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LIST PASIEN ONK-KL 01-12-2019

A Atas

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

1. A1 bed 2 Tumbol jeremiah/L/25 Fraktur 23/11/19 - rawat luka


thn /60.89.10 Zygoma
leu: 12.3 - analgesic
dextra
DPJP: dr. Nico Lumintang,
erit: 5.31 - antibiotik
SpB (K) KL
Hb/Ht:15.8 / 45.3 R/orif
(MRS : 23-11-2019)
tromb: 251
S: Nyeri pada pipi (-)
MCH : 29.8
O: Ku baik,
MCHC : 34.9
Regio zygoma dextra:
flatening (-) diplopia (-) MCV : 85.2
parestesia (-)

2. A2.B2 Kawuwung M. Ca mammae 01/12/19 Perbaiki KU


Martha/P/71th/143537 dextra
Leu:3.9
cT4N0M1 on
MRS: 01/12/2019
kemotherapy Eri;3.01
DPJP: dr. Marcelus Merung, +
Hb/Ht:10.0/26.9
SpB(K)Onk
Efusi pleura
dextra Sgot/Sgpt:68/51

S : kelemahan badan (+) Cl:92.2

O: KU sedang Kes CM Na: 127

Thirax : scar (+)

3 A3.B3 Laba Aisa/P/47thn/707554 Ca mammae 01/12/19


sinistra pro
MRS : 02-12-19 Leu:9,7
kemoterap i
DPJP : dr. Christian Eri;4,46
Manginstar SpB(K)Onk
Hb/Ht:12,2/34,8

Trom:410

Cl:92,5

Na:131

K 3,16

4 A5B2 Kawulusan Oktafian Abses regio 30/11/19 R/ drain jika.KU naik


Verby/L/32th/541356 femoralis
Leu:13.0 Analgetik
dextra + RVD
MRS: 01/12/19
on HRV Eri;3.54 Antibiotik
DPJP : dr. Christian
Hb/Ht:10.5/32.0
Manginstar SpB(K)Onk
Trom:581
S: nyeri pada paha kanan Cl:92.8

O: ku sedang Na:132

5 A6 B1 Tulangouw Leni Post insisi 28/11/19 Rawat luka


Marci/P/61th/377528 drainase ec
Leu:8.6 Analgetik
abses zygoma
(MRS:28/11/19)
sinistra Eri;3.71 antibiotik
Dpjp: dr. Christian
Hb/Ht:10.8/32.3 Cek lab
Manginstar SpB(K)Onk
Trom:315

S: nyeri berkurang MCH:29.0

O: ku baik Mchc:33.3

Regio zygoma sinistra: luka MCV:87.1


terbuka Sgot/Sgpt:24/21

Ur:39

Cr:0.8

Gds:98

NA/K/Cl:136/3.90/
97.0

6 A6 Bed 3 Tunggali hadija/P/57 tahun Fraktur 30/11/19 - O2


zygoma
MRS : 30-11-2019 Leu:14.9 - cegah cedera otak
DPJP : dr. Nico Lumintang, dextra Eri:4.08 - elevasi bed
SpB (K) KL 30derajat
Ht:35.3
- analgetik
Sgot/Sgpt:53/71
S: nyeri - - antibiotik

O: ku sedang

Regio zygoma dextra:


flatening sde, diplopia (-),
parestesia (-)

7 A6 bed 4 Lantu Ca mammae 26/11/19 -Analgetik


Saartje/P/77th/708157 s + efusi
Eri: 3.53 -Antibiotik
pleura dextra
Mrs: 27/11/2019
HB/HT 11.0/31.5
DPJP: Dr. dr. Victor Pontoh
Sgot: 80
SpB (K) Onk
Ur: 83

Cl: 97.9
S : sesak

O : Ku sedang

Regio mammae sinistra:


benjolan +
8 A6 Bed 6 Mokodompit Tumor 02/12/19 Cek DL, na K Cl
Rahmawati/P/44th/ 706923 mammae
Leu: 19,4 Antibiotik
dextra +
(MRS: 29/11/19) Analgetik
anemia Eri:3.84
Dpjp: dr. Christian Pro kemoterapi
Hb:10,3
Manginstar SpB(K)Onk
Ht:28,9

S : lemah badan Trom:746

O : KU sedang Mch:26,8

Regio mammae D benjolan Mchc:35,6


ukuran 15x15 cm Mcv:75,4

9 A6 bed 8 Rangkang CA mammae 30/11/19 -post ...


Altje/580123/P/54thn/28/8 sinistra +
Eri: 4.24 -analgesic
/1965 efusi pleura
bilateral + Ht: 35.4 -antibiotik
(MRS: 23/11/1965)
efusi
Albumin: 2.08
DPJP: dr Christian M, pericardiac
SpB(K) Onk Cl: 86.5

K: 6.13
S : Sesak berkurang Na: 127
O : Ku baik

Regio mammae sinistra:


benjolan +

10 A7.2 Pangemanan Revlos/L/61th fraktur 02/12/19 Analgesic


maxila
Dpjp: Sherly Tandililing SpB Leu:14.8 Antibiotic
sinistra
(K) KL
Eri;4.33 Pro ORIF elektif

Hb/Ht:13.6/38.2
S : Nyeri (+)
Trom:218
O : Ku sedang
MCH:31.5
Regio maxilla sin: edema
(-), flatening (-) Mchc:35.8

MCV:88.1

Sgot/Sgpt:59/38

Ur:22

Cr:1.0

Gds:130

NA/K/Cl:135/3.72/
96.3

11 A8.6 Murtini/P/42 th/ 703839 Post MRM ec 29/11/19 Rawat luka


Tumor
(MRS 8/11/19) phyloides Leu:33.3 Antibiotik
Dextra
Dpjp: dr. Christian Eri;3.68 Analgetik
Manginstar, SpB (K) Onk
Hb/Ht:10.6/31.4

Trom:297

MCH:28.9

Mchc:33.9

MCV:85.4

Sgot/Sgpt:16/7

Ur:20

Cr:0.5

Albumin : 1.53

NA/K/Cl:134/4.79/
104.2

12 A10.3 Runtu Sony/L/58th/709303 Abses 02/12/19 Rawat luka


Submandibul
(MRS:27/11/19) Leukosit 5,7 Analgetik
a Sinistra
Dpjp: dr. Sherly Tandililing Eri:3.12 antibiotik
SpB(K)KL
Hb/Ht:9.4/26
S : nyeri berkurang Trom: 259

O : KU sedang MCH : 30,1

Regio submandibula sin: MCHC : 36,2


luka terawat
MCV 83,3

A Teratai

No Ruangan Identitas Diagnosis Penunjang Tatalaksana


13 K1.B1 Samola Nurmin F Ca Mamme 21/11/2019
th
Ramayani/P/59 /564767 Dextra on
Leu:6.8
kemoterapi
MRS: 27/11/19
T4N3Mx Eri:2.63
Dpjp: dr. Christian
Hb: 7.9
Manginstar SpB(K)Onk
Ht: 21.3

S : lemah badan Trom:207

O : Ku sedang MCH:30.0

Mchc:37.1
Mcv:81.0

Sgot/Sgpt: 21/11

Ur:51

Cr:3.4

Gds:95

Na/K/Cl : 130/4.34/97.9

14 K2.B2 Nontje Tumilaar/P/68 Struma multi 19/11/2019 konsul ibs


th
/184830 nodusa non 02/12/2019
leu : 6.3
toksik
DPJP : dr Nico Lumintang, -Pro total
Eri : 4.91
Sp.B(K)KL tiroidektomi
Hb : 15.3 03/12/2019

Ht : 44.6

Trombo : 276

MCH : 31.1

MCHC : 34.3

MCV : 90.8

Eosinofil :253
HBSAG : Non reaktif

IgE total 27.2

TSHS 1.52

FT 4 : 1.27

FT 3 : 5,88
15 K2.3 Panelewen Frida Struma nodusa Total
Fritje/P/61/274410/ST unilsteral non thryoidektom
toxic + general i
MRS : 01-12-2019 weakness +
poststabposterior
DPJP: Sherly Tandiling, + LBP
Sp.B(K)-KL

S: kelemahan umum

O : KU lemah Kes CM

Reg colli

Massa (+) nodul (+)

Permukaan tidak rata

K2 B4 Kawani Elfin/P/46th Ca Mammae 28/11/2019 -Xebada 3-


Dextra On 0-3
/706904/ MRS : 16/11/19 Leu: 16.3
Kemotherapy
16 -cek lab
DPJP : dr. Marcell, M Eri: 4.41
darah
SpB(K)Onk
Ht: 34.9 -rencana
kemo
S: lemah badan Tro: 493

O: ku sedang Mcv: 79.1

TD : 100/60 Cl:94.4

Region : mammae dextra, Na: 130


massa (+), ulkus(+)

17 K2B7 Welly Tumor colli susp Pro eksisi


Ritto/L/70/015019/NL simpel cyst thyroid tumor tgl 4
bilateral
MRS : 02-12-19

18 K2 B8 Kalumata Christian/L/32th/ SCC Lidah Post 27/11/2019 -Kemo jika


56056/ MRS:21/11/2019 Radioterapi lab darah
Leu: 10.9
normal
Eri: 2.84
-cek darah
S : Nyeri (+)
Hb/Ht:8.1/23.7 ulang
O : KU sedang, konjungtiva
anemis (-) Trombo: 521

Regio Intra Oral : Massa (+) Albumin: 2.16

Cl: 96.5
19 K2 B10 Mahu Delly/P/60th/709293 Ca mamme 16/11/2019 -Biopsi
sinstra + cancer insisional
MRS: 27/11/19 pain Leu:17.0 konsul ibs
02/12/19
Dpjp: dr. Christian Eri:4.42
Manginstar SpB(K)Onk -rawat luka
Hb: 10.8
-analgetik
Ht: 32.7
S : Nyeri di payudara kiri(+)
Trom:565
O : KU sedang
MCH:24.3

Mchc:32.8

Mcv:74.1

Ur:17

Cr:0.4

Gds:86

Na/K/Ch :
122/4.55/90.8

A Bawah

A Bawah

No Ruangan Identitas Diagnosis Penunjang Tatalaksana


12. B 2.1 Tambuwun Merry/P/48th Post MRM ec ca 26/11/19 Antibiotik
DPJP: dr.Christian, Sp.B(K) mammae s H.8 Leu:4.5 Analgesic
Onk Eri:2.05 Sulfasferosus
S: Nyeri luka operasi Hb/Ht/:6.5/18.0 3x1
O: regio mammae sinistra: Trom:212 Cek lab darah
luka terawat Gds:121
Na/k/cl:139/4.48/10
3/7
13. B 3.3 Hendrik Takalumang/L/20th post 30/11/19 - Rawat
/705482 trakeostomi ec makro trakeostomi
DPJP : dr Nico Lumintang, prolong warnah : kuning /8jam
SpB(K)KL ventilator kekeruhan : jernih
Post craniotomi mikro
S : penurunan kesadaran decompresi ec erit : 3-4
O : KU: sedang, KS:sopor EDH leu : 0-1
regio colli tampak epitel : 0-1
trakeostomi terawat
14. B 8.4 Arnold Matheos/L/39th Sarcoma soft 27/11/19 -R/join operasi
MRS 19-11-2019 tissue tumor Leu : 12.9, digestif + plastic
DPJP: dr. Christian Erit : 3.54, -perbaiki KU
Manginstar, SpB(K)onk Hb/Ht : 10.1/27.8,
S: lemah badan, benjolan tromb :596
diperut Mcv: 78.5
O: abdomen: benjolan Cl: 94.6
uk.30 x20cm, ulkus (+) Na: 133
15. B 10.3 Selsiana /P/23th Post total 26/11/19 R/ aff drain
Dpjp dr. Christian M, SpB thyroidecomy Leu : 16.5, Rawat Jalan
(K) Onk H4 Erit : 4.34, Senin
Ht : 35.2
S : nyeri pada luka op gds: 201
O : Regio Colli : luka Magnesium: 1.69
terawat, drain ±100cc Cl: 97.5
Na: 134
16 10.4 Poha Rusni/P/53tahun Tumor 20/11/19 Pervaiki KU
DPJP : dr Christian Mammae Leu: 13.2 R/Biopsi
Manginstar,Sp.B(K)Onk Dextra Hb/Ht: 9.4/26.3
cT4N2Mx Susp. Tro: 611
Malignancy OT/PT: 25/19
Ur/Cr: 27/0.8
GDS: 330
Na/K/Cl :
85.6/3.17/133
17. B10.6 Papona Ca papiler 29/11/2019 -Pro total
Rosye/P/59th/509449 thyroid TSHS:0.67 tiroidektomi tngl
Dpjp: dr. Marselus Merung Ft4:1.35 : 3/12/19
SpB (K) Onk Ft3:4.47 -Konsul Ibs
2/12/19
S : benjolan dileher kiri Ro. Thorax PA:
O : Ku sedang Cardiomegali
Reg.coloi: benjolan(+)
fixed(+)
18. B 10.8 Paputungan Nonong Ca mammae Lab 24/11/19 UsG abdomen
DPJP: dr. Christian M, SpB sinistra on kemo Leu: 10.1 2/12/19
(K) Onk Eri: 3.20 Analgetik
Hb: 9.7
S : lemah badan dan nyeri Ht: 27.5
perut Sgot/sgpt: 63/125
O: regio mammae s
benjolan +
19. B11.1 Mogi Cornelly/61th/P Basalioma 19/11/2019 R/Wide and
Dpjp: Dr. dr. Victor Pontoh orbita sinistra Leu:9.0 deep eksisi
SpB (K) Onk Eri:4.56 Sulfasferosus
Hb: 13.6 2x1
S: lemah (+) Ht: 37.7 Cek lab darah
O: regio epicantus medialis Trom:277 Transfusi Hb>10
s. Luka ukuran 3x2cm MCH:29.8
kehitaman +, perdarahan Mchc:36.1
aktif - Mcv:82.7
Sgot/Sgpt: 22/19
Ur:51
Cr:1.1
Gds:116
Na/K/Cl:135/4.53/96
.4

20. B9.2 Tapimpin yunus/L/44th/ Post laparotomi 29/11/19 Cek DL


Dr. Victor Pontoh appendektomi Leu:13.8 Rawat luka tiap
SpB(K)Onk ec peritonitis ec Eri:4.28 hari
appendektomi Hb/ht:13.5/37.4 Diet TKTP
S : nyeri (-), Bab (+), demam perforasi Trom:180 Mobilisasi aktif
(-) Mch/mchc/mcv:31.6 Rawat jalan bila
O : kesadaran CM /36.2/87.4 leukosit <10.000
21. B11.3 Sahara Ca Mamae 30/11/19 Perbaiki KU
Bawoel/P/39thn/00489644 sinistra on Leu: 13.2 Hyponatremia
DPJP dr. Marselus Merung, kemotherapy Eri: 3.67 Hypokalemia
SpB(K)Onk + General HB/HT 10.4/28.6
(MRS: 23/11/19) weekness MCV : 78.0
Ur/Cr: 184:18.0
S : Sesak berkurang Cl:77.1
O: ku sedang K: 4.21
Na: 109
22. B9.4 Asek dandle/L/54th/709460 Post laparotomi 28/11/19 Antibiotic
MRS:28/11/19 eksplorasi Leu:15.8 Analgetik
DPJP : Dr. Victor Pontoh Eri:4.24 Rawat luka
SpB(K)Onk Hb/ht:13.1/38.2 Diet susu
Trom:296 6x100cc
S : Nyeri luka operasi Sgot/sgpt:33/24 R/aff drain
O : Ku sedang, kesadaran Ur:63 besok
CM Cr:1.1
Gds:77
Na/k/cl:136/3.89/10
1.6
23. B11.2 Omoniyati/P/43th Tumor mammae 30/11/19 -Oksigenasi
dr. Marselus Merung SpB D cT4N2M1 Leu 6.3 Antibiotik
(K) Onk Efusi Pleura Hb:10.2 -analgetik
S: Sesak nafas (+) menurun dextra Ht:30.8 - cek hasil
O: Reg mammae sinistra Mch: 24.6 biopsii
benjolan (+), fixed (+) Ulkus Mchc 33.2
(+) Mcv:74
Reg eks sup dextra : Edema Na/K/Cl:
(+) 140/3.59/105.3
24 B1.2 Lengkey Jopie Djonny/L/53 Posy laparatomi 28/11/19
tahun Perforasi Gaster Leu : 15.0
MRS22/11/2019 Hb/ht 9.5/26.0
DPJP : dr Sherly Tandililing OT/PT: 26/14
Sp.BKL Ur/Cer: 48/1.3
GDS: 375
Na/K/Cl:
93.6/4.36/1.30
ICU

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

31. Bed 8 Tampah Joseph/L/71 th/ -Post Lab : 01/12/2019 -nebuliser


705262 trakheostomi ec berkala
Leu: 9.8
gagal nafas on
DPJP: dr. Sherly Tandililing, -perbaiki Ku
ventilator Eri: 2.71
SPB(K)KL
-Post Hb : 9.4
S: penurunan kesadaran
craniotomy
decompresi e.c. Ht: 25.6
O: KU berat
SDH
Trom: 145
-Syok septik
MCH/ MCHC/MCV :
34.7 /36.7/94.5

NA/K/CL:
133/3.43/89.6

SGOT : 96 SGPT : 49
Anggrek

No Ruangan Identitas Diagnosis Penunjang Tatalaksana

32. Anggrek 2 Senduk lot Limpoma brachii 21/11/19 -Rawat luka


th
atas K214 Imanuel/L/50 /707033 dextra
Leu:8.1 -RJ Besok
MRS:28/11/2019
Eri:5.18
Dpjp: dr. Christian M, SpB
Hb/ht: 14.6/40.3
(K) Onk
Sgot/sgpt: 22/21

Ur: 49

Cr: 1.9

Gds: 89

Na/k/cl:
133/4.16/98.4

PICU

No Ruangan Identitas Diagnosis Penunja good Tatalaksana


33. Bed 3 Potabuga EDH regio Lab : 29/11/2918 -Pro ORIF
Erza/L/16th/709022 frontotemporo elektif jika Ku
Eri: 6.7
dextra baik
DPJP: dr. Sherly Tandililing,
Hb : 8.1
SPB(K)KL Fraktur zygoma -analgetik
dextra Ht: 23.1
-antibiotik
Fraktur Trombo: 101
S : penurunan kesadaran -rawat luka
clavicular
MCH/MCHC/MCV :
267.6/35.1/2.7

Sgot:244

Sgpt:583

Ur:83

Cr:1.4

Na/K/Cl :
162/499/124.6

Calsium: 8.58

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