KORAN BEDAH DIGESTIF

PALEM BAWAH

1 B2/7Damaris Bane06/04/1950723895

Dr.M. Ihwan Kusuma Sp.B-KBD

S: Keluhan tidak adaO: Abdomen distensi (-), peristaltik (-), abdomen supel, defans (-), tymphani, A: post operasi hari ke II laparotomi eksplorasi,Appendicyal tail syndrome

-cefepim 1gr/12jam/iv-ranitidin 50mg /8jam/iv-metronidazole 0,5gr/8jam/iv

Lab 29/8/2015RBC : 4,48WBC : 7,71HGB: 12,01PLT 355000Albumin : 2,4

2 B2/10Nurhadi Baso02/05/1953723864

Dr.M Ihwan Kusuma Sp.B-KBD

S: Nyeri perut kanan bawahO: KU baik, abdomen supel, peristaltik (+)A: periappendikular infiltrat & ileus obstruktif perawatan hari ke V

-Diet biasa-Awasi KU, TTV, tanda akut abdomen-RL 28 ttpm-Ciprofloxacin 0,2gr/12jam/iv-Ceftazidime 1gr/12jam/iv-Metronidazole 0,5gr/8jam/iv-Ranitidin 50mg/8jam/ivTunggu hasil CEA

Lab 27/08/2015-WBC : 18000-RBC : 3,78-HGB : 11,8-PLT : 245000

3 B2/7NY.SATINJA04/07/1963 (52 TAHUN)71860712/08/2015

Dr.dr. Ronald E. Lusikooy, Sp.B-KBD

PALEM ATAS1 B2/11/Bed 2

Alexander Banga24/04/1956708399

S: Keluhan tidak adaO:Composmentis, abdomen supel, peristaltik (+), produksi stoma (+)A: Adeno Carcinoma Sigmoid mucinosum diferensiasi sedang

-Awasi TTV-Diet lunak-rencana tutup kolostomi-tunggu jadwal operasi-spooling nacl 0,9% pagi dan sore

2 B2/8Farid M Tammaun31/12/1954721278

Dr.dr.Warsinggih Sp.B-KBD

S:Mata kuningO: Ku: baik, abdomen supel, peristaltik (+)A:Ikterus obstruktif e.c batu CBD

-Cefixime 200mg/12jam/oral-Vit K 1 amp/12jam/iv-rencana laparotomi eksplorasi CBD-tnggu jadwal operasi

3 B2/2 Bed 2Vender30/05/1968

Dr. M. Ikwan Kusuma, Sp.B-KBD

S: Keluhan tidak adaO: Ku: Baik, abdomen supel, peristaltik (+), hb: 11,0 post transfusiA: tetanus e.c susp perdarahan saluran cerna bagian atas dan bawah

-obat sesuai TS neuro dan GEH awasi TTV

Lab 27/08/2015WBC:7,32RBC:2,42HGB :11,0PLT: 204000HbsAg: ReactiveAlbumin:3,1

4 B2/7Nurlina15/08/1951708431

S: gelisahO:KU sedang, abdomen supel, peristaltik (+), stoma agak retraksi, produksi (+), urine 600cc/12jam, warna kuning, drain abdomen 100cc/24jam, drain rectal 20cc/24jamA: post operasi hari ke VII mile's procedure

- RL : KEN3B = 1500:500/24jam = 28ttpm-diet lunak-awasi ketat KU, TTV, tanda akut abdomen-imobilisasi-Rl 28ttpm-meropenem 1gr/8jam/iv-ketorolac 30mg/8jam/iv-paracetamol 1gr/8jam/ivOmeprazole 40mg/24jam/ivKaen3b 20 ttpm

GDS:163Na:152K:2,6Cl:120Ureum:49Cr: 0,88WBC:3800Hb: 10,4PLT: 140000

5 B1/6Hasan Basri23/02/1962461101

S: Nyeri perut kanan atasO:Ku baikA: cholelithiasis

-rencana echocardiografi-stop sementara ketorolac injeksiUsul : transfusi prc 1 bag

6 B2/6 B1Rafsanajani Datau06/08/1983722344

S: keluhan tidak adaO: Ku baik abdomen distended, ikut gerak napas, peristaltik (+)A: tumor mesenterium DD/ limfoma

-rencana laparotomi eksplorasi hari selasa 01/09/2015

WBC:10,0RBC:3,44HGB:9,2PLT 503000ALbumin 3,5SGOT : 57SGPT: 83

7 B2/1HJ. ROSLINI10/10/1964714600MRS : 17/08/2015

Dr. dr. Warsinggih, Sp.B-KBD

S : KELUHAN (-)O : KU : BAIKA : Post operasi hari ke IV pemasangan kateter tenkoff CAPD

-Diet biasa-Mobilisasi jalan-Ceftriaxone 750mg/12jam/iv-Asam mefenamat 500mg/8jam/iv

Lab 25/8/2015WBC :4,4RBC : 3,61HGB : 11,2PLT : 74000Ureum : 105Cr : 8,49

KORAN BEDAH DIGESTIF (SELASA, 01 SEPTEMBER 2015)

LONTARA 2 ATAS DEPAN1 ISO/Bed 1

Botting21-11-1950 (64 thn)718700DPJP: dr. Ibrahim

Carcinoma gaster POH 13 parsial gastrectomy Billroth II prosedur

Cefadroxil 500mg/8 jam/oralLanzoprazol 1 cap/12 jam/oralNeurodex 1 tab/12 jam/oralVIP albumin 2 caps/8 jam/oral

Edukasi:Rencana adjuvant kemoterapiUsul: berobat jalan control PoliGVAff hecting

PA:Adenocarcinoma gaster (differensiasi jelek)KGB dengan adanya sel tumor metastase

2 ISO/Bed 2Imran Dg Rate16-01-1971 (44 thn)711228DPJP: dr. Samuel

POH 0 ec choledocolithiasis

Hb: 11 gr/dlAPTT: 38,5 detik

CT scan abdomen:Cholelith dan choledocolith + Hepatosplenomegali + Efusi pleura bilateral

Foto thorax AP:TB paru aktif + Cardiomegaly dengan dilatatio aortae

3 K1/B1Sakman13-04-1990 (25 thn)723266DPJP: dr. Ikhwan

POH 8 Laparotomi + Splenectomy

Eritromycin 500mg/8 jam/oralAs.mefenamat 500mg/8 jam/oralRanitidin 150mg/8 jam/oral

Boleh pulangRawat jalan

Hb: 10,3 gr/dlPLT: 476.000/uL

4 K1/B2Hasriandi30-08-1987 (27 thn)722606DPJP: dr. Ikhwan

POH 14 laparotomi + repair laserasi hepar grade III pada segmen III + Colostomi ec perforasi colon transversum

Aff drain abdomen kiri dan kanan

Cefadroxil 500mg/8 jam/oralParacetamol 500mg/8 jam/oralMetronidazole 500mg/8 jam/oral

Rawat stoma colostomiDiet makan dan minum bebas

5 K1/B3Sahabu01-07-1986 (29 thn)715908DPJP: dr. Ibrahim

Abses regio flank dextra + Carcinoma colon ascendens

Drainase abses flank dextra Senin 31-08-2015

Ciprofloxacin 0,2gram/8 jam/IVPeriksa DR control post transfusi

Hb: 8,5 gr/dLNa: 128Albumin: 2,4 mg/dL

PA biopsy LGIE:Adenocarcinoma

6 K1/B4Budiman01-07-1969 (46 thn)723972DPJP: dr. Ronald

Tumor abdomen DD/ seminoma testis

IVFD Ringer Laktat 20 tpmCefazoline 1gram/12 jam/IVRanitidin 50mg/8 jam/IV

Ambil hasil CT scan abdomen – panggulPeriksa HCG, AFP

Tunggu hasil CT scan abdomen - panggul

WBC: 11.560/uLHb: 9,9 gr/dL

USG Abdomen:Kista heparTumor intraabdomen pada regio suprapubikFree fluid intraabdomen

7 K2/B1Darmawati27-03-1978 (37 thn)293841DPJP: dr. Samuel

POH 3 biopsi rectum Aff infus

Cefixime 200mg/12 jam/oralNa diklofenak 50mg/12 jam/oralNeurodex 1 tab/12 jam/oral

Usul: Rawat jalan praktek dr.

LGIE:Hemorroid eksternaHemorroid interna grade IPolip sesile rekti

PA:Adenocarcinoma recti

Samuel, Sp.B-KBD differensiasi baik

Foto thorax PA:TB paru sinistra lama suspek aktifTidak tampak tanda-tanda metastasis

8 K2/B2Paikaros31-12-1968 (46 thn)722945DPJP: dr. Ibrahim

Infected woundPost operasi pengangkatan kista kandungan di Mamuju

Levofloxacin 500mg/12 jam/oralRanitidin 50mg/8 jam/oralMetronidazole 500mg/8 jam/oralNeurodex 1 tab/12 jam/oralVIP albumin 2 caps/8 jam/oral

Rawat luka: GV/2 hari

Tunggu hasilLab kultur dan tes sensitivitas

Hb: 9,2 gr/dLWBC: 16.300/uLPLT: 445.000/uL

9 K2/B4Sulfiah Suardi15-01-1991 (24 thn)724009DPJP: dr. Ibrahim

Trauma tumpul abdomen (Hematom subcapsuler lien)

IVFD Ringer Laktat 20 tpmCefazolin 1gram/12 jamm/IVMetronidazole 0,5gram/8 jam/IVRanitidin 50mg/8 jam/IV

Tirah baring absolutObservasi tanda-tanda acute abdomen

USG Abdomen:Cairan bebas intraperitoneum suspek hematoma

CT scan Abdomen:Cairan bebas intraperitoneum

Hb: 10,1 gr/dL10 K3/B1

Saharuddin15-12-1970 (45 thn)669592DPJP: dr. Ronald

POH 4 laparotomi eksplorasi + Debulking tumor

IVFD RL:D5% = 2:1Cefiixime 1gram/12 jam/IVMetronidazole 0,5gram/8 jam/IVRanitidin 50mg/8 jam/IVKetorolac 30mg/8 jam/IV

GV hari ini

11 K3/B2Abdullah06-01-1974 (41 thn)723380DPJP: dr. Ibrahim

Tumor caecum dan colon ascendens suspek malignancy

Periksa lab CEA, SGOT, SGPT, Albumin, Elektrolit, GDS, HBsAg (Senin pagi)

Usul: Colonoscopy + LGIE

IVFD NaCl 0,9% 28 tpmRanitidin 50mg/12 jam/IVTramadol 50mg dalam 10cc aquadest/8 jam/IV pelan

Lengkapi pemeriksaan

12 K3/B3Syafaruddin25-12-1959 (55 thn)720836DPJP: dr. Warsinggih

POH 12 laparotomi + bypass jejeno-colon transversum ec tumor caecum perlengketan ke sekitarnya

Periksa IHC CD 20

Cefadroxil 500mg/8 jam/oralRanitidin 150mg/12 jam/oralNeurodex 1 tab/12 jam/oralVIP albumin 2 caps/8 jam/oral

PA:Angioimunoblastic lymphoma

LGIE:Hemorroid interna grade IPolip sesile kolon transversumTumor saekum

CT scan abdomen:Suspek massa caecumLymphadenopathy

paraaorta abdominalisAscites dan efusi pleura bilateralNephrolith kanan

Hb: 9,7 gr/dLWBC: 11.100/uL

13 K3/B4

14 K10/B1

15 K10/B2Hasnawati31-12-1966 (48 thn)723732DPJP: dr. Samuel

POH 4 Laparotomi eksplorasi + colostomy sigmoid ec tumor recti 1/3 tengah

IVFD RL:D5% 1000:1000Cefepime 1gr/12 jam/IVMetronidazole 0,5 g/8 jam/IVRanitidin 50 mg/8 jam/IVAnalgetik dari TS. APS

16 K10/B3Maneng20-2-1973 (42 thn)721643DPJP: dr. Warsinggih

POH laparotomi explorasi tutup colostomi

IVFD RL : D5%Ceftriaxone 1gr/12 jam/IVMetronidazole 0,5 gr/8 jam/IVRanitidin 50 mg/8 jam/IV

Analgentick dari T.S APS17 K10/B4

Ibakaria01-12-1956 (59 thn)681402DPJP: dr. Ibrahim

POH IV tutup colostomi

Terapi analgetik sesuai APSIVFD RL : D5%Cefepime 1gr/12 jam/IVMetronidazole 0,5g/8 jam/IVRanitidin 50 mg/8 jam/IV

18 K10/B5Tuminem10-5-1965 (50 thn)724099DPJP:

Post laparotomi + post colostomy ec. peritonitis generalisata + wound dehesens + defracted stoma

R/ Lapor trainee digestif dr. Winata,Sp.BAdvis=-Transfusi PRC 2 bag-Koreksi Albumin=(3,5-2,4)x0,8x60 25=2,112

-Infus Ringer Laktat 28 tpm-Cefatoline 1gr/12 jam/IV-Ketorolac 30mg/8 jam/IV-Ranitidin 50mg/8 jam/IV-Metronidazole 500mg/12 jam/IV

Boleh pindah perawatan.19 K10/B6

Rahmatia15-08-1963 (52 thn)724031DPJP: dr. Ibrahim

Periappendikuler infiltrat

RL : D5%Cefepime 1gr/12 jam/IVMetronidazole 0,5 gr/8 jam/IVRanitidin 50 mg/8 jam/IV Advice dr. Laode, Sp. BBoleh pindah ke R. perawatanDiet Lunak

20 K11/B1Firdaus05-05-1983 (32thn)379320DPJP: dr. Warsinggih

POH 20 laparotomi eksplorasi ec perforasi gaster + Hernia incisional

IVFD NaCl : D5% 1000:1000Cefepime 1gr/12 jam/IVVIP Albumin oral

26/8/2015RBC : 3,70Hb: 9,4PLT: 437.000Albumin: 2,7Na: 131

21 K11/B2La Ode Ishak01-02-1993 (22 thn)717469

Adenocarcinoma colon pro kemo II

IVFD RL:D5% 1000:1000Cefepime 1gr/12 jam/IVMetronidazole 0,5 gr/8 jam/IV(STOP)

DPJP: dr. Samuel Ranitidin 50 mg/8 jam/IV (STOP)Ketorolac 30mg/8 jam/IV

-Premedikasi* Dexamethason 2amp/IV* Dipenhidramin 2amp/IV*Ranitidin 2amp/IV*Ondansentron 2amp/IVTunggu 30 menit-Masukkan oxaloplatin 200 mg dalam Dextrose 200cc-Bilas dengan NaCl 0,9% 200 cc-ganti RL maintanance

22 K11/B3Supu Arang01-07-1950 (65 thn)639711DPJP: dr. Samuel

Adenocarcinoma 1/3 rectal

Instruksi kemoterapi:Pasang IV line NaCl 0.9% guyur 100 ccPremedikasi-ondansentron 1 ampul/IV-Ranitidin 1 ampul/IV-Dexamethason 1 ampul/IVDelladryl 2cc/intramuscularEloxatin dalam 300 cc dextrose 5% habis dalam 2 jam-guyur 100 cc NaCl 0,9% lanbuton maintanance 28 tetes/menit

Injeksi-Ondansentron 1amp/IV-Ranitidin 1amp/IV-Dexamethason 1amp/IV

Lab Lengkap 28/8/2015WBC: 12,7 PLT: 99.000RBC: 3,37 Albumin: 2,5Hb: 10.0 Na: 124HCT: 31 Cl:94

Urinalisa 28/8/2015Blood +++/200Lekosit +++/500Sedimen Lekosit: 50Sedimen Eritrosit : 50

23 K11/B4Sanja21-08-1964 (51 thn)723307DPJP: dr. Ronald

Ileus Obstruktif partial IVFD RL : D5% 1000:1000Cefepime 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IV

Foto polos Abdomen& BNO 3 posisi-small bowel obstruction

24 K11/B5Sahar Dg Ngemba05-01-1979 (36 thn)715045DPJP: dr. Warsinggih

Adenocarcinoma Colon pro Kemoterapi siklus III

IVFD NaCl 28 tpmCek DL-Lanjut Kemoterapi-Premedikasi* Dexamethason 2amp/IV* Dipenhidramin 2amp/IV*Ranitidin 2amp/IV*Ondansentron 2amp/IVTunggu 30 menit-Masukkan oxaloplatin 200 mg dalam Dextrose 200cc-Bilas dengan NaCl 0,9% 200 cc-ganti RL maintanance-Observasi tanda vital

26/8/2015WBC: 15.000

27Usman31-12-1952721709

D/ Tumor Recti 1/3 Distal

- tunggu hasil PA tanggal 4/9/2015

30 AD K3/B2DRS. Herman8/1/1954723272

Cholelitiasis - Tunggu jadwal - Laparoscopy cholesistectomy- Terapi lain sesuai TS Interna

KORAN BEDAH DIGESTIF Selasa 1-9-2015

LONTARA 1 BAWAH DEPAN- - - - - -

LONTARA 1 BAWAH BELAKANG1 K4/III/B5

Yustina1-3-1971721694

Tumor Gastroduodenal - tunggu hasil Lab- terapi lain sesuai TS Interna

UGIE : GERD Grade B, Massa Extraluminer

2Hamdani20-5-1977720 603

Hepatoceluler Carcinoma - Rencana biopsi- tunggu jadwal

AFP > 400

3Usman31-12-1952721709

D/ Tumor Recti 1/3 Distal - tunggu hasil PA tanggal 4/9/2015

LONTARA 1 ATAS DEPAN1. AD K1/B4

Hasfianty19/11/1992721382

Choledococyst type IV - Rencana Operasi, tunggu jadwal- Optimalisasi KU- Injeksi Vit K 1 amp/24jam/im

2. AD Lamahata31/12/1960722969

Tumor Gaster Suspek Malignancy

- Rencana UGIE- OMD- Diet Lunak- Optimalisasi KU- Terapi lain sesuai TS Interna

3. ADDRS. Herman8/1/1954723272

Cholelitiasis - Tunggu jadwal - Laparoscopy cholesistectomy- Terapi lain sesuai TS Interna

LONTARA 1 ATAS BELAKANG1.

M. Zudi7-5-1983721683

D/ POH 10 Laparatomi eksplorasi CBD

- IVFD RL:D5 1:1 28 tpm-Ceftriaxon 1gr/24jam/iv- Ketorolac (KP)- Aff Drain- Rawat Jalan

DR.dr.Warsinggih, Sp.B, KBD

2.Nurdin Panna2-5-1962668603

D/ POH 3 Laparatomi Eksplorasi ec

- IVFD RL:D5:Aminofusin 500:500:1000 28 tpm- Cefazidime-Metronidazole- Ranitidin- Analgetik sesuai TS Anestesi- Bahan Cairan- Sementara Puasa- Cek ulang DR

LONTARA 2 BAWAH DEPAN

LONTARA 2 BAWAH BELAKANG1

SaharuddinPOH 3 Laparotomi Eksplorasi

- IFVD RL;D5 2:1 28tpm- ceftazidime -metronidazole- ranitidin

dr. Samuel Sampetoding Sp.B-KBD

-ketorolac 1 amp/ 8jam Drips Exstra (KP)

LONTARA 2 ATAS BELAKANG1.

Nurdin Panna2-5-1962668603

D/ POH 3 Laparatomi Eksplorasi ec

- IVFD RL:D5:Aminofusin 500:500:1000 28 tpm- Cefazidime-Metronidazole- Ranitidin- Analgetik sesuai TS Anestesi- Bahan Cairan- Sementara Puasa- Cek ulang DR

LONTARA 3 ATAS BELAKANG1

Muliana31-12-1973722923

Tumor Abdomen - IVFD RL:D5 28tpm- Ceftazidime - ketorolac-Konsul

-cek lab ft4,TSH, FNA2

Marwing10/12/1972723613

Hemmoroid Grade III -Fleet Enema (8sore 5 pagi)-Fleet Fosfoda jam 8 malam- operasi senin 31/8/2015 jam 08.00

LONTARA 3 ATAS DEPAN1. K2 B5

Kasmiati 19 thn

D/ trauma tumpul abdomen IVFD RL 28 tpmCeftriaxone 1 gr/12jam/ivRanitidine 1 amp/8jam/ivKetorolac (KP)Diet lunakAwasitanda vital abdomen

Dr. ikhwan

2 K2 B5Darmawati

Ca Recti Dr. SamualSampetoding, SP. B-KBD

LONTARA 3 BAWAH BELAKANG- - - - - -

LONTARA 4 BAWAH DEPAN- - - - -

PCC1 PCC 402

Hj. Jumanang31-12-1960721152

D/Tumor Jejenum post op Post op reseksi anatomosis hari VI

RL:Clinimix:D5 500:1000:500-Meropenem 1gr/8jam/iv-Ketorolac 30mg/8jam/ IV- Ranitidin 50mg/8jam/ivKonsul GiziDiet cairUsul: analisa cairan pleura dan luka post op

2 PCC 407Baso Ahmad8/4/1992722999

D/POH 5 Laparatomy Eksplorasi CBD

RL 28 tpm-Meropenem 1gr/8ja/iv-Ketorolac 30mg/8jam/iv-ranitidin 50mg/8jam/iv-Metronidazole 500mg/12jam/ivMobilisasi jalanGV/2hari

3. PCC 330 Choledocolothiasis Rencana Operasi hari Dr. Ronald

Ny Retno selasa Lusikooy, SpB-KBD

4. PCC 213Ny. Adiba Arif58 th

Cholelithiasis Tunggu jadwal operasi dr. Ibrahim Labeda SpB-KBD

ICU/HCU1. B4

Bintang (64thn)72375419-11-1950

POH 3 Laparatomy Eksplorasi et causa perforasi gaster

IVFD RL:D51000: 1000 Meropenem OmeprazoleMetronidazoleAsam TraneksamatTakar Drain 24 jamBalance cairanPindah Perawatan

2. B7Wawan19-8-1965722203

D/ POH VI laparotomy reseksi Gastrectomy Total esopagostomyAnastomosis colon to gasterAnastomosis colon to esofagus

IVFD RL : D5% :Clinimix 500 : 500 : 1000 = 2000cc/24jam Meropenem 1 gr/8jam/ivOmeprazole 40 mg/12jam/ivMetronidazole 0,5/8jam/ivAnalgesik TS anestesiPuasa total GV/3 hariTakar drain per hariBalance cairan