Identitas : Dewi A, by/ 1 bulan

Ruang : Bona I hepato

BB/TB : 2,88 kg/50 cm
Register : 12.66.35.74
MRS : 04 Juni 2018
Diagnosis : Kolestasis

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : Jaundice GCS 456 4/6/5/18 : Jaundice Idx :
Patient reffered from HR 126bpm, RR 30 tpm, T 36.9 Lab 212121121 Lab
Hepatology outpatient clinic SpO2 99% DAT I/II/III
with chief complaint jaundice H/N: A(-)/I(+)/C(-)/D(-) Hb Sterkobilin I/II/III
since 2 weeks old Th : Simetric, retraction (-) HCT Urobilinogen I/II/III
C: S1S2 single, murmur (-) gallop (-) Biopsi
P: Vesicular breathing WBC USG 2 fase (05/6/2018)
sound, Rhonki -/-, Wheezing -/- Plt
Abd : soepl, Liver / Lien unpalpable Itx :
OT
Ext : warm, CRT<2” MP 0,5
PT B1 1/5 tab 5-3-0 (4/6-10/6)
Alb B6 1/5 tab
Urdafalk 3x25 mg
BUN Fluimucyl 3x12,5 mg
Creatinin

Bil Direk

Bil Total

PPT
APTT
Identitas : Ilyas/ 10 tahun
Ruang : Bona I hepato
BB/TB : 21 kg/122 cm
Register : 12.65.28.30
MRS : 04 Juni 2018
Diagnosis : Hepatoblastoma

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : Abdominal GCS 456 5/6/5/18 : Idx :
distension HR 126bpm, RR 30 tpm, T 36.9 Lab 212121121 Lab
Patient reffered from SpO2 99% DL /OT/PT/Alb/SE/FH
Hepatology outpatient clinic H/N: A(-)/I(+)/C(-)/D(-) Hb Konsul Hemato
pro TACE. Patient no fever, no Th : Simetric, retraction (-) HCT
pale, no icteric and no sign of C: S1S2 single, murmur (-) gallop (-) Itx :
bleeding. Patient with P: Vesicular breathing WBC TACE III
enlargement of liver since 5 sound, Rhonki -/-, Wheezing -/- Plt
months ago. Patient with Abd : soepl, Liver/ 4x4x5 cm sharp
OT
history of trauma in upper edge, hard consistency
right abdominal. Patient Spleen/ S3H3 PT
already got TACE in February Ext : warm, CRT<2” Alb
2018
BUN

Creatinin

Bil Direk

Bil Total

PPT
APTT
Identitas : Jihan, by/ 3 bulan
Ruang : Bona I hepato
BB/TB : 5,3 kg/61 cm
Register : 12.67.53.00
MRS : 04 Juni 2018
Diagnosis : Kolestasis

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : Jaundice GCS 456 4/6/5/18 : Jaundice Idx :
Patient came from HR 126bpm, RR 30 tpm, T 36.9 Lab 212121121 Lab
Hepatology as ouptient clinic SpO2 99% DAT I/II/III
with cief complaint jaundice H/N: A(-)/I(+)/C(-)/D(-) Hb Sterkobilin I/II/III
since 2 weeks old Th : Simetric, retraction (-) HCT Urobilinogen I/II/III
C: S1S2 single, murmur (-) gallop (-) Biopsi
WBC
P: Vesicular breathing USG 2 fase (26/6/2018)
sound, Rhonki -/-, Wheezing -/- Plt
Abd : soepl, Liver / Lien unpalpable Itx :
OT
Ext : warm, CRT<2” MP 1 mg
PT B1 ¼ tab 5-5-0 (30/5 - 20/6)
Alb B6 ¼ tab
Urdafalk 3x25 mg
BUN Fluimucyl 3x12,5 mg
Creatinin

Bil Direk

Bil Total

PPT
APTT
Identitas : Etika, by/ 3 bulan
Ruang : Bona I hepato
BB/TB : 4,5 kg/51 cm
Register : 12.67.60.27
MRS : 04 Juni 2018
Diagnosis : Kolestasis

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : Jaundice GCS 456 4/6/5/18 : Jaundice Idx :
Patient reffered from HR 126bpm, RR 30 tpm, T 36.9 Lab 212121121 Lab
Hepatology outpatient clinic SpO2 99% DAT I/II/III
with chief complaint jaundice H/N: A(-)/I(+)/C(-)/D(-) Hb Sterkobilin I/II/III
since2 weeks old Th : Simetric, retraction (-) HCT Urobilinogen I/II/III
C: S1S2 single, murmur (-) gallop (-) Biopsi
P: Vesicular breathing WBC USG 2 fase (26/6/2018)
sound, Rhonki -/-, Wheezing -/- Plt
Abd : soepl, Liver / Lien unpalpable Itx :
OT
Ext : warm, CRT<2” MP
PT B1
Alb B6
Urdafalk 3x25 mg
BUN Fluimucyl 3x12,5 mg
Creatinin

Bil Direk

Bil Total

PPT
APTT
Identitas : Fatkhur, by/ 6 bulan
Ruang : Bona I hepato
BB/TB : 4.6 kg kg/50 cm
Register : 12.66.50.19
MRS : 21 Mei 2018
Diagnosis : Atresia Bilier + Pneumonia + Sepsis + Hipokalemia + Hiponatremia

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Patient reffered from GCS 456 4/6/5/18 : Jaundice
Hepatology outpatient clinic HR 126bpm, RR 30 tpm, T 36.9 Lab 212121121
with chief complaint fever 10 SpO2 99%
days before admission, H/N: A(-)/I(+)/C(-)/D(-) Hb
seizure ( a day before Th : Simetric, retraction (-) HCT
admission), cough 10 days C: S1S2 single, murmur (-) gallop (-)
before admission P: Vesicular breathing WBC
sound, Rhonki -/-, Wheezing -/- Plt
Abd : soepl, Liver / Lien unpalpable
OT
Ext : warm, CRT<2”
PT

Alb

BUN

Creatinin

Bil Direk

Bil Total

PPT
APTT

Identitas : Malika Almira/ 2 tahun

Ruang : Bobo 2
BB/TB : 10 kg
Register :
MRS : 3 Juni 2018
Diagnosis : Febris + Post Liver Transplantation

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : jaundice GCS 456 4/6/5/18 : Febris Idx :
Patient came from HR 110bpm, RR 30 tpm, T 37 SpO2 Lab 212121121 Blood clture
emergency department dr. 99% Urine culture
Soetomo Hospital referred H/N: A(-)/I(+)/C(-)/D(-) Hb 7,1 Blood smear evaluation
from Anwar Medica Hospital Th : Simetric, retraction (-) HCT 24,2
because of febris. She felt C: S1S2 single, murmur (-) gallop (-) Itx :
febris since 12 days before P: Vesicular breathing WBC 16800 D5 ¼ NS 1000 ml/24 jam
admission, have admitted to sound, Rhonki -/-, Wheezing -/- Plt 196.000 Ceftriaxone 2x500 mg
Anwar Medica Hospital, got Abd : soepl, Liver / Lien unpalpable Paracetamol 3x cth1
OT 30
therapy Ext : warm, CRT<2” Tracolimus 2x 1,75
PT 10 Celcep 2x50 mg
Alb 3,88 UDCA x 100mg
Magnesium 2x 175 mg
BUN 26

Creatinin 1,17

Bil Direk 0,3

Bil Total 0,72

PPT 12,8
APTT 36,1

Identitas : Dzanetta/P/8 th
Ruang : Bobo 2
BB/TB : 21 kg
Register : 12.66.50.19
MRS : 19 Mei 2018
Diagnosis : Kista Duktus Choledocus

Subjektif Objektif Laboratorium/ Radiologi Problem Rencana

Chief complain : jaundice GCS 456 Lab 19/05 Nyeri Inj ceftriaxone 2x 1 gr iv
Patient came from HR 110 bpm, RR 30 tpm, t 37o C, T: abdomen Planned to surgery
Hepatology out patient clinic 90/50 SpO2 98% Hb 9,8
referred from Anwar Medica H/N: A()/I(+)/C(-)/D(-) HCT 31,1
Hospital with Choleducus Th : Simetric, retraction (-)
duct cyst, she felt pain at her C: S1S2 single, murmur (-) gallop(-) WBC 7990
upper right stomach, getting P: Vesicular breathing sound,
Plt 521.000
bigger in a day before Rhonki -/-, Wheezing -/-
admission Abd : distended. Pain at RUQ, OT 106
Liver: 12 cmx 10 cmx 8 cm
Spleen: not palpable PT 208
Ext : warm, CRT<2 “ Alb
BUN 5
Creatinin 0.47
Bil Direk 4,58
Bil Total 5,29
PPT 10,3
APTT 34,8

Amilase : 132
Lipase m: 303
CT Scan Abdomen : Gambaran kista
ductus koledokus