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LAPORAN JAGA II ILMU BEDAH KASUS ELEKTIF

MINGGU IV APRIL 2014


SEKSI: BEDAH ONKOLOGI
LAPORAN KASUS ELEKTIF

Diagnosis / Tindakan
No

Nama/
No.Reg

L/P

Umur
Tgl MRS Tgl. OPR
(th)
Dx Pre-Op

Lendra Wati
12161015

39

47

Musliyah
12109236
3

Endang Dwi
sulistiyani
12311576
Khusnul
Khotimah
12186149
Herawati
10633232
Nanik
12318678

55
P
44
P
50
p
48
P

Tindakan
Operasi /
Tindakan +
ICOPIM

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

Dx Final + ICD
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)

Jenis Terapi

Operator

OB/
Operas OBT
PPDS /
i/NonO /
Senior
p
OT/
OI
Neoplasma Non op Grup
Penyakit

Pembimbing

Sif
at Ketep
Op atan
er Dx
asi

Perawatan

M/ Tepat
Total
Waktu
B/
/
PeraTgg Op
T/ Miss/
watan
(Hari)
A Under
(Hari)

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

10

Khusnul
Huluq
12283278
Suminah
12067861
Masamah
10707776
Saini
12309557

17
L
60
P
49
P
49
p

11
Samsuni
12286557

44

12
Luih Muliati
12181785
13
14

Sumnah
12301624
Suminah
12067661

15 Sri mawanah
12268364
Laiqoh
Fardianah
10958245
17 Suryaningsih
12312983

55

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/04/14 22/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

55

14/04/14

46

22/04/14 23/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

22/04/14 23/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

P
43
P

16

21/04/14 22/04/14 Chemotherapy Session


ec Soft tissue sarcoma
regio pedis D (Z51.1)

KRS
Soft tissue tumour
23/04/14 regio femur D (C49.1)

45

14/04/14 23/04/14

56

22/04/14 23/04/14

Ca mamma D
T4bN0M0
(C.50.1)
Tumor ganas kulit
regio palpebra inf
D(BCC)
(C44.1)

Wide eksisi
(

MRM
(85.43)
Wide eksisi
(86.40)

Chemotherapy
Session ec Soft tissue
sarcoma regio pedis D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Soft tissue tumour
regio femur D (C49.1)

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

9 hari 11 hari

Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Ca mamma D
T4bN0M0
(C.50.1)
Tumor ganas kulit
regio palpebra inf
D(BCC)
(C44.1)

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

9 hari 11 hari

1 hari

Neoplasma

Neoplasma

Op

Op

Neoplasma Non op

OB VDY/TA
V/OSA

OB FDS/TA
V/OSA
-

2 hari

18
Supini
12116937
19 Siti Zahrowati
12268732
20

21

22

Suminah
12067661
Vida
Nurkhayati
12271152
Ernie
12269890

44
49

P
60
P
38
P

24

25

Munawaroh
12147465
Retno W
12202641

26 Siti Muntafiah
12215743
27

28

Suminah
12087661
Titik Suwarti
12210638

Kemoterapi
(99.25)

23/04/14 24/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

23/04/14 24/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

23/04/14 24/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

21/03/14

KRS
Multiple FAM Bilateral
26/03/14
(D24.0)

24/03/14

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

35

23
Sukariani
12285624

23/04/14 24/04/14 Chemotherapy Session


ec Ca Mammae D
(Z51.1)

45
52

24/03/14

P
44

24/03/14

P
42

24/03/14

P
47

24/03/14

P
P

62

24/03/14

KRS Chemotherapy Session


25/03/14
ec Ca Mammae D
(Z51.1)

Eksisi FAM
Bilateral
(85.21)

Kemoterapi
(99.25)

Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Multiple FAM Bilateral
(D24.0)

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

OB

KID
NOR

dr. IKA,
SpB(K)Onk

4 hari

5 hari

Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma

Op

(Z51.1)
39

Arbati
10.31.32.41

48

26/03/14

KRS
29/03/14

48

27/03/14

KRS Chemotherapy Session


28/03/14 ec Ca Mammae SD
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


28/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


28/03/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


28/03/14
ec Ca Mammae S
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

P
30

31

Karmini
12274248
Mutiawati S
12163960

32 Siti muntayiah
12215743
33

34

35

36

37

38

Kartinah
12291692
Siti
Mahmudah
12262894
Kariah
12102053
Sholipah
11015959
Sulastri
10574410
Napiyah
12022566

P
56

27/03/14

P
27/03/14
P

50
27/03/14

48
39

25/04/14

P
44

25/04/14

P
25/04/14
P

41
25/04/14

61
44

25/04/14

Ca mamma S
T4bN0M0
(C50.1)

MRM
(85.43)

Ca mamma S
T4bN0M0
(C50.1)
Chemotherapy
Session ec Ca
Mammae S
(Z51.1)
Chemotherapy
Session ec Ca
Mammae S
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae S
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)

Neoplasma

Op

OB dr. IKA,
SpB(K)
Onk/
FDS/ER
J
Neoplasma Non op -

1 hari

3 hari

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

39

40

Meda
Moedjiwati
10885494
Suciati
12298642

41 Dwi Rahayu
12109133
42

43

44

45

46

47

48

Mukzizah
12306678
Kartinah
12291692
Fatimah
60119052
Siti Sumarni
12253376
Sri Astuti
12302507
Churrotin
12327155
Umi
60127153

52

25/04/14

P
44

26/04/14

p
41

26/04/14

P
40

26/04/14

P
44

26/04/14

P
54

26/04/14

P
45

26/04/14

P
31

26/04/14

P
43

26/04/14

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS Chemotherapy Session


27/04/14
ec Ca Mammae D
(Z51.1)

Kemoterapi
(99.25)

KRS
30/04/14

46
P

KRS Chemotherapy Session


26/04/14
ec Ca Mammae D
(Z51.1)

26/04/14

KRS

Ca mamma S T3N1M0
(C50.1)

MRM
(85.43)

Ca Mamma S T2NoMo
Breast conserving
(C50.1)
surgery
29/04/14
(85.23)

Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Chemotherapy
Session ec Ca
Mammae D
(Z51.1)
Ca mamma S
T3N1M0
(C50.1)

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma Non op

1 hari

2 hari

Neoplasma

Op

1 hari

4 hari

Ca Mamma S
T2NoMo
(C50.1)

Neoplasma

Op

1 hari

3 hari

OB Dr.DSK,
SpB (K)
Onk/FD
S/ERJ
OB Dr.EHT,
SpB (K)
Onk/FD
S/NOR

49

Suwani
10951853

61

27/04/14

KRS Chemotherapy Session


28/04/14
ec Ca Mammae S
(Z51.1)

Kemoterapi
(99.25)

Chemotherapy
Session ec Ca
Mammae S
(Z51.1)

Neoplasma Non op

1 hari

LAPORAN JAGA II ILMU BEDAH PENGGUNAAN ANTIBIOTIKSEKSI: BEDAH ONKOLOGI


Outcome
No
1
2
3

Antibiotik

Outcome

ILO

Komplikasi

Morbiditas

Keterangan
Morbiditas

Sembuh + follow up
Sembuh + follow up
Sembuh + follow up

Alasan
Pulang
Paksa
-

Causa Mortalitas

Nama Antibiotik

Dosis (Satuan)

Jenis AB
Prof./Ter

Ras / Tdk Ras

2 hari

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up

cefuroxime
cefuroxime
cefuroxime
cefuroxime
-

1,5 gr
1,5 gr
1,5 gr
1,5 gr
-

Profilaksis
Profilaksis
Profilaksis
Profilaksis
-

Rasional
Rasional
Rasional
Rasional
-

45
46
47
48
49

Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up
Sembuh + follow up

cefuroxime
cefuroxime
-

1,5 gr
1,5 gr
-

Profilaksis
Profilaksis
-

Keterangan:
A= ahli; M=mandiri; B=Bimbingan; P=Preventable; R=Rasional; Prof=Profilaksis; Ter=Terapeutik; Ras=Rasional
Operasi/Non-Op/Re-op=1. Operasi, 2. Non-Operasi, 3. Re-Operasi
Grup penyakit = 1. Neoplasma, 2. Trauma, 3. Kongenital, 4. Infeksi, 5. Endokrin, 6. Degeneratif. 7. Lain-lain
Grup OB/OBT/OT/OI = 1. OB=Operasi Bersih; 2. OBT=Operasi Bersih Terkontaminasi; 3. OT=Operasi Terkontaminasi; 4. OI=Operasi Infeksi
Sifat Operasi= 1. Mandiri, 2. Bimbingan, 3. Ahli, 4. Trainee
Ketepatan Diagnosis = 1. Tepat, 2. Miss, 3. Under
Outcome = 1. Sembuh, 2. Sembuh+follow up, 3. Belum Sembuh, 4. Pulang Paksa, 5. Meninggal NP, 6. Meninggal P
Morbiditas = 1. Administrasi, 2. Diagnosis, 3. Pengelolaan, 4. Operasi, 5. Tidak ada
Jenis antibiotik = 1. Profilaksis, 2. Therapeutic, 3. Tanpa antibiotik, 4. Analgesik
Rasional/Tidak Rasional = 1. Rasional, 2. Tidak Rasional

RESUME BEDAH ONKOLOGI


MINGGU IV APRIL 2014
Kasus Bedah Divisi Onkologi
1. Jumlah Operasi
:
Darurat
:
Elektif
:
Jumlah Non Operatif :
2.

Laki-laki
Perempuan

:
:

6
6
43
1
48

5.

Outcome
Sembuh
Sembuh + Follow Up
Belum Sembuh
Pulang Paksa
Meninggal
Preventable
Non

:
:
:
:

49
-

:
:

Rasional
Rasional
-

Prevebtable
3.

4.

Ketepatan Diagnosis
Tepat
Miss
Under

:
:
:

49
-

Operator
Senior
PPDS Mandiri
Bimbingan
Trainee

:
:
:
:

3
2
1
0

Mengetahui

6.

Morbiditas

7.

ILO

8.

Komplikasi dini

Pelapor,

Kasubag/Senior,

Dr. Eddy Herman T., Sp.B(K)Onk

dr.Vidy/dr.Nurudin/dr.Firdaus