rekap terakhir urologi

14
PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015 Jeumpa 1 No Nama/Umum/CM Kamar DPJP Tanggal Masuk Diagnosa Tindak an Tangg al Op Hasil Lab Planing 1 Januddin Nafi/50 thn/105911 7 K7B4 DAH 25/07/20 15 CKD stage Ve.c obstruksi uropati+nefro litiasis bilateral+mul tiple batu ureter dex + trombositopen i Tgl 29/9/2015 Hb/ht/erit/ luko/trom 10,7/28/3,4/2 4,1/25 Pt/apt : 12,1/41,4 Inr : 1,12 Fibrinogen: 359 d- dimer:>10000 Sgot/ sgpt:43/25 Alb:2,64 Tgl 26/7/2015 Hb/ht/erit/ leu/trom 12,7/36/4,1/1 9,5/7 Ur/ Cr :167/6,77 Tgl 25/7/2015 Pt/aptt : 11,0/37,5 Hbsag negatif Tgl 31/7/2015 Hb/leu/ trom/LED 8,8/19,6/44/ 80 MDT: hipokrom mikrositer CT/BT:10/4 AFP:1,30 Hbsag:- Sgot/ sgpt:34/23 ALP:266 Alb :2,65 Ur/ cr :181/3,98 Transfusi trombosit /FFP 10 Kolf (+) Konsul HOM(+) Konsul anastesi +kardio (+) Rencana RPG Cek billirunu n – senin

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Page 1: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Jeumpa 1

No Nama/Umum/CM Kamar DPJP Tanggal Masuk

Diagnosa Tindakan

Tanggal Op

Hasil Lab Planing

1 Januddin Nafi/50

thn/1059117

K7B4 DAH 25/07/2015 CKD stage Ve.c obstruksi

uropati+nefrolitiasis bilateral+multiple batu ureter dex + trombositopeni

Tgl 29/9/2015Hb/ht/erit/luko/trom10,7/28/3,4/24,1/25Pt/apt : 12,1/41,4Inr : 1,12Fibrinogen: 359d-dimer:>10000Sgot/sgpt:43/25Alb:2,64

Tgl 26/7/2015Hb/ht/erit/leu/trom12,7/36/4,1/19,5/7Ur/Cr :167/6,77Tgl 25/7/2015Pt/aptt : 11,0/37,5Hbsag negatifINr 1,03

Tgl 31/7/2015Hb/leu/trom/LED8,8/19,6/44/80MDT: hipokrom mikrositerCT/BT:10/4AFP:1,30Hbsag:-Sgot/sgpt:34/23ALP:266Alb :2,65Ur/cr :181/3,98

Transfusi trombosit/FFP 10 Kolf (+)Konsul HOM(+)Konsul anastesi +kardio (+)Rencana RPGCek billirunun – senin

JEUMPA 2

No

Nama/Umum/CM

Kamar

DPJP

Tanggal Masuk

Diagnosa Tindakan

Tanggal Op

Hasil Lab Planing

1 Jumini/61thn/1059408

K7b1 26/7/2015 retensi urin e.c neurogenic bladder susp. Vesicolitiasis +DISLOKASI vl 4-5 +Fr. Parasimpasis

sup inf

Tgl 28/7/2015Hb/ht/erit/leuko/tro8,9/29/3,7/5,0/585CT/BT : 7/2Na/k/cl : 137/3,7/105GDS : 287Ur/cr : 22/1,09

Tgl 30/7/2015Hb/leu/trom9,4/18,2/690

USG Urologi (+)Konsul RM (-)Dr, ur/cr ulang (1/8)BNO ulang ( )

Page 2: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Jeumpa 4

No

Nama/Umum/CM

Kamar DPJP Tgl Masuk

Diagnosa Tindakan

Tgl Op

Hasil Lab Planing

1 Nurhayati/55 th/ 1051370

K1B1 JUF 20/6/2015 Post cystoscopy URS (D) + insersi DJ stent (D) +

repair fistula retrococutan +

post repair wound

dehisanse a/r flank (D) + post bivalve Pyelolitotmi

a.i batu staghorn

 debridement dan

ganti dj stent

(30/7/2015)

30/6/2015

30-7-2015

27/7/2015Hb: 9,1 Leu: 12,7 tromb:558

21/7/2015protein total:7,4 alb:2,90 Glb:5,0 Na:140 K:4,5 Cl:103 Ur:45 Cr:1,20 GDS:110

Aff catheterAff drainBno kontrol (+)

2 Saifullah / 41 th/ 844906

K2B1 JUF 16/07/2015

Post LE + Abses

Pararenal + Hidronefrosis ec batu ureter media + TOF + sepsis + PH

+ Acute Respiratory Syndrome

23/7/2015Hb:9,3 leu:17,1 tromb:273 na:131 k:3,7 cl:96 ca:8,8 mg:1,9 gds:72

24/7/2015SGOT:67 SGPT:51 Na:133 K:3,8 Cl:101 Ca:8,4 Mg:6,9

29/7/2015Hb/leu/trom/alb/glo9,5/13,1/545/2,8/3

Gds: 68Na/k/cl : 118/3,9/92

Ur/cr: 20/0,70

CT Scan Kontras/Non kontras (kamis, 30/7)

Susul hasil

Aff heatingGV/hariAB ganti ciprofloxacin 2x500Konsul IPD (hiponatremi&gout artritis)DR ulang

Page 3: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

3. Irfan Ilyas, 32 thn, 1055155

K2b2 JUF 29/7/2015 Nefrolitiasis PCNL 10/6/2015Hb/ht/erit/leu/trom

15,1/44/4,6/11,7/331CT/BT: 7/2Na/K/CL/Ca

144/3,9/104/9,4Ur/cr : 11/0,93

Urinalisa: leukosit (+)

8/7/2015Hb/leu/trom

15,4/10,2/348CT/BT:7/2Na/K/Cl:

142/3,6/102Ur/cr : 19/0,89

Jadwal op PCNL

4. Hamidah/64 thn/1058455

K1b2 JUF 17/7/2015 Partial MBO e.c tumor

intraabdomen dd Ca. Colon

sigmoid + hematuria e.c dd/ instrumen

Metastase tumor

Tgl 29/7/2015Protein: 6,2Alb/glo : 3,54/2,66Tgl 28/7/2015Urinalisa:Leukosit :+protein :+1Darah:+1Leukosit:20-25Erit:20-30

Epitel:4-6Tgl 26/7/2015Hb/ht/erit/leu/tro10,9/33/3,9/12,6/445CT/BT : 8/2Alb:2,79Na/K/Cl : 131/4,8/104Ur/Cr : 84/1,27GDS : 105

Hasil USG Urologi (+)

5. Saufana/ 10 thn/ 0998575

K5B1 DAH 21/7/2015 Post pyelolitotomi +nefrolitotomi sin+UNC a.i batu ureter

prox sin+multiple

batu ginjal sin

PCNL sinistra

29/7/2015

23/7/2015Hb:7,7 Leu:10,3 tromb:301LED:120 ct:2 bt:7 Na:144 K:3,2 Cl:102 Mg:2,0 Ca:9,7Ur:111 Cr:2,36

Tgl 26/7/2015Hb: 9,4Leuko : 10,9Ur/cr : 99/2,56

Tgl 30/7/2015Hb/ht/leu/trom9,3/28/16,7/449LED:96Ur/cr : 99/2,56

Transfusi 1 kolf

6. Ratna Julita/34 th/1009784

K5b3 DAH 10/7/2015 Post LE+Colostomy a.i ca recti

1/3 distal

Tgl 19/7/2015Hb:9,5

Leuko:12,2Trombo:415

Bladder trainingRencana PBJ

Page 4: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

+retensio urin Alb:3,72Glo:2,78

Na/k/cl/ca: 138/4,1/101/9,2Ur/cr : 12/0,30

7 Sakdiah/ 46 th/ 1058570

K5B4 DAH 21/7/2015 Post repair buli a/i

peritonitis ec trauma buli

intra peritoneal post

histrectomy

29/7/2015

22/7/2015Hb:12,7 leu:16,4 tromb:376

27/7/2015Prot. Total: 5,5Alb/glo : 2,83/2,67Na/K/Cl: 141/3,4/107Gds : 102Ur/cr : 19/0,47

Rawat LukaSpooling Na-cl-betadineKetorolac affRanitidine affGV rawat dengan aquacell+gentaMonitor urin output

8 M. akbar /20 th/ 1058209

K7b4 DAH 13/07/2015

post cytoscopy diagnostik+ins

ersi dj stet dex+radikal

orchidektomy dex+eksplorasi ureter bilateral

CKD + Hidronefrosis bilatetral post

bilateral nefrotomy

Op 27/7/2015

27/7/2015Hb/leuko/tro: 9,3/10,6/263

Na/k/cl:127/4,5/105Ur/cr : 66/3,14

25/7/2015Hb/ht/erit/leuko/trombo8,6/26/3,4/13,2/288Protein total :6,5Alb/glob : 2,90/3,60Na/k/cl : 125/4,9/103Gds : 90Ur/cr : 81/4,40

Tgl 30/7/2015Hb/leuko/trom9,3/6,3/323

Susul hasil BNO 3 posisiURS ulang (persiapan)Koreksi Na 2500ccCek DR, ur/crKonsul anastesi (senin)

9 Rukmini,58 thn,1057986

Iso 2 DAH 29/7/2015 HN dex e.c stenosis ureter dex+batu calix

inf sin

Post RPG

si+URS dex

Susul hasil BNO kontrol

Page 5: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

dilatasi +insersi DJ stent

10.

Zaini, 69 thn,1058325 K4B1 DAH

14/7/2015 Post nefrostomi dex a.i HN dexe.c

susp. Batu ginjal dex dd/

PUJO

30/7/2015

TGL 27/7/2015Hb/ht/erit/leu/trom

12,5/40/4,9/18,8/498Alb/glo;2,86/4,24Na/k/cl: 131/4/102

Ur/cr:30/0,73

GV, monitor nefrostomi, DR, alb/glo

MAMPLAM 1

No Nama/Umum/CM

Kamar DPJP Tanggal Masuk

Diagnosa Tindakan

Tanggal Op

Hasil Lab Planing

1 Jamaluddin/ 52 tahun/ 1057909

K9b3 DAH 19/07/2015

Nefrolithiasis bilateral + post insersi dengan

stent + hipokalemi +

CKD + anemia

23/07/2015Hb:8,1Leu:8,6

Tromb:146 Na:141 K:3,2 Cl:100 Ur:33 Cr:1,91

28/7/2015Hb/leu/trom/8,6/5,6/151

USG Urologi (+)Persiapan op tgl 3/8

2 Bustami/ 41 /1057508

K4b3 JUF 26/7/2015 Nefrolitiasis sin

+Ureterolithiasis

dex+hidronefrosis

dex+anemia sedang+limph

adenopati

URS+Insersi

DJ+Nefrolitotom

i sin

Tgl 26/7/2015Hb.ht/erit/leuk/tro8,3/26/3,3/5,7/212Alb/glo: 3,8/2,4

Na/k/cl: 123/4,2/100

Ur/cr : 38/1,17Hbsag : -

Cek DR, ur/cr ulang

3 Bundiamin/54 thn/

MAMPLAM 4

K6

Ca. Recti+fistel rectovesica

cystografi

Tgl 26/7/2015Hb/leu/CT/BT6,4/15,7/8/2Alb/glo: 2,77/3,53

Cystografi senin 3/8Dr, ur/cr, elektrolit, alb/glo

Page 6: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Na/k/cl: 120/3,0/102Ur:73

ulang

HCU

No

Nama/Umum/CM Kamar DPJP Tanggal Masuk

Diagnosa Tindakan Tanggal Op

Hasil Lab Planing

1. Abdul rasyid/ 73 th/ 1057936

K7b2 DAH 09/07/2015 Tumor ginjal (D)

22/7/2015Na: 141 K:4,4 Cl:106 ur: 38 Cr:1,72

26/7/2015Protein total : 9,0

Alb/glob: 3,32/5,6829/7/2015

Hb/ht/erit/leuko/trombo11,5/36/4,1/8,4/137PT/APTT: 16,6/67,8

INR/D-Dimer : 1,51/5766Alb:2,7k/cl/ca/

mg :4,3/104/8,1/1,6ur/cr : 27/1,84

Tgl 1/8/2015Hb/leuko/trom10,3/20,7/41

Pt/aptt/inr15,5/111,6/1,42

d-dimer : 2188,74Ph/pco2/po2/hco37,291/52,2/82/25,4

Na/k/cl/ca/mg133/3,3/104/9,5/1,9

Aff drain

Seurune 2

No Nama/Umum/CM Kamar DPJP Tanggal Diagnosa Tindakan Tanggal Hasil Lab Planing

Page 7: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Masuk Op1. Ibrahim/ K4b1 post

nefrostomy perkutan sin

a.i hidronefrosis

bilatal e.c batu ginjal dex + RSP batu ureter sin + sirosis

hepatis

Nefrostomy bilateral

APG

28/7/2015Aptt : 46,8

D-dimer: >10000Hbsag neg

Anti hcv negativBil total : 4,68Bil dir/ indi :

4,09/0,77Sgot/sgpt : 211/106

Tgl 26/7/2015Hb/leuko/trombo

8,0/10,2/464Na/k/cl :

130/3,7/105Ur/cr : 69/1,59

Tgl 30/7/2015Hb/leu/trom/LED

7,3/8,9/394/40ALP:233Alb:2,13Glo:4,87

Usg abdomen () hasilCek ulang ur/cr

2. Rosni, 62 thn, 0840624

K6b3 Post nefrostomi

a.i batu staghorn +multiple

nefrolitiasis dex dj stent

in situ

Tgl 28/7/2015Hb/leu/trom/led10,5/6,6/275/30UR/CR : 69/2,17

Urinalisa: leukosit(+), protein

+1, darah +Sedimen urin:

leu:40-60Erit 20-30

Tgl 1/8/2015Hb/leuko/trom9,1/18,3/381Ur/cr:98/2,93

Transfusi 1 kolfFoto BNO

GEURUTENo Nama/Umum/CM Kamar DPJP Tanggal

MasukDiagnosa Tindakan Tanggal

OpHasil Lab Planing

Page 8: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

1 samsuar/52 th/0873928

K6 DAH 24/06/2015 Post sistocopy TURBT +

post nefrostomi

S

27/7/2015Hb:8,2 leu:13 tromb:268 ur:53 cr:2,30

Tgl 29/7/2015Hb/leu/trom/alb10,1/27,5/2,4/2,99Ur/cr: 43/1,37

Ct scan buli 7/8/2015GV nefrostomi

IWNo Nama/Umum/CM Kama

rDPJ

PTanggal Masuk

Diagnosa Tindakan Tanggal Op

Hasil Lab Planing

1. T.Makmur/64thn/1059527

C2 JUF 29/7/2015 Hematuria Tgl 29/7/2015Hb/leu/trom8,8/10,6/403Ct/bt: 7/2Ur/cr: 38/1,13Gds 82

Usg ulang senin 3/8Ct scan kontras non kontras

Geulima 2No Nama/Umum/CM Kamar DPJP Tanggal

MasukDiagnosa Tindakan Tanggal

OpHasil Lab Planing

1. Saiful aidi, 54 thn,1059044

K7b4 JUF BPH

2. Ibrahim Daud,62 Thn,1059138

K7B6 JUF Susp BPH+Ca paru sin

Tgl 31/7/2015Na/k/cl

132/4,1/105Tgl 30/7/2015

UrinalisaLeuko:+,Protein+1,Darah+Sedimen urin: leu 6-8, erit

4-6,epitel 8-10

Tgl 25/5/2015Ur/cr : 28/0,65

Ct/bt: 8/2

USG Prostaturinalisa

IGD

Page 9: rekap terakhir urologi

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

No Nama/Umum/CM

Kamar DPJP Tanggal Masuk

Diagnosa Tindakan

Tanggal Op

Hasil Lab Planing

1 Firmanda/ 44th tahun/

Ca penis DLFoto thorax

2 Rasyid Yunus/ PCNL Cek DR,Foto thorax

3 Warman/ 40 tahun/

nefrolithiasis USG (+) di IGD