Kamis , 22 APRIL 2021 BEDAH DIGESTIVE SYA/DIP/FUD/MEI/MRS/NIS/ATA

BEDAH DIGESTIVE

Bangsal BED Nama Usia MRS Diagnosis Status DPJP Plan PemeriksaanPenunjang

Inf nacl 0.9% 20 tpm,

Suroto
IGD Post adhesiolisis + jahit benton repir Post op ampicilin, metamizol,
106 01532890 48 NG 20/4 hb 9,8 ht 29 al 15,2 at 114 ae 3.4 alb 2.1 na 126 k 3.0 cl 99
19/4 stoma ai Burst abdomen 20/4 ranitidin, as tranexamat, vit
MRS – DIP
k
17/4 alb 2.9
16/4 hb 6.8 ht 20 al 10.2 at 46 ae 2.67 gds 127 alb 2.5 cr 0.9 ur125
15/4 GDS 138 Alb 2.3 Na 142 K 2.3 K 1.13
Post relaparotomy repair
3/4 Hb 10.5 Ht 31 AL 13.5 AT 496 AE 3.90 PT 14.9 APTT 29.7 IR 1.190 GDS 92 OT 36 Pt 15
Sainem stump+ileustomy ai peritonitis
Poli Post op diet per sonde, pindah hcu, Ur 17 Cr 0.6 Na 138 K 2.7 Cl 108 Ca 1.22
108 01532955 57 generalisata ec leackage post IBB
28/3 15/4 pertahankan drain 1/4 ct scan abd kontras : massa proksimal colon desenden yang menginfiltrasi intra
FUD– SYA hemicolectomi S
mukosa submucosa muskularis propia menyebabkan ileus obs letak rendah dan
DPH 7
mendorong lien kea rah supero posterior. Multiple limfadenopati di ingunal bilateral
iliaca bilateral dan mesenterika. Multiple simple cist ren bilateral. Atrosklerosis pada
aorta abdominalis. Degenerative spen disease.
Nuri Co Post laparatomy eksplorasi + miking
Post op 20/4 hb 13.3 ht 40 al 34,5 at 121 ae4.39 alb 3.3 cr 6.0 ur 139 na 122 k 5.9 cl 93 cal i 1,07
115 01535024 31 ongyn procedure ai ileus letk tinggi in partu AR Perawatan post op
20/4 mg 1,72
ICU FUD– SYA 20/4 +fecal material prominen DPH 2
Muh Hasan Post laparatomi evakual korpal +
IGD Post op 18/ hb 13,5 ht 39 al 10,4 at 185 ae 4.59 alb 3,5 na 136 k 4,3
116 01534798 33 kontrol bleeding ai Laserasi hepar gr 4 AR inj.omeprazole
16/4 17/4 16/4 Hb 14.7 Ht 41 AL 18.2 AT 304 AE 5.00
FUD– SYA zona 7-8 DPH 4
Post laparatomy + reseksi anastomose
Purwanto
IGD ileum end to end ai peritonitis Post op 17/4 hb 17,4 ht 53 al 17,2 at 180 ae 5.74 goldar B pt 13.5 att 25,4 inr 1,060 gds 119 ccr
119 01534814 55 NG anal dilatasi, dulcolax supp
17/4 generlisata ec a.trombus mesentrica 17/4 1,2 ur 66 na 130 k 5.7 cl 102 hbsag NR
FUD– SYA
DPH 4
Post relaparatomy adhesiolisi + reseksi
16/4 AGD ph 7.380 be -11.2 pco2 20.0 po2 90.0 ht 39 co3 12.1total co2 12,7 o2 saturasi
Suwardi nekrotik ileum + jahit stant ai burst
IGD Post op pindah bangsal, Ro thorax, 97.0 arteri 1.40
120 01534107 59 abdoment +adhesi berat ileo ileal + NG
15/4 15/4 konsul paru 16/4 hb 11.9 ht 36 al 21.8 at 1595 ae 4.62 gds 193 alab 2.6 cr 4.0 ur 193
FUD– SYA nekrotik ileum
14/4 Hb 7.0 Ht 22 AL 11.3 AT 1856 AE 3.00
DPH 6
17/4 hb 13,7 ht 41 al 13,7 at 227 ae 5.55 pt 12,9 aptt 30.6 inr 1.000 gds 110 ur 165 alb 3.3
cr 2.8 na 137 k 4.9 cal ion 1.13 hbsag inderteminate
17/4 ABD 3 posisi :
Narno Post laparatomi graham phatch
IGD Post op Kesimpulan :
128 01534826 69 procedure ai Peritonitis generalisata ec NG pindah bangsal, diet MSS
17/4 18/4 1. pneumoperitoneum
FUD– SYA perforasi gaster DPH 4
2. ileus obs letak tinggi
3. fecal material prominen
4. terpasang GT dengan tip terproyeksi di gaster
18/4 hb 16 ht 47 al 9,9 at 268 ae 5.88 pt 13.3 aptt 28,0 inr 1,040 gds 109 cr 1.0 ur 78na
135 k 3.9 cl 94 hbsag NR
18/4 ABD 3 posisi
Kesimpulan :
Tn. Sumpeno 1. ileus obs letak tinggi
IGD Meteorismus susp ileus obstruksi dd
1A 01534840 62 KU NG share hasil ct scan 2. tak tampak gambaran pneumoperitoneum
17/4 paralitik
MRS – DIP 3. terpasang NGT dengan tip terproyeksi di gaster
Ro thorak :
1 bekas peradangan paru kanan
2. cor tak tampak kelainan
3. terpasang NGT dengan tip terproyeksi di gaster
 Kamis , 22 APRIL 2021 BEDAH DIGESTIVE SYA/DIP/FUD/MEI/MRS/NIS/ATA
18/4 hb 12,7 ht 36 al 6,2 at 203 ae 3,82 pt 13,4 aptt 37.1 inr 1.050 gds 87 sgot 21 sgpt 17
biltot 0,85 alb 3,9 cr 0,9 ur 23 na 138 k 3,0 cal ion 1,20
12/4 hb 13.0 ht 37 al 7.7 at 183 ae 4.23 pt 12.9 aptt 36.0 inr0.940 gds 120 sgot 27 sgpt 22
Suyatno biltot 1.16 bildek 0.43 bilin 0.73 alb 4.3 cr 0.7 ur 17 na 141 k 3.5 cl 108 hbsag NR
Poli Pro laparostomy eksplor cbd
1D 01531208 33 Obs jaundice ec susp batu cbd Pre op IBB 12/ 4 MRCP ABD :
17/4 Hari rabu
MRS – DIP Obstruksi bilier, intra dan ekstra hepatal
Multiple cholelithiasis
Parenchymal liver disease disertai hepatosplenomegali
Multiple simple cyst ren ( Bosniak 1)
16/4 hb 11.5 ht 39 al 7,4 at 570 ae 4,40 gds 84 CEA 1.18 hbsag NR Aanti HCV NR cr 1,1 ur
25
15/4/21 MSCT ABD
Kesimpulan :
1 Massa regio epigastrium hingga umbilicus dengan gambaran floating aorta sign yang
menempel pada pentoneum visceralis, menempel dan mendorong ginjal bilateral ke
inferior, menempel dan mendorong gaster ke anterior, serta menempel dan
mengencase aorta abdominalis, vena cava inferior, arteri lienalis mengarah gambaran
Iymphoma
2. Multipel lymphadenopathy di inguinal bilateral, parailiaca bilateral, paraaorta dan
Donny O2 5 lpm NK
Poli Massa epigastrium extralumensusp mesenterica
3D 01530745 31 Pre op NG Pro laparatomi reseksi tumor
16/4 lymphoma splenomegaly + dypsnoe 3. Ascites
Mel 2 MRS – DIP k/p spenektomi hari rabu
4. Hepatosplenomegaly
5. incidental finding : Pneumonic dan subpleural type pulmonal metastasis
6. Paralumbal muscle spasme
23/02/20 USG ABD
1. Hepatosplenomegaly
2. Lesi solid di epigastrium kemungkinan dengan infiltrasi ke lobus kiri hepar dan lien
Multiple nodul lien
3. Limfadenopati hilus lien dan hepar, paraaorta dan inguinal bilateral GB, pancreas,
kedua ren, VU, prostat tak tampak kelainan
4. Non visualisasi appendix

Poli 6/4 USG Abdomen

5B Yuli isnaini 34 Multiple cholelithiasis Pre op AR Laparstomy cholesistectomy
20/4 Kesan :multiple choleithiasis

Bu + diet mss, RL 20 tpm,

12/4 Hb 12.6 Ht 37 AL 12.0 AT 277 AE 4.71 GDS 84 SGOT 25 SGPT 13 Ur 21 Cr 0.8 Alb 4.1
Suwarsini metamizol 1gr/8jam,
Poli Post herniorepair lichtenstein ai Hernia Post op Na 139 K 3.8 Cl 110 HbsAg NR
5D 01510549 50 IBB ranitidin 50mg/12jam,
17/4 mediana (S) residif DPH 2 20/4 Ro Thorak : Cor dan pulmo tak tampak kelainan
MRS – DIP ampicilin gr/8jam, codein
29/3 USG Abdomen: Menyokong gambaran Hernia ingunalis kiri reponibilis
10mg 3x1, medikasi /2 hari
Sujari
Poli Post op Post rectopexy hari rabu, 13/4 Hb 12.5 Ht 38 AL 9.3 AT 829 AT 4.7 PT 19.5 APTT 34.1 INR 1.620 GDS 119 Alb 3.8 Ur
5E 01531536 44 Prolaps rektum DPH 1 IBB
17/4 21/4 diet cair 27 Cr 0.9 Na 142 K 3.5 Cl 110 HbsAg NR
MRS – DIP
Rina
Poli Post op Post laparratomy 19/4 hb 7.3 ht 21 al 5,7 at 314 ae 2.84 goldar B pt 13,4 aptt 30,6 inr 0,990 gds 82 alb 3,4
5F 01534453 37 App kronis + B20 DPH 1 AR
19/4 21/4 appendektomy cr 0,8 ur 39 na 138 K 3,5 cl 109 hbsag NR
MRS – DIP
Maryanto
IGD Anemia, cancer pain, GIST on kemo koreksi Hb, jika baik BLPL 22/4 hb 8.6 ht 28 al 5.8 at 45 at 3.69
6H 01527848 31 KU IBB
19/4 (Gelvenic) dgn MST u/ 30hari 19/4 hb 8.0 ht 27 al 11.0 at 476 ae 3.68 goldar A gds 132 ot 40 pt 17 cr 0.8 ur 24
MRS – DIP
7A Suwarti 77 Poli Post biopsi + biliodigest +braun Post op AR aff ngt, dc, BLPL 17/4 Hb 14.0 Ht 41 AL 6.1 AT 199 AE 4.39 Alb 3.4
01531465 6/4 anastomose ai massa caput pancreas 12/4 10/4 hb 12,4 ht 36 al 8,8 at 210 ae 3.90 pt 11.5 aptt 29.4 inr 0.870 gds 105alb 3.5 cr 0,6
MRS – DIP DPH 8 ur 25 na 142 k 3.2 cl 112
6/4 Hb 12.6 Ht 36 AL 5.6 AT 196 AE 4.06 PT 12.6 APTT 29.0 INR 0.910 GDS 99 Alb 4
 Kamis , 22 APRIL 2021 BEDAH DIGESTIVE SYA/DIP/FUD/MEI/MRS/NIS/ATA
5/3 CT Scan
Susp massa buli
Dilatasi CBD dsn ductus pancreatikus
20/2 USG Abdomen Cholelithiasis ( kronis proses )
Yusuf
IGD Konsevatif, Fleet enema /24
HCU Ag 2 D 01534791 33 Susp ileus obstuktif KU NG 18/4 hb 8,7 ht 25 al 23,2 at 205 ae 2.88 na 126 k 6,2 cal i 1.05
16/4 jam
MRS – DIP
Sri sulasmi Post Laparotomi parsial gastrectomy + pindah bangsal, diet cair
Poli Post op 16/4 hb 12.2 ht 37 al 16.8 at 470 ae 4.57 alb 3.2 na 127 k 3.5 cl 103
Anggrek 3 25 01534341 67 billrot II anastomose roux en Y ai Tumor IBB 6x50cc, aff ngt, aff dc, aff
13/4 16/4 15/4 hb 11.7 ht 36 al 13,5 at 504 ae 4,41 pt 13.7 aptt 30.5 inr 1.080
NIS – SYA gaster (antrhum ) T4N1M0 DPH 5 drain besok
Imam Mursid
Poli Adeno Ca Rekti post laparotomi + 15/4 Hb 9.9 Ht 28 AL 10.1 AT 374 AE 3.39
5A 01532758 51 KU IBB Pro kemo
13/4 colostomi 13/4 USG Hepatosplenomegali disertai nodul hepar metas,asites, simple cyst ren kiri
NIS – SYA
20/4 HB 10.1 HT 30 AL 6,4 AT 85 AE 3,19
14/4 Hb 10.5 Ht 31 AL 5.2 AT 73 AE 3.28
Sadinem
Poli Perbaikan KU CT Scan Abdomen:
2C 01493225 69 Adeno Ca Rektum on kemoterapi KU IBB
13/4 Kemoterapi Massa rectum yang menginfiltrasi uterus, dinding posterior buli, m levator ani, m
NIS – SYA
pubovaginalis, m obturator
Subpleural dan pneumonic type pulmonal metastasis
Sumastopo 20/4 hb 14.6 ht 43 al 10.9 at 295 ae 4.63 goldar A pt 12.2 aptt 28.6 inr 0.880 gds 83 sgot
Poli preparasi colon, diet cair,
4B 01504051 49 Fistel perianal post sigmoidostomy Pre op AR 17 sgpt 17 alb 3.4 cr 1.4 ur 29 na 135 k 3.7 cl 100 hbsag NR
19/4 mulai hari ini
NIS – SYA 31/3 hb 13,5 ht 39 al 13,6 at 360 ae 4,62 gds 90 cr 1,5 ur 36 hbsag NR
Post pemasangan stoma ai dehisensi
Rubiyem medikasi benton hipafix,
Flamboyan Co obgn subtotal sebagian total post laparatomy Post op 11/4 hb 13,4 ht 38 al 9,2 at 207 ae 4.53 pt 14.0 aptt 31.3 inr 1.100 gds 120 sgot 16 sgpt 8
6B 01530460 50 IBB plester dgn hipafix tepi
6 11/4 buka tutup h.7 ai ca ovari advance 16/4 alb 3.6 cr 0.8 ur 27 na 137 k 4.0 cl 114 hbsag NR hiv elisa NR
NIS – SYA stoma
stage DPH 5
17/4 Hb 10.2 Ht 30 AL 12.7 AT `143 AE 3.91
Pariyah diet cair, jika baik, besok
IGD Post hemicolectomi D ai tumor colon Post op 15/4 Hb 9.6 Ht 29 AL 11.5 AT 94 AE 3.64
7A 01533471 67 IBB BLPL, pertahankan drain
3/4 acenden extend transversum DPH 9 12/4 3/4 Hb 9.2 Ht 30 AL 15.3 AT 160 AE 4.01 Goldar B GDS 79 OT 43 PT 25 Ur 11 Alb 1.9 Cr
NIS – SYA bawa pulang sampai kontrol
0.7 HbsAg NR
poli
18/4 Hb 10.5 Ht 32 AL 6.6 At 440 AE 5.21 PT 13.2 APTT 24.5 GDS 94 SGOT 11 SGPT 11 Alb
3.9 Ur 20 Cr 0.8 Na 135 K 3.9 Cl 97
Tariyem 16/4 CT Scan Abdomen:
Poli Post laparatomy + TCD ai adeno ca Post op lanjut, jika baik besok usul
9A 01533105 53 IBB Massa rectosigmoid yang meluas ke jaringan perirectal dengan gambaran misty
rectosigmoid DPH 2 19/4 BLPL
NIS – SYA mesenteri serta subkutan regio perianal
Limfadenopati multiple paraaorta, parailliaca bilateral, mesenterium, presacral
13/4 10.6 Ht 36 AL 8.7 AT 596 AE 5.69 Ur 15 Cr 0.6 GDS 90 Alb 4.2 SGOT 18 SGPT 13
12B Paryadi 57 IGD Obs jaundice ec tumor preampula Pre op IBB Pre op jum’at 18/4 hb 13,5 ht 38 al 6,5 at 336 ae 4,22 pt 20,1 aptt 44,2 inr 1,710 gds 90 sgot 38 sgpt 36
01168893 18/4 vateri biltot 16,65 alb 3,1 cr 1,2 ur 1,4 na 134 k 2,7 cl 103 hbsag NR
NIS – SYA 17/4 MSCT ABD polos
Kesan
-Massa ampulla Vater kemungkinan sedikit meluas ke caput pancreas (ukuran I.k
1.86x1.4x1.88cm), mengakibatkan obstruksi, mendilatasi ductus pancreaticus, ductus
choledochus, ductus cysticus, ductus hepaticus comunis, serta ductus hepaticus dextra
et sinistra
-Hepatomegali
-Cholecystitis dengan akumulasi sludge
-Simple cyst pole superior (diameter 1.1cm) ren dextra
-Simple cyst pole superior (diameter 0.7cm) et inferior (diameter 1.1 dan 0.8cm) ren
sinistra -Tak tampak kelainan pada lien, vesica urinaria, prostat
-Tak tampak limfadenopati mesenterica, paraaorta, maupun parailiaca
 Kamis , 22 APRIL 2021 BEDAH DIGESTIVE SYA/DIP/FUD/MEI/MRS/NIS/ATA
-Spondylosis thoracolumbales
9/4 USG ABD
KESIMPULAN :
-Cholesistitis dengan akumulasi sludge (+)
-Borderline resistive index arteri hepatica masih mungkin awal fibrosis hepar -Simple
cyst pole superior ren dextra (ukuran 1.04cm) et sinistra (ukuran 0.9cm) -Tak tampak
kelainan pada Lien, Pancreas, vesica urinaria, maupun prostat
-Tak tampak limfadenopati paraaorta
17/4 Hb 10.5 Ht 33 AL 6.8 AT 160 AE 4.25 Alb 3.8
15/4 Hb 8.4 Ht 27 AL 4.7 AT 147 AE 3.63 Alb 3.5 Na 132 K 2.8 Ca 1.18
Sri Lestari Co Inf Nacl 0,9 % 20 tpm, inj
Flamboyan Post laparotomi biopsi ai tumor intra Post op 14/4 Hb 6.7 Ht 22 AL 9.2 AT 177 AE 3.38
4B 01534451 35 Interna IBB metamizol 1gr/8 jam, inj
8 abdomen susp lympoma dd GIST DPH 2 19/4 MSCT Abdomen:
NIS – SYA 14/4 ranitidin 50mg/12jam
Gambaran massa tumor soft tissue solid extra lumen gaster melekat hepar lobus sinistra
suspek limfoma dd GIST
Watik Co Post laparaskopy appendektomi + Inf Nacl 0,9 % 20 tpm, inj
Post op 17/4 hb 12,2 Ht 36 al 18.0 at 623 ae 4.30 pt 13.9 aptt 28.1 inr 1.090 gds 90 sgot 27 sgpt
10C 01534813 55 interna adhesiolisis ai Appendicitis kronis DPH NG metamizol 1gr/8 jam, inj
19/4 21 alb 3,6 cr 0.6 ur 10 na 134 k 2.7 ca 1.12 hbsag NR
NIS – SYA 17/4 2 ranitidin 50mg/12jam
Dwi yulianti Low intake, hipotensi, fistel inj. MP 125mg (extra),
IGD 18/4 15,7 ht 45 al 16,1 at 434 ae 5.30 goldar gds 156 alb 5.0 cr 1.9 ur 143 na 125 k 3.5 cl
2A 01510527 32 enterokutan moderate produk, AKI, KU IBB codein 3x10mg, cek ur,cr
18/4 90 hbsag NR
ATA - SYA Hiponatremi. besok
15/4 Hb 11.8 Ht 33 AL 15.2 AT 262 AE 3.89
Parto tego inj. MP 125mg (extra), 12/4 PT 11.3 APTT 30 INR 0.860 GDS 115 Ur 19 Alb 3.6 Cr 1.2 Ur 19 Na 136 K 3.0 Cl 106
Poli Post LAR + anastomose a/i adeno ca Post op
4B 01526666 71 IBB codein 3x10mg, cek ur,cr 16/2 Colonoskopi Massa rektosigmoid
11/4 rekti DPH 5 16/4
ATA - SYA besok 9/1/21 Colon in loop
Massa intra luminer Colon descendens
Miswan
Poli Tumor intraabdomen ec susp adeno ca Pro laparotomi reseksi 21/4 hb 10.8 ht 33 al 8,7 at 583 ae 4.98 pt 13,4 aptt 30,6 inr 1.040 gds 94 ur 21 alb 3.7 cr
Flamboyan 4C 01534687 57 Pre op IBB
20/4 colon tumor k/p stoma 0.8 na 129 k 4.5 cl 1.18
10 ATA - SYA
Ari widodo
Poli Trf PRC hingga hb >10, pro
5C 01511491 44 Adeno ca colon sigmoid + anemia KU IBB 20/4 hb 8,3 ht 27 al 16,1 at 869 ae 3.32
20/4 kemo 3 regiment
ATA - SYA
Nartini Snmc 1x1, inf pct 1gr/8jam,
Poli Adeno ca colon transversum
5D 011512781 55 KU IBB inf omz 40mg/12jam ivfd 19/4 sgot 163 sgpt 70 biltot 26.96 bildek 2.34 bilin 2,62
20/4 Peningkatan enzim transminase
ATA - SYA kabven 30tpm, curcuma 3x1
16/4 Hb 10.1 Ht 28 AL 16.6 AT 255 AE 3.40
15/4 Hb 9.4 Ht 26 AL 17.9 AT 332 AE 3.11 GDS 100 Bil tot 24.8 Bilirubin Direk 18.44 Bil
Indirek 6.36
CT Scan:
Puasa 5 hari, ivfd kabiven,
Sihitno Post laparotomi biliodigestai Obs Massa caput pancreas menyempitkan CBD
Poli Post op Inf Rl ; D5 ; Aminofluid, inj
6A 01531574 52 jaundice ec massa pancreas NG Multiple limfadenopati
15/4 20/4 ranitidin, metamizol,
ATA - SYA DPH 2 Hepatomegali
ampicilin, genta, metromods
20/2 MRCP :
Dilatasi ductus biliaris intra hepatal – ductus hepatikus komunis – ductus choledocus –
ductus pancreaticus ec massa tumor soft tissue semi solid extra hepatal menyatu dengan
struktur caput pankreas
Novita
IGD plan op Kamis, 22/4 raber 20/4 hb 13,6 ht 39 al 5,0 at 348 ae 4,50 pt 12.0 aptt 30.0 inr 0,920 goldar O gds 79 ur 16
14A 01442975 28 Hemoroid intrna grd 3 Pre op AR
20/4 interna alb 4,4 cr 0,7 ur 16 na 132 k 3,8 cl 111 hsag NR
ATA - SYA