Mrs.

Y/ 45 years old/ 01118113/ BPJS

Attending: dr. Salamullah, Sp.B(K)Onk

February, 23rd 2024

Redo
Reza
Delta
Alfath
Zharan - Alex
 VISI dan MISI Ilmu Bedah FK UNRI
• VISI
• Menjadi Pusat Pendidikan Dokter Spesialis Bedah Berbasis Riset yang Unggul dan Bermartabat dibidang
Teknologi Kedokteran dan Kesehatan Terutama Dalam Pelayanan “Acute Care Surgery” di Kawasan ASEAN
Pada Tahun 2035

• MISI
• Menyelenggarakan pendidikan dokter spesialis bedah yang mampu secara mandiri melayani kasus bedah
terutama dalam pelayanan “Acute Care Surgery “
• Menyelenggarakan penelitian berbasis riset yang unggul dibidang teknologi kedokteran dan kesehatan yang
berkontribusi dalam menyelesaikan masalah bedah terutama pelayanan “Acute Care Surgery”
• Menyelenggarakan pengabdian kepada masyarakat terutama dalam pelayanan “Acute Care Surgery”
• Menjalin kerjasama dengan institusi atau lembaga pendidikan lain dalam negeri dan dikawasan ASEAN
• Menyelenggarakan kepemimpinan dan tata kelola program studi spesialis ilmu bedah yang baik dan akuntabel
 Mrs. Y/ 45 years old/ 01118113/ BPJS
Attending: dr. Salamullah, Sp.B(K)Onk
Chief complaint:
Shortness of breath that has worsened since 4 days before admission

History of disease course:

- The patient came to the emergency room of Arifin Achmad Hospital with complaints
of shortness of breath that had been worsening since 4 days before admission.
Initially, the shortness of breath has been felt since 1 week before admission, but the
shortness of breath has worsened. Complaints of shortness of breath were felt to be
intermittent, it worsened when she was in activity.
- The patient with history of a lump in the left breast since February 2022 and has
been operated on. The lump was initially the size of a marble and enlarge over time
and rupture, she previously only went to alternative treatment for about one year, in
January 2023 she came to the doctor for her breast problems.
 Mrs. Y/ 45 years old/ 01118113/ BPJS
Attending: dr. Salamullah, Sp.B(K)Onk
History of disease course:
- Then a biopsy was performed in January 2023 and the results were Invasive
Carcinoma NST grade 3, lymphovascular infection (+) at left breast. She underwent 6
cycles of chemotherapy with cyclophosphamide 1000 mg, doxorubicin 80 mg, then
she was examined for IHK in June 2023 with the results of ER (-), PR (-), Her2 (-),
Ki67 (+) >20%. She was perfomed of Left Mastectomy on December 21, 2023 and a
histopathological examination was performed with the results of invasive carcinoma
Mammae NST grade 3 with paget disease, found lymphovascular invasion, incision
boundaries and tissue base still contain malignant tumor cells. After surgery, she
complained of left hand swelling
- Due to increased shortness of breath, she was taken to the Regional Hospital for
further treatment.
 Mrs. Y/ 45 years old/ 01118113/ BPJS
Attending: dr. Salamullah, Sp.B(K)Onk
Risk Factor
- Patient had her first menarche at 14 years old
- Patient is married
- Menopausal patient: (-)
- History of previous breast cancer / adjacent breast (-)
- Smoking (-)
- Family history of tumor (+) Breast tumor (+)
- History of HT (-)
- History of DM (-)
 Physical Examination

• Awareness : GCS 15
• Vital sign:
• VAS : 2-3 out of 10 scale
• BP : 127/77 mmHg
• RR : 26 x/m
• HR : 90 x/m
•T : 36,7 C
• SpO2 : 99% by O2 NC 4 lpm
• Karnofsky score : 60
 Physical Examination
• Head: normocephal • Heart: normal heart sound regular,gallop (-),
• Eyes: anemic conjuntiva (-/-), icteric sclera murmur (-)
(-/-), isochor pupil 2mm/2 mm, light
reflexes rec & indirects (+/+) • Abdomen:

• Mouth : normal - I: distended (-), bruise (-), wound (-)

• Neck: normal , enlarged lymph nodes (-) - A: normal bowel sound
• Breast: localized status - P: firm, tenderness at epigastrium (-),
• Chest : rebound tenderness (-), enlarged of hepar (-)
- I : asimetrical chest movement - P: tympani
- P: Left fremitus decreased from right • Extremity: CRT < 2”, warm (+), cyanotic
- P: dull percussion at the left chest, right (-), Motoric 55555/55555 55555/55555,
chest normal
Sensorics within normal limit
- A: vesiculat left < right chest
 Localized Status of Breast
Inspection Right Breast Left Breast

• Symmetrical Right and left breast was asymmetric

• Scar Scar (-) Scar (+)

• Skin disorder Mammae (+), scar Mammae (-), redness

(-) mass (-), ulcer (+), epitelisation (+).
(-), peu d'range (-),
skin dimpling (-)

Palpation Tenderness (-) Mass (-). tenderness

mass (-), (-), epitheltation (+)
temperature size 25x20 cm
change (-).
 Localized Status of Breast

Left Side Right Side

 Physical Examination

• Axilla Lymph Node

• Right axilla : Not Palpable of lymph gland enlargement
• Left axilla : Not Palpable of lymph gland enlargement
• Right of Supraclavicular : Not Palpable of lymph gland enlargement
• Left of Supraclavicular : Not Palpable of lymph gland enlargement
• Both of Infraclavicular : Not Palpable of lymph gland enlargement
• Both of Neck site : Not palpable of lymph gland enlargement
 Working Diagnosis Performed

- Left pleural effusion Therapy in

Treatment the emergency
in the emergency room
room:
-- IVFD NaCl
O2 NC 0.9% 20 tpm
4 lpm
- Left invasive ductal - Ceftriaxone 1 g iv
- Ketorolac 30mg/ 8 hours iv
carsinoma, DCIS Grade III, - Ketorolac 30 mg iv
- Omeprazole 40mg/ 12 hours iv
T4bN0M1 suspect (hepatic, - Omeprazole 40 mg

suspect pleural)+post left Plan :

Proposed:
MRM + Post chemotherapy -• PRC
Chest X Ray 4 bags
transfusion
- -• 25% albuminTest
Laboratory transfusion 2 flashes
Plan :
• Consult to Oncology Surgeon
• Chest X Ray
• Chest tube
• Laboratory Test
• ConsultOncologist
• Consult to internist
 Laboratory (February, 23rd 2024)

Type Value Unit Normal Value Type Value Unit Normal Value
Haemoglobin 8,5 g/dL 13,0 - 16,0 Urum 77 mg/L 17.1 – 49.2
HT 24,9 % 42,0 - 52,0 Creatinine 2,63 mg/L 0.55 – 1.30
WBC 12,41 10^3/µl 5,00 - 10,00 Natrium 126 mEq/L 135-145
Platelet 329 10^3/µl 150 - 400 Kalium 3 mEq/L 3,5 – 5,3
AST 17 U/L 10 – 40 Cloride 86 mEq/L 97-107
ALT 5 U/L 10 – 40 Nonreaktif
HBsAg Nonreaktif
Glucose 77 mg/dl < 200 mg/dl HIV nonreaktif Nonreaktif Nonreaktif
Albumin 2,9 g/dL 2,4-4,8
 Chest X-Ray (February, 23rd 2024)

• Airway: the trachea was pushed to

the right
• Bone: no discontinuity
• Cardiac: normal (CTR < 50%)
• Diaphragm: Blunt left costophrenic
angle
• Field of the lung: Homogen
consolidation at all field at the left
lung
 Diagnosis Performed
- Left pleural effusion Consult Dr. Salamullah, Sp.B-Onk:
- Left invasive ductal carsinoma, DCIS - Insertion of chest tube drainage of left
Grade III, T4bN0M1 suspect (hepatic, hemithorax
suspect pleural)+post left MRM + Post - IVFD NaCl 0.9% / 8 H
chemotherapy
- KSR 3 x 1
- Electrolyte imbalance
- Ceftriaxone 2 x 1 gr
- AKI
- Ketorolac 3 x 30 mg
- Anemia
ICD X:
- OMZ 2 x 40 mg
• C50 Malignant neoplasm of breast
- Transfusion PRC 2 kolf (+1)
• J90 Pleural effusion, not elsewhere classified
• E87. 8 for Other disorders of electrolyte and fluid balance, not elsewhere - VIP Alb 3x2 caps
classified
• N17.9 · Acute kidney failure, unspecified - Ondancetron 2x8 mg IV
• D64. 9 Anemia, Unspecified
 Operation Report (February, 23th 2024)
Diagnosis pre op Left pleural effusion + Left mammary Ca + Anemia

Operation name Chest tube installation + WSD

Diagnosis post op Left pleural effusion + Left mammary Ca + Anemia

- Patient in sitting position

- Aseptic and antiseptic the left hemithorax operating area
- Perform local anesthesia with lidocaine
- aspiration was carried out with a syringe-> serohemorrhage fluid (+)
- Insertion was carried out in the left safety triangle, mid line of the left axilla at the level of ICS 5
- Insertion with Chest tube 24 fr depth 11 cm --> initial serouhemorrhage fluid comes out 700 cc, undulations (+),
bubble - respiratory bubble (-) --> connected to WSD then clamped
- Fixation with Silk 0
- Cover with sterile gauze
- Operation complete
 Operative Report
Cranial Cranial Cranial

Caudal Caudal Caudal

 Operative Report
Undulation Post Chest Tube Insertion
 Follow up, 24 February 2024
S : Dyspnea decreased, pain decreased A:

O: -Left pleural effusion post chest tube insertion POD 1

GCS : E4M6V5 -Left invasive ductal carsinoma, DCIS Grade III, T4bN0M1 suspect
(hepatic,suspect pleural)+post left mastectomy + Post chemotherapy
BP : 121/78 mmHg - Electrolyte imbalance
HR : 72 bpm - AKI
RR : 23 x/m - Anemia
Temp : 36,9 C
P:
SpO2 : 99% NC 5 lpm
- Ceftriaxone inj 2x1 gram IV
Localized status of chest
- Ketorolak inj 3x30 mg IV
-I : symetrical chest movement
- OMZ 2x40 mg IV
-P: Left fremitus : right
- Ondancetron 2x8 mg IV
-P: left : Right resonant percussion - Monitor chest tube production, flow 500 cc/12 hours
-A: vesicular left : right chest - Transfusion PRC 2 kolf (+1)
WSD production : 500 cc serohemorrhagic - VIP Alb 3x2 caps
 Follow up, 25 February 2024
S : Dyspnea decreased, Fever (-) A:

O: -Left pleural effusion post chest tube insertion POD 2

GCS : E4M6V5 -Left invasive ductal carsinoma, DCIS Grade III, T4bN0M1 suspect
(hepatic, suspect pleural)+post left mastectomy + Post chemotherapy
BP : 118/72 mmHg - Electrolyte imbalance
HR : 81 bpm - AKI
RR : 22 x/m - Anemia
Temp : 36,7 C
P:
SpO2 : 99% NC 4 lpm
- Ceftriaxone inj 2x1 gram IV
Localized status of chest
- Ketorolak inj 3x30 mg IV
-I : symetrical chest movement
- OMZ 2x40 mg IV
-P: Left fremitus : right
- Ondancetron 2x8 mg IV
-P: left : Right resonant percussion - Monitor chest tube production, flow 500 cc/12 hours
-A: vesicular left : right chest - Transfusion PRC 2 kolf (+2)
WSD production : 300 cc serohemorrhagic - VIP Alb 3x2 caps
 Follow up, 26 February 2024
S : Dyspnea decreased, Fever (-) A:

O: -Left pleural effusion post chest tube insertion POD 3

GCS : E4M6V5 -Left invasive ductal carsinoma, DCIS Grade III, T4bN0M1 suspect
(hepatic, suspect pleural)+post left mastectomy + Post chemotherapy
BP : 117/78 mmHg - Electrolyte imbalance
HR : 883 bpm - AKI
RR : 20 x/m - Anemia
Temp : 36,6 C
P:
SpO2 : 99% NC 3 lpm
- Ceftriaxone inj 2x1 gram IV
Localized status of chest
- Ketorolak inj 3x30 mg IV
-I : symetrical chest movement
- OMZ 2x40 mg IV
-P: Left fremitus : right
- Ondancetron 2x8 mg IV
-P: left : Right resonant percussion - Monitor chest tube production, flow 500 cc/12 hours
-A: vesicular left : right chest -VIP Alb 3x2 caps
WSD production : 100 cc serohemorrhagic
THANK YOU