PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Jeumpa 1
N
o

Nama/Umum/C
M

Kamar

DPJP

Tanggal
Masuk

Diagnosa

Januddin
Nafi/50
thn/1059117

K7B4

DAH

25/07/2015

CKD stage Ve.c

obstruksi
uropati+nefrolitiasi
s bilateral+multiple
batu ureter dex +
trombositopeni

Tindaka
n

Tanggal
Op

Hasil Lab

Tgl 29/9/2015
Hb/ht/erit/luko/tro
m
10,7/28/3,4/24,1/25
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
12,7/36/4,1/19,5/7
Ur/Cr :167/6,77
Tgl 25/7/2015
Pt/aptt : 11,0/37,5
Hbsag negatif
INr 1,03

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

Planing

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

JEUMPA 2
N
o

Nama/Umum/
CM

Kama
r

DPJ
P

Tanggal
Masuk

Diagnosa

Tindak
an

Tangg
al Op

Hasil Lab

Planing

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

1

Jumini/61thn/10
59408

K7b1

26/7/2015

retensi urin e.c

neurogenic bladder
susp. Vesicolitiasis
+DISLOKASI vl 45 +Fr. Parasimpasis
sup inf

Tgl 28/7/2015
Hb/ht/erit/leuko/tro
8,9/29/3,7/5,0/585
CT/BT : 7/2
Na/k/cl :
137/3,7/105
GDS : 287
Ur/cr : 22/1,09

Tgl 30/7/2015
Hb/leu/trom
9,4/18,2/690

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

Jeumpa 4
N
o
1

Nama/Umum/
CM
Nurhayati/55 th/
1051370

Kamar

DPJP

K1B1

JUF

Tgl
Masuk
20/6/2015

Diagnosa
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

Tindak
an
debride
ment
dan
ganti dj
stent
(30/7/20
15)

Tgl
Op
30/6/2
015
30-72015

Hasil Lab
27/7/2015
Hb: 9,1 Leu: 12,7
tromb:558
21/7/2015
protein total:7,4
alb:2,90 Glb:5,0
Na:140 K:4,5 Cl:103
Ur:45 Cr:1,20
GDS:110

Planing
Aff catheter
Aff drain
Bno kontrol
(+)

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

2

Saifullah / 41 th/
844906

K2B1

JUF

16/07/201
5

Post LE +
Abses
Pararenal +
Hidronefrosis
ec batu ureter
media + TOF
+ sepsis + PH
+ Acute
Respiratory
Syndrome

3.

Irfan Ilyas, 32
thn, 1055155

K2b2

JUF

29/7/2015

Nefrolitiasis

PCNL

23/7/2015
Hb:9,3 leu:17,1
tromb:273 na:131
k:3,7 cl:96 ca:8,8
mg:1,9 gds:72
24/7/2015
SGOT:67 SGPT:51
Na:133 K:3,8 Cl:101
Ca:8,4 Mg:6,9

29/7/2015
Hb/leu/trom/alb/glo
9,5/13,1/545/2,8/3
Gds: 68
Na/k/cl : 118/3,9/92
Ur/cr: 20/0,70

10/6/2015
Hb/ht/erit/leu/trom
15,1/44/4,6/11,7/331
CT/BT: 7/2
Na/K/CL/Ca
144/3,9/104/9,4
Ur/cr : 11/0,93
Urinalisa: leukosit
(+)

8/7/2015
Hb/leu/trom
15,4/10,2/348
CT/BT:7/2
Na/K/Cl:
142/3,6/102
Ur/cr : 19/0,89

CT Scan
Kontras/Non
kontras
(kamis, 30/7)
Susul
hasil
Aff heating
GV/hari
AB ganti
ciprofloxacin
2x500
Konsul IPD
(hiponatremi
&gout
artritis)
DR ulang
Jadwal op
PCNL

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

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

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

29/7/2
015

Tgl 29/7/2015
Protein: 6,2
Alb/glo : 3,54/2,66
Tgl 28/7/2015
Urinalisa:
Leukosit :+
protein :+1
Darah:+1
Leukosit:20-25
Erit:20-30
23/7/2015
Hb: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

Epitel:4-6
Tgl 26/7/2015
Hb/ht/erit/leu/tro
10,9/33/3,9/12,6/445
CT/BT : 8/2
Alb:2,79
Na/K/Cl :
131/4,8/104
Ur/Cr : 84/1,27
GDS : 105
Tgl 30/7/2015
Hb/ht/leu/trom
9,3/28/16,7/449
LED:96
Ur/cr : 99/2,56

Hasil USG
Urologi (+)

Transfusi 1
kolf

Tgl 26/7/2015
Hb: 9,4
Leuko : 10,9
Ur/cr : 99/2,56
6.

Ratna Julita/34
th/1009784

K5b3

DAH

10/7/2015

Post
LE+Colostom
y a.i ca recti
1/3 distal
+retensio urin

Tgl 19/7/2015
Hb:9,5
Leuko:12,2
Trombo:415
Alb:3,72
Glo:2,78
Na/k/cl/ca: 138/4,1/101/9,2
Ur/cr : 12/0,30

Bladder
training
Rencana PBJ

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

7

Sakdiah/ 46 th/
1058570

K5B4

DAH

21/7/2015

Post repair
buli a/i
peritonitis ec
trauma buli
intra
peritoneal post
histrectomy

29/7/20
15

22/7/2015
Hb:12,7 leu:16,4
tromb:376
27/7/2015
Prot. Total: 5,5
Alb/glo : 2,83/2,67
Na/K/Cl:
141/3,4/107
Gds : 102
Ur/cr : 19/0,47

M. akbar /20 th/

1058209

K7b4

DAH

13/07/201
5

post cytoscopy
diagnostik+ins
ersi dj stet
dex+radikal
orchidektomy
dex+eksplorasi
ureter bilateral

Op
27/7/20
15

27/7/2015
Hb/leuko/tro:
9,3/10,6/263
Na/k/cl:127/4,5/105
Ur/cr : 66/3,14
25/7/2015
Hb/ht/erit/leuko/trom
bo
8,6/26/3,4/13,2/288
Protein total :6,5
Alb/glob : 2,90/3,60
Na/k/cl : 125/4,9/103
Gds : 90
Ur/cr : 81/4,40

CKD +
Hidronefrosis
bilatetral post
bilateral
nefrotomy

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

Tgl 30/7/2015
Hb/leuko/trom
9,3/6,3/323

Rawat Luka
Spooling Nacl-betadine
Ketorolac aff
Ranitidine
aff
GV rawat
dengan
aquacell+gen
ta
Monitor urin
output
Susul hasil
BNO 3 posisi
URS ulang
(persiapan)
Koreksi Na
2500cc
Cek DR, ur/cr
Konsul
anastesi
(senin)

Susul hasil
BNO kontrol

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

dilatasi
+insersi
DJ stent
1
0.

Zaini, 69
thn,1058325

K4B1

DAH

Nama/Umum/
CM
Jamaluddin/ 52
tahun/ 1057909

Kamar

DPJP

K9b3

DAH

Bustami/ 41
/1057508

K4b3

JUF

14/7/2015

Post
nefrostomi dex
a.i HN dexe.c
susp. Batu
ginjal dex dd/
PUJO

Tanggal
Masuk
19/07/201
5

Diagnosa

30/7/2
015

TGL 27/7/2015
Hb/ht/erit/leu/trom
12,5/40/4,9/18,8/498
Alb/glo;2,86/4,24
Na/k/cl: 131/4/102
Ur/cr:30/0,73

GV, monitor
nefrostomi,
DR, alb/glo

MAMPLAM 1
No
1

26/7/2015

Nefrolithiasis
bilateral + post
insersi dengan
stent +
hipokalemi +
CKD + anemia
Nefrolitiasis
sin
+Ureterolithias
is
dex+hidronefr
osis
dex+anemia
sedang+limph
adenopati

Tindak
an

Tanggal
Op

Hasil Lab
23/07/2015
Hb:8,1Leu:8,6
Tromb:146 Na:141
K:3,2 Cl:100
Ur:33 Cr:1,91

URS+In
sersi
DJ+Nef
rolitoto
mi sin

Tgl 26/7/2015
Hb.ht/erit/leuk/tro
8,3/26/3,3/5,7/212
Alb/glo: 3,8/2,4
Na/k/cl:
123/4,2/100
Ur/cr : 38/1,17
Hbsag : -

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

Planing
USG Urologi (+)
Persiapan op tgl
3/8

Cek DR, ur/cr

ulang

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

3

Bundiamin/54
thn/

MAMP
LAM 4
K6

Ca.
Recti+fistel
rectovesica

cystogra
fi

Tgl 26/7/2015
Hb/leu/CT/BT
6,4/15,7/8/2
Alb/glo: 2,77/3,53
Na/k/cl: 120/3,0/102
Ur:73

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

HCU
N
o
1.

Nama/Umum/C
M
Abdul rasyid/ 73
th/ 1057936

Kama
r
K7b2

DPJ
P
DAH

Tanggal
Masuk
09/07/201
5

Diagnosa
Tumor ginjal
(D)

Tindaka
n

Tanggal
Op

Hasil Lab
22/7/2015
Na: 141 K:4,4 Cl:106
ur: 38 Cr:1,72
26/7/2015
Protein total : 9,0
Alb/glob: 3,32/5,68
29/7/2015
Hb/ht/erit/leuko/tromb
o
11,5/36/4,1/8,4/137
PT/APTT: 16,6/67,8
INR/D-Dimer :
1,51/5766
Alb:2,7
k/cl/ca/mg :
4,3/104/8,1/1,6
ur/cr : 27/1,84

Tgl 1/8/2015
Hb/leuko/trom
10,3/20,7/41
Pt/aptt/inr
15,5/111,6/1,42
d-dimer : 2188,74
Ph/pco2/po2/hco3
7,291/52,2/82/25,4
Na/k/cl/ca/mg
133/3,3/104/9,5/1,9

Planing
Aff
drain

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Seurune 2
No
1.

2.

Nama/Umum/C
M
Ibrahim/

Kama
r
K4b1

Rosni, 62 thn,
0840624

K6b3

DPJ
P

Tanggal
Masuk

Diagnosa

Tindakan

post
nefrostomy
perkutan sin
a.i
hidronefrosis
bilatal e.c
batu ginjal
dex + RSP
batu ureter
sin + sirosis
hepatis

Nefrostomy
bilateral
APG

Post
nefrostomi
a.i batu
staghorn
+multiple
nefrolitiasis
dex dj stent
in situ

Tanggal
Op

Hasil Lab
28/7/2015
Aptt : 46,8
D-dimer: >10000
Hbsag neg
Anti hcv negativ
Bil total : 4,68
Bil dir/ indi :
4,09/0,77
Sgot/sgpt : 211/106
Tgl 26/7/2015
Hb/leuko/trombo
8,0/10,2/464
Na/k/cl :
130/3,7/105
Ur/cr : 69/1,59
Tgl 28/7/2015
Hb/leu/trom/led
10,5/6,6/275/30
UR/CR : 69/2,17
Urinalisa:
leukosit(+), protein
+1, darah +
Sedimen urin:
leu:40-60

Planing

Tgl 30/7/2015
Hb/leu/trom/LED
7,3/8,9/394/40
ALP:233
Alb:2,13
Glo:4,87

Usg
abdomen
() hasil
Cek ulang
ur/cr

Tgl 1/8/2015
Hb/leuko/trom
9,1/18,3/381
Ur/cr:98/2,93

Transfusi 1
kolf
Foto BNO

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

Erit 20-30

GEURUTE
No
Nama/Umum/C
M
1
samsuar/52
th/0873928

IW
No
1.

Nama/Umum/CM
T.Makmur/64thn/10
59527

Geulima 2
No Nama/Umum/C
M

Kamar
K6

DPJ
P
DAH

Tanggal
Masuk
24/06/201
5

Kama
r
C2

DPJ
P
JUF

Tanggal
Masuk
29/7/2015

DPJ
P

Tanggal
Masuk

Kama
r

Diagnosa

Tindakan

Tanggal
Op

Post
sistocopy
TURBT +
post
nefrostomi
S
Diagnosa

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

Tindakan

Tanggal
Op

Hematuria

Diagnosa

Hasil Lab
Tgl 29/7/2015
Hb/leu/trom/alb
10,1/27,5/2,4/2,99
Ur/cr: 43/1,37

Hasil Lab

Tanggal
Op

Ct scan buli
7/8/2015
GV
nefrostomi

Planing
Usg ulang
senin 3/8
Ct scan
kontras non
kontras

Tgl 29/7/2015
Hb/leu/trom
8,8/10,6/403
Ct/bt: 7/2
Ur/cr: 38/1,13
Gds 82
Tindakan

Planing

Hasil Lab

Planing

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

1.

Saiful aidi, 54
thn,1059044

K7b4

JUF

BPH

2.

Ibrahim Daud,62
Thn,1059138

K7B6

JUF

Susp
BPH+Ca
paru sin

Tgl 31/7/2015
Na/k/cl
132/4,1/105
Tgl 30/7/2015
Urinalisa
Leuko:
+,Protein+1,Darah+
Sedimen urin: leu 6-8, erit
4-6,epitel 8-10

Tgl 25/5/2015
Ur/cr : 28/0,65
Ct/bt: 8/2

USG
Prostat
urinalisa

IGD
No
1

Nama/Umum/
CM
Firmanda/ 44th
tahun/

Kamar

DPJP

Tanggal
Masuk

Diagnosa
Ca penis

Tindak
an

Tanggal
Op

Hasil Lab

Planing
DL
Foto thorax

PASIEN UROLOGI DIRUANGAN 2-3 agustus 2015

2

Rasyid Yunus/

Warman/ 40
tahun/

PCNL

nefrolithiasis

Cek DR,
Foto thorax

USG (+) di IGD