KORAN DIGESTIF SABTU 6 – 2- 2016

LONTARA 1

L1 Atas Depan
NO Nama Pasien Diagnosis Penunjang Planing Terapi
1 Darmawati IKTERUS KOLESTATIS E.C -ranitidin 150 mg/12 jam/oral
L1.AD.K4B4 SUSP. STEANOSIS CBD Lab Darah -CTM ½ tab/12jam/oral
740770 02/02/2016 -pro pindah lontara digest
WBC : 8.9
DPJP RBC : 3.87
dr. Samuel HB :11.8
Sampetoding Sp.B.K- HCT : 37
BD PLT : 281
Alkali fosfat : 627
MRS Gamma GT : 960
29-01-2016 Tumor Marker
Konsul CEA : 1.20
01/02/2016 CA 19-9 : <300

PA
Gastritis kronis erosius
non spesifik
Lontara 1 Atas Belakang
2 JAWIYA SAPPU TUMOR ABDOMEN Lab tgl -MST 10 mg/8jam/oral
(ADENOCARCINOMA COLON) Urinalisa : -ketorolac 1 amp /8jam/iv
K4/III/B3 (27-01-2016) -Terapi sesuai TS interna dan
742382 Warna kuning tua TS anastesi
11-3-1966 PH 6.0
Bj +/-
DPJP: Protein –
dr. Warsinggih, Glukosa –
Sp.B-KBD Bilirubin –
Urobilinogen –
MRS Leukosit 3
25-01-2016 Eritrosit 25
tanggal Konsul
25-1-2016 Tumor Marker
(26-01-2016)
CEA > 200.00

PA
(30-01-2016) :
adeno carcinoma colon

Lontara 1 RPK Bawah

3 RPK Bed 5 IKTERUS OBSTRUKTIF E.C. Lab darah -Perbaiki keadaan umum
Muhammad Sulaiman TUMOR AMPULLA VATTERI + sesuai T.S interna
737739 SEPSIS + 02-02-2016 - Pro Drainase Bilier
ANEMIA+TROBOSITOPENIA+ WBC : 10.4
DPJP HIPOALBUMIN + HIPOKALEMI RBC : 3.42
Dr.dr. Warsinggih HGB : 9.3
Sp.B.K.BD HCT : 29
PLT : 93
 MRS D-DIMER : 2.66
21-01-2016 GDS 137
(27-01-2016)
Konsul Albumin : 2.4
27-01-2016 Na/K/Cl : 143/2.5/106

Lab Darah (29-01-2016)

PT/APTT : 18,5/14.8
INR : 1.77
SGOT/SGPT : 237/103
Glukos : 123

KORAN PASIEN DIGESTIF LONTARA 2 TITIPAN

LONTARA 2 BAWAH BELAKANG (ORTHO)

N IDENTITAS PASIEN DIAGNOSIS PEMERIKSAAN PLANNING
O
1 K4b4 Adenocarcinoma Lab 02/02/2016 : - Observasi mual-
Maria Rupa recti pro Rbc 3,9 muntah
26-06-1962 kemoterapi siklus Wbc 3,53 - Siang boleh pulang
712698 VIII Plt 108
MRS : 31-01-2016 Hb 12,0

DPJP : Dr. SAMUEL Lab 01-02-2016

SAMPETODING Gds 130
Sp.B,KBD Ur/cr 19/0,50
Got/gpt 59/21
ALBUMIN 3,2
Na/K/Cl : 141/3,7/107

Foto Pelvis AP : (22-11-2016)

Kesan : Tanda-tanda tumor metastasis ke
tulan
- Alignment pelvis tidak intak
- Tampak lesi blastik dan litik pada ramus
inferior dextra et sinistra ossis pubis,
ramus superior dextra ossis pubis,
acetabulum dextra dan caput femoris
dextra disertai
destruksi ramus os pubis bilateral
- Mineralisasi tulang baik
- Kedua HIP dan SI joint baik
- Jaringan lunak sekitar kesan baik

Foto Lumbosacral AP/Lateral: (01-12-

2015)
Kesan :Spondylosis lumbalis,
Osteoporosis senilis,Tidak tampak tanda-
tanda metastasis pada foto lumbosacral
ini

- Alignment lumbosacral intak,tidak

 tampak listhesis
- Tidak tampak fraktur maupun destruksi
tulang,pedikel intak
- Osteofits pada aspek anterolateral CV
L1-L5
- Tidak tampak lesi-lesi litik maupun
blastik
- Mineralisasi tulang berkurang
- Diskus dan foramen intervertebralis
kesan baik
- Jaringan lunak sekitar kesan baik

Foto Thoracal AP/Lateral: (01-12-2015)

Kesan :Spondylosis Thoracalis,
Osteoporosis senilis,Tidak tampak tanda-
tanda metastasis ke tulang.

- Alignment pembentuk thoracal

intak,tidak tampak listhesis
- Tidak tampak fraktur maupun destruksi
tulang,pedikel intak
- Osteofits pada aspek anterolateral CV
Th VIII-XII
- Tidak tampak lesi-lesi litik maupun
blastik
- Mineralisasi tulang berkurang
- Diskus dan foramen intervertebralis baik
- Jaringan lunak sekitar kesan ba

2 K5b1 -Adenocarcinoma Foto Abdomen 3 Posisi (04-01-2016) - Pasang NGT

SARCE recti 1/3 medial Kesan :Gambaran large bowel obstruction - IVFD RL : DS =2:2
16/06/1967 -Dyspepsia Hasil Pemeriksaan : 28 tpm
438193 -Asites Udara usus terdistribusi tadak sampai ke - Inj.Omeprazole 40
MRS : 29-01-2016 distal colon mg /12 jam/iv
- Tampak dilatasi loop-loop colon dengan
gambaran step leader dan air fluid level
- Tidak tampak gambaran udara bebas
DPJP : DR.dr.IBRAHIM subdiafragma
LABEDA ,SP.B-KBD - Kedua psoas line dan preperitoneal fat
line intak
- Tulang-tulang yang tervisualisasi intak

3 K5B4 TUMOR GASTER LAB 28/1/2016 :

RABIAH Pewarnaan BTA Sputum 3x : Negatif IVFD RL 20 tpm
9-8-1969 -Ceftazidime 1 gr/12 jam/iv
733218 LAB 26/1/2016 : -Ranitidin 50 mg/ 8 jam/ iv
MRS : 30/1/2016 CEA 12.18 -Ketorolac 30 mg/8 jam/iv
Codein bila
Foto Thoraks PA/AP (26-01-2016) -Perikasa Lab lengkap
Bronchopneumonia bilateral suspek
DPJP : DR.dr.IBRAHIM spesifik
LABEDA ,SP.B-KBD
MSCT Whole Abdomen (Dengan
Kontras) (29-01-2016)
 Massa antrum pyloric
- Hydronephrosis dextra
- Hepatomegaly
- Ascites

MD (Maag Deudenum) : (20-01-2016)

- Suspek massa gaster, disertai ulkus
ventriculli
- Sotf tissue mass pada regio pylorus
kesan
extraluminer suspek limfoma

CT Whole Abdomen ( Tanpa Kontras

)(03-12-2015)
- Penebalan dinding gaster sugestif
massa gaster
(dibandingkan CT Scan tanggal 16
november 2015 : StQA)
- Hepatomegaly
- AsciteS

4 K7A/1 CHOLELITHIASIS Lab 30/1/2016 : -IVFD RL:DS =2:2

MAKKA Rbc 4.74 -Ceftazidime 1 gr/12 jam/iv
20-08-1959 Wbc 6.3 -Metronidazole : 500 mg /8
741689 Plt 264 jam/iv
MRS : 27/1/16 Hb 15.1 -Ranitidine 50 mg/8 jam/IV
Pt 11.0 -Ketotolac 30 mg/ 8 jam /IV
INR 1.06
Aptt 24.7
DPJP : DR.dr.IBRAHIM Gds 132
LABEDA ,SP.B-KBD Ur/cr 18/1.2
Bilirubin total 1.36
Bilirubin direk 0.29
Got/gpt 33/44
ALBUMIN 4.0
Hbsag REAKTIF
Anti HCV Non reaktif
Na/K/Cl : 140/3.5/107

USG whole abdomen 19/1/16:

Cholelith, Tampak echo batu ukuran
sekitar 1,09 cm dengan acoustic shaddow
5 7A/3 Tumor intra LAB 30/1/2016 : - Rencana operasi selasa/03-
MULYADI abdomen Wbc 12.2 02-2016
19-05-1985 Rbc 4.77
741837 Hb 9.7 - Inform consent ulang
Plt 500 -IVFD Ringer laktat
Gds 104 -Ranitidine 50 mg/8 jam/iv
MRS :19/1/16 Pt 12.6 -Ketorolac 30 mg/8 jam/iv
INR 1.21 -Ceftazidime 1 gr /12 jam/iv
DPJP : Aptt 30.3 - Inform concent Rencana
DR.dr.warsinggih,Sp.B Ur/cr 18/1.05 Operasi tertunda
-KBD Got/gpt 23/22 - Ambroxol 1 tab/8 jam/ oral
Albumin 2.7 - Paracetamol 1 tab/8 jam/
Hbsag non reaktif oral
Anti HCV non reaktif
Na/K/Cl 137/3.8/105

Lab 26/1/16 :
 Albumin 3.0

Lab 21/1/16 :
Wbc 14.8
Rbc 4.91
Hb 10
Plt 467

LAB 20/1/16 :
AFP 3.29
CEA 4.10

CT Whole Abdomen 19/1/16 :

-Absesdinding abdomen DD/ tumor

USG abdomen 18/1/16 :

-
massaparaaortaabdominalissuspeklimfo
ma
6 8/B4 Fistel Lab 31/1/2016 : -IVFD RL 28tpm
BASO BASATTU Enterokutaneus Albumin 3,1 -ceftazidime 1 gram/12j/IV
743406 -ketorolac 30mg/8j/IV
10-7-1969 Lab 29/1/16 : -ranitidin 50mg/8j/IV
Wbc 10.0 -Cek albumin
Mrs : 28/1/2016 Rbc 4.44 -cek hasil fistelografi
Hb 13.2
DPJP : DR.dr. HCT 39
WARSINGGIH Sp.B- Plt 279
KBD Pt 14.4
INR 1.38
Apt 29.4
Gds 80
Ur/Cr 18/0.82
Got/gpt 16/21
Albumin 3.7
HbsAg non reaktif
Anti HCV non reaktif
Na/K/Cl 147/4.0/113
CT Whole Abdomen 29/1/16 :
-Abses disertai defek region inguinalis
kanan
-kista lobus kanan hepar
7 8B/6 Abdominal pain Hasil Endoskopi :03-01-2016 -IVFD RL 20 tpm
ANTON ATONG suspek malignancy Anus : Tidak tampak dilatasi vena -Ceftazidime 1 gr/12 jam/iv
742395 hemoroid eksterna dan interna - Ketorolac 30 mg/8 jam/iv
20-4-1965 Rectum : Mucosa 3-10 cm dari anal verge -Ranitidine 50 mg/8 jam/iv
tampak ulserasi-ulserasi disertai - sulcolon 1 tab/8 jam/iv
Mrs : 21/1/16 perdarahan –perdarahan diskret
mukuopurulent,massatumor (-)
DPJP : Dr. SAMUEL
SAMPETODING Lab 25/1/16 :
Sp.B,KBD AFP : < 0.50
CEA : 0.59
PSA : 4.25
CA 19-9 : 3.22

Lab 24/1/16 :
Anti HCV (ICT) : Non reaktif

Colon in loop 28/1/16 :

-colon in loop dalam batas normal

CT Whole Abdomen 21/1/16 :

-Splenomegaly
- Efusi pleura bilateral terutamasinistra
- Lesilitiksklerotik T12 dandestruksi T10
suspek metastasis tulang

Foto Lumbosacral AP/Lateral :( (01-02-

2016)
Kesan : Spondylosis lumbalis
- Alignment lumbosacral intak, tidak
tampak listhesis
- Tidak tampak fraktur dan destruksi
tulang, pedikel intak
- Tampak osteofits pada aspek lateral
L2,L4 dan aspek anterior CL L1-L5
- Mineralisasi tulang baik
- Discus dan foramen intervertebralis baik
- Jaringan lunak paravertebra baik

:
Foto Thoracal AP / Lateral :( (01-02-
2016)
Kesan : Spondylosis lumbalis

- Alignment thoracal intak, tidak tampak

listhesis
- Tidak tampak fraktur dan destruksi
tulang, pedikel intak
- Tampak osteofit pada aspek lateral CV
L2
- Mineralisasi tulang baik
- Discus dan foramen intervertebralis baik
- Jaringan lunak paravertebra baik

USG Abdomen dengan hasil sebagai

berikut : (02-02-2016)
Kesan : Splenomegaly
- Hepar : ukuran tidak membesar,
permukaan homogen, tip tajam, tidak
tampak dilatasi sistem vaskuler dan bile
duct. Tidak tampak echo SOL
- GB : Kontraktil
- Pancreas : bentuk dan ukuran dalam
batas normal, tidak tampak dilatasi
duktus pancreatikus. Tidak tampak SOL
- Lien : ukuran membesar, echo parenkim
dalam batas normal. Tidak tampak SOL
- Kedua Ginjal : ukuran dan contour
dalam batas normal. Tidak tampak
dilatasi pelvocalyceal sistem, echo cortex
dalam batas normal. Tidak tampak echo
batu/SOL
 - VU : dinding tidak menebal, mukosa
reguler. Tidak tampak echo
batu/mass/SOL
- Tidak tampak echo cairan bebas cavum
peritoneum dan cavum pleura bilateRAL

LONTARA 2 BAWAH DEPAN ( URO )

8 K2B4 Tumor recti 1/3 Lab : 30-01-2016 -IVFD RL 20 Tpm

Asrul Ahmad distal RBC : 5,29 -Ceftazidime 1 gr/ 12 jam/iv
31/04/1994 susp.malignacy WBC : 14,57 -Ketorolac 30 gr/8 jam/iv
MRS : 29-01-2016 HGB : 12,0 -Ranitidine 50 mg/8 jam/iv
743416 PLT: 488 - Asam mefenamat 1 amp/8
jam
DPJP : DR.dr. Lab: 28-01-2016
WARSINGGIH Sp.B- GDS : 109
KBD Ur/Cr : 7/0,50
SGOT/SGPT : 12/8
Na/K /Cl : 140/3,7/109

CT Abdomen Atas/Bawah ( Tanpa

Kontras ) : 28-01-2016
- Massa rectosigmoid
- Hydronephrosis bilateral terutama
dextra

Foto Thoraks PA/AP : 28 -01-2016

Tidak tampak tanda-tanda metastasis
pada foto thorax ini
- Cor dan pulmo normal

USG Abdomen Atas + Bawah (Whole

Abdomen : 28-01-2016
- Sugestif massa recti
- Hydronephrosis dextra

9 K3/B2 ADENOCARCINOM Foto thorax AP (inspirasi kurang) AP : IVFD ringer laktat 20 tpm
ROSDIANA A RECTI 1/3 (01-02-2016) Ceftazidime 1 gr/12 jam/iv
31/12/1950 MEDIAL Kesan :Cardiomegaly dengan dilatatio et Ranitidine 50 mg/12 jam/iv
740670 elongatio aortae, Tidak tampak tanda-
tanda metastasis pada foto thorax ini
MRS : 29/1/2016
- Corakan bronchovascular dalam batas
DPJP : DR.dr.IBRAHIM normal
LABEDA ,SP.B-KBD - Tidak tampak proses spesifik aktif dan
lesi noduler pada kedua lapangan paru
- Cor : kesan membesar, aorta dilatasi,
dan kalsifikasi
- Kedua sinus dan diafragma baik
- Tulang-tulang intak

Lab 31-01-2016 :
 WBC 10,9
RBC 4,23
HB 11,4
PLT 413
Gds 109
Ur/cr 25/0,65
Sgot/sgpt 39/20
Na/k/cl 145/3,5/108

LAB 26-1-16 :
Albumin 4.2

CT ABDOMEN 11/1/16 :
Massa rectum dengan metastasis ke
hepar (DUKES D)

Colon in loop 7/1/16 :

Massa rectum 1/3 proximal

BNO 7/1/16 :
Tidak tampak kelainan pada foto BNO

ENDOSKOPI LGIE 18/1/16 :

Tumor rectosigmoid tipe stenosis

Patologi anatomi 21/1/2016 :

ADENOCARCINOMA (DIFFERENSIASI
BAIK)
10 K3/B3 FISTEL LAB 31-1-16 : - IVFD RL 28tpm
MIRNA ENTEROCUTANEUS Albumin 3,4 -Ceftazidime 1 gram/12j/IV
14/4/1999 -Ranitidin 50mg/8j/IV
743547 LAB 29-1-16 : -Ketoroloac 30mg/8j/IV
WBC 10.7
MRS : 29/1/2016 RBC 4.81
HB 12.4
DPJP : DR.dr. PLT 296
WARSINGGIH Sp.B- Pt/apt 11.4/28
KBD Inr 1.1
Gds 93
Ur/cr 13/0.57
Sgot/sgpt 20/13
Albumin 3.2
HbsAg non reaktif
Anti HCV non reaktif
Na/k/cl 143/3.7/110
PA :

K11/B2 Adenocarcinoma PA: 31-10-2015

Rosmiati Dg Ngangi Colon +Colostomy ADENOCARCINOMA COLON,
01/07/1973 +Abses Dinding MODERATELY DIFFERENTIATED DENGAN
743015 Abdomen KEDUA UJUNG BEBAS RESEKSI TUMOR.

MRS :02-02-2016

DR.RONALD Sp.B -
 KBD

11 K11 B3 Post laparotomy ec LAB PA 29-1-16 : - IVFD RL:DS: Aminofluid

HASLINDA tumor colon Appendicitis chronic dengan peradangan 500:500:1000
03/12/1980 chronic pada mesenterium -Ceftazidime 1 gram/12j/IV
742432 -Ranitidin 50mg/8j/IV
LAB 29-1-16 : -Ketoroloac 30mg/8j/IV
MRS : 22/1/16 WBC 8.0 - Jika demam paracetamol
RBC 4.49 amp 1 gr
DR.RONALD Sp.B - HB 10.9
KBD PLT 372
CT Whole Abdomen: (01-02-2016)
Massa intraluminer proximal colon
ascendens
- Ascites
- Efusi pleura bilateral minimal

KAMAR 1

No Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi

1 K1B1 Ca Recti Lab (4/2/2016) -Konsulgiziklinik
Jamaluddin WBC 6.0 RBC 3.52 -Konsul echo
1/7/1955 HGB 9.6 HCT 30 -Konsul perioperative
744328 PLT 262 PT 11.5 INR 1.11 -NGT
MRS : 4/2/2016 APTT 27.9 GDS 72 -Ceftazidine 1gr/12jam/iv
DPJP : Ur/Cr 13/0.58 SGOT/SGPT 22/9 -Ranitidin 50mg./8jam/iv
Dr. M HbsAgnonreaktif -IVFD RL 28tpm
IhwanKusuma, AntiHCVnonreaktif
Sp.B-KBD Na/K/Cl 130/4.5/103

2 K1B2 Post laparotomi eksplorasiec Lab (29/1/2016) IVFD aminofluid: RL:D5 =

Gassing peritonitis WBC 17.43 RBC 3.90 1000:500:500
Dg.Liwang gastricumecperforasigaster HGB 10.4 PLT 743 -Paracetamol0,5gr/8jam/iv
12-8-1958 Albumin 2.8 Na/K/Cl 135/4.4/102 -Ceftazidine 1 gr/12jam/iv
724746 Lab (26/1/2016) -Ranitidin 50 mg/8jam/iv
MRS : 16/1/2016 Albumin 2.2 -Omeprazole 40mg/12jam/iv
DPJP : Lab (18/1/2016) -Diet bubur/oral
Dr.dr.Ronald Wbc:14,67Rbc: 4,06
E.L, Sp.B-KBD Hb :10,8Hct:33,5
Plt: 184Pt/apt:12,4/35,6
Gds :101Ur/cr: 73/1,50
Sgot/sgpt:287/218
Albumin:2,4
Na/k/cl: 138/3,9/107
Foto thorax AP (asimetris)
(17-1-2016)
Kesan: edemaparu
-Dilatation et atherosclerosis aortae
-CVC
terpasangpadahemithoraxdextradengan
tip setinggiics III kanandepan
-double lumen
padahemithoraxdextrasetinggiics III
kanandepan
3 K1B3 -Post colostomy ecCa Recti + post Lab (29/1/2016) -Bolehrawatjalan
Gobels R Heryi kemoterapisiklus II+DM tipe 2 WBC 14.42 RBC 4.05 -Ondansentron /12jam/oral
19-02-1966 (45 -Adenocarcinoma Recti HGB 10.8 HCT 33.8 -Ranitidin 50mg/8jam/oral
tahun) PLT 307 -Neurodex/8jam/oral
 740103 Lab (28/1/2016)
MRS : 7/1/2016 WBC 18.39 RBC 3.59
DPJP: HGB 9.7 HCT 29.7
Dr.dr.Ronald PLT 301
E.L, Sp.B (KBD)

K1B4 POH 4 laparatomi eksplorasi

4 Sumaila echemangiomamesentrium Lab (2/2/2016) -IVFD aminofluid : RL: D5 : =
1/6/1959 WBC 7.5 RBC 3.85 1000 : 500 : 500
742264 HGB 10.3 HCT 32.6 -Minum 1 sendok/jam
MRS : 21/1/2016 Protein total 6.1 -Ceftazidine 1gr/12jam/iv
DPJP : dr. M. Albumin 2.8 Globulin 3.3 -Metronidazole 500mg/8jam/iv -
Ikhwan Kusuma, Lab (26/01/2016) Ketorolac 30mg/8jam/iv
Sp.B-KBD PT 12.5 INR 1.20 APTT 29.6

KAMAR 2

No Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi

1 K2B1 Cholelitiasis Lab (14/1/2016) -IVFD RL 28tpm
Damaris Post op 3 LaparoskopiCholesistectomy Bilirubin total 0.27 -Ceftazidine 1gr/12jam/iv
1/7/1958 Bilirubin direk 0.07 -Ranitidin 50mg/8jam/iv
740833 Lab (12/1/2016) -Ketorolac 30mg/8jam/iv
MRS : 1/2/2016 RBC 4.31 HGB 12.2 -Diet lunak
DPJP : dr. Samuel HCT 35.4 PLT 317
Sampetoding, Sp.B- PT 12.1 INR 1.16 APTT 23.1
KBD GDS 103 Ur/Cr 30/0.90
SGOT/SGPT 25/27
Na/K/Cl 146/4.2/115
FotoThoraks PA (13/1/2016)
Cardiomegaly dgnelangatio et
atherosclerosis aortae
USG abdomen (13/1/2016)
Cholelith

2 K2B3 -Post operasi Lab (27/1/2016) -IVFD RL 28tpm

Nuriati -Tumor abdomen susp.malignancy RBC 4.07 HGB 10.9 -Ceftazidine 1gr/12jam/iv
00/02/1958 HCT 34.0 PLT 287 -Ketorolac 30mg/8jam/iv
740785 PT 9.9 INR 0.95 APTT 29.2 -Ranitidin 50mg/8jam/iv
MRS : 11/1/2016 GDS 93 Ur/Cr 24/0.80 -Dietbuburlunak/oral
DPJP:Dr.dr.Ronald SGOT/SGPT 16/5 Albumin 3.1 -Mobilisasi
E.L, Sp.B (KBD) Na/K/Cl 139/4.1/109
CTscan abdomen (12/1/2016)
Lymphoma retroperitoneal
Foto thorax AP (26/1/2016)
Elevasidiafragma bilateral (proses
intraabdomen?)

K2B2
3 Junnu Cholelithiasis Lab (18/1/2016) -Rencana Colon in loop
04/01/1940 Bilirubin total 0.55
740151 Bilirubin direk 0.28
MRS : 19/1/2016 Lab (7/1/2016)
DPJP : WBC 5.3RBC 4.22
dr.M HGB 12.2PLT370
IkhwanKusuma,Sp. GDS 97 PT/APTT 10,2/26,4
B-KBD INR 0,96
 Ur/Cr 21/0,60 SGOT/SGPT 21/12
Albumin 4.0 Na/K/Cl 143/4.2/108
USG Abdomen (18/12016)
Cholelith

4 K2B2 Tumor intraabdomensusp. Tumor gaster Lab (3/2/2016)

Damaris Ramba RBC 3.33 HGB 8.7 HCT 26.9
6/8/1953 PT 11.5 INR 1.11 APTT 24.2
744192 GDS 99 Ur/Cr 26/0.69
MRS : 3/2/2016 SGOT/SGPT 21/14 Albumin 2.5
DPJP : HbsAgreaktif
dr. Samuel AntiHCVnonreaktif
Sampetoding, Sp.B- Na/K/Cl 13.1/4.0/106
KBD

ISO
No Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi
1 ISO B2 FistulEnterocutanes Lab (3/2/2016) -Cefepime 1gr/8jam
Pangloli Trombositopebia WBC 3.0 RBC 2.50 -Cotrim 480mg 2x2
17/7/1980 Anemiaff HGB 6.9 HCT 22 -Metronidazole 0,5mg /8jam
741888 PLT 89 PT 13.9 INR 1.34 APTT 27.6 -Albumin 25%
MRS: 19/1/2016 GDS 148 Ur/Cr 58/0.90 -Vit C tab 2x1/oral
DPJP : dr. M. SGOT/SGPT 29/35 Albumin 2.0 -Zinc tab 1x1/oral
Ikhwan Kusuma, Na/K/Cl 131/3.8/102
Sp.B-KBD Lab (19/1/2016)
WBC: 7400
Hb:11,8
Plt:328.000
Ur/cr:43/0,85
Na/k/cl: 139/3,6/109
Fistel : 450 cc/24 jam,cair,ampas (+)
Albumin: 1,8
Colon in Loop (3/2/2016)
-Kontras 300cc dimasukkanmelaluikateter di
anus,kontrastidakmengisimaksimal
-Tampak filling defect daerah colon sigmoid
dengankontrashanyaterisikesansampai
sigmoid berupagaris tipis 6,5cm
-Mukosa rectum regular tidaktampak
additional shadow

2 ISO B1 Carcinoma Colonmetashepar Lab (31/01/2016) -Ondansentron 4mg/12jam/IV

Makmur WBC 18.6 RBC 3.55 -Ranitidin 100mg/8jam.IV
10/11/1978 (37tahun) HGB 9.9 HCT 30.8 -Neurodex 3x1/oral
MRS : 28/01/2016 Lab (28/01/2016)
DPJP : dr. M. WBC 18.3 RBC 3.30
Ikhwan Kusumaa, HGB 9.2 HCT 28.3
Sp.B-KBD PLT 390 PT 12.6 INR 1.21
APTT 28.0 GDS 64
Ur/Cr 15/0.87
SGOT/SGPT 205/34
Albumin 3.2 Na/K/Cl 134/4.6/100
 KAMAR 3

Identitas
No Diagnosa Pemeriksaan Penunjang Instruksi
Pasien
1 K3B1 Cholelithiasis
Rahim IFVD RL 28 tpm
01-07-1975 Ketorolac 30mg/8jam/iv
(40 tahun)
744353
Ranitidine
MRS 05-02- 50mg/8jam/iv
2016
DPJP : dr
Ihwan
Kusuma,
Sp.B-KBD

2 K3 B3 POH 1 Heller myotomi Lab 26/01/2016 - IVFD RL : D5% :

Martinus procedure Wbc 8.82 aminofluid = 500 cc :
Bonggara Rbc 4.89 500 cc : 1000cc
yan Hgb 13.8 - diet bubur saring
30/03/1987 Hct 41.4 -Ceftazidime
743060 Plt 375 1gr/12jam/iv
Tgl MRS Pct 0.38 -omeprazole
26/01/2016 PT 13.0 40mg/8jam/iv
DPJP : INR 1.25 -ranitidine
Dr.dr.Ron APTT 27.4 50mg/8jam/iv
ald GDS 103 Ketorolac 30mg/8jam/iv
E.Lusikoo UR/CR 19 / 0.90 -gv / 3 hari
y, Sp.B – SGOT 31
KBD SGPT 24
Na 144
K 4.6
Cl 107
3 K3B3 Tumor Gaster Lab 02-02-2016 Terapi post op
Joni Karau PT APTT 12.6/28.3
741525 GDS 111
12-04- UR/CR 16/1.10
1974 SGOT/SGPT 20/15
Tgl MRS ALBUMIN 3.3
03-02- CEA 5,19
2016 NA/K/CL 142/2.8/97
 RBC 4.45
HGB 10.8
DPJP : dr. HCT 33.3
Samuel PLT 288
Sampetodi
ng, Sp.B,
KBD
4 L2AD Post operasi hari 35 Lab 21/01/2016 -Diet biasa
K3/B1 Laparatomi WBC 5.3 -Cefadroxil
H. eksplorasi+LAR+Anostom RBC 3.89 500mg/8jam/oral
Kosmani osis cholestestomy e.c HGB 11.5 -Ranitidin
(74 tahun) Adenocarcinoma HCT 34.9 150mg/12jam/oral
31-12- Rectosigmoid HCV 90 -Dulcolax
1941 PLT 178
735056 PT 11.2
MRS: 27- INR 1.08
12-2015 APTT 32.5
DPJP: Glukosa
Dr.dr. GDS 168
Ibrahim Ureum 19
Labeda, Kreatinin 0.70
Sp.B-KBD SGOT 58
SGPT 38
Albumin 2.5
Natrium 134
Kalium 3.0
Klorida 104

KAMAR 3

KORAN DIGESTIF 4-2-2016

LONTARA 2 ADKAMAR 10

Bed IdentitasPasien Diagnosa Pemeriksaan Penunjang Instruksi

1 Karla rahelkures ileus Lab 29-1-2016 Ketorolac
15tahun obstruktifeckistahepar Wbc 6,44 30mg/8jam/iv
4-3-2000 Rbc 3,21 Ranitidine
743707 Hb 9,5 50mg/8jam/iv
Hct 27,6 Tunggurencanaopera
 MRS: 1-2-2016 Plt 222 si
DPJP Got/gpt 80/140
dr. Ronald E. Bil total 19,5
Lusikooysp.b.kb Bildirek 17,1
d Alb 3,9
Ur/cr 14/0,6

MRCP 03-02-2016
-Cholestatik intra
danextrahepaticeccholedoch
al cyst intra danextrahepatic
(todani: tipeIVa)
-hepatomegaly
2 Salmawati POH 0 laparotomy Lab 01-02-2016 Ceftazidime
37tahun eksplorasi Wbc 9,0 1g/12jam/iv
27-3-1976 Rbc 4,51 Ketorolac
742305 Hb 14,0 30mg/8jam/iv
Hct 41 Ranitidine
MRS: 1-2-2016 Plt 265 50mg/8jam/iv
DPJP PT/APTT 11,6/30,3 Metronidazole
dr.M.Ihwankusu Got/gpt 23/49 1amp/8jam/iv
ma, sp.bkbd Alb 4,1
Ur/cr 15/0,53
Na/k/cl 142/4,1/109
3 Wone POH 0 laparotomy Lab 1/2/2016 Ceftazidime
66 tahun eksplorasi Wbc 6,0 1g/12jam/iv
1-7-1949 Hb 13,1 Ketorolac
740750 Hct 38 30mg/8jam/iv
Plt 257 Ranitidine
MRS:11/01/2016 Pt/aptt 11/25,2 50mg/8jam/iv
Got/gpt 19/12 Metronidazole
DPJP Alb 4.3 1amp/8jam/iv
dr. Ronald E. Ur/kr 98/1,17
Lusikooysp.b.kb Na/k/cl 139/3,5/103
d
Lab 23/1/2016
Ph 7,584
Pco2 36,4
So2 98,7
PO2 97,1
HcO3 34,8

Ct abdomen 14/1/2016
Massa heterogendengan rim
calcification
kesanberasaldarimesenteriu
 msusp.
Teratomamesenterium
Hepatomegali
Simple renalcystsinistra
4 Iddeseng Tumor caput pancreas Post transfuse RL:DS10% 20tpm
55tahun POH Hb 9,2 PRC 2 bag Ceftazidime
31-12-1959 16laparotomieksplorasi PLT 105 TC 5 bag 1gr/12jam/iv
733820 bypass Omeprazole
cholelitiastomosi+jejenum Lab 1-2-2016 4mg/24jam/iv
MRS: 21-11-2015 stomosi Wbc 3,12 -affkateter
DPJD Rbc 3,15
Dr. Samuel Hb 9,2
Sampetoding, Hct 28,3
Sp.B-KBD Plt 105
Na/k/cl 141/3,6/112

Sitologicairan ascites 27-1-

2016
Lesiinflamasi,
tidakadaselepitelmaligna
5 Anna yohana Tumor intraabdominal Lab 2-2-2016 RL 28tpm
40 tahun Wbc 8 Ceftazidime
7-4-1975 Rbc 4,14 1g/12jam/iv
744028 Hb 12,2 Ketorolac
Hct 36,5 30mg/8jam/iv
MRS: 2-2-2016 Plt 701 Ranitidine
Dpjp Gds 103 50mg/8jam/iv
Dr. Samuel Ur/cr 34/0,58 -check AFP, CEA,
Sampetoding, Got/gpt 259/256 CA 19-9
Sp.B-KBD Alb 3,5 -
Na/k/cl 143/5,0/110 tunggurencanaoperas
Pt/aptt 14,4/38,8 i

RO thorax PA/AP (2-2-

2016)
-cordanpulmo normal
-tidaktampaktanda-tanda
metastasis padafoto thorax
ini

Hasilct-scan whole
abdomen (3-2-2016)
-hepatomegalidisertai
multiple
lesiheterogenpadakedualobu
sheparsugestif local
 metastasis
-massapada abdomen
suspekberasallobuskananhe
par
-usul MSCT scan abdomen
dengankontras
6 RIA POH 4eksplorasi CBD Lab 30-1-2016 IvfdRL:DS 10% 2:1
2-6-1985 Wbc 10,22 28tpm
743046 Rbc 4,24 Ranitidine
Hct 36,6 50mg/12jam/iv
MRS:26/01/2016 Hb 12 Metronidazole
Dpjp : Plt 392 500mg/8jam
dr. Ronald E. Pt 12,5 Ceftazidime
Lusikooysp.b.kb Aptt 34,8 1g/12jam
d Gds 80 Ketorolac
Ureum 7 30mg/8jam/iv
Kreatinin 0,54 Minum 3-5 sendok
Sgot 110 Konsulinfeksi
Sgpt 196 tropical
Albumin 3,6 Gantiverban
Na/k/cl 144/3,9/108
Hbsag/antiHCVnonreaktive/
nonreaktive

Usg :
Cholestatic
intra/extrahepaticeccholedoc
olith

KAMAR 11
bed nama diagnosa PemeriksaanPenunjang Rencana
1 Edi Prayitno POH 6 drainage Lab 4-2-2016 IVFD RL:DS 28tpm
39 tahun bilierecikterusobstruktif WBC 37,1 Ceftazidim
05 /09/1977 RBC 3,2 1gr/12jam/iv
742052 HB 9,3 Ranitidin
HCT 28,1 30mg/6jam/iv
MRS: 19/1/2016 PLT 237 Ketorolac
Alb 2,6 50mg/8jam/iv
DPJP: Inj vitamin K
Dr. Samuel Lab 1-2-2016 1amp/im
Sampetoding, Wbc 26,6 Transfuse albumin
Sp.B-KBD Rbc 2,15 25%
Hb 6,0 Protransfuse 4 beg
Hct 17,9 PRC
Plt 73 Metil prednisolone
Pt/apt 12,6/40,9 125mg/iv
 Gds 334 Cek lab post transfusi
Ur/cr 79/1,7
Got/gpt 42/61
Alb 2,3
Total bil 23,03
Direkbil 19,6
Na/k/cl 133/3,0/100

2 AbdAsis POH 16enterodrainaseec Lab 30-1-2016 IVFD RL 28tpm

38tahun ascites+ hipertensi portal+ Wbc 9,5 Omeprazole
31/12/1977 spleenomegali Rbc 4,45 1amp/12jam/IV
740469 Hb 11,0 Aliran drain
Hct 34,4 500cc/2jam
MRS: 08/01/2016 Plt 381 Terapi lain
Pt/aptt 14/32,9 sesuaitsinterna
DPJP: Gds 145
DR. Ur/cr 33/0,85
dr.Warsinggih, Got/gpt 31/21
Sp.B-KBD Alb 2,8
Bil total 2,46
Bildirek 1,17
Na/k/cl 133/4/106

Lab 20/01/2016
WBC 7.74
RBC 4.35
HB 7.7
HCT 31]
PLT 481
PT 16.4
APTT 47.4
INR 1.58
SGOT/GPT 42/25
ALBUMIN 3.3

Foto thorax 8/1/2016

Efusi pleura sinistra

CT Abdomen 8/1/2016
-
Sirosishepatisdengantand
a-tandahipertensi portal
-Splenomegaly
-Nefrolithdextra
-Efusi pleura sinistra
 Sitologi 27-1-2016
Lesiinflamasikronik

3 Teru Susp. Mesenteral mixed dd/ Lab 3-2-2016 IVFD RL 28 tpm

65tahun lymphoma Wbc 8,09 Ranitidine
01/07/1950 Hb 10,2 15mg/12jam/IV
742200 Hct 34,1 Ciprofloxacin 50mg/
Plt 471 12jam/iv
MRS: 21/01/2016 Pt/aptt 11,8/29 Tunggurencanaopera
Gds 126 si
DPJP: Ur/cr 39/1,5
Dr. Samuel Got/gpt 25/33
Sampetoding, Alb 3,8
Sp.B-KBD Na/k/cl 143/4,8/109

Lab 20/01/2016
RBC 4.231
WBC 16.2
HB 10.9
HCT 33.0
MCV 78
MCH 25.7
GDS 174
UR/CR 45/1.33
SGOT/GPT 17/12
NA/K/CL 147/4.3/111

Echocardiografi 29-1-
2016
Ejeksifraksi 74%
Fungsisistolikventrikelkir
ibaik
LVH konsentrik
Disfungsi diastolic
ventrikelkiri grade I

4 jefrianto Fistula Lab 20/01/2016 Clinimix : ivlip

18tahun Enterocutaneuspostlaparotom RBC 4.16 2000cc/hari
13/05/1997 yeksplorasiec app akut (2 WBC 9.6 Ranitidin
741910 blnlalu) HB 11.7 50mg/8jam/iv
HCT 35.8 Ketorolac
MRS : PLT 420 30mg/8jam/iv
19/01/2016 Albumin 3.2 Amilkacin 250mg/
 PT/APTT 13.1/27.8 8jam/iv
DPJP: INR 1.26 Vip albumin 3x2
dr.Warsinggih, UR/CR 15/0.6 GV
Sp.B-KBD SGOT/GPT 15/6
NA/K/CL 135/4.0/102
5 Ismail Suspeklimfoma Lab 1-2-2016 Tunggurencanaopera
39 tahun Wbc 9,31 si
15-31976 Rbc 4,06
728994
Hb 10,8
MRS: 31/1/2016 Hct 35,8
DPJP Plt 221
dr.Warsinggih, Pt/aptt 10,9/34,2
Sp.B-KBD Gds 88
Ur/cr 23/0,9
Got/gpt 16/10
Alb 4,0
Na/k/cl 142/4,1/109
6 Syamsuddin dg Ileus obstruktifec tumor recti Lab 3-2-2016 RL 28tpm
ngawing 1/3 tengah Wbc 4,58 Ceftazidime
50tahun Rbc 4,81 1gr/12jam/iv
1-7-1965 Hb 13,9 Ketorolac
737012 Plt 182 30mg/8jam//iv
Pt/aptt 12,3/35 Ranitidine
MRS: 1-2-2016 Got/gpt 21/15 50mg/8jam/iv
DPJP Ur/cr 22/0,9
Dr. Samuel Gds 109
Sampetoding, Alb 3,7
Sp.B-KBD Na/k/cl 192/3,9/105
Lab 12-1-2016
Pt/aptt 11/33,8
Lab 11-1-2016
Wbc 5,7
Rbc 4,63
Hb 14,4
Hct 43
Plt 204
Gds 83
Ur/cr 19/0,97
Got/gpt 31/24
Alb 4,5
Na/k/cl 144/4,8/104

Lab 28-12-2015
AFP 1,18
CA 19-9 3,13
KORAN KAMIS, 5-2-16

LONTARA 3 ATAS DEPAN

No IDENTITAS DIAGNOSIS LABORATORIUM PLANNING
1. K5B4 S: nyeri post op ada - infus RL: D5 2:1 28 tpm
Intang O: KU sadar, sakit sedang - hitung produksi drain/24jam
46 tahun A: abdomen datar, supel, peristaltic - ranitidine 50mg/12jam/iv
742227 (+) normal. Drain: 100cc - ceftazidim 1gr/12jam/iv
Hb post transfuse 2 bag PRC: 10,3 - diet bebas
DPJP: MIK gr/dl

A: post op laparotomi mile’s

procedure ec tumor recti 1/3 distal
hari ke-5
2. K2B5 S: nyeri post op ada - infus RL 32 tpm
Nurhayah O: KU: sakit sedang/ sadar - ceftazidim 1gr/12jam/iv
741090 Abdomen : datar, supel, peristaltic - ketorolac 30mg/8jam/iv
30thn, (+), normal - ranitidine 50mg/8jam/iv
MRS: 27.1.2016 - diet bebas
A:POH ‘2’ laparoscopy
DPJP:IK cholecystectomy ec cholelithiasis
3. K6B2 S: nyeri pada saat membuka mulut - ketorolac 30mg/8jam/iv
Yunus O: KU: sakit sedang/ sadar - ranitidine 50mg/12jam/iv
743389 Abdomen : datar, supel, peristaltic - menunggu jadwal
4-6-1980 (36 (+), normal echocardiography dan endoscopy
tahun)
DPJP:W A: Akalasia esofagus
4. K6B4 S: benjolan pada lipat paha kanan - periksa lab : GDP, HbA1C,
Al Munir hilang timbul TTGO
741271 O: KU sedang, sadar - tunggu jawaban konsul EM dan
A: HIL dextra GEH
DPJP: SS Peningkatan enzim transaminase
P: rencana operasi

LONTARA 3 ATAS BELAKANG

No Identitas Pasien Diagnosa Pemeriksaan Penunjang Instruksi

S: demam, BAK susah - infuse RL : D5 28 tpm
K4B6 O: KU sakit sedang/gizi - ceftazidime 1gr/12jam/iv
Asbianti cukup/sadar. Suhu: 38,3’C - Ketorolac 30mg/8jam/iv
27/09/1981 Abdomen: datar, supel, peristaltic - ranitidine 50mg/8jam/iv
1. 742534 (+) terdapat kassa menutupi luka - boleh minum
MRS 23,01,2016 operasi, drain : 100cc. Hb post op - boleh diet bubur, minum bebas
10,3 gr/dl - durogesic patch 12,5mg
DPJP: IL A: post op “2” laparotomi - paracetamol 1gr/8jam/iv
eksplorasi + miomektomi
2. K4B4 S: nyeri post op (+), sudah mulai - IVFD RL : D5 2:1 28 tpm
Rusni mobilisasi - ceftazidime 1gr/12jam/iv
24-8-1969 (47 O: KU sedang, sadar - ketorolac 1gr/8jam/iv
tahun) Region abdomen: kassa tertutup - ranitidine 1amp/8jam/iv
743561 pada luka operasi, peristaltic (+) - metronidazole 500mg/8jam/iv
DPJP: SS A:POH 5 laparostomy eksplorasi - diet bebas
+ loop colostomy - mobilisasi
 PALEM
PALEM ATAS
1 B1/1 POH VI Laboratorium 02-02-2016 -IVFD RL:D5% 2:1 
H.Barri Laparotomi WBC: 8.300 28 tpm
13/3/1950 eksplorasi RBC: 3.590.000 - Aminofluid 1000 cc
739508 ec.Tumor HGB: 9,5 /24 jam/iv
HCT: 30%
MRS:26-1-2016 caecum -Ceftazidime 1
PLT: 223.000
GDS: 75 gr/12jam/iv
DPJP: Dr.dr.ibrahim Albumin: 3,1 -ketorolac
Labeda,Sp.B-KBD Na/K/Cl : 140/4,1/105 30mg/8jam/iv
Laboratorium 19-01-2016 -Awasi tanda akut
GOT/GPT: 18/28 abdomen
Ur/Cr : 54/1,1 -Diet bubur saring+air
PT/APTT : 11.1/34,7
GDS 100 putih
INR:0,97
Alb : 3.8
Protein Total 6,3

MSCT Whole Abdomen

(07/01/2016)
Kesan: Massa kolon area
flexura hepaticus
2 B2/2 BED 1 Susp. Ca Lab tgl 31-01-2016 -Durogesic Patch 25
Muh.Adnan Pankreas -Ureum: 13 mcg/72 jam
699517 Residif + -Kreatinin: 0,39 -Tunggu hasil
9-2-1972 Hepatits B Lab tgl 30-01-2016 pemeriksaan MRCP
MRS: 22-1-2016 - PT:11,9
-INR:1,14
DPJP: -APTT:25,6
Dr. dr. Ibrahim Lab tgl 29-01-2016
LabedaSp.B-KBD WBC:24.700
RBC:4.300.000
HB:10,9
HCT:36%
PLT:333.000
GDS: 82
Na/K/Cl:136/3.2/99
Lab tgl 27-01-2016
-Bil total: 6,62
-Bil direk: 5,20
- Gamma GT: 555
-HbeAg: Non reactive
-Anti Hbe: 0,01
 -Anti HBc:0,01
Tumor Marker
-AFP: 0,85
-CEA:2,59

CT Scan Abdomen (Tanpa

Kontras) 22/1/2016
Kesan: Massa pada pankreas
disertai tumor metastasis ke
hepar
Tanda tanda cholestatic
intrahepatik
B2/8/Bed 1 Tumor recti 1/3 Laboratorium 30/01/2016 - Hasil konsultasi ke
Sammani distal WBC 4.500 bag. Kardiologi: tidak
31/12/1930 RBC 4.200.000 ada kontra indikasi
MRS: 16/01/2016 HGB 10,7 operatif
HCT 35% - Rencana laparoscopy
DPJP : PLT 227.000 miles procedure hari
dr. Ikhwan Kusuma, Laboratorium 18/01/2016 selasa, 9 Februari 2016
Sp.B-KBD PT / APTT 12,7/ 24,5 -Terapi lain sesuai TS
INR 1.22 Ginjal Hipertensi
Ureum 44
Kreatinin 0,97
SGOT 8
SGPT 7
HBs Ag (ICT) Non Reactive
3 Anti HCV (ICT) Non
Reactive
Albumin 3.3
Natrium 143
Kalium 3,7
Klorida 115

Hasil Patologi Anatomi

22/01/16
Kesimpulan : Mucinous
Adenocarcinoma Recti

Colon in loop (27-01-2016)

Kesan: Massa rectum 1/3
proksimal suspek malignancy
4 B2/6 Colelithiasis CT Whole abdomen (18-01- -Pre op laparoscopy
Hj.Rohani Hipertensi 2016) cholesistectomy, hari
01-03-1961 Grade II Kesan: Choleliths Selasa 09 Februari
731717 2016
MRS:29-1-2016 Lab darah (21/01/2016) - Terapi lain sesuai TS
Wbc: 10.100 Ginjal Hipertensi
DPJP : dr. Ikhwan Rbc: 5.520.000
Kusuma, Sp.B-KBD Hgb:13,5
PLT: 492.000
GDP: 134
GDS: 133
GD2PP: 183
HbA1C: 5,7
PT: 11,3
APTT: 25,2
INR: 1,09
Ureum: 34
Kreatinin: 1,19
Bil.Total: 0,92
Bil.Direk: 0,26
SGOT: 20
SGPT: 18
Na/K/Cl: 144/2,8/100
5 B1/9 POH VII Laboratorium (30/01/2016) -OBH syrup 3 x 1 cth
Abd.Alim Amirullah Laparotomi -Albumin: 2,9 -Infus Ringer Laktat 28
26-01-1954 Hernioraphy -Na/K/Cl: 143 / 4,4/ 108 TPM
RM 743387 -RBC: 5.070.000 -Cefadroxyl 2X1
-HGB: 16,4 - Ranitidin 2X1
DPJP: -PLT: 233.000 -Asam mefenamat 3X1
dr.Warsinggih,Sp.B- -WBC: 12.300 -Diet bubur + susu
KBD -PT: 12,2 - Mobilisasi
-INR: 1,17
-APTT: 23,4
-GDS: 181
-Ureum: 57
-Kreatinin:1,04
-SGOT: 27
-SGPT: 27
-HbsAg: Non reactive
-Anti HCV: Non reactive
6 B2/1 BED 1 Tumor colon Laboratorium (03/02/2016) -Rencana operasi
Hj.Nuryana ascendens susp -PT : 10,4 - Menunggu hasil
17/07/1953 malignancy -APTT: 26 konsul perioperatif
RM 738602 -INR:1,00 bag.kardiologi
-Ureum:18
DPJP: DPJP : -Kreatinin:0,70
 Dr. dr. Ibrahim -GOT:17
Labeda, Sp.B-KBD -GPT:9
-Albumin:3,3
-Na/K/Cl: 143/4,6/108
Laboratorium (28/01/2016)
-WBC: 10.270
-RBC:5.260.000
-HGB: 11,2
-HCT: 39,3%
Laboratorium (29/01/2016)
-Tumor marker CEA: 19,47
Pemeriksaan UGIE:
Kesimpulan:
-Hemorroid interna grade I
-Tumor kolon asenden I
7 B2/4 bed 1 POH II Lab tgl 27-01-2016 -Infus Ringer Laktat
Hj.A.Karoma Biliodigestive WBC:8.400 2000 cc/24jam
31-12-1956 RBC:3.410.000 -Infus Aminofluid
741081 HB:10,4 1000 cc/24 jam
MRS:25-1-2016 HCT:31% -Inj meropenem
PLT:479.000 amp/24jam
DPJP: dr.Samuel GDS: 141 -Inj Omeprazole 40
sampetoding,Sp.B- Ureum: 18 mg/8jam
KBD Kreatinin: 0,62 -Inj Ketorolac
Bilirubin Total: 16,10 amp/8jam
SGOT: 37 -Balance cairan
SGPT: 25 -Puasa
Albumin: 3,2 -Takar drain/24jam
Bilirubin direk: 10,3 - Cek albumin,
Na/K/Cl:133/4,4/102 elektrolit, GDS
Lab tgl 18-01-2016
-Gamma GT: 303
-CEA: 1,97
-CA 19-9: 30,15

MSCT Whole Abdomen

(14-01-2016)
Kesan: Massa kaput pankreas
dengan kolestatik intrahepatik
dan ekstrahepatik serta
hydrops GB
MRI
Cholangiopancreatography
(18/1/16)
Kesan: Distenden GB dan
cholestatic intra dan
 ekstrahepatik ec stenosis
distal CBD Level proksimal
ampulla veteri

8 B2/13 BED 2 Fistel perianal CT Whole Abdomen (tanpa -Infus Ringer laktat 28
Ilhaidi Susp tumor kontras) 29-01-2016 tpm
14/12/1981 rectum Kesan: penebalan sirkuler - inj ceftazidime 1
RM : 626983 pada rektum sugestif massa gr/8jam
rektum -inj metronidazole
DPJP : dr. Ikhwan -inj ranitidin
Kusuma, Sp.B-KBD Foto Thorax (04-02-2016) 50mg/8jam
Kesan: Tidak tampak -inj ketorolac 30
kelainan radiologik pada foto mg/8jam
thoraks -Tunggi hasil LGIE
-Kultur pus
Laboratorium (04-02-2016) -Ganti verban 2 kali
WBC: 3.700 sehari
RBC: 3.570.000 - Rencana operasi
HGB: 9,3 tunggu jadwal
HCT: 28% -Konsul gizi klinik
PLT: 198.000 -Periksa CEA
PT:11,1
INR: 1,07
APTT: 23,7
GDS:96
UREUM: 19
KREATININ: 0,90
GOT: 23
GPT: 17
Na/K/Cl: 135/ 4 / 107

PALEM BAWAH

1 PalembawahB1/5 POH VI Lab 03/02/2016 -IVFD RL 28 tpm

J. P. Totonan Gastroktom ALB 2,4 -VIP Albumin
15/06/1940 i partial sachet 1x1
(75 Tahun) Lab 01/02/2016 -Drips albumin
729143 GDS 174 25% 1 botol
ALB 2,5 -inj ceftazidime
MRS Na/K/Cl 136/3,6/103 1gr/12 jam/IV
DPJP: -inj. Ketorolac jika
Dr. Samuel Sampetoding, SpB- Foto Polos Abdomen (01/02/2016) nyeri
 KBD - Meteorismus -inj omeprazole
- Terpasang gastric tube dan drain 40mg/12jam/IV
-Aminofluid
Patologi Anatomi (29/01/2016)
1000cc/24jam/drip
Adenocarcinoma gaster differensiasi
jelek dengan ujung reseksi jauh bebas s
tumor dan telah metastase ke kelenjar -N-
limfe mesenterium ace/8jam/nebulize
r
Foto Thoraks PA/AP (27/01/2016) -Diet susu 100cc
-Bronchopneumonia dextra via NGT feeding
-Dilatatio et atherosclerosis aortae -cek albumin
-Takar produksi
urin/hari
-Takar produksi
drain/hari
-Tunggu hasil
pemeriksaan
albumin, profil
lipid

2 Palembawah B2/2 bed 1 -Ikterus MSCT Whole Abdomen dengan -Interhistin 2x1
Darma patabang obstruktif kontras (03-2-2016) -Rencana operasi
9-3-1972 ec. Cholestatik intra dan extrahepatik ec tunggu jadwal
(44 Tahun) Calcified calcified cyst pancreas
742749 cyst
pancreas Lab 31-1-2016
MRS 28-1-2106 PT 12,1
DPJP:Dr.dr.ibrahimLabeda,Sp. APTT 30,8
B-KBD INR 1,16

Lab 25-1-2016
WBC 93
RBC 4,33
HGB 12,3
HCT 38,2
PLT 412
PT / APTT 16,6/35,7
INR 1,60
Ur/Cr 22/0,9
SGOT 62
SGPT 42
Bil.tot 28,72
Bil.direct 24,1
Na/k/cl 132/4/99
HBsAgnon reactive

MSCT Whole Abdomen (29-1-2016)

Cholestatik intra dan extrahepatik ec
 calcified cyst pancreas

USG abd 25-1-2016

Kesan:Choledocholithdisertaicholestat
ik intra danextrahepatik
3 Palembawah -POH VII Lab 3/2/2016 -Terapi sesuai TS
B2/3 bed 2 repair WBC 12.24 interna
Usman CAPD RBC 4,00
4/1/1979 -CKD stage HB 9,8
(37 Tahun) V HCT 30,9%
515599 PLT 133

MRS Lab 31/1/2016

DPJP: WBC 12.6
Dr.dr.Ibrahimlabeda, SpB-KBD RBC 3,26
HB 8,2
HCT 26%
PLT 192
UR/CR 126/7,01
Albumin 2,5

Foto polos abdomen (25-1-2016)

-Terpasang CAPD dengan tip berada
pada regio pelvis mayor setinggi CV
S1

4 Palembawah Ileus Lab 27-1-2016 -Cefadroxil 2x1

B2/6bed 2 obstruktif WBC 15,38 -Omeprazole 2x1
AndiBasri RBC 6,39 -Asam mefenamat
1/7/1964 HB 19 jika perlu
(52 Tahun) HCT 55,7 -Diet bubur saring
743238 PLT 189 dan air putih
PT/APTT : 12,1/32,4 -Boleh rawat jalan
MRS27-1-2016 INR : 1,16
DPJP: Dr.dr.Ibrahim Labeda, UR/CR 42/1,30
Sp.B-KBD SGOT/SGPT 15/15
ALB 42
NA/K/CL 144/3,6/108
HbSAG : Non reactive
Anti HCV : Non Reactive

Colon in Loop (02/02/2016)

Colon in loop dalam batas normal

Foto polos abdomen (02/02/2016)

Tidak tampak kelainan radiologik
pada foto polos abdomen ini
 Foto Abdomen 3 posisi (27/01/2016)
-Gambaran ileus obstruktif

5 PalemBawah POH II Laboratorium01/02/2016 -Infus RL : D5%=

B2/7 bed 1 Laparotomi WBC 6,0 2:! 32 tpm
Yohanis S RBC 4,55 -Aminofluid
31 / 12 / 1943 HB 10,4 1000cc/24jam
( 72 Tahun ) HCT 33 -Inj. Ceftazidime 1
739020 PLT 238 gram/12jam
-Drips
MRS Laboratorium30/01/2016 metronidazole
DPJP: Dr.dr.Ibrahim Labeda, WBC 7,3 500mg/8jam
Sp.B-KBD RBC 4,58 -inj. Ketorolac
HB 9,8 30mg/8jam
HCT 32 -Omeprazole
PLT 294 40mg/12jam
GDS 92 -Balance cairan
PT/APTT : 11,7/27,0 -puasa
INR 1,13 -awasi tanda akut
UR/CR 29/1,18 abdomen
SGOT/SGPT 18/29 -takar produksi
Albumin 3,2 caira/hari
Na/K/Cl 139/4,4/107

MSCT Scan whole abdomen 31-12-

2015
Kesan:massarectosigmoid
Endoscopy LGIE
Hemorroidinterna gr.2
Tumor rectum
PA 26-1-2016
Adenocarcinoma intramukosa
6 PalemBawah POH II Laboratorium 02/02/2016 -Infus RL 28 tpm
B2/8 bed 1 pemasanga Waktu bekuan 8’00 -Inj. Ceftazidime
Steldin n CAPD Waktu perdarahan 2’30 1gr/12jam
01 / 01 / 1958 PT/APTT : 10,9/31.0 -Inj. Ketorolac
( 58 Tahun ) INR 1,05 30mg/8jam
735851 Albumin 3,8 -Inj. Ranitidin 50
mg/8jam
MRS Laboratorium1/02/2016 -Diet bubur saring
DPJP: Dr.dr.Ibrahim Labeda, WBC 8,8 + air putih
Sp.B-KBD RBC 2,51
HB 8,1
HCT 24,9
PLT 160
GDS 124
PT/APTT : 10,9/29,5
INR 1,05
 UR/CR 70/6,90
SGOT/SGPT 15/14
Na/K/Cl 145/3,9/109
7 PalemBawah Tumor LGIE: -Infus RL 28tpm
B2/5 bed 2 Abdomen -Hemorroid interna grade I -Inj. Ranitidin
Rahmatia -Tumor saekum 50mg/12jam
18 / 11 / 1964 -Tunggu hasil
( 51 Tahun ) USG Whole Abdomen (19-01-2016): pemeriksaan darah
506788 -Multipel lesi isoechoic dengan tepi rutin
hipoechoic suspek tumor metastasis -Konsul
MRS ke hepar perioperative ke
DPJP: Dr.dr.Ronald E. -Cholelith interna dan
Lusikooy, Sp.B-KBD kardiologi
MSCT Whole Abdomen (22-01- -Rencana operasi
2016): tunggu jadwal
-Cholelith
 ICU

NO NAMA RUANGAN DIAGNOSIS LABORATORIUM RENCANA

1 Hamza Bed 8 S: keluhan tidak ada Lab (1/2/2016) IVFD
27/7/1955 terintubasi, WBC 2.41 Meropenem1 gr/ 12
61 thn O:KU lemah Hb 4.6 jam/iv
742055 Vital sign : HCT 13.7 Omeprazole 40 mg/24
MRS: TD 100/60mmHg PLT 36 jam/iv
N 98x/menit Prokalsitonin 2.23 Rawat stoma
GCS14 (E3M5V3) PT >90 Luka
DPJP: SS Abdomen: supel, BU + APTT 57.6 Balance cairan
lemah, luka verban kering GDS 95 Awasi tanda vital dan
Stoma intak + Ur 26 akutn abdomen
Produksi + Cr 0.21
Drain: minimal scroma SGOT 11
SGPT 4
A: Carcinoma recti POH3I Na 144
Laparatomi Eksplorasi + K 1.7
Miles Procedure Cl 124

Lab (30-01-2016
Bilirubin total 1.43
Bilirubin direk 0.98
Albumin 2.4

Lab (25/1/2016)
CEA 17.98
PSA >100.0
2 M. Nurdin Bed 7 S: Keluhantidakada, Lab (3/2/2016) Infus Clinimix:
05/05/1955 terintubasi Mikrobiologi: 1000:100 cc/24 jam
60 th O: KU sakit lemah Sputum, gram negative dan Amikasin 1.5 gr/24
742541` vital sign: TD 139/75 mmHg positif, basil basil tunggal jam/infuse
MRS: 22/01/2016 N: 96x/menit dan diplococcus, positif Sulbaktan 1 gr/ 8
GCS 7x (E2M5Vx) (1+), ekstraseluler, jam/iv
DPJP: IL Abdomen: luka verban PMN:4/lpk Meyamin 50 mg/12
kering, BU + normal jam/iv
Kimia darah: Acetylolame 3x1 tab
A:Hernia inkarserata pO2 128.8 Rawat luka
POH 12 laparatomi HCO3 38.1 Peptisol 44200 cc
eksplorasi +Reseksi
IleoillealHernioraphy (OK Lab (1/2/2016)
23-01-2016) WBC 25.18
Syok Septik Hb 14.5
HCT 44.1
PLT 239
Ur 72
Cr 0.80
SGOT 59
SGPT 39
Alb 3.0
Prokalsitonin 1.20
Na 145
K 4.2
Cl 105
Lab(27/1/2016)
Bilirubin total 3.12
Bilirubin direk 2.00

Lab (29/1/2016)
Laktatdarah 57.4
3 Bakka Tinri Bed 9 S: Keluhan terintubasi Lab (1/2/2016) infus RL 200cc/ jam
15/08/1956 O: KU lemah WBC 19.68 Meropenem 1 gr/12
59 thn T:100/70mmHg HGB 11.8 jam/iv
743613 N:97x/menit HCT 35.0 Levofloxacin 750
MRS: 30/01/2016 SpO2: 99% PLT 6* mg/24 jam/iv
GCS terintubasi, RC +/+ Ur 70 Amikasin 1250 mg/24
DPJP: IK Abdomen: sepal, BU normal, Cr 1.29 jam/iv
stoma intak SGOT 269 Omeprazole 40 mg/24
Drain: produksi (+) SGPT 111 jam/iv
Atas: 300 cc Prokalsitonin >200 Balance cairan
Bawah:100 cc Na 143 GV + rawat luka
K 4.2
A: Peritonitis Generalisata ec Cl 116
Perforasi Sigmoid POH IV,
Laparatomi Eksplorasi + Lab (31/1/2016)
Loop Colostomy PT 23.5
APTT 65.2
INR 2.24
Albumin 1.4
4 Era Lati Upo VIP 4 S: lemas Lab (3/2/2016) Infus RL/D5: 2/2
20-2-1944 O: KU sedang/gizi WBC 10.6 28tpm
71 tahun cukup/sadar Hb 14.2 Inj ceftriaxon 1 gr/12
743126 BP: 140/65 mmHg HCT 40.5 jam/iv
MRS: 30-01-2016 R: 20x/menit PLT 108 Metronidazole 500mg/
HR: 75x/menit Prokalsitonin 11.28 8 jam/iv
DPJP: RL Abdomen: datar, supel, BV _ PT 13.6 Ranitidine 50 mg/12
Output: drain subhepar, +-50 APTT 26.6 jam/ iv
cc\Drain T-tube +- 100cc INR 1.31 Ketorolac 30 mg/8
Urine 1500 cc/ 8 jam SGOT 69 jam/iv
IWL: 410 SGPT 79 Puasa
Input: infuse RL/D% : 2/2 Albumin 3.6 Balans cairan
2000cc infuse 50 cc Na 143
Input-output K 3.5
2050 cc- 2060 cc =10 cc Cl 110
A: POH 0 Eksplorasi CBD

Lontara 4 Bawah Depan

NO NAMA RUANGAN DIAGNOSIS PENUNJANG BARU RENCANA
1 Indahari K1B6 S: nyeri perut Lab (27/1/2016) IVFDRL:D51000:500cc/24jam
31-12-1968 O: KU sedang/sadar PT 9.9 Ceftazidime1gr/12jam/iv
47 thn Abdomen: supel, peristaltic APTT 25.9 Paracetamol500mg/8jam/drips
741650 normal INR 0.95 Awasi drain production/24 jam
Tgl Konsul: 31-12- Ur 14
2016 A: POH 4 drainage abses Cr 0.34
due to tumor abdomen SGOT 26
DPJP: IL SGPT 14
Alb 2.5

Lab (25/1/2016)
GDS 82
LDH 5.7
Na 134
K 3.5
Cl 94