LAPORAN HARIAN GASTROENTEROHEPATOLOGI Senin 22/7/2019

Junior : dr. Septian TM Madya : dr. Rizki Nandasari, dr. Annisa Permatasari Senior : dr Dewi Rachmawati dr Laurentsia

Kamar Identitas Diagnosis Pemeriksaan Penunjang Terapi Keterangan

Lantai 1 Maya Maulidia Fitriani Kista pankreas post biopsi 19/07/19 D5 ½ NS 15 tpm
Kamar 1 1121406/19020030 + melena ec susp Hb 10.3 eri 4.05 leu 9.35 ht 33 plt 333 RDW-CV 26.10 DC 0/3/49/41/7 Omeprazol 1x20mg (iv)
TL 05/05/2009 perdarahan cerna bagian 13/7/19 Menunggu hasil barium meal
MRS 06/07/2019 atas PT (K) 14.40 (P) 13.3 INR 1.02 APTT (K) 31.0 (P) 23.9
Banyuasin 12/07/19
BB 19 kg TB 123 cm PT (K) 13.10 (P) 13.3 INR 1.02 APTT (K) 31.0 (P) 25.9
5/7/19
Hb 4.4 eri 2.73 leu 4.64 ht 17 plt 497 MCV 63.0 MCH 16 MCHC 26 RDW CV 25.00
LED 8 DC 0/3/32/56/9 reti 1.4 amilase 14 lipase 15 LDH 152
Lantai 1 M. Gibran Pratama Post op laparatomi 19/07/19 D5 ¼ NS 10 tpm
Kamar 1 1131643/19021274 ekslporasi ai invaginasi Fe 13 TIBC 175 Ferritin 143.60 Ceftriaxone 2x300mg iv (5)
TL 27/12/18 18/07/19 Paracetamol 3x150 mg iv
MRS 17/07/19 GDT Omeprazol 1x10mg iv
Musi Banyuasin Eri : mikrositik hipokrom Ferrys syr 1x1cth
BB 4 kg PB 54 cm Leu : jumlah normal, left shift (0/0/7/54/27/12)
trom : jumlah normal bentuk normal
kesan anemia mikrositik hipokrom ec inflamasi kronis
Hb 8.7 RBC 3.76 leu 10.31 Ht 27 Plt 411 MCV 71.0 MCH 23 MCHC 33 RDW-CV 13.90 LED 6 DC
0/0/61/27/12 reti 2.0 alb 3.0 ur 11 cr 0.40 BSS 134 Ca 8.0 K 3.7 Cl 112 Na 147
Lantai 1 M. Raiz Alfarizi Kolestasis intrahepatik + 20/07/19 D5 ¼ NS gtt x x/m
Kamar 2 1121116/19021231 ascites ec PT (K) 14.40 (P) 21.8 INR 1.88 APTT (K) 32.7 (P) 53.4 Alb 3.3 Inj Vit K 1x2.4 mg im seri ke-2
TL 16/09/18 hipoalbuminemia + 16/07/19 Albumin 25% 30cc (1)(2)(3)
MRS 17/07/19 hipotiroid kongenital BT 15.80 BD 11.10 BI 4.70 ALP 371 SGOT 170 SGPT 44 GGT 228 Alb 1.8 FT4 0.85 Urdafalk 3x25 mg po
Banyuasin TSH 3.7786 Thyrax 1x25 mcg
BB 8.2 kg PB 65 cm Nystatin 4x1 cc
Lantai 1 Satria Perdana Agustus Marasmus kondisi III 13/07/19 Inj ampicillin 3 x 260 mg iv Jawaban konsul GEH :
Kamar 2 17-08-17 (diare prolong) + anemia Kultur urin: klebsiella oxytoca antibiotic Inj gentamicin 1 x 40 mg iv Lakukan kultur feses
1130408 / 190210499 defisiensi Fe + Ampicillin R Metronidazole 3 x 100 mg po (11) Berikan albendazole 1x400 mg
Belakang pasar pendopo Hematoschezia + Ciprofloxacin S Pemberian albendazole 1 x400 mg (single dose) po metronidazole
empat lawing splenomegaly Gentamicin R (single dose) po 3x100 mg (po)
BB 7.8 Kg PB 78 cm Kotri S F100 6x150cc (LLM) per oral
Lila 9 cm LK 45 cm Ceftriaxone R NB 3 x 1 Jawaban konsul respi:
BB/U <-3SD (7.8/12) Amikasin S Ferriz syrup 3 x 15 mg (5ml) po infeksi TB belum dapat
PB/U -3SD (78/86)  usia Ampicillin I disingkirkan
tinggi 1 tahun 1 bulan Aztreonam R saran: eksplore TB (mantoux, cek
BB/PB <-3SD (7.8/10) Cefazoline R BTA sputum,cekTCM
RDA = 10 x Cefepime S sputum,kultur BTA 1,II)
Kesan : gizi buruk perawakan Ceftazidime R
pendek Ertapenem S
Meropenem S
PiperacillinS
13/07/19
Kultur feces biakan salmonella, biakan shigella
12/0719
Hemversteel yang menempel pada corpus vertebrae T12 susp Spina Bifida T5 cor
dan pulmo normal
12/07/19
Hasil Hb analisa : HB F 0% HbA2 2.2% kesan GDT : curiga anemia defisiensi besi
kesimpulan : analisa HB saat ini tidak bisa dinilai karena pasien defisiensi besi

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 LAPORAN HARIAN GASTROENTEROHEPATOLOGI Senin 22/7/2019
Junior : dr. Septian TM Madya : dr. Rizki Nandasari, dr. Annisa Permatasari Senior : dr Dewi Rachmawati dr Laurentsia

sehingga kadar HbA2 bisa rendah palsu

11/07/19
Hb 7.3 eri 3.88 leuko 5.55 Ht 25 PLT 97 MCV 64.4 MCH 19 MCHC 29 RDW-CV 25.5
LED 18 DC 0/4/36/48/12/2.7 malaria – besi 7 TIBC178 ferritin 12.70
GDT anemia mikrositik hipokrom, anisopoikilositosis dangan trombositopenia curiga
anemia defisiensi besi
BT 0.9 BD 0.5 BI 0.4 fosfatase 104 SGOT 51 SGPT 57 gamaGT12 protein total 5.1
albumin 2.5 globulin 2.6
10-07-19
Kultur feses: salmonella (-), Shigella (-), klebsiella pneumonia ssp pneumonia,
KLebsiella pneumonia ssp pneumonia antibiotic ESBL, morganella morganii ssp
morganii
10-07-19
Feses rutin
Warna merah lunak amobe (-), eri 1-1 leuko 1-2 bakteri (+) jamur (-) telu cacing (-)
sisa makanan (-) lemak malabsosrbsi (-) darah samar tinja (+)
09-07-19
Hb 8.2 eri 4.32 leuko 6.20 Ht 28 PLT 116 MCV 65.0 MCHC 29 RDWCV
26.00 LED 22 DC 0/1/34/45/20/3.5 besi 14 TIBC 207 Saturasi
transferrin 6.7% ferritin 13 GDT anemia hipokrom mikrositer kesan gambaran
thalassemia
Lantai 1 By nuryati binti katiran Hirschprung disease post 9/7/19 D5 ¼ NS 10 tpm
Kamar 2 1130053/19020295 op laparatomy TAPT Plt 462 K 4.6 Metronidazol 3x50 mg po (11)
TL 31/5/19 8/7/19 Asi OD
MRS 8/7/19 Hb 11.0 eri 3.47 leu 6.66 ht 30 plt 14 RDW-CV 14.90 DC 0/2/16/75/7 ur 11 cr 0.46 Ca 10
Kep. Bangka belitung Na 140 K 6.4 Cl 111
BB 4.2 kg PB 56 cm
DPJP : Bedah
Lantai 1 Galang Fariel Alsaki Diare Akut dehidrasi 17/07/19 NaCl 0.9% 75 cc/kg = 650 cc dalam 4 jam
Kamar 2 1126860/19020891 ringam-sedang + muntah GDT NaCl 0.9% 15 tpm
TL 26/2/18 profuse Eri : mikrositik hipokrom, anisopoikilositosis, sel target, eliptosit KaEN 3A 15 tpm
MRS 14/7/19 Leu : jumlah cukup limfosit atipik (0/2/0/36/50/10) Ampicillin 3x550 mg (5)
BB 8.5 kg PB 74 cm trom : jumlah cukup clumping + Gentamisin 1x50 mg (5)
Kesan Gizi baik kesan anemia mikrositik hipokrom anisopoikilositosis, dengan limfosit atipik dan Zinc 1x20 mg
clumping curiga anemia def besi Oralit 50-100cc/BAB cair
Hb 10.3 eri 5.42 leu 10.67 ht 33 plt 216 RDW-CV 22.50 LED 2 DC 0/4/26/61/9 reti 0.8
ferritin 9.80 SI 19 UIBC 302 TIBC 321
15/7/19
Feses rutin :
Kuning lunak amoe – eri 0-1 leu 1-2 bakteri ++
Kuning
14/7/19
Hb 10.2 eri 5.45 leu 9.56 ht 33 plt 322 RDW-CV 22.50 Ca 10 GDS 77 Na 142 K 3.0 Cl 113
Lantai 1 Reza Anugrah Muntah profuse ec 16/7/19 NaCl 15 tpm makro NPM
Kamar 2 1073800/19020912 gastritis kronik LED 17 SGOT 30 SGPT 16 ur 17 cr 0.48 BSS 59 CRP <5 Clinimix 1250cc/24 jam NB 2x1
TL 4/07/2011 Urinalisa Omeprazole 2x20 mg (iv) MC 1.3 5x100cc
MRS 15/07/19 Kuning jernih bj 1.025 ph 5 keton + urobil 1 epi + leu 0-1 eri 0-1 bakteri - Sucralfat syr 3x5 ml (po)
Banyuasin 15/7/19 Aspilet 1x50 mg (po)
BB 14 kg TB 115 cm Hb 11.7 eri 4.78 leu 25.07 ht 35 plt 430 RDW CV 14.70 DC 0/0/92/6/2 BSS 145 ca 10 na Domperidone 3x3 ml (po)
Kesan : gizi buruk 147 k 4.6 Propranolol 3x3mg po

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 LAPORAN HARIAN GASTROENTEROHEPATOLOGI Senin 22/7/2019
Junior : dr. Septian TM Madya : dr. Rizki Nandasari, dr. Annisa Permatasari Senior : dr Dewi Rachmawati dr Laurentsia

Lantai 1 Fildan Sultan Alfarez Kolestasis ekstrahepatik + 22/07/19 D5 ¼ NS kec 10 tpm mikro
Kamar 2 1103649/19020915 edema anasarka + PT (K) 14.60 (P) 28.0 INR 2.55 APTT (K) 30.8 (P) 70.2 BT 32.00 BD 18.00 BI 14.00 Urdafalk 2x90 mg po
TL 07/09/18 Hipoalbuminemia ALP 123 SGOT 108 SGPT 39 GGT 19 Alb 3.4 Furosemide 2x10 mg iv
MRS 15/07/19 18/7/19 Inj vit K 1x3 mg im
OKU Alb 2.6 N-asetylsistein 2x100 mg po
BB 19 kg PB 64 cm 17/07/19 Albumin 25 % 36 cc (1)(2)(3)
Urinalisa Ampicilline 3x600 mg (7)
Kuning jernih bj 1.010 ph 6 keton - urobil 4 bilirubin + epi - leu 0-1 eri 0-1 bakteri - Gentamisin 1x 40 mg (7)
15/7/19 Pregistimilk 8x60 cc
Hb 8.5 eri 2.99 leu 9.95 ht 28 plt 159 RDW CV 19.90 DC 0/2/51/38/9 PT (K) 14.60 (P)
29.5 INR 2.72 APTT (K) 29.5 (P) 67.6 BT 17.50 BD 12.10 BI 5.40 ALP 222 SGOT 208
SGPT 67 GGT 31 Alb 1.5 ur 9 cr 0.42 ca 8 na 138 k 4.2 cl 109
Lantai 1 Kenzo Putra Anemia + trombositopenia 17/07/19 IVFD KaEN 3A maintenance
Kamar 4 1122896/19021172 ec CML + Diare akut Feses rutin Ceftriaxone 1x680 mg iv (6)
TL 21/10/18 tanpa dehidrasi Hijau lunak lendir amoe – eri 0-1 leu 0-1 bakteri ++ telur cacing – lemak – darah samar Zinc 1x20mg
MRS 16/07/19 tinja – Oralit 100cc/bab cair
Palembang Hidroxiurea 1x1250 mg po
BB 8.5 kg PB 70 cm PRC 1x120 cc
DPJP : Hemato TC 3x2 unit
Lantai 2 Kyla Suciansyah/Pr/7 tahun PHS relaps + Gastritis 18/07/19 IVFD D5 ¼ Ns gtt X
Kamar 4 bed 604146/RI19020377 erosiva Urinalisa : kuning, agak keruh, BJ 1.005 pH 7.0 protein (++) asc ac (-) gluko (-) keton (-) darah (++ Metilprednisolon 1 x 5 mg iv (1)  3 x 12.5
4 TL: 24-3-2012 +) bilirubin (-) urobil (1) nitrit (-) lekosit est (+) epitel (-) leu 6-10) eri (3-5) slinder (granular ++) mg iv
MRS: 08-07-2019 (P10) TDS TDD kristal (-) bakteri (+) mukus (-) jamur (-) Ceftriaxone 1 x 1.5 mg iv drip (12)
Alamat: Kertapati, palembang P50 93 56 16/7/19 Omeprazole 1 x 20 mg iv
Raber GEH Hp. 0858-3282-9232 P90 107 70 Hb 11.1 eri 4.13 leu 27.03 ht 33 tromb 758 RDW-CV 13.60 LED 35 DC 0/1/57/33/9 ca 9 na 140 K Ranitidin 2 x 25 mg iv
P95 110 74 5.3 Cl 105 crp 11 Surafat 3 x 6 mg syr po
BB: 15 kg TB: 114 Cm P99 117 81 14-07-2019 Ca glukonas 10% 7cc + D5% 3cc/8jam 
DPJP BB/U: 15/23 < P5
BNO 3 POSISI stok kosong
Dr. Yusmala, TB/U: 114/122 P5-P10
Preperitoneal line, psoes line kanan-kiri tidak jelas. Ontur kedua ginjal tidak jelas. Distribusi Captopril 2 x 12.5 mg (po)
Sp.A(K) BB/TB: 15/20 x100% = 75%
Kesan: gizi kurang udara dalam usus-usus berlebih di abdomen tenggah. Pada posisi tegak dan lateral dicubitus;
free air (-), air fluid level (-). Tulang-tulang yang tervisualilasi baik. GEH
± 3 Minggu Smrs, pasien mengeluh Kesan: ileus lokal di abdomen tengah A/ GIT bleeding ( pendarahan saluran
nyeri perut, hilaang timbul yang 13-07-2029 cerna) mungkin berkaitan dengan penyakit
dirasa semakin sakit. Mual (+) Ca 8.0 Fosfor 3.8nMg 2.10 Na 139 K 3.7 Cl 108 PHSnya
muntah (+) fr > 4x, demam (-), 12-07-2019
bayuk (-), pilek (-), Bak merah (-), Gastroskopi NPM
bab campur darah (+) nyeri sendir Esofagus: mukosa dalam bata normal A/ gizi kurang, perawakan pendek, feeding
(-) Gaster: lumen: banyak terdapat sekret kental dilakukan aspirasi problem ec gastritis erosif luas dd/ susp.
Kardial dan fundus: mukosa dalam batas normal Gastritis henoch schonlein
Korpus eosri pada banyak tempat, ulkus (-). P/ rute: oral
Antrum: hampir seluruh permukaan mukosa mengalami erosi. Pendarahan (-) Formula:
Duodenum: bulbus: mukosa erosi lebih dari 10 lokasi. Pars descenden: mukosa dalam batas Bubur/nasi tim 3x1porsi
normal Fullcream 3 x 200
11-07-2019 Snack 2 x
PT 13.50 APTT 28.2 INR 1.04 Protein totl 4.9 Alb 2.8 amilase serum 17 lipase 15 HBsAg non D10% 1200 cc/24jam
reaktif anti HCV non reaktif reagen 1 non reaktif Monitoring efikasi, toleransi, aksetabilitas

USG
Hepar ukuran 9.8 cm (7.5-13 cm)
Lien ukuran 6.17 cm (suggested 10 cm)
Gallbladele ukuran (6.4 cm)
Ginjal dextra ukuran 6.8 cm (suggested 9.8 cm)

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 LAPORAN HARIAN GASTROENTEROHEPATOLOGI Senin 22/7/2019
Junior : dr. Septian TM Madya : dr. Rizki Nandasari, dr. Annisa Permatasari Senior : dr Dewi Rachmawati dr Laurentsia

Ginjal sinistra ukuran 7 cm (suggested 9.8 cm)

09-07-2019
Hb 12.9 eri 4.86 leu 28.99 ht 38 tromb 652 RDW-CV 13.20 DC 0/0/90/8/2 SGOT 17 SGPT 8 Ur 21
Cr 0.37
Urinalisa : kuning, agak keruh, BJ 1.025 pH 6.0 protein (+) asc ac (-) gluko (-) keton (-) darah (++)
bilirubin (-) urobil (1) nitrit (-) lekosit est (-) epitel (-) leu 10-15) eri (25-30) slinder (granular ++)
kristal (-) bakteri (++) mukus (++) jamur (-)
Feses rutin : kuning kecoklatan, lembek, amoba (-) eri (0-1) leu (0-1) bakteri (+) jamur (-) telur
cacing (-) sisa makanan (-), lemak (-), darah samar (+)
Lantai 3 By. Ny. Fransiska Meteorismus + sindroma 19/07/19 D5 ½ ns 20 cc/jam
Kamar 1131608/19021100 down + susp. Hipotiroid BT 2.90 BD 2.00 BI 0.90 LDH 456 Ca 7.0 Toxo IgG 70.50 IgM 4.36 Rubella IgG 0.10 IgM 0.14 CMV Cefotaxim 3x250 mg (6)
TL 27/05/19 kongenital + susp CHD IgG 42.00 CMV IgM 4.08 HSV IgG 0.2610 IgM1.0253 Paracetamol bila T>38.5
MRS 16/07/19 asianotik 16/7.19
Kertapati, Palembang GDT
BB 5.1 kg PB 55 cm Eri : normositik normokrom anisositosis
Leu :jumlah cukup morfologi dalam batas normal 0/5/6/23/58/8
trom : jumlah cukup morfologi dalam batas normal
kesan : anemia nromositik normokrom anisositosis, curiga anemia penyakit kronik
Hb 6.8 RBC2.40 leu 4.18 Ht 22 Plt 197 MCV 90.8 MCH 28 MCHC 31 RDW-CV 16.10 LED 61 DC
0/4/26/64/6 reti 2.3 SGOT 94 SGPT 32 alb 3.2 au 2.0 cr 0.40 Ca 142 K 4.2 Cl 113 FT4 0.83 TSHs
2.82245 CRP <5
NICU By Ny. Susi Anggraini NKB-SMK + BBLR + 18/7/19 IVFD D10 1/5 NS + KCl 26 cc kec 3.5 cc/jam
1130495/19020342 Kolestasis Intrahepatik + Hb 10.5 eri 3.00 leu 22.56 ht 29 plt 212 RDW CV 21.60 LED 4 DC 1/4/70/17/8 it rasio Aminosteril 6% kec 2.5 cc/jam
TL 14/06/19 Hidrokel + DSD 0.20 BT 16.60 BD 12.30 SGOT 277 SGPT 249 Alb 2.8 ur 21 cr 0.36 ca 9.0 Na 144 K 4.8 Albumin 25% 11 cc (1)(2)(3)
MRS 09/07/19 Cl 114 CRP <5 PRC 30cc 20cc
Prabumulih Amikasin 1x25 mg iv
BB 2305 gr PB 51 cm Urdafalk 3x20mg po