KORAN BEDAH DIGESTIF

SENIN, 18 NOVEMBER 2013

PALEM ATAS (Fadzhil 08234560035)

No

Bed

Atas
B2/ 8
Bed 2

Identitas
Suhardin
17/07/1960
633951
MRS 23/10/2013
Askes
Dr. Ibrahim Labaeda,
Sp.B (K) KBD

KORAN BEDAH
DIGESTIF
Pemeriksaan
Penunjang
SENIN, 18
NOVEMBER 2013
Susp. PeriLab 15/11/13
Diagnosis

appendicular+

kista hepar
POH 3 post
laparotomi
eksplorasi
hari ke 13
post op.
Drainase
abses

Albumin 2,7
WBC 38,03 RBC 2,99 HGB 9,1
HCT 26,6 PLT 209
Lab 14/11/13
Ur/Cr 22/0,3
GOT/GPT 11/9
Na/K/Cl 132/4,3/103
PT 14,2 control 11,2 INR 1,08
APTT 27,2 control 23,2
Lab 11/11/13

Terapi
Sesuai TS. Bagian
Bedah Urologi

GDS 132 GOT/GPT 48/13

Albumin 2,4 CT/BT 800/300
PT 17,5 control 12,4
INR 1,44

Lab 08/11/13
GDS 179 Ur/Cr 10/0,6
GOT/GPT 11/6 Protein Total 5,8
Albumin 2,0 CT/BT 800/ 300
Hb 8,1 WBC 43,37 RBC 2,94 PLT 336
PT 19,9 control 11,4
INR 1,63
APTT 40,6 control 26,2
Na/K/Cl 133/4,3/97
Lab 6/11/2013
WBC 37.1 RBC 2.29 HGB 6.2 HCT 17.7 PLT 360
GDP 338 GD2PP 121
Lab 23/10/2013
GDS 157 Ur/Cr 17/0.5 SGOT/SGPT 17/20
Na/K/Cl 126/4.3/99 CT/BT 8/3 PT/APTT
14.9/30.8 HBsAg Reactive Anti HCV non reactive
Lab 24/10/2013
CEA 1.06
CT scan abd tanpa & dengan kontras
31/10/2013
Hidronefrosis dan psoas abses kanan
Kista hepar disertai hepatomegaly
USG testis 28/10/2013
Hydrocele dextra
USG abd 23/10/2013
Massa intraabdominal sisi kanan disertai
pelvocalyectasis dextra
Thorax PA 23/10/2013
Cor dan pulmo normal
Old fracture 1/3 tengah clavicula kanan,
costa III-VIII kanan belakang dan costa V-VI
kiri belakang
Echo 24/10/2013
Fungsi sistolik LV baik, RF 62%
Normal resting echocardiogram

Atas
B2/
10
Bed 1

Benny Salomo
MRS 17/10/13
Tgl lahir 28/05/1990
23 tahun
Tgl konsul 12/11/13
RM 532440
Askes

Fistel
uretrorectal
pars prostatika

Lab (11/11/2013):
AntiHIV : Non Reactive
Hasil PA (07/11/2013):

Acc Rawat Sama

urologi tgl.12/11/13

Peradangan kronik eksaserbasi akut ketiga

sediaan
Hasil Sitologi (07/11/2013):

Sediaan apusan tidak ada sel epitel maligna

Broncoskopi (01/11/13):

Gambaran peradangan pada bronkus lobus

KORAN BEDAH DIGESTIF

SENIN, 18 NOVEMBER 2013

LONTARA I Atas
(MARAWIA 08124213540 DAN FIRMAN 085255009664)
Ikterus
Lab (14/11/2013)
obstruktif DD/
CT 800 BT 300 PT 12,3 APTT 29,3 PROTEIN
cholangitis
TOTAL 6,0 RBC 4,29, HB 12,6, HCT 33,9, PLT
448, WBC 10,81
Lab (13/11/2013)
AFP 0,82 CEA 4,37CA 19-9100,94
Lab (12/11/2013)
RBC 4,57, HB 13,2, HCT 35,8, PLT 473, WBC
10,21
USG ABD (13/11/13)
Cholestatic intra dan extrahepatic

KORAN BEDAH DIGESTIF

SENIN, 18 NOVEMBER 2013

L1
BB
K7
KLS
III B4

A. Mansyur petta
sajo
09-09-1994
636445
MRS 09/11/13

L1
BB
K5
KLS
3
B1

Muliani
01-10-1994 (19
thn)
632021
MRS 08-10-2013
Jamkesmas

Peritonitis TB

L1.
BB
K4
/KLS
III
bed 3

Ambaling
51 tahun
MRS 7/11/2013
636051
Konsul interna
(12/11/2013)
JAMKESMAS

Ikterus
obstruktif ec.
Susp massa
caput pankreas

PA (06/11/2013)
Kesimpulan: perdarangan kronik granulomatous
ec proses spesifik (TB) + radang suppuratif
Lab (06/11/2013)
HBsAg (-), anti HCV (-), CT/BT 800/300,
PT/APTT 12,7/25,6, INR 1,05, Na/K/Cl
136/4,2/100.
Colon in loop
Kesan: perlengkapan loop-loop usus dengan
pembesaran KGB mesenterikal sesuai gambaran
peritonitis TB.
Lab (05/11/2013)
Alb 2,8, RBC 3,56, HB 9,0, HCT 27,8, PLT 927,
WBC 7,11
Lab (28/10/2013)
Ur/cr 19/0,3, SGOT/SGPT 29/24, Na/K/Cl
142/4,4/106
Foto thorax PA
Kesan: bronchopneumonia bilateral non spesifik +
efusi pleura dextra
USG Abdomen atas + bawah (18/10/2013)
Tampak echo cairan bebas yang terperangkap
pada region umbilical di dalam cavum peritoneum
disertai pembesaran KGB mesenterium.
Kesan: susp. Peritonitis TB.
Echocardiogram (18/10/2013)
Fx sistolik LV baik, EF 54%, Normal resting
echocardiogram.
CT Abdomen (22/10/13):
Kesan : massa distal resesuai duks A
Lab 13/11/13
PT 12,3 APTT 35,3
Lab 12/11/13
KOL TOTAL 252 KOL HDL 7,4 KOL LDL 133
TRIGLISERIDA 614
Lab 8/11/13
CEA 1,27 CA 19-9 35,91 ALKALI FOSFATASE
215 GAMMA GT 48
Lab 7/11/13
WBC 4,17 RBC 4,15, Hb 12,5, HCT 34,0, PLT 394
HbsAg (-), anti HCV (-),GDS 132, ur/cr 13/0,8, Bil.
Tot 20,3, bil.direct 21,61 SGOT/SGPT 21/47,
prot.tot 4,87, alb3,0, globulin 1,87, PT/APTT
24,8/41,9,
FOTO THORAX 7/11/2013
Kesan:
Bronchopneumonia dextra I sus. Spesifik
Cardiomegaly dengan dilatatio et
elongasi aortae
Susp efusi subpulmonal dextra
USG Abd 11/11/2013
Kesan:
Cholestasis intra dan extra hepatik
Poliposis GB
CT Abdomen tanpa kontras (11/11/2013)
Kesan :
Cholestatik intra dan extra hepatik ec.

Tunggu hasil CT scan

abdomen

Terapi TB sesuai Ts
interna
Saat ini pasien
menolak tindakan
operatif

Terapi sesuai TS.

Interna

16

Bed
1

Maryam saade
31/12/1968
RM: 625636
MRS: 23/10/13
ASKES
Dr. dr. Ibrahim
Labeda, SpB-KBD

17

Kmr
1
Bed
2

Feida P.
Paputungan
P/32thn/3-05-1981
RM 629187
ASKES
MRS 22/09/2013
Dr.dr.Ronald
E.L,Sp.B-KBD

LONTARA 2 DIGESTIVE
KAMAR 1 JEFMAN E MARZUKI H Y (081344600078)
S : KU : 05/11/2013
O : Abdomen =
Foto Thoraks PA
supel, peristaltic Kesan : efusi pleura dextra
(+),
Lab 15/11/2013
Colostomi :
Na/K/Cl 145/3,3/111 PT/APTT 15,7/26,4 INR 1,30
baik, produksi
BT 300 CT 600 GDS 107 Ur/Cr 10/0,5
feses (+)
SGOT/SGPT 15/7 Prot.Total 6,8 Albumin 2,5
Bilirubin Total 1.0 Bilirubin Direk 0.62
A : POH 17
Lab 15/11/2013
Laparotomi
WBC 18,92 RBC 3,25 HGB 9,2 HCT 26,9 PLT
explorasi +
540
colostomy ec
Lab 06/11/2013
tumor rekti 1/3
Na/K/Cl 137/3,7/103 PT/APTT 15,1/25,5 INR 1,25
distal ec
GDS 88 Ur/Cr 10/0,5 SGOT/SGPT 19/5 Prot.Total
multiple kista
5,1 Albumin 2,2 CRP kuantitatif 69
Lab 06/11/2013
WBC 14,8 RBC 3,20 HGB 9,2 HCT 27,0 PLT 222
PH 7,472 pCO2 42,1 SO2 98,4 PO2 107,5 HCO3
31,1 ctO2 16,6 BE 7,4
Lab 30/10/2013
WBC 10,5 RBC 3,24 HGB 9,0 HCT 27,4 PLT 630
GDS 192 GOT/GPT 25/5 Alb. 2,2 Na/K/Cl
138/4,2/106
Lab 22/10/2013
WBC 34,26, RBC 3,35, HGB 9,3, HCT 26,7, PLT
510 CT/BT 800/300, PT/ APTT 17,0/35,5, INR
1,39 GDS 94, Ur/Cr 94/57, Alb 1,7, as urat 3,4,
Na /K/Cl 141/3,5/109, SGOT/SGPT 30/8, HBsAg
non reaktif,
CT scan 24/10/2013
Kesan: massa rectosigmoid disertai ascites yang
terlokalisir
Lesi noduler susp. Metastasis tumor ke hepar
cholelithiasis
Foto abdomen 3 posisi 23/10/2013
Kesan subileus
Massa intraabdominal
Kolonoskopi (6/9/2013)
Kesimpulan: Tumor Rektosigmoid
S : (-)
Lab 13/11/2013
O : KU : baik
GDS 81 ur/cr 19/0,3 SGOT/SGPT 34/14 protein
Abdomen :
total 0,3 Albumin 2,3 Na/K/Cl 131/2,8/100 BT/CT
supel,
900/300 PT/APTT 15,7/26,2 WBC 3,0 RBC
peristaltik (+),
2,29 HGB 6,1 HCT 17,7 PLT 284
luka operasi
Lab 07/11/2013
kering,
Prot. Total 5,5 Albumin 1,9
A : POH 15
Lab 2/11/2013
Post. Op
WBC 7,6 RBC 3,12 Hb 7,8 HCT 25,2 PLT
laparotomy
220.000 Albumin 1,9 Na/K/Cl 136/3,5/102
eksplorasi ec.
Lab 24/10/2013
Ileus obstruksi
WBC 11,36 RBC 3,83 HGB 9,8 HCT 29,2 PLT
+ abses
246
mesenterium
WIDAL:
Salmonella typhi negative
Salmonella part A negative
Salmonella part B HB 1/160
Salmonella part C negative
Lab PA 23/10/2013
Peradangan grannulomatosa yang sesuai untuk
chron disease
Hasil salmonella part B HB 1/160
Lab 10/10/2013
HGB 11,01,HCT 34,01,MCV 79,PLT 374,WBC
11,5
Lab 7/10/2013
WBC 19,6 ; RBC 3,52; HGB 8,5; PLT 207; HCT
26,3; GDS 62Ur/Cr 26/ 0,6 Alb 3,1; Bil.tot 1,02;
Bil. Direc 0,6 GOT/GPT 120/165; Prot.Tot 5.1,
PT/APTT 12,4/26,5
Lab 27/9/2013
Pengecatan gram : Coccus positif, bacil gram
negative
Jamur (+)

KORAN BEDAH DIGESTIF

SENIN, 18 NOVEMBER 2013

Aff Infus
Obat oral :
Cefadroxil 2x500 mg
Ranitidine 3x150 mg
As.Mefenamat 3x500
mg
Rawat luka dan GV
VIP Albumin 3x2
Rawat Colostomi

R/ IVFD Aminofluid
1000
RL 500
NaCl 0,9 % 500
Panamin G 500
Albumin 20% 1
botol/hari
Vip Albumin 3x2 tab
Levofloxasin 500 mg/24
jam/iv
Ranitidin 1 amp/8 jam/iv
Rawat luka & GV/Hari

KORAN BEDAH DIGESTIF

SENIN, 18 NOVEMBER 2013
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