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KORAN bedah onkologi Rabu 4 mei 2015 LONTARA 2 ATAS BELAKANG KAMAR 6 Bed 1 Hajrah 29-9-1965 (50) 707078 MRS: 24- 05-2015 Alamat : jl. Flamboyant barat, Makassar DPJP: dr. Septiman, Sp.B(K)Onk S : kel - O : KU baik / compos mentis A : POH 2 tumor coli sinistra , debulking Infus RL 28tpm Ceftriaxone 1gram/12jam/iv Ranitidine 50mg/8jam/iv As. Traneksamat 500mg/8jam/iv Dexametason 1amp/8jam/iv GV / hari Aff kateter Lanzoprasole tab 2x1 Lab: Wbc: 8,7 Rbc: 4,97 Hgb: 14,6 Hct: 43 Plt: 399 Ct/Bt: 7'00/3'00 Pt: 10,1 Aptt: 20.7 Gds: 106 Ur/Cr: 16/0,50 Sgot/sgpt: 23/32 Alb: 4,1 HBsAg: non reactive Anti HCV non reactive Hasil PA Tgl 21-4- 2015 Neurofibroma No. PA 4307056 Tgl 6-5-2015 Jaringan yg mengandung sedikit fokus tumor soft tissue kemungkinan suatu

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KORAN bedah onkologi Rabu 4 mei 2015 LONTARA 2 ATAS BELAKANG KAMAR 6

Bed 1

Hajrah29-9-1965 (50)707078MRS: 24-05-2015

Alamat : jl. Flamboyant barat, Makassar

DPJP: dr. Septiman, Sp.B(K)OnkS : kel -O : KU baik / compos mentisA : POH 2 tumor coli sinistra , debulkingInfus RL 28tpmCeftriaxone 1gram/12jam/ivRanitidine 50mg/8jam/ivAs. Traneksamat 500mg/8jam/ivDexametason 1amp/8jam/ivGV / hariAff kateterLanzoprasole tab 2x1Lab: Wbc: 8,7Rbc: 4,97Hgb: 14,6Hct: 43Plt: 399Ct/Bt: 7'00/3'00Pt: 10,1Aptt: 20.7Gds: 106Ur/Cr: 16/0,50Sgot/sgpt: 23/32Alb: 4,1HBsAg: non reactiveAnti HCV non reactive

Hasil PATgl 21-4-2015NeurofibromaNo. PA 4307056

Tgl 6-5-2015Jaringan yg mengandung sedikit fokus tumor soft tissue kemungkinan suatu neurofibroma

Bed 2Besse manta1-7-1958713060MRS 2-6-2015

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

d/ ulcus carcinoma mammae sinistraRencana biopsy insisi tnggu jadwal(hari kamis)

Lab 26-5-2015HGB 10.7HCT 34.5

Hasil PATgl 27-5-2015Ulkus ca mammae sinistra

Bed 3 Rina15-2-1988710689MRS : 20-05-2015Alamat : Dusun Tappoci

DPJP: dr. William HamdaniSp.B(K)OnkS : rasa tdk nyaman pada hidung tenggorokan NGTO : baik, compos mentisDrain 50ccA : ameloblastoma mandibula sinistra POH IV segmental amelomandibulektomiAs mefenamat 2x500mgRanitidine 2x150mgCefadroxil 2x500mgBetadine kumur 3x1Diet cairGV/hariPasang NGT ulang09/5/15 :Wbc : 9,3Rbc: 5,14Hb: 13,8Hct: 42Plt: 305

Bed 4Hapidah P31-12-1950560095MRS: 30-05-2015Alamat: Enrekang

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

S : kel O : ku : cukupA : ca mammae dextra Anemia TrombositopeniaInfus futrolitLanjut instruksi dari TS KHOMCek darah rutin

LONTARA 2 ATAS BELAKANG KAMAR 7

BED 1SITI07-05-1971Alamat : Jln tarakkan lr 183 no. 46 mks

MRS : 28 mei 2015Residen : dr. febiDPJP: dr. Haryasena, Sp.B(K)Onk

S: nyeri pada leher dan panggulO: keadaan umum : sakit sedangVAS 4/10A: squama cell carcinoma Metastasis tulang

Infus felitroluitInj ceftriaxone 1g/12j/ivInj novalgin 1 amp/12j/ivInj ranitidine 1 amp 8j/ivUltracet 3x1 /tablet /oralDurogesic patchMST 10mgCek kalsium (hasil)Lab 28/5/2015GDS: 132Ureum : 48Creatinin; 1,00SGOT: 17SGPT: 9Asam urat : 4,9Natrium: 134Kalium: 3,9Clorida: 104

Hasil PA :22-5-2015metastase karsinoma sel skuamosNo PA : 4403745

BED 2Maryam M1-11-1981620666MRS : 16-05-2015Alamat :desakatumbanganlemo, kab. Polman.

DPJP : dr.DjonnyFerianto, Sp.B(K) onkS : kel O : ku : sedangAnemis (+)A : ca mammae dextraInfus futrolit 28tpmMaxiliv 2x1Periksa lab lengkapGV/hariAwasi tanda vitalLab 19/05/2015WBC : 8,4RBC : 1,88HGB : 10,0HCT : 6,1PLT :118CT : 8 00BT : 3 00PT : 20,5INR : 1,20APTT : 12,5GDS : 126Ureum : 87Creatin : 1,10GOT : 67GPT : 43Na/K/Cl : 129/3,4/93Albumin 3,3HBs Ag dan Anti HCV (ICT) (Non- reaktif)

Hasil PA ( 25-7-2014) :Invasif ductal carcinoma mammae, high grade malignancyNo PA : 3629726

BED 3Irmawaty 20-8-1977711874MRS : 31-5-2015

KJS BTKV

DPJP : dr rosie Sp.BTKVS : kel O : ku baikA : ca mammae bilateralRencana insisi biopsy tunggu jadwalLapor dok chris DPJP?Foto thorax 28-5-2015Efusi pleura dextra

Hasil PA :26-5-2015hapusan terdapat sel epitel maligna (malignant efusi)no PA : 4419580

BED 4Surtiah01-08-1979695661MRS: 22/4/2015

Alamat : japing japine tengah

DPJP: Dr. Septiman, Sp.B (Onk)

S : nyeri luka operasiO : ku : sakit sedang, compos mentisA : POH ke VI hemimandibulektomiAmeloblastoma dextra

Infus futrolit 30tpmCeftriaxone 1gram/12jam/ivRanitidine 50mg/8jam/ivKetorolac 30mg/8jam/ivBetadine kumur 3x1Diet via NGTKonsul dr chris untuk rencana rekonstruksi

Lab (26/4/15)WBC : 23HGB : 9.6PLT : 270GOT : 60GPT : 58HasilFoto Thorax (7/1/2015)Kesan: Cordanpulmo normal.Tidaktampaktanda-tandametastasispadafoto thorax ini.

Foto MSCT scan tanpakontras (7/1/2015)Kesan: AmeloblastomaMaxillarisKanan.

Hasil PA (01-04-2015) :Mixoma of the jawdenganinflamasiNo PA : 4275940

BED 5Mirkami1-7-1966679590MRS: 3/6/2015

alamat : papua barat

DPJP: dr. William HamdaniSp.B(K)OnkS : benjolan pada payudara kananO : ku baik. Compos mentisA : ca mammae dextraRencana operasi mastektomi radikal modified

BED 6Kursiah31-12-1934712874Alamat : LokaeSoppeng

MRS : 21-05-2015

DPJP: Dr. Septiman, Sp.B (Onk)

S : kel -O : ku sedang/ compos mentisA : POH VII biopsy insisiInfus futrolit 24tpmCek lab lengkapDR, GDS, elektrolitAwasi tanda vitalLab (22/4/15)WBC : 8,8RBC: 4,85HCT: 38HGB : 12,4PLT :189Hasil PA 28-5-2015Melanoma maligna pada region femur dan kaki kananNo PA : 4417308

LONTARA 2 ATAS BELAKANG KAMAR 8

Bed 1Fatmawati17-7-1982706724MRS: 03/6/2015Alamat : jl sudirman

DPJP: dr. William HamdaniSp.B(K)OnkS : tampak benjolan pada payudara kiriO : ku cukupA : ca mammae sinistraPost kemoterapi neoadjuvant 2 siklusPro MRM Rencana mastektomi radikal modified

LAB 25/5/2015WBC: 5.10RBC: 4.92HCT: 37.0HGB: 12.1PLT324

Bed 2Sumiana16-12-1958714008MRS: 31-05-2015

Alamat : jl laode boha

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

S: luka pada payudara kanan

O: KU sedang

A: Ulkus Ca Mammae dextra suspek metastase tulangPost biopsy insisi Infus futrolit 28 tpm Ceftriaxone 1 gr/12 jam/IV ketorolac 30 mg/8 jam/IV Ranitidin 50 mg/8 jam/IV Neurobion amp

Foto Pelvis 31/5/2015Lesi titik dan sklerotik pada regio trochanter mayor os femur dextra sesuai dengan gambaran metastase tulang Laboratorium 31/5/2015WBC: 13.7RBC: 5.12Hgb: 13.8Hct: 42.9Plt: 284Ureum:17Creatinin: 0.44SGOT: 37SGPT: 31

BED 3 Canning 1-1-1952700786MRS : 4-6-2015

Alamat : lingkungan lelong

DPJP: dr. William Hamdani, Sp. B (K) onkLab (25/5/15)WBC : 1.77RBC : 3,59HCT : 30.9HGB : 10PLT : 189

Bed 4Ny. Frida Kredidare690243/09-04-1981Alamat : Sorong

MRS : 23-05-2015DPJP: dr. Haryasena, Sp.B(K)OnkS : keluhan O : ku sakit sedang, compos mentisPLT 74A : sequamous cell carcinoma region lidahInfus fultrolit 28tpmTranfusi trombosit 2 unitDiet TKTPCek darah rutin post tranfusiRencana kemoterapi jika KU optimalLab (18/5/15)WBC : 0,8RBC : 3,26HCT : 27,0HGB : 9,7PLT : 124

Bed 5Halipah13-12-1960697574MRS : 4-6-2015

Alamat : pare-pare

DPJP: Dr. Septiman, Sp.B (OnkLab 3-6-2015GOT 44GPT 16Albumin 2.8Asam urat : 6.3Na: 135K: 3.7Cl : 103WBC 9.3RBC 3.12HGB 9.3HCT 28.7PLT 223

Bed 6Kartini dg.Kanang01-12-1956670530MRS: 25-05-2015DPJP: dr. Haryasena, Sp.B(K)OnkS : keluhan O : ku baikGDS : 119A : ca mammae dextra, post MRM metastase axilla dextraDM tipe 2Regulasi gula darahRencana operasi hari kamis 4-6-2015Terapi TS interna lanjutUsg mamma (27/5/2015)-lesi hiperechic region axilaris dextra suspek lymphadenopathy

GDS strip tgl 27-5-2015329