2 Nov 2015 Onkology
2
KM NAMA / TGL LHR U S I A NO RM MRS DIAGNOSA STATUS PLAN DPJP PEMERIKSAAN PENUNJANG TULIP (ISH,JOE) Dlm 8 tn. Winarno 8/8/45 7 0 0131826 4 29/1 0 BCC r. zigoma D Op 30/10 Post Eksisi luas WY 27/10 hb 13,9 al 6,6 at 163 pt 11 aptt 30, 30/10 gds 211 ot 17 pt 16 cr 1 ur 24 hbsag - Ny. Marinem 15/12/62 5 2 0125296 8 28/1 0 Ca duct mamae S TxNxM1 paru otak Perbaikan KU, konsul bedah saraf, edukasi keluarga WY 28/10 hb 11 al 8,9 at 205 M A W A R 1 (SQB, ADH) 6C Ny. painem 4 9 0131319 7 28/1 0 Ca mame s T4cN2a M0 , post kemo 1x brexel doxo kemo Perbaikna KU Hb> 10, pro kemo WY 1/11 hb 9.8 al 12.8 ht 31 at 349 28/10 ot 157 pt 113 cr 0,9 ur 70 6J Ny. Parni 19/5/54 6 1 0131737 9 18/1 0 Ca duct infiltratif mamae S TxNxMx, riw kemo 6 x diklaten, post MRM rdtx konsul radioterapi, paliatif KY 18/10 hb 11,8 al 19 at 473 ot 95 pt 102 cr 0,8 ur 52 na 125 k 2,7 cl 75, 17/10/11 KD 11 2073 biopsi eksisi ca duct infiltratif, 21/10 sitologi pleura tdk ada sel2 ganas 6L Ny. Veri N 1/11/92 2 3 0124865 3 31/1 0 Ca mukoepidermoid kemo Pro kemo DD 01/11 hb 10.1 at 30 al 7.3 at 194 29/10 gds 118 ot 13 7E Ny. Sumarmi 25/7/70 4 5 0131780 1 28/1 0 SNNT S Pre op ismolobektomi HK 20/10 hb 10,5 al 6,6 at 285 cr 0,5 ur 15 hbsag -, tsh 0,467 T3 1,11 T4 6,81,, usg nodul tiroid s 7G Ny. Sukinem 26/9/70 4 4 0131248 4 29/1 0 Ca duct inv mamae STxN0M0 post mastektomi, post kemo 6x riw tamofen 2th Op 31/10 Post Revisi MRM KY 30/10 hb 13.1 al 8.3 at 283 pt 13 aptt 32.8 ot 20 pt 15, 22/10 JL 12 5878 PA ca duct inv 7i Ny. Yuliati 1/7/61 5 4 0119364 1 27/1 0 Adeno ca papiler tiroid Op 29/10 Post total tiroidektomi + RND HK 30/9 hb 12 al 7 at 270 18/9 DU 1510223 Biopsi coli metas adeno ca tiroid papiler Melati 1 ( SQB) 1H Ny. Paliyem 19/8/49 6 6 0131800 1 30/1 0 Tumor r.colli susp. Ca tiroid Pro Total tiroidektomi HK 30/10 hb 11 al 10 at 250 usg tiroid multiple nodul tiroid bilateral, multiple nodul submandibula kiri, cea 3,49 ca 19-9 <3, TSH 0,36 ft3 4,68 ft4 12.4 , FNAB curiga ca kel. tiroid 3F tn. Kustribowo 11/10/84 3 1 0125642 6 28/1 0 NHL large B cell ann arbor 4 post kemo 1 10/10 haloxan 5000 mesna 5000 doxo 50 kemo Pro kemo 2 haloxan 5000 mesna 5000 doxo 50 HK 5/10 hb 10,2 al 6,9 at 424ot 24 pt 10 cr 1,2 ur 45 hbsag -, 19/9/14 FNAB 1400694 NHL large B cell, 3/2 usg abd massa paraaorta curiga limfoma hepatomegali, M A W A R 2 ( SOE, KAP, WAN) 1B Ny. Katinem 1/7/39 7 6 1318171 28/1 0 Ca duct inf mamae D T4bN0M0 Op 30/10 Post MRM HK 27/10 hb 12 al 5,9 at 267 pt 12 aptt 26 gds 446 ot 11 pt 9 cr 0,6 ur 26 hbsag -22/10 MF 112915 FNAB mamae D inf duct ca 1D Ny. Parsi 2/6/70 4 5 0131670 4 26/1 0 Invasive ca mamae d susp maligna T3N1M0 Op 30/10 Post MRM WY 271/0 hb 14 al 5,7 at 263 gds 430 , 15/10 hb 15 al 7 at 243 , 19/8 FNAB 1500639 inv ca mamae D 2C Ny. Jamiyem 1/1/47 6 8 0131058 1 30/1 0 Melanoma maligna r. pedis s Pre op Pro wide eksisi + rekonstrksi HK 31/10 7.0 ht 23 al 3.4 at 236 pt 13.3 aptt 27.4 INR 1020 ot 15 pt 13 ur 21 cr 0.6 albumin 3.3 na 142, k 3.1 cl 109 hbsag -,, 27/7 JI 52634 malignant melanoma 4C Ny. Sumarni 1/12/59 5 5 0130640 9 31/1 0 Ca Lobularis mammae (D) Pre op Post MRM DD 15/10 hb 12.8 ht 38 al 9.0 at 265 gds 115 ot 25 pt 17 ur 0.6 cr 12 4D Ny. Suyatmi 21/8/67 4 8 0130175 6 26/1 0 Tumor mamae d susp maligna T4cN3 M1 paru post biopsi insisi Op 27/10 Tunggu hasil PA, Konsul BTKV utk wsd bila hasil ro tho efusi pleura HK 27/10 ot 45 pt 8 ur 0.6 cr 26 na 138 k 5.0 cl 108 24/10 Hb 10,3 al 3,6 at 218 gds 108 ot 80 pt 22 cr 0,5 ur 14 hbsag -, 21/8 ro tho metas paru +, FNAB kesan metastases adenokarcinoma 4I Ny. Suyatmi 1/5/51 6 4 0127567 2 20/1 0 Adeno ca sternum dri tiroid Rencana konferensi lagi KY 13/10 hb 12 al 8,6 at 208 gds 91 ot 18 pt 12 cr 0,8 ur 28 TSH <0,05 FT4 13,91, 6/8/14 DU 1410048 PA adeno ca , 27/10/14 ct torak soft tisue massa dinding dada anterior. MRI Thorax : massa tiroid bilateral curiga malignan Senin 2 November 2015 BEDAH ONKOLOGI WAN/ADH/EKP/JOE/KAP/HRE/ISH/SQB/LHB/RISKIE/SUHRI
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Transcript of 2 Nov 2015 Onkology
KM NAMA / TGL LHR USIA NO RM MRS DIAGNOSA STATUS PLAN DPJP PEMERIKSAAN PENUNJANG
TULIP (ISH,JOE)
Dlm 8
tn. Winarno8/8/45 70 01318264 29/10 BCC r. zigoma D Op 30/10 Post Eksisi luas WY 27/10 hb 13,9 al 6,6 at 163 pt 11 aptt 30, 30/10 gds 211 ot 17 pt 16 cr 1 ur 24 hbsag -
Ny. Marinem15/12/62 52 01252968 28/10 Ca duct mamae S TxNxM1 paru otak Perbaikan KU, konsul bedah
saraf, edukasi keluarga WY 28/10 hb 11 al 8,9 at 205
M A W A R 1 (SQB, ADH)
6C Ny. painem 49 01313197 28/10 Ca mame s T4cN2a M0 , post kemo 1x brexel doxo kemo Perbaikna KU Hb> 10, pro kemo WY 1/11 hb 9.8 al 12.8 ht 31 at 349 28/10 ot 157 pt 113 cr 0,9 ur 70
6J Ny. Parni19/5/54 61 01317379 18/10 Ca duct infiltratif mamae S TxNxMx, riw
kemo 6 x diklaten, post MRM rdtx konsul radioterapi, paliatif KY 18/10 hb 11,8 al 19 at 473 ot 95 pt 102 cr 0,8 ur 52 na 125 k 2,7 cl 75, 17/10/11 KD 11 2073 biopsi eksisi ca duct infiltratif, 21/10 sitologi pleura tdk ada sel2 ganas
6L Ny. Veri N1/11/92 23 01248653 31/10 Ca mukoepidermoid kemo Pro kemo DD 01/11 hb 10.1 at 30 al 7.3 at 194 29/10 gds 118 ot 13
7E Ny. Sumarmi25/7/70 45 01317801 28/10 SNNT S Pre op ismolobektomi HK 20/10 hb 10,5 al 6,6 at 285 cr 0,5 ur 15 hbsag -, tsh 0,467 T3 1,11 T4 6,81,, usg nodul tiroid s
7G Ny. Sukinem26/9/70 44 01312484 29/10
Ca duct inv mamae STxN0M0 post mastektomi, post kemo 6x riw tamofen 2th
Op 31/10 Post Revisi MRM KY 30/10 hb 13.1 al 8.3 at 283 pt 13 aptt 32.8 ot 20 pt 15, 22/10 JL 12 5878 PA ca duct inv
7i Ny. Yuliati1/7/61 54 01193641 27/10 Adeno ca papiler tiroid Op 29/10 Post total tiroidektomi + RND HK 30/9 hb 12 al 7 at 270 18/9 DU 1510223 Biopsi coli metas adeno ca tiroid papiler
Melati 1 ( SQB)
1H Ny. Paliyem19/8/49 66 01318001 30/10 Tumor r.colli susp. Ca tiroid Pro Total tiroidektomi HK 30/10 hb 11 al 10 at 250 usg tiroid multiple nodul tiroid bilateral, multiple nodul submandibula kiri, cea 3,49 ca
19-9 <3, TSH 0,36 ft3 4,68 ft4 12.4 , FNAB curiga ca kel. tiroid
3F tn. Kustribowo11/10/84 31 01256426 28/10 NHL large B cell ann arbor 4 post kemo 1
10/10 haloxan 5000 mesna 5000 doxo 50 kemo Pro kemo 2 haloxan 5000 mesna 5000 doxo 50 HK 5/10 hb 10,2 al 6,9 at 424ot 24 pt 10 cr 1,2 ur 45 hbsag -, 19/9/14 FNAB 1400694 NHL large B cell, 3/2 usg abd
massa paraaorta curiga limfoma hepatomegali, M A W A R 2 ( SOE, KAP, WAN)
1B Ny. Katinem1/7/39 76 1318171 28/10 Ca duct inf mamae D T4bN0M0 Op 30/10 Post MRM HK 27/10 hb 12 al 5,9 at 267 pt 12 aptt 26 gds 446 ot 11 pt 9 cr 0,6 ur 26 hbsag -22/10 MF 112915 FNAB mamae D
inf duct ca
1D Ny. Parsi 2/6/70 45 01316704 26/10 Invasive ca mamae d susp maligna
T3N1M0 Op 30/10 Post MRM WY 271/0 hb 14 al 5,7 at 263 gds 430 , 15/10 hb 15 al 7 at 243 , 19/8 FNAB 1500639 inv ca mamae D
2C Ny. Jamiyem1/1/47 68 01310581 30/10 Melanoma maligna r. pedis s Pre op Pro wide eksisi + rekonstrksi HK 31/10 7.0 ht 23 al 3.4 at 236 pt 13.3 aptt 27.4 INR 1020 ot 15 pt 13 ur 21 cr 0.6 albumin 3.3 na 142, k 3.1 cl 109
hbsag -,, 27/7 JI 52634 malignant melanoma
4C Ny. Sumarni1/12/59 55 01306409 31/10 Ca Lobularis mammae (D) Pre op Post MRM DD 15/10 hb 12.8 ht 38 al 9.0 at 265 gds 115 ot 25 pt 17 ur 0.6 cr 12
4D Ny. Suyatmi21/8/67 48 01301756 26/10 Tumor mamae d susp maligna T4cN3 M1
paru post biopsi insisi Op 27/10Tunggu hasil PA, Konsul BTKV utk wsd bila hasil ro tho efusi
pleuraHK 27/10 ot 45 pt 8 ur 0.6 cr 26 na 138 k 5.0 cl 108 24/10 Hb 10,3 al 3,6 at 218 gds 108 ot 80 pt 22 cr 0,5 ur 14
hbsag -, 21/8 ro tho metas paru +, FNAB kesan metastases adenokarcinoma
4I Ny. Suyatmi1/5/51 64 01275672 20/10 Adeno ca sternum dri tiroid Rencana konferensi lagi KY
13/10 hb 12 al 8,6 at 208 gds 91 ot 18 pt 12 cr 0,8 ur 28 TSH <0,05 FT4 13,91, 6/8/14 DU 1410048 PA adeno ca , 27/10/14 ct torak soft tisue massa dinding dada anterior. MRI Thorax : massa tiroid bilateral curiga malignan
4H Ny. Suratmi22/3/77 28 01318575 28/10 Ca mamae d T4cN2CM1 paru Op 30/10 Post Biopsi insisi dgn LA WY 28/10 hb 15 al 11 at 343 pt 17 aptt 42 gds 230 ot 26 pt 41 cr 0,7 ur 17 hbsag -, 8/10 FS 15 360 FNAB mamae +
axila ca duct metas limfonodi axila
7B tn. Ary S23/9/76 39 01309633 24/10 Tumor lidah T4bN0M0 Op 27/10 Post Trakeostomi + biopsi insisi,
konsul gastro + paru HK 24/10 hb 13 al 10 at 269 gds 90 ot 25 pt 17 cr 0,6 ur 16 na 129 k 2,4 hbsag -
7B tn. Ary S23/9/76 39 01309633 24/10 Tumor lidah T4bN0M0 Op 27/10 Post Trakeostomi + biopsi insisi,
konsul gastro + paru HK 24/10 hb 13 al 10 at 269 gds 90 ot 25 pt 17 cr 0,6 ur 16 na 129 k 2,4 hbsag -
8E Tn. Supar31/12/51 63 01318228 27/10 Adeno papiler tiroid Pre op MRI, total tiroidektomi Kp RND KY 27/10 hb 13 al 6,4 at 202 cr, 1,2 ur 29 hbsag -, 17/10 ptra medica adeno ca tiroid papiler
Melati 2 (KAP)7A iskandar 17 01316383 26/10 Abses parotis d Antibiotik, fluktuasi -, nyeri - HK 24/10 hb 14 al 8,9 at 386 ot 18 pt 9 cr 0,8 ur 12
Mawar 3 (HRE, EKP)
2C Ny. Supiyem4/6/47 48 01304436 24/10 Ca duct inv mamae d T4bN2bM1 paru kemo Kemo selese, kemo ke 5 mulai
29/10 brexel 80 platosin 60 HK 25/10 Hb 12 al 8,7 at 350, 18/9 Hb 9,4 al 7 at 652 gds 144 ot 28 pt 9 cr 0,6 ur 26, 19/6 RS 1502895 PA invasive ca mamae D
Melati 3 (HRE, EKP)
1A Ny. Kusriyati24/5/55 60 00682426 28/10 Sccc r. inguinal, riw kemo brexel 50 carbo
300 5fu 5k erbitux 500 kemo Post kemo brexel 50 carbo 300 5fu 5k erbitux 500 mulai 30/10 WY 5/10 RS 1504287 squamous cell ca berkeratin, 30/10 hb 10.8 ht 35 al 3.2 at 184 gds 88 ot 21 pt 32 cr 0,7 ur 41 ,
2/10 RS 1504287 biopsi squamous cell ca berkeratin
20B Ny. isyuningsih 62 01308175 30/10 Ca mamae T4cN1M0 kemo Perbaikan KU Hb >10, pro kemo ke 3 epirubicin 50 paxus 210 DD 31/10 hb 11,5 ht 36 al 3.7 at 435 ot 21 pt 11 cr 0,6 ur 7, 5/9 RS 1503966 ca with osteoclastic giant cell
Wing melati (HRE,EKP)
Senin 2 November 2015 BEDAH ONKOLOGI WAN/ADH/EKP/JOE/KAP/HRE/ISH/SQB/LHB/RISKIE/SUHRI
1C tn. Sugito 2/5/65 50 01275329 28/10 NHL large b cell r. axila d, riw mabtera 600
5x , cyclo1k doxo 80 vincristin 2 10x kemo Pro kemo haloxan 6k mesna 6k carbo 450 etopusid 100 3hr DD 31/10 hb 9,8 ht 3.1 al 7.8 at 424, 29/10 hb 9,9 , 13/10/14 DU 14104313 Biopsi insisi NHL B cell besar, CD 20
+>30%, 23/9 usg abd metas -,
