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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