TULIP

1. Bahtiar / 46 thn / 1453842 Ny. Yanah / 31 thn / 1450596

DK : HIK Reponible OMD : Achalasia
Thorax AP : DK pra op : Achalasia esophagus + Hipokalemia
Ul : Normal Dx pasca op : akalasia esophagus + GERD grade III
Op : 4 feb 2020 post Heller myotomy POD 3
T tube : TD 110/70 N: 80x/m R:20x/m T: 36.8
Drain :
S: S) mual ( ) muntah ( ),
NGT :
15/2 30/1/20 Urine :
Hb 15
15/1/2020 27/01/20 30/01/20 5/2 P)
Leukosit 13,3
Hb
Erit 5,3312.3 9.4 9.6 RL:D5 2000 cc/hr
Leukosit
Hct 44,15.9 3.7 9.6 Ketorolac 3 x 30
Erit
Trombosit 2314.24 3.29 3.36 Tramadol extra
Hct 37.5 28.3 28.1 Inj.OMZ 1 x 40 mg
Albumin Puasa 2 x 24 jam ost op
Trombosit 249 16 125
Ur/Cr NGT + dipertahankan sd 10 hr
Albumin
OT/PT 28/14 POD 3
Ur/Cr
ALP 21/0.67 13/0.5
OT/PT
GDS 20/13 16/10 Ahmad / 1450811
GDS
Na/K/Cl 75 DK : abses perianal + Fournier gangrene
Na/K/Cl
PT/INR/APT 141/2.9/106
11,9/1,15/25,5 147/3.3/107 138/3/104 Colostomy sigmod op tgl 6/2
PT/INR/APTT
T 13.6/1.28/25. 13.2/1.22/31.7 Colon inloop : tidak ada massa intraluminal
CEA/Ca 19-9 7
CEA/Ca
Bil T/D/I19-9 25/1 6/2
0.99/0.89/0.10 1,02 0.95/ 0.07 P)IVFD RL:D5 2000cc/24 jam
Bil T/D/I
Hb 12.4 Inj ceftriaxone 2x1
Kolesterol
P)rl 2000cc
Leukosit total 15.5 Ketorolac 3 x 30
LDL/HDL/TG
Inj Keto 3x30mg
Erit 4.26 OMZ 2 x 40
Inj ranitidin 2x50mg 37.4
Hct Boleh diet jika sadar, diet bertahap
Trombosit 929
Albumin
Ur/Cr 24/0.87
Arlina / 43 th / 1437354
OT/PT
Tumor mesenterika paraumbilical
ALP
CT scan : massa solidkistik,
GDS 122 intraperitoneal region paraumbilical kanan, curiga berasal
dari
Na/K/Clmesenteril. 137/4.5/105
Simple cast hepar dan renal sinistra
PT/INR/APTT 12.1/1.13/ 29.4
Thorax dbn
CEA/Ca 19-9
Bil T/D/I
Asam urat 3.1
Massa 5 x 3 cm, batas tegas regular, permukaan halus (kanan)
21/01/20
Hb 13.7
Leukosit 10.2
Erit 4.97
HCT 41.9
Trombosit 486
GDS 77
SGOT 13
SGPT <6
Ureum 15
Creatinin 0.8
PT/APTT 10.1 / 0.91 /
26.1
Na/K/Cl 138/3.7/108
Alb
CEA/CA 19-9
Bil Tot/Dir/Indir

R operasi menunggu jadwal

Ny. Siti Aisyah / 73 th Maria via septiana / 19 th

DK : adeno ca recti DX dyspepsia dd appendisitias akut
Endoscopy ca recti Ivfd rl 2000 cc / 24 jam,
PA adenokarsinoma rectum Ceftriaxone2 x 1
CT massa malignant di rectum 1/3 distal ukuran 3.8 x 3 x 4 Omz 1 x 40
Thorax : cardiomegali Oral KSR 2 x 600
 NAC 3 x 200
23/01/20 26/01/2020 27/01/2020 2/2/20 Konsul paru (+) lapor hasil (+) jawaban (_)
Hb 8.5 11.5 11 10.5 Usg abd : ascites disertai suspek peritonitis ec tb
Leukosit 1.6 1.0 1.5 6.4
Erit 2.81 3.67 3.69 4.14 TD : 130/90
HCT 25.1 31.7 32.3 31.7
Trombosit 277 229 199 16.5 3/2 6/2
GDS 118 Hb 12.7 leukosit >25 lpb
SGOT 18 Leukosit 20.1 Epitel <10 / lpb
SGPT 9 Erit 3.95 Sputum pagi Mucoid
Ureum 15 84 HCT 37 Sputum swktu Mucoid
Creatinin 0.9 2.11 Trombosit 712 Sputum pagi Negative
PT/APTT GDS Sputum swktu Negative
Na/K/Cl SGOT 35 Bahan Sputum
Alb SGPT 27 Coccus gram
CEA/CA 19-9 positing
Bil Tot/Dir/Indir berbagai
bentuk
P) pro mils prosedur colostomy Ureum Basil gram
Jadwal op 04 negatif
NS 500 cc / 24 jam Creatinin
Inj ranitidine 2 x 1 amp PT/APTT
Codein 3 x 1 Na/K/Cl 133/2.6/92
Erdostein 3 x 1 Alb 3.7
Cetirizine 3 x 1 CEA/CA 19-9
Ventolin + combivent Bil Tot/Dir/Indir
 Kamar 8 Bed 6 Norhaili /
Tn. Rachmadli / th Ca ovarium + ileus obstruktif post op colostomy
DK : general peritonitis ec app perforasi
USG urologi ileus local di abdomen bawah kanan ec susp appendix perforasi Op 5/2/20
PA : kesimpulan : histerektomi, dan oovorektomi :
kistadenocarcinoma ovarii serosum
29/01/20 31/1/20
Hb 17.6 Advice dr agung Transfusi PRC 1 kolf
Leukosit 11.9
Erit 5.97
Hct 51.4
3/2 6/2
Trombosit 178
Hb 8.9 8.0
Albumin
Leukosit 7.7 17.4
Ur/Cr 99/4.77 100/1.98
Erit 3.33 3.19
OT/PT 38
Hct 26.6 25.6
ALP
Trombosit 747 605
GDS
Albumin
Na/K/Cl 3.3
129/4.8/94 134/3.7/103
Ur/Cr
PT/INR/APT 53/2.16
OT/PT
T
ALP
CEA/Ca 19-9
GDS
Bil T/D/I 131
Na/K/Cl 129/3.7/101 P)
PT/INR/APTT
RL:D5 3 tpm 10.6/0.98/31.5
Inj ceftriaxone
CEA/Ca 19-9 2x1gr
BilMetronidazole
T/D/I 3x500
Ranitidin
Asam urat 2x1 gr
Ketorolac 3x30 mg
OP 28/10/20
 Ny. Anah/34 th / post laparotomy eksplorasi (op 1/2/20) ai general Tn Aswan , 47 th, ICU , post LE ai ca gaster op 3/2/20
peritonitis ec bleeding intraabdomen + multiple trauma
PA (02/11/2020) fundus gaster : displasia sedang
Ny. Anah PA (07/12/19)cairan asites : mengesankan adenocarinoma
PA (16/01/2020)cairan pleura: 16-01-2020
Gastroscopy (23/10/2019) : massa gaster, esofagitis
Hb 10.1
Thorax (06/12/2020) : pulmo tak tampak kelainan
Thorax marker 07/01/2020: efusi pleura bilateral terutama sinistra
Trom235 CT scan abdomen(11/12/20) : penebalan dinding gaster disertai asites

ht 31.1 alb 2.308/01/2020

bil tot 0.89 bil30/01/2020
d 0.76 bil in 0.13
Hb 11.6 10.9
Leukosit 5.4 ec intraabdominal
General peritonitis 5.3 bleeding + Mild head Injury
Erit 4.97 4.28
+ Closed fracture pubic rami inferior superior sinistra + close
Hct 39 34.9
fracture of right404
Trombosit corpus mandibula
377 tranverse displaced+ close
fracture of left body of mandibule
Albumin 3.3 tranverse displace + closed
Ur/Cr 29/0.69
fracture tibia fibula distal complete dextra
OT/PT 16/8
GDS 108 113
PT/INR/APTT 11.3/1.03/11.4 12.5/1.17/30.6
HBaAg Non reaktif

P)
RL : D5 2000cc
Inj ceftriaxone 1gr
Inj ranitidin 2x50 mg

subtotal gastroscopy 3 feb 2020

 Wiji lestari, 76 th, post laparoscopy ai cholelitiasi + PJK o Elyzawati kusuma/ 62th/post herniorepair ai HIL inkarserata op
5/2/20
IVFD RL ; D5 2000cc/hr IVFD RL ; D5 2000cc/hr
Inj ceftriaxone 2 x 1 Inj ceftriaxone 2 x 1
Ketorolac 3 x 30 Ketorolac 3 x 30
Omeprazole 1 x 40 Omeprazole 1 x 40
NGT dialirkan NGT dialirkan
21/01/20
Hb 11.2 IPD drip novorapid, metronidazole 3 x 500
Leukosit 8,2
Erit 21/01/20
3.8
Hb
Hct 15.5
36.3
Leukosit
Trombosit 14.2
278
Erit
Albumin 5.2
Hct
Ur/Cr 45.2
35/0.65
Trombosit
OT/PT 399
Albumin
GDS
Ur/Cr
Na/K/Cl 35/0.65
137/4/106
OT/PT
PT/INR/APTT 21/18
GDS
CEA/Ca 19-9 209
Na/K/Cl 137/4/106
PT/INR/APTT
CEA/Ca 19-9
Bil T/D/I
 Anggrek lantai 3 Anggrek Lt 3 Kmr 14
1. Ny. Sri handayani/ 42 thn 2. Tn. Sugeng Sukirmanto / 60 thn /
DK : obstructive jaundice ec susp batu CBD + cholelithiasis op 6/2/20 DK : Post LEAdenoca Colon Descendent et Tranversum metastase hepar op tgl
3/2/20

Usg USG Abdomen : (20/01/2020)

21/01/20 5.2.20 cholelithiasis Nodul Hepar Lobus Kanan uk 2.9 cm
Hb 11.2 Massa iireguler mengobliterasi flexura lienalis colon descenden meluas sampai mid
Leukosit 8,2 colon descenden uk 4x5x7 cm
Erit 3.8 Kesan : keganasan colon desenden, metastase intrahepatal
Hct 36.3 Thorax : metastasis (-) cardiomegal
Trombosit 278 P) Colonoscopy : setinggi 70 cm tampak masa berbenjol-benjol, mudah rapuh,
RL:D5: 2000 berdarah
Albumin cc/hr PA : Adenocarcinoma moderate diff
Ur/Cr Inj ranitidine 2 CT scan : tampak lesi nodul hipodens, soliter, diameter 2.9 cm batas tidak tegas,
OT/PT x 50 gr tepi irreguler di lobus kanan hepar, massa intraluminalcolon fleksura lienalis
GDS Antrain 3 x 1 dengan metastase intrahepataldan perbesaran KGB paraaorta
Na/K/Cl Ceftriaxone 2x1 P
PT/INR/APTT gr RL : D5 2000 cc
CEA/Ca 19-9 Hp pro 3 x 1 Inj metronidazole 3 x 1 flsh
Bil T/D/I 4.99/4.04/0.95 UDCA 2 x 1 Omz 1 x 40 mg
Pro eksplorasi Ceftriaxone 2 x 1
Diet bubur (+) jika kentut Ketorolac 3 x 30

Ekspertise CT scan 19/01 16/01 29/01

Hb 9.7 10.4 10.5
Leukosit 19.3 16.6 22.9
Erit 3.34 3.69 3.75
Hct 28.7 31.2 31.4
Trombosit 408 408 407
Albumin
Ur/Cr 24/0.91
OT/PT 21/19
GDS 192
Na/K/Cl 143/3.8/113 137/3.0/108
(22/01)
PT/INR/APTT 10.8/0.98/24.5
CEA/Ca 19-9 87.22
ArniahLcopi + cholesistectomi MursyidahLcopi + cholesistectomi
BilCTT/D/I
abd : multiple cyst ren bilateral Thorax cardiomegaly
Hb 12.8 N
 20.01.20 Bil T 4.99
Hb 10.5 Bil D 4.04
Leukosit 6.7 Bil I 0.95
Erit 3.56
Hct 32.1 Op tgl 6/2/20
Trombosit 276
RL : D5 2000 cc
Albumin Inj ceftriaxone 2 x 1
Ur/Cr 73/1.52 Omz 1 x 40 mg
OT/PT 52/119 Ketorolac 3 x 30
GDS Diet jika pasien sadar
PT/INR/APTT Mobilisasi bertahap
HBaAg
Bil T/D/I 0.33/0.14/0.19

RL : D5 2000 cc
Inj ceftriaxone 2 x 1
Ranitidine 2 x 50 mg

Ketorolac 3 x 30
ASOKA 409-A

3. Ny.Saniah / 77 thn Kamar 8 Bed 6

DK : poat LE (op 6/2/20) ai Obstructive Jaundice ec Ca Caput Pancreas Tn. Sudjati
DK : post LE + insersi tub ai obs jaundice + cholesistektomii (op 5/2/20)
Endoscopy : Massa pada corpus gaster JGCA type 2 berbenjol-benjol, rapuh, USG urologi ileus local di abdomen bawah kanan ec susp appendix perforasi
mudahberdarah
CT Scan : hepar tampak multiple cyst uk 8mm-2 cm, tampak lesi dicaput pancreas,
amorf, batas tak tegas, uk 6x5 cm, tampak dilatasi ductus pancreaticus
HbThorax : tidaktampak metastasis
Leukosit
Drain:
Erit
Hct
27/11/19 24/01/20 6/2/20
Trombosit
Hb 9.4 11.5 8.5
Albumin
Leukosit 12.2 13.9 19.4
Ur/Cr
Erit 3.16 3.67 2.53
OT/PT
Hct 30.6 35.7 25.7
ALP
Trombosit 495 652 593
GDS
Albumin
Na/K/Cl 3.3
Ur/Cr
PT/INR/APT 15/0.93
TOT/PT 65/42
Amilase/lipase
CEA/Ca 19-9 395/1200
GDS
Bil T/D/I 191 118
Na/K/Cl 136/3.7/96 P)
PT/INR/APTT 10.3/0.93/33.1 12.2/1.14/30.4 RL:D5 2000 cc per 24 jam
CEA/Ca 19-9 Inj ceftriaxone 2x1gr
Bil T/D/I 2.65/2.21/0.44 7.15/5.95/1.20 Metronidazole 3x500
Kolesterol 338 Omeprazole 1 x 40
HDL/LDL/TG 16/275/237 Ketorolac 3x30 mg
OP 28/10/20
P)
RL : D5 2000 cc/hr
Inj ceftriaxone 2x1gr
Inj omeprazole 1x40mg
Inj ketorolac 3x30 gr

Raber Misransyah / 57 th / hemoroid eksterna

Muliyana post LE ai translokasi IUD ekstraluminal leuk 15.200
 Inj laxadin 2 x
IVFD RL 2000cc / 24 jam Salep
Cefazdil? 2 x 1
Metronidazole 3 x 500 Ramli/59 th/ cholelitiasis cholesistitis akut + CKD gr V + DM tipe 2
Furamin 3 x 1 USG abd : cholelitiasis dengan cholesistitis akut
Ketorolax 3 x 30 Thorax cardiomegali
Leu urine +
Eritrosit urine + 3-6

1/2/20 3/2
Hb 6/2/20
11.2’
Leukosit
Hb 13.2
13.3
Erit
Leukosit 3.93
5.5
Hct
Erit 31.9
4.76
Trombosit
Hct 210
38.6
Trombosit
Albumin 324
Ur/Cr
Albumin 101/5.2
OT/PT
Ur/Cr 13/0.7
ALP
OT/PT
GDS
ALP
Na/K/Cl
GDS 75
PT/INR/APT
Na/K/Cl 10.4/0.96/24.3
140/3.3/109
TPT/INR/APT 10.2/0.92/29.3
CEA/Ca
T 19-9
Bil T/D/I
CEA/Ca 19-9
Bil T/D/I