KORAN PASIEN BEDAH ANAK TANGGAL 9 Juli 2019

Total pasien 29 (FNM 2, AW 3; NT 5; UM 10; TH 9)

NICU: 6; L2: 6; L3: 6; L4: 1; PICU: 2; IGD: 4; RSUH: 2; PCC 2

NICU: 6 pasien

TH 4; UM; 1, NT; 1

NICU
No IDENTITAS DIAGNOSIS PLANNING Ket.
1. By.Ny.Fitri Stenosis duodenum -Terapi cairan dan antibiotic Lab 03/07/2019
TH Handayani sesuai Ts. Pediatri Na/K/L. 132/3.3/101
18 Juni 2019 - Puasa 28/6/2019
887412 - Pantau produksi OGT/24 jam WBC 7.7
IIA - Rencana operasi HB 15.9
duodenoduedenostomy, tunggu PLT 500
jadwal Bil total/bil direk
14.34/0.89
Prokalsitonin 0.50
2. By.Ny.Yuliana -Post-eksteriorisasi ileum proximal - Observasi tanda vital Lab 05-07-2019
UM 16 April 2019 ec ruptur omphalocale yang telah - Terapi cairan dan antibiotic SGOT: 42
881366 dilakukan + reseksi anastomosis sesuai Ts. Pediatri SGPT: 25
IIB ileum-ileum (H-25) - Rawat luka Na/K/Cl: 123/5.3/97
-Wound dehiscence - Enteral: 8 x 11 cc (ASI/susu
-Sepsis neonatroum formula) Lab 03-07-2019
- Bolus 5 cc ASI via stoma distal Calcium 9.9
- Masukkan produk stoma
proximal ke stoma distal Lab 30/6/2019
WBC 16.3
HB 12.4
PLT 339
Albumin 3.6
Na/K/Cl 135/5.8/106
3. By.Ny.Ecce - Post-repair defect ec Hernia - Awasi vital sign Lab 02-07-2019
NT Rahmawati Diafragmatika sinistra hari ke 14 - Terapi cairan dan antibiotic WBC 22.0
9-6-19 - Sepsis neonatorum sesuai Ts. Pediatric HB 12.5
886491 - Rawat luka per hari PLT 327
IIIA - Slinger tiap pagi, feses +, flatus + Na/K/Cl 140/3.4/111
4. By. Ny Salma Daud - Atresia intestinal Type III B post - Rawat luka Lab 3-7-2019
TH 19-4-19 ileostomy - Terapi cairan dan antibiotic Na/K/Cl 131/2.7/101
881218 - Post laparotomy reanastomosis sesuai Ts. Pediatric
IIIA ileum H-12 - Enteral 8 x 2 mL Lab 02/7/2019
- Fistel enterocutaneus - Rencana relaparatomy WBC 10.9
anastomosis ileum, tunggu HB 9.5
optimalisasi elektrolit PLT 517
Na/K/Cl 122/3.0/92

28/6/2019
Albumin 3.6
5. By Ny Dahlia POH-3 Divided colostomy ec MAR - Cefotaxim 100 mg/12jam/iv Lab 05-07-2019
TH 10-06-2019 letak tinggi dengan fistel - Paracetamol 30 mg/8jam/iv WBC 25.7
887946 rectovesica - Metronidazole 20 mg/12jam/iv HB 12.5
IIIA - Ranitidin 5 mg/12jam/iv HCT 37
- Puasa, rencana diet tunggu acc PLT 280
dpjp Prokalsitonin 18.3
GDS 439
 - Observasi ketat vital sign dan
tanda akut abdomen Lab 03-07-2019
- Terapi cairan dan parenteral WBC 29.7
sesuai TS. Pediatri NICU HB 11.5
- Enteral: stop intake oral HCT 34
- Rawat luka PLT 515
PT/APTT 14.5/24.7
GDS 78
Ur/Cr 68/0.46
SGOT/SGPT 75/31
Na/K/Cl 135/3.2/99
6. By.Ny.Rismayanti Ileus obstruktif suspek hirschprung -Awasi tanda akut abdomen Lab 06-07-2019
TH 12-6-19 disease -Terapi sesuai Ts. Pediatri WBC: 9.7
887291 - Optimalisasi KU HGB: 14.9
IIA - Rencana biopsy recti PLT: 44

Lab 04-07-2019
WBC: 6.5
HGB: 9.1
PLT: 39

Lab 03-07-2019
GDS: 54
7. By. Ny. Siska Suspek MAR Letak Tinggi Rencana divided colostomy Babygram 6/7/19
TH 30-6-2019 Fistel rectrourethra Optimalkan keadaan umum Kesan:
888219 Pneumonia bilateral Terapi sesuai TS Pediatri Udara usus tidak
IIB terdistribusi hingga
distal colon
Pneumonia bilateral
Terpasang gastric tube

L2AD: 6 pasien

FNM 2; TH 2; NT 1; UM 1

L2AD
No IDENTITAS DIAGNOSIS PLANNING Ket.
1. Yustisiya Dwi Peritonitis ecausa appendicitis - Cefadroxil 500mg Lab (3-7-19)
FNM 25-1-19 (16thn) perforasi post laparotomy kaps/12jam/oral WBC 9.87
845649 appendectomy hari – 12 - Metronidazole 500 RBC 3.04
K12.1 mg/8jam/oral HGB 8.9
- Sucralfat syrup 5ml/8jam/oral HCT 27.4
- Terapi lain sesuai TS pediatrik PLT 597
Histopatologi:
Kesan suatu
periappendisitas kronik
dapat menyokong
suatu perforasi
2. By.Ny Asti POH 6 PSARP -Cefadroxil syr 5ml/12jam/oral Lab (21-6-19)
TH 5 bulan 3 hari MAR letak tinggi -Metronidazole WBC 12.3
871605 post divided colostomy 500mg/8jam/oral Ur/Cr 4/0.16
K12.2 -Paracetamol 500mg/8jam/oral SGOT/SGPT 0.53/33
-Spooling kateter urine
500cc/24jam
-Diet bebas
 -Miring kiri-miring kanan, tidak
boleh terlentang
3. By.Ny Mariati -MAR letak tinggi tanpa fistel -Eritromycin 80 mg/12jam/oral Lab (4/7/19)
NT 4 bulan 14 hari -post divided colostomy -Metronidazol 40 mg/8jam/oral HGB 10.6
874380 -Nebulizer NaCl 0.9%/12jam HCT 32.8
K12.3 -Spooling stoma distal 2 kali PLT 623
dengan 80 cc NaCl 0.9% UR/CR 5/0.03
-Terapi lain sesuai TS pediatri
-Rencana operasi PSARP tanggal
08/07/2019
4. Rafika Iskandar -Ileus obstruktif total ec susp -menunggu hasil lopografi Lab (3-7-19)
FNM 13 tahun 9 bulan invaginasi post ileostomy -Terapi sesuai TS pediatri Na/K/Cl 127/2.3/77
880558 -Malnutrisi
K12.5 -Imbalance elektrolit
(hiponatremia dan hipokalemia)
-Post santulli procedure pada
jejunum
5. Khumayrah -Burst abdomen -Infus Asering 1000cc/24jam Lab (4-07-2019)
UM Ramadani -Fistel enterokutan -Ceftacidine 500 mg/12 Hb 10.7
7 tahun 10 bulan -Post Laparatomy Appendectomy jam/intravena HCT 35.3
887326 - Trombositosis -Metrodinazole
K12.6 - Anemia 250mg/8jam/intravena
-Paracetamol 500
mg/8jam/intravena
-Ambroxol syrup 5ml/8jam/oral
-Terapi lain sesuai pediatri
-Rencana operasi 08/07/2019
6 Uwais Ubaidillah Higroma colli dextra - Rencana skleroterapi Lab (19/06/2019)
TH 3 tahun 2 hari WBC 9.0
831986 RBC 4.31
K12/4 HB 12.3
HCT 36.8
PLT 455
Na/K/cl 129/4.3/107

L3AD : 6 pasien

AW 2; TH 2; NT 1; UM 1

No IDENTITAS DIAGNOSIS PLANNING Ket.

1. Nur Agni Fadilah POH 18 laparotomi removal tumor • Ceftriaxone Lab 3-7-19
TH 14-6-19 ovarium 800mg/8jam/iv AFP : 280.30
884599 • Ranitidin 25mg/12jam/iv Ca 125 : 410.28
K3.6 • Paracetamol Lab 6-7-19
500mg/8jam/iv WBC 17.0
• Diet bubur saring + susu Hb 10.3
• Terapi lain sesuai TS PLT 752
pediatric
• Komfirmasi hasil PA
ulang rencana hari ini
• Usul terapi oral dan aff
infus

2. Daud mappaselling Tumor coli sinistra + spondylitis TB - Rencana operasi Selasa, 9 Lab (25-06-19)
AW 10-7-2003 suspek malignancy Juli 2019 Wbc 5.48
881310 Hb 11.5
 K3.4 - Inj Cefotaxim Plt 512
1gr/12jam/iv
- Inj metronidazole
500mg/8jam/iv
- Terapi lain sesua TS
Pediatric
3. Ahmad Reza POH-6 Urethroplasty Etcausa - Spooling kateter setiap Lab ( 24-06-2019)
TH 10-10-2009 Hypospadia Penoscrotal hari Wbc 7.4
865526 - Aff infus Hb 11.7
K3.3 - Cefixime 2 dd 1 cth PLT 397.000
- Paracetamol syr 3x 1cth Ur/cr 18/0.50
- Diet TKTP Na/k/cl 138/4.3/104
- Mobilisasi jalan

4. Kaisar Maulana POH – 8 Reanastomosis colon - Ceftriaxone Lab (6-7-19)

AW 22-11-12 sigmoid + biopsy 500mg/12jam/intravena Wbc 5.8
878791 - Paracetamol Hb 11.6
K3.1 400mg/8jam/intravena Plt 531
- Diet susu 50cc/4jam
- Rawat luka

5. By.Ny.Sulaeha Fistel perianal post fistelectomy hari - Ceftriaxone Lab 25-06-2019

NT 21.03.2019 ke 1 125mg/12jam/intravena WBC 8.7
886254 Hb 11
K3.2 PLT 523

6. Alam saputra Suspek hirschsprung disease Lab 24-06-19

UM 8.4.2010 Post biopsy rectum fullthickness hari 1. Ceftriaxone WBC 9.5
886082 ke 1 500mg/12jam/intravena Hb 12.5
K3 5 PLT 363.000
GDS 95
Ur/cr 11/0.60
Na/K/cl 140/4.4/104

L4AD DAN L4AB : 1 pasien

UM 1

L4AD DAN L4AB

No IDENTITAS DIAGNOSIS PLANNING Ket.
1. Nur afifah shauma Suspect atresia billier belum dapat Cek msct scan abdomen dengan lab 3/7/19
UM adawiah amlin disingkirkan kontras Wbc 9.8
Tgl lahir 18/5/19 Lainnya : konfirmasi jika ada hasil Hb 8.6
887728 Plt 611
L4AB K7B6 HASIL MSCT Scan Abdomen
dengan kontras (08/07/2019) (MSCT Abdomen tanpa
(konsul) Kesan: Kontras 04/07/2019)
- Tidak tampak tanda- Kesan :
tanda kolestatik -gallbladder sulit
- Meteorismus dievaluasi
-Organ intraabdomen
lainnya dalam batas
normal

(Usg abdomen)
 Kesan : sugestif atresia
billier

PICU : 2 Pasien

UM 2

PICU
No IDENTITAS DIAGNOSIS PLANNING Ket.
1 By. Ny. Niran Limfangioma colli sinistra - Konsul perioperative pro USG Doppler :
UM 3 bulan Pneumonia skleroterapi, senin (8/7/19) gambaran
886946 - terapi sesuai Ts anak limfangiomakistik regio
Bed 9 - optimalisasi keadaan umum colli sinistra
MSCT Leher (1/7/2019):
Kesan: gambaran
hygroma collii sinistra
Lab (7-7-19)
WBC 7.2
Hb 8.7
Plt 314
Lab (4-7-19)
Alb 3.1
Na/K/Cl 133/5.5/94
2 By Ny. Indrawati POH 11 Abdominal Pullthrough Ceftriaxone 200 mg/ 24 jam/ IV Lopografi (14/06/19)
UM Patangka Paracetamol 50mg/8jam/iv kesan : malformasi
2 bulan MEBO Zalf anorectal dengan
879590 rawat luka gambaran fistel
Bed 6 ganti verban tiap hari rectovesica
foto babygram dalam
batas normal
lab (2-7-19)
WBC : 8.8
HB : 13.8
PLT : 365

IGD : 4 Pasien

UM 3; TH 1;

IGD
No IDENTITAS DIAGNOSIS PLANNING Ket.
1 Azril Fauzan/ 25-1- Hichsprung disease associated IVFD KAEN3B 850cc/24jam Lab (4-7-29)
UM 2018/ 831654/ UGD enterocolitis (HAEC) Ceftriaxone 400 mg/12jam/iv WBC : 7.65
Bed 5 Metronidazole 85 mg/8jam/iv HB : 11.2
Ranitidin 10 mg/12jam/iv PLT 432
Rectal washout max 20cc/kgBB HCT 33.5
Na/K/Cl: 131/3.5/99
GDS 125
2 Muh asyam Aqil/03- Fistel enterokutan Infus asering LAB (3-7-19)
UM 05- Cefotaxime 350mg/12jam/iv WBC : 8.9
2013/833381/ugd Transfusi prc 10cc/kgbb HB : 11.8
PLT : 770
HCT : 41
GDS 91
3 Nurul Yasmin Higroma colli sinistra Konsul pediatric Lab (01-07-19)
UM basri/30-03-2019 Rencana eksisi WBC: 8.4
 HB : 11.8
PLT 488
HCT
Na/K/Cl:135/5.2/105
Gds 91

4 By.Ny. Indah Hiscphrung disease Pasang Rectal tube decompresi Lab (6-7-19)
TH pradipta/06-03- selama 6 jam Wbc 12.53
2019/888223 Rectal high out 10cc/kgbb Hb: 10.3
Rencana biopsi rectum Plt : 439
fullthickness Hct 32.3
Na/K/Cl :
135/101/1.9
Gds: 94

RSUH : 2 pasien

UM 1; NT 1

RSUH
No IDENTITAS DIAGNOSIS PLANNING Ket.
1. Fauziyyah Ode Engke POH trans anal pull through (swason- - infus asering 400-450 cc/24 Lab (27/6/19)
UM 13-2-2019 like) et causa Hirschprung disease jam WBC 16.78
100022 - Cefotaxime 450 mg/12 jam/iv HGB 11.2
Katinting A K426 titip -Metronidazole 125 mg/8 PLT 583
kelas 3 jam/oral
-Paracetamol 125 mg/4 jam/iv
-Puasa sampai instruksi
selanjutnya
-Asam traneksamat 250
mg/8jam/iv
2. Pabian Yogi Prasetyo Epididimoorchitis sinistra dd/torsio -IVFD RL 1000 cc/24 jam Lab 3/7/2019
NT 22-11-12 testis -Cefotaxime 1 gr/12jam/iv WBC 7.80
122629 -Metronidazole 350 mg/8 RBC 5.41
Katinting A K426 jam/iv HGB 14.4
-Paracetamol 350mg/8jam/iv HCT 41.1
-Ranitidine 25 mg/12 jam/iv PLT 332
-Diet bebas MCV/MCH 76/26.6
-Bed rest
-Methylprednisolon 2 mg/8
jam/oral
-Betametason salep: oles di
scrotum

PCC : 2 pasien

AW 1; NT 1

PCC
No IDENTITAS DIAGNOSIS PLANNING Ket.
1 Noer Syamsu Pratama POH 1 herniotomi ec hernia -Pasang tampon Lab
AW 25-1-2018 inguinalis lateralis dextra -Puasa sampai instruksi WBC 8.0
831654 inkarserata selanjutnya RBC 4.85
Kamar 404 -Infus RL 20 TPM HGB 11.2
-Ceftriaxone 1gr/12 jam/iv HCT 34
-Omeprazole 2 gr/24 jam/iv PLT 389
 -Paracetamol 250 mg/8jam/iv MCV/MCH 70/33
-Rawat luka MCHC 33
Na/K/Cl 141/4.3/104

2 Muh. hipospadiapenoscrotal - foto thorax sudah ada

NT Nafis/5tahun/887872/PCC - lab lengkap sudah ada dari
Kamar 414 poli
- pro uretroplasti