JUMAT 17 AGUSTUS 2018 BEDAH ONKOLOGI RAH/OND/RAP/IYA/IKY//RVS/YES/ALF/PBP/TWN?

ADE
NAMA / TGL
No USIA NO RM MRS DIAGNOSA STATUS PLAN DPJP PEMERIKSAAN PENUNJANG
LHR
ANGGREK 1
8/8 USG mamae: Soft tissue mamae dekstra, tak tampak kelainan pada mamae sinistra, limfadenopathy aksila bilateral
6/8 HB 9.5 HT 30 AL 21.5 AT 345 AE 3.51 SGOT 35 SGPT 71 ALB 2.9 CR 0.5 UR 44 NA 136 K 3.1 CL 103
Cap KR IV
Sadikem Ts paru 1/8 hb 10.5 ht 32 al 16.2 at 440 ae 3.77 pt 13.3 aptt27.3 inr 1.02 GDS 110 SGOT 13 SGPT 17 ALB 3.6 UR 20 CR 0.4 NA
5A 60 01422410 Tumor paru kanan dd tumor WD Konsul
30/12/1958 6/8 128 K 3.5 CL 101 HBSAG NR
mediastinum
1/8 Thorax PA : 1. EFUSI PLEURA KANAN DAPAT merupakan sub pleural type pulmonal metastase, 2. Bone metastase di
costa 4 lateral kanaan, 3. Adanya massa paru kanan dan atelektasis paru kanan belum dapat disingkirkan
ASTER 5
9/8 hb 11.8 ht 40 al 3.6 at 194 ae 4.04 gds 90 sgot 20 sgpt 30 cr 0.8 ur 16 na 138 k 3.8 cl 1.18
21/6 PA : tiroid : struma dengan fokus adenocarcinoma pappiliferum folikuler patfem
adenocarcinoma pappiliferum 30/5 mri cervical polos : degeneratif disc disease berupa spondylosis cervicalis disertai dengan bilging, kompresi vc 4,5,6
Endah Neuro
2L 40 01177436 folikuler patfem Post total Kemo Inj Zometa HK disertai paraspinal muscle spasme, hambatan ringan aliran liquor cerebrospinalis setinggi level C 4-5, C5-6 dan C 6-7
19/11/1977 10/8
tiroidektomi 4/5 Bone survey : lesi titik pada 1/3 proximal os femur dekstra dapat merupakan bone metastase
4/3 PA : adenoma goiter

MELATI 3
15/8/2018 HB9.7 HT 29 AL 8.2 AT 255 AE 3.16 PT 12.9 APTT 34.8 INR 0.9 SGOT 32 SGPT 49 ALB 4.4 CR 0.6 UR 19
NA 133 K 4.2 CA 1.24 HBSAG NR
Suparno Interna Susp Limpadenopati colli Dextra dd
5A 60 01429333 Konsul Konsul 31/7/2018 USG Colli :
26/8/1958 16/8 NHL
Gambaran malignant limphadenopati ps level 2,3,5 regio colli kanan (uk± 3.4x1.97 pd level 2)
Reaktif limpadenopati pd level 2 & 3 regio colli kiri uk 2.3 x 1.35 cm pd level.
15/8 USG abdomen: tak tampak intra abdoominal metastase
11/8 hb 12.1 ht 35 al 18.7 a 291 ae 3.83 pt 14.4 aptt 27.3 inr 1.13 gds 161 alb 3.5 cr 0.8 ur 70 na 133 k 3.1 cl 105 hbsag rapid
NR
6/8 USG Tiroid : Massa solid kistik di isthmus tiroid dextra dan sinistra, curiga kompleks cyst dd malinant, tak tampak
limfadenopati dikedua supraclavicula, coli, submandibula, parotis
3/8 HB 13.2 HT 38 AL 15.9 AT 235 AE 4.37 PT 14.6 APTT 25.6 INR 1.11 GDS 121 SGOT 12 SGPT 16 ALB 3.4 NA 135 K
3.1 CA 1.30 ANTI HCV NR
General weakness + low intake ec 1/8 MRI BRAIN CONTRAS : 1. Multiple brain metastase, deviasi ke sinistra sejauh 1.5 cm, hemiventrikulomegali sinistra
B.Saraf Pro biopsi inciie
7C Junaidi 47 01419628 ca thyroid Pre Op HK mengarah ke obstruktif hydrocephalus, hipoplasia ACA dekstra segmen 1
17/7 Pro radioterapi
Brain metastasis ec suspek ca tiroid 31/7 CT SCAN THORAX IRISAN AXIAL REFORMAT SAGITAL : COMPLEX CYST DI REGIO ISTHMUS tiroid dan
massa solid pada thyroid sinistra, 2. Massa solid di paru dextra lobus inferior segmen medius, dapat merupakan suatu massa
metastasis dd massa primer, 3. Pneumonia di paracardial kanan dapat merupakan pulmonal metastasis pneumonic type, 4.
Limfadenopati di supra klaikula bilateral, di par aorta, subarina, dan peribronkus kanan
30/7 USG THYROID : MASSA solid kistik di isthmus thyroid dan thyroid sinistra, curiga compleks cyst dd malignant, tak
tampak lymphadenopaty di kedua supraclavicula, kedua regio colli, sublingual, kedua submandibula, dan kedua parotis
27/7 TSH 0.28 FREE T4 18.92
26/7 HB 12.6 HT 37 AL 12.7 AT 275 GOLDA b gds 109 cr 1.1 ur 53 na 136 cl 3.3 nacl 101
WING MELATI 3
15/8 Hb 10.4 Ht 32 Al 18.0 At 412 Ae 4.08
14/8 Hb 8.4 Ht 26 Al 15.8 At 369 Ae 3.36 mcv 78.7 mch 24.9 mchc 31,6 rdw 15.7 mpv 5 pdw 19 EOS 1.16 BAS 0.55 NET
78.27 LIM 12.77 MON 7.25 GOL DAR O GOLDAR rh (+) SI 21 TIBC 142 sat transferrin 14.8 fe > 12000.0
13/8 hb 9.6 hct 34 al 14.8 at 590 ae 4.01 mcv 84.2 mch 23.9 mchc 28.4 rdw 16.1 mpv 7.8 pdw 16 eos 0.10 bas 0.40 net 85.9
Rabdomiosarcoma dd Fibroma dd
lim 8.90 mon 4.70 pt 14,3 aptt 28.4 cr 0.5 ur 47 na 142 k 5.0 ca 1.26
Osteosarcoma dg metastase Hepar
6/8 USG Abdomen : 1. Massa Rekti, 2. Tak tampak intraabdomen metastase
Tasiin Massa Recti
2C 58 01416885 Interna WD konsul 2/5 Bone Survey : 1. Massa Malignant soft tissue pd regio proximal femur kanan yg mendestruksi pd ramus superior et
01/07/1960 Spondilosis lumbalis
inferior os pubis kanan & os ischium kanan dpt merupakan massa primer 2. Spondilosis lumbalis
HepatitisbB kronis
17/4 CT abdomen kontras :Lesi titik ekspansi dg tepi sklerotik pd os ischium kanan bag bawah dan ramus inferior os pubis
Anemia Hipokromik
kanan dg soft tissue mass besar pd cavum pelvis sisi kanan bentuk lobulated, batas tdk tegas tepi ireguler. Lesi tampak susah
dipisahkan dg musculus disekitarnya, Cenderung Maligna --> DD/ Osteosarcoma, soft tissue sarcoma, multiple limfadenopati
pd regio inguinal kanan kiri, multiple lesi kistik bentuk bulat non uniform pd hepar--> DD/ Nodul kistik, Kista hepar.
23/4 Tumor marker Psa 38.47 Cea 1.02 Tsh 513 Free t3 2.86 Free t4 13.90
FLAMBOYAN 6
15/8 HB 8.8 HCT 27 AL 13.5 AT 370 AE 3.55 MCV 7.51 MCH 24.8 MCHC 33.0 RDW 16.1 MPV 6.8 PDW 15 Eos 0.30
Purwanti IGD Ca epitel ductal mammae (S) T4C MRS
603B 54 01332046 WD WY bas 0,30 net 83.70 lim 8.70 mon 7.00 goldar A GDS 77 OT 20 PT 27 CR 0,1 UR 11 NA 125 K 2.9 CL 96 CA 1.63 HBSAG
16/09/1963 16’/8 N2M1(paru) transfusi PRC 2 Kolf
NR
Cancer Pain
Nur Hidayati IGD
603C 59 01427780 Ca mammae (D) TxNxM1 WD MRS WY
03/07/1969 16/8
(kontralateral)
14/8 pa : mammae : Maligna
Yuni Margiyati Poli Post MRM (S) ai Tumor mamae S 13/8 hb 12.6 ht 38 al 6.7 at 257 ae 4.25
606A 33 01426048 Post op Perawatan post op KY
19/6/1985 10/8 T3N0M0 Susp Maligna 24/7 AJH mamae sinistra : invasive carcinoma
20/7 HB 14.5 HT 41 AL 5.6 AE 4.98 Golda A RH + pt 13.6 APTT 29.2 INR 1.01 GDS 87 SGOT 13 SGPT 12 CR 0.8 UR 19
 NA 137 K 4.4 CL 106 HBSAG NR
20/7 Thorak PA : Tak tampak pulmonal metastase
20/7 USG Abdomen : 1. Tak tampak intraabdominal metastase, 2. Tak tampak efusi pleura bilateral maupun ascites
12/7 usg Mammae : Lymphadenopati axilla sinistra (+)
13/8 HB 11.9 HT 38 AL 7.2 AT 300 AE 4.85 GOLDA O RH + PT 12..3 APTT 29.3 INR 0.89 GDS 96 SGOT 24 SGPT 21
ALB 4.3 CR 0.5 UR 20 NA 138 K 4.7 CL 107 HBSAG NR
Post MRM ai Ca Mammae D 29/6 HB 10.8 HT 35 AL 6.4 AT 480 AE 4.48 GDS 101 SGOT 23 SGPT 24 CR 0.6 UR 15
T4bN1M0 4/6 FNAB : Mammae D : Masih tampak sel ganas viable
Sriwiwin Poli
606B 42 01410058 Post Kemo 3x seri ke 2 ( brexel Post OP Perawatan post op KY 5/2 FNAB : Mammae D : FNAB  Invasive Ductal Carcinoma
15/10/1975 10/8
100mg, doxorubisiin 70 mg) 15/5 usg abdomen : tak tampak intraabdominal metastase
15/5 usg mammae D : Lei hipoekoik, batas tak tegas, infiltratif diantara jaringan mammae yg normal probably malignant
lesion BIRADS C4a
15/5 thorax PA : Tak tampak pulmonal metastase
13/8 HB 12.8 HT 40 AL 7.3 AT 247 AE 4.58 GOLDA B RH + PT 14.0 APTT 30.8 INR 1.05 GDS 68 SGOT 15 SGPT 9
ALB 4.3 CR 0.7 UR 11 NA 136 K 3.8 CL 107 HBSAG NR TSH 0.97 FT4 15.22
30/7 hb 13.2 ht 38 al 6.6 at 370 ae 4.34 pt 13.3 aptt 29.6 inr 0.98 golda B RH + NA 135 K 3.6 Ca 1.19 hbsag NR TSH 1.47
Free T4 18.64
Septi Ayu Poli Post Isthmolobektomy (D) ai
606C 23 01427180 Post OP Perawatan post op) HK 30/7 thorax PA : tak tampak gambaran pulmonal metastase
24/9/1994 10/8 Struma Adenomatosa (D)
30/7 FNAB : AJH Tiroid : residif struma adenomatosa
25/6 USG LEHERR/TIROID : multinoduler goiter dextra, tak tampak kelainan pd thyroid sinistra, tak tampak limfadenopati
cervical bilateral
22/5 PA : Struma adenomatosa
14/8 FNAB : AJH TIROID : Struma Koloides
13/8 HB 14.1 HT 41 AL 5.4 AT 208 AE 4.51 GOLDA O RH + PT 15.1 APTT41.1 INR 1.16 GDS 110 AGOT 15 SGPT 11
Suwarno ALB 3.9 CR 0.7 UR 33 NA 137 K 4.0 CL 109 HBSAG NR TSH 0.54 FT4 16.9
Poli PRE OP
608B 4/2/1963 55 01424210 Struma koloides tiroid Bilateral Pro total tirodektomi JK 5/7 hb 14.0 ht 41 al 5.0 at 336 ae 4.48 golda O RH positif PT 12 APTT 31.5 INR 0.86 GDS 105 HBSAG NR TSH 0.84 FT4
10/8 20/8
17.91
5/7 THORax PA : tak tampak gambaran metastase paru
30/6 USG tiroid : struma nodusa thyroid bilateral
6/6 Ro thorak: pneumonia dan nodul dapat merupaka pneumonic dan nodular type pulmonal metastasis
Mu’alikah Poli Post eksisi luas Ca mamae (D) POST OP
608D 53 01258854 Perawatan post op HK 6/6 USG abdomen: tak tampk gambaran abdominal nodule merastasis\22/4 2015 ER neg PR neg HER 2positif31/7 FNAB:
06/08/1965 15/8 residif 16/8
infiltrating ductal carcinoma
12/8 HB 11.2 HT 34 AL 3.7 AT 140 AE 3.56
10/8 thorax PA : Oedem pulmonum, efusi pleura kiri dapat merupakan sub pleural type plmonal metastasis
10/8 thorax AP : Kardiomegali, Hidropneumothora kiri disertai dengan gambaran kolaps paru kiri, Terpasang WSD dari sisi
Tri Churiah IGD Ca Mammae S TxNxM1 paru,bone kiri dengan tip terproyeksi di SIC 6 posterior kiri
609C 49 00615928 KU Observasi Produk Wsd/hari HK
12/4/1969 10/8 Post kemo 6x (xelloda, zometa) 10/8 HB 8.6 HT 27 AL 4.0 AT 224 AE 2.86 GOLDA A SGOT 25 SGPT 11 CR 0.6 UR 13 NA 137 K 3.6 CL 105 HBSAG nr
27/11 PA : invasife ductal ca mammae grade II/III
11/12 MRI : Lesi litik maupun sklerotik hampir diseluruh corpus vertebra thoracolumbal yg sangat mungkin metastase, para
spinal musle spasm
15/8 Hb 15.1 Ht 45 AL 17.0 AT 224 PT 14.4 APTT 33.0 INR 1.130 GDS 201 Alb 4.4 Cr 0.8 Ur 34 Na 132 K 5.5 Cl 101
HbsAg NR
30/8 2017 tak tampak gambaran pulmonal metastase maupun bone metastase
Bentur Poli Post incisi drainage Abses coli post Post Op
611A 59 01353505 Perawatan post op HK 24/5 2017 USG thyroid: Massa residif padat di paratrachea dekstra, tak tampak massa di tiroid, limfadenopati collidi regio
18/08/1968 15/8 thyroidetomi 16/8
colli dekstra dan submandibula bilatera
21/6 PA: tiga limfonodi coli dekstra dengan metastasis carcinoma papilaer kelenjar gondok

10/8 MRI: Multiple nodul kistik di colli (D), Massa solid di kedua thyroid terutama kanan yang ekspansi ke rongga
thorakcenderung malignansi
8/8 USG Thyroid Doppler : 1. Massa solid multiple di thyroid dextra, 2. Massa solid di colli dextra, limfadenopati bilateral
6/8 hb 10.1 ht 32 al 5.5 at 197 ae 4.48 pt 18.3 aptt 32.9 inr 1.48 gds 98 sgot 26 sgpt 35 alb 3.7 cr 1.2 ur 22 na 138 k 5.1 cl 110
Pro Total Thyrodektomy
Djikan Poli hbsag nr anti HCV NR TSH 40.32 free t4 6.28
613A 78 00844455 Ca papilare thyroid post abrasi Pre Op Tunggu hasil MRI KY
15/7/1940 6/8 1/3 CERVICAL AP : massa di regio colli anterior yg mendefiasi trakea ke arah sinistra dan menyempitkan airway
Cek ATA & Tiroglobulin
1/3 usg leher : massa ditiroid bilateral dg keterlibatan limfonodi malignan, limfadenopati di middle cervical dextra et sinistra
8/3 FNAB ; tiroid D : benign colloid nodule, Colli D : Papilary tiroid carcinoma
28/2 MSCT Leher : multiple nodul tiroid dextra yg mendefiasi airway kearah sinistra
19/2 tsh 0.01
FLAMBOYAN 7
15/8 Hb 10.8 Ht 34 AL 7.3 AT 229
14/8 HB 8.6 HT 28 AL 7.9 AT 285 AE 3.27 GDS 265 SGOT 289 SGPT 56 ALB 3.4 CR 0.6 UR 26 NA130 K 5.2 CL 99
Invasif Ca ductal mamae 23/7 hb 10.0 ht 30 al 11.0 at 419 ae 3.83 gds 377 sgot 75 sgpt 30 cr 0.5 ur 24
Suminem Poli (D)TxNxM1 (paru) 23/7 thorax pa : pneumonia dan efusi pleura kanan dapat merupakan pneumonic dan sub pleural type pulmonal metastase
701B 51 01367983 KU Pro kemoterapi WY
4/6/1967 13/8 Post kemo 3x (paxus, carboplatin, 12/6 usg abdomen : metastase ke hepar
novelbin) 9/12/2016 PA : invasive ductal carcinoma nos grade III meluas ke putting metastase ke lima buah lymponodi
15/3 usg mammae : massa solid pada dinding dada kanan dengan kalsifikasi intralesi mengarah malignant sangat mungkin
massa residif
14/8 HB 11.3 HT 34 AL 7.1 AT 248 AE 4.35 PT 13.7 APTT 34.9 INR 1.02 GDS 121 SGPT 17 SGOT 10 ALB 3.9 CR 0.5
UR 22 NA 133 K 4.1 INR 0.93 HBSAG NR ANTI HIV NR FT4 20.84
Sumarti Poli
702B 48 01421431 SNNT bilateral Pre op Sub total tiroidektomi HK 22/6 hb 12.2 ht 37 al 9 at 365 golda B RH + PT 12 APTT 29 INR 0.9 GDS 96 NA 139 K 4.5 CL 107 HBSAG NR TSH 1.96
27/12/1969 13/8
FT4 20.98
4/7 PA : AJH tiroid, struma koloides
 4/7 usg biopsi : tampak nodul tiroid kanan kiri
22/6 usg tiroid : nodul tiroid bilateral dengan degenerasi kistik didalamnya
22/6 usg abdomen : tak tampak metastase intraabdomen
22/6 thorax PA : cor pulmo tak tampak kelainan
10/8 hb 14.5 ht 44 al 4.6 at 292 ae 4.79 golda B RH + PT 16.9 APTT 32.4 INR 1.34 GDS 127 SGOT 21 SGPT 19 ALB 4.0
NA 140 K 4.0 CL 108 ANTI HBSAG NR ANTI HCV NR CR 0.8 UR 42 AU 6.3
Post eksisi ai Ca Mammae S
3/8 Thorax PA : tak tampak gambaran metastase pada paru
Poli T4CN3Mx
702E Satini 63 01362268 Post op Perawatan post op JK 4/7 HB 12.6 HT 38 AL 6.8 AT 349 AE 4.21 GDS 128 SGOT 17 SGPT 14 CR 1.1 UR 41
9/8 Post kemo 2 siklus (xelloda,
3/8 USG ABDOMEN : Hidronefrosis sinistra berat disertai multiple nefrolitiasis sinistra, simple cyst ren sinistra
eiprubisin, cyclophospamid)
13/1 PA : ER positif, PR negatif, her-2 POSITIF SKOR 3
19/12 PA : mammae : invasiveductal carcinoma NST grade III
14/8 hb 13.5 ht 39 al 6.2 at 259 ae 4.42 PT 14.4 APTT 36.9 INR 1.09 SGOT 21 GDS 112 SGPT 19 ALB 4.4 CR 0.5 UR 20
NA 138 K 3.7 CA 1.05 HBSAG nr anti hcv nr ft4 13.97
27/2 hb 12.6 ht 37 al 6.8 at 269 ae 4.21 golda B RH + AP 14.3 APT 28.4 INR 1.08 GDS 79 SGOT 21 SGPT 17 CR 0.6 UR 15
NA 137 K 3.9 CL 109 HBSAG NR
Kasini Poli PRE OP
704A 46 01417252 Tumor mammae T4bN1M0 PRO MRM HK 27/7 THORAX PA : pulmonal metastase pneumonic tipe
10/6/1972 13/8 20/8
27/7 usg abdomen : tak tampak intraabdomen metastase
27/7 usg mammae : massa solid di mammae sinistra dengan kalsifikasi intralesi mengarah malignan (posisi pada jam 9-12 dan
1cm dari aerola)
26/4 PA : BIOPSI JARUM BENJOLAN SOLID MAMMAE : ca epithel ductus mamae
14/8 HB 12.7 HT 36 AL 6.9 AT 183 AE 3.88 PT 15.9 APTT 38.8 INR 1.240 GDS 168 SGOT 17 SGPT 11 ALB 4.1 CR 0.7
Ca mammae S residif + UR 32 NA 138 K 3.8 CA 1.03 HBSAG NR ANTI HCV NR
limfadenopati D 16/7 USG mamae: lesi massa residif di mamae sinistra post MRm, mamae dekstra dbn, limfadenopati axilla dekstra
Soni Poli Pre op
704D 61 01282187 Post MRM Pro deseksi axilla D HK 15/7 HB 12.3 HT 34 AL 4.3 AT 211 AE 3.77 GDS 108 SGOT 20 SGPT 9 ALB 4.0 CR 0.8 UR 33
01/07/1957 13/8 20/8
Post kemo 6x (paxus, epirubisin, 9/3 imunohistokimia : ER – PR – HER2 + SKOR 3 Ki67 –
doxorubisin) 16/7 usg abdomen : tak tampak gambaran metastase intraabdominal
26/2 PA Mammae S : INVASIVE CARCINOMA GRADE 3
14/8 hb 12.2 ht 36 al 4.7 at 232 ae 4.19 pt 13.7 aptt 36.0 inr 1.02 gds 90 sgot 33 sgpt 25 alb 4.0 cr 0.6 ur 28 na 137 k 3.5 cl 1.1
Ca mammae S TxN0M1(paru,
Sulastri Poli hbsag NR ANTIHCV NR ANTI HIV NR
704E 46 01378579 kontralateral) Pre op Pro MRM D HK
12/12/1971 13/8 21/5 HB 12.3 HT 37 AL 2.9 AT 304 AE 4.12 GDS 98 SGOT 29 SGPT 23 CR 0.7 UR 26
Post kemo 9x (paxus, carboplatin)
26/4/2017 PA : mamae & colli : Invasive Duct CA NST Grd 3 dg LVI (+) DG META
16/7 Hb 11.8 Ht 35 AL 9.2 AT 201 PT 12.9 31.9 INR 0.990 GDS 138 Alb 4.4 Cr 1.5 Ur 26 Na 131 K 3.9 Cl 100
29/6 MRI abdomen Residu mass di subcutis gluteus sinistra
Verrocous Ca Regio Perianal 17/4 USG gluteus kiri: massa resiu di regio gluteus kiri
Sri Sarjito Poli Pro wide eksisi joint op ts
705A 51 0137938 Post kemoterai Paclitaxel 210 mg, Pre op JK 10/4 Ro thorax: tak tampak gambaran pulmonal dan bone metastase
18/09/1967 19:17 digestif untuk stoma
Crboplatin 450 mg 10/4 USG thyroid: Nodl tiroid kanan multiple, limfadenopati coli bilateral
10/4 USG abdomen: tak tampak intraabdominal metastase
12/10 2017 PA: Perianal: Verocous carcinoma (giant malignant) condyloma/Buschke Lowesten Tumot
14/8 HB 11.1 HT 35 AL 9.3 AT 327 AE 4.43 PT 12.6 APTT 27.0 INR 0.91 GDS 81 SGOT 23 SGPT 19 ALB 4.0 CR 0.6 UR
28 NA 136 K 4.2 CA 1.1 HBSAG NR ANTI HCV NR FT4 11.53
25/7 HB 10.4 HT 31 AL 4.4 AT 295 GOLDA a rh + pt 13.2 aptt 27.6 inr 0.97 gds 76 sgot 21 sgpt 16 cr 0.6 ur 16 na 136 k 4.0
TRI PUJI R POLI Post biopsy eksisi Tumor mammae Post OP cl 109 hbsag NR
705C 33 01426441 Perawatan post op HK
3/12/1984 13/8 S T4bN1M0 16/8 25/7 USG MAMMAE : massa residif mammae sinistra
25/7 usg abdomen : kista ovarium kanan, limfadenopati inguinal kiri non suspicious metastasis
25/7 thorax PA : Tak tampak gambaran pulmonal metastasis
19/6 PA : AJH regio mammae sinistra : proliferasi epitel dengan sel atipik
15/8 Bone survey: Multipel lesi litik di calvaria, os scapula bilateral, os humerus kanan dan os femur bilateral serta kompresi
corpus VL 1dapat merupakan bone metstasis
14/8 HB 11.5 HT 35 AL 9.4 AT 277 AE 4.31 PT 14.5 APTT 31.5 INR 1.1 GDS 93 SGOT 106 SGPT 35 ALB 3.7 CR 0.7 UR
Misiyam POLI PRE OP 34 NA 139 K 3.7 CA 1.03 HBSAG NR ANTI HCV NR ANTI HIV NR
705E 56 01423386 Ca mammae D T4bN1M1 Pro Biopsi Insisi HK
16/2/1962 13/8 20/8 9/7 usg abdomen : multiple nodul liver metastase
9/7 usg mammae : ca mammae D diikuti limfadenopati axilla kanan kemungkinan maligna
9/7 thorax PA : nodular type metastase
22/6 PA mammae D : Malignant breast tumor, invasive tipe
14/8 HB 12.2 HT 37 AL 6.5 AT 318 AE 4.32 GOLDA B RH + PT 12.4 APTT 32.2 INR 0.89 GDS 89 SGOT 18 SGPT 13
ALB 3.7 CR 0.8 UR 27 NA 133 K 4.2 CL 108 HBSAG NR ANTI HCV NR FT4 15.25
31/5 HB 13.5 HT 39.2 AE 4.54 AL 7.9 GDS 99
Sarwidi Poli Post limfadenectomi Post OP
706B 50 01422641 Perawatan post op JK 22/6 cr 1.1 ur 24 hbsag NR
14/3/1968 13/8 (s)Limfadenopati colli (s) 16/8
21/6 TSH 0.55 FT4 14.14
4/6CT SCAN colli : multiple nodul bilateral, struma nodusa kiri
4/6 COLLI S : lesi ganas adenocarcinoma papiliferum
29/7 PA : Jar asal maksila kanan : Ameloblastoma tipe acanthomatous
Post total maksilektomi 29/7 hb 7.4 al 8.4 ae 4.5 at 568 ht 568 gds 111 anti hiv NR anti Hsag NR Anti HCV NR
Alim mualim Poli
707A 61 01258448 Ameloblastoma R. Buccal Pre op TRANSFUSI JIKA HB < HK 26/7 thorax PA : Pneumonia, dapat merupakan pulmonal metastase pneumonic type
4/9/1956 14/5
10 MGDL 3/7 CT Scan mata/nasofaring : massa maksila kanan yang meluas ke anterior dan mendesak cavum orbita kanan, septum
deviasi ke kanan
31/7 AJH Parotis (D) proses neoplasma salivary gland benign
25/7 USG abdomen: Tak tampak metastase intraabdominal
Nardi Poli
707 B 52 01425800 Tumor parotis susp malignancy Pre Op Pro Biopsi HK 25/7 Ro thorak: Tk tampak gambaran pulmonal dan bone metastase
08/07/1966 15/8
25/7 Hb 11.0 Ht 35 AL 12.1 AT 285 Gol Dar ) PT 14.0 APTT 35.2 INR 1.053 HbsAg NR
16/7 USG soft tissue mass: mengarah ke abses (proses infeksi) dd malignancy di parotis kiri dengan gambaran limfadenitis
707D Ahmad abdad 62 01427708 IGD CANCER PAIN & Bone metastasis Pre op Konsul hasil MRI WY 14/8 : serum Protoin electrophoresis : hipoalbuminemia dengan peningkatan Alpha 1, alpha 2 dan beta 2 globulin disertai
 11/9/1955 2/8 Multiple myeloma penurunan gamma globulin menyongkong kronis
Paraplegi inferior ec destruksi Vth 14/8 MRI: mengarah ke gambaran multiple myeloma, bone metastase (kompresi disertai destruksi Vth 9 dan VL 2 serta
9-10 ec MBD destruksi di proc transversus kanan kiri Vth 9 dan 12) yang menyebabkan hambatan subtotal aliran liquor cerebrospinalis
setinggi level Vth 9 dan Vth 11-12 serta hambatan partial aliran liquor cerebrospinalis setinggi level VL 2, oedem medulla
spinalis setinggi level Vth 6-8 dan setinggi level VL 1-3
13/8 PROTEIN TOTAL : 5.6 alb 3.4 glb 2.2
10/8 Bone Survey : Menyokong gambaran multiple myeloma, bone metastasis di os calvaria, Ramus inferior bilteral os pubis
dan 1/3 proksimal os femur kiri, VL 2, 1/3 media os radius kanan
10/8 usg tiroid : tiroid bilateral tak tampak kelainan
10/8 hb 12.1 ht 32 al 4.6 at 133 ae 3.68
9/8 HB 9.4 HT 28 AL 5,2 AT 128 AE 3.28
7/8 P5A 0.93 NORMAL
2/8 HB 10.6 HT 30 AL 4.3 AT 138 AE 3.30 GDS 116 SGOT 22 SGPT 11 ALB 4.6 CR 1.2 UR 31 NA 129 K 4.0 CA 1.25
HBSAG NR
2/8 thorax PA : gambaran bronkitis, tak tampak metastase
2/8 usg abdomen : kista multiple pada hepar, tidak tampak lesi/nodul di para aorta, hipertrofi prostat
31/7 mri vertebra cervicaco thoracal : gambaran infiltrasi massa tumor solid marrow dan ekstensi ke pedikel lamina dektra
mengakibatkan pendesakan kolom lateral dextra spinal canal thorachal dg stenosis moderate sampai berat level VTH disertai
multi fokal foci th 5, th 6, th 7, th 8, th 9, th 10 sesuai gambaran bone metastasis dg impending fracture patologis dd myeloma
multiple. Anular bulging diskus c6-7 mengakibatkan stenosis ringan spinal canal cervical tak tampak pendesakan neural
foramen dan iritasi radiks
15/8 Hb 8.5 Ht 26 AL 4.1 AT 44 PT 13.0 APTT 27.0 INR 1.000 GDS 125 Cr 0.7 Ur 57 Na 133 K 3.0 Cl 104
9/8 HB 9.9 HT 32 AL 4.5 AT 50 AE 3.77 ALB 3.1 HBSAG NR
23/7 hb 8.6 ht 27 al 5.9 at 75 ae 3.14 pt 14.9 aptt 30.0 inr 1.140
Kirman Interna Post Biopsi insisi NHL an ARBOR post OP 19/7 hb 8.4 ht 27 al 6.4 at 114 ae 3.01
707C 52 01408523 Perawatan post op HK
31/12/1966 9/8 4 15/7 5/4 USG ABDOMEN : splenomegali, lesi regio inguinal kiri dengan vaskularisasi meningkat
15/2 ct scan brain dg kontras : massa orofaring sisi bilateral yang mempersempit lumen orofaring dan meluas ke nasofaring
(tonsil), limfadenopati submandibula dan coli bilateral, septum nasi deviasi ke kanan
6/2 PA : Non hodgkin limfoma
14/8 HB 12.7 HT 37 AL 5.0 AT 241 AE 4.65 PT 15.2 APTT 39.1 INR 1.16 GDS 162 SGOT 23 SGPT 20 CR 0.3 UR 30 K
136 K 4.0 CA 1.05 HBSAG NR ANTI HCV NR
Sriwati Poli
708D 46 01374951 Tumor parotis D PRE OP PRO EKSISI LUAS WY 10/4 PA colli D : branchial cyst/cervical lymphoephitelial cyst
17/7/1972 13/8
7/4 hb 13.2 ht 38 al 7.1 at 296 ae 4.75
6/4 pt 15 aptt 22.5 inr 1.29 gds 110
16/8 CR 1.2 UR 49
14/8 HB 10.9 HT 34 AL 16.9 AT 467 AE 4.14
13/8 golda B
Kemoterapi jika :
Sumino Poli High grade malignant 9/8 hb 8.9 ht 28 al 23.3 at 480 ae 3.53 gds 80 sgot 14 sgpt 12 cr 1.7 ur 77 hbsag NR
711A 72 01427773 Kemo HB > 10 JK
6/8/1946 13/8 fibroliticocitoma Inguinal (S) 9/8 thorax PA : 1. Nodul di paru kanan curiga nodul metastasis (golf ball) DD/ nodul primer, 2. Efusi pleura kanan dapat
CR < 1.5
merupakan subpleural type pulmonal metastasis, 3. Aotosklerosis
9/8 usg abdomen : 1. Tak tampak metastasis intraabdominal, efusi pleura kanan, ascites, parenchymal renal disease bilateral
19/7 ro femur kiri : soft tissue mass di hip joint kiri
FLAMBOYAN 8
15/8 Hb 11 Ht 34 AL 14.8 AT 218 GDS 208 SGOT 40 SGPT 28 Alb 2.4 Cr 0.7 Ur 26 Na 122 K 4.3 Cl 95
14/8 AJH Femur dextra : dijumpai sel ganas, pendapat sarcoma
10/8 ALB 1.9
Marmi Interna
808A 54 01408523 STT femur D susp Maligna WD CT scan genu HK 9/8 hb 10.1 ht 32 al 21.5 at 218 ae 3.66 alb 1.8
15/12/1964 8/8
6/8 ro femur kanan AP/Lat : 1. Soft tissue mass di regio femur dextra, 2. Tak tampak fraktur / dislokasi
6/8 thorax PA : pneumonia dan nodul paru dapat merupakan pneumonic dan nodular type pulmonal metastase
6/8 hb 8.0 ht 25 al 22.9 at 281 ae 2.64
13/8 cr 1.5 ur 74 na 129 k 4.9 cl 1.36
Interna Limfadenopati regio ingunal, massa 13/8 usg tiroid : tiroid bilateral tak tampak kelainan, lesi colli sinistra merupakan gambaran limfadenopati maligna
808C Misdi 69 01428885 Konsul konsul
16/8 regio coli sinistra 9.8 usg abdomen : lamfadenopati para aorta, hidronefrosis dan hidroureter ringan dupleks ec tdk jelas, massa pada regio
inguinal kanan masih mungkin limfadenopati