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Koran Diges Bedah
Koran Diges Bedah
FEBRUARI 2013
NO.
IDENTITAS
Marawiah/P/5
5
tahun/
596065
BED 1
Konsul
25/1/2013
Lekoboddong,
Pangkep
08539789838
4
Kadek
Rosmiati
P/22thn/5885
77MRS19/01/
2013
BED 2
DIAGNOSIS
PEMERIKSAAN PENUNJANG
LONTARA II ATAS DEPAN (BEDAH DIGESTIF) KAMAR 1
D/ POH 6
Lab 30/1/2013
laparotomy
GDS 135 Ur/Cr 39/0,6 GOT/GPT 19/7 Alb 2,7 Na/K/Cl 148/3,2/106
explorasi ec
WBC 22,87 RBC 3,12 Hb 9 HCT 28,1 PLT 327
perforasi sigmoid Lab 28/1/2013
+tumor
AGD : asidosis respiratorik
rectosigmoid
lab 24/1/2013
WBC 24,03 RBC 3,77 Hb 11,3 HCT 33,4 PLT 291 Ur/Cr 38/1,3
RENCANAPINDAH GOT/GPT 24/4 Na/K/Cl 140/3,4/104 HbsAg (-)
PERAWATAN L2
BNO 3 posisi 24/1/2013
AD KM 1
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
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
D/
POH
7 Lab 25/1/2013
Laparotomy
Na 128 K 4,0 Cl 97 GDS 86 Ur/Cr 22/0,4 GOT 79 GPT 49 Albumin
Explorasi
+ 2,1
Jejunostomy ec
tu.
Lab 21/1/2013
rectosigmoid+co
Na:139 K:4,4 Cl:105 AFP:1,04 CEA:38,87 Ca-125:75,08 Alkali
lon transversum
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
Senahati/P/
39thn/
591916
MRS
01/02/2013
D/ Tu. Abdomen
BED 3
D/POH
4,
colostomy
ec.
Tumor Colorectal
Jawaban
Konsul Obgyn
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
Ket/PJ
aff
Desa mekar
sari, konawe
08524164119
8
(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
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 operasi
hari
senin Colon in Loop (17/1/13)
(4/2/2013)
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
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
RL
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
Jl.
Jambu
P.Kemerdeka
an 12
No.telp
08219169912
0
Jampi
L/47thn/5908
83
MRS 26/01/13
Bed 2
Km 12 masuk
kota Sorong
No.telp
08525467194
3
Ansar
dg.Haseng
L/47thn/5822
37
MRS
14/1/2013
Bed 3
Jl.Barawaju II
Panakukkang
MKS
No.telp
08234775717
4
Hematokhezia +
hemoroid
externa grad II.
Selesai
colonoscopy
awal bros
di
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
USG Abd 26/01/13
Kesan: kista hepar & kista ginjal bilateral
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
Lab 25/01/2013
CEA 0,638
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
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
IL
10
Salang
L/35thn/5727
18
MRS10/01/20
13
Bed 4
D/
Achalasia
Esofagus,
hipokalemi
operasi
hari
selasa 4/2/2013
Jl.
Laupa
Sersang
No.telp
08219067532
0
11
Hugo Donald
L/40th/582008
/
MRS 13/01/13
JAMKESMAS
Bed 1
Sillanan
Gadang Batu,
Toraja
08135501121
3
klatskin
RL
12
Basri
L/40thn/5820
34
MRS20/12/20
12
D/
POH
XVII
Miles Procedure
ec. Ca Recti
JAMKESMAS
BED 2
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
13
Tajuddin / L /
48
tahun/
591678
MRS
2013
D/
post
op
Laparatomi
explorasi hr keXVII
e.c.
perforasi
appendicitis ?
30-01-
Bed 3
Lampa Timur,
Pinrang
08234726548
5
14
Katanang
P/45thn
POH
laparatomi/
splenectomy
Bosa,
desa
lare,
palopo/
08125849460
4
Lab 29/1/2013
WBC 68,47 RBC 3,34 HGB 6,5 HCT 22,3 MCV 66,8 MCH 19,5 MCHC
29,1 PLT 351
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
15.
Junuhati
P/81
thn/582241
MRS
6/12/2012
JKM
Bed 2
Kab.
Wajo
desa
inrelo
kampung
longka
POH
31
Laparotomy e.c.
Tumor
rectosigmoid
Stadium IV susp.
Malignancy
(3/1/13)
Disfungsi diastolik
Lab 11/12/2012
CEA 82,45
CT Scan Abdomen Upper 7/12/2012
Fatty liver
USG Abdomen 6/12/2012
Tidak tampak kelainan radiologik
16
Sri Winarsi
P/48
thn/586868
MRS 03-12013
D/
Tumor colon
ascenden
Divertikulosis
Caecum
bed 3
Post op 5
hemicolectomy
dekstra
minasa upa
blok L/18 /
08135421224
4
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
Lab (5/1/2013)
RBC 4,94 HGB 10,2 HCT 34,7 MCH 20,6 MCHC 29,3 PLT 338
17
Marlian B.
P / 50 tahun/
588574
MRS 12-012013
Bed 4
Gorontola kab.
Pokuanto
dusun tengah
desa dudeulo/
08219357274
6
D/
Tumor recti 1/3
distal
Lab 30/01/2013
WBC 40,35 RBC 3,73 HGB 9,2 HCT 28,3 PLT 724 Ur/Cr 64/1,6
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
Hydronefrosis sinistra e.c suspek. Kinking ureter
Ascites
USG Abdomen ( 15/12/12)
Massa hypocondrium
dextra, suspek Tu. Extraluminer
18
Inadia
P/44
thn/579356
MRS
19/11/2012
JKM
Bed 5
Dusun
solo
tengah
desa
bina baru RT
1/RW 1 kec.
Kulo/
08534250771
6
D/ Tumor gaster
susp.
Malignancy
(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 01/02/2013
WBC 33,57 RBC 2,43 HGB 5,9 HCT 19,7 PLT 780
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
Sitti M. Koten
P/48
thn/581478
MRS
1/12/2012
JKM
Bed 6
D/ POH 32
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:
LVH
Disfungsi diastolik
Ascites
20
Mappangenre
L/51
thn/588899/
MRS
24/1/2013
JKM
Bed 1
Abbaliangge,
soppeng/
08529845299
9
21
Coang
dg.
Sese
L/59thn/58005
9
MRS
3/12/2012
JKM
Ongkoa, desa
laikan,
,angarabomba
ng, takalar
D/
Post
Laparatomi ec.
Peritonitis
generalisata ec.
Perforasi
jejunum
dan
colon
transversum
hari
12
(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
Bed 2
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.
22
Wari
L/67thn/59018
7
MRS
21/1/2013
Bed 3
D/
Tumor
Abdomen
Rencana colon
in loop dan CT
scan
Padang
sappang,
palopo/
08525487657
5
23
Andi Jahiding
L/50
thn/558167
MRS
16/01/2013
Bed 4
Pattukulimpoe,
kec.
Lapriaja
kab.bone/
08524083184
6
Foto MD 7/12/2012
Kesan: Tu. gaster daerah antrum pyloric disertai ulcus susp.
Malignancy
Lab 02/2/2013
WBC 14,60 RBC 4,08 HGB 11,7 HCT 35,0 PLT 178 GDS 83 Ur/Cr
74/0,9 Alb.2,2
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)
WS
10
B. Dg Sija
58thn/L/58311
2
MRS
30/1/2013
Jamkesmas
D/ HIL (S)
Lab 30/1/2013
CEA 4,40
Borong
raya
Lr.
Batua
manggala/
08234823718
3
25
Dg. Baco/L/68
thn/578218
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
Jl.tamalalang
26
M. Arifuddin
L/60thn/58832
6MRS:11/01/1
3
Kmr B2/2 Bed
1
JL. Pelita
2
No.144 MKS
D/ Tu Colon
Ascendens
POH 3
hernikolektomi
dextra ec.
Tumor flexura
dextra
PALEM ATAS
LAB 01/02/2013
WBC 16,27 RBC 4,48 HGB 12,1 HCT 36,3 PLT 387
IL
Lab 30/01/2013
GDS 512 kolesterol total 201 kolesterol HDL 46 kolesterol LDL 67
trigliserida 239
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
11
27
Siti Nurbaya
P/68thn/58976
9
D/ Post Hartman
procedure
+
Colostomy hari
11 (19/1/2013)
B2 Kamar
Bed 1
RENCANA
PULANG
28
B2/6 Bed 1
Jl. Kancil 3 No.
62 C palu
D/Cholelithiasis
Cholecystitis
Post op 6 open
cholecystectom
y
Boimin
L/52
thn/590452
Konsul
28/01/13
CKD stg V ec
nefropati
DM
post CAPD
B2/K 10
31
Nurmiah
P/41
587934
Konsul
27/01/13
th/
B2/K1 Bed 2
Yulianus julius
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
RL
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 01/02/2013
WBC 5,45 RBC 3,52 HGB 10,2 HCT 29,2 PLT 136
WS
Lab 30/1/2013
GDP 214 GD2PP 322
Lab 27/01/2013
Ur/Cr168/8,4 WBC 6,49 RBC 2,58 Hb 7,6 HCT 22,5 PLT 135
Jl.
Prof.Abd
rauf tarimana
kendari
08528037956
3
30
Lab 20/1/2013
CT:800 BT:200 PT:12,2 APTT:22,5
08134035411
1
29
MR
MRS
19/01/2013
Kariango
DS
pananrang
pinrang/
jl.
Berua
raya
graha amalia
blok C no. 8
MKS
08524267588
4
Kristian
L/55/584662
MRS 18-01-13
Lab 26/01/13
GDS 275 GD2PP 469
CKD stg V ec
nefropati DM
POH V CAPD
D/
Fistel
Lab 25/01/13
Fernitine 705,1
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
12
perianal
B2/9 Bed 1
32
DSN sabbang
loang
sassa
baebunta luwu
utara
08524242661
2
Yusuf Reli /
L/43thn/
561927
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
infiltrat
MRS
01/2/2013
B2 km 11
33
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
34
Belthia Bura
P/64
thn/589570
MRS:18-01-13
Kmr B1/9
Jl. H. Kalla II
campa
gaya
MKS
08134223363
6
D/cholecystolithi
asis
+
splenomegaly +
efusi
pleura
sinistra
post
chest tube hari
13 + Suspek Tu
Colon
PALEM BAWAH
LAB 01/02/2013
WBC 5,6 RBC 4,18 HGB 11,8 HCT 36,7 PLT 98 HBSAg (ICT) (-) Anti
HCV (ICT) (-)
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
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
13
IL
35
Yohana Labi
65
thn/P/590943
MRS
27/1/2013
D/Cholelithiasis
Kmr B1/1
Lab 30/01/2013
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
Kel.
Lemo
tator
komp.keuanga
n
blok.G
no.135 MKS
08529845046
4
36
Yohanis
lalang/60thn/L/
587959
MRS
25/1/2013
D/cholelithiasis
+ duble system
+ batu ureter
1/3 proximal
D/
disertai
hedronefrosis
B2 Km 6
Komp.SDN
endtrop/bumi
sudiang jraja
blok E No. 11/
08525402110
6
37
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
D/ Trauma
tumpul
abdomen +
ruptur lien
Post
Laparotomy +
Splenoctomy VIII
14
MP
38
Mardawiah
P/39
th/
588801
MRS
16/01/2013
POH 3
laparotomy
explorasi CBD
+T-tube
(op 30/1/2013)
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
39
Syamsuddin
L/56
th/
588709
MRS14/01/201
3
K1/III
Bed 3
Almt. babarura
D/ Tu. Colon
ascendens + Tu.
Rectosigmoid
15
RL
40
SAHRI/
L/
15thn/ 591421
MRS
01/02/2013
Tangatanga,
majene/
08234947090
7
41
Supardi/L/
47thn/ 587047
MRS
03/01/2013
D/
hepatomegaly +
splenomegaly
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
MSCT whole abd. 31/01/2013
-hepatomegaly dengan kalsifikasi tersebar pada hepar
-pneumonia sinistra
Foto thorax PA 30/01/2013
-Pneumonia sinistra limpadenopathy
-limpadenopathy
-cardiomegaly
-susp. Efusi pleura basal bilateral
Lab 29/01/2013
WBC 7,12 RBC 5,07 HGB 0,6 HCT 34,0 PLT 504 GDS 111 Ur/Cr
16/0,6 GOT/GPT 63/34 CT/BT 800/300 PT/APTT 13,3/28,0
Na/K/Cl 136/3,8/101 Alkali fosfat 871 Alb. 3,4 LDH 622 AFP 1,09
HBSAg (-)
LONTARA 1 BAWAH BELAKANG
D/ CKD stage V Lab 26/01/2013
on HD reguler Ur/Cr 88/5,0 GOT/GPT 38/33 Alb. 2,8 Na/K/Cl 136/3,96/103 WBC
pro CAPD
4,94 RBC 3,60 HGB 9,9 HCT 30,7 PLT 228
Lab 15/01/2013
Alb. 2,6
Terelu
mamuju/
08234719110
1
Lab. 12/01/2013
PT/APTT
10,3/26,7
GDP/GD2PP
180/255
Ur/Cr
110/6,8
Bil.tot/Bil.direk 0,4/0,2 prot.tot 5,1 Alb. 2,1 globulin 3,0 Na/K/Cl
141/3,8/109
USG 3/01/2013
-efusi pleura bilateral disertai ascites
-PNC dextra
42
Sakka
72Thn/588876
Kmr 12 bed 5
MRS
14/01/2013
Konsul
24/01/2013
Lappa
lompo/
16
PA rectum
43
Tn Abd Malik
L/67thn/58912
4
MRS
27/1/2013
D/HIM (D)
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 (-)
K2/ Bed 4
44
Sudiang/
08539750061
7
Siti Kumiati
Konsul interna
(29/01/2013)
46tahun/P
589819
MRS
20/1/2013
Markus kirin
L/46Th/588126
K12 B3
Konsul
13/1/2013
Saloso desa
saloso kec.
Rantepao kab.
Toraja utara/
08539776495
4
K11/ Bed 5
Bababura
tinambung
polewali
mandar/
08524108959
1
45
Lab 01/02/2013
PSA 0,768
D/ POH 14
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
17
46
Fitriani/p/32th
n/590200
MRS
22/1/2013
Km 1 bed 5
Labakkang,
pangkep/
08219616645
9
47
Chaeruddin
L/49th/586254
MRS 29-12-12
419 B
D/
Wound
dehisersi
Post
Op
appendectomy
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
48
49
Kristianto
L/36 thn/6052
MRS
04/01/2013
Kamar 411 B
Malawele/
08134497746
6
Sri Wahyuni
P/33thn/7298
MRS
02/01/2013
Kamar 401
Desa
ambalang
/
08539595246
0
D/POH
3
Fistelektomi
Post Colostomy
Pro
tutup
colostomy
Businesi P/S
POH
3
Fistelectomy
(30/1/2013)
D/
Ikterus
Obstruktif
e.c
tu.
Caput
pancreas
POH
16
Gastrojejunosto
my
+
Cholesistectomy
ec. Ca Caput
pankreas
Lab 31/01/2013
Malaria mikroskopik(+)
WS
IL
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
18
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
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
50
51
Salmawati
P/45
thn/004262
Kmr 306
Sudiang/
08134767874
7
Tandi/L/48
tahun/7365
MRS 252013
01-
Kmr 433
D/ Post op ec.
Tumor colon
Post
kemotherapi
siklus ke V
Pro kemo
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
D/ Dyspepsia +
ileus obstruktif
parsial
susp
tumor gaster
Lab 31/01/2013
WBC 7,80 RBC 3,27 HGB 8,6 HCT 25,5 PLT 148 LED JAM 1 14 JAM
II 34
Foto OMD 29/1/2013
Tidak tampak kelainan radiologi pada foto omd ini
RL
Susp.tumor
pangkreas
Lab 26/01/2013
WBC 8,39 RBC 4,22 HGB 10,9 HCT 32,1 PLT 188
Jayapura
08134486858
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
52
53
Rifka/P/ 21thn/
008025
MRS
01/02/2013
Tn. Rachmat
Muchtar
L/27thn/0064
64
MRS
31/1/2013
Kmr 403
JL..R.tangaya/
08524235120
D/
post
op
appendektomi
D/susp
Abdomen
Tu.
Lab 31/1/2013
CT 800 BT 300 PT 16,3 APTT 31,15 Ur/Cr 17/0,91
USG Abdomen 31/1/2013
Kesan : tanda-tanda invaginasi disertai cairan disertai cairan
bebas pada cavum
peritoneum
Foto BNO 31/1/2013
Kesan soft tissue mass rongga abdomen kanan
foto thorax PA 31/1/2013
kesan : KP duplex lama aktif disertai pleural reaction bilateral
PCC
19
Salmin
L/46thn/5895
53
MRS17/01/20
13
Kamar 218
D/ Cholesistolith
+ cholelithiasis
Tunggu jadwal
operasi tgl
4/02/2013
Sulteng/
08138822755
55
Ny. Asrin
L/591378
IL
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 (-)
D/cholelithiasis
pro laparaskopi
Kamar 219
Jl.beringin/
08124406259
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
56
Muh. Nizam
L/35thn/5630
41
MRS11/12/20
12
Umum/Tunai
Kamar 222
Panakkukang/
08115829000
D/ POH XXVII
Laparotomi
eksplorasi e.c
fistel
enterocutaneus
IL
PA 10/1/2013
Fistel dengan peradangan non spesifik
Lab 15/1/2013
WBC 6,4 RBC 3,99 HGB 11,5 HCT 34,8 PLT 256
Lab 13/1/2013
WBC 4,0 RBC 3,02 HGB 8,6 HCT 26,3 PLT 151 ALB 2,33
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
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 (-)
20
Margarina
Karoma
P/56thn/5878
89
MRS 8/1/13
Askes Wajib
Kamar 303
D/Tu.
Retro
peritoneum
POH
Laparotomi
explorasi
ileostomi
biopsi
5
+
+
Toraja
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 : -
RL
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
58
Damaris
Kamaro
P/85thn/5573
46
MRS 4/1/2013
Askes Wajib
Kamar 321
Telkomas/
08525565776
2
D/ Tumor Colon
ascendens
POH
10
Hemicollectomy
Dextra
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
Lab 01/02/2013
Alb. 3,2
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
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
21
WS
59
60
Tn Djamading
L/57thn/
591239
Kmr 306
Kec.tanete
bone
/
08525570657
5
Tarpin Adam
L/52thn/5879
06
MRS 8/1/2013
Askes Wajib
Kmr 410
D/HIL (D)
POH
hernioraphy
D/
ileus
obstruktif
parsial+
cholesistolith +
cholesistitis
POH
V
open
cholesistektomy
Kolaka/
08524198082
38
IL
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
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
Soppeng/
08529953335
0
62
Tn. Rachmat
Muchtar
L/27thn/0064
64
MRS
31/1/2013
Lab 17/1/2013
CEA 2,19
Foto Thorax 29/1/2013
kesan DBN
D/susp
Abdomen
Tu.
JL..R.tangaya/
08524235120
Massetang
L/43thn/
591637
MRS
30/1/2013
Soppeng
Lab 31/1/2013
CT 800 BT 300 PT 16,3 APTT 31,15 Ur/Cr 17/0,91
USG Abdomen 31/1/2013
Kesan : tanda-tanda invaginasi disertai cairan disertai cairan
bebas pada cavum
peritoneum
Kmr 403
63
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 (-)
Lab 30/01/2013
WBC 12,2 RBC 4,54 HGB 12,3 HCT 37,7 PLT 392 PCT 0,311
D/ Tu Recti 1/3
distal
Rencana colon in
loop
Senin 4/2/2013
22
RL
08114135810
(Nadia)
Julius
Ronaldo
L/50thn/5916
67
MRS
30/1/2013
JKD
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 11
(23-01-2013)
Vulnus
Excoriatum
Regio
Flank
Sinistra
ICU VIP 1
Kayu
Calla
Mamuju
Ni Wayan E
08534998268
9
67
Sabella
P/19thn/5899
00
JKD
ICU Bed 9
Bulurokeng
08134240049
3
D/ Post reseksi
anastomose
ileum
ec.
Valvulus
ileum
hari
13
(21/1/2013)
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
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
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)
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
23
68
Pattaungang/
L/42 tahun
ICU Bed 3
JL.hati
gembira
69
Husain/L/70th
n
590926
MRS 26/01/13
HCU Bed 3
Jl. Kapasaraya
No. 25 B Mks
08139247883
9
Husmawati
D/ POH 10
hemicolectomy
ec Tu colon
ascendens
(OP 25/1/2013)
POH3
laparotomy
explorasi ec tu.
Sigmoid dukes A
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 01/02/2013
GOT/GPT 29/32 Ur/Cr 23/0,5
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)
24
25