Screening Bedah onkologi

Senin, 03 Maret 2020

No Identitas Tanggal Ruangan Diagnosis DPJP Tanggal Rencana

Masuk Operasi
1. Relawati Marheni 25/02/2020 RB6 STT o/t (R) Knee post Insisi biopsy DR. dr. Kamal 26/02/2020 R/ Cek Lab Paska tranfusi 3 bag
P/42thn 3.1.1 POD-10 Basri Siregar Sp.B R/ Menunggu hasil Biopsi
62.92.68 (K) Onk

Lab (27/02/2020)
Hb/Leu/Ht/Tr : 7.4/29,810/23/486,000
Na/ K/Cl: 131/3.5/98

CT Scan Femur Kanan dengan Kontras IV

Massa Jaringan lunak (intramuscular) dengan tipikal dan perluasannya tersebut diatas proyeksi aspek latero-anterior femur hingga proximal cruris dekstra, susp.
Maligna.

2 Nuraija 02/03/2020 RB6 Rhabdomiosarcoma o/t (L) Gluteus + dr. Denny, Sp.B Rencana Transfusi PRC 100cc/hari
P/13thn Anemia (K) Onk
793031

Lab (02/03/2020)
Hb/Leu/Ht/Tr :
9.6/18,560/29/355
000
Na/K/Cl :
138/3.2/106
3. Aisyah Putri 01/03/2020 RB6 Post Superficial Parotidectomy dr. Suyatno Sp.B 02/03/2020 R/ Parotidectomy tgl 2/3/2020
Cahaya 3.3.2 (K) Onk + Frozen section
d/t Tumor Kelenjar Parotis
P/14thn
80.33.88 POD-1

Lab (02/03/2020)
Hb/Leu/Ht/Tr : 13/21470/38/399000
Na/ K/Cl: 138/4.4/105

Lab (11/02/2020)
Ur/Kr: 24/0.63
USG Parotis Kiri (29/01/2020)
Lesi solid di parotis kiri dengan ukuran 2,3 x 2 x 2cm
Gambaran benign
Pembesaran KGB Leher kiri multiple dengan ukuran 0,4-0,5 cm (reactive lymphadenopathy)
Sesuai gambaran pleomorfik adenoma parotis

Foto toraks anak AP (11/02/2020)

Normal
Tidak ada tanda metastasis

FNAB (29/01/2020)
C2 benign smear kesan suatu monomorfik adenoma

Frozen Section (02/03/2020)

C3 (Atypic Smear)

Sitologi Imprint (02/03/2020)

Adenoma dengan sebagian sel atipik.
4. Fuji Harianty 24/02/2020 RB 6 ® Breast CA T4cNoMo dr. Suyatno Sp.B R/ Cek Darah Post koreksi
P/32thn 3.4.1 +hiponatremi+ Hipocalemi (K) Onk
80.06.08
(tgl 24/02….Na :111, K:2.3)

Lab (26/02/2020)
Hb/Leu/Ht/Tr : 8.6/6950/25/306000
Na/ K/Cl: 125/2.0/100

Lab (02/03/2020)
Na/K :130/2.7
5. Dewi 24/02/2020 RB6 Thyroid neoplasma suggest malignant dr. Suyatno Sp.B Menolak Tracheostomy
P/57thn 3.4.2 + cT4N1M1 (paru) + impending (K) Onk
80.06.08 obstruksi

Lab (24/02/2020)
Hb/Leu/Ht/Tr : 8.9/22130/28/306
Na/ K/Cl: 130/3.0/97

Lab (25/02/2020)
Ur/Kr: 41/0.62
Free T4: 4.18
TSH: <0.01

USG Liver (25/02/2020)

Tidak tampak metastasis di liver maupun pembesaran Kelenjar limfe paraaorta

Foto toraks PA (24/02/2020)

Susp. Metastasis paru disertai pneumonia
Aorta elongasi
 Foto Cervical AP Lateral (24/02/2020)
Soft Tissue Mass regio colli bilateral terutama kiri sangat mungkin dari struktur tiroid

6. Siti Hanifah 28/02/2020 RB6 Neurofibroma dr. Pimpin Sp.B Perbaikan Hb

P/28thn 3.5.1 (K) Onk Sudah transfusi 2 bag, rencana cek hb
80.42.24 post ransfusi
R/ operasi menunggu assessment

Lab (27/02/2020)
Hb/Leu/Ht/Tr : 6.8/10690/22/954000
Na/ K/Cl: 131/5.5/103
Ur/Kr: 15/0.59

Foto Toraks (23/01/2020)

Nodul pada soft tissue toraks kanan

FNAB (16/01/2020)
C3 = atypical smear
7. Meni Sri 26/02/2020 RB6 Post (R) chest tube insertion + WSD DR. dr. Kamal Hitung produksi chest tube
wahyuni/P/33thn 3.5.3 d/t (R) pleural effusion + (L) Breast Basri Siregar Sp.B
80.59.12 neoplasma sugg. Maligna cT4bN1M1 (K) Onk
(paru)

Lab (26/02/2020)
Hb/Leu/Ht/Tr : 14/7640/41/428
Na/ K/Cl: 139/3.7/102

Foto toraks (26/02/2020)

Pleural effusion kanan + underlying disease
8. Ratna 25/02/2020 RB 6 Soft tissue tumor + Anemia dr. Suyatno Sp.B R/ transfusi 1 bag PRC
Siregar/P/55thn 3.6.2 (K) Onk
79.87.33

Histopatologi (24/08/2019) : Spindle cell carcinoma dd synovial carcinoma, fibrosarcoma, undiferentiated pleomorfik carsinoma
Lab (11/02/2020) : Hb/Leu/Ht/Tr : 12.4/7.660/39.2/241.000. Na/K/Cl : 138/3.5/103. Ur/Cr : 22/0.69. Free T4/TSH : 0.72/2.39

9. Bainar 26/02/2020 RB6 (R) Breast neoplasma sugg. Maligna DR. dr. Kamal Koreksi natrium
P/ 36 thn 3.9.1 cT4cN1M1 (paru) Basri Siregar Sp.B Pantau produksi chest tube
80.61.12 (K) Onk

10. Nila Sari 25/02/20 RB6. (R) Breast neoplasma sugg. Maligna DR. dr. Kamal Respkan xeloda
P/24thn 2.3.1 + post (R) MRM Basri Siregar Sp.B
73.32.20 (K) Onk

11. Junaidi 11/02/2020 RB6 STT sugg malignant DR. dr. Kamal R/ konsul palliative care
L/58thn 2.2.2 Basri Siregar Sp.B
80.62.21 (K) Onk

12. Liliyani 26/02/2020 RB6 (R) Breast neoplasma sugg. Maligna dr. Suyatno Sp.B R/ transfusi 2 bag
P/40thn 2.1.2 (K) Onk Rencana operasi jika Hb tercapai
80.42.16
13. Raihani 24/02/2020 Rb 6 Susp Ca. Tyroid + Dr. Suyatno, 02/03/2020 Menunggu hasil lab Kalsium post op
P/61 thn 1.3.1 Post Total tiroidectomy Sp.B(K) Onk
80.52.87 POD-1

Cytology (30/01/2020) : Benign follicular nodule pada lobus kiri, Malignant kesan papillary thyroid.
Lab (11/02/2020) : Hb/Leu/Ht/Tr : 12.4/7.660/39.2/241.000. Na/K/Cl : 138/3.5/103. Ur/Cr : 22/0.69. Free T4/TSH : 0.72/2.39
Foto Thorax (11/02/2020) : dbn

14. Erika Nur 21/02/2020 Rb 6 Post (L) chest tube insertion + WSD dr denny Rifsal 21/02/2020 R/ Pantau produksi Chest Tube ( jika
P/35 thn 1.3.2 + post (L) MRM d/t (L) breast Ca Sp.B(K) Onk <100cc/24 jam pleurodesis)
75.76.84 TxNxM1(tulang dan paru)+ Post AC
4x + Radiasi 30 x + Post kemoterapi
Tulang 5 x
Histopatologi ( 18/09/2018) : Invasive Ductal Ca Grade II
Bone Scan (25/09/2019) : Gambaran patologis pada tulang sesuai untuk proses metastasis
Lab (26/02/2020) : Hb/Leu/Ht/Tr : 13.4/13.930/37/223.000. Na/K/Cl : 135/4.2/103

15. Romana 25/02/2020 RB6 (R) Breast Neoplasm Sugg Malignant Dr. dr. Kamal, Rencana Insisional biopsy.
P/74thn 1.1.2 cT4bN1M0 SpB(K)Onk Dijadwalkan elective hari rabu
80.58.50

Foto Thorax (25/02/2020) : Pneumonia, Curiga Metastasis paru kanan atau efusi pleura kanan
Lab (25/02/2020) : Hb/Leu/Ht/Tr : 5.0/14.410/16/557.000. KGD : 101. Na/K/Cl : 134/4.9/104
USG abdomen (27/02/2020) : Nodul pada hepar, susp meta hepar
Lab (29/02/2020) : Hb/Leu/Ht/Tr : 13.1/10.730/40/326.000
16. Remiyah 29/02/2020 RB6 Post Debridement + Rotational Flap dr. Suyatno, 02/03/2020 Perawatan Luka
P/73thn 1.1.1 d/t Defect (L) Orbita d/t Basalioma SpB(K)Onk
79.33.12 Post wide eksisi
 POD-1

Hasil PA 2019 : C3 (Atypical Smear) di RS USU

Foto Thorax : (06/12/2019) & (19/02/2020) : Atherosclerosis dan elongasi aorta
Riw Wide Eksisi : 20/01/2020
Histopatologi (28/02/2020) : Basalioma Solid Type, invasi ke dalam bola mata dan tulang
Lab (29/02/2020) : Hb/Leu/Ht/Tr : 10.1/8.840/31/367.000
17. Tiur Suhimar 26/02/2020 RB6 (R) Breast Ca TxNxM2 (Bone and dr. Denny, Patau Hemodinamik
P/50thn 1.2.2 Brain) + Post (R) MRM + (L) Breast SpB(K)Onk Paliative Care
69.50.62 Ca TxNxM2 (Bone and Brain) + Post
(L) MRM + Post Adjuvant
Kemoterapi 54x + Radioterapi 9x
Histopatologi (2016) : Invasive breast carcinoma
Bone Scan (2018) : Tampak proses metastasis
Lab (26/02/2020) : Hb/Leu/Ht/Tr : 14.2/11.750/40/287.000. Na/K/Cl : 132/3.1/98. Ur/Cr : 54/0.72
Thorax (26/02/2020) : Infiltrat Paru kanan.

18. Mona Yolanda 02/03/2020 RB6 (R) Breast Neoplasm Pro MRM Dr. Denny, Sp. 03/03/2020 Rencana Right MRM
P/44th 2.4.1 B(K) Onk
795290

Foto Thorax (25/02/2020)

Kardiomegali + aorta elongasi

Lab (25/02/2020)
Hb/Leu/Ht/Tr : 5.0/14.410/16/557.000. KGD : 101. Na/K/Cl : 134/4.9/104

USG Liver (25/02/2020)

Tampak metastasis liver
 Lab (25/02/2020)
PT/APTT/TT: 11.4/32.9/16.0
BUN/Ur/Cr: 5/11/0.63
Na/K/Cl: 138/4/105

Lab (27/02/2020)
Hb/Leu/Ht/Tr : 9.5/4,070/29/238000
KGDS: 125

Hasil PA (histopatologi) (18/11/2019)

Invasive Carcinoma NSI grade III of Breast
19. Lilis/p/43th 02/03/2020 RB6 Multiple cyst o/t head Dr. Denny, Sp. 03/03/2020 R/ Eksisi luas
80.44.77 2.4.2 B(K) Onk

Foto Thorax (10/02/2020)

Normal

Lab (1/02/2020)
Hb/Leu/Ht/Tr : 14/5,23/42/310000. KGD : 110. Na/K/Cl : 138/4.1/104
PT/APTT/TT: 11.7/30/12
BUN/Ur/Cr: 11/24/0.72

USG Liver (25/02/2020)

Tampak metastasis liver
Hasil Sitologi (30/01/2020)
Suatu pembentukan abses pada leher belakang
Benign lesion pada pinggang
20. Turini 02/03/2020 RB6 (L) Breast Ca T2bN1M1 + Dr. dr. Kamal Rencana koreksi Natrium
P/48thn 3.10.3 Hiponatremia
785782

Lab (02/02/2020)
Hb/Leu/Ht/Tr : 9.9/9,160/30/170
KGDS: 278
Na/K/Cl : 124/5.7/97

PA Histopatologi (08/08/2019)
Invasive Breast Carcinoma NST Grd I LVI (-)

Foto Toraks (24/02/2020)

Susp. Kardiomegali + LVH
Infeksi dd/ Metastasis Paru disertai efusi pleura kiri
Metastasis pada tulang-tulang costae, Proximal Humerus

USG Liver (28/02/2020)

Tampak Efusi Pleura Kanan

Bone Scan (15/08/2019)

Gambaran Patologis pd tulang sesuai utk proses metastasis