KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
NO.

IDENTITAS

1.

Debora Lisu
Bua
P/61thn/5895
57
MRS
17/1/2013

DIAGNOSIS
PEMERIKSAAN PENUNJANG
LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 1
D/
Susp. Foto Thorax AP 21/1/2013
perforasi gaster
Susp. Hernia diafragmatika dextra ( Morgagni )
Dilatatio aortae
Boleh pulang

BED 1

Lab 17/1/2013
WBC 11,2 RBC 3,17 HB 8,4 MCHC 31,5 HCT 26,6 PLT 349 CT/BT
700/230 PT/APTT 11,1/23 GDS 106 UR/CR 32/0,6 GOT/GPT 46/28
PROT.TOT 7,4 ALB 2,7 HBSAG (+) Anti HCV (-)

Pondok asri 3
sudinag
08321642992

Kadek
Rosmiati
P/22thn/5885
77MRS19/01/
2013
BED 2

CT Scan Abdomen 18/1/2013

Hernia diafragmatika kanan berisi usus halus
Lab 18/1/2013
RBC 4,02 HGB 11,01 HCT 34,6 MCHC 31,9 WBC 7,6 Monosit 1,18

Aff infuse

Ket/PJ

FOTO BNO 17/1/2013

Gambaran meteorismus

D/
POH
7
Laparotomy
Explorasi
+
Jejunostomy ec
tu.
rectosigmoid+co
lon transversum

USG abdomen 17/1/2013

Over distended gaster
Meteorismus
Lab 25/1/2013
Na 128 K 4,0 Cl 97 GDS 86 Ur/Cr 22/0,4 GOT 79 GPT 49 Albumin
2,1
Lab 21/1/2013
Na:139 K:4,4 Cl:105 AFP:1,04 CEA:38,87 Ca-125:75,08 Alkali
fosfatase:71 LDH:367 Alb 3,0
PA 16/10/2012
Adenocarsinoma Colon Musinosum

Desa Tinading
Cab Toli-toli

Lab 12/01/2013
CT/BT 830/2 PT/APTT 13/21,7 GDS 84 UR/CR 20/0,6 GOT/GPT
25/18 Na 146 Cl 112 K 4,4 WBC 6,8 RBC 4,31 Hb 11,9 HCT 36,91
PLT 325

08529928742
9

Thorax PA 14/01/2013
Tidak tampak tanda-tanda metastasis pada foto thorax ini

Rahel
P/46thn/5497
08MRS17/01/
2013
BED 3
Rencana
tutup
colostomy
tunggu jadwal
pro
tutup
colostomy
Pampang
2
lorong 8
08218826965
4

D/ Ca Recti 1/3
prox.
Post
Hartman
procedure
Pro
tutup
colostomy
Rencana parade

CT Scan Abd. Upper Tanpa kontras 15/01/2013

- Tidak tampak densitas massa colon pada CT Scan Abdomen ini
- Susp. Metastasis tumor ke hepar
- Ascites
- Cholelith
Lab 29/1/2013
OCA 3,01 GDS 109 Ur/Cr 25/0,6 GOT/GPT 26/29 Prot.total 7.0
Albumin 3,1 CT/BT 800/200 PT/INR 10,6/1,07 APTT 25,3 Na/K/Cl
141/3,2/104 WBC 3,48 RBC 3,73 Hb 10,0 HCT 29,1 PLT 198 MCHC
34,4 MCV 78,0 MCHC 26,8
PA : Adenocarsinoma recti
Lab 26/11/2012
CT 200 BT 800 PT 12,1 APTT 22,0 GDS 94 UR/CR 18/0,6
GOT/GPT 30/29 ALB 4,1 NA 145 CL 108 K 3,8 WBC 2,4 RBC 3,48
HB 10,2 HCT 29,4 PLT 147 HbsAg (-) CEA 2,95
CT Scan 26/11/2013
Tu. Colon Ascendens, susp metastasis ke hepar
Lab 18/01/2013
GDS 253 UR/CR 22/0,6 GOT/GPT 30/16 ALB 3,7 NA 139 CL 105 K
3,8 RBC 3,6 HB 10,1 HCT 28,8 PLT 122
CT Scan Abd. Tanpa kontras 18/01/2013
Defect dan penonjolan loop usus ke dinding anterior abdomen sisi
kiri (post colostomy)

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
4

Juventina
P/42thn/5884
90
MRS
17/1/2013
Bed 4
Anj
:
cateter
epidural
Aff infus

aff

Desa mekar
sari, konawe
08524164119
8

D/POH
4,
colostomy
ec.
Tumor Colorectal
Jawaban
Konsul Obgyn
(23/1/2013)
Suspek
massa
intraabdomen +
Ascites
pro
evaluasi
Saran : Periksa
ulang
pemeriksaan
MSCT Abdomen
+
kontras
,
sitology
cairan
asites. Bila ada
hasil
dapat
dikonsul
ulang
ke bagian obgyn
divisi onkology

Lab 21/1/2013
AFP 3,68 CEA 6,00 Ca-125 10,89 LDH 600
Colon In loop 21/1/2013
Kesan : Massa daerah distal rectosigmoid
Thorax PA (18/01/13)
Elevasi diafragma kanan
Tidak tampak tanda tanda metastases pada foto thorax ini
USG Abdomen 18/01/13)
Tanda tanda sirosis hepatis. Asitess
Lab17/1/2013
WBC 8,59 RBC 4,76 HB 12,8 HCT 40,5 PLT 425 CT/BT 800/200
PT/APTT 11,3/25,5 GDS 88 UR/CR 33/1,1 GOT/GPT 21/10 ALB 3,5
HBsAg (-) Anti HCV (-)
Lab 11/1/2013
GDS 86 UR/CR 24/0,7 GOT/GPT 21/12 CT/BT 800/200 PT 10
APTT 19,6 INR 0,8 NA 147 K 3,4 Cl 109 RBC 4,61 HGB 12,9 HCT
39,71 WBC 6,9
Foto Thorax AP (Kurang Inspirasi) 11/1/2013
Tidak tampak kelainan radiologik pada thorax ini
USG Abdomen 11/1/2013
-Sesuai gambaran massa rectum

Elisabeth
P/ 60 thn /
588823/ MRS
23-01-2013
Bed 1
Griya
Alam
Permai
No.telp
08219996362
2

CT Scan 11/1/2013
Tidak ada Expertise
LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR ISOLASI
D/ susp. tumor CT Scan Abdomen 10/01/2013
caecum
Tumor caecum annular type denga nodul kelenjar limfe di
sekitarnya
Rencana
endoskopi
Colon in Loop (17/1/13)
1/2/2013
Tidak tampak kelainan radiologic kecuali Redundancy colon
descendens
Foto Thorax (17/1/13)
Elongatio et atherosclerosis aortae
Lab 17/01/13
GDS 76 Ur 42 Cr 0,5 GOT 20 GPY 18 Alk.Fos 89 Prot.total 7,9
Albumin 3,6 PT 10,5/10,6 APTT 28,9 / 26,7 Na 140 K 4,5 Cl 103
CEA 0,767
Urin Rutin 17/1/13
Warna kuning, pH 5 BJ 1,025 keton ++/50 sed.leukosit 1
sed.eritrosit 3 sed.epittel 6

Nurhayati
P/
thn/
585290
MRS 15/01/13
Bed 2
DSN
IV
Wasidongi
Sidrap
No.telp
08134224972
6

D/ Tu. Gaster
POH
Laparatomy
explorasi
(30/1/2013)
(HbsAg +)

LAB 29/1/2013
GDS 94 Albumin 3,1 WBC 6,41 RBC 4,90 Hb 10,8 HCT 35,8 MCV
73,1 MCH/MCHC 22,0/30,2 PLT 361
Lab 23/1/2013
GDS 85 UR/CR 19/0,4 Albumin 2,8 NA 141 K 3,7 Cl 111 CT 8 BT
3 PT 10,8 APTT23 INR 0,9 WBC 7,87 RBC 4,48 HB 10,5 HCT 33,7
PLT 342
Lab 19/01/13
RBC 3,44 HGB 7,6 HCT 25,4 PLT 395 WBC 5,5
Echocardiography 03/01/13
Kesan : normal echo
OMD 28/12/12
Kesan : obstruksi parsial 1/3 distal duodenum pars descendens
oleh massa extraluminer dengan kalsifikasi didalamnya

RL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
CT-abdomen upper (dengan kontras) 28/12/12
Kesan : susp. Teratoma mesenterium, Tu. Metastasis ke hepar,
Splenomegaly
USG abdomen 26/12/12
Kesan : metastasis Tu. Ke hepar, Splenomegaly, Ascites

7.

Ayyu
L/23thn/5817
26
MRS 10/1/13
Bed 1

Lab 26/12/12
WBC 7,6 RBC 3,96 HGB 8,5 HCT 27,1 PLT 424 CT/BT 800/300
PT/APTT 10,9/23 GDS 112 UR/CR 14/0,4 GOT/GPT 17/17 ALP 208
ALB 2,7 Na 142 K 4,4 Cl 109 HbsAg reaktif, Anti HCV non reaktif
LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 2
D/ Tu. Recti 1/3 PA 17/1/2013
distal
Sediaan jaringan tidak ada sel-sel maligna
Tunggu hasil PA
tgl 1/2/13

Colon in loop (7/1/13)

Foto polos abdomen :
Udara usu terdistribusi sampai ke distal colon
Tidak tampak dilatasi loop-loop usus, herring bone
appearane dan air fluid level
Kedua psoas line intak
Kedua preperitoneal fat line tidak tervisualisasi
Tulang-tulang intak
Lopografi :
Kontras dimasukkan sebanyak 100 cc melalui stoma
menggunakan catheter yang mengarah ke distal lalu
mengisi colon desendens, colon sigmoid, hingga ke
rktum
Tidak tampak filling defek maupun additional shadow
Kaliber lumen rektum sedikit menyempit, mucosa dan
haustra dalam batas normal
Mucosa, kaliber lumen dan haustra colon lainnya dalam
batas normal

Jl.
Jambu
P.Kemerdeka
an 12
No.telp
08219169912
0

Jampi
L/47thn/5908
83
MRS 26/01/13
Bed 2

Foto thorax (8/1/13)

Tidak tampak kelanan radiologik pada foto thorax ini

Hematokhezia +
hemoroid
externa grad II.
Tunggu
jadwal
colon in loop

Lab (4/1/13)
WBC 7,93 RBC 4,95 HB 15 HCT 44,4 PLT 294 BT/CT 300/800
PT/APTT 10,0 23,5 INR ,83 Na/K/Cl 138/3,8/100 GDS 87 Ur/Cr
19/0,8 GOT/GPT 24/51 Alb 3,9 HbSAg (-) anti HCV(-)
Lab 28/01/13
CT/BT 7/2 PT 11,3 INR 0,90 APTT 24,5 Alb 4,7 HbsAg (-)
Lab 26/01/13
WBC 8,08 RBC 4,84 HB 14,1 HCT 42,6 PLT 267 CT/BT 900/300
PT/APTT 13,1/24,8 GDS 101 Ur/Cr 13/0,8 GOT/GPT 24/29 Na/K/Cl
145/3,84/107

Km 12 masuk
kota Sorong
No.telp
08525467194
3

Colonoscopy
1/2/2013

Ansar
dg.Haseng
L/47thn/5822
37
MRS
14/1/2013

D/
Massa
duodenum
+
cholesistisis

Lab 29/1/2013
WBC 9,43 RBC 3,90 Hb 10,5 HCT 33,1 MCV 84,9 MCH/MCHC
26,9/31,7 PLT 803

Rencana parade

Lab 25/01/2013
CEA 0,638

Bed 3
Jl.Barawaju II
Panakukkang
MKS
No.telp
08234775717
4

USG Abd 26/01/13

Kesan: kista hepar & kista ginjal bilateral

Lab 24/01/2013
Bil. Total: 0,17 Bil. Direk: 0,14
Lab 23/01/2013
WBC:7,11 RBC:3,41 HGB: 9,5 HCT:29,2 PLT:335
Lab 21/1/2013
WBC:6,77 RBC:2,1 HGB:6,1 HCT:19,0 PLT:142

IL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Lab 18/1/2013
WBC 18,67 RBC 1,63 HGB 4,1 PLT 267 CA 19-9 312,5 CT/BT
800/300 PT/APTT 17,9/39,1
Lab 14/1/2013
WBC 8,05 RBC 3,81 HB 9,6 HCT 30,7 PLT 527 CL 98 NA 137 K 3,7
LDL 68 TG 66 AS.URAT 7,6 PT 15,4 APTT31,2 GDS 96 UR/CR
13/0,8 GOT/GPT 18/10 ALB 2,8 KOL.TOTAL 109 HDL 28
MSCT Whole Abdomen non kontras 13/12/2012
Massa pada duodenum pars transversum
Tanda-tanda colekthasis ringan
USG ABDOMEN 28/12/2012
Massa duodenum
Cholekth
Thorax AP 02/01/2013
KP Duplex lama aktif

10

Salang
L/35thn/5727
18
MRS10/01/20
13
Bed 4

D/
Achalasia
Esofagus,
hipokalemi
operasi
hari
kamis 31/1/2013

Jl.
Laupa
Sersang
No.telp
08219067532
0

BNO dan Esofagus maag duodenum 02/01/13

Massa duodenum
Lab 30/1/2013
Na/K/Cl 148/2,5/108
Lab 29/1/2013
Na/K/Cl 141/2,4/103
Lab 26/01/2013
WBC 5,52 RBC: 3,75 HGB: 11,9 HCT: 36,0 PLT: 237 CT/BT:
900/300 PT/APTT: 12,7/25,5 INR: 1,0
Lab 16/01/13
WBC 10,06 RBC 3,53 HGB 11,2 HCT 32,1 PLT 309 CT/ BT 700/
200 PT/ APTT 10,6/ 21,8 GOT/ GPT 37/ 26 GDS 32 Ur/ Cr 14/ 0,8
Alb 3,1 Prot. Total 7,4 Na/ K/ Cl 141/ 2,0/ 13
Lab 10/1/13
CT/BT 800/300, PT/APTT 12.3/26.6, GDS 95, Ur/Cr 14/0.8,
GOT/GPT 24/21, Alb 2.7, Na/K/Cl 138/1.9/98, WBC 10.1, RBC 3.22,
Hb 10.2, HCT 31.7, PLT 335

11

Hugo Donald
L/40th/582008
/
MRS 13/01/13
JAMKESMAS
Bed 1
Sillanan
Gadang Batu,
Toraja
08135501121
3

Foto Thorax AP 10/1/2013

Kesan: Double density sepanjang aorta ascendens dan batas
kanan jantung sangat curiga merupakan densitas dari esophagus
yang melebar
LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 3
D/ Tu Hepar Susp LAB 28/1/2013
HCC
AFP 31,45
dd/
tumor

klatskin

Foto Thorax 25/01/2013

Tidak tampak tanda-tanda metastasis + dilatatio et elongatio
aortae
MSCT Abdomen 25/01/2013
Cholestatis intrahepatik susp. Klatskin tumor
Cholelith
Distended colon
Lab 24/01/2013
WBC:9,22 RBC:3,67 HGB:9,0 HCT:24,5 PLT:391 GDS:114 Ur:18
Cr:0,4 Bil.total:21,40 Bil.direk:19,22 GOT:96 GPT:93 Albumin:2,6
Lab 17/01/2013
Na 124 K 4,2 Cl 90
Lab 14/01/2013
WBC 9,88, RBC 3,82 HGB 11,1 PLT 430, HCT 30,7, PT/APTT
10,7/29,0, CT/BT 800/500, GDS 99, Ur/Cr 23/0,6, GOT/GPT

RL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
65/133, Alb 3,1, Na/K/Cl 123/3,9/91 HbsAg (-)
Lab 11/12/12:
AFP:28,49
CT Scan Abd 4/12/12:
Kesan: Massa terutama pada lobus kiri hepar(Hepatoma)
MSCT Whole Abdomen dengan kontras 11/12/12
Kesan: Sesuai gambar hepatoma

12

Basri
L/40thn/5820
34
MRS20/12/20
12

D/
POH
XVII
Miles Procedure
ec. Ca Recti

USG Abdomen 4/12/12

Kesan: Massa pada lobus kiri hepar susp abscess dd/Hepatoma
Thorax 4/12/12
Kesan Pulmo normal, elongation aorta
Lab (15/01/2013)
RBC 4,63 HGB 9,1 HCT 30,4 PLT 217 WBC 19,4 GDS 149 Ur 37 Cr
1,0 GOT/GPT 22/14 Alb 2,6
Lab 13/01/2013
RBC 4.63 HGB 9.1 HCT 30.4 PLT 217 WBC 19.4 GDS 149 Ur 37 Cr
1.0 GOT 22 GPT 14 Albumin 2.6

JAMKESMAS
BED 2

USG abdomen 10/1/2013

Kesan: Tidak ada kelainan pada usg abdomen

Rampunan,
Enrekang
08539936496
7

Lab 07/1/13
WBC : 7,69, RBC : 5,93, HB : 10,4, HCT : 34,7, PLT : 271, PT : 11,2,
APTT : 22,0 GDS 190 Albumin : 3,6 SGOT 16 SGPT 13 Na 134, K :
3,9, Cl : 111
PA 18/01/2013
Adenomacarcinoma recti (differensiasi sedang) dengan bagian 2
cm dan 5 cm arah distal tumor bebas dari sel-sel epitel maligna
Lab 26/12/2012
CEA : 44,46
PA 02/01/2012
Adenocarsinoma differensiasi sedang pada anus dan rectum
Lab 22/12/2012
WBC 8,77, RBC 6,68, HGB 11,7, PLT 327, HCT 38,9, PT/APTT
11,3/21,6, CT/BT 700/230, GDP 103, GD2PP 215, TTGO 103,
Ur/Cr 27/0,7, GOT/GPT 13/11, Alb 3,7, CEA 124, Na/K/Cl
142/3,8/106

Foto Colon In Loop 14/12/2012

Kesan : Tu. recti 1/3 distal susp. malignancy
CT Scan Abdomen Tanpa kontras 14/12/2012
Kesan : Tu. rectum tanpa pembesaran KGB (DUKES A/ T2 NxMx)

13

Tajuddin / L /
48
tahun/
591678
MRS
2013

30-01-

D/
post
op
Laparatomi
explorasi hr keXVII
e.c.
perforasi
appendicitis ?

Foto Thoraks AP 14/12/2012

Kesan : Tidak tampak tanda-tanda metastasis pada foto thoraks
ini
Lab 30/01/2013
CT 930 BT 330 PT 9.3 APTT 33 GDS 97 Ur 16 Cr 0.8 GOT 59
GPT 25 Albumin 2.5 HBsAg (-) WBC 8.73 RBC 4.85 HGB 13.7 HCT
42 PLT 325

Bed 3
Lampa Timur,
Pinrang
08234726548

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
5

16.

Katanang
P/45thn
/
585557
MRS 07/01/13
Bed 1

LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 10

Splenomegali
Lab 31/1-2013
(kista lien)
RBC 2.79 hgb 7.1 HCT 23.1 PLT 242 WBC 6.6
Lab 29/1/2013
POH
4 WBC 68,47 RBC 3,34 HGB 6,5 HCT 22,3 MCV 66,8 MCH 19,5 MCHC
laparatomi/
29,1 PLT 351
splenectomy
Lab 30/1/2013
Hb 7,3 leukosit 63.400 trombosit 3900
Lab 28/01/13
WBC 9,97 RBC 5,14 Hb 9,8 HCT 31,8 PLT 281
Lab 27/01/13
WBC 11,6 HB 9,4 HCT 31,4 PLT 359
Lab 24/01/13
CT/BT 7/2 PT/APTT 14,2/25,3 INR 1,19 Na 144 K 3,7 Cl 110
HBSag non reactive anti hcv non reactive. UR/CR 31/0,4 GOT/GPT
22/12 GDP 84 GD2PP 116 WBC 8,76 RBC 4,17 Hgb 7,1 HCT 24,4
PLT 319
Lab 21/01/13
FE:3 TIBC:289 Feritine:5,96
Lab 17/01/13
CT/BT 800/300, PT 13, UR/CR 25/0,4, GDS 177, GOT/GPT
21/14, Alb 3,6 Na/K/Cl 138/3,9/105
HbsAg (-) anti HCV (-) Malaria (-)
Lab 09/01/2013
WBC : 10,41 RBC : 4,46 HGB : 7,4 PLT 337
Lab 28/12/2012
WBC : 12,59 HGB : 8 PLT : 225 CT/BT : 800/300 PT/APTT :
13,1/25
CEA : 2,75
Na : 137 K : 4,7 Cl : 107
USG Abdomen 26/12/12
Kesan: Hepatosplenomegaly

17.

Junuhati
P/81
thn/582241
MRS
6/12/2012
JKM
Bed 2

POH
30
Laparotomy e.c.
Tumor
rectosigmoid
Stadium IV susp.
Malignancy
(3/1/13)

Foto BNO 26/12/12

Kesan: Fecal impacted susp metastasis Tu ke tulang
CT Abdomen lower pelvis 27/12/12
Kesan Splenomegaly dengan kista
Lab 29/1/2013
GDS 172 WBC 16,71 RBC 3,44 HGB 9,1 HCT 27,3 MCV 79,4 MCH
26,5 MCHC 33,3 PLT 280
Lab 27/1/2013
Albumin 2,6 WBC 13,7 RBC 1,9 Hb 5,1 HCT 15,9 PLT 297
Lab 16/01/13
WBC 7,45 RBC 2,78 HGB 7,5 HCT 23,4 PLT 281Alb 2,1 GDS 75
PA 4/1/2013
Jaringan omentum dan peritoneum yang mengandung sel-sel
tumor dengan gambaran adenocarsinoma musinosum
Lab 3/1/13
Na 143 K 9,9 Cl 105
Lab 2/1/2013
Na 136, K 2.3, Cl 100, Alb 2.7
Lab 1/1/2013
GDS 97, Ur 14, Cr 0.3, Na 134, K 2.1, Cl 98, Alb 2,7
Lab 30/12/2012
WBC 7,38 RBC 4,52 HGB 11,6 HCT 34,8 PLT 232 MCH 25,7 MCHC

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
33,3
Lab 28/12/2012
WBC 25 RBC 4.09 HBG 10.9 HCT 33.3 MCV 81 MCH 26.6 PLT 286
PT/APTT 12.3/29.4 GDS 123 Ur/Cr 6/0.3 GOT/GPT 38/12 Alb 2.3 Na
137 K 2.1 Cl 102
Echocardiography 19/12/2012
Kesimpulan:

Fungsi sistolik LV baik, EF 63%

Dimensi ruang jantung normal

Fungsi ventrikel kanan baik

Katup-katup fungsi dan pergerakan baik

Disfungsi diastolik
Lab 11/12/2012
CEA 82,45
CT Scan Abdomen Upper 7/12/2012

Sesuai gambaran Tu. Sigmoid

Fatty liver
USG Abdomen 6/12/2012
Tidak tampak kelainan radiologik

18

Sri Winarsi
P/48
thn/586868
MRS 03-12013

D/
Tumor colon
ascenden
Divertikulosis
Caecum

bed 3

Post op 5
hemicolectomy
dekstra

Foto Thoraks 6/12/2012

Kesan: Pulmo normal. Dilatatio aortae
Lab 25/01/2013
WBC 8,46 RBC 5,25 HGB 11,7 HCT 38,3 PLT 384

IL

Lab 23/01/2013
GDS 133 Ur/CR 12/0,6 GOT 16 GPT 9 Prot.total 6,1 Alb. 3,2 Na 137
k 3,9 Cl 105 CT 800 BT 2 PT 10,3 APTT 19 HBsAg No reaktiv
Anti HCV Non reaktiv WBC 8,65 RBC 4,39 MCV 72,7 PLT 380 HB
9,3 HCT 31,9
Lab 14/1/2013
WBC 12,02 RBC 5,17 HGB 11 HCT 36,6 PLT 503
UR/CR 12/0,7 GDS 66 GOT/GPT 17/7 CT/BT 70/20 PT/APTT
5,8/20,5
COLON IN LOOP (10/1/2013)
Tumor colon ascendens
Diverticulosis caecum
Lab (7/1/2013)
CEA 2,2

19

Marlian B.
P / 50 tahun/
588574
MRS 12-012013
Bed 4

D/
Tumor recti 1/3
distal

Lab (5/1/2013)
RBC 4,94 HGB 10,2 HCT 34,7 MCH 20,6 MCHC 29,3 PLT 338
Colon in Loop 29/01/2013
Sesuai dengan gambaran Ca. Recti 1/3 distal
Lab 25/01/2013
CEA 59,85 Ca-125 436,8
Lab 24/01/2013
WBC 10,41 RBC 4,46 HGB 7,4 HCT 26,3 PLT 337
Lab 12/01/2013
CT 830 BT 2 PT 10,4 APTT 21,9 GDS 101 UR 25 CR 1,3 Bil.total
0,37 Bil,Direct 0,17 GOT 64 GPT 33 Prot.total 6,2 Alb. 3,0 Globulin
3,2 Na 136 K 4,3 Cl 99 HBsAG (-) Anti HCV (-) WBC 6,8 RBC 3,82
HCT 31,7 MCV 83 PLT 368
Lab 17/01/2013
CEA 46,13 CA 19-9 530,2
Lab 23/01/2013
CEA 54,57
CT Scan Abdomen 29/12/2012
Massa ekstra lumen suspek limfoma
Cholestatis intrahepatik e.c kista caput pancreas

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013

20

Inadia
P/44
thn/579356
MRS
19/11/2012
JKM
Bed 5

D/ Tumor gaster
susp.
Malignancy

Hydronefrosis sinistra e.c suspek. Kinking ureter

Ascites
USG Abdomen ( 15/12/12)
Massa hypocondrium
dextra, suspek Tu. Extraluminer
(Mesenterium)
Slight Hepatomegaly
Hydronephrosis sinistra ec. Susp Obstruksi di level ureter
Tanda tanda inflames region adnexa Dextra
Ascites
MSCT Abdomen Tanpa Kontras ( 18/01/13)
Massa rectum
Hydronephrosis sinistra
Ascites
Foto Thorax PA ( 16/12/13)
Pulmo normal
Elongatio Aortae
Pleural reaction Dextra
Lab 27/01/13
WBC 12,79 RBC 4,05 Hb 10 HCT 33 PLT 531
Lab 24/01/13
WBC 9,66 RBC 3,61 HGB 9,1 HCT 30,0 PLT 558
LAB 21/01/2013
WBC 8,66 RBC 2,40 HGB 5,9 HCT 20,3 PLT 638
LAB 17/01/13
WBC 10,36 RBC 1,76 HGB 4,6 HCT 15,4 PLT 401
Lab 17/01/2013
Alb 2,9
Lab 13/01/13
WBC 8,92 RBC 2,83 HGB 7,4 HCT 24,1 PLT 296
Lab 9/1/2013
WBC 11.98, RBC 1.35, HGB 3.4, HCT 11.8, PLT 453
Lab 29/12/2012
WBC 8.3 PLT 476 MCHC 31.9 MCV 82 HCT 32.5 HGB 10.3 RBC
3.97 Ur/Cr 6/0.4 Alb 2.9 Na138 K 4.1 Cl 102
Lab 25/12/2012
GDS 86, Alb 2,2, Na/K/Cl 135/3,5/100
Foto OMD 11/12/2012
Kesan : Tu. gaster susp. malignancy
Lab 29/11/2012
HBsAg (-), Anti HCV (-), CEA 4,35
Echocardiography 27/11/2012
Kesimpulan : Kontraktilitas LV baik, EF 58%
Foto Thoraks 27/11/2012
Kesan: Susp. efusi pleura kiri. Elevasi diafragma kiri (proses
intraabdominal?)
USG Abdomen 22/11/2012
Kesan : Massa hipokondrium kiri susp. massa intraluminer colon
flexura lienalis-colon descendens. Ascites dan efusi pleura kiri
CT Scan Abdomen Lower Non Kontras 21/11/2012
Kesan : Tu. Gaster. Atelektasis paru kiri. Efusi pleura kiri
Foto Thoraks 19/11/2012
Kesan : Efusi pleura sinistra. Cardiomegaly

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
21

Sitti M. Koten
P/48
thn/581478
MRS
1/12/2012
JKM
Bed 6

D/ POH 31
Hartman
Prosedur ec.
Tu.
Retrosigmoid
(02/01/2013)

Lab 27/1/2013
HGB 10,3 WBC 11,34 RBC 4,03 Hb 10,3 HCT 32,2 PLT 298
Lab 24/01/2013
Albumin 2,6
LAB 21/01/13
Albumin 2,4 (hipoalbuminemia)
Lab 16/01/13
WBC 15,19 RBC 4,45 HGB 11,5 HCT 34,5 PLT 274 Alb 1,7 Ur/ Cr
10/ 0,4 GOT/ GPT 24/ 16 As. Urat 2,2 GDS 52
Lab (07/01/2013)
Alb 2.0, Prot.total 7.9
Lab (03/01/2013)
WBC 17.33, RBC 3.81, HB 9.3, HCT 28.3, PLT 252,
Lab 1/1/13
CT 730 BT 230 PT 14,6 INR 1,1 APTT 25,7
HBsAg (+), Anti HCV Negatif GDS 72 Ur 11 Cr 0,4 GOT 48 GPT 21
Alb 2,5
Lab 2/1/13
WBC 7,96 RBC 4,40 Hb 10,6 HCT 33,2 PLT 314
Lab 31/12/12
Albumin 2,6
Foto Colon In Loop 13/12/2012
Kesan: Tu. rectosigmoid susp. malignancy
Echocardiography 12/12/2012
Kesimpulan:

Fungsi sistolik LV & RV baik, EF 67%

LVH

Disfungsi diastolik

Efusi pericard minimal

MSCT Whole Abdomen Non Kontras 7/12/2012
Kesan: Massa para iliaca susp. limfoma
Lab 5/12/2012
GDS 72, CEA 4,07
USG Abdomen 1/12/2012
Kesan:

Susp. massa adneksa

Ascites

22

Mappangenre
L/51
thn/588899/
MRS
24/1/2013
JKM
Bed 1

Foto Thoraks 1/12/2012

Kesan:

Cardiomegaly disertai dilatatio et elongatio aortae

Tidak tampak tanda-tanda metastasis pada foto thoraks

ini
LONTARA ATAS DEPAN (BEDAH DIGESTIF) KAMAR 11
D/ Tu Recti 1/3 Lab 15/1/2013
tengah
Gds 85 ur/cr 25/0,8 GOT/GPT 22/27 HBsAg (-) Na 141 K 4,5 Cl 105
CT 800 CT 300 PT 10,4/11,2 APTT 24,5/25,4 WBC 13,57 HB 9,1
HCT 28,5 PLT 563
Echocardiografi 17/1/2013
Normal echocardiogram
CT-Abd Upper (tanpa kontras) 16/01/13
Kesan: massa rectum (DUKES A)
USG Abdomen 15/1/2013
Tidak tampak metastasis pada USG abdomen ini

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Massa rectum
Multiple renal cyst bilateral disertai hidronefrosis dan hidraureter
sinistra

23

Coang
dg.
Sese
L/59thn/58005
9
MRS
3/12/2012
JKM
Bed 2

D/
Post
Laparatomi ec.
Peritonitis
generalisata ec.
Perforasi
jejunum
dan
colon
transversum
hari
9
(21/1/2013)

Lab 28/1/2013
Na/K/Cl 128/3,6/97 WBC 5,34 RBC 3,66 HCB9,3 HCT 28,7 MCV
78,4 MCH 25,4 MCHC 32,4 PLT 102
Lab 23/01/2013
GDS 103 Alb 2,30 WBC 7,96 RBC 3,27 HB 8,4 HCT 26,6 PLT 180
Lab 22/01/2013
PT/APTT 12,8/31,5 GDS 150 Ur/Cr 22/0,30 GOT/GPT 18/9 Alb 2,0
Na/K/Cl 138/3,86/109 WBC 12,06 RBC 3,25 HB 8,0 HCT 25,7 PLT
256
Lab 21/01/2013
Na/K/Cl 130/3,9/99
Lab 20/1/2013
WBC 4,01 RBC 3,13 HgB 8,4 PLT 300 CT/BT 3,00/12,2 APTT
27,3 GDS 159 Ur/Cr 18/0,5 Bil.total 0,78 Bil.Direct 0,47 GOT/GPT
17/7 Albumin 2,4 HBsAg (+) Anti HCV (-)
PA (27/12/2012):
Kesimpulan: mesenchymal tumor kemungkinan suatu embrional
rhabdomyosarcoma.
Lab (15/1/13)
WBC 4,56 RBC 3,27 HGB 8,8 HCT 27,7 PLT 285
Lab (10/1/2013)
Prot. Total : 5,3. Alb 2,0. WBC 3,85. Hb 8,1. PLT 291.

24

Wari
L/67thn/59018
7
MRS
21/1/2013
Bed 3

25

Andi Jahiding
L/50
thn/558167
MRS
16/01/2013
Bed 4

D/
Tumor
Abdomen
Rencana colon
in loop dan CT
scan

Foto MD 7/12/2012
Kesan: Tu. gaster daerah antrum pyloric disertai ulcus susp.
Malignancy
Lab 31/1/2013
PH 7,48 PCO2 31,4 SO2 93,8 HCO3 24,1 C+O2 14,4 C+O2 20,6 BE
-0,3
Kesan alkalosis respiratorik
Lab 28/1/2013
GDS 83 Albumin 2,5
Lab 21/1/2013
CT:800 BT:200 PT:15,0 APTT:35,4 GDS:44 Ur:86 Cr:1,30
GOT:179 GPT:19 Pro.tot:3,56 Albumin:2,40 As.Urat:12,2 Na:140
K:4,24 Cl:108 HbSAg:- WBC:10,90 RBC:3,92 HGB:10,6 PLT:312

D/
Post
colostomy
e.c
Ca
Colon
(Hartman
Procedure)

USG Abdomen 21/1/2013

Kesan : Ascites. Efusi Pleura D
Lab 28/1/2013
CEA 4263

WS

Foto BNO 3 posisi 30/1/2013

Tanda-tanda localized ileus regio abdomen kiri bawah
Tanda
Lab PA12/07/2012
Adenocarcinoma rescti diferensiasi sedang yang telah infasi
hingga lemak serosa dan metastasis ke kelenjar regionaldengan
kedua ujung dengan kedua ujung reseksi dan jaringan 3 cm dari
distal bebas tumor
Foto thorax AP 16/01/2013
- Dilatatio et elongation aorta
- Elevasi kedua diafragma (proses intra abdominal DD/Inspirasi
Kurang )

10

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Lab 16/01/2013
CT/BT 8,00/2,00 PT/APTT 13,5/31,2 INR !,09 GDS 76 Ur/Cr
57/1,4 GOT/GPT 119/39 Protein Total 7,9 Albumin 3,0 Hep.B
negatif RBC 5,76 Hb 14,1 HCT 45,0 PLT 243 WBC 16,5
26

B. Dg Sija
58thn/L/58311
2
MRS
30/1/2013
Jamkesmas

D/ HIL (S)

Echo Cardiography 11/12/12

Fungsi sistolik LV baik, EF 71% disfungsi diastolik
Lab 10/12/2012
CT/BT 800/300 PT/APTT 10,8/28,4 GDS 98 Ur/Cr 17/1,3
GOT/GPT 18/7 HBSAg (-) Anti-HCV (-) WBC 6,34 RBC 4,43 HGB
13,1 PLT 259

27

Dg. Baco/L/68
thn/578218

D/ Tu. Recti 1/3

proximal

Lab 30/1/2013
CEA 4,40

MRS
27/01/2013

Lab 08/01/2013
CT 800 BT 300 PT/APTT 11/24,5 GDS 126 Ur/Cr 29/1 GOT 21
GPT 26 albumin 3,7 HbsAg (ICT) nonreactive, anti HCV (ICT)
nonreactive Na/K/Cl 138/4,2/102 WBC 7,0 RBC 3,97 HGB 12,3 HCT
36,1 MCV 91 MCH 31,0 MCHC 34,1 PLT 421

Bed 6

Foto BNO 8/1/2013

Suspek vesicolith
Foto thorax 8/1/2013
KP sinistra lama aktif
Elongatio aortae
Foto colon in loop 18/12/2012
Suspek massa rectum proximal
Lab 11/12/2012
Ur/Cr 34/1,0 GOT/GPT 27/28 Na/K/Cl 140/4,9/103 CT/BT 700/200
PT 10,0control 10,0 INR 0,83 APTT 23,9 control 25,5 WBC 8,6 RBC
4,27 HGB 13,2 HCT 37,7 MCV 88 MCH 30,9 MCHC 34,9 PLT 327

28

M. Arifuddin
L/60thn/58832
6MRS:11/01/1
3
Kmr B2/2 Bed
1

D/ Tu Colon
Ascendens
POH 2
hernikolektomi
dextra ec.
Tumor flexura
dextra

JL. Pelita
2
No.144 MKS

PALEM ATAS
Lab 30/01/2013
GDS 512 kolesterol total 201 kolesterol HDL 46 kolesterol LDL 67
trigliserida 239

IL

Lab 27/01/2013
WBC 9,74 RBC 4,79 HGB 12,8 HCT 40,9 PLT 380 ALB. 3,9 Na/K/Cl
141/3,92/102 HBSaG (-) Anti HCV (-) BT/CT 630/2,00 PT/APTT
11,2/26,6 GDS 377 Ur/Cr 20/0,8 GOT/GPT 21/29 Ptotein total 6,5
CT Abdomen Full Tanpa Kontras 23/01/2013
Tu. Colon Ascendens
Lab 11-1-2013
RBC 4,38, HGB 12,1, HCT 38.1, PLT 399, CT/BP 6/2 PT 10,2 APTT
27,3 GDS 201, Ur/Cr 19/0,8.,, HbsAg (-), Anti HCV (-), GOT/GPT
18/10, Na/K/Cl 143/4.4/107
USG Abdomen (11/01/13) :
Kesan: -Appendicitis susp Perforasi -Massa paraumbilicalis kanan
susp.
Lipoma
DD/
penebalan
otot
Hipertrofi
prostat
-Pelvocalyrctasis dextra
Urinalisa (11/01/13) :
Kesan: Tidak ada kelainan

29

Siti Nurbaya
P/68thn/58976

D/ Post Hartman
procedure
+

Colon in loop (17/01/13) :

Sesuai gambaran tumor colon ascendens
Lab 22/1/2013
GDS:76 Ur:42 Cr:0,7 GOT:25 GPT:12 Albumin:2,4 WBC:15,35

11

MR

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
9
B2 Kamar
Bed 1

Colostomy hari
11 (19/1/2013)
5

Kariango
DS
pananrang
pinrang/
jl.
Berua
raya
graha amalia
blok C no. 8
MKS
08524267588
4
Kristian
L/55/584662
MRS 18-01-13
B2/6 Bed 1
Jl. Kancil 3 No.
62 C palu

D/Cholelithiasis
Cholecystitis
Post op 5 open
cholecystectom
y

Boimin
L/52
thn/590452
Konsul
28/01/13

CKD stg V ec
nefropati
DM
post CAPD

B2/K 10

Nurmiah
P/41
587934
Konsul
27/01/13

th/

Yulianus julius
27thn/590048
MRS
31/01/2013

CKD stg V ec
nefropati DM
POH 2 CAPD

D/
perianal

Fistel

34

WS

Lab 27/01/2013
Ur/Cr168/8,4 WBC 6,49 RBC 2,58 Hb 7,6 HCT 22,5 PLT 135

Lab 26/01/13
PT/APTT 10,3/18,4

WS

Lab 26/01/2013
CT/BT 730/230 PT 10,5 APTT 23,2 GDS 253 Ur/Cr 57/4,7
GOT/GPT 15/20
Prot. Total 6,5 Alb 3,2 Na/K/Cl 130/3,57/98 WBC 6,45 RBC 2,9 Hb
7,8 HCT 23 PLT 345
Foto fistulografi 28/01/2013
Kesan : blind fistel
Foto thorax 25/01/2013
Kesan tidak tampak kelainan radiologik pada foto thorax ini

B2/9 Bed 1
DSN sabbang
loang
sassa
baebunta luwu
utara
08524242661
2
Yusuf Reli /

Lab 18-10-2013
GDS 94 Ur/Cr 29/1.0 Bil. Total 0.6 Bil. Direk 0.14 GOT/GPT 13/25
Protein Total 7.3 Albumin 4.3 Kolesterol Total 285 Na 143 K 3.9 Cl
107 CT 700 BT 300 PT 9.8 INR 0.82 APTT 24.5 WBC 7.73 RBC
5.58 HGB 16.3 HCT 49.1 PLT 308
Lab 30/1/2013
GDP 214 GD2PP 322

Lab 25/01/13
Fernitine 705,1

B2/K1 Bed 2
33

RL

Lab 26/01/13
GDS 275 GD2PP 469

Jl.
Prof.Abd
rauf tarimana
kendari
08528037956
3
32

Lab 18/01/2013
WBC 7,73 RBC 5,58 HGB 16,3 HCT 49,1 PLT 308 BT/CT
700/300 PT/APTT 9,8/24,5 Na/K/Cl 143/3,9/107 GOT/GPT 13/25
Prot.tot 7,3 Alb. 4,3 kolestrol.tot 288 GDS 94 Ur/Cr 29/0,1
BiL.total/direk 0,6/0,4
Foto Thorax 18-01-2013
Tidak tampak kelainan
CT Scan Abdomen Lower/Elvis 18-01-2013
Cholecystitis disertai cholelithiasis

08134035411
1

31

Lab 20/1/2013
CT:800 BT:200 PT:12,2 APTT:22,5
USG Abdomen 19/1/2013
Kesan: Ileus Obstruktif

MRS
19/01/2013

30

RBC:3,82 HGB:9,4 HCT:30,2 PLT:388

Lab25/01/2013
WBC 5,65 RBC 5,39 HGB 15,8 HCT 47,4 PLT 283 BT/CT
800/300 PT/APTT 11,2/27,3 Na/K/Cl 142/5,0/106 GDS 95 Ur/Cr
27/0,9 GOT/GPT 27/18 kolesterol tot. 164 trigliserida 66 as.urat
7,7
D/

appendicitis

12

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
L/43thn/
561927

infiltrat

MRS
01/2/2013
B2 km 12

35

Jl. DG. Hayo

No.
100
MKS/0813440
0712
Ir. Abdul Hafid
L/53/383654
MRS
31/1/2013

D/Susp Tu.Colon

B1 km 7

Lab 31/1/2013
HbsAg (-) AntiHCV(-) CEA 0,395 Na/K/Cl 135/3,9/108 GDS 119
Ur/Cr 19/1,1 GOT/GPT 15/11 Alb 4,4 CT 600 BT 300 PT/APTT
10,6/23,1 WBC 10,63 RBC 4,53 HB 13,6 HCT 41,2 MCV 90,9 MCH
30,0 MCHC 33,0 PLT 304

MR

Jl.
Lamumpatue
lalabata
soppeng
36

Belthia Bura
P/64
thn/589570
MRS:18-01-13
Kmr B1/9
Jl. H. Kalla II
campa
gaya
MKS

D/cholecystolithi
asis
+
splenomegaly +
efusi
pleura
sinistra
post
chest tube hari
12 + Suspek Tu
Colon

PALEM BAWAH
Lab 30/01/2013
WBC 5,6 RBC 3,91 HGB 11,1 HCT 34,6 PLT 91 GDS 120 Na/K/Cl
143/3,5/11,3 Alb. 2,6
Lab 28/01/13
WBC 3,12 RBC 3,2 Hb 8,7 HCT 27,8 PLT 72
PA 23/01/13
Mesotel proliferaktif + lesi inflamasi
Lab (26/01/13)
WBC 2,45 RBC 3,43 HB 9,2 HCT 29,7 PLT 81

08134223363
6

Colon In Loop 25/01/2013

Tu. Colon Ascendens
Foto Thorax 19-01-2013
Kesan : - Efusi pleura massif sinistra
- KP dextra lama tenang
Lab 18-01-13
WBC 3,0 RBC 3,37 HGB 9,2, HCT 29,0 PLT 77 CT/BT 700/230
PT/APTT 12,8/28,9 INR 1,0 GDS 143 Ur/Cr 19/0,7 Bil.total 0,8
Bil.Direct 0,3 GOT/GPT 25/13 Albumin 2,7 Kol.total 135 HDL 33
LDL 85 TG 85
Lab 15-1-2013
WBC 3,87 RBC 2,76, HGB 7,3, HCT 23,2, PLT 86, CT/BP 8/4 PT 15,0
APTT 36,3
Lab 09-01-13
CEA 7,15 Fe 11,2 TIBC 128,6

37

Yohana Labi
65
thn/P/590943
MRS
27/1/2013
Kmr B1/1

D/Cholelithiasis

Foto MSCT abdomen axial dengan rekontruksi multiplanar

tanpa kontras:
Kesan: -Efusi pleura kiri
-Cholethiasis
-Splenomegali
CT- Abdomen tanpa kontras 01/2/2013
- cholestasis ec. Batu pada ductus choledocus
- Hepatomegaly & kista hepar
- Sludge galbleder
- Susp. Massa portio uteri
- Efusi pleura bilateral
Lab 30/01/2013

13

IL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Kel.
Lemo
tator
komp.keuanga
n
blok.G
no.135 MKS
08529845046
4

38

Yohanis
lalang/60thn/L/
587959
MRS
25/1/2013

WBC 18,1 RBC 2,83 HGB 7,0 HCT 23,3 PLT 466 Alb. 2,2
Lab 27/1/2013
WBC 22,33 RBC 2,13 HGB 5,1 HCT 17,6 PLT 373 BT 800 CT 300
PT/APTT 15,5/31,5 GDS 105 Ur/Cr 11/0,6 Bil..tot 0,85 Bil.direct
0,60 GOT/GPT 19/11
Prot.tot 4,65 Alb 1,6 HbsAg (-) Anti HCV (-) Na/K/Cl 135/3,1/102
as.urat 1,5

D/cholelithiasis
+ duble system
+ batu ureter
1/3 proximal
D/
disertai
hedronefrosis

Komp.SDN
endtrop/bumi
sudiang jraja
blok E No. 11/
08525402110
6

39

Muhammad
Yusuf/L/33
tahun/
383892/ MRS
25-01-2013
B1/8
BTN kodam III
Blok
D3/13
sudiang
makassar

USG Abdomen
Choleliths dan choledocolith
Massa bawah rahim dd/prolaps uteri
Lab 09/01/2013
WBC 5,9 RBC 4,5 HGB 14,2 HCT 42,1 PLT 186 GDS 80 Ur/Cr 31/1,5
GOT/GPT 17/14 as.urat 75 BT/CT 300/800 PT/APTT 24,1
Na/K/Cl 140/4,1/109

MR

Foto thorax 09/01/2013

-soft tissue density susp.Tu. paru sinistra DD/ pneumonia
-bronchopneumonia
BNO-IVP 14/01/2013
Kesan nefrolith

D/ Trauma
tumpul
abdomen +
ruptur lien
Post
Laparotomy +
Splenoctomy VII

CT-Abdomen upper tanpa kontras 19/01/2013

Hidronefrosis D/ ec.ureterolith
Kista ginjal
Cholelith
Lab 31/01/2013
PH 7,31 pCO2 51,7 SO2 53,1 PO2 36,7 HCO3 23,4 ctO2 8,3 ctCO2
24,3 BE -0,8
Lab 30/01/2013
WBC 13,03 RBC 13,89 HGB 10,4 HCT 33,4 PLT 58 GDS 133 Ur/Cr
58/0,9 GOT/GPT 53/60 Alb. 3,8 Laktat darah 20 CRP kuantitatif 59
PT/APTT 11,1/19,0
FOTO THORAX 30/1/2013
Tanda-tanda edema paru sinistra
Fraktur costa IV-IX sinistra belakang
Thorax AP 28/01/13
Fraktur costa IV IX kiri belakang
Lab 28/1/2013
AGD: Alkalosis metabolik terkompensasi sempurna
Lab 27/01/13
WBC 12,6 RBC 3,93 Hb 10,8 HCT 34,3 PLT 87 Na/ K/Cl
144/3,92/108
CT/BT 730/230 PT/APTT 12/29,6 GDS 120 Ur/Cr 34/0,9
GOT/GPT 102/90
Alb 3,1 AGD : alkalosis metabolik
Thorax AP 26/01/13
Pneumonia dekstra
Edema paru + efusi pleura bilateral
Fr. Costa V-VIII kiri belakang
Lab 26/01/13
CT/BT 8/2 PT/APTT 15/25,4 Na/K/Cl 144/4,3/112
AGD:Asidosis metabolic GDS 117 Ur/Cr 28/1,2 GOT/GPT 86/73 Alb
2,2
WBC 10,83 RBC 2,02 Hb 5,7 PLT 50
USG Abdomen 25/01/2013
Kesan: Cairan bebas cavum peritoneum (hematoperitonium**)
CT Abdomen Lower/ Elvis (tanpa kontras) 25/01/2013
Kesan: Fraktur kosta posterior kiri disertai laserasi lien
Efusi pleura bilateral

14

MP

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Lab 25/01/13
WBC 25,54 RBC 2,47 Hb 7 PLT 100 GDS 246 Ur/Cr 29/1,8 GOT/GPT
296/287
Prot Total 7,1

40

Mardawiah
P/39
th/
588801
MRS
16/01/2013

POH 2
laparotomy
explorasi CBD
+T-tube
(op 30/1/2013)

LONTARA 1 ATAS DEPAN

Lab 28/1/2013
WBC 9,60 RBC 4,22 Hb 12,4 HCT 37,3 PLT 523 Bil.tot14,6 Bil.Dir
13,0 CT 7,00 BT 3,00 PT 10,3 APTT 20,3
Thorax 23/01/2013
Tidak ada kelainan
CT Scan Abdomen Upper 23/01/2013
Cholestatic intra dan ekstra hepatik e.c batu proximal CBD
Cholelithiasis
Lab 18/01/2013
RBC 3,20 HB 11,7 HCT 35,4 PLT 406 WBC 7,8
Lab 16/01/2013
GDS 90 UR/Cr 27/0,4 GOT/GPT 116/197 Hep.B (-) PT 9,8 INR 0,8
APTT 22,7 Bil.tot 13,8 Bil,Direk 11,01 Prot,total 6,4 Alb 3,6
Globulin 2,8 RBC 3,98 HB 12,5 HCT 38,1 PLT 428 WBC 10,7
USG Abdomen 16/01/2013
Cholelith
/
Cholestatik
intra
choledocolithiasis

dan

ekstra

hepatic

e.c

Lab 15/01/2013
HBsAg (-) Anti HCV (-) GDS 106 UR/CR 22/0,5 Bil. Total 9,3 Bil.
Direk 8,9 GOT/GPT 123/126 AFP 167 Pro.total 6,3 Alb 4 Globuli 2,3
Kolesterol tot. 3,4 LDL 296 As.urat 4,2 WBC 7,56 RBC 4,35 HB
13,2 HCT 39,3 PLT 454

41

Syamsuddin
L/56
th/
588709
MRS14/01/201
3
K1/III
Bed 3

Tu.Rectosigmoid
dan Tu. Colon
Ascendens
+
cholelithiasis +
nephrolithiasis

LONTARA I ATAS BELAKANG

Lab 30/1/2013
WBC 5,50 RBC 3,72 Hb 9,7 HCT 30,3 PLT 414 Alb 2,3 MCV 81,5
MCH 26,1 MCHC 32,0 PLT 414
Lab 25/01/2013
WBC 5.02; RBC 3.09;Hb 7.9; HCT 25.2; PLT 405; CT 800; BT
300; PT 11.5; INR 0.96; APTT 27.8; CEA 68.42; Albumin 2.2
CT Abdomen Lower/Elvis 23/01/2013
Tu. Sigmoid dan Tu. Colon Ascendens
Cholelith
Splenomegaly
Foto Thorax 23/01/2013
Suspek Tumor mediastinum superior kanan DD/ pelebaran vena
cava superior
Cardiomegaly disertai dilatation et elongation aortae
Bronchopneumonia bilateral
Tidak tampak tanda-tanda metastase pada foto thoraks ini
Colon in Loop 23/01/2013
Sesuai dengan gambaran Tu. Rectosigmoid dan Tu. Colon
Ascendens
Nephrolith
Lab 17/01/2013
RBC 3,95 HgB 10,8 HCT 33,0 PLT 380 WBC 3,1

15

RL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Lab 16/01/2013
RBC 3,62 HgB 9,6 HCT 30,5 PLT 365 WBC 3,6

42

Hariati
P/42thn/
587036
Konsul
4/01/2013
Kmr12
Bed 2

Lab 14/01/2013
Na/K/Cl 136/4,6/105 PT/APTT 12,0/24,1 HBsAg : (-) HCV (-) BT/CT
2/8 GDS 58 Ur/Cr 61/1,5 GOT/GPT 18/13 Alb 2,4 WBC 4,88 Hb 9,7
PLT 412
LONTARA 1 BAWAH BELAKANG
D/
POH
16 PA 21/1/2013
laparotomy
+ kesimpulan : Cholecystitis Kronik
eksplorasi CBD
ec.
Lab 25/01/2013
Choledocolithias
DHF (IgG dan IgM) Negatif; WBC 7.25; RBC 4.25; Hb 10.7; HCT
is
+
T-Tube 33.9; PLT 290
(16/01/13)
Cholegografi
Cholangiografi 23/01/2013
Ductus choledocus paten
Lab 23/01/2013
WBC 6.45; RBC 3.30; HB 9.6; HCT 29.3; PLT 344; Na 136; K 2.5; Cl
106; PT 12.1; INR 1.01; APTT 23.0; GDS 85; Ur 9.5; Cr 0.3; Bil. Tot
7.0; Bil. Direk 5.2; GOT 57 GPT 45; Alb 3.3
Lab 17/01/2013
GDS 115 Ur/Cr 14/0,4 GOT/GPT 156/166 Na 143 K 2,7 Cl 108 WBC
10,55 RBC 3,08 HgB 9,1 HCT 27,9 PLT 410
Lab 16/01/2013
Ct 7,00 BT 3,00 PT 11,2 APTT 25,0 INR 0,93 GDS 77 GOT/GPT
97/100 WBC 7,9 RBC 3,0 HgB 8,9 HCT 26 PLT 462
MSCT abdomen non kontras (8/1/13)
Kolestasis intra/ekstrahepatik susp.kista caput pankreas
Lab 04/01/2013
Alkali fosfatase : 281 protein tot. : 6,2 Alb :3,1 Gamma GT : 268
CA 19-9 : 2,2
USG abdomen 03/01/2013
Cholelith
Urinalisa 03/01/2013
Protein : 75/+++ Bilirubin : 6/+++ urobilinogen 4/++ nitrit (+)
blood : 25/++ lekosit : 25/+

43

Sakka
72Thn/588876
Kmr 12 bed 5
MRS
14/01/2013
Konsul
24/01/2013

D/ Tu. Recti 1/3

distal,
susp.
malignancy
Metastatic
hepar
Optimalisasi
dari
T.S.
Interna
Tunggu
hasil
PA rectum

Lab 03/01/2013
Bil. Total : 12,1 Bil. Direk : 11,7
RBC : 3,72 HGB : 11,2 PLT : 212 WBC : 8,6
PAKIS
Lontara II Bedah Urologi
Lab 27/01/2013
PT/APTT 11,4/24,3 Ur/Cr 16,3/0,9 WBC 7,08 RBC 4,34 Hb 11,2 HCT
35,7 PLT 289
Lab 25/01/2013
WBC 7,25 RBC 4,24 Hb 10,7 HCT 33,9 PLT 290
Foto Thorax 21/01/2013
KP Dupleks lama aktif
Atherosclerosis aorta
USG Abdomen 21/01/2013
Hipertrofi prostat
Cystisis
Lab 19/01/2013
RBC 3.51; HB 9.4; HCT 29.6; PLT 281
Lab 16/01/2013
WBC 7.48; RBC 2.53; HB 6.0; HCT 21.1; PLT 119; CEA 2946; PSA

16

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
7.70
MSCT Whole Abdomen
Tu. Recti dengan metastasis ke hepar (DUKES D)
44

45

Tn Abd Malik
L/67thn/58912
4
MRS
27/1/2013
K2/ Bed 4
Siti Kumiati
Konsul interna
(29/01/2013)
46tahun/P
589819
MRS
20/1/2013

D/HIM (D)

D/cholecystolithi
asis

Lab 16/1/2013
WBC 7,8 RBC 5,57 Hb 17,1 HCT 49,6 PLT 247 CT 700 BT 300
PT/APTT 9,2/26,2 GDS 131 Ur/Cr 15/1,0 GOT/GPT 28/25 Na/K/Cl
140/3,8/101 HbsAg (-) Anti HCV (-)
BNO IVP 23/1/2013
Kesan: Hidronefrosis (D) grade III-IV ec batu staghorn
BNO abdomen polos 28/1/2013
tidak tampak kelainan
CT Abdomen upper tanpa kontras 23/1/2013
Kesan : massa ginjal kanan susp RCC tumor metastasis ke tulang
Nephrolith (D)
Choelith

K11/ Bed 5

USG Abd 19/1/2013

Kesan choelith
Hydronephrosis dan nephrolith (D)
Thorax 19/1/2013
Kesan : Cardiomegaly dengan dilatatio et athelosclerotic aortae
Lab 29/1/2013
Na/K/Cl 139/3,8/109 CT 800 BT 300 PT 1300 APTT 24,5 Ur/Cr
30/1,4 Bil.Tot 0,2 Bil.Dir 0,1 Alkali fosfatase 82 As.urt 10,5 HCT
25,5 PLT 682 WBC 13,85 RBC 3,42 Hb 7,7

46

Markus kirin
L/46Th/588126
K12 B3
Konsul
13/1/2013

D/ POH 13
Laparotomi
Eksplorasi ec.
peritonitis +
drainase abses
hepar
generralisata
e.c Ruptur
Abses Hepar
W VIII

Lab 20/1/2013
GDS 109 Ur/Cr 30/2,0 GOT/GPT 15/9 Cal.Tot 150 HDL 25 LDL 118
TG 94
Lab 23/01/2013
WBC 11,75 RBC 2,75 Hb 8,2 HCT 25,7 PLT 313
Lab 22/1/2013
WBC:12,98 RBC:2,47 HGB:7,4 HCT:22,9 PLT:287
Lab 21/1/2013
GDS:118 Bil.tot:1,8 Bil.direk:1,5 GOT:666 GPT:280 Pro.tot:4,2
Albumin:1,6 Na:134 K:5,0 Cl:111 RBC 1,74 HGB 5,1 HCT 15,9
WBC 22,64 PLT 36
Lab 19/01/2013
RBC 1.83 HGB 5.9 HCT 18.6 PLT 600 WBC 61.2 GDS 60 Bil.tots 3,1
bil direct 2,6
CT- SCAN 17/01/2013
Hidronefrosis grade 4 ec nefrolith , Abses Hepar
Lab tgl 14/01/2013
Bilirubin Total 5 Bilirubin Direk 4,9 AFP 0,7
Hasil Lab Tgl 10/01/13
Alb 2,5 pt/apt 17,6/30,1 Na/K/Cl 133/4,6/102 Ur/Cr 37/0,8 wbc
36190 plt 166 Hb 13,5
USG 10/01/2013
Susp Hepatoma, Meteorismus, Nefrolith Bilateral +Pelvicaliectasis
D
Lontara II Ortopedi

47

Rina
P/45

Lontara II Bedah Onkologi

Lontara III THT
Lontara III Kulit
D/ Ca. Recti 1/3 PA 29/01/2013
distal, POH 8 Kesimpulan : adenocarcinoma musinomum

(adenocarcinoma

17

WS

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
thn/589259
MRS 19/01/13

biopsi
narkose

dalam

Kmr 1 Bed 1

diperensiasi sedang)
Lab 28/1/2013
CEA < 0,200
Lab 16/01/13
CT 7 BT 3 PT 9,8 INR 0,82 APTT26,2 NA 139 K 3,2 CL 106 GDS
96 UR 27 CR0,7 GOT 16 GPT 20 WBC 5,86 RBC 4,23 HGB 12,6
HCT 37,8 PLT 260S
CT Scan (17/01/13)
Tidak tampak gambaran tumor colon

48

Fitriani/p/32th
n/590200
MRS
22/1/2013
Km 1 bed 5

49

Chaeruddin
L/49th/586254
MRS 29-12-12
419 B

D/POH
2
laparatomi
Dikonsul dgn D/
appendicitis
infiltrat
D/
Wound
dehisersi
Post
Op
appendectomy

Thorax PA (16/01/13)
Tidak ada kelainans
Lontara III Mata
Lontara IV Obgyn
Lab 30/1/13
RBC 3,89 HGB 9,4 HCT 29,3 PLT 426 WBC 11,9
USG 22/1/13
Kesan slight hepatomegaly
RSP
Lab 15/01/13
Salmonella typhi : O : 1/ 80 H : 1/160
Paratyphi : AO : 1/160 AH : 1/320
BO : 1/320 BH : 1/80
CO : 1/320 CH : 1/80

IL

Lab 29/12/2012
WBC 15.12, RBC 3.92, HGB 10.9, HCT 34, PLT 567, CT/BT
700/230, PT/APTT 11.3/26.1, Ur/Cr 19/0,8, GOT/GPT 23/13,
GDS 134, Na/K/Cl 131/4.7/96, Alb 2,7 HbsAg(-), Anti HCV (-)
Lab 31/12/2012
WBC 11,23 RBC 3,84 HGB 10,8 HCT 32,4 MCV 84,5 MCH 28,1
MCHC 33,3 PLT 512

50

Kristianto
L/36 thn/6052
MRS
04/01/2013
Kamar 411 B

51

Sri Wahyuni
P/33thn/7298
MRS
02/01/2013
Kamar 401

D/
Fistel
perianal
Post
Colostomy
Pro
tutup colostomy
Businesi P/S
POH1
Fistelectomy
(30/1/2013)
D/
Ikterus
Obstruktif
e.c
tu.
Caput
pancreas
POH
9
Gastrojejunosto
my
+
Cholesistectomy
ec. Ca Caput
pankreas
whipple
prosedur

MSCT Abdomen 10/01/2013

Cholelithiasis Multiple + Efusi D
Nefrolithiasis bilateral (batu kecil)
Defek
subcutis
di
abdomen
kiri
bawah
(Mc
Burney)tidakberhubungan dengan usus di sekitar defect, abses
subcutis
Lab 14/1/2013
WBC 7,53 RBC 5,06 HGB 13,9 HCT 40,1 PLT 242 BT/CT 30/80
GOT/GPT 43,1/44,0 UR/CR 20,9/0,8

Lab 21/12013
Wbc : 18,68 RBC 3,43 hb : 10,7 HCT : 30,3 PLT : 148 Na:130 K:20
Cl:99 SGOT :78,2 SGPT:61,6 ur:12,8 cr:0,3 Bil.tot : 18,8 bil.direk :
15,3
Urin : 500cc/12 jam, BAB (+) warna kehijauan
EKG14/1/2013
Tidak inverse
Imunoserologi 02/01/2013
HbsAg (-)
Tumor Marker 03/01/2013
CA 19-9 : 357,5
ADT 03/01/2013
Kesan : Anemia normositik normokrom susp. e.c penyakit kronik
dengan leukositosis tanda inflamasi

18

WS

IL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
CT Scan Abdomen 04/01/2013
Kesan : - Kolestatik intra & ekstra hepatic e.c massa
caput pancreas. Susp. Ileus
Lab 04/01/2013
Alkali fosfatase : 590
MRCP tanpa & dengan kontras 08/01/2013
Kesan :
-Stenosis distal CBD, Susp. Massa caput pancreas
-Hepatosplenomegaly
52

Salmawati
P/45
thn/004262
Kmr 306

53

Tandi/L/48
tahun/7365
MRS 252013

01-

D/ Post op ec.
Tumor colon
Post
kemotherapi
siklus ke V
D/ Dyspepsia +
ileus obstruktif
parsial
susp
tumor gaster

Kmr 433

Lab 31/1/2013
WBC 5,47 RBC 3,67 Hb 10,1 HCT 30,7 MCV 83,7 MCH 83,7 MCHC
32,9 PLT 116 PCT 0,14 Na/K/Cl 138/4,0/104 GOT/GPT 37/21 GDS
128 Ur/Cr 15/0,5

WS

Foto OMD 29/1/2013

Tidak tampak kelainan radiologi pada foto omd ini

RL

Lab 26/01/2013
WBC 8,39 RBC 4,22 HGB 10,9 HCT 32,1 PLT 188
Lab 25/01/2013
WBC 7,97 RBC 3,82 HGB 9,9 HCT 29,3 PLT 166 Na 132 K 3,2 Cl
105 GOT 10,1 GPT 9,5 Prot.total 4,9 Albumin 2,45 Ur 18,4 Cr 0,44
MSCT Abdomen 09/01/2013
Kesan : efusi pleura bilateral
Thorax 07/01/2013
Kesan: normal

54

Salmin
L/46thn/5895
53
MRS17/01/20
13

D/ Cholesistolith
+ cholelithiasis
Tunggu jadwal
operasi

Kamar 218

USG Abdomen 05/01/2013

Kesan : gambaran ileus obstruktif
PCC
CT Abdomen lower/elvis (tanpa kontras) 23-01-13
Kesan:
-Distended GB dengan cholelyth ujung distal
-Tanda-tanda cholecystitis
Urin Rutin 18/1/2013
Warna kuning, Ph 8s,0 Sedimen Leukosit 0-1, Sedimen eritrosit
0-1, sedimen epitel sel 1-2
Lab 17/1/2013
PT/APTT 11,0/31,9 GDS 79 Ur/Cr 21/1,1 Bil.total 0,3 Bil.direk 0,1
GOT/GPT 19/35 Prot.total 4,2 Albumin 3,0 Kol.total 148 HDL 27
LDL 119 TG 81 WBC 14,0 RBC 4,28 HGB 12,8 HCT 39,0 PLT 417
HBsAg (-), anti HCV (-)

55

Ny. Asrin
L/591378
Kamar 219

D/susp.
Colelithiasis
+ nefrolithiasis
(D)

USG Abdomen 17/1/2013

Over distended GB dengan choleliths
Lab 31/1/2013
WBC 5,6 RBC 3,47 Hb9,6 HCT 29,4 MCV 85 MCH 27,8 MCHC 32,8
PLT 371 PCT 0,242
Urin rutin 31/1/2013
warna : kuning
PH
: 5,5
BJ
: 1,016
Protein : negatif
Bilirubin : negatif
Leukosit : ++++/500
Blood
:+-/5
Lab 30/1/2013
WBC 4,8 RBC 3,27 Hb 8,0 HCT 27,5 MCV 84 MCH 24,6 MCHC 29,3
PLT 450 PCT 0,277 GDS 122 Ur/Cr 18/1,0 Bil.total 0,53 Bil.direct
0,16 GOT/GPT 36/19 Albumin 3,8 Na/K/Cl 144/3,3/109

19

IL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
55

Muh. Nizam
L/35thn/5630
41
MRS11/12/20
12

Foto Thorax PA 29/1/2013

Pulmo cor dalam batas normal
Dilatatio aortae, susp atherosclerosis
PA 10/1/2013
Fistel dengan peradangan non spesifik

D/ POH 21
Laparotomi
eksplorasi e.c
fistel
enterocutaneus

IL

Lab 15/1/2013
WBC 6,4 RBC 3,99 HGB 11,5 HCT 34,8 PLT 256

Umum/Tunai

Lab 13/1/2013
WBC 4,0 RBC 3,02 HGB 8,6 HCT 26,3 PLT 151 ALB 2,33

Kamar 222

Lab 10/1/2013
WBC 12.52, RBC 2.90, HGB 7.8, HCT 24.8, PLT 237 CT/BT
800/300, PT/APTT 13.1/27.1, INR 1,09 Ur/Cr 76/1,2 GOT/GPT
48/25,
Lab 3/1/2013
WBC 11,3, RBC 4,52, HGB 12,1, HCT 37,2, PLT 580 CT/BT
700/300, PT/APTT 12,2/26,2, INR 1,0 GDS 174, Ur/Cr 79/1,1
GOT/GPT 13/22, Prot. Tot 6,9, Bil.tot 1,07, Bil.direct 0,27 Alb 4,5,
Na/K/Cl 145/4,4/94,
UGIE 18/12/2012
Kesan : Esofagitis candidiasis grade 2
Foto OMD 13/12/2012
Kesan : Fistel enterocutaneus

57

Margarina
Karoma
P/56thn/5878
89
MRS 8/1/13
Askes Wajib
Kamar 303

D/Tu.
Retro
peritoneum
POH
Laparotomi
explorasi
ileostomi
biopsi

3
+
+

Lab 12/12/2012
CT/BT 930/330, PT/APTT 12,5/30,4, GDS 97, Ur/Cr 91/1,5,
GOT/GPT 28/21, Prot. Tot 6,2, Alb 4,5, Na/K/Cl 145/4,8/93, HbsAg
(-), Anti HCV (-)
Lab 23-01-13
CT/BT 730/330 PT/APTT 12,6/23,5 GDS 99 UR/CR 13/0,3 GOT/GPT
18/7 Alb 3,1 Na/K/Cl 137/2,8/107 WBC 8,4 RBC 3,62 HGB 10,5 HCT
31,6 PLT 529
Foto Thorax PA 21/01/2013
Foto thorax PA (kurang inspirasi). Kesan : Lab 18/1/2013
Prot.total 6,4 Albumin 3,2 Na 132 K 3,2 Cl 104 WBC 6,5 RBC 3,65
HgB 10,5 HCT 31,9 PLT 392
PA 18/1/2013
Peradangan kronis tidak spesifik tidak ada sel-sel ganas
CT scan Abdomen 14-1-2013
Kesan: Massa pada daerah rectosigmoid disertai tanda-tanda ileus
obstruksi
Lab 13/1/2013
WBC 7,14 RBC 3,74 HGB 10,7 HCT 32,9 PLT 283
Lab(10/1/13)
WBC 27.2, RBC 3.45, HB 10.1, HCT 31.2 PLT 349, Alb 2.6
Lab(10/1/13)
Alb. 2,6
Lab(8/1/13)
WBC 9,42, RBC 3,20, HB 8,9, HCT 29,2 PLT 41,9 Ur 30 Kr 0,5, GOT
20 GPT 21 Na 127CL93 K 3,6
CT 8 BT 2 PT 12, APTT 24 GDS 68 alb 2,9 HbsAg (-), Anti HCV (-)
BNO 3 Posisi
Kesan : massa pelvis, Ileus paralitik
Thorax 8/1/2013
Kesan: aspek bronchitis

20

RL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
58

Damaris
Kamaro
P/85thn/5573
46
MRS 4/1/2013

D/ Tumor Colon
ascendens
POH
7
Hemicollectomy
Dextra

Askes Wajib
Kamar 321

Thorax PA 30/1/2013
Kesan Bronchopneumonia bilateral
Kardiomegali dengan dilatasi aortae
Lab 27/1/2013
WBC 3,59 RBC 3,43 Hb 10,2 HCT 31,0 MCV 90,4 MCH 29,7 MCHC
32,9 PLT 202 PCT 0,19 Ur/Cr 40/0,7
Lab 25/01/2013
CEA 3,16
Lab 23/01/2013
WBC 19.2; RBC 4.03; HB 12.3; HCT 37.3; PLT 347

WS

Lab 19/1/2013
WBC 8,1 RBC 4,2 HgB 12,4 HCT 37,9 PLT 251
LAB (17-1-2013)
PT 11,4 APTT 29,1 CT 800 BT 230
\Lab 15-1-2013
Alb 3,0
Foto thorax PA 18/1/2013
CVC terpasang baik
Bronkpneumoni
Cardiomegaly dengan dilatio aorta serta atherocschlerosis
aorta
Foto thorax PA (11-1-2013)
Kesan: Bronkopneumoni bilateral cardiomegaly dengan dilatasi
aortae dan atherosclerosis aortae
Lab 10/1/2013
WBC 4.6, RBC 2.83, HGB 9.1, HCT 27.6 PLT 271 HbsAg (-), Anti
HCV (-), CT/BT 800/200, PT/APTT 11.1/32.6, GDS 105, Ur/Cr
26/0.7, GOT/GPT 15/9, Alb 2.1
Lab 5/1/2013
WBC 8.8, RBC 3.61, HGB 11.4, HCT 35.2, PLT 435 GDS 114, Ur/Cr
39/0.8, GOT/GPT 15/17, Alb 2.79, Na/K/Cl 140/4.5/109.

59

Tn Djamading
L/57thn/
591239
Kmr 306

D/HIL (D)
Rencana operasi
Jumat 1/2/2013

60

Tarpin Adam
L/52thn/5879
06
MRS 8/1/2013

D/
ileus
obstruktif
parsial+
cholesistolith +
cholesistitis

Askes Wajib
Kmr 410

POH
3
kolesistektomi

Kolonoscopi RS Medistra 4/10/2012

Kesimpulan: polip sigmoid dan tu.caecum
Lab 29/1/2013
WBC 8,7 RBC 5,46 Hb 15,7 HCT 47,0 MCV 86 MCH 28,7 MCHC
33,4 PLT 307 PCT 0,244 CT 800 BT 300 PT/APTT 9,8/25,4 GDS 96
Ur/Cr 28/1,1 GOT/GPT 20/26 Alk.Fosfatase 105 kol.total 202
as.urat 6,7
Foto Thorax PA 29/1/2013
Kesan DBN
Lab 19/1/2013
Kol.total 149 HDL 21 LDL 105 TG 117
Lab (17/1/2013)
WBC 11,5 RBC 4,47 HGB 13,8 HCT 42,4 PLT 505 PT 11,9 APTT
28,9 GDP 108
CT scan abdomen (14/1/2013):
Kesan: Efusi pleura bilateral, cholecystolith akut, meteorismus
Foto Thorax 9/1/2013
Tidak tampak kelainan
Foto polos abdomen 3 posisi 9/1/2013
Kesan: ileus paralitik
Lab 9/1/2013
WBC 20.30, RBC 4.87, HGB 14.8, HCT 43.4, PLT 228 GDS 125,
Ur/Cr 31/0.9, GOT/GPT 28/38, Alb 3.4, Na/K/Cl 133/4.0/99, HbsAg
(-) Anti HCV (-)

21

IL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
61

Ernawaty / 48
tahun / P /326
MRS
28/01/2013

D/ Polip Recti
POH
Polipektomi

Lab 28/1/2013
WBC 8,4 RBC 4,32 HGB 11,9 HCT 36,0 PLT 377 BT/CT 300/700 PT
9,7 INR 0,8 APTT 21,3 GDS 169 Ur/Cr 14/0,7 GOT/GPT 28/42
Prot.Total 6,9 Alb 3,8 Na/K/Cl 141/2,9/104 HbsAg non reactive
Lab 17/1/2013
CEA 2,19
Foto Thorax 29/1/2013
kesan DBN

62

Tn. Rachmat
Muchtar
L/27thn/0064
64
MRS
31/1/2013

D/susp
Abdomen

Tu.

USG Abdomen 31/1/2013

Kesan : tanda-tanda invaginasi disertai cairan disertai cairan
bebas pada cavum
peritoneum

Kmr 403

63

64

Massetang
L/43thn/
591637
MRS
30/1/2013
Soppeng
08114135810
(Nadia)
Julius
Ronaldo
L/50thn/5916
67
MRS
30/1/2013
JKD

Lab 31/1/2013
CT 800 BT 300 PT 16,3 APTT 31,15 Ur/Cr 17/0,91

Foto BNO 31/1/2013

Kesan soft tissue mass rongga abdomen kanan

D/ Tu Recti 1/3
distal
Rencana colon in
loop
Senin 4/2/2013

foto thorax PA 31/1/2013

kesan : KP duplex lama aktif disertai pleural reaction bilateral
UGD
Lab 30/1/2013
PT/APTT 11,8/23,2 CT/BT 700/200 GDS 103 Ur/Cr 15/0,7
GOT/GPT 23/17 Alb 4 Na/K/CL 144/4,76,107 HbsAg(-) RBC 4,4 HB
13,6 HCT 41,4 PLT 437 WBC 7,6
USG abdomen 30/1/2013
Tidak tampak tanda-tanda metastasis
Tidak tampak tanda-tanda dilatasi loop-loop usus
Massa rectum sulit dievaluasi

D/Tu.Anorectal

Lab 30/1/2013
CT/BT 930/830 PT 9,3 APTT 33 GDS 97 Ur/Cr 16/0,8 GOT/GPT
59/25 Alb 2,5 Na/K/Cl 135/4,5/107 HbsAg (-) WBC 8,73 RBC 4,85
HB 13,7 HCT 42 PLT 325

Lab 1/2/13
CT/BT 8/3 PT 11,6 APTT 21,6 GDS 101 Ur/Cr 12/0,6 GOT/GPT
50/39 Alb 3,1
Na/K/Cl 141/3,7/102 HbsAg (-) RBC 3,36 Hb 9,8 HCT 30,5 PLT 452
WBC 11,3

Jl.
Siratal
Mustakim
No.9,
Parepare
Yuli(0812427
28658)
Ambo(081343
662986)
65

Senahati
P/38th/59191
6
MRS1/2/13
Desa Ambapa
Hasna(08522
9346190)

D/ Tu Abdomen

66

Gede
Putra
Astaman
L/590280
MRS
23/1/2013

D/
Post
Debridement
Trauma Tumpul
Abdomen
+
Trauma tumpul
thoraks hari 10
(23-01-2013)
Vulnus
Excoriatum
Regio
Flank
Sinistra

ICU VIP 1
Kayu
Calla
Mamuju
Ni Wayan E
08534998268
9

ICU
Lab 30/1/2013
PT 12,1 APTT 23,5 INR 1,01 Na/K/Cl 132/4,8/99 Ur/Cr 43/0,6 Alb 3
WBC 14,55 RBC 3,62 Hb 10,2 HCT 31,7 PLT 304
Lab 28/1/2013
AGD : Alkalis metabolik terkompensasi sempurna
Lab 27/1/2013
GDS 109 Ur/Cr 33/0,8 GOT/GPT 51/34 Alb 2,2 Na/K/Cl
142/3,87/103 WBC 16,33 RBC 381 Hb 11,2 HCT 35 PLT 253
Foto Thorax AP (25/01/2013)
Kesan: contusio paru bilateral + old fract. 1/3 middle

22

RL

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013
Lab (25/01/2013)
AGD: asidosis respiratorik GDS 105 Ur/Cr 48/0,8 GOT/GPT 89/41
Alb 2,5 Na/K/Cl 145/3,9/109 WBC 11,13 RBC 3,98 HB 11,5 HCT
34,7 PLT 154

67

Sabella
P/19thn/5899
00
JKD
ICU Bed 9

D/ Post reseksi
anastomose
ileum
ec.
Valvulus
ileum
hari
12
(21/1/2013)

Lab 23/01/2013
CT/BT 8/3 PT /APTT 14,3/30,8 GDS 89 Ur/Cr 49/1,2 GOT/GPT
115/43 Prot Total 5,9 Alb 2,4 Na 140 K 3,4 Cl 109 Wbc 12,6 RBC
3,53 HB 10,2 HCT 30,8 PLT 146
USG ABDOMEN 23/01/2013
Tidak tampak tanda tanda laserasi organ intraabdomen
Efusi pleura dextra
Lab 1/2/2013
WBC 2,25 RBC 3,9 Hb 10,3 HCT 32,5 PLT 43
Lab 31/1/2013
AGD Alkalosis metabolik dan respiratorik (mixed vein)
WBC 2,34 RBC 3,5 HB 9,2 HCT 30,7 PLT 57
PA 23/1/2013
Peradangan kronik nonspesifik (sesuai perforasi)

Bulurokeng
08134240049
3

Lab 30/1/2013
AGD DBN
Lab 27/1/2013
PT/APTT 183/38,2 INR 1,42 GDS 136 Bil.tot 2,04 GOT/GPT
1459/266 Alb 2,4 Na/K/Cl 153/4,19/115 WBC 5,96 RBC 2,73 Hb 7,2
PLT 39
Thorax 27/1/2013
Pulmo normal
Cardiomegali

68

Marawiah/P/5
5
tahun/
596065
ICU bed 10
Konsul
25/1/2013
Lekoboddong,
Pangkep
08539789838
4

D/ POH5
laparotomy
explorasi ec
perforasi sigmoid
+tumor
rectosigmoid

Lab 29/1/2013
WBC 6,77 RBC 3,72 Hb 10,3 HCT 32,1 PLT 66
Lab (26/01/2013)
Jam 08.59 HB 5,7 transfusi WB 2 bag HB 8,2 transfusi PRC
2 bag HB 11,3
WBC 10,57 RBC 4,04 HCT 35 PLT 101 CT/BT 700/300 PT/APTT
12,7/29,2 GDS 106 Bil.tot 0,41 Bil.direk 0,19 GOT/GPT 101/83 Alb
1,8 Na/K/Cl 143/6,5/15
Foto Thorax AP (26/01/2013)
Kesan: pneumonia (D), edema paru + efusi pleura bilateral,
fr.coastae V-VIII kiri belakang
Lab 22/1/2013
WBC:11,8 RBC:4,29 HGB:11,9 HCT:36,3 PLT:490 GDS:114 Ur:50
Cr:1,0 GOT:30 GPT:17 Albumin:1,7 Na:136 K:3,6 Cl:100
Lab 21/1/2013
CT:700 BT:300 PT:11,9 APTT:19,0
BNO 3 posisi 21/1/2013
Kesan : Dilatasi loop-loop usus disertai tanda- tanda ileus
obstruktif. Fecal mass pada level colon ascendens
USG Abdomen 20/1/2013
Kesan : Cairan bebas minimal intraperitonium. Dilatasi loop loop
usus dengan peristaltic yang meningkat. Apendicitis belum dapat
disingkirkan.
Lab 30/1/2013
GDS 135 Ur/Cr 39/0,6 GOT/GPT 19/7 Alb 2,7 Na/K/Cl 148/3,2/106
WBC 22,87 RBC 3,12 Hb 9 HCT 28,1 PLT 327
Lab 28/1/2013
AGD : asidosis respiratorik
lab 24/1/2013
WBC 24,03 RBC 3,77 Hb 11,3 HCT 33,4 PLT 291 Ur/Cr 38/1,3
GOT/GPT 24/4 Na/K/Cl 140/3,4/104 HbsAg (-)
BNO 3 posisi 24/1/2013
Sesuai gambaran ileus paralitik
Lab 25/1/2013
CT/BT 8/2 PT/APTT 14,6/27,6 GDS 110 Alb 3,0
Thorax AP 25/1/2013
Pneumoperitoneum

23

KORAN BEDAH DIGESTIF SABTU, 2

FEBRUARI 2013

69

Pattaungang/
L/42 tahun
ICU Bed 3

69

Husain/L/70th
n
590926
MRS 26/01/13
HCU Bed 3
Jl. Kapasaraya
No. 25 B Mks
08139247883
9
Husmawati

D/ POH 8
hemicolectomy
ec Tu colon
ascendens

POH3
laparotomy
explorasi ec tu.
Sigmoid dukes A

Pneumonia D/
Cardiomegaly +dilatatio aortae
Lab 26/1/2013
WBC 7,52 RBC 3,37 Hb 9,6 HCT 30,3 PLT 253 GDS 153 Ur/Cr
35/0,9 GOT/GPT 15/5 Alb 1,5 Na/K/Cl 142/3,1/115
Thorax AP 27/1/2013
Cardiomegaly + tanda-tanda bendungan paru
Dilatatio et Elongatio Aortae
Elevasi diafrgama kanan
Lab 27/1/2013
AGD asidosis metabolik
WBC 7,52 RBC 3,37 Hb 9,6 HCT 30,3 PLT 253
Thorax AP 30/1/13
Kesan : Pneumonia D/
Lab 31/1/13
AGD : dbn
Lab 29/1/13
GDS 99 Ur/Cr 36/0,6 GOT/GPT 33/16 Alb 2,3 Na/K/Cl 144/ 3,7/110
WBC 10,56 RBC 3,61 Hb 9,3 HCT 27,9 PLT 183
Lab 27/1/13
GDS 156 Ur/Cr 37/0,7 GOT/GPT 41/27 Alb 2,2 Na/K/Cl 147/4,5/116
WBC 19,44 RBC 5,21 Hb 13,3 HCT 39,6 PLT 224
Lab 23/1/13
CEA 1,32
Lab 23/1/2013
CT/BT 800/230 PT/APTT 14,8/27,7 INR 1,19 Na 129 K3,8 Cl 103
CEA Menyusul GDS 129 UR/CR 40/0,8 GOT/GPT 11/10 Prot Tot 5,6
Albumin 2,4 Globulin 3,2 WBC 9,60 RBC 3,48 HGB 8,3 HCT 25,3
PLT 574
Foto Thorax (23/01/2013)
Dalam batas normal
USG Abdomen (21/01/2013)
Suspect massa pada colon ascenden DD/ Appendicitis Kronik
CT Scan Abdomen Lower/Elvis (Tanpa kontras)(21/01/2013)
Massa colon ascenden denga suspek metastases ke hepar
LAB (22/01/2013)
GDS 109, Prot Tot 5,78 Albumin 2,68 Globulin 3,10
LAB (21/01/2013)
GDS 130 UR/CR 36/0,9 GOT/GPT 11/10 WBC 9,9 RBC 4,01 HGB 9,4
HCT 30,2 PLT 901
Lab 30/1/2013
GDS 100 Ur/Cr 24/0,6 GOT/GPT 29/17 Alb 2,1 Bil. Total 1,21
Na/K/Cl 136/4,6/107 Bil.direk 0,69 WBC 10,35 RBC 4,45 HB 12,3
HCT 37 PLT 331
Thorax 30/1/2013
Pleural reaction dekstra
Elevasi diafragma dekstra
Lab 29/1/2013
CT/BT 8/4 PT/APTT 10,5/24,3 Alb 3,4 Na/K/Cl 13,8/4,75/102 RBC
4,36 HB 11,5 HCT 37,3 PLT 527 WBC 6,8
Thoraks 27/01/2013
Kesan : Pleural reaction dextra, dilatatio et elongatio aortae,
elevasi diafragma kanan (proses intraabdominal)
BNO 3 posisi 27/01/2013
Kesan : Gambaran ileus paralitik
Lab 26/01/2013
WBC 7,11 RBC 4,48 Hb 11,7 Hct 37,2 PLT 520 CT 800 BT 300 PT
11,1 APTT 23,4 GDS 99 Ur/Cr 44/0,9 GOT 34 GPT 25 Prot.tot 6,4
Alb 3,5 Glob 2,9 Na 136 K 4,0 Cl 102 HbsAg (-) Anti HCV (-)

24