REKAP PASIEN BEDAH UROLOGI

Senin, 09 Januari 2017

Total : 17 Pasien
Jeumpa 4:3 Pasien
NO

BED

K3B2
POD 4

DIAGNOSA
DPJP

ID

Saudah/Pr/
59 tahun/1-08-30-19

Obgyn
1. Ca cervix stage IV
A
2. HN on nefrostomy
3. Anemia
4. Hipertensi
5. Hipoalbumin
IPD
1.

K4B1
POD 5

Muhaimin/Lk/38
tahun/ 1-10-22-03

2.
3.
4.
5.

K2B2

Nabawi : 1 pasien

M. Hasan
Mahmud/Lk/67
tahun/1-11-49-70

CKD stage V ec
pool on HD
reguler
HHD
HN bilateral
Nefrolitiasis
bilateral
Susp cocigytis

Shock sepsis dd/

urosesis + AKI
Retensi urin ec susp.
BPH
LBP

DIAGNOSA RABER

1.

Post nefrotomi
bilateral

LAB
03-01-17
Hb/Ht/E/L/T
11,6/34/4,3/15,9/114
Albumin 2,51
Na/K/Cl 134/3,8/105
GDS 174
Ur/Cr 103/5,70/6,64

PLANNING

Konsul rawat alih ke Obgyn

Evaluasi produksi nefrostomi per

24 jam
GV per hari
TransfusiPRC 2 kolf/ hari
Konsul IPD u/ HD -> transfusi 2
kolf intra-HD
Konsul pulmo u/ biopsi massa
stoma

05-01-17
Alb 2,89

Post nefrostomi perkutan

bilateral ai CKD ec obs
uropati ec batu ureter
dekstra + nefrolithiasis
dekstra

06-01-17
Hb/Ht/E/L/T
6,9/20/2,4/7,1/112
CT /Bt 9/2
Na/K/Cl 132/3,7/102
GDS 157
Ur/Cr 119/6,40
08-01-17
Hb/Ht/E/L/T
13,7/39/4,7/26,3/264
Prot. Total/Alb/Glob
5,38/2,75/2,63
Na/K/Cl 135/5,3/105
GDS 68
Ur/Cr 98/5,20

Konsul neurologi (+)

Konsul IPD (+)
Kultur darah (-)
Kultur urin (-)
Cek lab DR, ur/cr, na/k/cl ulang
Konsul anestesi pro pasang CVP

NO

IDENTITAS

DIAGNOSA
DPJP

Nazaruddin
Rasyid/Lk/49
tahun/1-11-49-24

Retensi urin ec dd
1. BPH
2. Ca buli
+ gross hematuri

BED

K6B1

DIAGNOSA
RABER

LAB
06-01-17
Hb/Ht/E/L/T
13,4/39/4,7/9,0/241
CT /Bt 7/2
Na/K/Cl 144/4,0/113
Ur/Cr 16/1,10

PLANNING

USG urologi

JEUMPA 1 : 1 pasien
NO

BED

K5B4

IDENTITAS

T. Jamaluddin/Lk/57
tahun/1-11-42-92

DIAGNOSA
DPJP

DIAGNOSA
RABER

LAB
05-01-17
Hb/Ht/E/L/T
11,1/32/3,9/30,2/455
Ur/Cr 118/9,90

Urosepsis post URS

dekstra + CKD stage V
+ udem paru + efusi
pleura dekstra post
chesttube

06-01-17
Ur/Cr 179/11,60

PLANNING
-

Konsul anastesi (-)

Konsul kardio (+)
USG urologi hari ini
CT scan abdomen

JEUMPA 2 :1 Pasien
NO

BED

K7B6
POD 10

IDENTITAS

Salmiah/Pr/66
Tahun/
1-11-27-91

DIAGNOSA
DPJP

DIAGNOSA
RABER

Nefrolithiasis bilateral +
HN bilateral post
nefrostomi dekstra +
CKD stage V

IPD
CKD stage V ecdd/
1. PGDI dengan uremik
sindrom
2. HN
+ hiperkalemi sedang
(perbaikan) + hidronesfrosis
grade III-IV sinistra +
nefrolitiasis bilateral

LAB

05-01-17
Hb/Ht/E/L/T
10,2/32/4,1/7,6/300

PLANNING

Rencana PNC sinistra + open

ureterolitotomi
Konsul kardio (-)
Konsul anestesi (-)

GERUTEE 2 : 1 Pasien
NO

BED

IDENTITAS

K19

Taufik/Lk/29
tahun/1-11-43-86

DIAGNOSA
DPJP
Pneumonia

DIAGNOSA
RABER
HN sinister ec susp
ureterolithiasis sinistra

LAB

PLANNING

02-01-17
Hb/Ht/E/L/T
14,2/42/4,8/11,7/307

MAMPLAM 1 : 2 pasien
NO

BED

IDENTITAS

DIAGNOSA
DPJP

DIAGNOSA
RABER

LAB

PLANNING

K2B3

K2B4

M. Amin Daud/Lk/44
tahun/1-11-49-15

CKD stage V + nefropati

John Safrizal/Lk/49
tahun/1-11-45-79

Striktur uretra dengan

cystostomi post TURP

06-01-17
Hb/Ht/E/L/T
8,0/24/3,4/18,3/355
Ct/Bt 7/2
Na/K/Cl 135/6,4/104
Ur/Cr 147/17,80

USG urologi

03-01-17
Hb/Ht/E/L/T
12,4/40/4,9/12,1/277
CT /BT 8/2
Albumin 2,52
Na/K/Cl134/4,7/102
GDS 247
Ur/Cr 69/1,80

Uretrografi hari ini

MAMPLAM 2 : 1 pasien
NO

BED

K3B1
POD 4

IDENTITAS

Syakumi/Pr/72
tahun/1-0397-96

DIAGNOSA
DPJP
IPD
CKD stage V ec PGDI
on HD reguler + tumor
a/r palpebra superior
sinistra + anemia
hipokrom mikrositer +
multiple nefrolitiasis
dekstra

DIAGNOSA
RABER

Post PCN dekstra + inst DJ

stent dekstra ec HN dekstra
+ nefrolithiasis dekstra

LAB
06-01-17
Hb/Ht/E/L/T
9,3/30/4,1/14,7/241
Na/K/Cl 137/3,8/106
GDS 116
Ur/Cr 98/6,10

PLANNING

Susul hasil BNO

Pasang stoma bag (+)
Konsul IPD (-)
Mobilisasi

HCU : 1 Pasien
NO

BED

IDENTITAS

Bed 4

Sapril/Lk/41
tahun/1-11-43-99

DIAGNOSA
DPJP

DIAGNOSA
RABER
HN bilateral grade IV +
CKD stage V +
nefrolithiasis bilateral

PLANNING

LAB
05-01-17
Hb/Ht/E/L/T
8,3/24/3,0/17,2/279
Albumin 3,60
Procalcitonin 8,95

Nefrostomi perkutan bila sudah ada

hasil BNO

ISO : 2 Pasien
NO

BED

IDENTITAS

DIAGNOSA
DPJP

DIAGNOSA
RABER

LAB

PLANNING

K8
POD 3

Hasrial/Lk/62 tahun/
1-11-33-16

Post nefrostomi
perkutan sinistra ai HN
sinistra grade IV ai susp
batu ureter sinistra
proksimal + PNC
dekstra
IPD
1.

K5

Hasyem/Lk/64
tahun/0-03-53-14

2.
3.

AKI stage III

ecdd/ akut on
CKD
DM tipe 2
overweight
Nefrolitiasis
dekstra

HN dekstra + nefrolitiasis
dekstra

04-01-17
Hb/Ht/E/L/T
8,7/27/3,3/9,4/358
CT /BT 8/2
Na/K/Cl141/4,2/108
GDS 112
Ur/Cr 53/3,66

APG sinistra hari senin

GV nefrostomi per 2 hari

06-01-17
Hb/Ht/E/T/L
11,4/31/3,6/9,3/517
CT /BT 8/3
Na/K/Cl 135/6,1/111
Ur/Cr 145/2,0

Konsul anastesi (+)

Rencana URS persiapan open
bivalve nefrolitotomi

GEULIMA 1 : 1 pasien
NO

BED

IDENTITAS

K6B6

M. Husin/Lk/77
tahun/1-11-38-50

DIAGNOSA
DPJP
Saraf
Penurunankesadaranec
stroke iskemik

DIAGNOSA
RABER
Retensi urin ec neurogenic
bladder

PLANNING

LAB
05-01-17
Hb/Ht/E/L/T
10,7/33/3,/7,7/400

Susul USG urologi

Ganti FC per 2 minggu

GEULIMA 2 : 2 pasien
NO

BED

IDENTITAS

DIAGNOSA
DPJP

DIAGNOSA
RABER

Iso 1

Zaini Ismail/Lk/86
tahun/1-11-48-00

Hematuria due to
instrumentasi

K6B6

Sudiran/Lk/64
tahun/1-11-40-91

Hidrocele bilateral +
hipoalbumin + hipokalemi

PLANNING

LAB
07-01-17
Hb/Ht/E/L/T
11,9/32/4,3/15,9/365
CT /BT 7/2
Alb/Glob 3,70/2,24
Na/K/Cl 108/5,1/80
Ur/Cr 45/0,60
05-01-17
Hb/Ht/E/L/T
11,3/37/4,8/8,5/321
Albumin 2,76
Na/K/Cl 145/2,9/110
Ur/Cr 11/0,53

USG urologi
Urinalisis
FC (+)
Susul hasil BNO

Persiapan hidrocelektomi (konsul

kardio -)
Rencana TTNA dari paru

IW 1 : 1 pasien
NO

BED

IDENTITAS

DIAGNOSA
DPJP

DIAGNOSA
RABER

LAB

PLANNING

Suwarni/Pr/41
tahun/1-11-49-32

Susp tumor
intraabdomen dd abses
perirenal + batu
staghorn sinistra + HN
sinistra

07-01-17
Hb/Ht/E/L/T
9,1/27/3,1/12,1/431
CT/BT 7/2
Na/K/Cl 139/3,2/103
Ur/Cr 7/0,50

CT scan abdomen kontras-non kontras