REKAP PASIEN BEDAH DIGESTIVE 24 September 2016

Nama DM :

TOTAL PASIEN

: orang

1. Hayatul Akmalia (chief)

2. Khairul Rijal
3. Ade Novita

RS Lama
RS Baru

: orang
: orang

RS Lama
Mamplam 4
No Kamar
1
K3

IW 2
No Kamar
1
K3

Jeumpa 2
No
Kamar
1 K6b3

Identitas
Diagnosa
T.Joharsya Post Biopsi

h, lk, 28
Susp Ca

thn,
Recti
0991208 Ulkus

POD III
perianal dd /
1. Fistel

2.
malignancy

TB paru on
OAT

Terapi
Ivfd RL 20 gtt/i
Inj meropenem 1
gr/ 8 jam
Inj OMZ 40 mg /
12 jam
Inj ketorolac 30
mg/ 8 jam
IVFD PCT 1 gr /
8 jam
Rimstar tab 1 x III
Pectocyl syr 3 x
C1
Diet MB

Lab.
20-9-2016
Hb/ht/eri/leu/trom
8,1/25/3,2/16,6/461
MCV/MCH/MCHC/RDW/
MPV
80/26/32/15,6/8,7
Alb/Glb : 2,20/ 4,00
Na/K/CL 130/4,2/94
Ur/cr : 19/0,40

Planning
Biopsi (21/9/16)
susul hasil PA

Identitas
Ridho
Ramadhan
Saputra,
19 thn/
1103124
POD I

Diagnosa
Post

Appendectomy
ai general
peritonitis

Lab.
23-9-2016
Hb/ht/eri/leu/trom
13,8/41/5,0/28,2/247
Na/K/CL : 137/3,8/98
Ur/cr : 27/0,86

Planning

Identitas
Hj.
marwati/
49 tahun/
1102301
POD II

Diagnosa
Post

laparostomi +
bypass

gastrojejunostiu
m + bypass
cholecystojejuno
stomi ai
ikterus

obstruktif ec

Terapi
Ivfd RL 20 gtt/i
Drip PCT 1 gr / 8
jam
Inj. Fosmisin
2gr/12jam
inj metronidazol
500 mg / 8 jam

Terapi
Ivfd futrolit 20
gtt/ i
Inj cefoperazone
vial 1 gr / 12
jam
Drip pct 1 gr / 8
jam
Ranitidine amp/

Lab.
Planning
14/09/2016
Operasi
Hb/ht/E/T/L
(21/9/2016) susul
12,2/36/4,3/322/8,4
lab PA
SGOT/SGPT
152/101
Protot/alb 5,4/2,49
Na/K/Cl 135/2,5/91
21/9/16
Alb : 2,80, Alb/ Glo :
2,80/1,00

tumor pancreas

3
.

K5b1

K7b1

Muzainah/
76 thn/
0877121
AD 8

Fatimah /
56 thn/
1055610/
POD 1

12 jam
Inj vit k 1amp / 12
jam
Sucralfat syr 3
xc1
Inj ondancetron
amp/ 8 jam
Inj transamin amp
/ 8 jam
inj metoclopramid
amp / 8 jam
aminofusin
fls/hari
Abdominal
IVFD RL 20 gtt/i
Pain
Inj Ranitidin
ec susp Adhesi
amp /12 jam
post laparotomi MST 3 X 10 MG
eksplorasi
Diet MB

Post laparotomy
+ adhesolisis +

chocystectomi +
Explensi CBD +
T-TUBE + IOC

Jeumpa 1

Ivfd rl 20 gtt/i
Cepoferazone
sulbactan 2
gr / 12 jam
Fosen/ hari
Ketorolac 3%
amp/ 8 jam
Inj Ranitidin
amp /8 j
Vit K amp/ 8
jam
Transamin500
mg / 8 jam

Protein total : 4,3

Na/K/Cl : 3,20/133/3,4/93
22/9/16
Hb/ht/E/L/T
7,2/22/2,4/12,6/479
RDW : 19,9
Alb : 3,00
Protein total :4,1
23/9/16
Bil total : 16,7
Bil direct : 14,61
Amilase : 41
Lipase : 52
20-9-2016
Hb/ht/E/L/T
9,8/31/3,4/5,4/439
RDW/MVP : 19,2
Albumin : 2,65
kalium/cr /cr: 3,1/11/0,41
22/9/16
Hb/ht/E/L/T
11,2/37/4,2/5,6/121
Na/K/Cl : 141/3,5/99
14/09/2016
Hb/ht/E/L/T
10,9/33/4,2/7,8/417
GDS/UR/CR : 163/32/0,69
21/9/16
Bil total/ bil direct :
0,81/0,60
SGOT/SGPT : 37/59
Protein total/ alb/glo :
6,2/3,80/2,00
22/9/16
Na/K/Cl :140/4,6/103

Observasi tandatanda akut abdomen

Persiapan
kemoterapi
Echocardiograpi

operasi

No
1

Kamar
K6B5

Identitas
Faisal H.
M Ali /40
thn/
1081623
POD 19

Diagnosa
Tumor colon
residif + post
relaparotomy
reseksi
anastomosis
jejenum colon +
dgn stapter ai
tumor colon
residif

Jeumpa 4
No Kamar

Identitas

Diagnosa

Muhammad

Post
Laparoskopi
kolesistektomi
+ appendicitis
ai Cholesistitis
+ appendicitis
kronik

K5b2

iqbal/19
thn/
1102588
POD 3

Terapi
IVFD Futrolit 20 gtt/i
Inj Fosmisin 2 gr/24
jam
Drip albumin 20
%/hari
Drip parasetamol
1gr/8 jam
Inj Ranitidin 1
amp/12 jam
Aminofluid/hari
lifopundin fls / hari
inj metoclopramid
amp / 8 jam
inj omz vial / 12 jam
diet susu + ekstra
telur

Lab.
17/9/16
Hb/ht/Eri/leu/trom
11,2/34/4,3/8,2/205
Alb : 3,06
Na/K/Cl :
142/2,5/101/8,7
21/9/16
Na/K/Cl :139/2,6/98
22/9/16
Na/K/Cl : 135/2,9/99
Ur/Cr : 16/0,20

Terapi

Ket.

Lab.
ivfd nacl 0,9% 20 gtt/
i
inj ranitidin amp / 12
jam
inj ketorolac 3% / 8
jam
drip pct 1 gr / 12 jam
inj vit k
aminofluid fls / hari
lifopundin fls/ hari
Inj Novalgn/ 12 jam
Inj cebactan 1 vial /
12 jam
Inj Ondancetron
amp / 12 jam

Ket.

22/9/2016
Operasi
Hb/ht/eri/leu/trom
(21/9/2016)
13,2/41/5,5/15,4/38
susul lab PA
7
Diet sonde 6 x 100
Mcv/mch : 75/24
cc
Na/K/Cl :
mobilisasi
140/4,5/101
GDS : 150
CR : 0,80
20/9/16
Bil tot /bil dir:
0,35/0,19
SGOT/SGPT : 15/6
Fosfatase alkali :
106

2.

K6b2

Juariah/Pr/
50 thn/
1101431
POD 19

3.

K6B5

Post
laparotomy
eksplorasi
+ anastomosis
jejenum +
reseksi ileum
+
ileostomi ai
peritonitis ec
blunt
abdominal
trauma

Abidah/
1099560/
24 thn
AD V

Post repair +
mesh graft ai
hernia
ventralis

cefixim tab 100 mg 2 x 1

paracetamol tab 3 x 500
mg
sohobion tab 1 x 1
Diet lunak + peprisol

ivfd rl 20 gtt/i
inj fosmicyn 1 gr / 12
jam
Diet MB

4.

K7B6

Iskandar/
34 thn/
1102331
POD V

Post drainase Diet MB

abses ai abses Inj Futrolit 20 gtt/i
periumbilikal Inj Fosfomisin 2 gr/12 jam
Drip PCT 1 gram/ 8 j
inj metronidazol 500 mg / 8
jam
inj omeprazole / 12 jam
Jnj ondancetron amp / 8 jam

5.

K7b5

Hermanto /
45 thn/
1051527
AD 8

Tumor intra
abdomen

Diet MB
IVFD RL 20 gtt/i
Inj Fosfomisin 2 gr/12 jam
Drip PCT 1 gram/ 8 j
aminofluid fls / hari
lifopundin fls/ hari
durogesich patch 25 mg / 3
hari
Jnj ondancetron amp / 8 jam

16/9/2016
Hb/Ht/Eri/Leu/Tro
10,4/31/3,6/14,3/70
1
19/9/16
Hb/Ht/Eri/Leu/Tro
111,4/35/3,9/13,6/R
awat luka
642
ALB : 3,00
CR : 0,34

Persiapan
secondary hecting

17/9/2016
Rawat luka
Hb/Ht/Eri/Leu/Tro PBJ
m
14,3/42/4,3/9,0/340
22/9/2016
Hb/ht/eri /trom/ leu
13,3/39/3,9/11,9/37
0
MCV/RDW/MPV
101/35/14,8/12,7

17/9/2016
Hb/ht/eri/leu/trom
9,8/31/4,2/16,3/127
20/9/2016
Hb/ht/eri /trom/ leu
13,7/40/4,4/309/16,
7
Ur/cr : 27/0,60
Protein total : 5,1

PD
menyarankan
cek ulang
Ur/Cr /3 hari
Mobilisasi
Rawat luka

17/9/2016
CT-Scan abdomen
Hb/ht/eri /trom/ le
( susul hasil )
11,9/37/5,1/531/10
9
Ur/cr : 58/1,72
19/9/16
Ur/cr : 105/4,03
22/9/16
Urinalisis
Leukosit : Positif
Protein : positif (2)
Darah : positif

6.

ISO 1

Nurdin
hasan/
56 tahun/
109348
H-36

Post LE +
total
cholektomi +
effusi pleura
sinistra +
wound

POD II

IVFD Futrolit 20 gtt/i

Diet MB + ekstra telur
Inj. Levofloxacin 750/12j
drip. Sanmol 1 gr/8j
Inj. Ranitidin 1 amp/12
jam
Inj tramadol amp/ fls
Plasmanat 5 % 1 Fls /
hari

7.

K3B1

Nur Ibadah
53 thn/
1085924
AD III

Status
colostomy ec
ca recti

Ivfd RL 20 gt/i
Inj fosmicyn 2 gr/ 12 jam
Inj ranitidine amp / 8 jam
Jnj ondancetron amp / 8 jam

8.

K7B2

Iskandar
Husen /
71thn/
0814731
AD 5

Obstruksi
Jaundice

Diet mb
Ivfd RL 20 gt/i
Inj ranitidine amp / 8 jam
Drip PCT 1 gram/ 8 j
Inj celbactan 1vial /12 jam
Albumin 20 % 100 cc/ hari

23/9/16
Hb/ht/eri /Le o/tro
9,1/27/3,8/11,0/376
MCV/MCH/RDW/
LED :
72/24/14,6118
Bil total/ bil direct
0,17/0,21
Protein total : 5,5
alb/glo : 2,95/2,55
Na/Cl : 132/89
GDS : 109
Ur : 189
21/9/16
Na/K/Cl/Ca :
137/3,0/83/9,5
20/9/2016
Hb/ht/er/leu/tromb
11,2/32/3,8/15,8/32
0

Mobilisasi
Rawat luka dgn
gentamicin

20/9/16
Rencana
Hb/ht/er/leu/trom
colograpi
10,6/32/4,4/8,9/385
MCV/MCH/RDW :
74/24/14,9
Protein total/alb :
5,4/2,92
Na/K/Cl :
134/3,9/101
GDS : 101, Ur : 20
22-9-16
Susul hasil MRCP
Hb/ht/er/leu/tro
Transfusi TC
10,9/32/3,5/7,8/59
alb : 2,80
Ur/cr : 32/2,20
MCV/RDW :
31/20,4
Na/K/Cl :
138/4,6/103

9.

K5B2

Alpian
Juhri/
46 thn/
1103003

Abses Psoas
sinistra

Ivfd RL 20 gt/i
Inj ranitidine amp / 8 jam
Drip PCT 1 gram/ 8 j
Inj celbactan 1vial /12 jam
Drip PCT 1 gram/ 8 j
Drip metronidazole 500 mg/
18/9/16
8 jam

Hb/ht/er/leu/trom
12,0/33/3,8/741/17
Bil direct / alb :
CT Scan
abdomen selasa
9,10/2,62
Ur/cr : 38/2,74

Persiapan
drainase

10

K4b4

Usman/ 70
thn/
1093948
AD VI

Status
ileostomy post
herniography
ai HIL sin
AKI stage III
Hiponatremia
Hipokalemia

Ivfd Nacl 20 gt/i

Inj Fosmicin 2 gr/ 12 jam
Omz vial / 12 jam
Ondancetron amp / 8 jam
Kalitake sachet 3 x1
Diet MB

18/9/16
Hb/ht/er/leu/tro
12,0/33/3,8/741/17
Bil direct / alb :
9,10/2,62
Ur/cr : 38/2,74
22/9/16
Ur/Cr : 88/1,30

Balance cairan
Cek ur/cr / 3
hari
persiapan
ileostomy
Konsul pulmo

Massa intra
abdomen

IVFD Futrolit 1500 cc/ 24

jam
Inj Ceftriaxone 1 mg / 12 jam
Inj ketorolac 3 % / 8 jam
Inj ranitidine amp / 12 jam

Lab 23/9/16
Hb/ht/er/leu/tromb
11,5/36/4,5/14,6/
518
MCV/MCH/MCH
C/RDW
80/25/32/4,9/8,7
Na/K/Cl :
141/4,5/104
NB/NS/LIM :
0/74/17
GDS : 111
Ur/Cr : 22/0,90

Rabu Ct Scan
Abdomen ( 28-9-16)

11

12

K5B1

Syukri/
47 thn
1103292

ICU
No
Kamar
1 BED 2
.

2
.

BED

Serune 3
No
Kamar
1.
K3b

Identitas
Alimah/11
01612/ 16
thn

Diagnosa
Susp Internal
Bleeding ec
organ injury

Siti
Hawa/50
thn/
1100608/
POD 1

Post
Laparotomy
+ adhesidisis
berat + reseksi
ileum +
anasmosis
ileoleal ai
status
ileostomy +
adhesi
perineal berat

identitas
Karnani/
34 thn/
1102548
AD 7

diagnosa
Ileus obstruktif
ec adhesi post sc

Terapi
Diet sonde 6 x
200
IVFD futrolit 20
gtt/ i
Inj Fosmicin 2 gr/
12 jam
Inj Ranitidin 1
amp / 12 jam
Drip PCT 1 gr/ 8
jam
Aminofusid 1 fls/
12 jam
Diet ML
IVFD Futrolit
20gtt/i
Inj. Fosmisin
2gr/12jam
Inj. Ranitidin
1amp/12jam
Drip PCT 1gr/8j
Inj.
Metoclopramid
1 amp/8j

Lab.
22-9-2016
Hb/Ht/E/L/T
9,3/28/3,3/15,9/17
RDW : 15,7
Ca/Mg : 7,6/1,5
18-9-2016
Hb/Ht/E/L/T
8,2/26/3,0/20,5/18
MCHC/RDW : 31/16,7

Planning

20/9/2016
Hb/ht/eri/leu/trom
10,1/32/3,7/8,5/207
Na/k/Cl: 143/3,4/103
GDS : 102
Ur/cr : 23/0,46
Protein total/ alb : 5,0/3,08
glb : 1,92
22/9/2016
Hb/ht/eri/leu/trom
12,0/38/4,6/9,6/206
Na/k/Cl: 135/4,7/102
GDS : 115
Ur/cr : 12/0,30
Protein total/ alb : 4,1/2,40
glb : 1,92

Terapi
IVFD Furtolit 20 gtt/i
Omz vial / 12 jam
Drip pct 3 x 1gr
Inj metoclopramid amp/ 8
jam
Methilprednisolon 25
mg / 12 jam
Lipofurondin fls/ hari
aminofluid fls / hari

Lab
22/9/16
Hb/Ht/Er/Leu/trom
12,3/38/4,2/33,3/322
Alb : 3,40
Urinalisis :
Protein : positif 1
Darah : positif
20/9/16
Na/K/Cl: 147/3,4/107

planning
-Susul hasil foto
Thoraks
-Periksa ulang
albumin

2.

Iso 1

Nuraini /
0926286/
47 thn
AD 5
POD 2

Burst abdomen
+ ca ovarium on
kemoterapi +
anemia

Fosen enema / hari

Vancomycin
Aminofluid fls / hari
Diet lunak

23/9/16
Na/K/Cl : 140/4,3/100

Terapi sesuai TS obgyn

18/9/16
Hb/ht/er/l/tr
12,8/39/4,7/12,0/454

- Rawat luka
- Pantau TTV