LIST PASIEN DIGESTIVE

9 JANUARI 2017

IRINA A ATAS

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

1. A10 bed Cherry B. Icterus 7/1/16 6/1/17 IVFD NaCl 0.9% R/ EKG
Makalew/ L/ obstruktif e.c Leu 7764 Leu 9364 Ceftriaxone 2x1 gr Ekspertisi Foto
33th/ Paal IV cholelithiasis Eri 4.83 Eri 5.11 Metronidazole 3x500 thorax
Hb 15.4 Hb 16.0
drips
Ht 44.0 Ht. 46.6 RENCANA USG
BPJS RM : 491534 Tr 145 Tr 158 Ranitidine 2x1 amp
ABDOMEN
Kelas 2 MRS :6/1/17 Gamma GT SGOT 192 Ketorolac 3x1 amp
No.Hp : 473 SGPT 477 Diet rendah lemak
085240840644 Alkaline Bil total 7.59
fosfat 239 Bil direct 6.8
Anti HCV
non reaktif
DPJP :
HbsAg non
dr. F. Tjandra, reaktif
Sp.B-KBD PT 12.5
APPT 31.5
Koas : Lia
2. A8 bed 6 James Post 3/1/17 2/1/17 IVFD NaCl 0.9% :
Timpaulu/L/45t laparatomi Leu 8569 Leu 10400 Clinimix : Ivelip
h
/Teling eksplorasi e.c Eri 3.00 Eri 3.52 2 : 1 :1
peritonitis e.c Hb 9..6 Hb 11.2 Ceftriaxone 2x1 gr
laserasi Ht 27.4 Ht 33.2 Metronidazole
UMUM RM : 491173 duodenum + Tr 131 Tr 120 3x500
MRS : 2/1/17 vena cava Alb 2.25 SGOT 49 Ranitidine 2x1 amp
No Hp : SGPT 28 Ketorolac 3x1 amp
085340173664 Post repair GDS 180 As. Tranexamat
OP : 2/1/17 vena cava 2x500
Diet susu 6x50 cc
Pyloric Human albumin
DPJP :
exclusion, drips
dr. Toar M, drain
Sp.B-KBD anastomosis

Koas : Gaby
3. A7 bed 7 Denny Colesistitis dd 7/1/17 4/1/17 30/12 NaCl 500 cc/12 jam CT scan 3 fase
Pangemanan/L/4 Abses hepar Leu 14640 BT 5,62 Leu 24000 Aminofluid (5/1/17)
6th/Pineleng Eri 3.54 BD 4,79 Eri 3,21 100cc/12jam tunggu hasil
Hb 10.5 Anti HCV Hb 9,9 Ceftriaxone 2x1gr Diet rendah lemak
??
Ht 32.5 kualitativ (-) Ht 28,4 Metronidazole 3x1
RM :491059 Tr : 776 Elisa (-) Tr 485000 PCT 2x1 k/p
MRS : 30/12/16 Alb : 3.00 AFP 2,48 SGOT 143 Kapsul garam 3x1
No HP : Cl : 99 SGPT 86 Vipalb 3x2 caps
K : 5.80 Ur 44 Curcuma 2x1 tab
DPJP: dr. Na : 129 Cr 1,2
Ferdinand
Tjandra, SpB-
KBD

Koas : Hisky
4. A6 bed 2 Mely Palar/P/ 49 Cholesistitis 31/12/2016 GDS 98 6/1/17 NaCl 0.9 Hasil USG:
th/Tuwuley dd colelitiasis Leu 6628 Na 39 BT 0.38 500cc/12jam Fatty liver
Eri 4,38 K 4,10 BD 0.15 Ranitidin 2x1 Cholesistolitiasis
Hb 9,2 Cl 108 As Tranexamat 3x1 foto
Jamkesmas RM : 491058
Ht 29,7 Ur 15 Vit K 3x1
MRS : 30/12/16 Trom 338 Cr 0,8 Vit C 3x1 Foto thoraks :Dalam
No HP : MCH 21,0 SF 1x1
batas normal
MCHC 30,9 4/1/17 As.folat 3x1 tab
MCV 67,9 PT pasien
SGOT 31/15 13,1 RENCANA
DPJP: dr.
SGPT 11/10 APPT pasien LAPARATOMI
Ferdinand
28,6 HARI INI
Tjandra,SpB-
KBD
 LIST PASIEN DIGESTIVE
9 JANUARI 2017

Koas : Windy

IRINA A BAWAH

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

1. B1 Bed 2 Jantje Post peritoneal 6/1/2017 Ur 67/ Cr 1,0 31/12/2016 IVFD NaCl
Ngantung/L/62 drainage ec Uric acid 7,0 GDS 111 Leu 9142 0,9% : D5 : Th/ lain sesuai
th/Tondano peritonitis ec GDS 117 Na 132 Eri 2,78 aminofluid TS Interna
1:1:1/24 jam
perforasi gaster Albumin 1,51 K 6,26 Hb8,7
Omeprazole
RM : 490932 Cl 101,8 Ht 27,1 Rawat luka
2x1
BPJS MRS :28/12/16 3/1/17 Trom 244 Observasi tanda-
Ceftriaxone
tanda peritonitis
Kelas 1 No.Hp : Leu 8140 Ur 109 2x1
081244957882 Eri 3,27 Cr 1,5 Metronidazol
OP : 28/12/16 Hb 10,3 Na 135 3x500mg
Raber : Ht 31,5 K 4,75 Sukralfat syr
3x2 C
Interna, Rehab Tr 290000 Cl 105,3
Diet susu
Medik SGOT 50 6x500cc
SGPT 16 Human
DPJP : Albumin
dr. F. Tjandra, drips 112 gr
Sp.B-KBD

Koas : Cecil
2. B8 Onibala Johny/ Hernia 24/12/16 Ur 49 2/1/17 IVFD NaCl hasil spirometri
Bed 3 L/59th/ insisional Leu 6063 Cr 2,1 Leu 8319 0.9% 500cc/12 terlampir
Amurang Gout arthritis Eri3.44 GDS 172 Eri 3,58 jam
Omeprazole tx interna:
chronic Hb 9,5 Na 138 Hb 9,7
2x1 recolfar 1x0,5mg
Jamkesma RM : 33 69 86 Susp TB paru Ht29,1 K 3,86 Ht 29,6 PCT 3x500mg
s MRS :17/12/16 Tro180 Cl 104,6 Tr 237000 Ambroxol 3x1
PBI No Hp: MCH 27.8 MCH 27,0 R/ OPERASI As folat 3x1
082347311011 MCHC 32.9 25/12 MCHC 32,6 HARI INI
Raber: Interna MCV 84,4 PT 13.6 MCV 82,9 X-Foto thorax :
SGOT 20 APTT 29.4 UA 9,0 Pneumoni kiri
basal (27/12/16)
SGPT 16
DPJP : dr. EKG dbn
F.Tjandra,
SpB-KBD

Koas : Nancy
3. B8 bed 6 Pusung Nelwan/ - severe sepsis 3/1/17 6/1/17 - Aminofluid : Perbaiki KU Cek Dl, SGOT,
L/ 62th - Peritonitis ec Leu 14680 Leu : 25280 Nacl 0,9% 1:3 / RAWAT SGPT, Alb, PT,
App perforasi Eri 4,57 Eri : 4.02 24 jam LUKA APPT, Ur, Cr
RM: 27.64.80 PA laparatomi Hb 15,5 Hb : 13.9 - Meropenem
X-Foto thorax :
Jamkesma MRS: 3/1/17 explorasi hri ke Ht Ht : 40.3 3x1 gr Belum ekspertisi
s No Hp : 4 Trmb : 145 - Metronidazol
 LIST PASIEN DIGESTIVE
9 JANUARI 2017

Raber: Interna 8/1/17 MCH : 34.6 3x500 mg EKG :

Leu 16350 MCHC : 34.5 - PCT drips Sinus Takikardia
DPJP : dr. Toar Eri 3.80 MCV : 100.2 3x1 (3/1/17)
M, SpB-KBD Hb 12.8 GDS : 174 - Ranitidin 2x1
Pasien pasang
Ht 39.0 SGOT : 94 - Alb 20% Via drain
Trom 86 SGPT : 48 NGT
Koas : Alin MCH 33.7 Ur : 125 - Diet Clear
MCHC 32.8 Cr : 1.5 water 6x50cc
MCV 102.6 Alb : 2.13
SGOT 67 Cl : 103.1
SGPT 43 K : 5.48
Ur 97 Na : 142
Cr 1.0
GDS 180
Alb 2.06
Cl 119.0
K 5.5
Na 151
4. B4 bed 1 Munira Ikterus 31/12/16 GDS 107 Hasil USG: - Nacl 0,9% R/x-foto thorax
Berhimpun/ obstruktif ec Leu 7926 Na 135 Obstruksi bilier - Ceftri 2x1 pro
P/51th susp batu CBD Eri 3,84 K 4,46 extra hepatic ec - Rani 2x1 laparaskopik
- Keto 3x1 kolesistektomi
BPJS Susp Ca caput Hb 12,8 Cl 93,7 susp batu CBD
- Diet : rendah
Kelas 2 RM : 49.06.71 pancreas Ht 36,8 Alb 3,73 distal dd/ Ca lemak CT scan
MRS: 24/12/16 Trom 367 Caput pancreas abdomen :
No. Hp : SGOT 86 3/1/17 - batu multiple Tidak ada
081343836616 SGPT 49 Gamma GT K. empedu kelainan
B tot 11,56 115 - Ginjal, buli, (5/1/17)
B dir 10,09 AlP 116 lien, pancreas,
X-Foto thorax :
DPJP : dr. Ur 14 CEA 4,92 usus: N
DBN (3/1/17)
F.Tjandra, SpB- Cr 0,5
KBD TUNGGU
HASIL CT-
Koas : Indah SCAN
5. -

ANGGREK 1

N KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

O
1. B4 Sangeroki Post laparoskopik 3/1/17 29/12/16 29/12/16 Terapi lain sesuai TS
Khadija /P/ kolesistektomi Prot tot Leu Alb 2.87 Penyakit Dalam
60th/Kema hipoK (2,3) 5,23 13000 Na 132
hipoAlb (2,81)
JKN P 2,7 Eri 4.15 K 2.40 Rencana rawat
hiponatremi (132)
Non-PBI Ca 8,45 Hb 13.6 Cl 107.0 jalan dan kontrol
Kelas 1 MRS: 6-12-16 Mg 1,45 GDS 336 Ca 9.20 Poliklinik bedah
OP : 28-12-16 Alb 2,81 P 3.0
RM: 39.94.48 Glob 2,42 Mg 1.49 6/1/2017
TL : 5/1/1956 Na 132 CK 41 Albumin
 LIST PASIEN DIGESTIVE
9 JANUARI 2017

Raber : Interna K 2,30 CKMB 2,95

Cl 95 17
DPJP : 7/1/17
dr. F. Tjandra, SpB- Cl 101.0
KBD K 2.6
Na 133

2. B11 Tirayoh Hendriko/ Post laparatomi 24/12/2016 30/12/16 SGOT 33 - Aff vienflon KONTROL
L/ 63th eksplorasi Leu 17250 Leu SGPT 0.9 - Ibuprofen 3x200mg POLI BEDAH
Hemikolektomi Eri 5,44 13100 UA 4.4 - Metronidazole 12/1/2017
kanan
BPJS MRS:20/12/16 Hb 14,2 Eri 4.77 Prot 5.87 3x500mg
Kelas 2 OP:23/12/16 Ht 43,8 Hb 12.4 GDS 237 - Vip Albumin 3xII
RM : 489631 Trom 317 Ht 37.1 Alb 3.22 caps
Raber :Interna Mch 26,1 Trom 396 Glob 2.65 - BOLEH RAWAT
Mchc 32,4 Mch 26.0 Na 123 JALAN
Mcv 80,5 Mchc K 3.72 - Pengantar pulang
33.5 Cl 76.9 SUDAH dibuat
Mcv 77.8

ANGGREK 2

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

1 104 Jenny J - Ikterus Obstruksi 28/12/16 30/12/16 7/1/17 r/ lap.chole + internal
Sangeroki/P/64 ec.batu CBD + Leu 13220 P 3.6 Leu 7835 work up dari kardiologi cholangiografi +
th/Karombasa Kolestuliasis Eri 3,96 Mg 2.37 Eri 3.25 terlampir kemungkinan eksplorasi
- HipoMg
BPJS n Hb 12,2 Na 132 Hb 9.9 CBD (sudah edukasi ->
- HipoCa Terapi sementara
Kelas 1 - Elektrolit Ht 34,1 K 3.25 Ht 28.8 ttd penolakan tgl 6-1-17)
sesuai interna + kardio
MRS : 19-12- imbalance Trom 147 Cl 89.9 Trom 268
16 Mch 30,8 Ca 8.25 Mch 30.4 Cek DL,Bil direct, USG Abdomen :
RM 485412 Mchc 35,6 TSHs 1.52 MCHC 34.3 indirect, PT, APTT Cholelithiasis
Raber : Mcv 86,3 FT4 1.04 MCV 88.6 (tunggu hasil) X-Foto thorax :
Interna, Mg 4,27 Belum ekspertisi
Kardio Ca 7,47 5/1/17 PT EKG : DBN (22/12/16)
No Hp ; Ca 7,6 @detik 13.6 Echo :
08124453550 Mg 1,07 @INR 1.11 CAD IVP pro staging
Na 132 APPT PCI (3/1/16)
DPJP : K 4,52 26.7
dr. F. Tjandra, Cl 96,3
SpB-KBD

IRINA D

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

1 A1 dr. Nurhayati - Post laparatomi 5/1/17 4/1/17 Terapi sesuai TS Rawat luka tiap hari
Masloman/P/61 e.c. adhesive Leu 18250 Alb 4.09 Obsgin USG ginekologi :
BPJS th/Banjer bowel ileum + Eri 4.24 Cl 109 Hiperplasia
Kelas 1 MRS : 3/1/17 Ca. Hb 13 K 4.0 endometrium
RM: 130731 Endometrium Ht 36.2 Na 140 (25/12/16)
Raber : Obsgin Tromb 292 X Foto Thorax :
OP : 5/1/17 SGOT 11 Kardiomegali
DPJP : dr. F. SGPT 11 5/1/17 (29/12/16)
Tjandra, Sp.B- Ur 25 Mg 2.05
 LIST PASIEN DIGESTIVE
9 JANUARI 2017

KBD Cr 0.7 F 4.3

GDS 118 Ca 8.57
Cl 83
K 8.57
Na 110
2 A2 Bed 1 Wuwungan - Post laparatomi 29/12/16 29/12/16 5/1/17 Terapi sesuai TS Rawat luka
Annie/ 61th/ e.c sever bowel Leu 9500 PT 12.8 Leu 19280 Obsgin
PLN Sario + adhesive Eri 4.58 APPT 27.5 Eri 4.94 Observasi X-Foto Thorax :
Kelas 1 peritoneal Hb 12.9 Cl 93.2 Hb 14.1 Mobilisasi TB Paru (konfirmasi
MRS: 27/12/16 - Post biopsy Ht 38.2 K 3.87 Ht 41.9 lab)
RM : 489984 Tromb 332 Na 138 Tromb 395 Dillatio et
Raber : Obsgin atherosclerosis aorta
OP : 5/1/17 Pleural reaction

DPJP : dr. Toar

M, Sp.B-KBD

IRINA C

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

C4 111 bed 2 Mardiono Obstruksi ileus 3/1/17 29/12/17 Terapi -USG abdomen +
Koesman/L/52th/Perkami mekanik dd/. Leu 14740 Leu 14660 sesuai TS contrast :
l Paralitik Eri 4.13 Eri 4.07 interna Ileus obstruktif
BPJS Hiponatremi Hb 11.2 Hb 11.2 partial
Kelas 3 MRS : 21/12/16 Sepsi ec infeksi Ht 33.6 Ht 33.4 Menunggu Spondylosis lumbal
RM : 490459 intraabdomen Tromb 436 Tromb 435 jadwal (29/12/16)
Raber : Interna Post hematemesis SGOT 25 SGOT 17 kolonoskopi
melena SGPT 12 SGPT 9 dari Interna Sudah ada Hasil
DPJP : Ur 54 Ur 41 ekspertisi CT-Scan
dr. F. Tjandra, Sp.B-KBD Cr 1.0 Cr 0.8 Rencana
Cl 84.1 Cl 94 Endoskopi
K 4.12 K 3.30
Na 129 Na 131

IMC-C Bed 2

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

1 VVIP 15 Fredriich E. - Periappendicular 2/1/17 7/1/17 Ur 47 Terapi sesuai TS Observasi tanda-
Bawoleh/L/56th/ infiltrate dd/ Leu 31090 Leu 43500 Cr 1.3 Interna tanda peritonitis
Eri 2.19 GDS 70 Pertahankan NGT
BPJS Karombasan Tumor Colon Eri 3.70 Hb 5.5 Alb 2.25
Kelas 1 MRS : 2/1/17 Kanan Hb 9.5 Ht 17.0 X-Foto Thorax :
Cl 92.9
RM : 284451 - Anemia (5.5) Ht 28.6 Trom 497
K 3.65 Belum ekspertisi
Raber : Interna Tromb 347 MCH 252.2
MCHC 32.4 Na 130
DPJP : dr. F. SGOT 60 LED 70 Tunggu hasil CT-
Tjandra, Sp.B- SGPT 20 Eos 0 Scan Abdomen
KBD Ur 57 Bas 0
Net Bat 8
Cr 1.0 Net Seg 73
GDS 85 Limf 14
Cl 95 Mon 5
MCV 77.9
K 3.30
Na 134

IRINA B

NO KAMAR IDENTITAS DIAGNOSIS LAB TERAPI CATATAN

 LIST PASIEN DIGESTIVE
9 JANUARI 2017

1 K1 Piay - Susp Tumor Colon 7/1/17 5/1/17 Gamm Ondancentron 2x1 iv Hasil CT-Scan :
Arthur/L/67th/Kakas - Hiponatremi (126) Cl 92 Leu 11800 a GT Antasida syr 3x2 Nodul metastase
- Hipochlorida (92) K 4.30 Eri 5.28 87 Dulcolax 1x2 tab pada lobus kanan
malam sebelum tidur
BPJS MRS : 31/12/16 Na 126 Hb 14.9 Bil hepar
Niflex sch lanjutkan
Kelas 1 RM : 271584 Ht 44.8 Total dalam 2 liter air
Raber : Interna 6/1/17 Tromb 0.53 Fosen enema sore hari EKG : LAE +
Cl 89 313 Bil jam 07.00 LAFB
DPJP : K 5.5 SGOT 75 direct (31/12/16)
dr. F. Tjandra, Sp.B- Na 125 SGPT 26 0.24
KBD Ur 14 GDS
HARI INI OPERASI
Cr 0.9 92
No telp Cl 95
08981739282 K 4.80
Na 126
2 K3 Matialo - 4/1/17 SGOT 36 EKG : Belum
Hery/L/47th/Tompaso SGPT 16 ekspertisi
BPJS Baru Leu 10050 Ur 98
Kelas 1 Eri 3.31 Cr 10.0 Hasil Kultur
MRS : 4-1-17 Hb 10.4 GDS 94 darah tgl 28/12/16
RM :385194 Ht 31.8 Chl 97.0 BFA Positif. Hasil
Raber : Interna Trom 478 K 5.10 kultur tidak
MCH 31.4 Na 140 bakteri
DPJP : MCHC 32.7
dr. F. Tjandra, Sp.B- MCV 96.0 Konsul Interna tapi
KBD belum dijawab