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  • Laporan Pasien 23 Mei 2019.sgt

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    sigit
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    This document contains medical information about two patients. For the first patient, it summarizes that she has chronic myeloid leukemia, anemia, multiple infarcts, hemorrhoids or diverticulosis, diabetes, and an uterine mass. The treatment plan includes hydroxyurea, blood transfusions, aspirin, vitamins, physiotherapy, and metformin. For the second patient, it summarizes that she has severe anemia, ascites, pleural effusion, gallstones, and hyperbilirubinemia. The treatment plan includes blood transfusions, abdominal paracentesis, thoracentesis, and Coombs testing.

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    This document contains medical information about two patients. For the first patient, it summarizes that she has chronic myeloid leukemia, anemia, multiple infarcts, hemorrhoids or diverticulosis, diabetes, and an uterine mass. The treatment plan includes hydroxyurea, blood transfusions, aspirin, vitamins, physiotherapy, and metformin. For the second patient, it summarizes that she has severe anemia, ascites, pleural effusion, gallstones, and hyperbilirubinemia. The treatment plan includes blood transfusions, abdominal paracentesis, thoracentesis, and Coombs testing.

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    © All Rights Reserved
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    22 Ansichten4 Seiten

    Laporan Pasien 23 Mei 2019.sgt

    Hochgeladen von

    sigit
    This document contains medical information about two patients. For the first patient, it summarizes that she has chronic myeloid leukemia, anemia, multiple infarcts, hemorrhoids or diverticulosis, diabetes, and an uterine mass. The treatment plan includes hydroxyurea, blood transfusions, aspirin, vitamins, physiotherapy, and metformin. For the second patient, it summarizes that she has severe anemia, ascites, pleural effusion, gallstones, and hyperbilirubinemia. The treatment plan includes blood transfusions, abdominal paracentesis, thoracentesis, and Coombs testing.

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    © All Rights Reserved
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    von 4

    I.

    IDENTITAS
    Nama: Ny. Sugiarti / 39 tahun (CM: C755494)
    MRS: 18 Mei 2019 (Rajawali 3A)

    II. DATA
    1. Hb 7,8, MCV 28, MCH 87, WBC 156,800, PLT 223.000
    2. Retikulosit 0,6 %, Fe : 14, TIBC :219, Ferritin > 1600
    3. Hitung jenis : Bas:0/Eos:0/Stab:3/Segmen:64/Lim:4/Mon:2
    4. GDT : Lekosit : seluruh stadium granulositik (+) blas 1%
    5. LDH : 1200
    6. USG : hepatomegali, splenomegali (16cm), lesi inhomogen
    posterior uterus (curiga massa organ ginekologi)
    7. MSCT Scan Kepala : Infark lobus frontal kanan, nucleus caudatus
    kanan, corpus callosum, nucleus lentiformis kanan,
    mesencephalon kanan
    III. PROBLEM
    1. Lekositosis (156,800) + splenomegali schuffner 4 ---- CML ?
    2. Anemia NN (Hb 7,8 9,4 dengan MCV 28, MCH 87) + retikulosit N
    (0,6)
    ------- Anemia on Chronic Disease
    3. Hemiparesis Sinistra ec SNH (multiple infark)
    4. Hematokezia ------ hemorrhoid DD/ divertikulosis (perbaikan)
    5. DM tipe II (GDS 378, HbA1C :7,5 %)
    6. Lesi inhomogen uterus

    IV. PLANNING
    1. Hidroksiurea 3x500mg, WBCD, BMP, bcr-abl ------- Problem 1
    2. Transfusi PRC 3 kolf ------- Problem 2
    3. Aspilet 1x80mg, B komplek 3x1, Fisioterapi ------- Problem 3
    4. Metformin 2x500mg, Glimepirid 3mg pagi --- Problem 5
    5. USG ginekologi ------ Problem 6
    I. IDENTITAS
    Nama: Ny. Khaerul Alfathania / 19 tahun (CM: C755854)
    MRS: 21 Mei 2019 (Rajawali 3A)

    II. DATA
    1. Hb 4,5 MCV 21, MCH 69, WBC 3.180, PLT 229.000
    2. Fe : 15, TIBC :159, Ferritin : 79,6,
    3. Hitung jenis : Bas:0/Eos:1/Stab:0/Segmen:74/Lim:22/Mon:3
    4. GDT eritrosit : tear drop cell, pear shape cell, eliptosit, ovalosit
    5. Bilirubin total : 2,9, bil indirek 1,7, bil direk 1,2
    6. USG : hepatomegali (15cm), splenomegali (17,6cm), multipel
    cholesistolthiasis, ascites, efusi pleura dupleks
    III. PROBLEM
    1. Anemia berat MH ---------- Anemia def. Fe
    2. Ascites grade II
    3. Efusi pleura dupleks
    4. Multipel cholelsystolithiasis
    5. Hiperbilirubinemia indirek dominan

    IV. PLANNING
    1. Transfusi PRC, SF 2x1 ------- Problem 1
    2. Konsul sub gastro, pro pungsi ascites -------- Problem 2, Problem, 4
    3. Konsul sub pulmo, pro pungsi pleura diagnostik ------ Problem 3
    4. Coomb test direk-indirek, retikulosit ------ Problem 5

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