumen esophagus dan menyebabkan dilatasi di proximal esophagus. Stenosis 1/3 distal esofagus lab tanggal 19/3/2014 CT/BT: 8/3 PT/aPTT: 16.4/34.5 sgot/sgpt: 32/18 ur/cr: 34/0.7 wbc: 5660 hgb: 13.0 hct; 38.3 plt: 142000

45

433 WS

Dominggus 18/3/14 019779 08524101774 7

Ikterus obstruktif Massa caput pancreas

OPERASI (25/3/2014) Post Operasi bypass bilio digestif.

46

412 (A) IL

Ansar Abu Bakar 21/08/1963 MRS 18/3/14

IVFD KAMG 3: pan amin G 1:1 28 tpm ranitidine amp/12jam/iv inj ketorolac amp KP Rencana operasi bila keluarga setuju

47

ICU bed 6 IL

Andi Munawar 31/12/1964 019523 MRS 18/3/2014

Tumor abdomen bagian kanan susp. malignancy

Lab 22/3/2014 BT/CT: 700/400 PT/aPTT: 14.6/35.5 CT SCAN

Ceftriaxone 1gr/12j/iv ranitidine/8j/iv metrodinazole 0.5gr/12j/iv ketorolac/8jam/iv as.tranexamat/8jam/iv puasa

14

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

abdomen tggl 19/3/2014 kesan: massa heterogen ekstraluminer CT-Scan abdomen tanpa dengan kontras irisan axial,reformat sagittal dan coronal: kesan:susp. Angiomiolipoma denagn infiltrasi ke colon Lab 10/3/14 SGOT/PT 34 /24 GDS 222 Hbs Ag (-) Ur/Cr 14/0.8 balance cairan kesan: ileus paralitik ascites minimal dan effusi pleural bilateral Lab tanggal 19/3/2014 WBC: 6920 HGB: 11.6, HCT: 34.4, PLT: 366000, Na/K/Cl: 135/4.3/101 BNO 3 Posisi tanggal 19/3/2014 kesan: small bowel obstruction USG Abdomen tanggal: 19/3/2014 dilatasi Loop-loop usus

Colon in loop14/3/14 Soft tissue mass region abdomen dextra yang menyebabkan loop-loop usus terdesak kek caudal dan lateral sinistra Tidak tampak infiltrasi intraluminer foto thorax 23/3/2014 tidak ada kelainan Tn. Andi Daliluddin Takko tanggal lahir: 8/10/1938 73 tahun 019945 Foto tanggal 24/3/2014 kesan: small bowel obstruction 50

LAB Tanggal 22/3/2014 WBC: 20350 HGB: 10.1 Hct: 29.4 plt: 522000 Appendicitis + periapendicular infiltrat post laparatomi eksplorasi dan appendectomy H-I Hba1C: 4.5 ur/cr: 83/1.9 sedimen urine tanggal 20/3/2014 lekosit 1-3 LPB BT/CT: 2/8 sgot/sgpt: 15/20 USG abdomen tanggal 19/3/2014 kesan: massa area Mc Burney suspek massa intraluminer dd/ appendicitis Pemeriksaan IVFD RL 28 tetes/min ceftriaxone 1gr/12j/iv ranitidin amp/12j/IV ketorolac amp/8j/iv metrodinazole 0.5gr/12j/IV farmadol drips/8jam/iv GV hari ini mobilitas duduk Diet bubur

Kamar 425 dr. Mappincara Sp.B KBD

Tn.Amir 31/12/1960 019946

48

311 Perawatan Lepa-Lepa IL

Ileus obstruktif

Rencana terapi sesuai interna.

MSCT Abdomen 24/3/2014

51

421

Dalle

15

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

1/7/1943 020151 MRS: 26/3/2014 Histopathologi 18/3/2014 kesan: rhabdomyosarcoma dd/ undifferentiated carcinoma mesothelioma Ct scan 24/3/2014 Massa rectum (dukes B) foto thorax 26/3/2014 tidak ada kelaianan Kesedaran menurun + Tu. Caput Pancrea PCC Foto thorax PA/AP 20/03/2014 Foto thorax dalam batas normal Faisal, S.PD, M.Si 23/10/1972 41 tahun RM 655365 MRS 22/03/2014 JKN DR. dr. Ronald E. Lusikooy, Sp.B-KBD Laboratorium 19/03/2014 RBC 5,46 HGB 17,1 HCT 49,3 PLT 284 WBC 6,9 LED jam I 8 LED jam II 18 PT 11,2 INR 0,94 APTT 29,4 GDS 142 ur 27 cr 1,07 SGOT 45 SGPT 79 USG ab?domen atas + bawah 18/03/2014 Cholelith USG abdomen atas + bawah 19/03/2014 Cholelithiasis Laboratorium 312 IL RAHMA 13/08/1977 37 tahun 65 57 99 JKN Dr. dr. Ibrahim Labeda, Sp.BKBD 22/03/2014 JKN DR. dr. Ronald E. Lusikooy, Sp.B-KBD 19/03/2014 LED jam I 59 LED jam II 100 GDS 82 ur 22 cr 0,71 Asam urat 6,5 SGOT 31 SGPT 28 kolesterol total 230 HDL 59 LDL 144 trigliserida 110 RBC 3,99 HGB 12,6 HCT 37,1 PLT 265 WBC 7,5 PT 11,5 INR 1 APTT 26 Laboratorium 20/03/2014 RBC 4,12 HGB 11,8 HCT 34,5 PLT 362 WBC 6,3 LED jam1 23 LED jam II 48 PT 11,2 INR 0,94 APTT 28,9 GDS 99 ur 15 cr 0,64 SGOT 22 SGPT 11 Colon Inloop Sesuai gambaran hemoroid Foto thorax PA Tidak tampak kelainan pada foto thorax ini Laboratorium 20/03/2014 RBC 3,56 HGB 9,6 HCT 26,9 PLT 342 WBC 9,1 LED jam1 115 LED jam II 120 PT 11,4 INR 0,95 APTT 26,2 GDP 93 ur 49 cr 0,99 SGOT 27 SGPT 15 - GV + Rawat luka

52

422

Sriramsi Saleng

52

UGD rencana pindah ICU

Burhan 31/12/1960 020192 MRS: 26/3/2014 53 tahun

Hemoroid grade III

- Rencana op. hari ini

51

423 RL

POH2 Laparaskopi
cholisistektomi

- Aff infuse - Cefadroxy 2x500 - Metronidazole 500 3x1 - Asam Mefenamat 3x500 - Ranitidin 3x1 - GV + Rawat luka - Dulcolax supp

320 IL - Aff infuse - Cefadroxy 2x500 - Metronidazole 500 3x1 - Asam Mefenamat 3x500 - Ranitidin 3x1

52

309 RL

Wenoli Tamangga 12/04/1963 50 tahun RM 655538 MRS

POH2 Laparaskopi
Cholisistektomi

RIBUN 12/12/1949 64 tahun 624174 JKN Dr. dr. Ibrahim Labeda, Sp.BKBD

Tumor Spleen

- Cek Hb post transfusi - Rencana op. hari ini

16

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

17