SELASA, 5 September 2017 Mapping Bedah Onkologi FAT/TOP/ARV/AFF/ZIC/GIH/YES

KM NAMA / TGL LHR Umur NO RM MRS DIAGNOSA STATUS PLAN DPJP PEMERIKSAAN PENUNJANG

MAWAR 1
(31/8) Hb 10,3 AL 12,1 AT 449 OT 75 PT 90 GDS 112 Cr 0,7 Ur 39 Na 138 K 3,5 Cl 106 HbsAG NR
Awasi KU VS GCS Lateralisasi
Ca Mammae post MRM TxNxM1 (paru) USG Mammae (D) tak tampak massa residif, limfadenopati, Thorax Nodular dan Subpleural type pulmonal Metastase
Sri Rejeki Perbaikan KU, konfirmasi Raber
8D 17/08/1970
47 01335676 31/8 Rhabdomyosarcoma R. Temporoparietal (D) Konservatif
NS, BILA KU BAIK DAN GCS 15,
HK USG Abdomen Tak terdapat penyebaran, MSCT Massa solid di levator scapula sesuai fibrosarcoma, multiple nodul
post wide eksisi G4TxN1M1 (brain) parenkim metastase
Konsul radioterpi
15/7/2017 PA Pleimorfic Rhabdomyosarcoma dd Undifferentiated Pleomorphic Sarcoma
Warsiyem 25/4/2017 HB 12.5 AL 5.7 AT 436 OT 18 PT 17 CR 0.7 UR 41
8J 67 01354776 4/9 Ca Mammae Pre oP MRM
24/11/1950 21/4/2017 PA : MAMMAE SINISTRA INVASIVE CARCINOMA GRADE 3
MELATI 1
28/8/2017 HB 9.9 HT 31 AL 58.7 AT 45 AE 3.22 GDS 77 OT 31 PT 15 ALB 2.5 CR 1.8 UR 40 Anti Hbc total Equivocal, Anti HCV
NR
Bambang
3G 45 01389678 24/8 Multiple limpadenopati, hepato splenomegali, PRE OP BIOPSI EKSISI HK 26/8/2017 HB 10.6 HT 32 AL 59.9 AT 42 AE 3.37 ALB 2.6 NA 130 K 3.5 CA 1.15
28/8/2017
25/8/2017 HB 10.1 HT 29 AL 5.8 AT 42 AE 3.08 NA 136 K 3.7 CA 1.11
248/2017 HB 8.5, HT 29 AT46 NA 129 K 4.6 CL 0,
ANGGREK 1
Efusi pleura ganas sinistra jenis SCC , Tumor 1/9 HB 13.3 AL 12.4 AT 212 GOL DA B GDS 117 OT 13 PT 20 bil tot 0.59 prot ttl 5.1 ALB 3 CR 5.2 UR 235 NA 121 K 5.8 CL 87
Upriyati
1G 35 01390884 4/9 MAMMAE Sinistra , post pungsi pericard Work up Tunggu Hasil FNAB , USG 26/8 Thorak : Cardiomegali, efusi pleura bilateral . susp, massa luar hemi thorak29/8/2017 USG Thorak : Efusi pleura Dx,
22/7/1982
Efusi pleura Sn ebagian terorganisasi, penebalan pleura Sin

Efusi pleura para maligna loculated sinistra , 2/9 HB 12.4 AL10.8 AT 354 GDS 108 OT 24 PT21 29/8 HB 12.8 AL 8.7 AT 423PT 13.0 APTT 26.5 INR 1.04
Tukimin
2E 61 01389125 4/6 atelektasis parukiri , Hipertensi gr 1metastase Work up Konsul Staf 29/8/2017 Thorak : efusi pleura masif kiri massa paru (=),
26/6/1956
CA R. FEMUR Sinistra 31/8/2017 sitologi cairan pleura :tidak ada sel ganas

HCU ANGGREK 2
RIWAYAT TUMOR MAMMAE KIRI POST MRM
1/9 HB 11.8 AL 7 AT 136 GDS 87 OT 75 PT 53 CR 0,7 UT 54 NA 135 K 3.8 CA 1.18 HbsAg NR
Sumarmi TXNXM1 (BONE METASTAESE )
C 67 01390879 4/9 WORK UP KONSUL STAF 1/6/2017 Thorak PA : PNEUMONIA , BONE METAS (-),
10/1/1950 KEMO BELUM LEGKAP (BERHENTI KEMO
29/8/2017 CERVICAL : VC 6-7 DESTRUKSI, PROSES METAS VC6-7
SUDAH LAMA , ARSIRAN HILANG)
MAWAR 2
(29/8) hb 12.6 ht 42 al 10.3 at 370 GDS 107 PT 18 PT 18 CR 0.5 UR 34 NA 133 K 4.1 CL 101 HbsAg NR (13/4/2017) ER (-),
Ca mammae (D) T4N3M1 (paru) Perbaikan KU PR (-), HER(-)
Sugiati
1D 41 01352055 28/8 Post Kemo 6x brexel 100mg, carboplatin 450 Konservatif THORAK N USG (4/9), CT SCAN WY 22/4/2017 USG Doppler tak tampak massa residif hemithorak dextra , mama sinistra tak tamopak kelainan,
2/6/1976
mg, On kemo Novekbin 40 mg KEPALA KONTRAS (6/9) limphadenopati bilateral (-)22/4/2017USG abd : tak tampak intra abd metas taseHepar/lien /dll (-)
7/3/2017 PA: Invasive ca
30/8/2017 Hb 10.5 HT 35 AL 12.2 AT 89 AT 3.78 GDS 123 OT 195 PT 270 CR 0.3 UR 24 NA 134 K 4 CL 104 HbSAG NR
14/8/2017 BTA Sputum (-)
Perbaikan ku ,
Yuniar 28/7/2017 Thoral PA: infiltrasi di paracardial bilateral kanan, pleura retraction kiri, bronkopneumonia type metastasisi,
3B 46 0139420 28/8 Ca Mammae (S) TxN3cM1 PARU , HEPAR Konservatif XELLODA 2-0-2 HK
28/6/1971 tampak destruksi costa kanan lateral , COR (N)
(Raber Paru onkologi)
28/7/2017 USG Abd : multiple nodul hepar, efusi plura (D) pulmonal metastase
Bagian Paru USG Thorax
2/9 HB 11.5 AL 6.5 AT 228 CR 2.2 UR 62 LDH 1792 AFP 1
Biopsi Insisi
Rudi H Tumor R Gluteus (D) Susp Sarcoma 1/9/2017 USG Abdomen Massa solid di hipocondriaca sampai suprapubic, BNO ground glass appareance dan destruksi
4J 34 01387234 30/8 Pre OP (Raber Digestif) HK
10/04/1983 Tumor Intraabdomen (raber digestif) iliac wing (D)
(CT Scan Abdomen)

Ro Thorax (baru akan daftar)

Paniran (31/08) Hb 11,8 Al 15,8 At 370 OT 20 PT 13 Cr 0,7 Ur 46 GDS 105 Na 137 K 2,7 Cl 100 HbsAG NR
6B 61 01390831 31/8 SCC R. Buccal (D) T4BN1Mx Work UP Pasang NGT HK
16/11/1955 (22/08) FNAB SCC
Perbaikan KU
31/9 NA 136 K 4.1 CL 103 30/8/2017 HB 14.7 HT 43 AL 13.2 AT 390 GDS 78 OT 65 PT 65 ALB 3.3 CA 1.04 (28/08) cr 0.79 UR
Sulaiman
8A 35 01390226 28/8 Multiple Limfadenopati R. Colli Susp Limpoma Pre op Biopsi Insisi HK 23.1 4 HbsAg NR (28/8/2017 ) USG Thyroid : lymphoma susp NHL
6/4/1982
12/8/2017 Thorak : pulmo n COR t.a.k (29/8/2017) FNAB : Proses Radang
31/9 HB 11.3 AL 10.3 AT 339 (30/8) golA+ PT 14.8 APTT 28.9 INR 1.130 GDS 161 OT 29 PT 24 ALB 2.7 CR 1.4 UR 58
Malignant Histiocytoma R. femur (S)
Ngadiyo NA 128 CL 3 CA 98 HbsAg (31/7/2017) Thorak Pa: Pneumonia dd pneumonic metastase
8D 66 01372478 28/8 G3T2N0M1 (paru) , KEMO EPIRUBICIN 60 , Pre op Muccle group eksisi KY
1/6/2017 31/7/2017 USG ABD : Abd metastase(-), Hepar/lien/ren/pankreas t.a.k., efusi pleura (-)
MESNA 6000, HALOXAN 6000MG
2/3/207 PA: High grade maligaan
 4/9 HB 9.7 AL 25.7 AT 209 ALB NA 131 K 1.9 CL 93
(31/8) CR 1.0 UR 67 NA 133 K 3.4 CL 100 (29/8) GDS 83 AIYA NNB 3.6 AS URAT 5.4
24/8/2017 Thorak pulmo tampak penebalan hilus susu pneumonia
SCC Lidah TxN3M1 (paru) + HAP Perbaikan KU,
Supono 24/8/2017 USG Lymphadenopati multiple di colli anterior & colli kiri susp metastasis, Thyroid bilateral tak ada kelainan
8H 54 01372144 28/8 Post Kemo epirubicin 800 mg, brexel 80 mg, Work up (Raber Paru) HK
20/5/1953 30/8/2017 ct scan thorax : massa central paru kanan menempel pada aorta dan arteri pulmonalisdx dan mengencase
cysplatinn 60 mg (2x)
brongus primariusdan sekudung dx, soft tissue mass di r. Collli sn, limphadenopati di para aorta , supraclavicula
bilateral ,dan axilla bilateral, pneumonic metastase, nodul hepatal metastase, bone metastase, simple cyst ren dx pool
superior
Perawatan post Op 1/9 HB 18 AL 11.4 AT 165 GOL DA B PT 12.9 APTT 26.6 INR 1.030 CR 1.2 UR 34 NA 138 K 3.4 CL
Subari POST op
8J 55 01386160 21/8 BCC R. Nasalis (D) post wide eksisi dph 3 (Raber Plastik), Tutup Defek KY 10/8/2017 Thorak PA : cor dan paru tidak ada kelainan,
19/4/1962 30/8
Tunggu PA( bellum jadi) 10/8/2017 USG abd : tak tamapk metas hepar, nefrokalsinosis bilateral
Mawar 3
Samijem Liposarcoma Kemo : jaloxan 7000mg, mesna
4C 57 01381960 4/9 kemo 4/8 HB 13.5 AL 8.2 AT 267GOL DA AB GDS 161 OT 32 pt 48 alb 4.4 cr 0.6 ur 26 na 139 k 4.3 cl 108
21/08/1960 7000mg

3/9 HB 10.4 AL 4.3 AT 269 CR 1.4 UR 69 ( 31/8 )HB 7.1 AL 2.5 AT 152( 24/8/) GDS 123 OT 19 PT 12 CR 1 UR 50 GOL DA O
Perbaikan ku , tranvusi HB> 10.
Sukesi SCC R. Lidah , ON KEMO : Cysplatin 100 mg , 18/7/2017 Thorak Pa: Cardiomegali , paru t.a.k
6C 44 01152685 2/9 kemo Kelengkapan kemo terpenuhi HK
12/8/1972 epirubicin 50 mg, erbitux 400mg 21/12/2016 PA : SCC diff Baik
naik kemo

Kemo : epirubicin 50 mg
Sarwono 28/9 HB 12.1 AL 6.7 AT 310 GDS 110 OT 34 PT ALB 3.6 CR 1 UR 19
8C 62 01385175 4/9 Malignan fibrous gistiosi kemo haloxan 6000mg, mesna
6/8/1965 5/7/2017 PA: Malignan fibrous gistiositoma
6000mg

Melati 3
26/8/2017 HB 10.2 HT 30 AL 12.7 AT 463 AE 3.7 25/8/2017 GDS 427 GD PP 451 0OT 19 PT 16 NA 138 K 4,3 CA 1.23
Sri Purwanti Ca Mammae infiltratif (s) T3N1M1 (paru) Perbaikan KU
1C 45 01252259 24/8 Konservatif WY 25/11/2016USG doppler: tak tampak massa residif13/7/2017 USG Abd : T.ak metase abd.
10/2/1972 residif post Kemo : Xeloda (Raber BTKV)
12/4/2017 PA : invasive ca
1/9 HB 11.6 AL 7.2 AT 282 GDS 97 NA 136 K 4 CL 108 CA 1.23 ( 1/9/ 2017 )USG Abd : non visuatized app, hepar/lien/vu/dll
15 A RIZKA HUMAIRA 15 01385665 4/8 Post EKSISI FAM 1 bulan yg lalu , nyeri Konservatif OBSERVASI, ANALGETIK WY
t.a.k ( 24/7/2017) PA : FAM
Angrek 3
HALOXAN 6000mg, MESNA
32 Purwadi 53 01359952 1/9 NHL KEMO WY 3/8 HB 13.5 AL 8.2 AT 267GOL DA AB GDS 161 OT 32 pt 48
6000mg ( HARI INI PULANG )
FLAMBOYAN 6
Marlinda Neuro fibro R. Gluteal 3/9 HB 11.4 AL 8.4 AT 344 PT 12 APTT 30.7 INR 0.94 GDS 88 ALB 4.2 CR 0.7 UR 37 NA 137 K 3,9 CL 105 CA 1.27
606 B 25 01299753 31/8 Pre OP Pro debulking KY
24/11/1991 Riwayat operasi 6x 10/10/2016 PA : Neurofibroma
3/8 GDS 90 OT 22 PT 21 CT 0.6 UR 52 NA 121 K 4.9 CL 97 HBAsAg NR
31/8 HB 14.2 AL 10.4 AT 436 PT 13.3 APTT 28.8 INR 1.08 GDS 114 OT 15 PT 16 ALB 4.3 CR 0.7 UR 41 NA 137 K 4.3 CL 104
30/8 31 GDS 118 HBSAG NR TSH 092 FT4 17.53
Sumarni Perbaikan KU,
607 C 44 01390028 1/9 Ca Papilaly Thyroid T3NOMO Work UP HK 2/9/2017 Thorak PA : Cardiomelagi, pulmo n bone metaste(-)
2/2/1973 Usg Colli , Thorak
10/8/2017 Ro cervical : SOFT TISSUE MASSA R. COLLI mendorong ke penyempitan AIR WAY, VC7-VTH 3, spondilitis
cervicalis
8/8/2017 PA: Ca Papilaly Thyroid
3/9 HB 7.7 AL 12.6 AT 718 GDS 106 CR 0.7 UR 21 NA 130 K 3.6 CL 105
7/7/2017 PT 13.4 APTT 26 INR 1.090 OT 50 PT 63 ALB 3.4 HbsAg NR
Sarimin Ca R. Axilla undiff cell Perbaikan ku 7/7/2017 thorak pa : Elevasi hemidiagfragma kanan
608 B 51 00865771 2/9 kemo HK
8/10/1965 Cancer pain Tranfusi Hb > 10 7/7/2017 USG axila dextra : massa residu di axila kanan , limfadenopati sulit dinilai
7/7/2017 USG Abd : tak tampak metas intra abd, hepar/lie.vu.ren/ normal
22/10/2007 Metastase Undiff cell ca colli
2/9 HB 12.6 AL 6.8 AT 227 PT 12.3 APTT 29.3 INR 0.97 GDS 213 ALB 3.7 CR 0.6 UR 38 NA 137 K 3.7 CL 103
14/8/2017gds 138 hbSaG NR
Sri Ustin POST EKSISI EC. Tumor R. Colli (S) susp 7/8/2017 Thorak PA: NODULAR TYPE PULMONAL METASTASE n ardiomegaly
611A 01385797 30/8 POST OP Perawatan post OP HK
29/06/1960 Lymfoma 7/8/2017 USG Abd : fatty liver , tak tampak abd metastase
7/8/2017 massa cenderung dari thyroid kiri suspicius malignant DD massa di luar thyroid yang menginfiltrasi thyroid,
lomphadenopati limfonodi colli
3/9 HB 12.4 AL 7.4 AT 207 ALB 3.5 CR 0.6 UR 19 NA 136 K 4 CL 106 CA 1.25 (14/8) gds 349 ot 35 pt 36 cr 0.6 ur 14 na
128 k 4.4 cz 1.12 HBSAg NR PT 15.4 APTT 32.8
14/7/2017 USG Abdomen : T.a.k. intra abd metastase , hepar/lien.ren : t.a.k
Sunarti
611C 60 01386525 30/8 CA Mammae (S) T4BN0M0 Pre OP MRM JKP 14/7/2017 USG Doppler : lesi heteroechoic di mammae kiri cendrung malignansi, mammae dx tak tampak kelainan,
8/3/1957
limphadenopati axilla bilateral (-)
14/7/2017 Thorax PA: tak tampak kelainan pulmonal dan bone metastase
14/7/2017 FNAB : Invasive ductal ca
 2/9 HB 12.1 AL 10,4 AT 313 GDS 151 OT 161 PT 242 CR 0.8 UR 45 GDS 117 NA 117 K 4.7 CL 91 HbsAg R
Ca mama Tx N1M1 (brain ) 2/9Thorax: efusi pleura bilateral susp pulmonal metastase, cor sulit dinilai
Wagiyem Slamet
613 C 39 01322090 4/9 Post WSD KIRI (BTKV) KONSERVATIV Perbaian ku WY 10/8/2017 ct scan; tak tampa brian : mengarah ke brani metatase
24/6/1975
KEMO : XELLODAN 3-0-3 ARMIDEX 1X1 24/7 USG Dopller : massa residif kanan mamme (-) Mammae sinistra normal, limpodenopati (-)
24/7/2017 USG Abd : abd metas (-)
FLAMBOYAN 7
Sumarni
701 A 50 01391023 4/9 Ca mammae detktra Konsevatif Perbaika ku , tranfusi hb > 10 3/9 HB 3.9 AL 25.9 AT 761 PT 17 APTT 27.5 INR 1.5
31/3/1967
4/9 HB 11.9 AL 5.7 AT 215 PT 12.8 APTT 29,5 INR 0.94 GDS 159 OT 16 PT 8 ALB 4.1 CR 0.8 UR 28 NA 136 K 4.2 CA 0.94
Tami 31/8/2017 Thorak : cor n pulmo t.a.k
704 A 60 01390301 4/9 Tumor r. Sub mandibua Pre op Biopsi insisi dengan GA HK
2/1/1957 31/8/2017 USG Doppler masa solid sub mandibula dx susp malignansu, limfadenopati dextra, limfadenopati (-)
31/8/2017 USG abd : lesi solid hipo ekhoik di lobus sinistra hepar susp malignansi . hepar/lien/vu dkk t.a.k
2/9 HB 12.1 AL 14.9 AT 423, (12/9) TSH 0.52 FT4 18.78
10/8/2017 Thorax PA : Cardiomegalli LVH, pulmo metastase (-)
10/8/2017 USG Dopler kista multiple di thyroid ddextra, multiple lymphadenopati sub mandibula , infraauriciula, colli
Tumiyem
704 D 54 01386185 2/9 Lifadenopati R. Colli dextra konservatif Perbaikan ku WY bilateral, supraauricula bilteral, thyroid kiri t.a.k
1/7/1963
10/8/2017 CERVICAL AP lat : MASSA Colli kiri susp malgna , paracervical musclr spasme
28/6/2017 Massa nasofaring bilateral , siple cyst thyroid bilateral, giant limphodenopati colli sn, multiple bilateral, sub
mandibula, Gia, bone meats nt lymphodenopati
Wakinem Ca mammae susp metastase hepar, Ascites Simtomatik medikamentosa 02/9 GDS 133 ALB 2.7 HB 11.2 AL 147 AT 170 ALB 2.7 NA 127 K 3.9 CL 97 GDS 109( 31/8) OT 535 PT 52 CR 1.8 UR 678
704 E 50 01390842 1/9 konservatif
31/12/1966 ( BELUM PERNAH BEROBAT SEBELUMNYA) GDS /6 jam HBsAg NR
1/9 CR 0.4 UR 22 ( 8/8) HB 14.3 AL 10.2 AT 327 GDS 226 OT 43 PT 25
Kamsiah Ca mamma T4c N3c M1 (PARU , KONTRA 1/9/2017 Thorak efusi pleura bilateral susp pulmonal metastase , bone metas (-)
704 C 53 01214498 2/9 konservatif KONSUL BTKV
1/10/1963 LATERAL) 21/6/7017 USG abd fatty liver,GB/LIEN/PANKREAS DKK (-)
25/11/2014 fnab : ca ductal infiltrative mammae sinistra
2/9 TSH <0.5 FREE T4 20.07 ( 31/8) HB 13.7 AL 8.4 AT 319 NA 137 K 3.7 CL 103 CA 1.22 (22/8 )GOL DA 0+ PT 13.2 APTT 33.1
INR 0.97 GDS 259 OT 17 PT 18 CR 0.5 UR 16 HbsAg NR (24/8) TSH 0.85 FREE T4 12.78 (1/8) T3 1.42
22/8/2017 THORAK KARDIOMEGALI, METASTASE PULMO BONE (-)
Hartatik 0 Isthmolobectomy dengan 22/8/2017 USG ABD : FATTY LIVER (+), INTRA ABDOMEN METRASTASE (-)
708 B 55 30/8 Struma Nodusa BILATERAL Pre OP WY
1/7/1962 1388377 endoskopi 22/8/201 USG DOPPLER : LESI KICTIK SOLIT THYRI=OID KIRI MALIGNA BELUM DAPAT DISINGKIRKAN , STRUMA NODUSA
BILATERAL, LYMFADENOPATI SUB LINGUAL , SUB MANDIBILA BILATERAL DAN COLLI BILATERAL (+)
3/8/2017 USG THYROID : NODUL GOITER THYROID SINISR=TRA, SYMPLE CYST PROFUNDA TRAHEA, TAK TAMPAK KELAINAN
PADA THYROID DEXTRA
4/9 HB 12.7 AL 17.4 AT 147 ( 2/9) OT 41 PT 30 CR 2,2 UR 269 NA 125 K 5,1 CL 97 CA 1.03
30/7 Thorax PA: pulmo tak tampak kelainan, besar cor normal,
Pro tranfusi 6 kolf 7/8 MRI Lumbosacral : compresi corpus L2 disertai marrow replacement menyebabkan kanal dan foraminal stenosis susp
Siti Sri Pro kemo metastase, massa solid berlobulasi diparailaiaca kirimenyebabkan enhancement A/V iliaca kiri
708 C Setyaningsih 20 01388949 31/8 PNET R Femur kiri Work up Haloxan 6000, Mesna 9000 KY 1/8 PA: lesi ganas kesan tumor neurogen kesan PNET
12/2/1997 Doxo 60 mg 22/8 CT Scan Vetrebrae: gambaran massa di cavum abdomen; noduler type pulmonal metastase; efusi pleura bilateral dan
KONSUL INTERNA ascites
22/8 USG Abd: nodul metatase hepar lobus sinistra, insufisiensi renal bilateral, HN sedang bil, ascites dan efusi pleura
bilateral, bladder distensi mengarah keneurogenik bladder, lesi solid di inguinal S dg edema kutis
2/9 TSH >60FREE T3 <0.70 FREE T4 403 (31/8) Hb 12,4 AL 5,7 AT 285 Na 131 K 4.9 Ca 1,00
Alfiah Thyroiditis hashimoto Euthyrox 1x 100 mcg 6/9/2016 USG Colli: thyroiditis; tak tampak limfadenopati
708 D 29 01351 242 31/8 Konservatif HK
18/2/1988 post total thyroidectomi hipotiroid Stop PTU Thorax PA; tak tampak kelainan
PA: strumahashimoto
31/8 Hb 10,8 AL 9,1 AT 220 GDS 98 SGOT 28 SGPT 15 Cr 0,5 Ur 22 Na 133 K 3,4 Cl 102 HbsAg NR
16/8 USG Abd : tidak ada lesi intrabd
Perbaikan KU
Tukinah 16/8 Thorax PA: tidak ada lesi metas
708 E 83 01386988 31/8 SCC R Femur Sinistra post biopsi Konservatif Konsul hasil biopsi, MINTA HK
4/6/1934 30/8 Femur AP/Lat: STT pada 1/3 proximal regio femur kanan anterior, bone metastase tipe osteolitik pd trochanter mayor
REGIMEN KEMO
os femudextra
19/8 PA: SCC