Update Pasien Bedah Onkologi

04 Maret 2023
PPJT
Dokter Ruangan : NAI
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

ROI
Dokter Ruangan: RYU
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket
ICU GBPT
Dokter Ruangan : RYU
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

HCU-A
Dokter Ruangan : MHU
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

BEDAH Bougenvil
Dokter Ruangan : ARP
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

BEDAH Cempaka
Dokter Ruangan : MHU
No Ruangan Identitas MRS DPJP TGL OP Diangosa Problem Terapi / Tindakan Operasi Operator Ket

Dx Primer : Ca mamma D T2N0M0 dr. VDY,

Ny. Nani
dr. VDY, Dx Sekunder :History chemotherapy CDF 6x (22/9/2022- Perawatan Post Sp.B(K)Onk PA: IDC NOS
1 C Astuti/P/60th/1294286 28/02/2023 02/03/2023 Post MRM D + 2D Flap H+2
Sp.B(K)Onk 18/01/2022) partial respon Op /dr. DNA, grade II
7 Dx komplikasi: - Sp.B/RYU

Post Hemiglosectomy D + dr. HGB,

Dx Primer : Oral cavity cancer (Ca lidah) T2N1M0 VC Radikalitas + SOHND + Sp.B(K)Onk/d
r. VDY,
Tn DR Dr DSK Dx Sekunder : riwayat kemoterapi paclitaxel-cisplatin 4x Perawatan Post Rekonstruksi Lidah dengan Sp.B(K)Onk/d
2 C 17/2/2023 21/02/2023 PA: SCC
Agel/L/39th/12958614 SpB(K)Onk partial respon Op forearm free flap + tutup r. DNA,
Dx komplikasi :- defek forearm dengan STSG Sp.B/NAL/CA
H+11 X

Bedah Dahlia
Dokter Ruangan : ARQ
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

Bedah Eidelweiss
Dokter Ruangan : NOS
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

dr.
Wide eksisi hingga eksenterasi OS tipe VDY,Sp.B(K)
Ny. dr. Dx Primer : SCC regio Palpebra inferior S T4aN1M0 1 dan k/p Suprastructure Maxillectomy FNAB: Benign
Onk/dr HGB
1 E Suprihatin/P/57th/1293 2/24/2023 VDY,Sp.B(K) 5/3/2023 Dx Sekunder : DM type 2 (Hiperglikemia) + Hipertensi TAO S + VC+Total Parotidektomi S +
Sp.B (K) Nodular
8951 Onk Dx Komplikasi : - MRND tipe III S+ radial forearm free Colloid Goiter
flap/small ALT flap S +STSG Onk/NAI Join
op KL
Bedah Flamboyan
Dokter Ruangan : NOS
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

Dx primer : Soft tissue tumor klinis ganas regio

Dyspneu + edema
hemithorax S T2N1M1 Gx (Susp mediastinum) PA :
anasarka +
Tn. Togab/ L/ 33thn/ dr. ASD Dx sekunder : Hist of incisi biopsy 3x (RS DKT Sda Okt Langerhans
1 F 3/4/2023 1/3/2023 hipoalbumin Post tapping pleura H-4 Jaga 2
12882003 SpB(K)Onk 2021, RS Royal Nov 2021, RS Royal Feb 2023) cell
(3,09) + efusi
Dx komplikasi : dispneu + edema anasarka + histiocitosis
pleura bilateral
hipoalbumin (3,09) + efusi pleura bilateral

Bedah Gladiol
Dokter Ruangan : ARP
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

Dx primer : Non melanotic skin cancer (BCC) reg nasal Post wide eksisi + VC dr DNA
Ny dr VDY
1 G 2/20/2023 28/2/2023 Dx sekunder : HT stage II (-) radikalitas + forehead flap Sp.B/MHU/ PA : BCC
Minati/72th/12967214 SpB(K)Onk
Dx komplikasi:- H+4 ARP

Dx Primer : Ca Mamma S T4bN3cM0

Ny Sutija/P/50 dr VDY Pro insisi biopsi dengan GA
2 G 3/3/2023 5/3/2023 Dx Sekunder : - (-) Jaga 2 (-)
th/12986778 SpB(K)Onk + Cek IHK
Dx Komplikasi : -
Dx primer: Ca mamma S T4bN1M0 Her2 type (partial
respon) PA : Mixed
Ny Saminem/ P/ 64 th/ dr DSK Jaga 2
3 G 3/4/2023 6/3/2023 Dx sekunder : Hist of neoadjuvant therapy CAF 3x partial (-) Pro MRM S Invasive Breast
10992138 SpB(K)Onk Bimbingan
response Carcinoma
Dx komplikasi : -

Dx primer: Ca Mamma D T4bN2M0 Luminal A

Dx sekunder : Hist of insisi biopsi mamma D (RS PA : Invasive
Ny Kasimah/ P/ 44 th/ dr DSK 3/7/20236/3/20 MRM D k/p angkat
4 G 3/4/2023 Muhammadiyah Lamongan, Sept 22) + Hist of Chemo (-) Jaga 2 ductal
12952741 SpB(K)Onk 23 pectoralis mayor D
CAF 6x (RSDS, Okt 22-feb 23) partial response carsinoma
Dx komplikasi : -

Bedah Herbra
Dokter Ruangan : ARQ
Ascites permagna
No Ruangan Identitas MRS DPJP TGL OP Diagnosa on Problem
parasintesis Terapi / Tindakan Operasi Operator Ket
Dx Primer : Ca Mamma S T2N1M1 (Hepar, Paru) (PA: Infiltrating ductal catheter +
carcinoma of NST grade III Luminal B Her2Negatif ) Dilatated Post parasitensis cairan
Dx Sekunder :
- Hist of chemoterapy NAC CAF 6x (RS Husada Utama, April-Agustus Cardiomyopathy Ascites H+11
Ny. Dehra PA:Invasive
DR dr DSK 2022) partial response (Chemoterapy Perbaikan KU:
1 H Quartiani/P/41 20/2/2023 20/2/2023 - Hist of Hormonal teraphy Tamofen + Zoladex NAI ductal
SpB(K)Onk induced Konsul vaskuler, Neurobion
th/12960018 - On chemotherapy paclitaxel 1x (13 Februari 2023) carsinoma
Dx Komplikasi : Ascites permagna on parasintesis catheter + Dilatated cardiomypathy) + IV 2 x 1, Raber jantung,
Cardiomyopathy (Chemoterapy induced cardiomypathy) + Selulitis cruris Selulitis cruris Tunda Chemoterapy
pedis D et S + Neuropati pedis D et S pedis D et S +
Neuropati pedis D
Dx Primer : Ca Mamma D yT0N0M1 (suspect paru, pleura, mamma et S Transfusi PRC 2kolf/hari
kontralateral) luminal B
Dx Sekunder : Hist Of NAC Paclitaxel Carboplatin 3x (Sept - Nov 2019, Oksigenasi PA:Invasive
Ny Ervianti / 49 dr VDY Efusi Pleura D
2 H 03/03/2023 (-) RSDS) partial response + Hist OF MRM D (Jan 2020, RSDS) + Riwayat USG abdomen dari ruangan (-) ductal
th/P/60107999 Sp.B(K)Onk radiasi 35x (RS Karyadi Semarang, 2022) + On Tamofen (maret 2020 - Anemia (7,1)
sekarang, RSDS)
FNAB mamma S carsinoma
Dx Komplikasi : Efusi Pleura D + Anemia (7,1) Cek CEA, Ca 15-3

Bedah Melati
Dokter Ruangan : ARP
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket
Bedah Teratai
Dokter Ruangan : ARQ
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

Bedah Rosella/PPLK Lt. 1

Dokter ruangan: ARP/ARQ/NOS
No Ruangan Identitas MRS DPJP TGL OP Diagnosa Problem Terapi / Tindakan Operasi Operator Ket

Dx primer : Chemotherapy session On kemoterapi siklus ke 2

Ny. Yanti dr. VDY,
1 Rosella 03/03/2023 (-) Dx sekunder: Ca Mammae sT4bN1M0 (-) Gemcitabine 1000 mg + (-)
Syah/P/53/12951652 Sp.B(K)Onk
Dx komplikasi : - carboplatin 430mg
Dx primer : Chemotherapy session On kemoterapi siklus ke 6
Ny. Sri dr. DSK ,
2 Rosella 03/03/2023 (-) Dx sekunder: Ca Mammae S yT0N0M1(paru) (-) Docetaxel 127,5 mg + (-)
Sayekti/P/54/10171029 Sp.B(K)Onk
Dx komplikasi : - carboplatin 639 mg
Dx primer : Chemotherapy session On kemoterapi siklus ke 5
Tn. Ferri Adi dr. DSK,
3 Rosella 02/03/2023 (-) Dx sekunder: Oral cavity cancer T4bN3bM0 (-) Erbitux 650mg + (-)
Saputra/L/38/12907386 Sp.B(K)Onk
Dx komplikasi : - Gemcitabine 1520mg

RKL
Dokter Ruangan : NAI

BUFFER
Dokter Ruangan : MHU

Dx Primer: Ca mamma D yT0N0M1 (Paru, liver, suspect pleura) Anemia (7,9) +

Dx Sekunder: History of MRM D (Klinik Bedah Surabaya, 2019) + Ikterus obstruktif
Ny. History of adjuvant chemotherapy 18x (RS Soewandhi, lupa
dr VDY + hiponatremia
1 Buffer Rochmawati/P/31th/12 01/03/2023 01/03/2023 regimen) + on taceral Post Tapping Pleura H-4 Jaga 2
Sp.B(K)Onk Dx Komplikasi: Efusi Pleura D masif + Anemia (7,9) + Ikterus (130) +
991403
obstruktif + hiponatremia (130) + hipoalbumin (2,68) + loculated hipoalbumin
pneumothoraks D + lymphedema extremitas superior D (2,68)
 KONDISI RUANGAN per DPJP
04 Maret 2023
Ruanga Terapi / Tindakan
No Identitas MRS DPJP Rencana OP Diagnosa Problem Operator Ket
n Operasi
Dr dr DSK, Sp.B (K)Onk
Dx Primer : Ca Mamma S T2N1M1 (Hepar, Paru) (PA: Infiltrating ductal carcinoma of NST grade III Luminal B Her2Negatif )
Dx Sekunder :
- Hist of chemoterapy NAC CAF 6x (RS Husada Utama, April-Agustus 2022) partial response
Post parasitensis cairan
Ny. Dehra - Hist of Hormobal teraphy Tamofen + Zoladex Ascites H+10 PA:Invasive
DR dr DSK - Hist. of chemotherapy paclitaxel 1x (13 Februari 2023)
1 H Quartiani/P/41 2/20/2023 (-) Leukopenia 1,5 Perbaikan KU (-) ductal
SpB(K)Onk Dx Komplikasi :
th/12960018 - Ascites permagna
- Dilatated Cardiomyopathy (Chemoterapy induced cardiomypathy)
DL evaluasi carsinoma
- Selulitis cruris pedis D et S Konsul vaskuler
- Neuropati pedis D et S

Dx primer : Chemotherapy session On kemoterapi siklus ke 6

Ny. Sri dr. DSK ,
2 Rosella 03/03/2023 (-) Dx sekunder: Ca Mammae S yT0N0M1(paru) (-) Docetaxel 127,5 mg + (-)
Sayekti/P/54/10171029 Sp.B(K)Onk
Dx komplikasi : - carboplatin 639 mg

Dx primer : Chemotherapy session On kemoterapi siklus ke 5

Tn. Ferri Adi dr. DSK,
3 Rosella 02/03/2023 (-) Dx sekunder: Oral cavity cancer T4bN3bM0 (-) Erbitux 650mg + (-)
Saputra/L/38/12907386 Sp.B(K)Onk
Dx komplikasi : - Gemcitabine 1520mg

Dx primer: Ca mamma S T4bN1M0 Her2 type (partial respon) PA : Mixed

Ny Saminem/ P/ 64 th/ dr DSK Jaga 2
4 G 3/4/2023 6/3/2023 Dx sekunder : Hist of neoadjuvant therapy CAF 3x partial response (-) Pro MRM S Invasive Breast
10992138 SpB(K)Onk Bimbingan
Dx komplikasi : - Carcinoma

Dx primer: Ca Mamma D T4bN2M0 Luminal A

PA : Invasive
Ny Kasimah/ P/ 44 th/ dr DSK 3/7/20236/3/20 Dx sekunder : Hist of insisi biopsi mamma D (RS Muhammadiyah Lamongan, MRM D k/p angkat
5 G 3/4/2023 (-) Jaga 2 ductal
12952741 SpB(K)Onk 23 Sept 22) + Hist of Chemo CAF 6x (RSDS, Okt 22-feb 23) partial response pectoralis mayor D
carsinoma
Dx komplikasi : -

dr IKA, Sp.B (K)Onk

dr ASD, Sp.B (K)Onk

Dx primer : Soft tissue tumor klinis ganas regio hemithorax S T2N1M1 Gx
(Susp mediastinum)
hipoalbumin +
Tn. Togab/ L/ 33thn/ dr. ASD Dx sekunder : Hist of incisi biopsy 3x (RS DKT Sda Okt 2021, RS Royal Nov PA : Langerhans
1 F 3/4/2023 3/1/2023 efusi pleura Post tapping pleura H-4 Jaga 2
12882003 SpB(K)Onk 2021, RS Royal Feb 2023) cell histiocitosis
bilateral
Dx komplikasi : dispneu + edema anasarka + hipoalbumin (3,09) + efusi pleura
bilateral

dr VDY, Sp.B (K)Onk

Ny. Nani Dx Primer : Ca mamma D T2N0M0
dr. VDY, Post MRM D + 2D Flap PA: IDC NOS
1 C Astuti/P/60th/1294286 28/02/2023 02/03/2023 Dx Sekunder :History chemotherapy CDF 6x (22/9/2022-18/01/2022) partial respon (-) Senior
Sp.B(K)Onk Dx komplikasi: -
H+1 grade II
7

dr.
Wide eksisi hingga eksenterasi OS VDY,Sp.B(
Ny. dr. Dx Primer : SCC regio Palpebra inferior S T4aN1M0 tipe 1 dan k/p Suprastructure K)Onk/dr FNAB: Benign
Maxillectomy S + VC+Total
2 E Suprihatin/P/57th/1293 2/24/2023 VDY,Sp.B(K)On 5/3/2023 Dx Sekunder : DM type 2 (Hiperglikemia) + Hipertensi TAO Parotidektomi S + MRND tipe III HGB Sp.B Nodular Colloid
8951 k Dx Komplikasi : - S+ radial forearm free flap/small (K) Goiter
ALT flap S +STSG Onk/NAI
Join op KL

Dx Primer : Soft Tissue Sarcoma Gx cT2NxMx

Didit Caturyanto/L/46 dr VDY,
3 F 2/26/2023 3/3/2023 Dx Sekunder : Riwayat Insisi Supratumoral (Des 2022, RS Bunda Sidoarjo) (-) Post core bipsi H+1 Jaga 2 (-)
th / 12985210 SpBKOnk
Dx Komplikasi : -

Dx primer : Non melanotic skin cancer (BCC) reg nasal Post wide eksisi + VC
Ny dr VDY
4 G 2/20/2023 2/22/2023 Dx sekunder : HT stage II (-) radikalitas + forehead flap Senior PA : BCC
Minati/72th/12967214 SpB(K)Onk
Dx komplikasi:- H+4
Dx Primer : Ca Mamma S T4bN3cM0
Ny Sutija/P/50 dr VDY Pro insisi biopsi dengan
5 G 3/3/2023 5/3/2023 Dx Sekunder : - (-) Jaga 2 (-)
th/12986778 SpB(K)Onk GA + Cek IHK
Dx Komplikasi : -

Dx primer : Chemotherapy session On kemoterapi siklus ke 2

Ny. Yanti dr. VDY,
6 Rosella 03/03/2023 (-) Dx sekunder: Ca Mammae sT4bN1M0 (-) Gemcitabine 1000 mg + (-)
Syah/P/53/12951652 Sp.B(K)Onk
Dx komplikasi : - carboplatin 430mg

Anemia (7,9) +
Dx Primer: Ca mamma D yT0N0M1 (Paru, liver, suspect pleura) Ikterus obstruktif
Ny. Dx Sekunder: History of MRM D (Klinik Bedah Surabaya, 2019) + History of adjuvant
dr VDY + hiponatremia
7 Buffer Rochmawati/P/31th/12 01/03/2023 01/03/2023 chemotherapy 18x (RS Soewandhi, lupa regimen) + on taceral Post Tapping Pleura H-4 Jaga 2
Sp.B(K)Onk Dx Komplikasi: Efusi Pleura D masif + Anemia (7,9) + Ikterus obstruktif + hiponatremia (130) (130) +
991403
+ hipoalbumin (2,68) + loculated pneumothoraks D + lymphedema extremitas superior D hipoalbumin
(2,68)

Transfusi PRC 2kolf/hari

Dx Primer : Ca Mamma D yT0N0M1 (suspect paru, pleura, mamma kontralateral) luminal B Oksigenasi
Ny Ervianti / 49 dr VDY Dx Sekunder : Hist Of NAC Paclitaxel Carboplatin 3x (Sept - Nov 2019, RSDS) partial response + Hist Efusi Pleura D USG abdomen dari
8 H 03/03/2023 (-) OF MRM D (Jan 2020, RSDS) + Riwayat radiasi 35x (RS Karyadi Semarang, 2022) + On Tamofen (maret (-) (-)
th/P/60107999 Sp.B(K)Onk 2020 - sekarang, RSDS) Anemia (7,1) ruangan
Dx Komplikasi : Efusi Pleura D + Anemia (7,1) FNAB mamma S
Cek CEA, Ca 15-3

dr. HGB Sp.B(K)Onk

 Tunggu Antrian Operasi Pasien Bedah Onkologi
04 Maret 2023

Ruanga Terapi / Tindakan

No Identitas MRS DPJP Rencana OP Diagnosa Problem Operator Ket
n Operasi
VDY,Sp
Wide eksisi hingga .B(K)On
Dx Primer : SCC regio Palpebra inferior S FNAB:
eksenterasi OS tipe 1 dan k/p k/dr
Ny. dr. T4aN1M0 Suprastructure Maxillectomy HGB Benign
1 E Suprihatin/P/57th/1 2/24/2023 VDY,Sp.B(K 5/3/2023 Dx Sekunder : DM type 2 TAO S + VC+Total Parotidektomi Nodular
2938951 )Onk (Hiperglikemia) + Hipertensi S + MRND tipe III S+ radial Sp.B Colloid
forearm free flap/small ALT (K)
Dx Komplikasi : - flap S +STSG Goiter
Onk/NA
I Join op
Dx Primer : Ca Mamma S T4bN3cM0 Pro insisi biopsi
Ny Sutija/P/50 dr VDY
2 G 3/3/2023 5/3/2023 Dx Sekunder : - (-) dengan GA + Cek Jaga 2 (-)
th/12986778 SpB(K)Onk
Dx Komplikasi : - IHK

Dx primer: Ca mamma S T4bN1M0 Her2

PA : Mixed
type (partial respon) Jaga 2
Ny Saminem/ P/ 64 dr DSK Invasive
3 G 3/4/2023 6/3/2023 Dx sekunder : Hist of neoadjuvant (-) Pro MRM S Bimbing
th/ 10992138 SpB(K)Onk Breast
therapy CAF 3x partial response an
Carcinoma
Dx komplikasi : -
Dx primer: Ca Mamma D T4bN2M0
Luminal A
Dx sekunder : Hist of insisi biopsi
PA : Invasive
Ny Kasimah/ P/ 44 dr DSK 3/7/20236/3/2 mamma D (RS Muhammadiyah MRM D k/p angkat
4 G 3/4/2023 (-) Jaga 2 ductal
th/ 12952741 SpB(K)Onk 023 Lamongan, Sept 22) + Hist of Chemo pectoralis mayor D
carsinoma
CAF 6x (RSDS, Okt 22-feb 23) partial
response
Dx komplikasi : -