REKAP PASIEN BEDAH DIGESTIVE

Minggu, 13 November 2016

Nama dokter muda:
Total: 29 Pasien

Dini Masturina (Chief) (081360882136)

Herma Vania
(085260628485)
Maya Safira
(085270718826)
Huzaipi Pratama
(085361912681)
Dara Soraya
(082366705302)
Zatul Fina
(085261661177)
Thariq Mubarak
(081360644560)
NO

KAMAR

IDENTITAS

DIAGNOSA

TERAPI

LAB

PLANNING

JEUMPA 1 = 1 Pasien
1.

K5B2

Jaka Adi Keusuma

Lk/ 31th/ 1107053
POD XV

Post Laparotomy eksplorasi +debridement

cavum abdomen + adhesiolisis + end stoma
sigmoid a.i general peritonitis e.c perforasi
colon sigmoid

Diet ML
IVFD futrolit 30 gtt/i
Drip Lipofudin 1 fls/ hari
Drip aminofluid 1 fls/ hari
Drip PCT 1 gr/ 8 jam
Inj metoclopramide 1 amp/ 8 jam
Inj omeprazole 40 mg/ 12 jam
Inj bisolvon 1 amp/ 8 jam

8/11/2016
Hb/ L/ Tromb
10,8/28,6/419
Na/ K/ Cl/ Ur/ Cr
137/4,8/101/21/0,75
SGOT/SGPT/Albumin
49/54/3,36

Rawat luka
Rencana OP Secondary hecting
Senin (14/11/16)

Susp. Cholilithiasis + nefrolithiasis dextra

IVFD RL 20 gtt/i
Inj. Cebactam i vial/12 jam
Inj. Ranitidin 1 amp/ 8 jam
Inj. Ondacentron 1 amp/8 jam
Drip PCT 1 gr/8 jam
Diet ML

9/11/2016
SGOT/SGPT
404/309
Na/K/Cl
124/3,4/74
Ur/Cr
24/6,74
8/11/2016
Hb/ L/ Tromb
15/40,2/378
Bil. Tot/bi. Direct
0,48/0,39
SGOT/SGPT
404/309
Ur/cr
204/6,74

MRCP 15/11/2016
Tutup NGT, jika kembung buka

JEUMPA 2 = 1 pasien
1.

K6B6

Ti Hawa
61 thn/1108455

JEUMPA 4 = 14 Pasien
1.

K2B1

Rita Mutia
38thn/ 0879770

Ca recti 1/3 distal post kemoterapi + anemia

+ hipoalbumin

IFVD futrolit 20 gtt/i

Drip PCT 1 gr/ 12 jam
Drip albumin 20% 100 cc/ hari

2.

K3B1

Dahlia
52thn/ 0879765
POD V

Status Ileostomy

IVFD Futrolit 20 gtt/i

Diet susu

3.

K3B2

Neti Ismail Gading

40thn/ 1105916
POD XXIV

Post relaparotomi eksplorasi + Debridement

intestinal e.c perforasi ileus + HAP + wound
dehiscence

IVFD futrolit 20 gtt/i

Drip lipofudin 1 fls/ hari
Drip Aminofluid 1 fls/ hari
Drip PCT 1gr/ 12 jam
Inj amikasin 1 vial/ 12 jam
Inj omeprazole 40mg/ 12 jam
Inj bisolvon 1 amp/ 8 jam
Diet TKTP

4.

K3B4

Syafii D
48thn/ 1108590

Kolesistitis + Kolelitiasis

IVFD RL 20 gtt/i
Drip Tramadol amp/ 12 jam
Inj. Ketorolac 3% amp/ 8 jam
Inj. Ranitidin amp/ 12 jam
Inj. Cabactam 1g/ 12 jam

5.

K4B3

Hanafiah Ismail

Obstruksi jaundice ec tumor pankreas

IVFD Futrolit 20gtt/i

Inj ranitidin 1 amp/12
Inj. Vit K

6.

K4B4

Banta Mustajab
25 thn/ 1095462

Status ileostomy+ anemia

IVFD Futrolit 20gtt/i

Inj ranitidin 1 amp/12 jam
Sohobion tab 2x1
Diet 6x100 cc

3/11/2016
Hb/ L/ trom/ ct/ bt
6,3/ 7,5/ 369/ 9/ 3
Prot tot/ alb/ glb
5,0/ 2,00/ 3,00
Na/ K/ cl/ ur/ cr
141/ 3,4/ 109/ 160/ 24/ 0,60
28/10/2016
Hb/L/Trom
11,9/8,2/263
SGOT/SGPT
134/88
Na/K/Cl
142/5,0/102
Ur/Cr
23/0,7
3/11/2016
Na/ K/ Cl
131/ 4,4/ 93
29/10/16
Hb/L/Trom/Alb
11,0/ 16,8/ 942/ 3,10
Ur/Cr
14/ 0,20

Susul hasil CT scan

(11/11/2016)
Konsul Gigi dan Mulut (+)
Miles prosedure

10/11/2016
Hb/L/Trom
14,5/10,2/180
Na/K/Cl
139/4,1/103
Bil.tot/Bil.direct
0,60/92
SGOT/SGPT
92/71

Cholesystomy electif

Ileustomy Closure (11/11/2016)

Aff drain 14/11/206
Mobilisasi duduk

Rawat Luka Gentamisin

Mobilisasi
Konsul Rm (+)

Laparotomy eksplorasi + bypass

billiodigestif+biopsy (14/11/16)

5/11/2016
Hb/ L/ Tromb
8,2/17,1/629
Na/K/Cl/Albumin/Ur/Cr

Transfusi PRC III Kolf sampai

Hb 10 g/dL
Penjadwalan closure
Mobilisasi

132/3,6/96/3/22/0,40
7.

K5B1

Usman Abdullah

Hernia Bilateral

IVFD Futrolit 30gtt/i

Inj fosmidex 2 gr/ 24 jam
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

8.

K6B3

Hasanah
52 thn/ 1049254

Status colostomy ec ca colon rectosigmoid +

Hepatitis

IVFD Futrolit 20gtt/i

Inj fosmicyn 2 gr/ 12 jam
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

9.

K6B4

Kamaliah Bahar
Pr/66 th/ 1105645

Tumor Antrum gaster

Post laparotomy adhesiolisis
Reseksi tumor antrum dengan stepler
Anastomosis gastro yeyunustomi dengan
stepler
Anastomosis yeyunos yeyunostomi

NGT dekompresi
Clear water
IVFD futrolit : asering 20 gtt/i
Inj fosmisin 2 gr/ 12 jam
Inj ranitidine 1 amp/ 12 jam
Inj ketorolac 1 amp/ 8 jam
Drip aminofluid 1 fls/ hari
Drip lipofudin 1 fls/ hari
Duragesic patch 12,5 mg
Albumin 20% 200cc/ hari
Diet Susu 10 gtt/

POD XI

Herniotomy+
(14/11/2016)

mess

graft

5/11/2016
Hb/L/Trom/Ct/Bt
5,2/10,8/472/7/2
Na/K/Cl/GDS
142/2,9/108/122
5/11/2016
Hb/ L/ tromb/ Allb
8,1/ 10,6/ 244/ 2,5
Na/ K/ Cl
145/ 3,1/ 106

Ct Scan Abdomen kontras dan

non kontras 15/11/16

Evaluasi drain 1 dan 2/ hari

Rawat dan pantau ileustomy dan
produksi/hari
Mobilisasi duduk
Buka 2 jahitan

10.

K6B5

Fitriana
31 thn/1102221

Post abdominal perineal resection (miles

procedure) + total colectomy + ileustomy+
Biopsi KGB a.i Ca recti 1/3 distal

IVFD futrolit s/s asering 1500 cc/24 jam

Inj. Ketorolav 1 amp/8 jam
Inj fosmisin 2 gr/ 12jam
Inj ranitidin 1 amp/12 jam

8/11/2016
Hb/ L/ Tromb
10,8/12,5/545
Na/K/Cl
125/3,0/93

11.

K7B4

Zulfan M. Amin
35thn/ 1107796
POD IX

Peritonitis ec rupture hepar segmen VI & VII

Post LE
Post primary hecting hepar
Post drainage

IVFD Futrolit 30gtt/i

Inj fosmidex 2 gr/ 24 jam
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

7/11/2016
Na/K/Cl/Ca/Mg
136/3,9/103/7,6/1,2
3/11/2016
Hb/ L/ Tromb/ PT/ APTT/ D-dimer
9,1/ 13,2/ 55/ 13,4/ 45,7/ 2404,60
HBsAg = negative
Bil tot/ bil dir/ SGOT
0,41/ 0,47/ 1169
Na/ K/ Cl/ Ca/ Mg
140/ 3,7/ 106/ 7,8/ 1,6

Aff drain kiri (+)

14/11/16 aff drain kanan
Mobilisasi duduk

12.

K7B2

Ponijan
56thn/ 1107329
AD XIV

Adenocarcinoma duodenum

Diet MB TKTP
IVFD futrolit 20 gtt/i
Inj fosmisin 2 gr/ 12jam
Inj ranitidine 1 amp/ 12jam
Drip PCT 1 gr/ 8jam
Vit K/ 8 jam
IVFD lipofudin/ 12 jam
Drip aminofluid 1 fls/ 12jam
Drip albumin 1 fls 25% 100cc/ hari
IVFD futrolit 20 gtt/i
Inj fosmisin 2 gr/ 12jam
Drip tramadol amp/12 jam
Diet Ginjal

8/11/2016
Hb/ L/ Tromb
7/ 15,7/ 262
Prot tot/ alb/ glb
4,42/ 2,62/ 1,6
Na/ K/ Cl
130/ 3,6/ 102

Transfusi PRC 2 kolf/ hari

Transfuse FFP 2 kolf/ hari
Konsul anestesi
Wippley procedure

13.

K7B3

Zulkifli Miga
47 thn/ 1092786
AD IV

Ca recti 1/3 distal

8/11/2016
Hb/ L/ Tromb
10,2/12,3/393
Na/K/CL
138/3,4/99
Ur/Cr
55/3,47

Konsul kardio dan Echo

persiapan kemoterapi (+)
Konsul nefrologi
Susul hasil USG 14//11/16

14.

ISO2

Haslia aida
53 thn

cholelithiasis

IVFD futrolit 20 gtt/

Diman
41 thm/1108711

Ileus obstruktif ec appencical mass

IVFT Futrolit 20 gtt/i

Inj. Ketolrolac 3% amp/ 8 jam
Inj. ranitidin amp/12 jam
Inj. Fosmidex 2 gr/ 12 jam
Drip PCT 1 gr /12 jam
Diet cair 6x100 cc

11/11/2016
Hb/ L/ trom/ Alb
11,7/11,8/311
Na/ K/ Cl/ Ur/ Cr
131/3,8/95/42/0,50

Aff NGT(+)
Ct Scan

IR Marzuki

Obstruksi Jaundice ec choledocolithiasis +

Hipolabuminemia

Sesuai TS IPD
Drip PCT 1 gr/ 12 jam

11/11/2016
Hb/ L/ trom/ Alb
9,3/9,7/249
Na/ K/ Cl/ Ur/ Cr
127/3,3/89/9,1
Bil. Tot/ Bil. Direct/ SGOT/SGPT
11,39/10,21/44/36

Konsul paru (+)

Said razali
876170
POD VII

Post debridement a.i abses perineal + Abses

scrotum + post insisi drainage

Sesuai TS IPD

9/11/2016
Na/K/Cl/Albm
141/5,5/107/2,84

Rawat luka

Cholsistectomy perlaparoskopi
persiapan open (14/11/16)

PJT = 1 pasien
1.

K6B4

ISOLASI = 1 pasien
1.

K7

MAMPLAM 1 = 2 pasien
1.

K3B4

Ur/Cr
84/1,05
7/11/2016
Hb/ L/ trom/ Alb
12,8/12,2/445
Procalsitonin/Ur/Cr
4,10/98/1,50
3/11/2016
Hb/ L/ Tromb
5,9/ 8,1/ 293
Na/ K/ Cl/ GDS/ Ur/ Cr
133/ 4,2/ 102/ 161/ 73/ 1,40
Alb/ kol tot/ HDL/ LDL/ Tri
95/ 15/ 41/ 116
2.

K4B1

Hamka
64 thn/1091580

Obstruksi Jaundice ec dd/1. Ca caput

pankreas, 2. Ca ampula recti

Sesuai TS IPD

Konsul BTKV
Konsul Kardio
Konsul Anastesi
Rencana By pass

Laila

Obstruksi Jaundice ec dd/1. Ca caput

pankreas, 2. Ca ampula recti

Sesuai TS IPD

Daftar MRCP 14/11/2016

Halimah Insya
65 thn/ 1104530

Relaparotomi + adhesiolisi + repair gaster

dengan omental plug + tube jejunostomi ec
difuse peritonitis ec leakage gaster post LE
+ adhesis berat

IVFD futrolit 20 gtt/i

Aminofluid fls/ hari
Lipofudin fls/ hari
Amycasin 100 mg/ hari
Omeprazole 40 mg/ 8 jam
Ranitidine 50 mg/ 12 jam
Drip albumin 20%/ hari
Diet 6x200 susu

4/11/2016
Hb/ L/ tromb/ PT/ APTT/ D-dimer
13,3/ 31,1/ 218/ 11,5/ 40,1/ 296,75
SGOT/ SGPT
13/ 7
Na/ K/ Cl/ Ca/ Mg/ Ur/ Cr
135/ 4,5/ 96/ 8,8/ 1,9/ 15/ 0,35

Hafri Melisa Anwar

26 thn/1108799

Post LE+ appendectomy+aadhesiolisis ec

KET rectosigmoid + appendisitis + adhesis

IVFD Futrolit 20gtt/i

Inj, fosmidex 2 gr/12 jam
Inj Omeprazole 40 mg/12 jam
Drip paracetamol 1 gr/12 jam
Duragesic patch 12,5 meg/ hari
Diet cair 4x50 cc

12/11/2016
Hb/ L/ tromb/ PT/ APTT/ D-dimer
10,3/13,7/155/12,1/32,2/10000
Na/ K/ Cl/ Ca/ Mg/ Ur/ Cr
139/4,2/105/7,9/1,5/14/0,38

Mamplam 2 = 1 pasien
1.

K5B5

ICU Dewasa =1 pasien

1.

ISO 2

Seurunee 3= 1 pasien

1.

K6B6b

Mobilisasi

IW 1 = 2 pasien
1.

B4

Nurmi
66 thn/1108718

Susp. Hemangioma Liver

IVFD Futrolit 20gtt/i

Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

11/11/2016
Hb/L/Trom
9/13,7/294
SGOT/SGPT/Albm
54/77/3,1
Na/K/Cl
142/3,5/99

Daftar Ct Csan abdomen kontras

& non kontras 14/11/206
Transfusi 1 kolf

2.

ISO1

Salmawati A Majid
48 thn/1108809

Appendisitis akut
Post appendectomy

IVFD Futrolit 20gtt/i

Inj fosfomisin 2 gr/24 jam
Drip PCT 1 gr/12 jam
Inj ranitidine/ 12 jam
Diet MB

11/11/2016
Hb/L/Trom
14,5/15,9/284
Na/K/Cl/Ur/Cr
141/3,3/19/0,70

Awasi tanda akut Abdomen

Aff catete (+)
Rencana 4/11/16 PBJ

Abdominal pain ec colic abdomen

IVFD RL 20gtt/i
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

POD I
IGD = 1 pasien

1.

Murdani
21 thn/108782