koran uro update 29 jan 2014

KORAN SUBDIVISI BEDAH UROLOGI SELASA, 28 JANUARI 2014

LONTARA 2 UROLOGI KAMAR 1

1 AdriansyahTL : 26/10/198726 tahunRM : 575245JKN

Stricture urethra Lengkapi pemeriksaan Lab : 20/1/2014Wbc : 5.2 Rbc : 5.27 Hb : 15.1 Hct : 44.2 Plt : 232Ur : 23 Cr : 0.60

2 DavidTL : 9/12/1982RM : 644600JKN

Seminoma Testis + Hidronefrosis bilateral + anemis

Rencana URS + DJ stent bilateral

Lab : 22/1/2014WBC : 9.5 RBC : 3.25 Hb : 9.5 Hct : 27.6 PLT : 242 Ur : 70 Cr : 2.95 Na : 135 K : 4 Cl : 103

LONTARA 2 UROLOGI KAMAR 23 BAHARUDDIN

TL: 01/01/196450 thnRM 389407JKN

Ca. Buli-buli Kemoterapi Lab (22/01/2014)WBC 4,8 RBC 4.30 Hb 12.2 Hct 34,8 Plt 286Ur/Cr 35/0,92 Na/K/Cl 130/4,2/106


LONTARA 2 UROLOGI KAMAR 104 LA AFI

TglLahir: 15/1/199420thnRM: 624476MRS: 8/1/2014JKN

Kamar 10 bed 4dr.M.Asykar P. SpU

POH 10 Pyeloplasty Sinistra + Nefrostomi Sinistra + DJ stent sinistra

-Evaluasi produksi urin/drain per 24jam-Ciprofloxacin 2x500mg- PCT3x500mg-Ranitidin 2x1MobilisasiDiet biasa

Lab (19/01/2014)WBC 4,61, RBC 5,01, Hb 11,7, Hct 35,1, Plt 174 Ur/Cr 25/1,10 Na/K/Cl 140/3,6/110Hasil Lab (28/12/13):GDS: 95, CT/BT: 9/3, Ur/Cr: 27/1,0, GOT/GPT: 17/21, Albumin: 3,9, Na/K/Cl: 142/4,49/113, WBC: 7,45, RBC: 6,25, HGB: 14,7, HCT: 45,0, PLT: 321.USG Abdomen (8/1/2014):Kesan: Mild Hidronefrosis BilateralTidaktampak DJ Stent pada kedua ginjal

5 SAENITL 31-12-1950

Tumor Buli – buli + hidronefrosis

-Rencana TUR-BT Senin 27/01/2014

Lab (25/01/2014)WBC 5,0 ; RBC 1,92; HCt 16,7; PLT 174

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63thnRM 646139MRS: 20/01/2014JKN

Kamar 10 Bed 5

bilateral+ISKHematuri

-Puasa 8 jam-Inj.Ceftriaxone profilaxis 1 gr/ IV Pre Op-Transfusi PRC 3 Bag-Kontrol Hb post transfuusi setelah 3 Bag

Lab (22/01/2014)GDS 107 SGOT/SGPT 14/10Kimia urin lekosit +++/500 Blood +++/200

Mikroskopis(Sedimen) Lekosit >100, Eritrosit >100

Lab (20/01/2014)WBC 11,9, RBC 3,54, Hb 10,6, Hct 31,0, Plt 220 Ur/Cr 29/1,30 Na/K/Cl 139/4,1/113 PT/APTT 10,5/29,9IVP 17/01/2014Kesan: Fungsi kedua ginjal baikHydroureter bilateral bagian distal ec susp massa buli-buliUSG Abdomen (11/01/2014):Kesan: Massa buli – buli disertai pelvocalyectasis bilateralAscites dan efusi pleura bilateralPA (06-12-2013)Kesimpulan: Proses jinak, sesuai lymphangioma

6 ANWAR LONGSO64624708-08-1940MRS : 12/01/2014Kamar 10Bed 6

dr.M.Asykar P. Sp U

BPH Grade IVPOH 3 SistoscopyPro Open SistostomyAnemia Normositik NormokromCholelithiasis

Aff InfusChloramphenicole 3x1Rencana Op. Prostatektomi hari Rabu 29 Jan 2014Konsul Perioperatif

EchocardiogramFungsi Sistolik LV, EF66%Disfungsi Diastolik LVLVH (+)Tes Sensitivitas AntiBiotikChloramphenicole (s) ; Fosfomicin (s) ; Meropenem (s) Tetracyclyn (s)

Lab (19/01/2014)WBC 7,66, RBC 3,97, Hb 10,9, Hct 31,9, Plt 453Hasil Lab 1 6 /01/2014 PSA 39,63TRUS 96,1 TAUS 125ccthUrin rutin:

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Kimia urin Protein ++/100 Nitrit positif, Blood +++/200, lekosit ++/125Mikroskopis(Sedimen) Lekosit 12, Eritrosit >50Hasil Lab 15/01/2014WBC 8,38 RBC 3,29 HGB 9,1 HCT 26,8 PLT 484Hasil Lab ( 12 / 01 /1 4 ): GDS: 126, Ur/Cr: 30/1,1, Na/K/Cl: 140/4,5/111, WBC: 7,45, RBC: 2,12, HGB: 6,2, HCT: 18,6, PLT: 540.Foto Thorax AP ( 12/01/2014)Kesan :- Cardiomegaly disertai dilatatio et- Tidak tampak tanda-tanda metastase pada foto thorax ini.- Elevasi diafragma kanan (proses interhepatik)

USG Abdomen ( 12/01/2014)Kesan :- Tu. Buli-buli,- Hipertrophy Prostat,- Cholelithiasis disertai cholocystitis

7 MUDINTgl: 10-12-1950648253

Hipertrophy Prostat gr. II-IIIStricture Uretra

IVFD RL 28 TpmCeftriaxone 1 gr/ 12 jam/ IVLab. LengkapUrinalisis

Lab (25-1-2014)WBC 5,3 ; RBC 4,71 ; HB 13,9HCT 38,9 ; PLT 409SGOT 21 ; SGPT 17HBsag Non Reactive;Anti HCV Non Reactive;CT 6’30” , BT 2’PT 9,9, INR 0,80APTT 38,8 GDS 76;Ur 31 ; Kr 0,7

Foto Thorax (26-1-2014)Cord an Pulmo NormalAtherosclerosis Aortae

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8 NURLIA

RM: 629356

MRS: 25/01/2014

TTL: 10/06/1959

DPJP dr. Syakri syarir, Sp.U

JKN

Nefrolith D

Hidronefosis bilateral

DJ stent insitu S

IVFD NaCl 0.9%

Ceftriaxon 1gr/12jm

Tramadol amp/8jm

Ranitidin amp/8jam

As. Traneksamat amp/8jam

Diet Cair

Evaluasi urin

Awasi TV

Urine rutin 07/01/14

Kimia urine: protein + trace, nitrat + 5, blood +25, lekosit +70

Mikroskopis: lekosit 12, eritrosit 62

Darah rutin 07/01

WBC : 4,8 RBC : 4,13 HGB : 10,6 HCT : 31,7 PLT : 271 GDS 91, U/ k;54/1,6 GOT 17, GPT 9, CT/BT : 3.0/7.0 PT 13,3, INR 1.1. APTT 27,3 Na 143, K 4,1, Cl 103

9 Ny. HALIMAH

RM : 644735

MRS :

TTL : 10-09-1961

DPJP dr. Syakri syarir, Sp.U

JKN

POH6 laparotomi eksplorasi + radikal nefrotomi (S) + hemikolektomi

IVFD climmix : ivelip = 1000 : 100 24tpm

IVFD RL : DS = 1:1 = 24tpm

Ceftriaxone 1 gr/12j/iv

Ranitidin amp/8j/iv

Traneksamat 1amp/8jm

Tramadol 1amp/8jm

Lab : 25/1/2014

WBC:20.58 RBC:3.81 HGB:9.9 HCT:29.3 PLT:294 Albumin:4.5

Lab : 22/1/2014

RBC : 5.36 HGB : 13.2 HCT : 42.3 PLT : 272 WBC : 18.6 GOT : 27 GPT : 17 Albumin : 3.0 Na : 141 K : 3.88 Cl : 111 CT : 7’30’’ BT : 2’30’’ PT : 10.7 (10.0) INR : 0.90 APTT : 24.3 (23.7) GDS : 260 Ur : 19 Cr : 0.9

Lab : 20/1/2014

WBC : 10.60 RBC : 4.23 HGB : 10.8 HCT : 32.6 PLT : 309 GOT : 27 GPT : 18 Asam Urat : 3.9 Na : 132 K : 3.9 Cl : 104 CT : 6’30 BT : 3’00 PT:11.1(10.1) INR:0.90 GDS:22.7(33.1) Ur:13 Cr:0.7

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ANISA

RM : 647124

MRS : 27-1-2014

TTL : 30-12-1997

DPJP dr.Khoirul Kholis, Sp.U

POH cistostomi vesicourinaria

Batu vesica urinaria

IVFD NaCl 0.9%

Ceftriaxon 1gr/12jm

Ketorolac 1amp/8jam

Ranitidin 1amp/8jam

Awasi TV & balance cairan

Darah rutin (28-1-2014):

RBC : 3.34 HGB : 8.2 HCT : 26.1 PLT : 405 WBC : 23.1

Urin Rutin (24-1-2014) :

Warna : kuning keruh Ph : 7.0 Blood : +++/200 Leukosit : +++/500 eritrosit : >20 epitel : 5

Imunoserologi (HbsAg) : non reactive Anti HCV : non reactive

Ultrasonografi (23-1-2014):

Vesicolith disertai cystitis

Severe hidronefrosis dan hidroureter bilateral

Tidak tampak massa pada adnexa dan uterus

LONTARA 2 UROLOGI KAMAR 1210 Tn. JUN

Pombalowa40thn646242MRS: 12/01/2014K12 bed 2

POH-14 Drainase abses retroperitoneal sinistra + drainase perkutaneus sinistraPOH-14 laparotomi eksplorasi ec ileus obstruktif-ISK

-Ciprofloxacin 2x500mg-ranitidin 2x150mg-paracetamol 3x500mg-GV & rawat luka

MSCT Urografi dgn kontras (23/01/2014)Kesan : - drain pertama terpasang dari hipokondrium kiri dan ujung pada ginjal kiri-drain kedua terpasang dengan ujung cranial abdomen sisi kiri, dengan lintasan menyilang ke kanan, ujung caudal pada intravesical sisi kanan-abses pole bawah ginjal kiri dengan hidronefrosis, disertai tanda-tanda perlengketan-uretherolith sinistraLab 15/01/2014Urine Rutin :

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Kimia Urine : warna : kuning keruhpH : 6,5Berat Jenis : 1,015Protein : NegatifGlukosa : NegatifBilirubin : NegarifUrobilinogen : NormalKeton : +/15Nitrit : NegatifBlood : ++/80Lekosit : +/70Vit C –Mikroskopis :Lekosit : >20Eritrosit >100Torak –Kristal –Epitel 2Lain-lain : -Lab 15/01/2014WBC 5,5, RBC 4,56, HGB 14,1 HCT 39,7 PLT 154Lab 1 4 /01/2014 WBC : 11.03 RBC : 4.59 HGB : 14.0 HCT :Lab 12/01/2014CT/BT: 7’00/2’00 Alb: 3,0 HbsAg:-NA/K/CL: 132/4,7/106. PT/APTT: 14,5/29,8GDS: 108 UR/CR: 114/1,50. GOT/GPT: 23/20. Albumin : 3.0 RBC:4,69 HB:14,5 HCT: 41,8 PLT: 162. WBC:6,4

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Foto thorax AP 12/01/2014Kesan : Cor dan pulmo normal , Elevasi diafragma bilateral , Suspek efusi pleura sinistraFoto BNO 3 posisi 12/01/2014Kesan : Gambaran Ileus ObstruktifUSG Abdomen 12/01/2014Kesan :- Pelvocalyectasis ginjal kanan, ginjal kiri sulit dievaluasi-Dilatasi loop-loop usus disertai peristaltic yang meningkat

11 Tn.KARIM31/12/194073 thn648225MRS : 24/1/2014Kmr 12 bed 5

-POH-2 sistostomi ec stricture urethra

NaCl 0,9% 28 tpm-ceftriaxone 1gr/12j-ketorolac 30mg/8j-ranitidin 50mg/8j-mobilisasi

LAB 24/1/2014WBC 23,71 RBC 3,63 HGB 9,4 HCT 25,5 PLT 160 BT 2’00” CT 7’00” PT 12,7 INR 1,095 APTT 25,3 GDS 105 UR 175 CR 2,2 SGOT 31 SGPT 40 Na 132 K 3,85 Cl 112 HbsAg non reaktif Anti-HCV non reaktif

LONTARA 2 ISO

LONTARA 1

12 Hj.NURMI31-12-1952(61th)

- RM : 647037- MRS : 16-01-2014- JKN

- L1BBK6/IIB4

Anuria ec hidroureteronefrosis bilateralec :-batu ureter 1/3 proximal (D)-batu ureter 1/3 proximal (S)-batu calix inferior (S)

- POH 1 URS Dj Stent Bilateral Lab (2 6 -1-2014) WBC 6,65, RBC 2.81, HB 8.3, HCT 25.4, PLT 337, UR 50, CR 5.8Lab (25-1-2014)WBC 7.96, RBC 1.81, HB 6.2, HCT 18.3, PLT 236, UR 8, CR 0.8Lab (23-1-2014)WBC 5.1, RBC 2.63, HB 7.8, HCT 23.3, PLT 310, UR 214, CR 13.50,NA 120, K 5.8, CL 92CT scan abdomen (17-1-

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2014) :hydronephroureter bilateral, kistaginjalkanan, nephrolithiasis,, uretheroliths bilateralFoto thorax PA (16-1-2014): bronchopneumonia bilateral, cardiomegaliyLab (18-1-2014)BT : 3,00 CT : 8,00 PT 11.9(11.2) INR : 31.3 APTT : 31.3 (22.7)Ureum : 199 Cr : 12.6asamurat : 14.8Albumin : 3.2Na : 123 K : 7.4 Cl : 94Lab (16-1-14)GDS : 102 Cr : 8.3 Ur : 163 GOT : 15 GPT : 14 Na : 125 CL : 99 K : 5.8wbc : 11.97 Rbc : 3.23 Hb : 9.6 Hct : 27.2 Plt : 405USG abdomen (16/01/2014)hidronephrolithiasis bilateral grade III-IV, batu XFoto thoraks (16/01/2014)Bronchopneumonia bilateral, cardiomegaly

13 TN. Maretang- 31/12/1970 (44 thn)- RM 647341- MRS 19/01/2014 (tgl

konsul 25/01/14)

L1BBK6/IIIB3

Suspek divertikel buli2, kista fungsional adnexa (D)

- BNO/IVP USG Abd 23/01/14Suspek divertikel buli-buli, kista fungsional adnexa (D)Urinalisis 22/1/14Warna kuning keruh, PH 8.0, BJ 1.005, protein +/-, keton +-/5, mikroskopis (leukosit 2, eritrosit 5, epitel 1)Lab 19/01/14WBC 21.29, RBC 4.79, HB 13.6, HCT 38.9, PLT 678, GOT 113, GPT 68, alb 3.1, na 135, k 3.85, cl 102, GDS 103, PT 12.5 C 11.2, INR 1.00, APTT 25.9 C 22.0

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Lontara 1 ISO

LONTARA 2 DIGESTIVE

14 Ny. Mariana- 15/01/1963 (51 tahun)- RM 617634- MRS 06/01/2014

L2AD/K10B3

D/ suspek kista mesenterium dd/urinoma

- Rencana URSJoint op

Lab 25/01/2014RBC 451, HB 10.2, HCT 33.7, PLT 443Lab 23/01/2014WBC 3.9, RBC 361, HB 7.6, HCT 24.2, PLT 380, PROT 5.8, ALB 3.3Lab 16/01/2014WBC 7.53, RBC 307, HB 8.3, HCT 27.5, PLT 318, GDS 59, UR 30, CR 0.5, GOT 65, GPT 35, ALB 3.1, NA 141, K 3.8, CL 110Lab (06/01/2014)WBC 9.79, RBC 3.80, HB 6.6, HCT 23.8, PLT 608, BT 6’00, CT 2’00, PT 11.6 C 11.0, INR 1.00, APTT 20.5 C 23.5, GDS 97, UR 75, CR 0.40, GOT 38, GPT 6Ct-scan abd (31-12-13)Massa kistik berseptasi pada hipokondrium kiri, suspek kista mesenteriumFoto toraks (27-12-13)Tidak ada kelainanPA (17-07-13)Cervisitis kronik non spesifik

LONTARA 2 ONKO

NICU

ICU

LONTARA 3 THT

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LONTARA 4

RSUH

15 NURHAYATI01592018/6/1953MRS : 25/1/14 Dr. Syakir Syahril, SpU

Kamar 408

POH1 ureterolitomy - mobilisasi duduk- Inj. Ceftriaxon /12j- Inj. Ketorolac /8j- Inj. Ranitidin /8j- BNO kontrol

Lab 26/1/2014WBC : 5,44 RBC : 4,32 Hb : 12,1 HCY : 37,5 PLT : 359 Na/K/Cl : 140/3,9/106 CT/BT : 7/2 PT/APTT : 12,7/31,3 HBsAg : negative

16 SAENUDDIN1/7/1942RM : 645120MRS : 25/1/2014

Dr. Syakir Syahril, SpU

ICU

Post Op H 1 TURP IVFD RL 28 tpmCeftriaxon 1 gr/8j/ivInj Ketorolac /8jInj. Ranitidin /8jAs.Traneksamat 1amp/8jamSpooling 60tetesPindah fiksasi kateter ke SIAS

Lab 27/1/2014WBC : 23.1 RBC : 4,09 Hb ; 12,1 HCT : 35,9 PLT :273 LED : jamI : 32 Jam II : 64

USG abdomen 7/1/14- Siple renal cyst dextra- Pembesaran prostat susp benigaFoto polos abdomen 7/1/14Tidak tampak kelainan abdomen pada foto polos iniFoto thoraks AP :-kardiomegali dengan dilatation et elongation aortae- atherosclerosis aortae- scoliosis thorakhalis dextra

17 Ny. RAMLAH31/12/1954016208MRS23/1/2014BPJSKamar 313

POH 5 tumor ginjal (S)Nefrotomi radikal + radikal laparotomi

Ceftriaxone 1 gr/12j/ivKetorolac /8j/ivRanitidine /8j/ivOmeprazole 2dd1Pertahankan connecta (aff infus)

Lab :WBC : 10,11 RBC : 3,58 HCT ; 31,3 PLT : 144 Hb : 10,7 Na/K/Cl ; 134/4,0/107 GDS : 106 Ur/Cr : 31/1,0

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Ny. Isa Ira18/7/1937016118MRS 28/1/2014BPJSKamar 426

Rencana Aff DJ stent Rabu (29/1/2014)

Ciprofloxacin 2 dd1As. Mefenamat 3 dd1Ranitidin 2 dd 1Tidak konsul anestesi rencana local anestesi

LAB (20-1-2014) :WBC : 9.19 RBC : 3.94 Hb : 12.2 Hct : 36.6 Plt : 236 CT : 9 BT : 3 SGOT : 24 SGPT : 13 GDS : 111 Ur : 56 Cr : 1.7

Ny. Dira63th017930MRS : 28/1/14BPJSKamar 405

Kista Ginjal Bilateral AspiletInform consentRencana tindakan Open jika cardio dan anaestesi setuju

Lab (22-1-2014) :WBC : 7.21 Hb : 14.7 Hct : 43.2 Plt : 192 GDS : 108 GOT : 29 GPT : 34 Ur : 42 Cr : 0.8 Ct : 8 Bt : 3 Pt : 14.3 Aptt : 34.2 HbsAg : (-)

USG abdomen (22-1-2014) :Distended GB disertai colelithKista ginjal bilateral

CT Scan abdomen (21-2-2013):Colelithiasis multipleKista ginjal bilateral

PCCCVCU

INFECTION CENTER

UGD

PALEM BAWAH

18 SAEHETL : 1/1/1951

D/ BPH grade IPPOK

Pro autocopy rabu (9/1/2014)Cek Ulang Lab lengkap

Lab : tgl 15/1/2014GDS : 66 Na : 133 K : 3.9 Cl : 107

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RM : 287857 HT on treatment

PALEM ATAS

12


19 ANDI SAMI’UN- 55 tahun- 632029\- MRS 21/01/2014

dr. Khoirul Kholis, Sp.U

d/ batu ureter 1/3 distal (D), DJ Stent insitu (D)

- Pro aff DJ stent + URS- Konsul ulang evaluasi kelayakan

operasi kardiologi (27/01/2014)

Lab (2 3 /01/2014) WBC 6.3, RBC 4.66, HB 13.9, HCT 40.3, PLT 197, GDS 229, Alb 4.1, cholesterol total 216, HDL 36, LDL 192, Trigliserida 123, HBa1c 9.1, CT 7’30, BT 3’00, PT 11.6 C 12.5, INR 0.97, APTT 26.5 C 25.3Lab (20/01/2014)UR 68, CR 1.90, GOT 36, GPT 23, NA 129, K 5.2, CL 109Lab (20/01/2014)WBC 7.1, RBC 5.02, HB 15.4, HCT 43.2, PLT 209, GDS 204, BT 2’30, CT 7’30, PT 12.5 C 11.4, INR 1.04, APTT 27.4 C 24.0,Usg abdomen (19/12/2013)Posisi DJ Stent pada ginjal dekstra dan VU baik, tidak tampak urolithiasis pada USG abdomen iniBNO polos (26/9/2013)Suspek ureterolith dekstra dd/ kalsifikasi, spondylosis lumbalisMC-Scan abdomen (20/9/2013)Hidronefrosis dekstra ec. uretelithEcho (13/09/2013)Disfungsi sistolik dan diastolik LV, EF 29%, dilatasi semua ruang jantung, global hipokinetik, MR Mild, AR mild, TR mild – PH mild

13


20. MUSTAKIN13/10/1951 (63 tahun)

- RM 647968- MRS 25/01/14

Palm atas B1/9

Striktur uretra - Rencana operasi sachse (senin 27/01/14)

Foto thoraks (24/01/14)Dalam batas normalLab (24/01/14)RBC 4.60, WBC 3.6, HB 14.0, HCT 40.9, PLT 198, CT 8’00, BT 3’00, GDS 98, UR 19, CR 0.92, GOT 24, GPT 21, Na 143, K 4.3, Cl 106

21 DARIMA31/12/1939648265

-CHF NYHA II-Dislipidemia

-pemasangan kateter 18 (27/01/2014)

-

Lab(25/01/2014)Waktu bekuan 7.00, waktu pendarahan 2.30, PT 10.4, INR 0.90, APTT 23.7,GDS 118, Ureum 33, Kreatinin 1.0SGOT 36, SGPT 21, kolestrol total 263, kolestrol HDL 37, kolestrol LDL 212, trigliserida 127,CK 125,CK-MB 20.3, troponin T <0.02, asam urat 7.1

22 ARSID07/07/1963648001

D/ Kolik ureter ec. Susp. Batu ureter (D)-Hidronefrosis (D)

-IVFD NacL 0,9 28 tpm-pct 3x500mg-ketorolac amp/8j

Lab 26/01/2014Waktu bekuan 7.00,waktu pendarahan 2.30, GDS 118, ureum 47, kreatinin 1.8, SGOT 27, SGPT68

14

koran uro update 29 jan 2014

Documents

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