Kamis, 2 Juni 2016

MAPING BEDAH ONKOLOGI

MAP/AZR/MID/AAI/AYT/SOE/MOW/AULIA

KM

NAMA / TGL LHR

USI
A

NO RM

MRS

39

013185
17

31/5

24

012997
53

26/5

55

013404
82

24/4

DIAGNOSA

STATUS

PLAN

DPJP

Perbaikan KU
USG abd cek ER PR

HK

Post Op

Perawatan Post Op

JK
P

Konsulan
Paru

Tunggu hasil FNAB

Perbaikan ku TS paru
Ususl poliklinis

PEMERIKSAAN PENUNJANG

MAWAR 1
Suratmi
22/03/1977

4C
8G
1
5A

Mardalina
24/11/1991
ANGGREK
Ginah
10/1/1981

Ca mamma (S) T4cN2M1

(paru,kontra lateral) post khemo
6x brexel platocin
Neurofibroma R gluteus
Post eksisi

Tumor Mamma (D) T4cN2M1

(hepar)

01/06 hbb10.7 al 8,9 at 256s gds 124 ot 45 pt 54ur 34 cr 1,3 hbs Ag non
reaktif Ro thorax multiple nodul metastases PA carcinoma mamma
infiltratiff8uj
28/05 hb 10.4 al 7,6 at 291 gds 91 alb 4.0 cr 0.6 ur 35 na 139 k 3,5 cl 109
hbsAg nonreaktif PA diffuse neyrofibroma Ro Thorax dbn
01/;06 hb 4,8 hct 15 al 8.0 at 95 ggds 85 ot 67 pt 32 alb 2,2 ur 31 cr 0.5 abd 3
posisi pneumoperitoneum, ro thorax susp massa paru kanan, dengan
pneumonic reaktion usg Abd hepatal metastase usg mamma massa maligna
mamma D, usg abd multiple nodul liver metastase, lien metastase

MAWAR 2

1B

Sutarmi
02/09/1947

68

013332
08

23/5

Ca Mammae (S) TxN1M1 (bone)

post MRM

1D

Supi
01/10/1960

55

013082
55

01/6

Adeno ca Parotis

2C

Pariyem
09/09/1969

46

012694
13

31/5

Ca mamma (S) TxN2M1 (paru,

kontra lateral)
Post khemoterapi 5x brexel carbo

3A

Mulyani
07/08/1967

49

013272
91

27/5

Struma Adenomatosa
Tumor paruu kiri dd tumor
mediastinum
Efusi pericard

4I

Daliyah
04/08/1971

44

013399
71

01/6

Ca Mamma (S) post

mastektomigyuj

5A

Lanjarwati
20/12/1964

51

013234
11

28/9

8B

Ari wahyudi
26/04/1985

31

013405
72

30/5

8E

Sutardi
30/08/1952

65

012871
12

25/5

8G

8J

Yamin
05/08/1970
Edwin rahmat
20/03/1998
ANGGREK 2

1J

Baryanti
09/02/1968

12

Sumini

Ca Mamma (D) T4cN1M0, post

khemo 5x paxus carbo, 2x MTX
Tumor R mandibular susp
ameloblastoma
Post bipsi insisi
SCC R.Lidah post kemo 13x
(erbituk, curasil) +
Lymfadenopathy R.Colli (S)
Post RND

HK

31/05 hb 9,9 al 8,7 at 124 cfg gds 167 ot 46 pt 18 cr 2,9 ur 212 na 133 k 3,7
bjh29/05 hb 10.3 al 6,9 at 59 na 132 k 3,3 cl 103 alb 3.0 cr 2,4 ur 87 na 128 k
2,2 cl 92 Gol dar B, gds 109 ot 40 pt 13 cr 1,9 ur 76 HBsAg Nonreactive, 27/4
ER (-) PR (-) , 15/4 Hasil PA: Ca Epit Duct Mammae Inf Grd II/III dengan
metastase, Ro/Thorax PA: DBN, pelvis AP: multiple lesi litik di os ilii dextra,
dapat memungkinkan bone metastasis osteolitik type, Thoraco Lumbal AP dan
Lat: Lumbalisasi VS 1, spondylosis lumbales dengan penyempitan DIV L 5-VS1,
19/3 AJH: Invasisve carcinoma.
Ct kepala : osteodestruksi pada VC 1 dan VC2 mestastase osteoklasrtik pada
calvaria

Perbaikan Ku
CT Scan Partotis
Post kemoterapi paxus 5FU

W
Y

27/05 hb 8,5 al 4,1 at 303 gds 141 ot 17 pt 9 alb 4.0 ur 42 cr 1/7 nPA : asinic
sel carcinoma dd adenpo carcinoma USg R colli massa parotis kiri dengahn
limfadenopati kiri cenderungn ,maligna, ro thorax dbn, usg abd dbn

Perbaikan KU

W
Y

01/06 hb 7,6 al 3.0 at 51 gds 151 pt 14 alb 3,9 ur 19 cr 0.7 na 133 k 3.5 cl 99
PA carcinoma ductal infiltrative Ro thorax efusi pleura bilateral, usg abd dbn

Pre Op

Pro Total Throidektomy

Perbaikan KU dari TS
cardiokj

KY

Pre Op

Revisi Mastektomi

KY

Perbaikan KU

W
Y

Post Op
01/6jhb

Perawatan Post Op

HK

Post Op
01/6

Peraewatan Post Op

KY

Perbaikan KU

Terapi Paliatif
Usul BLPL

45

013401
54

18/5

Tumor R.Colli (S) susp Malignancy

T4N1M0 dd NHL post Biopsi Insisi

Post op
25/05

W
Y

18

013402
12

01/6

Tumor R mandibular (S)

Pre Op

Pro Eksisi

W
Y

48

012469
06

28/5

Ca mamme (S) T4bN1M0 post

khemo 3x paclitaxel 200
epirubizin 80

Opg

Pro MRM

W
Y

Hidroadenocarcinoma R. Temporal

Post Op

Perawatan Post Op

HK

30/05 hb 11.9 al 7,6 at 281 gds 89 ot 14 pt 10 ur 24 cr 0.4 na 140 k 3,6 cl 112

hbsag non reaktif tsh 0.13 t4 20.49 fththorax foto: edema pulmonum dgn
cardiomegali, efusi pleura bilateral,cervical AP lat Sponsilosis cervical, FNAB:
Struma adenomatosa, USG thyroid struma nodusa bilateral dengan kalsifikasi
17/05 hb 13,0 al 6,7 at 387 gds 90 ot 17 pt 30 ur 36 cr 0.9 alb 4,5 na 137 K 4.2
Cl 106 PA Ca mamma infiltrative grd 3, AJH ca epitel ductus Mamma Ro
Thorax dbn
01/06 hb 12,8 al 1.9 at 12 ot 33 pt 23 alb 2.8 ur 45 cr 0,5 PA :SCC, Ro thorax
dbn USG abd dbn
Hb 10.6 al 13.2 at 345 jhot 16 alb 4,3 ur 26 cr 0,7 Ct scan mandibular soft
tissue mass region mandibular bilateral disretai osteodestruksi simfisis, dan
corpus mandibula
26/05 hb 14,3 al 6,gds 176 ot 32 pt 23 alb 3,9 ur 309/05 hb 14.5 al 6,5 at 186
gd 111 ot 45pt 35 r 32 cr 0.9 na 136 k 4,2 cl 105 hbsg reaktif
AJH r colli metastasis ca sel squamosa PA : SCC
30/05 hb 10.5 al 58,318/5 hb 7,2 al 68,7 at 518 pt 17,4 aptt 28,7 gds 106 ot 20
pt 40 alb 2,4 cr 0,7 ur 15 na 126 k 4 cl 93 HBsAg rapid N0nreactive 18/5
Cervical AP Lat: soft tissue mass r.colli anterior kanan yang menyempitkan
trachea setinggi VC 5-6, thorax PA: dbn
PA : ca Mucoepidermoid berdeferensiasi buruk dd carcinoma squamosal
deferensiasi buruk
20/05 hb 14.1 al 6,4 at 137 gds 115 ur 17 cr 0.6 na 140 K 4.1 cl 107 hbsAg
Non reaktif ot 15 pt 8 PA Limfadenitis kronik non spesifik
31/05 hb 11.0 al 8,2 at 259 gds 100 ot 15 pt 7 ur 10 cr 0.6 na 139 k 4,5 cl 110,
usg abd dbn usg mamma massa mamma S curiga malignansi, infiltrasi kgb
axila, ro Thorax dbn AJH ca infiltratif

MELATI 3
88

013354

27/5

01/06 hb 8,5 al 8.0 at 213 gds 99 ot 18 pt 7 ur 30 cr 0.7 na 138 k 3,8 cl 105