KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

,LONTARA 2 UROLOGI KAMAR 1

1.

Paulus woko
20/8/1949 (64
th)
RM 627553
MRS
2/10/2013
JKM
K1 B1

POH 11-open
prostatektomi
dan
vesikolithotomi

Risal Parubak Rupture urethra

10-10-1980
pars bulbosa
(33 thn)
MRS. 28-102013
Askes wajib
L2 K1 B2
MR 634425

Ranitidine 150 mg
3x1
Asam mefenamat
500 mg 3x1
Vip Albumin 3 x1
caps
Diet TKTP
Mobilisasi jalan
Evaluasi drain/24j
GV + rawat luka
Bladder training

Kultur urin
Ciprofloxacin
2x500mg
As. Mefenamat
3x500 mg
Ranitidine 2x150
mg
Mobilisasi jalan
Rencana PER
4/11/13

Lab 12/10/2013
CT 8, BT 2, PT 10,5, APTT 29,5,GDS 107, UR/K
41/1,8, GOT 21, GPT 10, ALB 4,3, WBC 8,92, RBC
4,84 , HB 12,5, HCT 37,7, MCV 77,9, MCH 258, MCHC
33,2 , PLT 309, HbsAg/ AntiHCV Non Reactive.
NA/K/CL 142/4/107
Elektrolit 7/10/2013
Na/K/Cl: 149/3,0,102
Lab 17/9/2013
Asam urat 6,9 PSA 32,93
Urin rutin 17/9/13
Sedimen lekosit >20, lekosit 500
Radiologi 20/9/2013
Thorax PA : kardiomegali dengan dilatatio et elongatio
aortae (HHD)
BNO IVP : urogram normal, vesicolith divertikel vesica
urinaria
Lab 11/9/2013
RBC 4,53 WBC 10,8 HGB 12 PLT 199 CT/BT 8/3
PT/APTT 11,3 / 29,8 GDS 129 Ur/ Cr 38/1,2 GOT/GPT
35/15 Na 137 K 3,6 Cl 106
HbsAg / Anti HCV non reaktif
USG abdomen 11/9/2013
Vesicolith + hipertrofi prostat
TRUS 129,4
TAUS 193,9
Volume prostat 276cc
Echo (26/09/13)
Disfungsi sistolik dan diastolic, EF 47%
La lv DILATASI
Lvh +
Inferior dan posterior hipokinetik
MR Moderate
AR Mild
Kultur urin tdk ada pertumbuhan bakteri anaerob
Lab: (27-10-2013)
WBC 9,92 RBC 4,42 HGB 12 HCT 36,8 PLT 216GDS
170 UR/CR 16/0,8 GOT/GPT 20/19 Na/K/Cl
141/3,1/108
URIN RUTIN (27/10/13)
Protein :75/++ blood 250/++++ leukosit 100/++
sedimen leukosit 5 sedimen Eritrosit: 5
Foto pelvis + uretrocystografi (28/10/13)
Striktur uretra pars posterior, extravasasi kontras ke rg
extraperitoneal
Thorax AP
Gambaran Bronkhitis
URIN RUTIN (29/10/13)
Protein :25 blood 250/++++ leukosit 100/++ sedimen
leukosit 5 sedimen Eritrosit: penuh
1

3.

KORAN BEDAH
Hasmuddin
POH 4
01/8/1980
ureterolithotomy
(33thn)
ec Batu ureter
MRS.
pelvic junction
18/10/2013
Dextra
Jamkesmas
RM : 631696
K1B4

Tn Abd
Makmur
13/03/1935
RM: 633655
MRS:30/10/13
Msuk ltr 2
uro: 1/11/13
Jamkesmas
K1B3

Tu. Buli-buli
Tu. Colli
Anterior

UROLOGI MINGGU, 3 NOVEMBER 2013

IVFD NaCl 0,9%
Lab (21/10/13)
20 tts/mnt
WBC 6, 7 HB 10,9 PLT 420 SGOT/SGPT 34/39 CT
Inj Ceftriaxone 1
800 BT 300GDS 74 PT/APTT 12,5(12,4)/28,9(26,5)
gr/12j/iv
UR/CR 24/0,6 PROTEIN TOTAL 8,7 ALB 3,4 AS.URAT
Inj. Ketorolac 30
4,9
mg/8j/iv
Echo ( 16/10/13)
Inj ranitidine 1
-fungsi sitolik LV baik
amp/8j/iv
-LVH +
Cernevit
-EF 78%
vial/hr/drips
IVP (11/10/13)
Diet TKTP
Hydronefrosis grade II-III Dextra
Mobilisasi dudukNephrolite Dextra
jalan
Polos abdomen (8/10)
GV+ rawat luka
Uretrolith dextra
Thorax (11/10) tidak tampak kelainan
Lab (7/10/13)
CT 8, BT 3, PT 11,8 , APTT 29, PLT 568 , HB 10,6,
GDS 80, UR/K 23/0,8 , GOT 50, GPT 70, WBC 10,1 ,
RBC 3,68 , MCH 29, MCHC 34,3 , MCV 84.
Urine rutin (7/10)
Blood 10 , leukosit 100 , sedimen leukosit 6 , sedimen
eritrosit 100 ,
USG (21/10/13)
Hydronefrosis dextra
Simple renal cyst sinistra
FOTO POLOS ABDOMEN (8/10/13)
Ureterolith dextra
Kultur dan sensitivitas urin (21/10/13)
Cara manual, sample urine, tidak ada pertumbuhan
bakteri aerob
Optimalisasi KU
Lab 22/10/13
Pasang infus
WBC= 11,9, RBC=4,52,HGB=88, HCT=28,9, PLT=533,
IVFD NaCl 20
GDS=70, Ur/Cr=49/1,9, GOT/GPT= 19/15, Alb=4,0,
tts/mnt
As.Urat=4,7, CT/BT=8/3, PT =12,3(12,2),
Transfusi PRC unit APTT=23,5(25,4), HbsAg/antiHCV=negative, PSA=2,05
Inj. Ceftriaxone 1
Urin rutin 22/10/13
gr/12j/ov
Protein=75, sed.lekosit>20/lpb,sed.eritrosit.2/lpb,
Inj. Ranitidin 1
Echocardiografi 23/10/13
amp/8j/iv
-disfungsi diastolic LV
Inj ketorolac 30
-EF 75%
mg/8j/iv-> KP
Foto thorax PA 22/10/13
Lab perbaharui
Kesan; kardiomegali dgn dilatation aorta
Pasang kateter 24 Tidak tampak tanda2 metastasis pada foto thoraks ini
F triwayspooling
USG thyroid 24/10/13
Diet biasa
Kesan:massa thyroglossus
Rencana TUR-BT USG abdomen 23/10/13
-massa buli-buli
-Simple cyst ren dextra
BNO 22/10/13
-foto polos abdomen ini dlm batas normal kecuali fecal
material yang banyak
FNA 28/10/13
2

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

-benign cyst

LONTARA 2 UROLOGI KAMAR 2

5.

Andi Agung
Ahmad
4/7/1980
634335
MRS
26/10/2013
JKD
K2B1

6.

Saing
1/7/1932
630056
MRS
21/10/2013
ASKES
K2B2

Post POH 9
Laparotomi
Explorasi
Internal
Bleeding ec v.
ictum
penetrans
Laserasi colon
transversum
Laserasi ginjal
(s) grd II
PO Renorafi
sinistra hari ke
9 ec laserasi
ginjal sinistra
grade II
Laserasi
corpus gaster
Ca. Buli-buli
Hipertrofi
prostat Gr. III
susp.
Malignancy
Hidronefrosis
bilateral
Elektrolit
Imbalans

Pemberian infus
sesuai dari TS B
Digestive
Injeksi sesuai dari
ts B Digestive
Rawat luka +
GV/hari
Mobilisasi duduk
Cek lab post
transfusi

Lab 30/10/2013
WBC 6,4 RBC 2,38 HGB 6,4 HCT 19,6 PLT 212
Lab 26/10/2013
WBC : 14,24, RBC : 4,08, HGB : 11,7, HCT : 33,5, PLT :
290, GDS : 166, Ur : 13, Kr : 0,8, Alb : 3,5, Na/K/Cl:
142/4,3/113, HBsAg : non reactive, Anti- HCV : non
reactive

Rencana TUR
BT kalau perlu
nefrostomy
Sementara terapi
sesuai dr GH u/
penatalaksanaan
HD
Tramadol lab 3 x
50
Ranitidin rab 2 x
150
Rencana
TRUS/TAUS

Lab 02/11/13
WBC=5,62, RBC= 3,1, HGB=9,5, HCT=25,9, PLT= 105,
Ur=166, Na/K/Cl=126/5,9/107
Lab 28/10/2013
GDS 79 ur/cr 139/6,6 GOT/GPT 20/8 prot. Total 6,6 alb
3,7 as.urat 9,5 Na/K/Cl 127/5,6/105 WBC 8,6 RBC 2,69
HB 8 HCT 23,3 PLT 132
Foto thorax (25/10/2013)
kesan : cardiomegali dengan dilatasi aorta, tidak tampak
metastasis pada foto torax ini.
PA 16/9/13
Transtitional Cell Carcinoma (High Ggrade)
Urinalisis 26/9/13
Warna kuning muda, pH 5, BJ 1,015, protein 75, blood
250, leukosit 500, sedimen leukosit penuh, sedimen
eritrosit 4, sedimen epitel sel 1
PSA 23,57
Lab 3/10/16
WBC 7,1, RBC 2,79, HGB 8,4, HCT 25,5, PLT 173,
Na/K/Cl 138/5,3/109, SGOT 15, SGPT 8, Alb 3,9, GDS
101, Ur 92 Kr 3,8, CT/BT 800/300, HbSAg Non reactive,
Anti HCV Non reactive
CT Whole Abdomen 31/10/13
Pembesaran prostat dengan kesan infiltrasi buli2 sugestif
malignancy
Hidroureteronefrosis Bilateral
Kista ginjal kanan
Usul: MSCT Scan abdomen dengan kontras
3

7.

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Massiri
Tumor buli-buli Rencana TUR
Lab 31/10/2013
Laki-laki
Susp
BT (4/11/13)
PSA 19,43 Alkali Fosfatase 84
RM 348336
malignancy
Lengkapi
CT-Scan 29/10/13
31/12/1924
Kista ginjal
persiapan
-massa buli-buli dengan perluasan ke sekitarnya disertai
MRS
kanan
operasi:
metastasis ke tulang, hidronefrosis kiri, kista ginjal kanan,
19/10/13
Hidronefrosis
Informed konsen efusi pleura bilateral, cholelith.
Umum
Kiri
Lapor OK
Echo 25/10/2013
K2B3
Konsul anastesi
Fungsi sistolik LV baik, LVH(+) LA dilatasi, MR moderate,
Siap darah 2 unit AR Moderate, disfungsi sistolik
di bank darah
USG Abdomen Lower 19/10/13
Puasa 6 jam sblm Massa buli-buli diserstai hidronefrosis bilateral terutama
OP
kiri
AB profilaksis 1
Lab 22/10/13
jam sblm operasi RBC 4,221 HGB 11,4 HCT 35,4 MCV 84 MCH 27,0 PLT
350 MPV 7,3 GOT 13 GPT 9 NA 141 KAL 3,86 KLORIDA
113 HBsAg Non ractive, CT/BT 800/230 PT/INR
12,0/1,O0 APTT 27,2 GDS 100 UREUM 61 kreatinin 1,60
Urin Rutin 19/10/13
Warna merah, ph 7, protein 500/+++, blood 250/+++,
lekosit 10, sedimen epitel sel 4-5, protein neg, glukosa
neg
LONTARA 2 UROLOGI KAMAR 3

8.

Nurjannah
15/10/1959
54 thn
MRS
9/10/2013
RM 631207
ASKES
L2K3B1

Nefrolithiasis
(D)

9.

Ny Isa
Nefrolithiasis
14/03/1941
Sinistra
72 thn
633929
MRS: 01/11/13
ASKES

Ciprofloxacin
2x500mg
Asam Mefenamat
3x500mg
VIP albumin 3x2
tab
Rencana
Extended
pyelolitotomi (D)
RENCANA
OPERASI (Senin,
28 /10/2013)

As Mefenamat 3
x 500 gr
Tunggu jadwal
operasi

Hasil elektrolit darah 11-10-2013

Na 143 K 4,4 CL 109
Lab 3/10/2013
WBC 6,1 RBC 4,26 HGB 11,8 HCT 35,6 PLT 264 PT 11,0
c 12,4 INR 0,8 APTT 29,1 c 25,6 GDS 90 Ur/Cr 26/0,7
GOT/GPT 20/12 As urat 4,6 CT 800 BT 300 HBsAg (-)
Urin rutin
pH 5 BJ 1,020 prot 150 blood 250 Lekosit 500 Sedimen
lekosit >50 Sedimen eritrosit >10 Sedimen epitel sel 2
IVP 7/10/13
Fungsi sekresi dan eksresi kedua ginjal baik
Nephrolith dextra
Radioopaque setinggi CV L2-L3. 0,6cm.
Foto Thorax
Cardiomegaly dengan dilatation et elongation et
artherosclerosis aortae
Lab 29/10/13
WBC: 6,2 RBC: 3,42 RBC: 10,5 HCT: 32,4 PCT: 222
Lab 23/10/13
Alb: 3,6
Lab 22/10/13
CT/BT: 800/300 PT/APTT: 13,0/28,4 GDS: 94 Ur/Cr:
31/1,0 GOT/GPT: 25/18 As Urat: 4,4 Na/K/Cl:
141/3.,9/107 HbsAg & AntiHCV: Non Reaktive
Lab 23/10/13
WBC: 7,6 RBC: 4,72 HGB: 13,1 HCT: 40,5 PLT: 257
GDS: 115 Ur/Cr: 33/1,2 GOT/GPT: 26/26 Alb: 4,1 As
Urat: 6,7 Na/K/Cl: 140/4,3/105 CT/BT: 800/300
PT/APTT: 12,2/27,4
Urin Rutin 23/10/13
4

10

11

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

K3B3
Warna: kuning PH: 6 BJ: 1,005 Prot: (-) Glk: (-) Bil: (-)
Blood: 250 Sedimen leukosit: (6) Sedimen eritrosit: 7
dr. Asykar Sp
Sedimen epitel sel: 5
U
Foto thoraks 25/10/13
Cardiomegali dengan dilatation et elongation aortae
Foto polos abdomen (BNO) 24/10/13
Nefrolith bilateral
Ureterolith dextra
Foto IVP 28/10/13
Fungsi sekresi dan ekskresi ren bilateral baik
Hidronefrosis sinistra grade I
USG Abdomen bawah 24/10/13
Nefrolith sinistra
Ny. Ninu
POD 2
IVFD RL 20 tpm
Lab 14/10/2013
01/07/1961 52 cystoscopy +
Ceftriakson
WBC 6,1 RBC 3,12 HGB 8,6 HCT 26,9 PLT 575 Alb 2,2
thn
biopsy
1gr/12j/iv
GDS 298 Ur/Cr 12/0,4 GOT/GPT 95/54 NA/K/Cl
632378
Ulcus diabetic
Ranitidin
126/3,66/98
MRS
right foot
1amp/8j/iv
Lab 13/10/2013
10/10/2013
Ketorolac
WBC 6,05 RBC 3,21 HGB 8,9 HCT 25,6 PLT 458
1amp/8j/iv
Lab 12/10/2013
Diet DM
GDP 76 GD2PP 119 Kolesterol 68 HDL 10 LDL 46 TG 93
Terapi sesuai TS Lab 10/10/2013
BP + EM
WBC 7,09 RBC 2,54 HGB 6,8 HCT 19,6 MCV 77,2 PLT
5,6
GDS 255 Ur/ Cr 9/0,8 SGOT/SGPT 108/67 Na/K/Cl
122/4,5/193 kolestero total 89 HbsAg (-) as. Urat 3,5
Urine rutin 10/10/2013
warna: merah Ph 5,0 Bj 1,015 glukosa 300/++ PH 5,0
protein 150/++ Bil (-) urobilinogen (-) lekosit (500/+++)
sedimen lekosit (penuh) sedimen etitrosit (penuh)
sedimen torak (torak eritrosit 4-5) sedimen epitel sel (3-5)
USG Abdomen atas dan bawah
Kesan: Tu. Buli-buli disertai pelvpcalyectasis dextra
Usul : MSCT scan abdomen dengan kateter
MSCT Urografi (Stenografi) dengan Kontras 22-102013
Penebalan dinding buli-buli ( pada bagian posterior,
mukosa irregular), sesuai gambaran cystitis
Emfisema
Lab 22/10/13
GDP: 172
Lab 2/11/13
WBC: 5,45 RBC: 3,71 HGB: 10,3 HCT: 29,7 PCT: 335
Foto thoraks 10/10/13
Cardiomegali dengan dilatation aortae
Tidak tampak tanda tanda metastasis
Foto Pelvis AP 10/10/13
Tidak tampak kelainan
LONTARA 2 UROLOGI KAMAR 10
Hendrik
Cipang
L/21/2/1981

Hipertrofi Prostat IVFD Amikasin 800 Lab 29/10/13

Grade IV
gr dalam 100 cc Albumin 2,7
ISK
Nacl drops dalam PA 24/10/2013
5

32 thn
626621
MRS:
17/9/2013
K10 bed 4
JKM

12

Sumardi
31thn
631884
MRS:
9/10/2013
K10 Bed 1
JKM

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Obstruksi saluran 30 mnt/12j
PA 18/10/2013
cerna ec
Albumin / 24j
Hiperplasia glandula prostat
pendesakan
Spooling kateter
Urinalisa 21/10/2013
massa ke rectum dengan Nacl 0,9% Merah, PH 7 BJ 1,010 PROTEIN 75/++ UROBILINOGEN 4/+
+ NITRIT (+) BLOOD 250/+++++ LEUKOSIT 500/+++
SEDIMEN LEKOSIT PENUH, SEDIMEN ERITROSIT
PENUH, EPITEL 10-15, BAKTERI (+)
Lab 16/10/13
WBC 8,8; RBC 3,73; HGB 11,1; HCT 33,9; PLT 187; Ur/Cr
14/0,6
Lab 14/10/13
Albumin 2,0
Lab 10/10/2013
Na/K/Cl : 132/3,5/105
Lab 8/10/2013
GDS 150, Ur/Cr 12,2/0,5, GOT/GPT 64/43, Prot. Total 5,9,
Albumin 2,3
Na/K/Cl 126/2,8/99, CT/BT 8/3, PT/APTT
13,8(11,7)/28,6(24,8)
WBC 9,8,HGB 11,8, HCT 35,6, PLT 122, RBC 3,88
Lab 3/10/2013
Na 125 K 2,6 Cl 94
Lab 24/9/2013
WBC 4,4 RBC 4,44 HGB 13,8 HCT 42,7 PLT 186 GDS 119
Ur/Cr 31/0,7 GOT/GPT 54/34 alb 3,5 na/k/cl 138/3,2/105
USG Abdomen 23/09/2013
Sesuai Gambaran ileus obstruktif
Echo 17-9-2013
Fungsi sistolik LV baik EF 79%
LVH (+) mild
CT Whole Abdomen (11/09/2013)
Kesan : Massa Prostat.
Lab 10-9-2013
PSA: 4,83
Lab 6-9-2013
HBsAg reactive Na/K/Cl:138/37/108 Ur/Cr 15/0,8
Lab 10/9/2013
Urine rutin : warna kuning, PH 6,5, BJ 1,015, Prot 25,
sedimen leukosit > 50, sedimen eritrosit > 20, sedimen epitel
sel 2, sedimen lain-lain bakteri (+), hematuria
Tumor Buli-buli
IVFD Nacl 0,9% Hasil PA (29/10/2013)
suspek
tpm
Peradangan kronik non spesifik pada buli-buli
malignancy
Adona drips/12
Tidak ada gambaran malignitas
CT4N2M1
jam
Lab 19/10/13
POH 11
As tranexamat 1 WBC 12,67; RBC 4,24; HGB 12,8; HCT 6,3; PLT 227;
Cystoscopy biopsi amp/ 12 j/iv
PT/APTT 9,9(10,4)/24,8(25,3) INR 0,8; Albumin 2,7
Cefixime tab 2 x 1 18/10/13
mg
PSA 28,50
rawat luka
Lab 16/10/13
decubitus dengan Alkali Fosfatase 71
nebo cream
Urinalisis 16/10/13
Miring kanan
Warna kuning, pH 6,5, BJ 1,015, Protein 25/+, Leukosit
6

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

miring kiri
100/++, Blood 150/++++, Sedian leukosit 3, eritrosis 5, epitel
sel 3
Lab 8/10/2013
GDS 99, Ur/Cr 54/1,0, GOT/GPT 52/38, Na/K/Cl
144/3,6/105, CT/BT 6,3/3, PT/APTT 9,0(10,4)/21,2(25,4)
WBC 13,39,HGB 13,9, HCT 39,7, PLT 210, RBC 4,62
USG Abdomen (7/10/2013)
Gambaran massa buli-buii disertai pelvocalyectasis kiri.
Lab 8-10-2013
HBsAg reactive
Lab 10/9/2013
Urine rutin : blood 50/+++
Analisa Gas darah(16/10/2013)
pH 7,56 pCO2 43,7 SO2 96,7 PO2 16,2 HCO3 39,8 ctO2
16,5 BE 16,8
CT-scan urography (16/10/2013)
Massa Buli-buli & hydronefrosis kiri
Foto Thorax AP (16/10/2013)
Tumor metastasis paru-paru & tulang disertai cardiomegaly
danefusi minimal pleura kanan
Foto Lumbosacral AP/lateral (16/10/2013)
Tumor metastasis ke tulang
USG abdomen (16/10/2013)
Massa Buli-buli disertai pelviocalyectasis kiri
13 Jasmial
Hidronefrosis
Lab (17/09/2013)
11/07/1969
(S) Gr IV
GDS 109, HBSAg (-), Anti HCV (-), RBC 4,37, Hb 13,2, HCT
(43 thn)
Pelelayfuction
39,8, PLT 224, WBC 13,7 As urat 6,0
MRS 31/10/2013 Multipel
Urinalisa: warna kuning muda, ph 7 Bj 1,010 lekosit 25
K10.B2
Nefrolith (S) +
sedimen lekosit 7, sedimen epitel sel 3.
JKM
Kista Ginjal
echocardiografi
Kanan
Fungsi sistolik LV baik, EF 67%. Normal resting
echocardiogram
BNO-IVP (11/9/2013)
Ginjal kiri fungsi ekskresi tidak tampak SP 1 jam
pemeriksan
Thorax PA (20/9/2013)
Pulmo normal. Elongantio aortae.
14 Muh. Tahir Lajje Hipertrofi
NaCl 0,9% 28
Lab 28/10/2013)
12/03/1946
prostat gr III
tpm
PSA 1,15
(57thn)
Hidronefrosis
Ceftriaxone 1
USG (26/10/2013)
MRS 26/10/2013 bilateral
gr/12j/iv
Kesan: hipertr0fi prostat, hidronefrosis bilateral
RM 634325
ISK
Ketorolac
JKD
Suspek DVT
amp/8j/iv
Lab (26/10/2013)
K10.B6
Ranitidine
GDS 97, ur/cr 89/1,0, SGOT/SGPT 26/24, Alb 3,1, AS. Urat
amp/8j/iv
144,0, CT/BT 800/200, PT/APTT 12/28,8, Na/K/CL
Allupurinol tab
37/4,3/104, WBC 16,70,RBC 3,52, Hb 10, HCT 27,8, PLT
1x1
536
rawat cateter
Urin rutin (26/10/2013)
as. Traneksamat Warna kuning, ph 6,0, bj 1,015, prot. (+3)/150, keton
1 amp/8j/iv
(+2)/15, blood (+5)/250, leokosit (+3)/500, sedimen
Konsul BTKV utk leokosit 20, sedimen eritrosit 20, epitel sel 3
evaluasi Susp.
7

15

Bakri
634324
Tgl lahir :
04/03/1964
MRS 25-102013
Jamkesmas
L2 uro K10
B3

16

Cambede
1/7/1962 (51
thn)
MRS:
31/10/13
Jamkesmas

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

DVT
Evaluasi USG
TRUS dan
TAUS
POH 5
IVFD NaCL 0.9
Lab (26-10-2013) :
cystostomi
% 20 tpm
GDS 101, ur/cr 30/0,8, SGOT/SGPT 23/13, alb. 3,7,
Striktur urethra
Inj. Ceftriaxone 1 as.urat 5,7, CT/BT 800/200, PT/APTT 10,0/26,4, INR
pars posterior
gr/12j/iv
1,00Na/K/Cl 143/3,3/109, HbSAG (-) anti HCV (-)
Inj. Ranitidine 1 Wbc 15,71, Rbc 4,57, Hgb 14,1, Hct 38,6, Plt 282
amp/8jam/iv
Foto Urethocystography :
Ketorolac amp/8 Kesan : striktur urethra pars posterior
jam/iv
Thorax :
Mobilisasi aktif
Kesan : - pulmo dalam batas normal
CT abdomen
- Dilatation, elongation et atherosclerosis aortae
dgn kontras
Kultur urine
Multiple Kista
Ginjal Extended

As. Traneksamat
3x1
Neurodex tab
2dd1

Lab 25-10-13
WBC 9,9 RBC 3,77 HGB 10,4 HCT 31,8 PLT 365 BT/CT
300/800 PT/APTT 14/33,3 GDS 99 ur/cr 44/2,1
SGOT/SGPT 20/23 Alb 3,5 as.urat 10,4
Urinalisa: warna kuning pH 6,0 BJ 1,015 protein (+)
glukose (-) bilirubine (-) urobilinogen normal, sediman
lekosit 6, sedimen eritrosit 4, epitel sel 2.
USG Whole abdomen: nefrolith bilateral dengan tandatanda PNC
Foto Thoraks AP:
- Cardiomegaly dgn dilatayio et elangatio aorta
- Elevasi diafragma kanan (proses intrahepatik??)
Foto Polos Abdomen
- Spondylosis lumbalis
- Spina bifida occulta
28/10/2013
CT whole abdomen (tanpa kontras)
Multiple kista ginjal bilateral

LONTARA 2 UROLOGI KAMAR 11

16

A nurbia
31/12/1928
84 thn
RM :633102
MRS :
18/10/13
UMUM
L2K11B1

Transisional
Cell Carsinoma
Buli2

Amoxicillin 3x500
mg
Ranitidin 2x150
mg
Cek lab lengkap
Rencana TUR
BT (Rabu
6//11/13)
Rawat Kateter

Lab 21/10/2013
GDS 111, HBA1C 4,3
Lab 25/10/2013
WBC 8,51, RBC 4,07, Hb 9,2, HCT 28,9, PLT 278
LAB 22/10/2013
GDP2PP 667 GDP 64
Lab PA
Kesan: transitional carcinoma grade III
Lab 18/10/2013
CT 630 BT 200 PT 10,6(10.8) APTT 25.5(24.3) GDS
8

17

18

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

181 Ur/Cr 98/1.6SGOT/GPT 8/7
Lab 7/10/2013
WBC 16,5 RBC 2,86 HB 5,2 HCT 18,4 PLT CT / BT
800 / 300 {T/A{TT 10,6c10,8 /25,5 ct 24,6 GDS 181
GOT/GPT 8/7
Urine
Warna kuning, pH 8, BJ 1,010 ,protein 150/+++, blood
250/+++, leukosit 250/+++++, sedimen leukosit >5,
sedimen eritrosit penuh
Kesan : proteinuria, hematuria
USG Abdomen
Kesan : Massa pada dinding buli-buli susp. Ca buli-buli
Sitologi cairan urin
Kesan : hapusan tidak mengandung sel epitel maligna
Nursia
POH 19
Tramadol
Lab 20/10/2013
21/07/1975
nefrostomi
50mg/drips/8j
RBC 2.69 HB 7.1 HCT 22.3 HCT 22.3 PLT 619 WBC
38 thn
dextra
Ranitidin
15.52
632396
Hidronefrosis
50mg/12j/iv
Lab 16/10/2013
MRS
bilateral
Rawat luka/ GV
RBC 1,74 HB 4,7 HCT 14,6 PLT 467 WBC 20,8
10/10/2013
Ca. buli-buli
Takar prod.
Ur/cr 72/6.5 Na 120 K 4,3 Cl 95
JKM
Urin/hr
CT 8,0 BT 2,0 PT 10,7 INR 0,9 APTT 34,7
L2 K11 B3
Diet bebas
HBSAG reactive
Mobilisasi
Urinalisis
dr. M. Asykar
Tunggu jadwal
hematuria
A. Palinrungi,
APG (Rencana
CT_Scan Abdomen
Sp. U.
senin 4/11/13)
kesan: gambaran massa buli-buli + hydronefrosis bilateral
ascites minimal + efusi pleura bilateral
USG Abomen (10/10/2013)
Kesan : Massa buli-buli disertai hidronefrosis bilateral+
Ascites
Lab (27/10/2013)
WBC 12,23 HB 9,6 PLT 572 RBC 3,49 HCT 28,8
Lab 30/10/13
WBC: 6,6 RBC: 3,66 HGB: 9,9 HCT: 29,6 PLT: 589 GDS:
150 Ur/Cr: 38/1,3 GOT/GPT: 55/49 Pro tot: 7,6 Alb: 3,4
Na/K/Cl: 138/4,3/105
Mare
POH 4 URS +
Lanjut terapi TS
Lab (04/10/2013)
1/7/1938
DJ Stent
Digestif
WBC 5,9 RBC 3,52 HGB 10,5 HCT 32,3 PLT 190 GDS
RM 631400
Sinistra
Menunggu hasil
91 Ur/Cr 27/1,0 SGOT/SGPT 21/17
75 thn
Batu kaliks
BNO control
Lab (08/10/2013)
MRS
pole atas ginjal ( Rencana senin
Kolesterol total 308 kolesterol HDL 49 LDL 212
22/10/2013
Sinistra
4/11/13)
trigliserida 98 asam urat 6,0
JKM
Batu ureter
urin rutin 08/10/2013
L2K11B4
sinistra 1/3
kuning muda PH 5, BJ 1,010, blood 25, sedimen lekosit
distal
>50,
Hidronefrosis
sedimen eritrosit 7, sedimen epitel sel 12
Sinistra
lab (09/10/2013)
Multiple Kista
CT/BT 8/3 PT/APTT 11,7/32,6
ginjal sinistra
Urin rutin 21/10/2013
Multiple kista
Kuning muda PH 5. BJ 1,010, blood 25, sedimen lekosit
hepar
4, sedimen eritrosit 1, sedimen epitel sel 3
Echo 21/10/2013
9

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

-fungsi sistolik LV baik, EF 64%
-Disfungsi sistolik
-AR mild
USG Tiroid (08/10/2013)
-thyroid dalam di batas normal
-penonjolan trunchus brachiocephalica kanan
USG Whole abdomen (04/10/2013)
-sesuai gambaran caroli disease
-PNC bilateral
-hidronefrosis ginjal sinistra
Foto thoraks PA (11/10/2013)
Pulmo normal
Dilatation et longation aortae
Foto BNO-IVP (11/10/2013)
-non visualized urogram ren sinistra
-nephrolith sinistra (UPJ)
-uretrolith sinistra (UVJ)
-distorsi PCS kanan
Foto CT Scan abdomen axial (07/10/2013)
Multiple kista hepar dan ginjal kanan
Hidronefrosis sinistra + nephrolith dan ureterolith
Lab 29/10/13
WBC: 7,29 RBC: 3,63 HGB: 11,2 HCT: 32,0 PLT: 133
BT/CT: 300/900 PT/APTT: 11,3/32,5 INR: 0.90 GDS:
153 Ur/Cr: 26/1,20 GOT/GPT: 37/23 Na/K/Cl:
141/3,71/109 HBsAg: Non Reaktif AntiHCV: Non Reaktif.
Lab 1/11/13
Na/K/Cl: 140/3,8/111
LONTARA 2 UROLOGI KAMAR 12
19

Yamang (58
th)
31/12/1954
JKM
RM 629277
MRS
1/10/2013
K12B4

POH 13
Nefroektomi
radikal ec tu.
Ginjal Dextra
+
Divertikelektom
i Meckel
reseksi
anastomose
ileum
Hipertrofi
prostat gr II
Hipertensi
Gangguan
mental lainnya
akibat
kerusakan &
disfungsi otak
& penyakit fisik

IVFD NaCl 0,9%

20 tpm
Viccilin sx 1g/ 8
jam/iv
Ranitidine 1
amp/8ja
m/iv
VIP Albumin 4x2
caps
Diet TKTP
Mobilisasi duduk
GV + Rawat Luka

LAB 28-10-13
WBC 16,17 RBC 3,52 HB 10 HCT 29,7 PLT 292 ALB 2,6
GDS 183 Ur/Cr 78/1,4 GOT/GPT 75/60 Na/K/Cl
158/4,1/129 PT/APTT 11,5/31,5
12/10 LAB PT 9,9 APTT 27,3 Na 142 K 3,4 Cl 109
PSA 5,85
MSCT Urografi
Massa heterogen pole bawah ginjal kanan susp. Renal
Cell Carcinoma
Hypertrhophy Prostat
TRUS/TAUS : 41,9/41,8
Kultur dan sensitifitas 710/2013
Tidak ada pertumbuhan baktero aerob
USG Abdomen ( whole abdomen) 23/9/13
Massa pole bawah ginjal kanan
Hipertrofi pole bawah ginjal kanan
Prostat membesar dengan vol. 47,83 ml
Foto Thorax 23/9/13
Cardiomegaly disertai dilatation et elongation aortae
Tidak tampak tanda-tanda metastase pada foto thorax ini
LAB 23/9/13
10

20

21

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

GDS 111, ur/cr 37/1,7 SGOT/SGPT 39/28 AS. Urat 9,1
CT 8 BT 3 PT 11,8 APTT 31,3 WBC 6,7 RBC 4,77 HB
12,9 HCT 40,4 PLT 333
Urin Rutin 23/9/13
Warna Kuning kecoklatan
PH 6
blood 250
Protein 75
leukosit 3
Bilirubin 1
sedimen leukosit 25
Urobilinogen 8
sedimen eritrosit 2
Sedimen epitel sel 1
Echocardiography 26-10-13
Fungsi sistolik LV baik, EF 67%, LVH (+) ringan, disfungsi
diastolic
Blok Parafin 25-10-13
Divertikel dengan peradangan kronik aktif, Renal cell
carcinoma (differensiasi jelek)
Haruna
Hematuri ec
IVFD NaCL 0,9% Lab 28/10/13
628680
adenocarcinom 16 tpm
Na/K/Cl 138/3,1/106 Alb 2,7 GDS 86 Ur/Cr 25/0,7
1/7/1943
a prostat low
Inj. As.
Lab 23/10/13
MRS
grade +
Traneksamat 1
WBC 8,1 RBC 3,45 HB 10,2 HCT 31,8 PLT 173 Na/K/Cl
24/10/2013
transisional cell amp /8j/iv
134/3,7/107 CT/BT 8/3 PT/APTT 13,8/27,6
JKM
ca high grade
Vip albumin 4x2
USG 19/10/2013
K12B5
caps
Massa prostat yang infiltrasi ke buli-buli vol.259
Mobilisasi jalan
Hydronephrosis kanan & mild hydronefrosis kiri
Rencana
Kista Ginjal bilateral
orchidektomi
Lab 10/10/2013
bilateral
RBC 3,38 HGB 10,3 PLT 162 WBC 9,0 Na 143 K 4,1 Cl
Diet TKTP
110
Rencana
Lab 8/10/13
hormonal
Albumin 3,8 Kolesterol total 175 HDL 53 LDL 94 TG 79
Terapi zseluder
Lab 3/10/2013
GDS 118 ur/cr 39/1,1 GOT/GPT 46/8 alkali fosfatase 283
protein total 5,7 As. Urat 7,1
Lab 28/10/13
GDS 86
Ur/cr 28/0,7
Albumin 2,7
Blok Parafin PA (16/10/13)
Adenocarcinoma prostat low grade dan transisional cell
Ca. High Grade
MSCT 7/10/13
Massa prostat dengan infiltrative ke VU dan rectum
suspek malignansi + hidronefrosis dextra
BNO +IVP 25/9/13
Nonvisualized urogram rend extra
Sesuai gambaran hypertrophy prostat (suspek
malignansi), suspek tumor metastasis ke tulang (tipe
blastik)
Siru
Hipertrofi
Ciprofloxacin
Lab 24/10/2013
634079
Prostat Gr III
2x500 mg
Na/K/Cl 137/4/109 PSA 13,99 GDS 103 ur/cr 44/1,5
1-12-1932
Ranitidin 2x150
GOT/GPT 36/37 Alb 4,3 As.urat 7,5 CT/BT 8/3 PT/APTT
MRS 30-10mg
13,3/27,6 WBC 5,0 HB 11,6 HCT 33,6 RBC 3,56 PLT 177
11

22

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

2013
Allopurinol 100
Urine Rutin 24/10/2013
JKM
mg 1-0-0 Tunggu Kuning muda, pH 5, Bj 1,025, protein 75, blood 250,
K12B1
hasil TRUS/TAUS leukosit 500, sedimen leukosit penuh, sedimen eritrosit
Tunggu hasil
>10, sedimen Kristal uric acid +2, sedimen epitel sel 3,
Kultur Urine &
sedimen ragi +3
Sensitivitas
Foto Thorax 24/10/2013
Mobilisasi jalan
Bronchiectasis
Diet TKTP,
Cardiomegaly CTI= 0,58 disertai dilatation elongatio et
rendah purin
atherosclerosis aorta
Foto Polos Abdomen 24/10/2013
Osteoporosis senilis dengan tanda-tanda spondylosis
kembali lumbalis lanjut
Penipisan CV L4 dengan bentuk bikonkaf (mungkin ec
osteoporosis) disertai tanda-tanda degenerative disease
Foto USG Abdomen Atas + Bawah (Whole Abdomen)
24/10/2013
Hipertrofi prostat vol 66,8 cm2
Echocardiografi 25/10/2013
Fungsi Sistolik LV baik, EF 64%
Normal echocardiogram
Sangkala
POH 2 sachse + IVFD NaCl 0,9% Lab 7/10/13
RM 631499
vesicolitotomy 20 tpm
WBC 8,1 RBC 4,12 Hb 12,1 PLT 430 GDS 133 Ur/Cr
MRS 21/10/13
Chlorampenicol 1 32/0,8
TTL 2/4/1943
gr/8j/iv
SGOT/SGPT 24/21 As. Urat 5,1 PT/APTT 11/26,9
JKM
Ketorolac
HBsAg (-), PSA <0,07
K12B6
amp/8j/iv
Ranitidin
Urin Rutin ( warna kuning, pH 6, keton (-), nitrit (+),
amp/8j/iv
blood 250, leukosit 500, protein 500
Diet TKTP
Mobilisasi jalan
BNO /IVP tgl 11/10/13
Funsi sekresi dan ekskresi kedua ginjal baik
Vesicolith uk. 4,3x2,1 cm
Divertikel buli-buli
USG (4/10/2013)
Echo batu uk 2,1x0,65 cm di vesika urinaria
Kesan Vesicolithiasis

23

Kusno
RM 618597
MRS 21/10/13
TTL
13/12/1954
Jamkesmas

Sriktur uretra +
Post lystostomi

Allopurinol 0-0-1
Balance cairan
Diet rendah garam,
purin, kalium

X-RAY (4-10-2013)
Kesan : Pulmonal cardiomegaly plus dilatation plus
elongation et atherosclerosis aortae
Lab (30/10/13)
GDS 100
Calsium 4,8
Magnesium 2,7
Na/K/Cl 153/4,8/128

12

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

LONTARA 2 UROLOGI KAMAR ISOLASI

23

Masdin Kalla
L/52 thn
17-9-1960
MRS 22/10/13
RM 633827
Isolasi

Ulcus Ca testis
Hipoproteinemi
a

IVFD Nacl 0,9% :

dextrose 5% 28
tpm
Ceftriaxone 1
gr/12j/iv
Ranitidine 1
amp/8j/iv
Allopurinol
1x300mg
Albumin inj 20% 1
vial/24j
Cernevit 1 vial/
24j
GV setiap hari
Stop albumin inf.
Konsul Gizi Klinik

Lab 29/10/2013
Biakan dan resistensi (medium padat)
- Cara pemeriksaan : manual
- Sampel : urine
- Kultur dan sensitivity : tidak ada pertumbuhan
bakteri aerob
Lab 29/10/2013
Na 132 K 4,5 Cl 106 CT 8 BT 3 PT 17,0 INR 1,40 APTT
30,9 AFP 1,30 Beta HCG <2,00
Lab 2/11/2013
WBC=8,72. RBC= 3,13. HB=9,4. HCT= 26,1. PLT=37,9
LAB 23/10/13
CT/BT 800/300, GDS 37, Ureum 57, kreatinin 1,0, GDS
87, ureum 57, kreatinin 1,0, got 54, GPT 28, alb 2,3, as.
Urat 8,9, Na 136, HBSAG Reavtive, HCV non reactive,
WBC 14,30, RBC 2,73, HGB 8,0, HCT 23,1 MCV 84,6,
PLT 429,
USG Abd. Atas 23/10/13
tidak tampak tanda2 metastasis pada USG abdomen ini

PALEM
24

tn. Agin
633018
31/12/1960
(52th)
MRS:
24/10/13
Askes
PA B2/13 bed
1

BPH grd III

POH 7 TUR-P

Levofloxacin 2x1
As. mefenamat
3x1
Diet biasa
Mobilisasi jalan
Alprazolam 1 x
0,5 mg

Echocardiography 21/10/13
fungsi sistolik LV balik, EF 77%
disfungsi diastolik
TRAS: 71,0
TAUS: 73,1
Foto thorax PA(18/10/2013)
Pulmo normal, cardiomegaly
USG Abdomen(11/10/2013)
Prostat membesar(4,5x5,30 cm) permukaan licin
Lab 17-10-13
PSA: 7,19 GDS 217 Ur/Cr 29/1,2 GOT/GPT 23/14 As.urat
6,7 CT/BT 8/3 PT/APTT 1,05/3,09 Na/K/Cl 142/3,9/105
WBC 7,3 HB 14,6
Urin rutin: 17/10/13
warna:kuning muda, pH: 5, BJ: 1,010 leukosit 100
Lab 17/10/13
PSA 7,19

13

25

26

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Musdar
POH 5 TUR-P
Levofloxacin 2x1 Lab 25/10/2013
TL :
Tramadol 3x1
Na/K/Cl 136/4,5/100
21/11/1952
Diet biasa
Lab 28/10/2013
RM : 631250
Mobilisasi aktif
Na/K/Cl 141/3,96/108 GDS 193
MRS :
PA (6/11/2013)
Lab 21/10/13
14/10/2013
AFD 1,65 BHCG < 2,00 LDH 309
ASKES
USG Testis 18/10/13
Massa testis kiri susp. Seminoma
Palem Atas
Lab 17/10/13
B1/9
GDP 239, GD2PP 326, HbA1C 6,8, Kol. Total 138, HDL
34, LDL 85, Trigliserida 98, WBC 8,2, RBC 3,95, HGB
11,4, HCT 34,3, PLT 314
PSA 16/10/2013
3,46
Lab 3/10/2013
WBC 15,7, RBC 3,77, HGB 11,4, HCT 33,9, PLT 183,
CT/BT 800/300,
PT 12,4(10,0), APTT 34,1 (24,8),
GDS 350gr/dl, Ur/Cr 37/1,8,GOT/GPT 33/54,Asam urat
6,3
Lab 28/10/13
WBC: 8,16 RBC: 3,48 HGB: 10,4 HCL: 29,9 PLT: 214
Urin Rutin
pH 5,Bj 0,10, Glukosa :1000,bilirubin :
negative,urobilinogen:normal,Blood :50/250,lekosit
-,sedimen lekosit 30,erittrosit 2 epitel sel 3,
USG Abdomen
hipertrofi prostat 83,5cm
Thorax
Pulmo normal, Cradiomegali dengan dilatatio et elongatio
aortae
Lintong
POH 4 URS
Hitung produksi
Doppler vaskuler Superior Sinistra
03/03/1966
bilateral + EKL urin setiap pagi
AV-Shunt berfungsi baik
624144
(S) + replace DJ Cek kultur +
Lab 31/10/13
MRS
stent bilateral
sensitivitas urin
GDS 113 Bil.tot 4,5 Bil.direk 3,6 ALP 364 Albumin 1,9
17/10/2013
CT Scan control
Gamma GT 314
Elektro Kinetik (Senin, 4/11/13)
Lab 30/10/13
Palem Bawah Limotripsi
Cefadroxil 2 x
RBC 2,05 WBC HGB 6,1 HCT 18,6% PLT 166 Ur/Cr
B2/11
+ Batu pyelum
500
52/4,7 Albumin 2,0
Bed 2
bilateral
As mefenamat 3
Lab 28/10/2013
askes
+Batu ureter 1/3 x 500
Ur/cr 80/5,9 GDS 147 SGOT/SGPT 18/5 As Urat 8,0
proximal kanan Terapi lain sesuai Na/K/Cl 132/3,7/105 HBsAg nonreactive
TS Interna
RBC 2,16 WBC 14,0 HGB 6,4 HCT 19,5 PLT 196 CT/BT
700/230 PT/APTT 12,4/31,3
Lab 25/10/2013
GDS 199 Bil total 4,77 SGOT/SGPT 36/13 Albumin 2
Malaria DDR 23/10/2013: Hasil negatif
USG ABDOMEN 22/10/2013: hepatosplenomegali
dengan hidronefrosis kanan PNC dengan nefrolith kiri
Lab 20/10/2013
RBC 2,87 WBC 11,69 HGB 8,3 HCT 24,7 PLT 109 ur/cr
50/4,3
14

27

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Lab 17/10/13
WBC 7,8 RBC 1,76 HCT 14,5, HB 4,8 PLT 72, SGOT 27,
SGPT 4, Ct/BT 800/300, PT 11,9, APTT 30,7, GDS 222,
Ur 125, Kr 8,5, Albumin 2,1, Bil. Total 3,00, Bil. Direct
2,34
Lab 9/10/2013
WBC 8,24 RBC 8,24 HCT 26,8 APTT 22,9 GD2PP 141
ALBUMIN 2,8
HB 8,7 PLT 185 BT 3,0 GDS 111 GDP 123 Na 127 Cl 7,0
K 103
Lab 01/11/13
IVP 23/10/2013
WBC: 11,4 RBC: 2,95 HGB: 8,7 HCT: 24,8 PLT: 106
Lab 02/11/13
Alb: 2,4
Beny Salomo Vistel
Aff Infus
Foto thorax PA (29/10/2013)
28/5/1990
uretrovesica +
Cefadroxyl 2 x
Kesan : KP Duplex lama aktif dengan efusi pleura sinistra
MRS
tumor buli-buli 500
Lab 29/10/2013
17/10/2013
POH 2
As mefenamat 3
CT/BT 900/300 PT/APTT 13,1/26,6 INR 1,098
632440
Cystoscopy
x1
USG scrotum 18/10/2013
ASKES
biopsy
Tunggu hasil PA Kesan: Epididimitis kanan
Palem Atas
12/11/13
CT Scan thorax 23/10/13
B2/10
KP duplex lama aktif
Bed 1
Foto BNO 23/10/13
Fungsi sekresi & ekskresi kedua ginjal baik
Tidak tampak extravasasi kontras keluar dari lumen bulibuli
Fungsi ekskresi dan sekresi kedua ginjal baik
Tidak tampak ekstravasasi kontras keluar dari lumen bulibuli
USG abdomen 22/10/2013
-hepatosplenomegay
-hidronefrosis Dextra
-PNC dengan nefrolitic Dextra
Lab 11/10/13
Na/K/Cl 138/3,8/102, CT/Bt 3/8, PT/APTT 11,9/27,1,
Ur/Kr 12/0,8, GDS 98, GOT/GPT 18/19, Prot. Total 8,3,
Albumin 4,0, As. Urat 72, WBC 8,5, RBC 4,95, HGB 12,2,
HCT 36,8, PLT 370
Urine rutine
Warna kuning kecoklatan, pH 5, BJ 1,025, Protein 25
Foto Fistulografy 11/10/13
Kontras dimasukkan ke dalam salah satu muara pada
scrotum, tampak kontras keluar kembali melalui muara
yang lain
Kontras kemudian dimasukkan melalui OUE sebanyak
20cc, tampak kontras masuk hingga ke uretra pars
posterior. Tidak tampak kontras mengisi buli-buli (striktur
uretra pars posterior)
Tidak dapat dilakukan fistulografy karena kontras tidak
bisa masuk kedalam buli-buli
Foto thorax PA 11-10-2013:
15

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Efusi pleura sinistra
Bronkoskopi 01/11/13
Gambaran peradangan pada bronkus lateral
Tidak terdapat massa intraluminal
28

Suhardin
633951
17-7-60
MRS: 24/10/13
Askes
PA B2/13 bed
2

Abses psoas
kanan
Hidronefrosis
Dextra

Ceftriakson 1
gr/12j/iv
Metronidazole
0,5gr/8j/iv
Ranitidin
1amp/8j/iv
Tramadol
1amp/8j/iv
Transfusi albumin

29

Nelon Lowo
632512
17-12-1963
MRS: 24-1013
Akskes
PBB1/8

POH 2 URS +
EKL + DJ stent
sinistra

Aff Infuse
Ganti obat oral
Cefadroxil 2 x
500
As Mefenamat 3
x 500
Foto polos
abdomen control
Cek Ur/Cr control
hari ini
Diet rendah
garam

Lab 30/10/2013
Alb 1,98, LDH 1001 AFP 1,48 WBC 39,3 RBC 3,51 Hb
9,3 HCT 27,4 PLT 315
MSCT whole abdomen dengan kontras (31/10/2013)
- Tampak massa dengan bagian tepi/dinding tebal
menyangkut post kontras, ring enhancement, batas tegas
pada region sepanjang psoas kanan yang meluas ke
dingding abdomen serta mendesak ginjal kanan ke
cranial.
- hepar, GB, lien, ginjal kanan dan sinistra, loop usus &
tulang dalam batas normal.
Kesan: hidropyonefrosis & psoas abses kanan, kista
hepar disertai hepatomegaly.
Lab 25/10/2013
WBC 38,36 RBC 3,66 HB 9,8 PLT 388
Lab 24/10/2013
Kultur & sensitivitas = tidak ada pertumbuhan bakteri
aerob
GDS strip 66 GEA 1,06 WBC 35,74 RBC 2,95 HB 7,7
PLT 421
Lab 23/10/13
GDS 157, Ur/Cr 17/0,5 GOT/GPT 17/20, Na/K/Cl
126/4,3/99, CT/BT 8/3, PT/APTT 14,9/30,8 RBC 2,88 HB
7,6
USG abdomen 23/10/13
Massa intraabdomen sisi kanan disertai pelvocalyectosis
(D)
Lab 27/10/2013
Asam urat 7,2
Lab 11/10/13
CT/BT 7/3 PT/APTT 11,4/32,7 GDS 104 Ur/Cr 32/2,0
GOT/GPT 14/27 Na/K/Cl a42/3,85/108 WBC 18,46 HB
11,8
Foto polos abdomen 21/10/13
Kesan:- Nefrolith sinistra
-Susp ureterolith sinistra
Usul: USG abdomen
IVU
IVP 21/10/13
Non visualized ren sinistra
Neprolith et ureterolith sinistra
USG abdomen bawah 16/10/13
Kesan: Hydronephrosis sinistra ec nephrolith
Usul: BNO-IVU
Echocardiography
Fungsi sistolik LV baik
LVH (+)
16

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Disfungsi diastolik
EF 57%

30

31

Tn. Ishak
Peokodo
(60 thn)
MRS :
30/10/2013
Askes
PA B2/8

Tu Buli
Pulmo ( sudah
KP Duplex lama dijawab tanggal
aktif
31/10/13 jam
09.55 dengan
instruksi
pemeriksaan BTA
3x)
Terapi lain sesuai
TS Pulmo
Menunggu hasil
BTA
Cek lab ulang
urinalisa + kultur
urin

Yasno Wanci
RM 629071
05/01/1977
(36 Thn 9 Bln)
MRS 30/10/13
Askes
B2/1 Bed 1

Nefrolithiasis
Bilateral
Batu pole atas
ginjal kanan
Batu pole
bawah ginjal
kiri
Hidronefrosis
Bilateral
Post DJ Stent
D/S

Pro CT Scan
Abdomen tanpa
kontras
Pro Replace DJ
Stent

MSCT Abd. Bawah dengan Kontras (31/10/13)

Tumor buli-buli dengan infiltrasi ke rectum
Foto thorax 18/10/2013
Kesan: KP duplex lama aktif, dilatatio et atherosclerosis
aortae
Lab 18/10/2013
HBsAg nonreactive PSA 1,38 Alb 2,9 Kolesterol 175
Kolesterol HDL 33 Kolesterol LDL 114 TG 253 As urat 5,7
GDS 88 ur/cr 25/1,0 SGOT/SGPT 37/37 Na/K/Cl
136/3,6/106 WBC 9,2 RBC 4,02 HGB 11,1 HCT 34,8 PLT
283
Foto polos abdomen 18/10/2013
Kesan: Tidak tampak kelainan radiologic pada foto polos
abdomen ini
USG Abdomen bawah (lower) 18/10/2013
Kesan: massa buli-buli
Urin rutin (18/10/2013)
Warna: kuning muda, pH : 6,5, BJ : 1,010, protein : (-),
bilirubin (-), blood 500, vit C penuh
Lab 30/10/13
RBC 4,50 WBC 3,8 HGB 12,21 HCT 36,8 PLT 183 CT/BT
800/200 PT/APTT 10,3/31,4 HBsAg Non-Reactive AntiHCV Non-Reactive GDS 89 Ur/Cr 21/1,8 GOT/GPT 13/14
Na/K/Cl 142/3,7/109 Prot.Total 5,0 Albumin 4,4
Foto Thorax PA/AP (30/10/2013)
Tidak tampak kelainan radiologic pada foto thorax ini
USG Abdomen Atas (30/10/2013)
Nefrolith bilateral disertai hidronefrosis bilateral, Slight
hepatomegaly
Urin Rutin 30/10/13
Kuning muda, PH 6,0 BJ <1,005 Sedimen epitel sel 5,
eritrosit 10, lekosit 1
Foto Polos Abdomen 30/10/13
Terpasang DJ Stent pada kedua lintasan tractus urinarius
dengan kedua ujung proximal kiri dan kanan setinggi CV
L1 dan kedua ujung distal bergelung pada rongga pelvis.

Arifin
31/12
46 thn
63211
MRS
Askes

Dr. Kh
KMR
17

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

H Muhammad
29/10/1948
(65 thn)
620253
MRS: 01/11/13
Askes

Hipertrofi
prostat grade
11
Hernia inguinal
dextra
Reponible
Stroma noduler
non toxic
sinistra
Post NHS

Stop pemberian
aspilet
Rencana ganti
kateter urin
Cek status lama

Lab : belum ada

LONTARA 1
31 Rosnia
MRS
Tgl lahir
7/2/1970
RM 633213
Askes
L1AD RPK B6

- POH 10 biopsi
-CKD st V ec
nefropati
obstruksi
- tu buli2
infiltrasi ca
cervix ke bulibuli dan vagina
-hidronefrosis
bilateral

Jumaliah
RM 634785
MRS 29/10/13
ASKES

Massa buli-buli
+ Hidronefrosis
bilateral

Terapi ssuai
TS

Rin Riawati
TTL 5/11/1968
MRS 25/10/13
RM 634179
Dikonsul

POH 3 DJ stent
bilateral

tunggu
hasil PA
tgl 11/11

Terapi sesuai TS
interna
Foto BNO control

Lab 7/11/13
WBC 9,17 RBC 2,83. Hb 7,8. HT 23,2 PLT 428. UR/Cr
91/12. Alb 3,2. Na/K/Cl 131/ 4,8/ 102. CT/BT 8/ 2. CEA
3,53
Lab (28-10-2013)
Ur/Cr 68/8,5 Na/K/Cl 128/4,8/96 GDS 121 Alb. 3,4
Wbc 14,38 RBC 2,70 Hb 7,4 Hct 21,7 PLT 365
Lab (23-10-2013)
Ur/cr 133/10,7 Na/K/Cl 118/4,7/93 WBC 9,1 HB 8,9 RBC
2,16 HCT 18,0 PLT 395
Foto polos abd 3 posisi: ascites dengan tanda-tanda
su bileus
Lab (20-10-2013)
Ur/cr 128/9,7 albumin 2,7 asam urat 6,5 Na/K/Cl
125/6,1/99
USG abdomen : (24/10/13) kesan :
Hidronefrosis bilateral , simple cyst rend extra, efusi
pleura bilateral, penebalan dinding VU
Ct scan abdomen : kesan :
Penebalan dindung buli-buli, susp. Tu. Buli-buli,
hidroureter & hidronefrosis bilateral, ascites, efusi
pleura bilateral
Lab 7/11/13
WBC 5,8. RBC 3,28. HB 9,6. HCT 27,7. PLT 286. UR/CR
19/0,9.Na/K/Cl= 137/ 3,9/ 116.
Lab 5/11/13
GDP 128. GD2PP= 262
Lab 4/11/13
WBC=6,1. RBC=3,39. HB= 9,4. HCT= 28,5.PLT= 242.
GDS= 116. Ur/Cr=20/1,3. GOT/GPT=16/11. Alb 3,3.
Na/K/Cl = 146/2,7/108
Lab 6/11/13
WBC=16,6. RBC= 2,06. HB 6,2. HCT 18,5. PLT 258. PT=
13,3. APTT 30,8
Lab 4/11/13
GOT/GPT= 40/20
18

1/11/13

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Lab 3/11/13
WBC=11,10. HB= 7,8. PLT 126. RBC=2,62. Ur/Cr=
75/2,8 . Alb= 2,9. Na/K/Cl= 138/3,9/106

LONTARA 2 DIGESTIVE
35

By. Sakirah
TTL
24/112012
MRS
26/9/2013
RM 580305
L2 AD K12
B6

POH 6
rekonstruksi
buli-buli.+ POH
colostomy+PS
ARP

Terapi sesuai
bedah anak

Lab 3/11/2013
WBC 30,19 RBC 5,85. HB 12,4. HCT 39,0. PLT
475.CT/BT 830/ 230 GDS 73. Ur/Cr 18/0,4. GOT 62.
GPT 79. Alb 4,1. Na/K/Cl 143/5,5/ 112
Tes Sensitivitas Antibiotik
Ciprofloxacin & Meropenem
Lab 19/10/2013
WBC 23,21, RBC 5,21, HGB 11,3, HCT 35,2, MCV 67,6,
MCH 21,7, MCHC 32,1, PLT 382, PCT 0,37, PT 13,8
control 10,2, INR 1,0, APTT 34,0 control 24,9

Lab 10/10/2013
CT 73, BT 300, Alb 5,0, WBC 17,7, RBC 6,29, HCT
41,2, PLT 589
`LONTARA 2 ORTOPEDI
Dg Talli
TTL
31/12/1949
RM 634428
MRS 4/11/13
L2 ortopedi
7b/1
JKM

BPH grade II
KP duplex lama
aktif

Tunggu jawaban
konsul bag
pulmonologi

Ambo Masse
TTL 17-08-65
JKM
MRS 6/11/13
Kamar 6 bed
2

DJ stent insitu
Sinistra
Nefrolitiasis
dextra

Pro aff dj stent

(dari poliklinik)

Lab 29-10-13
PSA 20,21
Urin rutin= Glukosa (+++), protein (+), blood (+++),
Leukosit (++)
Lab 27/10/13
WBC=14,51. RBC=5,04.HB=15,2. HCT 43,7. PLT 266.
GDS=86. UR/CR 15/0,9. GOT / GPT 29/33. ALB 3,5
USG ABDOMEN (27/10)
HIPERTROPI PROSTAT
Foto Thorax 29/10
KP duplex lama aktif
Lab 31/10/13
WBC=6,8.RBC 5,22. HB 15,2. HCT 44,3. PLT 260. GDS
113. UR/CR 21/1,1. GOT/GPT 36/5,8. Alb 4,3. Na/K/Cl
143/4,3/ 107. CT /BT 8/2.
HbsAg AntiHCV non reaktive

LONTARA 3
38

I Gusti Putu
TLL
23/09/2011
RM 632610
13/10/2013
L3Kul-kel AD
K2B3

Tumor
retrovessica
susp. infiltrasi ke
buli-buli

Penjadwalan
operasi dari
bedah anak (Joint
op)
Rencana
cystoscopy

URIN RUTIN 19/10/13

Wrn kuning tua, PH 6.0, BJ 1,015, sedimen leukosit 1,
eritrosit 1, epitel sel 1.
LAB 13/09/2013
RBC 5.58, WBC 8.5, HGB 11.5, HCT 36.5, PLT 402,
SGOT 35, SGPT 17, na 147, k 5.17, cl 112, HBsAg non
reactif, anti HCV non reactif, CT 730,BT 3,00, PT
78/10.4, INR 0.80, APTT 24.1/24.8, GDS 92, Ur 91, Kr
19

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

0.4

LONTARA 4
39

Jenne
1/7/1958
622762
MRS
15/8/2013
JKM
L4 K3 B4

D/POH 8
nephrostomy
Fistel
vesicovaginalis
Fistel uretero
rectalis
Fistel
vesicocutaneus

GV luka abdomen
dan flark kiri
Asmet 3x500
Cefixime 2x100
Neurodex 2x1
Takar prod.
Nefrostomi dan
kateter urin

LAB 18/10/2013
WBC 9.3, RBC 3.49, HGB 10.4, HCT 31.4, PLT 379, Na
126, K 33, Cl 92
Lab 31/10/13
WBC 16,8, RBC 3,75, HB 11,6, HCT 34, PLT 469
Echocardiography (17/10/2013)
Kesan : fungsi sistolik LV baik ,EF 60% ,MR mild,
disfungsi diastolic.
LAB 7/10/13
HbsAg (-) HCV (-) Albumin 3,0-4,2
Urine :
Warna : kuning keruh PH 8 BJ 1,010 prot 25 blood 150
lekosit 25
Lab 25/9/2013
GDS 97 Ur 13 Cr 0,8 GOT 24 GPT 10 Alb 2,7

40

Ny. Ramlah
28/9/1969
Rm 630463
Mrs: 29/9/2013
Konsul
22/10/2013
L4k2b3

Hidronefrosis (D) Rencana operasi

ec. Susp
pembesaran
massa tumor ke
muara uretra ca
cervix

Lab 18/9/2013
CT 8 BT 3 GDS 88 Ur 18 Cr 1,0 GOT 15 GPT 5
MSCT abdomen
Fistel rectoureteral kiriFistel vesicovaginalis dan
ekstravasasi kontras ke ekstraperitoneal
Hidronefrosis ec stenosis distal ureter kiri
Foto Thorax PA
- Pulmo normal
- Aterosclerosis aorta.
Lab (31/10/2013
WBC 15,21 RBC 3,87 HB 9,6 HCT 28,7 PLT 530 GDS
127 Ur/Cr 71/1,3 GOT/GPT 17/20 Albumin 3,6 HBsAg
Non-reactive
MSCT Whole abdomen (16/10/2013)
- Ca cervix dengan hematometra dan
hidronefrosis (D) (sesuai FIGO IIIB)
Lab (9/10/2013)
- Ureum 23
kreatinin 1,1
USG abdomen (7/10/2013)
- Kesan hidronefrosis dextra
Foto thorax (4/10/2013)
- Pulmo normal
20

41

42

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

- Cardiomegaly dengan dilatasi aorta
Lab (1/10/2013)
WBC 11,9
HCT 23,5
RBC 4,9
PLT 569
HGB 9,6
Lab 29/10/2013
GDS 127 CT/BT 8/3 Ur/Cr 71/1,3 Albumin 3,6 HBsAg(-)
WBC 11,00 RBC 2,99 HGB 6,1 PLT 864
Lab 1/11/13
WBC 10,2, RBC3,63, HB 9,1
Na/K/Cl 135/5,2/101
Ur/cr 43/1,2
Albumin 3,7
Irruse
Hidronefrosis D Rencana URS +
USG Abdomen(2 negative5/10/2013)
43 thn
ec susp
DJ stent D
Kesan:
Mrs:
pembesaran
Ceftriaxone
massa segmen bawah rahim dengan infiltrasi uterus dan
23/10/2013
massa tumor ke 1g/24jam
hydronefrosis (D)
633985
muara uretra
Massa kistik adneksa bilateral
L4K3B2
Pre OP:
Foto thorax PA/AP(25/10/2013)
(nivas)
Siapkan darah
Kesan: tidak tampak tanda0tanda metastasis pada foto
500 cc
thorax ini
WB PMI
MSCT Whole abdomen dengan kontras(25/10/2013)
Kesan:
Ca cervix
Massa adneksa bilateral
Efusi pleura minimal dan bilateral
Lab(23/10/2013)
CT/BT 8/3 GDS 104 Ur/Cr 46/0,6 albumin 3,6 ABsAg(-)
WBC 11,72 RBC 4,39 HGB 9,9 HCT 30 PLT 430
Lab 1/11/2013
Na/K/Cl 133/4,4/98
Ur/cr 32/1,3
Albumin 3,6
WBC 6,1, RBC3,85, HB 9,0, HCT 25,3, PLT 345
Eme Ransiana Massa adneksa IVD NaCl 0,9%
Lab (31/10/2013)
53 tahun
Hidronefrosis
20 tpm
WBC 17 RBC 3,64 HB 10,3 PLT 589
25/05/1960
bilateral
Ceftriaxone 1
Lab(28/10/2013)
Hidroureter
gr/12j/iv
CT/BT 8/3 GDS 143 Ur/Cr 72/2,3 HBsAg(-) WBC 19,8
bilateral
Transfusi PRC 2 RBC 2,92 HGB 8,3 HCT 25,7 PLT 564
Batu PUJ (D)
unit
USG Abdomen Atas + Bawah (Whole Abdomen
Susp. TB paru
EKG + Echo
(16/10/2013)
Periksa BTA
Kesan :
-Massa Adneksa dengan tanda-tanda torsi
-Hidronefrosis bilateral
MSCT Whole Abdomen (18/10/2013)
Kesan :
-Massa adneksa
-Hidronephrosis grade IV e.c batu PUJ kanan
-Hidroureter kanan
Foto Thorax PA/AP (16/10/2013)
Kesan :
-Platelike atelectasis kiri
21

43

43

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

-Cardiomgaly dengan dilatation et elongatio aortae
-Tidak tampak metastasis pada foto thorax ini
CT Thoraks (tanpa kontras) (23/10/2013)
Kesan : KP dextra lama aktif
Rumaeda
Nefrolitiasis
Cefixime tab 2 x
Lab (28/10/13)
1/8/1962
dextra
100
WBC 6,2, RBC 4,71, HB 13,0, HCT 38,3, PLT 321
(51thn)
ISK
Asmet 3 x 500
Na/K/Cl 141/5,2/103 HBsAg non reactive
MRS 31/10/13
BT 700 CT 300 PT/APTT 12,9/26,7 GDS 112
JKM
Ur/cr 26/0,7 GOT/GPT 29/20 albumin 5,0
Asam urat 4,4
Urin rutin (28/10/13)
Blood 250
Leukosit 100
Sedimen leukosit 8 sedimen eritrosit >30
USG (28/10/13)
Kesan: Nefrolith dextra
Echo (29/10/13)
Kes: fungsi sitolik LV baik, EF 65 %, disfungsi diastolic
Foto Thoraks (28/10/13)
Kesan: pulmo normal, atheroskelerosis aortae
IVP(31/10/13)
Kesan: fungsi sekresi dan ekskresi kedua ginjal baik
INFECTION CENTER
Ayub Danari
25/071938
MRS
21/9/2013
RM 629136
IC Lt.2 ICU
k2b2

BPH grade II +
TB Paru

Urin rutin dan

kultur sensitivitas
TRUS/TAUS bila
KU baik
Terazosin 2mg 00-1
Alopurinol tab
100mg

Lab 25/10/2013
As urat 6,0
Foto thorax 17/10/2013
Kp dupleks lama aktif, efusi pleura D, dilatasi aorta
PA(10/10/2013): Evaluasi sitologi cairan pleura, lesi
hemoragik tidak mengandung epitel malignant
PA(30/9/2013): evaluasi sitologi cairan pleura, AV shunt
tidak terdapat sel epitel malihnant
LAB 17/10/2013
Albumin 2,9
Lab 15/10/2013
Albumin 2,6
Lab 11/10/13
Ur/cr 14/0,7 prot tot 4,3 albumin 2,1 HbSAg (-) Anti HCV
(-) GDS 153 RBC 4,49 hb 9,9 HCT 29,8 PLT 240
Urin rutin : warna kuning jernih BJ 1,010 prot 25/+ leukosit
150/++ sed. Leukosit 4-8 sed. Eritrosit 0-2 sed. Eppitel sel
1-3.
Lab 5/10/2013
Ur/Cr 49/1,0, WBC 8,71, RBC 3,77, HGB 10,9, HCT 32,0,
PLT 277
Lab 7/10/2013
HBA1C 4,6, Albumin 2,2
Foto thorax 24/9/2013
- Efusi pleura massif dextra
- Tidak tampak densitas massa pada kedua paru
USG Abdomen
- Efusi pleura dextra
- Hipertrofi prostat (uk: 3,9x4,7x4,3x4x2 )
22

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

ICU
Hendrik
Cipang
L/21/2/1981
32 thn
626621
MRS:
17/9/2013
K10 bed 4
JKM

Adnan
TTL 1/1/96
RM626404
VIP 1
MRS 5/9/2013

POH 3 Radical
Prostatektomi

Kolik ginjal/
ureter + HN
dekstra.

Awasi TTV

Periksa urinalisis
dn kultur urin

Lab 7-11-13
WBC 20,48. RBC 2,64. HB 7,8. HCT 22,5. PLT 122.
Lab 6-11-13
WBC= 6,7. RBC 3,98. HB 11,9. PLT 161.Na/K/Cl
126/3,2/93. GDS 96. Ur/Cr 14/0,4. GOT/GPT 29/16. Alb 3,0
PA 24/10/2013
PA 18/10/2013
Hiperplasia glandula prostat
Urinalisa 21/10/2013
Merah, PH 7 BJ 1,010 PROTEIN 75/++ UROBILINOGEN
4/++ NITRIT (+) BLOOD 250/+++++ LEUKOSIT 500/+++
SEDIMEN LEKOSIT PENUH, SEDIMEN ERITROSIT
PENUH, EPITEL 10-15, BAKTERI (+)
Lab 16/10/13
WBC 8,8; RBC 3,73; HGB 11,1; HCT 33,9; PLT 187; Ur/Cr
14/0,6
Lab 14/10/13
Albumin 2,0
Lab 10/10/2013
Na/K/Cl : 132/3,5/105
Lab 8/10/2013
GDS 150, Ur/Cr 12,2/0,5, GOT/GPT 64/43, Prot. Total 5,9,
Albumin 2,3
Na/K/Cl 126/2,8/99, CT/BT 8/3, PT/APTT
13,8(11,7)/28,6(24,8)
WBC 9,8,HGB 11,8, HCT 35,6, PLT 122, RBC 3,88
Lab 3/10/2013
Na 125 K 2,6 Cl 94
Lab 24/9/2013
WBC 4,4 RBC 4,44 HGB 13,8 HCT 42,7 PLT 186 GDS 119
Ur/Cr 31/0,7 GOT/GPT 54/34 alb 3,5 na/k/cl 138/3,2/105
USG Abdomen 23/09/2013
Sesuai Gambaran ileus obstruktif
Echo 17-9-2013
Fungsi sistolik LV baik EF 79%
LVH (+) mild
CT Whole Abdomen (11/09/2013)
Kesan : Massa Prostat.
Lab 10-9-2013
PSA: 4,83
Lab 6-9-2013
HBsAg reactive Na/K/Cl:138/37/108 Ur/Cr 15/0,8
Lab 10/9/2013
Urine rutin : warna kuning, PH 6,5, BJ 1,015, Prot 25,
sedimen leukosit > 50, sedimen eritrosit > 20, sedimen
epitel sel 2, sedimen lain-lain bakteri (+), hematuria
Lab 7/11/13
WBC= 9,28. RBC 4,46. HB 11,9. HCT 36,2. PLT 343
Lab 5/11/13
Alkalosis Metabolik terkompensasi sebagian
Lab 28/10/13
23

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

Konsul dari
WBC= 10,44. RBC= 4,22. HB 11,2
anestesi
HCT 35,0. PLT 391. Na/K/Cl= 143/4,5/109.
6/11/13
GDS= 121. Ur/Cr= 17/0,3. Alb=3,4. GOT/GPT= 29/87
PICU
CVCU
RSUH
45

Tn. Lambertus
MRS :
25/10/2013
RM : 012682
412

- Retensi urine
ec. Susp.
Kontraktur
- Bladder neck
- CHF NYHA III

- Pasang kateter
- Pasang simino
- Hammal 0,4 mg
0-0-1
- Balance cairan
- Terapi lain
sesuai Ts
Interna

Lab 27/10/13
Ur/Cr 287/10,4
Lab 30/10/13
Ur/Cr 158/4,3 Na/K/Cl 136/4,3/96 WBC 4,65 RBC
3,69HGB 10,2
Echo 30/10/2013
VH dengan hipertropi septal, TR mild-moderate PH mild

46

Yunus
L/ 12-07-1968
MRS
16/10/2013
RM014659
Lantai 4/ K 414

Post op
Pyelolitotomi hr
16 e.c Multiple
batu ren (D)

- IVFD NaCl
BNO :
0,9% 28 tpm
- Kontur ginjal kanan sulit dievaluasi
- Meropenem
- Tampak ujung drain tube pada region
1g/12j/IV amp/
hipokondrium kanan setinggi CV L2, ujung
8j/ iv
cranial DJ stent bergelung pada hipokondrium
- Ranitidine
kanan setinggi CV T12 dan ujung caudal
amp/8j/iv
bergelung pada rongga pelvis
- Vip albumin 3x3
- Tampak beberapa buah bayangan radiopak
- Affhecting
bergerombol di hipokondrium kanan setinggi
selang seling
CV l1-L2 dan beberapa pada rongga pelvis
- Pasang conecta
(neprolith dextra et vesicolith)
infus
- Osteofit pada aspek bilateral CV L1 s/d CV L5
- Mobilisasi aktif Kesan : kontur ginjal sulit dievaluasi, posisi ujung
cranial DJ stent lebih tinggi dari posisi neprolith
(mungkin ujung DJ Stent berada di luar PCS)
Lab 25/10/2013
WBC 10,17 RBC 3,38 HB 9,8 PLT 184 Na/K/Cl
134/3,9/101 Ur/Kr 102,5/1,9
Lab 24/10/2013
WBC 7,08 RBC 2,98 HB 8,7 PLT 165
Lab 23/10/2013
WBC 8,29 RBC 2,74 HB 7,9 PLT 166
Lab 22/10/2013
WBC 8,44 RBC 2,69 HB 8,5 PLT 189 Ur/Kr 82/2,4
Na/K/Cl 130/4,4/98 alb 3,0 GDS 145
Urin: Protein 25/+; blood 25/++; lekosit 100/++
BNO:- drain tube terpasang pada regio hipochondrium
kanan dengan ujung setinggi CV L2
- tampak DJ-stent dengan ujung proximal dan
ujung distal berada didalam rongga pelvis
- Tampak bayangan batu bulat multiple pada
region hipochondrium kanan (nephrolith)
24

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

- Tulang-tulang intak, tampak spur formation
pada aspek lateral CV L1-5 ( spondylosis
lumbalis)
Analisa batu: warna abu-abu kehitaman, 1 batu
berukuran 2x2x1cm, 2 batu berukuran 1x1x0,5cm, 2
batu berukuran 0,5x0,5x0,2cm, 3 batu berukuran
0,2x0,2x0,2cm, permukaan halus, bentuk bulat tidak
beraturan. Calcium 40, oksalat 50, phosphate
2,5.kalsium 17%,fosfat 2,5%
Kesan : batu memiliki ikatan kalsium-oksalat 84%, sisa
unsur
Lab 17/10/2013
WBC 15,24 RBC 4,06 HGB 12,7 PLT 194
Lab 8/10/2013
Na/K/cl 134/3,8/104 prot total 7,2 alb 4,1 GDS 106
as.urat 7,9 Ur/Kr 60,7/1,8
Foto thorax: cardiomegaly disertai dilatation et
elongation aortae
CT-Scan Abd 4/10/2013
- Nefroliths dextra disertai hidronefrosis dextra
- Simple renal cyst sinistra

47

YAKUB
RASYID
14/08/1959
MRS : 26/10/13
ASKES
Kamar 419

48

Ny.A.Markis
11/08/1953
MRS:
30/10/2013
ASKES
Kamar 407

POH 1 URS + DJ
stent (D) Bivalve

- IVFD NaCl
0,9% 28 tpm
- Ceftriaxone
1g/12j/iv
- Ranitidin amp
8j/iv
- Takar produksi
urin/24j
- Boleh diet
- Mobilisasi
duduk
Post Nefroctomi - VFD NaCl 0,9%
Hari II e.c Batu
28 tpm
staghorn (s)
- Ceftriaxon 1
g/12J/iv
- Ranitidin amp/8j/iv
- Takar produksi
urin/24j/
- Obs. TV
- Takar produksi
drain/24j
- Diet biasa

USG Abd 3/10/2013

- Nefrolith kanan
- Kista ginjal kiri
Hipertrofi prostat (ringan)
Foto BNO 24/10/2013
Materiorisme dengan impacted fecal mass
Lab 28/10/2013
WBC 16,9 RBC 4,71 HGB 12,3 Na/K/Cl 135/4,2/105
ur/cr 28/1,4

Lab 28/102013
Asam urat 3,9
Foto BNO/IVP 24/10/2013
Batu staghorn et non visualized ginjal kiri
Fungsi eksresi dan sekresi ginjal kanan baik
Foto polos abdomen AP 21/10/2013
Batu staghorn ginjal (s)
Lab 18/10/2013
WBC 8,78 RBC 4,81 HGB 13,9 Plt 311 HbsAg (-) Anti
25

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

HCV (-) Na 133 K 4,4 Cl 102 SGOT 15 SGPT 11 GDS
100 Ureum 31 Kreatinin 0,9s
Lab Urin 18/10/2013
Blood Positif 2(50 rbc/ul)ss
USG Abdomen 17/10/2013
Severe Hidronefrosis (s)
Simple renal cyst (d)
UGD
49

Syaharuddin
L/31/12/1937
MRS:
01/11/2013
RM 015424
Lantai 4
K426

Retensi urin e.c - IVFD NaCl 0,9%

Hipertropi prostat
20 tpm
- Cek urinalis kultur
urin
-TRUS + TUS
-Echocardioghraph
y
-Konsul kardio

Lab 01/11/2013
PT 16.5 APTT 40.9
Na 141 Cl 102 K 4.1
SGOT 67 SGPT 49 GDS 220 Plt 70
Ureum 37.6
Kreatinin 0,9
Lab urin rutin 01/11/2013
Blood positif 3 (250 rbc/ul)
USG Abdomen 01/11/2013
- Hydronephrosis bilateral dengan hypertrophy
prostatascites minimal

PCC
50

Lina kogoya
P/ 5-12-1968
MRS
22/10/2013
RM 633809
Lantai 2 k213

POH 1 URS +
DJ stent

Instruksi post op
- Ceftriaxon 1
gr/12j/iv
- Ketorolac
amp/8j/iv
- Ranitidin
amp/8j/iv
- Foto BNO
dibuat kemarin
tgl 31/10/2013
- Hasil biopsy tgl
8/11/2013
- Mobilisasi
duduk

Lab 29/10/2013
Ur 14 cr 0,8 Na/K/Cl 136/3,8/105
Lab 28/10/2013
WBC 4,15 RBC 4,04 HCT 32,7 HB 11 PLT 168 ur/cr
16/0,8 GDS 362
Lab urin 25/10/2013
Protein (-) glukosa 1000/++++
Lab 25/10/2013
WBC 4,5 RBC 3,16 HB 8,6 PLT 175
Lab 23/10/2013
CT/BT 7/3 PT/APTT 12,8/27,8 GDS 179 Ur/Kr 12/0,9
GOT/GPT 25/8 Na/K/Cl 143/4,3/108
CT abd dgn kontras 23/10/2013
- Hidronefrosis (D) dengan tanda-tanda delay
function
- Hepatosplenomegaly
Lab 22/10/2013
CT/BT 7/3 PT/APTT 12,8/27,8 GDS 179 UR/KR 12/0,9
GOT/GPT 25/8 Na/K/Cl 143/4,3/108
USG 22/10/2013
- Hepatosplenomegaly
26

KORAN BEDAH UROLOGI MINGGU, 3 NOVEMBER 2013

- Nefrolith dan hidronefrosis (D)
Urin: protein 25/+, blood 25/++, lekosit 100/++

51

Nelly Gidion
P/ 9-1-1955
MRS
2/11/2013
RM 635400
Lantai 3 k321

Nefrolithiasis
- IVFD Fentrolit 20 Lab 29/10/2013
Bilateral disertai
WBC 13,0 Hb 11,5 RBC 3,53 HCT 32,5
tpm
Hidronefrosis (D) -Broadcep
Kolesterol total 278 Kolesterol LDL 168
Ureum 36
1g/12j/iv
Kreatinin 2,92
-Dynstat 1
amp/12j/iv
Foto Thorax 29/10/2013
-Ranitidin 1
- Bronchitis lama
amp/8j/iv
- Cardiomegalli dengan HHD/CHF
USG Abdomen 29/10/2013
- Nephrolithiasis multiple kanan dengan
hydronephrosis sedang kanan
- Nephrolitiasis multiple kiri berbagai ukuran
- Dyspepsia (gastritis
- Sus. Cystitis

27