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1. Tn. Jaini 45th/1-79-09-78/Post op Re LE aiperforasi gaster

Ku !"eri #$u hati

RP% &s 'enge$uh(an n"eri u$u hati ) 'inggu%*R%. !"eri terse+ut hi$ang ti'+u$ ,an ti,a(

'ena$ar. &s (e'u,ian +ero+at (e +i,an(a'pung ter,e(at ,an ,i+eri o+at 'inu'na'un (e$uhan uga ti,a( +er(urang. &s(e'u,ian +ero+at (e pus(es'as ,an

,i,iagnosis 'aag. !a'un (arna (e$uhan ti,a( uga +er(urang os (e'u,ian ,iruu( (e R%#$in untu( ,i$a(u(an pe'eri(saan $e+ih $anut.*ua$/*untah /- 2e'a' -.


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%tatus 3enera$is

• *ata (onungtia ane'is -/- s($era i(teri( -/-•

*u$ut 'u(osa $e'+a+ • Leher p K36 -/-

Kepa$a/

$eher

• gera(an ,a,a si'teris retra(si -• P asi'etris 6% (a:(i• P sonor• ; ron(hi -/-


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oto ($inis


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>asi$ La+oratoriu')9/11/)015

te's Resu$t !or'a$ a$ue #nit

>e'ato$og"

>e'og$o+ine 7.3 14.00 - 18.00 g/,$

Leu(o@"te 7.9 4.0 – 10.5 thousan,/u$

Eritro@"te 2.70 4.00 – 5.50 'i$$ion/u$

>e'ato@rit 22.7 32.00 – 44.00 o$A

Tro'+o@"te 129 150 – 450 Ri+u/u$


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>asi$ La+oratoriu'0C/1)/)015


>e'ato$og"

>e'og$o+ine 7.1 14.00 - 18.00 g/,$

Leu(o@"te 11.1 4.0 – 10.5 thousan,/u$

Eritro@"te 2.59 4.00 – 5.50 'i$$ion/u$

>e'ato@rit 22.7 32.00 – 44.00 o$A

Tro'+o@"te 112 150 – 450 Ri+u/u$


7/32

>asi$ La+oratoriu'1)/1)/)015


>e'ato$og"

>e'og$o+ine 9.7 14.00 - 18.00 g/,$

Leu(o@"te 10.9 4.0 – 10.5 thousan,/u$

Eritro@"te 3.39 4.00 – 5.50 'i$$ion/u$

>e'ato@rit 30.3 32.00 – 44.00 o$A

Tro'+o@"te 612 150 – 450 Ri+u/u$

GDS 114


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9/32

>asi$ La+oratoriu'15/1)/)015


>e'ato$og"

>e'og$o+ine 12.6 14.00 - 18.00 g/,$

Leu(o@"te 17.1 4.0 – 10.5 thousan,/u$

Eritro@"te 4.68 4.00 – 5.50 'i$$ion/u$

>e'ato@rit 41.1 32.00 – 44.00 o$A

Tro'+o@"te 466 150 – 450 Ri+u/u$

Ureu 30 10-50 Mg/dl

!re"#$%$% 0.7 0.7-1.4 Mg/dl


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thora(


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o$$o< up tera(hir

Subjektif: -

Objektif:

T2 110/70 ''hg

! 99?/' regu$er (uat ang(at

RR )4?/'

T CD.5B

;+,o'en

ta'pa( ,atar L& 'ere'+es @airan (ehiauan

; +ising usus 'enurun

P ti'pani

P !T 2* -

Tata$a(sana 2 B$ini'i? RL 25)000@@/)4a'

n. Beftria?on )?1 grn. *etroni,a=o$ C?500'gn. Tra'a,o$ )?1n. Raniti,in C?1 a'p

3anti per+an C?1


12/32


13/32

oto ($inis


14/32

$a+oratoriu'

16/11

18/11

19/11

20/11

22/11

23/11

26/11 29/11

04/12

>+ 9.1 7.C 4.8 4.8 D.C 8.9 11.1 14.C

Leu 10.C 8.C 11.) )D )).4 18.1 11.5 1C.0

Erit C.)5 ).D4 1.D8 1.D4 ).40 C.C9 4.19 5.CD

>t )8.5 )C.1 14.D 14.9 )0.) )8.D C4.8 44.

8 Tro'+

555 CD4 175 109 1CD 1CC 405 D7)

PT/;P TT

9.4/)1.7

!a/(/@$ 14C/C.9/11 1C1.9/C.D/10). 1C8/4.1/10

$ + t i


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$a+oratoriu'10/12 11/1

211/12 13/12 14/12 15/12 17/12 18/1

2

>+ 5.8 7.D 10.D D.) D.9 7.C

Leu )9.5 )7.9 C4.8 C1.9 1D.9 14.D

Erit ).)C C.08 C.94 ).DC ).85 ).89

>t 18.5 )C.5 C1.9 )0.D )C.1 )C.8

Tro'+ 497 )97 )9) )D4 )DD )71

PT/;P TT

8.9/11.4

!a/(/@$

141/C.7/111

1DC/5.C/1)7

32% 101

#r/@r )77/7.D

)95/D.5

)80/4.8

)71/5 C1C/5.5

%3&T/PT

>6s;g 0.)Drea(ti

f

;$+ ).4


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oto thora(s

Bor ,a$a' +atas nor'a$

Pu$'o @uriga no,u$ u( 1 @' oer$ap@ostae (anan +e$a(ang inter@ostaeparu


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#%3

• ;s@ites

• Ta( ta'pa( 'etastase $ier

•

Lier 36 $ien pan(reas Ren unor'a$


18/32

En,os(opi

• *assa u$seratie +u$+us ,uo,enu'


19/32

%tatus genera$is

• *ata (onungtia ane'is -/- s($era i(teri( -/-• *u$ut 'u(osa $e'+a+• Leher p K36 -/-

Kepa$a/

$eher

• gera(an ,a,a si'teris retra(si -• P si'etris 6% (a:(i• P sonor• ; ron(hi -/-


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o$$o< up tera(hir

%u+e(tif sa,ar -

&+e(tif T2 1C0/90 ''hg

! 115?/' regu$er (uat ang(atRR )C?/' T CD7B

Thora(s 6% (a:(i Rh- Fh -

;+,o'en ta'pa( @e'+ung; +ising usus P ti'paniP supe$

Tata$a(sana -2 !% C000 @@/)4 a'-n. Beftria?one )?1 gr-Pro >2 sesuai P2


21/32


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oto K$inis

$ + t i


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$a+oratoriu'

15/12 16/12 (post

op)>+ 14.) 14.C

Leu 19.7 )7.D

Erit 4.7 4.7D

>t 4).C 4C.1

Tro'+ D57 D48

PT/;PTT 1C.4/)D

!a/(/@$ 1C1/4/10C 1C)/4.7/104

32% 1)D )01

#r/@r 5)/1.)

%3&T/PT )0/1D

;$+ ).7

Protein

tota$

4.7


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%tatus genera$is


Kepa$a/

$eher



25/32

o$$o< up tera(hir

%u+e(tif $e'ah n"eri perut

&+e(tif T2 1C0/90 ''hg

! 8)?/' regu$er (uat ang(atRR )0?/' T CD7B


;+,o'en ,atarP n"eri te(an -P ti'pani; +ising usus

Tata$a(sana - 2 RL 25 C000@@/)4 a'-n. Beftria?on )?1 gr-n. *etroni,a=o$e C?500'g-n. Raniti,in )?1 a'p-n. Ketoro$a@ C?1 a'p


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!". 6eri"ani/'assa gaster

• K# n"eri u$u hati

• RP% Pasien 'enge$uh(an n"eri u$uhati hi$ang ti'+u$ D +u$an s'rs'e'+erat 1 +u$an s'rs. 2isertai'ua$ he+at ,an 'untah ri


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oto K$inis

$a+oratoriu'


28/32

$a+oratoriu'8/12 15/12

(postop)

17/12

>+ 1).7 10.) 9.7

Leu 8.1 )C )).4

Erit 5.5C 4.05 C.7)

>t 44.C CC.) C0.5

Tro'+ 407 401 C87

PT/;P TT

1).)/C1

!a/(/@$

1C4/C.8/109

1)8/C.7/98

32% )DD 87

32P/32)JPP

80/1D9

#r/@r )5/0.8

%3&T/

PT

)0/)) 5)/D)

;$+ 4.4 C.5


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&*2

• i$$ing ,efe@t tepiirregu$er pa,a fun,usgaster

• Kesi'pu$an

• Pri'ar" 'u@osa$'a$ignantfun,usgaster tu'our susp;,eno@a


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BT s@an

• *assa fun,us gaster 'enginG$trasi$o+us (iri hepar


31/32

%tatus genera$is


Kepa$a/

$eher



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o$$o< up tera(hir

%u+e(tif $e'ah n"eri perut H

&+e(tif T2 110/90 ''hg

! 1C7?/' regu$er (uat ang(atRR ))?/' T C7CB


;+,o'en ,atar L& +ai(P n"eri te(an -P ti'pani; +ising usus

Tata$a(sana - 2 RL 25 C000@@/)4 a'-n. Beftria?on )?1 gr-n. *etroni,a=o$e C?500'g-n. Raniti,in )?1 a'p-n. Ketoro$a@ C?1 a'p-R/ Ku$tur ,arah

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