Sabtu , 2 April 2018 UROLOGI ISH/FAT/SWR/IYA/RIR/IHI

RUANG PJ BED NAMA USIA RM MRS DIAGNOSIS STATUS PLAN DPJP KETERANGAN
(31/5) Hb 15,9 Ht 50 AL 24,9 AT 363 AE 5,86 PT 12,8 APTT 30,8 GDS 222 SGOT 31 SGPT 24 Alb 4,9 Ur 20 Cr 1,2 Na
Sutardi Pneumonia + Asma akut berat + susp Balanitis
ANGGREK 1 IYA 3D 55 01421005 Ko paru Work up Konsul WB 138 K 4,8 Cl 106
27/01/1963 Xerotica Obliterans
(1/6) Hb 11,4 HT 32 AL 17,8 AT 344 AE 3,58 GDS 103 Alb 3,6 Cr 3,7 Ur 75
Sukidi Poli
RIR 5B 57 01414495 Batu ureter proksimal (D) + Batu ureter distal (S) Work up Perbaikan KU WB
12/12/1960 31/5
(27/5) Alb 3,6 Na 140 K 4,1 Cl 98
Sukiman Poli Medikasi
RIR 5D 34 01417345 Post Redebridement wound ec Fornier gangrene Post op WB (25/5) Hb 10,3 Ht 30 AL 11,8 At 3002 Na 134 K3,1 Cl 102
MAWAR 2 05/07/1983 15/5
(22/5) Kultur urin : Bakteri E.Coli, Sensitif : Cefepime,Gentamicin,Ceftriaxone
(30/5) Hb 12,6 Ht 40 Al 4,5 AT 252 Ae 5,6 PT 14,2 APTT 45,4 INR 1,070 GDS 155 SGOT 17 SGPT 18 ALb 4,2 cr 1 Ur 18 Na 138 K 4,3 cl
Ca Buli Buli
Setiyono Poli 104
RIR 7A 37 01405676 Post TURB Pre op Sistoskopi evaluasi + TURB WB
3/2/1981 30/5 (7/2) PA : Uropoetika Cell carcinoma Gr 3, invasi sampai kel lapisan muskularis
Post Radio teraphy 33x
(27/4) USG Abd : penebalan dinding bulicircular ketebalan 10mm
WING MW Ilham Poli (31/5) Hb 12,4 Ht 37 AL 8,3 AT 380 PT 15 APTT 42 cr 0,5 ur 18 Na 136 K 3,9 cl 108 HBSAg NR
RIR J 12 01403684 Hipospadia penile type Pre op Chordectomy + uretroplasty SA
2 15/6/2006 30/5
(30/5) Hb 8,2 Ht 26 AL 10 AT 62 AE 3,28 PT 17,9 APTT 40,8 INR 1.440
(28/5) USG : Massa bulli disertai hidronefrosis berat (D/S)
(25/5) Hb 12,3 Ht 41 Al 9,3 At 93 (24/5) ISK, nitrituria, proteinuria, silinderuria, kristaluria
(24/5) bone survey : kompresi korpus Vth12,VL3 -5, lesi litik di calvaria, lesi blastik di 1/3 distal os femur kiri
WING MLT Tukiman
IYA 1F 72 01416907 Ko interna Ca Buli Buli Raber interna konsul WB dapat merupakan bone metastase
3 1/2/1942
(24/5)BNO : kompresi VL 3-5 dapat merupakan bone m,etastasis
(21/5) Thorax PA : Pneumonia type pulmonal metastase
(17/4) PA : infilt high grade papillary urothellial Ca
(13/4) USG ABD : Massa buli-buli 5,03 x 4,02 x 5,49 , hidronefrosis sedang kanan kiri

Siman Poli Ureterolithiasis bilateral (11/5) USG ABD : terpasang DJ stent

IHI 601C 66 01416684 Pre op Ureterolithotomy WB
17/6/1951 30/55 Post dj stent (april 2018) (10/5) Hb 12 HT 34 AL 5 AE 3,95 PT 13,9 APTT 35,2 INR 1,0090 Ur 73 cr 2,6 Na 136 K 4,3 Cl 106

(30/5) Hb 14 HT 44 AL 8,8 Cr 3,5 Ur61 AU 7 Chol 203 Tg 170 HBSAg NR

Kultur urin : no growth
Poli Urosepsis + Batu renal (S) Pro RPG-URS-DJ stent (S)
IHI 602C Sugiyanto 54 01119563 Pre op SA (21/5) BNO susp nephrolithiasis (S)
FLB 6 25/5 (post ESWL 2015) Kultur urin + kultur darah +
(21/5) Hb 13,6 Ht 38 AL 8,9 cr 2,4 Ur 48
(8/5) tampak multiple nephrolithiasis (S), nefrokalsinisis bilateral dan simple cyst ren (S)

(31/5) Hb 5,9 Ht 17 AT 117 AE 2,3 (30/5) Hb 4,9 Ht 16 AT 191 AL 6,1

(28/5) Hb 8,5 ht 127(26/5) Hb 7,2 (24/5) Hb 7,4
(28/4) USG Urologi : Massa tumor dinding VU blood clot
Perbaikan KU +
Ny. Soeparmi IGD Hematuri + TCC buli T3N0M0 post Kemoterapi (25/2) PA : Buli : karsinoma urothelial infiltrative dgn diferensiasi skuamosa, didapatkan infiltrasi sel tumor ke
IHI 606B 73 01366304 Pre op pro sistoskopi evaluasi BM
8/11/1944 5/5 dan Radioterapi + anemia tunika muskularis, tdk didapatkan invasi tumor ke lumen angiolimfatik.
masukan pengawasan jaga
(23/2) Thorax PA : Aortosclerosis, tak tampak proses metastasis.
(18/12/17) USG abdomen : Penebalan dinding bladder dg tepi irregular curiga suatu residual mass,
hepar/lien/pancreas/kedua ginjal tampak kelainan.
(30/5) Hb 9,0 Ht 31 AL 5,8 AT 647 AE 3,66
Perbaikan KU ( trf PRC 1)
Sri mulyono Poli (9/3) PA : mikro : Tu epithelial berpola epithel transisional,padat dan infiltrative. Gambaran invasi lapisan otot
IHI 705B 57 01403194 Ca Buli Buli T3N0M0 on Kemo siklus 4 kemo Gemcitabin 1000 1,8,5 SA
28/1/1961 31/5 polos sukar diidentifikasi, sel sel atipi, pleomorphic, sebagian seldg inti atipi, bulat dan besar
Cisplatin 75mg 2
Dx PA : (residif) invasive Uroportika Cell Carcinoma, Grade 3
(31/5) Hb 10,4 Ht 28 AL 103,9 AT 219 AE 3,22
Suyanto Poli (25/5) Hb 10,8 Ht 32 AL 75 AT 311 AE 3,69 PT 15,1 APTT 23,7 INR 1,150 cr 1,1 ur 38 Na 132 K 4 Cl 99 HBSAg NR
IHI 705D 55 01405166 Scc penis T4N2M1 ( paru ) Perbaikan KU Tunggu hasil kultur darah WB
12/9/1962 28/5 (15/1) PA : SCC dengan keratinisasi

(30/5) Kultur urin : pertumbuhan 3 jenis koloni curiga kontaminasi

Suyati Ca cervix IIIB residif + hidronefrosis+ hidroureter Irigasi?
IHI 709D 56 01402214 Ko obgyn Post op WB (27/5) Hb 11,4 Ht 33 Al 8,1 AT 205 AE 4,02
01402214 bilateral Lap op (-)
FLB 7 (24/5)Hb 10 Ht 29 AL 6,0 AT 188 Cr 3,9 Ur 54 USG : hid ronefrosis sedang, Hidroureter bilateral
(28/5) Hb 9,5 HT 29 AL 7,9 AT 301 Cr 6,4 Ur 120 AU 9,7 Na 140 K 5,2 Cl 111HBSAg NR
Kemo (22/5) USG : Masa VU menginfiltrasi prostat & rectum volum 100,3ml, tampak vaskularisasi intra lesi , HN berat bilateral, Ren (D)
Perbaikan KU
Darso semito Poli Riw 12,4x6,3cm Ren (S) 11,2x6,19cm
IHI 712C 72 01416650 Ca Buli Buli T3N0M0 Pro kemo 1 WB
31/12/1945 31/5 TURP+TURB (24/4) PA : mikroskopis : Tu epithelial,padat, infiltrasi sampai lapisan muskularis,nekrosis luas. Sel2 yg atipi,polimorfi,inti bulat
gencis
april 2018 besar,mitosis cukup
(19/4) BNO : Susp nephrolithiasis (D) DD ureterolithiasis (D), spondilosis lumbal
(31/5) Na 136 K 2,9 Cl 102 (28/5) Na 140 K 2,6 Cl 102
Bleo 28unit (2,9,26)
M Alfin Poli Seminoma testis post kemoteraphy susp Kemo (27/5) Na 139 K 2,5 Cl 99 (25/5) Hb 13,2 Ht 39 AL 8,2 PT 13,8 APTT 38 INR 1,030 Alb 4,2 Cr 1 Ur 30 Na 140 K 2,6 cl 99
IHI 712D 17 01376330 Etop 190mg (1-5) SU
1/8/2000 24/5 metastase inguinal 2/5 (22/7) Hb 13,5 Ht 39 AL 6,7 AT 269 cr 0,8 Ur 20
Cis 37,8mg (1-5)
(17/3) PA : tumor ganas dari germ cell, sesuai Yolc sac tumor
 (24/5) Hb 8,8 Ht 27 AL 31 AT 454 AT 3,6 PT 18,6 INR 1,510 Alb 2,9 Cr 2,3 Ur 4,1 Ca 1,65 Urin : leukosituria,
TB paru DD mikosis + AKI + Hepatitis B + Anemia Pro URS Eritrosituria
Suratno IGD
FLB 8 IHI 805c 56 01417427 + Hidronefrosis bilateral + batu ureter D/S + HN Pre op Litotripsi BM (18/5) USG thorax marker : efusi pleura (D) minimal
15/5
kiri dgn multiple ren (S) DJ stent (D/S) (18/5) USG urologi :HN berat kanan disertai difus parenkimal renal disease, HN ringan kiri dgn multiple cyst ren
kiri
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