Documente Academic
Documente Profesional
Documente Cultură
Lantai 1
Lantai 2
Kmr 3 Adika Jaunawi/Lk/09-06-03 Demam netropenia + anemia Sandinum 1x5 tab 13-12-15
Bad 7 898942/RI15025825 aplastik R/ transfusi TC 3X9 UNIT Hb 9.0 RBC 3.6 WBC 1.0 Ht 26 PLT 20.000 MCV 78,7 MCH 27 MCHC 34 LED 50 DC
BB 38 kg Inj Ceftidim 3x1,5 gr (1) 0/0/9/88/3 ANC 162
TB 137 cm Kultur darah dan urin 06-12-15
Ds. Tabarena Ds II bengkulu Hb 8.6 RBC 3.19 WBC 1.9 Ht 25 PLT 3 DC 0/0/7/91/2
085380066574 27-11-15
MRS 17-11-15 Hb 9,7 RBC 3.610.000 WBC 1.800 Ht 28 PLT 8 LED 50 DC 0/0/4/94/2
25-11-15
Hb 8,8 RBC 3.200.000 WBC 1.500 Ht 25.000 PLT 44.000 DC 0/0/12/83/5
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
18-11-15
URINALISIS
Kuning jernih BJ 1.050 Ph urine 6,0 prot – gluk – keton + darah ++ bilirubin – nitrit 2
lekosit esterase – epitel – lekosit 0-2 eritrosit 0-2 silinder – kristal – bakteri + mukus – jamur
-
17-11-15
Hb 7,7 RBC 2.940.000 WBC 2.000 Ht 22 PLT 1 MCV 75,2 MCH 26 MCHC 35 LED 56
DC 0/0/12/85/3/0,1 ANC 240
17/12/15
Aemia Aplastik+ R/ Trasfusi TC 3X90 uit
Trombositopenia+ Demam Ij Ceftazidime 3x1,5 gr(3)
eutropeia Inj Asam traneksamat 3x250 mg
Sadimun 1x5 cap
r/ hasil kultur urin + darah
Rani Andini/Pr/06-05-00 Anemia Aplastik R encana Tranfusi PRC 1X150 cc 11-12-15
812942/RI 15032067 Trombositopenia Berat Rencana TC 3x8 unit Hb 6.2 RBC 1.81 WBC 3.6 Ht 18 PLT 9 MCV 101,1 MCH 34 MCHC 34 LED 40 DC
TB 142 cm BB 35 kg Parasetamol Tab 3x500 mg 0/0/55/39/6
Lr HJ Daisyah karya jaya kertapati Inj ampisilin 3x1 gr (5)
palembang Inj Gentamisin 2x90 mg (5)
082371736505 Sandimun 1x5 cap
MRS 11-12-15
M.Zakky Ridho/Lk/08-09-12 Susp.ALL DD/AML IVFD D5 ½ NS gtt 10 makro Laabbbb di foto dewi
BB 13kg TB 92cm Inj Ceftazidim 3x650 mg (6)
926449/RI 15032525 Inj Mikasin 1x200 mg iv (3)
Jln. Letnan Mukmin No 235 RT 05 RW Transfusi TC 3X3 uit (1) (2) (3)
02 Sei Pangeran,Ilir Timur I, Dexametason 3-3-2 (5)
Palembang Menunggun hasil kultur urine 18-12-15
MRS 16-12-15
IVFD D5 ½ NS gtt 10 makro
Inj Ceftazidim 3x650 mg (7)
Inj Mikasin 1x200 mg iv (4)
Dexametason 3-3-2 (5)
Menunggun hasil kultur urine 18-12-15
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
Rio bin Dedi /Lk/25-07-02 PNET Kemoterapi sesuai Prosedur PNET 3-11-2015
861416/RI 324120 Konsul THT Hb 12,0 RBC 4.76 WBC 14.8 Ht 38 PLT 339 MCV 79,0 MCH 25 MCHC 32 LED 10 DC
BB 3kg TB 126 cm Konsul Gilut 0/2/39/50/9 BT 2 CT 19 SGOT 14 SGPT 43 BSS 103 Ur 27 Creat 0.58 Na 142 K 3.6
HbSAg Non Reaktif
Dusun IV Simpang Gardu RT 03 RW Konsul Kardiologi
06 Teluk Kijing, Kec Lais,MUBA
Telp 0823 7788 4011
MRS 15-12-15 Konsul ulang ke Gilut pro ekstraksi dan
konservasi
R/ ECHO menunggu jawaban konsul
cardio
Sheila Anggita/Pr/17-11-13 Tumor Willms Pro kemoterapi VCR Ifosfomid hari ini
878050/RI 15032357 (pulang)
BB 7,5 kg tb 66 cm
Ds 4 Desa SAKATIGA Indralaya OI
082282491428
MRS 14-12-15
Tri Islami/Pr/27-03—06 Thalasemia B Mayor +susp Inj Ampisilin 3x500 mg (3) (-)
927036/RI 15032332 BP Inj gentamisin 2x40 mg (3)
BB 15 kg TB 108 cm Inj PCT 3x200 mg
Desa Saleh Agung,Air Salek Banyuasin O2 nasal 1L/mnt (prn)
082282366243 Menunggu jawaban konsul respirologi
MRS 14-12-15
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
MRS 16-12-15
Lantai 3
Ovi Anjani / Pr/06-11-2012 Retinoblastom a OD Pro- IVFD D5 1/5NS gtt 6 makro 14-12-2015
904722/15032455 Kenoterapi Kemoterapi Etoposide 70,5 mg (IV) HB 10,0 RBC 3.47 WBC 6.5 Ht 30 Thrombosit 225 MCV 86,5 MCH 29 MCHC 33 LED 31
DC 0/1/33/60/6 Biliribun total 0,40 Bilirubin Direk 0,13 Bilirubin indirek 0,27 AST/SGOT
BB kg, TB cm Kemoterapi Vincristin 0,7mg (IV)
43 ALT/SGPT 1 Protein total 8,1 Albumin 4.7 Ureum 15 Kreatinin 0,37 Ca 9.5 Na 142 K
Desa Pagar Ruyung, Kec.Kota Agung, Inj. Ondansentron 4mg pre & post Kemo 4.0
Lahat Cetirizine 1x1 cth (PO)
Putri Rahma Oktarini / Pr/ 23-10-2012 Osteosarcoma + Ami std Risk IVFD D5 1/2NS → Ifosfamide 2745mg + 14-12-2015
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
896656/15032282 + Hipocalsemia mesna 2700mg kec 10 gtt makro (12jam) HB 11,7 RBC 4.01 WBC 4.5 Ht 35 Thrombosit 159 MCV 87,5 MCH 29 MCHC 33 LED
BB 36 kg TB 149 cm → D5 500cc + mesna 2700 mg kec 10 gtt 29 DC 0/2/57/31/10 Retikulosit 2.2 Biliribun total 0,50 Bilirubin Direk 0,31 Bilirubin
Jl. Merdeka No.13 Kel. Kedondong makro 12 jam berikutnya indirek 0,19 AST/SGOT 34 ALT/SGPT 23 Protein total 8,0 Albumin 5.0 Ureum 10
Raye, Kec. Banyuasinn III, Kab. IVFD D5 1/2NS + KCL 24cc + Ca Kreatinin 1,24 Ca 6.5 Na 137 K 4.4
Banyuasin Glukonas 10% 24cc kec 37 gtt makro
Drip Ca Glukonas 20cc dalam D% 100cc,
habis dalam 1jam/8jam
Balance /12jam
Kemoterapi ifosemide & doxosubicine (2)
Inj. Ondansentron 2x8mg
M. Angga Saputra / Lk / 22-02-2013 ALL HR fase konsiliasi + Curcuma 3x1 tab 12-12-2015
908700/15032058 anemia perbaikan + Alinamin-F 2x1 tab CA 8.9 Na 138 K 4.3
BB 15 kg PB 78 cm thrombositopenia + Mecocobalamin 2x1 tab
peningkatan fungsi hati + 11-12-2015
Tepi sungai kedukan, Kel 3-4 ulu, Kec obesitas + polineuropati Cotrimoksasol syr 2x1cth HB 6.7 RBC 2.46 WBC 3.2 Ht 21 Thrombosit 81 MCV 84,1 MCH 27 MCHC 32 LED 34
Seberang Ulu I, Palembang parsial Bmp 1x1 tab DC 0/0/52/45/3 AST/SGOT 290 ALT/SGPT 198 Protein total 6, 8 Albumin 3,9 Ureum 18
Hidrasi 1 ½ maintenance dgn D5 ¼ NS gtt Kreatinin 0,27 Ca 7,4 Na 144 K 3.8
20 makro s/d pukul 12.00 pagi
Inj. Leucoconia 8.4mg pukul 00.00 wib &
06.00 wib
Arwanda Jerry Jerro / Lk/ 15-04-2004 Anemia hipoplastik + Transfusi TC 11 unit (3) 10-12-2015
888069 / 15031973 thrombositopenia Sandimon 2x 5tab (PO) HB 10,8 RBC 3.41 WBC 3.6 Ht 32 Thrombosit 44 MCV 93.8 MCH 32 MCHC 34 LED 45
BB kg, TB cm Asam mefenamat tab 3 x500 mg (PO) DC 0/0/28/61/9 AST/SGOT 23 ALT/SGPT 22 Ureum 14 Creatinin 0,43 Ca 9,3 Na 137 K
3,4
Prabumulih no.27, Kel. Sukajadi, Kec. Rencana pulang → tunda
Prabumulih Timur 920373
Adrian Alfino/ Lk / 04-02-2010 Undifentiated pleomorfik IVFD D12,5 + 75cc NS 3% 60 cc/jam 14-12-2015
864823 / 15031191 sarcoma + Hiponatremi Inj. Ampicilin 3x50mg (5) CA 8.4 Na 133 K 4.8
(perbaikan)
BB kg, TB cm Inj. Gentamisin 2x40 mg (5)
12-12-2015
Dusun IV , Kel. Muara Burnai, Kec. Inj. Asam Tranesamat 3x150mg HB 9.5 RBC 3.66 WBC 21.4 Ht 30 Thrombosit 208 MCV 80,6 MCH 26 MCHC 32 LED
Lempuing Jaya, Kab. Ogan Komering Radioterapi (3) 60 DC 0/0/74/17/9 retikulosit 0.5 Fe 16 TiBC 170 Bilirubin total 0.47 Bilirubin direk 0.20
Ilir Bilirubin indirek 0.27 AST/SGOT 39 ALT/SGPT 15Albumin 3,1 GDS 66 Ureum 15 Asam
F135 3 x 200 cc
Rcn FFP 1x1 unit urat 2.5 Kreatinin 0,35 Ca 8,4 Phospor 3.2 Mg 2.33 Na 129 K 4.3 Cl 103 Ferritin 365.60
CRP kuantitaif 215
Ganti verban → deep kembali
Urinalisa : warna kuning, kejernihan agak keruh, berat jenis 1.030 Ph 5.0 protein (-) glukosa
(-) keton (-) darah (-) bilirubin (-), urobilinogen 1, nitrit(-), lekosit ekstrase (-)
Sedimen urine : epitel (+)1, lekoit 2-4 Eritrosit 1-2 Silinder (-) kristal (-) bakteri (-) mukus
(-), jamur (-)
M. Fauzi Azka Syahputra / Lk/ 13-12- ALL HR fase intensifikasi + IVFD D5 ½ NS gtt 10 makro 14-12-2015
2010 anemia + thrombositopenia + Transfusi PRC 1x150cc, TC 6 unit HB 8.0 RBC 2.96 WBC 0.5 Ht 24 Thrombosit 26 MCV 80,7 MCH 27 MCHC 34 LED 63
904029 / 15032459 hipocalcemia Nystatin 4x300.000 DC 0/0/20/72/8 retikulosit 0.1 Bilirubin total 0.56 Bilirubin direk 0.26 Bilirubin indirek 0.29
BB kg. TB cm AST/SGOT 41 ALT/SGPT 195 Albumin 5.0 Ureum 25 Kreatinin 0.21 Ca 6.9 Na 134 K 3.9
Tunda kemoterapi
Komp Kencana Damai Blok H-04, kel. Obs demam & perdarahan
Sukamaju, kec, Sako, Palembang Calnic syr 2x1 cth
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
Flora Adiya Meca / Pr / 07-11-2006 ALL High Risk fase IVFD D5 ½ NS gtt 30 makro (hidrasi ½ 16-12-2015
858549 / 15032308 maintenance + AKI std injury maintenance) Ureum 11 Asam urat 2.0 Kreatinin 0.33 Ca 9.7 Na 143 K 3.7
BB kg, TB cm Dexametasone tab 4-4-4
Desa Sukamulya, Kel. Sukamulya, Kec. Kotrimoksasol syr 2 x ½ cth
Lempuing, Kab. Ogan Komering Ilir Cek fungsi ginjal ulang hari ini
Rencana pulang bila fungsi ginjal baik
Pandu Akbari Meyland0 / Lk/ 27-05- ALL fase induksi + AIHA + IVFD D5 ½ NS gtt 15 makro 16-12-2015
2004 neutropeni tanpa demam + Inj. Omeprazole 1x20mg HB 9.8 RBC 4.08 WBC 1.1 Ht 29 Thrombosit 46 DC 0/0/11/84/5 PT time kontrol 15”,
846368 / 15029254 thrombositopenia + Ampicilin 3x1 gr (IV) Pasien 13.1” INR 1.01 APTT kontrol 34.8, pasien 26.8AST/SGOT 21 ALT/SGPT 209
BB kg, TB cm peningkatan F5 hari +
Hipertensi grd II + faringitis Inj. Gentamisin 2x 80mg (2)
Jl. Perum OPI Lrg, Gugur I Blok R No. akut + stomatitis +axional Inj. Ondansentron 2 x 6mg
11. RT/RW 47/14, Kel 15 ulu, Kec polineuropati sensorik & Kenalog anabase 2x1 sue
Seberang ulu I, Palembang. motorik Curcuma tab 3x1
Hp 082183805341
Nystatin tab 3 x500000
Captopril 3 x 12,5
Mecocobalamin 2x16mg
Alinamin-F 1x11 mg
Calnic syr 2x1cth
Kometerapi Leonase (8)
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
MAWAR A
Bagus
Nurul
Adila
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
Anisa
Savtri
Thalasemia
Wildo
Loisa
LAPORAN HARIAN BOKS Hemato-Onkologi Periode November 2015
Madya : Irma Yenni/Senior: Medina Athiah, Dika Amalia)
Rabu, 16 Desember 2015
Aisyah