REGISTER PASIEN BEDAH DIGESTIF

19-2-2018 Malam

RKBB
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Elita/pr/19-12-1970 1039076 29-1-2018 Tumor intra abdomen + efusi pleura Pro laparatomi eksplorasi + HF 4.1 Tgl 14-2-2018
dx + hipoalbumin Post chest tube dx ( 29-1-2018) Albumin 2,6
Na 138 ; K 3,5
2 Theng eddy 1014564 14-2-2018 Adeno ca recti 1/3 distal meta hepar Post colostomi per laparoscopy HF 3.1 IO
yanto/lk/6-1-1971 RT : Massa
keras, terfiksir

RKBC
No Identitas MR MRS Diagnosis Tindakan DPJP Kamar Keterangan
1 Nurzilli/pr/1-1-1956 1014200 18-1-2018 Poorly diff Adeno ca colon ascendens Kemoterapi Folfox IV siklus 3 seri 2 AL 5.3 Kemo hari ke I
post Hartman procedure 19-2-18

2 Ahmad yani/lk/10-9- 1046612 9-2-18 Trauma pilar + v. Laceeratum regio Post colostomi + debridement 8-2-18 HF 2.2 RB plastik
1990 anal Lab 19-2-18
HB : 9,6
3 Abidin/lk/24-9-1959 1045398 1-2-2018 Adeno Ca colon descenden Post laparatomi eksplorasi + hartman AL Pindahan ICU
procedure (1-2-2018)

RBE
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Syamsuri/lk/15-4- 1045203 30-1-2018 Burst abdomen +perforasi jejenum + Post repair burst + post Laparatomi HF 4.3 Tgl 15-2-2018
1968 fistula enterokutan eksplorasi + adhesiolisis berat + Hb 12,1
jejunostomi double barel(31-1-2018) Alb 2,5
test norit (-) leuko 10rb
2 Rudilah Hartiny/pr/9- 791443 13-2-2018 Ileus obstruktif ec Adhesiva + striktur Post laparotomi eksplorasi adhesiolisis EF 5.8 Rawat jalan
9-95 jejunum opx kamis 15-2-2018 besok
3 Rubaidah bt m goni/ 1047773 17-2-2018 Pankreatitis akut susp severe CAD Konservatif EF 5.3 Lab 16-2-18
pr/ 22-7-55 kompensata Pro echo 20-2-18 Hb 12,2
Amilase 140
Lipase 80
4 Iindarti/ pr/ 4-3-72 1047773 18-2-2018 Tumor recti 1/3 distal Pro biopsi eksisi 20-2-18 EF 5.1 Konsul obgyn
Dd/massa recto buli pro Usg

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 konfirmasi 20-2-
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OGAN
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

1 Heriyadi/lk/39 thn 1044200 9-2-18 Abses regio inguinal dextra Post drainase abses EF 14 Ku badan
lemah
13-2-18

2 Hamarudin bin 459061 28-1-2018 Perforasi gaster pre pyloric Post laparotomi eksplorasi (15-2-2018) EF 11 Luka op basah
maid/lk/19-2-53 CKD on HD Lab 17-2-18
Hb 9,2 ; leuko
20800 ; ur
150 ; cr 5,00 ;
na 144; K 5,2

RPK
No Identitas MR MRS Diagnosis Tindakan DPJP Kamar Keterangan
1 Ridwan arif/lk/ 18-2-2018 CKD on HD Pro CAPD (19-2-2018) AL 3.1 Hipertensi di
IBS
2 Lego bin supar / lk / 1039093 19-1-2018 Tumor omentum Post laparotomy eksplorasi + debulking HF 4.3 Rawat jalan
25-6-1966 PA/ metastasis mucinous adeno ca + drainase ascites (6-2-2018) besok
omentum
3 Bahari sitorus Tumor intra abdomen Pro laparotomi eksploari AL ADMISI

4 Bambang luwito Adeno ca recti Pro kemo folfox IV Al ADMISI

SARAF BAWAH
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

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ROW
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Maimunah bt 1045333 31-1-2018 Tumor intra abdomen Pro laparotomi eksplorasi EF 6.2 Batal op 19-2-18
Hairi/pr/7-9-1941 Susp massa mediastinum Pro Ct scan thoraks (Anestesi)
Pro Spirometri (PDL)
2 Paijo bin samidi / lk/ 1043271 17-2-2018 Ikterus obstruktif e.c sumbatan distal Post explore CBD (19-2-2018) HF 2.5 Lab 18-1-2018
7-4-53 CBD Hb 8,5
Albumin 2,6
3 M. Zais 1046220 7-2-18 Fistula Enterocutan hight output Pro perbaikan KU EF 3.1 Tgl 15-2-18
Ardiansyah/lk/1-9-92 Perawatan luka Hb : 9,5
Leu : 10.300
(Luka bertambah lebar)
Ht : 30
Plt : 555.000
GDS : 85

4 Lismawati / pr / 23-6- 974668 4-2-18 SSI post hernioplasty per laparotomy + Perbaikan KU AL 4.3 Lab 10-2-2018
1963 anemia a.i hernia incisional , /r Mobilisasi jalan Hb 12 Alb 3,3
perforasi gaster
5 Samsudin lindang/ lk/ 1047548 15-2-18 Tumor esofagus susp ganas CT scan cervicothoracal 23-2-18 HF 5 Ku lemah
10-961 Post Syok septic
Martin bin aldi/ lk/ 8- 1027003 24-1-2018 App infiltrat konservatif EF 5.5 Demam naikturun
6 3-85 Lab 18-2-18
Hb 13,8; leuko
25100; LED 50 ;
neutrofil 84

MATA
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Martin Sirman/lk/5- 1027003 24-1-2018 Perforasi Duodenum + Tumor Pro colonoscopy biopsi HF 5.2 Batal op 19-2-18
9-1987 rectosigmoid + Infiltrasiprostat + Pro sistoskopi kp TURB (urologi, DIT) Lab 18-2-18 :
fistula recto vesica + Anemia Hb 6,4; wbc
sepsis 5800; PLT 39rb ;
r/ sistoscopi + laparotomy eksplorasi + alb 2,3; ur 144;
adhesiolisisberat + suture primer cr 3,08; Na 132;
duodenum + colostomy tgl 29-12-17 K 3,0
wound dehiscense

2 Naya bt semanaf/ pr/ 1017667 15-2-2018 Well diff adeno ca recti 1/3 proksimal kemoterapi folfox IV siklus 3 seri 2 AL 6.3 Kemoterapi hari

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 9-4-54 post colostomy I 19-2-18
3 Hernayati ibnu/pr/ 8- 1002819 17-2-18 Muscinous adeno ca recti kemoterapi folfox IV AL 2.2 Kemoterapi hari
8-57 I 19-2-18
4 Zul iskandar 972074 Ca recti type papiler meta hepar + Pro Miles per laparoskopi 20-2-18 AL ADMISI
dinding abdomen

MUSI ELOK 1.1

No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

1 Abu rani H bin/ lk /9- 1046514 29-1-2018 Tumor caecum Post hemicolectomi dx + anastomoses HF 6 Flatus (+)
6-1969 ileocolontransversum per stapler Aff drain (+)
15-2-18

MUSI ELOK 2.1

No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Hj. Djuariah/pr/31- 1041022 4-1-2018 Adenoca recti + Fistula recto vagina + Post colostomi (8-1-2018) HF 2 Tgl 11-2-18
12-1942 hipoalbumin + ulcus decubitus Post repair colostomy (23-1-18) Hb 10,6;WBC
10500; alb 2,9;
gds 104; na 138;
K 5,2

RB : b. plastik
Usul rawat jalan
2 Istianah bt ismail /pr/ 1046242 6-2-18 Ikterus obstruktif ec sumbatan CBD Pro explore CBD 20-2-18 EF 1 tgl 15-2-18
24-6-1943 ec Ca caput pankreas Senin 12-2-2018 HbA1c : 6,3
ALP : 484
CA 19-9 : 239,4 ;
hb 13,3; leuko
4800; biltot
16,21; bildir
13,37; bilindir
2,84; Na 145; K
5,0

MUSI ELOK 2.2

No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

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LEMATANG 1.1
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

LEMATANG 1.2
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

RUPIT 1/YASMIN A
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

1 SS Konsul pdl

RUPIT 1.2/YASMIN D
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan

1 A Rahman bin M 881904 31-1-18 Tumor piloroduodenum Pro Bypass gastrojejunostomi EF 2.2
yunus / lk / 14-6-61 20-2-18

MAWAR BEDAH
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Sulianah/pr /12-6-61 1003559 19-1-2018 Adeno ca recti 1/3 distal post Perbaikan KU AL 2.2 Tgl 18-2-2018
colostom post kemo 2 seri+ Pro assessment ulang Albumin 3,0
hipokalemi Usulcek CEA K 2,2
2 Sari susanti/pr/28-1- 104670 19-2-18 Multiple cyst intraabdomen Pro laparotomi eksplorasi SS 4.8
90

MAWAR KEBIDANAN
No Nama MR MRS Diagnosa Tindakan DPJP Kamar Keterangan
1 Roliana bt ramli/pr 919492 11-2-2018 Fistula enterocutan Joint op obgyn 21-2-18 Konsul obgyn
/28-3-59

ICU
1 Maimunah bt M 1033594 25-1-2018 Striktur oesophagus 1/3 proximal Post Post operasi explorasi esofagus + HF 13
Mis/pr/13-6-1963 endoscopi stenting
(8-2-2018)

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