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7/25/2019 lap.harian 8.1.16
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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !Senior $rni !e&mita # !ika AmaliaKami&# ' Januari 201(
Lantai 2
NO Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
Hana binti Hadi
/Pr/04-08-03
!"83 / #$03#8%%
&& "0 kg T& #$0 'm
Desa &andar (a)a* +ir ,ugian. Oganomring Ilir
H 08$3%840%!%"
12,#-#!-!0#$
+LL H2 ase induksi demam netroeni anemia
trombositoenia oral'andidiasis
I56D D#!*$ 7 N, !0 gtt makro
Inj. eta9idim 3:! gr #;!<
Inj. +mikasin #: $00 mg ;<
Dri lu'ona9ol #: $00 mg ;#<ur'uma 3:# tab
=rdaak 3:# tab
La'tula' s)r 3:# 't
Tunggu asil kultur dara selesai
4/#/#%Hb $*3 >& $00 2& #.8%0..000 Ht #$ trombosit 4$000 L?D 3$ D 0/!/$4/38/%
&olirubin total #0.48 &il.direk .! bil.indirek #.# +LP8" ,@OT !! /,@PT !3 ɣ -@T 8!Protein total $.8 +lbumin !* globulin !. ureum #8 reatinin 0.!"
!%/#/#%
=rinalisaA>arna kuning muda jerni* &( #.0!0 H %.0 Protein ;< @lukosa ;-< eton ;-< dara ;-<
bilirubin ;-< urobilinogen # lekosit esterase ;-<. ,edimen urinA eitel ;< lekosit 0-#/lberirosit !-3/lb* silinder granular ;<* ristal ;-<
!$-#-#%Hb 8*4 ?ri 3.080.000 >& #"00 Ht !$ Plt !$ 15 80*! 1H !" 1H 34 D #/0/0/$/4
!#-#-#% H urin 8.0
6era bt ,ubandi/Pr/
## tn
!80!8/2I #$0330#3
&& 30 kg T& ##3 'm
Oki desa tanjung makmur a)u +gungOI
08!!3#8#"04%
12, !#-#!-#$
1L +nemiaierleukositosis
trombositosis ierosotemia
Hidrasi alkalisasi D$ 7 N, &i'nat !0meB ke' 83 ''/jam
Hidro:ilurea #:#"$0 ;$<
&alan'e 'airan / % jamek PH urin /% jam
ek D2 /!4 jam
0"/0#/#%Hb *#* >& !40.300 2& !.!40.000 Ht !8 trombosit 8!$000 15 8"*% 1H !8
1H 3! L?D #$ bil.total 0.!! bil.direk 0.$8 bil.indirek 0.#4 ,@OT !! ,@PT % +lbumin3* ureum 3$ reatinin 0.%# +u 3 a .4 Na #3" Posor $." 4.3 l #0# 1g !.!# 2Pkuantitati C $ PH urin "
$/#/#%Hb *4* >& !$!."00 2& 3.380.000 Ht 30 trombosit "4000 15 8"*% 1H !81H 3! L?D 33 D 0/!/8%/#0 /! ,@OT !% /,@PT $ rotein total "* +lbumin 3*
globulin 4.0 ureum !$ reat inin 0.% +u 4*4 a .$ Na #3" Posor $.8 4.3 l 0#
H urin 00.00 %*0
Noal Eodama / L / 8 bln #" ari
30$4!/#%000$0"
Desa arang Inda
08!3"38##"8
&& 8*" kg T& "! 'm
12, 0%-0#-#%
1assa region asialis
+nemia
I56D D$ F N, % gtt/menit makro
onsul mata
PT s)r G 't bila T38*$0
T-,'an keala
O! nasal # L/menit
ek laboratorium DPL* @DT* ,tatus besi*
2P
Hasil konsul mata A 5OD dan 5O, belumdaat dinilai* sus.2abdomiosar'oma O, lagotalmus O,
DD/ sus.retinoblastoma O,
P/ 'lorameniol ?O 3:# ;OD,<
,aran A T-,'an
Hasil konsul P+ A akan dilakukan 6N+&setela ada konirmasi radiologi
0"/#/#%
Hb "*4 >& ".300 2& 3.300.000 Ht !3 trombosit !#$.000 15 %%.8 1H !!1H 33 L?D #" D 0/0/"/"#/!! besi 8% TI& !4" &il. Total 0*48 bil.direk 0*!#
bil.indirek 0.!" ,@OT "% ,@PT #4 rotein total %.! +lbumin 4.0 ureum #0 reatinin0.3$ +u #4.%0 a#0.# Na #3$ 4.8 l #03
6erritin #4!$.00
+bdul +9i9 /L/ " t " bln +nemia +lastik I56D D$ F N, gtt #$/menit makro 0%/0#/#%
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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !Senior $rni !e&mita # !ika AmaliaKami&# ' Januari 201(
#!!#$/#%0004$#
Pakuan ja)a kab.O=
08$"$883$0!
&& #8 kg T&##0 'm
12, 0%-0#-#%
,andimun !:! tab
2/ transusi >? #:#$0 ''
Hb 8*4 >& 3.800 2& 3.0%0.000 Ht !$ trombosit #$0.000 15 8!." 1H !81H 33 L?D !% D 0/0/"#/#$/#4 &il.Total !.4# bil.direk #.$! bil.indirek 0.8 ,@OT!" ,@PT !8 rotein total ".4 ureum #4 reatinin 0.40
+mad +rians)a /Lk/4 tn #0 bln
&&#$ kg T�$ 'm
@ri)a 'ita utama blok L no 08 Lk IIIndrala)a
08$3%"0##!#3
12, !"-#!-!0#$
+LL H2 ase induksi
anemiatrombositoenia iokalsemia ionatremia
I56D +?N3& l #0 meB #3 gtt
Inj. etria:on #:#*$ g ;##<
Inj. +mikasin #: !0 mg;8<
Dri lukona9ol #:#80mg ;!<
alni' s)ru !:# 't
2/ Transusi P2 !:#$0''* 'ross mat'
4/#/#%Hb $.% >& %.!00 2& #.80.000 Ht #" trombosit "0000 L?D 4! D 0/0/$/3# /#0PT #$*! ;#4.00< IN2 #.!#* +PTT 3"*! ;3%.3 < ,@OT 8! /,@PT 4 +N 3%$8
2onal (utama H/ Lk/ #!tn
!%#3#/#%000#4
Pengaringan ,emdang +ji
08!!8#0$30!
&& 40 kg T&#$! 'm
12, 4-#-#%
+LL H2 ase induksi d)sesia
Transusi P2 #$0 '' ;#< ;!< ;3<
I56D D$ F N, !0 gtt
Omera9ol #:40 mg
La'tula' !:!'t
Inj.'eta9idim 3 : "00 mg ;!<
ultur dara dan urin
PT 3:$00 mg
2/ emo 52 #*%mg tunda
Do:o 33 mg tunda
De:ametason $-$-$ tunda
4/#/#%Hb %*8* >& 4.800 2& !.3%0.000 Ht # trombosit $000 15 8#*4 1H ! 1H
3$ L?D 44 D 0/0/#3/83/4 &il. Total 0*%4 bil.direk 0*3! ,@OT #! /,@PT 3$ roteintotal $*4 +lbumin 3*# ureum 4% reatinin +u 3*4
+dika (aunai /Lk/-0%-!003
884!/#%0#0!0#"%
&& 3$ kg T& #38 'm
Desa Tabarena Dusun !* &engkulu
HA 08$3000%%$"4
12, !#-#!-!0#$
+nemia +lastik demamnetroenia anemia trombositoenia
D#!*$ #/! N, !$ gtt makro
Transusi P2 #$0 '' ;#< ;!< ;3<
Transusi T ;#< ;!< ;3<
Inj. +s.trane:amata 3 : $00 mg
Inj. eta9idim 3 : #*$ g ;<
Inj. Omera9ol #:!0 mg
+ntasida s)r 3 : $ mg
+minousin ke' $ gtt makro
onsul THT kesan O1+ +D, std
ieremis tonsillitis kronis eksaserbasiakut tremen9a 3:# tab* edukasi diet
lunak* antibioti' sesuai T, anak
"/#/#%=rinalisisA >arna kuning jerni* &( #.0#0* PH ".0 @lukosa ;-<* rotein;-<* eton ;<* dara;<* Nitrit #* lekosit esterase ;-<* ,edimen urinA eritel ;-<* lekosit 0-!* eri !-4 bakteri ;<1ukus ;<
%-0#-#%Hb %*" 2& !*$80.000* >& 800 Ht # trombosit #000 D 0/0/$/8/%
!8-0#-#%Hb "* 2& !*0.000* >& #300 Ht !! trombosit 8000
!#-0#-#%
Hb #0*$ >& !000 2& 4.04.000 Ht 30 trombosit $000 15 "$*! 1H !% 1H3$ L?D 8# +N #!0 D 0/0/%/!/! &olirubin total 8*" +,T/,@OT !0 +LT/,@PT 3$
+lbumin %.% ure um 3# reatinin 0.$# +u 4*# a .% Na #4! 3.! l #03?do Pernando/Lk/ 0/08/!003
!83/#$0338!!
&& 3" kg T& #$3'm
(l. Let (aimas Lr. ebon No.#380. bukitke'il. Palembang
08$380$"8384
12, 30-#!-#$
Hierleukositosis e' +LL H2 trombositoenia anemia
I56D D$ 7 N, &i'nat #$ meB !$ gttmakro
De:a $-$-$
ek PH/% jam
&alan'e/% jam
2/ kemo ari ini 52 7 dosis ;#mg<
0"/0#/#%=rinalisis A arna kuning muda* jerni &( #.0#0 PH ".0 rotein ;-< glukosa ;-< dara ;<leukosit esterase ;-< sedimen A eitel ;-< leukosit 0-# eritrosit !0-30 silinder ;-< kristal ;-<
bakteri ;<
%/#/#%Hb #0*$ >& #04.00 2& 4.4#0.000 Ht 3$ trombosit $"000 D men)usul*
=reum 3$ +s.=rat !.30 kreatinin 0.3a ." Na #4# 4.4 Posor $.0
4/#/%
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P urin A %*0
P& (ia n ka mila / Pr /$-#!-#%
3#!$4/#%000$%0
&& !! kg T& #!4'm
(l. Perumaan gri)a sri mul)a
08!#80$$""!$
12, "-#-#%
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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !Senior $rni !e&mita # !ika AmaliaKami&# ' Januari 201(
Lantai 3
NO Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
Pandu +kbari 1e)lando / Lk/ !"-0$-
!004
84%3%8 / #$0!!$4&& 3$kg* T& #40 'm
(l. Perum OPI Lrg* @ugur I &lok 2 No.##. 2T/2> 4"/#4* el #$ ulu* e',eberang ulu I* Palembang.
H 08!#8380$34#
+LL ase konsolidasi
+IH+ anemia
trombositoenia eningkatan ungsi ati
I56D D$ F N, : gtt/menit
De:ametason # am sebelum kemo
De:ametasonur'uma !:# tab
+mi'illin 3:#gr ;!<
@entami'in !:80mg ;!<
2en'ana transusi >? 3:#$0''
Para'etamol tab 300mg 3 : seari
O! nasal # L
4/1/16
H& 3.8 2& #.380.000 >& 300 Ht #! Trombosit 4$000 15 8$*$ 1H !8 1H 3!
L?D #$0 D 0/0/30/%#/ 2etikulosit %.8 &iliribun total #*%" &ilirubin Direk #*#3 &ilirubinindirek 0*$4 +,T/,@OT "" +LT/,@PT !%" +lbumin 3.% =reum #$ reatinin 0*#8 a 8.%
Na #3 $.#
16-12-2015
H& .8 2& 4.08 >& #.# Ht ! Trombosit 4% D 0/0/##/84/$ PT time kontrol #$J*
Pasien #3.#J IN2 #.0# +PTT kontrol 34.8* asien !%.8+,T/,@OT !# +LT/,@PT !0
1. Kakk) 2ido/Lk/!t$bln
!%44/#%000!%!
(l. Letna 1ukmin no.!3$ ilir timur I
08!!338$0$#3
&& kg T& 'm
12, 04-0#-#%
+LL H2 ase induksi eningkatan ungsi ati
I56D D$ F N, : gtt/menit
Inj.Ondan'entron ! : 4 mg
emoterai 1T #T* Leonase
ur'uma !:# 't
De:ametasone 3-!-!
otrimo:a9ole !:#/! 't
Diet N& 3:# orsi 6.#00 !:#00 ''
0%/0#/#%L, A makroskoik Molume #.$ ml* tidak berarna agak keru* &( #.0!0 PH 8.0 leukosit #%
P1N 83 1N #" 'ell blas ;-< none ;-<* andi ;<
Puji Pratama / L / #!t % bl
!"8%/#$03!8"0
Desa L I &abat toman ab.1usi&an)uasin
08#3%84$3344
&&4% kg T# 'm
12, #-#!-#$
Hierleukositosis ;selesai< e.'+1L 1assa mediastinum massa tonsil sus.gangguan endengaran
rurigo
I56D D$ 7 N, 0 ''/jam
Transusi P2 #$0 '' ;#<
Transusi T #0 unit ;#<
Inj.eta9idim 3:# g ;#"<
Hidroksil urea #:$00 mg ;%<
+lourinol #:300 mg sto
2/ kemoterai
Diet N& 3:# orsi 6 #00 !:#00
"/#/#%
Hb 8*3 Leuko #.400 Ht !3 Tr $0.000 D 0/$/$/!/%# +N "0
esanA anemia* leukositosis trombositoenia* netroenia
3/#/#%
H& ".3 2& !.#$0.000 >& %8.!00 Ht !0 Trombosit 3#000 15 4 1H 34 1H 3%L?D 40 D 0/8/$/#%/"# =reum !$ reatinin 0*4% += #.4 a 8.8 1g !.%" Posat 4.8 Na#3 3.4 l #0$ PH urin "
+ndi Iraan / L / #3 t bl
!$808/#$033$40
(l.Damai no #3 talang (aa ,elatanLaat
08!3""03
&& 40 kg T0 'm
12, !8-#!-#$
Demam netroenia anemia
+lastik trombositoenia ionatremia iertensi stgII melena
I56D D$ 7 N, !$ '' N, 3 :: gtt
makro
N)statin 4:$00.000 I=
Tramadol 3:4 mg oral
+linamin 6 !:#
6urosemide !:40 mg oral
La'tula' s)r !:# 't
alni' tab !:# tab
,andimin #:4 tab
0%-0#-#%
Tinja
1akroskoik A arna 'oklat keitaman* konsistensi lembek
1ikroskoik A +moeba negati* eritrosit !-3* leukosit #-!* bakteri ositi* jamur ositi* darasamar ositi
?lektrolit A a #0.3 1g #.%8 Na #3 4.4 l ###
30/#!/#$
ultur urine A steril
2amat +kbar Heri)adi/ lk/4t
&&A #4kg T& 8'm
Desa kembang tanjung
+LL Pro kemoterai Hidrasi degan D$ F N, ;ro kemoteraiP+<
- P+
H& ##. >& ".00 Ht 3$ Trombosit 38.000 15 88.# 1H 30 1H 34 L?D 3"D 0/%/48/3!/#4 2etikulosit #. L?D 3" =reum #! reatinin 0*33 a #0.3 Na #38 4.4
,@OT !$ ,@PT #3+N 3."!
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08#3%"$4%440
12, "/#/#%
- 1T +2+ I Prednison IT
- 1T iM
Tegar aji/ lk/ 3t
&& ##g T& 88'm
(l. TaBa Lr. 1ad)a II
08!#"8%"8!$3
12, "/#/#%
+nemia e' sus. Deisiensi6e dd/ keganasan
ek DPL* oomb test* @ambaran daratei
2/ Hb analisa
2/ transuse P2 bila terdaat gangguan
oksigenasi !:#$0 ''Para'etamol #$0 mg bila T !8*$o
H& %.! 2& 4."!0.000 >& ".000 Ht !4 Trombosit !0.000 15 $#.$ 1H #31H!% L?D 0 D 0/$/!8/%0/" 2etikulosi t 0*8 &esi ;e< #0. TI& "$0.Protein total ".$* +lbumin 4.8 @lobulin !."olesterol HDL $!
=reum #$ reatinin 0*!$
6eritin !.#4
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MAWAR A
Identitas Diagnosis Tatalaksana Pemeriksaan Lanjutan
2ai/Lk/-#0-##
!3084/#$033$$4
&&A kg P&A 'm
(l. ProMinsi ,k) L
08$3%%#44!$4
12,A !8-#!-#$
+LL ,2 ase induksi I56D D$#/4 N, %4 gtt ma
emoterai leonase
otrimo:a9ol !:# 't
N)statin dro 4:!00.000 I=
Prednisone !-!-#
4/#/#%
H& #!.8 2& 4.4"0.000 >& #.300 Ht 38 Trombosit #%8.000 15 8$.! 1H !1H 34 L?D 8 D 0/0/4"/$#/! =reum !! reatinin 0*3# a .# Na #3% 4.# l #0"
,@OT #" ,@PT #%IN2 #"* PTT #8.# ;#4< +PTT 3%*3 ;3%.3<
?lmira utrid a)u/ Pr/!"-0!-#!
8"8!%#/#%000$4
&&A #$kg T&%kg
(l. Dusun # desa sejagung
08!3"#448%
12,A "/#/#%
Neuroblastoma 2/emoterai
52 0* mg
?tooside #!!mg
islatin 48*8 mg
)'loosamide 3%%mg
"/#/#%
H& #0.3 2& 3.!#0.000 >& 4.%00 Ht ! Trombosit ".000 15 # 1H 3! 1H3% L?D 3" D 0/!/%8/#%/#4 2etikulosit 3.8 bilirubin total 0.3! bilirubin direk 0.##
bilirubin indirek 0.!# =reum #8 reatinin 0*38 +=!.% a .4 Na #3$ 3.3 ,@OT 3#,@PT 3!