Pasien masuk dari Poli Onkologi 4-10 Agustus 2017 HRE/SQB/ARV/RAP/AFF/ZIC/GIH/DAV/YES

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

MAWAR 1
10/8/2017 hb 19.5 ht33 al 6.5 at 253 PT 12.7 APTT 27.2 INR 1.01 GDS 163 ALB 3.8 CR 0.8 UR 20 NA138 K 3.9
CL 106 CA 1.18
8/8/2017 Hb 11.6 HT 36 AL 10 AT 284 AE 4.98 BT 2 menit 30detik CT 10 menit OT 16 PT 12 BUN 13.5 Cr 0.97
Sinem GDS 115 CEA 1.2 HbsAg NR
5H 01388365 10/8 CA infiltrating ductal mammae (D) T4bN1M0 Pre op Pro MRM (D) JKP
12/4/1968 16/3/2017 Thorak PA : COR sedikit membesar pulmo
15/3/2017 USG Mammae : ca massa dalam batas normal metas ke lymphonodi axilla dextra
15/3/2017 USG abd: massa padat central cenderung malignant, tak tampak intraabdominal metastasis
16/3/2017 FNAB: Infiltrating ductal Ca
9/8/2017 HB 13.6 HT 39 AL 11 AT 226 AE 4.49 PT 12.1 APTT 24.9 INR 0.87 GDS 195 OT 20 PT 19 ALB 4.4 CR
0.5 UR 25
Ca mammae (S) 3/8/2017 HB 13.7 HT 41 AL 10.5 AT 342 AE 4.64 PT 11.8 APTT 28.6 INR 0.84 GDS 131 OT 23 PT 20 CR 0.6 UR
Yus Rusti 18 NA 139 K 4.2 CL 102 CA 1.17 HB sAg NR
7F 37 01373094 8/8 Op Simpel Mastektomi WY
11/5/1980 Riw. Kemo: brexel 100 mg, Epirubisin 750 mg 6/4/2017 Thorak PA: Pneumonia dapat merupakan gambaran pulmonal metastase
(5x) 6/4/ 2017 USG :Lesi solud heteroecoic mammae sinistra kesan maligna ,limphodenopati axilla kiri
infraclavicula , symple cyst mammae kanan, tak tampak limfadenopati axilla kanan : MULTIPLE NODUL
HEPAR METASTASE
9/8/2/017 HB 11.1 HT 36 AL 9.4 AT 382 PT 11.8 APTT 30.5 INR 0.920GDS 105 ALB 3.9 CR 0.7 UR 27 NA 142 K
3.5 CL 110 CA 1.24 7/6/2017 Thorak PA : COR dan Pulmo taktampak kelainan
7/6/2017 USG Abd : tak tampak metas hepar dan paru, fatty liver
7G Ini Kartini 01388250 9/11 Ca mammae D residif TXN1Mo Pre OP Pro MRM WY
6/10/2017 PA mammae: Well Differentiated infiltrating Ductal Ca
3/8/2017 FNAB mammae : Invasive Ductal Ca

10/8/2017 GOL DA O NA 138 L 4.1 CL 105 CA 1.25 HbsAg NR 9/8/2017 HB 11.4 HT 36 AL 6.1 AT 385 AE 3.56
PT 12.3 APTT 31.1 INR 0.97 GDS 83 PROT TTL 6.6 ALB 3.6 CR 0.6 UR 36
20/7/2018HB 12 HT 40 AL 6.9 AT 302 PT 13.2 APTT 33.1 INR 0.97 GDS 96 OT 17 PT 9 ALB 4.1 K 4.3 CL 108
HbsAg NR
Wiji Supadmi 18/7/2017 Thorax PA : Tak tampak pulmonal metastase
8C 53 01382826 9/8 Ca mammae D T3N1Mx Pre OP MRM JKP
9/2/1994 18/7/2017 USG Dplpler : masa solid dengan central neorotik mammae dextra , mammae siistra tak
tampaknkelainan, tidak tampak limfadenopati ke du Axilla.
24/7/207 MAMMOGRAFI : Lesi densita tinggi di mammae Dx susp Maligna, suspicious limfadenopati axilla
kanan , mammae Sn dalam batas normal
22/7/21017 FNAB mammae Dx : Ca ductal
10/8/2017 HB 11.7 HT 36 AL 9.1 AT 341 AE 3.92 PT 10.7 APTT 27.9 INR 0.800 GDS 101 ALB 3.9 CR 0.7 UR 22
NA 137 K 3.8 CL 107 CA 1.19
31/7/2017 Hb 13.2 HT 38 AL 11 AT 309 AE 4.35 Golda O PT 11.5 APTT 27.9 GDS 92 HbsAg NR
Amanah 31/7/2017 Thorax PA: tak tampak pulmonal dan bone metastasis
8H 57 01238135 10/8 Fibrolipoma Pre op Eksisi HK
5/6/1960 25/7/2017 USG Ante Brachii: tampak lesi hipoechoic ireguler, loblated, amorf, spikul (+) dengan vaskularisasi
prominen regio antebrachii proyeksi stratum muscularis mengarah ke fibrosarcoma DD rhabdomyosarcoma
terfiksasi
30/10/2015 PA: antebrachii sinistra: esi jinak mikroskopik sesuai fibrolipoma
10/8/2017 GOL DA O HbsAg NR 9/8/2017 HB 11 HT AL 3.4 AT 281 AE 3.73 PT 13.4 APTT 29.7 INR 1.09 GDS
124 ALB 3.6 CR 0.5 UR 20 NA 138 K 3.7 CL 115 CA 1.19
5/7/2017 HB 12.3 HT 36 A3.7 AT 207 AE 4.18 PT 12.9 APTT 30 INR 1.940, OT 31 PT 31 HbsAg cr 0.6 ur 15
Winarti
8I 50 01386067 9/8 Struma Nodusa thyroid bilateral Pre op Sub total/total tiroidectomi TSH < 0.05Free t3 3.68 Free T4 12.84
12/12/1966
24/7 /2017 Thorak COR dan Pulmo tak tampak kelainan
18/07/2017 Thotak PA: tak tampak gambaran metastas tulang DAN PARU
19/7/2017 USG tyrhoid : Struma nodusa thyroid bilateral terKKKKKKKKutama synistra
27/7/2017 HB 11.5 HT 39 AL 11.1 AT 308 AE 6.02 PT 13.5 APTT 27.7 INR 1.000 OT 22 PT INR 1.000 ALB 4.2
CR 0.4 UR 28 HbsAg NR Free T4 13.71
Sumirah Tumor Coli (D) susp lim8 26/8/2017 Thorax PA : Pulmonal metastase nodulartype
8K 56 01384284 10/8 Pre op Biopsi insisi dengan GA HK
1/9/2017 poma 26/8/2017 USG Abd :mssa solid di cavum pelvis sangat mungkin dari organ ginekologis curiga residif mass
26/8/2017 USG Dopller : massa tiroid limfadenopati di regio parotis kanan kiri , submandibula kanan kiri,
coli kanan kiri, supraclavicula kanan kiri
MAWAR 2
 1/8/2017 HB 10.1 HT 31 AL 11.5 AT 434 AE 3.46 OT 26 PT 27 Cr 2.1 Ur 52 Golda AB PT 11.9 APTT 25.2 INR
10.86 GDS 142 Alb 4.0 HbsAg NR
Ca Mammae (D) T4c N2M1 (paru)
2/5/2017 Thorax PA: nodular type pulmonal metastasis
Saminem
4B 56 01375345 10/8 Pre Op Pro Mastektomi simpel WY 2/5/2017 USG Abd: tak tampak efusi pleura maupun ascites, tak tampak intraabdominal metastasis
1/4/1961 Riw. Kemo: brexel 100 mg, carboplatin 700
2/5/2017 USG Mammae: Massa mammae (D) high suspicious malignant, metastasis axilla bilateral, dilatasi
mg
lactiferus mammae (S), cenderung massa intraductal mammaeb
17/5/2017 PA: lesifibrokistik kiri: invasif lobular carcinoma
10/8/2017 Hb 11.9 HT 33 AL 27 AT 114 AE 3.88
9/8/2017 HB 10.8 HT 33 AL 4.0 AT 94 AE 3.68
6/8/2017 HB 8.8 HT 25 AL 4 AT 58 AE 2.99 AP 11.2 APTT 20.5 INR 0.850 GDS 80 ALB 3.5 CR 1 UR 41 NA 135
K 3.8 CL 103 CA 1.23 HbsAg NR
SCC Ca R.Pedis (S) +Tumor R. Femur (S) 22/7/2017 Thorak PA : COR, Paru tak tampak kelainan
Samirah +Trobositopenia, Perbaikan KU 4 TC/hari , obat premed 4/5/2017 USG Abdomen Hidronefrosis, (S) sedang, Tak tampak intrabdomen metastasis, Hepar, lien,
4D 61 01375723 5/8 PRE OP HK
1/3/1956 Kemoterapi : Paxus 210mg, Carboplatin 400 tranfusi, Wide eksisi pankreas, ginjal kanan, Blader tak tampak kelainan
mg, leucogen 1 amp 2/8/2017 Pedis AP dan LAT: Soft tissue mass pada R. Ankle kiri curiga benign
3/8/2017Femur AP dan lat : Soft Tissue mass di regio 1/3 medioproksimal os. Femur (S) disertai reaksi
periosteal di R. 1/3 medial os. Femur (S), Infiltrasi massa ke bone
14/10/2016 PA Femur (S) : Radang tuberculosa
31/3/2017 PA FNAB pedis: SCC
7/8/2017 OT 26 PT 14
6/8/2017 HB 11.1 HT 33 AL 7.2 AT 365 AE 4.13
24/7/2017 HB 12.3 HT 40 AL 9 AT 462 PT 13.2 APTT 31.3 INR 0.970 GDS 87 OT 27 PT 13 ALB 4 CR 0.8 K 4.1
01381329 Pro Wide Eksisi
Sokarto CL 109
5E 66 Konsul Plastik 5/8 BCC R. Palpebra Dektra Pre OP ct scan kepala centrasi orbita HK
11/8/1950 18/7/2017 Thorak PA : Pneumonia kemungkinan peumonic type pulmonal metastasis
Konsul Mata (10/8/2017)
18/7/2017 USG Abdomen : Tak tampak intraabdominal metastase
9/6/2017 CT-SCAN kepala kontras : malignant soft tissue mass pada palpebra kanan tak tampak gambaran
brain metastasisi, tak tampak osteodestruksi
10/8/2017 Hb 10.6 HT 30 AL 11.4 AT 345 AE 3.59 Alb 3.6 Na 140 K 4 Cl 108
8/8 HB 9.1 HT 28 AL 9.2 AT 401 AE 3.24 PT 12.7 APTT 27.1 INR 0.92 GDS 131OT 66 PT 29 CR 0.8 UR 15
Parwuni 31/7/2017 Thorak PA da LAT: Soft tissue mass hemithoraks kiri susp massa payudara kiri, tak tampak
8F 44 01385821 9/8 Tumor mammae S T4CN1M0 op Pro Eksisi WY
23/3/1973 pulmonal dan bone metastase
31/7/2017 USG abd :tak tampak intra abd metastase
19/8/2017 FNAB mamma S : Carcinoma mammmae
MELATI 3
10/8/2017 Hb 13.9 HT 40 AL 7.6 AT 322 AE 4.43 PT 12.3 APTT 36.5 INR 0.970 GDS 81 Ct 0.7 Ur 23 Na 138 K
4.0 Cl 107 Ca 1.24
Jami
4C 47 01388011 10/8 SNNT (D) Op Pro Isthmolobektomi (D) WY 19/2/2016 T3 0.757 T4 5.26
19/9/2017
7/8/2017 USG Thyroid: complete cyst thyroid kanan yang mendesak tyroid kiri dan trachnea kearah
kontralateral dan a.carotis communis ke lateral, nodul thyroid kiri
10/8/2017 HbA1c : 7.6 GDS 123 GD PP 116 HsAg NR
9/8/2017 HB 12.6 HT 37 AL 6.7 AT 334 AE 4.11 PT 12.4 APTT 29.2 INR 0.980 GDS 89 ALB 3.7 CR 2.3 UR 69 NA
142 K 3.6 CL 109 CA 1.33
Lasiman
11B 60 00627736 9/8 Gint sell of tendon R. Digiti IV manus D, Pre op Eksisi dengan GA JKP 26/7/2017 hb 14.4ht 40 al 5.8 at 318 gol da O PT 12.6 APTT 32.4 INR 0.910 GDS 323 ALB 4.5 CR 2.5 UR 68
16/12/1956
NA 135 K 4.5 CL 102 CA 1.17 HbsAg NR
5/10/2917 PA : radang kronis displasia ringan
26/7/2017 FNAB : Giant cell of Tendon Sheath