KORAN BEDAH DIGESTIF

SENIN, 2 DESEMBER 2013

12
L1 AB
No
Bed
K7B1
1. B1/
1 K9
1.

Haidir
Identitas
637992
Ny.3/10/1954
Darna
MRS 21/11/2013
Tanggal
lahir : 26JAMKESDA
02-1955
RM : 620753
ASKES

13
L1 AB

Mansyur D.g Lili

639904
JAMKESMAS

14
2

L1 AD
Mariani
K5B5 Ny 637217
B2/
Sallama
31-12-1974
K4/2
31/12/1966
46 MRS
Tahun13-11-2013
JAMKESMAS
636819
MRS 12/11/2013
KONSUL 14/11/13
Askes Wajib
Dr.dr Ibrahim
Labeda, Sp.B KBD

3
15

B2/
K8/1

Suhardin
17/07/1960
53 Tahun
633951
MRS 23/10/2013
KONSUL 17/11/13
Askes

LONTARA I (Waty 082-349-770-101 )

PALEM ATAS (Rita Herawany 085-242- 551-105)
Tumor
abdomen BEDAH
Lab 19/11/2013
KORAN
DIGESTIF
Diagnosis
Pemeriksaan
Penunjang
CT/BT 8/3
PT/APTT 12,4/27,3
GDS 99 Ur/Cr
2MRIDESEMBER
2013
21/1,1
Bil. Tot
1,27 Bil.
Dir 0,84 GOT/GPT 55/55POH SENIN,
7
abdomen
22/11/2013
Prot.tot
explorasi CBD
Kesan
: 8,9 Alb 3,0 globulin 5,9 Na/K/Cl
HBsAg/AntiHCV
+ T tube
- 136/4,7/102
Tidak tampak
kolestatik intra(-)
dan ekstra
WBC
10,76 RBC 3,91 HGB 12,4 HCT 35,3 PLT
hepatik
- 375
Batu ductus cysticus disertai cholecystitis
18/11/2013
- Lab
Hepatomegaly
8/3 PT/APTT
12,8/25,9
GDS 83
- CT/BT
Incidental
finding : fraktur
kompresi
CVUr/Cr
Th
24/0,9
10-11 Bil. Tot 1,3 Bil. Dir 0,82 GOT/GPT 48/51
Prot.tot
Alb 2,8 Na/K/Cl 134/4,72/104
Foto
thorax7,4
20/11/2013
HBsAg/AntiHCV
(-)
Kesan
:
WBCnormal
10,93 RBC 3,84 HGB 12,1 HCT 34,3 PLT - Pulmo
375
- Cardiomegaly
disertai dilatatio aortae
USG Abd 19/11/2013
tampak tanda-tanda kistik caput pancreas
LabTidak
19/11/2013
Organ-organ
abdomen
batas
HbA1c;
5,2, alkaliintra
fosfatase
954,dalam
Gamma
GT normal770, Na/K/Cl: 145/4,7/109, PT : 13,0 control
12,6, APTT : 29,4 control 24,4, INR 1,08 .

Lab 12/11/2013
RBC : 4,56. HGB : 12,5. HCT : 37,0, PLT : 363.
WBC : 9,0.
Ileus obstruktif GDS
01/12/2013
: 137, G2PP : 132, ur/cr : 13/0,90. As.urat :
partial
3 posisi
3,5.Foto
Bil.totabdomen
: 5,21, bildirek
: 3,73. GOT : 385,
GPT-sesuai
: 344 gambaran ileus obstruktif letak tinggi (SBO)
-susp.Ascites
Thorax
PA/AP
CT Foto
abdomen
12/11/2013
-Efusi pleura dextra
- Gallstone
- Cholecystitis
- Hepatomegali
Ileus Obstruktif
Lab 25/11/2013
Terapi lanjut
ec. Susp. Tumor LabCA
K 1amp/12j/IM
Adenocarsino
27/11/13
1. VitDiet
bebas
19-9 <3,00
caput
pancreas GDS
ma
Colon
150,
Na/K/Cl
128/4,0/104
peptisol
2 x 250
CT-Scan Thoraks (tanpa kontras) 20/11/2013
Rencana
explorasi
Ascendens
LabMultiple
26/11/13
cc
nodul pada kedua paru susp. Tu.
Residif
WBC
13,4, RBC
3,78 Hb 9,8, HCT 29,4 PLT
2. CBD
Injeksi
Metastase
paru
Kamis
05/12/2013
525CT Scan Abd (tanpa kontras0 19/11/2013
sohobion
1
LabHepatomegaly
22/11/13
amp/12 j/ drips
WBC
: 16,2. HGB
: 7,8.
: 3,13.
HCT
3. Durogesic
Cholestatik
intra
danRBC
ekstra
hepatic
ec.: 24,8.
Susp.
PLTStenosis
: 6,58. (Anemia
mikrositik
hipokrom,
patch 12,5 mg
distal CBD,DD:
Batu
lusen distal CBD
trombositosis,leukositosis)
4. Terapi sesuai
Cholelisistitis disertai sludge GB
Colon
Loop 21/11/2013
TS Interna
LabIn18/11/2013
Tidak
5. Rencana
Bil.tampakcolon
Total 23,5 ascendens dan 1/3 proximal
colon
transversum
operasi setelah
Lab
15/11/2013
LabGOT/GPT
19/11/13 53/72
kemoterapi
WBC:9,5,HGB:11,0,HCT:30,6,PLT:553
USG Abd. 15/11/2013
LabCholestatik
18/11/13 intra dan ekstra hepatic ec.?
CEACholelithiasis
: 1,8, CA 19-9 : 9,99
LabLab
16/11/13
14/11/2013
WBC:14,37,HGB:9,11,HCT:27,7,PLT:507
AFP 0,82 CA-199 <3,00
Hasil
PA13/11/2013
10/06/13
Lab
Adenocarsinoma
colon
WBC 7,91 RBC
3,64, moderatelu
HGB 11,0 HCT 31,1 PLT 284
differentiated
dengan144/3,3/108
kedua ujungPT/APTT
reseksi 13,2/28,2
ALB 3,5 Na/K/Cl
bebas
tumor
GDS 134 Ur/Cr 14/0,2 Bil. Tot 25,10 Bil Direk 20,45
Foto
thoraks PA
13/11/13
GOT/GPT
54/74
Prot. Tot 7,9 Alkali Fosfatase 213
Tidak
tampak
tanda
tanda
pada
gamma GT 285 Kol.
Totmetastasis
271 Kol. HDL
11foto
Kol. LDL
thorak
167ini
TGL 458
MSCT
abdomen 13/11/13:
Labscan
28/11/2013
Massa
colon ascendenas
Perdarahan
BT = 3,00 dengan tanda tanda
obstruksi
usus
proximalnya
Bekuan
CT di
= 8,00
Hepatospenomegali, tidak tampak tanda tanda
metastasis
ke hepar.
28/11/2013
LabPemeriksaan
13/11/13 : MRCP cholestatis e.c batu pada
Na/K/Cl
CBD135/4,2/108, Bilirubin total : 0,1,
Bilirubin
direkkontras)
: 0,1, Alkali
fosfatase
69, pada GB dan
(dengan
tampak
juga:batu
Gamma
GT
:
18
Ductus cysticus
POH 19
Lapartomi
eksplorasi
hemicolectomi
(D) + drainase
abes ileum
terminal+abes
hepar + abses
perinefrik.
DM tipe 2

Dr. Ibrahim
Labeda, Sp.B (K)

Terapi
IVFD RL: NaCL
0,9% 1:1 = 28tpm
Inj ceftriaxon 1 gr/
12j/ IV
Inj.metronidazole
0,5 gr/8 jam/iv
Inj.ranitidin amp/8
jam/iv
Inj.sanmol 1
gr/8jam/iv (KP)
Minum air putih +
teh
Durogesic patch
12,5 mg
Minum dan makan
bebas

Lab 26/ 11/ 2013

GOT : 32, GPT : 9, Albumin : 2,5
Lab 15/11/13
Albumin 2,7
WBC 38,03 RBC 2,99 HGB 9,1
HCT 26,6 PLT 209
Lab PA 15/11/13
Kesimpulan : Radang suppuratif dengan
undifferentiated pleomorfik sarcoma
Lab 14/11/13
Ur/Cr 22/0,3
GOT/GPT 11/9
Na/K/Cl 132/4,3/103

GV dgn woundress
Aff hecting luka
operasi seluruhnya
IVFD RL: NaCL
0,9% 1:1 = 28tpm
Inj meropenem 1 gr/
8jam/ IV
Inj metronidazole
0,5 gr/8jam/ IV
Ranitidin 1amp/8j/iv
Ketorolac
2
1amp/8j/iv
Diet bubur

LONTARA 2 DIGESTIVE KAMAR 1 RIMA (085242248468

16

Bed 1

Tn. Fitriadi
07/06/1986
RM: 639833
MRS: 29/11/13
JKD

KORAN BEDAH DIGESTIF

D/ POH 2
29/11/2013
SENIN, 2Lab
DESEMBER
2013
herniorafi
HIL(S)
GDS: 126 , GOT/GPT: 101/126 , Prot.total: 6,48 ,
inkarserat
alb: 3,40 , Na/K/Cl: 127/3,24/107 , HBsAg: non
reactive , WBC: 7,79 , RBC: 4,82 , HB: 13,4 , PLT:
272

dr.Mappincara,
SpB-KBD

17

18

Bed 2

Bed 3

Tn. Dg.Nai
14/12/1958
634948
28/11/2013
JKM
Dr.Warsinggih,
Sp.B. KBD

A/ hematoma
scrotum post
herniorafi

Lab(28/11/2013)

Tn.A.Amba Bonggo
1/7/1948
RM: 637692
JKD
Dr. Samuel , Sp.BKBD

POH 4
laparatomi
eksplorasi
Hartmann
procedure

PA ( 21/11/2013)
Adenocarcinoma colon sigmoid(diff.
sedang) dengan kedua ujung reseksi
bebas tumor.

GDS: 87. Ur/Cr: 16/0,6 , GOT/GPT: 35/61,

Na/K/Cl: 137/4,4,/117, RBC: 416/HB: 12,1, HCT:
37,7, PLT: 333, WBC: 10,1

Lab 17/11/2013
WBC: 9,9 , HGB: 7,5, HCT 25,7 PLT; 293, RBC;
4,25, Na/K/Cl; 141/3,0/108, ALB: 3,5, CT/BT;
700/300, PT/APTT: 12,7/24,0, GDS: 143, Ur/Cr:
48/1,2, GOT/GPT: 23/10, Total prot: 6,09, HBsAg:
(+), Anti HCV(-)

IVFD aminofluid 1000

RL 500 D5 500
28
Tpm
Cernevit 1 vial/24jam/iv
Ceftriaxone
1gr/12jam/iv
Ketorolac 1 am[/8
jam/iv
Ranitidine 1 amp/8
jam/iv
RL:NaCl = 1000:1000
28 tpm
Ciprofloxacin 1
gr/12jam/iv
Ketorolac 1
amp/8jam/iv
Ranitidine 1
amp/8jam/iv
Diet biasa
Diet biasa
Cefadroxil 2x500 mg
Ameprazole 2x20 mg
Asam mefenamat 3x
500 mg
Pro kemoterapi

Foto thorax PA
Kesan: pulmo normal, dilatation aortae

19

Bed 4

Ambaling
51 tahun
MRS 7/11/2013
636051
Konsul interna
(12/11/2013)
JAMKESMAS

POH 8
laparotomi
explorasi e.c
cholesistojejuno
stomi + Braun
anastomosis

Lab 28/11/2013
Bil. Total 14,88 , bil.direk: 10,65 , GOT/GPT:
117/29 , alkali phospat: 223, Gamma GT: 71
Lab 18/11/13
ct/bt 700/230 pt/apt 11,0/30,1 inr 0,92 bil tot 23,3
bil direk 24,8 got/gpt 68/18 alb 3,1 wbc 3,44 rbc
4,22 hb 12,9 hvct 35,4 plt 433
Echo (18/11/2013):
Kesan:
fungsi sistolik LV baik, ef 75%
disfungsi ddiastolik
Lab 13/11/13
PT 12,3 APTT 35,3
Lab 12/11/13
KOL TOTAL 252 KOL HDL 7,4 KOL LDL 133
TRIGLISERIDA 614
Lab 8/11/13
CEA 1,27 CA 19-9 35,91 ALKALI FOSFATASE
215 GAMMA GT 48
Lab 7/11/13
WBC 4,17 RBC 4,15, Hb 12,5, HCT 34,0, PLT
394 HbsAg (-), anti HCV (-),GDS 132, ur/cr
13/0,8, Bil. Tot 20,3, bil.direct 21,61 SGOT/SGPT
21/47, prot.tot 4,87, alb3,0, globulin 1,87,
PT/APTT 24,8/41,9,
FOTO THORAX 7/11/2013
Kesan:
Bronchopneumonia dextra I sus. Spesifik
Cardiomegaly dengan dilatatio et
elongasi aortae
Susp efusi subpulmonal dextra
USG Abd 11/11/2013
Kesan:
Cholestasis intra dan extra hepatik
Poliposis GB
CT Abdomen tanpa kontras (11/11/2013)

GV/2 hari
Bubur saring
Minum bebas
Aff drain
Aff CVC
Terapi injeksi lanjut

KORAN BEDAH DIGESTIF

SENIN, 2 DESEMBER 2013