Rabu, 23 Mei 2018 BEDAH DIGESTIF ISH/GIH/PBP/TWN/DEF

P
BED Nama Usia Tgl msk Diagnosis Status Plan Pemeriksaan Penunjang
DR
21/5 ; HB 9.7 HT 32 AL 11.2 AT 350 GOL DARAH O
Rohmani Post Laparotomi dheliolisis + hemicolectomy kanan + 20/5 hb 10.3 ht 30 al 12.5 at 360 AE 3.92
Poli Post OP
3 01417199 42 stoma ai ileus obstruktif ec P6 ec tumor colo AR Perawatan Post OP 19/5 cut off di flexura hepatica menyokong gambaran obstruksi ec massa bowel intra lumen di flexura
16/5 21/5
ransversum hepatica
19/5 Hb 9.9 Ht 32 AL 16.2 AT 505 AE 4.19
18/5 Hb 10.1 Ht 32 AL 4.5 AT 252 AE 3.66 PT 14.3 APTT 27.7 INR 1.130 GDS 78 SGOT 152 SGPT 47 Alb
2.0 Cr 0.6 Ur 30 Na 138 K 2.5 Cl 103 HbsAg NR
Siswo IGD Perbaikan KU
14 59 Post Sigmoidestomi ai Adeno Ca Rekti KU AR 12/5 PA : adenoma ca differnsiasi baik
01419653 18/5 Diit Cair 8x300 mg
5/5 : Ro Thorax : Cor & Pulmo Normal
5/5 : BNO 3 Posisi : Ileus obstruktif
20/5 PT 12.1 APTT 24.9 INR 0.950 Hbsag NR
Cipto Interna Post laparotomi eksplorasi ai Ileus obstruktif letak
7 59 Pre OP AR Perawatan Post OP 20/5 bno 3 posisi : menyokong gambaran ileus obstruktif letak rendah
Sarwono 20/5 rendah
18/5 HB 10.9 HT 35 AL 8.6 AT 148 AE 4.46

20/5 Hb 9.1 ht 26 al 5.3 at 155 ae 2.95

Tarjo Post laparotomi bilodigest ai Obstruksi joundice ec Post OP Post laparotomi bilodigest
A 54 14/5 AR 19/5 Protein total 4.4 Alb 2.3 Na 132 K 3.5 Ca 1.14
01417638 suspek tumor pankreas 17/5 Puasa 2 hari
18/5 Alb 2.3
1.0 Ur 41 Na128 K 2.8 Cl 69 HbsAg rapid NR
Daryono Poli Post Laparotomi Appendiktomi reseksi ileocaeca Post Op
B 34 Perawatan Post OP 16/5 Hb 14.3 Ht 41 AL 16.5 AT 247 AE 4.58 Alb 3.7 Na 137 K 4.2 Cl 110
01415145 14/5 anastomose ileotransversum 16/5
AR
Perbaikan KU
21/5 ; hb 8.9 ht 28 al 12.8 at 518 ae 3.53
RGB
Mesiyem IGD Koreksi HB + Na
C 35 Susp. Ca Gaster WD IBB 20/5 Hb 5.1 ht 17 al 9.9 at 644 ae 2.23 pt 13.6 aptt 26.4 inr 1.060 gds 72 alb 2.6 cr 0.3 ur 21 na 124 k 3.8
01418235 20/5 Transfusi prc JIKA hb < 10
cl 97 ca 1.07 hbsag NR
mg/dl
Post TCS ai fistel rectovagina Perawatan post op
Karolina IGD Post op 20/5 Hb 8.1 ht 23 al 8.5 at 166 ae 2.81 Alb 2.3 na 132 k 2.7 cl 106
F 21 Post laparotomi eksplorasi ai peritonitis generalisata IBB Diet MSS
01417657 27/4 28/4 27/4 hb 6.5 hmt 18 AL 7.0 AT 114 PT 21.0 APTT 29.0 gds 104 alb 2.9 ur 36 cr 0.8 Na 138 K 3.6 hbsag NR
ec kontusinonal buli Transfusi PRC 1 kolf
CF shaft tibia (D) segmental type 20/5 Hb 9.0 ht 27 al 5.2 at 106 ae 3.20
Samadi
K 61 IGD CF ramus inferior pubis (S) konsul IBB Awasi tanda akut abdomen 19/5 Hb 9.1 ht 25 al 8.7 at 134 ae 2.89 gds 378 alb 3.2 Cr 1.3 UR 75 NA 134 K 3.3 CL 104 HbsAg NR
01419661
COR 19/5 Ro thorax : Efusi pleura kanan
16/5 Hb 11,5 AL 18,4 AT 349
15/5 PT 15,2 APtt 27,2 gds 116 SGOT 24 SGPT 15 Alb 2,8 Cr 0,6 Ur 28 Na 139 K 2,8 HBsAg (-)
Sunardi Paru Post OP
2D 58 Post Appendectomi ai Appendicitis kronis AR Perawatan Post OP (Poli Klinis) 9/5 USG Parenchymal kidney disease bilateral, Nefrolithiasis sinistra, Non visualized appendiks
01418130 3/5 18/5
7/5 Hb 10,4 Ht 37 AL 11,3 AT 376Alb 2,8 Cr 0,7 Ur 21
ANG 1 3/5 SGPT 19 SGOT 29 Alb 3,1 Cr 0,7 Ur 26 Na 132
18/5 hs-CRP 0,74
Yamto Paru Post OP 8/5 USG : BPH gr III, Hernia Scrotalis
4B 70 Post Herniorepair ai Hernia Scrotalis (D) AR Perawatan Post OP (Poli Klinis)
01418393 6/5 18/5 6/5 Hb 12.8 Ht 39 AL 12.8 AT 287 AE 4.43 PT 12.7 APTT 29.3 INR 0.970 GDS 104 Alb 3.5 Cr 0.7 Ur 30
Na 149 K 3.8 Cl 111
12/5 Hb 13,0 Ht 38 AL 8,1 AT 288
Lusia Marti Obsgin Post Laparatomi biopsi + Appendictomi ai Post OP
7I 38 AR Perawatan Post op 9/5 Hb 13.1 Ht 36 AL 7.9 AT 273 AE 4.32 Golda O PT 12.7 APTT 29.5 INR 0.970 GDS 106 Alb 4.4 Cr 0.8
Widarsih 10/5 Appendicitis kronik 10/5
Ur 13 Na 135 K 3.2 Cl 101 HbsAg rapid NR
17/5 Hb 11.6 Ht 38 AL 15.9 AT 334 AE 4.92 GDS 137 Alb 3.0 Na 132 K 3.4 Cl 105
14/5 Hb 12 Ht 39 AL 11.5 AT 274 AE 5.12 Golda A Rh + PT 13.6 APTT 39.1 INR 1.010 GDS 84 SGOT 19
Mawar 1 SGPT 12 Alb 3.7 Cr 0.5 Ur 9 Na 136 K 3.4 Cl105 HbsAg NR Tumor marker 3.84
27/4 PA ; Biopsi massa rectosigmoid ; Adeno Carcinoma
Inatun Poli Harman procedur ai Post OP
7J 48 AR Perawatan Post OP 27/4 Colonoscopy : Hemoroid externa, Massa di recto sigmoid
01416790 13/5 Adeno Ca Rectosigmoid 17/5
21/4 Ro thorak : Tak tampak gambaran pulmonal ataupun bone metastase
23/3 Usg Abdomen ; Stomach mukosa berkean tipis dengan floating massa mungkin dari bloode cloting
tukak dengan perdarahan tidak jelas, struktur echoparenchim hepar gambaran normal, Organ2 intra
abdomen yang lainnya normal
Mujiatun IGD 21/5 Hb 3.0 ht 11 al 16.5 at 924 ae 1.38 sgot 16 ur 0,4 27
4A 57 Susp CA gaster KU AR Transfusi sampai Hb > 10
01413651 21/5
18/5 PA : Pankreas : Symple Cyst
14/5 Bil total 0.56 bil direct 0.21 bil indirect 0.35
9/5 Hb 12.6 Ht 38.2 AE 4.67 AT 233 AL 5 LED 45 Golda O Rh + PT 14.6 APTT 31.2 INR 0.93 SGOT 19
Gina SGPT 8 Alb 4 GDP 101 Urea N 7.1 Ur 15 Cr 0.57 Na 143 K 3.8 Cl 104 HbsAg NR
Poli Post Laparotomi eksplorasi + Cystojejenustomi Perawatan Post OP
4B Marsinah 61 Post OP AR 9/5 USG abdomen : Kista pankreas ( 17 x 10 )mm
13/5 jejenojejunostomi (Braun Anastomose ) + PA
01416905 10/4 CT abdomen : Lesi densitas cairan kental yang tidak menyangat kontras batas tegas tepi reguler
ukuran 16.33cm x 8.41cm x 13.36cm di regio epigastrium yg tampak mendesak dan menempel dengan
lobus kiri hepar, gaster dan pankreas dengan batas yang masih tegas dapat merupakan dd/ : 1. Kista hepar,
2. Kista mesenterium
21/5 Alb 2.6 Na 133 K 3.3 Cl 106
Post laparotomy cholesito yeyenostomy + gastro 19/5 Alb 2.5 Na 130 K 2.0 Cl 100
Sugiyo Poli Post OP
4C 50 yeyenustomy + yeyenus yeyenostomy + biopsi teman AR Perawatan post OP 18/5 Hb 12.3 Ht 34 AL 6.2 AT 317 AE 4.32 Golda A PT 18.7 PTAPTT INR GDS 159 Cr 1.3 Ur 29 Na 130 K
01418863 17/5 21/5
ai ileus obstruktif ec tunor pankreas 2.1 Cl 99 HbsAg NR
17/5 Ro Thorax PA : tak tampak gambaran pulmonal metastase
 17/5 Usg Abdomen : Massa dicaput pankreas yang menyebabkan pelebaran IHBD, CBD dan ductus
pankreasticus serta hydrops GB, 2. Ascites
11/5 Hb 11.9 Ht 36 AL 9.8 AT 301 AE 4.44 PT 16.6 APTT 37.6 INR 1.310 GDS 89 sgot 72 sgpt 58 Bil tot
32.7 Bil direk 23.2 bil indirek 23.25 bil indirek 9.51Alb 2.7 Cr 1.3 Ur 28
18/5 Cholecystitis Chronis
16/5 Hb 12.5 HT 36 AL 9.8 AT 244 AE 3.80 Alb 140 K 3.1 Cl 107
15/5 Golda A Biltotal 2.01 bildirect 1.36 bil indirect 0.65 HbsAg NR
Pardi Poli Post Laparotomi eksplorasi biliodigest ai Obstruksi Post OP 12/5 Hb 12.2 Ht 33 AL 6.0 AT 264 AE 3.56 PT 12.6 APTT 29.7 INR 0.960 GDS 106 Alb 3.8 Cr 0.7 Ur 23 Na
4F 51 AR Perawatan post OP
01416425 11/5 Joundice ec Cholelithiasis 16/5 139 K 3.9 Cl 103
8/5 Ro Thorax : cor dan pulmo tak tampak kelainan
6/5 usg abdomen : cholelitiasis disertai dilatasi ductus hepaticus dextra et sinistra dan duc tus hepaticus
communis, 2. Cystitis, 3. Ascites, 4. Lien/pankreas/ren bilateral/prostat tak tampak kelainanan
17/5 Hb 11.9 Ht 39 al 13.00 at 324 ae 4.88 GolDa O rh+ PT 13.8 APTT 35.2 INR 1.030 GDS 98 SGOT 18
SGPT 19 Alb 3.5 CR 0.6 Ur 21 Na 141 K 4.1 Cl 4.1
Ristinah IGD Post OP Perawatan post OP 14/5 Hb 12.8 HT 43 AL 17.8 AT 390 AE 5.35 PT 12.8 APTT 30.0 INR 1.530 GDS 87 SGOT 20 Alb 3.7 cr
4G 33 Pro appedictomy ai Appendicitis kronnis AR
01073460 15/5 18/5 0.6 ur 1.5 na 136 k 4.0 cl 159 hbsag NR
Mawar 2 14/5 APPENDIKOGRAM : non visualized appendiks
Usg abdomen : menyokong gambaran appendiksitis akut, tak tampak kelaian pada hepar
18/5 PA : Mesenterium : Malignant GIST DD Leiomyosarcona
18/5 Na 138 K 3.6 Cl 107
16/5 Hb 10.3 HT 30 AL 12.5 AT 280 AE 3.45 Na 132 K 4.1 CA 1.14
12/5 Hb 10.5 Ht 29 AL 7.4 AT 309 AE 3.31 PT 12.6 APTT 27.1 INR 0.970 GDS 79 Alb 3.4 Cr 0.8 Ur 17 Na
Daniel 140 K 3.8 Cl 109
IGD Post OP
4I Novianto 43 Post laparotomy biopsi ai Tumor Mesenterium AR Perawatan post OP 9/5 FNAB : dijumpai sel ganas, ke sarcoma, GIST.
6/5 15/5
01418392 9/5 Marker biopsi USG : Tampak lesi hiperekoik di retro vesika urinaria disuprapubis sedalam 8.49 cm dari
permukaan kulit. Dilakukan USG guiding
6/5 Hb 10.8 Ht 33 AL 8.8 AT 301 AE 3.71 PT 12.9 APTT 26.3 INR 0.990 GDS 100 SGOT 30 SGPT 18 Alb
3.5 Cr 0.8 Ur 25 Na 139 K 3.7 Cl 109 HbsAg NR
6/5 Ro : Pneumonia
17/5 Alb 2.8
Isno IGD Pro Miles prosedure Laparotomi eksplorasi ai adeno Post OP
6F 69 AR Perawatan Post OP 15/5 HB 11.0 HT 31 AL 10.7 AT 293 AE 3.40 PT 12.7 APTT 28.5 INR 0.970 GDS 108 ALB 2.9 CR 0.8 UR
01414797 15/5 ca rekti 16/5
23 NA 135 K 3.1 CL 105 HBSAG NR
11/5 Hb 10.9 Ht 30 AL 6.3 AT 415 AE 3.29
9/5 Hb 9.1 Ht 25 AL 6.8 AT 429 AE 2.67
Post laparotomy + biopsi ai obstruksi joundice ec 8/5 Hb 8.6 Ht 26 AL 6.1 AT 542 AE 2.66 Golda B Rh + PT 14.2 APTT 35.9 INR 1.070 GDS 98 SGOT 127
Suparno Poli Post OP
8E 56 Klatskin tumor AR Perawatan Post OP SGPT 113 Alb 2.9 Cr 1.0 Ur 28 Na 136 K 3.8 Cl 103 HbsAg NR
01417072 8/5 14/5
4/5 MRI abdomen atas kontras : 1. Hepatomegali, 2. GB dan ductus cysticus tak tervisualisasi (post op?)
3. Batu di CBD proksimal yang menyebabkan penyempitan parsial di CBD proksimal dan dilatasi IHBD
kanan kiri dan common hepatic duct
Marto suwito IGD Post Laparotomi appendictomi ai Peritonitis Post OP
8D 62 AR Perawatan Post OP 20/5 Hb 14.3 ht 39 al 7.4 at 296 ae 4.38 alb 3.3 na 134 k 4.8 cl 109
01419682 19/5 Generalisata ec susp. Appendicitis perforasi 19/5
16/5 appendikogram ; non filling appendiks menyokong gambaran appendicitis kronik
16/5 Usg Abdomen : 1. Non visualized appendiks, 2. Lymphadenopati mesenterium regio iliaca dekstra
Arif Yulianto Poli Appendicitis kronis Pro appendictomy
8J 24 Pre OP AR dapat merupakan gambaran kronisitas organ di regio tersebut
01418107 15/5 B20 Konsul interna
3/5 Hb 13.5 ht 42 al 8.4 at 264 ae 4.94

Perawatan Post OP 18/5 Hb 12,2 AL 1,5 AT 51 AE 4,29

HCU Ida Susanti Post OP
E 33 Obsgin Post Laparotomi eksplorasi ai peritonitis generalisata AR Pro Fasciotomi 17/5 Hb 11,5 AL 1,4 AT 86 AE 4,01
Melati 1 01404404 17/5
16/5 Cr 2,7 Ur 54

HCU
Neuro
Sami Poli
Mawar 3 4C
01351851
50
16/5
Ca Pankreas Kemo AR Pro Kemoterapi 17/5 Hb 10,2 Ht 29 AL 24,4 AT 613 AE 3,76

18/5 Hb 12,0 AL 13,9 AT 439 AE 3,92 Alb 2,7

Suparman Post Laparotomi biliodigest ai Obstruksi Jaundice ec. Post OP 15/5 Albumin 2,5
6B 64 Interna AR Perawatan Post OP
01418056 Colangiosarcoma 18/5 14/5 Hb 9,1 Ht 29 AL 7,9 AT 309 Alb 2,3
11/5 OT 88 PT 44 BIL Total 16,56 Direk 12,73
Sarwoto Poli Post OP
9B 60 Post Herniorepair ai HIL (D) AR Perawatan Post OP 17/5 Hb 14,2 Ht 40 AL 7,3 GDS 236Na 138 K 3,5 Cl 107
01299034 16/5 18/5

IGD Abdominal pain ec iliaca dextra ec stamp appendicitis Konsul

20A Cantika 19 AR 18/5 HB 13.2 HT 38 AL 5 AT 218 AE 4.58 Golda A
18/5 dd cholitis 20/5

Melati 3 18/5 Hb 10,4 HT 32 AL 8,1 AT 273 AE 3,44 SGOT 46 SGPT 22 Cr 0,5 Ur 43

17/5 Gamma GT 56 Bil Tot 0,35 Direk 0,15 Indirek 0,20 Alk Fos 68 AFP 284,84
14/5 Cr 1.0 Ur 111 Anti HBc-Total positif anti HCV NR
Post Laparotomy eksplorasi + release volvulus band
Miran IGD Post OP 12/5 Hb 14.3 Ht 45 AL 8.4 AT 370 AE 4.77 PT 14.5 APTT 30.9 INR 1.150 GDS 149 SGOT 47 SGPT 43 Bil
3B 55 + Appendektomi ai Ileus obstruksi ec ileum band + AR Perawatan Post OP
01418727 13/5 13/5 tot 0.92 Alb 4.6 Cr 2.3 Ur 145 Na 132 K 5.3 Ca 1.02 HbsAg NR
App perforasi
12/5 BNO 3 posisi : 1. Ileus obstruksi letak tinggi, 2. Tak tampak gambaran pneumoperitoneum
12/5 ro Thorax pa : Cor dan pulmo tak tampak kelainan
 Igd
Natini
604A 63 18/5 Massa Intra Abdomen Pre OP AR Pro Laparatomi 18/5 Hb 10.5 AL 8,3 AT 451 Alb 2,8 Na 130 K 3,2 HBsAg (-)
01419652

19/5 Hb 10,0nHT 29 AL 17,1 AT 326 AE 3,89 Alb 3,2

Tri Harjanto Poli AR 18/5 Hb 10,9 AL 16,4 AT 369 Alb 2,6 Na 129
608 C 45 Ca Recti + Anemia KU Perbaikan KU
01334575 14/5 17/5Hb 8,8 Ht 26 AL 14,6 AT 386 AE 3,57
14/5 Hb 8,6 AL 23,7 AT 620 AE 3,94 SGOT 159 SGPT 90 Cr 1,4 Ur 45 CEA 36,05 AFP >400

14/5 Hb 11,8 AL 11,7 AT 283 Na 137 K 4,2 Ca 1,13

10/5 Hb 7.1 Ht 21 AL 2.3 AT 48 AE 2.46 Alb 1.7 Cr 1.0 Ur 108 Na 141 K 4.1 Cl 112
8/5 Hb 12.8 Ht 39 AL 15.8 AT 299 AE 5.10 GDS 116 Alb 3.6 Na 136 K 4.8 Cl 108
FLB 6 609B
Wasis Wahidi
48
Poli Post laparotomy reseksi anterior anastomose Post OP
AR
Perawatan post OP
Kondisi stabil pindah RGB
7/5 PT 14,6 APTT 36,0 INR 14,6
3/5 Hb 13 Ht 38 AL 9.7 AT 233 GDS 88 Alb 3.5 Cr 0.3 Ur 15 Na 135 K 4.1 Cl 103
01103625 2/5 sigmoid-rectum E to E ai Tumor sigmoid 8/5 19/4 HB 12.7 Ht 38 AL 6.7 AT 353 SGOT 48 SGPT 26 Na 136 K 3.5 Cla 1.15
Puasa 2 hari
17/4 CT abdomen: Tumor sigmioid yang meluas sampai dinding abdomen kiri, metastase hepar
17/4 Kolonoskopi: Ca rigmoid
18/4 PA: sgmoid: adeno Ca well differentiated
20/4 Thrak: tak tampak metastase

Mujiyanto IGD
610A 34 Trauma Tumpul Abdomen Konsul Konservatif 19/5 Hb 12,5 Ht 37 AL 7,0 AT 134 AE 4,89
01419452 18/5 IBB
Wahyu 13/5 Hb 11,9 AL 9,9 AT 423 Na 131 Ca 1,07
Poli Post Gastrotomi + Biopsi ai Susp Ca Gaster + Post OP AR
613B Widada 54 Perawatan post OP 12/5 Hb 9,5 Ht 30 AL 10,8 AT 490
9/5 ANemia 14/5
01416642 4/5 Hb 9,7 Ht 31 AL 17,4 AT 576 SGPt 12 SGOT 19 Cr 1,0 Ur 54 Na 138 K 4,4 Cl 104 CEA 0,52
14/5 Cr 3,8 Ur 96
9/5 Alb 2,6
6/5 Hb 10.7 Ht 31 AL 8.9 AT 212 AE 3.84 PT 13.3 APTT 24.3 INR 1.030 Cr 1.0 Ur 48 Na 128 K 3.8 Cl 94
4/5 Na 130 K 2.9 Ca 0.94
3/5 Hb 6.9 Ht 21 AL 17.1 AT 343 GDS 292 Bil total 12.43 direk 9.29 Alb 2.2
6/3 Perawatan post op Kultur: vancomysin cotri sensitif
Post ileostomi ai Wound dehisence post ileostomy ai
Sringatun Interna post op diit sonde TKTP 2/5 Hb 8.2 Ht 25 AL 10.3 AT 163 GDS 54 bil total 0.93 bil direk 0.61 indirek 0.32 Alb 2.3 Na 133 K 2.8 Cl 97
614A 52 adhesiolisis + ca ovari AR
01287926 Obgyn 23/4 Transfusi FFP 2 kolf/hari Ca 0.95
Ulkus + bula R cruris D
Kulit Pro debridement BTKV 24/4 alb 3.1
21/4 Hb 11.9 AL 8.6 AT 160 PT 12.8 APTT 21.7 GDS 75 Cr 0.9 Ur 96 Na 131 K 3 Cl 99
18/4 hb 10.7 hmt 8.6 AL 8.6 AT 168 alb 2.5 Na 144 K 3.8
17/4 hb 11.9 hmt 34 AL 8.4 AT 187 alb 2.4 Na 137 K 2. 21/3 HBsAg NR
Kultur darah : no growth, Kultur pus : sensitif amikasin, ampicillin sulbactam, gentamicin, amoxiclav,
ceftazidime, meropenem