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REKAP BEDAH DIGESTIF TANGGAL 16 NOVEMBER 2015

No

K/B

Identitas

1.

Thamrin, 60th, 1069625


Dpjp Dr. Ferry E, Sp.B
(K) BD

2.

3.

4.

IS
O

5.

6.

Munawir, 20 th,
1069948
Dpjp Dr. Ferry E, Sp.B
(K) BD
Yoffizar Rahman, 21 th,
106776
Dpjp Dr. Ferry E, Sp.B
(K) BD
Syawardi, 31 th,
1069741
Dpjp Dr. Ferry E, Sp.B
(K) BD
Ramadani, 48 th,
1070434
Dpjp Dr. Muslim, Sp.B
(K) BD
Safrizal, 19 th, 1070956
Dpjp Dr. Muslim, Sp.B
(K) BD

JEUMPA 1

PO
D
13

11

Diagnosis

Lab

Post LE + Biopsy gaster +


Repair Perforasi gaster +
omental patch a.i general
peritonitis ec perforasi
gaster
Parsial MBO ec dd Tumor
intraabdomen, Pseudocyst
Pankreas

13-11-15:
Hb: 14 Ht: 43 E: 5,0 L: 11,1 T:560 Alb: 3,68
Na:139 K: 4,5 Cl: 105 GDS: 112 Ur: 54 Cr:
0,67

Off Kateter
Mobilisasi

13-11-15:
Hb: 11,6 Ht: 36 E: 4,5 L: 8,1 T:333 Alb:
3,98 Na:143 K: 3,9 Cl: 104 GDS: 99 Ur: 31
Cr: 0,67
15-11-15:
Hb: 11,3 Ht: 36 E: 4,7 L: 20,1 T:695
Na:138 K: 5,2 Cl: 101

Ct scan (+)
Rencana OP
senin/16-11-15

15-11-15:
Alb: 3,21 Na:124 K: 3,5 Cl: 82 GDS: 112
Ur: 39 Cr: 0,63

Off drain
Perawatan Luka +
Stoma
Kultur darah (+)
Ct Scan Rabu/1815
Kultur darah
Diet Lunak NGT
Cek Lab post OP
Evaluasi TTV
Evaluasi drain

Post LE + Adhesiolisis +
Reseksi Tumor + Biopsi
KGB a.i adhesi + Ca Rekti
1/3 distal
Post LE + Adhesiolisis +
Reseksi Ileum + Ilesotomy
a.i Total MBO ec Hernia
Interna + Adhesi
Susp.Ca Pankreas, Tumor
Intraabdomen

Post LE + Appendectomy
a.i Appendicitis Perforasi

15-11-15:
Hb: 14,3 Ht: 46 E: 5,4 L: 13,6 T:767 Alb:
3,13 Na:141 K: 5,3 Cl: 101 Ur: 29 Cr: 0,79
14-11-15:
Hb: 13,1 Ht: 40 E: 4,7 L: 16,5 T:473 GDS:
87 Na:138 K: 3,5 Cl: 98 Ur: 37 Cr: 0,81 CT:
7 BT: 2

Planning

Hasil PA (+)
Konsul Kardio (+)

JEUMPA 2
Identitas

No

K/B

1.

No
1.

JEUMPA 3
K/B
Identitas
6
2
Suryana, 35 th, 10

2.

3.

PO
D

Samsiah Abdullah, 35
th, 1069950
Dpjp Dr. Muslim, Sp.B
(K) BD

POD
6

Diagnosis

Lab

Planning

Adenocarcinoma
gallbladder metastase ke
Perihillar Hepar + CHF +
MR Moderat +
Pneumonia

12-11-15:
Hb: 10,4 Ht: 31 E: 4,2 L: 14,0 T:265 Alb:
3,20 Na:134 K: 3,7 Cl: 99

Kemoterapi
Echo (+)

Lab
14-11-15:
Hb: 10,3 Ht: 31 E: 3,4 L: 6,7 T:269

M. Saleh, 60 th,
1068162
Dpjp Dr. Ferry E, Sp.B (K)
BD

Diagnosis
Post Hemoroidectomy
+Polipectomy a.i
Hemoroid Stage IV +Polip
Recti
Ileus Paralitik, Post LE ec
Perforasi Gaster + Efusi
Pleura Sinistra Minimal +
Pneumonia

Abdullah, 27 th,
1069634
Dpjp Dr. Ferry E, Sp.B (K)
BD

Susp. Tumor Gaster +


Efusi Pleura Bilateral +
Tumor Colon Sinistra +
Post WSD dextra

14-11-15:
Hb: 8,6 Ht: 27 E: 3,3 L: 3,7 T:276 Alb: 2,94
Na:130 K: 3,9 Cl: 97

12-11-15:
Hb: 11 Ht: 33 E: 3,6 L: 8,0 T:276 Alb: 2,91
Na:135 K: 4,2 Cl: 101

Planning
Transfusi PRC
Rendam larutan PK
Cek DR post transfusi
Cek Albumin
Ct scan Abdomen
Cek DR, Albumin,
Elektrolit, GDS,
Off NGT
Cek DR, Albumin,
Elektrolit, Ur/Cr
Transfusi PRC
LE + Billroth

Senin/16-11-15

No
1.
2.
3.
4.
5.
6.
7.
8.

K/
B
1
1
6
5
7
6
7
7

JEUMPA 4
Identitas
1
2
5
2
2
2
1
5

POD

Diagnosis

Lab

Planning