KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

PALEM
Palem Bawah
Abdul Aziz
B1/5
TL: 26-12-1961
RM : 769915

Peritonitis TB + DM
tipe II

Lab 1/9/2016
GDS:276
Lab 29/8/2016
WBC: 13,9
RBC: 3,87
HGB: 11,5
HCT: 35
PLT : 381
PT/APTT : 9,3/26,5
INR : 0,89
Ur/Kr: 27/0,79
SGOT/SGPT: 14/9
Na/K/Cl: 121/3,4/88

DPJP: : dr. M.
Ikhwan Kusuma,
Sp.B-KBD

Infus RL 20
tetes/menit
Metronidazole
500mg /8jam/iv
Omeprazole 40
mg/8jam/iv
Terapi lain sesuai
TS

USG Abdomen
Atas+Bawah
29/8/2016:
Pelvocalyectasis
billateral terutama
kanan
Foto thorax PA/AP
29/8/2016
Pneumonia dextra
Dilatatio et elongatio
aortae
Palem bawah
B2/2
Bed 11
Petrus Karangan
TL : 7-11-1946
RM: 613743
MRS: 26-8-2016
DPJP: DR. dr.
Ibrahim Labeda,
Sp.B-KBD

Susp Tumor gaster

Lab : 28/8/2016
WBC : 17,6
RBC : 3,47
HGB: 8,4
HCT :28
PLT : 302
PT/APTT: 10,7/25,9
INR: 1,03
SGOT/SGPT: 13/7
Gamma GT : 13
CT Whole abdomen
(tanpa kontras)
:tumor hepar suspek
metastasis
Foto thorax AP:
26/82016
Tidak tampak tanda-

Infus NaCl 0,9 %

28 tetes/menit
Ceftazidime
1gr/12jam/iv
Ketorolac
30mg/8jam/iv
Omeprazole 40
mg/24jam/iv
Ondansentron
4mg/8jam/iv
Diet lemak

Rencana OMD
Selasa 6/9/2016

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

tanda metastasis
Dilatatio aortae
Cor dan pulmo
normal
Palem bawah
B2/3

Tumor Inguinalis

Tgl 30/8/2016
WBC 16,3
RBC 4,49
Hb 12
HCT 37
PLT : 362

Infuse RL 28 tpm
Paracetamol 500
mg/8jam/ oral : bila
nyeri

POH-18
Hematochesia
Post
hemoroidektoomy
stappler

Lab 02/09/2016

Infuse RL28 tpm

Cocktail/12
jam/drips
Ardium 3x1

AndiSumena
TL : 01-01-1971
RM: 766710
MRS: 24-8-2016
DPJP: dr. M.
Ikhwan Kusuma,
Sp.B-KBD
Palem Bawah
B2/7
Fahmi hidayatullah
TL: 20-10-1992
RM : 768051
DPJP: :
Dr.drWarsinggih,
SpB-KBD

Palem bawah
B2/11
Sofietje
TL : 15-09-1958
RM: 754684
MRS: 16-8-2016
DPJP: DR. dr.
Ibrahim Labeda,
Sp.B-KBD

WBC : 8,04
RBC:3,12
HGB 8,8
HCT : 26,8
PLT: 340

Cek darah rutin

post transfuse
Diet lunak

29/8/2016
PT/APTT: 10,3/30.1
INR : 0,96
Waktu bekuan : 7,3
Waktu perdarahan :
2,3
SGOT/SGPT : 18/16
Ur/Kr : 20/1
Na/K/Cl: 146,4,4/105
Tumor Duodenum

Lab (30/08/2016)
WBC 6,6
RBC 3,98
Hb 10,5
HCT 34
PLT 213
GDS 87
PT/APTT:10,3/29,1
INR: 0.96
MSCT Whole
abdomen
dengankontras
(10/05/2016) :

Terapi lain sesuai

TS interna

Rencana operasi
whiple procedure
Senin 5/9/2016

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Massa duodenum
dengan distended gaster
Hepatosplenomegaly
PalemAtas
B1/5

Ileus obstruktifpost
laparatomi

Lab 27/8/2016
GDS: 105
Ur/Cr 34/0,35
SGOT/SGPT: 20/7
Asam urat : 3,1
LAB 25/8/2016
WBC 16,5
RBC 4,25
HB 10,3
PLT 651
PT/APTT 10,4/263,6

Adenocarcinoma
colon

Lab 26/8/2016
WBC : 6,9
RBC: 5,26
HGB: 11,8
HCT: 39
PLT: 241
GDS: 111
Ur/Kr: 31/0,7
SGOT/SGPT: 87/73
Na/K/Cl: 144/4,4/105

Tumor
intraabdomen Susp
tumor gaster

Lab (16/08/2016)
WBC 7,1
Hb 13,2
RBC 4,29
PLT 193
PT/APTT: 10,2/32,7
INR: 0,95
Ur/Kr: 41/1
SGOT/SGPT : 34/33
GDS: 101

Elisabeth K
RM : 769210
TL : 06/08/1960
MRS : 22-08-2016
DPJP :
Dr.drWarsinggih,
SpB-KBD

PalemAtas
B1/8
Imelda
RM : 769683
TL : 15-5-1955
MRS : 26-08-2016
DPJP :Dr. dr.
Warsinggih, SpBKBD
PalemAtas
B2/2
AlianasThalib
RM : 768508
TL : 01-07-1956
MRS : 23-08-2016
DPJP :Dr. dr.
Warsinggih, SpBKBD

Kolestrol total 173

Kolestrol HDL 28
Kolestrol LDL 111
Trigliserida 77
HbsAg (-)
Foto Thorax AP/PA
19/8/2016 : tb lama

-infus RL:DS:
aminofluid:
1:1:1:28 tpm
Duragesic patch
25mg
-Ceftriaxone
1gr/12jam/iv
-Paracetamol
1gr/8jam/iv
-Omeprazole
40mg/24jam/iv
-Nutrisisesuai TS
Interna
-Terapi lain sesuai
APS
Rencanakemoterapi

As mefenamat
500mg/8jam/oral
UGIE : GERD
grade B, antral
gastritis
Lansoprazole 30
mg/12 jam/oral

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

paru tenang
USG Doppler:
Hemangioma hati
PalemAtas
B2/6

POH 0 stapler
haemorrhoidektomy

Lab 31/8/2016
WBC : 7,9
RBC: 6,46
HGB: 10,6
HCT: 40
PLT: 262
GDS: 83
Ur/Kr: 23/0,6
SGOT/SGPT: 21/17
Na/K/Cl: 142/3,9/101

Ca recti 1/3 distal

Lab 20/8/2016
WBC: 4,9
RBC : 3,82
HGB: 10,8
HCT : 33
PLT : 415

Fadli Darmawan
RM : 543516
TL : 25-3-1994
MRS : 31-08-2016
DPJP :Dr. dr.
Warsinggih, SpBKBD
PalemAtas
B2/13
BED 2
NY.Siani
RM : 765086
TL : 17-7-1951
MRS : 13-08-2016

Deda
RM : 770057

Rencana operasi
5/9/2016

Lab 14/8/2016
Ur/Kr: 17/0,62
SGOT/SGPT: 17/7
POH 2 CAFD

H.Sudarmin,SH,M
H
RM : 701265
TL : 12-11-1960
MRS : 19-08-2016
DPJP :Dr. dr.
Warsinggih, SpBKBD
PalemAtas
B1/6
Bed 1

Diet lemak
Aff catheter

Lab 15/8/2016
PT /APTT: 10,9/28
INR: 1,02

DPJP : dr. Samuel

Sampetoding,
Sp.B-KBD

PalemAtas
B2/9
Bed 2

IVFD RL 20tpm
Ceftazidime
1gr/12jam/iv
Ranitidin
5mg/8jam/iv
Ketorolac
30mg/8jam/iv
Ganti tampon/6jam

ca recti 1/3 tengah

Lab 1/9/2016
PT/APTT : 11,4/32,4
INR: 1,07
GDS: 159
Ur/Kr: 200/9,2
SGOT/SGPT: 47/68
Na/K/Cl: 136/5,4/100
Lab 30/8/2016
WBC: 7
RBC: 2,73
HGB: 8,3
PLT : 131
Lab 29/8/2016
WBC: 10,0
RBC: 3,81
HGB: 9,8
PLT : 260
PT/APTT : 10,1/25,8

Cefadroxil
500mg/12jam/oral
As.Mefenamat
500mg/8jam/oral
Spooling NaCl
0,9% 500cc/hari via
CAFD
Terapi lain sesuai
TS GH

IVFD RL 28 tpm
Ceftazidime
1gr/12jam/iv
Ranitidin
50mg/8jam/iv
Ketorolac 30mg/iv

CT scan pelvis

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

TL : 12-12-1953
MRS : 29-08-2016
DPJP : dr. Samuel
Sampetoding,
Sp.B-KBD
PalemAtas
B2/3
BED 1

INR: 0,97
GDS: 86
Ur/Kr: 17/1,06
SGOT/SGPT: 13/9
Na/K/Cl: 147/3,7/111

Neurobion 1
amp/24 jam/drips

POH II MILES
Procedure ec
adenocarcinomarect
i 1/3 distal

Lab 29/8/2016
WBC: 20,4
RBC: 4,18
HGB: 12,1
HCT : 38
PLT: 220
GDS: 226
Ur/Kr: 34/1,24
SGOT/SGPT : 25/18
Na/K/Cl : 138/3,6/96

Infus RL 28
tetes/menit
Ceftazidime
1gr/12jam/iv
Metroidazole
0,5g/8jam/iv
Ketorolac
30mg/8jam/iv
Ranitidin
150mg/8jam/iv

Adenocarcinoma
gaster

Lab 30/8/2016
WBC : 17,1
RBC: 3,3
HGB: 9,8
HCT :30
PLT :341
CEA : 5,35
UR/KR : 45/1,5
Na/K/Cl: 137/3,7/104

Aryudi arsyad
RM : 768825
TL : 2-5-1981
MRS : 26-08-2016
DPJP : dr. Samuel
Sampetoding,
Sp.B-KBD
PalemAtas
B2/1
Elishabet
RM : 764126
TL : 12-12-1954
MRS : 13-08-2016
DPJP :Dr. dr.
Warsinggih, SpBKBD

PalemAtas

Diet natrium bebas

Rencana
gasterektomi
kluarga sudah
setuju( tunggu
jadwal)

CT whole Abdomen :
hidronefrosis sinistra
ec. Nefrolith
Tumor colon
sigmoid

Patanggai
RM : 728236
TL : 31/12/1958
MRS : 3-09-2016
DPJP:
Dr.dr.Ronal
Lusikooy,Sp.BKBD

Lab 15/8/2016
WBC : 5,3
RBC: 4,6
HGB: 12,8
HCT :39
PLT :267
UR/KR : 24/0,8
SGOT/SGPT: 18/10

Rencana operasi
Laparoskopi
sigmoidektomi rabu
7/9/2016
Diet susu+sari buah

LONTARA 1
Lontara 1 bawah
Belakang

Abses hepar

Lab 20-8-2016:
Prokalsitonin 0.88

Terapi lain sesuai Ts

Interna

Tunggu jadwal
drainase abses

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Kamar 6/III Bed 6

Lab 26-8-2016:
WBC 9.7
RBC 3.69
HB 11.2
HCT 34
PLT 302
Alb: 2.5
Lab 21-8-2016
Ur/cr : 36/0,64
Sgot/sgpt 22/16
Na/K/Cl :
148/3.6/107

Mukhtar Ali
TL: 3-8-1985
(41 tahun)
RM: 768236
MRS: 15-8-2016
Konsul: 18-8-2016
DPJP: Dr. dr.
Warsinggih, Sp.BKBD

Lontara 1 bawah
Depan
Kamar 4/II Bed 1
Hamitta Langga
TL: 31/12/1962
(53 thn)
RM: 767802
MRS: 10/8/2016
Konsul: 22/8/2016
DPJP: dr. M.
Ikhwan Kusuma,
Sp.B-KBD

Tumor Oesophagus 1/3

distal

CT whole
abdomen 15-82016
Multiple abses
hepar, nephrolith
sinistra, Ascites
Efusi pleura dextra
Tidak tampak tandatanda ileus
MSCT thorax
tanpa kontras
25-8-2016
Efusi pleura
bilateral terutama
kanan, Multiple
abses hepar
Lab 17-8-2016
WBC 10.1
RBC 5.20
HB 11.3
HCT 37
PLT 373
Alb 3.5
Na/K/Cl : 142/
4.0/101
Lab 19-8-2016
AFP 7.30
CEA 1.78
USG whole abd
10/8/2016
Organ2
intraabdomen yg
terscan dlm batas
Normal

hepar

Terapi lain sesuai

TS Interna
tunggu jadwal
OMD

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Lontara 1 Bawah
depan
Kamar 1/III Bed 2

POH IV Laparotomi
ekplorasi ec tumor
gaster unresectable

Hasna
TL: 25/8/1969
(47thn)
RM 767647
Konsul 25/8/2016
DPJP: dr. M.
Ikhwan Kusuma,
Sp.B-KBD

Lontara 1 Atas
Depan
Kamar 5/III Bed 6

POH V Laparoscopy
kompleks ec abses
hepar

Abdul Latif
TL : 10-4-1970
(46thn)
RM : 766182
MRS: 28-7-2016
DPJP : Dr. dr.
Warsinggih, Sp.BKBD

Lontara 1 Atas
Depan
Kamar 5/III Bed 4
Nurdin
TL : 2-10-1936

POH 14 drainase
asicites +
Icterus obstruktif ec
batu CBD

MSCT Thorax dgn

kontras15/8/2016
Massa distal
esophagus sampai
fundus gaster
Lab 26/8/2016
Alb 2.7
Lab 25/8/2016
WBC 16.7
RBC 4.58
HGB 11.9
HCT 37
PLT 112
Lab 21/8/2016
Ur/Kr 33/0.62
CT whole
abdomen tanpa
kontras 9/8/2016
Penebalan dinding
gaster suspek massa,
limfadenopati
paraaorta
abdominalis,
hydronefrosis
sinistra, ascites,
cystitis, efusi pleura
bilateral minimal
MRCP 19-8-2016:
Abses lobus kanan
hepar, cholelith
disertai
cholecystitis, efusi
pleura dextra
Lab 28-8-2016:
WBC 6.8
RBC 3.30
HB 9.7
HCT 30
PLT 357
Alb 2.8
Ur/Kr 12/ 0.62
Urinalisis 26-82016
Bilirubin +++/>=6
Nitrit positif
Blood +++/200
Lekosit +-/ 15

Terapi lain lanjut

sesuai TS Interna
GV/3 hari

Terapi lain sesuai

TS Interna

IVFD D5:RL 1:1 28

tpm
Cefotaxim 1 gr/ 12
jam
Omeprazole 40mg/
24 jam

Takar produksi urin

GV/3 hari

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

(79thn)
RM : 767853
MRS: 11-8-2016

Sed. Lekosit 14
Sed. Eritrosit 98
sed. Epitel sel 1
Sed.lain bakteri 18,
mucosa 1
Lab 24-8-2016
WBC : 4.7
RBC 3.41
HGB 10.6
HCT 31
PLT 192
Lab 25-8-2016
Ur/Kr 24/0.4
Alb 1.7 gr/dl
SGOT /SGPT 48/32
Na/K/Cl :
122/3.6/93
Lab 02-09-2016
Alb 1,8 gr/dl

DPJP : Dr. dr.

Warsinggih, Sp.BKBD

Vip Albumin 3x2

MRI cholangio
pancreatografi
tanpa kontras 168-2016
Choledocolith yang
menyebabkan
cholestatic intra dan
extrahepatik,
cholesystitis disertai
abses GB, acites,
efusi pleura bilateral

Lontara 1 Atas
Belakang
Kamar 2/III Bed 4
Faisal M.
TL: 3-10-1972
(43 thn)
RM: 597028
MRS:
Konsul: 18-8-2016
DPJP: Dr. dr.
Warsinggih, Sp.BKBD

CKD Pro repair CAPD

Lab 26-8-2016:
WBC 22.2
RBC 2.58
HB 6.7
HCT 20
PLT 478
Ur/Cr:
Na/K/Cl :
D-dimer >5
Lab 23-8-2016
Alb 2.8
Urinalisa 18-82016:
pH: 8.5
Protein +++/300

Terapi lain lanjut

sesuai TS interna

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Glukose +++/500
Blood ++/80
Lekosit +-/15
Sedimen lekosit 2
Sedimen eritrosit 9
Sedimen epitel sel 2
USG Whole
Abdomen
11/8/2016:
Slight
hepatomegaly, PNC
bilateral, Simple
renal cyst bilateral,
Ascites dan efusi
pleura bilateral

LONTARA 2 ATAS DEPAN

Lontara 2 Atas
Depan
Kamar 1 Bed 1
Muh. Natsir dg
Tinggi
Umur: 58 tahun
TL: 31-12-1957
RM: 769834
MRS: 27-08-2016
DPJP: dr. Samuel
Sampetoding, Sp.BKBD

Ileus obstruksi
partial
Ascites
Efusi pleura
bilateral post
WSD

Lab 1-09-2016
WBC 18,9
RBC 3,60
HGB 10,5
Ur 39
Cr 0,59
Alkali fosfatase 804
Protein total 5,5
Alb 2.3
Gamma GT 365
Lab. 27/08/2016
PT/APTT/INR :
25.4/31.7/2.42
GDS : 102
Ur/Cr : 42/0.73
Bil. Tot : 9.04
Bil. Direk : 8.03
SGOT/SGPT : 78/52
Alb : 2.1
HBsAg : Non reactive
Anti HCV : Non
reactive
Na/K/Cl : 140/4.5/107

Analisis gas darah

(28/08/2016)

IVFD RL : D5 =1:1 /
28 tpm
Neurobion 1
amp/24J/IV
PCT 1gr/8j/IV
Ranitidin 50
mg/8j/IV
Ceftazidim 1
gr/12j/IV
Terapi lain sesuai Ts.
Interna

Awasi tanda vital

dan akut abdomen

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

pH : 7.519
pCO2: 32.9
SO2 : 90.3
PO2 : 52.5
HCO3 : 27.1
ctO2 : 16.1
ctCO2 : 28.1
BE : 4.0
Imunoserologi
(28/08/2016)
Prokalsitonin : 5.42
USG Abdomen Atas +
Bawah (Whole
Abdomen )
(27/08/2916):
Kesan : Loculated
ascites
Efusi pleura bilateral
Operasi pasang WSD
(29/08/2016)
e.c Efusi pleura sinistra
Operasi pasang WSD
(30/08/2016)
e.c Efusi pleura dextra
Lontara 2 Atas
Depan
Kamar 1 Bed 2
Yan Lintin
Umur : 55 tahun 11
bln
TL : 06/10/1960
RM : 770377
MRS : 01/09/2016
DPJP : Dr.dr.
Warsinggih, Sp.BKBD

Lontara 2 Atas
Depan
Kamar 1 Bed 3

Post Laparatomy
e.c tumor gaster

Lab. 01/09/2016
WBC : 8.33
RBC : 4.43
HGB : 12.9
HCT : 38.3
PLT : 156
PT/APTT/INR :
13.2/27.3/1.24
GDS : 47
Ur/Cr : 28/0.81
SGOT/SGPT : 19/11
Alb : 2.4
HBsAg : Non reactive
Anti HCV : Non
reactive
Na/K/Cl : 142/3.1/107

IVFD RL : D5%+ 1:1

/28 tpm = 2:2 = 28
tpm
Ceftriaxone 1
gr/12j/IV
Ranitidin 50mg/8j/IV
Antrain 1 gr/8j.Iv

Tidak dilanjutkan
pemeriksaan CT
Abdomen krn
masih banyak
kontras di
lambungnya

POH II
Laparatomy
eksplorasi +

Lab 02/09/2106
WBC : 22.15
RBC : 3.54

Ceftazidime 1
gr/12j/IV
Metronidazole

Kultur pus +
jaringan

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Pia
Umur : 54 tahun
TL : 10/03/1962
RM : 770658
MRS : 03/09/2016

drainage abses
hepar e.c. abses
hepar

Icterus obstruktif
e.c Cholelithiasis

DPJP:
Dr.dr.Ronal
Lusikooy,Sp.BKBD

L2 Atas Depan
ISO Bed 1
Suardi
Umur : 48 tahun
TL : 15/07/1968
RM : 755556

0.5gr/8j/IV
Ranitidin 50
mg/8j/IV
Antrain 1 amp/8j/IV

Lab. 30/08/2016
Na/K/Cl : 143/4.7/104
PT/APTT/INR :
16.9/28.6/1.48
GDS : 148
Ur/Cr : 28/0.7
Bil. Tot : 0.42
Bil. Direk : 0.20
SGOT/SGPT : 13/14
Alb : 3.7
AFP : 1.71
HBsAg : Non reactive

DPJP:
Dr.dr.Ronal
Lusikooy,Sp.BKBD

Lontara 2 Atas
Depan
Kamar 1 Bed 4
Jueni
Umur : 61 tahun
TL : 31/12/1954
RM : 769337
MRS : 24/08/2016

HGB : 9.9
HCT : 30.8
PLT : 825

Ileus Obstruksi
e.c suspek batu
CBD
Cholelithiasis

Operasi Laparatomy
eksplorasi + drainage
abses (03/09/2016)
Lab 24-8-2016
RBC 3.13
HGB 11.0
HCT 33.0
WBC 12.6
PT 11.3
APTT 25.2
GDS 100
Ur 29
Cr 0.91
Bil. Tot 7.74
Bil. Direk 5.62
Sgot 62
Sgpt 100
Alb 3.2
Na 142
K 3.7
Cl 104
Lab 29-8-2016
Alkali fosfatase 388
Gamma GT 286
CA 19-9 >500.0
S : Nyeri perut
O : sakit sdg/
composmentis
Abdomen supel,
peristaltik (+)

IVFD asering 28
tpm
Neurobion 1
amp/24jam
Ketorolac
30mg/8jam/iv
Ranitidine
50mg/8jam/iv
Vit. K 1
amp//24jam/iv

Rencana operasi
selasa 6/9/2016

IVFD RL 20tpm
Ceftriaxone
1gr/12jam/IV
PCT 1 gr/8jam/IV
Omeprazole
40mg/12jam/IV

Menunggu hasil
MRCP

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

MRS : 31/08/2016

Lab. 31/08/2016
WBC : 22.63
RBC : 4.48
HGB : 13.4
HCT : 38.4
PLT : 251
PT/APTT/INR :
12.0/30.7/1.05
GDS : 152
Ur/Cr : 26/0.74
Bil. Tot. : 14.90
Bil. Direk : 14.15
SGOT/SGPT : 59/87
Alb : 3.7
HBsAg : Non reactive
Anti HCV : Non
reactive
Na/K/Cl : 139/4.0/99

DPJP : Dr.dr.
Warsinggih, Sp.BKBD

USG Abdomen atas

+ Bawah (Whole
Abdomen)
(31/08/2016) :
Kesan :
Hepatosplenomegaly
Cholestatic intra dan
ekstrahepatik e.c.
batu CBD
Cholelith dg tandatanda cholecystitis
Organ-organ
intraabdomen lainnya
dalam batas normal.
L2 Atas Depan
ISO Bed 2
Banda
Umur : 88 tahun
TL : 01/07/2016
RM : 770140
MRS : 31/08/2016

Suspek Tumor
Hepar

IVFD RL 28 tpm
Ranitidin 50
mg/8jam/IV
PCT 1gr/8jam/IV
Ceftriaxone
1gr/12jam/IV

Menunggu hasil
CT-Scan triphase

Ranitidin

Rencana

Lab 01/09/2016
WBC: 9.5
RBC:2.72
HGB: 8.5
HCT: 26
PLT: 187

DPJP : Dr.dr.
Warsinggih, Sp.BKBD

Lontara 2 Atas

S : Nyeri perut
O : sakit sdg/gizi
cukup/Composmenti
s
Abdomen supel,
peristaltik (+)

POH-5

Laboratorium (1-9-

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Depan
Kamar 2 Bed 1
Johani
Umur: 60 tahun
TL: 31-12-1966
RM: 754527
MRS: 1-09-2016

Laparatomy
eksplorasi +
colostomy e.c
ileus obstruktif
e.c ca. recti 1/3
distal

DPJP: dr. Samuel

Sampetodang,
Sp.B-KBD

Lontara 2 Atas
Depan
Kamar 2 Bed 2

POH-50 Miles
operasi e.c
Adenocarcinoma
recti 1/3 distal

Armila Jamil
Umur: 43 tahun
TL: 24-1-1973
RM: 732549
MRS: 1-09-2016
DPJP:
Dr.dr.Ronal
Lusikooy,Sp.BKBD

Lontara 2 Atas
Depan
Kamar 2 Bed 3
Indo Esse
Umur: 42 tahun
TL: 01-07-1974
RM: 769853
MRS: 27-08-2016
DPJP: dr.Samuel
Sampetoding, Sp.BKBD

Susp tumor
gaster

2016):
WBC: 10,4
Hb: 4,13
RBC: 4,13
PLT: 355.000
PT/APTT: 11,3/19,7
GDS: 135
Ur/Cr: 56/0,75
Albumin: 3,9
HbsAg: Non Reactive
Na: 145
K: 2,9
Cl: 104

S: tidak ada keluhan

O : sakit sedang/gizi
cukup/composmentis
Lab 12-8-2016
WBC: 3,7
RBC:3,9
HGB: 10,2
HCT: 32
PLT: 453
GDS: 117
Ur: 12
Cr: 0.42
SGOT: 20
SGPT: 10
Na: 143
K: 4.4
Cl: 106
S: sakit perut
O : abdomen suspe
A; tumor gaster
Lab 2/8/2016
AFP: 0,75
CEA: 1,24
Lab 28-8-2016
WBC: 4.3
RBC: 4.64
HGB: 11.3
PLT: 94
GDS :113

50mg/8jam/iv
Paracetamol
1gr/8jam/iv
Ceftazidim
1gr/12jam/iv
Diet minum

kemoterapi

Lapor dr. Samuel

Sampetoding, Sp.BKBD:
-aff infus, terapi oral
Cefadroxil 2x500mg
As.Mefenamat
3x500mg
Ranitidin 2x150mg
KSR 2x1
-Mobilisasi jalan
-Diet bebas
-Konsul GH
Rencana
kemoterapi

Asam Mefenamat
500mg/8jam/oral
Ranitidin
150mg/12jam/oral
Paracetamol
1gr/8jam/oral

Instruksi dari
KGEH:
-Rencana Lab
PT/APTT,
SGOT/SGPT
-Konsul kardio
untuk kelayakan
UGIE

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Ur/cr : 12/0.54
Alb : 2.8
Sgot : 16
Na : 136
K 3.3
Cl 105

Lontara 2 Atas
Depan
Kamar 2 Bed 4

Ikterus Obstruktif
e.c Suspek tumor
caput pankreas

Sarpiah
Umur: 36 tahun
TL: 15/09/1979
RM: 768591
MRS: 16-08-2016
DPJP: dr. Samuel
Sampetodang,
Sp.B-KBD

Lontara 2 Atas
Depan
Kamar 3 Bed 1
Hendri
16-9-1990
766514
MRS : 19-8-2016
DPJP : DR. dr.
Ibrahim Labeda,
Sp.B-KBD

Tumor colon
ascendens

MSCT Whole
Abdomen Non kontras:
-Distended gaster e.c
susp. Massa antrum
pylorie
-Susp. Tumor
metastasis ke hepar
-Efusi pleura bilateral
Laboratorium
(30/08/2016)
WBC: 4,55
RBC: 2,87
Hb: 8,5
PLT: 229.000
Na: 136
K: 2,2
Cl: 103
Laboratorium (31-082016)
Na: 135
K: 3,4
Cl: 105
S: tidak ada keluhan
O: sakit sedang/gizi
cukup/composmentis
Abdomen supel,
peristaltik (+)
Lab 31-08-16
WBC : 5
RBC : 4.1
HB : 10,5
PLT : 376
HCT : 36.7
Albumin : 3.7
SGOT/SGPT: 15/12
Ur/Kr: 13/0,8
Na : 141
K : 4,1
Cl : 105

IVFD RL 28tpm
Ceftazidime
1gr/12jam/iv
Ranitidin
50mg/8jam/iv

Instruksidr.Julianus,
Sp.B
-Periksa CA199,
alkali fosfatase,
Gamma GT
-Periksa Ct-Scan
Upper Abdomen
kontras
-Konsul KGEH
untuk pasang UGIE

IVFD RL 28 tpm
Neurobion 1 amp/
24jam/ iv
Paracetamol
1gr/8jam/iv

Rencana operasi
hari kamis
08/09/2016

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Lab 2/8/2016
CEA: <0,5
Foto polos abdomen
(01/09/2016) :
Kesan : Suspek
nephrolith sinistra
Colon Inloop
(01/09/2016) :
Kesan : Massa colon
ascendens bagian
proximal
CT whole abdomen
tanpa kontras
(02/08/2016):
-suggestif massa cecum
dan tanda invaginasi
- nefrolith sinistra
LGIE (08/08/2016):
Tumor polipoid kolon
transversum (stenotik)
IBD (proktokolitis)
derajat sedang.

Lontara 2 Atas
Depan
Kamar 3 Bed 2
Muh.Rong
Umur 58 tahun
TL : 31-12-1957
RM : 770073
MRS : 29-08-2016
DPJP : Dr.dr.Ronal
Lusikooy,Sp.BKBD

Hematochezia
Suspek tumor
colon

Hasil PA (10/8/2016) :
peradangan kronik aktif
non spesifik (tumor
caecum)
S: nyeri perut
O: sakit sedang/gizi
cukup/composmentis
Abdomen supel,
peristaltik (+)
Lab -1/9/-2016
WBC: 9,8
RBC: 4,27
HGB: 10,4
HCT : 24
PLT: 427
PT/APTT: 9,9/26,6
INR: 0,96
Ur/Kr: 36/0,91
SGOT SGPT: 20/27
Albumin: 3,4

IVFD RL 28 tpm
Ceftazidime
1gr/12jam/iv
Ranitidin
50mg/8jam/iv

Reancana colon in
loop
Kolonoskopi

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Lontara 2 Atas
Depan
Kamar 3 Bed 4
Dg Nangring
Umur : 42 tahun
TL : 01/01/1974
RM : 770713
MRS : 04/09/2016
DPJP : Dr.dr.Ronal
Lusikooy,Sp.BKBD

POH I
Laparatomi
eksplorasi e.c.
vulnus ictum
region abdomen

S : Post operasi
O : status generalis
masih tersedasi
Status vitalis
BP : 100/70 mmHg
HR : 80x/menit
RR : 16x/menit
S : 36.5C
SPO2 : 100%
Operasi Laparatomi
eksplorasi e.c. vulnus
ictum region abdomen
+ episerasi
(04/09/2016)

-Instruksi Post
operasi :
IVFD RL : D5% =
2:1 = 28 tpm
Ceftazidime
1gr/12jam/IV
Metronidazole
0.5gr/8jam/drips IV
Omeprazole 40
mg/12jam/IV
Wound care
Terapi nyeri sesuai
Ts. Anestesi

Lab. 04/09/2016
WBC : 22.90
RBC : 4.93
HGB : 15.8
HCT : 47.8
PLT : 270
PT/APTT/INR :
9.8/21.6/0.94
GDS : 109
Ur/Cr : 28/0.74
SGOT/SGPT : 25/24
Alb : 4.2
HBsAg : Non reactive
Anti HCV : Non
reactive
Na/K/Cl : 143/4.0/104

Lontara 2 Atas
Depan
Kamar 10Bed 1

POH 4 Miler
procedure

Mariam
TL:10.9.1970
(45Thn)
RM : 736205
MRS: 5.08.2016
DPJP : dr. M.
Ikhwan Kusuma,
Sp.B-KBD
Lontara 2 Atas

Lab 26/8/16
WBC: 11,2
RBC: 4.28
Hb: 10,6
PLT: 485
Lab 27-8-16
Alb 2,8
GDS 102
SGOT/SGPT: 24/22

Post colostomy

Lab 31/8/16

-IVFD RL 28 tpm
-Ranitidin
50mg/8jam/iv
-ketorolac
-Paracetamol
1gr/8jam/iv
-koktail drips
Boleh minum 1
sendok / jam

-ivfd RL 20tpm

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Depan
Kamar 10Bed 2

e.c adeno recti

pro kemoterapi

Suharti
TL:17.8.1997
(39Thn)
RM : 760717
MRS: 31.08.2016

Anemia

DPJP : DR. dr.

Ibrahim Labeda,
Sp.B-KBD

WBC: 11.6
RBC: 2.05
Hb: 4.0
PLT: 524
Pt 11.0
Apt 32.6
Gds 90
Ur 18
Cr 1.02
SGOT 12
SGPT 27
Alb 2.5
Na 139
K 3.2
Cl 102

Ceftazidme
Neurobion
Duragesic patch
Albumin drips

Cek hb post
transfusi

IVFD RL 28 tpm
Ceftazidime
1gr/12jam
Ranitidine 50mg
Amlodipine 10mg
Paracetamol
1gr/8jam/drips

Cek hb post
transfusi

CT Scan(4-8-2016)
Gambaran ileus
obstruktif
Cholelith
Kista hepar
Efusi pleura bilateral

Lontara 2 Atas
Depan
Kamar 10Bed 3

-ileus obstruktif
partial e.c cancer
colorectal

Siti Alifa
TL:30.12.1965
(50Thn)
RM : 768594
MRS: 16.08.2016
DPJP : dr. Samuel
Sampetodang,
Sp.B-KBD
Lontara 2 Atas
Depan
Kamar 10Bed 4
Idawati Wartabone
TL:20.6.1973
(43Thn)
RM : 765755
MRS: 1.08.2016

Lab urin(4/8/2016)
Darah: +++/300
Protein: +++/300
Glukosa: ++/250
Lab 29/8/16
Albumin 3,6
Na/K/Cl: 159/2,3/117
GDS 98
WBC: 9,4
RBC: 2,45
Hb: 6,8
PLT: 183

Premedikasi
dexametason dan
dypenhidramin

-POH XIII
ileostomy

PA 10/8
Adenocarcinoma
recti
differensiased
dan metastase

Lab 27/8/16
WBC: 9,6
RBC: 2,98
Hb: 8,3
PLT: 515
CT Scan whole
abdomen:
-ca recti

IVFD RL 28tpm
Ceftazidime 1
gr/12jam
Ranitidine
50mg/8jam
Ketorolac 30mg/8jam
Albumin/drips

Transfuse PRC 1
bag

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

DPJP : Dr.dr.
warsinggih, Sp.BKBD
Lontara 2 Atas
Depan
Kamar 10Bed 5

peritoneum
hepatitis dengan
hati tidak ada sel
maligna
Hematochezia
Tumor colon
descenden

Arifa
TL:26.8.1950
(66Thn)
RM : 765477
MRS: 22.07.2016

Post

Darmayani
TL:31.12.1984
(31Thn)
RM : 769521
MRS: 29.08.2016
DPJP : dr. M.
Ikhwan Kusuma,
Sp.B-KBD

Lontara 2 Atas
Depan
Kamar 11 Bed 1
Mannu
TL: 01-12-1930
RM : 756699
MRS: 06-05-2016

RL 28 tpm
Ceftazidime
1gr/12jam/iv
Omeprazole
Antasida tab
Suparful syr

USG abdomen (22-72016)

Slight hepatomegaly
Nefrolith dextra
Simple renal cyst
sinistra
Ascites minimal
Efusi pleura minimal
bilateral

DPJP : dr. Samuel

Sampetodang,
Sp.B-KBD

Lontara 2 Atas
Depan
Kamar 10Bed 6

-ascites
-fatty liver
-hydronefrosis sinistra
grade 1
-ileus obstruktif
Lab 22/8/16
WBC: 13,1
Hb: 11,1
PLT: 422
HCT 34

Burst Abdomen

Colon in loop 1-82016:

Susp. Massa colon
descendens
Lab 25/8/16
WBC: 4,5
RBC: 4,29
Hb: 10,1
HCT 35
PLT: 291
PT 12,1
APTT 24,9
GDS 103
Ur 15
Cr 0,62
Bilirubin total 0,75
SGOT 85
SGPT 224
Alb 4,1
Na/K/Cl: 145/3,6/107
Lab 29-8-2016
WBC 7.06
RBC 3.66
HCT 35.1
Hb 11.0
PLT 202
Albumin 3.8
PT/APTT 9.5/26.8
Ur/Cr 148/0.86

IVFD RL 28 tpm
Ketorolac
30mg/8jam/oral
Ceftazidime
1gr/12jam/iv
Ranitidine

Aff infus
Ganti obat oral

Terapi oral lanjut

Rencana repair
wound

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

DPJP : Dr.dr.
Warsinggih, Sp.BKBD

Lontara 2 Atas
Depan
Kamar 11 Bed 2

Na/K/Cl
141/5.3/106

POH 32
Laparotomy
Eksplorasi +
ileostomy

Benjamin Ripi
Umur: 58 tahun
TL: 01-01-1958
RM: 766853
MRS: 02-08-2016

Lab 18-08-2016:
WBC 5.49
RBC 3.62
Hb 10.8
PLT 205
Ur/Cr 60/0.50
Albumin 2.9
Na/K/Cl 143/3,7/ 106
Lab 29-8-2016
Albumin 2.9
Lab 27-8-2016
Ur/Cr 42/1.76
Albumin 2.3
Na/K/Cl 124/2.4/95
Lab 23-08-2016
WBC: 19,8
RBC: 3.10
HGB: 9,1
PLT: 491
Albumin: 2.5
Na/K/Cl 148/4.1/109

DPJP: dr. Samuel

Sampetodang,
Sp.B-KBD

IVFD RL:NaCl 28
tpm
Cefotaxim
1gr/12jam.iv
Neurodex 1dd1
Ranitidine
50mg/8jam/iv
Paracetamol 500 mg
3dd1
Albumin drips
Vit C II-II-0
Terapi sesuai TS GH
dan Gizi

USG 19/8
Dalam batas normal
Lab 17 -08-2016
Ur/cr : 88/2.10
SGOT/SGPT : 28/8
GDS 107
Lontara 2 Atas
Depan
Kamar 11 Bed 3
Andika Putra
767167
27-12-1998
MRS: 15-8-2016
DPJP: Dr.dr.
Ibrahim Labeda,
Sp.B-KBD

Tumor
intraabdomen

Lab 30-8-2016
PT/APTT 13.5/38.6

hepatomegali

Lab 19-8-2016
WBC 11.5
RBC 4.01
HGB 9.9
HCT 31
PLT 644
Hbs Ag 0.00
Anti HCV 0.18

Lab 18-8-2016
CEA 0.99

IVFD RL 28tpm
Duragesic patch 2mg
Ranitidine
50mg/12jam/iv
Paracetamol 1gr (jika
demam)

Rencana biopsy.
Tunggu jadual

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

CT whole abdomen 58-2016

- suspek massa
intraluminer (sigmoid)
- hepatomegaly

Lontara 2 Atas
Depan
Kamar 11 Bed 4
La Maronta
Umur : 56 tahun
TL : 01/07/1960
RM : 768904
MRS : 19/08/2016
DPJP : Dr.dr.
Ibrahim Labeda,
Sp.B-KBD

Ikterus obstruktif
e.c.
choledocolithiasi
s

Foto thoraks 5-8-2016

- tidak tampak tandatanda metastasis
- cor dan pulmo normal
S : Keluhan tidak ada
O: KU sedang/sadar
Abdomen supel,
peristaltic (+)
Lab. 26/08/2016
WBC : 9.2
RBC : 3.37
HGB : 10.0
HCT : 30.6
PLT : 556
Lab. 19/08/2016
PT/APTT/INR :
11.0/26.0/1.06
CT/BT : 800/300
GDS : 106
Ur/Cr : 11/0.61
SGOT/SGPT : 125/74
Protein tot. : 6.9
Globulin : 4.4
HBsAg : Non reactive
Na/K/Cl : 137/3.7/106
Lab. 22/08/2016
Alkali fosfate: 850
Lab. 27/08/2016
Asam urat : 4.7
Lab. 30/08/2016
Albumin : 3.2
USG Abdomen
Atas+Bawah (Whole
Abdomen (19/8/2016)
Kesan : Nephrolith
sinistra

IVFD RL
Ceftazidime 1
gr/12j/iv
Ranitidin 50 mg/8j/iv

Rencana operasi
tunggu jadwal

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Efusi pleura bilateral
CT Whole Abdomen
tanpa kontras
(21/8/2016)
Kesan : Hepatomegaly
disertai cholestatic intra
dan ekstrahepatic e.c.
choledocholiths
Choleliths
Ascites dan efusi
pleura bilateral

Lontara 2 Atas
Depan
Kamar 11 Bed 5
Abeng
769905
3-12-1940
DPJP : dr. M.
Ikhwan Kusuma,
Sp.B-KBD

Lontara2 Atas
Depan Kamar 11
Bed 6
La ode abdul razak
2/6/81
Mrs: 26/8/16
768876
DPJP: Dr.dr.Ronal
Lusikooy,Sp.BKBD

POH 21
laparatomi
eksplorasi ec
perforasi gaster+
infected wound

Cholelithiasis
+ anemia

Foto thoraks PA
(29/8/2016)
Kesan : Cardiomegaly
dg dilatation et
elongation aortae
disertai tanda-tanda
bendungan paru
Pleuropneumonia
dextra
Lab 28-8-2016
WBC 8.0
RBC 3.88
Hb 12.9
Plt
926
PT/APTT 13.5/27.2
GDS 101
Albumin 2.5
Ur/Cr 20/0.62
SGOT/SGPT 17/9
HBsAg reactive
Na/K/Cl 143/3.0/96
Lab 31-8-2016
WBC 4.0
RBC 3.47
Hb 9.7
HCT 29.3
PLT 149
Lab 28-8-2016
WBC 3.81
RBC 3.48
Hb 9.4
PLT 131
HCT 32

IVFD RL 28 tpm
Ceftazidine
1gr/12jam.iv
Metronidazole
500mg/8jam/drips
Ketorolac
30mg/8jam/iv
Diet bubur saring
Mobilisasi duduk
GV luka/hari

IVFD RL 28 tpm
Ranitidine
50mg/8jam/iv
Ketorolac
30mg/8jam/iv

Aff drain

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

LONTARA 2 ATAS BELAKANG
LONTARA 2 BAWAH DEPAN
Lontara 2 Bawah
Depan
Kamar 11 Bed 1

POH 4 explorasi
CBD
Choledecolitiasis +
fistel GB duodenum

Badariah
TL: 25-08-1949
(67Thn)
RM: 766654
MRS: 25-08-2016
DPJP: Dr.dr.
Ibrahim Labeda,
Sp.B-KBD

Lab. Tanggal
03/08/2016
WBC 7.79
RBC 4.68
Hb 12.1
PLT 303
HCT 38.4
SGOT 26
SGPT 32
CT/BT 8/3
PT/APTT 10.3/29.8
GDS 121
Ur/Cr 18/0.60
Bil. Total 0.73
Bil. Direk 0.44
SGOT/SGPT 26/32
Albumin 3.6
Na/K/Cl 147/4.3/105

Guyur 500 cc RL
Infus RL : DS : 1:1
Ceftazidime 1 gr /
12 jam / iv
Ranitidin 50 mg / 8
jam / iv
Ketorolac 30 mg /
8 jam / iv
Takar produksi
drain dan T-tube /
24 jam
Awasi KU dan
Vital sign
Diet bubur, minum
biasa

CT scan Abdomen tanpa

kontras (04-08-2016)
-Kolelitiasis inta dan extra
hepatic e.c cholecolith
disertai cholongitis
USG Abdomen atas +
bawah (whole abdomen
01-08-2016)
-cholestatic intrahepatic
dan ekstrahepatic ec.
Cholelocholith
-Cholecystitis

Lontara 2 Bawah
Depan
Kamar 11 Bed 5
Rosna
TL : 17-09-1971

POH 4 laparoskopi
cholisistektomi

ECG (08-08-2016)
-Fungsi sistolik ventrikel
kiri dan ventrikel kanan
baik
-Disfungsi diastolic
ventrikel kiri gradi I
Lab (26/08/2016)
WBC 8.1
RBC 4.51
Hb 12.6
PLT 272
HCT 38

Infus RL 28 tetes /
menit
Ceftazidime 1 gr /
12 jam / iv
Ranitidin 50 mg / 8
jam / iv

Aff infus pasang

ulang ditempat
lain

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

RM :767450
MRS : 25/8/2016

Lab (8/8)
Ur/Cr 24/0,60
Bil.Total 0.522
Bil.Direk 0.22
SGOT/SGPT 23/22
Alkali Fosfatase 94
Albumin 4,4
Na/K/Cl 146/4,3/107

DPJP : Dr.dr.
Ibrahim Labeda,
Sp.B-KBD

Lontara 2 bawah
depan
Kamar 11 bed 6
Nanro
TL : 01-12-1968
RM :751010
MRS : 27-08-2016

Suspek tumor
caceum

Laboratorium:
WBC: 4,33
RBC: 3,92
HB: 9,8
PLT: 283.000
Na: 143
K: 3,3
Cl: 103

DPJP: dr.Samuel
Sampetoding ,
SpB-KBD

Ketorolac 30 mg /
8 jam / iv
Paracetamol 5 mg
3x1
Cefadroxcyl 500
2x1
Omeprazol

Rencana
colonoscopy senin
5 september 2016
Bowel preparation
mulai besok
-Diet sari buah
-Flat phosphosoda
17.00
-Flat enema jam
21.00
-Besok jam 05.00
flat enema

LONTARA 2 BAWAH BELAKANG

Lontara 2 Bawah
Belakang
Kamar 5 bed 1
Apgreid Paripurna
Mandake
TL : 26-6-1968 ( 46
Tahun )
RM :7s69126
MRS : 1-9-2016
DPJP : Dr.dr.
Ibrahim Labeda,
Sp.B-KBD
Lontara 2 Bawah
Belakang
Kamar 8 Bed 1
Juma Dg. Rowa
TL: 31.12.1958 (57
Thn)
RM: 768800
MRS: 18.8.2016
DPJP: Dr.dr.Ronal

Kista Herpar

Laboratorium (3-92016)
Bil.Total: 0,55
Bil. Direk: 0,16

Paracetamol 500 mg
tab / 8 jam / oral

Tumor gaster

Lab. Tanggal
31.08.2016
WBC 13.4
RBC 3.64
Hb 9.5
HCT 30
PLT 421

Drip coctail / 8 jam/

iv drips dalam RL
500cc
Ceftazidime 1 gr/12
jam/iv
IVFD RL 28 TPM
Ranitidin 1 amp / 8
jam
Neurobion 1 ampul /
24 jam / drips / iv

Lab 18.8.2016
GDS 96

Rencana CT-Scan
Abdomen Atas
dengan kontras IV

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Lusikooy,Sp.BKBD

SGOT 49
SGPT 9
Albumin 2,3
Ureum 39
Kreatinin 0,76
Natrium 143
Kalium 3,8
Klorida 110

Diet bebas

Lab tgl 26/8

CEA 4,68
USG Abdomen
19.08.2016
Sugestif tumor
gaster
Asistes minimal
Limfadenopati
paraaorta abdominal
LONTARA 3
Lontara 3 Atas
Depan
Kamar 4 Bed 3
Suriah
06/06/1960 (
56thn)
769217
MRS : 22/08/2016
Dpjp : dr. Ihwan
Kusuma, Sp. BKBD

Tumor Recti 1/3 distal

Lab (25/8/2016)
FT4 0.97
TSHs 2.00
Lab (24/8/2016)
WBC : 11.2
RBC : 4.54
HGB : 10.9
HCT : 35
PLT : 581
Lab (22/8/2016)
PT/APTT/INR:
12.6/30.9/1.23
Na/K/Cl :
136/3.9/99
GDS : 101
Ur/Cr : 29/0.46
SGOT : 18
SGPT : 17
Alb : 2.9
Foto Thorax
(24/8/2016):
-pneumonia
bilateral
Dilation, elongation
et atherosclerosis

IVFD RL 20 tpm
Ceftriaxone
1gr/12jm/iv

STOP
Levofloxacin 750
mg/8jm/iv
Omepraxole
40mg/8jam/iv
As.trenaksamat 1
gram/8jam/iv
Paracetamol 1
gram/jam/iv
bila demam

Konsul interna
(pulmo + GH)

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

aortae
USG Abd atas+
bawah(23/8/2016)
Suspek massa recti
Kista ginjal kanan
LGIE (29-08-2016)
Massa tumor
polipoid rectum
tipe stenotik

Lontara 3 Atas
Depan
Kamar 5 Bed 3
Syamsurianti
19/10/1986 (
29thn)
765954
MRS : 22/08/2016
Dpjp : dr. Samuel
Sampetoding, Sp.
B-KBD

Hipoglikemia
Tumor paraaorta
abdominalis DD
Lymphoma

PA (23-08-2016)
Adenocarcinoma
recti diferensiasi
sedang
Lab (02/9/2016)
WBC : 4.5
RBC : 4.23
HGB : 10.7
HCT : 33
PLT : 205
GDS : 50
Ur/Cr : 14/0.40
SGOT/SGPT :
152/149
Alb : 2.8
Lab (26/8/2016)
Bil total 0.77
Bil direk : 0.43
Antibody malaria
negatif
LAB (26-8-2016)
PT/APTT/INR:
12.6/30.9/1.23
Na/K/Cl :
136/3.9/99
Foto Thorax
(16/8/2016):
Cor normal
Observasi nodul
soliter pada
parakardial sinistra
MSCT Whole
Abdomen dengan
kontras
(16/8/2016):

IVFD RL 20 tpm
Neurobion
1amp/24jm/iv
cefriaxone
1gr/12jm/iv
Ketorolac
30mg/8jam/IV
Ranitidine
50mg/12jm/iv

Rencana
Endoscopy
Bila ku baik
rencana UGIE
Lab lengkap darah
rutin got gpt cek
hbsag anti hcv
albumin

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Massa paraaorta
abdominalis
sugestif lymphoma
Penebalan sirkuler
dinding duodenum
suspek massa
splenomegaly
Lontara 3 Bawah
Belakang
Kamar 4 Bed 2
Nurmiati
10/05/1940 (76thn)
769765
MRS :
DPJP :

Hematochezia e.c
hemoroid

Lab (03-08-2016)
WBC : 19.4
RBC : 3.20
HGB : 9.1
HCT : 28
PLT : 269
CEA : 1.66

Ardium 3x2 tab

STOP cocktail
IVFD RL 28 tpm
Transfuse PRC 1 bag

Rencana
coloscopy

CT kepala tanpa
kontra (26-082016)
- Infark cerebri
bilateral
- Brain atrophy
Foto thorax AP/PA
(26-08-2016)
Cardiomegally dgn
dilatation et
atherosclerosis
aortae
USG whole
abdomen (27-082016)
PNC bilateral
LONTARA 4
Lontara 4 Bawah
Depan
Kamar 2 Bed 1
Warniati
08/08/1989 (27 thn)
585559
MRS : 05/08/2016
Dpjp :
Dr.dr.Warsinggih,

Carcinoma ovarium
stadium III

Lab ( 30/08/2016):
WBC : 10.7
RBC : 3.65
HGB : 9.4
HCT : 29
PLT : 225
Alb : 1.8
Na/K/Cl :
139/4.3/108
Lab (03-08-2016)
Alb : 2.8

terapi lain sesuai TS

obgyn

-Observasi tandatanda ascites

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

Sp.B-KBD
Lontara 4 Bawah
Depan
Kamar 5 Bed 2

Ca ovarium +
masive ascites+
efusi pleura

Margareta Lerebulan
TL:10/06/1965
(51thn)
RM : 764844
MRS : 15/08/2016
DPJP: Dr.dr.
Ibrahim Labeda,
Sp.B-KBD

Protein total : 5.3

Hasil Lab
(30/08/2016) :
Natrium : 128
Kalium: 4.1
Klorida: 98
WBC : 13.9
RBC : 3.48
HGB : 10.3
HCT : 32.4
PLT : 405

Terapi lain sesuai TS

Obgyn

Foto thorax AP/PA

(20-08-2016)
-Tidak tampak
tanda-tanda
metastasis pada foto
thorax
-Cor dan pulmo
normal
Foto thorax AP/PA
(04-08-2016)
-Pneumonia dextra
-Elongatio aortae
-Chest tube
terpasang pada
hemithorax dextra
dgn tip etinggi costa
IV kanan depan

ICU
ICU
Bed 2
Anny Alositandi
TL: 14-8-1976
RM : 752999
DPJP: dr. Samuel
Sampetoding,
Sp.B-KBD

-Ca recti 1/3 distal

infiltrasi uterus

Lab 31/8/2016
GDS: 110
Na/K/Cl: 137/2,6/98

-Fistel rectovagina
Lab (31/08/2016)
WBC 3,71
RBC 3,21
Hb9,2
HCT 28,1
PLT : 180
PT/APTT 11/25,8
GDS 100
GOT/GPT 11/6

Injkesi leukogen 1
amp/24 jam /SC

-alirkan drainase
3000cc/hr
- GV jika verban
rembes

KORAN BEDAH DIGESTIF SENIN,5 SEPTEMBER 2016

CT Abdomen dgn
kontras
(04/08/2016)
Massa segmen bwh
rahim yg
menginfiltrasi distal
uterus dan rektum
disertai
hidronefrosis
bilateral (FIGO Iva)
Uteromegaly disertai
hematometra
DJ stent terpasang
pd traktus urinarius
dextra
Hepatomegaly
ICU
Bed 8
Sanawia dg ngaseng
TL: 01-7-1967
RM : 764814

POH IV
relaparatomi
anastomese end to
end ileotransversa ec
tumor ileocaceal

DPJP: dr. Ihwan

Kusuma, Sp. BKBD

ICU
VIP 4
Abd.rasyid junus
TL: 12/12/1939
RM : 746641
DPJP: dr. Samuel
Sampetoding,
Sp.B-KBD

INFECTION CENTER

Lab (04/09/2016)
WBC 8,1
RBC 3,97
Hb 11,2
HCT 36
PLT : 191
Ur/cr ; 25/0,52

POH 3 laparatomi +
hemoikolektomi
dextra ec tumor
colon ascendent

Lab (04/09/2016)
WBC 10,7
RBC 3,67
Hb 9,3
HCT 30
PLT : 131
Ur/cr ; 69/2,17

Infuse RL :DS 1:1

28 tpm
Ceftazidime 1 gr/12
jam/IV
Metronidazole 250
mg/8 jam/IV
Ranitidine 50 mg/8
jam/IV
Keterolac 30 mg/8
jam/iV

Takar drain /24 jam

Awasi KU dan TV

Infuse RL :DS 1:1

28 tpm
Ceftriaksonre 1
gr/12 jam/IV
Metronidazole 250
mg/8 jam/IV
Ranitidine 50 mg/8
jam/IV
Keterolac 30 mg/8
jam/iV

Puasa
Takar drain/24 jam
Terapi sesuai TS