Download - Koran Onko 18 Maret 2015

LONTARA 2 ATAS BELAKANG KAMAR 4

Bed 1Muh Yasin01-11-2011Alamat: Pinrang battombong matiro sompe70.15.87MRS: 10-03-2015dr. Haryasena, Sp. B (K) Onk

S: keluhan tidak adaO: keasadaran umum baik/compos mentis

Vital signsN: 86x/menitP: 20x/menitS: 36,8oC

A: Post eksisi luas hari 2 soft tissue tumor region patella dextra posterior

-Post op eksisi luas hari-2- RL 24 tpmceftriaxone 500mg/12j/iv- Ranitidin 25mg/12j/iv-ketorolac 15mg/8jam/iv

Lab 11-03-2015WBC 9.0RBC 4.76HGB 11.8PLT 532PT 10.8APTT 25.8Natrium 143Kalium 4.4Klorida 110BT 3.00CT 7.30GDS 77Ureum 25Kreatinin 0.35SGOT 38SGPT 13

Lab 17-02-2015Kalsium 11.4

Foto Thorax PA 16-02-2015Kesan: bronchopneumonia

Foto Genu Dextra AP/lateral 18-02-2015Kesan: Soft tissue mass region distal femoris sampai genu medial dextra

MSCT scan ekstremitas (dengan kontras) 25-02-2015Kesan: Lipoma region popliteal dextra

Bed 2Muis Adjulani12-9-1971702381(L)

S: Nyeri pada wajahO : KU sakit sedang/sadarVital signsT: 110/70mmHgN: 80x/menit

Rencana operasiTunggu jadwal

Lab 24-02-2015WBC 10.2RBC 4.74HGB 12.9PLT 452PT 9.6

P: 20x/menitS: 36,8oC

A: Basalioma at face region

APTT 27.8SGOT 15SGPT 17Natrium 144Kalium 4.1Klorida 105GDS 111Ureum 15Kreatinin 17

Bed 3Mursalin Tjanne05-05-1942Alamat: Jl. Pembangunan kendari barat70.25.11MRS : 09-03-2015dr. Haryasena, Sp. B (K) Onk

S:Tidak ada keluhanO:KU baik/ Sadar

Vital SignsT: 150/90 mmHgN: 84 x/menitP: 20 x/menitS: 36.8oC

A:Tumor region buccal dextra

Rencana operasiTunggu keadaan umum optimalKonsul kardioTerapi lain sesuai TS kardio dan internaEKG ulang hari ini

Lab 11-03-2015WBC 5.8RBC 4.86HGB 14.3HCT 44PLT 183PT 10.1APTT 29.6SGOT 26SGPT 19Ureum 33Kreatinin 1.20Natrium 145Kalium 3.3Klorida 105CT 8”00BT 2’30HBsAg Reactive

Foto Thorax PA/AP 24-02-2015Kesan: -Tb paru duplex lama aktif-tidak tampak tanda-tanda metastasis-dilatation aortae

Bed 4Humaedi21-03-1973Alamat: J;. Sejiwa no 7068.07.72MRS: 11-03-2015dr. Djonny Ferianto, Sp. B (K) Onk

S: tidak ada keluhanO: keadaan umum baik/sadar

Vital signsT: 110/70mmHgN: 80x/menitP: 20x/menitS 36.8oC

A:Post eksisi biopsy

Lab 10-03-2015LED 31/60BT 2’00CT 8’00PT 10.1APTT 24.9GDS 107Lab 10-03-2015WBC 4.0RBC 4.56HGB 12.0

haro 1 Metastasis carcinoma colli

PLT 284LED 31/59

Foto Thorax PAKesan-dilatatio aortae-tidak tampak tanda-tanda metastasis


BED 1Dg.Suba01-10-1950Alamat: Tamboe mattiro tasi maros baru60.32.49MRS: 11-03-2015dr. Djonny Ferianto, Sp. B (K) Onk

S: tidak ada keluhanO: keadaan umum baik./sadar

Vital signsT: 110/70mmHgN: 80x/menitP: 20x/menitS: 36,5oC

A: carcinoma mammae sinistra

-post operasi hari -1 Lab 12-03-2015WBC 4.8RBC 3.45HGB 10.3HCT 30PLT 416

Foto thorax PA/AP 09-03-2015Kesan: -cardiomegaly disertai dilatation aortae-tidak tampak tanda-tanda metastasis

Bed 2Cristina28-06-1973Alamat: BTP blok AC2 no 27165.75.59MRS: 05-03-015dr. Haryasena, Sp. B (K) Onk

S: nyeri pada luka payudara kananO: KU sakit sedang/sadarVital sign:T: 120/70mmHgN: 84x/menitP: 20x/menitS: 36,7oCA:Ulcus carcinoma mammae dextracT4cN2M1Karnofsky 70%Efusi pleura dextraPOH-5 chest tube + WSD-Efusi pleura dextra

Ringer laktat 28 tpmCeftriaxone 1gr/12jam/ivKetorolac 30mg/8jam/ivRanitidin 50mg/8jam/ivDiet biasaGanti verban/ hariRencana kemoterapi

Lab 05-03-2015WBC 7.9RBC 5.48HGB 13.2PLT 388HCT 40.9PT 9.7INR 0.90APTT 24.7Natrium 138Kalium 3.8Klorida 102BT 3.00CT 8.00GDS 104Ureum 21Kreatinin 0.60SGOT 58SGPT 31Albumin 3.4HBs Ag Non Reactive

Anti HCV Non Reactive

Foto thorax PA/AP 05-03-2015Kesan: bronchopneumonia dd/lesi-lesi mikronodul suspek tumor metastasis ke paru

USG Abdomen atas + bawah (whole abdomen) 05-03-2015Kesan: efusi pleura dextra

Bed 3Bijawan DG Bone68507510-6-1965MRS: 16-3-2015

S:Nyeri pada mammae dextraO:Keadaan umum sakit sedang/ compos mentisVital Sign:T: 120/70 mmHgN: 80 x/menitP: 20x/menitS: 36.8 oCA:Ca Mammae Dextra


Pemeriksaan PA (16/7/2014)-Invasif ductal carcinoma mammae, Moderate grade malignancy

Echocardiografi(19-01-2015)

- Fungsi sistolik ventrikel kiri baik

- Ejeksi Fraksi 62%

- Hipertropi ventrikel kiri

- Disfungsi diastolic ventrikel kiri

Bed 4Nurhaedah20-07-197569.41.62MRS: 11-03-2015dr. Haryasena, Sp.B(K)Onk

S: Keluhan tidak adaO: keadaan umum baik/sadarVital signT 110/70mmHgN 84x/menitP 20x/menitS 36.8oCA: Nodul tiroid

Rencana operasiTunggu jadwalPeriksa lab lengkap

Lab 17-3-2015WBC 20.4RBC 4.24HGB 12.8PLT 312HCT 37PT 11.1APTT 26.7Ureum 24Kreatinin 0.60SGOT 19GDS 253

Lab 5-3-2015GDP 129GD2PP 121HBA1c 145Natrium 145Kalium 4.0Klorida 110

Foto Thorax PA 25-02-2015Kesan:-soft tissue density region colli-tidak tampak tanda-tanda metastasis pada foto iniCT thyroid/leher tanpa kontras 03-03-2015Kesan:-massa thyroid lobus kiri


BED 1Muti mainnah06-01-1975682425Cendana pura, luwuk banggaiMRS:06/3/2015dr. Haryasena, Sp.B (K) Onk

S: Sesak berkurangO: KU sakit sedangTensi 120/80 mmHgNadi 86x/menitPernafasan 18x/menitSuhu 36,5A: ca mammae bilateral

Efusi pleura dextra post chest tube

RL 28 tpmOndancentron/8 jam/ivCeftriaxone 1 gr/12 jam/ivKetorolac 30 mg/8 jam./ivRanitidine 50 mg/8 jam/ivSanmol inf/8 jamAmbroxol syr 2x1 CTerapi lain sesuai bedah thoraxFoto Thorax Kontrol

Tgl 9/3/2015WBC:5,2RBC:4,37HGB:12,1PLT:328Ur:19Cr:0,50SGOT/SGPT:29/18Albumin:3,9As.urat:4,1Na/K/Cl:141/4,5/107

Hasil PA: invasive ductal carcinoma mamma moderat malignancy

BED 2Murni16/10/1980668874Jl.muh.yaminMRS:13/03/2015

S: Benjolan pada payudara kiriO: KU sakit sedangTensi 110/70 mmHgNadi 86x/menitRespirasi 18x/menit


Tgl 12/3/2015Wbc:8,3Rbc:4,64Hgb;12,3Plt:360Na/K/Cl:144/3,5/101

Dr. William Hamdani, SP.B(K)ONK

Suhu 36,5A:fibroadenoma mamma sinistra

Gds:99Ur/cr:15/0,70As.urat:5,4Sgot/sgpt:17/9Ct/bt:2,3/8,0Pt/apt:10,2/28,1

Hasil PA 13/8/2014Fibroadenoma mammae

BED 3Rasna1/12/1975605784Jl.Teuku UmarMRS:14/03/2015dr. Haryasena, Sp.B (K) Onk

S: tidak ada keluhanO: KU sakit sedangTensi 120/80 mmHg, Nadi 86x/menit, Respirasi 18x/menit, suhu 36,5

A: carcinoma mamma dextra

Cek darah post transfusi

Laboratorium16/3/2015Wbc:4,5Rbc:4,13Hb:12,6PLT:54

BED 4Sennang29/5/1945703766LuwuMRS:09/03/2015dr. William Hamdani, Sp.B (K) Onk

S: keluhan tidak adaO: keadaan umum sakit sedangT:120/80N:86RR:18S:36,5A: Nodul thyroid

Rencana operasi total tiroidektomiMenunggu jadwal

Laboratorium 5-3-15WBC 5,82RBC 4,47HGB 13,4HCT 41,4PLT 227Ur/Cr 22/0,9Na/K/CL 142/4,0/126

Hasil PA: neoplasma follikulare thyroidea


BED 1Hasniyah B.07-06-1980

MRS : 17-2-2015

RM : 685734

DPJP : dr. Haryasena,Sp.B (K)Onk

S : keluhan nyeri luka operasiO : KU sakit sedang/ gzi cukup/ sadarTd: 120/80N: 79P: 20S : 36,8

NGT: produksi (-)Drain: produksi 55cc/24jam

A : POH IV wide exciseTumor axilla dextra

Cefadroxyl 2x1Ranitidine 2x1Asam mefanamat 3x1Aff drainBolehlpulang

Hasil lab (3-03-2015):WBC :5,1RBC : 4,35HGB : 10,6HCT:33PLT: 442CT : 7’00BT: 2’00Na/K/Cl : 141/4,3/106GDS : 111Albumin : 4,0Ur/cr : 31/0,60GOT/GPT : 17/9FNA : Bukan suatu limpoma, inti yang sangat seluler mengarah ke suatu low grade sarcoma. DD/ malignant peripheral nerve streath tumor-Malignant Fibrous HistiocystomaMSCT Axilla Dextra tanpa kontras : Soft tissue mass regio axilla dextra, tanda-tanda benigna

BED 2Dg. Bintang10-03-1960MRS: 13/03/2015RM: 660202DPJP: dr. Djonny Ferianto ,Sp.B (K)Onk

S: benjolan pada payudaraO: : KU : sakit sedang/gizi cukup/sadarLokalis: tampak benjolan dengan permukaan berbenjol benjolA: tumor mammae sinistra

-operasi biopsy insisi-antibiotic profilaksis ceftriaxon 1gr/IV-marking site

Hasil lab (5/3/2015)WBC: 10,7RBC: 4,05HGB: 11,0HCT: 34PLT: 334CT: 8’00BT: 2’30Alumin: 3,5Ur/Cr: 32/0,90GOT/GPT: 20/19Na/K/Cl : 141/3,5/106GDS: 201

BED 3Suriati31-12-1969

MRS : 2-03-2015RM : 533257

S : benjolan pada leherO : KU : sakit sedang/gizi cukup/sadarN: 80

- persiapan operasi- inform consent/ persetujuan tindakan operasi- konsul anestesi- lapor OK

Hasil lab 3-3-2015WBC : 11,3RBC : 4,56HGB : 14,6 HCT: 43PLT: 303Na/K/Cl : 141/3,5/108GDS : 141Albunin: 3,8

DPJP :dr.Septiman, Sp.B(K)Onk

P: 20S: 36,8Status lokalis tampak benjolan pada rahang bawah padat kenyalFNA: suspek amyloblastomaA : Ameloblastoma

- antibiotic profilaksis ceftriaxon 1gr/IV- PRC 4 bag disiapkan

Ur/cr : 21/0,80GOT/GPT : 12/17PT: 9,4INR: 0,90APTT:27,5BT: 2’00 CT : 6’00Hasil PA 27-11-2014suspekameloblastoma

BED 4Nursina

30-11-77 RM : 698775MRS : 24-2-15Alamat : Jl. Cakalarang, Bau-Bau

DPJP : dr.Djonny Ferianto, Sp.B (K) Onk

S : keluhan batuk berdahakO:- keadaan umum sakit sedang- drainase : kiri 20cc, kanan 5ccA:- POH-6 total thyroidectomy

IVFD RL 28tpm- ceftriaxone 1gr/12j/ivranitidin 50mg/8j/iv- calcitriol 2x50mg/iv paracetamol 3x1000 mg/iv ketorolac30mg/8j/iv-neurobion+vit c drips- Aff drain 1

Hasil lab (10-03-2015):WBC: 23,3RBC: 3,57HGB: 10,3PLT: 274GDS: 150Ur/Cr: 24/0,50SGOT/SGPT: 24/14Na/K/Cl: 141/5,0/110Albumin: 3,5PT/APTT: 9,9/23,8INR: 1,00PA (30-1-15)- susp. lesi kistik tiroid dengan belum dapat disingkirkan

CT Cervical NK(25-2-15)- massa kistik berseptasi thyroid lobus kiri- nodul thyroid lobus kanan- lymphadenopathy paratrachea kanan dan cervical kiri

BED 5Putri31/12/1972MRS : 11-03-2015

RM : 703317


S: nyeri pada luka operasiO: KU sakit sedang/ gizi cukup/sadarProduksi drain +/- 10ccA: POH IV subtotal thyroidectomy

Cefadroxyl 2x1Ranitidine 2x1Asam mefanamat 3x1Aff drainAff infus

Hasil Lab 12-3-2015WBC : 4,8RBC : 4,88HGB : 14,3HCT: 43PLT: 227Na/K/Cl : 143/3,7/102GDS : 106 Ur/cr : 6/0,50GOT/GPT : 27/10PT: 10,6 INR: 1,00APTT:24,7

BT: 2’30 CT: 8’00

BED 6Gahin25-03-1954MRS : 13-03-2015

RM : 629437


S: bengkak pada bekas luka operasiO: KU sakit sedang/ gizi cukup/sadarA: carcinoma mammae dextra

- operasi biopsy insisi- antibiotic profilaksis ceftriaxon 1gr/IV-- marker site

Hasil Lab 6-3-2015WBC : 6,1RBC : 3,94HGB : 11, 9HCT: 37PLT: 225Na/K/Cl :136 /2,6/101GDS : 226 Ur/cr : 15 /0,50GOT/GPT :26 /6PT: 10,2 INR: 0,96APTT: 22,7BT: 2’00CT: 8’00Alb:3,1


Bed 1Viane Rumayan70400102-04-1973MRS : 16-3-2015

Alamat : jl.Goa ria

DPJP :dr.HaryasenaSp.B (K)Onk

S: Keluhan tidak adaO: Keadaan umum baik, compos mentis

Vital signTD: 110/70 mmHgN: 80X/menitP: 20x/menitS: 36.7

A : Ulcus regio frontal

Rencana BiopsiTunggu jadwal

Laboratorium (8-3-2015)WBC: 2.0RBC: 4.51HGB: 14.2HCT: 42PLT: 421PT/APTT: 9.5/27.7Albumin: 4.2CT/BT: 8’00/3’00”INR: 0.9GDS: 101Ur/Cr: 13/0.6SGOT/SGPT: 11/24Na/K/Cl: 144/4.3/107HbsAg: non reactiveAnti HCV:Non reactive

Hasil FNA (9-3-2015)Hasil : Radang granulomatous supuratif

Bed 2Masny Madily

S: keluhan tidak ada


Laboratorium (05-03-2015)WBC: 7.16

15-06-1987703701MRS : 16-3-2015

Alamat : kebon cengkeh Ambon

DPJP : dr.Septiman, Sp.B (K) Onk

O: Keadaan umum baik, comos mentis


A: Tumor regio vertex

RBC: 5.21HGB: 12.9HCT: 41.3PLT: 330CT/BT: 8’00”/3’00”PT/APTT: 10.0/28.3GDS: 85Ur/Cr: 10/0.55SGOT/SGPT: 21/20Na/K/Cl: 139/4.8/112HbsAg: non reactiveAnti HCV:Non reactive

Hasil FNA(05/03/2015)Hasil : Kista epidermoid

BED 3Hapida. P1-1-1950560095MRS : 27-02-2015

Alamat : Kabere

DPJP : dr. William Hamdani, Sp.B(K)Onk

S : Keluhan : tidak adaO : KU : baik, compos mentis

A :Carsinoma mammaedextraT4cN0M0Kornafsky 80%

- Cek Darah rutin post transfusi 6 jam

Laboratorium(17-03-2015)WBC: 3.2RBC : 3.82HGB : 12.5HCT : 34MCV :89MCHC : 33PLT : 98

BED 4Murhalima61101121-01-1972MRS : 16-03-2015Alamat : PosoDPJP : dr.Septiman, Sp.B (K) Onk

S: keluhan tidak adaO: Keadaan umum baik, comos mentis


A : Tumor mammae bilateral

Rencana biopsi tunggu jadwal

Laboratorium (10-2-2015)WBC: 7.2RBC: 4.86HGB:13.4HCT: 41PLT: 287MCV: 80MCH: 28PT/APTT: 10.3/24.3GDS: 82Ur/Cr: 13/0.5SGOT/SGPT: 27/34Na/K/Cl: 144/4.1/110CT/BT: 8’00”/2’30”

BED 5MAGDALENA

S : Nyeri pada mulut

Rencana operasi tunggu jadwal

Hasil Lab PA (18-2-2015)Malignant epithelial tumor,

01/07/1934701425MRS : 04-03-2015

Alamat : dulir, kab lembata NTT

DPJP :dr. DjonnyFerianto, Sp.B(K)Onk

O: Sakit sedang, compos mentis

TD: 110/70N: 80X/menitP: 20X/menitS: 36.7A: Oral cancer

Belum acc anestesiOptimalisasi KURL: Destrose= 1:1=20 tpmCeftriaxone 1 gr12 jam/ivKetorolac 30 mg/8 jam/ivRanitidin 50 mg/8 Jam/iv

-Terapilanjut dari TS.gizi dan TS endokrin metabolik-GV / hari

yang sudah metastase ke submandibula

Laboratorium 17-3-2015WBC: 9.6RBC: 2.47HGB:7.4HCT: 21PLT: 342MCV: 86MCH: 30

Hasil lab (13-3-2015)Na : 131Kal: 2.4Cl : 94

BED 6AGUSTINA KAHAR02-08-1968693850MRS: 17-03-2015

Alamat: Galesong Takalar

DPJP :dr. DjonnyFerianto, Sp.B(K)Onk

A: Adenocarcinoma mammae

Rencana operasi Hasil FNA 23-12-2014Adenocarcinoma mammae


K9B1Bachtiar18/10/1962 (52 tahun)MRS : 14-03-2015RM : 704750Alamat : jl. Kapasa raya komp. PND/ 085242285910

DPJP : dr. Djonny Ferianto,Sp.B-Onk

S : Nyeri pada mandibula kananO : kesadaran : kompos mentisA : Abses submandibula dextra

- Ringer laktat 28 tpmceftriaxone 1 gr/ 12 jamketorolac 30mg/8 jam/ivranitidin 50mg/8 jam/iv- metronidazole 500 mg/8 jam/iv- Cek Elektrolit

Lab 13-3-2015:Wbc : 16,7Rbc : 4,43HGB : 13,7HCT : 41PLT : 388PT/APTT : 9,7/ 36,8INR : 0,90Na/K/Cl : 141/4,7/111Ur/Cr : 49/1,80GOT/GPT : 29/57

K9B2Salahuddin31/12/1971 (43 Tahun)MRS : 13/3/2015RM : 697704Alamat : Kareppekang, Bukit Tinggi, Bulukumba / 082187904340

DPJP : dr. Djonny Ferianto, Sp.B (K) Onk

S : Benjolan Pada Leher Kiri DepanO : SS/GC/CMA : Carcinoma Thyroid

- Ciprofloxacin 2x500 mg-Post Kemoterapi siklus (17/3/2015)

Lab 14/3/2015LED : 66/81

Foto Thorax PA (13/3/15) :- pulmo normal- cardiomegali dengan dilatatio aortae

Foto Skull AP/lateral (13/3/15) :Soft tissue swelling regio submandibula

Lab 5/3/2015WBC : 18,01RBC : 4,90HGB : 13,7HCT : 41,6PLT : 312GDS : 137Ur/Cr : 37/1,00SGOT/SGPT : 21/19Albumin : 3,7Asam Urat : 6,9Na/K/Cl : 148/4,5/111

Foto Thorax PA 13/2/2015Kesan :-Goiter Intrathoracic-Cardiomegaly dengan dilatatio et elongation aortae

Hasil FNA :Neoplasma thyroid suspek malignant

Hasil PA :Adenocarcinoma papiler variant

folikulerK9B3Izak Koipuy24/12/1943 (71 Tahun)MRS : 13/3/2015RM : 665783Alamat : Dusun Murai Baru Aru Tengah Dobo / 085299151788DPJP : Dr. dr. Septiman, Sp.B (K) Onk

S : Benjolan pada pipi kananO : SS/GC/SadarA : - Sarcoma Wajah

- Rencana Kemoterapi- Cek Foto Thorax- Cek Echocardiography- KSR 2x1 tab- Vip Albumin 2x2 tab

Hasil Foto Thorax (16/3/2015) :Gambaran Bronchitis

Hasil USG Abdomen (16/3/2015) :-Splenomegali-Tidak tampak tanda-tanda metastasis pada USG Abdomen ini

Lab 14-3-2015Wbc 16,7Rbc 3,79Hgb 10,5Hct 31Plt 308GDP 101Ur/cr 13/1,00GOT/GPT 21/19Na/K/Cl 140/3,3/107Albumin 2,7

K9B4Runauld S E Abrahams02/02/1963 (52 Tahun)MRS : 13/3/2015649612Alamat : Jl. PR Kayadog / 085243063785

DPJP : dr. Djonny Ferianto, Sp.B (K) Onk

S :

O : SS/GC/CMA : POH-2 eksisi luas ec. Tumor Mandibula

Lab 17/3/2015Wbc 26,0Rbc 2,91Hgb 8,4Hct 26Plt 147

Foto Thorax PA 06/03/2015Nodul Soliter Pada ParuKanan Suspek Metastasis

K9B5Syamsuddin Laen31/12/1952 (62 tahun)MRS: 10/2/2015700789Alamat : Batu Rumpun Enrekang / 081355984936

S : Perdarahan dari luka bekas operasiO : KU: lemah/anemisHb = 4,7, WBC = 10,3, PLT = 183A : RhabdomyosarcomaPOH 22 Biopsi Insisi

-Ringer Laktat 28 tpm-Ceftriaxone 1gr/12 jam/iv-Ranitidin 50 mg/8 jam/iv-Ketorolac 30 mg/8 jam/iv-Cocktail /8jam-Cek HB Post

Lab 17/3/2015WBC 9,6RBC 2,30HGB 6,4HCT 19PLT 204

Lab 12/3/2015WBC 10,4

DPJP: Dr. dr. William Hamdani, Sp.B (K) Onk

Transfusi (4 Bag WB Biasa)-Terapi lain sesuai TS.BTKV

RBC 1,79HGB 5,5HCT 17PLT 166

Lab 10/3/2015WBC 10,3RBC 1,53HCT 13,9HGB 4,7PLT 183CT/BT 8,00/3,00PT 10,4 Kontrol 10,6INR 1,00APTT 31,3 Kontrol 25,2Lab 2/3/2015Wbc 11.7RBC 1.02Hgb 3.0Hct 10PLT 276Lab 27/2/2015Wbc 9.1Rbc 2.06Hgb 5.9Hct 17.6Plt 344Patologi anatomi 17/1/2015Rhabdomiosarkoma (embrional pleomorfik)

K9B6Abu01/01/1960 (55 Tahun)MRS : 13/3/2015RM : 467954Alamat : Jl.Prof Dr.Ir. Sutami No.29 MKS / 082194340060

DPJP : Dr.dr. Haryasena, Sp.B (K) Onk

S : Benjolan Pada Leher KananO : SS/GC/SadarA : POH-1 Biopsi Insisi

-Ranitidin 30 mg/8jam/iv-Ketorolac 50 mg/8 jam/iv

Lab 10/3/2015WBC : 3,9RBC : 3,56HGB : 10,8HCT : 35PLT : 243GDS : 93Ur/Cr : 15/0,80SGOT/SGPT : 25/25Na/K/Cl : 143/4,2/107

ICUBED 9Runauld S E Abrahams02/02/1963 (52 Tahun)MRS : 13/3/2015649512Alamat : Jl. PR Kayadog / 085243063785DPJP : dr. Djonny Ferianto, Sp.B (K) Onk

S :

O : Ku baikA : POH-1 eksisi luas ec. Tumor Mandibula

- Besok ganti verban bagian leher

- Terapi lanjut

Lab 06/3/2015Wbc 11,82Rbc 4,71Hgb 12,2Hct 39,8Plt 268Bt/Ct 2’30/8’00Pt/apt 10’4/25’7Gds 69Ur/cr 15/0.60Got/gpt 24/28Na/K/Cl 140/3,5/98HbsAg non reactif

Foto Thorax PA 06/03/2015Nodul Soliter Pada ParuKanan Suspek Metastasis

LONTARA 1 BAWAH BELAKANGKamar 5 II B 1Ny. Rahmat24-10-1964/ 50 tahunRM : 703323MRS : 02-03-2015Tgl konsul : 10-03-2015Alamat : Jl. Yojokodi, Palu

DPJP : dr. William Hamdani, Sp.B (K) Onk

S : kel : lemasO : keadaan umum sakit sedang/ sadar

- Region colli : Luka : verban kering, luka kering

A : post op biopsi Limfadenopati susp. Limfoma Maligna

- Ringger laktat 24 tpm

- Ceftriaxone 1 gr/ 12 jam/ intravena

- Ketorolac 30 mg/ 8 jam/ intrvena

- Ranitidin 5o mg/12 jam/ iv

- Ganti perban = rawat luka

- Terapi lain sesuai TS interna

Lab (10-03-2015)WBC :12.3RBC :4.22HGB : 11.1HCT :35PLT : 154

Lab (12-03-2015)Ur/Cr : 13/0.49SGOT/SGPTNa/K/Cl : 136/2.8/101Albumin : 2.4

Foto thorax (2-3-2015)Efusi pleura bilateralLab (11-03-2015)CA 12-5 : 542.03

Usg Abdomen (2-3-2015)Kesan :

- multiple lesi lobulated pada daerah paraaorta suspek limfoma

- Ascites dan efusi pleura bilateral

MSCT wholeAbdomen Non Kontras (11-03-2015)Kesan :- massa quadran kanan atas abdomen susp. Lymphoma- hepatosplenomegaly dengan tanda-tanda fatty liver- ascites- Efusi pleura bilateral terutama kanan

Kamar 5 III B4Dg Tiro Bin Tadara31-12-1951/ 53 tahunRM : 704199MRS :Tgl konsul : 17-03-2015

S : benjolan pada leher, ketiak dan perut

O : keadaan umum sakit sedang/ sadar

A : Limfadenopati susp. Limfoma Maligna

- Rencana biopsi eksisi bila setuju

Lab (14-03-2015)Hematologi rutinLED : 11/28

Foto thorax :TB paru duplex lama tenangDilatation et elongation aortae

USG Abdomen :SplenomegalySlight hepatomegalyascites

PALEM BAWAHB2/K5Hasan21-10-1958RM :702470

MRS: 04-03-2015Alamat: Jl.Lapawawoi KR Sigeri

DPJP : dr. HaryasenaSp.

S: Keadaan umum baikO : Sakit berat/ gizi baik/sadar

Tanda vital TD 110/70 P:16x/i N : 86x/I S: 36,5C

A: Soft tissue tumor regio inguinal

Tunggu hasil PATerapi lain sesuai TS Interna

Hasil laboratorium tgl 14-3-2015 :PT/APTT 11,9/1,04Bil.Direk 0,33Bil.Total 0,48Alkali fosfatase 305SGOT/SGPT 110/78Prot.Total 5,2Albumin 2,8Hbs Ag Non reactiveAnti HCV(elisa) 6,63

B(K)Onk Reactive

B2/6.2Ang Chui Leng70060411-3-1946MRS : 10-2-2015Alamat : jln Towuwa

DPJP : Dr, septiman, Sp.B (K) Onko

S : Benjolan pada leher, batuk0 : Sakit sedang / gizi cukup/ composmentisTD: 140/80 N :80x/i P:20x/I S: 36,8 C

FNA benignNodul thyroidFT4 2,96TSHS 0,5A : Nodul thyroid

Perbaikan KURencana operasi jika keadaan umum optimalTunggu hasil USG colliTerapi Lanjut sesuai TS NS

Hasil PA : benign Folikulare Nodul ThyroidHasil lab tgl 9-2-2015WBC : 11,5RBC : 4,22HCT : 40,3PLT : 182HGB : 13,5CT : 7.00BT : 2,00GDS : 113Sgot/Sgpt : 15/16Na /K/ Cl : 147/3,9/115FT4 : 2,96TSHs : <0,05HbsAg non reactive

B2/K9.B1SianaRM 14072907-08-1972MRS : 16-3-2015

Alamat : JL. Bone Raja Blok J No.8

DPJP : dr. Haryasena Sp.B(K)Onk

S : Benjolan di payudara kananO : Sakit sedang/gizi baik/sadar

Tanda vital TD 140/80 P:16x/i N : 86x/I S: 36,5C

A :Tumor mammae dextra

Rencana operasi eksisi tumor tanggal 18 maret 2015Persiapan operasi-Lapor OK-Konsul anastesi-Inform consent-Puasa 6-8 jam-Antibiotik profilaksis Ceftriaxone 1gr/intravena-Marking site-Persiapan darah 2 bag PRC disiapkan

Hasil laboratorium tgl 17-3-2015 :WBC : 6,3RBC : 4,43HCT : 36PLT : 228HGB : 12,1CT/ BT : 7’30/2’00PT/APTT : 10,0 / 24,6GDS : 86Ureum : 18Creatinin : 0,58Sgot/Sgpt : 24/15Na /K/ Cl : 143/5,5/111Albumin : 4,0HbsAg non reactiveUSG mammae 16-2-2015Nodul mammae dextra(BI-RADS III)Multiple mikrokalsifikasi

mammae bilateral dengan jaringan sikatrik pada kuadran bawah mammae dextra susp. Post infeksi

B2/K9.B2HasbiahRM 70460207-03-1978MRS : 16-3-2015

Alamat : JL. Bone Raja Blok J No.8

DPJP : dr. Haryasena Sp.B(K)Onk

S : Benjolan di payudara kananO : Sakit sedang/gizi baik/sadar Tanda vital TD 110/70 P:16x/i N : 84x/i S: 36,5CA :Tumor mammae dextra

Rencana operasi Biopsi Insisi tanggal 18 maret 2015Persiapan operasi-Lapor OK-Konsul anastesi-Inform consent-Puasa 6-8 jam-Antibiotik profilaksis Ceftriaxone 1gr/intravena-Marking site-Persiapan darah 1 bag PRC disiapkan

Hasil laboratorium tgl 13-3-2015 :WBC : 6,33RBC : 4,42HCT : 39,1PLT : 404HGB : 13,1CT/ BT : 7’30/3’00PT/APTT : 10,9 / 31,9GDS : 97Ureum : 26Creatinin : 0,50Sgot/Sgpt : 56/74Na /K/ Cl : 146/4,4/104HbsAg non reactive

Lab.PA 25-02-2015FNA tumor mammae dekstra

B2/12.2Marhama Mallapi690379MRS : 13-3-2015Alamat : Buntu Lobo

DPJP : : dr. Septiman Sp.B(K)Onk

S : Nyeri pada ketiakO: sakit sedang/ gizi cukup / compos mentisTanda vital: TD: 120/80 N :84x/i P: 16x/i S: 36,8 CA : limfoma Maligna

Duragesic patch 12,5 mgRencana kemoterapi jika KU stabilTungu jawaban konsul metabolic endokrin

Hasil PA : diffuse Longe Cell LymphomaHasil lab tgl 12-3-2015WBC : 6,61RBC : 3,94HCT : 40,3PLT : 517HGB : 10,9CT : 7.30BT : 3.00GDS : 325Sgot/Sgpt : 20/19Na /K/ Cl : 145/3,7/106

B2/13.2Ruth Waraki677267MRS : 13-3-2015Alamat :

S : nyeri ulu hatiO: sakit sedang/ gizi cukup/ compos mentisTD 120/80 mmHg P:18x/i

IVFD RL;D5 2:2 20 tpmCeftriaxone 1 gram/12 jamKetorolac 30 mg/8jam/iv

Hasil laboratorium tgl 15-3-2015 :WBC : 32,6RBC : 4,51HCT : 35

Bintuni

DPJP : dr. HaryasenaSp.B(K)Onk

N : 80x/i S: 36,5CA: oral Cancer

Ranitidine 50 mg/8jam/ivOndansentron 1 amp/8jamRencana kemoterapi jika KU stabil

PLT : 572HGB : 11,5

Hasil laboratorium tgl 9-3-2015 :WBC : 14,0RBC : 3,15HCT : 25PLT : 463HGB : 7,6Ureum : 16Creatinin : 1,70Sgot/Sgpt : 19/10Na /K/ Cl : 144/32/106

PALEM ATASB2/3 /Bed 1Rismawati68923712/2/1970MRS : 10-03-2015Alamat : jl. Malimpung. Pinrang

DPJP : Dr. dr. William Hamdani, Sp.B (K) Onk

S: Nyeri seluruh badanO: sakit sedang/ gizi cukup/ composmentisA: tumor mammae dextra pro kemo

- Rencana kemoterapi jika KU optimal

- IVFD Nacl +

- Neurobion 1 amp/8jam

- HP pro 1x1 tab

- Duragesic pain 25mg

- Terapi lain sesuai TS interna

Hasil laboratorium tgl 12-3-2015 :Bilirubin total:1,48Bilirubin direk1,14Alkali fosfatase 417Protein total 7,6Albumin 3,5

Hasil laboratorium tgl 10-3-2015 :WBC : 7,6RBC : 4,21HCT : 40,4PLT : 298HGB : 13,5CT : 7,00BT : 3,00GDS : 133Ureum : 34Creatinin : 0,60Sgot/Sgpt : 144/45Na /K/ Cl : 142/4,2/106HbsAg non reactive