LONTARA 2 ATAS BELAKANG KAMAR 4

Bed 1

Muh Yasin

01-11-2011Alamat: Pinrang battombong matiro sompe70.15.87

MRS: 10-03-2015dr. Haryasena, Sp. B (K) OnkS: keluhan tidak adaO: keasadaran umum baik/compos mentisVital signs

N: 86x/menit

P: 20x/menit

S: 36,8oC

A: Post eksisi luas hari 2 soft tissue tumor region patella dextra posterior-Post op eksisi luas hari-2- RL 24 tpm

- ceftriaxone 500mg/12j/iv

- Ranitidin 25mg/12j/iv

-ketorolac 15mg/8jam/ivLab 11-03-2015

WBC 9.0RBC 4.76HGB 11.8PLT 532PT 10.8APTT 25.8Natrium 143Kalium 4.4Klorida 110BT 3.00

CT 7.30

GDS 77Ureum 25Kreatinin 0.35

SGOT 38SGPT 13Lab 17-02-2015Kalsium 11.4Foto Thorax PA 16-02-2015Kesan: bronchopneumonia

Foto Genu Dextra AP/lateral 18-02-2015

Kesan: Soft tissue mass region distal femoris sampai genu medial dextraMSCT scan ekstremitas (dengan kontras) 25-02-2015

Kesan: Lipoma region popliteal dextra

Bed 2

Muis Adjulani12-9-1971

702381

(L)

S: Nyeri pada wajahO : KU sakit sedang/sadar

Vital signsT: 110/70mmHg

N: 80x/menit

P: 20x/menit

S: 36,8oCA: Basalioma at face regionRencana operasi Tunggu jadwalLab 24-02-2015

WBC 10.2RBC 4.74HGB 12.9PLT 452PT 9.6APTT 27.8SGOT 15SGPT 17Natrium 144Kalium 4.1Klorida 105GDS 111Ureum 15Kreatinin 17

Bed 3

Mursalin Tjanne05-05-1942

Alamat: Jl. Pembangunan kendari barat70.25.11MRS : 09-03-2015

dr. Haryasena, Sp. B (K) OnkS:

Tidak ada keluhanO:

KU baik/ SadarVital SignsT: 150/90 mmHg

N: 84 x/menit

P: 20 x/menit

S: 36.8oC

A:

Tumor region buccal dextraRencana operasi 19-3-2015Terapi lain sesuai TS kardio dan interna

EKG ulang hari ini

Lab 11-03-2015

WBC 5.8RBC 4.86HGB 14.3HCT 44PLT 183PT 10.1APTT 29.6SGOT 26

SGPT 19

Ureum 33

Kreatinin 1.20

Natrium 145

Kalium 3.3

Klorida 105

CT 800

BT 230

HBsAg Reactive Foto Thorax PA/AP 24-02-2015Kesan: -Tb paru duplex lama aktif

-tidak tampak tanda-tanda metastasis

-dilatation aortae

Bed 4

Humaedi

21-03-1973Alamat: J;. Sejiwa no 7068.07.72

MRS: 11-03-2015

dr. Djonny Ferianto, Sp. B (K) OnkS: tidak ada keluhan

O: keadaan umum baik/sadarVital signsT: 110/70mmHg

N: 80x/menit

P: 20x/menit

S 36.8oCA:Post eksisi biopsy haro 1 Metastasis carcinoma colli Aff infus Cefadroxyl 2x1

As. Mefenamat 3x1

Ranitidine 2x1Lab 10-03-2015

LED 31/60

BT 200

CT 800

PT 10.1

APTT 24.9

GDS 107Lab 10-03-2015

WBC 4.0RBC 4.56HGB 12.0PLT 284LED 31/59Foto Thorax PA

Kesan

-dilatatio aortae

-tidak tampak tanda-tanda metastasis

LONTARA 2 ATAS BELAKANG KAMAR 5

Bed 1

Bed 2

Cristina

28-06-1973Alamat: BTP blok AC2 no 27165.75.59

MRS: 05-03-015

dr. Haryasena, Sp. B (K) Onk

S: nyeri pada luka payudara kananO: KU sakit sedang/sadar

Vital sign:

T: 120/70mmHg

N: 84x/menit

P: 20x/menit

S: 36,7oCA:

Ulcus carcinoma mammae dextracT4cN2M1

Karnofsky 70%

Efusi pleura dextra

POH-5 chest tube + WSD

-Efusi pleura dextraRinger laktat 28 tpm

Ceftriaxone 1gr/12jam/iv

Ketorolac 30mg/8jam/iv

Ranitidin 50mg/8jam/iv

Diet biasa

Ganti verban/ hari

Rencana kemoterapiLab 05-03-2015

WBC 7.9RBC 5.48

HGB 13.2PLT 388

HCT 40.9PT 9.7INR 0.90APTT 24.7Natrium 138Kalium 3.8Klorida 102BT 3.00

CT 8.00

GDS 104Ureum 21Kreatinin 0.60SGOT 58SGPT 31Albumin 3.4

HBs Ag Non Reactive

Anti HCV Non ReactiveFoto thorax PA/AP 05-03-2015

Kesan: bronchopneumonia dd/lesi-lesi mikronodul suspek tumor metastasis ke paru

USG Abdomen atas + bawah (whole abdomen) 05-03-2015

Kesan: efusi pleura dextra

Bed 3Bijawan DG Bone685075

10-6-1965

MRS: 16-3-2015

S:Nyeri pada mammae dextraO:

Keadaan umum sakit sedang/ compos mentis

Vital Sign:

T: 120/70 mmHg

N: 80 x/menitP: 20x/menitS: 36.8 oCA:

Ca Mammae DextraRencana operasi19-3-2015Lab 16-3-2015

WBC 9.6RBC 4.61HGB 13.1PLT 189

HCT 38PT 10.8APTT 28.5

Ureum 17Kreatinin 0.69SGOT 19

GDS 253Pemeriksaan PA (16/7/2014)-Invasif ductal carcinoma mammae, Moderate grade malignancyEchocardiografi(19-01-2015)

Fungsi sistolik ventrikel kiri baik

Ejeksi Fraksi 62%

Hipertropi ventrikel kiri

Disfungsi diastolic ventrikel kiri

Bed 4

Nurhaedah

20-07-1975

69.41.62

MRS: 11-03-2015

dr. Haryasena, Sp.B(K)OnkS: Keluhan tidak ada

O: keadaan umum baik/sadar

Vital sign

T 110/70mmHg

N 84x/menit

P 20x/menit

S 36.8oCA: Nodul tiroidRencana operasi

19-3-2015

Lab 17-3-2015WBC 20.4RBC 4.24HGB 12.8PLT 312HCT 37PT 11.1APTT 26.7Ureum 24Kreatinin 0.60SGOT 19GDS 253Lab 5-3-2015

GDP 129

GD2PP 121

HBA1c 145

Natrium 145Kalium 4.0Klorida 110

Foto Thorax PA 25-02-2015Kesan:-soft tissue density region colli

-tidak tampak tanda-tanda metastasis pada foto ini

CT thyroid/leher tanpa kontras 03-03-2015

Kesan:

-massa thyroid lobus kiri