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KORAN BEDAH ONKOLOGI JUMAT, 04 APRIL 2014
LONTARA 2 BEDAH ONKOLOGI (KAMAR 4)
1IkbalBed 129 tahun01/01/1984656476MRS27/3/2014
S: KU: baik, sadarTumor Colli (D)+POH biopsi eksisiIVFD RL 28 tpmceftriaxone 1gr/12jm/ivranitidine 1amp/12jm/ivketorolact 1amp/8jm/ivLab 25/03/2014Hb: 10,9, WBC: 12,8, PLT: 344 , HCT :33,9 , RBC:3,83GDS: 86, Ur:15, Cr: 0,92, sgot; 17, SGPT: 12, as.urat :5,9, Na: 138. K:4,0, Cl: 96
CT Scan 26/03/2014Massaregio cervicalis sisi kanan susp.lymphomamaligna
FNA 27/03/2014Soft tissue tumor (suspect benign) dengan inflamasi
2TipeBed 315/8/194863 tahunRM 654486MRS21/3/2014JKN
Dr.Septiman Sp.B(K)-OnkS: KU: lemas, sesak (+) A; POH 12 tracheostomyMultinodusa thyroid susp. Malignancy+ POH 11 tracheostomy
Karnofsky 50-60%
IVFD RL 28tpmCeftriaxone 1gr/12j/ivRanitidine 1amp/8j/ivKetorolac 1amp/8j/ivNebulizer /12 j/ nasal kanulObservasi TTVSuction
Lab 17/3/2014WBC : 10,3 , Hb: 14, HCt : 41,6 , PLT: 302, BT: 2, CT : 6, Pt: 13,3 INR : 1,1 , ApTT: 29,4, GDS : 95, Ur: 54, cr: 1,1, GOT: 22, GPT: 12Prot. Total : 5,6, albumin : 3,2, globulin: 2,4, Na: 146 , k: 4, Cl: 112
FNANeoplasma thyroid susp. Malignant
Foto thorax 20/3/2014 Gambaran tumor metastasis paru dilatatio et elongatio aortae Elevasi diafragma kanan ( proses intrahepatik?)
CT Scan 19/3/2014Massa thyroid lobules kanan disertai lymphadenopathy parafarings cervical post. Kanan susp malignancy
3.Tn. SyamsuddinBed 412/06/197736 tahunRM 650533MRS 01/04/2014S : KU: (-)Ca tiroidLab 17/03/2014Wbc 6.0, Rbc 4.98, Hgb 14.9, Hct 45.8, PLt 209, BT 2.00, CT 7.00, PT 10.8, APTT 21.0, GDS 88, Ur/CR 27/0.90, SGOT/SGPT 56/78, Na/K/CL 139/3.7/105Hasil FNA (12/03/2014):Struma Coloides CysticUSG Thyroid 11/03/2014 :Massa kistik Thyroid lobus kananUSG Abdomen 25/03/2014 :Tidak tampak kelainan pda USG abdomen iniFoto Thorax 14/03/2014 : Soft tissue mass region colliyang mendesak trachea kiri Tidak tampak tanda-tanda metastasis pada foto thorax ini
LONTARA 2 BEDAH ONKOLOGI (KAMAR 5)
4Ny. Reni6/6/198033 thnJKNRM 651127MRS 20/3/14dr. Septiman Sp.B(K)Onk
Bed 1
S: kel : (-)
O: Ku; baik
Ulkus Ca Mammae sinistracT4cN3bM1 (pleura)
Tu. Mammae (D) susp. Malignans cT4aN2cM1 (pleura)
Allopurinol 2x300 mgCiprofloxacin 500mg 2x1 tabRanitidin 150 mg 2x1 tabAs. Mefenemat 500mg 2x1 tab
Pro. Biopsi insisi bilateralLab 22/03/14WBC: 7.6 RBC: 3.511HB: 10.4 HCT: 30.9PLT: 0.124Ur: 68 Cr: 1.9Na: 138 K: 2.6 CL: 94
LAB 18/03/2014WBC 7,82 RBC 4,13 HGB 11,9 HCT 34 PLT 288 LED 100 UR 26 CR 1,76 Na 133 K 3,2 Cl 91 asam urat 9,7
Elektrocardiogram 20 maret 2014Pemeriksaan echo tidak dilakukan secara ideal akibat massa pada mamma sinistraFungsi sistolik LV normal, EF 65%Global normokinetikAR trivial, TR trivial
USG abdomen 20/2/14Organ intraabdominal dalam batas normalTidak tampak tanda-tanda metastase pada organ intra abdominal yang terscan saat ini
Foto thorax 17/2/14Efusi pleura sinistra
Lab (21/2/14)Gambaran darah tepiAnemia normositik normokrom suspek penyakit kronik disertai leukosit dengan tanda infeksi
5Ny. Agus minggu10/1/1954RM 625933MRS /03/2014UMUMdr. Septiman Sp.B(K)Onk
Bed 2
Ca Mammae (D) post MRM +pro kemoterapiInjeksi leucogenRencana kemoterapiLab 2/4/2014WBC:4,5 RBC:3,69 HGB: 11,0, HCT:32,7 PLT:88
Lab 24/3/2014Na:141 CL: 4.4 K:99GDS:94 Ur:32,Cr:0,83,As urat:5,8,SGOT;61,SGPT:23 albumin:3,4
6Ny. Akipa S28/2/1983RM 655233MRS 16/03/2014UMUMdr. Septiman Sp.B(K)Onk
Bed 3
S:Kel : timbul bintik-bintik merah di kulit
O :Ku : sedang
POH 8 biopsi insisi ca. mamma (D) cT4cN3cMx (susp. Otak)IVFD RL 120tpmCeftriaxone 1gr/12j/ivRanitidine 1amp/ 8j/iv
Lab 28/03/14Na:121 CL: 83 K: 3.4 SGOT:58 SGPT :84
LAB 19/03/2014WBC 5,68 RBC 4,63 HGB 12,7 HCT 36,4 PLT 155 Na 122 K 3,2 Cl 61
LAB 16/03/2014WBC 9,6 RBC 4,02 HGB 11,1 HCT 32 PLT 240 GDS 62 UR 24 CR 0.4 GOT 44 GPT 46 ALBUMIN 3 Na 111 K 2,2 Cl 65 CT 8 BT 3
USG Abdomen (16/03/2014)Tidak tampak kelainan
7Ny. marwiah17-1-1958RM 647409MRS1 /04/2014JKNdr. Septiman Sp.B(K)Onk
Bed 4
Struma nodul -rencana operasiLab 21/1/2014TSHs:0,31 Free T4:0,87Lab 27/3/2014GDS:143 Ur:16,Cr:0,60SGOT;22,SGPT:17 CT:730 BT:200 PT:12,4 APTT:25,9 WBC:7,0 RBC:3,96HGB: 12,0, HCT:35,1 PLT:211Foto thorax 20/1/2014:Kesan: pulmo normalEchocardiograph 23/1/2014Kesimpulan: fungsi sistolik dan diastolic LV baik:EF:63Usg tiroid 20-1-2014Kesan: multiple nodul thyroid kanan dan nodul tiroid kiri dengan degenarasi ksitik (TIRADS III)
LONTARA 2 BEDAH ONKOLOGI (KAMAR 6)
8Nanik suwarni05/03/1970Bed 4619924JKNMRS 21/03/2014
S : kel :-O : Ku : baikD/ Lymphoma maligna+asitesTransfusi PRC Allopurinol 3x100mgCeftriaxon 1gr/12j/ivRanitidine 1 amp/8j/ivLab (01/04/2014)Asam Urat 9,7 WBC 13,76 RBC 3,56 HB 9,4 HCT 28,9 PLT 624
Lab (25/03/2014)Na/K/Cl : 134/4,5/98BT/CT 3/7, GDS 143, Ur/Cr 66/0.90,SGOT/SGPT 41/12; as. Urat 7,9;Lab (22/03/2014)RBC 3,75 HB 10,3 HCT 31,4 PLT 452 WBC 10,3
Lab (22/03/2014)Na/K/Cl : 129/3,8/103BT/CT 3/7, GDS 143, Ur/Cr 39/0.70,SGOT/SGPT 43/10; GDS 84;; as. Urat 6,3;
Hasil Serologi 26/3/2014: Kesimpulan Lesi InflamasiFoto thorax PA:-soft tissue mass pada hemithorax sinistra- cord an pulmo normal- tidak tampak tanda-tanda metastasis pada foto thorax ini
Echo (24/3/2014)Fungsi sistolik LV baik, EF 68%, Disfungsi diastolic LV-Global normokinetik-MR trivial
PA 19/11/2013Limphoma maligna mammae sinistra dan axilla dextra
9Wandie 10/5/1970Bed 2653157JKNMRS 01/04/2014
S:Kel: -O: KU: baik
D/ Basal cell carcinoma Instruksi post op IVFD RL 28 tpm Ceftriaxon 1gr/12j/ivKetorolak 30mg/8j/ivRanitidine 1 amp/iv/8jKalnex 1amp/8j/ivLab (11/03/2014)RBC 4,29 HB 10,5 HCT 31,4 PLT 241 WBC 5,2 Albumin 4,1 Na 141, K 3,9 CL 104 HbsAg: non Reactive GDS 151, ur/cr 20/0,82 SGOT/SGPT 25/13
Foto kepala AP Lateral 10/3/14Kesan: soft tissue mass suspek destruktif pada regio zygomaticom axilla sinistra
CT Scan kepala 3/3/14Primary bone tumor os maxilla sinistra susp. Chondrobalstoma
Foto thorax PA 5/3/14Kardiomegali dengan dilatation aorta Kalsifikasi pada kedua paru Tidak tampak tanda-tanda metastasis pada foto thorax ini
Sitologi FNA 10/3/14Malignant tumor menyokong suatu Basal Cell Carsinoma
10Rahmatia 7/8/67Bed 3 656374JKN MRS 02/04/2014S:Kel: -O: KU: baik
Ca mammae Dextra cT4bN1MoInstruksi post op IVFD RL 28 tpm Ceftriaxon 1gr/12j/ivKetorolak 30mg/8j/ivRanitidine 1 amp/iv/8jKalnex 1amp/8j/ivLab (01/04/2014)RBC 4,12 HB 12,1 HCT 37,3 WBC 8,9 PLT 373 Na 141, K 4,0 CL 102 HbsAg: non ReactiveLab (25/03/2014)RBC 4,46 HB 12,9 HCT 40,4 WBC 8,6 PLT 433 Na 141, K 4,0 CL 102 GDS 97, ur/cr 17/0,6 SGOT/SGPT 24/14 Lab (21/03/2014)Asam urat 4,2 albumin 4,0FNA 21/3/2014Kesimpulan: adenocarsinoma mammaeFoto Thorax PA (24/03/2014)Kardiomegali dengan dilatation et elongatioaorta Tidak tampak tanda-tanda metastasis pada foto thorax iniUSG (24/03/2014)Tidak tampak tanda-tanda metastasis pada USG abdomen ini Echo Fungsi sistolik dan diastolik LV normal EF 67%LVH (+)Global normokinetik
11Hj. Nurhaeni 24/4/1975Bed 4640310JKNMRS 01/04/2014
Ca thyroid papillareLab (24/04/2014)RBC 4,39 HB 12,4 HCT 39,4 WBC 8 Na 143, K 4,2 CL 107 HbsAg: non Reactive GDS 86, ur/cr 32/0,6 SGOT/SGPT 13/12 Asam urat 3,8
PA(7/03/2014)Kesimpulan: adenocarsinoma papiler variant follicular thyroidea
Foto thorax PA 26/2/14 cor dalam batas normal tidak tampak tanda-tanda metastasis pada foto thorax ini
USG 3/12/13Nodul thyroid lobus kanan (TIRADS 2)Massa thyroid lobus kiri (TIRADS 2)Penebalan istmus
LONTARA 2 ONKOLOGI (KAMAR 7)
12Ny. TiaTL 30/06/1970JKNRM 607639MRS 01/04/2014K7B1Dr.William.H, Sp.B(K)-OnkS: kel (-)O: Ku baikMassa tumor mammae (D)Ulkus mammae (S)-Ca mammae (D) cT3N0M0
-Ulkus mammae (S) cT4N0M0
Stadium IIIB-simple mastektomi (3/4/14)CT- Thorax tanpa kontras:-Tidak tampak metastasis ke paru-Massa regio mammae dextra
USG Abdomen:Tidak tampak tanda- tanda metastasis pada USG Abdomen ini
Lab 18/3/14:WBC: 13,97, RBC: 3,62, HB: 11,1 HCT: 32,5 PLT: 251Lab 13/03/2014Kimia KlinikGDS;108ur;11cr;0,60 AST;32ALT;24NA;145K;4,5Cl;103,Ca 9,3 HbsAg;non reactive
13Tri MulyaniTL 18/0/1983MRS 19/03/2014RM 577035JKNK7B2Dr.William.H, Sp.B(K)-Onk
S: kel : (-)O: Ku: baik
Ameloblastoma amndibula dextra
POH X Henimandibulektomi dextra
-cefadroxil 2x1-As. Mefenemat 3x1-aff NGT-aff hecting-oral hygiene-cek albumin
Lab 24/3/14:WBC: 25,7, RBC: 4,63, HB: 12,0HCT: 36,7 PLT: 235Lab 24/03/2014HemostasisBT; 3,00CT; 8,00 PT;13,1 INR;1,10APTT;27,8Kimia KlinikGDS;179ur;16cr;0,70,30AST;21ALT;11NA;137K;4,5Cl;107 HbsAg;non reactive
MSCT Kepala3 dimensi non kontras Uniloculer ameloblastoma mandibulaFoto thorax Cor dan pulmo dalambatas normal Tidak ada tanda-tanda metastasisFoto mandibula AmeloblastomaPatologi Anatomi Ameloblastoma
14Ny. RugaTL 01/07/1957JKNRM 655705MRS 01/04/2014K7B4Dr.William.H, Sp.B(K)-OnkS: kel: (-)O:Ku: baikMassa pada buccal (D). granuler (+), eritem (+), pus (+)
Tumor buccal (D) susp. malignancy-biopsi insisi (3/4/14)Foto Thorax PA: -Cardiomegaly dengan dilatatio et elongation aortae-Tidak tampak tanda- tanda metastasis pada foto thorax ini-Efusi pleura dextra minimal
USG Abdomen:Tidak tampak tanda- tanda metastasis pada USG Abdomen ini
Hasil PA:Suspect carcinoma cell squamous
Lab 20/3/14:WBC: 8,9, RBC: 3,73, HB: 10,4 HCT: 31,9 PLT: 275Lab 31/03/2014HemostasisBT; 2,00CT; 7,30 Kimia KlinikGDS;92ur;15cr;0,58 AST;32ALT;15
15Ny. LianaTL 09/06/1984JKNRM 644848MRS 01/04/2014K7B5Dr.William.H, Sp.B(K)-OnkS: Kel (-)O: Ku baik Massa tumor ginggiva maxilla (D)
Osteoma maxilla (D)
Menunggu jadwalFoto panoramic:-Kalsifikasi pada corpus mandibula dextra susp. Bone island-Abses periodontal
Hasil FNA 28/03/14:FNA kesan tumor tulang (osteoma dapat dipertimbangkan)
Lab 12/3/14:WBC: 6,2, RBC: 4,74, HB: 14,0 HCT: 44,7 PLT: 304HemostasisBT; 3,00CT; 7,30 PT;12,4 INR;1,03APTT;26,3Kimia Klinik 12/3/14:GDS;95 ur;13 cr;0,70 As.urat 3,5 AST;16 ALT;12 NA;144 K;4,3 Cl;105
16 Siti MamiTL 01/07/1967JKNRM 610415MRS 01/04/2014K7B6Dr.William.H, Sp.B(K)-OnkS: kel: benjolan sepanjang bekas operasi payudara kananO: Ku: baikNodul sepanjang garis insisi operasi mammae (D)-Ca mammae residif dextra-rT4bN0M0-karnofsky 80%-Rencana eksisi tumor mammae (D)USG Abdomen:Tidak tampak tanda- tanda metastasis pada USG Abdomen ini
Foto Thorax PA:-Cardiomegaly dengan dilatatio et elongation aortae-Tidak tampak tanda- tanda metastasis pada foto thorax ini
Darah rutin 27/3/14:WBC: 7,7, RBC: 4,93, HB: 13,1 HCT: 40,5 PLT: 262Kimia Klinik 27/3/14:GDS;75 ur;17 cr;0,70 As.urat 5,9 AST;28 ALT;8 NA;147 K;4,0 Cl;105 Ca;9,5 Tu.marker ca 125; 125,22
LONTARA 2 BEDAH ONKOLOGI (KAMAR 8)
17HasmiaTL 14-03-1970RM 654643MRS 03-04-2014K8 Bed 6
Lab 21-03 2014WBC:10,3 RBC:3,89 HGB:9,8 HCT:31,5 PLT:310GDS:90 Ur:29 Cr:0,80 Asam urat:5,2 SGOT:18 SGPT:18 Na:140 K:4,3 Cl:103. HbsAg: Non Reactive
18/3/14: Foto Thorax PA: TB Paru duplex lama aktif Abses paru dextra Pneumothorax sinistra Soft tissue density pada hemithorax sinistra (konfirmasi:kasa pembalut)
20/3/14: USG Abdomen: Tidak ada tanda-tanda metastasis pada USG abdominal saat ini.
18SyamsiahTL 01-07-1943RM 649839MRS 03-04-2014K8 Bed 3
Lab 26-03 2014WBC:9,4 RBC:4,20 HGB:12,1 HCT:38,0 PLT:201; LED I/II: 28/55GDS:144 Ur:27 Cr:0,80 Asam urat:5,4 SGOT:20 SGPT:11 Na:144 K:4,1 Cl:102. TSHs: 0,18; Free T4: 0,97CT/BT: 7.00/2.00; INR: 0,98; PT/APTT: 11,8 control 11,5/26,9 control 26,1
20/2/14 PA: Suspek Neoplasma Folikulare Nodul Thyroid
21/2/14: Foto Thorax PA: Cardiomegaly disertai dilatation, elongation, et atherosclerosis aorta Soft tissue mass region colli bilateral yang telah memasuki aperture thoracis superior Tidak tampak tanda-tanda metastasis pada foto thorax ini
21/2/14: USG Abdomen: Tidak ada tanda-tanda metastasis pada USG abdominal saat ini.
6/2/14: CT-Scan Leher Tanpa Kontras:Masa Lobus Thyroid bilateral dengan kalsifikasi didalamnya meluas ke mediastinum superior.
26/2/14: Echocardiogram: Fungsi sistolik LV baik, EF 68% LVH (+) Disfungsi diastolic LV Global normokinetik AR mild moderate
LONTARA 2 BEDAH ONKOLOGI (KAMAR 9)
19.Muh. Yusuf/50 thTL31-12-1963MR 655041MRS 14/3/14K9B1Dr.Septiman Sp.B(K)-Onk
S : batukO: KU : sedangHB: 8.3Ca tiroidIVFD : RL 24 tpmCeftriaxone 1 g/12 jamRanitidine 1 amp/; 8jRencana transfusi PRC 2 bag
FNA 20/3/14Kesan: malignant tumor (suspek adenokarsinoma)Lab 20/03/2014RBC: 3.66, Hb: 10.5, HCT: 31.8, WBC: 12.7, PLT: 107Lab 17/03/2014GDS: 63, U/K: 67/1.06, AST/ALT: 30/56USG : tu metastasis ke hepar, asites, efusi pleura bilateralLumbosakral AP/Lat: Destruksi CV Th 9, CV L1, CV L2 (Tu metastase ke tulang, spondylosis lumbalisCT Leher : Massa thyroid bilateral disertai destruksi lamina thyroidea, cartilage cricoidea, dan os clavicula (S) sugestif malignancy, retentioin cyst sinus maxillaries bilateralLab 16/03/2014Alb : 2.0Lab 15/03/2014RBC 2.08 HGB 5,7 HCT 17,2 PLT 186 WBC 15,7 PT/APTT 19,7/17,5 GDS 15 Ur/Cr 62/1,1 SGOT/SGPT 145/56 Na/K/Cl 128/5.4/109HbSag Non reactiveAlbumin 2.0
20Ambo Dalle/75 thTL31-12-1939MR 656003MRS 1/4/14K9B6
S:Kel(-)O: KU sedangSuspek Ca tiroid Biopsi 03/04/14Lab:27/3/2014WBC 24400, RBC 4.10, HGB 12.2, HCT 36.9, PLT 335, GDS 99, UR 18, CR 0.86, AS URAT 3.8, SGOT 17, SGPT 21, Na/K,Cl 132/4.3/91,CT/BT 7.30/3.00, PT/APTT 13.8/33.2
Foto thorax 17/3/2014Kesan: cor dalam batas normal
USG Abdomen 12/3/14Kesan: tidak tampak tanda-tanda metastasis pada USG abdomen ini
CT Scan leher tanpa kontras 24/3/14Kesan: massa thyroid dextra disertai limphadenopati opsilateral
PA 24/3/14Kesan: malignant epithelial tumor, asal sulit ditentukan dengan FNA
21Kupa/63thnTl:1-7-1950MR 544836Mrs 1/4/14Kmr8 bed 3Dr.Djonny Ferianto, Sp.B(K)OnkS: kel (-)O: ku: baikFibrosarcoma regio brachii sinistraop amputasi 3/4/14PA 14/3/14Fibrosarcoma grade 2
Lab 20/3/14WBC 9.3, RBC 4.40, HGB 13.2, HCT 40.2, PLT 358
22Hadiman/20thn11-10-1993652242Mrs 1/4/14Kmr 9 bed 4dermatofibrosarcomaRencana biopsi
23Ansar,16 thn5-10-1998655654Mrs 2/4/14Kamar 9 bed 2Ca colliRencana biopsi
UGD
INFECTION CENTER (IC)
24Dg. Tanning01/07/196746 thnRM 653873MRS 06/03/2014Dr. Septiman, Sp. B (K) Onk
Lt.1S: kel (-)O : KU: baikPost op. biopsi tu. coliRenc. Terapi sesuai TS. Interna dan TS. BTKVPA (19/03/2014)Adenokarsinoma papiler
Lab (20/03/2014)CEA 2,10
Lab (18/03/2014)PT/APTT 12,4/26,4INR 1,03Lab (17/03/2014)WBC 11,59 RBC 4,30 HB 11,9 HCT 37,9 PLT 281 SGOT/SGPT 22/11Na 141 Kal 4,2 Cl 99
Lab (25/3/2014)TSHs 0,73 FT4 1,17
Lab (26/3/2014)GDS 160 SGPT 11 prot.tot 7 Alb 2,6 Glob 4,4 Na/K/Cl 142/3,8/98
25Nur Aziz samad 9/6/1956 (57 thn)652529JKNL1 K2 B1Ku: Benjolan pada leher kananLimfadenopati region colli DRencana biopsy insisi jika keluarga setujuLab 31/3/2014RBC 3,70 WBC 15,7 HB 11,3 HCT 33,5 PLT 339 Ur/Cr 23/0,8 GOT/GPT 72/105 Na/K/Cl 130/4,5/92 PT/APTT 13,1/28,7
Foto thorax (1/4/2014)Kesan : Kp duplex aktif Efusi pleura kanan bronchiectasis kiri,susp.massa paru kanan
TTNA (27/2/2014)Non small cell lung cancer (Undifferentiated large cell tipe)
26Heliani26/2/1963(51 thn)656827Umum/tunaiL1K1B1Ku: sesak nafasCa MammaeRencana biopsy insisi jika keluarga setujuLab 27/3/2014RBC 4,73 WBC 7,5 HB 14,7 HCT 44,2 PLT 283 Ur/Cr 11/0,64 PT/APTT 11,4/22,1CEA : 5,72 Ca 125 : 150,52
FNA Mammae (10/3/2014)Karsinoma mammae
FNA Leher (10/3/2014)Metastase karsinoma
LONTARA 1 ATAS DEPAN
27Agustina Mesa31/12/1971(42thn)628842JKNL1 AD K5B3Ku: sesakLimfoma MalignaRencana kemoterapi jika KU memungkinkanLab(30/3/2014)GDS 89 ur/Cr 40/0,8 GOT/GPT 41/20 Na/K/Cl 138/2,9/108 PT/APTT 15/21,9
Lab(1/4/2014)RBC 3,62 WBC 34,8 HB 10,5 HCT 34,8 PLT 361
Foto Thorax(3/4/2014)Kesan: Efusi pleura bilateral terutama kiri
LONTARA 1 ATAS BELAKANG
LONTARA 1 BAWAH BELAKANG
28Cristina28/6/1973 (40 thn)657559JKNL1BB K5B1 Kls IIIKu: benjolan pada payudara kananUlcus Ca Mammae DRencana biopsy insisi jika keluarga setujuLab(1/4/2014)RBC 5,46 WBC 8,4 GB 14 HCT 40,8 PLT 248 GDS 102 Ur/Cr 18/0,7 GOT/GPT 45/42 Na/K/Cl 145/3.1/102 Alb 3
Foto thorax (1/4/2014)Kesan: Efusi pleura dextra
LONTARA 1 BAWAH DEPAN
LONTARA 2 DIGESTIF
LONTARA 2 ORTOPEDI
LONTARA 2 UROLOGI
LONTARA 3 NEUROLOGI
LONTARA 3 BEDAH SARAF
LONTARA 3 KULIT
LONTARA 3 THT
LONTARA 3 MATA
LONTARA 4 OBGYN
ICU
29.Welstin TekaTL 04/02/1981RM 648262MRS 25/1/14JKNK7B3Dr.Septiman Sp.B(K)-Onk
S : kel (-)O : Ku : baikMasaa tumor mandibula sinistra
POH 2 henimandibulektomi sinistra -IVFD RL 28 tpm-ceftriaxon 1gr/12j//iv-Ketorolac 1amp/12j/iv-Intake oral via NGTLab 31/3/14:Albumin 2,5Lab 31/3/14:WBC: 11,7, RBC: 4,82, HB: 11,8HCT: 37, PLT: 282Lab 31/03/2014HemostasisBT; 3,00CT; 8,00 PT;11,3INR;0.90APTT;24,8Kimia KlinikGDS;93ur;13cr;0,40,30AST;30ALT;26 NA;135K;4,1Cl;112 HbsAg;non reactiveEmbolisasi 28/02/2014Telah dilakukan embolisasi pada feeding arteryyang mensuplai tumorPatologi Anatomi 17-02-2014AMELOBLASTOMAEchocardiogram 02/02/2014Fungsi sistolik LV, EF64% dan sistolik LV normal
PAKIS
R S U H
30NurhanaRM 019780Tgl lahir1/1/1973Tgl MRS15/3/2014
L4K431 bed 1
dr. John Pieter, Sp.B(K) onk
S: kel : (-)O: ku :cukup-tu. Mamma sinistra susp. Malignancy- cT4bN0M1 (hepar, tulang belakang)- stadium IVKarnofsky 70% - optimalisasi KU-rencana besok transfuse 6 bag trombositjika normal, rencana biopsy insisiLab 01/4/2014WBC 4,69 HGB 11,6 HCT 34,6 PLT 125
Lab 27/3/2014WBC 6,79 HGB 11,1 HCT 33,3 PLT 35
Lab 23/3/2014protein total 7,4GOT/GPT 164/62albumin 3,6Lab 22/3/2014WBC 13,78 RBC 2,32 HGB 14,3 HCT 42,4 PLT 44 PT 15,1 APTT 35,6 CT/BT 7/3 Na/K/Cl 129/3,5/104
Thoraks PA : dalam batas normal
USG Abdomen : metastasis tumor ke hepar dan splenomegali
Foto pelvis AP : -gambaran suatu metastatic bone disease
Foto lumbosacral AP/Lat : -lesi litik dan blastik pada beberapa korpus vertebra lumbalis, suspek suatu metastasis bone disease-Spondilosis lumbalis dan osteoporosis
Ct-scan : tidak tampak lesi patologik pada parenkim otakhyperostosis os frontoparietalis kiri
Hasil FNA : kemungkinan suatu keganasan asal epitel kel. mamma
31RadianaRM 020022Tgl lahir 3/12/1969Tgl MRS 22/03/2014
L4 431 Dr.dr.wiliam, Sp.B onkS : kel : (-)O : ku : sakit sedang, sadar-Tumor mammae S suspek malignancyCT4aNoM1 (meta ca ovarium) stadium IV-kornofsky 70%
- optimalisasi KU
- tunggu hasil PALab 28/3/2014WBC 15,8HGB 10,9HCT 31,9PLT 4,8
tgl 25/3/2014, Hasil ADT :-anemia mikrositik hipokrom suspek causa penyakit kronik DD/ defisiensi Fe-leukositosis ringan tanda-tanda infeksi
tgl 10/4/2008, hasil PA :a. bahan uterus uteri : -adenomiosis-adenokarsinoma endometrioid ovaris D/+S dan diferensiasi sedang jaringan tanpa labelb.bahan sigmoid :-adenokarsima diferensiasi sedangujung-ujung usus bebas tumor
tgl 23/3/2014, foto thorax:tidak tampak tanda-tanda metastase
tgl 24/3/2014, hasil MSCT Scan abdomen : kesan-massa rongga pelvis yang menginfiltrasi rectum-penebalan local mukosa buli-buli-pemebesaran KGB paraorta abdominalhepatosplenomegalidistended loop-loop usus-kista ginjal kanan
32Nuraida DjanoRM 018106Tgl lahir 14/11/1971Tgl MRS 26/03/2014
L4 406 Dr.irwan gunawan, Sp.B(K)Onk
S : kel : (-)O : ku : sakit sedang, sadar-ulkus Ca mammae S-Ct4cNN1M0 stadium IV B-Ca mammae DCt4bN0M0 stadium IV B-kornofsky 70%kemoterapi neoadjuvant siklus Vi hari kamis, 3/4/2014
lab 29/3/2014 :GDS 118HbA1c 4,9
lab 27/3/2014 :Na/K/Cl : 137/3,3/110GOT/GPT : 13/7asam urat : 11Ur/Cr : 88/3,3PT/APTT : 17 inr:1,48/35,2
USG tgl 29/1/2014 ;kesan :-pelyocylyectasis kiri-efusi pleura kanan minimal
33NurmaRM 020061Tgl MRS 1/4/2014Tgl lahir31/12/1971
L4 ruang 406Dr.dr.Haryasena, Sp.B, K(onk)S : kel : (-)O : ku : sakit sedang, compos mentisUlkus Ca mammae (s)Biopsi insisi, rabu 2/4/2014lab GDS 84GOT/GPT : 19/15Ur/Cr : 23/0,7PT/APTT : 15,3 inr:1,29/34,1WBC 5,4PLT 215HGB 13,3HCT 40
34Muh.dada massaRM 020284Tgl MRS 1/4/2014Tgl lahir1/2/1955
L4 ruang 433Dr.irwan gunawan, Sp.B, K(onk)S : kel : (-)O : ku : sakit sedang, compos mentisTumor mammae (D) suspek malignancySimple mastektomy, rabu 2/4/2014Lab 29/3/2014WBC 10,8HGB 13,3HCT 39,6PLT 296Na/K/Cl 135/4,9/102Ur/Cr 33/0,8
USG:Kesan : PNCdengan nefrolith dextra Tidak ada nodul mtastase hepar
Hasil PA dari Rs.salewangang maros :Mencurigakan suatu malignant epiteltumor +lesi kistik
35nurlaila syamsuRM 001057tgl MRS 27/3/2014tgl lahir 7/6/1956prof.daniel, Sp.B onkS : kel : (-)O : ku : baikKemoterapi, rabu 2/4/2014
36Andi hawangRM 019944tgl MRS 2/3/2014tgl lahir 23/3/1965dr.septiman Sp.B onk
L4ruang 423S : kel : (-)O : ku : baikCa mammae (D)CT4cN3M1Stadium IVKornofsky 60%IVFD RL 28 tpmRanitidine 1 amp/8j/ivSohobion /12j/ivDiet bebasCek darah lengkapLab 29/3/2014WBC 13,6HGB 8,4PLT 353Na/K/Cl 128/2,2/99GOT/GPT 66/22Albumin 3,3Ur/Cr 35/1,93
37Maya angrainiRM 019296tgl MRS 2/3/2014tgl lahir 7/9/1997dr.irwan gunawan Sp.B onk
L4ruang 423S : kel : (-)O : ku : baikTumor mammae (s)Wide eksisi, kamis 3/4/2014Lab 29/3/2014WBC 7,74HGB 11PLT 286GOT/GPT 16/11Waktu bekuan 8Waktu perdarahan 2
38St.radhiyah syam RM 020287tgl MRS 2/3/2014tgl lahir 12/9/1966dr.haryasena Sp.B onk
L4ruang 426S : kel : (-)O : ku : baikTumor mammae bilateralWide eksisi, kamis 3/4/2014Lab 29/3/2014WBC 9,22HGB 13,6PLT 252 Hasil foto thorax :-cor dan pulmo normal-tak ada tanda-tanda metastase
PCC
39219Ny.nasrah TL 31/12/1962RM 655374MRS 1/4/14
S: kel: -O: ku: SS/GC/CMBasalioma Alanasi SPOH 2 wide exwaDarah rutin 1/4/14:HGB 13,3;HCT 38,8;PLT 337; WBC 10,5 ; GDS 14 ; Ur/Cr 26/0,9 ; GOT 15; GPT 25
40204NasiaTL:13/12/65RM:656783MRS: 3/3/14S:Kel O:Ku:SS/GC/CMStruma Multinoduler non toxicPOH 0 subtotal thyroidectomy.Darah rutin (3/4/14) HGB:13PLT:279HCT:37.9WBC:8.1UR/KR:16/0.48GOT/GPT:17/18GDS:132
41326Karlina23/8/85656044MRS: 3/3/14S:Kel (-)O: KuSS/GC/CM
Tu. Mamma assesorius reg. Axilla dextra POH 0 Diseksi Axilla DextraDarah rutin (3/4/14) HGB:14.1PLT:313HCT:39.9WBC:10.3UR/KR:26/0.98GOTGPT:27/47GDS:132
42309 Ratnawati 8/2/96633868MRS 2/4/14S: kel: -O: ku: SS/GC/CMCa mammae Spost MRMPro kemoterapi adjuvant sik I
43405Ny. NurdianaTL 25/11/1963RM 656260MRS 31/3/2014Dr. Septiman, Sp. B (K)-OnkS: kel: lemahO: ku: SS/GC/CMSoft tissue tumor reg. femur dextraPOH 3 Eksisi tumorPA:14/3/14:Differentiated liposarcoma
MRI extremitas bawah kanan 25/3/14:Lesi pada m.gracilllis kanan disertai infiltrasi ke jaringan sekitarnya sesuai gambaran rhabdomyosarcoma
Darah rutin 25/3/14:RBC 4,47;HGB 13,1;PLT 211; WBC 10,5 ; GDS 124 ; Ur/Cr 33/0,77 ; GOT 15; GPT 25
44406Tn. IbrahimTL 3/10/42RM 647863MRS 30/3/14Dr. SeptimanS: k: LemahO: Ku: ss/gc/cmA: general weakness post kemoterapi siklus III lymphoma maligna
-IVFDN NaCl 0,9% 28 tpm-Ceftriaxone 1gr/2j/iv-Ondancentron 1 amp/12j/iv-Sanmol 1 btl dripsDarah rutin (30/3/14)RBC : 3.1Hb : 9,7HCT : 27.7PLT : 25GOT:73GPT: 58ALB: 30NA: 138K: 4.1CL: 106
45Hj. Titin Sulastri424Tgl Lhr21/3/1981MRS 20/3/2014RM608115Dr.William.H, Sp.B(K)-OnkS: lemasO: Ku: sedangTD:100/70 mmHg
A: POH MRM Ca. Mammae sinistraTxNxM1(tulang belakang)Karnofsky80%
Terapi sesuai TS.HOMTunggu jawaban konsul dr.Triko,Sp.OT
Darah rutin (31/3/14)RBC : 3.32Hb : 10.3WBC : 10.0HCT : 30.6PLT : 36GOT:190GPT: 82
46407NurhayatiMRS 1/4/14S: lemahO: SS/GC/CM
A: Ca mammae metastase intracranialRencana kemoterapi
47Cornelia Kareth415TL 12/6/1959MRS 28/3/14Dr.septiman, Sp.B (OnkS:KU: baik O: sakit sedang
A: ulkus ca. Mammae bilateralPost kemoterapi paksus, doxodarah rutin 29/3/14RBC: 5.38WBC:19.1HGB:14.3MCV:78HCT:42.2MCH:26.6PLT:49.6
48330Ny. SalpiatiTL 28/7/78MRS 31/3/14RM 580532Dr.septiman, Sp.B (OnkS:KU: baik O: SS/GC/CM
A: Nodul tiroidPOH 2IsthmolobektomyFNA: Neoplasma folikular tiroideaUSG: sesuai adenoma tiroid kel. IsthmusFT4: 0,891TSHS: 2,76
49323St. AisyahTL 12/3/74MRS 31/3/14RM 657161Dr.septiman, Sp.B (Onk
S:KU: baik O: SS/GC/CM
A: Ca mammae sinistraPost kemo doxo, paksus
50416 Sarinah 12/7/42502226MRS: 1/4/14S:Kel: -O: KU: SS/GC/CM
Soft tissue tumor regio D occipital POH 1 wide eksisi darah rutin 1/4/14WBC:9,8 Ur/Cr:39/1,19HGB:12 SGOT/SGPT: 29/17HCT:34,1PLT:236
51419Tn. MunandarTL 4/8/1985MRS 1/4/2014RM 653426Dr.William.H, Sp.B(K)-Onk
S:KU: baik O: SS/GC/CM
A: SCC leher dextraNeo adjuvant khemoterapy siklus II
PALEM ATAS
52Juniyanti Sampe Kua15/01/197638 tahunJKN655758B2/10 Bed 2
dr. Septiman, Sp.B(K)ONK
S : Keluhan : nyeri tulang belakangO: KU baikCa. Mammae (D) post MRM CTxNxM1 Stad IV metastasis tulang belakangRL : D5 1:2 28 tpm
Durogesic patch 12.5 mg/ 3 hri
Cefadroxil 2x1
Konfirmasi Hasil PANeurodex 3x1Lab 21/03/2014WBC : 11,15 RBC : 3,39 HGB : 10,0 HCT : 30,4, PLT : 271, Na/K/Cl : 142,4,2,102, ALT : 28, AST : 36, Ur/Cr: 16/0,56, CT: 7,30, BT: 3,00, PT : 11,9 control 11,0, INR:0,99, APTT:25,3 control 23,8Lab 15/03/2014CA 15-3 49.8Lab 12/03/2014Creatinin 0.62WBC 9.7 RBC 3.5 HGB 10.6 HCT 31.6 PLT 457CEA 19.35
Lab 14/03/2014GOT 38 GPT 25 Alkali phosphatase 75Foto Thorax 14/03/2014Bronchitis aspectFoto Thorax 24/03/2014Cor & pulmonal normalTidak tampak tanda-tanda metastasis pda foto thoraks ini USG 24/3/2014 :Slight hepatomegaly dengan tumor metastasis ke hepar
CT SCAN Th 11 LumbosacralMetastasis pada Th 11-12 spine, seluruh lumbal spine, os. Illium, os. Ischium, dan os. SacrumAnterior spondylolisthesis S2 terhadap S3OA S1 joint bilateral
PALEM BAWAH
53Hapsah Sahebo07/09/1962RM 654334JKNB2/3 Bed 2
Dr. Djonny F, Sp.B(K)ONK
Foto klinis (-)S : Keluhan (-)O: KU baikPOH X biopsy insisi e.c. Ca Mamma (D) CT4CN2Mx Stadium III C
Karnovsky 50%Terapi sesuai TS Interna
GV + rawat luka
Durogesic patch 12.5 mg/ 3 hriRawat lukaOptimalisasi KU & GVFoto lumbosacralKontrol ulang PALab 22/03/2014WBC : 9,2 RBC : 3,72 HGB : 11,3 HCT : 32,4, PLT : 341 Na/K/Cl 134/3,2/106 Albm 3,0LabHbA1C 5.9 Albumin 3 RBC 3.56 WBC 187 HB 10.6 HCT 30.9 PLT 389FNAAdenocarcinoma mammaeHasil PA21/3/2014:Invasif ductal ca mammae moderate grade malignancyThoraxElevasi diafragma kanan (proses intrahepatik)Observasi mikronodul suspek metastasis ke paru
Ruang kemoterapi
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