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PASIEN DIGESTIF HIM - 06 NOV 2018 (R1, R2B, R3, R4B)

N
TINDAKAN/
O IDENTITAS KM MRS OPS DPJP DIAGNOSA RENCANA PENUNJANG KET.
RIWAYAT TINDAKAN
R1B
1. Tn. Bambang Wiyono/ 1.4 01/11 MM Tumor rectosigmoid Pro Colonoscopy biopsi Konsulan TS
57 Th/ C702588 curiga ganas?TNM? (07/11/18) Interna
Preparasi colon
R2B
2. Tn. Rosidi/ 40 Th/ 3.2 31/10 JS Tumor colon ascenden TNM? Rencana hemicolectomi MSCT Abdomen
C718822 dextra (09/11/18) dgn kontras
Hb = 10.7
3. Tn. Buhrom/ 57 Th/ 3.5 30/10 JS Tumor rectum 1/3 distal Post laparotomi Ultra LAR
C713184 TNM? koloanal anastomose (05/11/18)
4. Tn. Ribad/ 28 Th/ 7.1 30/10 PB Tumor pelvis ganas DD/ Post laparotomi biopsi Perbaikan KU
C713335 Limfoma maligna, Adeno Ca poor (18/10/18) Raber TIM nyeri
diff, NEC Konsul TS Interna
5. Tn. Abdullah Faqih/ 50 5.4 01/11 ERI Fistel enterocutan moderate output Pasang VAC (01/11/18) Fleet enema tiap pagi (selama Alb = 2.2
Th/ C720526 Post Laparotomi sigmoidectomi 5 hr)
(Agustus 2018 di RSUD Transfusi Albumin 100 cc
Kardinah Tegal)
6. Tn. Kaswadi/ 57 Th/ 4.1 02/11 ERI Tumor hepar lobus sinistra c/ HCC Pro Laparotomi reseksi tumor Antri ICU (17)
C700715 TNM? hepar
7. Tn. Subekti/ 38 Th/ 5.2 02/11 MG Tumor intra abdomen, DD/ Tumor Post Colonoscopy (06/11/18) MSCT Abdomen tripase dgn Hb = 12
C720617 colon ascenden kontras (05/11/18) Alb = 2.6
TNM?
8. Tn. Puji Slamet/ 30 Th/ 5.3 02/11 PB Adeno Ca recti well diff T4N1bMx Post Colostomi (06/11/18) MSCT Abdomen
C716790 Colonoscopy
Hasil PA
9. Tn. Marino/ 60 Th/ 7.2 04/11 MG Adeno Ca Resti residif T4N1M1 Post LAR + ileostomi (25/01/17 Pro Repair hernia (08/11/18) Hb = 15.5
C682752 (paru) on KT + Hernia insisional + di RSUD Tugu) + Post tutup Konsul TS Interna sub Nefro Leuko = 16.800
Azotemia stoma (Mei 2017) + Post KT Tromb = 269.000
12x GDS = 174
Ure = 127
Cre = 2.1
10. Tn. Kasnanto/ 48 Th/ 7.5 14/10 PB Tumor intra abdomen Post Nefrostomi bilateral Perbaikan KU CEA = 3.35 Raber TS
C246964 Squamous cell ca buli well diff (30/10/18) Pro Colostomi (08/11/18) Hb = 4.1 Interna +
Azotemia + Anemia dalam koreksi MSCT Abdomen tripase dgn Urologi
Kontras
R3A
11. Ny. Sumiyati/ 51 Th/ 2.6 06/11 PB Tumor intra abdomen c/ Tumor Pro Laparotomi biopsi MSCT Abdomen Konsulan TS
C716236 pankreas metas hepar (08/11/18) Interna
TNM?
12. Ny. Susilowati/ 49 Th/ 1.5 01/11 ERI ASBO + retraksi stoma Post Laparotomi + colostomi Pro Laparotomi adhesiolisis BNO 2 posisi
C702535 Adeno Ca Sigmoid T4N1M0 (17/12/17 di RSUD Tidar komplex + reseksi revisi
Magelang) stoma (05/11/18)
Post KT 6x
PASIEN DIGESTIF HIM - 06 NOV 2018 (R1, R2B, R3, R4B)
R3B
13. Tn. Suyono/ 71 Th/ 1.2 29/10 MM Tumor Rectum (1/3 apa?) curiga Post Colonoscopy + Biopsi Raber TS
C719289 ganas, TNM? (06/11/18) Interna
14. Tn. Anwar/ 41 Th/ 1.6 29/10 MG Tumor gaster metas ke hepar std IV Tunggu Hasil PA Usul lepas rawat Konsulan TS
C719038 TNM? Terapi non operatif Interna
Bila hematemesis/ melena -->
Pro Gastrektomi
R4B
15. Ny. Novitasari/ 42 Th/ 1.3 02/11 PB Ikterik obstruksi ec Pro Laparoscopy USG abdomen Raber TS
C720600 Cholesistolithiasis cholesistektomi (08/11/18) MSCT Abdomen Interna

16. Ny. Khoirum/ 33 Th/ 6.2 01/11 PB Kista ovarii + adhesi jejunun- ileum Post laparotomi repair perforasi Konsul TS Bedah Saraf Konsulan TS
C716322 Paraparase inferior ileum (01/11/18) Obgyn
17. Ny. Sunarti/ 63 Th/ 2.4 25/10 MG Tumor colon ascenden Post laparoscopy + laparotomi Konsulan TS
C325709 TNM? hemicolectomi dextra Interna
(31/10/18)