KORAN BEDAH TUMOR ( Senin, 28 -09-2015)

No. Identitas Pasien S-O-A Planning Penunjang Instruksi Tambahan

1 Kamar 4 bed 1

2 Kamar 4 Bed2Hasma Dg. Ngati10-2-1971722664MRS: 9-9-2015DPJP: Dr. William H, SpB(K)Onk

S : keluhan tidak ada

O : keadaan umum baik, gizi cukup, compos mentis

A : Tumor region labialis oris superior

Post OP. Biopsi:RL 28 tpmCefadroxil 1g /12jam /IVRanitidin 50 mg/ 12 jam/ IVKetorolac 30mg / 8jam /IV

GV+Rawat Luka/ 2hariBila sadar boleh minum sedikit2 dgn sedotan

PA : Basalioma

Lab (8/8/2015)WBC : 9.9RBC: 4.85HB: 14.5HCT : 44PLT: 308GDS : 136Na/K/Cl: 152/4.4/117

Post biopsy insisi (23/9/2015)

GV/hari

3 Kamar 4 Bed3Rabasia25-12-1960724558MRS : 20-9-2015DPJP : dr. Septiman, SpB (k) Onk

S : Demam, sakit pada rahang

O : KU sakit sedang, gizi cukup, compos mentis

A : SCC region orbita dextraNodul thyroid ishtmus

Operasi wide eksisi

Asam Mefenamat 500mg 3x1Ranitidin 150 mg 3x1

Lab (21/9/2015)WBC 5200RBC 4,27HB 9,9HCT 31PLT 248PT/aPTT 10,9/32,3GDS 72Ur/Cr 40/0,65GOT/GPT 34/32ALB 4,2HbsAg-Na/K/Cl 144/4,3/110

Rencana operasi minggu depan Join operasi dengan bagian mata

4 Kamar 4 Bed4Nurhayati12-12-1984722061MRS: 21/9/2015DPJP: Dr. William Hamdani, SpB(K)Onk

S : Pre Kemoterapi suklus II

O : keadaan umum baik, gizi cukup, compos mentis, Hb: 9.6

A : Ca Mammae Dextra; Chemotherapy siklus II; Anemia

Post transfuse PRC 2 bagRencana kemoterapi, jika KU optimal

Diet Tinggi Protein

Lab (23/9/2015)WBC : 14,8RBC : 4,15HB : 12,1PLT : 803Alb : 3,2

Kemoterapi 25-9-2-15

5 Kamar 5 Bed 1Hasmirah17-7-1971700199MRS : 21/9/2015DPJP : dr. haryasena,SpB(k)Onk

S : nyeri kepalaO : KU sakit sedang/gizi cukup/CMT :130/90mmhg, n : 92x/menit, p : 20x/menitA : Ca mammae sinistraLeukopenia

IVFD NaCl 0.9% 28tpmCefazolin 1g/12jam/iv (skintest)Ranitidine 50mg/8jam/ivNeurobion amp/ 24jam/ drips

Lab (24/9/2015)WBC 2.2HB : 10.7PLT : 133HCT : 31.2

Tunggu hasil cek darahPerbaiki KU

6 Kamar 5 Bed 2Sinar71533315-3-1983MRS: 27/09/2015DPJP: dr. Haryasena, Sp. B(K) Onk

S: benjolan pada payudara kiriRiwayat kemoterapi 3xO: keadaan umum: sakit sedang/ gizi cukup/ composmentisA: adenocarcinoma mammae sinistra

Rencana MRM Selasa 29-9-2015 Lab (22-9-2015)WBC: 8300HB: 10,2PLT: 370

7 Kamar 5 bed 3trince mola64681331-11-1961MRS: 16-9-2015DPJP: DR. DJONNY FERIANTO SP.B(K)ONK

S: sesak berkurangO: KU: Baik, RR : 24x/menit, produksi WSD lancer, Undulasi ada.A: ca mammae dextraefusi pleura dextra

Allopurinol 300 mg 2x1Rencana kemo bils optimalMaxiliv caps / 12j/oral

Lab (25-09)WBC 11.09HB 11.2HCT 34.0PLT 371GDS 78Ur/cr : 13/0.30Alb : 3.7Na/K/Cl : 140/4.0/102Lab (25-09)SGOT/SGPT: 83/31As.urat : 3.6

Pro kemoterapi, terapi lain sesuai btkv

8 Kamar 5 Bed 4

9 Kamar 6 Bed 1Nurhayati5-9-1970723680MRS : 28/9/2015DPJP : dr. Haryasena, SpB (k)Onk

S : benjolan payudara kiriO : KU baikTD : 160/100 mmHgRegio mamma (S) :Teraba massa tumor kuadran sentral ukuran + 6x5 cm, konsistensi padat keras, berbenjol, mobileA : Tumor mamma sinistra

Instruksi post operasiIVFD RL 28 tpmCefazidin 1g/12j/ivRanitidin 50mg/12j/ivKetorolac 30mg/8j/ivTidak puasa

Lab (29/9/2015)WBC : 7,5HB : 14HCT : 39PLT : 328PT/aPTT : 11,2/1,05GDS : 158Ur/Cr : 22/0,74GOT/GPT : 16/13Albumin : 3,8CEA : 1,26 Ca 15-3 : 10,4USG mamma (27/8/15)Massa mamma (S) (BIRADS 4C)Patologi anatomi (28/9/15)Epitelial tumor mammae curiga malignitas

POH 0 biopsi insisi

10 Kamar 6 Bed 2Hj nuryanti7-8-1968726259MRS: 29-9-2015DPJP: dr. Septiman, Sp.B(K)Onk

S: -Status lokalis :Regio mamma (D) : teraba massa tumor regio lateral superior ukuran 2x1cm, konsistensi padat kenyal, mobile, nyeri tekan (-)FNA : fibroadenoma mammaA : tumor Mamma dextra

Rencana FNA dengan USG buiding Hasil Lab (28/9/2015)FT4 : 1,04TSHs : 2,61Hasil Lab (17/9/2015)WBC : 8,4RBC : 5,11HB : 15HCT : 43PLT : 309PT/APTT : 10,3/25.2GDS : 112Ur/cr : 16/0,6SGOT/SGPT : 21/24Na/k/cl : 145/4,3/105

Usg mamma (21-9-15)Multiple nodul mamma dextra (BIRADS US kategori 2)

11 Kamar 6 Bed 3Arniati1-12-1973711173MRS: 29/9/2015DPJP: dr. Septiman, Sp.B(K)Onk

S : lemahO : KU sedangWBC : 2330PLT : 28000Hb 5,3A : ulkus ca mamma (D)AnemiaLeukopenitrombositopenia

Transfusi WBC 2 bagPremed : dexametason 1amp/ivIVFD RL : DS 2 : 2 (28tpm)Neurobion 1amp/24j/drips

Hasil Lab (29/9/2015)WBC: 2,1HB: 5,2HCT : 15PLT: 26GDS: 97SGOT/SGPT: 53/236Na/K/Cl: 132/3.1/93

Hasil PA (18-5-15)Invasif ductal ca mamma, high grade malignancy

12 Kamar 6 Bed 4Rahmawati27-7-1960717401MRS : 29/9/2015DPJP : dr. Haryasena, SpB (k)Onk

S : -O : KU ;baikTD : 130/90HR : 80x/mRR : 20x/mS : 37 CA : carcinoma mamma (D) pro kemoterapianemia

cek hb post transfusi Hasil lab (1/10/15)WBC :3,4RBC : 3,8Hb : 10,4PLT : 153HCT : 30,9

Hasil lab (28/9/2015)GDS : 90Ur/cr : 16/0,7SGOT/SGPT : 54/27Albumin : 3,6Na/K/Cl : 140/4/105

MSCT Kepala (AX+cor) non kontras

(2-7-15)Gambaran metastasis pada calvaria cranii, sinus frontal dan parenkim otak

Hasil PA (18-5-15)Invasif ductal ca mamma, high grade malignancy

13 Kamar 7 Bed 1Marice W7218156-12-1999MRS : 8-9-2015DPJP: dr. Haryasena, Sp.B(K) Onk

S : -O: vomitus(-) drain (-)A : PO Hemimandibulectomi Dextra (17-09-2015)

Cefadroxil 500 mg 2 dd 1Asam mefenamat 500 mg 2 dd 1Ranitidine 150mg 2 dd 1Dexamethason tab 3dd1Diet sesuai gizi klinik via NGTGanti verbanRawat luka tiap hariBetadin kumur 3x/hariDulcolax

Lab 10-09-2015PT/APTT : 10,2/27,9GDS : 78UR/CR : 19/0.70Sgot/sgpt : 15/16Na/K/Cl: 145/4.1/111Foto Skull

Lab (18-09)Alb 3.3Hb : 9.2HCT : 28.5WBC: 10.4PLT: 168

14 Kamar 7 bed 2Veronika 7240531-5-1975MRS : 21-9-2015DPJP : dr. Septiman, SpB (k)Onk

S: Benjolan pada payudara kiriO : KU sakit sedang/gizi cukup/ compos mentisPA : Invasif ductal carcinoma high grade malignancyA : Ulcus Ca Mammae Sinistra

P/Infus RL 20 tpmCeftazidim 1 gr/12jam/ivRanitidine 50 mg/8jam/ivDurogesic patch 12,5 mcgAlb 25% 1 botl/24jam/dripsGV dan rawat lukaDulcolax

Lab (21/9/2015)WBC : 30,2HB : 10,9HCT : 32,7PLT : 519PT/aPTT : 11,5/21,5GDS 90Ur/Cr : 34/0,64GOT /GPT : 64/19ALB : 2,2Na/K/Cl 134/4,9/105

Pro Kemoterapi

15 Kamar 7 Bed 3Darmi5-7-1980726255MRS: 25-9-2015DPJP: dr, Septiman, Sp.B(K)Onk

S: Benjolan di daerah wajah sebelah kiri

O : KU: Sakit sedang/gizi cukup/compos mentis

A: Tumor sinus Maxillaris susp malignancy

Biopsy insisi hari ini 28-9-2015

16 Kamar 7 Bed 4Azizah14-05-1978721498

S : luka di payudara kananO : KU sakit sedang, gizi cukup, CMPA : Invasif ductal carcinoma (high grade malignancy)

rencana kemoterapiRL 28 tpmLevofloxacin 200mg/12jam/ivRanitidine 50mg/8j/iv

Lab 22-09-2015WBC 28,1HB 8,0HCT 26

Kemo + Doxo

MRS 3-9-2015DPJP : dr. Djonny Ferianto Sp.B(K)Onk

A : ulkusCa Mammae D post core biopsyAnemia, Leukositosis, Hipoalbuminemia

Paracetamol 1 g/8j/ivvip albumin 3x4 capsGV+rawat lukacek albumin post transfuse + DRMetronidazole 500mg/8jam/iv

PLT 340GDS 102Ur/Cr 12/0,4GOT/GPT 26/-Pt/aPTT 13,3/24,7Na/K/Cl 136/3,8/104Lab 25-09-2015Wbc: 26.9Hb: 10.2Hct: 32Plt: 543Albumin: 2.5

17 Kamar 7 Bed 5

18 Kamar 7 bed 6Kartini1-10-1978656366MRS : 7-9-2015DPJP : dr. William H, SpB (k)Onk

S : LemasO : Ku baik, CMA : Ulkus Mammae DHipoalbuminemiaAnemiaImbalance elektrolit

RL 30tpmRanitidin 50mg/8j/ivondansetron8mg/jam/ivdrips neurobion 1amp/12jamNaCl 3% 14 tpmLevofloxacin 200mg/12jam/ivGV + Rawat lukaTransfusi PRC 2 bag

Lab 22/9/2015WBC 16,0HB 8,4HCT 24,3PLT 171GDS 50ALb 2,0Na/K/Cl 120/4,2/93RBC 2,78Lab 26-09-2015WBC: 9.0HB: 8.6HCT: 25PLT: 84RBC: 2.80GDS: 106Alb: 1.6Na/K/Cl: 124/3.5/109SGOT/SGPT: 91/25

Rencana KemoBeri albumin lagiKonsul Gizi

19 Kamar 8 bed 1Asniati5-3-1971721799MRS : 3-9-2015DPJP: Dr. Haryasena, Sp.B (K) Onk

S : keluhan tidak adaO : KU sakit sedang, gizi cukup, CM Albumin: 2,7A : Ameloblastoma

Betadine kumur 3x sehariVip Albumin 4x2 capsAlbumin 25%

Lab (26-09-2015)Albumin: 2,7

(16-9-2015)WBC: 21300HB: 12,4PLT: 508

Diet tinggi protein

20 Kamar 8 bed 2

21 Kamar 8 bed 3Ratna1-7-1974

S : nyeri ulu hatiO : KU stabil, sadarTanda vital dalam batas normal

Infus RL 28tpmCefazolin 1gr/ 12jam/ ivRanitidine 50mg/8jam/iv

Lab (9-9-2015)WBC: 11600HB: 13,1

Diet via NGTMenunggu jawaban konsul gizi klinik

722658MRS : 8-9-2015DPPJP : Dr. William H, SpB(K)Onk

Luka : verban kering, edema (-), hematom (-)A : maxillectomy

Ketorolac 30mg/12jam/ivAsam tranexamat 500mg/8jam/ivbetadine kumur 3x/hari

PLT: 298PT/APTT: 10,3/27,7GDS: 86Ur/Cr: 30/0,67SGOT/SGPT: 16/33Albumin: 4,0

Aff kateter.

22 Kamar 8 bed 4

23 Kamar 8 bed 5Hj.Sarmianti29-5-1972725378MRS : 14-09-2015DPJP : Dr. Haryasena, SpB(K)Onk

S : batuk kadang-kadang, berkurangO : KU baik, gizi cukup, sadarGDP : 142Ronki tidak adaWheezing tidak adaA : Tumor Maxilla sinistra susp. MalignancyObservasi coughDM tipe 2

Betadine kumur 3x/hariCefadroxil 500 mg 2x1

Terapi lain sesuai Pulmo dan endokrinHub dr gigi jika sudah ada jadwal op.

Lab (23-9-2015)HBA1c : 7,5Lab (10-9-2015)WBC: 13900HB: 15,8PLT: 321PT/APTT: 10,3/24,7GDS: 93Ur/Cr: 19/0,57SGOT/SGPT: 26/29Albumin: 4,4

24 Kamar 8 Bed 6Siti Umi Hidayanah17-03-1975711702MRS: 19-9-2015DPJP: dr. djonny ferianto Sp.B(K)Onk

S: keluhan tidak adaO: KU sakit sedang/gizi cukup/sadarA: ulcer carcinoma mamma dextra

Injeksi leukogen 0,1cc subkutan

Rencana Operasi senin28/9/2015

Lab (26/9/2015)WBC 3,9RBC 3,71Hb 11,7HCT 34PLT 343Lab (24-9-2015)PT/aPTT 9,5/26,2GDS 83GOT/GPT 17/37Alb 3,4Na/K/Cl 144/3,4/110

MRM hari senin, 28-9-2015

25 Kamar 9 bed 1M. Kamir72677910/11/1959MRS : 22/9/2015DPJP : Dr. Haryasena, Sp.B (K) Onk

S : Benjolan pada leherO : Keadaan umum sakit sedang, gizi cukup, sadarLab : Na/K/Cl : 127/4,3/94WBC : 40,85A : Tumor colli sinistra suspek malignancy

IVFD NaCl 0,9% 28 tpm dg NaCl 0,3% 24 tpmO2 3 liter/menitInj. Metilprednisolon 1 amp/8jam/ivKetorolac 30 mg/8jam/ivRanitidin 50 mg/8jam/ivCefazoline 1 gr/12jam/iv (skin test)

Lab (26/9/2015)Albumin : 3,2Lab (25/9/2015)FT4 : 1,11TSHs : 0,45Lab (22/9/2015)WBC : 40,9RBC : 4,5PLT : 290PT/APTT ; 11,6/33,1GOT/GPT : 20/22Na/K/Cl : 127/4,3/94

26 Kamar 9 bed 2BURHAN

s: keluhan nyeri di lehero: sakit sedang/gizi cukup/cm

IVFD RL 28tpm ranitidine50mg/8jam/iv

Lab (18/9/2015)WBC 37,5

Biopsi Insisi

7264903/4/197418/9/2015DPJP: dr. Djonny Ferianto S, S.B(K)Onk

BP : 110/70 mmHgHR : 65x/menitRR 28x/menitTemp : 36,5 °CA: tu colli dextra ec keganasan

novalgin 1 gr/8jam/ivmetilprednisolon 1 mg/8jam/ivCefazolin 1gr/ 12jam/IV

FNA : High grade malignant Tumor

RBC 5,2HB 15,1PLT 333Ur/Cr 42/0.92GOT/GPT 34/101PT/aPTT 11,4/24,6Na/K/Cl 143/4/108Lab (23/9/15)FT4 : 1,23TSHs : 6,50

27 Kamar 9 bed 3Sudirman71326818/06/197825/09/2015DPJP : Dr. Haryasena, Sp.B (K) Onk

S : Benjolan di leher, post transfusiO : Ku sakit sedang/gizi cukup/cmA : Pro Kemoterapi siklus VI SCC Regio Supraorbita sinistra Tumor metastase preorbita bilateral Anemia

Lab (26/09/20150WBC : 7,2RBC : 3,33HGB : 10,0HCT : 29,9PLT : 619

Pro Kemoterapi

28 Kamar 9 Bed 4Kane1-7-1943349110MRS: 4-9-2015DPJP: Dr. Djonny Ferianto,SpB (k)Onk

S: nyeri luka operasi di hidungO: KU sakit sedang/ gizi kurang/ cmBP ; 120/80 mmHgHR : 84x/menitA: Basal Cell CarcinomaPost Debulking

terapi sesuai ts ginjal hipertensiTerapi sesuai GIZIgv/hariinfus RL 28 tpmCefadroxyl 500mg/12jam/oralranitidine 150mg/8j/oralAsam Mefenamat 500 mg/8jam/oral

Lab (21-9-2015)WBC: 15,9RBC: 4,01HB: 11,4PLT: 422Lab (15-9-2015)PT/APTT: 10,4/32,4

Post OP Maxilectomy H-6Ganti verband hari kamis (surgical cell tidak boleh dibuka)Cara GV : basahi NaCl tunggu 15 menit, baru buka, tutup dengan kasa basah)

29 Kamar 9 Bed 5

30 KAMAR 9 BED 6Muhamad Azaz72449225-11-2007MRS: 13-09-2015DPJP : Dr. William H SpB(K)Onk

S: benjolan semakin membesarO: Keadaan umum sakit sedang,gizi cukup, sadarReg facialis D massa + ukuran 15 x10x 8 cm, hiperemis, nyeri tekan tdk adaA: Ameloblastoma Anemia

IVFD RL 20 tpmCefazoline 1 gr/12jam/ivRanitidin 50 mg/8jam/ivKetorolac 30 mg/8jam/iv

FNA: suspek Ameloblastoma

Lab (18/9/2015)WBC : 11,6RBC : 4,8PLT : 561Albumin : 3,4

Post Op hari III

31 ICUSamsani 21-02-1979725128MRS: 11/09/2015DPJP: Dr. Haryasena, SpB(K)Onk

S : keluhan tidak adaO : Ku Sakit sedang, gizi cukup, CMA : struma nodusa non toxic

Amlodipine 5g 1dd1OmeprazoleParacetamoleCefazolinFenthanylKetorolac

Lab (8/9/2015)WBC: 107400GB: 14,7RBC: 5,42PLT: 249FT4/TSHs: 1,39/<0,05Na/K/Cl: 146/4.5/106

FNA (16/9/2015): bening follicular nodul thyroid

POH 2

32 PALEM ATASB2/7 S: keluhan tidak ada transfuse PRC 2 bag Hasil PA 17-9-2015 Tunggu Hasil ECHO

Putu Irta01-07-1989682875MRS:14-09-2015DPJP : Dr. William H SpB(K)Onk

O: Keadaan umum baik, sakit sedang, sadar TD: 130/80mmHg, Nadi:80kali/menit Hb= 8,5A: chemoterapi sessionCa sinonasal

premedikasi 1amp dexamethason/ ivranitidine 1amp/iv (extra)ondansentron 1amp/iv (extra)diet biasa

kesan: malignant epithelial tumor yang sulit ditentukan jenisnya secara asti karena hanya terdaat sedikit kelompok tumor, umumnya menunjukkan jaringan normalkemungkinan suatu tumor maligna kelenjar liur atau basal cell carinoma

Rencana kemoterapiRencana Pulang

33 Palem atas B2/9 B2Rosmina72155412/6/1965MRS : 10/9/2015DPJP : dr. septiman, SpB (k) Onk

S :tidak ada keluhanO : Ku: sakit sedangA: sarcoma retroperitonealChemotherapy session

Ketorolac 3gr/iv (extra)Durogesic patch 12.5mg (extra)

Rencana Kemoterapi

34 Palem atas B2/2 B2Muh Ahsyar72155412/6/1965MRS : 10/9/2015DPJP : dr. septiman, SpB (k) Onk

S: tidak ada keluhanO: Keadaan umum, sakit sedang, sadarPA : maligna tumor sel kesan asal ephitel (carcinoma)A: POH 2 biopsi Insisi

iVFD nacl 0.9% 28tpmlanzoprazol 40mg/24jam/ivketorolac 30mg/8jam/ivceftazidin 1gr/12jamdiet biasa

35 Palem Bawah B2/12 Musriawaty 69177925/11/1971MRS : 16/9/2015DPJP : Dr. Haryasena, Sp.B (K) Onk

S : nyeri pada pinggangO : KU ;skt sedang/gizicukup/sadarA : carcinoma mamma (D)CtxNxMI stadium IVKarnofsky 60%

Advice dr haryasena, sp.B (K) onkPremedikasi : dexametason 1amp/iv Ranitidin 1amp/ivDrips zomeha 4mg ivHabis dalam 15 menit

Terapi lain lanjut

Lab (25/9)WBC: 10,2RBC : 4,28HB : 10.9HCT: 35PLT: 364Alb :2.8CEA : 0,85Ca 15-3 : 31,09

Lab (18/9)Ur/Cr: 12/0.5GOT/GPT: 31/89Na/K/CL: 144/4.8/109MRI (30/9/15)-lesi intraosseus CV l1-s2 dngn destruk CV L4 sesuati tumor metastatis ke vertebra lumbosacral disertai massa para verebral yg menginfiltrasi m. Psoas kiri dan kanalis spinalis level CV L3-5 menyebabkan stenosis canalis spinalis CV L3-4 dan L4-5-bulging disc pd CV L4-5 yg menekan thecal sac dan

mengiritasi ke2 nerve root disertai facet joint edema kiri-facet joint edema kiri pd CV L3-4 dan kanan pd CV L5-S1-MR-myelography : tampak stenosis parsial canalis sinalis CV L3-4 dan CV L4-5

36 Palem Bawah B2/11 H.M. Yusuf71700715/06/1955MRS : 1/10/2015DPJP : Dr. Haryasena, Sp.B (K) Onk

S : benjolan di leher dan ketiakO : KU baik/CMTD : 140/90A : chemotherapy session

Rencana kemoterapi Hasil lab (1-10-15)WBC: 8,07Hb : 12,2PLT 179Neutrofil 50,8GOT/GPT : 18/13Ur/cr : 19/1,1GDS : 107As urat: 7,9Na/k/cl : 141/4/107

PA (8-9-15)Diffuse small lymphositic lymphoma (non hodgkin lymphoma)