uro kompre ots
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Uro Kompre OtsTRANSCRIPT
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KOMPRE BEDAH KOMPRE BEDAH UROLOGIUROLOGI06 MARET 2015
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BOUGENVILE
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BOUGENVILE 1.5Tn. Edy Suryono (50 tahun)
NO MR : 55-46-01-00
Tgl Masuk : 28 Februari 2015DPJP : dr. Ronald Tanggo, Sp. UKonsul : dr. Donnie L. Gaol, SpPDPH : 6PO : 1Diagnosis Bedah :
1. Kolik Ureter e.c Susp. Vesicolithiasis + CKD stage V2. Hipertensi grade II3. Multiple Stones of Urinary Tract
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Diagnosis Penyakit Dalam :1. Kolik Ureter e.c Susp. Ureterolithiasis2. Hiprtensi3. CKD stage V4. ISK
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Sikap : USG Foto Thoraks Pro URS - Litotripsi Terapi Konservatif
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Pemeriksaan Laboratorium27 – 02 - 2015
Pemeriksaan Hasil Normal
Bakteri (+) Positif Negatif
Silinder Negatif Negatif
Kristal (+) Ca Oxalat Negatif
Pemeriksaan Hasil Normal
Natrium 143 mmol/L 136 – 145
Kalium 4.0 mmol/L 3.5 – 5.1
Clorida 106 mmol/L 99 – 111
AGD dan Elektrolit
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Pemeriksaan Hasil Normal
Hemoglobin 14. 6 g/dl 14 – 16
Leukosit 11.4 g/dl 5 – 10
Hematokrit 45. 6 % 40 – 48
Trombosit269 ribu/uL 150 – 400
Hematologi Darah
Kimia Klinik
Pemeriksaan Hasil Normal
Ureum Darah 103 mg/dL 15 – 45
Kreatinin Darah 4.96 mg/dL 0.70 – 1.10
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Pemeriksaan Hasil Normal
Warna Kuning Merah
Berat Jenis 1.030 1.003 – 1.030
PH 6.5 5.0 – 9.0
Blood +2 Negatif
Leukosit Esterase Negatif Negatif
Nitrit Negatif Negatif
Protein +2
Bilirubin Negatif Negatif
Aseton Negatif Negatif
Reduksi Negatif Negatif
Urobilinogen 0.2
Leukosit 8 – 10 / lpb 1 – 3
Eritrosit 2 – 4 / lpb 0 – 1
Epitel +1
UrinalisaUrin Lengkap
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Pemeriksaan Laboratorium02 – 03 - 2015
Kimia Klinik
Pemeriksaan Hasil Normal
Ureum Darah 159 mg/dL 15 - 45
Kreatinin Darah 7.18 mg/dL 0.70 – 1.10
Pemeriksaan Hasil Normal
Masa Pendarahan 1.30 menit 1- 3
Masa Pembekuan 14 menit 10 - 16
Hemostasis
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Pemeriksaan Laboratorium03 – 03 - 2015
Pemeriksaan Hasil Normal
GDS 98 mg/dl < 200
SGOT/ AST 15 U/L 10 – 34
SGPT/ ALT 23 U/L 9 – 43
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USGKesimpulan:
Hepar, Kandung empedu, Limpa, Pankreas dalam batas normal
Hidronephrosis grade 2 dengan nephrolithiasis dextra
CKD ginjal kiri BPH Cystitis Kronis
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RADIOLOGI03 MARET 2015
Foto Thorax Cor dalam batas normal Pulmo: Tak ada infiltrate Sinus dan diafragma dalam batas normal Costae dan tulang-tulang normal
Kesan: foto Thorax normal
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Foto BNO
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DURANTE OP
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BANGSAL MELATI
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MELATI 8.1 Nn. Siti Sundari ( 31 thn)MR: 55430100 Tanggal masuk : 2 Maret 2015 DPJP : dr. Sultan P. Gultom, SpPD Konsul : dr. Ronald SpU PH : 4 PO : - Diagnosa interna : Hydronephrosis ginjal dextra Diagnosa Bedah : Hydronephrosis ginjal dextra
Sikap : Rencana :
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Foto BNO DAN IVP (4 Maret 2015)
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BNO POLOS 7 MENIT
20 MENIT 45 MENIT
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120 MENIT POST VOID
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Gambaran BNO: - tulang-tulang baik - gas udara dalam usus normal - tidak tampak gambaran batu radioopak - kontour ginjal baik - Psoas shadow simetris
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gambaran IVP : - Excresi ginjal kiri normal , yang kanan tak
tampak sistem pelviocalyceal nya sampai 120 menit
-Sistem pelviocalyceal kiri normal -ureter kiri tidak melebar -Buli : besar dan bentuk normal , residu urin
normal Kesan : non visualized ren dextra
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USG ( 2 Maret 2015 )
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Kesimpulan : Hepar, kandung empedu, limpa,pankreas
dalam batas normal vesika urinaria menebal, uterus normal
Kesan : Hydronefrosis ginjal kanan, tidak terlihat jelas
kista, appendiksistis ? ( donghunt sign negatif )
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LAB DARAH ( 2 Maret 2015 )
Pemeriksaan Hasil Normal
Hb 13,5 g/dl 14-16 g/dl
Leukosit 9,3 ribu/ul 5-10 ribu/ul
Trombosit 210 ribu/ul 150-400 ribu/ul
Hematokrit 41,4 % 40-48 %
GDS 89 mg/dl < 200 mg/dl
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Lab darah 3 maret 2015Pemeriksaan Hasil Normal
Laju Endap Darah 35 mm/jam < 15 mm/jam
Hemoglobin 12,9 g/dl 14-16 g/dl
Leukosit 7 ribu/ul 5-10 ribu/ul
Eritrosit 4,24 juta / ml 4,5-5,5 juta/ml
Hematokrit 39,0 % 40-48 %
Trombosit 221 ribu/ul 150-400 ribu/ul
MCV 91,9 % 80-90 %
MCH/HER 29,2 % 27-31 %
MCHC 31,9 % 32-36 %
Basofil 0 % 0-1 %
Eosinofil 0 % 0-3 %
Batang 6 % 2-5 %
Segmen 69 % 50-70%
Limfosit 24 % 20-40 %
Monosit 1 % 2-8%
Retikulosit 0,9 % 0.9 -1,1 %
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Morfologi darah tepi ( 3 maret 2015 )
Pemeriksaan Hasil Normal
Eritosit DT Normokrom normositik, anisotosis (+) poikilositosis (-)
Leukosit DT Kesan jumlah cukup,morfologi normal
Trombosit DT Kesan jumlah cukup , morfologi normal
Kesan : Shift to the left dan monositopenia
SGOT 8 U/L 10-34 U/L
SGPT 24 U/L 9-43 U/L
Ureum 17 mg/dl 15-45 mg/dl
Creatinin 0,91 mg/dl 0,7-1,1 mg/dl