MAPPING BEDAH UROLOGI

Selasa, 13 Agustus 2019

KAMAR IDENTITAS LAB PLANNING TERAPI

RAUDAH 1
6/5 T. Hanan, lk, 59, 1217151 Lab 12/08/2019
Dx. Colic Renal +CHF FC Hb/Ht/E/L/T: 16.6/49/5.8/21.2/172
NYHA III-IV GDS:107
Ur/cr:96/5.20
Na/K/Cl: 141/4.4/109
RAUDAH 2
7/5 Refa tazwir, lk, 16 th, 1217065 Lab 09/08/2019 POD 6
Dx. Trauma ginjal dekstra post Hb/Ht/E/L/T: 11,0/31/3,7/9,0/178
nefrotomi Lab 07/08/19
Hb/Ht/E/L/T: 8,5/24/2,9/17,7/162
Na/K/CL: 140/5,0/111
Ur/Cr:72/1,70
Albumin: 2,90

RAUDAH 4
4/1 Darwin M, lk, 58, 1214893 Lab 10/08/2019
Dx. Ca Prostat Hb/Ht/E/L/T: 9.8/29/3.5/5.8/349
Albumin: 2,80

RAUDHAH 5
7/4 Darmasyamsulridwan, lk, 37 th, Lab: 08/08/19 DPJP B. Digestif Novalgin 1 amp/8 jam
1214438 Hb/Ht/E/L/T: 9,9/30/3,5/6,8/278 Tidak ACC alihrawat Omeprazole 40 mg/8 jam
Dx. Post orchidectomi Albumin: 3,30 Saran: Open Biopsi Albumin 20 % / hari
Ur/ Cr: 21/0,49

Lab: 04/08/19
Hb/Ht/E/L/T: 9,1/28/3,3/7,7/327
Na/K/Cl: 142/3,5/111
Ur/Cr: 28/0,60
GDS: 120
Albumin: 2,70

7/3 TasliatulMiftah, lk, 12 th, Lab 05/08/19 P/ POD 4 (post - Cefotaxim 1 gr/12j
1216860 Hb/Ht/E/L/T:12,7/38/5,1/7,9/339 cordectomy - Paracetamol 1 gr/8j
Dx. Hipospadi tipe Na/K/CL: 145/4,5/108 ureteroplasty)
 phenoscrotal Ur/Cr: 32/1,28
Albumin:
GDS: 100
CT/BT: 3/9
Hbsag: negatif
6/5 Anwar Arsad, lk, 46 th, Lab: 04/08/19 P/ CT Scan K/NK Th/
1166692 Hb/Ht/E/L/T: 10,4/29/3,7/16,7/181 (08/08/19) - inj. Ceftriaxone 1 gr/12 j
Dx. Tumor Ginjal Dextra Na/K/Cl: 141/1,6/101 Rencana eksplore flank - inj. Novalgin 1 gr/ 8 j
Ur/Cr: 20/0,40 persiapan neferctomy - inj. Ranitidin / 12 j
GDS: 131
dekstra - KCL 50 mg (ekstra)
Lab 09/08/19 Koreksi albumin
Albumin: 1,45
6/2 Junaidiyahya, lk, 37 th, Lab 09/08/19 CT Scan 09/08/19 Ketorolac 30 mg/ 8 jam
1199501 Hb/Ht/E/L/T: 8,8/27/3,2/15,1/557 Susul hasil CT scan Ranitidine 50 mg/ 12 jam
Dx. Hematuria blood cloth Na/K/Cl: 139/4,1/109 Transfuse PRC Novalgin 1 amp K/P
ec.Cabuli Ur/Cr: 30/1,40 Ceftriaxone 1 gr/ 12 jam
Lab 07/08/19
Hb/Ht/E/L/T: 9,2/28/3,3/15,1/683
Na/K/Cl: 141/4,0/108
Ur/Cr: 31/1,30
GDS: 128
CT/BT: 2/8
4/4 Abdurrahman Az, lk, 69 th, Lab 23/07/19 Rencana Op rabu Th/
1213355 Hb/Ht/E/L/T : 15,8/48/5,7/8,7/301 Konsul ulang paru - inj. Novalgin 1 gr/ 8 j
Dx. Tumor ginjal dekstra Na/K/Cl: 144/4,1/104 Cek DR, albumin, -combiven / 8 jam
Ur/Cr: 40/1,25 elektrolit, Ur/Cr - Fulmicort / 12 jam
GDS: 265
- Meropenem 500 mg 24 jam
HBsAG: negative
PT/aPTT: 13,90/34,80 Agda cyto
INR: 1,03 Thorax ulang
4/1 Jasli Evendi , lk, 41th,1197233 Lab 31/07/19 - P/ Op Kamis Ketorolac 1 amp/8 jam K/P
Dx: Nefrolitiasis sinistra, Hb/Ht/E/L/T : 13,4/39/4,5/6,1/177 - Post op ICU
uretrolitiasis bilateral Na/K/Cl : 147/4,4/110 Cek DR
GDS : 107
Ur/Cr : 29/1,60
PT/aPTT: 13,90/32,80
INR: 1,03
3/1 Ibrahim berahi, lk, 62 th, Lab 06/08/19 P/TURP Tramadol 1 amp/8j
1214390 Hb/Ht/E/L/T :10,3/32/4,5/7,8/416 Rencana op. (kamis) Omeprazole 40mg /12j
Dx. Susp. Caprostat metastasis Na/K/Cl : 139/4,0/105 Tambah
hepardan spine Ur/Cr : 24/0,78 Konsul kardio
PT/aPTT: 15,5/33,40
Thorax ulg
Hbsag: negative
PSA: 1000
 2/1 M. Yusuf ramli, lk, 59 th, Lab 07/08/19 Trnsfusi PRC 2 kolf -cefotaxim 1 gr/12j
1217049 Hb/L:6,7/8,7 Konsul IPD dengan -novalgin 1gr/12j
Dx. Cabuli +CKD stg IV Na/K/Cl : 143/4,3/111 CKD
Ur/Cr : 195/8,75 Konsul kardio
CT/BT: 2/7
Hbsag: negative
RAUDAH 6
4/5 Ti makamhusen, pr, 72, Lab 03/08/19 P/ CT SCAN abdomen Ketorolac 1 amp/ 8 jam
1216712 Hb/Ht/E/L/T: 8,8/26/3,0/16,7/473 dan pelvis K/NK Ranitidine 50 mg/ 12 jam
Dx. Kolik renal ec tumor Na/K/Cl: 140/3,7/103 (08/08/19)
ginjalsinistradd/ absesperirenal Ur/Cr: 28/0,80 Cek PT/APTT. Susul
CT/BT: 2/7 GDS: 135
thorax konsul paru
2/5 Nurmala A. jalil, pr, 51 th, Lab 10/08/19 P/ CT Scan urologi NK
1217364 Hb/Ht/E/L/T: 12,8/36/4,7/11,8/254
Dx. Susp. Batu saluran kemih + Na/K/Cl: 135/3,8/101
AKI stg 3 post renal Ur/Cr: 149/7,50
CT/BT: 2/7 GDS: 116 Hbsag: negatif
1/1 Rubiahraman, pr, 55 th, Lab: 03/08/19 P/ POD 4 Th/
1216768 Hb/Ht/E/L/T:10,6/31/3,8/16,9/425 Mobilisasi - ceftriaxone 1 gr/ 12 jam
Dx. Nefrolithiasisdekstra + Ur/Cr: 47/1,00 GDS: 128 Aff DC - ketorolac 30 mg/ 8 jam
Hidronefrosisdekstra Na/K/Cl: 141/4,0/104
PT/aPTT/INR: 17,90/42,70/1,42 Hbsag: negatif

ZAMZAM 4
K5 Ysbainur, lk, 57, 1160239 Lab: 11/08/19 Th/
Dx. Colic renal dd BSK/ISK Hb/Ht/E/L/T:11.9/34/3.9/8.5/163 Mekobalamin 500 mg/ 8 jam
GDS: 91 Bil.Tot/dir/indir”0.68/0.3/0.38 Paracetamol 1000 mg 8 jam
Ur/cr:44/1.2 SGOT/SGPT: 84/78 As. Traneksamat 500 mg/ 12 jam
Na/K/Cl: 139/4.0/111
ZAMZAM 3
K1 Syamsiah sulfa, pr, 60 th, Lab 07/08/19 P/ CT Scan urologi Cefoporazone 1 gr/12 jam
1192777 Hb/Ht/E/L/T:8,1/23/2,9/34,3/715 K/NK (susul hasil) Tramadol 1 gr/8 jam
Dx. Abses ar. Flank sinistra Ur/Cr: 107/2,20 GDS: 262 Rencana Op (kamis) Paracetamol 1 gr/8 jam
Na/K/Cl: 131/5,8/99 Kalitake
PT/aPTT/INR: 14,3/30,30
Novorapid
Hbsag: negative Albumin:3,10
Levemir
AQSA 1
K10 Zulkifli, lk, 79, 1215054 Lab 05/08/19 P/
Dx. Retensi Urine c Blood Hb/Ht/E/L/T: 10.4/31/3.5/28.7/93 Spooling Urine
Cloth post TURP Na/K/Cl : 129/4.3/98
Ur/cr:31/0.9