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Tanggal SOAP7 April 2015 - 10 April 2015 Nyeri perut kanan atas (+) Sens: CM TD: 110-120/80-90mmHg HR: 80-86x/i RR: 20x/i T: 37,2-37,5C Obstructive jaundice ec Susp. Ca caput pankreasIVFD RL 20gtt/IInj. Cetriaxon 1gr/12jam Inj. Ketorolac 1amp/8jam Inj. Ranitidin 1amp/8jamOmeprazole tab 2x1 (Hari I IV) IVELIP 100ml/24jam (Hari I IV)Plasbumin 20% (Hari I IV)Transfusi darah 175cc (Hari I IV) 11 April 2015 - 14 April 2015 Nyeri perut kanan atas (+) Sens: CM TD: 100-120/80-85mmHg HR:80-90x/i RR: 20x/i T: 37,0-37,5oCObstructive jaundice ec Susp. Ca caput pankreasIVFD RL 20gtt/I Inj. Cetriaxon 1gr/12jamInj. Ketorolac 1amp/8jam Inj. Ranitidin 1amp/8jam Laboratorium Patologi Klinik (13/4/2015)Laboratorium Patologi Klinik (14/4/2015)

Hb: 12,40g%Hb: 12,00g%Eritrosit: 4,61x106/mm3Eritrosit: 4,48x106/mm3 Leukosit: 12,17x103/mm3Leukosit: 11,84x103/mm3Hematokrit: 36,50% Hematokrit: 35,40%Trombosit: 230x103/mm3(N)Trombosit: 184x103/mm3(N) MCV: 79,20 fLMCV: 79,00 fLMCH: 26,90 pg MCH: 26,80 pg MCHC: 34.00 g%MCHC: 33.90 g% RDW: 17.30% RDW: 17.40%-Alb: 2,4 g/dL Bilirubin total: 13,49mg/dL Bilirubin direk: 10,63mg/dLNa/K/Cl: 122/3,1/91mEq/LTanggal SOAP 15 April 2015 - 16 April 2015 Nyeri perut kanan atas (+) Sens: CM TD: 110-120/80-90mmHg HR:80-90x/i RR: 20x/i T: 37,4-37,5C Obstructive jaundice ec Susp. Ca caput pankreas IVFD RL 20gtt/i Inj. Cetriaxon 1gr/12jam Inj. Ketorolac 1amp/8jam Inj. Ranitidin 1amp/8jam Albumin = (3-2,4)x55kgx0.8 = 31,2 gram = 2 botol Plasbumin 20% 2 Fls (Hari I & II) 17 April 2015 - 20 April 2015

Nyeri perut kanan atas (+) Sens: CM TD: 110-120/80-90mmHg HR:80-90x/i RR: 20x/i T: 37,0-37,5C

Obstructive jaundice ec Susp. Ca caput pankreas IVFD RL 20gtt/i Inj. Cetriaxon 1gr/12jam Inj. Ketorolac 1amp/8jam Inj. Ranitidin 1amp/8jam Albumin = (3-2,6)x55kgx0.8 = 17,6 gram = 1 botol Plasbumin 20% 1 FlsLaboratorium Patologi Klinik (17/4/2015)Laboratorium Patologi Klinik (19/4/2015)

Laboratorium Patologi Klinik (20/4/2015)

Hb: 11,10g%Hb: 10,90g%Hb: 9,50g%

Eritrosit: 4,17x106/mm3 Eritrosit: 4,00x106/mm3Eritrosit: 3,48x106/mm3 Leukosit: 13,58x103/mm3Leukosit: 11,37x103/mm3

Leukosit: 13,43x103/mm3Hematokrit: 32,90%,Hematokrit: 31,70%Hematokrit: 28,30%Trombosit: 249x103/mm3(N)Trombosit: 305x103/mm3(N) Trombosit: 404x103/mm3(N)MCV: 78,90 fLMCV: 79,30 fLMCV: 81,30 fL, MCH: 26,60 pgMCH: 27,30 pgMCH: 27,30 pg, MCHC: 33.70 g%MCHC: 34.40 g%MCHC: 33.60 g%, RDW: 17.80%RDW: 18.00%RDW: 18.70%, Albumin: 2,6 g/dLKGDs : 77.00mg/dL

PT/APTT/TT/INR : 24,8/ 43,5/23,8/1,82

Ureum/Kreatinin10,80/0,43mg/dLNa/K/Cl: 122/4,1/98mEq/L

Albumin: 2,4 g/dL D-dimer : 2000ng/mLNa/K/Cl: 128/2,7/104mEq/L

Albumin: 2,5 g/dLBilirubin total: 18,22mg/dLBilirubin direk: 15,04mg/dLKGDs : 81.40mg/dL

PT/APTT/TT/INR :19,5/39,5/19,4/1,45

Na/K/Cl: 141/3,1/106mEq/L

Tanggal 20 April 2014Persiapan Operasi

SIOPersonal HygeinePuasa mulai pukul 00.00WIBInj. Cefotaxime 1gr/12jam sebelum operasiBowel preparation - Kanamicin 4x25mg - Metronidazole 3x500mg - Klisma 2x1

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Tanggal 21 April 2014Laporan Operasi

Dx Pra Bedah : Tumor Caput Pankreas + Hepatik Failure Unspecific + Unspecific Severe Protein Malnutrition.Dx Pasca Bedah : Tumor Caput Pankreas + Obstruksi Bile Duct + Hepatik Failure Unspecific + Unspecific Severe Protein Malnutrition.Indikasi Operasi : TumorNama Operasi : Exp. Laparatomi + Drainase External + Bypass (gastrojejunostomy)Jumlah Perdarahan : 1000 cc Durasi Operasi : 4 jam 00 menit

Tanggal SOAP 22 April 2015 - 24 April 2015 Nyeri perut kanan atas (+) ikterik (+), nyeri luka operasi (+), drain(+)1100cc/24jam T: 40CCa Caput Pankreas Post Double BypassIVFD RL 20gtt/ITPN : IVELIP 1 botol/12jam Dextrose 20gtt/I Inj. Cetriaxon 1gr/12jam Inj. Ketorolac 1amp/12jam Inj. Ranitidin 1amp/12jamPCT drips/ 8jamPost Bypass (gastrojejunostomy)