INSTRUKSI POLI ONCOPEDI SEPTEMBER 2020
No Identitas
1 Sukirno, M
2 Severinus, M
3 Raset, M
4 Tan Swat Lien, F, 68 yo
5 Erisa, F, 18 yo
6 Khaira, Girl, 1 yo
7 Maria Dwi, F, 42 yo
RM Tanggal Diagnosis Plan Advis dr.THA Note
1926231 3-Sep-20 Atrophic nonunion of the right femur with Tidak usah X-ray, tunggu LLD sama
severe shortening deformity in patient with
neglected close fracture of middle third of the
right femur post Fibrous release and Skeletal
traction 4 months ago at Sardjito General
Hospital
1936441 3-Sep-20 Chronic wound of the right leg in patient with - cek lab DR,KED, CRP, Alb 085641622730
chronic osteomyelitis of the right proximal fibula - besok jumat datang ke poli, dan lapor dr.THA
Cierny Mader IVA post wound excision 2 years - jika ada peningkatan tanda infeksi rencana
ago at private hospital in Yogyakarta by General mondok masuk AB injeksi
surgeon, post debridement and open biopsy 1
year ago at private hospital in Yogyakarta by
Orthopaedic surgeon, post fibula osteotomy 1
month ago at Sardjito General Hospital
1924527 3-Sep-20 Union of the middle third of the left tibia post -bulan desember mondok ROI, evaluasi X-ray
ORIF 7 months ago at Sardjito General Hospital sebelum ROI
- bila bagus lanjut ROI, bila belum lanjut
evaluasi
1717883 3-Sep-20 Non union of the left medial malleolus, in - Ro Thoracolumbal, Lumbosacral, ankle
patient with close fracture of the left ankle ORIF - MRI spine
1 year ago - Kontrol ulang kamis depan
1906634 3-Sep-20 Primary benign bone tumor of the right - Daftarkan mondok 2 minggu lagi 08882661790
proximal tibia due to giant cell tumor - Pastikan megaprosthesis ready
Campanacci II
1942997 3-Sep-20 Lytic lesion of the left distal femur due to Susp - AJH guided USG 082327377787 (Tika)
Osteomyelitis dd Osteosarcoma - jika tidak kooperatif minta pakai anes
1671408 3-Sep-20 Multiple lytic lesion of the right femur and tibia Nwb dengan crutch, pelacakan ke obgyn dan RPS : 3 bulan smrs OS
due to MBD ajb ulang di tumor tibia terpeleset dan mengeluh
nyeri di tulang kering. OS
setelah itu ke rs panti
nugroho dan kemudian
dirujuk ke sardjito karna ada
gambaran tumor. OS sempat
di ajh didapat adanya curiga
osteosacoma
 INSTRUKSI POLI ONCOPEDI SEPTEMBE

No Identitas RM Tanggal
1 Severinus, M 1936441 4-Sep-20
 INSTRUKSI POLI ONCOPEDI SEPTEMBER 2020

Diagnosis Plan
Chronic wound of the right leg in patient with
chronic osteomyelitis of the right proximal fibula
Cierny Mader IVA post wound excision 2 years
ago at private hospital in Yogyakarta by General
surgeon, post debridement and open biopsy 1
year ago at private hospital in Yogyakarta by
Orthopaedic surgeon, post fibula osteotomy 1
month ago at Sardjito General Hospital
2020

Advis dr.THA Note

Kultur dasar luka ulang di poliklinik dan kontrol 085641622730
Kamis minggu depan untuk pemberian
antibiotik sesuai kultur yang baru

No Identitas
1 Purnomo Bernadi, M, 44
yo
2 Putri, F, 14 yo
3 Suhardi, M, 64 y.o
4 Ahmad Jumal, M, 49 y.o
5 Kisut, M, 56 y.o
6 Abdulloh, M, 20 th
INSTRUKSI POLI ONCOPEDI S
RM Tanggal Diagnosis
1901179 7-Sep-20 Atrophic non union of the right distal femur in
patient with history of open fracture of the right
femur post ORIF 1 year ago post removal of
implant, antibiotic beads implantation and
external fixation 11 months ago post
debridement, removal of antibiotic beads and
removal of external fixation 9 months ago at
Sardjito General Hospital
1943022 7-Sep-20 Primary malignant bone tumor of the right distal
femur due to susp. osteosarcoma
621255 7-Sep-20 Union of the right ankle, Union of the right talar
neck post ORIF ankle 10 months ago at Sardjito
General Hospital
1943298 7-Sep-20 Primary malignant soft tissue tumor of the right
shoulder region with susp secondary infection
1943290 7-Sep-20 Primary benign bone tumor of proximal phalanx
of the left little finger due to susp. Recurrent
GCT Campanacci III post tumor excision 2 years
ago at Wonosari District Hospital by
Orthopaedic Surgeon, dd Soft tissue tumor, dd
Infection process
1943322 7-Sep-20 Wound dehisence in patient with neglected
open fracture of supracondylar of the right
femur post skeletal traction 1 month ago, post
ORIF and removal of skeletal traction 3 weeks
ago, post Debridement 1 week ago at Private
hospital yogyakarta by Orthopaedic surgeon
with plate exposed
Neglected close fracture of middle third of the
right tibia post ORIF 1 month ago at Private
hospital yogyakarta by Orthopaedic surgeon
1 Severinus, M 1936441 4-Sep-20 Chronic wound of the right leg in patient with
chronic osteomyelitis of the right proximal fibula
Cierny Mader IVA post wound excision 2 years
ago at private hospital in Yogyakarta by General
surgeon, post debridement and open biopsy 1
year ago at private hospital in Yogyakarta by
Orthopaedic surgeon, post fibula osteotomy 1
month ago at Sardjito General Hospital
STRUKSI POLI ONCOPEDI SEPTEMBER 2020

Plan Advis dr.THA No Hp

Pro ORIF and bone Mondok hari ini, rencana operasi kamis 087839814822
grafting

Pro core biopsy Fast track core biopsy Rabu 9/9/20 089652847255

Pro removal of implant Fast track removal of implant Selasa 8/9/20 083145167123

Pro core biopsy X-ray shoulder 3 posisi

Fast track core biopsy Kamis 10/9/20

AJH ulang 081225805719

Pro debridement and Mondok hari ini 081328229222

wound closure
Kultur dasar luka ulang di poliklinik dan kontrol 085641622730
Kamis minggu depan untuk pemberian
antibiotik sesuai kultur yang baru
 Note

Ahmad Jumal, M, 49 y.o., dengan

Primary malignant soft tissue tumor
of the right shoulder region with susp
secondary infection
Kisut, M, 56 y.o.,
KU : Benjolan bahu MRsejak
1943290
1 thn lalu
RPS : 1 TSMRS os merasa bengkak
KU
pada : benjolan
bahu kanan di tangan
dengan kiriukuran bola
pimpong pada bahu kanan dan nyeri.
RPS
Lalu :os memeriksakan ke RS PKU
Sejak
Wonosobo24 tahunke dryang laluumum
Bedah muncul
benjolan di tangan kiri sebesar
dikatakan tumor, lalu diberi obat. ujung
Dan
jempol. Tidak ada nyeri.
direncanakan operasi namun pasien Benjolan
membesar
blm :punya perlahan.
bpjs. Lalu Pada tahun 2018
RPS 2 bulan smrs OSosmengalami
mengurus
benjolan
bpjs, dan sebesar
kembali telur ayam,
memeriksakan danpada
1
kecelakaan dengan luka terbuka
dilakukan
bulan OS operasi
ini. kemudian pengangkatan
Tumor semakin membesar
paha. ke rsud Sleman
tumor
sebesardijeruk
RSUDBali,
Wonosari
danterbukaoleh Sp.OT.
nyeri,
dikatakan ada fraktur di
Sekitar
penurunan 6 bulan
beratsetelah
badan operasi
disangka. Lalu
femur kanan dan fraktur tertutup di
benjolan
os dirujuk kembali muncul
ke RSS untuk dan tumbuh
penanganan
tibia.
lebih OS kemudian APS dari
cepat daripada sebelum operasi. rsud
lanjut.
seleman dan ditangani sangkal
Saat itu tidak diobati dan pasien
putung. 1 bulan kemudian os ke JIH
hanya
ST lokalisminum herbal
shoulder serta terapi sinar
dextra
dan
di dilakukan
RSU Permata operasi
Husada. 2 kali
Oleh pada
karena
L : swelling
femur (+) deformity
dan tibia. Kemudian (+)dilakukan
tumor in
keluhan
size tidak
20x15x10 membaik
cm pasien
discharge (+) pus1 (+)
operasi Debridement pada femur
kemudian
Fminggu
: NT (+)yangke Poli
NVD Orthopaedi
(-) solid, terfixirRSUD
Wonosari danlalu. OS kemudian
dirujuk ke RSUP Dr.
M : limited
dirujuk
Sardjito.ke rs sardjito untuk
penanganan lebih lanjut
RPD : Tumor (-), HT (-), DM (-), Asma
(-), Alergi dingin

Pemeriksaan Fisik
KU baik, CM
TD 120/70 mmHg
N 82 x/menit
RR 18 x/menit
T 36.5 Celsius

St. Lokalis Left Hand

L : lump (+) pada dorsum manus,
venektasi (-), swelling (-), deformity
 INSTRUKSI POLI ONCOPEDI SEPTEMBER 2020

No Identitas RM Diagnosis Plan Advis DPJP Note

Tanggal No HP
1 Dwijo, M, 72 y.o 1939356 10-Sep-20 Close pathologic fracture of middle third of the GV dan aff hecting Cefixime 2x 100 mg
right femur due to MBD post ORIF 2 weeks ago Osteocal 2x500 mg
Vit C 3x1 tab