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LIST PASIEN DIGESTIF 24 JULI 2019

Anggrek 1

1 B12 Helny Nova Lendo/P/50th Cholelitiasis Pro laparoscopy


cholesistectomy
RM : 45.50.18
Lab
DPJP : dr. Toar Mambu, Sp.B-KBD
EKG
S: Neyri perut kanan atas
Transfusi PRC sampai hb ≥
10 gr/dl

2 B3 Conny Karamoy/P/44 th Post fistulektomi ec Rawat luka


fistul perianal
RM : 57 44 88 Antibiotik

DPJP : dr. Ferdinand Tjandra, Sp.B- Analgetik


KBD
Cek lab post op
S: Nyeri luka operasi

Anggrek 2

1 209 Widikdo/L/64 tahun Cholelitiasis Pro laparascopic


cholesistectomy
RM : 00.99.23

DPJP : dr. Toar Mambu, Sp.B-KBD

S: Nyeri perut kanan atas

IGD Lt. 4
LIST PASIEN DIGESTIF 24 JULI 2019
1 7A Jane Marrie Manoppo/P/72th Ikterus obstruksi ec LAB 17/07/2019 Pro MRCP menunggu
cholesistolithiasis jadwal
RM : 45.01.08 Leu : 8,7 eri : 3.44 HB 11.0
Hrt : 31.7 trombosit 83
DPJP : dr. Ferdinand Tjandra,
Sp.B-KBD

S : Kuning seluruh tubuh (+)

2 8B Abas Hassan/L/65th Post laparascopy Menunggu hasil lab


konversi open
RM: 57.50.98 eksplorasi CBD + Pantau produksi drain
insisi CBD Rawat luka
DPJP: dr. Toar Mambu, Sp.B-
intraopratif
KBD
cholangiografi + Cegah infeksi
insersi T Tube

Boarding Edelweis
LIST PASIEN DIGESTIF 24 JULI 2019
1. B4B1 Yetty Sumarauw/P/57th Post laparascopy Rawat luka
unroofing kista hepar
RM : 57.37.22 ec. multiple kista Mobilisasi

DPJP : dr. Toar M SpB(K) KBD hepar segmen 6 dan 8 Diet clear water

S: BAB(-) Kentut (+)

Irina B
1. B6 Ponumbol Petrus/L/67th Ca recti Pro LAR

RM : 56.30.43

DPJP : dr. Toar D B Mambu


Sp.B-KBD

S :Nyeri perut

O : Abd : datar, lemas ,BU(+)


LIST PASIEN DIGESTIF 24 JULI 2019

Nyiur

1 K8 Mado Plons/L Post laparatomi Rawat luka + stoma


reseksi tumor recti Antibiotik
RM : 57.02.32
Analgetik
DPJP : dr. Toar Mambu,
Sp.B-KBD Diet susu 6x50cc

Konsul gizi untuk koreksi


S : Nyeri luka operasi hipoalbumin

Konsul rehab medik

Mobilisasi

IRINA A ATAS

1 A6 bed Nayoan Agnes/P/36th Post miles procedure Lab 23/07/19 Rawat luka
2 ec AdenoCa recti
RM : 51.64.43 Leu 9.3 eri 2.94 Hb 8.4 Hct 24.7 Cek lab
Tromb 247 Na 126 K 3.99 Cl
DPJP : dr. Ferdinand 87.7 Analgetik
Tjandra,Sp.B-KBD
Antibiotik
S: -
Masih di IBS
O:
LIST PASIEN DIGESTIF 24 JULI 2019
2 A6 bed Potabuga Suryani/P/47th Adeno Ca recti t4 N2 Lab 17/07/2019 Transfusi 2 bag PRC –
5 M1 suspek cek lab post transfusi
RM : 55.88.94 metasatasis hepar on
radioterapi ke 3 analgetik iv
DPJP: dr. Toar Mambu,SpB- Leu 14.0 Eri 3.37 Hb 8.9 Ht 27.1
KBD Trom 576 MCH 26.4 Pro radioterapi ke 4

S : lemah badan + nyeri di Hb> 10 boleh rawat


anus Lab 22/07/19 jalan

O: Leu 11.2 eri 2.75 Hb 7.1 Hct


21.6 Tromb 442 MCH 25.8
R. Anus : benjolan(+) nyeri (+) MCV 78.5 Ur 22 Cr 0.4 Alb 2.07
Cl 92.8 Na 127

3 A7 bed Harry Kojo/L/45 tahun Obstruksi Usus Lab 11/07/2019 Antbiotik


1 Mekanik partial
RM : 54 26 60 SGOT/SGPT 42/53 Analgetik
Post laparotomi
DPJP : dr. Toar eksplorasi + stoma Kal 3.34 Mobilisasi bertahap
Mambu,Sp.B-KBD Hari ke 5 Lab 19/07/19 Kontrol lab
S : kembung
Leu 11.9 Hb 13.2 Hct 42.5
O : Abd : Trombo 297

I : datar Lab 21/07/19

A : BU(+) Leu 8.3 eri 3.81 Hb 11.5 Hct


SGOT 27 SGPT 43 Albumin 3.22
Pal : NT(+) Na 135 K 2.80 Cl 106.0
Per : Timpany
LIST PASIEN DIGESTIF 24 JULI 2019
4 A7 bed Ayal Ricky/L/22 th Pos laparotomi Rawat luka
3 repair lateralis colum
RM : 57.71.52 transversum Hari ke Analgetik iv
1 Antibiotik iv
DPJP : dr. ferdinand
Tjandra, Sp.B-KBD
Diet lunak
S : nyeri luka post op
Mobilisasi bertahap
O : Abdomen

I : luka post op baik, pus (-)

A : BU (+)

P : NT (+)

P : Timpani

5 A7B5 Heskiel Halir/L/55Th Trauma tumpul Lab 15/07//2019 Aff infus- ganti oral
ginjal
57.61.74 Leu 14.2 Eri 3.58 Hb 10.8 Ht 30.2 Aff kateter
Trom 198
DPJP dr. Toar Mambu, SpB- Mobilisasi
KBD Lab 21/07/19
Acc rawat jalan jika
S:- Leu 12.5 eri 3.59 Hb 10.7 Hct KU optimal
30.0 Tromb 474 SGOT 28 SGPT
O : Abd : 24 Bilirubin total 1.46 Bilirubin Rawat jalan, kontrol
direct 0.33 Albumin 2.90 Cl 132 poli
I Datar,

A BU(+),

P NT (-)

P Timpani
LIST PASIEN DIGESTIF 24 JULI 2019
6 A7b8 Frans A. Moniung/L/67th Post herniotomi + Lab 15/07/2019 Aff infus, aff catheter
pemasangan mesh
RM : 57.65.86 ec HIL sinistra Leu 12.5 Eri 4.98 Hb 14.3 Ht Acc rawat jalan
Reponible 40.4 Trom 222
DPJP : dr. Ferdinand
Tjandra, Sp.B-KBD Lab 22/07/2019

S:- Leu 7.1 eri 4.63 Hb 13.2 Hct 36.7


Tromb 280 MCH 28.5 MCVC
O : Regio Ingunalis sinistra : 36.0 MCV 79.3
luka post op baik

7 A8B1 Adam Evrillah/P/39th Klostkin tumor Lab 12/07/2019 Rencana laparoscopy


dengan kemungkinan
Pindah RM 57.45.00 Leu 10.5 eri 4.31 Hb 12.4 Ht 37.2 bypass
ICU SGOT/SGPT 173/211
bed 20 DPJP : dr. Toar Mambu, Post reseksi CBD +
Sp.B-KBD hepatektomi kanan Lab 20/07/2019
(utama) _
S : nyeri perut kanan atas, biliodigestif Na 132 K 3.56 Cl 94.6 Leu 11.6
mual muntah anastomosis Eri 4.28 Hb 13.0 Hct 37.8 Tromb
cholangiocarcinom 346 SGOT 147 SGPT 164
O : sclera = ikterik +/+
Abdomen : a bismut tipe IV
lobus kanan hepar
Inspeksi ikterik

Auskultasi BU (+) N

Palpasi NT (+) kanan atas

Perkusi timpani
LIST PASIEN DIGESTIF 24 JULI 2019
8 A8B7 Karel Palar/L/59th HIL Sinistra Lab 22/07 Pro Herniotomy +
strangulata mesh
081353 Leu 11.6 eri 4.68 Hb 13.6 Hct
39.3 Tromb 239 MCH 29.1 Konsul pre op 24/07
DPJP dr. Toar Mambu, SpB- MCHC 34.6 MCV 84.0
KBD

S : benjolan disertai nyeri di


lipat paha kiri sejak 1 jam
SMRS

O : R. Inguino-scrotal
sinistra = benjolan (+) 10x6
cm, hiperemis (+), NT(+),
kenyal

Abdomen :

Inspeksi datar, lemas

Auskultasi BU (+)

Palpasi lemas

Perkusi timpani
LIST PASIEN DIGESTIF 24 JULI 2019
9

10

IRINA A BAWAH

1. B 7.4 Manarisip Frans L

2. B 5.3 Koloay Kristian Kolik abdomen ec Lab 13/07/19 Antipiretik jika demam
Heinsje/L/59th obstruksi usus
Leu 23.7 Eri 4.15 Hb 11.7 Ht 34.0 Antibiotik
mekanik parsial ec
57.63.89 skibala susp kolitis Trom 447 Cl 91.1 Na 130 Konsul Interna
LIST PASIEN DIGESTIF 24 JULI 2019
DPJP : dr. W. Sumanti,
Sp.B-KBD

S : nyeri perut hilang


timbul

O:

Abd :
I : cembung
A: BU (+) normal
P :lemas
P:Timpany

3. B9.1 Coloay Adri Hematochezia ec. Lab 16/07/2019 Pro..


Lukas/L/49th Suspek tumor kolon
kanan Leu 5.8 Eri 3.37 Hb 10.6 Ht 31.8
DPJP: dr. Toar Mambu, Trom 93
Sp.B-KBD Anemia

S: BAB darah (-)

O: Abdomen:

Ins: datar

Aus: BU (+)

Pal:

Perk: timpani

4. B11. Togas Yuvilly/L/35th Melena + suspek Lab 18/07/2019 R/ kolonoskopi


3 tumor colon dextra
57.57.92 Leu 8.5 Eri 4.52 Hb 11.6 Ht 35.5
Elektrolit imbalance Trom 469 MCHC 32.9
LIST PASIEN DIGESTIF 24 JULI 2019
DPJP : dr. W. Sumanti,
Sp.B-KBD

S :BAB kehitaman

O:

Abd
I : Datar

A : BU (+) normal

P : Lemas

P : Tympani

6. B9.8 Rey Adri/L/41th ILO post laparotomy Lab 16/07/2019 Analgetik


distal pancreatectomy
DPJP : dr. Toar ec abses pancreas + Leu 13.2 Eri 2.99 Hb 8.1 Ht 24.3 Antibiotik
Mambu, Sp.B-KBD necrotizing pancreas Trom 470 SGOT 61 Ur 64 Cr 2.3
Konsul interna
RM : 57.12.16 Anemia
Transfusi PRC 1 bag/hari
S : luka operasi keluar General weakness
nanah Rawat luka
Electrolit imbalance
O:

Abd

I : luka operasi tampak


keluar nanah
LIST PASIEN DIGESTIF 24 JULI 2019
A : BU(+)

P : nyeri tekan(+)
sekitar luka operasi

P : timpani

7 B8.6 Tambengii Steven Post laparatomi Lab 18.7.19 Mobilisasi


- S/L/19th reseksi anastomosis
Leu 17.4 Eri 5.26 Hb 15.4 Rawat luka
side to side ileo ileal
57.49.17 Ht 45.3 Trom 355
ec perforasi ileum + Terapi sesuai TS ICU
DPJP : dr. W. Sumanti, adhesive band + ILO
+ fistula enterokutan Diet susu 6x50cc
Sp.B-KBD
S : Luka bekas operasi Elektrolit imbalance
keluar feses, flatus(+)
Hipoalbumin
O:
Anemia
Abd :
I : luka operasi ada
rembesan feses
A : BU(+)
P : defans muscular (-)
P : Tympani
LIST PASIEN DIGESTIF 24 JULI 2019

A TERATAI

1 Kelas Kairupan Ronny/L/60th Peritoneal Lab 17.07.2019


2B12 Carsidnotase post
57.33.05 laparatomi biopsy + Leu 26.7 Eri 3.29 Hb 9.0 aht 26.7 Diet bebas
Ileostomi diversi + Trom 824 SGOT/SGPT 37/13 Ur
DPJP: dr. Toar Mambu, Sp.B- 71 Alb 2.50 Antibiotic
ovenlektomi biopsy
KBD
+ Aki + Elektrolit Analgetik
S: Nyeri Luka operasi minimal Imbalance
Mobilisasi
O: Abdomen : I: datar,Luka
terawat, A: BU(+), P: NT(-), Per: Transfusi PRC bila Hb
timpani >10gr/dl

ICU
LIST PASIEN DIGESTIF 24 JULI 2019
B8 Vendro Kaeng/L/26th Post.. Drainage ec … Cek albumin
peritoneum
RM : 57.23.20 Terapi tetap

DPJP : dr. Ferdinand Tjandra,


Sp.B-KBD

S : perut kembung, bengkak di


kaki

Abd : drain (-), auskultasi


terdengar pelan, palp : Tegang
: perk : Redup

B 20 Hasan Abas/L/67th Ikterus obstruksi ec


cholecocholitiasis +
RM : 57 50 98 cholesystits kroni +
mirizzi syndrome +
DPJP : dr. Toar Mambu, Sp.B-
striktur CBD
KBD
Post laparoskopi
S:
konversi, insisi CBD,
O: insersi T-tube

B21 Lantemona Imelda/P/44 th Proximal CHD injury

RM : 44.69.60

DPJP : dr. Ferdinand Tjandra, Post eksplorasi bilier


Sp.B-KBD

S:

O:
LIST PASIEN DIGESTIF 24 JULI 2019