awakoran digestive 7 jan (autosaved)

KORAN BEDAH DIGESTIF Jumat, 4 JANUARI 2013

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 1NO. IDENTITAS DIAGNOSIS PEMERIKSAAN PENUNJANG Ket

/PJ1. Susana

Modouw/P/66 thn/ 586327/MRS 30/12/2012BED 1

D/ Tumor gaster susp. malignancy

Rencana OMD (9/1/2013)

Lab 30/12/2012WBC : 8,77, RBC : 4,07, HB : 9,5, PLT :354, Albumin : 2,4, Na : 132, K:3,4, Cl : 100, HBsAg (-), Anti HCV (-), CT/BT : 6/3, PT/APTT : 14,2/22,7, GDS : 73, Ur/cr : 10/0,5, GOT/GPT : 48/15, Protein total : 4,9

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2. HasnaP/29 thn/585098MRS 22/12/2012BED 4

D/ Susp Abses Hepar DD/ hepatoma

Lab 5/1/2013WBC 7,76. RBC 4,47. Hb 12,9. HCT 39,5. PLT 482.

Lab 2/1/2013AFP 2,23ALP 226

Lab 30/12/2012WBC 7.89, RBC 2,92, HGB 8,2, HCT 26, PLT 636, Alb 2,8, Na/K/Cl 152/4,9/114, CT/BT 8’00”/3’00”, GDS 75, Ur/Cr 22/0,6, PT/APTT 11,2/23.9, INR 0,9

CT Scan Abdomen 27/12/12Massa extraluminer pada curvature minor gaster kanan kesan gastrointestinal stromal

Lab 26/12/2012WBC 31,29, RBC 3,07, HGB 8,2, HCT 26,5, PLT 106, Alb 2,2, Na/K/Cl 150/3,9/116, CT/BT 8’00”/3’00”, GDS 96, Ur/Cr 67/0,7, GOT/GPT 112/131, PT/APTT 15,6/20, INR 1,29

USG Abdomen 20/12/2012Kesan:

Massa heterogen hepar susp. hepatoma DD/ abses hepar

CT Scan Abdomen 21/12/2012Kesan:

Hepatomegaly dengan multiple massa hepar susp. hepatoma DD/ abses hepar

Efusi pleura dextra

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3 Lasia/P40 thn/ 582277/MRS 02/01/2013BED 2

D/ Tumor Abdomen e.c. susp. Angiomyolipoma

Lab Urine Rutin 18/12/2012Ph 6, Bj 1,020, protein (-), Glukose (-), Bilirubbin (-), Urobilinogen (-), Keton (-), Nitrit (-), blood (-), lekosit (-).

CT Scan Abdomen dengan kontrasMassa retroperitoneal susp angiomyolipomaUterin fibroid

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LONTARA II DIGESTIF ISOLASI4. Dg. Sayu

P/56 D/ tumor gaster susp.

Lab 2/1/2013Albumin 2,1, GDS 93


thn/582857MRS 10/12/2012Bed 1

malignancy Lab 28/12/2012WBC 4.4, RBC 3.58, HGB 10.2, PLT 230Lab 25/12/2012CT/BT 7’30”/2’00”, PT/APTT 11,0/23,5, INR 0,9, GDS 91, Ur/Cr 28/1,0, GOT/GPT 11/7, As. urat 6,1, Nak/K/Cl 137/3,7/106Lab 17/12/2012CEA 2,08Echocardiography:

• Fungsi sistolik LV baik, EF 73%• LVH• MR mild• Disfungsi diastolik

USG Abdomen 10/12/2012Kesan:

Adanya tumor pada gaster sulit dievaluasi, organ abdomen lain dlm batas normal

OMD dari TakalarKesan:

Multiple ulcus gaster, tumor gaster, ulcus duodenum

5 Yusmianti/P/20 thnBed 2

D/ POH 2 (4/1/13) laparotomi eksplorasi + splenorafi

Lab (5/1/13)RBC 2,45 HGB 6,5 HCT 19,6 PLT 200 WBC 10,74Lab (4/1/13)RBC 2,21 Hb 6,0 HCT 18,9 PLT 262 WBC 8,6Lab (3/1/13)BT/CT 8”/2” PT/APTT 10,6/17,5 GDS 131 Ur/Cr 22/0,7 GOT/GPT 39/30 Alb 3,6

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 26. Amirullah/L/

27thn/ 586437

D/ POH 5 (1/1/2013) Laparatomi eksplorasi ec Vulnus ictum abdomen, vulnus ictum mesenterium, perforasi gaster

Lab 1/1/2013WBC 16,7, RBC 4,62, HGB 13,21, HCT 41,1, PLT 152, CT 8’30”, BT 3’00, PT/APTT 10,9/-, GDS 124, UR/CR 26/0,9, GOT/GPT 14/4,4, HBsAg (-), Anti HCV (-)Urin rutin (1/1/2013)Protein(+)/25kesan proteinuria

7. H. LatolaL/71 thn/585228MRS 27/12/2012Bed 2

D/ Tumor rectosigmoid

(Rencana Colon in Loop, Senin)

Lab (2/1/2013)GDS 84, WBC 10,38, RBC 5,36, HGB 14,9, HCT 43,5, PLT 285Foto Thoraks 23/12/2012Kesan:

Cardiomegaly dengan dilatatio et elongatio aortae (HHD)

Foto Abdomen 3 Posisi 23/12/2012Kesan: Sesuai gambaran ileus obstruktifLab 23/12/2012WBC 12,05, RBC 5,46, HGB 14,8, HCT 45,9, PLT 256, Ur/Cr 43/0,8, GOT/GPT 23/13, Alb 3,4, GDS 96, Na/K/Cl 146/4,2/108, HBsAg (-), Anti HCV (-)

9. Kasim D/ ileus Lab 28/12/2012


L/75 thn/585988MRS 28/12/2012JKMBed 4

obstruktif e.c. susp. Tu. Colon Ascendens

WBC 8.69, RBC 3.89, HGB 110.5, HCT 32.3, PLT 325, Alb 2.3 Globulin 4.0 CT/BT 8’00”/2’00”, PT/APTT 13.2/23.4, GDS 61, Ur/Cr 33/0,7, GOT/GPT 30/17, Na/K/Cl 141/3.7/ 106 HBsAg reaktif (ict reaktif) CT Scan abdomen full tanpa kontras 29/12/12

Ileus obstruktif e.c massa colon asendensFoto Polos Abdomen 3 posisi 28/12/2012Kesan : Ileus ParalitikAGD 28/12/12Alkalosis respiratorik

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 310.

Muhammad Dg Tama/ L/40thn/586204/MRS 29/12/2012BED 1

POH 7 Laparatomi eksplorasi ec Vulnus Ictum Abdomen Penetrans + Protrusion colon transversum + laserasi hepar grade I

Burst wound abdomenPOH 1 repair wound (4/1/13)

Lab 31/12/2012WBC : 10,4,RBC : 3,96, HB : 12,11, HCT : 37,41, PLT : 167, GDS :79, Albumin : 2,1, Na ; 141, K : 4,6, Cl : 112Lab 30/12/2012WBC : 11,84, RBC : 3,94, HB :11,9, HCT : 35,4, PLT :184, GDS : 79, Albumin : 3,3, Na: 144, K: 4,6, Cl : 113

11.

BasriL /40 thn/582034MRS 20/12/2012BED 2

Ca. Recti 1/3 distal susp. Malignancy

(Rencana Op)(Rencana Hasil PA keluar tgl 06/01/2013)

Lab 22/12/2012WBC 8,77, RBC 6,68, HGB 11,7, PLT 327, HCT 38,9, PT/APTT 11,3/21,6, CT/BT 7’00”/2’30”, GDP 103, GD2PP 215, TTGO 103, Ur/Cr 27/0,7, GOT/GPT 13/11, Alb 3,7, CEA 124, Na/K/Cl 142/3,8/106Foto Colon In Loop 14/12/2012Kesan:

Tu. recti 1/3 distal susp. malignancyCT Scan Abdomen Tanpa kontras 14/12/2012Kesan:

Tu. rectum tanpa pembesaran KGB (DUKES A/ T2 NxMx)

Foto Thoraks AP 14/12/2012Kesan:

Tidak tampak tanda-tanda metastasis pada foto thoraks ini

12 KeniL/37 thn/584603MRS 02/01/2013BED 3

D/POH 2 drainase abses ec. Abses hepar meluas sampai sub kutis

Lab 21/12/2013WBC 7,3, RBc :2,91, HB :8,7, HCT : 25,4, PLT : 35,6, Na ; 129, K:3,7, Cl: 93, GDS :165, Ur/Cr: 28/0,6, GOT/GPT :65/87, Albumin : 2,7, as.urat :2,7, CT/BT : 8/2, PT/APTT : 13,3/21,4, HBsAg (-), Anti HCV (-)

13 KabiruddinL/38

Tu. Abdomen susp.

Lab 3/1/13WBC 10.50 RBC 3,73 HGB 9,7 PLT 668 ALB

N n


thn/441315MRS 10/12/2012BED 4

lyposarcoma POH 17 Laparatomi eksplorasi ec. Tu. abdomen ( 19/12/12)

2,5 Na 132 K 4.4 Cl 99 PT/APTT 11,4/24,9 GDS 83Hasil PA 26/12/2012SOFT TISSUE SARCOMA SUSPECT LYPOSARCOMA DE DIFFERENTIATEDLab 29/12/12WBC 10.26 RBC 3,41 HGB 8,7 HCT 29,0 PLT 603 GDS 96 Ur/Kr 19/0,8 ALB 22,2 Na 141 K 4.4 Cl 105Echocardiography 10/12/12Sinus takikardiLV RV baik, EV 65%Foto Thorax PA 7/12/2012Subpulmonal effusion sinistraElevasi diafragma kanan (proses abdominal)CT Scan Abdomen 7/12/2012Susp. Lymphoma MalignaPA 24/7/2012Fibroma


Nur AzizahP/18 thn/584832MRS 20/12/2012UmumBed 1

POH 15 debridement ec Laserasi pankreas grade II blunt abdominal trauma

Lab 24/12/2012WBC 23,66, RBC 4,45, HGB 12,8, HCT 39,3, PLT 244Lab 23/12/2012WBC 20,15, RBC 2,99, HGB 8,6, HCT 26,7, PLT 236, GDS 94,Ur/Cr 17/0,4, GOT/GPT 28/27, Alb 2,3, Na/K/Cl 138/4,2/106Lab 22/12/2012WBC 20,8, RBC 3,46, HGB 10,6, HCT 31,5, PLT 217, PT/APTT 12,4/28,3, INR 1,0, GDS 89, Ur/Cr 31/0,3, GOT/GPT 20/24, Na/K/Cl 143/3,9/108Lab 20/12/2012WBC 15,0, RBC 3,64, HGB 10,8, HCT 33,0, PLT 226, CT/BT 6’30”/2’00”, PT/APTT 12,8/28,4, INR 1,09, GDS 90, Ur/Cr 22/0,5, GOT/GPT 34/41, Prot. tot 3,69, Alb 3,4, Na/K/Cl 143/3,52/107, HBsAg (-), Anti HCV (-)USG Abdomen 20/12/2012Kesan: Cairan bebas minimal intraperitoneum

MP

15.

JunuhatiP/81 thn/582241MRS 6/12/2012JKMBed 2

POH 3 Ileostmy e.c.Tumor retrosigmoid Stadium IV susp. Malignancy (3/1/13)

PH: 25

Lab 2/1/2013Na 136, K 2.3, Cl 100, Alb 2.7 Lab 1/1/2013GDS 97, Ur 14, Cr 0.3, Na 134, K 2.1, Cl 98, Alb 2,7Lab 30/12/2012WBC 7,38 RBC 4,52 HGB 11,6 HCT 34,8 PLT 232 MCH 25,7 MCHC 33,3Lab 28/12/2012WBC 25 RBC 4.09 HBG 10.9 HCT 33.3 MCV 81 MCH 26.6 PLT 286 PT/APTT 12.3/29.4 GDS 123 Ur/Cr 6/0.3 GOT/GPT 38/12 Alb 2.3 Na 137 K 2.1 Cl 102 Echocardiography 19/12/2012

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Kesimpulan: Fungsi sistolik LV baik, EF 63% Dimensi ruang jantung normal Fungsi ventrikel kanan baik Katup-katup fungsi dan pergerakan

baik Disfungsi diastolik

Lab 11/12/2012CEA 82,45CT Scan Abdomen Upper 7/12/2012

• Sesuai gambaran Tu. Sigmoid• Fatty liver

USG Abdomen 6/12/2012Tidak tampak kelainan radiologikFoto Thoraks 6/12/2012Kesan:

• Pulmo normal• Dilatatio aortae

15

Hijrawati /P/ 46 thn/ 526702MRS 29/12/2012Bed 3

D/ ileus obstruksi parsial

Lab 04/1/2013WBC 4.6, RBC 3.65, HGB 10.2, HCT 33, PLT 153, Alb 3.8, Na 145, K 4.4, Cl 112Lab 29/12/2012WBC 11.40, RBC 4.03, HGB 11.1, HCT 34.4, PLT 275, CT/BT 8’00”/3’00”, PT/APTT 10,1/22, Ur/Cr 47/0,7, GOT/GPT 40/38, GDS 66, Na/K/Cl 124/3,9/86, HBsAg(+), Anti HCV (-)

USG Abdomen (30-12-12)- Tumor metastasis ke hepar- Limfadenopati paraorta abdominalis

DDLymphoma- Hipertropi prostat- Efusi fleura bilateral- Ascites

Foto Thorax (30-12-12)- Efusi fleura kanan

CT Scan Abdomen (10-12-12)- Massa Ovarium kanan dengan

perluasan ke buli-buli- Hidronefrosis dan hidroureter Kanan- Tanda – tanda ileus obstruktif

16 Dg. Ngasse

P/42 thn/540345MRS 14/12/2012JKMBed 4

D/ Adenocarcinoma RectiPOH 8 Jejenostomy + Sigmoidectomy

Lab 31/12/2012WBC 10.2, RBC 3.22, HB 10.3, PLT 294Lab 27/12/2012

Lab 29/12/2012WBC6.6 RBC 3.50 HGB 11.1 HCT 33.7 MCV 96 MCH 31.6 MCHC 32.8 GDS 85 Alb 2.8Lab 19/12/2012CT/BT 8’30”/3’00”, PT/APTT 11,1/27,3, INR 0,9, GDS 78, Ur/Cr 16/0,9, GOT/GPT 22/8, Na/K/Cl 143/4,5/108, WBC 5,84, RBC 2,84, HGB 8,8, HCT 26,6, PLT 292Foto BNO 3 posisi 17/12/2012

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Kesan: Tidak tampak kelainan radiologik pada foto BNO 3 posisi ini kecuali fecal impactedFoto Thoraks AP 16/12/2012Kesan: Elevasi diafragma kiri (proses intraabdominal?)USG Abdomen 16/12/2012Kesan:

• Hidronefrosis dextra• Ascites

17

InadiaP/44 thn/579356MRS 19/11/2012JKMBed 5

Tumor gaster susp. malignancy

PH: 43Pro UGIE

Lab 29/12/2012WBC 8.3 PLT 476 MCHC 31.9 MCV 82 HCT 32.5 HGB 10.3 RBC 3.97 Ur/Cr 6/0.4 Alb 2.9 Na138 K 4.1 Cl 102Lab 25/12/2012GDS 86, Alb 2,2, Na/K/Cl 135/3,5/100Foto OMD 11/12/2012Kesan : Tu. gaster susp. malignancyLab 29/11/2012HBsAg (-), Anti HCV (-), CEA 4,35Echocardiography 27/11/2012Kesimpulan:

Kontraktilitas LV baik, EF 58%Foto Thoraks 27/11/2012Kesan:

Susp. efusi pleura kiri Elevasi diafragma kiri (proses

intraabdominal?)USG Abdomen 22/11/2012Kesan:

Massa hipokondrium kiri susp. massa intraluminer colon flexura lienalis-colon descendens

Ascites dan efusi pleura kiriCT Scan Abdomen Lower Non Kontras 21/11/2012Kesan:

Tu. gaster Atelektasis paru kiri Efusi pleura kiri

Foto Thoraks 19/11/2012Kesan:

Efusi pleura sinistra Cardiomegaly

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Sitti M. KotenP/48 thn/581478MRS 1/12/2012JKMBed 6

Tumor rectosigmoid susp. malignancy

PH: 25

Lab 1/1/13CT 7’30” BT 2’30” PT 14,6 INR 1,1 APTT 25,7 HbSag Positif Anti HCV Negatif GDS 72 Ur 11 Cr 0,4 GOT 48 GPT 21 Alb 2,5 2/1/13WBC 7,96 RBC 4,40 Hb 10,6 HCT 33,2 PLT 314 Lab 31/12/12Albumin 2,6Lab 29/12/2012WBC 9.91 RBC 4.69 HBG10.7 HCT 33.4 PLT 236 APTT/PT 25.3/12.0 GDS 95 Ur/Cr 12/0.5


Bil tot 0.80 Bil.direk 0.42 GOT?GPT 44/19 Prot 5.3 Alb 2.4 Na 136 K 2.9 Cl 104Lab 26/12/2012WBC 9,14, RBC 3,79, HGB 8,2, HCT 25,9, PLT 460, Na/K/Cl 135/3,3/102 Lab 21/12/2012Alb 3,0Lab 17/12/2012Alb 1,9, Na/K/Cl 129/2,9/97, WBC 13,25, RBC 4,94, HGB 10,1, HCT 31,9, PLT 359Foto Colon In Loop 13/12/2012Kesan: Tu. rectosigmoid susp. malignancyEchocardiography 12/12/2012Kesimpulan:

Fungsi sistolik LV & RV baik, EF 67% LVH Disfungsi diastolik Efusi pericard minimal

MSCT Whole Abdomen Non Kontras 7/12/2012Kesan: Massa para iliaca susp. limfomaLab 9/12/2012HBsAg (+), Anti HCV (-)Lab 5/12/2012GDS 72, CEA 4,07USG Abdomen 1/12/2012Kesan:

Susp. massa adneksa Ascites


Cardiomegaly disertai dilatatio et elongatio aortae

Tidak tampak tanda-tanda metastasis pada foto thoraks ini


Usman SommengL/38 thn/582132MRS 11/12/2012JKDBed 3

D/ Ikterus obstruktif ec. Choledocolithiasis

POH 22 laparatomi Eksplorasi CBD

Colon in Loop (2/1/2013)Kesan : paten CBD

Lab 2/1/2013Na/K/Cl 111/3,6/90, GDS 121, ur/cr 136/ 3,8Bil tot 18,9, bil direct 17,8Hb 12,7, WBC 15,21, PLT 810LAB 28/12/2012WBC 15.21, RBC 4.09, HB 12.7, HCT 34.3, PLT 8,0, Bilirubin Total18,9, Bil. Direk 17,8, Na 111, K 3,6, Cl 90, GDS 121 CEA : 15,12CA 19-9 : 83,85, AF : 246

USG : kolestatik intrahepatik e.c choledocholelithiasisCholangiography 2/1/13Kesan : paten CBDLAB 28/12/2012WBC 21.09, RBC 4.17, HB 12.8, HCT 36.1, PLT 856 ,Bilirubin Total 23, Bil. Direk 20,


GOT/GPT 78/87 Albumin 3.8, Na 125, K 4.3, Cl 90Lab 25/12/2012WBC 12,31, RBC 4,00, HGB 12,1, HCT 34,6, PLT 665, GDS 104, Bil. 23,5, Bil. direk 20,5, Alb 3,2, Na/K/Cl 136/3,4/99CT Scan Abdomen Lower 7/12/2012Kesan:

Cholestatic intrahepatik dan CBD ec choledocolitiasis

Lab 6/12/2012Bil. tot 37,47, Bil. direk 30,38, GOT 47Foto Thoraks 6/12/2012Kesan: WNL

21.

HartaL/28 thn/584040MRS 17/12/2012JKDBed 4

D/ POH 8 Drain Abses ec Abses hepar

Lab 3/1/13WBC 7,23 RBC 2,88 Hb 8,7 HCT 27,0 PLT 96 GDS 103 Ur/Cr 25/0,4 GOT/GPT 39/21 Alb 1,5 CT/BT 7’00”/3’00” PT/APTT 13,3/27,2CT/BT 7’00/ 3’00, GDS 103, Ur/Cr 25/0,4 Alb 1,5Lab 20/12/2012Alb 1,7, Na/K/Cl 151/4,3/118Lab 19/12/2012Ur/Cr 71/0,6, Bil. tot 3,52, Bil. direk 2,75, Alb 1,6Lab 17/12/2012WBC 15,0, RBC 4,55, HGB 13,3, HCT 40,4, PLT 229, GDS 132, Ur 94 Cr 0,9 SGOT 169 SGPT 94 Na 146 K 5,3 Cl 108 CT 7’30” BT 2’30” PT 17,7 INR 14 APTT 42,9USG Abd 17/12/12Massa lobus kanan hepar suspek hepatoma, DD abses heparAscitesTes Widal 17/12/2012Salmonella Thypi (-)CT Scan Abdomen 17/12/2012Kesan:

Multiple abses hepar DD/ hepatoma Ascites

22.

Massiri /P/ 32 thn/ 586205MRS 29/12/2012Bed 6

Rajja Hasil foto BNO 3 posisi 6/1/2013: sesuai gambaran

D/ post Reseksi ileum ec Vulnus ictum abdomen penetrans

Lab 3/1/2013WBC 11,92 RBC 2,87 Hb 8,6 HCT 24,8 PLT 250Na/K/Cl 136/3,5/111, GOT/GPT 15/10

Lab 30/12/2012 GDS 122, Alb 2,6Lab 2/1/2013WBC 9,39 RBC 2,96 Hb 7,3 HCT 21,2 PLT 230 GOT/GPT 15/10 Na 136 K 3,5 Cl 111Lab 30/12/2012GDS : 122Alb : 2,6

Lab 29/12/2012RBC 3.73, HGB 11.61, WBC 8.51, HCT 36.4,


ileus paralitik

Foto Thoraks Kesan Cor dan pulmo dalam batas normal

PLT 246, CT/BT 6’00”/2’00”, PT/APTT 116/17,7, Ur/Cr 21/0,8, GOT/GPT 16/13, GDS 108, Na/K/Cl 142/3,8/112, HBsAg(-), Anti HCV (-)

PALEM ATAS23

Rahmat/L/62thn/ 583250/19/12/12 B1/ 7/ASKES

D/ POH II laparatomi + eksplorasi CBD + cholesistectomi

Lab 3/1/2013WBC 9,43. PLT 124. Hb 10,4Lab 1/1/2013Bil.total: 7,44, Bil.Direct; 6,31Lab 29/12/12GDS 80 Bil. Tot 10.8 bil. Direk 10.1 GOT 150 GPT 154 HB 8 RBC 2.64 WBC 8.8 PLT 11.5 MRCP kontras 19/12/12Kolestasis intra dan ekstrahepatik e.c stenosis / cholangitisCT scan 12/12/12Choledocholelith disertai cholestasis intra dan ekstra hepatic

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24.

Saodah SaenabP/61 thn/265131MRS 18/12/2012B2/4

D/ Ikterus Obstruktif ec Choledolithiasis

(Rencana op Senin 7 januari 2013)

Lab 02/01/2013WBC : 6,81, RBC : 4,54, HB : 12,8, HCT :38,6, PLT :296Ur : 23. Cr : 0,7. GDS : 141. GOT/GPT : 19/16. Bil. Total : 0,9. Bil. Direk : 0,53. GGT : 209Lab 21/12/2012CT/BT : 8/3, PT/APTT : 16,3/27,3,Lab 19/12/2012WBC 8,02, HGB 12,5, PLT 334, CT/BT 7’00”/2’30”, PT/APTT 11,9/ 21,5, GDS 149, Ur/Cr 23/0,6, GOT/GPT 42/123USG Abdomen 12/12/2012Kesan:

Tidak tampak kelainan radiologik pada USG abdomen saat ini

CT Scan Abdomen 13/12/2012Kesan:

Kolestatik intra & ekstrahepatik ec choledocolith

Dilatasi GB ec cholecystolith

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26

Siani Onu/P/ 57 thn / 584302 / MRS 28/12/2012B1/4

D/ Hidronefrosis gr. II.Cholesistolithiasis

(Konsul dari bedah urologi)

CT-Scan (19/12/2012)Sludge GBPelvocalyectasis ginjal kananAterosclerosis aorta abdominalis & A. Iliaca bilateralBNO-IVP (26/12/2012)Kesan : Hidronefrosis kanan gr. II-IIILab 05/1/2013CT/BT : 8’00/2’30. PT/APTT : 11,9/19,8. GDS : 122. Ur/Cr : 34/0,9. GOT/GPT : 15/9. Alb : 3,5. Na : 142. K : 3,9. Cl : 110.WBC : 6,71. Hb : 11,0. PLT : 331.USG 22/12/2012

S


- Hidronefrosis Grade II – III dengan multiple nefrolith

- Multiple cholelith- Sistitis Kronik

LAB 20/12/2012As. Urat 10.6LAB 18/12/2012GDS 135, Ur/Cr 52/1.2, Bil.Total 1.5, Bil.Direk 0.32, GOT/GPT 13/9, Alb 4.1

PALEM BAWAH28 Rukiah/P/63

thn/ 577923MRS 03-01-2013

Kamar B2/8 Bed 1

Tu. Recti 1/3 distal + post ULAR + Post ileaotomy

PA 12/12/12Adenocarcinoma Rectum Mode Vately

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LONTARA 1 ATAS DEPANLONTARA I ATAS BELAKANG

29

A. KaharuddinL/60 thn/583945MRS 16/12/2012Masuk Bangsal 24/12/2012Kamar 7 Bed 2

D/ Ileus Obstruktif Parsial

Lab 24/12/12WBC 5,91, RBC 4,23, HGB 11,2, HCT 35,0, PLT 178, GDS 57, Alb 2,7, Na 142, K 3,8, Cl 107CT Scan Abdomen 17/12/2012Kesan:

Ileus obstruksi dengan tu. rectum Multiple nodul hepar susp. metastasis

Lab.16/12/20120WBC 6,51, RBC 4,38, HGB 11,8, HCT 36,2, PLT 223, CT/BT 7’00”/2’00”, PT/APTT 12,4/28,4, GDS 104, Ur/Cr 16/1,0, GOT/GPT 14,8, Alb 3,3, Na/K/Cl 139/3,5/108, HBsAg (-), Anti HCV (-)

30

Frendi KopeL/15 thn/585049MRS 21/12/2012Kamar 7 Bed 4

D/ Trauma Tumpul Abdomen

Lab 21/12/12WBC 13,6, RBC 4,30, Hb 11,6, HCT 37,1, PLT 352, GDS 89, GOT 20, GPT 24, Cr 0,8, Ur 35, PT 16,1, APTT 34,4CT Urografi + Kontras 22/12/12Kesan :

- Massa kistik retroperitoneal sesuai gambaran urinoma

- DD/ Kista meenterium

LONTARA 1 BAWAH BELAKANGLontara II Bedah Urologi

31 Tn. Sambolangi/L/67 thn/ 581528 MRS 26/12/12Konsul tgl 29/12/12

D/ HIL S Lab 06/12/12PSA 2,25Lab 03/12/12Na 132 K 3,7 Cl 95 HbsAg Reactive Anti HcV Non Reactive CT 8’00” BT 3’00” PT 11,5 APTT 24,5 GDS 105 Ur 22 Cr 0,7 GOT 57 GPT 27 Prot Tot 6,1 Alb 3,1 As. Urat 4,6 WBC 32,25 RBC 4,18 HB 11,9 PLT 554MSCT whole abdomen( 12/12/12)Kesan :

- Ca Prostat dgn infiltrasi ke buli-buli- Fusiform aneurisma aorta abdominalis infrarenalis


Foto thorax ( 03/12/12)Kesan :

- Emfisema Pulmonum- Dilatatio et elongatio aorta

USG Abdomen ( 03/12/12)Kesan :

- Tu. Buli buli- Hipertrofi prostat- Hidronefrosis bilateral- Aneurisma aorta abdominalis disertai trombus

Lontara II Bedah OrthopediLontara II Onkologi

Lontara III Kulit32 Dahlan

L/33 thn/586244MRS 29/12/12Kamar 2 bed 1

D/ Trauma tumpul Abdomen

Lab 29/12/12WBC20,53 RBC 4,2 Hb 14,0 HCT 41,4 PLT 224 CT 7’00” BT 2’00” PT 9,6 INR 11,2 APTT 21,3 GDS 157 Ur 35 Cr 1 GOT 97 GPT 100 Na 143 K 4,2 Cl 111 HBsag negativeUSG 29/12/12

- Tidak tampak tanda-tnda laserasi pda organ-organ terscan

- Cairan bebs intraperitoneum susp.hematoperitoneum

RSP33

Jaka GisanjayaL/20 thn/4585MRS 19/12/2012Kamar 419

D/ Abses incisional Post Laparotomy Eksplorasi

Lab 29/12/12WBC 20,73 RBC 4,07 HGB 12,2 HCT 34,9 PLT 614 GOT 25,5 GPT 21,6 GDS 85,6 Ur 24,0 Cr 0,6

Lab 27/12/2012WBC 16,8, RBC 4,43, HGB 12,7, HCT 36,5, PLT 518

Lab 21/12/2012WBC 13,9, RBC 4,86, HGB 13,9, HCT 40,0, PLT 299

Lab 03/01/2013WBC 11,60 RBC 4,14 HGB 12,0 HCT 35,8 MCV 86,5 MCH 29,0 MCHC 33,5 PLT 946

Imunoserologi 03/01/2013HIV (-)

Foto BNO Polos 19/12/2012Kesan:

Tidak tampak kelainan radiologik pada foto BNO saat ini

USG Abdomen 19/12/2012Kesan: Gambaran meteorismus (subilens)

34

Chaeruddin / L/ 49 thn

D/ Appendisitis Wound

Lab 29/12/2012WBC 15.12, RBC 3.92, HGB 10.9, HCT 34,


586254MRS 29-12-12

dehisersi Post Op appendectomy

PLT 567, CT/BT 7’00”/2’30”, PT/APTT 11.3/26.1, Ur/Cr 19/0,8, GOT/GPT 23/13, GDS 134, Na/K/Cl 131/4.7/96, Alb 2,7 HbsAg(-), Anti HCV (-)

Lab 31/12/2012WBC 11,23 RBC 3,84 HGB 10,8 HCT 32,4 MCV 84,5 MCH 28,1 MCHC 33,3 PLT 512

35

BurhanuddinL/68thn/007276MRS 2/1/13Kamar 412B

D/ POH I Hernioraphy e.c HIM S Reponibilis

Lab 2/1/13WBC 6,45 RBC 3,91 Hb 7,5 HCT 23,8 PLT 209 CT 9’00” BT 3’00” PT 14,6 INR 1,21 GOT12,9 GPT 11 Al 3,9 Ur 22,5 As.Urat 5,9 GDS 111

Foto thorx 2/1/13Tidak tampak kelainan ada foto radiologi ini

36

Kristianto/L/36 thn/6052MRS 04/01/2013Kamar 411 B

D/ Fistel perianal Post Colostomy Pro tutup colostomy

Lab 03-01-2013WBC 8,20 RBC 4,77 HGB 13,0 HCT 38,4 MCV 80,5 MCH 27,3 MCHC 33,9 PLT 258 PT 14,1 INR 1,16 APTT 34,5 CT 9’ BT 3’ SGOT 28 SGPT 46,3 Albumin 4,24 GDS 133 Ureum 14,7

Sri Wahyuni /P/33 thn/7298MRS 02/01/2013

Kamar 407

D/ Ikterus Obstruktif e.c tu. Caput pankreas

Lab 02/01/2013WBC 12,2 RBC 3,09 HGB 9,9 HCT 28,7 MCV 92,9 MCH 32 MCHC 34,5 PLT 328SGOT 15,9 SGPT 145,9 GDS 67,9 Ureum19Na 136 Kalium 3,1 klorida 105

Lab 04/01/2013PT 14,8 INR 1,24 APTT 34,7 Bil.total : 32,33 Bil.Direk : 24,40 Albumin : 2,7 Kolesterol total : 131 Kolesterol HDL : 3,6 Kolesterol LDL : 149 Trigliserid : 252 As. Urat : 1,53

Imunoserologi 02/01/2013HbsAg (-)

Tumor Marker 03/01/2013CA 19-9 : 357,5

ADT 03/01/2013Kesan : Anemia normositik normokrom susp. e.c penyakit kronik dengan leukositosis tanda inflamasi

CT Scan Abdomen 04/01/2013Kesan : - Kolestatik intra & ekstra hepatic e.c massa caput pancreas

- Susp. Ileus

38

Armawati /P/40 thn/7375MRS 05/01/2013

D/ CholecystitisSusp. CHolelithiasis

Lab 05/01/2013WBC 10,06 RBC 4,20 HGB 12,3 HCT 36,2 MCV 86,2 MCH 29,3 MCHC 34,0 PLT 507NATRIUM 139 KALIUM 3,9 KLORIDA 102Protein Total 7,7 Albumin 4,0 GDS 88


Kamar 318 As. Urat 5,3 Ureum 18

38

Hamka Cinta L/49th/007271MRS 2/1/13Kamar 311

D/ POH 1 Hernioraphy HIL D Reponobilis

Lab 2/1/13WBC 10,55, RBC 5,17, Hb 15,4, HCT 43,1, PLT 233, CT 7’00”, BT 4’00” PT 13,2 INR 1,06 APTT 34,7 HBsAg -, GOT 22,2 GPT 28 Al4,57 GDS 90,6 Ur21,9

Thorax 2/1/13Tidak tamak kelainan rdiologi pad foto thorax

P C C38

Muh. Ali PawellangiL/69 thn/030641MRS 27/11/2012Konsul 4/12/2012Askes wajibKamar 224

D/ Ca esofagus 1/3 tengah – 1/3 distal

Lab 3/1/2013WBC 14,5, RBC 4,01, HGB 9,4, HCT 29,9, PLT 420,Lab 27/12/2012Protein total 51, albumin 2,5Lab 22/12/2012WBC 7,2, RBC 4,04, HGB 9,5, HCT 29,7, PLT 390, Ur/Cr 25/0,7, GOT/GPT 21/13, TG 159, Na/K/Cl 144/2,8/112Lab 14/12/2012WBC 8,4, RBC 4,04, HGB 9,6, HCT 29,8, PLT 288, GDS 76,CT/BT 2’00”/6’00”, PT/APTT 11,6/32,4, Ur/Cr 24/6,7, GOT/GPT 20,14, Prot.Tot 44, Alb 2,7, Na/K/Cl 140/3,4/109Lab 10/12/2012Prot. Tot 7,0, Alb 2,1Echocardiography 10/12/2012Kesimpulan:

LVH (+) PE (+) minimal AR (+) kalsifikasi katup Disfungsi diastolik

Foto OMD 5/12/2012Kesan:

Tu. Malignant 1/3 tengah & distal esofagus disertai ulcus carcinogenic

Lab 3/12/2012WBC 20,5, RBC 4,90, HGB 11,5, PLT 304, Ur/Cr 61/0,80, GOT/GPT 22/26, Na/K/Cl 136/3,8/104CT Scan AbdomenKesan:

Tumor esofagus 1/3 distal Efusi pleura kiri Ascites


Bronkitis tidak spesifik Arterosklerosis aorta Tidak tampak tanda metastasis tumor

ke paruCT Scan Abdomen 30/8/2012Kesan:

Tumor esofagus dgn efusi pleura

RL


bilateral Vesicolith Hipertrofi prostat

Esofagografi 28/8/2012Kesan:

Tu. Esofagus 1/3 distal39

Muh. NizamL/35 thn/563041MRS 11/12/2012Umum/TunaiKamar 218

D/ fistel enterocutaneus

Rencana OP 9/1/2013

Lab 3/1/2013WBC 11,3, RBC 4,52, HGB 12,1, HCT 37,2, PLT 580 CT/BT 7’00”/3’00”, PT/APTT 12,2/26,2, GDS 174, Ur/Cr79/1,1, GOT/GPT 13/22, Prot. Tot 6,9, bil.tot 1,07Alb 4,5, Na/K/Cl 145/4,4/94,UGIE 18/12/2012Kesan:

Esofagitis candidiasis grade 2Foto OMD 13/12/2012

Fistel enterocutaneusLab 12/12/2012CT/BT 9’30”/3’30”, PT/APTT 12,5/30,4, GDS 97, Ur/Cr 91/1,5, GOT/GPT 28/21, Prot. Tot 6,2, Alb 4,5, Na/K/Cl 145/4,8/93, HbsAg (-), Anti HCV (-)

IL

40

Bachtiar BattoriL/58 thn/471664Askes WajibMRS 10/12/2012Konsul 14/12/2012Kamar 331

D/ca. Recti + fistel perianal

PA 26/12/2012Sediaan hapusan mengandung sel malignaLab 27/12/2012Albumin 2,7Lab 22/12/2012WBC 8,8, RBC 4,24, HGB 9,6, HCT 31,8, PLT 458, LED I/II 7/21, Prot. Tot 4,8, Alb 3,0, Glob 1,8Analisis Cairan Ascites 21/12/2012Warna kuning, Cairan 20 cc, Rivalta positif, Prot. 3,2, LDH 722, Sel 1200, Hitung jenis sel MN 90, PMN 10Lab 20/12/2012Alb 3,0Lab 18/12/2012WBC 7,4, RBC 4,21, HGB 9,5, HCT 31,4, PLT 379, Alb 2,8Foto BNO 17/12/2012Kesan:

Susp. Nefrolithiasis sinistraFoto Fistulography 17/12/2012Kesan:

Fistel rectocutaneusFoto Colon In Loop 17/12/2012Kesan:

Tu. Recti susp. MalignancyLab 14/12/2012WBC 9,6,RBC 3,86, HGB 8,2, HCT 27,2, PLT 349, Prot.Tot 4,8, Alb 3,0Foto Thoraks AP Supine 13/12/12Kesan:

Pulmo, cor dalam batas normal Elevasi diafragma DD/Efusi pleura

dextra

IL


Lab 13/12/2012CEA 71,88, Ur/Cr 23/0,8CT Scan Abdomen 12/12/2012Kesan:

Nefrolith +hidronefrosis grade IV kiri Ascites Splenomegaly

Lab 12/12/2012WBC 8,0,RBC 3,76, HGB 8,1, HCT 27,1, PLT 336Lab 11/12/2012FE 4,2, TIBC 294, Ferritin 21,61USG Abdomen 10/12/2012Kesan:

Hidronefrosis dengan nefrolithiasis sinistra

Ascites41 Naomi

MingguP/55 thn/582659MRS 8/12/2012Konsul 13/12/2012Askes WajibKamar 425

D/ Observasi susp. AppendisitisTu. Paru D/Efusi pleura D/

Lab 6/1/2013WBC 29,9, RBC 3,15, HGB 8,6, HCT 27,9, PLT 92USG thorax 2/1/2013

- Tampak efusi pleura kanan- Marker terpasang pd linea axillaris

posterior kanan- Kedalaman

Lab 27/12/2012WBC 19,7, RBC 3,43, HGB 9,1, HCT 29,2, PLT 469Lab 26/12/2012Ur/Cr 19/0,6 SGOT/SGPT 10/8 Lab 18/12/2012WBC 14,6, RBC 3,23, HGB 8,5, HCT 27,2, PLT 328Tes Widal 26/12/2012Salmonella Typhi H: 1/80Salmonella Typhi part A HA 1/320Salmonella Typhi part B HB 1/80Salmonella Typhi part C HC 1/80 OC 1/160Malaria Mikroskopis 18/12/2012DDR tidak ditemukanTes Widal 18/12/2012Salmonella Typhi part A HA 1/320Salmonella Typhi part B HB 1/80Salmonella Typhi part C HC 1/60 OC 1/180Kesan:susp paratyphi ALab 17/12/2012WBC 13, RBC 4,17, HGB 10,7, HCT 34,5, PLT 377, Alb 2,8Lab 14/12/2012WBC 16,2, RBC 3,67, HGB 9,7, HCT 31,1, PLT 332

Lab 12/12/2012WBC 15, 8, RBC 3,18, HGB 7,9, HCT 26,1, PLT 314, Prot.Tot 5,4, Alb 2,3 Urinalisa 12/12/2012

RL


Urinalisis dalam batas normalCT Scan Abdomen 11/12/2012Kesan:

Tidak tampak tanda-tanda hidronefrosis

Lesi pada pulmo kanan bawah Efusi pleura Hepatomegali

Lab 10/12/2012Bil. Tot 0.92, Bil. Direk 0,66, ALP 332, GGT 96, CEA 25,65USG Abdomen 8/12/2012Kesan:

Hidronefrosis dextraFoto Thoraks AP 8/12/2012Kesan:

Efusi pleura masif dextraLab 8/12/12WBC 14,8 RBC 37,8, HGB 9,2, CT 30,6, PLT 278, Na/K/Cl143/4,74/105

42

Dahniar TupaP/50 thn/585629MRS 5/1/2013Kamar 317

D/ Cholelitiasis Lab5/1/2013WBC 5,5, RBC 3,92, HGB 12.4, HCT 37,2, PLT 172GDS 116,Ur/Cr 19/1,1, GOT/GPT 16/18, PT/APTT 10,1/25,1, Alb 4,3, bil total 1,7,Na/K/Cl 141/4,4/110, HCV: nonreaktif, HbsAg non reaktifEcho 28/12/2012Kesan:

Fungsi sistolik LV baik, EF 67% Disfungsi diastolic

Lab 27/12/2012WBC 5,92, RBC 4,32, HGB 13,5, HCT 38,3, PLT 169 GDP 158,Ur/Cr 28/0,7, GOT/GPT 19/15, CT/BT 8’00’’/3’00’’, PT/APTT 10,0/25,3, Alb 4,5, alkali fosf 76,Gamma GT 15, Na/K/Cl 141/3,9/106,USG 27/12/2012Kesan: Cholelith Thorax 27/12/2012Kesan: pulmo normal, elongation et atherosklerosisiaortae

43

Tn. RachmadiL/55thn/586495MRS 1/1/13Kamar 217

D/ HIL S Reponibilis POH III Herniografy

Lab 3/1/13RBC 4,51 WBC 13,3 Hb 12,8 HCT 39,4 PLT 350 CT 8’00” BT 2’00” PT 11,6 INR 0,9 APTT 26,8 Ur 29 Cr 0,7 GOT 17 GPT 21 HBsAg Non reactiveFoto thorx 2/1/13Foto thoraks dalam batas normal

UGD45

Siman/58thn/586499/MRS 1/1/2012

D/ Ileus Obstruktif

Lab 01/01/2013WBC : 12,41, RBC :2,72, HB:7,4, HCT : 22,9, PLT :329, CT/BT : 8/2, PT/APTT : 12/31,7, GDS :65, Ur/Cr : 24/0,6, GOT/GPT : 82/61, albumin : 2,6, Na : 129, K : 4,2, Cl : 95 HBsAg (-)

4 Sukku dg D/ ileus Lab (04/1/13)


6 beta 51thn/ 586407MRS 4/1/13

obstruktif Ur/Cr 149/2.1, GOT/GPT 31/18, Alb 1.7, GDS 96,Na : 135,K :4.0,Cl :95Lab (05/1/2013)RBC 4,51 WBC 13,3 Hb 12,8 HCT 39,4 PLT 350 CT 8’00” BT 2’00” PT 11,6 INR 0,9 APTT 26,8 Ur 29 Cr 0,7 GOT 17 GPT 21 HBsAg Non reactive

USG AbdomenKesan:

- Susp. massa rektum disertai metastase ke hepar DD/ Massa adneksa

- Asites

47

Corawali/43/58671/MRS 3/1/2012

Tu abdomenTu recti 1/3 distal

Lab (3/1/13)WBC : 10,00, RBC :2,87, HB 3,8 HCT : 16,8, PLT :449, CT/BT : 8/2, PT/APTT : 14/25,4, GDS :88, Cr : 0,7, GOT/GPT : 10/14, albumin : 3,7, Na : 140, K : 3,8, Cl : 105, HBsAg (-)

48

Sri winarsih/48/586868/MRS 3/1/2012

Tu. Abdomen Lab 5/1/2013Hb 10,2 WBC 6,9 PLT 338Lab 4/1/2013Hb 9,4, WBC 7,8 PLT 317

Lab (3/1/13)WBC : 8,2, RBC :4,45, HB 7,1 HCT : 25,7, PLT :321, CT/BT : 8/3, PT/APTT : 10/18 GDS :94, Cr : 0,6, GOT/GPT : 16/19, albumin : 3,5, Na : 143, K : 4,4, Cl : 112, HBsAg (-)

ICU49

Rapik papa sindi/31 thn/ 586481MRS 1/1/13

D/ Vulnus Ictum penetrans + ileus

LabRBC 3,96 HB 12,11 HCT 37,41 PLT 167 PT/APTT 10/24,2 Ur/Cc 14/0,4GOT/GPT 35/59 ALB 1,7

50

RaupeL/67 thn/582222MRS 14/12/2012JKD

D/ POH 19 Laparatomi Eksplorasi e.c Ileus obstruksi ec volvulus

LAB 31/12/2012Analisa Gas DarahpH 7.46, pCO2 55.4, sO2 99.2, pO2 132.1, HCO3 38.5, c + o = 21.4, c + O2 = 33.0, BE2 12.2Lab 30/12/2012GDS 75, Ur 31, Cr 0,9, SGOT 47, SGPT 24, Alb 1,4, Na 131, K 3,8, Cl 97, RBC 3,42, WBC 19,7, HGB 9,6, HCT 29,1, PLT 134Lab 21/12/2012WBC 7,11, HGB 10,5, HCT 30,6, PLT 200, Na/K/Cl 129/3,7/99, Alb 2,3, GDS 104Lab 18/12/2012WBC 12,14, RBC 4,01, HGB 11,3, HCT 33,6, PLT 133, GDS 113, Ur/Cr 35/0,8, GOT/GPT 33/18, Alb 2,2, Na/K/Cl 140/3,6/105Lab 16/12/2012


GDS 109, Ur/Cr 42/0,6, GOT/GPT 22/13, Alb 2,2Lab 16/12/2012WBC 7,42, RBC 4,61, HGB 12,9, HCT 38,9, PLT 202, GDS 101, GOT/GPT 17/12, Alb 2,4CT Scan Abdomen (Tanpa Kontras)Kesan:

Ileus obstruktif lesi setinggi ileum terminalis

Ascites

awakoran digestive 7 jan (autosaved)

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