List Pasien Bedah Onkologi

02 Maret 2021
NO. IDENTITAS TGL RUANGA DIAGNOSIS DPJP Pemeriksaan RENCANA
MASUK N
1 Jacquelin 17/02 Rb6 • Decreased DR. Dr. Laboratorium (26/02) : Bone Scan + Head CT Scan + Iv Contrast, USG
e/ P/ /2021 Consciousness Kamal Basri 9,3/26.350/223.000 Liver bila transportable
55th/ (Hari • (L) breast Sp.B(K)Onk Alb : 2,7 Transfusi PRC 1 bag (175 cc)
82.67.98 Rawat Neoplasm Sugg Ur/Cr : 118/0,69 Diet Tinggi Protein via NGT
ke 14) Malignant KGD (02/03) : TS Neurologi  Rencana MRI Spine
cT4aN2M1(liver,bo TS Interna  Injeksi Novorapid 10-10-10
ne,brain) Radiologi Injeksi Lantus  0-0-14
• Soft Tissue Tumor Ro Thorax (tgl ) : tidak
o/t (R)upper arm tampak metastasis paru
• Neurogenic
Bladder Retention Histopatologi:
• DM tipe II Lengan (tgl ): Benign
• Anemia (9.3) Lesion
• Hipoalbuminemia( Mammae (tgl ): Invasif
2.7) Breast Carcinoma NST
grade I
Raber Interna dan
Neurologi
NO. IDENTITAS TGL RUANGA DIAGNOSIS DPJP Pemeriksaan RENCANA
MASUK N
2 Turiana/ 23/02 Pavi • Post (L) Simple DR. Dr. Laboratorium (25/02) Aff drain substernal, axila bawa pulang
P/ 50th/ /2021 lt7 Mastectomy d/t Kamal Basri 12,6/ 10.450 / 247.000 R/ PBJ Besok
35.99.30 (Hari (L) Malignant Siregar Sp.
Rawat phyllodes Tumor (K)Onk Radiologi:
ke-8) (POD 5) Thorax Xray (tgl ): tidak
• (R) Breast cancer tampak metastasis
TxNxM1(Bone)
• Post MRM (2014) Histopatologi (tgl ):
post AC 6x post Malignant Phyllodes
Radiotherapy 30x
Drain :
Substernal : /24 jam
Axilla : /24 jam
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
3 Siti 19/02/20 Rb6 • Ca Thyroid T3N1M1(lung, DR. Dr. Kamal Basri Laboratorium (24/02) Susul Jadwal Bone Scan
Rajana/Pr/60 21 bone) Siregar Sp.(K)Onk 11,7/ 7.640/ 239.000
thn/ 81.64.49 (Hari • Paraplegia
rawat ke- Radiologi :
12) MRI Whole Spine
tanpa kontras (tgl
27/10/2020)
Metastasis bone
Ro Thorax (tgl
21/10/2020): sugestif
metastasis paru
dengan limfadenopati
hilus kana

Histopatologi:
FNAB (tgl ): Condong
Papillary Thyroid
Carcinoma
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
4 Reza/ L/ 39th/ 21/02/2021 Pavi Lt 7 • Post debridement Dr. Deny Rifsal Laboratorium (27/02) Menunggu
82.72.19 (Hari rawatan d/t Neck Abscess Sp.B(K)Onk 9.7/ 8.970/ 505.000 Regimen Kemo
ke -10) POD Na/K/Cl (01/03) TS Plastik 
• SCC lidah T4N1M0 124/4.3/94 Debridement
• DM tipe II Ur/Cr : 13/0.44 Hari Rabu
Albumin : 20.0
KGD Puasa : 85
KGD 2PP : 111

Radiologi (20/02) :
Soft tissue swelling disertai emfisema
subkutis supraklavikula bilateral
sampai axilla kanan

Histopatologi tgl :
Keratinizing Squamous Cell
Carcinoma, moderately differentiated

5 Erdina/ P/ 22/02/2021 RB6 • Fibrosarcoma Dr. Deny Rifsal Laboratorium (22/02) •Transfusi PRC
37th/ 81.41.56 (Hari ke- ) GxT4N0M0 o/t (L) Sp.B(K)Onk 2,0/ 15.020/ 269.000 7 bag (sudah
Shoulder Post NAC Na/K/Cl : masuk 6 bag)
8x with Progressive 131/2.7/97 •Lengkapi
disease berkas rujukan
• Anemia (2.0) Radiologi : ke Dharmais
• Hipokalemia (2.7) Ct Scan (tgl ) : soft tissue tumor ( dr. Dedy)
malignant, susp malignan lifoma •Head CT Scan
IV Contrast
Histopatologi (tgl 27/02 ):
Fibrosarcoma
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
6 Tiurlan/ P/ 68th/ 22/02/2021 Rb6 • (R) Thyroid Neoplasm Sugg DR.dr Kamal Laboratorium (24/02) Susul Hasil
82.73.22 (Rawatan ke- Malignant cT3N1M1(Lung) Basri Siregar 9,7/ 7.600/ 192.000 Neck CT Scan
9 ) Sp.B(K)Onk Na/K/Cl : IV contrast
137/3.8/108
Ur/Cr (25/02): 34/0,92

Radiologi:
USG Thyroid (tgl )->Tirads
4
Ro Thorak (Tgl 22/02):
sesuai gambaran
metastasis paru
USG Liver (25/02) : tidak
tampak metastasis

Histopatologi:
FNAB (Tgl ) : thy 5.
Malignant Smear

7 Rizky/P/29th/ 24/02/2021 RB6 • Post (L) chest tube insertion DR. Dr. Kamal Laboratorium (01/03): • Transfusi PRC
82.74.06 (Rawatan ke- + WSD d/t (L) Pleural Basri Siregar Sp. 7.8/18.420/250.000 3 bag
7 ) effusion POD 6 (K)Onk •Pantau Drain
• (R) malignant phyllodes Drain (+)200cc/24 jam •Rencana Core
tumor seroushemoragik Biopsi Ulang
• Anemia (7.8)
Radiologi :
Chest X-Ray (tgl 24/02 ):
efusi pleura bilateral

Histopatologi (tgl 20/02 ):

Benign Stromal Lesion
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
8 Hotmauli/ P/ 34th/ 24/02/2021 Rb6 • Decreased Consciousness DR. Dr. Kamal Laboratorium (25/02) Head CT scan
74.98.30 (Hari rawat • (L) Breast cancer T4cN3M1 Basri Siregar Sp. 10,6/ 6.890/ 437.000 dgn iv contrast
ke -7) (brain, lung,bone, (K)Onk ( Selasa)
contralateral) post Radiologi: dengan
chemotherapy 8 cycle Ro THorax(23/02): tidak pendampingan
tampak gambaran anestesi
metastasis
Bone Scan : (26/08/2019)
tampak gambaran
metastasis

Histopatologi (16/01):
Invasive ductal carcinoma
grade II, TILS ringan

9 Dumariannur/P/53th/ 24/02/2021 ICU Pavi Post Wide Excision + dr. Suyatno Laboratorium : Menunggu
71.96.12 (Hari rawat Reconstruction + Thoracotomy Sp.B(K)Onk 10,2/ 7.240/ 243.440 hasil PA
ke-6) (POD4) d/t Fibrosarcoma o/t (L) Pindah ruangan
Back G2TxN0M0 Radiologi : menunggu acc
Thorak Ct-Scan (22/12): DPJP
massa solid pleura kiri
dengan tipikal sugestif
malignant

Histopatologi (26/02) :
Suatu Fibrosarcoma grade
I
Operasi :
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
10 Marsaulina/Pr/62thn/ 26/02/2021 Rb6 • (L) Breast Ca TxNxM0 post DR. Dr. Kamal Laboratorium (26/02): Inj Leukogen 2
82.15.31 (Hari Rawat MRM Basri Siregar Sp. 8.4/ 220/ 56.000 Vial -> Hari ini
ke-5) • anemia (8.4) (K)Onk Na/K/Cl: vial ke-2
• leukopenia (220) 108/2,6/73 Transfusi PRC
• trombositopenia (56.000) Ur/Cr : 79/2.29 2 bag
• hiponatremia (108) Tapping
• hipokalemia (2.6) Radiologi (26/02) Seroma
• AKI std I Chest X-Ray: tidak tampak
gambaran metastasis
Bone Scan : Tampak
gambaran metastasis

Histopatologi:
Invasive ductal carcinoma
grade III
Reg kemo : cisplatin
+Brexel

11. Samsudin/L/40 23/02/2021 Rb6 Limfadenopati Colli dd NHL Dr. Denny Rifsal Laboratorium R/
th/82.38.21 (Hari rawat Siregar, Sp.B(K) (25/02/2021): Limfadenekto
ke-8) Onk 8,5/7.780/192.000 mi
Albumin : 2,6 Susul hasil
Ur/Cr : 26/0,54 Swab
Na/K/Cl ; 135/3,8/101 Diet MB
AGDA : ekstra protein
pH/pC02/p02/HCO3/TCO2/
BE/ SaO2 :
7,28/8,0/184/3,8/4,0/-
19,9/99
FNAB (10/01) : Condong
suatu NHL
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
12 Susanti/P/37 tahun 17/02/2021 Rb1 Limfadenopati Dr.dr. Kamal Lab (25/02) R/ Review
82.58.44 (Hari rawat generalisata (metastatic Basri Siregar, 10.4/47.300/162.000 slide dari RS.
ke -14) carcinoma) + (R) pleural Sp.B(K) Onk Albumin : 2.8 Murni Teguh
effusion Ur/Cr : 83/1,78 Btkv: Thorax
drain kanan
PA (24/02/2021): Malignant Lesion (Senin)
Histopatologi gambaran Metastasis Diet TKTP
Carcinoma Rencana Joint
Conference
dengan Obgyn

13 Fingki Ledia/P/23th 28/02/2021 Rb6 Post Eksisi d/t (R) dr. Suyatno, Lab (19/02) R/ Pantau
82.18.87 (Hari rawat Hygroma Colli - POD 1 Sp.B(K)Onk 12,3/5.900/263.000 Drain
ke-3) Susul Hasil PA
Na/K/Cl
141/4.1/105
Albumin : 4.8

CT Scan Neck IV Contrast

(17/11/2020) : Suspek Limfangioma
dd/Kistik Limfangioma, kista
dermoid

FNAB(01/07/2019) : NHL sugg

Small Lymphositic Lymphoma

Histopatologi (16/11/2019): Benign

Lesion
NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
14 Keristina/P/42 tahun 28/02/2021 Rb6 Post Nodul dr. Suyatno, Lab (25/02) R/ Susul
79.26.64 (Hari rawat Excision d /t (R) Sp.B(K)Onk 10.1/9.390/338.000 Hasil Biopsi
ke-3) Breast Ca
cTxNxM1 (bone) Na/K/Cl : 142/3.8/107
post MRM susp Ur/Cr : 19/0.63
Recurent - POD 1 KGDS : 107

Foto Thorax (13/01) Tidak tampak gambaran

Metastasis
USG Liver (13/01): Tidak tampak metastasis
Bone Scan (18/01/2021) : Gambaran
patologis pada tulang sesuai proses
metastasis

15 Roslina br 28/02/2021 Rb6 Post Incisional dr. Suyatno, Lab (15/02): R/ Susul
Payung/P/61th (Hari rawat biopsy d/t (R ) Sp.B(K)Onk 10.3/10.650/287.000 Hasil Biopsi
58.34.71 ke-3) Breast Ca Na/K/Cl : 134/3.5/103 PBJ (02/03)
cTxNxM1(lung)
susp residif - POD Foto Thorax (15/02): Solitary Pulmonary
1 Nodul ec Metastasis Paru

USG Liver : Tidak tampak metastasis

Head CT Scan : tidak tampak metastasis

Histopatologi (2014): Invasive Ductal

Carcinoma, Gr III dengan metastasis pada 5
kgb

Operasi : Insisi Biopsi (01/03)

NO. IDENTITAS TGL MASUK RUANGAN DIAGNOSIS DPJP Pemeriksaan RENCANA
16 Siti Gahara/P/42 28/02/2021 Rb6 • Post Tracheostomy dr. Denny RIfsal, USG Leher + Thyoid (20/01) : lesi maligna Raber BTKV
tahun (Hari Rawatan with impending Sp.B(K)Onk disertai lesi solid dan kistik dengan Rencana
82.53.31 3) obstruction d/t pembesaran KGB Leher Radiasi ke-5
Anapalstic thyroid Ca menunggu
T4bN1M1(lung) Ro Thorax (01/03) : Nodul multiple kedua regulasi HD
• Post (L) Chest tube paru + Effusi paru kiri masih mungkin
insertion d/t (L) metastasis
Emphyema. Soft tissue mass regio colli bilateral dd/
massa thyroid sugg malignant

17 Masitah/P/67th 01/03/2021 Rb 6 • (L) Breast Ca dr. Denny RIfsal, Lab (25/02) MRM Hari
81.78.66 (Hari Rawat T4bN1Mx Post NAC Sp.B(K)Onk 11.5/6.950/207.000 ini
ke-2) 6x Ur/Cr : 32/0.8
Na/K/Cl : 137/4.2/102
KGDS : 102

USG Liver (08/02)

Tidak tampak gambaran metastasis liver

CT Scan Thorax IV Contrast (25/09/2020) :

Massa mammae kiri + lymphadenopathy
aksila kiri dan sugestif + sugestif proses
metastasis

Histopatologi (03/09/2020)
Invasive Breast Carcinoma NST, WHO grade
III
Regimen Kemo : doxorubicin –
cyclophosphamide -5FU (2020)