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KORAN PASIEN BEDAH DIGESTIF KAMIS 14 MARET 2016

LONTARA 2 ATAS DEPAN

KAMAR 1

No

IdentitasPasien Diagnosa PemeriksaanPenunjang Instruksi

1. BAHARUDDIN4.12.107012.03.2016749239

-apses hepar 12-03-2016WBC13.0RBC3.66HGB11.6HCT35MCV95MCH32MCHC33PLT515RDW-SDRDW-CV11.9PDW7.7MPV8.1PCT0.00NEUT75.0LYMPH15.0MONO8.6EO1.2

BASO0.2W!"# B$!#%8&00W!"# '$%()*%2&30PT13.1+NR1.26APTT26.2GDS10,#)$#1,)$"/%/%0.70SGOT21SGPT33A#/%3.1 #)"3.9HB A 4+CTN% R$"/$A%"/ HCV 4+CTN% R$"/$N")/#136/#3.8)/(103

-IVFD RL 28 pm

-cetaidime 1 gr!12 j!i"

-ranitidine #$mg!8j!i"

-ketoro%ac &$ mg!8j!i"

-metronida'o%e #$$ mg !8j!i"

2 (ahran )asu%i%i1$-$&-1*#+,,$*1

)R( &!&!2$1+

DP/P Dr.dr.

I0rahim La0eda(p.-3D

4a Recti 1!& dista% Lab 7/3/201650c ## r0c #.1+

Hb 10.9hct &+.*

Lab 4/3/2016

50c +$ r0c 1*

Hb 7,1 hct 2,

P%t &$

Pt!inr!aptt 1$#!$.**!28&

6r!cr 21!$,*

7ot!gpt!a%0 1!11!&,

Na!k!c% 11!&8!1$#

F! !"#a$% 29/2/2016

t0 paru %ama akti %esi minima%

F! &'( )( '* 29/2/2016

7am0ara0 massa rectum 1!& dista%

F! *'% ab+-( 03/3/2016

7am0aran meteorismus

(us massa rektum dista%

IVFD Na4% $* 2$ tpm)enunggu hasi% 49:

)enunggu jad;a% operasi

&. ARIFUDDIN749059-MRS:11/3/2016

-suspek tumor

apdomen

11-03-2016WBC12.2RBC2.65HGB5.3HCT19MCV71

-IVD RL 28 tpm-

Neuro0ian 1

amp!2j!drips

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Dr.).Ihk;an

3usuma .(p.-3D

MCH20MCHC28PLT597RDW-CV1,.3PDW10.5MPV7.2PCT0.,3NEUT85.70

LYMPH7.2MONO5.1EO1.5BASO0.06PT9.8+NR0.9,

APTT21.5GDS77#)$#56)$"/%/%0.73SGOT30SGPT17HB A 4+CTN% R$"/$

A%"/ HCV 4+CTN% R$"/N")/#130/#,.6

)/(96A#/% 33

-omepraso% $mg!12j!i"

-susu

,+,$

)R( 2#!$2!2$1+DP/P dr. Rona%

9.L (p. 3D

P?@ 1 Laparoskopiesoagocardiomiotom

A ec :ka%asia esoagus

Lab 02/03/2016

Pt!inr!aptt 121!11+!28Lab 01/3/2016

54 ,# R4 #$+

PLB &+8 HB 9,

@4B

Inj R% 2$ tpm

Neuro0ion 1 amp da%am

#$$cc Na4%

$*!2j!drips

(usu & < 2$$ cc

KAMAR 2

N

o

IdentitasPasien Diagnosa PemeriksaanPenunjang Instruksi

1 '-"a

$1-$,-1*2

,& tahun>,46904

)R( 2!$2!2$1+DP/P dr.).Ih;an 3usuma

(p. 3D

P?@ VIII

Drainage acites

ec.tumor intraa0domen dd

tumormesenterium

Lab 0/3/2016

Na!3!4% 1&8!*!1$,

Lab 02/3/2016

54 *+ r0c

HB 9,1 @4B 2*

PLB 2+ 7D( 1

6r!cr 2#!$+$

7pt!got &+!2#:%0umin 2&

Na!k!c% 1&,!2+!1$

Lab 24/2/2016

54 112 R4 8#

@ 1&* @4B &

PLB 8+ 7D( 8*PB!INR!:PBB 1&*!1&2!2*+

6r!cr 1#!1$#

-4eadroksi% #$$

mg!12jam!ora%

-)a

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7pt!got &+!2#

:%0umin &&

Na!k!c% 1+!$!1$*

Lab 02/3/2016

54 *+ r0c HB 9,1 @4B 2*

PLB 2+ 7D( 16r!cr 2#!$+$

7pt!got &+!2#

:%0umin 2&Na!k!c% 1&,!2+!1$

4B 5ho%e :0domen 2!$2!2$1+C Banda-tanda cirrhosis hepatis

disertai ascites

C Nepro%ith de,++&8

)R( 22!$2!2$1+DP/P dr. Rona% 9.L (p.3D

Post operasi%aparatomi

0iopsi

Lab 07/3/2016

:%0umin 2.

Na!3!4% 1&&!2.8!*!.*

Lab 0/3/2016:%0umin 2.+

Na!3!4% 1&&!2,!1$2

Lab 23/2/2016

54 *+ R4 &.88PLB 1#& @g 1$+

@4B &216r!cr &&!$+#

N!3!4% 12#!&2!*,

7ot!gpt &$!1$:%0umin 18

7ds +&

Lab 0250352016

50c *.+

@0 *.1@ct 2*

P%t 2+

7D( 16r!4r 2#!$.+$

:%0umin 2.&Na!3!4% 1&,!2.+!1$

-IVFD RL 28tpm

-m!p"#$%&! 40 m' /

12 (#m/)*

-D%mp!")+%,!1/8(m/%"#&

-V)p #&m), 3 4

t#

-#,t) !,' N

-L 18 m! +#m

100 N#& 0.9/12(/)*

A+*)!

")mp!"#,

1#mp/8(/)*

B%&! m##, p!"

%,+!

& AMARIAH31.12.196310.03.2016749026

D". M.I";#,

m#.

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N#ba)a"

18!$!1*1

=, tahun>2&+##,

)R( 1+!$2!2$1+

DP/P dr. Rona% 9.L (p.

3D

P?@ III

LaparaskopA

cho%esistektomi

Lab 29/2/2016

54 1& R4 2**

PLB &1, @g 8*PLB 2$

Inus RL 28 tpm

?mepra'o%e $

gr!12jam!i"

4eta'idine 1

gr!12jam!i"

Ranitidine #$ mg!8

jam!i"?r0umin sachet & < 1

Diet 0u0ur

Rencana 67I9 hari

/umat

: kateter

ISOLASI

B-+ Naa D)a(%a P--#)$%aa(P-((a( R-(&a(a

1 ASR8L

AHMAD

Laki-%aki

21 tahun

1,-$-1**

,&1+

)R( 2#-$2-2$1+

DPP

DR. D#.

:a#%)()",

S*.B5KBD

Bumor Recti

1!& dista%(uspek

Fiste%

Recto"esica

8#-!"&%!#a*" 07/3/2016

Bidak tampak istu%a recto"esica maupun

rectourethra

Lab 0/3/2016

N#//& 140/2t#$)+)m! 1 '"/12(#m/)*

-R#,)t)+), 50 m'/8 (#m/)*-!t%"% 30 m'/8(#m/)*-V)p #&m), 32t#-SR #'.12(.)*-"#,>) A&m),1#&>/#")-Sp%%&),' #t!t!"-R#;#t #m# U"%&%')-#"#!t#m%& 1'"/8(#m/)* ?()# +!m#m@-M!,,'' #)& A

2. (ampeang

&1-12-1*,2

,,,,,

)R(

2!&!2$1+

dr. Rona%d 9.

LusikooA

(p.-3D

Bumor Recti

1!& dista%

P?@

i%eostomA

La0 ,!&!2$1+

49: ,.,$

La0 1!&!2$1+

50c 1+.2&$@g0 11.1

@ct &2.$

P%t 2+#.$$$

R0c &.#$.$$$

PB!INR!:PBB *.!$.*$!2,.,

7D( 1&2

6r!4r 82!$.*

I"d RLD( 21 2$tpm

Ranitidin #$mg!8jam!i"

3etoro%ac &$ mg!8jam!i"Vip a%0umin & < 2

:d"ice

3onsu% rencana endoskopi

: inus

%adder training

4earo

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(7?B!(7PB 1&!11

:%0umin &.$

Na!3!4% 1&*!&.*!1$*

KAMAR 3

ed Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi

1. DA=ARUDDIN74889527/07/195513.03.2016D".M.I;#,m#.

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&.

. D AINNA=IR5199295/7/1943

12/03/2016Dr.I0rahimLa0eda.(p-3D

-hernia inguina%is ni%atera%25-11-2011RET10

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RDW-CV16.9PDW16.0MPV8.6PCT0.28NEUT67.20LYMPH20.7MONO9.7EO1.3

BASO0.08RET10

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DP/P

+#. Sa-'

Sa*-!+)(,

S*.B5KBD

ke%enjar mesoko%on

Lab 27/2/2016

R0c # 50c +8

@0 111

@ct &

P%t 1+$

Pt!inr!aptt 121!11+!&$&6r!cr 2$!$++

7ot!gpt 1*!*

Na!k!c% 11!&.2!112

La0 2-&-1+

Pt!inr!aptt 1*.1!1.8&!2*.

6r!cr 2,!$.#2

7ot!gpt 1*!1&

:%0umin 2.&

Na!k!c% 1$!.$!111

7D( ,,

4urcuma &

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50c 1#2#

R0c

@0 1$*@ct

P%t 2#$

PB 112INR 1$8

:PBB 2##7D( 1$2

7ot!gpt ++!28

:%0 &6r!cr 11!$+

Na!3!4% 1&*!&,!1$&

La0 $+-$2-2$1+

50c 112

R0c 2@0 11

@ct P%t &1

PB 112

INR 1$8

:PBB 2+7D( &12

7ot!gpt *$!28:%0 &&

6r!cr 11!$+

Na!3!4% 1&,!1!1$@0s:g Non reacti"e

6(7 :0domen $+-$2-2$1+-)assa heterogen susp. )assa rectum

-)u%tipe% %esi nodu%er hiperechoic padakedua %o0us hepar susp. )etastasis

-Lesi isoechoic undus uteri susp. )Aoma

uteri intramura%

4B :0domen :tas!a;ah non kontras $,-

$2-2$1+4a recti =tumor recti 1!& dista% susp.

)a%ignancA>

Foto thora< P:!:P $+-$2-2$1+

-?0ser"asi mu%tip%e %esi nodu%er suspek

metastasis ke paru-Di%atatio e%ongatio et atherosc%erosis

aortae

+ (uuda Didi

+2 tahun1&-+-1*#

,#*$,

)R( 1,-2-2$1+

DP/P DR.+#.:a#%)()",

S*.B5KBD

P?@ *Laparoskopi

ko%esistektomA Einsisi drainage a0ses

hepar

:dhesio%Asis

Lab 250352016

50c &.#

R4 .,#

@7 11.*

@4B &,P%t 2#$

PB!:PBB 1&.&!22.,

INR 1.28

4B!B ,$$!2$$

7D( 1$2

6r!4r &2!$.#

(7?B!(7PB 1*!8

:%0umin 2.&

Na!3!4% 1&,!&.2!1$*

IVFD RL 2$ tpm

4eta'idim 1 g!12j!i"4ipro%o

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F! Ab+-( 3 *%)%) 29502516

- 7am0aran i%eus o0struksi

- Berpasang gastric tu0e dengan tip kesan0erada da%am gaster

jam

KAMAR 11

B-+ Naa D)a(%a P--#)$%aa(P-((a( R-(&a(a1 9di PraAitno

&* tahun

$# !$*!1*,,

,2$#2

)R( 1*!1!2$1+

DPP

D#. Sa-'

Sa*-!+)(,

S*.B5KBD

P?@ 1 drainase0i%ier E ikterus

o0struksi ec

cho%edoco%ithiasis

4B (can 18-2-c2$1+-cho%estatic intra dan e

@4V =->

La0 1#-2-2$1+54 ,*R4 2,

PLB 1#2

@7 ,@4B 21&

PB 1

INR 1&:PBB &,2

7D( 1#*:L 22

N:!3!4L 1&2!&&!1$8

La0 1-2-2$1+

7D( +&

La0 1&-2-2$1+54 112

R4 1&

@7 $@4B 12,

PLB 22$

)(4B 5ho%e :0domen Non 3ontras 21-1-2$1+

-(%ight hepatomega%A dengan sho%estatic e

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-9usi p%eura minima% de

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La0eda (p.-

3D

6r!cr 2#!1$$

(7?B!(7PB 22!1,

:%0umin &

P: $#-12-2$1

3esimpu%an adenocarcinoma recti diernsiasi0aik

6(7 tidak tampak tanda-tanda metastasis pada

6(7 a0domen in

6 ,!8

Dg.)ado

&1-12-1*#2,+&*$

)R( 22-$2-2$1+

DPP +#.

R(a'+ E.

L%)$, S*.B5

KBD

P?@1

%aparotomA

ekp%orasi Edrainage a0ses

Lab 0650352016

:%0umin 22

;T S&a( 21/02

:0ses @epar

8SG

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3amar #!0ed 1

Rosma;ati

$1!$,!1*,$,18&2*

)R( 2$!$2!2$1+

DPP +#. R(a'+ E.L%)$, S*.B5KBD

Bumor recti 1!&

dista% susp.

ma%ignancA

49: #&$

La0 $+-$&-2$1+:%0umin 2*

La0 $-$&-2$1+Natrium 12

3a%ium 213%orida **

La0 2+!$2@0 *.8

:%0umin 2.*

3a%ium 2.

4o%on in %oop 2+!$2

)assa recti 1!& dista%

Fotothora< 2$!$2!2$1+C :spek 0ronchitis

C Nodu%pu%modes

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LAB 20/1/16

:FP &.2*

49: .1$

LAB 2950252016

R4 .1+54 18.2

@7 1$.$@4B &1

PLB +8*

:%0umin 2.+

(iti:minah

3amar # 0ed

1*!$1!1*+*

,,818

Dr. dr. Rona%d 9.

LusikooA (p.-3D

Ikterus

?0strukti susp.

Bumor 4aput

Pankreas

L: $2-$&-2$1+

R4 .#1

54 *.$

@7 12.8

@4B &,

PLB 1*

PB 11.&

INR 1.$*

:PBB 2,.,

7?B!7PB 21!2#*

:%0umin &.#

7D( 1+8

6r!4r &$!$.8

i%. Bota% 1#.+

i%. Direk 12.#

@s:g non-reacti"e

8SG :HOLE ABDOMEN

-Bidaktampakcho%e%ith

-?rgan intraa0domina% Aang

terscanda%am0atas norma%

IVFD RL 28 tpm

InjeksiRanitidin #$mg!8jam!i"

Visite dr. Rona%d (p.-3D

-)R4P

Nurmi%a 3amar # 0ed &

,,+&

2,!1!1*,*

dr. Rona%d 9. LusikooA(p.-3D

4ho%e%ithiasis L: 2*-$2-2$1+

R4 #.1*

54 &.8,

@4B &.1

PLB 2$+

@7 11.&

PB 1$.+

INR 1.$2

:PBB &1.#

7D( ,#

6r!4r 2+!$.#+

i% Bota% &.#1

i% Direk +&

7?B!7PB +&!1&&

:%0umin &.#

Protein Bota% +.8

Na!3!4% 12!&.$!11$

6(7 5@?L9 :D?)9N =2*-$2-2$1+>

4ho%e%ith

IVFD RL 2$ BP)?mepra'o%e $ mg!2 jam!IV

Vit 3 I)!hari

:dona!12 jamRencana %aparotomA

eksp%orasi 4D hari /umat

(arce

3*&

&81*&

:denocarcinom

a recti 1!& dista%

La0 $,-$&-2$1+

54 &,8

@7 111

@4B &2

IFVD N:4L $* &$ tpm

Ranitidine #$mg!8j!i"

Neuro0ion drips!2 jam

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1+-$+-1*+,

DP/P Dr.dr.I0rahimLa0eda(p.-3D

PLB 2+*

RD5 18

PB 1+2

:PBB 2*#

INR 1##

7D( *,

6r!cr !$#

(7?B!(7PB 2+!1#:%0umin &,

Natrium 11

3a%ium 2+

3%orida 111

6(7 a0domen atas E 0a;ah =;ho%e

a0domen>

3esan ascites

LONTARA 2 8ROLOGI

N? ID9NBIB:(P:(I9N

DI:7N?(I( P9)9RI3(::N B9R:PI

1. 3&2@j. @asna

,++$8

&1-12-1*,2

)R( ,-$&-

2$1+

DPP D#.+#.

:a#%)()",

S*B5KBD

4ho%e%ithiasis ;T S;AN ABDOMEN24/2/20164ho%e%Ath tanpa o0struksi

6(7 :D?)9N =22!2!2$1+>4ho%ecAsto%iths

La0 22-$2-2$1+54 ,&

R4 #@7 1&*

@4B 1

PLB 2+&PB!INR!:PBB 11!$*+!28,

7D( 11

6r!4r 2&!$+&i% Bota% $#

i% Direk $1+

(7?BJ(PB 21!12:%ka%i Fosatase +8

Rencana operasi (enin

2. 3113a%"in

,1&$,#!11!1**

3onsu% 1#!$2!2$1+

DPP +#.

Sa-'

Sa*-!+)(,S*B5KBD

P?@ +4?L?(B?)

due to Fiste%Rectourether

LGIE @emoroid interna grade IK ID =proktitis>derajat 2 =munkin muara iste%J>

Lab 16/02/2016

49: &.12

- IVFD RL 20

tpm- I,(.

!>t#$)+),!

1'"/12(#m/).

*- I,(

R#,)t)+),!

50m'/8(#m/)

.*

- I,( !t"%&%#30m'/8(#m/)

.*

- D)!t MB

&. Dahniati3amar 11 0ed 1

2#!,!1*,1,,+1*

Dr. )uh.Ikh;an3usuma

@ematoche'ia9c 4o%itis

@ipoa%0uminemia

D) tipe 2

4o%on in %oop =,!&!2$1+>Redundant co%on sigmoid dan decenden

La0 $&-$&-2$1+

54 *1

R4 &$@7 *8

-IVFD RL!D# 11 2$

tts

-4eadro

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(p.-3D @4B &$

)4V 88

PLB &&&7D( strip 21*

La0 2*!$2!2$1+50c 12.#,$

@g0 ,.@ct 22,

P%t 282.$$$

R0c 2.#2$.$$$

PB!INR!:PBB 1$.8!1.$!2,.+

7D( 2826r!4r 2!$#1

(7?B!(7PB &!1

:%0umin 2.$Na!3!4% 1&&!.,!1$#

La0 1!&!2$1+

50c 1&.1$$

@g0 1$.*

@ct &.1P%t 2+#.$$$

R0c &.,1$.$$$

-Pro co%on in %oop

-Lengkapi pemeriksaan

LONTARA 1

N?

N:): DI:7N?(I( P9)9RI3(::N P9N6N/:N7 PL:NNIN7

C :. (uardiL1:3,#2&&

$+!1$!1*,*

&+ tahun

)R( 12-$2-

2$1+Bangga% 3onsu%

12-$2-2$1+

DP/P

Dr. dr.5arsinggih

(p-3D

C :0ses@eparC Post 4hest tu0e 5(D

9mpiemathoraca%is

8SG ab+-(

;0c #.*r0c &.+#

hg0 *.*hct &&

p%t $

pt 1&.2inr 1.2#

aptt &

gds 111ur!kr 8! $.#

got!gpt 2&!11

a%0 2.+na!k!c% 11!2.+!1$

(ito%ogi =1,!2>Radang supurati

4B (can =12!2>

C Bunggu hasi%e"a%uasi anestesi

C Pro %aparoskopi

drainage a0ses

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3ista E a0ses

C 3:():NL1: 3,

&1-$,-1*++

,+,22

3onsu% $+-$&-

2$1+

DP/P Dr. dr.5arsinggih

(p-3D

9(DR on @D regu%arPro pemasangan

4:PD

8SG ABDOMEN ATAS BA:AH:HOLE

ABDOMEN 2350252016

3esan PN4 0i%atera%

9usi p%eura kananLa0 =2,!$2!1+>

;0c 1$22

hg0 *2r0c &2,

hct 2,#p%t 18+

ur!cr *8!1+*&

natrium 1&8ka%ium ,

k%orida 1$*

h0a1c +.$

ko%estero% tota% 18,

hd% 1*%d% 1#$

trig%iserida 8

La0 =2#!2>Pt 11.&:ptt 2+.1

7ds 12$

6r!kr 21!$.*7ot!gpt #&!&

Na!3!4% 1!&.+!1$1

6sg a0d =2#!2>

Periappendicu%ar ini%trate

C Pemasangan 4:PD(e%asa 8!&!2$1+

C

C aminL1: 3+ 1

1!,!1*#*

,1*&$2

-3onsu%anestesi3onsu%

28!2!2$1+

DP/P Dr. dr.

5arsinggih

(p-3D

9(RD on 4:PD La0 $+-$&-2$1+54 *1

R4 2

@7 ,$@4B 22

PLB $PB 11

:PBB *

INR 11$7D( 1&+

6R!4R 1,!11&

(7?B!(7PB 1&!,:%0umin 1*

La0 =&!&>

gds **

ur!kr 1&+!1&.8a%0 2.

na!k!c% 1&8!&.#!1$&

Lab 2/2/2016

54 12.&+

R4 2.*2@7 8.

@4B 2#.+

PLB 11

La0 21!2!2$1+7ot!gpt !12

-Bunggu /ad;a% ?Pdan ketersedian a%at

-?ptima%isasi 36

dari B( Interna

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FotoPo%os:0d =28!2>

(u0i%eus7am0aran asites

Berpasang

Fotoa0d & posisi =28!2>

-(entina% %oop-7am0aranasites

-Berpasang 4:PD

C /unaid

L1:D 3#

$1!$,!1*#&,#,&

)R(2+!$2!2$1+

DP/P dr.(amue%

(ampetoding(p.-3D

@epatoma DD!

Bumorhati

24/2/2016

7amma 7B #*

4: 1*-* 1$8*L: =18!2>

@ 12.

54 +*PLB 1*&

1!2!2$1+7ds 88

6r!kr 1#!$8#7ot! gpt ,&! 21

:%0 &.&Na! k! c% 1$!&.8!1$8

Foto po%os a0d =2#!2>

)aag duodenum norma%

Foto thora< =1,!2>

-Locu%ated eusion de%) *'-#a b)'a!-#a'

La0 $#-$&-2$1+

PB 1+&:PBB &+#

INR 1#+

:%0umin 2&Natrium 1&2

3a%ium &83%orida 1$$

La0 =2!&!1+>

;0c 1&.r0c &.#&

hg0 *.&hct &$

p%t 8,

ur!kr 2$!$.#got!gpt 2$!*

protein tota% +.1a%0 2.2

g%o0u%in &.*

-?ptima%isasi 36

- Pro %aparoskopi

drainage a0ses

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Lab 29/2

PB 1+.,

INR 1.+:PBB $.2

2450252016

49: 2,

Na!3!4% 12,!&,!*+

6(7 sp%enomega%A

C /a;iAa(upu

L1:D 31

11-&-1*++,2&82

3onsu%28!2!2$1+

dr. 5arsinggih(p.-3D

:denocarsinoma co%on E

cancer pain

Post kemoterapisik%us II

tahap I

La0 $#-$&-2$1+

:%0umin &+

Protein tota% ++:sam urat 11

La0 =2!2>50c ,.

R0c .&*

@g0 11.&@ct &+.

P%t #12

La0 =1*!2>Na!k!c% 12*!&.*!*+

La0 =11!2>

7ds 1#&6r!kr 2! $.

7ot!gpt 11!11

)(4B a0d =2*!2>

-)assa 1!& dista% rectum

-)assa pd region hipochondriumsmpai%um0a%0i%atera% kesanekstra %umina%

-Bidaktampaktanda metastasis %ien

6sga0d =2&!2>

-)assa 0esar regionparaaortaa0domina%issisikanansugesti

%Amphoma

-Bidaktampaktanda metastasis hepar-)u%tipe%%esihipodenspd%iensusp. )etastasis

4B (can a0d =2#!1!2$1+>)assa isodensregio para aorta

a0domina%assusp. LAmphoma mesenterium

Bunggu hasi% 4o%on

in %oop

C @atija

L13#2#!+!1*+$

## Bahun

,1#,&

3onsu%

2,!2!2$1+

DP/P

dr.5arsinggih(p.-3D

Bumor Regio

9pigastrium dd!Limoma

Lab 4/3/2016

a%0 2.+

La0 =1!&!2$1+>

;0c ,.$

r0c .#2hg0 11.+

hct &,p%t &,#

a%0 2.&

;T Ab+-(

1750152016

)assa

paraaortaa0domina%issusp%AmpadenopathA

9usi p%eura 0i%atera%

-Rencana

4o%onoskopi=tunggu jad;a%>

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La0 2&!$2!2$1+

7ds *,6r! 3r 1,!$.,1

i%. Bota% $.#

i%. Direk $.&7?B!7PB &2!28

Na!3!Na 1! #.$ 1$1C /u0aedah

L1 3#!III!$1!$,!1*,2

,*1+

)R(

1$!$2!2$1+

3onsu% dariinterna

2,!$2!2$1+

DP/P

dr. Rona%d 9.LusikooA (p.-

3D

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junction-

Ikteruso0struksiec.Bumor

duodenum pars II

Lab 4/3/2016

;0c 8.$r0c &.+

hg0 *.#

hct 2*p%t 1#

Lab 1/3/2016

;0c #.#

r0c 2.8#

@0 ,.$hct 22

p%t 1#,pt 11.

inr 1.$8aptt 2#.*i0rinogen 2#8.

gds 1##

ur!kr #2!$.#got!gpt 8,!#&

i% tota% 2&.,,

i% direk 18.$8:%ka%i osatase #+*

protein tota% #.1

:%0 2.*g%o0u%in 2.2

gammagt 81na!k!c% 1&+!.1!1$+

La0 =1+!2>49: &.$1

4:.1*.*M &$$

:FP 8 protesdiskusi

8GIE

Bumor gastro-duodena% junction curigama%ignancA

7astropati hipertensi porta% derajat ringansedang

P: peradangankronikakti u%cerati"e dgn @.pA%ori tidakada

-Rencana )R4P

=pengantar ada>-?r0umin caps 2gds ,#

pt 1&

inr 1.2#

C IVFD RLNa4% $*

:minousin#$$#$$1$$$

C 4eta'idime 1gr!12jam!IV

C Ranitidin #$

mg!8jam!i"C Paracetamo% 1

gr!8jam!i"C (ementara puasa

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21/29

dr. Ikh;an

3usuma (p.-

3D

aptt 2+.,

na!k!c% 12!.#!*$

Lab 29/2/2014

49: 1.2#

i%. Bota% 2&.$$i%. Direk 1+.*1

:FP M#4a 1*-* 2.##

La0 =2+!$2>:%0 2.,

MS;T ab+-( 2/3/2016

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6-7-1985

?31 t#,@

M" :

5-3-2016

Dp(p : I

')$)p/ #+#"

A+ : I :< p!&< +#,

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A: )),' !#,

,%"m#& : ,!") t!#, :

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R : p),!,t!" m!,!)

M%# &)),!"## m## p#+# #"#

(#m 5-8

N!") t!#, ?-@

H#,+%,! : +#"# ?-@

>!! ?-@ &!,+)" ?-@

A: #"t)#& %t")

HB 13

L 279

/A 10.7/26

DS 82

U"/" 18/0.66

S/S 13/11

A& 3.7

N#//& 147/4.3/113

12/3/2016

L##, p!m!")##,

%&%,-),-&%%p

D)!t "

D&% pp

3. 2B4

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748325

15/7/1985

?31 t#,@

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5/3/2016

D: I

S : B!,(%, #,t#$)+)m! 1'"/12(#m/

)V

R#,)t)+), 50 '/12(#m )*

! p%t t"#,>)

R!,#,# !,+%%p

?LI@ 13/3/2016

A"+)#, 21 t#

St%&!+ 32

4 4B2

S#tt#

24/4/1960

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16

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R!,#,# %&%,%%p

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5 6B3

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10-01-

1958

MRS: 26-2-

2016

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S: N!") p#+# p!"t )")

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: U: S!+#,'< #+#"A+: "p!&< p!")t#&t)

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#" %p!"#)< t#mp#

!,(%, +) "!')%, &m#

&)")

A : A! I&)# ),)t"#

%a'l lab (/3/2016)

=B 21.3

RB 3.30L 511

H 31

%a'l lab (6/3/2016)

=B 21.5

RB 3.24

HB 9.7

L 506

/A 14.7/26.5

IVFD RL 28 tpm

!>t#$)+),m!

1'"/12(#m/)*

M!t"%,)+#$%&! 500

'/8(#m/)*

!t%"% 30m'/8(#m/)*

R#,)t)+), 50m'/12 (#m/)*

RNANA RASI HARI

INI

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%a'lLab (2*/02/16)

/A 12.1/28.0

INR 1.16

DS 193

UR/R 95/1.65

S/S 42/40

NA//L 137/5.6/113HBSA NNRAIF

ANI HV NNRAIF

%a'l CT S!an Abdomen

(2&/2/16)

-m##!t"#&m),!"p#+#"%,''#

p!&*)

)))")'!t)>m##m&)&)%p%

#),)t"#

-,!p"%&)t),)t"#

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6 6B4

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747186

21-8-1976

?40 t#,@

MRS: 28-2-

2016

D: RL

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#;# t!"# +#,

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!)& !# +"#),

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L

- L#"'! B-!&& &mp%m#

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=B 10.7

RB 3.57

HB : 9.5

L 448

ALB 2.5

ASAM URA 5.3

RALSININ 0.52

N#//& 130/2.6/91

%a'l lab (26-2-2016)

=B 7.3

RB 3.95

HB 10.3

H 32.0

L 333

/A 12.9/23.2

INR 1.24

DS 84

U"/" 27/0.7

S /S 21/11

A& 2.6

N#//& 135/3.1/98

V t)#p#")

IVFD RL 28 tpm

!>t#$)+)m! 1'"/12(#m )*

M!t"%,)+#$%&!

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R#,)t)+), 50 '/12(#m )*

V)p A&m), 52

!"#p) ), !#) HM

LONTARA 3 ATAS .ELAAN$

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L3AB

4/1

AMISA

1/07/65

9/3/2016

748804

DR.D".=#"),''.t#$)+)m!1'"/12(#m/)*-m!t"%+),#$%&!0 RL:D5 1:1 28tpm

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LONTARA * .AWA% DEPAN

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N

NAMA DIANSIS MRISAAN NUNAN INSRUSI

1. 1B1

N"(#,,#

746016

01/07/1968

?48

t#,@

MRS :

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6

D : I

S: N!") %p!"#)

: U: #)< #+#"

A+: p!&< !")t#&t)

!#, ,%"m#&

BAB ?-@ Ft ?-@

D"#), 200

A/ %t-L#p#"#t%m H#")-1

#+!)#)

%a'l Lab (/3/2016)

=B 12.8

RB 4.32

HB 12.2

H 38L 171

%a'l lab (1/3/2016)

7.30

B 3.00

/ A 10.4/ 26.4

ALB 3.5

%a'l Lab (1/2/2016)

=B 19.62

RB 3.79

HB 10.1

H 32.2L 234

/Aptt 12.1/29.1

DS 91

UR/R 45/0.78

S/S 7/10

N#//& 145/3.7/119

%a'l Lab (22/02/2016)

LDH 361

!"#p) !#)'),M),m !+))t-!+))t

2. 1B2

S)t) S#"%

728604

1-1-1977

?39

t#,@

M" :

20/2/201

6

D : SS

S : N!")p!"t: U : !+#,'/#)

A+ : p!& ?@) p&!"# )t!"#&

- !"#p) !#) S%',

- ##" +"#),/ 24(#m

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3

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PC+

IU

N

NAMA DIANSIS MRISAAN

NUNAN

INSRUSI

1. BD 5

N";#t)

748592

31/12/1966?56 t#,@

MRS :

8/3/2016

D : IL

S : &)t +) !*#)

U : p#)>/ #+#"

S 15

A+ : p!& ?@