PETA BEDAH DIGESTIVE

Sabtu, 20 Desember 2014

YKT/WAN/AFO/NRM/EKP/KAP/MID/WHY/ISH/HRE/AIP/ARV/AHS/DLI

BGS

Mwr 1

Mwr 2

Mwr 3

Mel 1

KM

NAMA

U
S
IA

RM

MRS

DIAGNOSA

STS

Tgl
OP

SEN
I-OR

Post laparotomy eksplorasi +

ileostomyAdeno Ca Rekti

Post
OP

3/12

IBB

1E

Astuti

39

0127617
5

22/11

3D

Sarni

58

0122757
0

Konsulan
interna

4E

Nn.Siska Maria

20

0127301
0

25/9

4H

Katirah

56

0127222
8

16/12

15/12

Melanoma maligna recti

Ikterik obstruktif e.c batu

CBD + hepatomegali

63

4B

Dwi Utomo

32

0128318
5

18/12

Fistel Enterocutan High

Output + Ileus Parsial

4H

Leni Marlena

34

0127697
9

19/12

Adeno Ca Colon Ascenden

8C

Ahmad Amir

55

0128090
7

12/12

Post Laparotomy Eksplorasi

+ sigmoidostomy ai Adeno
Ca recti

8E

Sugiman

61

0128203
2

19/12

HIL Reponibel (D)

Pre op

8G

Sumarno

65

0128067
8

19/12

HIL Reponibel (D) + TB Paru

aktif + HbsAg (+)

Pre op

1A

Sumarji

50

0127676
1

15/12

Tumor intra abdomen susp.

Limfoma post laparotomi
biopsi

Post
op

2B

Warinem

63

0121344
2

16/12

6A

Wajib

51

0110329
2

17/12

BPJS

(14/12) Hb 9.5 ht 29 AL 15.0 Tr 648 Er 3.41 Alb

2.6 ur 55 cr 0.5
(06/11) Alb 3.5 Na 139 K 4.3 CA 1.01
(04/11) CEA 8.11

BPJS

(10/12) Hb 7.2 Ht 23 L 7.4 Tr 364 Na 127 K 3.5 Alb

2.6

AR

Diet cair, rawatluka

dengan Prontosan cair
dan Gel

BPJS

(28/11) alb 3.5 Cr 0.5 Ur 55 Na 133 K 3.4 Cl 99Hb

12,1 AL (12,3) AT 575 GDS 94 prot 7,5 alb 4 glob
3,5 Cr 0,3 Ureum 60 Na 118 K 3,2 Cl 82

AR

Laparotomy + eksplorasi
CBD

BPJS

(2/12) Hb10.2 ht 32 L 17.5 tr 638 sgot 126 sgpt

33 bil tot 17.3 bil dir 13.86 alb 3.4 cr 1.1 ur 24
(18/12) Hb 7,9 AL 8.2 AT 394 Ur 41 Cr 0.7 GDS
104 Na 137 K 3,8 Cl 107 HbsAg (-)
Colon in loop (12/11) massa rectum
PA 28 juni lesi neoplasma maligna lymphoma B
cell.
(18/12) Hb 11,7 AL 5,1 AT 3,7 PT 15,7 APTT 20,5
INR 1.330 GDS 91 Alb 2,9 Cr 0,8 Ur 39 Na 133 K
3,9 Cl 103 HbsAg (-)
(3/12) Hb 9,3 AL 7,2 AT 450 PT 13,4 APTT 27,5
INR 1.040 GDS 96 OT/PT 28/5 Cr 0,7 Ur 15 HbsAg
(-)

BPJS

AR

Pro Laparotomi

BPJS

IBB

Pro Laparotomi
Eksplorasi

BPJS

IBB

Perawatan Post Op

BPJS

Pro Herniorepair

BPJS

IBB

Pro Herniorepair

PKMS

IBB

Perawatan post op

BPJS

(18/12) Hb 10 AL 8.7 AT 411 Alb 3,1

Tumor anorektalT4NxMx dg
fistel rectovagina

IBB

perbaikan KU, staging,

tunggu hasil biopsi

BPJS

(18/12) USG Abd: Massa solid rectum

(17/12) Hb 10,9 AL 8,1 AT 244 HbsAg (-) CEA
54,48

Fistel Perianal + Fistel

Rectovesica

IBB

Perbaikan KU, Transfusi 2

kolf PRC, konsul Urologi,
Colon in loop

BPJS

(17/12) Hb 8,9 AL 17,6 AT 339 GDS 107 Alb 2,5 Cr

3,0 Ur 95 Na 132 K 3,0 Cl 102 HbsAg nonreaktif

OP

20/1
2

Pre op
Post
op

16/1
2

18/1
2

(8/12) Hb 13 Ht 40 L 55 Tr 194 Alb 4.5 CEA 6.47

PA: Adeno Ca
(9/12) Hb 15,3 AL 5,0 AT 226 PT 13,1 APTT 32,4
INR 1.010 GDS 94 Alb 4,3 Cr 1,0 Ur 39 Na 136 K
4,0 Cl 107 HbsAg (-)
(27/11) Hb 15 AL 9,9 AT 175 PT 13,8 APTT 26,9
INR 1,080 GDS 116 Alb 4,1 Cr 0,9 Ur 32 Na 134 K
4,0 Cl 102 HbsAg Reaktif

Cholestasis intra hepatal dan

cholangitis
Hidrop vesica fellea post
laparotomi bilio digest

Post
op

IBB

Perawatan post op

BPJS

(17/12) Cr 0.6 Ur 20 Na 125 K 2.7 Cl 88

(11/12) Hb 12,6 Ht 38 L 12,4 Tr 514 Sgot 489 Sgpt
297
(1/12) alb 2.7 Na 126 K 2.9 Ca 1.05 CEA 8.28
USG: Mengarah gambaran Cholestasis intra
hepatal dan cholangitis, Hidrop vesica fellea
MRCP: Massa di caput pancreas cenderung
maligna yg menyebabkan ostruksi bilier berat
dengan gambaran abrupt cut off pada ujung CBD
disertai hidrop GB, Cholecysitis dan pelebaran
berat ductus pancreticus

HIM D + BPH grade III post

Herniorepair, post TUR-P

Post
op

IBB

Perawatan post op

BPJS

(13/12) Hb 11.9 L 9.9 Ht 36 Tr 315 Ur 30 Cr 0.9

Perbaikan KU
USG Abdomen, Colon in
loop

BPJS

Pro Cholesistectomy

IBB

Perbaikan KU, Colon in

loop

IBB

Usg Abdomen (19/12)

Appendicogram (19/12)

BPJS

42

0127933
5

Konsulan
Interna

1B

Suwarno

92

0126748
7

Raber
Uro

4C

Sulastri

35

0127683
8

9/12

Endang Kastuti

48

0086169
8

17/12

65

0128161
0

4/12

Susp. Aeno Ca Recti

39

0128255
8

Konsulan
Interna

Appendicitis kronik

Wiji Lestari

PEMERIKSAAN PENUNJANG

Pro colostomi

Sri Wijayanti

1B

PJM

AR

1C

Supono

Pre op

Tuminem

14A

Wing

Fistel Enterokutan post

laparotomy ileostomy

3E

12A

Perawatan Post Op
Edukasi Keluarga

Tumor duodenum

0125336
8

Mel 3

PLAN

Adeno Ca Recti

Cholelitiasis

OP

Pre op

20/1
2

IBB

(12/12) Hb 12.1 Ht 35 L 15.4 Tr 305 Pt 14.7 APTT

18 Na 130
sgot 31 sgpt 12 Ur 43 Cr 0.5 CEA >
200.
(31/10) PA: Adeno Ca Recti
(8/11) Hb 12,5 AL 6,4 AT 255 GDS 102 OT/PT
31/25 Bil total 0,60 Bil direk 0,10 Bil indirek 0,50
Cr 0,9 Ur 26 HbsAg nonreaktif
(8/12) Hb 11.2 L 8.9 AT 471
(4/12) Hb 8.9 Ht 27 L 9.9 Tr 395 Gds 134 Alb K 3.1
CEA 3.03
PA: Adeno Ca Recti
(15/12) Bilirubin direk 6.30 bil ind. 0.30 Alb 4.0
OT/PT 41/25
(13/12) Hb 12,5 Ht 36 L 9.4 Tr 285 Ur 26 Cr 0.5 Na