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KORAN

BEDAH DIGESTIF (17/10/18)

ICU
N Identitas
Diagnosis Hasil Lab Radiologi Planning DPJP
o Pasien
7-10-18
PLT: 87.000
Infus RL: D5% :
GOT: 57
aminofluid
Albumin: 2,8
P. Sinapati 500:500:1000
Ureum : 7,3 Foto Thorax : Pulmo dbn
856600 Ceftriaxone 1 gr/12
Bil.Total : 0,48
72 tahun/31- POH 16 Laparatomi cholesistectomi ec jam/IV
Bil. Direk: 0,35 Foto thorax 12-10-2018: terpasang ETT
1 12-1945 cholelitiasis Metamizole 1 gr/8 WS
pada trakea dengan tip +/- 8,7 cm diatas
ICU bed 3 jam/IV
12-10-18 carina, tanda edema paru, dilatatio et
MRS: 26-9- Omeprazole 40
WBC 17800 elongatio aortae
2018 mg/12 jam/IV
HGB 11,4
Terapi lain sesuai TS
PLT 120.000
anestesi
CRP kuantitatif 206,1
Prokalsitonin 27,94
8-10-18
PLT: 83.000 Foto Thorax 2-10-2018 :
ALb: 2.5 Efusi pleura dextra+ Tanda-tanda
CRP Kuantitatif: 143.1 Edema paru

Hj. St. Aminah 12-10-18 Foto thorax 10-10-2018: terpasang ETT Infus RL: D5%
854422 WBC 13400 pada trakea dengan tip setinggi +/- 3,78 1000:500
55 tahun POH 22 Laparatomi Ileostomi + burst RBC 3,01 cm diatas carina; terpasang DLC pada Terapi sesuai Ts
2 SM
ICU bed 4 abdomen ec carcinoma recti HGB 8,6 hemithorax kanan melalu subclavia anestesi
MRS: 2-9- Ureum 122 dengan tip setinggi costa III kanan kesan Rawat stoma
2018 Kreatinin 0,8 pada cavoatrial junction; susp massa GV+rawat luka/hari
paru dextra disertai multiple lesi noduler
PA:17-9-18 susp. Metastasis tumor ke paru;
Metastase cardiomegaly+edema paru; dilatatio
Adenocarsinoma ke aortae
Omentum dan Hepar
Lab (14/10/2018) - IVFD RL :
Foto thorax PA/AP
WBC :3.9 Aminofluid =
(12/9/2018)
RBC :2.64 1000:1000 per 24
Kesan : tidak tampak tanda metastasis.
Sanu HGB : 9.1 jam
01-07-1958 POH 14 Laparatomy Eksplorasi ec Hernia HCT : 26 - Meropenem 1
Foto Polos Abdomen 3 Posisi
3 60 tahun Internal PLT : 75 gram/8 jam/ IV SM
(13/10/2018)
855383 Ileus Paralitik GDS : 61 - Ranitidin 50 mg/
Kesan:
VIP 1 Prokalsitonin : 21,82 12 jam/ IV
- Small bowel obstruction disertai
Natrium : 136 - Vit C 1 ampul/ 24
pneumoperitoneum suspek peritonitis.
Kalium : 4,7 jam/ iv
- Asites
Klorida : 104 - Puasa
KORAN BEDAH DIGESTIF (17/10/18)
Hematology - Drainase
(01/10/2018) hemoragik
PT : 16.1 asites/bekas drain
INR : 1.59 - Awasi TTV
Aptt : 31.3 - Rencana operasi re-
Kimia Darah laparotomi
(3/09/2018)
Ur : 28
Cr : 0,70
Bilirubin total : 3.06
Bilirubin Direk : 1.26
Sgot: 35
Sgpt :15
Analisa Gas Darah
(14/10/2018)
PH : 7,520
SO2 : 99,2
PO2 : 159,5
ctO2 : 14,1
PCO2 : 27,0
ctCO2 : 23,1
HCO3 : 22,3
BE : -0,8
(09/10/2018)
Albumin: 2.1
Tumor Marker
05-10-2018
CEA : 2.11
Foto thorax PA/AP (29-9-2018):
Sastia Bahreni 10-10-2018
Terpasang ETT pada trakea +
Nurdin SGOT 55
pneumonia dextra + lymphadenopathy
855086 SGPT 45
dextra
43 tahun/12-9- Albumin 3,4
Terapi lain sesuai TS
1974
4 HELLP Syndrome Foto thorax PA/AP 14-10-2018: obgyn, GEH dan gizi IK
VIP 4 13-10-2018
terpasang ETT pada trakea dengan tip klinik
MRS: 7-9- WBC 12700
setinggi +/- 2,3 cm diatas carina;
2018 RBC 3,24
cardiomegaly + bendungan paru;
Konsul Obgin: HGB 9,3
dilatatio et atherosclerosis aortae; efusi
12-10-2018 HCT 29
pleura dextra
KORAN BEDAH DIGESTIF (17/10/18)
16-10-2018
WBC 4,3
RBC 2,69
HGB 8,1 - IVFD RL : D5 :
HCT 25 Aminofluid =
PLT 155 500:1000:1000
- Ceftriaxone 1
Analisa cairan asites gram/12 jam/IV
Dg Kanang Volume 10 - Metronidazole 500
12-12-1975 Warna kuning tua mg/ 8 jam/ IV
Foto thorax PA/AP (16-10-2018): nodul
42 tahun POH II Laparatomi double bypass ec ikterus Kejernihan keruh - Omeprazole 40 mg/
5 soliter suspek tumor metastasis ke paru, IL
857761 obstruksi ec tumor caput dan corpus pankreas pH 8 24 jam/ IV
dilatatio aortae
HCU 1 BJ 1,015 - Ketorolac 30 mg/8
Bekuan positif jam/ IV
Leukosit 140 - Vit. K amp/ 8
Jenis Leukosit PMN jam/IV
70% MN 30% Puasa makan
Rivalta + Minum 1 sdm per
Glukosa 98 jam
Protein 2600
Albumin 1700
LDH 270
UGD
Hasil Lab (15/10/18)
WBC : 11,2
RBC : 4,03
HGB : 11,8
Hasil Foto Thorax (15/10/18) IVFD RL 20 tetes
HCT : 36
Tidak tampak kelainan radiologi pada per menit
PLT : 243
foto thorax ini Ceftriaxone 1 gr/ 12
PT : 12,6
Rahma Nur jam/ iv
APTT : 25,3
859293/ 07 Ikterus Obstruktif ec. Susp. Batu CBD + Hasil USG Whole Abdomen Metronidazole 500
1 GDS : 127 IL
Mei 1987 Cholelith (15/10/18) mg/ 8 jam/ iv
Ureum : 21
Zona Hijau Hepatosplenomegaly Ranitidin 50 mg/ 12
Kreatinin : 0,40
Cholelith jam/ iv
Bilirubin Total : 3,52
Ascites Minimal Ketorolac 30 mg/ 8
Bilirubin Direk : 3,32
jam/ iv
SGOT/SGPT : 54/217
Albumin : 3,2
Na/K/Cl : 141/2,6/100
HbsAg : Non Reactive
Rahmatiah Hasil Lab (15/10/18) Hasil CT-Scan Whole Abdomen IVFD RL 28 tetes
840434/ 31 WBC : 9,3 (15/10/19) per menit
2 Ca Recti 1/3 Proximal SM
Desember RBC : 4,03 Sugestif massa rectosigmoid Inj. Ranitidin 50 mg/
1964 HGB : 10,9 Kista lobus kanan hepar 12 jam/ iv
KORAN BEDAH DIGESTIF (17/10/18)
Zona Hijau HCT : 34 Renal cyst dextra Inj. Ketorolac 30
PLT : 345 Kista adnexa sinistra mg/ 8 jam/ iv
PT : 10,1 Hernia incisional regio umbilical Duragesic patch 25
APTT : 25,4 mg/ 3 hari
GDS : 120 Hasil Pemeriksaan Patologi Anatomi
Ureum : 23 (03/04/18)
Kreatinin : 0,71 Kista endometriosis
SGOT/SGPT : 16/18 Adenocarcinoma recti differensiasi baik
Albumin : 3,9
Na/K/Cl : 141/3,9/104
Hasil Lab (15/10/18)
WBC : 15,26
RL + Ketorolac 3%
RBC : 3,87
20 tetes per menit
Hayati HGB : 10,8
Tramadol 100 mg/ 8
856709/ 31 HCT : 34,7
jam/ iv
3 Desember Tumor Intraabdomen PLT : 211 IK
Omeprazole 40 mg/
1965 GDS : 103
12 jam/ iv
Bed 6 Ureum : 14
Duragesic patch 25
Kreatinin : 0,71
mg
SGOT/SGPT : 236/68
Na/K/Cl : 142/4,1/107
LONTARA 1
Lab (11-10-2018)
Rawat Bersama
WBC 10.69
Terapi sesuai TS
Hgb 9.1
Vopy markuri interna
HCT 29.8 MSCT Abdomen :
L1AD K6B3 ceftriaxon 1
PLT 493 massa Heterogen lien
857142 gr/12j/iv
1. Tumor suprarenal GDS 61 SM
28-03-1987 Metronidazole
Ur/Cr 26/0.53 CT Angiografi :
MRS : 8-10- 500mg/8jam/iv
SGOT/SGPT 32/61 Tumor Suprarenal
2018 Omeprazole
Albumin 3.2
40mg/12j/iv
CEA 0.59
Na/K/Cl 137/4.7/103
Hbsag Non Reaktif
Lab (14/10/18) - Foto Polos Abdomen: Gambaran
small Bowel Obstruksi. - Terapi sesuai TS
Adryansa RBC 2.28 - Colon In loop (9/10/18): Tidak Dapat interna
L1BD K2/2/2 Hgb 6.3 dilakukan pemeriksaan karena - Rencana
Post hematokezia ec chronic disease dd tumor
2. 680151 WBC 2.6 kontras tidak masuk sampai usus Laparatomi IL
colon sigmoid
02/07/1981 HCT 19 halus. eksplorasi total
MRS: 10/09/18 PLT 107 - LGIE (24-9-18): Crohns Disease. colectomy
- Foto thorax (31-8-18): Pneumonia -
12/10/2018 sinistra, efusi pleura sinistra,
KORAN BEDAH DIGESTIF (17/10/18)
Ur/Cr 66/3.83 Dilatatio aorta.
Albumin 2.3 - MSCT abdomen non kontras: Atrofi
kedua ginjal, Crohns Disease, efusi
(7/10/2018) pleura sinistra
SGOT/SGPT 247/277
LONTARA 2 TITIPAN
6/10/2018
PT/APTT/INR =
10.0/26.6/0.95
Ur/Kr = 11/0.78
SGOT/SGPT = 17/2

Syahruddin 2/10/2018
1/10/2018 - Rawat luka setiap
847834 WBC = 6,8
(Foto thorax PA/AP) hari DR. Dr.
12-05-2001 RBC = 4,30
- TB Paru lama aktif lesi luas - - Menunggu IBRAHIM
1 (17 tahun) - ABSES SUBKUTIS REGIO INGUINAL HGB = 10,9
- Scoliosis thoracalis dextroconvex jadwal joint LABEDA,
L2BB K7A B2 HCT = 33
operasi dari TS SP.N-KBD
MRS : 01-10- PLT = 366
- Orthopedi
2018 Neut = 72,8
Lymph = 16,1%

1/10/2018
GDS = 93
HBsAg = Non
Reaktive
3/10/2018
Ur/Kr = 25/1,64
HbsAg Non Reaktive
9/10/2018
AntiHCV (-)
PA - Infus RL : D5%
Na/K/Cl = 143/3,6/106
- MESOTEL REAKTIF DENGAN 1000:500 = 28 tpm
Abd Azis LESI INFLAMASI - Ceftriaxon
26/9/2018
Tandiwa 1g/12j/iv
WBC = 6,8
857125 27/9/2018 - Ranitidin DR. dr.
RBC = 4,04
19/8/1969 (49 MSCT Whole Abdomen (Dengan 50mg/12j/iv RONALD E
2 POH - 12 LAPARATOMI EKSPLORASI HGB = 11,5
tahun) Kontras) - paracetamol 1gr/8 LUSIKOY,
HCT = 36
L2BB K7B B2 - Massa Mesenterium jam/ intravena SP.B-KBD
PLT = 576
MRS : 2-10- - Metamizole
Neut = 70,2
2018 26/9/2018 1g/8j/iv
Lymph = 15,4%
MSCT Whole Abdomen (Tanpa - Diet bubur saring
PT/APTT/INR =
Kontras) - Mobilisasi jalan
11,9/25,3/0,99
- Suspek Massa Mesenterium
GDS = 104
Ur/Kr = 24/1,73
SGOT/SGPT = 65/17
KORAN BEDAH DIGESTIF (17/10/18)
8/10/2018
Na/K/Cl = 135/3.0/98

5/10/2018
WBC = 10,6
RBC = 4,72
HGB = 12,4
HCT = 37 4/10/2018
PLT = 174 MSCT Whole Abdomen (Tanpa
- Rencana OMD
Neut = 74,8 Kontras)
- Infus NaCl 0,9% :
Lymph = 15,8% - Massa antrum gaster
D5% : Aminofluid
Jarre Albumin = 2,8 - Ascites
1:1:2 = 28
857659 Fraksi Lipid - Efusi pleura bilateral terutama sinistra Dr.
tetes/menit
10-3-1958 (60 Kolesterol SAMUEL
- Omeprazole
3 tahun) - TUMOR ANTRUM GASTER Total/HDL/LDL/TG = 2/10/2018 SAMPETOD
40mg/12j/oral
L2BB K8B6 137/14/61/257 Foto Thorax AP/PA ING, SP.B-
- Terapi gizi sesuai
MRS : Asam urat = 5,3 - Terpasang CVC pada hemithorax KBD
TS gizi klinik
1/10/2018 Calsium = 8,6 dextra melalui subclavia dengan tip
- Operasi batal
Magnesium = setinggi dengan costa III kanan depan
karena tidak ACC
Pending/menyusui kesan pada vena cava superior
Anestesi
Darah Laktat = 39,3 - Dilatatio, elongation, et atherpsclerosis
Na/K/Cl = 135/3/96 aortae

3/10/2018
4Albumin = 2,8

1/10/2018
SGOT/SGPT = 98/58
HBsAg Non Reaktive
4/10/2018
PT/APTT/INR =
11,2/1,07/18,9 - Infus RL : D5% :
WBC = 19,8 4/10/2018 Aminofluid = 500 :
Setriani Santi
RBC = 5,31 Foto Thorax AP/PA 500 : 1000 30 tpm
858127
HGB = 14,1 - Tidak tampak kelainan pada foto - Ceftriaxon DR. Dr.
10-1-1992 (26 POH-12 RESEKSI ANASTOMOSIS
HCT = 43 thorax ini 1g/12j/iv IBRAHIM
4 tahun) ILEOILEAL + ADHESIOLISIS +
PLT = 443 - Omeprazole LABEDA,
L2BB K9B2 APPENDECTOMI
Neut = 72,3 Foto Abdomen 3 Posisi 40mg/12j/iv SP.N-KBD
MRS : 4-10-
Lymph = 16,8% - Gambaran ileus obstruktif - Mobilisasi jalan
2018
GDS = 94 - Diet bebas
Ur/Kr = 42/0,53 - Rawat luka
SGOT/SGPT = 11/12
Na/K/Cl = 140/3/95
Nini Herlina TUMOR INTRA ABDOMEN SUSPEK 9/10/2018 9/10/2018 - Infus Ringer Laktat DR. dr.
5
Umar DISTAL ILEUM WBC = 7,6 Foto Thorax AP/PA 20 tpm RONALD E
KORAN BEDAH DIGESTIF (17/10/18)
856185 RBC = 4,56 - Tidak tampak kelainan pada foto - Diet clear water LUSIKOY,
1-5-1995 (23 HGB = 13,1 thorax ini - NaCl 0,9% 1000cc SP.B-KBD
tahun) HCT = 40 - Cor dan pulmo dalam batas normal via rectal (16.00)
L2BD K11B4 PLT = 354 - Flet enema 1 botol
MRS : Neut = 54,3 4/10/2018 via rectal (16.30)
9/10/2018 Lymph = 28,9% CT Whole Abdomen (Tanpa Kontras) - Fiet fosfosoda/oral
PT/APTT/INR = - Sugestif massa distal ileum DD/infeksi ½ botol pukul 17.00,
10,1/27,7/0,96 spesifik ½ botol pukul 17.30,
GDS = 115 dicampur 1 gelas air
Ur/Kr = 22/0,78 2/10/2018 - rencana operasi
SGOT/SGPT = 17/8 Colon – Inloop hemikolektomi
Albumin = 4,0 - Massa pada ileum terminal dextra (15/10/2018)
Na/K/Cl = 140/4,5/103 Foto Polos Abdomen
- Tidak tampak kelainan radiologic pada
3/10/2018 foto polos abdomen ini
Alkali Fosfatase = 53
CEA = 0,63 18/9/2018
USG Abdomen Atas+Bawah (Whole
Abdomen)
- Kista fungsional ovarium kiri
- Organ- organ intraabdomen lainnya
yang terscan dalam batas normal
LONTARA 2 DIGESTIF
Lab (11/10/2018)
WBC : 29.44
USG abdomen atas dan bawah (whole Infus RL 28 tetes per
RBC : 4.80
abdomen) menit
HGB : 14.1
Muh (11/10/2018) - Ceftriaxone 1gram
HCT : 42.0
Syakirullah Kesan : / 12 jam / IV
PLT : 360
Darwis organ organ intraabdomen yang terscan - Metronidazole 500
Dr.
13-01-19995 POH 5 Laparatomi ec Vulnus Ictum saat ini dalam batas normal mg/8 jam/iv
Kimia Darah dr.Warsingg
1 23 tahun Abdomen + Laserasi Hepar - Omeprazole 40 mg
(11/10/2018) ih SpB-KBD
858889 Foto thorax AP/PA / 12 jam / IV
Ureum: 32
L2AD (11/10/2018) - Ketorolac / 8
Kreatinin : 1.53
K1/B2 Kesan : jam/iv
Sgot: 41
Tulang-tulang intak - Minum sendok 5
Sgpt : 39
Cor dan pulmo dalam batas normal sendok/jam
Na : 143
- Aff drain
Cl : 107
K : 4.7
OktavianusTa Lab (7/09/2018) MRI IVFD RL : D5 :
dr. Samuel
nggu S. POH 11 Laparotomi bypass WBC : 4.2 CholangioPancreatografidengankontras Aminofluid = 500 :
Sampetodin
2 26-10-1977 cholangiosystojejunostomi ec RBC : 2.78 (3/10/2018) 500 : 100 cc per 24
g, Sp.B-
40 tahun Cholangiosarcoma HGB : 9.1 Kesan: jam
KBD
856672 HCT : 27 kolestatikintrahepatikdanekstrahepatikec - Ceftriaxone 1
KORAN BEDAH DIGESTIF (17/10/18)
L2AD PLT : 269 stenosis distal CBD suspekmassa gram/ 8 jam/ IV
K1/B3 Hematology - omeprazole
(22/09/2018) CT whole abdomen tanpakontras 40mg/12 jam/iv
PT : 17.2 (03/9/2018) - Diet bubur halus
INR : 1.71 Kesan : Hepatosplenomegal - GV per 3 hari
Kimia Darah Kolestatikintrahepatikdanekstrahepatike - Rencana endoskopi
(7/09/2018) csuspekmassa distal CBD untuk biopsi
Ur : 37 Cholecystutisi
Cr : 0.62
Albumin: 2.5
Bilirubin total ; 8.9
Bilirubin direk: 8.59
Na :139
Cl :104
K :3.2
(22/09/2018)
Sgot ;58
Sgpt :46
Tumor marker:
(28/9/2018)
AFP : 1.33
Lab (03/10/2018) PatologiAnatomi
WBC : 7.06 (23/10/2017)
RBC : 4.04 MixoidLiposarcoma of Mesenteric
HGB : 11.6
HCT : 35.4 Foto thorax Ap/PA
PLT : 252 (24/10/2018)
IVFD RL 28 tpm
Hematology Kesan efusi pleura sinistra
Ceftriaxon 1 gram pe
(05/10/2018)
r 12 jam iv
Usman PT : 12.4 CT whole abdomen tanpakontras
Metamizole 1 gram
Mangkala INR : 1.03 (23/9/2018)
per 8 jam iv
12-3-2018 APTT: 30 Kesan : massa kistik berseptasi kesan Dr. dr.
POH 20 Chest tube Ranitidin 50 mg per
3 41 tahun Kimia Darah ekstralumen Warsinggih,
Mixoid Liposarcoma of Mesenteric 12 jam iv
817345 (05/10/2018) Suspek tumor mesenterium Sp.B-KBD
Vip albumin 3x2 cap
L2AD Albumin: 2.6 Efusi pleura sinistra
s
K1/B4
Terapi Ts BTKV ter
(03/10/2018) MSCT whole abdomen dengan kontras
uskan
Ur : 55 (02/10/2018)
Cr : 1.0 Kesan : massa patologik ekstralumen
Sgot : 27 suspek berasal dari mesenterium
Sgpt : 12 Efusi minimal pleura bilateral
Na : 139
Cl : 109
K : 4.4
KORAN BEDAH DIGESTIF (17/10/18)
Hematologi:
(07-10-2018)
PT : 10.6
INR : 1.01 MSCT whole abdomen (dengankontras)
APTT: 27.1 (3/10/2018)
Albumin : 3.8 Kesan : tumor solid rongga pelvis
HbSAg : NR suspekmassaresidif
Siti Hasnani
Lab (26/10/2018) Hepatomegaly
31-08-1967 - Rencana
WBC : 10.6 CT Scan whole abdomen (tanpakontras) Dr. dr.
51 tahun Laparatomi
Ileus obstruktif parsial ec RBC : 5.21 (1/10/2018) Ronald E.
4 781054 eksplorasi eksisi
Tumor colon residif HGB : 14.3 Kesan: suspekmassasegmenbawahrahim L., Sp. B-
L2AD tumor join op
HCT : 44 Foto thorax AP/PA KBD
K2B1 vaskular
PLT : 312 (/10/2018)
Ureum: 14 Kesan : tidak tampak tanda metastasis
Kreatinin : 0.60 Cardiomegali dilatasi aorta
Sgot : 19 Colon in Loop (12/10/2018)
Sgpt : 23 Massa distal colon sigmoid
Tumor marker :
(26/09/2018)
CEA > 200.0
Lab (4/10/2018)
WBC : 13.98
RBC : 3.65
HGB : 9.4
MSCT whole abdomen normal
HCT : 29.3
dengankontras
Haryanti PLT : 399
(27/9/2018) Cefadroxil 2 x 500
22-06-1981 Kimia Darah
Cholestatik intra hepatic dan ekstra mg/oral dr. Ihwan
37 tahun POH 13 laparatomy eksplorasi CBD + (04/10/2018)
5 hepatic ec batu pada common bile duct Paracetamol 3 x 800 Kusuma, Sp.
857354 laparotomy Cholisystectomy Ur : 24
mg/oral B-KBD
L2AD Cr : 0.40
Patologi anatomi : Mobilisasi jalan
K2B2 Sgot :79
(05/10/2018)
Sgpt :91
Cholecystitis kronik
Albumin: 2.9
Na : 139
Cl : 106
K : 3.6
Lab (24/9/2018) Colon Inloop (28/9/2018) IVFD Ringer laktat
Mintje WBC : 7.4 Kesan : Massa proximal Rectum 28 tpm
Kawangun RBC : 4.71 Ceftriaxone 1 gram/
Dr. dr.
23-4-1950 HGB : 11.0 Foto polos abdomen 12 jam/ iv
POH 7 Laparatomy + Colostomy + biopsi Ronald E.
6 68 tahun HCT :35 (28/9/2018) Ranitidin 50 mg/12
hepar L., Sp. B-
856864 PLT : 336 Kesan: suspek massa recrosigmoid jam/iv
KBD
L2AD Hematology Ketorolac/ 50 mg / 8
K2B3 PT : 10.6 Foto Thorax jam /iv
INR : 0.87 (28/9/2018) Makan bebas
KORAN BEDAH DIGESTIF (17/10/18)
APTT: 27.6 Kesan : tidak tampak metastasis
Kimia Darah Elongatio et atherosclerosis aortae
Ur :34
Cr : 0.70
Sgot : 20
Sgpt : 15
Na :144
Cl :104
K : 3.2
Lab (09/10/2018)
WBC : 7.1
RBC : 4.08
HGB : 11.7
PLT : 345
Hematology
PT : 14.7
Foto Thorax
APTT: 35.7
(09/10/2018)
Kimia Darah
Kesan : Cardiomegaly disertai dilatation
Ur :11 IVFD RL 28 tpm
aortae
Cr : 0.42 Omeprazole 4 mg/12
Asna Pulmo dalam batas normal. Dr.dr.
Bilirubin total : 23.16 jam/iv
858711 Ibrahim
Ikterus obstruksi ec suspek tumor kaput Bilirubin direk : 22.45 Metamizole 1 gram/
7 21/9/1964 CT-Whole Abdomen (tanpa kontras) Labeda,
pankreas Sgot : 541 8 jam/iv
L2AD (12/10/2018) SpB-KBD
Sgpt : 588 Tramadol 50 mg/8
K2B4 Kesan :
Na :142 jam/iv
- Suspek massa kaput pankreas
Cl :102
- Hepatomegaly disertai focal fatty liver
K : 3.2
- Distended GB disertai cholelith
Tumor Marker
- Batu VUJ Sinistra
(11/10/2018)
CEA : 12.77
CA 19-9 : >500.0
Fungsi Hati:
Alkali Fosfatase :
13.76
Gamma_GT: 2394
Lukman Basri -koreksi albumin
859255 14-10-2018 25%
CT whole abdomen
11-12-1985 WBC : 3,69 -RL 28 TPM
-tdk tampak pembesaran KGB paraaorta Dr. dr.
(32 th) HGB : 12,9 -ranitidine 50mg/12
-Limfadenopati paraaorta abdominal abdominalis Ibrahim
8 L2AD HCT : 38,5 jam/iv
-hipoalbuminemia -hepatosplenomegali Labeda,
K3B1 PLT : 269 -Ceftriaxone 1 gr/12
-efusi pleura bilateral terutama dextra Sp.B-KBD
MRS : 14-10- Ureum urine : 2 jam/iv
-Batu VUJ sinistra
2018 -Ketorolac 30 mg/8
jam/iv
KORAN BEDAH DIGESTIF (17/10/18)
16/10/2018 -
RL 28 tpm
Mappaenre
WBC: 6,94 - Ceftriaxone 1
849523
RBC : 3,84 gr/12 jam/iv
31-12-1952 Colon in loop
HGB : 9,5 - Ranitidine 50
(65th) Massa 1/3 tengah colon transversum
HCT:28,8 mg / 12 jam / iv Dr.
L2AD
9 Adenocarcinoma distal colon ascendens PLT:519 - Metamizole 1 Warsinggih,
K3B2 PA :
GDS:101 gr/ 8 jam/iv Sp.B-KBD
MRS : 7-10- Adenocarcinoma dengan gambaran
UR/CR: 12/0,7 - ranitidine 50mg/
2018 signet ring cell
Protein total: 5,5 12 jam/iv
Alb : 3,2 rencana op bila KU
Na/K/Cl : 128/4,7/93 optimal
10/10/2018
WBC: 11,7 -
RL 28 tpm
Jamaluddin RBC : 5,37 -Ceftriaxone 1
858851 HGB: 13,3 CT whole abdomen gr/12 jam/iv
31-12-1948 HCT:42,2 -multiple lesi hipodens pada kedua lobus - Ranitidine 50
POH 6 drainage ascites ec suspek tumor Dr.
1 (69 th) PLT:395 hepar suspek hepatoma dd/ metastasis mg / 12 jam / iv
hepar Warsinggih,
0 L2AD PT/APTT: 13,5/34,7 -ascites - Ketorolac 30
Sp.B-KBD
K3B3 GDS : 128 -efusi minimal pleura bilateral mg/8 jam/iv
MRS : 10-10- UR/CR: 40/0,77 -dilatasi loop-loop usus - Follow up hasil
2018 SGOT/SGPT: 39/48 PA (sitologi)
ALBUMIN: 3,4
Na/K/Cl: 138/4,7/99
- RL : D5 28 tpm
Umar MSCT whole abdomen (kontras) - Ceftriaxone 1
13-10-2018
850943 -massa gaster suspek GIST gr/12 jam/iv
WBC: 4,63
20-07-1954 -hepatomegali disertai tumor metastasis - Metronidazole
RBC : 4,5
(64 th) -spenomegali 500mg / 8 dr. M. Ihwan
1 HGB: 13,1
L2AD POH 6 Laparatomy biopsi ec tumor lien -nephroliths bilateral jam/iv Kusuma,
1 HCT:40,1
K3B4 - Metamizole Sp.B-KBD
PLT:183
MRS : 9-10- Foto thoraks PA/AP 1gr/8jam/iv
Albumin : 2,7
2018 -dilatatio elongatio aortae - Cocktail/8jam/iv
Na/K/Cl : 147/ 3,9/109
-pulmo dalam batas normal - Diet bubur
GV per 2 hari
15-10-2018
WBC : 7,66 -RL:D5:Ns
Asmah
RBC : 3,99 500:500:500/24jam
849218 MRI :
HGB : 11,3 -Ceftriaxone 1 gr/12
1-7-1960 -tidak tampak tanda kolestatik intra dan Dr. dr.
PLT :95 jam/iv
1 (58 th) -ikterik ec. Retensi stone post laparoskopi ekstrahepatik Ibrahim
SGOT/SGPT : 58/90 -Ketorolac 30 mg/8
2 L2AD kolesistektomy -tdk tampak struktur GB Labeda,
ALB : 2,6 jam/iv
K10B2 -hepatomegaly Sp.B-KBD
Koles total : 234 -Ranitidine 50 mg /
MRS : 10-10-
HDL : 5 12 jam / iv
2018
LDL : 175 -HbsAg (-)
TG : 312
KORAN BEDAH DIGESTIF (17/10/18)
13/10/2018
BIL Total : 3,71
Bil Direk : 3,54
-RL:NaCl =
13/10/2018 1000:1000/24jam 28
-WBC:3,58 tpm
Nurul Inayah
-HGB:11,9 -levofloxacin 500
856730
-PLT:330 CT whole abdomen : mg/ 12jam/ iv
25-12-1999
-HCT:38,1 Suspek abses iliacus dan abses psoas -metronidazole 500
1 (18 th) -POH 1 laparatomi drainase abses Dr.Samuel
-PT : 11,1 dextra mg/8jam/iv
3 L2AD -Abses Psoas Sampetoding,
-APTT : 26,5 -metamizol 1 gr/ 8
K10B4 Sp.B-KBD
-GDS : 103 jam/ iv
MRS : 23-9-
UR/CR: 21/0,5 -ranitidine
2018
SGOT/SGPT: 24/15 50mg/12jam/iv
Na/K/Cl : 141/4,3/104 -mobilisasi duduk
-ukur drain/12jaM
RL:NS:D5 = 500 :
15-10-2018
Sitti Ola 500 : 500/24jam
WBC :19,44
857270 -omeprazol 40mg/
RBC: 3,67
31-12-1964 24jam Dr. dr.
-Tumor intra abdomen HGB : 10,2 CT whole abdomen:
1 (53 th) -Metamizole 1 gr/ 8 Ibrahim
-anemia PLT : 461 Massa heterogen dengan kalsifikasi
4 L2AD jam/iv Labeda,
GDS : 72 renal sinistra
K10B5 -Ceftriaxone 1 gr/12 Sp.B-KBD
UR/CR : 26/0,9
MRS : 13-10- jam/iv
SGOT/SGPT : 15/5
2018 -tunggu CT scan
Na/K/Cl : 133/4,1/102
urografi
16-10-2018
Remmang
WBC: 8,22 RL:NaCl:aminofluid
853005
RBC: 4,53 PA : 500:500:500/24jam
1-7-1977
HGB: 12,1 -adenocarcinoma muci- nosum colon -diet bubur biasa
(41 th) -POH 14 extended hemicolectomy dextra + Dr.
1 HCT : 35,9 dgn kedua ujung reseksi bebas tumor -mobilisasi jalan
L2AD biopsi hepar Warsinggih,
5 PLT: 487 -app kronik -Ceftriaxone 1 gr/12
K10B6 -adeno ca colon ascendens + meta hepar Sp.B-KBD
GDS : 107 -nodul hepar dgn gambaran meta adeno jam/iv
MRS : 29-9-
UR/CR:21/0,20 ca mucinosum -omeprazol 40mg/
2018
Alb : 2,6 24jam
NA/K/Cl : 129/4,3/99
Maing 8/10/2018 - Diet biasa
BNO 3Posisi( 7/10/2018)
858571 WBC: 17,27 - Aff drain
-Pneumoperitoneum
17-07-1957 HGB15,8 - cefixime 100
Dr.dr.Ronal
Kamar 11 Bed HCT:46,8 mg/12 jam/oral
1 POH 7 Laparatomi Eksplorasi + Foto Thoraks PA/AP (09/10/2018) d E.
1 PLT:258 -Ranitidine 50 mg/12
6 Peritonitis Generalisata ec perforasi gaster - Terpasang CVC pada hemithorax Lusikooy,Sp.
MRS:08/10/20 PT/APTT:14,2/37,0 jam/iv
dextra B-KBD
18 GDS:115 - Paracetamol 500
- Efusi minimal pleura dextra
UR/CR:46/0,91 mg/8 jam/oral
- Cardiomegaly disertai dilatatio aortae
SGOT/SGPT:26/22 - Boleh rawat jalan
KORAN BEDAH DIGESTIF (17/10/18)
Na/K/Cl:144/4,1/107
- Infus
RL:D5:Aminofluid
8/10/2018
1000:500:1000/24
Rusman WBC: 12.48 Foto Thoraks PA/AP (09/10/2018)
jam
Radeng RBC: 3.58 - Terpasang CVC pada hemithorax dextra
- Levofloxacin 750
783272 - POH 8 Laparotomi eksplorasi + HGB: 11.2 dengan tip kesan pada atrium dextra Dr.dr.Ibrahi
mg/12 jam/iv
1 24-06-1963 adhesiolisis + bypass iliocolica HCT: 32.8% - Slight cardiomegaly disertai dilatation er m
- Metronidazol 500
7 Kamar 11 Bed PLT:299 elongation aortae Labeda,Sp.B
mg/8 jam/iv
2 GDS 129 - Old fracture 1/3 medial os clavicular -KBD
- Omeprazole 40
MRS:11/10/20 UR/CR:27/0,69 sinistra
mg/12 jam/iv
18 SGOT/SGPT: 26/14 - Pulmo dalam batas normal
- Analgetik sesuai
Na/K/Cl:134/3,1/97
TS Anestesi
- Aff drain
13/10/2018
WBC: 8.93 Foto Thorax AP (13/09/2018)
RBC: 5.02 - TIdak tampak tanda-tanda metastasis
Mansu
HGB: 13.1 pada foto thorax ini
837207
HCT: 40.2% - Dilatatio, elongation et atherosclerosis - Rencana operasi
31-12-1961 dr. Samuel
1 - Post colostomy e.c tumor rectum 1/3 PLT: 356 aortae 16/10/2018
Kamar 11 Bed Sampetodin
8 proximal PT/APTT: 10.0/25.3 Spuling NaCl per
3 g. Sp.B-KBD
INR: 0.95 PA (23/03/2018) rectum
MRS:
GDS: 187 - Kelenjar getah bening dengan
11/10/2018
Ur/Cr: 40/0.99 gambaran sinus histiositosis, tidak
SGOT/SGPT: 28/24 tampak gambaran malignitas
Na/K/Cl: 142/4.4/103
13/10/2018
WBC: 10.7
RBC: 3.61 -IVFD
HB: 9.9 Aminofluid:RL:NS
HCT: 31% 1000:500:500/24
PLT: 279 jam
Zainuddin Protein total: 4.2 - Duragesic patch 25
PA (07/09/2018)
855116 Albumin: 2.1 mcg/3 hari
- POH 17 Gastrostomy Feeding -dapat menyokong suatu
16-11-1958 Globulin: 2.1 -ceftriaxone 1 gr/12 Dr.M.Ikhwa
1 - Ca Gaster adenocarsinoma
Kamar 11 Bed Na/K/Cl: 148/3.1/115 jam/iv n Kusuma,
9 - Hipoalbumin
4 -omeprazole 40 Sp.B-KBD
- Maag Duodenum (13/09/2018)
MRS : 13/10/2018 mg/12 jam/iv
-massa curvatura minor gaster DD/GIST
08/09/2018 WBC: 12.06 -metamizol 1
RBC: 2.18 gr/8jam/iv
HB: 5.9 -Antacid syr 3x1 oral
HCT: 19.4% -minum bebas
PLT: 369 -
Albumin: 2.4
Na/K/Cl: 145/2.9/109
KORAN BEDAH DIGESTIF (17/10/18)
Ur: 95
Cr: 0.76

05/10/2018
WBC:15,19
HGB = 9,3
HCT = 29
PLT = 282
Albumin = 2,3

7/10/2018
Albumin: 2,2
12/10/2018
WBC = 47.7
HGB = 11.2
-Infus RL:D5:NaCl
HCT = 32%
0.9% 500:500:1000
PLT = 326
- Ceftriaxone 1
PT/INR/APTT=13.3/1.
gr/12jam/iv
29/24,3
-Metronidazole 500
Hali GDS=97
Foto Thorax PA/AP (12/10/2018) mg/8 jam/iv
859050 Ur/Cr = 260/4.15
- Cor dan pulmo dalam batas normal - Ketorolac 30 mg/8
15-01-1984 SGOT/SGPT = dr. Samuel
2 - POH 4 Laparotomi - Terpasang gastric tube dengan kesan jam/intravena
Kamar 11 Bed 264/145 Sampetodin
0 Ruptur Abses hepar pada gaster - Omeprazole 40
5 Albumin: 2.5 g. Sp.B-KBD
mg/12 jam/iv
MRS Bilirubin total: 7.43
-Minum 10 sendok
:12/10/2018 Bilirubin direk: 4.00
air/jam
Na/K/Cl = 130/5.0/90
-Diet bubur + telur
rebus
15/10/2018
- Transfusi PRC 4
WBC = 19.4
bag
HGB = 7.0
HCT = 21%
PLT = 265
07/10/2018 Colon in Loop (12/10/2018)
WBC = 11,3 - Massa Rectosigmoid - IVFD RL:D5%
HGB = 11,4 25 tpm 1:1
Bakri
HCT = 35 Foto Polos Abdomen (12/10/2018) - Ceftriaxone 1
848527
PLT = 558 - Tidak tampak kelainan radiologic gr/12 jam/iv Dr.dr.Ibrahi
31-12-1950
2 POH 0 Laparotomy eksplorasi + PT/INR/APTT:10,4/08 pada foto ini - Metronidazole m
Kamar 11 Bed
1 Colostomy ec Adeno Ca Rectosigmoid 7/27,6 500 mg/8 jam/iv Labeda,Sp.B
6
Ur/Cr = 36/0,7 20/09/2018 (CT Whole abdomen - Ranitidine 50 -KBD
MRS:
SGOT/SGPT = 23/23 tanpa kontras) mg/12 jam/iv
04/10/2018
Albumin:3,5 -Organ intraabdomen dalam batas - Ketorolac 20
CEA:7,15 norma mg/8 jam/iv
Na/K/Cl = 134/4,1/96 - Boleh minum
KORAN BEDAH DIGESTIF (17/10/18)
PA (25/09/2018) biasa
- adenocarsinoma rectosigmoid Mobilisasi duduk

Echo (21/09/2018)
-disfungsi diastolik ventrikel kiri derajat
ringan

MRI Pelvis dengan kontras


(8/10/2018)
-massa rectosigmoid dengan fat
stranding sekitarnya (DUKES B)
ISO
09/10/2018
WBC: 6.2
Simon Ruruk
RBC: 4.54
Palindungan
HGB: 11.6
828395 PA (12/012018)
HCT: 36.2
15-07-1954 Adenocarcinoma rexti intramucosa
PLT: 331
Kamar ISO 1 diferensiasi sedang
GDS: 236
MRS: 15-10-
Ur/Cr: 15/0.60
2018
SGOT/SGPT: 19/13
Na/K/Cl: 139/3.7/100
LONTARA 3
LAB 11/10/2018

Ur/Kr = 31/0.5
SGOT/SGPT = 19/14 Infus RL :D5
GDS = 88 1500:500/24Jam
Colon in loop kesan
Ismail Sudarno Na/K/Cl = 137/3,2/104 Moxifloxacin
Massa rectum
856204 40mg/12jam/iv
POH IV Colostomy double barrel ec
1 27-6-1969 WBC = 12,4 Ranitidine RL
Adenocarcinoma recti 1/3 distal (Foto thorax PA/AP)
L3AD K6B1 RBC = 11,1 50mg/12jam/iv
- tidak ada tanda metastasis
HGB = 3,97 Ketorolac
HCT = 35 30mg/8jam/iv
PLT = 389 Diet air gula

CEA = 51,39
Albumin = 3,0
LAB 13/10/2018 USG Infus RL :aminofluid
Arisman
Kolestasis intra dan ekstra hepatic 1000: 1020 /24jam
856882
WBC = 12,6 Ceftriaxone
2 1-7-1996 POH IV LAPARATOMI EKSPLORAS CBD IL
RBC = 3,90 MSCT Whole Abdomen 1gr/12jam/iv
L3AD K2B4
HGB = 11,9 -cholestasis intra dan ekstra hepatic Metronidazole
HCT = 34 -batu distal CBD 500mg/12jam/iv
KORAN BEDAH DIGESTIF (17/10/18)
PLT = 323 Omeprazole
ALBUMIN = 3,9 Foto thorax 40mg/24jam/iv
Tidak tampak kelainan pada radiologik Analgetik sesuai ts
anestesi
Mobilisasi
Diet bubur + telur
Minum bebas
15-10-2018
WBC 3.3
HGB 12.3
HCT 38 Infus RL 28
PLT 69 tts/menit
Ulfiyah A Albumin: 2.5 Ceftriaxon 1 gr/12
Rajamuddin Na/K/Cl: 134/3.9/102 jam/iv
Tumor Adrenal Kiri
11-09-1982 Ketorolac 30 mg/8
Hepatosplenomegali
3 36 thn 13-10-2018 jam/iv( bila nyeri) WS
Hiperbilirubinemia
Tgl MRS: PT/APTT:13.2/34.2 EKG
13/10/2018 INR: 1.28 Nebulizer NaCl
L3AD K2B6 GDS: 82 Tranfusi Albumin 25
Ur/Cr: 25/0.32 %
Bil. Total 5.98 Transfusi TC 6 bag
Bil.Direk 5.83
SGOT:173
SGPT:120
10/10/2018
WBC 15.14
HGB 11.3 Infus Rl+D5% 1000
HCT 33 cc:1000cc/24 jam
PLT 229 Ceftriaxon 1 gr/12
USG Whole Abdomen (25/9/2018)
Muliana PT/APTT: 13.5/25.3 jam/iv
-hepatomegaly disertai massa
01-07-1989 INR: 1.32 Ketorolac 30 mg/iv
-Splenomegaly
29 thn GDS 162 (bila nyeri)
4 857033 POH 7 Laparatomi eksplorasi+ Removal Ur/Cr: 13/0.65 Diet Bubur biasa RL
CT Scan Abdomen (27/9/2018)
Tgl MRS Tumor Bilirubin Total: 0.85 Rawat luka
-Hepatomegaly
08/10/2018 Bil. Direk: 0.53 Takar Produksi
-Splenomegali
L3AD K2B1 SGOT: 29 drain/24 jam
SGPT:14 Takar produksi
Na/K/Cl: 141/3.5/106 urin/24 jam
Prokalsitonin 1,46
08/10/2018
AFP <0,50
Halia 14/10/2018 Infus RL 28 tpm
Tumor intraabdomen suspek teratoma
3-5-1958 WBC =32,4 CT Scan Whole Abdomen Ceftriaxone
5 mesenterium SM
856916 RBC=3,89 - sugestif teratoma mesenterium 1gr/12jam/iv
L3AB HB= 11,4 Omeprazole
KORAN BEDAH DIGESTIF (17/10/18)
K4B5 HCT = 34 40mg/24jam.iv
PLT = 491 Foto Thorax AP/PA Vip albumin
12/10/2018 - tidak tampak metastasis 2cap/8jam/oral
WBC = 17,8 - Cardiomegaly disertai dilatation et Post transfusi PRC 6
RBC = 3,59 elongation aorta bag
HGB = 9,8 - Elevasi diafragma dextra Paracetamol
HCT = 30 - old frakture 1/3 medial os clavicula 500mg/oral/extra
PLT = 522 sinistra
Albumin = 3,0 Planning:
CEA = 5,65 Laparotomy
PT = 10,9 eksplorasi
INR = 1,04 Perbaiki TD
APTT = 25,9 170/100mmHG
GDS = 134
UR/CR = 30/0,38
GOT/GPT = 129/46
PROT TOTAL = 7,2
ALBUMIN = 3,1
GLOBULIN = 4,1
NA/K/CL =
137/3,2/103
LONTARA 4 BAWAH DEPAN
Ati Rosmiyati Rad (29/9/2018)
03/03/1970 (48 CT whole abdomen non kontras, Kesan: Rawat luka dan
11/10/2018
thn) massa kompleks adnexa, ascites, bebat tekan
1 POH 17 Drainase Ascites Albumin 2.2 WS
840211 hydronephrosis sinistra, efusi pleura -metimazole 1 gr/8
L4BD dextra jam/iv (bila nyeri)
4/2
Rad (5/10/2018) -Infus RL 28
Lab 13/10/2018 CT whole abdomen non kontras, Kesan: tts/menit
Na/K/Cl: 133/3.1/96 massa adnexa dengan ascites dan efusi -Ceftriaxon 1 gr/12
Roslinda
pleura (gambaran meigs syndrome), jam/iv
28/02/1975 (43
Lab (5/10/2018) fatty liver -Rantitidin 50 mg/12
thn) POH 5 Drainase ascites
2 Tumor marker: jam/iv SM
858087
AFP: 1.33 Rad -Ketorolac 30 mg/8
Biru
CEA: >200 Foto thorax (10/10/2018): jam/iv
CA 125: >600 -Alirkan drain 500
BNO 3 posisi (4/10/2018): Gamb. cc/24 jam
AsciteS
PALEM ATAS
M. Arfah 15/10/2018 11/10/2018 (MSCT Whole Abdomen -IVFD Ringer Laktat Dr. dr.
1 819050 -POH ke-23 double bypass biliodigestive WBC = 11,1 Non Kontras : Dextrose 5% = Ronald E.
06-04-1978 RBC = 2,85 -Cholestatik intra dan extra hepatic ec 1000cc : 500 cc/24 Lusikooy, Sp.
KORAN BEDAH DIGESTIF (17/10/18)
(40 tahun) HGB = 9,0 massa caput pancreas (dibandingkan jam B-KBD
B2/13 bed 1 HCT = 24 msct scan pada tanggal 18/9/2018 -Levofloxacin 750 KJS
MRS: PLT = 429 -Pneumobilier mg/24 jam/IV line
04/09/2018 Neut = 77,4% -Hepatosplenomegaly -Omeprazole 40
Lymph = 11,6% -Ascites mg/24 jam/IV line
Albumin = 2,9 -Efusi pleura bilateral -Duragesic patch 25
Ur/Cr = 39/0,29 -Terpasang stent dengan tip di ductus mg/3hari
Na/K/Cl = 123/4,0/94 cycticus dan area duodenum -Diet lunak
-Vitamin K 1 amp/8
PA (25/09/2018) jam/IV line
7/10/2018 -Limfoma maligna non hodkin diffuse -Onoiwa 4 cups/8
GDS = 94 large cell dd carcinoma differensiasi jam/oral
2/10/2018 jelek -Rawat luka
WBC = 11,7 -hepar dengan gambaran abses, tidak
RBC = 3,18 ada sarang tumor metastasis
HGB = 9,4
HCT = 27 21/09/2018 (Foto thorax PA/AP)
PLT = 261 -Tidak tampak tanda-tanda metastasis
Neut = 87,5% pada foto thorax ini
Lymph = 7,5% -Pneumonia dextra
Ur/Cr = 63/0,53 -Cor dalam batas normal
Bilirubin total = 7,18
Bilirubin direk = 5,37 19/09/2018(MSCT Whole Abdomen
Protein total = 6,2 Non Kontras
Albumin = 2,7 -Cholestatik intra dan ekstrahepatik e.c.
Globulin = 3,5 massa caput pancreas
Na/K/Cl = 134/3,9/105 -Hepatomegaly
-Ascites
24/09/2018 -Efusi pleura bilateral
Analisis cairan
Warna = merah
Kejernihan =keruh
BJ = 1.015
Hitung jumlah leukosit
= 1890
Hitung jenis lekosit =
MN : 70%/PMN : 30
%
Rivalta = positif
Protein = 1700
Albumin = 1100
LDH = 485

20/09/2018
SGOT/SGPT = 67/93
KORAN BEDAH DIGESTIF (17/10/18)
Alkali fosfatase = 851
Albumin = 2,8
Gamma GT = 623
15/10/2018
Na/K/Cl = 137/3,1/106

14/10/2018
WBC = 8,1 PA (04/10/2018)
HGB = 10,1 -Adenocarcinoma recti differensiasi
HCT = 30 sedang dengan kedua ujung reseksi
PLT = 482 bebas tumor
Neut = 70,8% -Tidak ditemukan kelenjar getah bening
Lymph = 13,3% pada resektan, kemungkinan adanya -Infus ringer laktat :
metastasis pada kelenjar getah bening dextrose 5% =
12/10/2018 lainnya belum dapat ditentukan 1000cc : 500cc/24
Mariana Albumin = 2,8 jam
850489 GDS = 88 01/08/2018 (MSCT thorax dengan -Ceftriaxone 1
05/03/1948 (70 -POH ke-18 laparotomi + low anterior kontras) gram/12 jam/IV Dr.dr.
2 tahun) resection 18/09/2018 -Nodul kalsifikasi paru bilateral -Ketorolac 30 mg/IV Warsinggih,
B2/12 bed 2 -Carcinoma recti 1/3 proximal PT/APTT = 10,3/29,1 27/07/2018 (CT Whole Abdomen tanpa (bila nyeri) Sp.B-KBD
MRS: Ur/Cr = 30/1,00 kontras) -Omeprazole 40
17/09/2018 SGOT/SGPT = 19/21 -Suspek tumor colon sigmoid mg/12 jam/IV
HBsAg = N-R -Diet susu 4x20cc
Na/K/Cl = 146/3,7/109 26/07/2018(PA/AP thorax) -Rawat luka/hari
-Bronchopneumonia bilateral Mobilisasi jalan
03/08/2018 DD/metastasis tumor ke paru
AFP = 1,20
CEA = 147,13 03/09/2018 (LGIE)
Ca-125 = 7,36 Tumor rekti tipe stenosis

30/07/2018
Bilirubin total = 0,33
Bilirubin direk = 0,19
Albumin = 3,7
15/10/2018
- Infus ringer laktat :
CEA = 1,74
dextrose 5% =
Andi Bobo 3/10/2018 (Esophagigraphy)
1000cc : 500cc/24
857014 04/10/2018 -Dilatasi esophagus ec massa pada
jam
05-04-1949 WBC = 5,1 gaster dr. M.
-Tumor esophagus -Rencana MSCT
3 (69 tahun) RBC = 3,57 Ikhwan,
abdomen tanpa
B1/4 HGB = 11,2 3/10/2018 (Maag Duodenum) Sp.B-KBD
kontras
MRS: HCT = 32 -Massa gaster
-Cek hasil CEA
4/10/2018 PLT = 157
-KSR 1
Neut = 57,6%
tab/8jam/oral
Lymph = 28,9%
KORAN BEDAH DIGESTIF (17/10/18)
Albumin = 3,1
Ur/Cr = 13/0,57
Na/K/Cl = 131/2,8/95
14/10/2018 12/10/2018 (Foto polos abdomen)
WBC = 10,5 -Small bowel obstruction
-Ceftriaxone
RBC = 3,11 -Soft tissue mass region abdomen dextra
1gr/12jam/intravena
Nurul Izzah HGB = 9,5
-Infus RL 28 tpm
859161 HCT = 29 12/10/2018 (CT whole abdomen)
-Omeprazole
23-11-1998 PLT = 353 -Small bowel obstruction ec. suspek
40mg/12jam/intrave dr. M.
(19 tahun) Neut = 57,9% invaginasi
4 -Tumor Mesenterium na Ikhwan,
B2/3 Lymph = 27,9%
-Metamizole Sp.B-KBD
MRS: GDS = 97 12/10/2018 (USG abdomen atas +
1gr/8jam/intravena
13/10/2018 Albumin = 3,6 bawah)
-Rencana operasi
Ur/Cr = 33/0,72 -Small bowel obstruction
laparotomi explorasi
SGOT/SGPT = -Tidak tampak tanda-tanda appendicitis
-Diet bebas
114/104
Na/K/Cl = 143/4,4/104
16/10/2018
CEA = 1,67

15/10/2018 11/10/2018 (CT whole abdomen)


WBC = 15,7 -Suspek periapendicular infiltrate dd/
RBC = 3,56 massa -Metronidazole
Mursalim HGB = 10,3 -Ascites 500mg/8jam/intrave
838601 HCT = 31 na
01-01-1949 PLT = 445 09/10/2018 (PA/AP thorax) -Rencana dr. M.
5 (69 tahun) -Massa intraabdomen suspek limpoma Neut = 80,3% -Normal laparoskopik Ikhwan,
B1/3 Lymph = 10,4% removal tumor kamis Sp.B-KBD
MRS: D-Dimer = 2,29 09/10/2018 (USG Whole Abdomen) 18/10/2018
9/10/2018 -Tidak tampak tanda metastasis pada -Stop pengencer
09/10/2018 foto ini darah
SGOT/PT = 130/137 -Organ organ intraabdomen yang
Albumin = 3,7 terscan dalam batas normal
Asam urat = 7,0
Ur/Cr = 32/1,20
Na/K/Cl = 138/3,9/105
15/10/2018
Alimin
WBC = 9,4
Muhammad
RBC = 5,48
799533 Dr. dr.
HGB = 15,6 -Rencana kemoterapi
05-10-1973 -Adenocarcinoma recti post miles pro kemo Ronald E.
6 HCT = 46,5 sesi 2, tunggu
(45 tahun) ke-10 Lusikooy, Sp.
PLT = 290 ketersediaan obat
B2/9/bed 1 B-KBD
Neut = 69,9%
MRS:
Lymph = 18,9%
16/10/2018
GDS = 109
KORAN BEDAH DIGESTIF (17/10/18)
Ur/Cr = 21/0,80
SGOT/PT = 46/58
Na/K/Cl = 143/4,1/103
CEA = 30,90
PALEM BAWAH
Darah Lengkap
16/10/2018
GDS : 139
12/10/18
protein total : 5,2
Foto Thoraks PA/AP (15/10/2018)
Albumin : 3,0 - Terapi
Kesan : Hydropneumothoraks sinistra
LDH : 409 lanjut
dengan kolaps pulmo sinistra,
10/10/2018 sesuai TS
dilation et atherosclerosis aortae
GDS 104 Endokri
MSCT Thorax (10-10-18):
8/10/18 metabolic
Kesan : Tension hydropneumothorax
Andi Awang CEA >200.0 dan TS
sinistra, atelectasis sinistra, susp.
856642 25/09/18 Pulmonolog
- Cholelithiasis Massa paru sinistra.
1 17/08/1940 WBC 13.9 i IL
DM tipe 2 MSCT Abdomen non kontras
MRS: 04/10/18 HGB 10.7 - Rencana
(25/09/2018) :
K B1/1 HCT 31% Operasi
Cholelith, efusi pleura sinistra,
Bil. Tot 0.91 laparoskopi
simple cyst renal sinistra.
Bil. Direk 0.47 cholesystot
- Thorax (25/09/18) :
Alkali fosfatase 909 omy bila
- sinistra, efusi pleura sinistra,
HbsAg Non reaktif optimal.
cardiomegaly.
Cek hasil lab
Pemeriksaan
mikrobiologi
Specimen : cairan
pleura
Kesan : NormaL
Darah Lengkap
(1/10/18)
Hj. Mariah
WBC : 7,8 - MSCT abdomen non kontras (9-8-
Zainal Rencana operasi
RBC : 4,08 18): Tumor recti 1/3 distal,
399340 - Adenocarcinoma recti 1/3 distal Selasa batal
HGB : 12,0 hepatomegali, kista hepar, hernia IL
05/12/1942 - - Hernia insisional Cek hasil lab
HCT 35% insisional, spondilosis lumbalis.
MRS: 05/10/18 -
PLT : 401 Foto thorax (06-08-18): Normal
2 K B1/3
NEUT : 54,90
GDP : 93
CEA 37.1
A.Cesy Darah lengkap Infus NaCI 0,9%
-Tumor gaster
3 Fausiah (13/10/2018) - + Neurobion IK
-General weakness
633469 WBC : 11,02 Lab lengkap
KORAN BEDAH DIGESTIF (17/10/18)
14/3/1969 (49 RBC : 2,51 Transfuse PRC 2
thn) HGB : 5,9 bag/hari
MRS :13/10/18 HCT 18,4 Paracetamol 1
K B2/1 PLT : 241 gr/8 jam.iv
GDS : 141 Cek hasil lab
Ur/kr : 37/0,83
SGOT/SGPT : 57/49
Na/K/CI : 138/3,0/102
Pemeriksaan Analisa
Gas Darah
(15/10/2018)
pH : 4,497
So2 : 94,5
Po2 : 67,8
ctCO2 : 30,7
Hco3 : 29,5
- CT Thorax (tanpa kontras) :
Ridwan Hatibe Be : 5,7
5/10/2018
857787 Darah Lengkap
- Tumor gaster 1/3 proximal suspek ganas - Kesan : stenosis ujung distal esofagus Ceftriaxone 1
4 13/8/1959 (3/10/18) IK
suspek striktur DD/ massa gr/12 jam/iv
(59 tahun) WBC: 9,85
esofagogastric, cor dan pulmo dalam
K B2/2 RBC : 4,26
batas normal
HGB : 11,2
HCT: 33,2
PLT: 333
PT/APTT: 10/26,2
GDS: 213
Ur/Cr: 31/0,9
SGOT/SGPT: 9/6
Na/K/Cl: 144/4,2/105
Darah Lengkap
(16/10/2018)
WBC: 16,2 - RL 28 tpm
RBC : 4,46 - Injeksi
HGB : 13,5 ceftriaxone,
Bioster HCT: 38 metamizole,
859027 PLT: 242 omeprazole
- -Ikterus obstruktif
5/6/1945 Bilirubin total : 11,95 - Terapi lanjut
5 - Anemia - SAM
MRS: Coomb’s test : positif sesuai TS
-
11/10/2018 (+2) Gastroenterohepat
K B2/4 (11/10/18) ologi.
WBC: 17,6 - Cek radiologi foto
Hb: 8,5 thoraks
HCT: 25,6
PLT: 317
PT/APTT: 45,2/35,2
KORAN BEDAH DIGESTIF (17/10/18)
GDS: 213
Ur/Cr: 45/1,70
Bil.Tot: 12,16
Bildirek: 5,88
SGOT/SGPT: 10/44
Na/K/Cl: 134/2,9/103
Darah Lengkap
(15-10-18)
WBC : 5,38 - MSCT Whole abdomen dengan
RBC : 4,09 kontras (9/10/2018) - Infus
HGB : 11,3 Kesan : sesuai gambaran massa Ringer
HCT : 34,2 proximal rectum Laktat
Udin Badru
PLT : 148 - Foto thorax (08-10-18): Tidak dextrose
855571
- POH 5 laparatomy + low anterior resection (12-10-18) tampak metastasis, cardiomegaly 5%
6 01/08/1952 WS
ec tumor recti 1/3 proximal WBC : 7,9 disertai dilatation etelongatio aortae. - Injeksi
MRS: 06/10/18
RBC 3.53 - USG Abdomen whole (13-09-18): ceftriaxone,
K B2/6
HGB : 9,5 Tidak tampak tanda metastasis, organ metrindazol
HCT 29 intraabdomen normal. e, ranitidine
PLT : 193 - CT Scan abdomen: Sesuai -
GDS : 113 gambaran massa proximal rectum
CEA >200.0
Alb : 2,8
Infus Ringer
Darah Lengkap
Laktat : Dextrose
(16/10/2018)
5%, Aminofilin
Gds : 75
Ceftriaxone 1
(13/10/18)
Foto Thoraks PA/AP (9/10/2018) gr/12
Wbc 15,6
La Sanifu Kesan : jam/intravena
Rbc 3,89
664523 -cardiomegaly dengan edema paru dini Metamiral 1
- POH 8 laparatomy LAR ec. Tumor Hgb 10,
7 10/3/1967 -dilatio aortae cap/8 jam/iv WS
rectosigmoid Hct : 31
MRS: 28/9/18 -elevasi diafragma dextra Ranitidine 59
Plt : 423
K B2/6 - -terpasang CVC pada hemithoraks mg/12
Neut : 86,5
dextra dengan tip kesan atrium kanan jam/intravena
(2/10/2018)
Mobilisasi duduk
Ur/Cr 22/0,80
Minum air putih
Sgot/sgpt19/ 24
12 jak/jam
Albumin 3,6
Cek hasil lab
Darah Lengkap Foto thoraks (13/10/2018) - Infuse
P. Tarigu
(16/10/18) Kesan : NaCI 0,9%
856941
Wbc 11,3 - dilatio et artherosclerosis aortae - Injeksi
12/12/1951 (66
Rbc 3,9 - -elevasi et artherosclerosis aortae metronidaz
8 tahun) - Cholelith + anemia IL
Hgb 10,5 - Pulmo dalam batas normal ol,
MRS :
Hct 33 CT Whole Abdomen tanpa kontras omeprazol
13/10/18
Plt : 447 (13/10/2018) - Dexamethas
K B2/10
(13/10/18) Kesan : on 1 tab
KORAN BEDAH DIGESTIF (17/10/18)
Gds : 122 - Tidak tampak densitas massa -
Ur/kr : 37/1,53 patologik pada CT Scan Abdomen ini
SGOT/SGPT : 53/57 - Gambaran fatty liver
Na/K/CI : 148/4,1/109 - Ascites minimal
Efusi pleura bilateral
Darah rutin
(15/10/2018)
Wbc 11,87
MSCT Whole Abdomen dengan
Halma Rbc 3,58
kontras (13/10/2018)
855221 Hgb 10,9
Kesan : - Rencana
1/7/1959 (59 Hct 32,7
- Adenocarcinoma Sigmoid - Hepatomegali disertai massa lobus kemoterapi
9 tahun) Mcv : 91,3 IK
- Pro kemoterapi I kanan hepar susp. Hepatoma I, tunggu
MRS : Plt : 657
- Tidak tampak lesi patologik pada konfirmasi
16/10/2018 (trombositosis)
kolon
K B2/3 Gds : 91
Ur/kr : 17/0,60
SGOT/SGPT : 33/15
Na/K/CI : 141/3,6/102
Darah rutin
(8/10/2018)
Wbc 5,4
M.Yusuf
Rbc 4,25
Mukhtar
Hgb 8,1 - Transfusi
858465
Hct 27,9 - Foto thorax PA/AP (08-10-18): PRC 2bag
31/12/1939 (78
1 - Hernia Inguinalis Pectoralis Sinistra Residif Plt : 330 Kesan : tidak tampak kelainan - Premedikasi
tahun) IL
0 - Anemia Pt/aptt : 103/22,7 radiologik pada foto thoraks ini. :
MRS :
Gds : 132 dexamethas
16/10/18
Ur/kr : 27/0,90 one
K B1/8
SGOT/SGPT : 23/13
Alb : 4,1
Hbs Ag : non reactive
Na/K/CI : 141/5,0/106