STASE BEDAH ONKO EWB 2 MAR 2020

N IDENTITAS MRS KMR DPJP DIAGNOSIS RIWAYAT RENCANA PENUNJANG KETERANGAN

O
R1A
R2A
1. Sukimah/ 53 23/2 2.1 YAN Tumor mammae dextra c/ Pasca biopsy insisi + Pemulihan pasca Hasil lab 24/2/2020 Produksi drain: 5cc/24
th/ C792933 (Mau ganas T4bN0M0 FS ganas MRM operasi H+7 Hb: 11,5 leu: 16.500 jam
pindah dextra (24/2/20) Perawatan luka tromb: 283.000 Usul Rawat Jalan
bed
5.3) GDS: 110
SGOT: 23 SGPT: 14
ur: 19, cr: 0,9
Nat: 142 K: 4,1 cl:
103
PPT: 12,1(K:15,1)
PTTK: 28,4 (K: 29,
4)
2. Ny. Diana/ 28/2 2.5 BIS melanoma maligna regio pasca wide eksisi + Perbaikan Ku Hasil lab 28/2/2020 GDS hari ini : 228
61/th/ C hemithorax dextra TxN0M0, biopsi PA (6/2/2020), Rencana wide eksisi + Hb:11,1 leu: 10.000
806515 + bronchopneumonia + RS aro pekalongan) diseksi axilla dextra tromb: 327.000
hiperglikemia ur: 28 cr: 0.9
Nat: 139 K: 4.0 cl: 94
PPT: 10.6(K:10.5)
PTTK: 32.5 (K: 32.5)
3. Ny. Suwarni/ 26/2 4.1 DH Papiler Ca Thyroid Pasca Pemulihan pasca Hasil PA 2006: Produksi drain: 10cc/
51 th/ 769118 TxN1Mx isthmolobektomy operasi H+3 Adeno follikuler 24 jam
sinistra (2006, RS Perawatan luka tiroid
sultan Agung) pasca
Total thyroidektomy
(28/2)
4. Ny. Ramini/ 27/2 5.2 BIS Invasive ca of NST gr II MRM 2018 KT 6x Pemulihan pasca Hasil lab 26/2/2020 Produksi drain: 3
57 th/ mammae sinistra residif ( Doxo, pacli), Pasca operasi H+4 Hb: 11,5 leu: 5.300 cc/24 jam
C678356 local Wide eksisi (27/2/20) Perawatan luka tromb: 194.000 Usul rawat jalan dan
GDS: 74 Aff drain (Acc dr BIS)
ur: 30 cr: 1.0
Nat: 141 K: 3,4 cl:
111
PPT: 13,4(K:11,3)
PTTK: 46.0 (K: 30.9)
5. Ny. Surip/ 70 25/2 6.1 BYT Basosquamous cell Riwayat wide eksisi Pemulihan operasi H+4 Hasil lab 27/2 Raber Plastik
th/ C613256 carcinoma TxN1Mx region (2017, RSDK) Perawatan luka Hb: 12 leu: 6.700
nasal, anemia Wide eksisi + FS tepi tromb: 230.000
dan dasar bebas GDS: 100
tumor + rekonstruksi
 STASE BEDAH ONKO EWB 2 MAR 2020

pasca ur: 3p, cr: 1,2

keganasan(27/2) Nat: 145 K: 2,u cl:
110
PPT: 10,9(K:11,1)
PTTK: 39,8 (K:
32,1)
6. Wati/ 47 th / 14/2 6.2 BIS Invasive lobular carcinoma MRM dextra(2018, Perbaikan KU Hasil lab 14/2 Post tapping pleura
C612369 nuclear gr III mamae dextra RS tugu), ER 26x Rawat bersama Gizi Hb: 10,6 leu: 9.300 21/2
stadium advance, malnutrisi, (2018, RSDK), KT klinik Tromb: 558.000 Hasil: 600 cc
bronchopneumonia, Efusi 17x(grexel, doxo, Rawat bersama interna GDS : 56 serohemorrhage
pleura dextra, suspect efusi curasil, cisplatin, Ur: 49 cr: 1,3 Post tapping pleura
pleura sinistra, 2018,RS tugurejo) Mg: 0,67 kalsium: 1,9 dextra (26/2): 700 cc
pasca pericardiac Nat: 129 K: 4,3 cl: cairan kuning jernih
window 89
PPT: 18,8 (K:11,2)
PTTK : 57,3(K:33,1) TS interna :
Hasil Ro thorax 18/2 Inj. Metal prednisone
Efusi pleura dextra, Inf. Levofloxacin
suspect efusi pleura Nebulizer flixotide
sinistra Nebulizer combivent
R3B
R4A
7. Ny. Herawati/ 26/02 2.3 BIS SNNT sinistra c/ ganas Riw. Laminektomi + Pro TT Hb 12.6, TSHs 2.71,
47 Th/ T2N1M0 internal fiksasi (Juli FT4 10.32
C765954 Paraparase inferior e.c. canal 2019, RSDK) -- PA =
stenosis V. L1-2, L3-4 metastasis malignant
epitelial tumor tiroid
8. Ny. 01/03 1.1 YAN Giant Fibroadenoma Riwayat Eksisi Rencana MRM dextra Lab 01/3/20 Raber Interna
Marchamah / mammae dextra dd/ Benign (2016) RS Tugurejo (2/3/20) Hb : 11,9 leu : 14,1
47 th / Phylloides, DM type II Semarang Tromb: 464.000
C799014 PA = Giant GDS : 238
fibroadenoma Nat : 138 K:3,9
mammae Cl:105
PPT:10,8 (K:10,2)
PTTK : 34,6 (K:31,0)