REKAP BEDAH DIGESTIF TANGGAL 01 November 2015

JEUMPA 1
No
1

K/B
2

Identitas
M. Muslim, 911318,
33 th

Yoftizar Rahman, 21
th, 1067767
Tgl Op 19/10/15

No
4

K/B
6

Identitas
Aisyah Ahmad, 47
th, 1065801

Tgl Op 20/10/15
Aiyub, 48th, 1067710
Tgl Op 18/10/15

Diagnosis
Post draine abses
hepar +
trombositopenia +
hiperkalemia
Post laparotomy
eksplorasi ec
peritonitis ec
perforasi ileum +
reseksi ileum +
ileustomy
Ca recti +
hipoalbumin +
anemia +
hipoglikemia

Lab
28.10.15
Hb 10,1 ht 31 er 3,8 leuko 12,0 trom 930

Planning
mobilisasi

Diagnosis
Ca Recti1/3 medial
+ hipoalbumin

Lab
29/10/2015
Hb 10,5 ht 31 Er 4,0 Leu 6,7 Trom 88 alb 3,24 Na 139
K 3,3 Cl 97
Hasil PA well differentiated adenocarcinoma

Planning

Diagnosis
Post cystoscopy
diagnostic ec fistel
urethrorectal + post
TURP + DM tipe 2 +
hipokalemia +
anemia
Post laparotomy
eksplorasi + repair
caecustomy +
appendictomy a/i
appendisitis perforasi
Susp ca recti 1/3

Lab
29.10.2015
Hb 1154 ht 36 Er 4,6 Leu 23,0 Trom 461 protein total 6,1
alb 3,00 glo 3,00 Na 140 K 5,1 Cl 98 gds 329 Ur 30 Cr 0,60

Planning

30/10/2015
Alb 2,68 gds 74 hn 11,0 ht 34 k 3,2 cl 7,4 leuko 17,0 na
136 trom 76

Awasi tanda akut abdomen

30.10.2015
Hb 11,9 Ht 36 Er 5,0 Leu 14,2 Tr om 624 Alb 3,10

26/10/2015
Hb 11,6 ht 39 er 5,1 leuko 14,9 trom 432 protein total 5,8
alb 3,10 glo 2,70 na 144 k 4,8 cl 103 gds 72 ur 20 cr 0,50

JEUMPA 2

Ainul mardhiah

JEUMPA 3
No
6.

K
3

B
2

Identitas
Kardiansyah,52 th,
1066798

Ansari, 70 th,
1066025
Tgl Op : 02.10.2015

Saniyah, 52th,

28/10/2015

1068055

medial

Hb 10,8 Ht 35 Er 4,2 Leu 8,9 Tr 304 Na 145 K 3,9 Cl 106

GDS 87 Ur 17 Kr 0,43

Post laparotomy
eksplorasi a/i
perforasi caecum +
post appendectomy

28/10/2015
Hb 10,2 ht 32 Er 4,3 Leu 20,4 Trom 304
29/10/2015
Alb 2,80 glo 3,00na 148 k 3,4 cl 105 gds 78

Abdul salam, 59 thn,

1068689

JEUMPA 4
NO K

Identitas

Diagnosis

Lab

Planning

10

Erlis, 52 th, 1066440

Abdominal discomfort
ec dd gastristis

Rabu 4/11/2015 ct scan

abdomen kontras non
kontras

11

Nurida,53h, 1068043

Post open
cholesistectomy a/i
cholelithiasis +
porcelen gallbladder

12

Hanisah, 61th,1067751

Tumor intaabdomen

13

Mahdi, 61th, 1068447

Status kolonostomi +
Ca. recti

20.10.15
Hb 9,6, Ht 30, Er 3.8, leu 8,8, Trom 181, Alb 2.80 Glo
2,70 Na 140 K 2,6 Cl 96, GDS 109 Ur 9 Kr 0,28
22/10/2015
Alb 2,90 Na 138 K 2,7 Cl 98
28/10/2015
Na 141 K 2,8 Cl 100
20.10.2015
Hb 13,1 Ht 38 Er 4,5 Leu 7,8 Tr 324 MCV 85 MCH 29
MCHC 34 SGOT 61 SGPT 71 Prot tot 7,3 Alb 3,81 Glo
3,49 Na 146 K 3,9 Cl 102 GDS 84 Ur 28 Kr 0,56 Bil tot
0,40 Bil Dri 0,20
19.10.2015
Hb 10,5 Ht 31 Er 3,7 Leu 5,3 Tr 133 Na 145 K 3,5 Cl 99
GDP 158 Hb-A1c 12,20 Ur 12 Kr 0,39 Alb 2,39 Glo 3,41
Kol tot 125 HDL 11 LDL 68 Trig 208
23/10/2015
Alb 3,01 GDP 182
24/10/2015
Hb 11,3 ht 34 er 4,0 leu 7,4 trom 124
27/10/2015
Hb 9,7 ht 26 er 3,1 leu 4,6 trom 248 protein total 6,0 alb
3,18 gl0 2,82 na 138 k 2,8 cl 95 gds 120 ur 20 cr 0,91

14

Abdullah Hamid

Post laparotomy
adhesiolisis + reseksi
ileum + anatomosis
side to side dgn stapler
a/i post ileustomy

15

Mukhtar, 46 thn,

Post laparotomy

26/10/2015
Hb 12,2 ht 38 Er 5,8 Leu 11,1 Trom 195 protein total 6,4
alb 3,41 Glo 2,99
Na 144 K 4,4 Cl 102 Gds 150 Ur 25 Cr 0,75
Hasil PA suatu colitis akut dgn hyperplasia jaringan
limfoid
29/10/2015

1068959

16

Mawaddah

17

Api ali,36 thn,

1068840

18

19

Sairah yatim, 73 thn,

1068802
m. nasir, 55 thn,
0879828

20

Eman,39 thn,0806988

eksplorasi a/i perforasi

difusa ec perforasi
ileum + internal
bleeing+debridement
abdominal+reseksi
ileum+ileostomy+repai
r mesentrium ai ruptur
mesentrium
Status colostomy
Post laparotomy
eksplorasi + colostomy
+ trauma pilar
Total mbo ec tumor
colorectal
HIL dextra

Hb 12,1 ht 35 Er 4,1 Leu 8,7 Trom 167 Na 139 K 4,5 Cl

104 alb 2,49 ur 60 cr 1,23

22/10/2015
Hb 14,9 ht 43 Er 5,2 Leu 4,6 Trom 309 Na 146 K 4,2 Cl
101 gds 109 ur 11 cr 0,58
28/10/2015
Hb 9,8 ht 28 Er 3,1 Leu 9,5 Trom 120
26/10/2015
Hb 11,2 ht 34 Er 4,5 Leu 3,7 Trom 405
29/10/2015
Hb 13,8 ht 42 er 5,2 leu 12,8 trom 169 na 143 k 3,8 cl
103 gds 134 ur 14 cr 0,70

HIL dextra (post op)

GEURUTE
No
21

K/B
17

Identitas
Habibah, 80 thn, 938287

Diagnosis
Status colostomy a/i
reseksi colon sigmoid
+ retensi urin

Lab
22/10/2015
Hb 10,2 ht 30 Er 3,5 Leu 13,2 Trom 502
24/10/2015
Protein total 6,4 alb 2,65 glo 3,75 Na 143 K 5,3 Cl 108
Ur 47 Cr 0,75

22

10

Drs. Abdullah Rayeuk,77

thn, 1069035

HIL sin residif

28/10/2015
Hb 12,9 ht 38 Er 4,3 Leu 16,6 Trom 233 Na 144 K 4,0 Cl
103 gds 98 Ur 21 cr 0,91

No
23

IW

K/B
3

Identitas
Khadijah,56th,1066875

Diagnosis
Post LE +
appendictomy a/i
peritonitis

Lab
29.10.2015
Hb 8,8 ht 24 er 3,1 leuko 11,4 trom 355 alb 3,25 na 157
k 3,2 cl 104

Planning

ICU
Planning

ICU

No
24

K
B

B
1A

Identitas
Fatitah, 57th, 1064123

Diagnosis
Wound dehision ec post LE
ex tumor kolon

Lab
27/10/2015
Hb 10,1 ht 32 Er 3,8 Trom 299 Leuko 8,2 alb 3,19 Na 138 K 2,8 Cl
89 Ur 15 cr 0,41

25

ISO
1

B2

M. Dani, 32 thn, 1068835

28/10/2015
Hb 14,8 ht 44 Er 5,1 Trom 577 Leu 20,5 alb 2,62 ur 42 cr 0,80

26

5A

27

M. Daud Hasan,63 thn,

1068951
Amirullah,49 thn, 1068966

Post laparotomy eksplorasi

+ appendectomy ai general
peritonitis
ec
perforasi
appendeix
MBO ec tumor colon
tranversum
Post herniodectomy

28

5B

Hamdani, 45 thn, 1068391

Hemorrhoid grade IV

27/10/2015
Hb 15,1 ht 45 Er 5,5 Trom 84 Leuko 19,4 alb 3,48
28/10/2015
Hb 3,6 ht 12 Er 1,8 Leuko 13,4 trom 264 na 130 k 4,0 cl 98 gds 114
ur 23 cr 0,86

Planning

Endoscopy dari IPD

Ct scan abdomen

Serune 1
No
29

Identitas
Ali azmi, 18 th, 1067882

Diagnosis
Post op VATS
thoracotomy

Lab
Hb 10,8 ht 32 er 3,7 leuko 38,0 trom 564 na 139 k 4,3
cl 97 ur 39 cr 0,48

Planning

K/B
1

K/B
4

Identitas
M. SYARIF

Diagnosis
Post laparotomy
eksplorasi ec general
peritonitis

Lab

Planning

No
31

K/B
A

Identitas
Ainun mardhiah,48
thn,0884438

Diagnosis
Post laparotomy
eksplorasi +
debulking tumor +
adhesiolisis

Lab

Planning

No
32

K/B
1

Identitas
Hasbi isa,58 thn, 1062196

Diagnosis
HIL

Lab

Planning

HCU
No
30

Serune 3

PJT