lap.harian 6.1.16
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Transcript of lap.harian 6.1.16
7/25/2019 lap.harian 6.1.16
http://slidepdf.com/reader/full/lapharian-6116 1/4
LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !&Senior $rni !e'mita # !ika AmaliaSela'a# 5 Januari 201(
Lantai 2
NO Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
Adika Jaunawi /Lk/9-06-00!
"9"9#/$60$00$%6
&& !' kg T& $!" (m
Desa Ta)arena* Dusun + &engkulu,. 0"'!00066'%#
1 $-$-0$'
Anemia Alastik 2 demamnetroenia2 anemia 2
trom)ositoenia
D$+' 2$/ N1 ' gtt makro
Trans3usi P4 !5$'0((
Trans3usi T4 9 unit $7 7 !7
Inj8 As8trane5amata ! 5 '00 mgInj8 4e3taidim ! 5 $+' g 97
Inj8 Omeraol $50 mg
Amino3usin ke( ' gtt makro
-0$-$6,) 6+% &4 +'"08000+ :&4 "00 ,t $9 trom)osit $000 D4 0/0/'/"9/6
"-0$-$6,) %+9 &4 +9908000+ :&4 $!00 ,t trom)osit "000
$-0$-$6,) $0+' :&4 000 &4 #80#8000 ,t !0 trom)osit '000 4; %'+ 4, 6 4,4!' L<D "$ AN4 $0 D4 0/0/6/9/ &oliru)in total "+% A1T/1=OT 0 ALT/1=PT !'Al)umin 686 ure um !$ >reatinin 08'$ Au #+$ 4a 986 Na $# > !8 4l $0!
<do Pernando/Lk/ 09/0"/00!
99"9!/$'0!!"
&& !% kg T& $'!(m
Jl8 Let Jaimas Lr8 >e)on No8$!"08 )ukitke(il8 Palem)ang
0"'!"0'%"!"#
1!0-$-$'
,ierleukositosis e( ALL , 2 trom)ositoenia 2 anemia
I;?D D' @ N1 2 &i(nat $' me ' gttmakro
De5a '-'-'
'/$/$6,) $0+6 :&4 $0!800 &4 #8#'08000 ,t !6 trom)osit%!000 D4 menBusul+ 1=OT $+1=PT $' )il8 Total 9+"4a 989 Na $#$ > #8$ 4l $06 P*osor #8%
#/$/6P* urin . 6+0
A*mad AriansBa* /Lk/# t*n $0 )ln
&&$' kg T&$0' (m
=riBa (ita utama )lok L no 0" Lk II
IndralaBa
0"'!6%0$$$!
1 %-$-0$'
ALL , 3ase induksi 2
anemia2trom)ositoenia 2demam netroenia selesai72 *iokalsemia2 *iokalemia
2 *ionatremia selesai7
I;?D >A<N!& 2 >4l $0 me $! gtt
Inj8 4e3tria5on $5$+' g $$7
Inj8 Amikasin $5 0 mg"7
Dri 3lukonaol $5$"0mg
4alni( sBru 5$ (t*
/ Trans3usi P4 $5$'0((+ (ross mat(*
#/$/$6,) '86 :&4 6800 &4 $8"908000 ,t $% trom)osit %0000 L<D # D4 0/0/'9/!$ /$0PT $'+ $#8007 IN $8$+ APTT !%+ !68! 7 1=OT " /1=PT #9 AN4 !6'"
,ana )inti ,adi
/Pr/0#-0"-0!
9%"9! / $'0!$"66
&& %0 kg T& $'0 (m
Desa &andar JaBa+ Air 1ugi*an8 Ogan
>omring Ilir
, 0"'!6"#066%
1$9-$-0$'
ALL , 3ase induksi 2
demam netroeni2 anemia 2trom)ositoenia 2 oral(andidiasis
I;?D D$+' 2 @ N1 0 gtt makro
Inj8 4e3taidim !5 gr $7
Inj8 Amikasin $5 '00 mg 97
Dri 3lu(onaol $5 '00 mg $7
4ur(uma !5$ ta)
Crda3ak !5$ ta)
La(tula( sBr !5$ (t*
#/$/$6
,) '+! :&4 '00 &4 $8"6088000 ,t $' trom)osit #'000 L<D !' D4 0//'#/!"/6&oliru)in total $08#" &il8direk 989 )il8indirek $8$9 ALP"% 1=OT /1=PT ! ɣ -=T "Protein total '8" Al)umin +9 glo)ulin 89 ureum $" >reatinin 08%
6/$/$6Crinalisa.:arna kuning muda jerni*+ &J $800 , 680 Protein 27 =lukosa -7 >eton -7 dara* -7
)iliru)in -7 uro)ilinogen $ lekosit esterase -78 1edimen urin. eitel 27 lekosit 0-$/l)
erirosit -!/l)+ silinder granular 27+ >ristal -7
7/25/2019 lap.harian 6.1.16
http://slidepdf.com/reader/full/lapharian-6116 2/4
LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !&Senior $rni !e'mita # !ika AmaliaSela'a# 5 Januari 201(
'-$-$6,) "+# <ri !80"08000 :&4 $%00 ,t ' Plt ' 4; "0+ 4, % 4,4 !# D4 $/0/0/9'/#
$-$-$6 , urin "80
?era )t 1u)andi/Pr/
$$ t*n
9"0"/I $'0!!0$!
&& !0 kg T& $$! (m
Oki desa tanjung makmur >aBu Agung
O>I
0"!$"$%0#6
1 $-$-$'
4L 2 Anemia
*ierleukositosis 2trom)ositosis 2 eningkatanL<D
,idrasi alkalisasi D' @ N1 2 &i(nat 0
me ke( "! ((/jam,idro5ilurea $5$'00 !7
&alan(e (airan / 6 jam
4ek P, urin /6 jam
4ek D >>/# jam
'/$/$6
,) 9+#+ :&4 '8%00 &4 !8!"08000 ,t !0 trom)osit %9#000 4; "%+6 4, "4,4 ! L<D !! D4 0//"6/$0 / 1=OT 6 /1=PT ' rotein total %+9 Al)umin !+9glo)ulin #80 ureum ' >reat inin 0869 Au #+# 4a 98' Na $!% P*osor '8" > #8! 4l 0$
, urin 00800 6+0
u*ammad >*ada3i/ lk/"t*
"!%""/$6000!60
Jl8 >, A*ari lr Pinang
0"$%$9"9096
&& $"kg T& $$$
1'-0$-0$6
,emo3olia A ro sirkumsisi 2*emartrosis region genu
sinistra
Aa3a(t
onal Jutama ,/ Lk/ $tn
96$!$/$6000$9#Pengaringan 1emdang Aji
0""$09'!0
1 #-$-$6
ALL , 3ase induksi 2 sus
dBsesia
/ trans3usi P4
I;?D D' E N1 0 gttOmeraol $5# mg
La(tula( 5(t*
/ >emo ;4 $+6mg
Do5o !! mg
De5ametason '-'-'
#/$/$6
,) 6+"+ :&4 #8"00 &4 8!608000 ,t $9 trom)osit '000 4; "$+# 4, 9 4,4!' L<D ## D4 0/0/$!/"!/# &il8 Total 0+6# )il8direk 0+! 1=OT $ /1=PT !' rotein
total '+# Al)umin !+$ ureum #6 >reatinin Au !+#
Danu PraBogo/Lk/$#-0%-$'
96%6/$'0!%!%
Dusun $ desa Pagar Dewa
,0"$"'"66
1$"-$-0$'
,eato &lastoma Post >emoterai
4ek D/
#/$/$6
,& 989 &4 !86 :&4 $$00 ,t 9 T*rom)osit '$#8000 4;%'+6 4, 6 4,4!#L<D D4 0/%/6$/#/" &iliru)in total !8' &iliru)in direk $8'9 &iliru)in indirek $8$6A1T/1=OT ## ALT/1=PT % Al)umin #8 Creum '! Asam urat 9 >reatinin 086$ 4a "89 Na
$$ > #+! 4l 9' L?= # AN46"!
Lantai 3
7/25/2019 lap.harian 6.1.16
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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !&Senior $rni !e'mita # !ika AmaliaSela'a# 5 Januari 201(
NO Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
Pandu Ak)ari eBlando / Lk/ %-0'-00#
"#6!6" / $'09'#
&& !'kg+ T& $#0 (m
Jl8 Perum OPI Lrg+ =ugur I &lok No8
$$8 T/: #%/$#+ >el $' ulu+ >e(1e)erang ulu I+ Palem)ang8
, 0"$"!"0'!#$
ALL 3ase konsolidasi 2AI,A 2 anemia 2trom)ositoenia 2
eningkatan 3ungsi *ati
I;?D D' E N1
De5ametason $ am se)elum kemo
De5ametason
4ur(uma 5$ ta)
Ami(illin !5$gr
=entami(in 5"0mg
en(ana trans3usi :< !5$'0((
Para(etamol ta) !'0mg
4/1/16
,& !8" &4 $8!"08000 :&4 !900 ,t $ T*rom)osit #'000 4; "'+' 4, " 4,4 !L<D $'0 D4 0/0/!0/6$/9 etikulosit 68" &iliri)un total $+6% &iliru)in Direk $+$! &iliru)in
indirek 0+'# A1T/1=OT %% ALT/1=PT 6% Al)umin !86 Creum $' >reatinin 0+$" 4a "86 Na $!9 > '8$
16-12-2015
,& 98" &4 #80" :&4 $8$ ,t 9 T*rom)osit #6 D4 0/0/$$/"#/' PT time kontrol $'F+Pasien $!8$F IN $80$ APTT kontrol !#8"+ asien 68"A1T/1=OT $ ALT/1=PT 09
8 GakkB id*o/Lk/t*')ln
96##9/$60006
Jl8 Letna ukmin no8!' ilir timur I
0"!!"'0'$!
&& kg T& (m
1 0#-0$-$6
ALL , 3ase induksi 2 eningkatan 3ungsi *ati
I;?D D' E N1 5 gtt/menit
Inj8Ondan(entron 5 # mg
>emoterai TH $T+ Leonase
4ur(uma 5$ (t*
De5ametasone !--
4otrimo5aole 5$/ (t*
Diet N& !5$ orsi 2 ?8$00 5$00 ((
06/0$/$6L41 . makroskoik olume $8' ml+ tidak )erwarna agak keru*+ &J $800 P, "80 leukosit $96
PN "! N $% (ell )las -7 none -7+ andi 27
Puji Pratama / L> / $t* 6 )l
9%"96/$'0!"%0
Desa L> I &a)at toman >a)8usi&anBuasin
0"$!6"#'!!##
& kg T&$#$ (m
1 $9-$-$'
,ierleukositosis selesai7 e8(AL 2 assa mediastinum
2 massa tonsil 2sus8gangguan endengaran2 rurigo
I;?D D' @ N1 90 ((/jam
Trans3usi P4 $'0 (( $7
Trans3usi T4 $0 unit $7Inj84e3taidim !5$ g $%7
,idroksil urea $5'00 mg 67
Alourinol $5!00 mg sto
/ kemoterai
Diet N& !5$ orsi 2 ? $00 5$00
!/$/$6
,& %8! &4 8$'08000 :&4 6"800 ,t 0 T*rom)osit !$000 4; 9# 4, !# 4,4 !6
L<D #0 D4 0/"/'/$6/%$ Creum ' >reatinin 0+#6 AC $8# 4a "8" g 86% P*osat #8" Na$!9 > !8# 4l $0' P, urin %
Andi Irawan / L> / $! t* 9 )l
9'"0"/$'0!!'#0
Jl8Damai no $! talang Jawa 1elatan
La*at
0"!%999%0!9
&& #0 kg T&$#" (m
1 "-$-$'
Demam netroenia 2 anemia
Alastik 2 trom)ositoenia 2*ionatremia 2 *iertensi stgII 2 melena
I;?D D' @ N1 2 ' (( N1 ! 55 gtt
makro
NBstatin #5'008000 IC
Tramadol !5# mg oral
Alinamin ? 5$
?urosemide 5#0 mg oral
La(tula( sBr 5$ (t*
4alni( ta) 5$ ta)
1andimin $5# ta)
0#-0$-$6
Tinja
akroskoik . warna (oklat ke*itaman+ konsistensi lem)ek
ikroskoik . Amoe)a negati3+ eritrosit -!+ leukosit $-+ )akteri ositi3+ jamur ositi3+ dara*
samar ositi3
<lektrolit . 4a $08! g $86" Na $!9 > #8# 4l $$$
!0/$/$'
>ultur urine . steril
MAWAR A
7/25/2019 lap.harian 6.1.16
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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !&Senior $rni !e'mita # !ika AmaliaSela'a# 5 Januari 201(
Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
a3i/Lk/9-$0-$$
9!0"#/$'0!!''#
Jl8 Proinsi 1kB L
0"'!66$##'#
1. "-$-$'
ALL 1 3ase induksi I;?D D'$/# N1 6# gtt ma
>emoterai leonase
4otrimo5aol 5$ (t*
NBstatin dro #5008000 IC
Prednisone --$
#/$/$6
,& $8" &4 #8#%08000 :&4 $8!00 ,t !" T*rom)osit $6"8000 4; "'8 4, 94,4 !# L<D " D4 0/0/#%/'$/ Creum >reatinin 0+!$ 4a 98$ Na $!6 > #8$ 4l $0%1=OT $% 1=PT $6
IN $%+ PTT $"8$ $#7 APTT !6+! !68!7
DikB Tri Ananda/Lk/$0-$-$0
96$"/$60006$
Negeri atu &aru
&& $0+' kg T& %0(m
1. 0#-0$-$6
ALL 1 3ase Induksi >emoterai
;4
#/$/$6,& "8! :&4 8%00 ,t ' T*rom)osit #$ D4 0/0/$$/"6/! AN49% &T 08"# &D 0+# &I08#0 1=OT 0 1=PT ! Al) #+ #Creum >reatinin 0+$#