KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

PALEM ATAS N o Bed Identitas Diagnosis Pemeriksaan Penunjang Terapi 650884 Dr. Samuel S. Sp. B. KBD acendence WBC 9,7 Ur 34 Cr 0,8 GDS 76 LAB 3/3/14 Ph 7,59 pCO2 20,1 pO2 104,1 SO2 98,6 Eecf -7 HCO3 16,2 O2Ct 13,8 As laktat 7 LAB 2/3/2014 WBC 12,66 RBC 4,31 HGB 8,8 HCT 28,1 PLT 700 Alb 2,5 Na/K/Cl 127/3.2/101 17/2/14 GDS : 61Pro. Total : 4,8 Albumin : 2,2 WBC : 11,45 RBC : 4,449 HB : 9,4 HCT : 29,7 MCV : 66,1 MCH : 20,9 PLT : 223 PA 18/2/14 Adenocarcinoma colon difrensiasisedang, dengankeduaujungi nsdsbebas tumor LAB 11/3/2014 GDS 132 GD2PP 170 Safri Laki-laki 12-12-69 645747 JKN Dr. Samuel S, Sp. B-KBD LAB 9/3/14 RBC 4,41 Hb 12,0 HCT 36.9 PLT 450 WBC 8.4 Bil. total 1,02 Prot. Tot. 3.89 Kol. Tot. 158 HDL 34 LDL 93 TG 156 4/3/14 GDS 93 HbA1c 6,1 Ur/Cr 32/0,65 GV Cermevit 1 amp/24 jam/drip

B2/6 WS

Muntaha 01/07/1955 Laki-laki MRS 10/03/2014 Dr. Warsinggih, Sp.B.KBD

POH 4 Colostomi + Fistektomi

Lab (11/03/2014) WBC 8,16 RBC 4,23 HGB 12,4 HCT 36,6 PLT 233 CT/BT 3/7,30 PT/APTT 11,7/22,5 INR 0,97 Ur/Cr 35/1,0 GOT/GPT 18/25 Alb 3,8 Na/K/Cl 145/5,6/116

IVFD RL 16tpm Ceftriaxone 0,5g/8j/iv Metronidazole 1amp/8j/iv Ketorolac 1amp/8j/iv Ranitidin 1amp/8j/iv Mobilisasi GV pagi sore Diet lunak Kultur darah

B2/4 RL

Ny. Nimrah 20-10-1980 Perempuan MRS 14/3/2014 Dr. dr. Ronald EL, Sp.BKBD Yohan Sampe Limbong 391632 23-12-1950 Laki-laki MRS 17-32014 Dr. Samuel S, Sp. B-KBD

Polips Recti + Hemoroid grade III

Lab (15/3/2014) RBC 4,54 WBC 9,3 Hb 10,6 HCT 32,7 MCV 72 MCH 23,4 PLT 419

Adona 3x1 Rencana LGIE rabu

B2/2

HIL dextra residif

Lab (14/3/2014) RBC 5,30 WBC 10,2 Hb 14,9 HCT 45,1 MCV 85 MCH 28,1 PLT 232 GOT/GPT 15/13 GDS 112 Ur/Cr 7/3 As urat 6,5

Rancana operasi Rabu 5 B2/6 Bed 1 SS

Ileus obstruktif parsial

Rencana operasi Laparotomi eksplorasi Rabu, 19 Maret 2014

B1/4 SS

Tn. JK samban 10/9/1940

PALEM BAWAH POH 31 Lab 3/3/14 Hemicolectomy RBC 4,29 Hb 8,8 dextraec. Tu. Colon HCT 28,2 PLT 397

Ciprofloxacin 2x500mg VIP Alb 3x2 Antasida 3x1

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

PA (13/1/14) Kolesistitis kronik CT (5/3/14) Pneumobilier Pankreatitis kronis Lab (08/03/2014) WBC 8,7 RBC 3,49 HGB 10,9 HCT 32 GDS :96 Ur/Cr : 34/0,5; SGOT/SGPT : 15/14; prot total : 5,8; alb : 3,5; Lab (4/3/14) WBC 5.02 RBC 2.86 HB 7.7 HCT 24.0 PLT 408 UR/CR : 92/12.3 Na 130 K 4.4 Cl 96 Lab (26/2/2014) CT 7.00 BT 2.30 PT 13.1 INR 1.10 APTT 23.7 RBC 2.45 HB 6.9 HCT 20.8 PLT 475 WBC 4.5 Na 131 K 4.0 Cl 99 Ur/Cr : 85/9.15 USG Abd (25/2/14) - PNC bilateral -Ascites & efusi pleura bilateral Lab (12/03/2014) RBC : 4,16; WBC : 10,0; HGB : 14,0; HCT 42,8; PLT :212; Ur/Cr : 25/0,92; Albumin : 3,8; Na/K/Cl : 130/4,0/103; GDS : 112; bil.total : 12,21; bil. Direk : 9,61; CT/BT :7,00/3,00; PT/APTT : 14,7/28,6; INR: 1,23 Lab (12/3/2014) WBC 7,4 RBC 3,79 HB 10,7 HCT 32,4 PLT 312 PT/APTT 11,9/22,4 INR 1,00 GDS 222 Ur/Cr 59/2,60 GOT/GPT 28/18 Na/K/Cl 139/3,3/109 Lab (07/03/2014) Ur/Cr : 96/3,89; Albumin : 2,2; Na/K/Cl : 139/3,9/104; RBC : 4,38; WBC : 8,70; HGB : 12,4; HCT 37,0; PLT : 229; Hasil lab 4/3/2014 RBC: 4.73, HGB:15.0, HCT: 43.9, PLT:263, WBC: 11.2, BT:3, CT:7, PT:12.3, INR:1.03, APTT:25.6, GDS: 99, UR: 26, CR: 0.8, SGOT/SGPT:30/2 2, Alb:3.9, Na: 145, K: 3.9, Cl: 104, LAB 15/3/2014 WBC 8.4 RBC 3.07 Hb 8.9 HCT 26.6 PLT 269 Ur/Cr 89/10.10 As. Urat 8.9 Na/K/Cl 135/4.8/105 CT/BT 7/230

B 2/13 Bed 2 RL

Nurbaety Perempuan 31-12-77 647967 MRS 8-32014 Dr. dr. Ronald EL, Sp.BKBD

Wound rehisensi post laparotomi

Levofloxacin 2x1 tab GV/hari Mobilisasi jalan Diet biasa 9 B2/5 Bed 1 WS

B2/5 Bed 1 WS

I Bunga 01/12/1930 JKN 639124 Perempuan Dr. warsinggih, Sp.B.KBD

CKD Stage V POH 6 CAPD

Terapi sesuai TS interna GV Ciprofloxacin 2x500

B2/4 bed 1 WS

Sulaeman 5/5/1967 651234 JKN MRS 15/2/2014 Dr. warsinggih, Sp.B.KBD

CKD stg V POH 7 CAPD Jadwal HD : selasa jumat

Ceftriaxon 1 gr/12 jam/iv Ranitidin 50 mg/8 jam/IV Ketorolac 30 mg/8jam/iv GV/3 hari Diet biasa B1/bed 1 653261 JKN MRS 11/3/2014 SS Rabiun 59 tahun 14-8-1954 Laki-laki dr. Samuel Sampetoding, Sp.B-KBD

10

POH-5 Herniotomy unilateral + Hernioraphy

IVFD RL:D5 500:500, 100 cc/24 jam Ceftriaxone 1 gr/12 j/iv Ketorolac 1 amp/8 j/iv Ranitidin 1 amp/8 j/iv Minum bebas Pertahankan kateter 2 minggu

B2/10 IL

Akhmad nasrul 31/12/1963 Laki-laki JKN 14/03/2014

Batu CBD + GB Stone

Ciprofloxacin 2x500 Vit. K 1 amp/24 jam/IM Rencana operasi tgl. 19/3/2014

11

B2/1 644804 Jkn WS

Rafael LT 04/08/1983 Laki-laki MRS 12/03/2014

POH-2 post CAPD

Ceftriaxon 1 gr/12 j/iv Metronidazole 0,5g/8j/iv Ranitidin 50 mg/8j/iv Ketorolac 30 mg/8j/iv Aff kateter

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

PT/APTT 12.4/25.0 INR 1.10 LAB 12/3/2014 WBC 6.3 RBC 2.85 Hb 8.2 HCT 25.0 PLT 261 Ur/Cr 65/7.80 Alb 3.7 Na/K/Cl 135/4.9/108 PT/APTT 12.6/22/3 INR 1.10 Lontara 1 Lab 13/3/2014 RBC 6,26, WBC 9,0 HGB 17,3 HCT 51,0 PLT 254 GDS 167 UR 106 CR 1,80 BIL TOT 1,47 BIL DIREK 0,48 GOT 32 GPT 30 ALB 3,5 PROTEIN TOTAL 7,6 NA/K/CL 134/3,8/106 HBSAG (+) PT 12,7 APTT 20,5 INR 1,10 BNO 3 POSISI 13/3/14 KESAN: gambaran ileus obstruktif Lab 15/3/2014 RBC 5.57, WBC 9.5, HB 15, HCT 45.8, PLT 214, BT 330, CT 800, PT 15,8(11,8), APTT 36.3 (25.2), GDS 169, Ur 78, Cr 1.30, GOT 21, GPT 30, Na 137, K 3.1, Cl 112 Thorax (12/3/14) Cor & pulmo normal, tidak tampak tanda-tanda metastase pada foto 652564 JKN MRS 26/2/2014 thorax ini CT abd (11/3/14) Sesuai gambaran massa colonascendens, efusi pleura minimal bilateral Colonoskopi (7/3/14) IBD (proktitis) derajat sedang tumor kolon (ascenden/saekum) curiga malignancy Lab 4/3/2014. RBC:4.48, WBC:6.6, HBG:11.2, HCT:34.9. Lab (1/3/14) RBC 3.92 HGB 9.6 HCT 29.9 PLT 475 WBC 8.2 Lab (27/2/14) GDS 104 CEA 1.24 CT 7.00 BT 3.00 PT 13.2 INR 1.10 APTT 29.7 CT Scan 26/2/14 Kesan: massa proksimal colon ascenden Lab(12/3/14) Protein total 3.9 albumin 2.1 CEA 2.26 USG Abdomen (4/3/14) Kesan : ascites MSCT abd (12/3/14) Kesan : Massa recti (DUKES B) Colonoskopi 7/3/2014 Kesan:-hemorroid externa -hemorroid interna Lapor OK Konsul anestesi Siap darah Antibiotik profilaksis Klisma 2kali

12

L1AD K1/Bed1 MP

Johanis Toding 9/11/1954 654912 JKN

POH 3 Hortman Procedure

IVFD RL : D5 1:1 Ceftriaxone 1gr/12j Ketorolac /8 jam Ranitidine /8 jam Boleh minum sedikitsedikit Mika-miki Rawat kolostomy GV

14

L1 BB K7/III/Bed 2 (MP)

13

L1AB K4/III/6 (MP)

Haruna Dg Ngempo, 42 tahun 1/12/1971 Laki-laki

Risal HN 26 tahun 10-1-1988 Laki-laki 622305 JKN MRS 24/2/2014

Adenocarcinoma Recti 1/3 Distal Diferensiasi Sedang

-Tunggu hasil analisa cairan -Tunggu hasil perioperatif -Cek Hb post transfusi 8.6 -Transfusi PRC 2 bag

Post Op. Laparotomy Eksplorasi

-Rencana operasi Selasa 18-3-2014 -Persiapan operasi: Inqformed consent

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

gr 2 -tumor rectum curiga malignancy Lab 13/3/2014 WBC 5.90, RBC 3.14x106, HGB 9.1, HCT 26.6, PLT 378 Lab 14/3/2014 GOT 14, GPT 8, Albumin 2.7 Lab 15/3/2014 Urinalisa : Leukosit +++/500, Blood +++/200 Lab 17/3/2014 WBC 6.82, RBC 2.91x106, HGB 8.6, HCT 26.9, PLT 481 Urin rutin 17/3/2014 Protein : trace, blood ++/80, lekosit ++/125, Mikroskopik : lekosit 10, eritrosit 7 Feses 17/3/2014 Warna coklat, konsistensi cair, lendir (+) LONTARA 2 DIGESTIVE KAMAR 1 USG abdomen 1203-2014 - Tidak jelas gambaran massa pada colon Suono - Sludge GB 47 tahun - Nefrocalcinosis 10-03-1967 bilateral Laki-laki Suspek Ca.Recti - Dilatasi minimal JKN loop-loop usus 654720 Lab. 16/03/14 RBC 2.44 HGB 6.6 HCT 21,3 PLT 437 WBC 21,2 PT 12,4/11.5 INR 1,10 APTT 28.9/23.1 GDS 88 UR 165 CR 4,40 GOT/GPT 16/11 Na 128 K 4,4 Cl 107 HbsAg nonreactive Anti HCV (-) Prot.tot 3,8 Albumin 2,3 Globulin 1,5 HbS Ag Non Reactive Lab. 18/03/14 GDS 95 UR 160 CR 3,60 Na 148 K 4,5 Cl 120 Anti HCV (-) Albumin 2,9 TIBC 89 Lab (13/3/14) RBC 6.13 HGB 16.5 HCT 49.2 PLT 272 WBC 18.8 CT 8.00 BT 3.00 GDS 138 Ur 23 Cr 0.8 SGOT 20 SGPT 26 Alb 3.2 Na 133 K 3.6 Cl 105

15

Bed 1 SS

O2 6-8 Lpm via sungkup IVFD NaCl 0,9% 28 tpm Transfusi PRC 2 unit Balance cairan Awasi TV Lanjut terapi dari TS GH Koreksi albumin 4 btl Koreksi natrium Koreksi Hb 3 unit PRC

16

Kamar 1 Bed 2 RL

Fadli Said 23/3/1983 632361 MRS 13/3/14 Dr. Ronald L, Sp.B-KBD

Abses Gluteus

-NaCl 0.9% 28 tpm -Ceftriaxone 1gr/12j -Ranitidin 1amp/8j -Ketorolac 1amp/8j Metronidazole 500mg/8j -Rawat luka (pagi & sore) -Diet bebas -mobilisasi

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

Lab 12/03/2014 WBC 21,2 RBC 4,26 HB 12,1 HCT 36,1 PLT 271 CT/BT 600/300 GDS 235 Ur/Cr 26/0.60 GOT/GPT 16/13 Na/K/Cl 134/3,9/98 CEA : 12,12 Cefadroxil 2x200mg Ranitidin 2x150mg As.Mefenamat 2x500mg Rawat Luka/GV mobilisasi duduk Diet DM 1700 B Com C 3x2 Kalak 1 x1 GOT/GPT 19/21 Na/K/Cl 136/3,5/109 HbsAg (-) Anti HCV (-) LONTARA 2 DIGESTIVE KAMAR 2 Lab 15/03/2014 WBC 9,7; RBC 2,37; HGB 6,7; PLT 254; GDS 113 Nat 131; kal 2,1; klor 100 Lab 13/03/2014 WBC : 14,7. RBC : 2,72. HGB : 7,5 HCT : 22,9. PLT : 216 -IVFD RL 28 tpm -Ceftriaxone 1gr/12j -Ranitidin 1amp/8j -Ketorolac 1amp/8j Metronidazole 500mg/8j Ur/Cr 30/0,6 Alb 1,6 Na 128 K 2,0 Cl 100 POH 11 Miles prosedur POH 7 repair colostomi PA 11/03/2014 Adenocarsinoma recti differensiasi jelek dengan ujung distal masih mengandung sel tumor PA 10/03/2014 Cervisitis kronik Lab 03/03/2014 HCT 35,2 PLT 231 CEA >200 CT-Scan Abdomen 26/02/2014 Tumor Recti (DUKES B) + Fistel Rectovagina USG Abdomen 21/02/2014 Levofloxacin 500mg/12j/iv Metronidazole 500mg/8j/iv Ranitidin 50mg/12j/iv Vip alb 3x2 SF 1x1 Rawat luka/GV, rawat stoma Mobilisasi Diet bebas Cek lab lengkap post koreksi Hb,GDS, elektrolit dan albumin

17

Bed 3 SS

Tn. Muh.Ali 1/07/1952 RM 652386 MRS 24/02/2014 JKN Dr.dr.Samuel Sampetoding Sp.B-KBD

POH 5 Miles Procedure ec. Ca Recti 1/3 DIstal

18

Bed 1

LONTARA 2 DIGESTIVE KAMAR ISOLASI Lab 17/03/2014 WBC 13,7 RBC 3,8 Ricky HB 5,3 Sandang HCT 20,0 PLT 449 Elmanto CT/BT 730/300 21-04-1992 POH 2 PT/APTT RM 655384 Appendictomy 15,4/22,7 MRS GDS 96 17-03-2014 Ur/Cr 25/1,00 Umum GOT/GPT 15/5 HbsAg (-) USG ABDOMEN Susp. Appendicitis perforasi Urin Rutin 13-03-2014 Nitrit +Leukosit ++/80 Lab Rutin 12-03-2014 LED 42/71 WBC 16,9 RBC 4,99 HB 15,4 HCT 44,8 PLT 270 CT/BT 800/330 PT/APTT 15,6/30,2 GDS 80 Ur/Cr 18/0.80

20

Kamar 2 Bed 1 SS

Ny. Martini Dg Mapato 13/03/1962 (51 thn) RM 652088 Perempuan MRS 21/02/2014 dr. Samuel Sampetoding, Sp.B KBD

19

Bed 2

Midon 10-02-1988 RM 654738 MRS 12-03-2014 JKN

Periappendicular Infiltrat Perawatan hari ke 7

-IVFD RL 28 tpm -Ceftriaxone 1 gr/12j/iv -Metronidazole 0,5 gr/8j/iv -Ranitidin 1 amp/8j/iv -Diet bubur

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

Organ intraabdominal yang terscan dalam batas normal Fistel rectovaginal sulit dievaluasi Foto thorax Cor dan pulmo normal Elevasi kedua diafragma (susp.proses intraabdomen??) Lab Tanggal 17/03/2014 WBC 23,3; RBC 3,90; HGB 10,1; PLT 501; GDS 55 PT/APTT 13,8/26,1 CT/BT 7,30/3,00 INR 1,15 Ur/cr 14/0,40 GOT/GPT 83/24 Prot.tot 4,9; alb 2,3 Nat 133; kal 3,8; Cl 98 Lab Tanggal 12/03/14 Alb 2,2 CEA 200.000 Nat 134; kal 4,0;klor 100 USG ABDOMEN 10/03/14 Tumor metastase ke hepar, hepatosplenomegal i dan ascites Lab Tanggal 17/03/2014 WBC 11,7; RBC 3,36; HGB 8,9; 12/03/14 HCT 27; PLT 634 PT/APTT 11,4/24,0 INR 0,95 Lab tgl 13/03/2014 WBC 10,85 RBC 3,46 HB 8,4 HCT 226,3 PLT 788 CT 7,30 BT 2,00 PT 11,5 INR 0,96 APTT 25,9 GDS 125 Ur/Cr 17/0,47 GOT/GPT 88/54 Alb 2,6 NA/K/Cl 139/4/99 HbSag Non reactive MRI Cholangio Pancreatografi 13/03/14 Kesan : Cholestatik ductus biliaris ec. Batu distal CBD LONTARA 2 DIGESTIVE KAMAR ISOLASI Lab. 16/03/2014 RBC 3.08 HGB 9.2 HCT 27 PLT 119 - Burst Abdomen WBC 45.0 post. Laparatomi ec. Protein Total 3,0 Abd. Rahman Perforasi appendiks Albumin 2,2 01-01-1940 - Fistel Na 126 (74 thn) enterocutaneus high K 3,0 RM 654147 output Cl 105 Laki-laki - Hipoalbuminemia MRS - Electrolyte Lab. 13/03/2014 10/03/2014 imbalance RBC 3,57 - Leukositosis HGB 12.0 HCT 32 PLT 202 WBC 31,8 GDS 54 Ureum 85 (4-2,7) x 0,8 x 50 = 52gr ~ 2 btl albumin 25% Inj. Vit K 1 amp/im/hr (3 hr)

21

Kamar 2 bed 3 RL

Ny.Sri Ana 23/06/1982 RM 654137

Tu. Anorectal susp. Malignancy Fistel rectovagina Hipoalbuminemia

Tunggu jawaban konsul obgyn IVFD NaCl 28 tts/i Ceftriaxone 1gr/12j/iv Ranitidin 50mg/12j/iv Koktail /drips/ganti cairan Vip alb 25% Koreksi albumin botol II Koreksi Natrium: (146-122)x0,6x35 = 378mEq ~ 1,5 kolf NaCl 3% Diet bebas TKTP Susu ensure 4x200 cc

23

Bed 1 RL

22

Kamar 2 bed 4 IL

Ny. Jumriah 8/08/1974 RM 653118 MRS

Ikterus Obstruktif ec. Susp distal CBD

Tunggu jawaban konsul perioperatif Vip albumin tab 3x2 Koreksi albumin :

IVFD RL : D5% : Clinimix 500 : 500 : 1000 /24jam Ceftriaxone 1gr/12j/iv Metronidazole 0.5g/8j/iv Ranitidin 50mg/12j/iv Koreksi Natrium : (140122)x0.6x40=432mEq ~ 1.68 kolf NaCl 3% Koreksi Albumin : (4-1.8)x0.8x40=70.4 g ~ 3 kolf albumin 25% -Balans cairan -Takar produksi fistel, takar produksi urin -peptisol 25cc/jam via oral -rawat luka/gv 2x sehari

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

Kreatinin 0.8 SGOT 24 SGPT 23 Protein Total 4.9 Albumin 1.8 INR 2,40 PT 27,8 APTT 42,3 Na 121 K 4.20 Cl 106 LONTARA 2 DIGESTIVE KAMAR 3 Lab 17/03/2014 WBC 7,34; RBC 4,66; HGB 11,8; HCT 33,8; PLT 400; GDS 65 CT/BT 7,00/3,00 PT/APTT 12,3/30,3;INR 1,03 Ur/cr 43/0,80 Bil tot 0,53 Bil. Direk 0,28 GOT/GPT 48/31 Alb 3,0 Usman Daulasi 54 tahun 29-10-1959 Laki-laki JKN 615660 HbsAg non reactive Anti HCV non reactive CEA 122,66 CT Abdomen atas bawah 15/03/2014 Tidak tampak densitas massa pada abdomen dan ascites Lab 14/03/2014 RBC 3,89; WBC 6,4; HGB 9,7; PLT 348 CT/BT 800/300 PT/APTT 13,1/34,3 -rawat kateter -mobilisasi kanan-kiri -Rencana repair burst abdomen jika kondisi optimal INR 1,10 GDS 89 Ur/cr 38/0,80 GOT/GPT 35/23 Nat 140; kal 3,5; Cl 107 Hasil PA 14/11/2013 Metastase Adenokarsinoma Musinosum pada Mesenterium Lab 18/03/2014 GDS 230 Ur/cr 265/2,21 Nat 145; kal 4,8; Cl 109 Rencana dekompresi abdomen (NGT) Persiapan operasi: Inform consent Lapor ok Konsul anastesi Puasa 25 IVFD RL:D5%:Aminofluid 500:500:1000/24j Ranitidin 50mg/12j/iv Alirkan NGT, balance cairan Ganti infuse Ambil hasil PA Bed 3 WS IVFD RL:D5:aminofluid 500:500:1000/24j Meropenem 1gr/12j/iv Omeprazole 40mg/24j/iv Takar prod drain/hr Balance Cairan Awasi TV Koktail/ drips/ ganti cairan

24

Bed 1 (SS)

Tumor abdomen

Muhammad Amin 11/6/1959 RM 652977 MRS 14/3/14

Hasil Lab 16/03/2014 POH 6 Ileostomy WBC 7,6; RBC 3,86; HGB 11,1; PLT 79 PT/APTT 11,5/23,1 CT/BT 6,303,30 INR 130 GDS 151 Ur/cr 236/1,60 Bil total/bil direk 17,34/15,38 Nat 145; kal 3,9; Cl 118 Lab 16/03/2014 WBC 13,7; RBC 2,95; HGB 9,5; PLT 110

Konsul TS. Endokrin Metabolik Konsul TS .GH

26

Bed 4 IL

Baddu 31-12-1951 62 tahun MR 645112 MRS 25-01-

POH 22 log meyer procedure Hiperbilirubinemia Electrolyte imbalance Hipoalbuminemia

IVFD NaCl 3% 14 tts/i Albumin 25% 1 btl/hr Diet bebas mobilisasi

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

2014 DR.dr Ibrahim Labeda, Sp.B,KBD Protein tot 3,4 Alb 1,7 Globulin 1,7 GDS 130 Ur/cr 22/0,80 GOT/GPT 223/63 Bil tot 20,84; bil direk 17,47 Nat 121; kal 2,5; Cl 88 Hasil PA 26/2/14 CHOLECYSTITI S CHRONIC AKTIF Kol: 118, HDL:34, LDL: 117, TG: 111 USG ABDOMEN (6/3) Choleliths dgn cholecystitis Lab WBC: 6.9, Hb: 11,7, PLT: 190, GDS: 128, Ur/Cr: 7/0,56, GOT:165, GPT: 248 ALP: 599, GGT: 267, Bil.tot: 8,18, Bil.dir: 6,25, prot.tot: 6,2 Foto Thorax PA -pulmo normal -cardiomegaly dengan dilatatio et elongatio aorta EKG Sinus rhytme dengan ICRBBB Echocardiograph y -fungsi sistolik LV baik, EF 68% -fungsi diastolik LV -WH (+) CT-Scan -Massa caput pankreas disertai tanda-tanda cholestatik intra maupun extrahepatik -Sludge pada GB

27

Bed 6 IL

LONTARA 2 BEDAH DIGESTIV KAMAR 10 LAB 10/03/2014 WBC.6, rbc 5.35, hgb 12.2, hct 38.8, plt 283, gds 81, ur/cr 13/0.65, Sri Wahyuni got/gpt 20/18, 12/09/1988 na/k/cl 142/3.9/104 Post laparotomy e.c RM 650659 Hasil PA Adeno Ca. colon MRS 18/02/2014 Sigmoid 12/03/2014 Adenocarcinoma differensiasi sedang pada kedua sediaan,

Xeloda 2x2 VIP Albumin 3x2 Rawat stoma Tunggu hasil USG Abdomen

29

Bed 3 SM

Saheriah 1-7-1958 RM 653470

Ikterus Obstruktif ec Tu. Caput Pankreas

IVFD RL : Aminofluid = 500 : 500/125 Inj. Ketorolac 30 mg/8jam/iv Inj. Ranitidine 1 amp/8jam/iv Adona : inj. Vit K 3 hari Rencana parade

28

Bed 1 WS

Ayu indira 18-02-1994 RM 653862

POH 6 open Cholecystektomi

Lab 10/03/14 WBC 8,94 RBC 4,09 HGB 12,4 PLT 289. BT; 3,00, CT:8,0, GDS :89, Ur :8, Cr:0,3 SGOT 70, SGPT 421, Albumin 4,0. Bil tot: 2,19 Bil.Dir: 1,30 prot.tot:7,4 Hbsag(-)

Cefadroxil 2x500 mg Ranitidine 3x1 Asam mefenamat 3x1 Diet biasa GV 30 Bed 1 (SS) Jefry Foster 27 tahun 01-01-1987 JKN

LONTARA 2 KAMAR 11 Post ileostomi pro tutup ileostomi CT-scan Abdomen(030320 14) Spooling rectum

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

MR 610341 Tidak tampak kelainan pada CTscan abdomen ini kecuali masih terlihat sisa kontras Foto Thorax PA (05032014) Efusi pleura dextra USG abdomen 11/12/2013 Hepatomegaly, ascites. Laboratorium 12/03/2014 Protein total 4.6 Albumin 3.1 Na 137 K 3.7 Cl 101 Hasil lab 20/02/2014 Hb 15.7, WBC 6.6, PLT 262, RBC 5.45x106, CT 730, BT 300, PT 12.5 kontrol 10.2, INR 1.00, APTT 15.1 kontrol 24.0, HbsAg non reactive, anti-HCV non reactive, GDS 75, Ur 23, Kr 0.6, SGOT 17, SGPT 28, Alb 3.8, Na 135, K 4.1, Cl 104 Lab 12/3/2014 Ur/cr: 15/0.66, protein total: 4.2, Albumin: 2.1, Na:134, K: K: 3.3, Cl: 98 Echo 11/314 -fungsi sistolik dan diastolic LV baik, EF 67% -Global normokinetik Lab 11/3/14 WBC:11.87, RBC:4.85, HGB:13.3, HCT: 38.7, PLT:442, GDS: 73, Alb:2.4, Foto thorax Kesan: cor dan pulmo normal Lab 6/3/2014 CT 730, BT 300, PT 13.3 kontrol 12.2, INR 1.11, APTT 26.5 kontrol 24.1, Prot.total 5.5, Alb 2.2, Na 132, K 3.2, Cl 95, HbsAg non reactive, anti HCV non reactive, CEA 2.66, WBC 14800, RBC 3.55x106, HGB 8.7, HCT 28.5, PLT 642000 Lab 5/3/2014 GDS 84, Ur 16, Kr 0.6, SGOT 9, SGPT 7. Lab. 3/3/14 RBC 4,40 HGB 12,1 HCT 37,6 PLT 360 WBC 7,9 CT 730 BT 300 PT 10,8 INR 0,90 APTT 23,4 GDS 102 UR 25 CR 1,20 GOT/GPT 20/18 Albumin 3,9 Na 143 K 4,2 Rencana operasi kamis tgl 20/3/2014 Hari ini diet cair Klisma

31

Bed 3 (RL)

Masteria 32 thn 5-1-1982 Laki-laki JKN 633520

POH 8 ileustomi

Terapi oral Cefadroxil 2x500mg Asam mefenamat 3x500mg Ranitidine 3x1

32

Bed 4

Abd. Samad Suhaeb 54 tahun 13/3/1959 JKN MRS 5/3/2014 Dr. Ibrahim Labedda, Sp.B-KBD

33 IVFD RL 28 tpm Ceftriaxone 1 gr/12j/iv Ranitidin 30 mg/8j/iv Koreksi hipoalbuminea albumin 25% 1 kolf Konsul perioperatif

Bed 6

Zainuddin 1/1/1953 618032 MRS 17/3/14 dr. Samuel Sampetoding, Sp.B -KBD

Tu. Recti 1/3 distal

Tu Recti 1/3 Distal

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

Cl 105 HbsAg nonreactive Anti HCV (-) CEA 4,66 PA 07/03/14 Adenocarcinoma differensiasi sedang LONTARA 2 ONKOLOGI LONTARA 2 UROLOGI Darah rutin 23/3/14 WBC:12.4, RBC: 4.92, HB: 11.3, HCT: 35.3, PLT:456 Fistel rectovesica + Adenocarcinoma Colon Biopsi 5/3/14 Adenocarcinoma Colon differensiasi baik 20/02/2014 RBC 4,92 HGB 11,3 HCT 35,3 PLT 456 WBC 12,4 Rencana colostomy hari Senin 17/3/14 IC Foto thoraks PA (12/3) -Efusi pleura snistra massif Perdarahan (12/3) BT : 300, CT 700, PT : 12.1 c 11.7, APTT 26 c 25.2 Lab rutin (5/3) WBC : 9.85, RBC : 4.61, HB : 11.8, HCT : 36.3, PLT : 191 Lab (9/3/14) GDS 66 UR 49 CR 1.0 SGOT 21 SGPT 98 ALB 2.4 Na 128 K 2.1 Cl 104 WBC 9.3 RBC 3.47 HB 10.6 HCT 31.4 PLT 167 Thorax (9/3/14) 36 St. Nurbaya 15/9/1972 652558 Dr. Samuel Sampetoding, Sp.B KBD LONTARA 3 BEDAH SARAF LONTARA 3 KULKEL LONTARA 4 NIFAS HCU CT Scan abdomen (17/3) -Massa kompleks adneksa kiri disertai ascites sugestif malignancy -Susp abses subcutan dinding Abses Subkutan anterior abdomen region abdomen Lab rutin (9/3) RBC : 3.09, Hb : 10.1, HCT : 30,3, PLT : 440, WBC : 26.6, CT : 300, VT : 800, GDS : 45, Ur/Cr : 56/0.7, GOT/GPT : 35/18

Lontara IV Ginekologi Kamar 4

M ilyas 40 tahun 645026 34 K2 bed 3 DPJP : Dr. Smuel Sampetoding <Sp.B,KBD

37

35

Kamar 5 Bed 1 RL

Fadli Said 23/3/1983 632361 MRS 13/3/14 Dr. Ronald L, Sp.BKBD

20/02/2014 GOT 24 GPT 16 LONTARA 2 ORTHOPEDI Lab (13/3/14) RBC 6.13 HGB 16.5 HCT 49.2 PLT 272 WBC 18.8 Abses Gluteus CT 8.00 BT 3.00 GDS 138 Ur 23 Cr 0.8 SGOT 20 SGPT 26 Alb 3.2 Na 133 K 3.6 Cl 105 LONTARA 3 MATA LONTARA 3 BEDAH THT

Lantai 1 Bed 3 MP

Tn. Ambo Tang 4/1/1954 Dr. Mappincara, Sp.B-KBD

POH-1 eksisi+biopsi Soft tissue tumor gluteus D Efusi pleura susp. TB Paru CHF NYHA Grade 2 Empyema

Instruksi post op : -IVFD RL 28 tpm -Ceftriaxone 1 gr/12j/iv -Ketorolac 30mg/8j/iv -Ranitidin amp/8j/iv -Pemeriksaan PA pengantar (+) -Tidak puasa

-NaCl 0.9% 28 tpm -Ceftriaxone 1gr/12j -Ranitidin 1amp/8j -Ketorolac 1amp/8j Metronidazole 500mg/8j -Rawat luka (pagi & sore)

ICU Hermanto 3/08/1980 RM 654066 JKN Dr. Samuel Sampetoding, Sp.B KBD - POH 6 laparatomi ec. Hernia diafragmatika - Reposisi hernia diafragmatika, repair diafragmatika Cek DR, bil I /II albumin ,elektrolit,ur/cr Masukkan cairan/ NGT kecil 50cc/ jam ( susu,air gula) K 2,7 koreksi Albumin 2,6 WBC 13.000 GV

38

ICU Bed 5 SS

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

CVC terpasang pada hemithorax kanandengan ujung tip setinggi CH Th 6 Lab (8/3/14) CT 8.00 BT 3.00 PT 14.7 INR 1.30 APTT 25.2 RBC 5.33 HB 16.2 HCT 48.1 PLT 224 WBC 18.7 PA (21-1-14) Hasil : Adenocarcinoma recti Lab 25/02/2014 Tn. Azis Karim 31/12/1940 Mr 649168 MRS 21/02/2014 JKN dr. Samuel Sampetoding, Sp.B-KBD WBC 14,1 RBC 3,94 HB 11,1 HCT 33,8 PLT 241PT/APTT 11,41/25,1 GDS 201 SGOT 19 SGPT 13 Na/K/Cl 129/34,0/110 Akali phospatase : 199 Chol.tot:104 Chol.Direk:11,8 Chol LDL :38 Trigliserida:112 CEA: 3,25 Lab 15/3/2014 WBC 7,83 RBC 4,55 HGB 12,6 HCT 36,1 PLT 470, TIBC 156 Fe 60,6 ferritin 161,8 Na 139 K 2.6 Cl 96 GDP 147 Mobilisasi duduk MP Dr.Mappincar a, SpB-KBD Kolesterol tot 118 Kolesterol HDL 36 Kolesterol LDL 63 TG 99 Albumin 3,3 Lab 12/3/2014 WBC 9,3 RBC 5,03 HGB 15,6 HCT 42,6 PLT 279 BT 3 CT 7 GDS 121 SGOT/PT 50/67 ur/cr 87/1,6 Pem rad 13/3/14: elongatio aorta USG abdomen 14/3/2014 Kesan: hepatomegaly dengan ascites Lab 13/3/2014 WBC 26 RBC 4,020 HGB 11,4 HCT 33,9 PLT 364 Bil direct7,9 Bil> indirect 0,9 HbsAg (-) Lab 16/3/2014 PT 15,.6 APTT 32,1 HbsAg (+) Anti HCV (-) SGOT 55 Diet sesuai TS gizi klinik Bladder training Cek albumin

42

409

Yermias Touma Dr. Ronald E.LSpB-KBD

Ca. recti 1/3distal

Aff infuse Ciprofloxacin 2x500mg As. Mefenamat 3x500mg Ranitidine 3x500mg Mobilitas duduk Diit: bubur makanan bebas

39

ICU SS

POH 19 miles procedure ec. Ca rekti 1/3 distal POH 2 Repair Colostomy

Transfusi PRC 1 bag Transfusi albumin 2x100cc Terapi lain lanjut ICU

43

417

Yunike Dr. dr.Ibrahim Labeda Sp.B,SpBKBD

Ileus obstruktif parsial

Cefotaxim 1gr/12 jam Ranitidin 1 gr/8jam Puasakan Balance cairan

44

405

RSUH Daniel T. 18/8/1944 (69 thn) MR 015613 MRS 26/1/2014 DR. dr. Warsinggih, Sp.B-KBD Raehang Instruksi post operasi IVFD RL 20 tpm Ciprofloxacin 500mg 2x1 As. Mefenamat 500mg 3x1 Bed rest 24 jam Bila sadar baik boleh makan Terapi lanjut

Suprianto DR. dr. Warsinggih, Sp.B-KBD

Ikterus obstruktif

Rencana eksplorasi CBD rabu 19/3/14 Inform consent Persetujuan tindakan Lapor OK, konsul anastes, antibiotik ceftriaxone 1 gr/IV Siapdarah 2 bag PRC Vit K amp / IM(2 hari)

40

422

Tumor rectosigmoid Hipoalbuminemia TB on treatment

45

433

Dominggus 18/3/14 019779 08524101774 7 Dr.dr. Warsinggih, Sp.B-KBD

Ikterus obstruktif Massa caput pankreas

41

426

Ileus obstruktif partial

Lab 14/3/2014

Lab 15-3-14 WBC 7,48 RBC 3,94hgb 11,8 hct 30,6 plt 369 CT 10,BT 3,PT 31,7 INR 3,38 APTT 52,8 SGOT/PT 104/61 Bil direct 38,4 bil. Tot 50,9 GDS 90

IVFD RL 28 tpm Inj Vit K 1 amp/ 12 jam/IM Inj. Ranitidin 1 amp/8 jam /IV

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

Kolestrol tot 184 Ur/cr 39/0,9 HbsAg (-), anti HCV (-) Foto radiologi 15/3/14:cor dan pulmo normal Tidak tampa tandatanda metastasis pada foto thorax ini USG Abdomen15/3/14:k olestatik intra dan extra hepatic, lesi mixechoic pada area caput pancreas susp massa caput pancreas, distended GB diserta sludge di dalamnya MSCT 17 maret 2014: massa pancreas dengan dilatasi duktus bilier serta distended GB, nodul soliter hepar, ascites Ansar Abu Bakar 21/08/1963 MRS 18/3/14 Dr. dr.Ibrahim Labeda Sp.B,SpBKBD Andi Munawar 31/12/1964 019523 MRS 18/3/2014 Dr. dr.Ibrahim Labeda Sp.B,SpBLapor Dr. dr.Ibrahim Labeda Sp.B,SpB-KBD Lab lengkap CT scan thoracoabdominal Foto thorax AP IVFD KAMG 3: pan amin G 1:1 28 tpm Lapor Dr. dr.Ibrahim Labeda Sp.B,SpB-KBD CT scan abdominal Foto thorax AP IVFD KAMG 3: pan amin G 1:1 28 tpm KBD PCC MSCT scan abdomen dengan kontras 15/3/2014 Massa mesenterium dengan ascites disertai peritoneal implant sugestif malignant CT abdomen atas/bawah tanpa kontras 12/3/2014 Dilatasi gaster ec. massa extralumen region hipoondrium knan suspect limfoma dd/ massa mesenterium + fatty liver + ascites dan efusi pleura dextra Laboratorium 12/3/2014 PT 12,9 INR 1,08 CEA 0,65 APTT 24,7 GDS 158 bilirubin total 0,50 bilirubin direk 0,17 alkali phospat 64 gamma GT 28 Anti HCV (elisa) dan HbsAg (elisa) nonreaktif Na 141 K 3,8 Cl 111 RBC 4,19 HGB 12,6 HCT 36,6 LT 366 WBC 11,5 Laboratorium 11/3/2014 Ur 27 cr 1,20 SGOT 48 SGPT 32 protein total 4,5

48

402 IL

Marten Pangalinan 25/5/1961 52 tahun RM 654570 MRS 11/3/2014 UMUM Dr. dr. Ibrahim Labeda, SpBKDB

D/ Ileus obstruksi partial ec. Tumor abdomen asal mesenterial suspect malignancy

Terapi sesuai TS GEH Rencana operasi jika keluarga setuju

46

425 (1)

Stenosis 1/3 distal esofagus

47

425 (2)

Tmor abdomen bagian kanan susp. malignancy

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

albumin 4,1 RBC 4,26 HGB 12,5 HCT 32,7 PLT 407 WBC 14,2 Laboratorium 17/3/2014 SGOT 87 SGPT 49 Albumin 2,8 PT 13,7 INR 1,14 APTT 24,8 RBC 4,53 HGB 12,6 HCT 37 PLT 349 WBC 9,9 Laboratorium 12/3/2014 SGOT 65 SGPT 69 Laboratorium 7/3/2014 Albumin 2,6 Drs. Bustan 12/7/1963 50 tahun RM 640893 MRS 29/1/14 JKN Dr. dr. Ibrahim Labeda,SpBKBD Laboratorium 6/3/2014 Ur 29 cr 0,62 Bilirubin total 0,51 bilirubin direk 0,41 Foto thorax PA/AP 3/3/2014 Efusi pleura dextra Laboratorium 26/2/2014 PT 12,5 INR 1,04 APTT 28,9 Fe 19 TIBC 70 MSCT whole abdomen non kontras 24/2/2014 Tidak tampak massa patologik intraabdomen + Efusi pleura dextra suspect empyema MSCT thorax tanpa kontras 14/2/2014 Efusi pleura dextra dengan atelektasis segmental paru dextra suspect ec. Tumor paru Echocardiogram 11/2/2014 Fungsi sistolik LVD RV baik EF 71% Foto thorax AP + lateral Spondilosis thoracalis Laboratorium 29/1/2014 BT 2 CT 8 - Terapi sesuai TS pulmo dan BTKV - Optimalisasi KU CT whole body tanpa kontras 27/1/2014 Suspek cholelithiasis + efusi pleura dextra Laboratorium 23/1/2014 GDS 173 Laboratorium 18/3/2014 PT 14,2 INR 1,20 APTT 35,7 GDS 119 ur 18 cr 0,60 Asam urat 3,7 Bilirubin total 0,74 Bilirubin direk 0,18 SGOT 40 SGPT 27 Na 135 K 3.4 Cl 104 HbsAg dan anti HCV nonreaktif

49

430 IL

D/ Cholesistolithiasis + efusi pleura dextra

50

410 WS

Agustina Matarru 15/8/1962 51 tahun RM 633693 MRS 18/3/2014 JKN DR. Dr. Warsinggih, Sp.B-KBD

Teapi injeksi lanjut Rencana operasi laparotomi chole Kamis, 20/3/2014 Persiapan operasi: Informed consent Persetujuan tindakan Konsul anestesi Lapor OK Cukur pubis Siap darah 2 bag PRC Puasa 8 jam pre operasi

D/ Cholelitiasis + cholesistisis

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

RBC 6,29 HGB 14,2 HCT 55,4 PLT 387 WBC 14 USG abdomen atas + bawah 18/3/2014 Hepatomegaly + cholecystitis ec cholelith Foto thoraks PA/AP 18/3/2014 Pulmo dalam batas normal + cardiomegaly dengan dilatation aortae + elevasi diafragma kanan (proses intrahepatik?) CT abdomen atas/bawah tanpa kontras 18/3/2014 Cholsistitis ec cholelith Laboratorium 14/3/2014 Albumin 3,6 Laboratorium 10/3/2014 Albumin 2,5 D/POH 27 laparotomi + reseksi anastomose jejunum ec thrombus VMS cabang jejunum Laboratorium 12/3/2014 D-dimer 3,40 PT 16,1 INR 1,35 Fibrinogen 290,5 APTT 25,4 Laboratorium 6/3/2014 Prokalsitonin 24,29 Foto thortax PA/AP Cefspan 2x200 Vip albumin 3x3 Mobilisasi jalan Tidak tampak kelainan radiologik pada foto thorax ini Laboratorium 3/3/2014 GDS 183 ur 26 cr 0,60 SGOT 35 SGPT 34 Albumin 2,4 Na 125 K 4,0 Cl 102 Laboratorium 2/3/2014 RBC 2,98 HGB 9,0 HCT 26,9 PLT 119 WBC 15,3 Analisa gas darah: alkalosis respiratorik dan metabolik Laboratorium 1/3/2014 RBC 2,33 HGB 7,1 HCT 21,2 PLT 131 WBC 19,9 ur 28 cr 0,50 SGOT 36 SGPT 41 Laboratorium 26/2/2014 GDS 136 BT 2 CT 7,3 PT 13,2 APTT 22,8 INR 1,10 Na 133 K 4,4 Cl 101 Laboratorium 23/2/2014 Analisa gas darah: alkalosis metabolic Protein total 4,9 Laboratorium 20/2/2014

51

317 SS

Ismunandar 20/01/1986 28 tahun RM 613364 MRS 17/02/2014 JKN Dr. Samuel Sampetoding, Sp.BD

KORAN BEDAH DIGESTIF Kamis, 20 MARET 2014

BT 3,3 CT 7,3 PT 12,4 INR 1 APTT 19,8 Protein total 5,7 USG abdomen atas + bawah (whole abdomen) 17/2/2014 Tidak tampak kelainan pada USG abdomen ini