LAPORAN KEADAAN PASIEN DIGESTIF TANGGAL 10 APRIL 2014JEUMPA 3 : (DM RAIHANUN)

NOIDENTITASTANGGAL MASUK DIAGNOSA PRA OPERATIFTEMUAN INTRA OPERATIFTINDAKANDIAGNOSA PASCA OPERATIFPLANING TERLAKSANAMASALAHPEMERIKSAAN PENUNJANGRENCANA

1

Buchari/Lk/55 tahun/982389

DPJP : dr.muslim sp.b KBD

22-3-2014K7B6

OP : 01/4/2014

POD : 8

Post ileostomy + laparotomi eksplorasi

ileostomy closure + reanastomosis ileotransversum

Post relaparotomi + colostomy + anemiaFosen (+)Metoclorpramia

sucralfat syrupbisolvon ampdiet cair

Lab 25/3/2014Hb :13.6Ht :39Tro :251Leu :11,6Alb:3,3Glob:3,5Protein total:6,8Na:141K:4,6Cl:114

Lab 1/4/2014Hb :9,3Ht :27Tro :317Leu :6,0Alb:2,0Glob:2,6Protein total:4,6Na:134K:2,8Cl:100

Lab 2/4/2014Hb :11,7Ht :31Tro :327Leu :8,2Alb:1,8Glob:2,5Protein total:4,4Na:132K:2,8Cl:104Ur 40Cr 1,0

Lab 4/4/2014Hb :11,2Ht :30Tro :584Leu :9,6Alb:2,2Glob:2,4Protein total:4,6Ur 39Cr 0,7

Lab 5/4/2014Hb :9,5Ht :27Tro :621Leu :7,7Eri : 3,3LED: 25Alb:2,1Glob:3,2Protein total:5,3Na/k/cl : 136/3,8/103MDT: 0/0/7/64/26/8

Test feeding (+)Cek albumin, globulin (10/04/2014)

2.Mariah/ PR/ 64 th/ 991429

DPJP : dr. Ferry Erdani, Sp.B KBD27-3-2014K4B3

Post bilio digestive + T tube

Lab 30/03/2014GDS : 288Ht : 30L : 12,1T : 134Hb : 10,1E : 3,4Pro: 5,8Alb: 1,4Glob: 4,4Ur: 39Cr: 0,5Na: 138K: 3,1Cl: 115

Lab 1/4/2014Hb : 9,2Ht :35Tro :134Leu :15,5E 3,0Bil total 14,15Bil direct 11,0

Lab 3/4/2014Bil total 17,33Bil direct 14,31SGOT 215SGPT 123Alk Fospatase 234Prot total 6,0Alb 1,5Glob 4,5Ur 54Cr 1,0GDP 46LAB 5/4/14PROT TOT:5,9ALB:1,8GLOB:4,1

Lab 7/4/14Hb 11,1Ht 29E 3,6Leu 16,9Trom 177Led 76Bill total 9,1Bill direct 18,22Sgot 304Sgpt 108Alk posfat 171Prot total 9,1Albumin 3,2Globulin 5,9Cr 0,8Ur 49GDS 55Ambil hasil MRCP

3Agung perdana/lk.27 thn/996719Op 4/4/14

POD 2appendicitisPost appendectomyFutrolitCeftriaxoneKetorolac

Tramadol(stop)RanitidineOndansetron

Diet sonde cairLAB 5/4/14gds :122E: 5,0HT:41L:11,0T :386Hb:13,8Prot:6,1Alb:3,1Glob:3,0Ur:31Cr:1,1K:5,2NA:143

Rencana PBJ

6.Rusli/lk/43 thn/997252

DPJP : dr. Muslem, Sp. B (K) BDOP tgl 5/4/14

POD 5General peritonitis ec perforasi gaster + sepsis + Ca buliLaparotomy eksplorasi repair gasterPost laparatomy explorasi repair gaster + ca. buliLab 5/4/14Hb :13,0Ht :39Tro :64Leu :16,1Na:136K:4,0Cl:106Ur 46Cr 1,3

Lab 6/4/14Hb :12,4Ht :38Tro :286Leu :22,9Na:140K:3,8Cl:109Pro.total: 3,9Alb: 2,1Glo: 1,8

4Epi Liana, 30 thn,pr9877774

DPJP: dr. Muslem,Sp.B (K) BDFibromiksoma Lab 8/4/2014Hb :12,0Ht :33Tro :56Leu :6,1LED: 47Prot. Total : 6,9Alb: 3,2Glo: 3,6Cr: 1,0Ur: 50GDP: 89MDT: 0/0/2/70/15/13Poto polos abdomen 3 posisi

5Muhammad Tahir, lk, 29 thn997527

DPJP: dr.Muslem, Sp. B (K) BD7 apr 2014Parcial mecanical bowel obstruction due to ca. Pancreas post whipple procedureAmbil hasil labLftPuasa sementaraFto polos abdomen 3 posisi cyto

6Hamdani 12 apr 2014Trauma tumpul abdomen dgn hemodinamik stabil Hasil lab 12 apr 2014-04-13Gds 147Ht 40Leu 15,8Trom 212Hb 15,2Ct 7 Bt 2Erit 5,0K 4,6N 142Cl 107

7Zainal abidin7 april 2014HIL sin Rencana operasi senin