REKAP PASIEN BEDAH ANAK (Senin, 28 Maret 2016)

PPDS Bedah Anak

1. dr. M. Reza (085260906091)
2. dr. Marshal Agreno (0811666986)

No.
1

Kamar
Level 3
AD 24

Level 3
AD 7
POD 7

Level 2
AD 4

Identitas
By. Risna sari, LK, 14 hari
TL : 05-03-2016
Alamat : Aceh besar
CM : 1002850

DM Bedah Anak
1.Fera Mulidar (081360204575)
2. Nur Arfah Rizki (085262336715)
3. Deny Heriyanto (085262298198)

NICU
Diagnosa
Suspect Atresia Esofagus +
PDA + trombositopenia

Tgl masuk : 05/03/2016

BB : 1,9 kg
By Suryan Sari
TL: 20/03/2016
CM: 1-08-43-66

Post colostomy a/i atresia ani

+ atresia doudenum + sindrom
down

Tgl Masuk: 22/03/2016

Tgl Operasi : 22/03/2016
By Agustina, lk
TL: 23-03-2016
CM: 1-08-48-06

Malformasi anorektal letak

rendah fistel perianal +
hidrocephalus

Tgl Masuk: 25/03/2016

Level 1
AD 10
POD 5

By Nurliza, pr
TL: 16-03-2016
CM: 1-08-41-44
Tgl Masuk: 19/03/2016
Tgl Operasi : 24/03/2016

Hischprung Disease

Total Pasien 11 orang

NICU : 4 orang
Jeumpa 2 : 5 orang
Jeumpa 3 : 1 orang
Seurune 2 : 1 orang

Px. Penunjang
Lab 18/3/2016
Hb/Ht/E/L/T
9,4/28/3,0/22,8/9
Ht jenis:
4/0/0/60/23/13
Alb : 2,80
Na/K/Cl : 132/2,6/90

Terapi
Head up 45 derajat
Suction / 30 menit
IVFD N5 190 cc/24 jam

Planning
Rencana operasi bila
trombosit> 50.000 /m3

Lab (25-03-2016)
Hb/Ht/E/L/T
15,8/45/4,4/6,3/202
Diftel : 0/0/0/64/15/21
CT/BT : 7/2
Na/K/Cl : 133/5,3/94
Ur/Cr : 52/1,15
GDS : 245
Lab (26-03-2016)
Hb/Ht/E/L/T
13,5/39/4,0/15,6/281
Diftel : 1/1/0/51/34/13
CT/BT : 7/2
Na/K/Cl : 136/4,1/103
GDS : 68
Ur/Cr 42/0,78

IVFD 5:1 300 cc/hari

Diet ASI bebas
Bila abdomen distensi dilatasi
fistel dengan NGT no 6
Inj Ceftriaxone 150 mg/8 jam

Rencana operasi : Rabu,

30-03-2016 join B. Saraf
PSARP dan VP shunt

ASI ad libitum
IVFD 4:1 + Ca glukonas5 cc/jam

Wash out 2x/hari

Rencana operasi : Selasa,
29-03-2016

Seurune 2
1.
K3b2
AD 9

M.Asyari, Lk, 3bulan

CM : 1084113
TL : 26/01/2016

Tumor lidah +
trombositopenia

Lab 23/03/2016
Hb/Ht/E/L/T
13,2/38/4,7/6,3/6
Ht jenis:
1/0/0/20/76/3
CT/BT : 9/3
Ur/Cr : 15/0,29

IVFD 4:1 400 cc/hari

Inj ampisilin 65 mg/8jam
Inj gentamisin 10 mg/12jam
Diet susu via OGT
Transfusi TC 40 cc
Cek DR, elektrolit, PT/APTT,
INR

Post laparotomy eksplorasi +

Reseksi tumor + anastomosis
End jejunojejunostomy

Lab 18/3/2016
Hb/ Ht/ Er/ Leu/trom
11,6/36/4,9/21,0/273
Htjenis :
3/0/0/56/34/7
CT/BT : 7/2
Albumin : 4,33
Na/K/Cl : 143/4,3/102
GDS : 84
Ur/Cr : 14/0,45
Lab 22/03/2016
Hb/Ht/E/L/T
13,1/40/4,8/12,7/359
Ht jenis:
4/1/0/66/22/7
Na/K/Cl : 139/2,4/89
Lab 25/03/2016
Na/K/Cl : 136/4,4/89
Lab 24/03/2016
Hb/Ht/E/L/T
9.7/33/4,4/23.4/529
Diftell : 0/0/0/80/13/6
Prot tot/Alb/Glo :
6,3/4,23/1,87
Na/K/Cl : 148/5,3/116

IVFD KaEN 3B 1 : 500 cc/hari

Inj Meropenem 1gr/12jam
Inj Antrain 400 mg/12jam
Inj Ranitidin amp/12jam
Inj Alinamin F amp/8jam
Aminofusin peed 400 mg/hari
Inj Ondansetron 4 mg/ 12jam
D10% 200cc
Drip Albumin 100cc/hari

Tgl Konsul: 20/03/2016

JEUMPA 2
1
ISO 2
AD 7
POD 9

2.

3.

M. Azam Haikal, 2 tahun 11

bulan, LK
CM : 1076047
TL : 11/04/2013

Dr. Mun

Tgl masuk : 18/03/2016

Tgl Operasi : 20-03-2016

K7B2
AD 28
POD 11

M. Al Bakir, Lk, 5 th
CM : 1081120
TL : 01/03/2011

Dr. Dian

Tgl Konsul: 01/03/2016

Tanggal operasi : 17-03- 2016

K3B2
AD 6
POD 5

M.Asyrat, Lk, 1th

CM : 1-04-35-24
TL : 09/03/2015

Dr. Dian

Tgl masuk : 23/03/2016

Tgl operasi : 24/03/2016

4.

Cut Aldila
AD 1
Tgl masuk : 28/03/2016
Tgl operasi :

Post repair anus posterior

Post colostomy clossure a/i

Atresia ani

Status illeostomy

Rencana operasi THT

selasa, 29/3/2016

Inj meropenem 500 mg/12jam

Inj antrain 200 mg/12jam
Aminofusin peed 250 cc/hari
Diet MB

IVFD 4:1 500 cc/hari

Inj Ceftriaxone 300 mg/12jam
Inj Antrain 120 mg/12jam
Diet susu 15 cc/3jam

PBJ hari ini

Rencana operasi : Selasa,

29-03-2016

5.

Muhammad Zaki

Stenosis ani + fistel perineum

Rencana operasi : Selasa,

29-03-2016

Fistel perianal

Rencana operasi : Selasa,

29-03-2016

AD 1
Tgl masuk : 28/03/2016
Tgl operasi :

JEUMPA 3
1

Agus Andika

AD 1
Tgl masuk : 28/03/2016
Tgl operasi :