REKAPAN BEDAH ANAK RABU, 05 DESEMBER 2018

1. RB2A Wahyu 27/11/2018 Suspek peritonitis + R/ Repair CAPD (03/12/2018)

3.4.5 Richard/L/12 CKD on HD post Hb/Ht/Leu/Plt : 8,7/26/8.190/340.000
tahun/67.02.25 CAPD GDS : 90
BUN/Ur/Cr : 32/68/23,19
DPJP: dr. Erjan, (29/11/2018) Ca/Na/K/Cl : 8,3/136/3,9/105
Sp.B, Sp.BA BNO : perselubungan PT/APTT/INR : 17,6/28,5/1,50
homogen di rongga pH/pCO2/pO2/HCO3/Tot CO2/BE/SaO2 :
pelvic minor dd 7,43/33/185/21,9/22,9/-1,8/100
retensio urin, suspek PCT : 0,20
massa.
Analisa cairan asites :
(28/11/2018) Warna/Tprotein/LDH/Glu/PH/WBC/RBC/MN/PMN:
Echocardiography : Jernih/0,8/30/193/8/0,021/0/85,7/14,3
normal heart structure
and function Kultur Darah (28/11/2018) :
Tidak ada pertumbuhan bakteri
(29/11/2018)
Thorax AP erect :
Tidak ada kelainan
Cor dan Pulmo

(29/11/2018)
USG Lower
Abdomen: Hernia
scrotalis kanan dengan
komponen usus dan
cairan di dalsamnya.
Struktur testis normal.
2. RB2A Abdul Hakim 25/11/2018 Diffuse Peritonitis d/t Diet M1 (25/11/2018)
3.5.1 /L/17 tahun/ perforasi Ileum R/ PBJ Hari ini Hb/Ht/Leu/Plt: 10,1/31/19.690/313.000
76.32.58 Terapi sesuai RM 8.1 KGDs: 97
(26/11/2018) Ca/Na/K/Cl: 8,1/132/4/98
DPJP:dr.Erjan, Thorax AP erect: PCT: 5,57
Sp,B- KBA Tidak tampak kelainan PT/APTT/TT/INR:
pada cor dan pulmo 16,5(14,5)/29,9(32,3)/19(12,5)/1,17
Albumin: 2,9
Abdomen Supine + BUN/Ur/Cr: 12/26/0.82
erect:
Sesuai gambaran ileus Urinalisa
bstruktif. War/Glu/Bil/Kett/Ber/Ph/Pro/Ni/Leu/Dar:
Kemungkinan akibat Kuning/-/-/-/1-01/6.5/+2/-/-/-
 perlekatan. Tidak
tampak perforasi.
3. RB3 Aldo Siregar/l/10 1/12/2018 Post ileostomy + Terapi sesuai ts anak (3/12/2018)
3.3.3 tahun/75.69.18 anemia+ hyponatremia Albumin : 3,7
+ hipokalemia
(1/12/2018)
Hb/Ht/Leu/Plt : 7,8/21/13.230/407.000
PT/APTT/INR : 15,7(14,4)/29,3(33)/1,1
KGDs : 100
BUN/Ur/Cr : 44/94/0,56
Na/K/Cl : 117/2,3/<50
4. RB4 Saipul Bahri/L/ Post eksplorasi R/ rawat luka, pantau (1/12/2018)
3.6.2 12 tahun/ laparotomi tanda-tanda Hb/Ht/Leu/Tr : 13,4/43/24.560/674.000
61.62.16 appendectomy + Fistel peritonitis, Albumin : 1,4
enterocutaneus dipakaikan kolostomi
bag (29/11/2018)
Ca/Na/K/Cl : 6,1/130/3,4/96
5. RB4 Naufal Septian/ 25/11/2018 Stenosis duodenum dd Terapi sesuai RM8,1 Hb/Ht/Leu/Plt: 11/32/7260/374000
3.6.5 L/ 2 bulan atresia duodenum dan TS anak PT/APTT/INR:17,6(15,2)/26,5(33,9)/1,17
76.32.44 R/ Operasi hari Rabu SGOT/SGPT: 37/21
(28/11/2018) (05/12/18) Kgds: 82
USG upper abdomen: Ca/Ca-ion/Na/K/Cl: 9/1,23/136/4/96
sugestif gambaran Ur/Cr/BUN: 47/0,43/22
piloric stenosis Kolestrol/TG/HDL/LDL: 130/86/34/73
(26/11/2018)
Abdomen erect +
supine:
Distensi intestinal.
Usul: Barium Enema
6. RB4 Pirza Anando 02/12/2018 Hernia Inguinalis R/ Terapi sesuai RM (3/12/18)
3.7.4 1 tahun/76.39.47 Lateralis reponible + 8.1 dan TS anak Hb/Ht/Leu/PLT: 8.5/31/9380/640000
Anemia Observasi benjolan
(2/12/18)
(03/12/2018) PT/APTT/INR: 114,3/34,5/0,94
Abdomen 3 posisi : Albumin: 4,5
Kesan : Ileus KGDs: 94
Obstruktif BUN/Ur/Cr: 11/24/0,39
Na/K/Cl: 135/5,2/100
7. RA4 BS Revan Nugraha/ Hidrosefalus post PV R/ rawat luka , (04/12/2018)
anak L/ 6 tahun/ Shunt pemberian antibiotic Hb/Ht/Leu/Tr : 9,9/29/8.020/429.000
3.7.1 75.25.83 sesuai TS anak PT/APTT/INR : 15,1/2,6/1,06
(30/11/2018) Albumin : 2,9
Thorax : KGDs : 112
 - VP shunt Bun/Ur/Cr : 4/9/0,26
terpasang Na/K/Cl : 126/2,6/96
- Jantung dan paru
dalam batas
normal
8. PerinaLvl I Trie Kanza 27/11/18 Gastroskizis R/ Terapi sesuai TS (03/12/2018)
P//5 hari anak Hb/Ht/Leu/Plt: 16,7/49/14.230/281.000
76.35.31 (27/11/18) Usus tetap digantung PT/APTT/TT/INR: 13,3/30,6/-/0,53
Thoraks: dan di bungkus KGDs: 27
Sugg. Gastroschisis Albumin : 2,9
abdomen kiri BUN/Ur/Cr: 11/24/0,67
Sugg. Neonatal Na/K/Cl/Ca : 134/6,0/102/9
pneumonia
Saran: MRI Abdomen (28/11/18)
Tidak ada pertumbuhan bakteri aerob dan jamur
(29/11/18)
D-dimer : 9062
Albumin/KGDs: 2,0/50
Ca: 7,2
Na/K/Cl: 111/4,9/86
CRP kuantitatif: 0,7
Procalcitonin: 14,39

9. NICU By. Silvia Dewi 21/11/2018 Atresia Bilier +  Terapisesuai TS (3/12/2018)

(konsul) L/1 bulan Sangkaan Sepsis + anak Hb/Ht/Leu/Plt: 13,9/41/17.590/83.000
76.30.04 Susp. Down Syndrome  R/ Operasi saat PH/PCO2/PO2/HCO3/BE/SAO2: 7.2/16/121/7,3,1/-
+ BBLR usia pasien 2 17,2/ 100
bulan Na/K/Cl: 136/5,0/98
22/11/18
Thorax AP/Supine : (28/11/2018)
Curiga aspirasi Urinalisa
pneumonia kanan War/Glu/Bil/Ket/Ber/Ph/Pro/Ni/Leu/Dar:
Kuningjernih/-/-/-/1,005/6.5/+1/-/-/-
23/11/18
USG GB/ Billiary: (01/12/2018)
Atresia Billier dengan Hasil Kultur :
kontraksi GB yang Bakteri Aerob : pseudomonas aeruginosa
tidak terlihat Antibiotic ® : ceftazidim, ciprofloxacin, meropenem,
(23/11/2018) tetraciclin, netilmicin
BNO / Abdomen : Antibiotik (S) : Amikacin
Suspek Asites

Echocardiography:
 Normal heart structure
and function
10. NICU By. Ny Nurida 27/11/2018 Conjoint twin tipe Terapi sesuai T.S (27/11/2018)
Sihombing I omphalopagus + anak Hb/Ht/Leu/Plt:17,3/50/6.160/246.000
L/ 11 hari omphalitis + KGDs:88
76.34.47 Hiperbilirubinemia IT ratio: 0,1
BUN/Ur/Cr: 9/19/0,48
27/11/2018 Ca/Na/K/Cl: 9,7/135/4,3/102
DPJP: dr. Erjan, Baby Gram : Procalcitonin : 0,45
Sp.B, Sp.BA Penyatuan jaringan CRP kualitatif : <0,7
lunak dinding Bil Total/direk: 18,9/0,7
abdomen atas
sepanjang +/- 5 cm

28/11/2018
USG /
Echocardiography :
Normal heart structure
and fuction

11. NICU By. Ny Nurida 27/11/2018 Abdominal conjoint Terapi sesuai T.S (27/11/2018)
Sihombing II twin tipe anak Hb/Ht/Leu/Plt:18,7/51/7.250/119.000
L/11 hari omphalopagus + KGDs:90
763451 omphalitis + IT Ratio: 0,03
hiperbilirubinemia BUN/Ur/Cr: 10/21/0,5
DPJP: dr. Erjan, Ca/Na/K/Cl: 8/134/5,2/100
Sp.B, Sp.BA CRP kualitatif : <0,7
28/11/2018 Procalcitonin : hasil menyusul
USG / Bil Total/direk: 17,8/0,5
Echocardiography :
Normal heart structure
and fuction

12. PICU Bramantio 21/11/2018 Dx: Post Laparatomy  Terapi lanjutsesuai (2/12/2018)
Bed 3 L/5tahun/ d/t Diffuse peritonitis TS Anak Hb/Ht/Leu/Plt: 11,0/ 33/38.830/ 179.000
76.28.71  Susul hasil USG Kalsium Ion: 0,99
26/11/2018 abdomen Albumin: 2,4
DPJP: dr. Erjan, Abdomen 3 posisi: Bun/Ur/Cr: 7/15/0,27
Sp.B, Sp.BA curiga Ca/Na/K/Cl: 7,60/128/3,4/82
hepatosplenomegali.
Tidak tampak (30/11/2018)
gambaran ileus dan Hb/Ht/Leu/Plt: 9,6/29/17.420/104.000
 perforasi KGDs: 107

(29/11/2018)
Hb/Ht/Leu/Plt: 9,6/29/40.710/189.000
Kalsium ion : 0,89
Bil total/direk : 5,2/4
ALP/SGOT/SGPT: 116/16/12
?-GT/albumin :137/2,3
Bun/Ur/Cr: 9/19/0,3
Ca/Na/K/Cl: 7,2/130/3/91

(27/11/2018)
Ca/Na/K/Cl: 7,8/123/3,6/92
Kol. Tot/Tg/HDL/LDL: 70/160/10/28

(26/11/2018)
PT/APTT/TT/INR:
23,5(14,5)/62,5(31),20,7(15,6)/1,74
Albumin : 2,4
Ca/Na/K/Cl: 7,5/126/4,9/95

13. Perina By Ester Samosir 1/12/2018 Dx: Post  Terapi sesuai TS (2/12/2018)
Level I P/3 Hari sigmoidostomy d/t anak Hb/ Ht/ Leu/Plt: 14,9/ 43/20.320/ 50.000
76.39.08 Atresia Ani with  Evaluasi stoma PT/APTT/INR: 15,6/29,3/1,03
fistula Albumin: 3,3
DPJP : dr Erjan KGDs: 91
SpB, Sp.BA Hasil ECHO Bun/ Ur/Cr: 9/19/0,51
PFO Na/K/Cl/Ca: 136/5,5/105/7,9
PDA Procalcitonin: 9,49
Mild TR
Saran: ECHO ulang 1
bulan lagi