Screening Bedah Digestif

Rabu, 25 September 2019

NO. Ruangan Identitas Diagnosa Laboratorium Radiologi Rencana

Pasien
1. RB2A Marsani Post laparotomi d/t 23/09/2019 - Susul
3.5 Panggabean appendisitis perforasi Hb/Eri/Leu/Ht/PLT: hasil PA
79.10.16 12.3/4.17/13.480/34/344.000
L/46 tahun Albumin : 2.6
Na/K/Cl : 144/4.1/106

21/09/2019
PT/APTT: 22.5/54.6
INR: 1.68
2. RB2A Yusup Post op hernioraphy 23/09/19 Susul
3.5 Sinukaban Hb/Eri/Leu/Ht/PLT: hasil
791215 15.7/5.93/10680/48/329000 foto
L/53 tahun PT/APTT/INR: 13.6/28.7/0.98
GDS: 114
Na/K/Cl: 136/4.8/101
3. RB2A Relianna Tumor intra abdomen 15/9/2019 19/09/2019 Konsul
3.3 Hutabarat Hb/Eri/Leu/Ht/PLT: MSCT scan whole abdomen IV paru
79.03.12 10.9/3.69/7270/32/255000 contrast: hepatomegali dengan
P/57 tahun abses dd/infected cyst, lobus
kiri hepar disertai efusi pleura
bilateral
14/09/2019
Thorax: kardiomegali
Abdomen: susp. massa pada
abdomen
5. RB2 Jhonni Obs. Jaudice d/t 18/09/2019 05/09/2019 Susul hasil foto
onko Sitompul cholecystolithiasis Hb/Eri/Leu/Ht/PLT: Thorax: tidak tampak thorax
1.1.1 79.06.12 8/2.65/12240/23/214000 kelainan pada cor dan
L/49 tahun Albumin: 2.8 pulmo
KGDs: 148 Abdomen: peritonitis
Na/K/Cl: 131/3/102
19/09/2019
Bilirubin total/direk: 29.8/19.8
20/09/2019
BUN/ur/cr: 11/24/0.96
6. RB3 Ridawati HCC 21/09/2019 ??/??/2019 Cek hasil lab
1.2.3 Paulina Hb/Eri/Leu/Ht/PLT: MSCT scan whole post transfusi
Marbun 3.6/1.31/19320/12/309000 abdomen IV contrast: dan substitusi
59.15.15 hepatomegali dengan tepi albumin
P/41 tahun lesi primer hepar
berseptasi dengan
vaskularisasi intralesi.
Susp. hemangioma
dd/HCC yang mendrorong
aorta, pankreas, dan
sebagian usus ke kiri serta
menekan ginjal kanan
13/05/2019
Thorax: metastase pada
paru kanan
8. ICU Bini Sepsis + post eksplorasi 21/09/2019 -
PasBed 79.09.97 laparatomi d/t hernia Hb/Eri/Leu/Ht/PLT:
Bed 1 P/57 tahun umbilical strangulata + 10.9/3.74/13800/32/419000
tersier peritonitis d/t Albumin: 1.6
leakage KGDs: 137
BUN/ur/cr: 19/41/0.73
Na/K: 136/4.3
9. ICU Tiodor Post relaparotomi d/t 23/09/2019 21/09/2019
PasBed Lumban leakage post laparotomi Albumin : 2.2 Thorax: tidak tampak
Gaol d/t gaster perforation BUN/Ur/Cr : 14/30/0.56 kelainan pada cor dan
79.10.54 22/09/2019 pulmo
P/78 tahun Hb/Eri/Leu/Ht/Plt:
11.7/4.2/6.660/35/145.000
pH/pCO2/pO2/HCO3/TCO2/BE/Sat
7.22/26/145/10.6/11.4/-15.5/99.0
Na/K/Cl : 137/4.1/102
KGDs: 138
9. Paviliun Binsar H M Adenokarsinoma 19/09/2019 02/09/2019
Lt.5 Nasution Gastroesofageal Hb/Eri/Leu/Ht/PLT: Barium Esofagus
5.17.2 788877 Junction (GEJ) 13/4.56/7750/38/251.000 Stenosis distal esofagus
L/44 tahun Albumin : 4.3 masih mungkin ec massa
KGDs : 64 dinding esofagus distal
Na/K/Cl : 138/4.2/106 Saran: CT Scan Esofagus
dengan kontras IV.

03/09/2019
CT Scan Thorax IV
Kontras
Susp. Massa distal
esofagus sampai fundus
gaster dengan stenosis
 distal esofagus ec. Ca.
Esofagus; DD/GIST.
10. Rb2A. Pebri NS Diffuse peritonitis d/t 24/09/2019 24/09/2019
3.5 Nababan perforasi apendisitis Hb/Eri/Ht/Leu/Plt: Foto sudah ada, bacaan
79.13.05 13.9/4.41/39/33.500/463.000 belum
L/37 thn KGDs: 147
BUN/Ur/Cr: 20/43/0.73
Na/K/Cl: 124/4.8/86
PT/INR/APTT: 14.5/1.05/29.5
11. RB2A Yahya Burst abdomen post 24/09/2019 24/09/2019 Transfusi prc 2
3.5.5 Antonius laparotomy eksplorasi + Hb/Eri/Ht/Leu/Plt: Foto sudah ada, bacaan bag, wb 1 bag
Purba repair + 9.9/3.0/27/16.160/22.000 belum
79.14.12 trombositopenia KGDs: 86
L/50 thn BUN/Ur/Cr: 13/28/0.5
Na/K/Cl: 126/4.0/94
12. HCU Sularni Tumor gaster susp. 24/09/2019 24/09/2019
IGD 79.13.26 Malignant + Anemia Hb/Eri/Ht/Leu/Plt: Foto sudah ada, bacaan
Bed 1 P/70 thn berat 3.9/1.32/13/24.200/287.000 belum
KGDs: 181
BUN/Ur/Cr: 63/135/1.17
Na/K/Cl: 147/4.1/106
13. RB2A Zuraidah Tumor ganas + Post 24/09/2019 24/09/2019 Analisa cairan
3.2.4 79.13.25 laparotomi + Metastase Hb/Eri/Ht/Leu/Plt: Foto sudah ada, bacaan pleura dan
P/50th pleura 10/3.95/31/7.590/439.000 belum sitologi c.
KGDs: 79 pleura
BUN/Ur/Cr: 13/28/0.72
Na/K/Cl: 139/3.9/102
14. RB1 Nurjani Post primary suture d/t 23/09/2019 23/09/2019 Diet TPN 3-5
3.4.2 69.51.79 perforasi rectum + Hb/Eri/Ht/Leu/Plt: Foto thorax PA: Susp. hari, rectal
P/43th anastomosis colon 11.3/4.08/34/21.150/286.000 Kardiomegali dd LVH tube
rectum 16/09/2019 dipertahankan
BUN/Ur/Cr: 8/17/0.66
Na/K/Cl: 134/3.9/101
15. RB3 Darwin Post apendektomi d/t 13/09/2019 13/09/2019 Susul hasil PA
1.1.2 Lubis apendisitis kronik Hb/Eri/Ht/Leu/Plt: USG Appendiks
26.38.33 14.3/4.67/39/8.700/163.000 Sesuai gambaran
L/50 thn PT/INR/APTT: 12.9/0.93/26.5 apendisitis akut.
17/09/2019 Saran: CT Scan Upper dan
Na/K/Cl: 141/4.1/102 Lower abdomen dengan
kontras