EXCELLENCE IS NEVER ACCIDENT…

IT’S RESULT OF

HIGH INTENTION,SINCERE EFFORT,

INTELLIGENT DIRECTION, SKILLFULL EXECUTION,

ANDTHE VISION TO SEE OBSTACLES AS OPPORTUNITIES

(ANONYMOUS)

LAPORAN JAGAMinggu, 18 Oktober 2015

Chief : dr. Esti Widiasari (EWI)Jaga 3 : dr. Wadhe (WOS) / dr. Indra (IND) / dr. Monica

(MYU)Jaga IGD : dr. Zulfadli (FDL) / dr. Dian (DIW) / dr. Adi (ADY)IPI : dr. Umar (MAR) / dr. Anto (AYT)Bangsal : dr. Marthin (MRT) /dr. Jiwandono (DON)

REKAP KUNJUNGAN IGD

No Identitas Diagnosis Tindakan

1. Ny. Pt48 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. P61 th01317379

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

inwardTapping Yellow clear fluid150cc Cytology examinationRadiotherapy consultMedical Physics and Rehabilitation consultIVFD NaCL 0.9% 20 dpmAspar-K 3x1Re-staging

Rawat Inap

Rawat Jalan

No Identitas Diagnosis Keterangan

1 Ny. S48 th01067198

Contusio Musculorum R Genu (D) Asam mefenamat 3 x 500mg

2 nn.T19 th01317371

Vulnus ekskoriasi R Antebrachii (D) Asam mefenamat 3 x 500mg

No Identitas Diagnosis Keterangan

1 Ny. D49 th01317372

Ca ductal mamae (D) T4dN1M1 MRS Paviliun

2 Ny. E53 th01317556

Ca lobular infiltrat T4bN0M1 (paru+tulang) + Post radioterapi + Post kemoterapi

MRS Paviliun

3 An. A4 th01317385

EDH R Parietal (D) Craniotomy MRS Paviliun

Pavilliun

No Identitas Diagnosis Keterangan- - - -

Meninggal

APS

No Identitas Diagnosis Keterangan- - - -

No Identitas Diagnosis Tindakan

- - - -

Konsulan

Nama : Ny. PnUmur : 48 Thn No CM : 01297541Adm : BPJS

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 SMRSRiwayat biopsi insisi bulan april 2014, Hasil PA : Ca epitel ductal invasifRiwayat kemoterapi 3 kali (Brexel-carboplatin)Riw. KB (+) suntik tiap tiga bulan selama 24tahunJumlah anak 4, riw menyusui (+), melahirkan anak I usia 18 tahunRiw Menarche pertama usia 12 tahunRiw keluarga menderita penyakit serupa (-)

Menopause (-)

Keluhan Utama : Nyeri pada payudara kanan

Secondary Survey

Vital sign : TD : 130/80mmHg N : 90x/mnt RR : 26x/mnt T : 36.8cKarnofsky skor : 80 %Kepala : t.a.kMata : t.a.kTelinga : t.a.kHidung : t.a.kMulut : t.a.kLeher : t.a.kThorax:

I : Pengembangan dada ka=ki P : Fremitus (+/+) P : Sonor / SonorA : SDV (+/+), ST (-/-)

Abdomen : t.a.kEkstremitas : t.a.k

Status LokalisR. Mammae (D) :I : Tampak ulkus (+) uk 8x5x3 cm, Pus (+),

Peau d’orange (+), 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 BangsalStaging ulang

Jam Datang 09.30Jam Triage 09.45Jam Bedah 09.50 Jam Lab 10.00 – 10.50

Jam radiologi 10.10– 11.00Jam Diagnosa 11.10

Jam MRS 11.20

NAME : Mrs. PAGE : 61 Y.OMR : 01317379SP : BPJS

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.oMarriage history : 20 y.oFirst pregnancy : 21 y.oFamily history of breast cancer : (-)Contraseption History : Using IUD for about 2 yearsThe patient have been performed mastectomy at Klaten General Hospital in 2011Chemotherapy History : 6 Cycles of Cyclophospamide/Adriamycin/5-FU regiment

Chief Complain : Dypsnoe

PHYSICAL EXAMINATIONSVital SignBP : 120/70 mmHg Pulse : 96 tpm RR : 28 tpm Temp : 36,4 °C Karnofsky score : 60%

Head : no abnormalityEyes : no abnormalityNose : no abnormalityMouth : no abnormalityEar : no abnormalityNeck : no abnormalityChest : I : chest expansion right > left

P : fremitus right > left P : sonor/dullness A : vesicular breath sound (+/+↓), additional sound (-/-)

Stomach : no abnormalityLimbs : no abnormality

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

LOCAL PHYSICAL EXAMINATIONS

5 55 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 lpmIVFD RL 20 tpmInj. Metamizole 1 gr / 8 HoursInj. Ranitidin 50 mg / 12 HoursBlood examinationChest X-ray, Thoracolumbal AP/L X-ray

PLAN II :InwardTapping Yellow clear fluid150cc Cytology examinationRadiotherapy consultMedical Physics and Rehabilitation consultIVFD NaCL 0.9% 20 dpmCorrection of hypocalemia : ∆Kx0.4xBW : (3,7-2,7)x0.4x50 = 20meq

Aspar-K 3x1Re-staging

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

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 : Ny. SUmur : 46 Thn No CM : 01317383Adm : 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 obat-obatan, 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 : 36,9°C

• 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

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

STATUS UROLOGIS

Hidronefrosis Ren (D) gr III

ASS I : Dx Emergency : UrosepsisDx 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 : UrosepsisDx Primer : Renal cell carcinoma TxNxM1 (paru), post nefrektomi (s)Dx Kompilkasi : Anemia

HiponatremiaDx Lain-Lain : -

PLAN II :MRSKultur urin + darah Transfusi PRC 1 kolfKoreksi Na dengan NaCL 0,9%CT scan abdomen dengan kontras

04:11