KORAN bedah onkologi Rabu 4 mei 2015

LONTARA 2 ATAS BELAKANG KAMAR 6

Bed 1
Hajrah
29-9-1965 (50)
707078
MRS: 24-052015

S : kel O : KU baik / compos

mentis

A : POH 2 tumor
coli sinistra ,
debulking

Alamat : jl.
Flamboyant
barat, Makassar

Infus RL 28tpm
Ceftriaxone
1gram/12jam/iv
Ranitidine 50mg/8jam/iv
As. Traneksamat
500mg/8jam/iv
Dexametason
1amp/8jam/iv
GV / hari

Aff kateter
Lanzoprasole tab 2x1

DPJP: dr.
Septiman,
Sp.B(K)Onk

Lab:
Wbc: 8,7
Rbc: 4,97
Hgb: 14,6
Hct: 43
Plt: 399
Ct/Bt: 7'00/3'00
Pt: 10,1
Aptt: 20.7
Gds: 106
Ur/Cr: 16/0,50
Sgot/sgpt: 23/32
Alb: 4,1
HBsAg: non
reactive

Anti HCV non

reactive
Hasil PA
Tgl 21-4-2015
Neurofibroma
No. PA 4307056

Bed 2
Besse manta
1-7-1958
713060
MRS 2-62015
DPJP: dr.
Haryasena,
Sp.B(K)Onk

d/ ulcus carcinoma
mammae sinistra

Rencana biopsy insisi

tnggu jadwal
(hari kamis)

Tgl 6-5-2015
Jaringan yg
mengandung
sedikit fokus
tumor soft tissue
kemungkinan
suatu
neurofibroma
Lab 26-5-2015
HGB 10.7
HCT 34.5
Hasil PA
Tgl 27-5-2015
Ulkus ca mammae
sinistra

Bed 3
Rina
15-2-1988
710689
MRS : 20-052015
Alamat :
Dusun Tappoci

DPJP: dr.
William
HamdaniSp.
B(K)Onk
Bed 4
Hapidah P
31-12-1950
560095
MRS: 30-052015
Alamat:
Enrekang

S : rasa tdk nyaman

pada hidung
tenggorokan NGT
O : baik, compos
mentis
Drain 50cc

As mefenamat 2x500mg
Ranitidine 2x150mg
Cefadroxil 2x500mg
Betadine kumur 3x1
Diet cair
GV/hari

A : ameloblastoma
mandibula sinistra
POH IV segmental
amelomandibulekto
mi

Pasang NGT ulang

S : kel
O : ku : cukup
A : ca mammae
dextra
Anemia
Trombositopenia

09/5/15 :
Wbc : 9,3
Rbc: 5,14
Hb: 13,8
Hct: 42

Plt: 305

Infus futrolit
Lanjut instruksi dari TS
KHOM
Cek darah rutin

DPJP: dr.
Haryasena,
Sp.B(K)Onk

BED 1
SITI
07-05-1971
Alamat : Jln
tarakkan lr
183 no. 46
mks
MRS : 28 mei
2015
Residen : dr.
febi
DPJP: dr.
Haryasena,
Sp.B(K)Onk

LONTARA 2 ATAS BELAKANG KAMAR 7

Lab 28/5/2015
S: nyeri pada leher
Infus felitroluit
GDS: 132
Inj ceftriaxone
dan panggul
1g/12j/iv
Ureum : 48
O: keadaan umum :
Inj novalgin 1
Creatinin; 1,00
sakit sedang
amp/12j/iv
SGOT: 17
VAS 4/10
Inj ranitidine 1 amp
SGPT: 9
A: squama cell
8j/iv
Asam urat : 4,9
carcinoma
Ultracet 3x1 /tablet
Natrium: 134
/oral
Metastasis tulang
Kalium: 3,9
Durogesic patch
Clorida: 104
MST 10mg
Cek kalsium (hasil)
Hasil PA :
22-5-2015
metastase
karsinoma sel
skuamos

No PA : 4403745
BED 2
Maryam M
1-11-1981
620666
MRS : 16-052015
Alamat
:desakatumba
nganlemo, kab.
Polman.

S : kel
O : ku : sedang
Anemis (+)

A : ca mammae
dextra

Infus futrolit 28tpm

Maxiliv 2x1
Periksa lab lengkap
GV/hari
Awasi tanda vital

Lab 19/05/2015
WBC : 8,4
RBC : 1,88
HGB : 10,0
HCT : 6,1
PLT :118
CT : 8 00
BT : 3 00
PT : 20,5
INR : 1,20
APTT : 12,5
GDS : 126
Ureum : 87
Creatin : 1,10
GOT : 67
GPT : 43
Na/K/Cl :
129/3,4/93
Albumin 3,3
HBs Ag dan Anti
HCV (ICT) (Nonreaktif)

DPJP :
dr.DjonnyFer
ianto,
Sp.B(K) onk

Hasil PA ( 25-72014) :

BED 3
Irmawaty
20-8-1977
711874
MRS : 31-52015
KJS BTKV
DPJP : dr
rosie
Sp.BTKV

S : kel
O : ku baik
A : ca mammae
bilateral

Rencana insisi biopsy

tunggu jadwal
Lapor dok chris DPJP?

Invasif ductal
carcinoma
mammae, high
grade malignancy
No PA : 3629726
Foto thorax 28-52015
Efusi pleura
dextra
Hasil PA :
26-5-2015
hapusan terdapat
sel epitel maligna
(malignant efusi)
no PA : 4419580

BED 4
Surtiah
01-08-1979
695661
MRS:
22/4/2015
Alamat :
japing japine
tengah

S : nyeri luka operasi

O : ku : sakit sedang,
compos mentis
A : POH ke VI
hemimandibulektom
i
Ameloblastoma
dextra

Infus futrolit 30tpm

Ceftriaxone
1gram/12jam/iv
Ranitidine 50mg/8jam/iv
Ketorolac 30mg/8jam/iv
Betadine kumur 3x1
Diet via NGT

Konsul dr chris untuk

rencana rekonstruksi

DPJP: Dr.
Septiman,
Sp.B (Onk)

Lab (26/4/15)
WBC : 23
HGB : 9.6
PLT : 270
GOT : 60
GPT : 58
HasilFoto Thorax
(7/1/2015)
Kesan:
Cordanpulmo
normal.
Tidaktampaktandatandametastasispada
foto thorax ini.

Foto MSCT scan

tanpakontras
(7/1/2015)
Kesan:
AmeloblastomaMax
illarisKanan.
Hasil PA (01-042015) :
Mixoma of the
jawdenganinflamasi

No PA : 4275940
BED 5
Mirkami
1-7-1966
679590
MRS:
3/6/2015

S : benjolan pada
payudara kanan
O : ku baik. Compos
mentis
A : ca mammae
dextra

Rencana operasi
mastektomi radikal
modified

S : kel O : ku sedang/

Infus futrolit 24tpm

Cek lab lengkap

alamat :
papua barat
DPJP: dr.
William
HamdaniSp.
B(K)Onk
BED 6
Kursiah

Lab (22/4/15)
WBC : 8,8
RBC: 4,85

31-12-1934
712874
Alamat :
LokaeSoppen
g

compos mentis
A : POH VII biopsy
insisi

DR, GDS, elektrolit

Awasi tanda vital

MRS : 21-052015

HCT: 38
HGB : 12,4

PLT :189
Hasil PA 28-52015
Melanoma
maligna pada
region femur dan
kaki kanan
No PA : 4417308

DPJP: Dr.
Septiman,
Sp.B (Onk)

LONTARA 2 ATAS BELAKANG KAMAR 8

LAB 25/5/2015
S : tampak
Rencana
WBC: 5.10
benjolan pada
mastektomi
payudara kiri
radikal modified RBC: 4.92
O : ku cukup
HCT: 37.0
A : ca
HGB: 12.1
mammae
PLT324
sinistra
Post
kemoterapi
DPJP: dr.
neoadjuvant 2
William
siklus
HamdaniSp.B(
Pro MRM
Bed 1
Fatmawati
17-7-1982
706724
MRS: 03/6/2015
Alamat : jl
sudirman

K)Onk

Bed 2
Sumiana
16-12-1958
714008
MRS: 31-052015
Alamat : jl laode
boha
DPJP :
dr.Haryasena
Sp.B(K)Onk

S: luka pada payudara

kanan
O: KU sedang A: Ulkus Ca Mammae
dextra suspek metastase
tulang
Post biopsy
insisi

Infus futrolit
28 tpm
Ceftriaxone 1
gr/12 jam/IV
ketorolac 30
mg/8 jam/IV
Ranitidin 50
mg/8 jam/IV
Neurobion
amp

Foto Pelvis 31/5/2015

Lesi titik dan sklerotik
pada regio trochanter
mayor os femur dextra
sesuai dengan gambaran
metastase tulang
Laboratorium 31/5/2015
WBC: 13.7
RBC: 5.12
Hgb: 13.8
Hct: 42.9
Plt: 284
Ureum:17
Creatinin: 0.44

SGOT: 37

SGPT: 31
BED 3

Lab (25/5/15)
WBC : 1.77
RBC : 3,59
HCT : 30.9
HGB : 10

Canning
1-1-1952
700786
MRS : 4-6-2015

PLT : 189

Alamat :
lingkungan lelong
DPJP: dr. William
Hamdani, Sp. B
(K) onk
Bed 4
Ny. Frida
Kredidare
690243/09-04-1981
Alamat : Sorong
MRS : 23-05-2015

DPJP: dr.
Haryasena,
Sp.B(K)Onk
Bed 5
Halipah
13-12-1960
697574
MRS : 4-6-2015

S : keluhan
O : ku sakit
sedang,
compos mentis
PLT 74
A : sequamous
cell carcinoma
region lidah

Infus fultrolit
28tpm
Tranfusi
trombosit 2 unit
Diet TKTP
Cek darah rutin
post tranfusi
Rencana
kemoterapi jika
KU optimal

DPJP: Dr.
Septiman, Sp.B
(Onk

Kartini dg.Kanang
01-12-1956
670530
MRS: 25-05-2015

PLT : 124

Lab 3-6-2015
GOT 44
GPT 16
Albumin 2.8
Asam urat : 6.3
Na: 135
K: 3.7
Cl : 103
WBC 9.3
RBC 3.12
HGB 9.3
HCT 28.7
PLT 223

Alamat : parepare

Bed 6

Lab (18/5/15)
WBC : 0,8
RBC : 3,26
HCT : 27,0
HGB : 9,7

S : keluhan
O : ku baik
GDS : 119
A : ca
mammae
dextra, post

Regulasi gula
darah
Rencana operasi
hari kamis 4-62015
Terapi TS

Usg mamma (27/5/2015)

-lesi hiperechic region

axilaris dextra suspek
lymphadenopathy
GDS strip tgl 27-5-2015

DPJP: dr.
Haryasena,
Sp.B(K)Onk

MRM
metastase
axilla dextra
DM tipe 2

interna lanjut

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