List Pasien Digestif 10/12/2019

A Atas

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

1 A7.6 Saifudin H. Aji Post Hartmann e.c tumor Lab 10/12/19 - rawat luka
rectosigmoid susp malignancy
709708/L/49th T3NxM0 Leu 17,2 Analgetik

MRS 30-11-19 Hipoalbuminemia Eri 3,19 Antibiotik

DPJP: dr Toar Mambu, SpB- Hb 9,5

KBD
Ht 26,4

Trom 281
S: lemah badan
Mch/mchc/mcv
O: KU sedang Kes CM
29,7/35,9/82,7
CA-, SI-

Abd : Datar, luka basah, pus +,

drain subkutis produksi 20 cc
pus +, stoma viabel, produksi
fekal +

A: BU + N

P: Soepel, Defans

P: Timpani

2 A8.2 Kuhu Mari/P/79th/710545 Post sigmoidestomy ec timor Lab 10/12/19 Analgetik

 MRS :09-12-19 rekti Leu 2,3 Antibiotik

DPJP: dr. Michael Tendean, Eri 4.03 Mobilisasi

Sp.B(K)BD
Hb 12.2 Diet bubur
Ht 33.3 rawat luka
S: BAB via stoma Trom 309

O: Mch/mchc/mcv

I datar, stoma viabel, 30,3/36,6/82,6

A BU (+) Sgot/pt 28/11

P lemas

P timpani

3 A8.5 Suawah Rekky General weakness Lab 10/12/19 Perbaiki KU

johny/L/52th/795854 (hiponatremi, hipokalemi,
hipochlorida) Leu 23,6 Koreksi
MRS: 10/12/19 elektrolit
Tumor rekti Eri 2,85
Dpjp: dr Toar Mambu, SpB- Transfusi PRC 1
KBd Anemia Hb 8,0 bag/hari
Ht 22,5

S: lemah badan Trombo 379

O: KU sedang, KS CM Mch/mchc/mcv
28,2/35,7/79
Abdomen
 I datar

A BU+

P lemas, nyeri tekan

P timpani

A Bawah

N0 Ruangan Identitas Diagnosa Penunjang Keterangan

4 B7.5 Tomayahu Post sigmoidestomy ec obdstruksi Lab 10/12/19 Rawat luka

suleman/67th/L/515752 mekanaik usus total ec
adenocarcinoma anorektal + Leu 8,7 Mobilisasi
MRS: 10-12-19 anemia Eri 3,64 Obat sesuai
DpJP: dr. Michael Tendean, Sp.B-
KBD Hb/Ht 7,8/23,4 Tnggu hasil lab

Trombo 487 Aff ngt dan kateter

Mch/mchc/mcv
21,4/33,3/64,3

5 B7.6 Bugis Yaher/L/60th/700149 Fistula rectovesical Lab 8/12/19 Rencana

colonoscopy
DPJP : dr Toar Mambu, Leu 6,8
SpB.KBD
Eri 3,5
MRS: 5/12/19
Hb/Ht 9,6/27,8

Trombo 209
 S: BAK nyeri + tercampur dgn Mch/mchc/mcv
feses 27,4/34,4/79,5

O: KU sedang, Kes CM

Abd : OT/PT 20/13

I : datar Ur/Cr 23/1,6

A : BU + Na/k/cl
136/2,43/99,5
P Supel, nyeri tekan + suprapubik

P Timpani
PT 15,9/14,5

APTT 36,7/35,9

INR 1,2/1.08

6 B1.2 Tumor recti susp malignancy Leu 7,8 -r/ biopsi

Kaat Adrian/80th/L/708266 Eri 4,04

DPJP : dr. Toar Mambu Hb/Ht 12,7/37,2

Sp.B(K)BD
Trombo 245
MRS: 11-12-19
Mch/mchc/mcv
31,3/34/92,1

7 10,6 Bunde ekawati esi/P/23th/704842 Ikterus onstruktif ec batu crysk Lab 26/11/19
cbd
DPJP: dr. Michael Tendean, Leu 10,2
Sp.B-KBD
Eri 4,36
 Hb/Ht 12,1/34,5

Trombo 448

Mch/mchc/mcv
27,4/35.1/79,1

8 10.8 Adenocsrcinoms recti + gener Lab 12/12/19 Transfusi prc sampai

weaknezs hb 10
Leu 8,9
Ruata smeike/P/48/566325 Perbaiki KU
Eri 3,14
MRS: Konsul nyeri
Hb/Ht 6,7/20,4
DPJP: dr Michael Tendean,Sp.B-
KBd Trombo 612

Mch/mchc/mcv
2,14//32/97

A Teratai

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

9 Kelas I 4B Mahmud Hematochezia Lab 07/12/2019 Rencana biopsi

Asni/L/57th/710311
Ht 35.4
DPJP: dr. Ferdinand
Tjandra, Sp.B(K)BD MCH 25,8

MCV 72.3

S: Bab darah (-) GDS 202

 O: Cl 96.4

I: datar K 3.19

A: BU +

P: Lemas

P: tympani

10 Kelas I 5b Pakaya Choledocolithias 3/12/19 R/

SudarminL/64/707891 is post PTCA Laparascopic
Leu 10,7 Cholecystecto
Eri 4,89 my sampai
DPJP: dr Toar Mambu, kemungkinan
SpB.KBD Hb/Ht 15/42,4 open
cholecystecto
Trombo 201
my

S: nyeri MCH/MCHC/MCV
30,7/35,4/86,7
O:

KU sedang
OT/PT 25/33
Kes CM
Ur/Cr 35/1,7

GDS 81
Abd :
Na/K/Cl
I: datar 142/3,77/97,8
 A: BU+

P: Lemas PT 12,3/14,9

P: Tympani INR 0,9/1,1

APTT 29/37

11 Kelas II Vecky Tumor sigmoid Lab 2/12/19 Konsul IBS u/

bed 6 Wowor/49th/L/453518 dd malignancy kolonoskopi
Leu 7,3 12/12/19
MRS 10-12-19
Eri 3,81
DPJP: dr. Ferdinand
Tjandra, Sp.B(K)BD Hb 10,1

Ht 32

Trom 355

Mch/mchc/mcv

26,5/32,6/81,4

12 Kelas II Zakaria Engelin Cholelithiasis + Lab 09/12/2019

Bed 4 Jelce/P/44th/71.03.67 Cholecystitis +
Cholangitis + Leu 21,2
DMT2 + Eri 3,86
DPJP: dr. Ferdinand Hiponatremia
Tjandra, Sp.B(K)BD Hb 11,1

Ht 31,7

MCH 28,8
 MCHC 35,2

MCV 82

Bilirubin total 13,46

Direct 11,28

GDS 317

ICU

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

13 ICU Latando -Post reseksi 9/12/19 -Transfusi

Bambang/L/66th/706777 ileum+ileostomy PRC
BED 6 double barrel ec Leu 11
DPJP: dr. Toar tumor sigmoid- Rawat luka,
Mambu,Sp.B-KBD Eri 3,38 stoma
rectum
Hb/Ht 8/24 Diet bubur
-DM T2
Trombo 235 saring TKTP
S : lemah badan, kontak + -anemia
MCH/mchc/mcv Terapi lain
O : ku berat, kesadaran CM -CKD sesuai TS
Abd : 26/36/72 anestesi

I Luka terawat, pus

minimal, stoma viabel, OT/PT
produksi fekal
 A BU + normal Bil Total

P Soepel, defans (-) Bil Direct

P timpani

Ur/Cr

Fosfor

Mg

Albumin

Ca

Na/K/Cl
150/2,78/117

PT17/13

APTT 43/33

INR 1,28/1,02

14 ICU Kampong Amos -Post rebair burst 9/12/19 Rawat

abdomen e.c post luka+Stoma
BED 11 707723/L/62th laparatomi Leu 16,2
adhesiolisis + Tunggu hasil
MRS: 01.12.19 ileostoma e.c Eri 2,76 lab
adhesive band
DPJP : dr Ferdinand Tjandra Hb/Ht 8/22 Diet Susu
Sp.B – KBD
Trombo 171 Terapi lain
Anemia sesuai TS
MCH/mchc/mcv Anestesi
S: On sedasi Hipoalbuminemia
29/36/79 Antibiotic
O : KU berat, Kes On sedasi Elektrolit Imbalans

Abd Analgetik
OT/PT 47/21 Koreksi
I datar, drain produksi kurang
lebih 100 cc serohemorargik. Bil Total albumin,
Stoma viabel produksi cair, anemia dan
kehitaman. Luka terawat, pus Bil Direct elektrolit
-, rembesan -, kulit hiperemis.

A: BU + N
Ur/Cr 88/1,3
P: Soepel

P: Timpani
Fosfor

Mg

Albumin

Ca

Na/K/Cl
 138/3,88/99

PT15/13

APTT 45/33

INR 1,18/1,02

15 ICU Bed 4 Taroreh Post 9/12/19 Rawat luka

Leonardus/L/30thn/705356 kolesistektomi +
hepatojejunostomy Leu 14,5 Rencana aff
DPJP : dr Ferdinand Tjandra dextra + Logmire drain
Sp.B – KBD Eri 3,03
procedure + eksisi Transfusi PRC
hillar Hb/Ht 9/25 + TC
cholangiocarcino
S: Lemah badan, BAB + Trombo 87 Koreksi K +
ma
kehitaman, sudah cuci darah MCH/mchc/mcv albumin

30/36/82 Cek lab

Hematemesis
O: KU sedang, Kes CM Terapi lainnya
Melena sesuai TS
SI +, CA(-) OT/PT
Anemia + Clear water,
NGT produksi 600cc Trombositopenia Bil Total 9,29 spooling NGT
kehitaman
AKI Bil Direct 8,28
Hipoalbuminemia
Abd :
HipoK Ur/Cr 237/4.2
I datar, luka kering, pus-,
 drain produksi minimal

A BU+ normal Fosfor

P soepel, defans – Mg

P timpani Albumin 2,65

Ca

Na/K/Cl
150/2,93/108,3

PT13/13

APTT 29/33

INR 1/1,02

16 ICU Bed Manurung Post 9/12/19

24 Irma/P/49th/34.60.33 Hemicolectomy
Tumor Colon Leu 12,5
Descendens Eri 4,76
DPJP: dr. Toar
Mambu,Sp.B-KBD Hb/Ht 12/35

Trombo 370

MCH/mchc/mcv
 25,8/34,6/74,8

OT/PT 16/10

Bil Total 0,42

Bil Direct 0,17

Ur/Cr 10/0,4

Fosfor 3,5

Mg 1,74

Albumin 3,49

Ca 8,14

Na/K/Cl
137/2,99/97,3

PT13/13

APTT 29/33

INR 1/1,02

17 ICU Makaghee Alexius Tumor Lab 06/12/19 - persiapan

/L/69th/706022 Intraabdomen operasi
Bed 20
susp GDS: 67
malignancy,
 MRS : 23-11-2019 CKD 4 Albumin 3.25 -konsul ibs
9/12/19
DPJP : dr. Ferdinan T, SpB- Anemia Cl 95.4
KBD
132
s: nyeri perut di kiri (+)

O : abd :

I : embung

A : BU (+)

P : teraba mass auk 10 x 20

cm kuadran kiri

P : timpani

18 ICU Sumendap Aneke/P/ 39thn/ CKD on HD ec 08/12/19 -R/CAPD

445920/ HNS
Bed 19 Leu:8,1
MRS : 04-12-2019 Hipertensi
Erit:3,29
DPJP : dr. Toar Post nefrostomi
Mambu,Sp.B-KBD ec nefrolithiasis Hb/Ht:10/30
dextra et sinistra MCH,MCHC,MCV :
31/34/91
S: Lemah badan
Ur :33
O: KU Cukup Kes CM
Cr :4,8
R. brachii sinistra : AV
Fistula Thrill+ Na/K/CL :
 R. abd : datar, supel BU + 133/4,41/100

Anggrek

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

19 Anggrek 1 Bernadus Ca sel hati 11/12/19 Direncanakan

B9 wahan/L/66th/573500 stadium C hepatektomi
(Childpugh A) Leu 6,5
DPJP: dr. Michael
tendean,. Sp.B-KBD Susp metastasis Eri 2,57
tulang. Parastesa Hb/Ht 7,9/21,8
LMN kompresi
vertebra lumbal Trombo 283
1. Hep B
MCH/mchc/mcv
30,7/36,2/84,8

20 Anggrek 2 Pinotoan Ikterus 08-12-19 Rencana

(Lt 1) Semuel/L/69th/710306 onstruktif ec operasi 12-13-
susp malignancy SGOT/PT: 65/47 2019
K116 MRS : 7-12-19
Gamma GT 375 Vit K
Bilirubin total 40,29 As tranexamat
Bilirubin direct
 29,95 Vit C(-)

Protein total: 5,06

Albumin 3,27

Globulin 1,79

Alkaline fosfat 405

Ant hcv (-)

HbsAg (-)

Anti HiV (-)

21 Anggrek 2 Manurung Post laparatomi 9/12/19 Aff ngt

(Lt 2) irma/49th/P/346033 reseksi tumor ec
tumor sigmoid Leu 12,5 Aff kateter
K211 DPjP: DPJP : dr. Toar
Mambu,Sp.B-KBD Eri 5,76 ...

Hb/Ht 12,3/35,6

Trombo 370

MCH/mchc/mcv
25,8/34,6/74,8

22 Anggrek 2 Giroth CKD on HD ec 08/12/19 -Batal

(Lt.2) Robby/L/43thn/453092 HNS pemasangan
Leu:8.1 CAPD karena
K204 MRS : 05-12-2019 Hipertensi hipertensj faal
Erit:3,63
DPJP : dr. Toar Post nefrostomi dR OK Ibs.
 Mambu,Sp.B-KBD ec nefrolithiasis Hb/Ht:10,7/29,1Akan di
evaluasi
MCH,MCHC,MCV : kembalii
29/36/80
S: sedak
Ur :57
O: KU cukup Kes CM
Cr :7
Reg. abd: Datar, BU+N,
Supel, Timpani Na/K/CL :142/4/107

IRINA B, C, Nyiur, D

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

23 IRINA B Teguh Dwi Post Lab 9/12/19 Rawat luka

Priyanto/51/L/574342 pancreaticojejun
K8 ostomy +DM + Leu:6,2 ...............
Anemia + Erit:2,82
DPJP dr. Michael Tendean, Koagulopati +
SpB-KBD Hipoalbuminemi Hb/Ht: 8,9/24,4
a + Konstipasi +
Trombo 182
Kelemahan
anggota gerak MCH,MCV, MCHC
S: nyeri berkurang,
bagian bawah + : 31/86/36
Kelemahan umum
Penurunan
O: KU sedang, kes CM, Fungsi Hepar SGOT 843

SGPT 446
 SI (-), CA (+) anemia 8,6 Ur/Cr 69/0,4

Abd: Luka operasi (+) Gds 218

Eks : Purpura (+) Albumin 2,21

Bilirubin total 12.73

Bilirubin direct
10.07

Na/k/cl
124/3.88/82,7

PT 16,9/13,7

APTT 29,9/33,7

INR 1,27/1,02

24 Irina C2 Tinggal I Ikterus hepatik 11/12/19 Menunggu

gede/23th/L/709137 dd onbstruktif hasil usg
K213 bed Leu 27,4
2 Usul untuk
Eri 1,10 dilakukan
DPJP: dr. Michael Tendean, MRCP
Sp.B-KBD Hb 4,9
 Ht 14,4

Trom 104

Mvh/mchc/mcv

44,5/34/130,9

25 Nyiur Suatan Itje Post repair 8/12/19 Rawat Luka

Maria/P/62th/418801 stoma +
8B Refreshing Leu 7,8 Rawat Stoma
DPJP: dr Michael Tendean , wound e.c
SpBKBD Eri 3,6 Antibiotik
prolaps toma
post hartman Hb/Ht 10/29 Analgetik
procedure e.c
S: Tampak luka merembes Trombo 610 Mobilisasi
obstruksi usus
cairan mekanik total e.c MCH/MCHC/MCV Jahit ulang tepi
tumor rectum 29/36/81 stoma yang
O: KU Cukup Kes CM
suspek lepas
Reg. abd : Datar, tampak malignancy +
luka operasi terawat, darah jahitan tepi Bila tidak ada
GDS 156 keluhan, besok
-, pus -, pada bagian tengah stoma terlepas
luka merembes cairan Albumin 2,65 rencana RJ
minimal. Tampak stoma
Na/K/Cl
pada perut kiri bawah,
133/2,17/80
tampak jahitan pada medial
stoma terlepas, keluar cairan
berwarna kuning, produksi
stoma +.
 A: BU + Normal

P: Supel, Nyeri tekan –

P: Timpani

26 Nyiur Vicky Post Rencana RJ

Tumundo.L.61th/709368 kolonoskopi, 13/12/19
K12
Tumor Rectum As traneksamat

DPJP: dr. Michael Tendean, Vit C

SpB-KBD

S: Sukar BAB
O: Abd : tenang

27 Irina D Sagay P3A1 dengan 8/12/19 Acc

atas Kartini/64th/P/707564 hidronefrosis pendampingan
bilateral, Leu 7,8 operasi tgl
K A9 MRS : 10-12-19 limfsdenopati 12/12/19
Eri 3,6
DPJP: dr.Michael Tendean, (kgb mammae)
+ susp Hb/Ht 10/29 Persiapan usus
Sp.B-KBD 11/12/19
perlengketan.
Trombo 610
Riw laparatomi
MCH/MCHC/MCV
29/36/81
 GDS 156

Albumin 2,65

Na/K/Cl
133/2,17/80

EDELWEIS I & II

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

28 Edelweis Kilapong wisye/P/65thn Ikterus obstruksi Lab 3/12/19

2 ec batu CBD
MRS: 3/12/19 DD: susp Eri: 3.90
Kamar 5B Cholangiocarcin Ht:31.6
Dpjp dr. Toar Mambu, SpB-
KBD oma
Gds: 286

Cl: 85.4
S: Lemah badan
K: 2.41
O: KU sedang Kes CM
Na:131
Mata : SI(+)

Abd : Datar, BU+N, Soepel,

 Tympani 6/12/19

GDP :160

Na/K/Cl :
134/3.2/93.2

29 Edelweis Tampenawas Hematochezia Lab 07/12/19

2 Esky/L/51th/708913 e.c susp tumor
kolon kiri Leu 5.7
Kamar MRS: 23-11-2019
12.A Anemia Eri: 3,51
DPJP : DPJP: dr. Michael
Tendean,Sp.B-KBD Hemorrhoid Hb: 10,3
interna grade 1 Hct : 29

S: BAB darah (+) Trom 299

O: KU sedang, ks: CM

CA(-), SI (-) MCH/MCHC/MCV

Abd: datar BU (+) soepel 29/35/82

timpani