IRINA A BAWAH

N KAM IDENTITA DIAGNOSIS LAB TERAPI CATATAN

O AR S

1 B1 Manitik Post laparatomi H-3 01/2/17 28-01/17 26-01/17 -IVFD NaCl EKG:dbn
Bed 1 Wesley/L/3 Debalking tumor + Leu 8660 Leu 5471 Leu 5653 0,9%:aminofl
6th illeustomu ec tumor Hb 15,7 Hb 13,2 Hb 14,0 uid=1:1= 20 CT Scan Abd:
intra abdomen + Ht 3650,9 Trom 286 Trom 302 gtt/m -Susp. Abses lien + multiple
RM : abdomen bard Trom 373 SGOT/PT Cl 95,5 - Ranitidin lympadenopathy mesenterium dd 1.
41.91.11 Laserasi serosa usus SGOT 47 16/10 K 4,45 50mg 2x1 i.v Lympoma 2. Abdominal TB
OP : 1-2-17 halus SGPT 42 GDS 92 Na 140 - Ceftriaxone -Ascites
Ur 38 Na 138 1 gr 2x1 i.v
-Post laparatomi e.c Cr 0.9 K 4.1 01/02/17 - As. PA:
DPJP : dr. obstruksi usus Gds 210 Cl 100 Leu 8660 Tranexamat Radang menahun non spesifik pada
Toar mekanik parsial ec Albmin 2.82 PT Eri 6.04 500mg 3x1 colon desendens & rectum
Mambu massa intraabdomen Mg/Ca/P 15,7/12.7 Hb 15.7 i.v
Sp.B-KBD -Post kemoterapi ec 1,56/8,67/6,7 APPT Ht 50.9 - Ketorolac USG abd: dbn
adenoCa colon Cl 103.0 23,1/28.9 Trombo 3x1amp
Coass asenden K 4.40 373 - Rawat luka Hapusan darah tepi : kesan susp.
Na 137 MCH 25.9 -Diet air gula Infeksi bakterialis akut
MCHC 6x100cc
30.8
MCV 84.2
SGOT 47
SGPT 42
Ur 38
Cr 0.9
GDS 210
Fosfor 6.7
Mg 1.56
Alb 1.56
Na 137
K 4.40
Cl 103.0
Calsium
8.67

2 B9 Dotulong -Trauma tumpul 01-02-17 28-01/17 24-01/17 -As. CT Scan

Bed 8 Jeremia/L/3 abdomen Hb 13,2 Hb 9.6 Hb 9.0 Mefenamat
4 thn -Hematom lien Leu 13.880 Leu 11.920 Leu 16.480 3x1 -Hapusan darah tepi : infeksi
- fraktur costae VI- Ur 28 Trom 182 Trom 149 -Omeprazole bakterialis akut
RM : X posterior dextra Cr 0.7 SGOT 43 SGOT 287 2x1
49.26.95 -Fraktur Na 133 SGPT 140 SGPT 427 -Observasi
DPJP : dr. paramsimfisis K 3,95 Ur 68 Ur 66 -Terapi lain
W. mandibular Cl 94,9 Cr 0.7 Cr 0.9 sesuai
Sumanti, GDS 141 GDS 134 TS Thovask,
Sp.B-KBD Na 134 Na 140
K 4.20 K 4.70 Urologi,
Coass Cl 105.0 Cl 110.0 Orthopedi,
PT Plastik
11.8/12.7
INR
0.92/1.01
APPT
23,5/28.9
3 B7 Alex -Ikterus Obstruktif 01/02/17 31/1/2017 -IVFD EKG:dbn
Bed 7 Takahindan ec susp Ca caput OT/PT 85/54 Leu 10070 Clinimix
geng/L/62th pankreas Gamma GT Hb 13,2 ivelip 20 gtt CT Scan abd: obstruksi billier, susp
Pinda -Disfagia ec gaster 508 Tro 262 -NaCl 0,9% : sludge pada GB
han RM:48.90.8 obs Ur/Cr 170/5,6 Ur 149/Cr Aminofluid
dari 8 -AKI Alb 2,08 4,4 1 : 1 = 30 tpm X-foto Thorax:dbn
C1 MRS : -HipoAlb AF 785 Cl 83,2 -Sucralfat
31/1/17 Anti HCV (-) K 2,80 3x1C USG abd: susp app kronis
Anti HIV (-) Na 130 -Antrain
DPJP : HbsAg (-) Netrofil seg 3x1amp
dr. F. : 94
Tjandra,
Sp.B-KBD

4 B5 Joison -Post 01/02/17 30/1/17 27/1/17 -IVFD NaCl

Bed 1 Maki/L/ Ileostomy e.c Prot: 5,18 Leu 5757 Leu 9048 0,9% = 30gtt
52th/ Tumor tumpul Alb: 2,77 Hb 10,1 Hb 11,0 -clinimix
raringis abdomen Glo: 2,41 Trom 192 Trom 281 ivelip = 20gtt
-AKI SGOT 14 SGOT 22 -Kapsul
MRS : - Elektrolit 02/02/17 SGPT 15 SGPT 25 garam 3x1
28/1/17 Imbalance Leu 4747 Na 128/ Na123/ -Diet Lunak
RM : -HipoAlb Hb: 11,1 K2,70 K3,10 TKTP
486592 Tro 170 Cl 101,0 Cl 99,0
No.HP: Na 134 UR/CR UR/CR
OP K 4,47 95/3,5 100/4,0
Cl 102,3 GDS 94 GDS 89
DPJP : AntiHCV
dr. Billy (-)
Salem HbsAg
Sp.B-KBD (-)

Coass
Saranita

5 B Denny Peritonitis ec susp 03-02-17 -IVFD NaCl EKG : sinus takikardia 114x/m
Embram/L/ perforasi gaster Leu 19380 0,9% 20gtt
PB 62 thn Eri 3.37 -Ceftriaxone
Hb 8.2 2x1gr iv
MRS : 03- Ht 26.3 -Ranitidin
03-2017 Trombo 348 2x1 amp iv
MCH 24.2 -Ketorolac
DPJD : MCHC 31.1 3x1amp iv
dr.W.Suma MCV 77.9
nti, SGOT/PT:
SpB(K)BD 33/14
Ur/Cr: 61/4.1
GDS 63
Na 136
K 4.10

ICU
1 Fransience -Ikterus 30/1/17 23/1/17 PT : -IVFD NaCl 0,9% CT scan abd :
Talumewo/P/ obstruktif e.c Leu 9676 Leu 8286 12.2/12.8 20tpm Kesan
46th/ Poopo susp batu CBD Hb 11,5 Hb 11,6 APPT : -Ranitidin 2x1 Hepar :
dd/ tumor Trom 399 Trom 437 24.5/29.8 Tab tampak adanya
MRS : 24/1/17 periampula OT 39/PT 30 OT 36/PT 24 INR -Vit C 3x1 massa kistik
RM : 48.05.47 Na 138/K3,90 Na139/ 0.96/1.02 -Vit K 1x1 dgn gambran
No.HP: Cl 103,0 K3,50 -As. Tranexamat airfluid level
OP UR/CR28/0,6 Cl 105,0 3x1 didalamnya
DPJP : Bil tot/dir UR/CR - terapi lain & dgn pnebalan
dr. F. Tjandra, 13,38/11,92 21/0,5 Instruksi sesuai ts ddg pd daerah
Sp.B-KBD Gamma GT2 Bil tot/dir interna dustus
Alk.fosf 305 11,59/10,34 choleductus
Coass Risky antihcv/hiv(-) PT R/ Eksplorasi
HbsAg (-) 15,1/12,9 CBD + X-Foto
PT 27,1/12,8 aptt kemungkinan thorax:
aptt44,7/29,8 36,8/29,5 whipple prosedur/ Kesan :
INR INR P3D (03/02/17) Normal
2,77/1,02 1,27/12,9
EKG: normal

2 Dani -Post laparatomi 31/1/17 29/1/17 27/1/17 -IVFD NaCl : EKG : Normal
Mamengko/L/58 eksplorasi ec Leu 10.470 Leu 21490 Leu 16.060
D5%: Clinimix :
thn obstruksi usus HB 8,8 HB 9,5 HB 11,3
metalik total e.c HT 28,1 HT 30,2 HT 35,9 2:1:1
RM : 48.78.177 adheme band Trom 219 Trom 236 Trom 338
- Meropenem 3x1
MRS 27/1/17 -syok septik + OT 47 GDS 81 OT 22
AKI PT 16 Na 131 PT 9 - Ranitidin 3x1
DPJP : dr. Billy Ur 126 K 3,70 Ur 73
- Ketorolac 3x1
Salem, Sp.B- Cr 2,4 Cl 103 Cr 2,1
KBD Alb 1,93 GDS 139 i.v
Na 138 Na 127
- Omeprazole 2x1
Coass Reny K 4,28 K 3,70
Cl 98,9 Cl 92,0 i.v
-Konsul penyakit
dalam