A TERATAI

1 Kelas TaraweMariaty/P/51thn Tumor 04/08/2018 (klinik X Foto Thorax - Pro Operasi

II bed 4 RM : 54.05.34 phylloidesmammaedextra PATRA) (4/8/2018) Klinik simple
MRS : 15/008/2018 Leu 5.4, Eri 4.43, Hb 12.6, PATRA mastectomy
DPJP : Dr.dr VP, Anamnesis : Ht 38.8, Trombo 242, Kesan : Cor-Pulmo : dextra
SpB(K)Onk SGOT 28, SGPT 28, GDP dalambatas normal
Benjolansekitar 3 tahun. 95, Ureum 19, Creatinin
Makin lama 0.16
makinmembesar
Kemo : (-)
2 Kelas Koloay Desny/P/47th Tumor Mammae Sinistra Lab : 14/08/2018 Lab 18/08/2018 - -Pro Biopsi ?
II bed 3 RM : 54.16.84 susp malignancy (siloam) Leu 6.2, Eri 3.82, Hb 11.1, - Rawat luka
MRS : 16/08/2018 Leu 6.77, eri 2.68, Hb 7.7, Ht 34.8, Trom 317, MCH - Konsul interna
DPJP : dr. MM, SpB Ht 23.8%, GDS 110, Na 29.0, MCHC 31.8, MCV
(K)Onk 139, K 3.5, Cl 104 91.1, SGOT 174, SGPT 53,
Ur 16. Cr 0.5, GDS 78, Cho
104.0, K 3.7, Na 135, PT
pasien 13.5 kontrol 14.4,
INR pasien 1.10 kontrol
1.19, APPT pasien 22.5
kontrol 32.2
3 Kelas 1 Kirojan Oleke Ca Papiler Tyroid Lab 15/08/2018 Lab 18/08/2018 - X Foto Thorax - R/ Pro Total
bed 4b RM : 53.89.64 Leu 7.0, Eri 4.70, Hb 13.5, Leu 5.4, Eri 4.51, Hb 13.3, Kesan : Tyroidektomi
MRS : 19/08/2018 Anamnesis : Ht 42,8, Trom 299, MCH Ht 39.4, Trom 275, MCH Normal (21/08/2018)
DPJP : dr. Marcellus 28.7, MCHC 31.4, MCV 29.5, MCHC 33.8, MCV
Merung, SpB (K)Onk Benjolan dileher sejak ± 1 91.2, SGOT 23, SGPT 21, 87.4, LED 33, SGOT 20, - EKG
tahun yang lalu. Awalnya Ur 23. Cr 0.7, GDS 84, SGPT 14, Ur 40. Cr 0.7, Kesan : Dalam
kecil dan makin lama Cho 99.9, K 4.00, Na 139, GDS 96, Cho 103.4, K Batas Normal
semakin membesar. PT pasien 11.7 kontrol 4.47, Na 141, TSHS 0.572,
15.2, INR pasien 0.91 FT 4 : 1.41, FT 3 : 6.21, PT
kontrol 1.28, APPT pasien pasien 11.7 kontrol 15.2,
27.4 kontrol 34.7 INR pasien 0.91 kontrol
1.28, APPT pasien 27.4
Lab 16/08/2018 kontrol 34.7
Albumin 4.20
 ANGGREK 2
1 K102 Michael F.M Limfadenopati colli Lab 09/08/2018 Lab 11/08/2018 Pemeriksaan cairan - Rencana
Monihara/L/31st bilateral susp. Malignancy Leu 15.6, Eri 6.26, Hb Leu 17.5, Eri 5.93, Hb 15.9, Pleura : Kesimpulan biopsy dengan
RM : 54.10.60 17.4, Ht 50.3, Trom 460, Ht 51.7%, Trom 410, MCH EKSUDAT GA
MRS : 09/08/2018 Anamnesis : SGOT 75, SGPT 66, Ur 26.8, MCHC 30.7, 30.7, X Foto Thorax - Perbaiki KU
DPJP : dr. Christian Benjolan dileher tidak 48, Cr 0.9, GDS 87, Cl 97, Terlampir (09/082018)
Manginstar, SpB (K)Onk diketahui sejak 3 bulan K 4.7, Na 129 LED (Laju Endap Darah)
yang lalu. 001 Eosinofil 0%
Benjolan diketiak bawah 002 Basofil 0%
dialami sejak +/- 1 bulan 003 netrofil batang 10%
004 netrofil segmen 73%
005 limfosit 7%
006 monosit 10%
006 monosit 87.2 fL

Kimia Klinik
Protein Total 6.45, GDS 54,
Fosfor 3.4, Magnesium
2.50, Albumin 3.44, LDH
1250, Cho 85.5, K 4.23, Na
127
2. K104 Mandagi Jeane/P/62th Tumor mammae sinistra Lab 18/08/2018 - X Foto Thorax - Konsul BTKV
RM54.00.25 susp. Malignancy Leu 7.2, Eri 5.19, Hb 13.9, Hasil : Efusi - Tx sesuai
MRS : 19/08/2018 (T4N3MX) + Efusi Pleura Ht 45.3, Trom 299, MCH pleura sinistra KPO
DPJP : dr. Christian sinistra 26.8, MCHC 30.6, MCV
Manginstar, SpB (K)Onk 87.4, SGOT 30, SGPT 17,
Anamnesis : Ur 23. Cr 0.5, GDS 66,
Sesak nafas dialami Cho 101.0, K 3.90, Na
penderita sejak 1 hari 139, PT pasien 13.6
SMRS. Riwayat benjolan kontrol 14.4, INR pasien
di payudara kiri (+) sejak 1.11 kontrol 1.19, APPT
1 tahun SMRS. Awlanya pasien 36.5 kontrol 32.2
benjolan berukuran kecil
dan makin lama semakin
membesar.
3. Masengi Roosye/P/70th - General Lab 18/08/2018 - X Foto Thorax - Observasi
RM : 49.30.31 weakness Leu 10.5, Eri 3.35, Hb 9.7, Terlampir TTV tiap jam
MRS : 20/08/2018 Ht 31.2, Trom 256, MCH jika TDS <
 DPJP : dr. Marcelus - Efusi pleura 28.9, MCHC 31.0, MCV 90mmHg atau
Merung, SpB (K)Onk sinistra 93.0, SGOT 19, SGPT 14, pulse pressure
- Liposarkoma Ur 41. Cr 0.8, GDS 117, < 20mmHg
region femur Cho 95.0, K 3.40, Na 128, - -> Guyur
dextra PT pasien 17.8 kontrol NaCl 0.9%
14.4, INR pasien 1.58 1,5L
kontrol 1.19, APPT pasien - Observasi
27.0 kontrol 32.2 kembali

NYIUR
1 Rorong Joice R/P/52th - General Lab : 14/08/2018 Lab 16/08/2018 EKG (14/08/2018) - Transfuse
RM : 50.78.96 weakness Leu 2.8, eri 3.83, Hb 10.9, Leu 10, Eri 3.54, Hb 10.3, X-Foto Thorax trombosit
MRS : 16/08/2018 - Ca mammae Ht 32.3%, Trom 81, SGOT Ht 30.5%, Trom 85, GDS sampai >
DPJP : dr. MM, SpB dextra post post 16, SGPT 12, Ur 36, Cr 81, Cl 90, K 3.1, Na 108 150.000
(K)Onk MRM on 1.1, GDS 107, Cl 93, K - Transfuse
kemoterapi 2.9, Na 111 wholeblood
- Anemia + - Rawat luka
trombositopenia - Pro chemo
- Elektrolit - Tx lanjut
imbalance sesuai KPO

Anamnesis
Benjolan dialami
penderita satu setelah
tahun yang lalu, awalnya
kecil dan makin lama
membesar, riwayat
operasi dan kemoterapi.