KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

KORAN BEDAH DIGESTIF,JUMAT 28 MARET 2014

PALEM ATAS

NoBedIdentitasDiagnosisPemeriksaan PenunjangTerapi

2B1/7KurniawatiTL 01/03/1969RM 656111MRS 22/3/2014JKND/Tumor AbdomenPost OP Laparotomi Kista Hepar-IVFD Asering 28tpm-Ketorolac 1amp/12j-Ranitidin 1amp/8j/iv-Cek hasil lab-cek hasil foto

3B2/4RLNy. Nimrah20-10-1980PerempuanMRS 14/3/2014Dr. dr. Ronald EL, Sp.B-KBD

Polips Recti + Hemoroid grade IIILab (15/3/2014)

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

Lab (21/3/14)CEA 1,73

Tunggu hasil biopsiUSG abdomen

4B2/11SSUsman Daulasi54 tahun29-10-1959Laki-lakiJKN615660Dr. Samuel S, Sp. B-KBD

Tumor mesenteriumLab 17/03/2014

WBC 7,34; RBC 4,66; HGB 11,8; HCT 33,8; PLT 400; GDS 65CT/BT 7,00/3,00PT/APTT 12,3/30,3;INR 1,03Ur/cr 43/0,80Bil tot 0,53Bil. Direk 0,28GOT/GPT 48/31Alb 3,0HbsAg non reactiveAnti HCV non reactiveCEA 122,66

CT Abdomen atas bawah

15/03/2014Tidak tampak densitas massa pada abdomen dan ascites

Lab 14/03/2014

RBC 3,89; WBC 6,4; HGB 9,7; PLT 348CT/BT 800/300

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

Hasil PA14/11/2013

Metastase Adenokarsinoma Musinosum pada MesenteriumCernevit 1g/24jFarmadol (k/p)

5B2/11RLSyamsuddin Lipi31/12/1938653893Dr. dr. Ronald EL, Sp.B-KBD

Haemorrhoid rectum Gr.IVLab 20/03/2014GDS 120 Na 131 K 3,7 Cl 100Ardium 3x1

6B1/7644804JknWSRafael LT04/08/1983Laki-lakiMRS 12/03/2014Dr. dr. Warsinggih, Sp.B.KBD

POH-8 post CAPDLAB 15/3/2014WBC 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

LAB 12/3/2014WBC 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 1.10Ciprofloxacin 2x500 mg

PALEM BAWAH

7B1/4SSTn. JK Samban10/9/1940650884Dr. Samuel S. Sp. B. KBD

POH 27Hemicolectomy dextra ec. Tu. Colon acendenceLAB 2/3/2014WBC 12,66 RBC 4,31 HGB 8,8 HCT 28,1 PLT 700 Alb 2,5 Na/K/Cl 127/3.2/101

17/2/14GDS : 61Pro. Total : 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

PA 18/2/14Adenocarcinoma colon difrensiasisedang, dengankeduaujunginsdsbebas tumor

Lab 3/3/14RBC 4,29 Hb 8,8 HCT 28,2 PLT 397 WBC 9,7 Ur 34 Cr 0,8 GDS 76LAB 3/3/14Ph 7,59 pCO2 20,1 pO2 104,1 SO2 98,6 Eecf -7 HCO3 16,2 O2Ct 13,8 As laktat 7

Ciprofloxacin 2x500mgVIP Alb 3x2Neurodex 1x1GV

8B2/6 Bed 1SSSafriLaki-laki12-12-69645747JKNDr. Samuel S, Sp. B-KBDPOH-6 post laparotomi eksplorasi e.c. hernia internaLAB 19/3/14WBC 12.3 RBC 4.35 HGB 11.4 HCT 36.1 PLT 287

LAB 18/3/14WBC 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)PneumobilierPankreatitis kronisRL:D5%:Aminofluid=500:500:1000 / 24 jamCeftriaxon 1 gr/12 j/ivRanitidin 50 mg/8j/ivTakar drain/24 jamBoleh minum 2 sdm/jamBalans cairanAff NGT

9B 2/13 Bed 2RLNurbaetyPerempuan31-12-77647967MRS 8-3-2014Dr. dr. Ronald EL, Sp.B-KBDWound rehisensi postileostomi

Lab (08/03/2014)WBC 8,7 RBC 3,49 HGB 10,9 HCT 32GDS :96 Ur/Cr : 34/0,5; SGOT/SGPT : 15/14; prot total : 5,8; alb : 3,5;Levofloxacin 2x1 tabGV/hariMobilisasi jalanDiet biasa

10B2/4 bed 1WSSulaeman5/5/1967651234JKNMRS 15/2/2014Dr. Warsinggih, Sp.B.KBD

CKD stg V POH 12 CAPDJadwal HD : selasa -jumatLab (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

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

Ciprofloxacin 2x500 mgGV/3 hariDiet biasa

11B2/10ILAkhmad Nasrul31/12/1963Laki-lakiJKN14/03/2014Dr. Ibrahim Labeda, SP.B-KBDPOH-6 post eksplorasi CBD e.c. Batu CBD + GB StoneLab (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: 1,23IVFD RL:D5%: Aminofluid 500:500:1000 / 24 jam Ceftriaxon 1 gr/12 jam/ivMetronidazole 0,5 gr/8 jam/ivRanitidin 50 mg/12 jam/ivKetorolac 30 mg/8 jam/iv

12B2/5 Bed 1WSI Bunga01/12/1930JKN639124PerempuanDr. dr. Warsinggih, Sp.B.KBD

CKD Stage V POH 12 CAPDLab (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 GDS 222 Ur/Cr 59/2,60 GOT/GPT 28/18 Na/K/Cl 139/3,3/109Lab (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; Terapi sesuai TS internaGVCiprofloxacin 2x500PCT (KP)

13B2/1 2SSTn. Nataniel05/11/1958648648Dr. Samuel S, Sp. B-KBD

Tu. Sigmoid Tunggu hasil labFenitoinAlprazolam 0,5 mg 1x1

14B1/2RLAsriadi Abbas28/6/1983RM 655757MRS19/3/2014Kolesistolithiasis dan kolesistitisLab rutin (19/3/2014)RBC : 4,73; HB : 14; WBC : 8.1; HCT : 40.7; PLT 182CT : 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 : 0.14IVFD RL 28 tpmKetorolac 30mg/8j/ivRanitidin 50mg/12j/ivDiet lunakRencana operasi laparoskopi cholecystectomi hari Senin, 23-3-2014

Lontara 1

13L1ABK1/Bed1MPJohanis Toding9/11/1954654912JKNHBSAG(+)POH 7 Hortman Procedure ec Tumor Colon SigmoidBNO 3 POSISI 13/3/14KESAN: gambaran ileus obstruktif

Lab 15/3/2014

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 2.6Diet buburRawat stomaCeftriaxone 1gr/12j/ivMetronidazole 0.5 gr/8j/ ivKetorolac /8 jamRanitidine /8 jamKoreksiKalium 25 cc dalamNaCl 28 tpmGV

14L1ABK4/Bed3

Hambali31/12/1960654053JKN

Tumor Colon AscendensFoto Thorax 11/3/14KESAN: cardiomegaly dengan dilatatio et elongatio aortae

LGIE11/3/14Tumor Colon Ascendens Curiga Malignancy

Lab 15/3/2014RBC 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 20/3/2014Massa colon ascendensdengantanda-tanda ileus obstruktif

Tunggu hasil kolonoskopi

L1BDRPKBed 4Usman10/7/81JKN654140Laki-laki

Tumor Colon Ascendens23/3/14WBC 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

CT Scan Abdomen17/3/14KESAN: Massa colon ascendensdisertai ascitesDilatasi loop-loop ususEfusi Pleura bilateral

Thoraks AP14/3/14Efusi pleura bilateralPerbaikan KUTunggu hasil Hb post Transfusi

L1BBK5(III)Bed 1Husna8/2/47JKN655782Perempuan

Ikterusobstruktifecsuspbatu CBD dd. Ca caput pankreas20/3/14HGB/HCT 12.2/37.4 WBC 10.1 PLT 267BT 3 CT 8 PT 13.2/11.3 APTT 26.1/24.6INR 1.10 Alb 3.3 Ur 15 Kr 0.4 SGOT/SGPT 106/158 Bil tot 14.98BilDirek 12.24HBSAG (-)Tunggu hasil CEA

LIADKIBed IDarwati 15/06/1970Batu Distal CBD22/3/14WBC 13.9 RBC 3.2 HGB/HCT 10.5/31.3 PLT 452 CT 3 BT 8 PT 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 CBDRencana Op kamisPerbaiki KUKoreksi albumin

Diet rendah lemak

LONTARA 2 DIGESTIVE KAMAR 1

15Kamar 1 Bed 1RLSaleng 1/7/1941655759MRS 19/3/2014Tumor abdomen suspek tumor mesenteriumLeukositosistrombositopeniaLab(19/3/2014)RBC 4.15HGB 11.8HCT 34.8PLT 80 WBC 18.1CT 6.00 BT 2.00 GDS 149Ur 49Cr 1.20SGOT 36 SGPT 41Na 138K 3.7 Cl 110

Foto thorax PA/AP (19/3/2014)Kesan : cardiomegaly dengan dilatatio et elongatio aortaeElevasi diafragma dextra (proses intrahepatik)

CT Whole Body (20/3/2014)Kesan : massa mesenteriumIleus obstruktifEfusi pleura bilateralUsul : MSCT scan abdomen dengan kontrasUSG abdomen (20/3/2014) Kesan : suspek massa colon sigmoid dengan tanda-tanda infiltrasi buli-buliUsul : MSCT scan abdomen dengan kontras

IVFD RL : DS % 1:1 28 tpmCeftriaxone 1gr/12j/ivMetronidazole 0.5 gr/8j/ ivRanitidine /8 jamAwasi tanda vital dan akut abdomenPindahkan iv line

16Kamar 1 Bed 4ILAgus1/7/1988RM 656210MRS 23/3/2014JKNPOH-1 laparatomi ekspolarsi e.c laserasi lien grade IITCG GCS 10 perbaikan GCS15Contusion paretal DextraPneumocephaleFraktur linear temporobasalLab (16/3/2014)WBC 12,3 RBC 2,53 HB 8,0RBC 2,53PLT 124

IVFDS Nacl : DS% : AminofluidCeftriaxone 1gr/12j/ivKetorolac /8j/ ivRanitidine /8 jamDiet lunak

17Kamar 1 Bed 3SSAzis karim31/12/1940RM 649168MRS21/03/2014JKNCa recti 1/3 distalLab (16/3/2014)WBC15,7 RBC 2,63 HB 7,4RBC 2,63PLT 281

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

Rawat kolostomiGV/3 hariVIP albumin 3x2 cap

18kAmar 1 bed 2ILJudin matili3/6/1959RM 655980MRS 21/3/2014JKNTumor esofagushasil endoskopi (11/3/2014)hasil : tampak mukosa dan sisa makananskope masuk 35cm tampak mukosa berbenjol, merah dan mudah berdarah dengan lumen hampir tertutup total IVFD RL:DS % : clinimix 500:500= 1000/24jam

LONTARA 2 DIGESTIVE KAMAR ISOLASI

17KAMAR ISO Bed 2WSMidon10-02-1988RM 654738MRS12-03-2014JKNPost AppendectomyPerawatan hari ke 3Lab Rutin12-03-2014

LED 42/71WBC 16,9 RBC 4,99 HB 15,4HCT 44,8 PLT 270 CT/BT 800/330PT/APTT 15,6/30,2 GDS 80 Ur/Cr 18/0.80 GOT/GPT 19/21 Na/K/Cl 136/3,5/109HbsAg (-)Anti HCV (-)

-IVFD RL:DS 1:1 28 tpmCeftriaxone 1gr/12j/ivMetronidazole 0.5 gr/8j/ ivRanitidin 150 mg/8j/ivKetorolac /8 jam/ivDiet lunakMobilisasi dudukRawat luka/GV

Kamar iso bed 1SSJohan tiranda4/7/1968MRS 26/3/2014Adenocarsinoma sigmoid, siklus kemoterapi Kemoterapi

LONTARA 2 DIGESTIVE KAMAR 2

Kamar 2 bed 1RL

Mainan31/12/1930MRS 25/3/2014JKNCa recti 1/3 distal, kemoterpaiKemoterapi siklus IV

20Kamar 2 bed 2ILA.Zaenab Dg. Sanginging 11/12/1956RM 655412MRS 17/03/2014-POH 5 Post laparatomy eksplorasi e.c ileus obstruksi-reseksi anastomose e.c tumor colon transversum-ileostomi e.c perforasi caecumLAB 20/03/2014

WBC: 13,2RBC: 5.08HB: 11,2, PLT: 316, GDS: 117, Na/K/Cl : 138/3.2/104, Albumin 2,4

Hasil Foto Thorax 17/03/2014-Cor dan pulmo tidak tampak kelainanPneumoperitonium Hasil Foto Abdomen 17/03/2014Gambaran ileus obstruktif dengan pneumoperitonium

Hasil foto thorax PA/AP post pemasangan CVC Kesan : cardiomegaly

Aff infus, ganti obat oralCevofloxacin 2x500mgRanitidin 2x150 mgDiet bebasMobilisasi dudukRawat luka/GVAff kateter, aff drainaseRawat luka/stoma

22Kamar 2 bed 4ILNy. Jumriah8/08/1974RM 653118MRS 12/03/14Ikterus Obstruktif ec. batu distal CBDLab rutin (20/3/2014)WBC : 11.18; RBC : 3.91; HB : 10.6; HCT : 31.4; PLT : 539

Lab Tanggal17/03/2014WBC 11,7; RBC3,36; HGB 8,9; HCT 27; PLT 634

PT/APTT 11,4/24,0INR 0,95

Lab tgl 24/3/2014HGB 7,7RBC 2,82MCV 83MCHC 32,9PLT 628WBC 13,0

MRI Cholangio Pancreatografi 13/03/14Kesan : Cholestatik ductus biliaris ec. Batu distal CBD

Rencana transfusi PRC 2 unitRencana operasi explorasi CBD+IOC SF 1x1Vipalbumin 3x2 capDiet bebas

Kamar 2 bed 3 ILSri ana23/6/1982RM 654137MRS 10/3/2014Adenocarsinoma recti diferensiasi moderat Fistel rectovaginaHasil Lab 17/3/2014WBC: 23,3, RBC: 3.90, HB: 10,1, PLT: 501, HCT: 32,1, Na 133, K 3,8, Cl:98Hasil biopsy tgl 20/3/2014Gambaran adenocarsinoma diferensiasi sedang pada kedua sediaanIVFD RL 28 tpmCeftriaxone 1gr/12j/ivRanitidin 150 mg/8j/ivKetorolac /8 jam/ivVIP albumin 3x2 cap

LONTARA 2 DIGESTIVE KAMAR 3

LONTARA 2 BEDAH DIGESTIV KAMAR 10

24Bed 3SMSaheriah1-7-1958RM 653470MRS17/03/2014Ikterus Obstruktif e.cTu. Caput PankreasLAB 21/03/2014Protein total: 6.3, Albumin: 3.4

LABWBC: 6.9, Hb: 11,7, PLT: 190, GDS: 128, Ur/Cr: 7/0,56, GOT:165, GPT: 248ALP: 599, GGT: 267, Bil.tot: 8,18, Bil.dir: 6,25, prot.tot: 6,2

Foto Thorax PA-pulmo normal-cardiomegaly dengan dilatatio et elongatio aorta

EKG Sinus rhytme dengan ICRBBB

Echocardiography-fungsi sistolik LV baik, EF 68%-fungsi diastolik LV-WH (+)

CT-Scan-Massa caput pankreas disertai tanda-tanda cholestatik intra maupun extrahepatik-Sludge pada GBRencana op. double bypass

25Bed 4RLAinia Taraju7-10-1968RM 649435MRS19/03/2014POH 3 eksplorasi CBD + cholelithiasisFoto Thorax 18/03/2014-Pulmo normal-Cardiomegaly

MSCT Scan Abdomen (1-3-2014) Kesan :- Kolestatik ec Batu di Pangkal CBD- Choleliths- Splenomegaly

Echocardiograph-Fungsi sistolik LV baik, EF 66%-Global normokinetik-Fungsi sistolik RV baik

Instruksi post opIVFD RL:D5% = 1:1 28 tpmInj. Ceftriaxone 1 gr/12jam/ivInj. Ketorolac /8jam/ivInj. Ranitidin / 8jam/ivDiet bubur saring

26K 10SSMarliana15-1-1963RM 617634MRS20/3/2014

Tumor Abdomen24/3/2014WBC 7,68, RBC 3,76, HB 8,9, HCT 28,9, PLT 56920/3/2014 :Darah rutin :Hb : 6,8 HCT : 21,3PLT : 739BT : 3,00 CT 8,00RBC:2,88 PT: 13,2 APTT: 26,3GDS:117 SGOT 25 SGPT : 15Protein total :6,3Albumin 3,1Na; 136 cl 107 Kalium 5,0Ur:7,4 Cr : 1,00Polos abdomen 3 posisi 20/3/14:Gambaran ileus obstruktif Rencana kemoterapiTransfusi PRC 2 bag

K10Bed 5Elizabeth1/11/196350 tahun647514MRS26/3/2014Adenocarsinoma colonLab 17/3/2014WBC 4,7RBC 3,49HB 10,1Hct 31,9GDS 97UR/CR 22/0,7SGOT/SGPT 42/26Na 142K 4,1Cl 106Rencana kemoterapi

LONTARA 2 KAMAR 11

27Bed 1(SS)Jefry Foster27 tahun01-01-1987JKNMR 610341POH 6 tutup ileostomi Post ileostomi ec appendicitis perforasi Lab 22/3/2014RBC 4,23 WBC 10,3HGB 15,6 HCT 36,8 PLT 172 albumin 3,1

Lab 19/3/2014RBC 5,4 WBC 5,9HGB 15,6 HCT 44,7 PLT 259 CT 2 BT 7GDS 77 Ur 15 Cr 0,80 SGOT 36 SGPT 73 Prot.total 7,1 Albumin 4,5Na 142 K 3,5 Cl 108

CT-scan Abdomen(03032014)

Tidak tampak kelainan pada CT-scan abdomen ini kecuali masih terlihat sisa kontras

Foto Thorax PA (05032014)Efusi pleura dextra

IVFD RL : Dext5% : aminofluid 500:500:1000/24 jamCeftriaxone 1gr/12j/ivKetorolak/8j/ivRanitidin/8 j/ivPuasa Balance cairan

K11ILMirtodi 43 tahun1/1/1971RM633372MRS 23/3/2014

Tu. Abdomen DD/Tu.Hepar 23/3/2014 :Darah rutin :Hb : 9,8 HCT : 27,5PLT : 460BT : 3,00 CT 8,00RBC:3.13 PT: 17,1 APTT: 26,3GDS:101 SGOT 701 SGPT : 270Na; 127 cl 96 Kalium 4,6Ur:35cr:0,5

Mirtodi 43 tahun1/1/1971RM633372MRS 23/3/2014

Tu. Abdomen DD/Tu.Hepar

28Bed 3(MP)Haruna Dg Ngempo,42 tahun 1/12/1971Laki-laki652564

JKNMRS 26/2/2014

POH 9 laparatomi + hemikolektomi kanan ec Tumor Colon Ascendens

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

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 21/3/2014INR 1,06GDS 90 Ur 9 Cr 0,5 SGOT 17 SGPT 9 Prot. Total 5,9 Albumin 2,2Na 138 K 4,0 Cl 98

CT Scan 26/2/14Kesan: massa proksimal colon ascenden

IVFD RL 28 tpm Ceftriaxon 19/12j/ivPct 3x500mgRanitidine 1amp/8j/ivRawat luka per 2 hari Mebilisasi duduk/jam Diet bubur saring

29Bed 4ILAbd. Samad Suhaeb54 tahun13/3/1959JKNMRS 5/3/2014

Adenocarcinoma RektosigmoidLab 22/3/2014WBC 19,94 RBC 4,68HGB 12,7 HCT 39,60PLT 644GDS 66 Ur 17 Cr 0,58 SGOT 21 SGPT 13 Albumin 2,5Na 138, K 5,3 Cl 101

Lab 20/3/2014WBC 20,3 RBC 4,73HGB 12,7 HCT 40PLT 298CT 730 BT 2 PT 12,7 APTT 30,6 INR 1,06GDS 41 Ur 9 Cr 0,5 SGOT 17 SGPT 9 Prot. Total 5,9 Albumin 2,8Na 138 K 4,0 Cl 98

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

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

Echo 11/314-fungsi sistolik dan diastolic LV baik, EF 67%-Global normokinetik

IVFD RL 28 tpmCeftriaxon 1g/12j/ivRanitidine 1amp/8j/ivTerapi lain sesuai TS Gizi Klinikoperasi

30Bed 5RLAce Lunrang3/4/1953655146MRS 20/3/2014

Haemoroid grade IVLab (21/3/2014) WBC 6,36 RBC 4,64HGB 13,2 HCT 37,9 PLT 265CT 8 BT 2PT 12,6 APTT 26,2 INR 1,05GDS 96Ur 24 Cr 0,80SGOT 27 SGPT 38Prot.total 5,9 Albumin 3,5Na 144 K 3,7 Cl 104

USG abdomen (17/3/2014) Hipertrofi prostatCystitisPelviocalyectasis bilateral dan hidroureter kananIVFD RL 28 tpmCeftriaxone 1 gr/12j/ivardium 3x1Ketorolac 30mg/8j/ivRanitidin amp /8j/ivKompres hemoroid dengan Nacl

31Bed 6SSZainuddin1/1/1953618032MRS 17/3/14

POH -7 Miles ProcedureTu. Recti 1/3 distal22/3/14WBC 20,3 RBC 4,02HGB 11,7 HCT 40PLT 217

Lab. 19/3/14RBC 4,63HGB 13,1HCT 39,4PLT 344WBC 7,64

CT 730BT 200PT 10,7INR 0,89APTT 24,43GDS 98UR 30CR 1,38GOT/GPT 18/12Albumin 4,2Na 142 K 4,3 Cl 101HbsAg nonreactiveAnti HCV (-)CEA 4,66

PA 07/03/14Adenocarcinoma differensiasi sedang

IVFD RL 28 tpmpantat 10 ccCeftriaxone 1gr/12j/ivranitidin 30mg/8j/ivketorolak 30 mg/8j/ivdiet bubur biasa mobilisasi duduk GV+rawat luka Aspirasi drain dari anus 5 ml/hari

LONTARA 2 ONKOLOGI

32Lontara 2 onkologiKamar 6 bed 1

Nanik suwarni5/3/1970Rm 619929POH 2 Drainase AscitesLab 25/3/2014Ureum 66Kreatinin 0,90Asam urat 7,9SGOT 41SGPT 12NA 134KALIUM 4,5CL 98

LONTARA 2 UROLOGI

33Lontara 2UrologiKamar 12 Bed 6Kasman5/1/1977656672MRS : 26/3/2014Hemorroid externaLab 26/3/2014HB 14,0RBC 5,01HCT 42,1PLT 232WBC 7,8

LONTARA 2 ORTHOPEDI

LONTARA 3 MATA

LONTARA 3 BEDAH THT

LONTARA 3 BEDAH SARAF

LONTARA 3 KULKEL

LONTARA 4 NIFAS HCU

34Lontara IVGinekologi Kamar 1SSSitti Mauliah18/6/1990RM 644729MRS 20/3/2014

Fistel enterocutaneus low outputLab 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 11.3; INR : 1.10; APTT : 27.5 c 24.6; GDS:104; Ur/cr : 15/0.5; GOT/GPT: 17/12; Prot total : 6.9; Albumin 3.4; Na/K/Cl: 137/3.9/102Terapi lanjut dari TS ObgynRawat luka+gv konek kolostomy bagTakar produksi colostomy/24jam

34Lontara IV Ginekologi Kamar 4SSSt. Nurbaya15/9/1972652558

Abses Subkutan region abdomenCT Scan abdomen (17/3)-Massa kompleks adneksa kiri disertai ascites sugestif malignancy-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 : 35/18Terapi lanjut dari TS ObgynRawat luka 2 x sehariRencana joint operasai untuk debridement bila Ts. Obgyn merencanakan untuk operasi

IC

35

Lantai 1 kamar 3MP

Tn. Ambo Tang4/1/1954

POH-5 eksisi+biopsi Soft tissue tumor gluteus DEfusi pleura susp. TB ParuCHF NYHA Grade 2Empyema

Foto thoraks PA (12/3)-Efusi pleura snistra massifPerdarahan (12/3) BT : 300, CT 700, PT : 12.1 c 11.7, APTT 26 c 25.2

Lab rutin (5/3)WBC : 9.85, RBC : 4.61, HB : 11.8, HCT : 36.3, PLT : 191

-IVFD RL 28 tpm-Ceftriaxone 1 gr/12j/iv-Ranitidin amp/8j/iv-Pemeriksaan PA pengantar (+)-Diet bebas

36ICU ICDr.Murni Rauf ,Sp.B-KBDRahmi Rasyid21/05/1992POH 1 laparatomi eksplorasiFoto polos abdomen-ileus obstruktif (SBO)-pneumoperitoneumFoto thorax-TB paru duplex aktif

Lab rutin (24/3/2014)RBC 3,19, WBC 16,42, HGB 8,8, HCT 27,5, PLT 91x103.Ur 60, cr 0,2SGOT 44, SGPT 103, albumin 1,7Na 140K 2,8Cl 101

-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/ivTakar produksi urine /24 jam-balance cairan-awasi TTV -lab control : DR.elektrolit, albumin

ICU

37Bed 2(MP)

Risal HN26 tahun10-1-1988Laki-laki622305

JKNMRS 24/2/2014

POH 3 Miles Procedure ec Adenocarcinoma Recti 1/3 Distal + Fistel perianalLab(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)

Colonoskopi 7/3/2014Kesan:-hemorroid externa-hemorroid interna gr 2-tumor rectum curiga malignancy

Lab 18/3/2014WBC 9.2, RBC 3.21x106, HGB 9.8, HCT 29.3, PLT 555

Lab 14/3/2014GOT 14, GPT 8, Albumin 2.7

Urin rutin17/3/2014Protein : trace, blood ++/80, lekosit ++/125,Mikroskopik : lekosit 10, eritrosit 7Feses 17/3/2014Warna coklat, konsistensi cair, lendir (+)

IVFD RL28 tpmCeftriaxon 1g/12j/ivPct 3x500 mgRanitidine 3x1Vip. Albumin 3x3 tabPeriksa lab Rencana operasi 25/3/2014Diet cair Persiapa operasi Informed consent + persiapan bedah Lapor OK Lapor anestesi puasa 8 jam pre opBerikan antibiotic ceftriaxon 1g pre opSiapkan 4 unit darah Cukur bulu pubis Klisma Pukul 17.00= Fleet enemaPukul 18.00= fleet phosfusida Pukul 19.30= flit phosfusida botol 05.00= flit enema

38ICUBed 5SSHermanto3/08/1980RM 654066JKN

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

Lab (23/3/14)GDS 67 Ureum 21Kreatinin 0,40 Asam urat 1,5SGOT 17 SGPT 23RBC 3,04HB 9,4PLT 387WBC 15,6Natrium 119Kalium 8,4Clorida 91Lab (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 167Thorax (23/3/14)Efusi pleura bilateralSusp. Atelektasis Lobus superior paru dextraThorax (9/3/14)CVC terpasang pada hemithorax kanandengan ujung tip setinggi CH Th 6Lab (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 18.7Pertahankan dekompresiDiet TKTP NGT 25 cc/jamGVNeurobion /24jamKoreksi albuminTerapi lanjut ICU

39ICUVIP 2Amir K656168JKN31-12-1966MRS : 23/3/2014

POH 5 ec Volvulus JejunumLab 24/3/2014GDS 152PT 11,3APTT 23,3Ureun 110KreatininSGOT 21SGPT 14Albumin 2,7Na 137, K 5,6 cl 108PLT 3,87RBC 4,05Hb 11,6Hct 35,1Wb 10,6Takar produksi NGTMobilisasi dudukFisioterapi napasPuasaCeftriaxon 1gr/12j/ivMetronidazole gr/jRanitidine amp/8j/iv

40ICUBed 8Martinus Payung22/11/1979MR 654119JKNPOH 19 ec. Laparotomi explorasi v. ictumTerapi injeksi lanjutLanjut terapi thoraks dan ICU GV dan Aff HectingBNO 3 posisi

41ICUBED 2HERMAN`31/12/1989656091jknPOH 8 laparotomi explorasi ec. Pancreatitis hemoragikLab 22/3/2014RBC 5,91HB 18,6HCT 55,5PLT 104BT 3,00 CT 6,00PT 15,4 APTT 28,7Natrium 132Kalium 4,3CLorida 109SGOT 30SGPT 12Allbumin 2,6GDS 146

Pasang drain hisap di sebelah kiri Pasang drain biasa disebelah kananPuasaNutrisi parenteralInjeksi lanjut ICUKoreksi albumin

RSUH

42426MPRaehang (64thn) MRS: 15/3/14

Ileus obstruktif partialLab tanggal 26/3/2014WBC: 8140hgb: 9.8HCT: 28.6plt: 71000Na/K/Cl: 128/3.5/97

Lab tanggal 22/3/2014WBC: 6360, PLT: 74000, Hb: 10.7, HcT: 31.1

tanggal 19/3/2014Na/K/Cl: 135/3.3/100hbsAg positive

Lab tanggal 20/3/2014WBC: 5320, HB: 10.4, HcT: 30.7, PLT: 64000

Lab 14/3/2014Kolesterol tot 118 Kolesterol HDL 36Kolesterol LDL 63TG 99Albumin 3,3Meropenem 1gr/12jam/IVfarmadol drips 0.5gr bila demamGV dan rawat lukaMobilisasi duduk

43406ILYunike(45)MRS 14/3/14MR: 019765

POH-IV laparotomi eksplorasi e.c. multiple abses intraabdominalLab tanggal 22/3/2014WBC: 6360, PLT: 74000, Hb: 10.7, HcT: 31.1

Lab tanggal 19/3/2014Na/K/Cl: 133/3.5/95CEA: 0.81, Ca 125; 135.98

lab tanggal 20/3/2014PT/aPTT: 16.9/29.3SGOT/SGPT: 19/12protein total; 4.9albumin: 2.4ur/cr: 30/0.5WBC: 21830HGB: 12.3HCT: 35.9PLT: 282000

CT Scan Abdomentanggal 15/3/2014kesan: small bowel obstruction disertai adanya soft tissuemass pada rongga pelvis susp. Loop-loop usus yang adhesi dd/ abses

USG Abdomen14/3/2014Kesan: hepatomegaly dengan ascites

Lab 13/3/2014WBC 26 RBC 4,020HGB 11,4 HCT 33,9 PLT 364Bil direct7,9Bil> indirect 0,9 HbsAg (-)IVFD asering: D5: aminofluid

metrodinazole 0.5gr/12jam/ivomeprazole amp/12jam/ivketorolac amp/8jam/iv

Balance cairandiet minum + bubur saringmobilisasi dudukGV hari ini

44Kamar 423WSSuprianto15/3/1427/12/196654

Ikterus obstruktifPost op hari III eksplorasi CBDLab tanggal 27/3/2014WBC: 10780HB: 17.8PLT: 196000HcT: 50.1

Lab tanggal 19/3/2014AFP: 5.96bilirubin direk: 19.4bilirubin total: 21.4gdp: 119colestrol total: 169

20/3/2014WBC: 20530HGB: 15.7, HCT: 43.7PLT: 190000

Lab 16/3/2014PT 15,.6 APTT 32,1 HbsAg (+) Anti HCV (-) SGOT 55 Foto radiologiCholelithCuriga batu pada duodenumIVFD asering : D5% 1;1 28 tpm Inj. Ranitidin 1 amp/8 jam /IVInj. ketorolac 30 mg/8 jamInj. Ceftriaxone 1amp/ 12jam

diet bubur lunakminum bebas

Awasi tanda-tanda akut abdomen

45

433

WS

Dominggus18/3/14019779085241017747

Ikterus obstruktifMassa caput pancreas

Lab 22/3/2014SGOT: 91 SGPT:59Na/K/Cl: 134/2.1/103BT/CT: 7/3gamma GT: 159protein total: 6.0, albumin:2.7

Lab 15-3-14WBC 7,48 RBC 3,94hgb 11,8 hct 30,6 plt 369 CT 10,BT 3,PT 31,7 INR 3,38APTT 52,8 SGOT/PT 104/61 Bil direct 38,4 bil. Tot 50,9 GDS 90 Kolestrol tot 184Ur/cr 39/0,9HbsAg (-), anti HCV (-)

Foto radiologi 15/3/14kesan:cor dan pulmo normalTidak tampa tanda-tanda metastasis pada foto thorax iniUSG Abdomen15/3/14:kolestatik intra dan extra hepatic, lesi mixechoic pada area caput pancreas susp massa caput pancreas, distended GB diserta sludge di dalamnyaMSCT 17 maret 2014: massa pancreas dengan dilatasi duktus bilier serta distended GB, nodul soliter hepar, ascites

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

46412 (A)ILAnsar Abu Bakar21/08/1963MRS 18/3/14

Stenosis 1/3 distal esofagusCt scan thorax tanggal 18/3/2014penebalan dinding esophagus secara sirkuler pada 1/3 distal yang menyempitkan lumen esophagus dan menyebabkan dilatasi di proximal esophagus.

lab tanggal 19/3/2014CT/BT: 8/3PT/aPTT: 16.4/34.5sgot/sgpt: 32/18ur/cr: 34/0.7wbc: 5660hgb: 13.0hct; 38.3plt: 142000

IVFD KAMG 3: pan amin G 1:1 28 tpmranitidine amp/12jam/ivinj ketorolac amp KP

Rencana operasi bila keluarga setuju

47ICU bed 6ILAndi Munawar 31/12/1964019523MRS 18/3/2014

Tumor abdomen bagian kanan susp. malignancy Lab 22/3/2014BT/CT: 700/400PT/aPTT: 14.6/35.5

CT SCAN abdomen tggl 19/3/2014kesan: massa heterogen ekstraluminer

CT-Scan abdomen tanpa dengan kontras irisan axial,reformat sagittal dan coronal:kesan:susp. Angiomiolipoma denagn infiltrasi ke colon

Lab 10/3/14SGOT/PT 34 /24GDS 222 Hbs Ag (-) Ur/Cr 14/0.8

Colon in loop14/3/14Soft tissue mass region abdomen dextra yang menyebabkan loop-loop usus terdesak kek caudal dan lateral sinistraTidak tampak infiltrasi intraluminer

foto thorax 23/3/2014tidak ada kelainan

Ceftriaxone 1gr/12j/ivranitidine/8j/ivmetrodinazole 0.5gr/12j/ivketorolac/8jam/ivas.tranexamat/8jam/ivpuasabalance cairan

48311Perawatan Lepa-Lepa

ILTn. Andi Daliluddin Takkotanggal lahir: 8/10/193873 tahun019945

Ileus obstruktifFoto tanggal 24/3/2014kesan: small bowel obstruction

MSCT Abdomen 24/3/2014kesan: ileus paralitikascites minimal dan effusi pleural bilateralLab tanggal 19/3/2014WBC: 6920HGB: 11.6, HCT: 34.4, PLT: 366000,Na/K/Cl: 135/4.3/101

BNO 3 Posisi tanggal 19/3/2014kesan: small bowel obstruction

USG Abdomentanggal: 19/3/2014dilatasi Loop-loop usus

Rencana terapi sesuai interna.

50Kamar 425dr. Mappincara Sp.B KBDTn.Amir31/12/1960019946

Appendicitis + periapendicular infiltrat

post laparatomi eksplorasi dan appendectomy H-ILAB Tanggal 22/3/2014WBC: 20350HGB: 10.1Hct: 29.4plt: 522000

Hba1C: 4.5ur/cr: 83/1.9 sedimen urine tanggal 20/3/2014lekosit 1-3 LPB

BT/CT: 2/8sgot/sgpt: 15/20

USG abdomentanggal 19/3/2014kesan: massa area Mc Burney suspek massa intraluminer dd/ appendicitisIVFD RL 28 tetes/minceftriaxone 1gr/12j/ivranitidin amp/12j/IVketorolac amp/8j/ivmetrodinazole 0.5gr/12j/IVfarmadol drips/8jam/ivGV hari ini mobilitas dudukDiet bubur

51421Dalle1/7/1943020151MRS: 26/3/2014

Pemeriksaan Histopathologi18/3/2014kesan: rhabdomyosarcoma dd/ undifferentiated carcinoma mesothelioma

52422Sriramsi SalengCt scan 24/3/2014Massa rectum (dukes B)

foto thorax 26/3/2014tidak ada kelaianan

52UGDrencana pindah ICUBurhan31/12/1960020192MRS: 26/3/201453 tahunKesedaran menurun + Tu. Caput Pancrea

PCC

51423RLFaisal, S.PD, M.Si23/10/197241 tahunRM 655365MRS 22/03/2014JKNDR. dr. Ronald E. Lusikooy, Sp.B-KBDPOH2 LaparaskopicholisistektomiFoto thorax PA/AP 20/03/2014Foto thorax dalam batas normal

Laboratorium 19/03/2014RBC 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 18/03/2014Cholelith- Aff infuse- Cefadroxy 2x500- Metronidazole 500 3x1- Asam Mefenamat 3x500- Ranitidin 3x1- GV + Rawat luka- Dulcolax supp

52309RLWenoli Tamangga12/04/196350 tahunRM 655538MRS 22/03/2014JKNDR. dr. Ronald E. Lusikooy, Sp.B-KBDPOH2 LaparaskopiCholisistektomiUSG abdomen atas + bawah 19/03/2014Cholelithiasis

Laboratorium 19/03/2014LED 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- Aff infuse- Cefadroxy 2x500- Metronidazole 500 3x1- Asam Mefenamat 3x500- Ranitidin 3x1- GV + Rawat luka

312ILRAHMA13/08/197737 tahun65 57 99JKNDr. dr. Ibrahim Labeda, Sp.B-KBDHemoroid grade IIILaboratorium 20/03/2014RBC 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 InloopSesuai gambaran hemoroid

Foto thorax PATidak tampak kelainan pada foto thorax ini- Rencana op. hari ini

320ILRIBUN12/12/194964 tahun624174JKNDr. dr. Ibrahim Labeda, Sp.B-KBDTumor SpleenLaboratorium 20/03/2014RBC 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

- Cek Hb post transfusi- Rencana op. hari ini

11