PALEM ATAS

B2 K1 Bed 1Donald Hi Mallu

14-12-1965/ 49thn696577

MRS 19-01-2015SM- Hemoroid Interna Grade III - Hemoroid Externa Grade V-Post operasi hari 9Open Hemorroidektomy

Riwayat : BAB campur darah, terdapat benjolan pada anus,

Rencana Op : 9-2-2015-Infus Ringer Laktat: Dextrose 5% 2:2 28tpmCeftriaxone 1gr/12j/iv-Ranitidin 50mg/8j/iv-paracetamol 1 gr/12jam/iv-amlodipin10mg 1x1-Adona 1ampul/8j/ivVenosmil tab 3 x 1 -makan bubur, jus buahLab 4/2/2015Wbc 5.6Rbc 4.68Hgb 10.2Hct 33Plt 224Gds 86Ur 26Cr 1.0As. Urat 5.3Got 24Gpt 23Kol total 223Tg 67Na 143K 3.8Cl 104Lab 3/2/2015HB 7,8Laboratorium (23/01/2015)WBC :4.17RBC : 4.66HGB : 9.0HCT : 32.4PLT : 319CT : 7.30BT : 3.00 PT : 10.9 k 11.1APTT: 25.9 k 25.3Foto polos abdomen 27/1/2015-Tidak tampak kelainanColon inloop 27/1/2015-Tidak tampak massa intraluminer pada abdomen-Colitis pada proximal rectum sampai rectosigmoid

B2 K2 Bed 2Rosmiati03-09-1963 /51 thn693507MRS 16-01-2015

SM

Tu corpus gaster POH 5 partial gastrektomi/ bilroot II

Riwayat : Masuk dengan nyeri perut bag. Atas, disertai bab warna kehitaman yang terjadi sejak 10 tahun, memberat dalam 2 bulan terakhir

-ivfd aminofluid; nacl 0,9%;d 5%= 1000;500;500 cc/24 jam-ceftriaxon 1 gr/12 jam/ivMetronidazole 0,5 gr/8 jam/iv-ketorolac 1 amp/8 jam/iv-ranitidin 1 amp/8 jam/iv-awasi ttv-balance cairan- Boleh minum 5 sendok/jamLab 8/2/15Rbc 4,36Wbc 7,9Hgb 10,5Hct 33Plt 338Gds 111Got 38Gpt 25Albumin 2.8Na 137K 3,9Cl 104

Lab 3/2/2015Rbc 4,59Hgb 11,9Hct 35Plt 398Gds 191Got 38Gpt 25Albumin 2.8Na 140K 4.9Cl 109Laboratorium (20-1-2015) WBC: 7,88RBC: 4,97HGB: 11,8PLT: 505HCT: 38.4Protein total: 6.7Albumin: 3.2Globulin: 1.3CEA: 0.76

GDS: 201Laboratorium (16-1-2015) post transfusiWBC: 6,3RBC: 4,16HGB: 9,7PLT: 578HCT: 30GDP: 103Ur/Cr: 13/0,50GOT/GPT: 8/8PT/APTT: 8.8/28.1Albumin: 2,8CT/BT:6,00/2,00Elektrolit: Na/K/Cl: 140/4,2/107

Laboratorium (22/12/2014)AFP: 2,16CEA: 0,59

Foto Thorax (20-1-2015)-Pulmo normal-Cardiomaegaly dengan dilatation et elangatio aortae-Tidak tampak tanda-tanda metastatis pada foto

Hasil PA (06-01-2015)-peradangan kronik aktif kesan suatu massa ulseratif

Hasil UGIE 31-12-2014Tumor Gaster

USG abdomen (18-12-2014)Tumor Gaster susp GIST

B2 K3 Bed 2Diana Malik23-09-1967/47thnMRS28-01-2015

RL

Post op colostomy Ca. recti 1/3 distal+ ikterus obstruktif intraoperatif

Methylprednisolone 3 x 4 mgHp pro 3 x 1

Slinger 2x/ hrRectal was + analTraining P/S

Lab 6/2/2015Bil tot : 5,87Bil direk : 4.7SGOT : 164SGPT: 90Usg abdomen 2/2/2015-Tidak tampak tanda2 obstruksi biliaris-Tidak tampak tanda2 metastasis pada usg abdomen ini-spelenomegaliPA 2/2/2015Bahan/lokalisasi: rectumKesimpulan: peradangan kronik, tidak ada gambaran malignitasLaboratorium (28-01-2015)WBC : 4.7RBC : 3.36HGB : 10.5HCT : 31.3PLT : 139GOT/GPT : 115/84Bilirubin total: 9.76Bilirubin direk: 8.96Na/ K/ Cl : 143/4.0/108Ureum : 12Kreatinin : 0.5Bil.total: 9.76Bil. Direk: 8.96Pro. Total: 5.3Alb: 3.4

Laboratorium (15-01-2015)WBC : 4.2RBC : 3.73HGB : 11.5HCT : 34.0PLT : 174PT: 11.4 c 10.1APTT: 33.4 c 24.5GOT/GPT : 136/77Bilirubin total: 9.28Bilirubin direk: 7.63

B2 K8 Bed 1Jawis13-06-1965/49 tahun 696666MRS : 13-01-2015

RL

POH-17 pemasangan kateter CAPD

-Cefadroxil 1 tab/12 jam/oral-terapi lain sesuai ts GH-GV +rawat luka/2 hari

Lab 5/2/2015Wbc 3.1Rbc 2.07Hgb 6.0Hct 19Plt 50Pt 12.5Aptt 31.8Gds 116Got 46Gpt 48Lab 31/1/2015Ur 275Cr 9.1Na 130K 6.1Cl 100

Laboratorium (22/01/2015)WBC : 5.0RBC : 3.08HGB : 8.6HCT : 26.2PLT : 173GDS : 119GOT/GPT : 139/297Albumin : 1.8Na/ K/ Cl : 128/5.2/100Ureum : 198Kreatinin : 8.3PT : 13.4 k 11.4APTT: 31.9 k 24.9SGOT: 139SGPT: 297

Laboratorium (20/01/2015)WBC : 5.59RBC : 3.27HGB : 8.6HCT : 26.3PLT : 141CT : 7.30BT : 3.00 GDS : 103GOT/GPT : 16/11Albumin : 2.2Na/ K/ Cl : 149/4.6/106Ureum : 209Kreatinin : 9.70PT : 12.8 k 10.9INR : 0.94APTT: 30.8 k 25.3Bil. Total: 0.96Bil. Direk: 0.68Protein total: 7.9Albumin: 1.8

Laboratorium (13/01/2015)WBC : 4.0RBC : 2.90HGB : 7.8HCT : 24.6PLT : 176

Laboratorium (31-12-2015)CT : 7.30BT : 3.00 GDS : 103GOT/GPT : 16/11Albumin : 2.2Na/ K/ Cl : 137/4.0/101Ureum : 180Kreatinin : 9.6PT : 9.8 k 10.7INR : 0.94APTT: 25.6 k 24.1

B2 K4 bedNurhaedah15/10/1975 (39 tahun)565618Tgl masuk 1/2/2015Konsul dari interna diges tgl 7/2/2015

IL

Cholelitiasis Rencana operasi laparoskopi +kolesistektomi hari rabu 11/2/2015 Terapi sesuai TS GHLab 3/2/15Na/k/cl 145/4.4/107PT: 9.9, Aptt: 26.9CT/BT : 7.3/2.3UR/CR : 14/0.7Bil tot : 0.41Bil direct : 0.2Sgot/sgpt : 22/16ALP/GGT : 100/22

Lab 2/2/15Rbc 4.32Hgb 13.3Hct 40Plt 316Wbc 9.9Got/gpt 19/13Lab 3/2/15Na/k/cl 145/4.4/107

B2K7St maemunah31/12/54 (60 th)699372Konsul dr endokrin metabolic tgl 7/2/2015

Abses dinding abdomen Cek ulang dr, alb, gdsUsg abdomen kontrol

Terapi lanjut sesuai bagian endokrinUSG 8/2/2015Abses pada kuadran kanan bawah dinding abdomen

Lab 8/2/2015Rbc 3.82Hgb 11.9Hct 35Plt 328Wbc 6.3GDS 140Albumin 3