KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

LONTARA 2 UROLOGI KAMAR 1

Usman
651908
21/03/2014
JKN
Bed 2
01/02/1950
DPJP: dr. m. askar. Sp.U

Batu ureter 1/3 distal bilateral

Kinking ureter 1/3 proksimal
Batu pole atas ginjal dextra
Hidroureter sinistra
Hidronefrosis bilateral

Pro URS + DJ stent bilateral

Informed consent
Persetujuan tindakan
Lapor OK
Konsul anestesi
Puasa
Antibiotic prophilaksis ceftriaxone 2
gram IV, ijam pre operasi, skin tes

Darah rutin (20/02/2014)

WBC: 5,6; RBC: 3,72; HCT: 33,6; PLT: 339; LED:
71/102
Kimia darah (20/02/2014)
GDS: 109; Ureum: 46; Kreatinin 1,52; Asam urat:
10,9; GOT: 30; GPT: 22

LONTARA 2 UROLOGI KAMAR 2

3

Muh. Ilyas
TL : 1/4/1973
RM : 645026
MRS : 12/2/2014
JKN
Dr. M. Asykar
Palinrungi, Sp.U
Kamar 2 bed 2

- Adeno carsinoma bulibuli

- Tumor sigmoid
- Fistel rectovesica
- POH-6 colostomy

Terapi sesuai Ts. Bedahdigestif

PatologiAnatomi 03/03/2014
Adenocarcinoma Colon, Differensiasibaik
Hasil Endoskopi (26/2/2014)
- Hemorrhoid grd II
- Polipsesilerekti
- Tumor sigmoid susp. Malignancy
LAB 23/02/2014
RBC 4.92 WBC 12.4 PLT 456 HGB 11.3 HCT 35.5
LAB 20/02/2014
BT/CT 3/7 PT/APTT 13.2/30.2 HbsAg nonreactive
anti HCV non reactive CEA 5.53 GDP 115
WBC 12.55 RBC 4.48 PLT 393 HGB 9.8 HCT 31.4
Lab (16/2/2014)
WBC 12,9 RBC 4,59 HGB 10,1 HCT 32,6 PLT 400
Ur/Cr 9/0.70, GDS 170 SGOT/SGPT 15/15
Na/K/Cl136/3,2/106
USG 12/2/2014
Massa di dalambulibuli yang tidakmelekat di
dindingbulibuli
Urine Rutin (12/2/2014)
Warna: kuningtua pH 6,0 BJ 1,030 protein ++/100

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

glukosa (-) bilirubin (-) urobilinogen: normal
keton(-) nitrit (-) blood: +++/200 lekosit +++/500
vit.C (-)
Mikroskopis (sedimen) lekositpenuh, eritrositpenuh,
torak (-), kristal (-), epitel: 5, lain-lain +2 granula kasar
LONTARA 2 UROLOGI KAMAR 3

RISNAWATI
Tl 17-6-1969
MRS 15-3/14
RM 642268
Bed 2
JKN
DPJP:
dr.
Muh.AsykarPalinrungi,
Sp.U

Dahlia
TL 7-6-1960
MRS 16-3-14
RM 652235
Bed 4
JKN
DPJP:dr.
Muh.AsykarPalinrungi,
Sp.U
MUHANI
TL 31-12-1946
MRS 17/3/2014
RM 651910
JKN
DPJP:

-Batu staghorn bilateral

-DJ stent insitu bilateral

Batu ureter 1/3 proksimalDextra

HidronefrosisDextra

BatuPyelumDextra +
HydronefrosisDextra

POH 1 Aff DJ Stent bilateral

POH 1 ESWL
ObathipertensiAmlodipin 1x10 mg
dilanjukan

Rencana ESWL hariSelasa 18/3/2014

FotoPolos Abdomen 10-3-14

- Tampak DJ stent
terpasangpadakedualintasantraktusurinariusdengan
ujung cranial kananbergelungsempurnapada region
lumbalkanansetinggi CV L1-L2, ujung cranial
kiribergelungtidaksempurnapadarongga pelvis
Lab (5/3/2014)
WBC 7.3 RBC 3.9 HGB 10.5 HCT 32.7 PLT 281
LED I/II 44/77
PT : 12.0 c 13.1 INR : 1.0; APTT : 26.7 C 26.1
BT 2/CT 730
Ur/cr: 23/0.9 GDS 87
USG Abdomen 3/3/2014
Terpasang DJ stent bilateral
Lab (24/2/2014)
WBC 8.1 RBC 4.14 HGB 12.1 HCT 36.3 PLT 291
PT : 12.0 c 11.4 INR : 1.0; APTT : 26.7 C 24.0
BT 3/CT 80
Ur/cr: 26/0.75 GDS 86 GOT/GPT 21/36
Na/K/Cl 144/3.8/108
Foto BNO IVP 28/2/2014
Hydronefrosisdextragr.IIecbatu ureter
USG Abdomen 12/2/2014
Hydronefrosiskananecsuspekbatu ureter
USG aorgan abdomen lain dalambatas normal

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

dr.
Muh.AsykarPalinrungi,
Sp.U
LONTARA 2 UROLOGI KAMAR 10
Matius Raba
TL: 1-1-1963
MRS: 26-2-2014
RM: 625262
Bed 3
JKN
DPJP:
dr. Syakri S, SpU

- Batustaghorn bilateral
- hidronefrosisbiolateral
- CKD stage V
P : POH 9 Ekstended pielolitotomi
dextra + DJ stent insitu dextra

- IVFD Nacl 0,9 % 20 tpm

-Cefadroxil 2x500mg
-As. Mefenama 3x500mg
-metronidazole 3x 500mg
-Ranitidine 2x1
-Rawat luka +GV/hari

Lab (15/3/2014)
G2PP :87,GDP:69
Lab (7/3/2014)
PT : 12.6 c 10.8
INR : 1.10; APTT : 29.5 C 24.7
Ur/cr: 50/5
Lab 7/3/2014
Hb: 9.3; RBC: 2.89; WBC: 4.2; HCT: 27.4; PLT: 230
Fotopolos abdomen (3/2/2014)
Lab (4/3/2014)
PT : 12.1 c 10.8
INR : 1.00; APTT : 36.3 C 24.7
Ur/cr: 52/4.9
Laboratorium (24/2/2014)
PT : 12.1 c 10.8
INR : 1.00; APTT : 36.3 C 24.7
Ur/cr: 52/4.9

Ongga Yare
TL : 30/03/1956
MRS : 18-3-2014
RM : 654470
Bed 2
JKN
DPJP : dr. Syakri, SpU

- ca buli-buli

Nacl 0,9 % 20 tpm

Transfusi PRC 2 bag
Periksa lab DR post transfuse

Lab (13/3/2014)
PT : 13.7
INR : 1.14; APTT:2,30
SGOT: 22, SGPT: 10,HB :7,4, WBC: 5,7, RBC:3.59,
HCT:26.0, PLT : 258
Foto thorax PA (12/3/2014)
Efusi pleura dextra minimal

USG abdomen 11/3/2014

Kesan: hidronefrosis bilateral e.c massa buli-buli
Simplen renal cyst dextra

Minggu
TL : 01/07/1938

Hypertrophy prostat grade.III

POH 1 TUR-P

NACL 0,9 % 20 TPM

USG abdomen 8/3/2014

Kesan: hipertrofi prostat

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

MRS : 18-3-2014
RM : 654049
Bed 5
JKN
DPJP : dr. Syakri, SpU

10

KUBA
TL : 31-12-1935
MRS : 18-3-2014
RM : 650926
BED 4
JKN
DPJP : dr. Syakri, SpU

Carsinoma Prostat
POH 1 Ureterosistoskopi +
internal ureterotomy

Lab 12/3/2014 :
HB 11,6
Plt 333
HCT 34,9
BT 3,00
CT 8,00
SGOT 18
SGPT 20
Na : 138
K: 3,8
Cl : 105
PSA : 8,15
Ureum : 27
Kreatinin : 0,70
pH ; 5,5
Lab 17/3/2014
PSA >100
Lab 27/2/2014
HGB 11,6
HCT 35,4
WBC 7,1
RBC 4,02
PLT 298
BT 800
CT 300
GDS 97
Ureum 25
Kreatinin 0,70
SGOT 24
SGPT 14
Natrium 145
Kalium 4,1
Klorida 105
Foto Thorax PA 27/2/2014
Kesan : susp. Tanda-tanda metastasis ke paru
Pleural reaction
Dilatation, elongation et atherosclerosis aortae
Bulging diafragma dextra

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

LONTARA 2 UROLOGI KAMAR 11
11

Halima Mahmud
616862
61 tahun
JKN
TTL 1/7/1952
MRS 20/3/2014
Bed 4
Dr. Syakri Syahrir,
Sp.U

Carcinoma buli-buli
cT4N0M0
Karnofsky 90%

Pro kemoterapi siklus 3 hari ke -15

Lab 19/3/2014
WBC 2420, HGB 9.3, RBC 3.32x106, HCT 26.7, PLT
170000, GDS 146, Ur 13, Kr 1.34, SGOT 20, SGPT
19
Hasil PA 29/8/2014
Transisional cell carcinoma

LONTARA 2 UROLOGI KAMAR 12

Johaseng dg nimang
655405
17/03/2014
JKN
Bed 6
01/07/1948
DPJP: dr syakri syahrir.
Sp.U

Tumor buli-buli susp malignancy

Konsul ginjal hipertensi

Tunda operasi
Optimalisasi KU
Rencana operasi hari senin
\konsul perioperatif

Darah rutin (19/03/2014)

RBC: 4,14; WBC: 11,95; PLT: 520; HCT: 31,5
Kimia darah (17/03/2014)
Glukosa 101; ur/cr: 35/4; GOT/GPT: 23/17; Na/K/Cl:
136/4,8/104
Kimia urine (19/03/2014)
Ph:6,5; warna: kuning kemerahan; berat jenis:1,010;
protein: trace; blood:+++/200; lekosit: ++/125

15

Foto thorax PA (18/03/2014)

Kesan: Cor dan pulmo dalam batas normal
Tidak tampak tanda-tanda metastasis pada foto

Rias rasyid
655948
21/03/2014
Umum
Bed 1
12/02/1996
DPJP: dr. syakri
syahrir. Sp.U

Hematuria post trauma tumpul

abdomen

IVFD NaCl 0,9% 28 tpm

Inj ceftriaxone 1 gram/12jam/IV
Inj ketorolac amp/8jam/IV
Inj ranitidine amp/8jam/IV
Bed rest total
Parasetamol tab 500 mg/ 3x1
Transfuse PRC 2 unit
Cek darah rutin post transfuse

USG abdomen (17/03/2014)

Kesan: Massa buli-buli
Hydronefrosis bilateral
Darah rutin (21/03/2014)
RBC: 2,79; HGB: 8,3; HCT: 25,3; PLT: 451; WBC:
10,8
Kimia klinik (21/03/2014)
BT/CT: 300/800; GDS: 106; Ur/Cr: 25/0,70;
GOT/GPT: 15/16; Na/K/Cl: 137/3,7/105

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

Awasi tanda vital, tanda-tanda akut
abdomen, sepsis

Urine rutin (21/03/2014)

Protein: +++/300; Keton: +/5; blood: +++/200; lekosit:
++/125
USG abdomen (21/03/2014)
Massa intravesikal susp hematoma
Massa ginjal kanan susp abses
MSCT urografi dengan kontras (21/03/2014)
Laserasi grade IV segmen bawah ginjal kanan
Bekuan darah dengan emophysema buli-buli
Fraktur oblique simpisis puibis kanan

LONTARA 2 UROLOGI KAMAR ISO

16

Kamaruddin
655101
14-3-2014
JKD
Bed 1
01-07-1942

Tumor buli-buli susp Malignancy

IVFD NaCl 0,9% 16 tpm

Asam traneksamat 250 mg/12j/iv

Darah rutin (18/03/2014)

RBC: 3.79; HGB: 10.5; HCT 31.3; PLT: 254; WBC:
9,3
Urine rutin (14/03/2014)
Urin Rutin
Warna : merah; pH: 5, Protein: +++/300; urobilinogen:
8; keton: 8, blood: +++(200), lekosit: +++(500)
Kimia Darah (14/03/2014)
Glukosa darah
GDS: 160
Fungsi ginjal
Ureum: 232, Cr: 7,3
Na: 127, K: 4,9 ; Cl 106
Darah rutin (16/03/2014)
RBC: 4,11; HGB: 11,4; WBC: 14; PLT 232
Foto Thorax (15/3/2014)
-Dilatatio, elongation et atherosclerosis aortae
-Lesi-lesi nodular yang tersebar miliar dikedua paru

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

susp. Tumor metastasis dd/ TB paru
USG abdomen (14/03/2014)
-Hidronefrosis bilateral\
- Massa buli-buli
-Hipertrofi prostat
LONTARA 2 ORTOPEDI
LONTARA 2 DIGESTIVE
LONTARA 2 ONKO
LONTARA 1
BPH grade III

1
7

Baco tang
68 thn
652980
Pakis k5b1
Konsul 12/03/2014
jkn

R/ sesuai TS.BTKV
Optimalisasi KU
Kultur urine

Lab 10/03/2014
PSA 7,65
Lab 10/03/2014
Wbc 18,37, rbc 4.12, hb 10,1, hct 31,0, plt 437
Ct thorax 05/03/2014
Massa hemithoraxkiri yang
mendestruksitulangdisertaiefusi pleura kiri
Susp. Malignant Mesothelioma
Usg abdomen 28/02/2014
Hipertropiprostat
Foto thorax 28/02/2014
Soft tissue mass regiohemithoraxkiri yang
mendestruksitulang

Susp bladder neck kontractur

1
8

Kube
61 thn
4600
31/12/1952
Lt1abk1b5
JKN
Konsul12/03/2014

Blader training

Lab 12/03/2014
Wbc 11,97, rbc 3.38, hb 8,7, hct 26,6, plt 333, ur/cr
59/2.0, asamurat 6.2, na 138. K 3.7, cl 100
Lab 10/03/2014
ur/cr 69/2.10, alb 2.10, na 139. K 3.3, cl 91

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

1
9

2
0

2
1

Tu.buli buli

Rencana tur-BT
Optimalisasi KU
Terapi sesuai TS. Pulmo dan interna

Hidronefrosis bilateral
Ca cervix

Optimalisasiku
HD
Rencanauretrolithotomibila optimal

Hidronefrosis (D)
Batu ureter proximal(D)
CKDstage V

Rencana urethrolitotomi
Tunggu hasil foto thorax AP/Lateral
PT/APTT
Terapi sesuai TS. Interna

Tancu
64 thn
652838
Umum
Lt1abk3
Tglkonsul 13/03/2014

Kenny tambunan
39 thn
544216
Lt1bbk6b1
jkn

Zakaria dg Gassing
49thn
418959
L1AB K4
JKN

Lab 19/03/2014
SGOT 58 SGPT 40 ALK. PHOS 79
Lab 11/03/2014
alb 2.9, bt 3,00, ct 9,00, inr 1.17, aptt 30.8
Msct abdomen 11/03/2014
Massa buli-buli
Fatty liver
lab 08/03/2014
alb 2.4, na 132, k 3.6, cl 100
Lab 06/03/2014
Wbc 15,03, rbc 3,67, hb 10.0, hct 27.9, plt 231, ur/cr
15/0.70
Usg abdomen 03/03/2014
Hepatomegaly
Massa buli buli
Cystitits
Lab 13/03/2014
ur/cr 148/12.03, na 131, K 3.6, cl 98
Lab 12/03/2014
Wbc 10,8, rbc 3,69, hb 10.6, hct 30.8, plt 124
Lab 08/03/2014
Wbc 7,6, rbc 2,70, hb 7.7, hct 22.3, plt 120,ur/cr
110/9.50, alb 2.8
Fotoct abdomen 06/03/2014
Hidronefrosis bilateral
Tidak tampak tanda metastase
Lab 17/03/2014
HBA1C 4,0 UR 144 CR 5,77 AS.URAT 11,9 NA 137
K 4,7 CL 105 WBC 26,67 RBC 3,51 HGB 10,5 HCT
31,9 PLT 475
Fotopolos abdomen 12/03/2014
tanda tanda ileus obstruktif
Lab 10/03/2014
ur/cr 242/5.70, na 138, K 4.4, Cl 107
Lab 08/03/2014
Wbc 13,1, rbc 4.33, hb 13,1, hct 39,8, plt 287,GDS 80,
ur/cr 197/6,50, sgot/sgpt 32/39, na 131, K 6,3, Cl 116,
HBsAg (ICT) Reactive, anti HCV non reactive
URIN ; protein ++/100, eritrosit 20-30

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

2
2

2
3

2
4

Orchitis
Kolik ureter ec susp. BSK

Optimalisasi KU

Hidronefrosis bilateral

Optimalisasi KU

Bakri dg. Sikki

20/5/1960
638622
Jkn
Lt. 1 ab k5b3

Hindong dg. Gassing

15/5/1965
Jkn
LT 1 AD K5 B4

Surya Darma
1-11-1955
652009
JKN
LT 1 BD K2B2
DPJP dr.M.Asykar.P,
Sp.U
PINDAH LT.2 URO

- Batu ren (s) POH 5 extended

- Pyelolitotomi + multiple kista ren
bilateral POH 2 unrofing kista (S)

Optimalisasi KU
IVFD NaCl 0,9% 28 tpm
Ceftriaxone 1 gr/12j/iv
Ranitidine inj/8j/iv
Ketorolac inj/8j/iv
As. Traneksamat 500gr/8j/iv
VIP albumin 3x2 caps
Diet bebas
Mobilisasi duduk
Takar produksi drain/24jam

Gas darah; ph 7.354, pco2 30,3, po2 184,7, so2 99,8,

BEecf -8,7, HCo3 17,1, TCO2 18,0.
CT scan abdomen atasbawah08/03/2014
~ hidronephrosisdextra
~ Nephrocalcinosisdextra
~ ureter olithdextra
Foto thorax PA/AP 08/03/2014
~ cordanpulmodalambatas normal
~ elevasidiafragmakana
Lab. 12/3/2014
SGOT 14 SGPT 10 UR16 CR 0,90 RBC 4,57 HGB
13,5HCT 41,3 PLT 299 WBC 35,4

CT WHOLE ABD 17/3/2014

- Massa segmen bawah rahim disertai ascites sugestif
malignancy
- Hidronefrosis bilateral
- Efusi ppleura bilateral
- cholelith
Lab. 16/3/2014
RBC 2,98 HGB 8,3 HCT 25,8 PLT 258 WBC 9,8
Lab tgl 20-3-2014
Wbc 13,57 rbc 3,28 HGB 9,0 HCT 27,1 PLT 168 UR
64 CR 3,02
Lab tgl 15-3-2014
RBC 4,01 HGB 11,4 HCT 34,0 WBC 7,5 PLT 238
CT/BT 800/300 PT 11,7 INR 1,00 APTT 24,3
GDS 101 UR 57 CR 3,00 SGOT 23 SGPT 14
Lab tgl 6-3-2014
Ur/cr 53/2.78
Lab 3-3-2014
LED I/II 65/55
Lab 28-2-2014

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

Ur/cr 57/2.40, RBC 3.68, HB 10.7, HCT 31.8, PLT
314 WBC 8.5, as.urat 8.3, HbsAg reactive
24-12-2013 CT scan abd
Polycystic disease dgnhepatomegali
Nefrolith bilateral
20-12-2013 USG abd
Polikistik disease padahepardanginjal
LONTARA 3 Saraf
LONTARA 4 OBGYN DEPAN

2
5

Lince Randongkir
20-05-1972
654713
JKN
LT 4 BD K5B1
MRS 13/3/14
Konsul 19/03/14
DPJP dr Khoirul kholis,
Sp.U

Ca. cervix stadium 3B

AKI Post renal

Optimalisasi KU
Rencana URS Bilateral + pasang DJ
stent bilateral

Lab 17/03/14
RBC 2,76 HGB 7,4 HCT 22,4 WBC 10,36 PLT 160
UR 220 CR 30.60 Na 136 K 6.5 Cl 102
USG Abdomen 17/3/14
Massa segmen bawah rahim
Hidronefrosis Bilateral
Tanda tanda kongestif liver
Asites
Efusi Pleura Bilateral

RPK
UGD
ICU
NICU
PICU
CVCU

26

Muslimin
31/12/1954
603598
MRS 12/3/2014
B1/6
Dr. ChoirulCholis,
Sp.U

POH 9 URS + pasang UK D+ DJ

Stent D
Batustaghorm S
Batu ureter 1/3distal D
Hidronefrosis

Terapi lanjut

Lab12/3/2014
CT/BT 3/8, GDS 94, Ur/Cr83/24, GOT/GPT 13/10,
Alb 2.9 RBC 3.18, HGB 9.5, HCT 28.7, WBC 15.9

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

PALEM BAWAH
Misiah
13-02-1962
653087
K 12 Bed 2

Ca cervix infiltrasi buli-buli

Hidronefrosis bilateral
POH 9 citoskopi biopsi

Mansyur
07-09-1934
653314
K4

POH 2 open prostatektomi

27

28

29

Badulu
21-07-1945
481079
B1/6
Dr. ChoirulCholis,
Sp.U

POH 2 TUR-BT ec tumor buli-buli

Fitri
1/04/1993
653626
B2/5
Dr. ChoirulCholis,
Sp.U

POH 2 nefroktomi

Rencana nefrostomi D hari senin bila

keluarga setuju
Persiapan oprasi :
Informed consent
Persetujuan oprasi
Siap darah 1 bag PRC
Konsul Anastesi
Lapor OK
Puasa
AB profilaksis
Cek Darah Lengkap Ulang
Transfusi saat HD
IVFDNacl 28 tpm
Ceftriaxon 1g/12 jam
Ketorolac 1gr/8 jam
Ranitidin 1g/8 jam
Kalmex amp/8jam/hari
Stop metronidazole
Boleh duduk berdiri
Diet Makan Minum
Takar drain perhari
IVFDNacl 28 tpm
Ceftriaxon 1g/12 jam
Ketorolac 1gr/8 jam
Ranitidin 1g/8 jam
As. Tranexamat 500g/8jam
Spoling kateter dengan Nacl 0,9 %
dipertahankan
Boleh mika miki
IVFDNacl 28 tpm
Ceftriaxon 1g/12 jam
Ketorolac 1gr/8 jam
Ranitidin 1g/8 jam
Kalnex amp/8 jam
Terapi nyeri sesuai anastesi via
epidural
Boleh mika-miki

Lab 17/03/2014
GDS 73 ur 84 cr 6.13 na 125 k 4,6 cl 9,6 wbc 17,45
rbc 2,92 hct 23,3 plt 325 ur 100 kr 5,60
Hasil PA tanggal 12-03-2014
Urotelial cell carcinoma
Hasil USG 19/3/2013
Hidronefrosis Bilateral

Lab 06/03/2014
WBC 3,9 RBC 3,94 HGB 11,6 HCT 34,1 PLT 214
CT/BT 730/200 PT 12,0 GDS 100 ur/cr 26/0,70
SGOT 18 SGPT 8 Na 135 K 3,8 Cl 95
PSA 51,12
USG abdomen 11/03/2014:
Kesan: hipertrofi prostat
Lab 05/03/2014
WBC 11,4 RBC 4,40 HGB 13,1 HCT 39,1 PLT 206
CT/BT 730/200 PT 12,3 GDS 110 ur/cr 41/1,50
SGOT 23 SGPT 13 Na 145 K 4,3 Cl 102
MSCT-Urografi
Massa buli buli disertai hidronefrosis
Urogram ginjal kiri normal
Multiple kista ginjal kanan
Lab 05/03/2014
WBC 8,4 RBC 4,34 HGB 12,3 HCT 36,2 PLT 487
Lab 17/03/2014
CT/BT 800/200 PT 12,6 GDS 207 ur/cr 17/0,7
SGOT 21 SGPT 15
USG Abdomen 05/03/2014:

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

Boleh duduk
Takar drain perhari
Awasi TV
Aff kateter

Kesan: Severe Hidronefrosis Dextra

Susp. Kista Ren Dextra
MSCT Whole Abdomen Non Kontras 07/03/2014
Kesan: Kista Ren Dextra DD/ hidronefrosis
MSCT Urografi dengan Kontras11/03/2014:
Kesan: Severe Hidronefrosis Dextra
Non fungsional ren dextra

PALEM ATAS
Tn.Ariansyah
TL 2-3-1966
MRS 17-3-14
RM 650471
Bed 3
JKN
DPJP:
Dr. Muh.Asykar
Palinrungi, Sp.U

Batu staghorn dextra

Stenosis uretra
Hidronefrosis dextra
DM tipe II

Rencana oprasi extended

pyelolitotomi hari senin 24/3/2014

Lab 05/03/2014
WBC 12,90 RBC 4,57 HGB 13,00 PLT 659 HCT 39,9
Na 143 K 4,3 Cl 105 CT/BT 800/ 200 SGOT 38
SGPT 40
Lab 24/02/2014
GDS 87
USG Abdomen (3/2/2014)
- Fatty degenerative of the liver
- PNC dengan nephrolithiasis staghorn/multiple
kanandenganhydronefrosisberatkanan
- Post nephritis kiridengan Kristal-kristal
insufficiency renalis
- cystiti
BNO IVP (13/2/2014)
- Batustaghorn calculi rendextra
- Ureterolihiasisdextra
- Hydronefrosisdextragr.III-IV
- Susp.Hipertrofiprostat

30

RSUH
31

SITI Mardiana
TL: 22/7/1959
RM: 019576
Dr. Khoirul Kholis,
sp.U

D/batu pyelum ginjal (D)

Hidronefrosis (D)
Batu ureter 1/3 distal (S)
-POH 2 pyelolitotomy+ DJ stent in
situ (D)

IVFD NaCl 0,9% 28 tpm

Ceftriaxone inj 1g/12j/iv
Ketorolac 1 amp /8j/iv
Ranitidin amp/8j/iv
As Tranesamat 1amp/8j/iv

Lab 10/3/2014
WBC: 6.01, RBC: 4,37, HB: 13,6, HCT : 41,2,
MCH: 31,1, MCHC: 33,0, PLT : 232, GDS: 132,
SGOT: 21, SGPT:12, Ur/Cr: 32/0,7, CT:7, BT:3,
APTT: 33,4

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

Minum bebas
Diet bubur
Takar urine/12 jam
Takar drain/24 jam
Mobilisasi miring kanan dan kiri
Tunggu hasil BNO

32

33

34
35

Ny. Masna
TL : 23/07/1957
56 tahun
RM : 019728
TglKonsul : 14/3/2014
KMR : RSUH 415
dr. Syafri BakriSpU
D/ AKI DD/ Akut On
CKD + BSK
Tn. H. Darwis
54tahun
RM:019915
Tgl konsul : 20/3/2014
RSUH Kamar 408
dr. Syarif Bakri,SpU

Nuralim
23 thn
RM: 010318
Dr.SyakriSyahrir,Sp.U
KMR:306
Tn Muh Yusuf
59 tahun
RM:019819
Dr. Khoirul Kholis,

- POH 5 ureterolitotomi dextra+

DJ stent dextra
D/ batu UPJ (D)+ hidronefrosis

D/ vesicolithiasis + hidronefrosis +
CKD stage V

IVFD NaCl 0,9% 28 tpm

Ceftriaxone inj 1g/12j/iv
Ranitidin amp/12j/iv
Aff drain
GV

CT Scan :batu ureter 1/3 distal (D)

Lapor dr. Syarif, SpU

USG Abdomen (21/2/2014)

Nefrolitiasis disertai hidronefrosis dextra
MSCT-Scan
Ureterolith destra disertai hidronefrosis
Suspek ureterolith sinistra
cystitis
Lab (27/02/2014)
WBC : 6.9, RBC : 4.13, HGB : 10.9, HCT : 34.9,
PLT : 247, GDP : 93, SGOT : 20, SGPT : 12, Ur : 70,
Cr : 3.0
MSCT-Scan Abdomen (05/03/2014
- Hydronefrosis (D) grade III danUreterolithiasis (D)
1/3 tengahdenganukuran diameter = 3.5 mm
- Kistaheparukuran diameter = 2 cm
- Spondylosislumbalisdan Scoliosis lumbalis
Lab 20/3/2014
WBC: 9.22, RBC: 3.57, HB: 10.9, HCT : 30.5,
MCH: 30.5, MCHC: 35.7, PLT : 244 Ur/Cr102/4,6,
CT:7, BT:3, APTT: 29,7, PROTEIN TOTAL: 6,5,
ALBUMIN:4,09
USG Abdomen (17/2/2014)
Hidronefrosis bilateral
Batu buli-buli

D/seminoma testis post kemoterapi

Tumor abdomen

IVFD NaCl 0,9% 20 tpm

Awasi KU
Lapor dr. Syakri,SpU

WBC: 10,13 RBC: 3,37

HB : 9,8 HCT: 29,3 PLT: 312 UR/CR: 13/0,7

D/ Vesicolithiasis

Rencana operasi Senin tanggal 24

Maret 2014

USG Abdomen (17/3/2014)

-vesicolith
-cholelith

KORAN SUBDIVISI BEDAH UROLOGI MINGGU 23 MARET 2014

Sp.U

36

Hj. Rosmiati Malik

14/5/1948
Dr. Muh.Asykar
Palinrungi, Sp.U

Foto polos abdomen (18/3/2014)

-suspek vesicolith

D/ hidronefrosis + PJK

Lapor Dr. Muh.Asykar Palinrungi,

Sp.U
-CT Scan abdomen

Lab 17/3/2014
WBC: 7,45, RBC: 4,41, HB: 13,6, HCT : 40.1,
MCH: 30.6, MCHC: 33.9, PLT : 253
Urinalisa-hematuria
-proteinuria
- leukosituria
Echocardiogram 21/3/2014
-disfungsi diastolic tipe 1 e.c HHD

PCC
Tn. Hamid
TL: 01/07/1962
51 tahun
MRS 07/03/2014
RM 652259
KMR : 322
BPJS
35

POH IX Pro extended

pyelolithotomi sinistra

S : kelnyeripadalukaoperasimenurun
O : KU : baik
Abdomen datar, supel, peristaltic(+) N
Luka operasi : verband kering, pus Urine: warna kekuningan, produksi
kesan cukup.
- Cravit 500g 1x1
- Celebrex 100g 2x1
- Glisodin 2x1
- Ambroxolsyr 2x1 cth
-dietbiasa
-Imobilisasi jalan
-decobaltzalt 2x1
-GV/hari
- evaluasi BAK

Lab (08/3/2014)
Na/K/Cl : 145/41/108
CT: 630 BT: 230 PT: 31,1 APTT: 25,3 INR:1,10