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Sabtu 20 Oktober 2018 UROLOGI TOP/DNT/ALF/MMA/THD/SAQ

RUANG PJ BED NAMA USIA RM MRS DIAGNOSIS STATUS PLAN DPJP KETERANGAN
Jabtung 18/10 Hb16.4 AL 13.3 AT 131 Ur 41 Cr 1.1 Na 153
HCU jantung ALF B Sadiyo 55 01113755 Hematuria, retensi Urine Konsul Workup
17/10
USg Abdmn : Serve Hidronefrosis kanan curiga PUJO,
Anak Hematuria
HCU neo ALF n.inf By.Ny.Ratih 9 hri 01434945 Konsul CT Scan kontras tunggu WB Hb 17 AL 13 AT 92 Albmn 39 Ur 98 Cr 1.7
12/10 Hidronefrosis (D)
hasil
18/10 ur 163 cr7.3 Na 127 K 4.9
\Hb 10.5 Ht 32 Al 16.3 AT 281 Ur 90 cr 7.8 Na 111 K 4.2 Cl 80 Hbsag NR
USG Abdmn : Lesi hipoecoic inhomogen d poyeksi cervix dgn corakan vaskuler (+) dpt merupakan mssa
Pasang DJ stent D/S klo residual, penebalan dinding VU dgn cervix mengabur,DD infiltrasi massa cervix,cystitis. Multiple nodul d
Retensi Urine
IGD gagal open nefrostomi S lobus kanan hepar mengarah metastasis, hidronefrosis bilateral e.c uropathy obstruktif
HCU mel 1 ALF H Siti mahmudah 37 014-9527 Adeno Ca Ovarii Perbaikan KU WB
12/10 (Cr < 5 ) MRI abdmn bawah : massa residif d cervix,lapisan myometrium dan endometrium, lymfadenopati inguinal
CKD
Kejar interna perbaikan KU bilateral
PA : ovarium bilateral : adeno carcinoma differnsial buruk,metas ke servix,uters,omentum dan limfonodi
pelvis kanan kiri.
Abdmn : ground glass opacity d cavum pelvis dpt merupakan buli penuh DD massa, Fecal material prominent
18/10 Hb11 AL6.7 AT 252 Alb 3.1 Ur24 Cr 1.7
Cloth retensi 16/10 hb 8.9 hct 28 leu 8.5 trom 273 cr 4.0 ur 50 na 132 k 4.2 ca 1.24
IGD
RGB ALF C Waltini 70 01424829 Hematuri e.c susp Ca bulli Post op Post Open nefrostominS BM 14/10 Hb 8.2 Ht 25 AL 10.2 AT 234Ur 130 Cr 12 Na 131 K 5.9Cl 98
11/10
Anemia Gravis, SKD 11/10 Hb 3.5 Ht 11 AL 9,9 AT 242 PT 14 APTT 30 GDS 94 Ur 80 Cr 9.5 Na 133 K 5.5 Cl 97 Hbsag NR
USG Uro tumor buli post VU, Hidronefrosis bilateral grade IV
16/10 hb 10.8 hct 33 leu 18.6 trom 350 gol darah AB gds 98 alb 3.3 sgot 10 sgpt 8 ur 101 cr 2.2 na 132 k 4.8 cl 97 Hbsag NR
Onkologi
Mel 1 MMA 5E Sri yanti 46 th 01436106 Ca cervik IIIB post nephrostomi konsul Work up 5/10 PA: ca cel squamos, non keratinisasi
17/10
USG: hidronefrosis sedang bilateral dengan penebalan dinding VU bag. Bawah O.K infiltrasi Ca ke ureter dan VU
hematuria 16/10sitologi : mencurigakan selganas epithelial,invasive uropetika cell carcinoma
Interna
Wing mel 3 MMA 1D Santoso 64 01435485 Hidronefrosis berat S Konsul Workup 15/10 USG abdn : CKDkana disertai simple cyst kidney kanan, hidronefrosis berat kiri kemungkinan obstruks d PUJ
18/10
CKD stage 5 17/10 Hb 9.4 AL 11 AT 293 Ur 173 Cr 11 Na 134 K 4.3 Caion 0.9
Workup USG Multiple nefrolitiasis (S), Hepar/Len/pancreas/ren S/bladder/Uterus TAK
Interna
MMA 5B Suminiwari 74 00217654 Multiple Nefrolitiasis Ren (S) Konsul Kultur Lumbal AP/Lat Fraktur kompresi VL1-VL4, spondylosis lumbalis
16/10
antibiotik Hb 11.3 Htc 35 AL 5.3 AT 260 Eritrosit 4.57 Ur 43 Cr 1.7
Post HD Hb 11.3 AL 15.7 AT 402 AE 4.3 Ur 98 Cr 9.2 Na 128 K 3.6 Ca ion 1.28
12/10 Hb 3.8 Ht 11 AL 12.2 AT 576 GDS 87 Ur 192 Cr 14.5 Na 120 K 5 Cl 89
MEL 3 PA : Transisional Cel carcinoma
Hematuria, TCC buli
IGD Open nefrostomi Sitologi Dijumpai sel ganas epithelial
MMA 5C Sarni 56 01425545 Hidronrfrosis,Hidro ureter D/S Perbaikan KU
13/10 Kejar interna perbaikan KU BM Urinalisa red Leu 500 Protein 100 squamos 2-4 transisional 2-4 bulat 4-6 yeast like 188
Anemia
USG massa buli menyebabkan obstruktif uropati, hidronefrosis dan hidro ureter bilateral, acites
BNO tak tamppak bayangan batu radioopac d sepanjang traktus urinarius , grounglass appearance d cavum pelvis dd massa buli,b
uli penuh, spndylosis lumbalis
IGD Raber interna
SAQ 602B Tukiman 67 th 01435148 Ca bulli T4N0M1 paru Perbaikan KU WB 16/10 hb 9.2 hct 28 leu 51.5 trom 213 ur 3.3 cr 296 na 141 k 3.9 cl 113 HbSag NR
17/10 Pro radioterapi
Gross hematuri
9/10 Hb8.6 Ht 28 AL 10.9 AT 151 AE 3.2
Susp trauma bulli dd rupture buli
IGD USG :
SAQ 605C Amin 20 01435022 TTA hemodinamik stabil Post op Post Open nefrostomi WB
7/10 Hb 11.5 AL 18.5 PTA15 APTT 28 Ur 29 Cr 1.7
Flamboyan 6 Burger vertical shear
Uretro grafi
OF MALEOLUS MEDIA
Diskusi di bangsal
Kolik renal, low intake 16/10 na 127 k 3.3 cl 100 LDL 57 HDL 39 kolesterol 103 as. Urat 2.3
Igd Konsul interna,
SAQ 606B Karmin 45 01417603 Nefrolitiasis (s) Perbaikan Ku WB Na 121 K 3.6 Cl 93
12/10 urinalisa, asam urat
Anemia Hiponatremi Hb 9.8 Htc 28 AL 11.5 AT 378 Apt 13 APTT 30 GDS 99 Ur 40 Cr ).5 Na 109 K 4.4. Cl 80
USG Urologi,BNO IVP
Histopatologi : cervix : non keratinizing squamous cell carcinoma
Interna Konsul selasa USG : Ca cervix menyebabkan hidronefrosis bilateral derajad ringan dgn hidroureter bilateral, countracted kidney dextra
SAQ 812E Endang 54 01435009 Ca crvix std 3B dgn Uropati Obstruktif Konsul
Flamb 8 15/10 Pro DJ stent Urinalisa : orange cloudy Leu 500 protein 300 eri 1 E.Transisional 10-15 Granulated 1-2 yeast like cell 881.3
Lab Hb 11.2 AL 9.7 AT 376 Ur 114 Cr 13 Na 140 K 2.6 C 1.26
Retensi urin
Post 9/10 Hb 9.3 Ht 31 AL 9 AT 181 GDS 237 Ur 50 Cr 1.7 Na 129 K 4.5 Cl 100
Clot retensi
THD 903A Jonatan 50 01432620 IGD Post op Cystocopy evakuasi blood WB 9/10 Hb 9 Ht 27 AL 8.2 T 172
Ca recti infiltrate bulli
Cloth + biopsy k/p turB PA : Adeno Ca Recti
DM, Anemia
15/10 alb 3.7 cr 1.0 ur 20 HbSag NR
6/10 Sitologi Urine Belum dapat menyimpulkan, saran konfirmasi dgn histopatologi
Retensi urine
Interna 4/10 Hb 10 Htc 31 AL 9.1 AT 316
THD 903B Herlin 28 01381098 Massa Ren sinistra ec DD RCC DD abses Pre op Embolisasi BTKV tunda SA
2/9 2/10 Hb 8.2 Ht 24 AL 13.3 AT 292 Ur 16 Cr 1.0
B20 dgn terapi ARV Konfrence selasa
Flamboyan 9 Thorax PA : Pneumonia
Urinalisa : warna merah,cloudy AL 250nprotein 100 nitrit + eri 1 makros eri 1733 Leu 56.5
Workup USG : Hidronefrosis grade 2 bilateral e.c obstruksi post renal, anuri, ascites
Digest Hidronefrosis Grade 2 bilateral
THD 905C Harsono 60 01435507 Konsul Tunggu hasil ct scan Hb 10.7 AL 11 AT 432 PT 14 APTT 27 OT 22 PT16 Ur 267 Cr 16.9
16/10 Tumor recti Susp malignansi
BC ketat
BNO IVP : Vesikolitiasis, Hidroureter Sn 1/3 proksimal disertai dgn kinkin 1/3 medial sting VL 4 sisi sinistra, Anatomi,letar,Fungsi re
Pro Sachse + Open n dan ureter dextra normal, fx pengosogan buli normal, spondillosis lumbalis, levokoliasis lumbalis
Poli
THD 906C Sularman 58 01430854 Vesikolithiasis Pre op Vesicolitotomy WB USG : Vesikolitiasis
12/10
(Tunda OP) selasa 10/10 Hb 12 AL 8.5 AT 307 AE 4.4 PT 12 APTT 28.5 GDS 85 Ur 47 cr 1 Hbsag NR
Urinalisa orange L 500 Nitrit + Protein 100 Eri 1 yeast like cell 106 smal 0.4