Koran Bedah Digestif Lontara 2 Kamar 2 Jum'at, 11 Agustus 2018

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KORAN BEDAH DIGESTIF LONTARA 2 KAMAR 2

Jum’at, 11 Agustus 2018

NO NAMA RUANGA DIAGNOSIS PENUNJANG PENUNJANG RADIOLOGI RENCANA DJPP


N AWAL BARU
1 Hasnaeni L2AD Rencana laparatomi Lab( 7/7/2018) Lab( 4/8/2018) Thorax Xray Daftarkan ERCP Dr. dr. Ibrahim Labeda,
19/11/1966 K2B1 explorasi CBD Wbc : 9.19 Wbc : 9.0 Kesan : Cardiomegaly, hari Selasa, Sp B-KBD
51 th Rbc : 4.76 Hb :13.9 Pulmo normal instruksi dr. Silvi
847084 Hb :13.4 Plt : 367
Plt : 349 Ur/cr : 20/0.47 MSCT
Ur/cr : 13/0.4 Sgot/sgpt : 25/23 Kesan : Hepatomegaly,
Sgot/sgpt : 39/39 Pt : 10.4 choledocolitis, athrophy
Pt : 10.1 Apt :28.8 renal sinistra
Apt :25.5 Na/k/cl : 143/4.6/102
Na/k/cl : GDS : 184
145/4.6/102

2 Henni Rezky L2AD POH 7 Colostomy Lab( 26/7/2018) Lab 4/8/2018 Foto thoraks 26/7/2018 Optimalisasi KU Dr. dr. Ronald E.
15/1/1992 K2B2 double barel ec. Wbc : 20100 Wbc : 29.0  21.6 Observasi multiple lesi Lusikooy, Sp.B-KBD
26 thn Adenocarsinoma recti Rbc : 4,23 Hb :10,4 12,2 nodular
836231 1/3 distal Hb :9,5 Plt : 385 579
Plt : 751000 Patologi Anatomi
Ur/cr : 19/0,45 Kesan : Insitu
Sgot/sgpt : 17/9 adenocarsinoma recti
Pt : 11,3, Apt :26,5 diff moderate
Na/k/cl :
143/3,5/103

3 H Sitti B L2AD Abses subcapsuler Lab (18-7-2018) Lab (2/8/2018) Thorax Xray Pro laparaskopi Dr. dr. Ibrahim Labeda,
57 thn K2B3 hepar WBC :8.61 WBC : 12.7 Kesan : Efusi pleura drainase abses Sp B-KBD
31-12-1960 +aki+Hydronefrosis RBC : 4.12 HGB 12.8 bilateralatherosclerosis (Selasa, 7/8/2018)
847686 grade II g sinistra Hb :11.7 PLT 367 aortae
MRS: 30/07/2018 HCT: 36.7 Pt/ApTT CT Whole Abdomen Join Urologi
PLT :379 kontras(9-7-2018)
PT/ APTT: 11.7/ Hydronephroureter
22.1 sisistrasuspek sludge
ur/cr: 27/ 1.01 GB
SGOT/SGPT: 21/13 MSCT abdomen non
Na/K/Cl : kontras
134/4.3/105 (10-7-2018)
-hepatomegali disertai
abses subcapsuler
batu ureter sinistra cv
L3-L4 hirdronefrosis
gd2, efusi pleura dextra
KORAN BEDAH DIGESTIF LONTARA 2 KAMAR 2
Jum’at, 11 Agustus 2018

4 Karlina L2AD Ikterus obstruktif ec Lab 1/8/2018 Lab (06-08-2018) CT scan Abdomen Tunggu hasil Mrcp Dr. dr. Warsinggih,
51 thn K2B4 cholelithiasis WBC 5.6 1/8/2018 Sp.B, KBD
12.09-1966 HB 12.1 Bilirubin total : 10,39 Kesan : Cholelith,
851236 PLT 449 Bilirubin direct : 9,25 organ organ intra
MRS: 2/8/18 Pt/ApTT 9.9/27.8 Alkali fosfatase : 186 abdomen ter scan
GDS 137 Albumin : 3,7 normal
Ur/Cr 25/1.26 Gamma_GT : 31
Bilirubin Total 8.85
Bil. Direct 7.51
GOT/GPT 42/38
Albumin 3.8
Na/K/Cl :
142/4.4/10.1

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