KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

LONTARA 2 UROLOGI KAMAR 1

1.

Lalang
Tgl lahir: 1/1/1940
74 thn
RM: 627387
Tgl MRS: 6/1/14
JKN
Kamar 1 Bed 1

2.

Tn. Buhasang
18/08/1956 (57 thn)
RM: 643309
MRS: 07/01/13
JKN
K1B3

Nasaruddin(47thn)
TL 31/12/66
RM 641657
MRS: 6/1/14
JKN
Kamar 2 Bed 2

Ca Prostat +
striktur uretra
pars pendulosa

IVFD NaCl 0,9% 28tpm

Ceftriaxon 1gr/12/iv
Ranitidin amp/8j/iv
Ketorolac amp/8j/iv

Lab 27/12/13
GDS: 94
Ur/Cr: 46/0,90
As. Urat: 7,0
POH II
GOT/GPT: 22/27
orchidectomy
Alb: 3,8
subcapsular
Na/K/Cl: 141/4,7/109
bilateral
POH II sachse
BT/CT: 200/80
PT/APTT: 12,7/25,9
INR: 1,06
WBC: 7,1; RBC: 3,82; HgB: 11,8
HcT: 33,4; PLT: 316
Foto thorax PA 27/12/13
Kesan: elongation et elongation aortae
Tidak tampak tanda-tanda metastasis pada foto
thorax ini.
USG Abdomen (27/12/2013)
Kesan: Cholelith
Lab 22/11/13
HbsAg: no reactive
Anti HcV: non reaktif
PSA: 7.70
Urine 27/12/13
Warna: kuning, PH: 5,5, BJ: 1,030, Nitrit: (+),
blood: +/25
Hasil Kultur urin:
Sensitif terhadap meropenem
BPH Grade III
Ciprofloxacin 2x500mg
Lab 24/12/2013:
ISK
Asam Mefenamat
GDS: 112, Ur/Cr: 26/1,1, GOT/GPT: 22/13,
3x500mg
Na/K/Cl: 133/4,1/105, HBsAg: non reactive, Anti
Ranitidin 2x1
HCV: non reactive, WBC: 15,02, RBC: 4,62,
HGB: 16,5, HCT: 45,0, PLT: 218
TRAS/TAUS: 52,1/52,6
USG Abdomen (232/12/2013)
- Hypertrophy prostat
Foto Thorax PA (127/12/2013)
- Pulmo Normal
- Dilatatio, elongation et atherosclerosis
aortae
PSA (27/12/2013): 13,68 ng/ml
LONTARA 2 UROLOGI KAMAR 2
Vesicolitiasis
IVFD NaCl 0,9% 28tpm Lab 2/1/14
Ceftriaxon 1gr/12j/iv
HbsAg: non reaktif
ISK
Ranitidin amp/8j/iv
BT/CT: 230/730
Ketorolac amp/8j/iv
PT/APTT: 13,0/25,6
Post
Takar Produksi Urin
INR: 1,08
vesicolitotomy H/hari
GDS: 102
III + sistoskopi
Diet Biasa
Ur/cr: 16/1,01
GOT/GPT: 31/63
Na/K/Cl: 138/4,2/102
WBC: 9,5; RBC: 4,73; HgB: 16,2
1

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

M.Nasir (49thn)
TL 31/12/1963
RM 643312
MRS 23/12/2013
JKM
Lt.2 K2 B4

HcT:44,6
PLT: 305
Kultur Urin (3/1/2014):
Tidak ada pertumbuhan bakteri aerob
Foto Thorax PA (20/12/2013):
Kesan: Cor dan pulmonal dalam batas normal
Foto BNO-IVP (19/12/2013):
Kesan:
Hidronefrosis sinistra grade II disertai hidroureter
kiri
Vesicolitiasis
USG Abdomen (12/12/2013):
Kesan:
Pelvocalyectasis bilateral
Vesicolitiasis
Hipertrofi Prostat Ciprofloxacin 2x500mg
Lab 7/1/201
Grade II +
Ranitidin 2x1
WBC: 9,5, RBC: 4,49, HGB : 13,6, HCT: 38,4,
Bladder Neck
Asam Mefenamat
PLT: 367
Kontraktur
3x500mg
Lab 4-1-2014
Bladder Training
Na/K/Cl: 131/3,56/100
POH III
Lab 2-1-2014
Cystoskopi +
GOT/GPT: 56/91
Bladder Neck
Hasil PSA: 7.88
Incision
Kultur Urin (6/1/2014):
Hasil: Tidak ada pertumbuhan bakteri aerob
Urin Rutin (27/12/2013)
Warna kuning, pH 7,0 Bj 1.005, Blood 3+,
Leukosit 2+, Sed Leukosit 15-20, Sed Eritrosit 2226 Sed Epitel Sel 2-9
Kultur & Sensitivitas Urin (27/12/2013)
EPT 2-5, Bld 3+, Leu 2+, SG 1.005, pH 7,0
Lab (27/12/2013)
Bil tot 0,74, Bil dir 0,20, Prot tot 5,8, Albumin 3,6,
Glo 2,2, HBsAg/Anti HCV Non-Reaktif
CT Kepala (25/12/2013)
Tidak tampak kelainan pada CT Scan kepala ini
USG Abdomen (24/12/2013)
Hipertrophy Prostat
Hasil TRUS/TAUS: 19,8/21,0
Foto Thorax (24/12/2013)
- Pulmo normal
- Elongatio Aortae
Lab (24/12/2013)
CT 200, BT 300, PT 11,9/11,2, INR 1.00,
APTT 31,1/21,8, GDS 76, Ur/Cr 12/0,7,
SGOT/SGPT 327/87, Chol tot 132 HDL 50, LDL
80, Trigl 66, CK-MB 133, Trop T <0,02, As. Urat
3,2, Na/K/Cl 118/3,7/89
LONTARA 2 UROLOGI KAMAR 3

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

5

6.

Ervina Patandiangan
644790
13/04/1978 (35 thn)
3/1/2014
JKN
L2K3B3

La Afi
Tgl Lahir:
15/1/1994
20thn
RM: 624476
MRS: 8/1/2014
JKN

-Tu. Ginjal
Dextra

Lengkapi pemeriksaan

Spirometri (10/01/2014)
FVC : 104% , FevF1 : 111% , Kesan : Normal
Foto Thorax (09/01/2014
Kesan : Cor dan pulmo normal tidak terdapat
tanda-tanda metastasis
LAB (08/01/2014) Post transfusi
RBC : 3,95 HGB : 11,9 WBC : 12 PLT : 366
HCT : 34,7
LAB 06/01/2014
WBC : 6,3 HGB : 9,4 HCT : 28 RBC : 3,07
PLT : 297
3/1/2014
WBC: 11.06, RBC:2.46, HB: 7.6, HCT: 22.4, PLT:
258, Malaria mikroskopi (DDR): negative,
PT/APTT: 12.3/23.1, INR: 1, GDS: 111, Ur/Cr:
1.3/0.6, GOT/GPT: 26/8, Na/K/Cl: 146/3.5/116,
CTAbd:
Tu Ginjal kanan, sesuai Grawits, Efusi pleura
bilateral terutama kanan, Cholelith,

LONTARA 2 UROLOGI KAMAR 10

Hidronefrosis
Rencana Pyeloplasti
Hasil Lab (28/12/13):
Sinistra
GDS: 95, CT/BT: 9/3, Ur/Cr: 27/1,0, GOT/GPT:
Post Nefrostomi
17/21, Albumin: 3,9, Na/K/Cl: 142/4,49/113, WBC:
7,45, RBC: 6,25, HGB: 14,7, HCT: 45,0, PLT: 321.
USG Abdomen (8/1/2014):
Kesan: Mild Hidronefrosis Bilateral
Tidak tampak DJ Stent paada kedua ginjal

Kamar 1 bed 2

Buntu
01/12/1959(54th)
RM643223
MRS07/01/2014
JKN
L2K12B1

BPH Grade II
Vesicolithiasis
ISK

Muddin
01/07/1963
50th
RM : 645366
MRS : 07/01/2014
JKD
K12B5

Ca Buli-buli

LONTARA 2 UROLOGI KAMAR 11

LONTARA 2 UROLOGI KAMAR 12
POH 2
TUR-P + Litotripsy
IVP (02/01/2014)
Defect padaPCS ginja kiri Susp. Massa (kista)
Vesicolith, Cystitis
LAB (24/12/2014)
PSA : 6,48 HbsAg : Non reactive,
HGB : 15,8 WBC : 3,4 RBC : 4,9 PLT : 222 GDS
126,Ur/Cr :18/0,64 , SGOT: 24 , SGPT : 22
ECG : LVH, Disfungsi diastolik
Na/K/Cl : 139/3.2/104
BT : 200
CT : 800
Lengkapi
pemeriksaan

LAB (09/01/2014)
RBC : 3,7 , HB : 9,6 , HCT : 29,5 , PLT : 460 ,
WBC : 35,3
LAB (08/01/2014)
RBC : 3,61 , HB : 8,7 , HCT : 26,8 , PLT : 491 ,
WBC : 34,7
USG Whole Abdomen (08/01/2014)

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

Kesan : Massa Buli-buli
LAB (07/01/2014)
GDS : 107 , Ur/Cr : 24/0.8 , GOT/GPT : 12/9 ,
Albumin : 3,2 , CT : 800 , BT : 200 , PT : 10,8 ,
APTT : 25,3 , Na/K/Cl : 139/3,6/107
RBC : 3,25 , WBC : 35 , Hb : 7,3 , HCT : 23,5 , PLT :
603
Urinalysis (06/07/2014)
Ery : 250/mikroL (+++++)
Pro : 500mg/dL (++++)
LAB (06/01/2014)
RBC : 2,83 , HB : 7,1 , HCT : 21,5 , PLT : 545 ,
WBC : 34,9
9.

10.

Daud
06/07/1950
RM : 643714
Tgl MRS :
09/01/2014
JKN
Kamar 12 bed 3

Tn.Nurdin Radjak
1/6/1957
RM: 641941
Jaminan:JKM
MRS: 14/12/2013
L1AB K4(III)B3

BPH Grade II
ISK

Batupyelo (D)
+Batu Calyx
superior (D)
Batu calyx media
(S)
HN (D)+PNC(S)
ISK
Anemia

Lengkapi
pemeriksaaan

LONTARA 2 ISO
LONTARA 1
Ceftazidine 1 vial/12
jam
Lain lain sesuai TS
interna
Cek ulang kultur urin
dan sensitivitas
Informed consent
Konf. TS Anestesi
Konf. TS Interna
U/ transfuse PRC &
Renc. URS + DJ Stent
hari senin 13/1/14

Urin Rutin (02/01/2014)

Leukosit (++) , Blood : ++(80) , Mikro :
Leukosit(45),Eritrosit(8)
PSA (31/12/2013)
PSA : 24,54
USG Abdomen Bawah (27/12/2014)
Kesan : Hypertrophy prostat disertai cystitis
LAB (27/12/2014)
GDS : 103 , Ur/Cr : 18/0.8 , GOT/GPT : 24/20 ,
Albumin : 3,6 , CT : 800 , BT : 300 , PT : 11,6 ,
APTT : 25,6 , Na/K/Cl : 135/3,8/113 , HBsAg : Non
Reactive
LAB (27/12/2014)
RBC : 4,6 , HB : 12,9 , HCT : 38,6 , PLT : 260 ,
WBC : 10,18
Foto Thorax (27/12/2013)
Elongatio aorta, Pulmo dalam batas normal

9/1/14
Echocardiografi : disfungsi sistolik an diastolic LV,
EF 48%, MR trivial
8/1/14
Urinalisa: warna kuning keruh, proein +++, nitrit +,
blood +++, lekosit ++
USG: nephrolith bilateral, hdronephrosis dextra, PNC
sinisra, Cystitis
Lab 7/1/14
Hb: 6.8; Ur/Cr: 116/9.25
Lab 4/1/14
Ur/Cr: 128/6.2, Na/K/Cl: 135/3.9/108, WBC: 8.34,
RBC: 2.7, HB: 8,0 HCT:23.8, PLT: 263, BT/CT:
3/8, PT/APTT: 12.1/34.9, GDS: 100,GOT/GPT:
20/17,Alb: 3.4
Lab 31/12/13
Bt : 3 CT 7 PT 13,8 APTT 29,7 INR 1,15
Na/K/Cl : 134/4,6/103
Ur/Cr : 167/7,05
Wbc 5,1 Rbc 2,09 Hb 9,1 Plt 337
4

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

11

Murni
15-10-1956 (57thn)
RM 643876
MRS/Konsul : 4-114
L1ADK6B1
JKM

Ca Buli buli
Ca Cervix
CKD Stg V

Pasang kateter
24F+Urogard+Spooli
ng NaCl 0.9%
Cocktail/12jam/IV
Ceftriaxone
1gr/12j/IV
Cek ulang:
PT APTT
Elektrolit
Urinalisa dan kultur
urin
Visite dr Syakri
Sp.U :
-rencana cystoscopy +

12.

H. Muslimin
5-5-65 (48thn)
RM 640945
MRS/Konsul:4-114
L1BBK7(III)B4
JKM

Kolik uretra susp

BSK
Hidronefrosis
Tu. Metastase
Hepar

Lab 23/12/2013
CT/BT 8/2.30 PT/APTT 13.4/33.4 INR 1.12
Ur/cr 200/11.9 as.urat 8 TIBC 191
Na/K/Cl 130/5.2/97 Wbc 8.2 Rbc 2.97 Hb 9.3 Hct
25.8 Plt 367
Lab 21/12/2013
Wbc 11.85 Rbc 2.91 Hgb 8.5 Hct 25.8 Plt 290 Pt/apt
12.7/26.5 Ur/Cr 157/9.1 as.urat 5.1 Na 132 K 4.6 Cl
102 Hbsag (-) Anti hcv (-)
Lab 17/12/13
-PNC sinistra
-Nephrolith bilateral disertai pelvocolyectasis dextra
-Cholelith
Foto polos Abdomen 17/12/13
-Nefrolith sinitra
CT Scan abd tanpa kontras (14/12/13)
PNC sinistra dengan nefhrolithiasis bilateral
Foto thorax 14/12/13
Pulmo dalam batas normal
9/1/14
CT/BT: 7/230 PT/APTT: 106/29 INR 0,81
Ur/Cr:48/7,62 Na/K/Cl:130/3,8/100 WBC: 7,1 RBC:
3,06 Hb:8,7 HCT: 26,3 PLT: 216
7/1/14
GDS: 88, GD2PP:171, WBC: 8, RBC: 3.05, HB: 9.4,
HCT: 28.3, PLT: 244
6/1/14
CT: Massa buli-buli dengan hidronefrosis dan
hydroureter bilateral, kalsifikasi uterus
3-1-14
Ur 137 Cr 13,7 Alb 3 Na 129 K 4,8 Cl 99
Wbc 12,6 Hb 6,8 HCT 20,1 Plt 306

31-12-13
GDP 81 GD2PP 165 HbsAg dan antiHCV nonreaktif
PT 10,2 APTT 19,1 INR : 0,809
GOT 26 GPT 17
USG : Hidronefrosis bilateral
Minta status lama
8/1/14
BNO : tidak tmpak kelainan pada foto abdomen ini,
USG: lesi pada hepar susp. Tu metastase, HN dextra
Foto thorax AP: observsi nodul soliter setinggi ICS I
paru kanan depan
2/1/2014
Kultur BJ: 1.005, Leukosit: +, Blood: +, AFP: 2.52,
CEA: 1, PSA: 2.27
31-12-13
PT 12,8 INR 1,09 APTT 23,7
AsUrat 5,3 Na/K/Cl 129/4,6/102
GOT/GPT 29/30 Alb 3,8 GDS:101 Ur/Cr: 17/0.9
Wbc 9,78 Hb 13,3 HCT 37,5 Plt 272
LONTARA 2 DIGESTIVE

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

13

Bentar
10/12/1989
MRS: 25/12/2013
643511
JKD
L2ADK11B6

Post repair bulibuli ec rupture

buli-buli
intraperitoneal
hari 16

Aff kateter OUE

Observasi tanda
tanda retensi urine
Lain lain sesuai TS
digestif
Observasi tanda
retensi urin

8/1/14
BT/CT: 2/730, PT/APTT: 14.3/27.7, INR:1.19,
Ur/Cr: 34/0.63, GOT/GPT: 30/30, Na/K/Cl:
134/4.7/106, GDS: 94, As. Urat: 2.2, Alb: 2.8, WBC:
10.4, RBC:3.63, HB: 10.2, HCT: 30.2, PLT: 738
4/1/14
Ur/Cr: 32/0.5, GOT/GPT: 31/39, Na/K/Cl:
123/4.4/199, RBC: 4.17, HB: 11.6, HCT: 36.8, PLT:
766, WBC: 26.3
30-12-13
Na/K/Cl 137/3,8/112
Wbc 8,2 Rbc 3,3 Hb 10,1 Plt 149
Lab 28-12-13
Wbc 8,28 Hb 7,2 Plt 89 PT 11,8 APTT 25,6 INR
1,0Ur 26 Cr 0,7
Lab 25/12/13
WBC 9,17 RBC 2,86 HB 8,3 HCT 24,2 PLT 61
GOT/GPT 245/317 Alb 2,2 Na/K/Cl 136/4,47/115
PT/APTT 14,6/32,3 GDS 110 Ur/Cr 42/1,4
USG Abdomen 25/12/13
Ruptur buli-buli dengan hemoperitoneum
Uretrografi 25/12/13
Ekstravasasi kontras ke intraperitoneum s/ rupture
buli buli, fraktur ramus superior et ramus inferior os
pubis bilateral

LONTARA 2 Onko
NICU
ICU
LONTARA 3 THT
LONTARA 3 SARAF

14

Agus Maruf
32 tahun
Mrs 2/12/2013
Ttl: 27/8/1968
416
Dr. Syarif Bakri,
Sp.U

Nefrolithiasis bilateral
+ HN bilateral+ LBP
e.c. fr. Kompresi VL1

LONTARA 4
RSUH
Tunggu hasil USG
Abdomen dan lab ALP
dan PSA
Bladder training
Fisioterapi lanjut
Konsul rawat sama
anestesi

Lab 2/1/14
WBC 9,84 rbc 3,59 hgb 9,4 plt 647 hct 29,7
Got/gpt 13/18 ur/cr 21/1,0
Lab 31/12/13
Wbc 6.67, rbc 3.55, hgb 9.4, hct 29.3, plt
506
Lab 30/12/13
Wbc 6.41, rbc 2.68, hgb 6.7, hct 21.7, plt 525
Urin rutin 22/12/13
warna coklat tua, blood +++/250, bilirubin
(-), protein +30, pH 7.0, BJ 1.050, leukosit
+25, vit. C +10, sed. Urin, eritrosit penuh,
leukosit 8-10, epitel 0-2.
Lab 22/12/13
PT 13.9, inr 1.14, APTT 29.9, alb 2.5
Foto lumbosacral ap/lat
Muscle spasm, frakturkompresi CVL1
Urinrutin 2/12/2013
Color: merah blood ++ protein ++ glukosa +
leukosit + vit.C +
6

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

15.

Heriadi
24/3/1986
01.74.93
MRS 8/1/2014
ASKES

Kolik Abdomen e.c

batu ureter 1/3
proksimal (D)
Hidronefrosis (D)
Hiperurisemia

Mobilisasi
Nacl 0,9% 20 tpm
Cefttriaxone 1 gr/12j/iv
Tramadol/drips

Lab 2/12/2013
Wbc 10.01 rbc 5.07 hgb 12.7 hct 39.7 plt 438
na/k/cl 138/4.5/100 sgot/sgpt 39/49 gds 99
as.urat 9.5 ur/cr 58/1.6
Lab 16/12/2013
WBC 16,96 RBC 3,73 HGB 11,6 HCT
39,7 PLT 156
Lab (8/1/14)
WBC: 8,25 RBC: 5,32 HGB : 14,9 HCT:
43,7 PLT: 268 As. Urat: 9,9 Ur/Cr:
35/1,9
CT Scan Uro tanpa Kontras (8/1/14)
Hidronefrosis ureter dextra e.c ureteolith

Kamar 421
dr. Syarif Bakrie
Sp.U
PCC
CVCU
INFECTION CENTER
UGD
PALEM BAWAH
16

Saehe
TL: 1/1/1931 (83)
RM: 297857
MRS: 8/1/2014

Hipertropy prostat
Hipoalbuminemia

Palm bawah
B2/K9B2

17

Daliman
11/11/1950
643291
MRS:23/12/2013
ASKES
B 2/11 BED 1
Dr. Kholis, Sp.U

Neurogeic
bladder
suprasegmental
ec spinal cord
injury
Destruksi V L I
POH 8
dekompresi +
stabilisasi
posterior
DM tipe 2
Hipoalbuminemi
a (2.2)

PALEM ATAS
- Bladder training
- Lain-lain terapi sesuai Ts
ortopedi
- -Cefixime 2x100 mg
- Terapi endo lanjut
- Diet dm
- Duduk
- Observasi jika retensi pasang
ulang kateter

Lab 8/1/2014
BT/CT: 300/830
PT/APTT: 12,9/48,6
GDS: 87
Ur/cr: 6/0,5
GOT/GPT: 44/14
Alb. 2,9
HbsAg/anti HcV non reactive
WBC: 7,56
HcT: 29,4
PLT: 539

Lab 7/1/2014
Urin rutin: Blood +++, Leukosit +++
Lab 6/1/2014
WBC: 8.3, RBC: 3.39, HB: 10, HCT: 28.9,
PLT: 325, GDS: 87, Ur/Cr: 21/0.55,
GOT/GPT: 37/64, prot. Total: 5.4, Albumin:
2.2, Na/K/Cl: 139/4.5/107
Hasil kultur urin 6/1/14
Ceftazidime, Meropenem, Ofloxacin,
Cefepime, Norfloxacin
Lab 2/1/2014
Thoraks ap/lat : tampak plat+screw
terpasang CV Th12-L2 kedudukan baik,
Tampak osteofit pada aspek anterior CV
Th6-11, Mineralisasi tulang berkurang,
Discus an foramen intraertebralis baik,
jaringan lunak para vertebra baik
Lumbosacral AP/Lat: tampak plat+screw
terpasang CV Th12-L2 kedudukan baik,
tampak garis fraktur pada aspek
7

KORAN BEDAH UROLOGI MINGGU, 12 JANUARI 2014

anterosuperior CV L1, Tidak tampak tanda
tanda osteomyelitis, tampak osteofit pada
anterolateral CV L5-L6, tampak
lumbalisasiS1 menjadi L6, Osteoorosis
senilis, Discus intervertebralis sedikit
menyempit pada CV Th12-L1, Jaringan
lunak paravertebral baik
Lab 30/12/13
Ur/Cr: 22/0.94
Lab 23/12/13
WBC:10.65 RBC:3.90 HGB:11.3 HCT:33.1
PLT:192 Ur/Cr:69/0.8 Alb:3.6 BT:3,00
CT:800 PT:11.4 INR:0,90 APTT:20.0
Na/K/Cl:137/4.9/107 HbsAg non reactive