lap.harian 7.1.16

7/25/2019 lap.harian 7.1.16

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LAPORAN HARIAN BOKS Hemato-Onkologi Periode Januari 2015 Junior !e"i RS# $%i !&Senior $rni !e'mita # !ika AmaliaRa(u# ) 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 7.1.16



'-$-$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 !+# 4a Na > 4l

Lantai 3

7/25/2019 lap.harian 7.1.16



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 2

AI,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)inindirek 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!"%0Desa L> I &a)at toman >a)8usi&anBuasin

0"$!6"#'!!##

&&#6 kg T&$#$ (m

1 $9-$-$'

,ierleukositosis selesai7 e8(

AL 2 assa mediastinum2 massa tonsil 2sus8gangguan endengaran

2 rurigo

I;?D D' @ N1 90 ((/jam

Trans3usi P4 $'0 (( $7Trans3usi T4 $0 unit $7

Inj84e3taidim !5$ g $%7

,idroksil urea $5'00 mg 67

Alourinol $5!00 mg sto

/ kemoterai

Diet N& !5$ orsi 2 ? $00 5$00

6/$/$6

,) "+! Leuko $98#00 ,t ! Tr '08000 D4 0/'/'/9/6$ AN4 9%0>esan. anemia+ leukositosis trom)ositoenia+ netroenia

!/$/$6

,& %8! &4 8$'08000 :&4 6"800 ,t 0 T*rom)osit !$000 4; 9# 4, !# 4,4 !6L<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 anemiaAlastik 2 trom)ositoenia 2

*ionatremia 2 *iertensi stg

II 2 melena

I;?D D' @ N1 2 ' (( N1 ! 55 gttmakro

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)

06-0$-$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 7.1.16



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 ICPrednisone --$

#/$/$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+$#

lap.harian 7.1.16

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