LIST PASIEN - DIVISI UROLOGI MINGGU, 17 Mei 2015

IRINA A ATAS (4 pasien)

NoKamarIdentitasDiagnosisTerapiLABKet

1.

A 7Bed 1

T:110/70N:82R:20S:36,5Wempi Runtulalo (L)44 thn44.66.05

MRS 09/05/2015Perawatan H-8

dr. Richard M, Sp.U Susp. ca buli Anemia berat (Hb 6,6) CKD Stage V Hipertrofi Prostat Hiponatremia IVFD NaCl 18 gtt/m As. Traneksamat 3x1 inj Ranitidine 2x1 inj Cefrtiaxone inj 2x2gr

Spooling kateter Kontrol divisi ginjal Kateter 3 way Transfusi PRC 1 bag sampai Hb 10 mg/dL

Rencana: USG Urologi (tanggal 25)09/05/2015Leu 21000Eri 2,29Hb 6,2Ht 18,4Tromb 343Ur 175Cr 8,0GDS 120Na 126K 4.5Cl 10614/05/2015Leu 7917Eri 2,43Hb 6,6Ht 19,4Tromb 198Ur 172Cr 9,2Na 132K 3,9Cl 111KPJ : Edmond

2.A.7Bed 4

T: 120/70N: 62R: 24S: 36,9

Yan Rarung (L)61 thn23.43.45

MRS : 26-2-2015Perawatan H-80

Dr. Ainun A, SpU

Ca buli dd ca prostat Malnutrisi Stiffness genu (S) Anemia sedang (Hb 8,8) Hipoalbuminemia sedang (Alb 3,23)

Cefixime 2x100mg As. Mefenamat 3x500mg Latihan fisioterapi Mobilisasi bertahap Transfusi PRC 1 bag sampai Hb 10 mg/dL Diet TKTP

Terapi lain sesuai interna

09/05/2015Leu 5538Eri 3,01Hb 8,8Ht 26,2Trom 124Ur 51Cr 1,0Prot Total 6,13GDS 127Alb 3,23Glob 2,97Na 140K 3,44Cl 109,2

16/04/2015SGOT 30SGPT 6

Pemeriksaan Sputum 3xSPS : Negatif

05/05/2015PSA: 100

14/04/2015As.Ur 7Kol 181HDL 29LDL 99TGL 263

Urinalisis14/04/2015Kristal : as.urat 5-6/LPBEri : 6-8/LPBLeu:5-6/LPBEpi:30-40/LPBBJ: 1015pH: 9Leu: +++Prot +Eri ++++

USG Kolelitiasis

KPJ: Randy L

3A7BED 6

T:140/90N:60R:22S:36,9Tinondihang Kadir Abdul (L)46 thn40.83.81

MRS : 15 5 -2015Perawatan H-2

dr. Richard M, Sp.U Gross hematuri ec Ca buli dd ca Prostat Post miles procedure Anemia ec gross hematuri AKI dd CKD ec HNS HipoNa (122) HipoK (2,3) Hipertensi IVFD NaCl 20 gtt As. Traneksamat 3x1 inj Ceftriaxone 2x1 inj Ranitidine 2x1 inj Periksa lab lengkap +albumin

Terapi lain sesuai interna

Rencana: USG Urologi CT-Scan urologi dengan kontras 14/05/2015Leu 11.600Hb 9,87Ht 27,6Trom 207GDS 105Cr 1,9Ur 23Na 122K 2,3Cl 89KPJ:Chris

5.A7Bed 7

T: 120/70N: 82R: 20S:36,9Alusingsing Hendrik (L)71thn44.64.75

MRS 15/05/2015Perawatan H-2

dr. Richard M, Sp.U Gross hematuria ec. Susp. Ca Buli dd/ ca prostat IVFD NaCl 0,9% As. Tranexamat 3x1 inj Spooling kateter

Rencana:USG UrologiKateter UrineUrinalisisCT-Scan abdomen15/05/2015Leu: 7704Er : 3,97Hb : 11,0Ht : 33,4Tromb : 282Ur 36Cr 1,2GDS 95

USG Urologi11/05/2015Massa buli-buliHipertrofi prostatKPJ:Billy

IRINA A BAWAH ( 5 pasien)

NoKamarIdentitasDiagnosisTerapiLABKet

1B1Bed 2

T: 130/80N:88R:20S:36,5Maaniya Suharto (L)52 tahun43.00.86

MRS 12/05/2015Perawatan H-7 Batu multiple ginjal (D) Post nefrotomi CKD stage IV Hidronefrosis (D)

As. Mefenamat 3x500mg k/pRencana: RPG URS DJ Stunt PCN APG Sitoskopi

Cek list perlengkapan persiapan operasi 18/5/2015: EKG X-Foto Thoraks Cross Med Lab Inform Consent Puasa 8 jam sebelum operasi

09/05/2015Leuko 6464Er 4,72Hb 12,5Trom 242CT 8BT 2PT 11,7APTT 31,7GDP 95GD 2 jam pp 226SGOT 21SGPT 10Ur 63

Cr 2,1Protein total 8,62Alb 4,41Glob 4,21Cl 99,7K 4,10Na 135

EKG Normal

USG Urologi Nefrolitiasis (D) Hidronefrosis DD : Hipogenesis

KPJ :Ryan

Produksi Urin : 1500 cc/12 jam

2.

B2Bed 1

T:120/80N:64R:20S:36,6Umahit NurlainaP24thn/40.23.49

MRS 10/05/2015Perawatan H-7

Post repair fistel ec. Fistel vesico vagina IVFD RL 20gtt Ciprofloksasin 2x500 Ranitidin 2x1 amp Ketorolac 3x1 Vip Alb 3x4 caps Rawat luka Periksa lab : DL, Na, K, Cl, GDS, Ur, Cr

13/05/2015Leu 19620Eri 4,76Hb 9,5Ht 31.1Trom 226MCH 20MCHC 31MCV 65

Ekg normal

Alb 4.33Glob 3.75

Produksi Urin: Via Kateter 750 cc/24 jam Via Sistektomi 500 cc/24 jam, warna kuning kemerahan Urin drain hemoragik 50cc/24jamKPJ :Maya

3.B10Bed 8

T:120/60N:88R:20S:36,6Yulianti (P) 14 tahun43.81.29

MRS 11/5/2015Perawatan H-6 Tumor buli susp. Malignancy CKD ec susp. Nefropathy obstruksi dd malignancy Amenore IVFD RL Ceftriaxone 2x 1 vial amp Ranitidine 2x1 amp Ketorolac k/p Cek Lab. Lengkap

Pro :konsul obs13/05/2015Leu 12980Eri 3,85Hb 9,6Ht 29,6%Trmbo 464Mch 25Mchc 33Mcv 77

BNO IVP ( 23-2-2015): Uretheroladonefrosis (S) Tumor intravesika

BIOPSI Buli (11-3-2015): Jaringan ikat dengan keganasanKPJ : Wina

4.B8Bed 4T: 110/70N: 78R: 22S: 36,5

Gosal Denni Herman (L) 45 thn43.19.27

MRS 4-5-2015Perawatan H-13

dr. AlwinMonoarfa, Sp.B, Sp.U

Metastasis tumor testis sinistra Post orchitectoumy Hipoalbuminemia (Alb 2,69

IVFD RL : NaCl Inj tramadol k/p Ranitidin 2x1 amp Rencana :Kemoterapi BEP Diet tktp Penolakan pasang NGT + Kateter Transfusi 1 bag PRC sampai HB >10

16/05/2015Leuko 9270Er 3,97Hb 9,8Ht 31,0Trom 324MCH 25MCHC 32MCV 78GDS 85Alb 2,69Cl 97,6K 4.01Na 138

05/05/2015Prot. Tot:684Glob: 3.96

06/05/2015SGOT 32SGPT 8Ur 42Cr 1,0

EKG LAH T inverted di V1-V2 T flat di V4-V5 e.c elektrolit imbalance dd anemia dd iskemik miokard

KPJ:Eka

5B5Bed 4T:110/60N:82R:20S:36,7Farid Baso (L)44thn445854

MRS 07/05/2015Perawatan H-10

Dr. Ainun A, Sp.U Gross hematuri ec susp. Ca Buli General weakness Anemia (Hb 6,5)

IVFD RL 20 gtt/m Inj Ceftriaxone 2 x 1 gr Inj Ranitidine 2 x 1 IV Inj Ketorolac 3 x 1 IV Transfuse, PRC 1 bagSampai 10

Spooling kateter Konsul Interna Kurangi makanan tinggi kalium

Rencana: CT scan abdomen dengan kontras (tanggal 25/5/2015)

16/05/2015Leu 14.650Eri 3,21Hb 6,5Ht 21,6Trom 374MCH 20MCHC 30MCV 67

Urinalisa07/05/2015Warna = kuningKekeruhan = jernihBJ 1,010pH 6Nitrit negProtein ++Glu normKeton negUrobilinogen normBilirubin negDarah/Eri ++++

16/05/2015Na 137K 2,70Cl 111,0

Feses08/05/2015Darah negCacing negEri 2-3/LPBLeu 10.20/LPBEpitel 10-20Telur/cacing negBakteri negJamur neg

KPJ:Randy Manappa

Produksi Urin : 3000 cc/6 jam

IRINA B (2 pasien)

NoKamarIdentitasDiagnosisTerapiLABKet

1K. 14 B

T:120/70N:68R:20S:36,8 Arifin kubeng (L)45thn44.36.71

MRS 5/5/2015Perawatan H-12

dr. Ainun A, Sp.U Post URS + Uroterolitotomi (s) ec. Ureterolitiasis + nefrolitiasis (s) Terpasang DJ stent (s) Cefixime 2x200 mg As.mefenamat 3x500 Rawat luka Vip albumin 3x2 caps

Rencana : Cek DL, Ur, Cr Tampung urin/24jam Diet TKTP Mobilisasi Rawat jalan tgl 18/5/2015 Kontrol untuk rencana RPG +ESWL nefrolitiasis (s)Foto BNO : Tampak DJ Stent (s)16/5/2015Leu 8463Er 5,33Hb 15,0Ht 44,4Trom 316MCH 28MCHC 34MCV 83

07/05/2015PT 12.7APTT 20INR 1.01

2K. 3

T:N:R:S:Jantje Kolinu (L)17.46.61

MRS 30/4/2015Perawatan H-17

( Pasien konsul dari bag. Interna)

dr. Ainun A, Sp.U Ca ginjal dextra (RCC) + divertikel buli Keluarga menolak dilakukan operasi Terapi lanjut sesuai interna15/05/2015Leu 7542Er 3,20Hb9,1Ht 28,9Trom 210Ur 73Cr 4,6Prot total 6,76GDS 72Na 132K 3,11Cl 92,705/05/2015LED 25Eos 4Baso 1Netrofil batang 3Netrofil segmen 71Limfosit 13Monosit 8

19/5/2015Hasil PA Urin : Radang Akut

Anggrek I (1 pasien)

NoKamarIdentitasDiagnosisTerapiLABKet

1B8

Sumendap Aneke (P)34thn44.59.20

MRS 08/05/2015Perawatan H-9

dr. Ainun A, Sp.U

( Pasien konsul dari Bag. Interna )

Post URS + Litotripsi + cistoskopi ec vesikolitiasis +uriterolitiasis dextra + nefrolitiasis bilateral

Rencana: Tunggu hasil lab Takar urine/24 jam Terapi lanjut sesuai interna

08/05/2015Leu 10.230Er 3.81Hb11.8Ht 33.8%Trom 266Ur 88Cr 7.8Na 132K 4.10Cl 106GDS: 1712/05/15Leu 8954Er 3.42Hb 10.3Ht 30.7Trom 252MCH 30MCHC 34MCV 90

11/5/2015Ur 87Cr 8,6

NyiurNoKamarIdentitasDiagnosisTerapiLABKet

1.K. 17

T:N:R:S:

Hamzah Bastian (L)39thn44.34.09

MRS 28/04/2015Perawatan H-19

Nefrolitiasis DextraRencana: RPG ESWL Kontrol di poli bedah

12/05/2015Ur 84Cr 5,3GDS 88Na 129K 3,24Cl 92,9K 7,34Leu 7849Eri 2,58Hb 7,0Ht 21,6

14/05/2015Ur 48Cr 4,0GDS 91Na 133K 3,0Cl 103K 3,0Leu 6320Eri 2,54Hb 6,95Ht 21,6Fosfor 1,9Calcium 8,06