REKAP PASIEN BEDAH DIGESTIVE

Rabu, 09 November 2016

Nama dokter muda:
Dini Masturina (Chief)
Herma Vania
Maya Safira
Huzaipi Pratama
Dara Soraya
Zatul Fina
Thariq Mubarak
NO

KAMAR

Total: 22 Pasien

IDENTITAS

DIAGNOSA

TERAPI

LAB

PLANNING

Jeumpa 1= 1 Pasien
1.

K5B2

Jaka Adi Keusuma

Lk/ 31th/ 1107053

Post Laparotomy eksplorasi +debridement

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

IVFD futrolit 30 gtt/i

Drip Lipofudin 1 fls/ hari
Drip aminofluid 1 fls/ hari
Drip metronidazole 500 mg/ 8 jam
Drip PCT 1 gr/ 8 jam
Drip albumin 20% 100cc/ hari
Inj fosmisin 2 gr/ 12 jam
Inj metoclopramide 1 amp/ 8 jam
Inj omeprazole 40 mg/ 12 jam
Inj bisolvon 1 amp/ 8 jam
Diet 6x250 cc susu

1/11/2016
Hb/ L/ Tromb
10,1/ 14,5/ 594
Prot tot/ alb/ glb
5,2/ 2,70/ 2,50
Na/ K/ Cl/ Ur/ Cr
145/ 5,2/ 111/ 48/ 0,70

Abdul Saut Situmeang

80 thn/1108085
POD III

Hernia Inguinalis Lateralis dextra Inkaserata

IVFD RL 20gtt/i
Fosmidex 1 gr/12 jam
Inj Ranitidin 1 amp/12 jam
Inj PCT 1 gr/8 jam

6/11/16
Hb/ L/ Trom
14,1/23,6/358
Na/K/CL
139/3,1/101

Yusniwati
63 tahun/ 1096023
POD V

Post laparotomy ai asites multiple kista

hepar + kista bilateral ginjal

IVFD Futrolit 20 gtt/i

Inj fosmisin 2 gr/ 12 jam
Ranitidin 1 amp/ 12 jam
Ketorolac 1 amp/ 12 jam
Diet MB

1/11/2016
Hb/ L/ trom/ CT/ BT
12,3/ 13,7/ 308/ 7/ 2
Bil tot/ bil dir/ bil in/ SGOT/ SGPT
33,14/ 31,58/ 1,56/ 164/ 42
Na/ K/ Cl/ GDS/ Ur/ Cr
134/ 2,4/ 100/ 117/ 42/ 1,54

POD XI

Jeumpa 3 = 1 Pasien
1.

K7B2

JEUMPA 4 = 15 Pasien
1.
K1B1

Rawat luka

2.

K1B2

Kasri
66thn/ 1107210
AD V

Cholelithiasis

IVFD futrolit 20gtt/i

Inj vit K/ 8 jam

28/10/2016
Hb/ L/ Trom/ CT/ BT
13,1/ 8,7/ 347/ 7/ 2
Bil tot/ bil dir/ bil ind
0,38/ 0,16/ 0,22
SGOT/ SGPT/ prot tot/ alb
18/ 12/ 7,8/ 4,46
Na/ K/ Cl/ GDP/ GD2PP
143/ 4,4/ 100/ 242/ 261
Ur/ Cr
38/ 0,50
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
25/10/2016
Hb/ L/ Trom
10,9/10,6/249
Na/ K/ Cl/Ur/Cr
147/4,4/106/17/0-97

Cholesistectomy perlaparoscopy
(+)

3.

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

4.

K3B1

Turini
54 thn/1106523

Ca Anorectal

IFVD futrolit 20 gtt/i

5.

K3B2

Neti ismail gading

40thn/ 1105916
POD XXII

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

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

Rawat Luka Gentamisin

Rencana debridement elektif

6.

K4B1

Ibnu Abbas
58 thn/1009006

Hemoroid Interna grade III-IV

IVFD Futrolit 30 gtt/i

Fosfomisin 2 gr/12 jam
Inj ketorolac 30 mg/8 jam
Inj ranitidin 50 mg/12 jam
Drip tramadol amp/ 8 jam

12/10/2016
Hb/ L/ Trom
13,3/8,3/273
Na/ K/ Cl
136/3,5/97

Hemoroidectomy (+)

7.

K4B2

Fadli
51 thn/ 1107579
POD VII

Post relaparotomy + debridement abdomen +

remove packing + repair primer hepar ec
laserasi hepar gr III post packing ai trauma
tumpul abdomen

IVFD Futrolit 30 gtt/i

Drip lipofudin 1 fls/ hari
Drip aminofluid 1 fls/ hari
Inj fosmisin 2 gr/ 12 jam
Inj ketorolac 3%/ 8 jam
Inj ranitidine 1 amp/ 8 jam

2/11/2016
Hb/ L/ Trom
11,7/ 10,8/ 138
Prot tot/ Alb/ Glb
4,7/ 2,50/ 2,00
Na/ K/ Cl/ GDS/ Ur/ Cr

Rawat luka

CT scan jumat (11/11/2016)

Trasnfusi PRC 3 kolf

Biopsi (+)

Diet cair 6x250 cc oral

Drip albumin 25% 100 cc/ hari (selama 3 hari)
IVFD Futrolit 20gtt/i
Inj ranitidin 1 amp/12 jam
Sohobion tab 2x1

149/ 4,4/ 111/ 69/ 105/ 1,40

5/11/2016
Hb/ L/ Tromb
8,2/17,1/629
Na/K/Cl/Albumin/Ur/Cr
132/3,6/96/3/22/0,40

Transfusi PRC III Kolf sampai

Hb 10 g/dL
Penjadwalan closure

8.

K4B4

Banta Mustajab
25 thn/ 1095462

Status ileostomy+ anemia

9.

K6B2

Sumtiah Umar
56 thn/0912355
POD VIII

Post
LE+cystoyyenustomy+yeyenusyeyenustomy
ai obstruksi jaundice ec tumor pankreas

IVFD Futrolit 20 gtt/i

Drip aminofluid 1 fls/24 jam
Inj Omeprazole 40mg/ 12 jam
Inj cebactam 1 vial/ 12jam
Drip PCT 1 gr/ 8j
Albumin 20% /24 jam
Inj Vit K 1 amp/8 jam
Diet ML

5/11/2016
Hb/ L/ tromb
8,2/17,1/629
Na/K/Cl/Albumin/Ur/Cr
132/3,6/96/3/22/0,40

Koreksi albumin
Pantau Hemodinamik

10.

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/i

5/11/2016
Hb/ L/ tromb/ Allb
8,1/ 10,6/ 244/ 2,5
Na/ K/ Cl
145/ 3,1/ 106

Aff drain kiri (+)

Kista Liver+ adhesi peritoneal

IVFD futrolit 30 gtt/i

Inj cefoperazone sulbactam 1gr/12 jam
Inj ketorolac 30 mg/8 jam
Duragesic patch 12,5 mg
Inj ranitidin 1 amp/12 jam
Inj vit K 1 amp/8 jam

7/11/2016
Hb/ L/ tromb/
11,8/18,9/199
Na/K/Cl
143/3/106

Post relaparotomi + adhesiolisi +

debridement + eksplorasi CBD + ekstraski
batu ec ikterik obstruktif a/I batu CBD +

Diet TKTP
IVFD Futrolit 20gtt/i
Inj cebactam 1 vial/ 12jam

2/11/2016
Prot tot/ alb/ glb
6,1/ 3,20/ 3,00

POD VI

11.

K6B6

Cut manyak
71 thn/ 0890204
POD VI

12.

K7B3

Abdul manaf
73 thn/ 1106026

13.

K7B4

POD XII

leakage empedu + adhesi post kolesistisis

Inj omeprazole 1 vial/12 jam

Codein 3x1 tab
Ambroxol 3xCI
Drip PCT 1 gr/ 8j

31/10/2016
Hb/ L/ Tromb
9,6/ 18,4/ 284
Bil tot/ bil dir/ SGOT/ SGPT
4,46/ 3,90/ 21/ 18
Na/ K/ Cl/ GDS
134/ 4,2/ 97/ 198

A.Jalil
Lk/ 78th/ 1107126

Aneurism aorta abdominal

Diet MB
IVFD Futrolit 20 gtt/i
Inj/ Omeprazole 40mg/ 12 jam
Inj. Ondancetron 1 amp/ 8 jam
Drip PCT /8 jam
Albumin 20% 100 cc fls/ hari
Drip KCL 1 flc/ 500cc

2/11/2016
Hb/ L/ tromb
9,7/ 5,0/ 203
Prot tot/ Alb/ Glb
4,8/ 2,90/ 2,00
Na/ K/ Cl/ GDS/ Ur/ Cr
139/ 2,8/ 102/ 70/ 10/ 0,70

Coloscopy sesuai ts IPD

AD X

14.

K7B5

Ponijan
56thn/ 1107329
AD IX

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

3/11/2016
Hb/ L/ Tromb
5,6/ 7,5/ 234
Prot tot/ alb/ glb
4,2/ 2,40/ 2,00
Na/ K/ Cl
135/ 3,4/ 102

Transfusi PRC 2 kolf/ hari

Transfuse FFP 2 kolf/ hari
Konsul anestesi
Wippley procedure

15.

K7B6

Faisal M Ali
40 thn/ 1107127

Ca colon residif post laparotomy + anemia

IVFD futrolit 20 gtt/i

Inj fosmisin 2 gr/ 12jam
Inj ranitidin 1 amp/12 jam
Diet MB

6/11/2016
Hb/ L/ Tromb
9.8/9,9/121
Na/K/Cl
140/2,8/104

Koreksi kalium
Konsul Fisioterapi (+)

M Asy syauqi
4058250

Retroperitoneal sarcoma
Post laparostomi

Sesuai TS IPD
Drip PCT 1 gr/ 12 jam

30/10/2016
Hb/ L/ trom/ Alb
9,6/ 15,9/ 788/ 2,80
Na/ K/ Cl/ Ur/ Cr
120/ 2,6/ 70/ 74/ 0,90

Isolasi = 1 pasien
1

K1

HCU = 1 orang
1.

B5

Said razali
876170
POD IV

Abses scrotum
Post debridement + abses perineal + insisi
drainage

Sesuai TS IPD

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

IVFD futrolit 20 gtt/i

Iripinem 1 gr/ 12 jam
Ranitidine/ 12 jam
Morpin 2 mg/ jam
Omeprazole 40 mg/ 8 jam
Albumin 20%/ hari
puasa
IVFD Futrolit 30gtt/i
Inj fosmidex 2 gr/ 24 jam
Inj ketorolac 3%/ 8 jam
Inj ranitidine/ 12 jam

4/11/2016
Hb/ L/ Tromb/ PT/ APTT/ D-dimer
9,3/ 13,2/ 161/ 25,3/ 70,7/ 9005,70
HbSag = negative
SGOT/ SGPT/ prot tot
218/ 105/ 5,4

ICU = 3 orang
1

B6

Nazariah
63 thn/ 0933670
POD IV

Post LE + adhesiolisis + biopsy + Primary

suture ec general peritonitis ec perforasi
gaster

2.

B3

Zulfan M. Amin
35thn/ 1107796
POD III

Peritonitis ec rupture hepar segmen VI & VII

Post LE
Post primary hecting hepar
Post drainage

3.

ISO 2

Halimah Insya
65 thn/ 1104530

Relaparotomi + adhesiolisi + repair gaster

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

IW1 = 1 orang

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

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
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

Rawat luka

1.

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

5/11/2016
Hb/L/Trom/Ct/Bt
5,2/10,8/472/7/2
Na/K/Cl/GDS
142/2,9/108/122

Ct Scan Abdomen kontras dan

non kontras 15/11/16