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REKAP PASIEN BEDAH DIGESTIVE

Selasa, 29 November 2016

1. IW-1
2 Seureune 2
3. Seureune 3
4. Jeumpa 3
5. HCU
6. MP 1
7. Jeumpa 4
8. Jeumpa 1
9. MP 2
10. ICUD

Nama dokter muda:


Mutiya Agussa
Risya Mentari
Yola Ovianty
Shahnaz Rizka
Fauziatul Amra

IW-1 : 2 Pasien
No
Kamar

Identitas

Diagnosis

Terapi

Lab

Planning

27/11/2016
Hb/Ht/Er/L/T
10,9/33/3,9/5,7/196
Albumin: 3,03
Na/K/Cl/Ca:
142/2,3/101/7,8
Ur/cr: 15/0,40
22/11/16
Hb/ht/E/L/T
11,1/34/3,9/215
Hbsag
Albumin :2,78
Na/k/cl
138/3,0/102
Ur/cr
17/0,4
28/11/20116
Hb/Ht/E/L/T
12,6/38/4,5/9,2/407
Na/K/Cl : 135/3,7/105
Gds: 98
Ur/cr : 17/0,30

Tunggu hasil biopsi


CT-Scan (2/12/2016)
Cek albumin pos trf (-)
Konsul kardio tole op

2C

Syamaun
110676
64 tahun

Tumor
Colorectal
dd Ca Recti

IFVD
futrolit
20gtt/i
s/s assrg 20 gtt/i
inj. Fosmisin 2
gr/12 jam
drip PCT 1gr/8j
Inj.Transamin
1amp/8j

Loby

Nur Fatta
1110512
23 tahun
Ad: 2

Tumor intra
abdomen

IVFD Rl 20 ggt/m
Drip Paracetamol
1gr/8jam
Inj.Ranitidin
50mg/8jam

ICU D : 1 Pasien
No
Kamar
1
Bed 6

: 1 Pasien
: 1 Pasien
: 2 Pasien
: 1 Pasien
: 2 Pasien
: 2 Pasien
: 14 Pasien
: 1 Pasien
: 2 Pasien
: 1 Pasien

TOTAL : PASIEN

Foto polos 3 posisi


Ct
scan
Abdomen
(29/11/2016)

Identitas

Diagnosis

Terapi

Lab

Planning

Masniar
33 tahun
1106790

Peritonitis dipose
ec
lekage
anastomotis

Diet Air Susu 6x100


IFVD futrolit 20gtt/i
s/s assrg 20 gtt/i
inj. Pelastin 2 gr/12
jam
inj.ketorolac amp/8j
drip tramadol/8j
inj ranitidine amp/12
drip aminofluid/hr
drip lipofundin/hr
PCT 1 gr/8j drip
Albumin 25% (H3)

25/11/16
Hb/ht/E/L/T
9,6/32/3,8/25.2/374
Albumin : 2,35
Na/K/Cl
144/3,3/108/
ur/cr
24/0,30

Trf PRC 1 kolf


Fosen enema/hr

POD 1

22/11/16
Hb/ht/E/L/T
12,2/40/4,9/15,4/325
Albumin : 2,54
Na/K/Cl
139/4,2/112/7,6

Seureune 3 : 1 Pasien
No
Kamar
Identitas
1

Hasanah
52 tahun
1049254
AD 23
Pod 4

6c

Diagnosis

Terapi

Lab

Planning

Post LE +
adhesiolisis
+biopsy hepar
ec
status
colostomy ec
dada ca colon
rectosigmoid

IVFD futrolit 20gtt/i


Drip KCL 25 mg dalam 500
cc
Inj. Ranitidin amp/12j
Inj.fosmisin 2 gr/12j

25/11/16
Hb/ht/E/L/T
11,2/35/4,1/11,9
Na/K/Cl/ca/mg
147/2,7/104/8,1/1,5

Mobilisasi
TRF prc 1 kolf
Persiapan kemo
Cwk Albumin

25/11/16
Na/K/Cl/Ca/Mg
148/2,8/103/8,4/2,0

HCU : 2 pasien
No

Kamar

Identitas

Diagnosis

Terapi

Lab

Planning

Bed 4

Faisal
39 tahun
1107766
POD IV

Post
LE
+
Cholesistectomy
+ erupsi abses +
yeyunostomy

Diet 6x100
IVFD Futrolit 20gtt/i
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam
Lipofundin/hr
Duragesic patch/3hr

27/11/16
Hb/Ht/E/L/T
9,6/29/3,3/18,0/347
Albumin : 3,03
Biltot/bildir
16,32/14,80
Na/K/Cl
136/3,9/102
Ur/Cr
49/0,80

Evaluasi Drain +
rawat luka

Bed 1

Hamka
64 thn
1091580

Obstruksi
Jaundice
ec
dd/1. Ca caput
pankreas, 2. Ca
ampula recti

IPD

27/11/2016
Hb/ht/eri/le/T
11,0/32/3,8/34,6/19
Pt/APTT: 11,6/45,2
Albu: 2,41
Na/K/Cl : 144/3,3/117
Ur/Cr: 107/1,30
25/11/16
Na/K/Cl
150/2,3/117
24/11/16
Hb/Ht/E/L/T
7,8/22/2,7/33,8/19
Albumin : 2,46
Na/K/Cl
148/1,6/116

P/
Perbaikan KU

Mamplam 1 : 1 Pasien (pria)

No

Kamar

Identitas

Diagnosis

K2B5

M. Yacob
78 tahun
1033091

Tumor
intraabdomen

MP2 = 2 Pasien
No
Kamar

Terapi

Identitas

Diagnosis

Terapi

K6b4

Fatimah/66 thn/

Obs.Jaundice ec
Ca
Caput
Pancreas

K6B2

Jamaiyah
65 tahun
1110007

Obs.Jaundice ec
susp. Ca Caput
Pancreas

Jeumpa 4 : 12 Pasien
No
Kama
Identitas
r
1
K1B2
Amiruddin
78 tahun
1108490
POD IV

IPD

Lab

Planning

24/11/16
Hb/ht/E/L/T
12/37/4,5/5,9/252
Albumin : 3,64
CT/BT : 2/8
KGDS : 132
Na/K/Cl
135/2,7/73
Ur/Cr
124/3,30

Konsul kardio
Konsul anes
Ct-Scan (susul hasil)

Lab

Planning

23/11/2016
Hb/Ht/E/L/T
11,6/30/4,0/11.10/43
5
bil.tol: 30,73
bil.direct: 28,66
albimun: 3,27

Ct
scan
1/12/2016

23/11/16
Hb/Ht/E/L/T
10,9/31/3,9/10,3/368
PT/APTT
CT/BT
2/8
Biltot/bildir/sgot/sgp
t
23,10/21,40/106/101
Albumin : 3,07
Na/K/Cl
136/3,8/113

Ct scan Abdomen :
29/11/16
Konsul kardio dan anes

Diagnosis

Terapi

Lab

Post LE + reseksi
colon sigmoid +
reseksi sekum +
colostomy ec Ca.
Recto Sigmoid

Diet Bubur
Inj.bisolvon 1amp/8jam
IFVD futrolit 20 gtt/i s/s asrg 20
gtt/i
Drip aminofluid /hr
Drip lipofudin/hr
Inj. Fosmisin 2 gr/12j
Inj. Ketorolac 3 %/8j
Inj.Ranitidin amp/12j
Duragesic patch/3 hr
Inj. Metoclopramid/8j

25/11/16
Hb/ht/E/L/T
14,9/44/5,3/13,0/394
Albumin : 3,33
KGDS : 141
Na/K/Cl
139/3,8/108
ur/cr
13/0,81
21/11/16
Hb/ht/E/L/T
13,9/42/4,7/10,4/411
Albumin
Na/K/Cl
139/3,7/102
Ur/Cr
23/1

tgl

Planning

K2B1

Rita Mutia
38 tahun
0879770
POD XI

Ca Recti 1/3 distal


post kemo + anemia
+ hipoalbumin

IVFD Futrolit 20 gtt s/s asrg 20


gtt/i
Drip aminofluid fls/hr
Drip lipofudin/hr
Drip metronidazol/hr
Drip albumin 20%/hr
Inj. Cefepim 1gr/12j
Inj. Ranitidin amp/12j
Inj. Metroclopamide/8j
Inj. Metoclopramide/8j
Makan Lunak

K4B1

Sayid Yusuf
72 tahun
0858431
POD I
AD XII

Post op

Diet lunak + juice


IVFD futrolit 20 gtt s/s asrg 20
gtt/i
Drip lipofudin fls/hr
Drip aminofluid /hr
Drip albumin 20% 100 cc.hr
Inj ranitidin amp/8jam

K5B1

Syarbaini
50 tahun
1109918
POD VI

Post LE + reseksi..
Anastomosis end to
end debridement ec
difus hallow organ
yeyunum

Diet Puasa
IVFD Futrolit 20 gtt/I s/s asrg 20
gtt/i
Drip lipofundin/hr
Drip amnifluid/hr
Drip PCT.8j
Inj fosmisin/12j
Inj. Ranitidine/12j
Duragesic patch 12,5mg/3hari
Fosen enema/hr
Metronidazol drip
Albumin drip 25%
Metoclopramid/8j
Diet Susu 6x100
IVFD Futrolit 20 gtt s/s assrg 20
gtt
Drip lipofudin/hr
Drip aminofluid/hr
Drip metronidazol/8j
Inj.fosmisin 2 gr/12j
Inj.ketorolacamp/8j
Frosen enema/hrs
Diet Susu 4x50cc
IVFD Futrolit s/s ass 20 gtt/i
Inj. Vit K amp/8j

K5B4

Yusriadi
29 tahun
0991876
POD VIII

Post
LE
+
Adhesiolisis+anasto
masis dngan stepler
ai Status Ileostomi

K6B1

Laili
47 tahun
1108489
POD VI

Post LE CBD +
chlodeocostomy ai
Obs. Jaundice ec Ca.
Pankreas

23/11/16
Hb/ht/E/L/T
10,3/31/3,8/13,3/382
Albumin : 3,21
KGDS : 83
Na/K/Cl
140/3,2/112
Ur/Cr
11/0,49
19/11/16
Hb/ht/E/L/T
8,7/27/3,4/17,0/460
25/11/16
Biltot/bildir
0,69/0,50
24/11/16
Hb/Ht/E/L/T
11,8/34/4,2/7,8/400
Albumin : 3,22
Na/K/Cl
134/5,1/103
KGDS :175
Ur/Cr
35/0,8
19/11/16
Hb/ht/E/L/T
10,0/29/3,6/4,4/390
28/11/2016
Hb/ht/e/l/t
10,6/34/3,8/19,2/139

Trf
albumin
selama 3 hari

TRF Albumin
Cek ulang darah
cyto
Thoraks foto cyto

24/11/16
Hb/Ht/E/L/T
13,3/38/4,7/8,4/173
Albumin : 2,41
Na/K/Cl
142/3,7/113
Ur/Cr
71/1,00
21/11/2016
Hb/ht/E/L/T
15/44/51/23,7/224
Ur/cr/na/k/cl
31/0,8/141/4,8/0,9

Mobilisasi
Cek albumin

26/11/16
Hb/ht/E/L/T
9,9/29/3,1/5,2/233
Albumin : 2,92
KGDS :100
K/Cl
3,1/110
Ur/Cr
27/0,5

TRF Albumin
PRC 2 kolf

23/11/16
Hb/Ht/E/L/T
7,9/23/2,5/8,9/249
Hbsag : Albumin : 2,88
Na/K/Cl
145/3,1/108
KGDS : 114
Ur/Cr
19/0,50

8.

K6B3

Hayaton
19 tahun
0904725
POD 1V

Colostomy closure
+adhesi .. ec ca
ovarium

Diet susu 4x50


Fosen enema

9.

K6B4

Kamaliah
Bahar
66 tahun
1105645
POD 27

Tumor antrum gaster

IVFD Futrolit s/s assrg 20 gtt/i


-drip aminofluid /24 jam
-drip lifofundin/24 jam
-drip PCT/8j
Inj. Ranitidin 1 amp/8 jam
-inj metronidazol 500 cc/8j
-inj. Omeprazol amp/12 j
-drip albumin 25%
-ambroxol syr 3xc1
Ondan 8 ml/8j

10.

K6B5

Fitriana
31 tahun
1102221
POD 20
AD 18

Post laparotomi +
miles prosedur +
total colectomy +
ileostomy ai Ca.
Recti 1/3 distal

-IVFD Futrolit s/s assrg 20 gtt/i


-drip aminofluid /24 jam
-drip lifofundin/24 jam
-drip PCT/8j
Inj. Ranitidin 1 amp/8 jam
-inj metronidazol 500 cc/8j
-inj. Omeprazol amp/12 j
-drip albumin 25%
-ambroxol syr 3xc1

11.

K6B6

Suriani
53 tahun

Massa Intraabdomen

0988765

Post op Le+Reseksi
tumor+

AD III

26/11/16
Hb/Ht/E/L/T
12,3/36/4,4/9,3/141
25/11/16
Hb/Ht/E/L/T
10,6/31/3,8/3,7/101
23/11/16
Hb/Ht/E/L/T
19,9/58/7,2/2,6/107
CT/BT
2/7
Albumin : 4,44
Na/K/Cl
144/3,7/102
KGDS : 113
Ur/Cr
37/0,60
23/11/16
Hb/Ht/E/L/T
10,6/34/4,3/11,4/121
Albumin : 3,21
Na/K/Cl
138/2,5/99
KGDS : 107Ur/Cr23/0,4
27/11/2016
Na/K/Cl
139/3,8/106
26/11/16
Hb/ht/E/L/T
11,4/34/4,2/5,4/197
Albumin : 2,94
Na/K/Cl
136/4,2/105
Ur/Cr
6/0,20
23/11/16
Hb/Ht/E/L/T
12,2/36/4,6/5,5/211
Albumin : 2,76
Na/K/Cl
136/3,4/108
KGDS : 87
Ur/Cr
6/0,2
27/11/16
Hb/ht/E/T/L

10,2/32/4,5/445/16,3
Albumin : 3,50
Na/K/Cl
137/4,4/103
KGDS : 55
Ur/Cr

45/1,80

-Rawat Luka

Rawat
Luka
dengan
gentamisin
Trf albnumin
GV

12.

K7B2

Diman
41 tahun
1108711
POD XI

13

K3B1

Azhar Daud
62 tahun
1110266

14

K3b2

Fuadi
47 tahun
0981887

Hil Dex
Post Herniraphy +
mess ORAFT

IVFD Futrolit 20 gtt/mnt


Inj.fosmicyn 2gr/12 j
Inj.ketorolac 3% /8j
Inj.Ranitidin /12 jam

15

K7B

Nuzulul Hadi

Mechanical
Obstruksi
Colonectal

IVFD futrolit 30gtt/m


Aminofluid + Lipofundin/hari
Fosmicin 2gr/12 jam
Drip Pct 500mg/8jam
Omeprazole 40mg/8 jam

1110431
23 thn

Post Drainage Abses


post laparotomi ai
abses
retro
peritoneal

Hernia Scrotalis
Dextra + CHF

bowel
ec

-Nasi Lunak+ jus


IVFD Futrolit 3/3 ass 20 gtt/i
-Inj. OMZ 1amp/8 jam
-inj. Kalnex 1 amp/8 jam
-inj. Vit K 1 amp/8 jam
-drip albumin 10% /24 jam
-Lipofundin /24 jam
-drip pleastri 1 gr/ 12 jam
-drip metronidazol 500 mg/ 8 j

IVFD Futrolit 1500cc/hr


Inj. Fosmisin 2gr/12j
Inj. Ranitidin amp/12j

26/11/16
Hb/ht/E/L/T
12,8/39/4,7/26,4/498
Albumin : 3,33
Na/K/Cl
135/4,4/100
Ur/Cr
11/0,50
24/11/16
Hb/Ht/E/L/T
12,6/36/4,6/26,6/549
22/11/16
Hb/ht/E/L/T
12,1/35/4,4/22,3/529
Albumin : 3,00
KGDS : 76
Na/K/Cl
131/4,4/100
Ur/Cr
8/0,47s
25/11/16
Hb/ht/E/L/T
10,3/32/3,5/8,9/200
CT/BT
3/8
KGDS : 97
Na/K/Cl
138/4,2/107
Ur/Cr
96/1,4
11/11/2016
Hb/Ht/E/L/T
14,8/44/4,8/269
Na/k/Cl
144/4,2/102
Ur/cr : 21/0,94

Mobilisasi duduk
Lab hasil (+)

Rencana op
Rabu

26/11/2016
Hb/Ht/E/L/T
8,2/26/3,6/28,0/479
Ct/BT: 2/7
Na/K/CL
109/4,3/77
Ur/Cr
32/0,80
Gds: 91

Jeumpa 1/ 1 paasien
No
1.

Kamar

Identitas

Diagnosis

Iso-1

M. Husein
62 tahun
1109454

Massa abdomen
illeocaecal dekstra

Jeumpa 3 : 1 Pasien

ar

Terapi

Lab

-Diet MBs
-IVFD Futrolit s/s
assering 20 gtt/i
-Inj. Ranitidin 1
amp/12 jam
-Drip PCT 1 gr/8
jam
-Fosen enema/hari
Sucralfat syr 3X1

26/11/16
Albumin : 2,57
23/11/16
Albumin : 2,29
17/11/2016s
Hb/ht/E/T/L
10,7/31/4,2/343/23,9
CT/BT
2/7
Na/K/Cl
134/4,2/101
Ur/Cr
41/1.10

Planning

Rencana OP
Senin 28/11/16
Post Op ICU

No
1.

Kamar

Identitas

Diagnosis

K6B2

Sawidiah
76 tahun
1110255

Status
ec.Ca
distal

Terapi

Colostomy
Recti 1/3

Lab

Planning

27/11/2016
Hb/Ht/E/L/T
10,8/33/4,0/6,2/396
25/11/16
Hb/ht/E/L/T
9,8/31/3,7/8,6/446

Ct
scan
Abdomen
kontras d non
K

CT/BT: 2/7
KGDS : 100
Na/K/Cl
143/4,0/114
ur/cr
63/0,9

Konsul kardio
tole op

PJT :
No

Kamar

Identitas

Diagnosis

Terapi

Lab

Planning