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MAPPING BEDAH UROLOGI

Sabtu, 03 Juli 2019

KAMAR IDENTITAS LAB PLANNING TERAPI


RAUDHAH 5
2/1 Zulkifli Abdullah, lk, 49th, Lab 30/7/19 - persiapan Th/
1216346 Hb/Ht/E/L/T : 13,7/41/5,1/13,4/358 percutaneous - inj. Ceftriaxone 1 gr/12 j
Dx: Piohidronefrosis Sinistra Na/K/Cl : 142/4,1/110 nephrectomy sinistra - inj. Paracetamol 1 fls/12 j
GDS : 114 emergensy
Ur/Cr : 53/3,20
CT/BT : 2/8

4/1 Jasli Evendi , lk, 41th,1197233 Lab 31/7/19 - Op (RIRS) tgl


Dx: Nefrolitiasis sinistra, Hb/Ht/E/L/T : 13,4/39/4,5/6,1/177 1/8/2019
uretrolitiasis distal dextra Na/K/Cl : 142/4,1/110 - Post op ICU
GDS : 114
Ur/Cr : 53/3,20
CT/BT : 2/8

5/2 Alexia Wellyo Leatemia, lk, 46 Lab 29/7/19 - Hasil CT Scan Th/
thn, 1216052 Hb/Ht/E/L/T : 11,7/33/4,1/23,9/510 Urologi - PCT Drip 1 gr/8 J
Dx. 1. Post Insersi DJ Stent Na/K/Cl : 139/3,9/104 - Foto BNO
Dextra ec Ureterolitiasis Dextra GDS : 136 - Cek Lab
Ur/Cr : 19/1,10

6/2 Tgk. Abdurrahman Aly, lk, 60 Lab 30/7/19 - CT Scan Abdomen Th/
th, 1215750 Hb/Ht/E/L/T: K/NK - PCT Drip 1 gr/ 8j
Dx. Tumor Ginjal Dextra 10,4/32/4,0/16,4/446 - Urinalisa - Inj. Fusmucyn 1 gr/12 J
Alb :2,40 Ur/Cr: 10/0,70
GDS: 150
Na/K/Cl : 135/4,4/96

Lab 29/7/19
Kolesterol Total : 141
HDL : 11
LDL : 107
As. Urat : 3,2
7/6 Ismail Hasyim, lk, 74th, Lab 26/7/19 - Op Hari Ini Th/
1209223 Hb/Ht/E/L/T: 8,3/25/3,2/9,1/361 - Op Joint Bedah - Novalgin 1gr/8j IV
Dx. Adenocarcinoma buli Na/K/Cl : 137/3,3/106 Digest - Ranitidine 500mg/12j IV
PT/APTT : 1,03/36,10 - Post OP ICU D - Albumin 25%/24 j IV
Alb : 2,40
- Dulcolax tab 2 tab
GDS/Ur/Cr : 134/30/1,30
RABER dengan digestive - Diet Susu 6x250 cc
Lab 28/7/19
Hb/Ht/E/L/T: 11,3/34/4,3/7,6/363
Na/K/Cl : 141/3,5/111
Alb : 2,70
GDS/Ur/Cr : 123/39/1,2

RAUDAH 6
3/2 Maryam Aji, pr, 53 th, 1215928 Lab 29/7/19 - AFF Kateter Th/
Dx. Psoas Abses Hb/Ht/E/L/T: 10,6/31/3,9/8,5/516 - CT Scan Abdomen - CEFIXIME 2X100 MG
K/NK - As. Mefenamat tab 3x500 mg
Lab 26/7/19 - Ganti oral - ranitidine 150 mg tab 2x1
Na/K/Cl : 144/3,5/105
RABER IPD(EMD)
HbsAg : Non Reaktif
Dx. 1. Abses Psoas PT/APTT : 1,01/35,60
2. DM TIpe 2 GDS/Ur/Cr : 143/30/0,90

RADIOLOGY 29/7/19
CT SCAN ABD TANPA KONTRAS : SOFT TISSUE
SWELLING DI REGIO ILIAKA KANAN DENGAN
DENSITAT UDARA DI DALAMNYA DAN
TERPASANG DRAI
5/2 Juhariah M. Isa, pr, 46th, Lab 28/7/19 - Rawat luka Th/
1214554 Ur/Cr : 156/5,40 - Hasil Kultur - inj. Cefoperazine 1 gr /12 J
Dx. Nefrolitiasis dextra - Cek DR - Inj. PCT 1 gr/8 J
Lab 29/7/19 - Inj. Ranitidin 500 mg/ 12 J
Hb/Ht/E/L/T : 9,2/27/3,5/9,1/228
RABER IPD(GH) - Amlodipin 10 mg tab 1x1
Dx. 1. AKI Stg 3 Post renal dd Lab 31/7/19
- Bicnat 500 mg/8 J tab
acute on CKD Ur/Cr : 132/3,70 - Drip Resfar 5 gr dlm 200 ml Dex 5% (hbs 4 Jam)
2. Post OP Nefrolitotomy Na/K/Cl : 138/4,1/114 - Inj. Metronidazole 500 mg/ 5 J
RAUDAH 2
4/2 Putri Maulida,Pr, 6th, 1214688 Lab klinik mina(29/7/19) - cek DR, PT/APTT, - Inj Ceftriaxone 500gr/8j
Dx: Trauma ginjal kanan + Hb/ht/E/L/T : 8,0/25,5/3,18/8,7/418 - Inj Paracetamol 500mg/8jam
adesi

RAUDAH 4
Iso 2 Sana komansyah, lk, 50th, Lab 17/7/19 - Post CAPD
1214145 Hb/Ht/E/L/T : 8,5/24/2,8/8,9/18 - POD 2
Dx: CKD stage 5 GDS : 135 - Balance cairan
Ur/Cr : 106/9,96
Alb : 3,74

ZAMZAM 3
K3 Sholahuddin Ritonga, lk, 41th, Urinalisis 23/07/19 - Transplant Th/
1025077 Warna : Kuning ginjal - Herbeset CD 200mg/24j PO
Dx. CKD stg V on HD Post Kejernihan : Keruh - POD 6 - Adalat oros 60mg/24j PO
Transplantasi Ren Dextra Leu : 1-2 - Observasi - Hytroz 25mg/24j PO
Eri : 0-1
urin - Bisoprolol 5mg/24j PO
Epitel : 2-3
- Prograf 1mg/12j PO
Lab 02/8/19 - Micardis 160mg/24j PO
Hb/Ht/E/L/T: 10,5/31/3,9/10,1/311 - Alprazolam 0,25mg/24j PO(malam)
GDP/Hb-A1c: 72/5,10 Albumin : 4,00 - Clonidine 0,75mg/8j PO
Ur/Cr : 32/1,10 - Rifampisin 250 mg/ 24 J PO
Na/K/Cl : 138/4,6/109 - Isoniazid 500 mg/ 24 J PO
SGOT/SGPT : 25/22 - Pirazinamid 500 mg/ 12 J PO
PT/APTT : 0,95/30,90 - Etambutol 500 mg/ 12 J PO

K6 Yulis Ratna Sari, pr, 29th, Lab 31/7/19 - Pendonor Th/


1130643 Hb/Ht/E/L/T: 12,9/37/4,1/10,5/290 ginjal - Inj. Ceftriaxone 2 gr/24 J
Dx. Living Kidney Donor Post Ur/Cr/Ca/Mg : 28/0,90/8,4/2,2 - POD 5 - Inj. Paracetamol 1 gr/8 J
Nefrectomy Sinistra Na/K/Cl : 141/4,2/106 - Pantau - Inj. Ranitidin 5 gr/ 12 J
Tanda2 Vital - Kaltropen Supp/ 8 J
Urinalisis 29/07/19
- Produksi urin - Drip PCT 1 gr/ 8 J
Warna : Kuning per hari
RABER IPD(GH) Kejernihan : Keruh - Rencana GV :
Dx. 1. Post Nefrectomy Leu : 4-6 konfirmasi
2. Living Kidney Donor Eri : 8-10 DPJP
Epitel : 3-5 - AFF DC

K20 Rabaisah Ibrahim, pr, 50 th, Lab 29/07/19 - CT Scan


1108381 Hb/Ht/E/L/T : 8,8/26/3,3/8,0/365 Abdomen
Dx. Post Nefrectomy Dextra ai Alb : 1,80 - Saran
Nefrolithiasis Dextra Ca : 7,2 transfusi
GDS : 135 Ur/Cr : 86/0,90
sampai hb
Na/K/Cl : 140/3,2/121
RABER BEDAH DIGESTIVE >10
Dx. Parsial MBO ec susp. RADIOOGI LUMBOSACRAL AP/LAT :
Adhesi + anemia + hipoalbumin KES : SPONDYLOSIS LUMBALIS ILEUS
NABAWI

6/1 M.Taib, lk, 67th, 1213432 Lab 03/7/19 - POD 2 Th/


Dx: Vesikolitiasis + Hb/Ht/E/L/T : 11,3/30/3,6/11,4/348 - GV POD ke 3 - Inj. Ceftriaxone 2 gr/24 j
Ureterolithiasis Distal Sinistra CT/BT : 2/7 - Pertahankan - Inj. Ketorolac 30 mg/8 j
GDS : 132 kateter - Inj. Ranitidine / 12 j
Ur/Cr : 21/0,92
Na/K/Cl : 141/3,1/101

Lab 31/7/19
Ca : 8,6
Na/K/Cl : 140/4,1/104

RADIOLOGI 4/7/19
THORAX PA : TB PARU DAN AORTOSCLEROSIS
USG GINJAL : NEFROLITHIASIS BILATERAL
USG VESIVA URINARIA/PROSTAT :
HYPERTHROPY PROSTAT, BULI TAK TAMPAK
KELAINAN