Sabtu, 26/9/2020 UROLOGI MDB/FID/KIS/SIW/UJI

R P B N R D S P KETERANGAN
J ED AMA SIA M RS IAGNOSIS TATUS LAN PJP

20/9/20 hb 11,7 ht 37 al
18,6 at 312 ae 4,86 pt 15,1 aptt 31,6 inr 1.080 gds 119 alb 2,4 cr 0,9 ur 21 na 133 k 2,4 cl 102

14/9/20 hb 9,6 ht 30 al
10 at 269 ae 4,09 pt 14 aptt 32,4 inr 1,050 gds 104 cr 0,9 ur 36 na 136 k 3,0 cl 106 HBSAG
REACTIVE rapid covid nr

24/9/20 AGD : ph 7.499

be 1.6 pco2 43 po2 83 hco3 26,6 tot co2 27.9 o2 96

D
xE: 3/6/20 CT Abdomen :
Gambaran pembesaran ren sinistra lesi solid di intra parenkim ren sinistra yang mendapat feeding
arteri dari arteri renalis sinistra mengarah gambaran renal cell carcinoma. Ileus obstruktif letak
D rendah. Splenomegaly. Efusi pleura sinistra. Multiple lymphadenopathy di inguinal bilateral,
H x P : Tumor Ren (S) Susp. Maligna P illiaca bilateral serta paraaorta bilateral yang mengencase aorta abdominalis terutama segmen
cT4N1M1 (pulmo, otak) ost op P
CU S 1 T 0 bifurcation aorta abdominalis.spondylosis lumbalis.
ost Sitoreductif Nefrectomy
IW 8 n. Suparman 9 1502780 oli 19/9 r. AG
D 2 (S)
C 9/9/20 Tindakan oklusi
x K : Anemia, hipoalbumin, 5/9 feeding arteri renalis sinistra.
empaka
D 18/8/20 USG Thoraks
x L : Paraparese. AF NVR. Marker : Efusi Pleura kiri
Pneumonia

12/8/20 CT Kepala :
Multiple lacunar infark di corona radiata bilateral, thalamus bilateral, putamen kiri, capsula interna
bilateral, nucleus caudatus kiri. Brain atropi.

21/9/20 Ro Thoraks :
Pneumonia. Efusi pleura kiri. Cor tak tampak kelainan.

7/9/20 Ro Thoraks :
Tak tampak gambaran pulmonal metastase.

20/9/2020 Hb 12.1 Ht
34 Al 4.9 At 174 Ae 4.22 Pt 12.9 Aptt 30.1 Gds 215 SgOt 18/pt 28 Alb 3.9 Cr 1.5 Ur 18 hsCRP
D 6.11 Na 137 K 3.4 Cl 97 Hbsag NR
x E : Kolic Renal
22.9.20 AGD : PH
M D 7.360 BE 0.4 PCO2 47.0 PO2 88 Ht 55 HCO3 26.6 Tot CO2 28.0 O2 sat 96 Laktat arteri 2.1p
elati x P : Susp. Uretrolithiasis P FiO2 80%
S 9 T 0 W
ro BNO IVP Jika Swab
IW -B n. Yahdi 7 1515119 o Paru 23/9 ork up r. WB
1 D Negative 19/9/20 USG :
x K : Hidronefrosis Hidronefrosis (s) grd 2 dg hidroureter prox ec obstr post renal

D Gastritis
x L : COVID-19 (+) + DM type II
Thoraks 19/9/20 Ro
Toraks : dbn

S 1 A 0 D P P 21/9/20 Urinalisa :
IW 1-I n. Oktania 1bln 1510797 o Pediatri 17/9 xE: re op ro USG Evaluasi bulan depan r. WB Yellow. Cloudy. BJ 1.013. eritrosit ++/positif2. Epitel squamous 1-2.

D 17/9/2020 GDS 79 Alb

x P : Hidronefrosis bilateral 4.0 Ur 3 Cr 0.2 Na 132 K 3.3 Cl 98 Ca 1.19

D 16/9/2020 Hb 9,6 Ht 30
 Al 19,1 at 442 Ae 3,52 Gds 79 Alb 4,0 Cr 0,2 Ur 3 Na 132 K 3,3 Cl 98 Cal 1.19 HBsAg negative
Rapid test covid negative.

M
23/8/20 Ro Thoraks :
elati
Cor tak membesar. Gambaran Bronchopneulonia. Tak tampak limfadenopati hilus kanan kiri
x K : ISK Kompleks
2 26/8/20 USG Abdomen
D : Mild Hidronefrosis duplex. Distensi vesika urinaria disertai cystitis. Tak tampak kelainan lain
x L : CP Hipotonia + CMV pada sonografi organ organ intraabdomen lainnya.
Congenital + Hypotyroid subklinis.
21/9/20 Kultur Urine :
Organism Escherichia coli. Saran : Gentamicin, Amp Sulbactam, Cefefime, Meropenem

22/9/20 Kultur Darah :

No Growth

D 20/9/20 hb 13,5 ht 39 al
xE: 9,4 at 239 ae 4,46 sgot 20 sgpt 19 cr 1,0 ur 28 na 137 k 3,6 cal 1,19

A P
D hbsag nr
nggrek ro Kemo Etopuside 100mg +
T x P : CA Testis (S) Non Seminoma
S 2 0 P Cisplatin 20mg 5hari
n. Gregorius 7/9/20 hb 13,8 ht 41 al
3 IW 0 5 1471393 oli 20/9 ro kemo r. AG
Bayu D 10,2 at 369 ae 4,83 sgot 18 sgpt 25 cr 0,9 ur 28 na 141 k 4,5 cal 1,17
H
xK:
ari 5/5
22/5/20 PA : Testis
D Sinistra : Ganas, Histologi sesuai untuk Yol Sac Tumor
xL:

D 21/9/20 hb 9,3 ht 28 al
xE: 11,4 at 299 ae 3,23 cr 10,6 ur 145

F
D 21/9/20 Urinalisa :
lam
x P : Hidronefrosis bilateral Yellow. Cloudy. Leukosit 500. Protein ++/positif2. Leukosit ++/positif2. Epitel squamous 2-3.
K 6 N 0 P P Epitel transisional 0-1. Granulated 3-4. Leukosit 0-1. Small round cell 0.1.
6 IS 06A y. Winarti 5 1514779 o Obgyn 23/9 re op ro konsul r. SH
D
xK: 24/4/20 USG
Abdomen : Massa di cervix uteri yang menginfiltrasi dinding bladder. Hidronefrosis sedang
D bilateral. Tak tampak intraabdominal metastase. Tak tampak efusi pleura bilateral maupun ascites.
x L : CA Cervix IIIB + AKIN Tak tampak limfadenopati di paraaorta. Hepar/GB/Lien/Pankreas tak tampak kelainan.

D 22/9/20 hb 15,1 ht 45 al
xE: 10,8 at 274 ae 5,28 gds 132 sgot 19 sgpt 18 cr 0,7 ur 17
P
ro kemoterapi
D 6/8/20 CT Abdomen :
T x P : CA Testis (Seminoma) (D) Tak tampak sisa jaringan maupun massa residif pada regio testis. Parenkim hepar dan lien dalam
K 7 0 P E batas normal. Tulang yang terlihat dalam batas normal, metastasis (-).
n. Mico
IS 03B 4 1511602 oli 23/9 ro kemo topuside 181mg (hari3/5) r. SH
Handika D
xK: 21/7/20 PA : Testis
C Dextra : Seminoma Testis
isplatin 36,2mg (hari3/5)
D
xL:
F
K 7 T 0 D P P 23/9/20 hb 7,8 ht 30 al
lam
IS 04B n. Suparno 0 1509912 oli 23/9 xE: ro Kemo ro Kemoterapi Gemcitabine r. WB 6,7 at 271 ae 3,93 sgot 17 sgpt 16 cr 1,2 ur 25
1.590mg (hari1)
7 D 28/8/20 USG Urologi :
x P : CA Buli T2aNxM0 C Massa residif di bladder. Ren bilateral/prostat/tak tampak kelainan.
isplatin 159mg (hari2)
D 7/9/20 Ro Thoraks :
x K :Anemia Aortosklerosis. Pulmo tak tampak kelaianan.
 D 15/9/20 PA : Buli :
xL: Invasive High Grade Urothelial Carcinoma Invasi ke Tunika Muskularis Propia.

24/9/20 hb 10,4 ht 30 al
5,5 at 95 ae 3,40 HbA1c 8,5 GDP 304 GD2PP 507
D
xE:
23/9/20 hb 10,1 ht 30 al
P 4,2 at 67 ae 3,59
D ro kemoterapi Gemcitabine
x P : CA Buli T2NxMx 1510mg (hari1) + Cisplatin
K 7 T 0 P 105,7mg (hari2) 22/9/20 hb 11,2 ht 32 al
IS 06C n. Pardi 8 1487693 oli 21/9 ro kemo r. WB 3,4 at 42 ae 3,77
D
xK: R
aber Interna 18/9/20 hb 11,9 ht 36 al
5,4 at 94 ae 4,11 sgot 28 sgpt 22 cr 1,8 ur 70
D
x L : Trombositopenia + DM
19/12/19 PA :
Transisional Cell Carcinoma berdifferensiasi jelek

D 23/9/2020 Hb 9,9 Ht 28
xE: Al 10,1 At 115 Ae 3,57 Alb 3,4 Cr 3,8 Ur 84 GDS 110 Sgot 72 Sgpt 70 Pt 14,4 Aptt 30,5 Inr
1.010 HBsAg negative
D
x P : Hematuria 25/9/20 Urinalisa :
U 9 T 0 P P Warna Red. Kejernihan Cloudy. Protein ++++/positif4. Glukosa +/positif1. Bilirubin ++/positif2.
JI 01B n. Soekiman 8 1515204 o Paru 25/9 D re op ro USG Urologi + BNO r. SH Eritrosit +++/positif3. Epitel squamous 0-1
x K : Anemia
24/9/20 Ro Thoraks :
D Pneumonia atypical covid 19. Cor tak tampak kelainan.
x L : Covid-19 Negatif + AKI dd
AKut on CKD

U 9 N 0 D P P 25/9/20 hb 9.7 ht 29 al
JI 04B y. Debara 1 1507551 oli 21/9 xE: re op erbaikan KU r. AG 11,4 at 244 ae 3,41 hbsag nr anti hcv nr
Fitriana
D R 24/9/20 hb 9,0 ht 29 al
x P : Susp. Neurogenic Bladder aber Interna 11,6 at 319 ae 3,32

D B 23/9/20 hb 7,6 ht 25 al
x K : Inkotinensia Urine ladder Training 9,8 at 239 ae 3,00 cr 5,4 ur 143
F
lam
D T 22/9/20 hb 5,8 ht 19 al
x L : Anemia, Insiff Renal unggu hasil kultur urine 10,3 at 341 ae 2,28 gds 92 sgot 8 sgpt 6 alb 3,1 cr 5,6 ur 144 na 131 k 4,9 cl 111 hbsag nr
9
21/9/20 Rapid test nr

14/9/20 hb 6,3 ht 21 al
8,1 at 297 ae 2,52 cr 5,3 ur 141. Urine warna orange, cloudy. Leukosit 500. Protein ++/positif2.
Eritrosit ++/positif2.

22/9/20 Urinalisa :
Orange. Cloudy. Bj 1.014. leukosit 500. Protein +++/positif3. Eritrosit +++/positif3. Epitel
squamous 3-4. Granulated 1-2. Small round cell 1.2

14/9/20 USG Urologi :

Severe hidronefrosis bilateral e.c uropati obstruktif. Insufisiensi renal bilateral. Cystitis.

14/9/20 Ro Abdomen :
Tak tampak bayangan radioopaque disepanjang tractus urinarius. Nefromegaly bilateral.
Terpasang fiksasi internal (Rod+Screw) yang terproyeksi setinggi corpus Vth11- VL2.

26/8/20 USG Urologi :

 Hidronefrosis berat dan Hidroureter proximal bilateral. Debris buli.

28/8/20 CT :
Hidronefrosis berat bilateral disertai hydroureter hingga UVJ bilateral e.c Susp. VUR. Cystitis
disertai Susp. Neurogenic bladder.

D 25/9/20 hb 8,1 ht 27 al
xE: 16,3 at 393 ae 3,64 gds 129 cr 0,6 ur 44 na 130 k 5,1 cl 92 hbsag nr rapid covid nr

D T
x P : Hematuria + CA Buli ransfusi PRC
U 9 T 0 W
JI 04C n. Triyanto 6 1514646 GD 25/9 ork up r. SH
D P
x K : Anemia ro USG Urologi + BNO

D
xL:

D 22/9/20 hb 11,9 ht 36 al
xE: 9,3 at 345 ae 3,95 pt 12,6 aptt 29,7 inr 0,860 gds 129 sgot 9 sgpt 12 alb 3,9 cr 0,7 ur 16 na 125 k
4,0 cl 88 hbsag nr rapid covid nr
D P
x P : Tumor Buli + HN D/S ost op P 21/9/20 USG
U 1 N 0 Abdomen : Massa cervix uteri yang meluas ke corpus uteri dan vesica urinaria. Hidronefrosis
ost TURBT + Nefrostomy
JI 002B y. Samiyati 5 1511792 oli 24/9 r. AG ringan kanan. Hidronefrosis berat kiri. Hepar, GB, Pancreas, Lien tak tampak kelainan. Tak
D 2 (D/S)
xK: 5/9 tampak metastasis intraabdomen.

D 21/9/20 Ro Thoraks :
x L : CA Cervix Nodular type dan subpleural type pulmonal metastase. Cor tak tampak kelainan.

25/9/20 hb 10,4 ht 27 al
13,0 at 128 ae 3,71 pt 13,2 aptt 28,9 inr 0,910 gds 82 sgot 71 sgpt 17 alb 3,3 cr 5,5 ur 86 na 105 k
F D
3,3 cl 75 hbsag nr
xE:
lam
24/9/20 Rapid nr
D
1 x P : CA Prostat T4N1Mx + HN D/S
0 U 1
S
0 + AKI dd Akut on CKD P
P 25/9/20 USG Urologi :
dr. Ficky Cahyo ro Pasang DJ Stent D/S k/p Lesi solid heteroechoic batas tegas tepi ireguler yang pada CDFI tampak vaskularisasi intralesi
JI 007A 6 1515165 oli 24/9 re op r. SA
Utomo Percutaneous Nefrostomi D/S mengarah massa residu di prostat yang menginfiltrasi dinding posterior buli dan sebagian rectum.
D
Hidronefrosis ringan bilateral disertai hydroureter 1/3 proximal bilateral. Insufisiensi renal
xK:
bilateral. Cystitis. Incidental finding: ascites dan efusi pleura kanan. Multiple suspicious
limfadenopathy di regio inguinal bilateral.
D
xL:
18/9/20 PA :
Adenocarcinoma prostat, gleasson 8(4+4)