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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 ( )
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
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
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
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
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
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
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
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