Duty Report

Monday, Jan 12th 17

Surgical Resident : Muliyadi, MD

Attending surgeons on duty

Pediatric surgery
: dr. Yessi Eldiani, SpBA
Digestive surgery
: dr. tan suhardi SpB(K)BD
Orthopedic surgery
: dr. edli warman, SpOT
Plastic & reconstructive surgery : dr. Anastasia, SpBP
(RE)
Neurologic surgery
: dr. lukman maruf, SpBS
Oncologic surgery
: dr. Taufik, SpB(K)Onk
TCV surgery
: dr. Dandreas A lensoen, SpBTKV
Urologic surgery
: dr. haryono, SpU

TOTAL
Outpatient

Inpatient

Operation

Inpatient

Patient Identity
Name
: Mrs. Y
Age
: 51 y.o
RM numb. : 818423
Taken from autoanamnesa

 Chief Complaint
Shortness of breath
History of Present Illness
Patient came with complaint of shortness of breath since a week
before admission. shortness of breath is felt constantly so
debilitating patients, patients can sleep when using two pillows. A
day before admission, patient complained shortness of breath
getting heavier. Patient also said she had lost weight since a few
months . Defecate well.Urinate well. Reduced appetite. Dizziness
(+), body ache (+). 2 years ago, the patient discharged of
hospitalization with the diagnosis of cancer mammae.

 History of Past Illness

the patient has been diagnosed with invasive breast cancer since
12 August 2015 and the patient has received chemotherapy twelve
times since 2015.Patient had no history of hypertension, diabetes,
heart disease, or trauma before..

Family History
-

Biopsy result 12 august 2015

The specimen representing
invasive ductal mammary
carcinoma. The HER2 was
expressed
with
strong
intensity. This tumor is
eligeble for anti HER2
Targeting therapy

Physical Examination
CM
RR 26x/menit ; T 37,0oC ; BP 104/77 mmHg ; P 102x/menit
Eye : CA -/- ; SI -/Cor : Normal heart sound, gallop (-), murmur (-)
Pulmo : Vesicular -/+, rh -/-, wh -/Abdominal : soepel (+0
Extr : Warm, CRT < 2
pa

 Local state mammae

There are masses of various sizes in black on the breast reddish
colored breast with irregular shapes, with the wound of soft tissue
and pus, tenderness (+) in palpation.

Supporting Examination

Working Diagnosis
Efusi pleura sinistra et causa carcinoma mammae

Treatment

installation of drainage intrapleura

pleurodosis
Omeprazole 2 x 40 mg
Ketorolac 3 x 30 mg

THANK YOU