KORAN BEDAH DIGESTIF SELASA, 5 MARET 2019

LONTARA 2 ATAS DEPAN KAMAR 2

NO. IDENTITAS PASIEN KELUHAN DIAGNOSIS HASIL LAB RADIOLOGI PLANNING DPJP
1 L2AD/K2B1 Lemas - Adenocarcinoma Lab 03-03-2019 MRI Pelvis (kontras) - Infusclinimix : NaCl : D5 1000 IL
HAFSAH recti 1/3 distal WBC 10,6 (28/2/2019) : 500 : 500
871869 RBC 3,80 -Massa1/3 distal rectum kesan - Ranitidin 50mg/12jam
02-05-1986 HGB 9,4 telah menginfiltrasi mesorectal - Neurobion 1 ampul/24jam
(32 Tahun) PLT 367 fascia dan uterus - Pro kemoterapi
- FU darah rutin
USG Kandungan 18/02/2019
Massa rectum yang
menginfiltrasi uterus
2 L2AD/K2B2 Nyeriuluhatibe Adenocarsinomagaster Ureum Urin 04-03'19 MSCT whole abdomen 11-02- - Infus RL : D5%:Clinimix SM
NURBAYA rkurang 6 2019 500:500:1000 /24jam
871664 Lab 02-03-2019 Tumor gaster - Ceftriaxone 1 gr/12jam iv,
15-08-1957 WBC 8,7 Foto Thoraks 02-03-2019 - Ranitidine150 mg/12jam/iv
(61 Tahun) RBC 3,75 -Terpasang CVC pada - Metamizole 500 mg/8jam/ iv
HGB 10,7 hemithorax dextra dengan tip - Pro gastrectomy Bill Roth
PLT 211 kesan pada IVC 5/3/2019
PT 10,4 -Efusi pleura sinistra
INR 1,00 -Cardiomegaly
APTT 23,7
Ur/Cr 33/0,58
Albumin 2,8
Na/K/Cl 136/3,8/110
3 L2AD K2B3 Nyerilukabeka - POH 4laparotomi Lab 27-02-2019 Fotothoraks PA/AP 21-02- - Infusclinimis : RL : D5 IK
HJ.HATIJA s op biopsy ec tumor WBC 7,2 2019 1000:500:500
873442 intraabdomen RBC 4,30 - Multiple lesinodulersuspek - Ranitidin 50mg/12jam
05-10-1957 HGB 11,2 tumor metastasis keparu - Ceftriaxone 1gr/12jam
(61 Tahun) PLT 444 - Cardiomegaly - Ketorolac 30mg/8jam
GDS 116 disertaidilatatio aortae - Diet bebas
Albumin 3,0 - Takarproduksi drain /24jam
Na/K/Cl 137/3,8/106 CT whole abdomen 14-02- - Hasil biopsy 5 Maret 2019
2019
Massa
kompleksadneksasinistra
Suspekmassa distal rectum
Lesinodulerpadapulmo
bilateral, lobuskananhepardan
 lien suspek tumor metastasis
Gambarancarcinomatosis
peritoneal
4 L2AD K2B4 Lemas - adenocarsinoma Lab 28-02-2019 Fotothoraks PA/AP 20-02- - InfussesuaiTSgiziklinik SM
RAILEM A SALLATA colon on kemoterapi WBC 18,0 2019 - Ceftriaxone 1 gr/12jam iv,
796583 - Ulcus decubitus RBC 4,09 Terpasang CVC - omeprazole 40mg/24 jam iv,
12-10-1969 HGB 11,5 padahemithoraksdextradengan - metamizole 500mg/8jam iv
(49 Tahun) PLT 561 tip kesanpadacavoatrial
Albumin 3,0 junction
Na/K/Cl 139/3,8/105
Fotopolos abdomen 18-02-
2019
Terpasang DJ stent
padatraktusurinariussinistra (tip
proximal setinggi CV L5)
USG Abdomen atas+bawah
(whole abdomen) 18-02-2019
- multiple
lesihiperechoicpadakedualobus
heparsuspek metastasis DD/
hemangioma
- nephrolithsinistra
- moderate
hydronephrosissinistradengante
rpasang DJ stent di dalamnya
- Sludge GB

LONTARA 2 ATAS DEPAN KAMAR 3

NO. IDENTITAS PASIEN KELUHAN DIAGNOSIS HASIL LAB RADIOLOGI PLANNING DPJP
1 L2AD nyeriluka post POH Ureum Urin 4/3'19 Endoskopi 14/02/2019 - Clinimix : RL : D5 1000 : 500 : SM
K3B1 opsudahberkur 8laparotomieksplorasie 0.04 Kesan: hemoroid interna derajat 500
Agustinus Ari ang, sudah cpankreatitisakut Lab 02/3/2019 1 - Omeprazole 40mg/24jam/iv
11-08-1970 BAB Alb 2,3 - Metamizole 1 gram/8 jam/iv
39 Thn Lab 28/2/2019 Foto abdomen 3 posisi - Meropenem 1g/8jam/iv
645343 Glukosa 105 30/01/2019 - Bilas drain NaCl 0,9 % 60tpm
MRS 30-01-2019 Ur/Cr 11/0,30 Kesangambaran ileus obstruksi - Diet bubursaring
Albumin 2,1 - Aff drain kateter
Na/K/Cl 135/3,1/106 - Transfusi albumin
 - Follow up lipase/amylase
2 L2AD Nyeriluka post -POH Lab 2-3-2019 Foto Thoraks 25/02/2019 - Infusclinimis: RL: D5 IK
K3 B2 op 4laparotomieksplorasi + Alb 2,1 -Cardiomegaly 1000:500:500
Jumardin kolostomiec tumor recti Lab 28-2-2019 -Pulmo normal - Ceftriaxone 1 gram /12
05/12/1968 1/3 distal WBC 9,01 Biopsi 15/02/2019 jam/intravena
873448 -post drainase ascites RBC 3,62 Adenocarcinoma recti - Ranitidine 50mg/12jam/iv
50 tahun HGB 10,2 - Ketorolac 30mg/8jam/iv
Mrs : 13/2/2019 PLT 436 - Rawatlukaper 3 hari
GDS 116
Albumin 1,9
Na/K/Cl 130/3,8/103

3 L2AD Nyeriluka post POH Lab 28-02-2019 Foto thorax P23/2/2019) - Infusclinimx : RL : D10 WS
K3B3 opberkurang 7laparotomiecperforasi WBC 6,94 -Terpasang ETT 1000:500:500
LahikoLahatu appendicitis RBC 5,55 padatrakeadengan tip setinggi - Meropenem 1g/8jam
874699 HGB 16,2 +/- 7,6cm diatas carina - Metamizole 1g/8jam
28-09-1953 PLT 659 -Dilatatio, elongation et - Ranitidin 50mg/12jam
GDS 128 atherosclerosis aortae - Aff drain
Albumin 3,6 -Pneumonia bilateral - Affkateter
Na/K/Cl 132/5,3/99 - Diet buburbiasa
USG whole abd (22/2/2019) - Rencana pulang
-Hyperthrophy prostate
-Gambaran ileus obstruksi
4 L2AD Lemas tumor recti 1/3 distal Lab 01/3/2019 Foto Thorax 02/03/2019 - InfusNaCl 0.9%:clinimix:D5 SM
K3B4 post ileostomy WBC 10,13 -Terpasang chest tube 500:1000:500/24 jam
RahmanPepuloi RBC 3,69 -Hidropneumothorax sinistra - ceftriaxone 1 gr/12jam/iv
869023 HGB 9,9 (perburukan) - paracetamol 1gr/8jam/iv
Mrs 4/2/2019 PLT 203 -Efusi pleura dextra (perbaikan) - ranitidine 50mg/12jam/iv
GDS 97 -Atherosclerosis aorta - vip albumin 2caps/8jam/oral
Ur/Cr 58/1,18 - Ondansetron 4mg/8jam/oral
SGOT/GPT 58/21 MSCT Thorax contrast
Albumin 2,3 (25/2/2019)
Na/K/Cl 129/4,4/102 -terpasang chest tube
padahemithoraxsinistradengan
tip setinggi ICS V posterior
sinistra
-pleuropneumonia bilateral
-atherosclerosis aortae
-simple renal cyst sinistra
-multiple
lesinodulerkedualobusheparsuge
stif tumor metastasis kehepar
-lesilitikdisertaidestruksi CV
Th4 sugestif tumor metastasis
ketulang

Endoskopi (14-2-2019)
Kesan:Massa diffuse
ekstraluminer abdomen

Foto thorax 25/2/19

-pleuropneumoniadextra
-atherosclerosis aortae
-terpasang chest tube