Minggu, 7/6/2020 UROLOGI DAV/GAN/WID/SYA/LIN

PJ BED NAMA USIA RM MRS DIAGNOSIS STATUS PLAN DPJP KETERANGAN

ICU LIN 107 Ngaisah 51 01070930 MRS Post laparotomi eksplorasi + Post Op Perawatan Post OP dr. SA 6/6 Lab Hb 10.6 Ht 32 AL 3.8 AT 218 AE 3.43 GDS 71 Alb 2.5 Cr 3.6 Ur 76 Na 134 K 3.3 Cl 101
3/6/2020 appendektomi ai peritonitis 6/6/2020 5/6 Lab Hb 8.0 Ht 24 AL 6.1 AT 188 AE 2.6 Cr 2.9 Ur 51 Na 133 K 3.0 Cl 101 Rapid test Covid 19 Negatif
Co. Interna generalisata ec appendicitis 4/6 Urinalisa warna Dark yellow cloudy leukosit 500 Protein ++ eritrosit ++
5/6/2020 perforasi + massa 4/6 USG abdomen Lesi heteroechoic (solid, kistik) dan bersepta, batas tegas, tepi ireguler, berdinding
retroperitoneal (S) + tebal di regio iliaca kiri (inferior ginjal kiri) yang pada CDFI tampak Sebagian hipervaskular di perifer. DD
hematoma DPH 1 abses, masa curiga malignan. Efusi pleura bilateral. Ascites. Cholelitiasis. Chronic kidney disease disertai
Post eksplorasi ai Hematom complex cyst ginjal kanan.
retroperitoneal (S) + susp 3/6 lab Hb 6.1 Ht 19 AL 8.2 AT 153 AE 2.02 GDS 146 SGOT 21 SGPT 15 Alb 2.9 Cr 4.6 Ur 78 Na 134 K
massa ren (S) DPH 1 4.2 Ca Ion 1.39
3/6 Abdomen 3 posisi tak tampak gambaran ileus maupun pneumoperitoneum. Meteorismus dengan
fecal material prominen.
3/6 Ro Thorax cardiomegaly dengan edema paru dan efusi pleura bilateral minimal
20/5 Serologi HBsAg NR Anti HCV NR
Melati 1 SYA 11E Sadimin 71 01505358 Co. Pulmo PDP covid 19 Work Up Work up diagnostic 4/6 Lab Hb 10.7 Ht 33 AL 19.6 AT 284 AE 4.10 GolDar O GDS 101 SGOT 21 SGPT 15 Alb 3.6 Ur 61 Cr
5/6/2020 Retensi urine ec Susp BPH Diagnostic 1.0 hs-CRP 4.94 Na 132 K 3.8 Cl 94 HBsAg NR
4/6 Ro Thorax pada foto thorax tanggal 5 juni 2020 pukul 10:12 kesan Pneumonia unilateral kanan
Anggrek 3 WID 30 Suratmi 63 01445948 Poli Ca Buli T2N1M1 On Kemoterapi Kemoterapi: dr. WB 5/6 Lab Hb 11.7 Ht 3.7 AL 8.6 AT 293 AE 3.87
3/6/2020 Kemoterapi Gemsitabin 1310 mg 3/6 Lab Hb 6.4 Ht 20 AL 9.7 AT 374 AE 2.04 SGOT 50 SGPT 15 Alb 2.8 Cr 1 Ur 31 Na 135 k 3 Ca ion
Cisplatin 91.7 mg 1.08
24/1/2019 PA Sitologi urin : mencurigakan uropoetica
Melati 2 SYA 5H Muazzam 2 01503492 Poli Post Sistoskopi evaluasi + Post Op Mobilisasi bertahap dr. AG 4/6 Rapid tes Covid 19 Negatif
Irsyadul Ibad 3/6/2020 biopsy massa tumor aitumor 5/6/2020 Pertahankan kateter 1-2 4/6 Lab Hb 11.5 Ht 34 AL 11 AT 456 AE 5.23 GolDar B GDS 94 SGOT 26 SGPT 8 Ur 20 Cr 0.4 Alb 4.3
buli susp. Maligna DPH 2 minggu Na 139 K 4.1 Cl 104
12/5 lab hb 12.9 ht 36 AL 9.2 AT 415 AE 5.5 Cr 0.4 Ur 25 Na 136 k 4.1 cl 101
6/5 Lab Ur 32 Cr 0.4 Urinalisa warna yellow cloudy. Leukosit 500
2/5 USG abdomen masa dinding posteroinferior buli batu negatif
13/5 Ct abdomen non kontras: lesi solid diserta penebalan dinding inferior buli susp sistitis dd masa buli.
Hepatospleno megali. Cholelithiasis. Spina bivida.
Flamboyan 6 WID 8B Sadimin Gito 69 01505090 Poli BPH grade III + divertikel VU Pre Op Pro Turp Senin 8/6/2020 dr. SA 6/6 Lab Hb 9.3 Ht 28 AL 10.6 AT 299 AE 3.43
Wiyono 2/6/2020 Perbaikan KU dari TS 5/6 As.urat 7.5
kardiologi 4/6 AGD PH 7.430 BE 1.9 PCO2 40 PO2 70 HCO3 26.6 Total CO2 27.9 O2 Saturasi 95.0
3/6 Lab Hb 11.9 Ht 36 AL 7.8 AT 194 AE 4.03 PT 12.0 APTT 31.0 INR 0.860 GolDar O GDS 163 SGOT
21 SGPT 22 Ur 383 Cr 1.4 As.Urat 9.3 Na 139 K 3.9 Cl 109
1/5 Lab Hb 12.1 Ht 37.8 AL 6.4 AT 270 AE 4.13 GolDar O Bt 2’10” CT 6’25” SGOT 37 SGPT 38 Ur 31 Cr
1.1 GDS 89 HBsAg Negatif
31/5 Ro Thorax cardiomegaly dan pulmo normal.
6/5 USG Upper Lower Abdomen Gastritis Akut. Divertikel VU Tak tampak kelainan pada hepar , vesika
felea, lien, pancreas, kedua ren dan prostat.
Flamboyan 7 LIN 1A Gregorius 25 01471393 Poli Ca Testis S Post kemoterapi Kemoterapi hari ke 2 dr. AG 5/6 Lab Hb 15.9 Ht 48 AL 6.5 AT 302 AE 5.84 PT 11.9 APTT 34.7 INR 0.850 GolDar B GDS 78 SGOT 21
4/6/2020 Orchidectomy Bleomycin 30mg SGPT 25 Alb 4.5 Ur 28 Cr 0.9 As. Urat 7.5 Na 137 K 5 Cl 108
Etoposide 200mg 22/5/20 PA: ganas, sitologi sesuai yolk sac tumor, pangkal irisan bebas tumor
Cisplatin 20mg
Flamboyan 9 WID 6C Karto Dikromo 83 01505223 Poli Retensi Urin Pre Op Pro TUR-P + Biopsi Prostat dr. AG 6/6 Serologi HBsAg NR Anti HCV NR
3/6/2020 BPH Selasa 9/6/2020 6/6 BNO Fecal material Prominent. Spondhilosis lumbalis.
Susp Ca. Prostat 5/6 Urin rutin yellow, cloudy, leukosit 500 eritrosit +3
CKD 4/6 Lab Hb 13.5 Ht 42 Al 12.6 AT 301 AE 5.05 GolDar O PT 13.8 APTT 24.8 INR 1.030 GDS 128 SGOT
28 SGPT 22 Alb 3.5 Cr 3.8 Ur 317 As. Urat 14.1 Na 153 K 5.3 Cl 105 PSA 63.36
2/6 rapid tes covid 19 negatif
30/5 Ur 310 Cr 11.48
29/5 HIV Negatif
28/5 Hb 11.7 AE 4.29 Ht 35.5 GolDar O Bt 2’ CT 12’ SGOT 9 SGPT 12 HBsAg NR
28/5 USG Abdomen Pembesaran prostat mengarah BPH grade IV
IGD Ny. Martin 81 01503805 IGD 6/6 Lab Hb 11.3 Ht 34 AL 12.7 AT 284 AE 4.05 GolDar O Ur 21 Cr 0.8 Na 140 K 2.8 Cl 98 HBsAg NR
7/6/2020