Download - BEDAH UROLOGI
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BEDAH UROLOGI
6 MARET 2015
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BANGSAL EDELWEIS
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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