Update Dig 8 Nov 15 Edited Sore (1)
7
UPDATE PASIEN BEDAH DIGESTIF MINGGU KE II NOVEMBER 2015 (11 November 2015) Bedah D Dokter Ruangan : NOR No Bed Identitas MRS Tgl Op Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP 1. 2 Ali Makki/ 48 thn/ L/12421889 23/10/15 Tumor retroperitoneal + HIL D reponible Pro laparotomy eksplorasi TAO Dr. VS 2. 38 Adi Setiawan / L / 40 12440679 12/9/1 5 Ca Colon Ascendens + Rectum, post total rectocolectomy Total rectocolectomy 3. 7 M. Zainul / L / 43 / 12428013 29/10/15 29/10/ 15 Bile duct Injury staisberg Grd I Post Hepatojejunostomy + Jejunojejunostomy Dr. OMY 4. 37 Syukur / L / 45 / 12411698 6/11/15 Ca colon Ascenden T3 Nx M1 (para aorta) Pro colonoscopy + laparatomi eksplorasi TAO Dr. OMY 5. 35 Purwanto / L / 52 / 10319587 4/11/15 Cholelitiasis + cholesistitis + icterus obstruktif Pro MRCP Dr. OMY Bedah C Dokter Ruangan : AFD No Be d Identitas MRS Tgl Op Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP 1. 16 Yudi Setiawan / L / 32 th / 10935418 2/11 /15 Upper GI bleeding susp Ulcus Peptikum DD diverticle Meckel Lanjutkan terapi medikamentosa Dr. OMY 2. 20 Hari Purwanto / L /36 th / 12427271 9/11 /15 Tumor intra abdomen susp limfoma dd teratoma Pro laparatomi biopsi TAO Dr. DON Bedah B Dokter Ruangan : AFD
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Transcript of Update Dig 8 Nov 15 Edited Sore (1)
UPDATE PASIEN BEDAH DIGESTIF MINGGU KE II NOVEMBER 2015
(11 November 2015)
Bedah D Dokter Ruangan : NOR
No Bed Identitas MRS Tgl Op Diagnosis Planning Pre/Post OpProblem / Keputusan VB
TAO DPJP
1. 2 Ali Makki/ 48 thn/ L/12421889
23/10/15 Tumor retroperitoneal + HIL D reponible
Pro laparotomy eksplorasi TAO Dr. VS
2. 38 Adi Setiawan / L / 4012440679
12/9/15 Ca Colon Ascendens + Rectum, post total rectocolectomy
Total rectocolectomy
3. 7 M. Zainul / L / 43 / 12428013
29/10/15 29/10/15 Bile duct Injury staisberg Grd I Post Hepatojejunostomy + Jejunojejunostomy
Dr. OMY
4. 37 Syukur / L / 45 / 12411698
6/11/15 Ca colon Ascenden T3 Nx M1 (para aorta)
Pro colonoscopy + laparatomi eksplorasi
TAO Dr. OMY
5. 35 Purwanto / L / 52 / 10319587
4/11/15 Cholelitiasis + cholesistitis + icterus obstruktif
Pro MRCP Dr. OMY
Bedah C Dokter Ruangan : AFD
No Bed Identitas MRS Tgl Op Diagnosis Planning Pre/Post OpProblem / Keputusan VB
TAO DPJP
1.16
Yudi Setiawan / L / 32 th / 10935418
2/11/15
Upper GI bleeding susp Ulcus Peptikum DD diverticle Meckel
Lanjutkan terapi medikamentosaDr. OMY
2.20
Hari Purwanto / L /36 th / 12427271
9/11/15
Tumor intra abdomen susp limfoma dd teratoma
Pro laparatomi biopsi TAODr. DON
Bedah B Dokter Ruangan : AFD
NoBed
Identitas MRS Tgl Op Diagnosis Planning Pre/Post OpProblem /
Keputusan VBTAO DPJP
1 22tn. Jarkoni / L / 41th /
124390235/11/15 Ca Caecum T4bN2M1 Pro Colonoscopi TAO
Dr. MDP
2 23tn. Amir Ngadi / L /
47 / 123946465/11/15 Ca Rectum 1/3 distal Pro miles procedure TAO
Dr. DNY
3 11Abd. Hadi / L / 45 / 124554340 1/11/15 PAI dd Ca Caecum Konservatif (antibiotic)
Dr. IWK
4 12 Nanang S / L / 34 / 3/11/15 9/11/15 Cholelitiasis + Choledocolitiasis Post op cholesistectomy + TAO Dr.
12454815choledocolitotomy + IOC OMY
Bedah A Dokter Ruangan : KID
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post OpProblem / Keputusan VB
TAO DPJP
1. 1Samanitun / P / 64th / 12394442
19/10/15
6/11/15
Hernia Sikatrikalis residifPost repair Hernia sikatrikalis, Observasi
Dr. IWK
2. 13Martha / P / 44th / 12438051
6/11/15
Susp Ca Rectum + sigmoidostomi status Pro Colonoscopy TAO ?
3. 4Vika D/ 22 thn/P/ 12448341
7/10/15
TB abdomenFistula high outputComplicated intraabdomen infectionOpen abdomen
Rawat lukaDr. DNY
ICU A Dokter Ruangan : NUX
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VBTAO
DPJP
1. 8
Yacobus / L / 57 / 12247423
2/10/15
16/10/15
12/10/15
Fistel enterecuta High Output post hemicolectoy e.c malignancy
- Post Explorasi laparotomi end to end anastomose + Jejunocolotransversotomy-Post Laparotomi + Reseksi ileum + Sigmoidectomy + Ileotomy + Sigmoidostomy + open abdomen + cuci cavum + bogota bag
Dr. DON
2. 9Mukna / L / 70 th / 12455385
4/11/15
4/11/15
Peritonitis Generalisata ec Gangrenosa Gall Bladder
Post explorasi laparatomi + cholesistectomi + cuci cavum abdomen
Dr. OMY
3. Hanifah / P / 42 th / 12456131
9/11/15
9/11/15
Perforasi gallbladder Laparatomi eksplorasi + partial cholesistectomi
Dr. OMY
Bedah F Dokter Ruangan : DUN
No No. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1. F2-12
M. Arifin / L / 20 thn / 12453649
29/10/15
29/10/15
Penetrating abdominal injury Post repair abdominal
injuryPro KRS Senin
Dr. IWK
Bedah G Dokter Ruangan : DUN
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post OpProblem / Keputusan
VBTAO DPJP
1. G1-2Muadi / L/ 77th / 12452557
24/10/15
27/10/1513/10/15
Burst Abdomen + susp. Leakage jahitan dome buli (post repair buli h-13, riwayat vesicolitotomi h27) + pneumonia + disritmia + sepsis berat
Pro relaparatomi repair burst + sistografi via sistotomi dengan c-arm (uro)
SepsisPneumonia
Dr. DON
2. G1-5Heri / L / 20th / 12455684 5/11/15
6/11/15
Appendic perforasi post op appendictomy h-4 Post op Appendictomi Pro KRS rabuDr. OMY
3. G1-4Askan / L /57 th / 11045943 6/11/15
7/11/15
HIL dextra incarserata post herniotomy + appendic perforasi post laparatomi appendictomi h-4
Post herniotomi + laparatomi appendictomi h-4
Rawat lukaDr. OMY
4. G2-5Mujianto / L /28th / 12453558 9/11/15
Post laparatomi susp perdarahan anastomosis colon tranversum
Dr. IWK
5.G5-12
Sunomo / L / 44 / 12381516 8/11/15
Ca Rectum 1/3 Distal unresectable + Sigmoidostomy Status Post kemoterapi 6x, Post radioterapi 5x + Dehidrasi Sedang
Perbaikan KU Pro pindah bedah DDr. OMY
6. G5-3Sampeni / P / 52 / 12451965 8/11/15 Choledocolitiasis + Mild Cholangitis
Pro Cholecystectomy + Explore Ductus + Choledocolithotomy + Pro MRCP dari ruangan
Pro pindah bedah D TAODr. OMY
7.
Bedah H Dokter Ruangan : RAW
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post OpProblem / Keputusan
VBTAO DPJP
1. H1Rumiasih / P / 59 th / 12442407 7/11/15 Susp. Ca rectosigmoid Pro colonoscopi TAO
Dr. DON
2.Marlina / p / 55 / 12374892 1/11/15
Ileus obstruksi e.c Massa distal CBD dd Cholangitis moderate
Pro MRCP TAODr. IWK
Bedah E Dokter Ruangan : ERK
NoNo. Bed
Identitas MRS Tgl Op Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1. - - - - - - - - -
Bedah Melati Dokter Ruangan : RKD
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1.
R. Transisi Dokter Ruangan : NOR
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1.
ROI 2 Dokter Ruangan : NUX
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1.
ROI 1 Dokter Ruangan : NUX
NoNo. Bed
Identitas MRSTgl Op
Diagnosis Planning Pre/Post Op Problem / Keputusan VB TAO DPJP
1.Muslihah / P / 40 / 12454178
4/11/15
4/11/15
Peritonitis generalisata ec perforasi colon descenden + severe sepsis + koagulopati
Post relaparatomi + repair primer colon descenden + adhesiolisis + cuci cavum abdomen + colotranversotomi
Dr. OMY
2.Indra / L / 18 th / 12456162
8/11/15
8/11/15
Appendic perforasi Laparatomi EksplorasiDr. OMY
3.Andik / L / 43 / 12456047
7/11/15
7/11/15
Internal Bleeding post laparotomy explorative + OF Antebrachii D 1/3 tengah + OF Condyler femur D + OF Cruris D 1/3 Proximal grd II + CF Colum femur + Ruptur Hepar grd I + Hematome retroperitoneal Zona II
Post Laparotomi eksplorasi
4.Mukiyem / P / 55 th / 10182861
9/11/15
9/11/15
HIL D Inkarserata Post HerniotomyDr. OMY
5.
RKL: EMS/KID
NoNo Bed
Identitas MRSTGL Op
Diagnosis Planning pre/post op Problem / Keputusan Visbes TAO DPJP
1.Mera
kNy. Yanik / P / 52
th / 124234205/11/1
5Fistel enterocutan + ca ovarium post
debulking + hipoalbuminTunggu hasil ctscan hipoalbumin
Dr. OMY
2.Mera
kNy. Djumaiyah / P /
55th / 1227368630/10/
15Ca ovarium + frozen pelvis Pro joint op 11/11/15 TAO
Dr. DON
3Kemunin
g
Ny. Sutiyah / P/ 50 th / 12427748
2/11/15
Ca GEF Unresectable + jejunostomy status + chemotx sessin
Pro kemoterapiDr.
DON
