Sabtu, 15 September 2018 BEDAH DIGESTIF LHB/JRM/RAP/BOB/DNT/IKY/WID/BAM/API

FU BED Nama Usia Tgl msk Diagnosis Status DPJP Plan PemeriksaanPenunjang

4/9 kutur : E. Coli. S gentamicin/ciprofloxacin/amikacin/ceftazidim

2/9 Hb 11,1 Hct 33 Al 9,9 At 348 AE 4,16 Alb 3,4
I : Post laparotomi explorasi drainage kista pankreas + 23/8 MSCT Whole Abd : a. Lesi subhepatal di intraperitoneal berdinding tebal disertai gambaran udara dan
kistojejenostomi +biopsi +PA ai kista pankreas cairan didalamnya membentuk gambaran air fluid level, lesi berhubungan dengan ileum DD : 1. Abses dengan
Post Op I
Perawatan Post Op fistel ke ileum 2. Massa 3. Divertikulum terinfeksi b. Lymphadenopati paraaorta
Purwadi Poli 10/8
901A 48 II : Post Relaparotomi Braun Anastomose + nekrotomi AR Diet tinggi protein 20/8 Kultur darah: No Growth
01426935 6/8 Post op II
dinding kista ai kista pankreas + necrotic dinding kista Medikasi 13/8 PA : Pankreas : Kista
27/8
2/8 cxr : tak tampak gnram pulmonal metastase
Hiponatremia 2/8 usg abd : 1. Massa kistik g memenuhi sel regio abd kuadran kanan yg mendorong gaster ke superior dan
ginjal kiri, bladder dan prostat ke infeior serta sisterna kolon ke sisi kiri 2. Dilatasi gaster

14/9 Hb 9,1 Hct 28 AL 11 AT 300 AE 2,96 Alb 2,2 Cr 0,6 Ur 26

I. Post Laparatomi + Post Biliodigest + PA ai obs jaudice ec Post Op 12/9 Hb 10,1 Hct 31 AL 11,9 AT 273 AE 3,51
Gunung Poli massa caput Pankreas 23/8 Perawatan post Op 8/9 Na 132 K 2,3 Calsium Ion 1.01
903B 66 AR
01429316 20/8 II. Post Relaparotomy + adhesiolisis a/I PG + adhesi Post Op 4/9 Hb 11 Hct 33 AL 27,3 AT 435 AE 3,55 Alb 2,5 Na 126 K 2,6 Cl 98
4/9 28/8 PA fibrosis/ proses radang
25/6 usg abd : billiary obstruction + hydrops gall bladder
14/9 Hb 13,1 Hct 40 AL 17,8 AT 506 AE 4,78 Alb 3,1 Na 128 K 5,3 Cl 101
8/9 alb 2.4
Iwan Wibowo IGD Post LE + release band + appendektomi ai ieus obstruksi Post op 7/9 hb 13.4 ht 42 al 17.2 at 351 ae 5 alb 2 na 134 k 4.9 cl 107
905B 35 AR Perawatan post op
01431548 7/9 ec band ileum 7/9 6/9 hb 10 al 14.2 at 500 ae 4.23 sgot 9 sgpt 10 ur 35 cr 180 gds 80 pt 15.3 aott 13.7 inr 1.06
6/9 thoraks PA gambaran BP. Efusi pleura (D)
6/9 BNO : gambaran ileus obstrukttius
13/9 Hb 10,7 Hct 34 AL 7,9 AT 375 AE 4,64
12/9 Hb 9,4 Hct 30 AL 6,5 AT 361 AE 4,20
Sarmin Efendi Poli Laparotomy Biopsi + PA a/I Tumor Intra Abdomen Susp Post Op 4/9 Hb 8,7 hct 30 AT 472 PT 26,8n GDS 90 PT 26,8 GDS 90 Alb 3,2 K 3,9 CL 075 HbsAg NR CEA 1,74 PSA
905E 45 AR Perawatan Post Op
01431342 10/9 NHL 13/9 0,32
1/9 CT scan Mamse inguinal den59 CT scan massa suprapubic inguinal konrest
23/8 Usg Abd Massa solid regio suprapubik, hepatomegali

1/3 Hb 13,2 Hct 42 AL 8,1 AL 313 AE 4,74 PT 13,4 APTT 28,6 GDS 146 OT 14 PT 11 Cr 0,7 Ur 17 Na 145 Kn
Poli
Soeparjo 4,0 Cl 102
907A 71 13/9 HIM D/S Pre Op AR Pro Herniorepair
0190728 19/2//18 Lumbosacral AP lat. Mild Levoskoliosis. Nefrolitiais kanan

13/9 Hb 5,2 Hct 17 AL 12,1 AT 650 AE 2,18 PT 14,3 APTT 24,7 GDS 111
Transfusi PRC 2
Tuminem Poli Tumor Intra Abdomen OT 35 PT 11 Alb 2,8 Cr 0,7 Ur 21 Na 129 K 4,2
907B 66 KU AR kolf/hr
01431324 14/9 Anemia 13/9 USG Abd : Massa padat intra abdomen, nodul hepar susp. Metastase
CT scan kontras
13/9 Ro Thoraks PA : pneumonia

14/9 Hb 7,8 Hct 25 AL 2,1 AT 64 AE 2,57 Alb 1,7 Na 132 K 2,5 Cl 106
13/9 Hb 5,7 Hct 19 AL 3,6 AT 122 AE 1,84 PT 20,8 APTT 39,7 GDS 82 Alb 1,3 Cr 0,5 Ur 24 Na 118 K 3 Cl 94
Pro Laparotomy 24/8 CIL : Fistel Intracutan
Hasan S Poli
907D 39 Fistel enterocutan Pre Op AR eksplorasi 7/8 Foto Polos Abdomen : Ileus Obstruksi Letak Rendah
01407110 12/9
1/8 Hb 10,9 Hct 30 AL 4,1 AT 128 AE 3,44
1/8 fistulografi : Fistel enterocutan regio infraumbilical
5/1 FNAB : proses radang kronis
BOB 5/9 Hb 11,1 Hct 33 AL 3,2 AT 321 AE 3,80 PT 13,3 APTT 31,0 GDS 100 OT 39 PT 15 Alb 2,7 Cr 0,8 Ur 24 Na
133 K 2,1 Cl 96 CEA 29,45 CA 125 118
Mikem Poli 5/9 USG ABD Massa Rectosigmoid ascites HNF kiri Nefrolitiasis
912D 68 Tumor Rectum T4N0M0 Susp Malignancy Pre Op AR Pro Biopsi Rectum
01430819 13/9 5/9 Ro thoraks PA tak tampak gambaran pulmonal metastases
16/8 Kolonoskopi Massa Rectum
1/8 CIL gambar massa intraluminer di regio sigmoid
9/9 Hb 11,6 Hct 37 AL 6,3 AT 273 AE 3,93 PT 12,1 APTT 23,9 Alb 4 Cr 0,5 Ur 13 Na 135 K 4,3 Cl 110 HBsAg
NR
6/9 Hb 9,5 Hct 30 AL 5,7 AT 361 AE 3,28 PT 12,5 APTT 28,2 GDS 143 OT 106 PT 165 Bil tot 18,73 bil direk
Post Op
Lilik Poli 14,06 Bil indirek 4,7 Alb 4,1 Cr 0,7
913B 25 Post Cholesistektomy + PA a/I Cholelitiasis 12/9 AR Perawatan Post Op
01429858 6/9 4/9 MRI Abd Kontras Choledocolitiasis, Cholelitiasis, hepatomegali
21/8 Hb 14 Hct 42 AL 9,4 AT 258 AE 2,74 PT 12 APTT 23,8 GDS 118 OT 109 PT 339 Bil Tot 27.11 Bil
Direk19,88Cr 0,6 Ur 18 Na 132 K 4,5 Cl 106
16/8 Usg Abd Cholestasis intra dan ekstra hepatal Cholelitiasis