lap.harian 8.1.16

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#/#%

7/25/2019 lap.harian 8.1.16



#!!#$/#%0004$#

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&#0$ '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/#/%

7/25/2019 lap.harian 8.1.16



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, "-#-#%

7/25/2019 lap.harian 8.1.16



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&#4# '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 T&#48 '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."!

7/25/2019 lap.harian 8.1.16



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

7/25/2019 lap.harian 8.1.16



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!

lap.harian 8.1.16

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