Pasien Digest DES 2014

Preview:

DESCRIPTION

data contoh ajah

Citation preview

IDENTITASRUANGDIAGNOSISPENUNJANGKETERANGAN

Tn. Jamaah /36 th/ C491811/ 7889158/ dr. MM/ MRS: 15-12-14R2B2.6Dx/ Prolaps rectum post laparotomy + ileostomy 4 bln yll

Post tutup ileostomy (23/12/14)

Tn. Teguh Setyono/ 36 th/ 7892302/ dr. PBR2B3.2Dx/ Multiple polip Vesika feleaPost laparoskopi kolesistektomi (23/12/14)

Tn. Ponco/ 45 th/ 7892142/ dr. ERIR2B3.3Dx/ CholelitiasisPost laparoskopi kolesistektomi (22/12/14)

Tn. Sunarto/ 54 th/ C412981/ 7880864/ dr. PBR2B3.5Dx/ Adeno Ca recti well diff recurrentPost LAR + Ileostomi (Nov 2013)Post KT 6xMSCT (Nov 2013):Penebalan fokal irregular minimal pada mukosa dinding anorectal (tebal 1,3 cm sepanjang 2,6 cm) disertai penyempitan lumen didaerah tersebut. masih mungkin rekurensi massa.

Lab tgl 2-12-2014Hb : 10,5 ; L : 7.500Tr: 367.400 ; GD II : 119 ; Na/K/Cl : 132/4,6/98Ur/Cr : 21/1,24 ; Alb: 4,0 ; HbsAg : -PPT/PPTK ; 12,7/10,9APTT/APTTK : 47,2/33,2Post Miles Procedure (11-12-14)

Tn. Sutarno/ 34 th/7893978/ dr. ERI/ R2B4.5Dx/ Wound dehiscence post laparotomy + ileostomy a.i peritonitis generalisata Lab 18/12Hb: 13 ; Leu : 15 rb ; GDS:122 ; Alb:3,3 ; Ur/Cr: 146/1,0Pro distal lopografi

Ny. Muntomimah/ 37 th/ 7864305/ dr. ERIR5B2.5Dx/ Adeno Ca well diff sigmoid T4bN1M1 post Laparotomi (reseksi + stoma) maret 2014Post KT 9x progresif responsPost ER cito 1x (alat rusak)KT xelloda oleh InternaPro eksisi tumor + rekonstruksi (23/12/14)

Ny. Anggraeni/ 56 th/ 7892319/ dr. ERIR5B4.3Dx/ Tumor caecum c/ ganas CHF NYHA II Pro Echocardiografi tgg hasilRencana Hemikolektomi dekstra

Ny. Sutimah/ 43 th/ 7885586/ dr. PBR5B5.4Dx/ fistula colocutan e.c tumor rectosigmoid DD/ adeno Ca, absesHb: 11Alb : 2,9Pro laparotomy reseksi tumor k/p Hartmann prosedurDan pasang DJ stent