REKAPITULASI PASIEN BEDAH DIGESTIF TANGGAL 9 Juni 2014

Residen

: dr
dr
dr
dr
dr

Dokter Muda

: eka kemalasari (Chief/ICU, HCU)

Kazi muntazeri( jp3,serune 2)
Mecita afdhilah (gerute)
Erli marlina (JP1, Mamplam2, Geulima 2)
Putri rahmi (JP2)
fazlun (JP4, MP1)

NO

Hasan (ICU, HCU)

Nazir (JP2)
Rynaldi (JP3, Serune, Gerute)
Mohan (JP1, Mamplam 2, Geulima)
Jauhari (JP4, Selawah)

IDENTITAS

TANGGAL

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081349494308
081265774737
081288777341
085271123515
081274881482

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081360764110
08116825510
085314765252
085276892721
085260888883
085277015010

DIAGNOSA

PEMERIKSAAN PENUNJANG

RENCANA

JEUMPA 1/dr Mohan/dm erli marlina

1.

Alfian Maya/lk/ 31/ 999507/

JKRA
Iso 2
082368774799
Pidie
DPJP : dr. Muslim, Sp.B

Masuk RS:
23/04/14
OP:
23 /4/2014
POD 44

Post
laparotomi
e.c
perforasi
Duodenum + gastrojejunostomi +
jejunustomi feeding

Lab 31/5/2014
Hb/Ht : 11,1/33
E/L/T : 3,9/10,8/319
Protein ttal : 6,1
Alb/glob : 2,90/3,20
Ur/cr : 23/0,70
Na/K/Cl : 128/4,1/101
Diftell : 1/0/1/67/16/15
3/6/14
Albumin/globulin: 2,8/4,2
Kreatinin /ureum: 0,7/32
Gula darah acak : 104

-GV 3x / hari
-Cek fistel (jumlah, banyak cairan)

juni 2014

Na/k/cl : 133/4,7/102

2.

Hamdani, 39 thn, cm 1-00-47-46,

k3B2
No hp : 081362945400

Tgl msk : 30 mei 2014

Pod 3

Psoas abses

6/.6/14
Hb/ht/ert/leu/tro:11,2/34/44/9,3/3,9
C/b: 2/7
Albumin /g;obulin: 2,6/3,1
Hdl :29
Ldl:55
Trigliserida :98

Dr muslim, Sp.B

Jamal gam, 84 thn, k7b6, cm

1004763
Dr yusuf SpB
No hp : 081362552277

21 juni 2014
Pod 5

Post op peritonitis ileum ec perfusi

gaster + sepsis

3/6/14
Hb / ht/ert/leu/tro : 10,6/32/4,5/9,9/174
Albumin /globulin : 5,4/2,90
Na/ka/cl : 55/4,3/113
Gds:110
Ureum/kreatinin: 97/1,08

fahrurazi , 39 thn , 1002100, k7B4

no hp : 085373743933

3 juni 2014

wound dehescense post laparotomy

explorasi + stoma a/I perforasi ileum
terminal

3/6/14
hb/ht :13,3/41
ert/leu: 5,4/106
na/k/cl:137/4,7/97
kgds:84

Rusli,k6b4, 1005681
N0 hp : 085276123015
Dr fery, SpB

6 juni 14

Parsial mechanial bowel abdomen +

hepatitis B

5/6/14
Hb/ht/ert/leu/trom:12,2/35/4,3/10,0/257
Hepatitis/ hbsag : positif
Na/k/cl : 140/3,5/90
Gds :89
Ureum/kreatinin: 32/0,56

Ngt kleb dlu

Kunsul ipd
Rencana pasang t tube

Samsuar,20 thn cm 1005884, k7b2

7 juni 14
Pod 1

Post op app akut

7/6/14
Hb/htert/leu/tro:16,1/48/5,7/28,4/333
C/b:3/9
Na/k/cl: 144/3,8/98
Gds:213
Ureum:20
Kreatinin:0,91
4/6/.14
Hb/ht/ert/leu/tro:14,6/43/5,2/11,0/262
Na/k/cl:141/3,5/100
Ureum: 21
Kreatinin: 0,55
Gds : 118

Samsul bahri, k7B2, cm 1005386

K7b3
Dr ferry, SpB

4 juni 14
Pod 3

Parsial melanical bowel obstruksi

Masuk RS
29/3/2014

Fistel recto vesika+ DVT

Lab 29/5/2014
Hb/Ht : 10,8/33
E/L/T : 3,6/7,0/231
Diftell : 3/0/0/62/21/14
Na/K/Cl : 134/3,2/103
Protein total : 7,0
Alb : 3,0
Glo : 4,0
Ur/cr: 321/0,4

2 juni 14

Abses liver

3/6/14
na /k/cl:238/2,4/94
2/6/14
hb /ht:9,8/28
4/6/14
na/k/cl: 138/2,8/94

JEUMPA 2/dr Nazir/dm putri rahmi

1

Rosdini/pr/59/999298/K7B4/
085210013002
DPJP : dr.Ferry, Sp.B

jelika bancin,54 thn,1004989, k6B2

p/ rencana operasi

Safiah ,80 thn, 1005808

K6b1
No hp :081360290250

6 juni 14

Batu cbd + hidrop visica veliza +

dispepsia

6/6/14
Hb/ht/erit/leuk :9,3/28/3,1/9,1
Ct/bt:2/7
Trom: 439
Sgot : 108
Sgpt:48
Na/k/cl : 142/2,7:102
Ureum: 47
Kreatini: 0,80

3 juni 14

Pot Choledecolitiasis

16/5/14hb/ht/ert/leu/tro:
12,4/34/4,2/12,0/443
Albumin /globulin: 5,5/3,6
Kratin /ureum : 10,9/32
Na/k/cl: 142/5,2/110

M. Juned, lk, 76th, 1001021,

k7b2/JKRA/
085260138362
Aceh besar

Masuk RS
3/4/14

Post op. Lparotomi dranage

a.i Ca caput pankreas

DPJD:
Dr. Ferry, Sp B

POD 18

JEUMPA 3/dr Rynaldi/dm kazi muntazeri

1

Syarifuddin, 60 thn , cm, 1002691

Kib1
No hp : 082161916796

JEUMPA 4/dr Jauhari/dm fazlun

1.

OP 14/5/14

Lab 30/5/14
Hb/Ht: 11,0/29
E/L/T: 3,3/11,8/499
Ur/cr: 4,4/1,0
Bil total: 8,04
Bil direct: 7,40
Alk posfatase : 665
Protein total : 7,4
SGOt/SGPT: 11,2/6
Alb/glob : 3,1/4,3
Na/K/Cl: 138/3,5/108
GDS : 248
Diftell : 3/0/2/48/42/5
Foto thoraks: (20/5/2014)
TB paru, fibrotic yang luas pada apex paru kanan

p/ aff drain
choliografi daftar senin
mobilisasi

Sulaiman ali, 66 thn. k8b2

Sabirin/ Lk/ 54 th / k13

1001145/
A.selatan

Ct scan hari rabu , kalau bisa hari senin konfirmasi

lagi

Masuk RS
04/5/2014

Pos op Tumor intra abdomen

Lab 30/5/2014
Hb/Ht : 9,5/29
E/L/T : 3,4/4,2/80
Ur/cr : 19/0,20
GDS : 135
Na/K/Cl : 127/1,5/ 77
Diftell : 0/0/4/80/11/5

Tgl msk 29/5/14

Pod 9

Ruptur ginjal D grad 4 repair

hepar grad 2, 3 + fr pelvis
servikal joint

Lab 2/6/2014
Hb : 8,1
Ht : 23
Ertritrosit : 2,8
Trombo: 122
Albumin : 2,90
Ureum : 53
Kreatinin: 1,37

DPJP : dr.M. Yusuf, Sp.B

Nurajinah

Lukman hakim,42 thn, k2b1

Duffran nurhalim/Lk/18th
1004675

05/6/14
Hb/ht/ert/leuk/tro :10,7/31/3,6/14,1
Albumin: 2,70
Na/k/cl: 140/4,0/98
Ureum:55
Kreatinin : 1,21
5/6/14
Hb/ht/ert/leu/trom: 10,2/3,1/36/14.1/264
Albumin: 270
Globulin : 290
Na/k/cl : 140/4,0/90
Yreum /kreatinin : 55/1,21
7

Andi idhan

Yessi amansyah

MAMPLAM 1/SEULAWAH/dr Jauhari/dm fazlun

1.

T. lahmuddin, lk, 40th,

Aceh timur, 983738
K8B3

Masuk RS
OP:
POD 20

DPJP:dr. Ferry,Sp.B

Ca Kaput pankreas

Lab 23/5/2014
Hb/ht: 10,4/32
E/L/T:3,2/10,4/292
Ct/bt:7/3
Alb/glob:4,6/2,7
Ur/cr: 38/0,5
Na/K/Cl: 145,4,3/111
Prot total: 7,3
GDP : 77

Diftell : 0/0/2/90/3/5

Yusrizal,32 thn, k4b2

Abses hepar

Aiyub, k1B1

hemoroid

Operasi rabu

Novizark3b2

coletiasis

Rencana opersai

MAMPLAM 2 / DM ERLI
1

1 juni 14

Ca caput pankreas clotiasis

Lab 2/6/14
Hb/ht: 12,6/353,3/3,8
Albumin/globulin:

Masuk RS
7/4/2014

Fistel retrovagina

Lab 26/5/2014
Hb/Ht: 10,8/28
E/L/T : 3,6/22,8/312
Na/K/Cl: 130/3,2/91
Alb/glob: 3,4/43
Protein total : 77
Ct/Bt : 7/3
Ur/cr : 17/0,5
KGDP : 135
Diftell : 2/0/3/81/8/6

Anidar, 50 thn, K1B1

GEULIMA 2/dr Mohan/dm erli marlina

1

Mayang sari/ 40 th/ 836434/

ISO 2
0852141239307/
Banda
DPJP: dr Ferry Sp B

OAT 28

-Fisioterapi
-Op bedah plastik (tutup defect)

M.husen / lk / 44 thn /
1004308 / k6b3
Pidie

Masuk RS
26/5/2014

Colestitis + colelithiasis +
Nefrolithiasis D + hepatomegali +
anemia

Lab 31/5/2014
Hb/ht : 8,1/26
E/L/T : 2,8/19,6/553
Ur/cr : 21/0,50
Kgd : 79
Na/K/Cl : 141/3,2/114
Diftell : 1/0/0/65/26/8

Masuk RS

Ca caput pankreas

Lab 26/5/2014
Hb/Ht : 13,3/41
E/L/T : 4,9/13,7/282
Na/K/Cl : 142/4,0/106
GDS : 118
Ur/cr : 18/0,68
Diftell : 4/0/0/67/19/10
5/6/14
Hb/ht/ert/leo:11,8/35/4,4/9,0
Ureum : 0,5
Kreatinin: 26

Dpjp : dr.yusuf,Sp.B

Fadlon M yusuf/37 thn

K5B4/1004310/mns blang pidie jaya/
JKRA
085362171412

Bahtiar,46 thn k3b2

Rencana operasi

Rencana operasi (tungg setuju keluarga)

SEURUNEE 3/dr Rynaldi/dm kazi muntazeri

1

Nurjannah, k7b1

GEURUTEE/dr Rynaldy/dm mecita afdhilah

M,isa,70 thn k20

Post hermionphy a/i hil D

Umiaton,58 thn, cm 999210, k11

Dr ferry Erani Sp B

Post laparatomi + colostomi + miles

prosedure

Siti aminah,35 thn, k6

Dr ferry E,SpB

Partial mechanicalb bowel obstruction

di rectum + stenosis lumen

Sudarnigsih, 40 thn, cm 122945

Dr ferry E SpB, k7

Cholesistekctomi perlaparoskopi

Rahmawati, 36 thn cm 1005591, k1

Cholelitiasis
+
appendisitis kronis

Alkausar ,23 thn,1005525, k9

No hp : 081360261151

6 juni 14

Post abses perianal

cholecyctitis+

5/6/14
Hb/ht/ert/leu/tro
15,0/44/5,5/11,6/231
c/b: 2/7
gds:340
06/6/14
Na/k/cl : 42/3,8/98

RHCU
DM
FAZLUN
/
DR
JAUHARI

Rohani ,57 thn,cm 963309

Tgl msk 03-6-14

Hari rwatan 6

Tb paru + tb ileus + post i;eustomi dg

post repair stroma +hipokalemia
sedang + hipokalemia

ICU/dr Hasan/dm eka kemalasari

1

Nuraini abbas/Pr/ 46 thn/B5

1004838/blang pulo muara 1
Dpjp : dr.M.Yusuf, Sp.B
No hp : 085260417656

Masuk RS
Op : 31/5/2014
POD 7

Post
laparotomi
colostomi

repair

stoma+

Lab 31/5/2014 (p0st Op)

Hb/Ht : 11,1/35
E/L/T : 4,4/8,3/414
Diftell : 0/0/0/89/6/5
Na/K/Cl : 139/3,4/113
GDS : 204
Ur/cr : 31/0,50
SGOT/SGPT : 86/62
Agda
C02 : 27,6
kelebihn basa : 3,5
Ph :7,47
hc03 : 27
Bikarbonat : 103 saturasi 02 : 98,3
Pco2 :36,10
04/6/14
Hb/ht/ert/leu/tro:
12,2,38/24,6/25,9/214
Na/k /cl: 147/2,5/100
Gds: 295
Ureum/kreatinin: 28/0,47

Mahmuddin, 35 thn, 1005369, iso 2

No hp : 085296961005

Geulima 1

m.furqan , k4b2
dr muslim

4 juni / 14
Pod 3

Post laparatomi ai abdomen perinitis

injury close fr

5/6/14
Hb : 9,8
Albumin : 25
Globulin: 2,90
Na/k/cl : 146/3,4/107
Ureum: 40
Kreatinin : 1,17

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