PASIEN BEDAH ONKOLOGI RSUP HAM MEDAN

TANGGAL Mei 2018

RB1

TGL OPERASI
HASIL
NO RUANGAN IDENTITAS DIAGNOSIS (KETERANGAN RENCANA KETERANGAN
PEMERIKSAAN
)

1. 3.2 Annisa Post fourquater d/t 13/9/2017 2/5/2018: R/ gv /hari 23/5

Amalia/71.90.43 osteosarcoma + post Hasil PA: fourquater d/t Hb/Ht/leu/trombo:
chest tube insertion osteosarcoma osteosarcoma 10,9/36/15460/
chondroblastic type 831000
6/4/2018: 6/5/2018: Albumin/KGDS :
MTCTscan: lesi primer Chest tube 3/ 82
proximal os humerus insertion Na/K/Cl:
kiri dengan massa 128/3,7/101
jaringan lunak sekitar
disertai komponen
nekrosis dan abses ec
susp. Chondrosarcoma
dd osteosarcoma.
21/05/2018
Foto thorax: effuse
pleura kiri dengan
ujung chest tube di ICS
4 kiri.

2. 3.3 Normah/p/76thn/ Post Total 16/5/2018 Hb/Ht/leu/trombo

740576 Thyroidectomy + Post 11,2/33/5,170/
Tracheostomy 134,000
3. 3.6 Inyet Br Basalioma o/t upper 18/5/18 21 Mei 2018 = Hasil lab Post Op
Sembiring/62.32.71 eyelid (R) Hasil PA: Wide Eksisi + Fz 21/05/18:
Invasive breast Hb/Ht/Leu/Eri/Plt
carcinoma no special :
type (NST) + 10.4/30/11.260/3.4
moderately 8/407.000
differentiated KGD ad random :
97

4. 3.6 Muspida /p/41 (L) Breast Ca T4BN0M0 22-5-18 R/Insisi Biopsi(sudah Hasil lab (11-5-18)
tahun/74.31.75 dilakukan tgl 22-5-18) Imunoserologi :
CA 15-3=23,5U/L
R/PBJ (tgl 23-5-18)
Hasil X-Ray(11-5-
18)=kardiomegali

RB2A

RUANGA HASIL TGL OPERASI

NO IDENTITAS DIAGNOSIS RENCANA KETERANGAN
N PEMERIKSAAN (KETERANGAN)

Lab 18/5/18
Hb/ht/leu/tromb :
Invasive ductal 12,9/40/4,930
Ca Mamae (R )
1. PONIYEM / 72.95.55 carcinoma 28/5/18 MRM /253,000
T4bN1M1
dextra grade II
Na/K/Cl:
142/4,3/103
2. KHAIRIAH / 73.68.66 Ca Mamae (R) T3N0M0 Invasive ductal 28/5/18 MRM Lab 23/5/18
carcinoma Hb/Ht/Leu/Trom
dextra grade II b 11,9/37/5,160/
318,000

Na/K/Cl :
136/4/103

3. RB 2A 324 Mulyani (L) parotid tumor 25/05/18

suggest benign post Hb/ht/leu/eri/tro
superficial m
parotidectomy 10/30/12980/4,06
/373000

Apri indah Scc lidah post R/ koreksi Hb/ht/leu/eri/tro

RB 2A 322 hemiglossectomy kiri natrium dan m
+post adjuvan kemo kalium 11/29/4460/3,7
3x +aki + GE + 1/247000
elektrolit imbalans
Na/k/cl
123/2,6/96
4. Arni girsang SCC bucal + hiponatremi Keratinizing scc cek lab post koreksi Na: 119
+ hipokalemia elektrolit 27/05 (lbp K: 2.8
28/04)
 5. Leo Anggi Post above knee 26/5/18 above Cek lab post
amputation + susp. knee amputation operasi (lbp
Rhabdomyosarcoma dilayangkan 27/05)
o/t left knee + anemia

Mirnawati Liposarcoma ot left leg well - Perbaikan KU

diferentiated
liposarcoma

7. RB2A 214 Mariani (L) Ca mammae Thoraks : susp. R/ MRI 21/05/2018

TxNxM1 (Paru) + Post Metastase Hb/Ht/Leu/trom :
mastectomy intrapulmonal 11,7/33/8.930/27500
0
Na/K/Cl : 136/2,8/89

8. Rb2a Halima tussakdiah (L) Breast invasive ductal 22/05 MRM + R/ perbaikan KU Lab (26/05/18)
(2.2.4) lubis neoplasma susp carcinoma STSG PBJ Hb/E/L/Ht/Plt :
malignan post (L) (grade II) 11,5/4,17/2610/
MRM + STSG 168000
Na/k/Cl :
135/3,8/103
9. Rb2a Hasbi Sima NHL + Anemia + diffuse large B R/ kemoterapi Lab (25/05/18)
(3.1.3) Hiponatremia cell lymphoma Hb/E/L/Ht/Plt :
9,6/3,46/10220/
Foto cervical : 30/319000
kesan Na/K/Cl :
pembesaran 127/3,8/103
KGB
Dd/
lymphadenopathy
Lymphoma

RB2B

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)
1. 3.3.3 AhmatRahmadan / L / Liposarcoma o/t inguinal Thorax PA: left Kemoterapi, setelah 18/5/2018
19/4/18 17 thn / 73.12.82 G3T4N1M1 paru + CKD lung nodular selesai perbaikan fungsi Hb/Ht/L/T :
Stage V + anemia berat metastase multiple ginjal 6.1/29890/417.000
Histopatologi: round BUN/Ur/Cr:
cell liposarcoma 50/107/2.78
Na/K/Cl :
136/5.2/103
Alb : 2.5

6. 3.3.6 Makmur/L/55 tahun LimfadenopatiColliSinistr 19/5/2018 :

add NHL Hb/Ht/Leu/Plt :
10.2/31/13.380/97.
000

3/3/5 Risana Ginting/74.25.55 (L) tumor parotis Adenoma kelenjar 23/5/2018 R/paratidectomy Hb;16,1
parotis Leu;9320
Hematokrit; 48
Trom;187.000
Kgds;84

2. 3.6.3 Siti aisyah Breast ca (L) TxNxM1 Thorax : efusi pleura Pleurodesis bila produksi 14/05/2018
(pleura,tulang) + post masif yang drain < 200 cc Hb/Ht/Leu/tromb :
MRM + post pemasangan mendesak 12,8/42/14.910/544
chest tube + WSD+ mediastinum ke .000
leukositosis kanan KGDs : 95
Bone scan :
gambaran sesuai
metastase tulang

3. 3.6.1 RismabrPeranginangin/ (L) Breast Ca TxNxM1

P/55thn (Pleura) + Post
Pemasangan Chest Tube
+ WSD
4. 3.4.4. H. Chandra Sihombing Limfadenopaticolli dd 20/5/2018:
L/31th/ Susp. NPC Hb/Ht/Leu/Plt:
4.4/13/15220/3153
000
Kgds :84
Na/K/Cl :
140/4/105
BUN/Ur/Cr
:12/26/0.43

125. 2.4.2. Ernawati / P/ 51 tahun (L) phyloides tumor -PA: gambaran Rencana Mastektomi Hb/Leu/HT/PLT:
T4bN0M1 (liver) + histologik sediaan paliatif (23 Mei 2018) 9,8/19,240/30/432,
Anemia + Hiponatremia+ fibroadenoma 000
Hipokalemi+ mammae Na/K/Cl:
hipoalbumin 130/2,6/95
-USG liver KGD ad Random :
(14/5/2018) 167
metastase liver Albumin: 1,6
- Thorax
(11/5/2018): tidak
tampak kelainan
pada cor dan pulmo
Massa mammae
payudara kiri

6. 3.3.6 Makmur/L/55 tahun Limfadenopati Colli Thorax : suggestif 19/5/2018 :

Sinistra dd NHL pneumonia Hb/Ht/Leu/Plt :
Usg upper abdomen 10.2/31/13.380/97.
: 000
Pemb.KGB paraorta
multiple ukuran 1-
3cm
7. 3.6.2. Hasanah Basaliomao/t frontal 16/5/2018

8. 2.4.3. SelmiSianipar

9. 3.7.2 Magdalena Susp.Rhabdomyosarcoma Vertebra lumbal 22/05/16

Femur (L) :spondylosis Hb/ht/leu/plt :
lumbalis 9,4/28/13,750/3650
Pelvis : tidak 00
tampak kelainan
pada foto pelvis

10. 3.5.3 Risana Ginting/74.25.55 (L) Tumor parotis 23/05/18

T3N0M0

11. 3.7.1 Siti Aminah/64.37.19 Proptosis Bulbi Ct Scan orbita : 23/05/18 09/04/2018
Right Retrobulbar Hb/ht/ Leu/Plt :
Mass 13/39/6380/307.00
Thorax : 0
Cardiomegaly

RB3
 HASIL TGL OPERASI
NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

1. 3.3.1 Minta Deliana Thyroid Neoplasma Foto thoraks : susp. Total thyroidectomy Hb/eri/leu/ht :
13/5/2018 P/68 thn/ 74.17.87 curiga ganas T3M0N0 Metastasis 12.1/4,34
intrapulmonal, juta/41.560/37%
cardiomegaly
FNAB : C2 (benign
smear)

2. 3.1.3 Rosmini/P/44thn/ Breast ca (L) TxN0M1 Foto thorax : efusi R/ trf PRC 2 bag 26/5
67.89.67 (paru, tulang) + post Trf Trombocyte
pleura kanan, Hb/leu/plt:
mastektomi + post concentrate 7 bag
kemoterapi ke-11 limfadenopati hilus 8,3/11.290/20.000
kanan Na/K/Cl:
144/3,1/105
USG liver : tidak
BUN/ur/cr :
tampak metastase 48/103/4.3
PT/INR/Aptt/tt :
hepar
11.7/0.84/34.0tt6t
PA : invasive breast 17.5
KGD : 140
carcinoma, grade III
IHC :
Estrogen res : +
Progesterone res : -
HER-2 : +1
KI-67 : -
3. 1.5.1 Iyemtinah/P/72.42.83 Breast Ca (R) + Kemoterapi Hb/Leu/Plt/Eri/Ht :
T4bN1M1 + post
14.7/12.680/290.00
pemasangan WSD (H13)
0/5.28/46
KGDs : 97
BUN/Ur/Cr :
8/17/0.48
Na/K/Cl :
134/1.9/81

4. 1.7.1 Post rotation advanced

Sesuai dgn high Hb/Leu/Plt:
Mardiana/P/43tahun/73. flap + Post wide eksisi ec.
grade adult 17/05/18 R/ transfusi PRC 1 bag 9,1/16000/480000
74.84 Fibrosarcoma (H+5) +
fibrosarcoma
anemia sedang

RUANG KEMOTERAPI
HASIL TGL OPERASI
NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

1. 3.1 Ely/73.09.24 SCC lidah

2. 2.3 Apri indah SCC lidah

 3. 3.3 Warningsih Breast Ca

VIP PAVILIUN

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

RA 1

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

HB/Ht/Leu/Trombo
- IVFD RL 20gtt/i 13,3/41/290/131000
- IVFD Aminofluid Kgd
14gtt/i 121
- inj. Ceftriaxone
1gr/12jam
NHL o/t (R) Breast +
Rismawati/ P/ 47tahun - inj. Ranitidine
1 1,2,2 Kemoterapi Siklus III + - -
71.62.67 50mg/12jam
Leukopenia
- inj. Ketorolac
30mg/8jam
- PCT 3x 500mg
- Codein 3 x 20mg
- O2 nasal kanul 2-4l/i
 RA 3

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

22/5/2018:
27/4/2018: (cek lab post operasi)
-Cervical PA/L: Hb/Ht/leu/plt:
Soft tissue mass pada -IVFD RL 20 gtt/i 132,6/36/12100/
leher sisi kanan -IVFD amino fluid 14 227000
dengan sedikit gtt/i KGDs: 73
pendorongan trakea ke -seftriaxone 1 gr/ 12
Yusniar Nasution/P/52 21/5/2018:
1. Post ismulobectomy kiri. jam
3.1.1 tahun/74.19.54 ismulobectomy
-Foto Thoraks: -Ranitidin 50 mg/12
Normal jam
-USG small organ: -ketorolac 30mg/12
Mass dengan stabil jam
mix dengan kistik
pada tiroid kanan.

RA 4

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)
 Hasil lab(19-5-18)
Hb/Eri/Leu/Trom
R/inj.leukogen(sdh
Jasa Ca Laring + 10,1/3,45/3,030/131.000
1. masuk tgl 22 jam
3.1.1 Bangun/L/65tahun/73.35.05 Trakeostomi
20.00)
Na:95

R/ Cek lab (DL, KGD,

Susp. Limfadenopati dd
2. 3.4.3 Sudibio/L/36tahun/73.73.28 HST, elektrolit, LFT,
NHL, HL
RFT, albumin)

IGD

HASIL TGL OPERASI

NO RUANGAN IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
PEMERIKSAAN (KETERANGAN)

Hb/ht/leu/trom :
10,2/31/12930/500000
Kgd/bun/ur/cr :
(l) BREAST
YATINA/P/5443951 118/7/15/0.7
IGD NEOPLASMA SUSP.
TAHUN/7 Na/k/cl :
MALIGNANT
122/2.6/92