Mapping Digest 19 Juni 2014
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19 Juni 2014 PETA DIGESTIVE YUD/RSA/TOM/VIA/PUR/LFK/JAT/AZR BGSL KM NAMA USI A RM MRS DIAGNOSA STS Tgl OP SENIOR PLAN PJM PEMERIKSAAN PENUNJANG LAIN2 RES 6E Ny. Puji Lestari 39 0125591 7 16/6 Cholelithiasis Post op 17/ 6 IBB Pro Laparoskopi BPJS 26/5 Hb 12.4 AL 5.8 AT 208 OT 19 PT 13 Bil tot 0.3 BD0.1 Bi 0.2 Hbsag(-) JAT Mw1 6I Ny supatmi 37 0124558 1 16/6 Hemoroid ekterna dengan Anemia - - - Perbaikan KU BPJS 17/6 hb 9.1 15/6 hb 4.4 al 16 at 158 na 133 k 4.4 JAT 7F Sri Sunarti 40 0125303 2 9/6 Ikterik obstruksi ec batu CBD - - AR Pro MSCT BPJS 14/6 gamma gt 23 Alk Fos 72 Prot tot 7.1 Alb 3.3 Glob 3.8 Anti HBC TOT (-) Anti HCV Non reaktiv Hbsag (-) Inter na JAT 1F Tn.Sutiman 42 0125783 4 10/6 Periappendicular infiltrat Post op 18/ 6 AR Perawatan post op BPJS 9/6 14,3/41/4,8/216 ptaptt 12,8/34,1 AZR 3B Sarmin 63 0125649 5 30/5 HIL Inkarserata tereduksi spontan BPH Gr III Pre Op - AR Tunggu jadwal op Joint BPJS 30/5 15,3/43,1/14,9/297 ESBL + PSA 4.86 Urolo gi AZR 6D Katimun 63 0125452 0 14/6 Tumor esophagus 1/3 distal ec bariers esophagus high grade dysplasia - - Pro MSCT BPJS 14/6 hb 6.8 al 8.5 at 481 gds 123 ur cr 104 0.9 PUR Mw 2 7D Warso Wiyono 63 0125613 1 6/6 Hemorrhoid eksterna +BPH - - - Menolak pasang DC BPJS 12/6 ur 36 cr 1.9 psa 5.43 10/6 11,6/35/5,5/235 LFK 8H Tn.Muntolib 58 0125668 3 14/6 Hepatoma lobus (D) Susp Maligna - - IBB MSCT Abdv+kontras BPJS 2/6 hb 16.6 AL 7.4 AT 191 ot 275 pt 156 na 128 k 4.4 hbsag (-) AFP 94.10 BT 0.52 BD 0.3 Bi 0.12 ur 19 cr 0.8 AZR 8I Tn.Sukriyanto 46 0125691 8 14/6 Susp ca Colorectal - - IBB Perbaikan KU BPJS 14/6 hb 9.4 al 19.2 at 69 alb 2.2 na 119 k 3.6 cl 89 CEA 3.64 LFK Mw 3 1C Tn. Sadiman 61 0115314 7 10/6 Tumor intra abdomen - - AR Pro MSCT BPJS 12/6 hb 9.9 al 7.2 at 478 14/6 na 141 K 2.5 cl 1089/6 8,7/27/9,8/493 urcr 1,4/59 elk 136/2,9/100 10/6 CEA 5,34 JAT 2A Tn.Parman 70 0125569 3 17/6 Abses Hepar Pre Op - IBB Pro Insisi Drainage BPJS 6/6 Anti Amoeba (-) hb 11 al 7 AT 487 gds 89 gamma gt 137 alk fosf 135 bt 028 bd 0.26 bi 0.02 alb 3.6 glob 2.2 kol tot 92 ldl 36 hdl 33 tag 110 na 136 k 5 ca 109 hbsag – cea 1.7 afp 2.33 10 b Jemitun 56 0122480 1 Adeno Ca Recti - - - Pro Kemo BPJS 16/6 hb 9.7 al 15.5 at 596 18/6 ur 19 cr 0.2 JAT Mlt 1 1F Tn Lasiman 40 0125771 2 Kons 18/6 Ikterus Obstruktif ec Choledokolitiasis - - IBB MRCP/CT ABDMN CEK CA 19-9 BPJS 16/6 HB 11.1 AL 15.4 AT 354 OT 224 PT 111 UR 28 CR 0.5 NA 128 K 3.6 CA 1.06 11/6 USG HIDROPS VESICA FELEA DGN PELEBARAN CBD DAN KOLEDOKOLITHIASIS 9/6 GAMMA GT 508 ALK FOS 881 BT 18.70 BD 15.10 BI 3.6 PROT TOT 7.2 ALB 2.7 GLOB 4.5 ANTI HBC TOT +, ANTI-HCV NONREAKTIVE 3B Tn Sahidi 54 0125681 1 17/6 Sir hep + hipertensi portal , susp ca caput pankreas Pre Op - IBB Pro By pas billiodigest BPJS 14/6 alb 2.2 hb 10.8 al 16.3 at 398 12/6 na 128 k 3.2 ca 1.05 CA 19-6 >500 4/6 Hbctotal + anti HCV – 6/6 usg sir hep + hipertensi portal endoskopi gastropati hipertensi portal cacing + duodenum 9/6 MSCT hepatomegali susp ca caput pankreas dd massa duodenum PUR Mlt 3 9C Banteng 0104391 9 13/6 Post miles procedure ai adeno ca recti - - Kemoterapi BPJS 26/5 hb 14.5 al 6.0 at 199 ot 24 pt 13 ur 28 cr 1.2 cea 0.56 INter na PUR 10 B Ny Karsi 48 0116798 0 13/6 Ca caput pankreas - - - Perbaikan KU BPJS 15/6 Hb 10.3 AL 10.3 At 35 PUR 13 A Ny. Kariyatun 57 0125829 5 14/6 Tumor Intra Abdomen - - - USG Abdomen, Colon in loop BPJS 13/6 CEA 2.62 12/6 Na 137 K 4.2 Cl 107 Hbsag (-) 10/6 Hb 10.6 al 15.3 at 404 ur 47 cr 1.7 PUR
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Transcript of Mapping Digest 19 Juni 2014
19 Juni 2014 PETA DIGESTIVE YUD/RSA/TOM/VIA/PUR/LFK/JAT/AZR
BGSL KM NAMA USIA RM MRS DIAGNOSA STS Tgl OP SENIOR PLAN PJM PEMERIKSAAN PENUNJANG LAIN2 RES
6E Ny. Puji Lestari 39 01255917 16/6 Cholelithiasis Post op 17/6 IBB Pro Laparoskopi BPJS26/5 Hb 12.4 AL 5.8 AT 208 OT 19 PT 13 Bil tot 0.3 BD0.1 Bi 0.2
Hbsag(-) JAT
Mw16I Ny supatmi 37 01245581 16/6 Hemoroid ekterna dengan Anemia - - - Perbaikan KU BPJS
17/6 hb 9.115/6 hb 4.4 al 16 at 158 na 133 k 4.4 JAT
7F Sri Sunarti 40 01253032 9/6 Ikterik obstruksi ec batu CBD - - AR Pro MSCT BPJS14/6 gamma gt 23 Alk Fos 72 Prot tot 7.1 Alb 3.3 Glob 3.8 Anti HBC
TOT (-) Anti HCV Non reaktiv Hbsag (-) Interna JAT
1F Tn.Sutiman 42 01257834 10/6 Periappendicular infiltrat Post op 18/6 AR Perawatan post op BPJS 9/6 14,3/41/4,8/216 ptaptt 12,8/34,1 AZR
3B Sarmin 63 01256495 30/5HIL Inkarserata tereduksi spontan
BPH Gr III Pre Op - AR Tunggu jadwal op Joint BPJS 30/5 15,3/43,1/14,9/297 ESBL + PSA 4.86 Urologi AZR
6D Katimun 63 01254520 14/6Tumor esophagus 1/3 distal ec bariers
esophagus high grade dysplasia - - Pro MSCT BPJS 14/6 hb 6.8 al 8.5 at 481 gds 123 ur cr 104 0.9 PUR
Mw 27D Warso Wiyono 63 01256131 6/6 Hemorrhoid eksterna +BPH - - - Menolak pasang DC BPJS
12/6 ur 36 cr 1.9 psa 5.43 10/6 11,6/35/5,5/235 LFK
8H Tn.Muntolib 58 01256683 14/6 Hepatoma lobus (D) Susp Maligna - - IBB MSCT Abdv+kontras BPJS2/6 hb 16.6 AL 7.4 AT 191 ot 275 pt 156 na 128 k 4.4 hbsag (-) AFP
94.10 BT 0.52 BD 0.3 Bi 0.12 ur 19 cr 0.8 AZR
8I Tn.Sukriyanto 46 01256918 14/6 Susp ca Colorectal - - IBB Perbaikan KU BPJS 14/6 hb 9.4 al 19.2 at 69 alb 2.2 na 119 k 3.6 cl 89 CEA 3.64 LFK
Mw 3
1C Tn. Sadiman 61 01153147 10/6 Tumor intra abdomen - - AR Pro MSCT BPJS12/6 hb 9.9 al 7.2 at 478
14/6 na 141 K 2.5 cl 1089/6 8,7/27/9,8/493 urcr 1,4/59 elk 136/2,9/100 10/6 CEA 5,34
JAT
2A Tn.Parman 70 01255693 17/6 Abses Hepar Pre Op - IBB Pro Insisi Drainage BPJS6/6 Anti Amoeba (-) hb 11 al 7 AT 487 gds 89 gamma gt 137 alk
fosf 135 bt 028 bd 0.26 bi 0.02 alb 3.6 glob 2.2 kol tot 92 ldl 36 hdl 33 tag 110 na 136 k 5 ca 109 hbsag – cea 1.7 afp 2.33
10b Jemitun 56 01224801 Adeno Ca Recti - - - Pro Kemo BPJS 16/6 hb 9.7 al 15.5 at 596 18/6 ur 19 cr 0.2 JAT
Mlt 11F Tn Lasiman 40 01257712
Kons 18/6 Ikterus Obstruktif ec Choledokolitiasis - - IBB
MRCP/CT ABDMN CEK CA 19-9 BPJS
16/6 HB 11.1 AL 15.4 AT 354 OT 224 PT 111 UR 28 CR 0.5 NA 128 K 3.6 CA 1.06 11/6 USG HIDROPS VESICA FELEA DGN PELEBARAN
CBD DAN KOLEDOKOLITHIASIS 9/6 GAMMA GT 508 ALK FOS 881 BT 18.70 BD 15.10 BI 3.6 PROT TOT 7.2 ALB 2.7 GLOB 4.5 ANTI HBC
TOT +, ANTI-HCV NONREAKTIVE
3B Tn Sahidi 54 01256811 17/6Sir hep + hipertensi portal , susp ca
caput pankreas Pre Op - IBB Pro By pas billiodigest BPJS
14/6 alb 2.2 hb 10.8 al 16.3 at 398 12/6 na 128 k 3.2 ca 1.05 CA 19-6 >500 4/6 Hbctotal + anti HCV – 6/6 usg sir hep + hipertensi
portal endoskopi gastropati hipertensi portal cacing + duodenum 9/6 MSCT hepatomegali susp ca caput pankreas dd massa
duodenum
PUR
Mlt 39C Banteng 01043919 13/6 Post miles procedure ai adeno ca recti - - Kemoterapi BPJS 26/5 hb 14.5 al 6.0 at 199 ot 24 pt 13 ur 28 cr 1.2 cea 0.56 INterna PUR
10B Ny Karsi 48 01167980 13/6 Ca caput pankreas - - - Perbaikan KU BPJS 15/6 Hb 10.3 AL 10.3 At 35 PUR
13A Ny. Kariyatun 57 01258295 14/6 Tumor Intra Abdomen - - -USG Abdomen, Colon in
loop BPJS13/6 CEA 2.62 12/6 Na 137 K 4.2 Cl 107 Hbsag (-)
10/6 Hb 10.6 al 15.3 at 404 ur 47 cr 1.7 PUR
17C Danang D 44 01199942 11/6 Multiple cholelithiasis Post Op 13/6 AR Cholesistektomi BPJS12/6 hb 15.2 al 5.6 at 203 pt 13 aptt 26.8 gds 84 na 139 k 4.1 cl
107 31/5 bt 1.23 bd 0.42 bi 0.83 hbsag (-) PUR
Wing 3 1B Ny legiyem 73 01257739
17/6 di konsul 18/6
Hernia ingunalis lateralis irreponibel BPJS17/6 HB 9.5 AL 4.7 AT 141 OT 18 PT 13 CR 8.8 UR 193 NA 138 K 6.8 CL 112 HBSAG – 18/6 HBA1C 5.9 GDS 83 KOL TOT 176 LDL 124 HDL
35 TAG 129 Interna
RGB
Bambang 17 01200680 9/6 Fistel enterocutan Post op 18/6 AR Perawatan post op BPJS 9/6 14,0/41/7,4/318 gds 100 elk 136/4,4/108 ptaptt 14,3/30,610/6 pt 14.3 aptt 30.0 OT 20 PT 6 Alb 3.6
Tn. Danu 18 01257633 8/6 Ileus paralitik Post op 17/6 IBBPuasa s/d bu +,
perawatan post op dan TPN
BPJS11/6 Alb 2.8 ur 33 cr 0.5 sgot 43 sgpt 2310/6 11,9/36/7,1/456 elk 134/4,0/105
Suyono 62 01256370 2/6 Abses hepar Post Op 17/6 AR Perawatan post op BPJS12/6 pt 14 APTT 14 aptt 28.4
2/6 11,5/33/16,5/233 gds 137/30 biltot 1,30 bildir 0,70 bilindir 0,60
Ang 23A Tn Subiantoro 50 01258443 18/6 SOP ec Metastase dd tumor primer dgn
CEA 16.85BPJS 14/6 hb 12.6 al 13.8 at 488 gds 109 ot 13 pt 19 ur 22 cr 0.7 na 137
k 4.5 cl 105 hbsag – led 36 PSA 0.95 CEA 16.85 Ca 19-9 13 BTA -Neuro
