EXCELLENCE IS NEVER ACCIDENT

ITS RESULT OF
HIGH INTENTION,
SINCERE EFFORT,
INTELLIGENT DIRECTION,
SKILLFULL EXECUTION,
AND
THE VISION TO SEE OBSTACLES AS OPPORTUNITIES
(ANONYMOUS)

LAPORAN JAGA
Minggu, 18 Oktober 2015
Chief
Jaga 3
Jaga IGD
IPI
Bangsal

:
:
:
:
:

dr. Esti Widiasari (EWI)

dr. Wadhe (WOS) / dr. Indra (IND) / dr. Monica (MYU)
dr. Zulfadli (FDL) / dr. Dian (DIW) / dr. Adi (ADY)
dr. Umar (MAR) / dr. Anto (AYT)
dr. Marthin (MRT) /dr. Jiwandono (DON)

REKAP KUNJUNGAN IGD

Rawat Inap
No

Identitas

Diagnosis

Tindakan

1.

Ny. Pt
48 Thn
01297541

Ca epitel ductal mammae (D)

T4cN3cM1 (paru) Post kemoterapi 3
kali

-O2 3 Lpm
-Inf. RL 20 tpm
-Inj. Metamizole 1g/8 jam
-Lab DR
-Ro. Thorax
- MRS Bangsal
- Staging ulang

2.

Ny. P
61 th
01317379

- Recurent Left breast Cancer

TxNxM1 (Lung + Bone) + Post MRM
+ Post chemotherapy 6 Cycles
- Left pleural effusion
- Hyponatremia
- Hypocalemia
- Compression fracture VTh VIII IX

inward
Tapping Yellow clear fluid150cc
Cytology examination
Radiotherapy consult
Medical Physics and Rehabilitation
consult
IVFD NaCL 0.9% 20 dpm
Aspar-K 3x1
Re-staging

awat Jalan
No

Identitas

Diagnosis

Keterangan

Ny. S
48 th
01067198

Contusio Musculorum R Genu (D)

Asam mefenamat 3 x 500mg

nn.T
19 th
01317371

Vulnus ekskoriasi R Antebrachii (D)

Asam mefenamat 3 x 500mg

Pavilliun
No

Identitas

Diagnosis

Keterangan

Ny. D
49 th
01317372

Ca ductal mamae (D) T4dN1M1

MRS Paviliun

Ny. E
53 th
01317556

Ca lobular infiltrat T4bN0M1 (paru+tulang)

+ Post radioterapi + Post kemoterapi

MRS Paviliun

An. A
4 th
01317385

EDH R Parietal (D)

Craniotomy
MRS Paviliun

Konsulan
No

Identitas

Diagnosis

Tindakan

Meninggal
No

Identitas

Diagnosis

No

Identitas

Diagnosis

Keterangan

AP
S

Keterangan
-

Nama
Umur
No CM
Adm

: Ny. Pn
: 48 Thn
: 01297541
: BPJS

Keluhan Utama :
Nyeri pada payudara kanan

RPS :
Dua hari SMRS pasien mengeluh nyeri pada payudara kanan yang
semakin lama semakin bertambah, disertai timbul benjolan di payudara
kanan yang awalnya sebesar kelereng dan bertambah besar. oleh
keluarga pasien dibawa ke RSDM

RPD :
Riwayat timbul benjolan di payudara kanan 1 tahun SMRS
Riwayat biopsi insisi bulan april 2014, Hasil PA : Ca epitel ductal invasif
Riwayat kemoterapi 3 kali (Brexel-carboplatin)
Riw. KB (+) suntik tiap tiga bulan selama 24tahun
Jumlah anak 4, riw menyusui (+),
melahirkan anak I usia 18 tahun
Riw Menarche pertama usia 12 tahun
Riw keluarga menderita penyakit serupa (-)
Menopause (-)

Secondary Survey
Vital sign : TD : 130/80mmHg N : 90x/mnt RR : 26x/mnt T : 36.8c
Karnofsky skor
: 80 %
Kepala
: t.a.k
Mata
: t.a.k
Telinga
: t.a.k
Hidung
: t.a.k
Mulut
: t.a.k
Leher
: t.a.k
Thorax:
I
: Pengembangan dada ka=ki
P : Fremitus (+/+)
P : Sonor / Sonor
A : SDV (+/+), ST (-/-)
Abdomen : t.a.k
Ekstremitas
: t.a.k

Status Lokalis
R. Mammae (D) :
I : Tampak ulkus (+) uk 8x5x3 cm, Pus (+),
Peau dorange (+), skin dimpling (+), retraksi
nipple (+), nipple discharge (+)
P : Massa (+) uk 8x5x3 cm, konsistensi keras,
berbenjol benjol, terfiksir pada dinding dada,
R. Supraklavicula (D) :
P : Teraba pembesaran KGB Uk 2x1cm,
Terfiksir (+), NT (-)
R. Aksilla (D) :
P : Teraba pembesaran KGB Uk 2x1cm, terfiksir
(+),NT (-)

ASS I :
Ca epitel ductal mammae (D) T4cN3cMx Post kemoterapi 3 kali (Cyclophospamide doxorubicin)

PLAN I :
-

O2 3 Lpm
Inf. RL 20 tpm
Inj. Metamizole 1g/8 jam
Lab DR
Ro. Thorax

ASS II :
Ca epitel ductal mammae (D) T4cN3cM1 (paru) Post kemoterapi 3 kali
(Cyclophospamide doxorubicin)

PLAN II :
MRS Bangsal
Staging ulang

Jam Datang

09.30

Jam Triage

09.45

Jam Bedah

09.50

Jam Lab

10.00 10.50

Jam radiologi

10.10 11.00

Jam Diagnosa

11.10

Jam MRS

11.20

NAME
AGE
MR
SP

: Mrs. P
: 61 Y.O
: 01317379
: BPJS

Chief Complain :
Dypsnoe

Recent Illness :
Three days prior admission patient have a dypsnoe and feel pain on the left arm
pit mass. Headache (-), back pain (+). Then patient was taken to Klaten General
Hospital by her family, got IV line therapy, and drugs injection. Due to lack of
facility, patient then referred to dr.Moewardi General Hospital.

Past Illness:
History of menarche : 14 y.o
Marriage history : 20 y.o
First pregnancy : 21 y.o
Family history of breast cancer : (-)
Contraseption History : Using IUD for about 2 years
The patient have been performed mastectomy at Klaten General Hospital in 2011
Chemotherapy History : 6 Cycles of Cyclophospamide/Adriamycin/5-FU regiment

PHYSICAL EXAMINATIONS
Vital Sign
BP : 120/70 mmHg
Pulse
RR : 28 tpm
Temp
Karnofsky score : 60%

: 96 tpm
: 36,4 C

Head : no abnormality
Eyes : no abnormality
Nose : no abnormality
Mouth : no abnormality
Ear
: no abnormality
Neck : no abnormality
Chest : I : chest expansion right > left
P : fremitus right > left
P : sonor/dullness
A : vesicular breath sound (+/+), additional sound (-/-)
Stomach : no abnormality
Limbs : no abnormality

LOCAL PHYSICAL EXAMINATIONS

Left Breast Region:
I : Mass and ulcer from previous Mastectomy
4x3x2cm, redness (+), satellite nodules (+)
P : Hard mass , reguler border, fixed to chest wall (+)
pain (+)
Right and Left Supraclavicular Region :
P : Lymph node (-)
Right and Left Infraclavicular Region :
P : Lymph node (-)
Left Axillary Region :
I : Operation scar (+)
P : Lymph node (-)
Right Axillary Region :
P : Lymph node (-)

LOCAL PHYSICAL EXAMINATIONS

Thoracolumbar Region :
L : Swelling (-)
F : Pain (+) at VTh VIII IX, Sensoric + +
+ +
M : Motoric 5 5
5 5

ASS I :
- Recurent Left Breast Cancer TxNxMx + Post Mastectomy + Post
chemotherapy Cyclophospamide/Adriamycin/5-FU 6 Cycles
- Susp. Left pleural effusion
- Susp. Vertebral metastase

PLAN I:
O2 3 lpm
IVFD RL 20 tpm
Inj. Metamizole 1 gr / 8 Hours
Inj. Ranitidin 50 mg / 12 Hours
Blood examination
Chest X-ray, Thoracolumbal AP/L X-ray

ASS II :
- Recurent Left breast Cancer TxNxM1 (Lung + Bone) + Post MRM +
Post chemotherapy Cyclophospamide/Adriamycin/5-FU 6
Cycles
- Left pleural effusion
- Hyponatremia
- Hypocalemia
- Compression fracture VTh VIII IX

PLAN II :
Inward
Tapping Yellow clear fluid150cc Cytology examination
Radiotherapy consult
Medical Physics and Rehabilitation consult
IVFD NaCL 0.9% 20 dpm
Correction of hypocalemia : Kx0.4xBW : (3,7-2,7)x0.4x50 = 20meq
Aspar-K 3x1
Re-staging

Arrival time

14.10

Triage time

14.20

Surgery Dept. time

14.30

Laboratory time

14.40 15.40

Diagnose time

16.00

Inward time

16.10

THANK YOU

Dr.BM

Nama
Umur
No CM
Adm

: Ny. S
: 46 Thn
: 01317383
: BPJS

Keluhan Utama :
Nyeri pinggang kiri

RPS :
Dua hari SMRS pasien mengeluh nyeri pinggang kiri
terus menerus, karena nyeri tidak berkurang oleh
keluarga pasien dibawa berobat ke RS Amal sehat
Sragen. Disana pasien dipasang infus, injeksi obatobatan, tambah darah dan dilakukan pemeriksaan USG
perut. Karena keterbatasan sarana pasien dirujuk ke
RSDM dengan diagnosa Ca Renal.

RPD :
Riwayat operasi pangangkatan ginjal kiri di RSUD
Sragen tahun 2015, hasil PA : Renal Cell Ca

PEMERIKSAAN FISIK
VS : T : 150/80mmHg
N : 104 x/mnt
Rr : 20 x/mnt
S : 36,9C
Kepala
: t.a.k
Mata : t.a.k
Hidung
: t.a.k
Mulut : t.a.k
Telinga
: t.a.k
Leher : t.a.k
Toraks
: t.a.k
Abdomen
: t.a.k
Ekstremitas : t.a.k

STATUS UROLOGIS
Regio Flank (D/S) :
I : bulging (-/-), Massa (-), Scar OP (-/+)
P : ballotement (-/-)
P : NKCV (-/+)
Regio Suprapubik :
I : Distensi (-)
P : Nyeri tekan (+)
Regio Genitalia Eksterna :
I : OUE tidak hiperemis

Hidronefrosis Ren (D) gr III

ASS I :
Dx Emergency : Urosepsis
Dx Primer
: Renal cell carcinoma TxNxMx, post
Nefrektomi (s)
Dx Kompilkasi : Dx Lain-Lain : PLAN I :
IVFD NaCl 0,9% 20 tpm
Inj Ceftriaxone 1 gr/ 12 jam
Inj Metamizole 1 gr/ 8 jam
Cek DL, elektrolit, urinalisa
Ro Thorax, BNO

ASS II :
Dx Emergency : Urosepsis
Dx Primer
: Renal cell carcinoma TxNxM1 (paru),
post nefrektomi (s)
Dx Kompilkasi : Anemia
Hiponatremia
Dx Lain-Lain : PLAN II :
MRS
Kultur urin + darah
Transfusi PRC 1 kolf
Koreksi Na dengan NaCL 0,9%
CT scan abdomen dengan kontras

04:11