MR Thalasemia Baru

8/17/2019 MR Thalasemia Baru

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Laporan JagaKamis, 29 April 2016DM BIBBUR

DM IZAT

DM DEAR


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An. X/12 tahun/BPJS NPBI

K !uhan Uta"a# L "a$

R%&a'at P n'a(%t S (arang#

Pa$% n )%( !uh(an *a)an ! "a$ )an "a!a$ * ra(t%+%ta$. K !uhan ! "a$ )%$ rta% ) n

&a,ah 'ang pu-at. K !uhan ,antung * r) *ar 0 ( !uhan $ r%ng * r( r%ngat 0 ( !uhan "a

* r(unang (unang 0 pu$%ng 0. Na3$u "a(an " nurun "ua! 0 "untah 0 $ $a

) "a" 0 *atu( 0 p%! ( 0 )%ar 0 BAK 0 nor"a! BAB 0 nor"a!.


3/16

R%&a'at P n'a(%t Dahu!u

Pa$% n )%)%agno$%$ " n) r%ta tha!a$ "%a $ ,a( u$%a 4 tahun

R%&a'at K !uarga

A'ah %*u )an anggota ( !uarga !a%n t%)a( " nga!a"% ( !uhan 'ang$a"a $ p rt% 'ang )%a!a"% pa$% n

R%&a'at P ngo*atan

Tran3u$% PR5 t%ap *u!an $ ,a( u$%a 4 tahun


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P " r%($aan 6%$%(

Keadaan Umum

Tampak lemas dan pucat

Tanda-tanda Vital

Tekanan darah : 80/60 mm !

"adi : 128 #/menit

$rekuensi na%as : &2 kali/menit

Temperatu A#illa : &6,1 '

(tatus )i*i

+erat adan sekaran! : 2 ,. k!

Tin!!i adan : 129 cm

+erat adan deal : 2 k!

Tin!!i adan ideal : 1.0 cm

(tatus )i*i : era akan endek 3T+ 4 ++ setara anak usia 8,. th5


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K pa!a

B ntu( # nor"o- pha!

U(uran # " $o $ 3a!

Ra"*ut # h%ta" t%p%$ t%)a( "u)ah )%-a*ut

7a,ah # $%" tr%$ ) 3or"%ta$ 0 3a-% $ -oo! ' 0 $%ano$%$ 0

Mata # an "%$ 0 %(t r%( 0

T !%nga # * ntu( nor"a! po$%$% nor"a! 0 $ -r t 0

8%)ung # ) 3or"%ta$ 0 p rnapa$an -up%ng h%)ung 0

Mu!ut # $%ano$%$ 0

T nggoro(an # h%p r "%$ 0 Ton$%! T1/T1


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L h r

In$p ($% # $%" tr%$ "a$$a 0

Pa!pa$% # tra( a )%t ngah p "* $aran ( ! n,ar !%"3 r g%ona! 0

Thora($

5or

In$p ($% # %-tu$ -or)%$ ta( ta"pa(

Pa!pa$% # %-tu$ -or)%$ ta( t ra*aP r(u$% # r )up *ata$ ,antung )a!a" *ata$ nor"a

Au$(u!ta$%# S1S2 tungga! ($tra$%$to!/ga!!op/"ur"ur # / /

Pu!"o

In$p ($% # $%" tr%$ r tra($% /

Pa!pa$% # (r p%ta$% 0 3r "%tu$ ra*a N/N

P r(u$% # $onor )%$ "ua !apang paruAu$(u!ta$%# + $%(u!ar / rhon(% / &h 9%ng /


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A*)o" nIn$p ($% # :at )%$t n) ) 0

Au$(u!ta$% # *%$%ng u$u$ 0 ; (a!%/" n%t

P r(u$% # t%"pano r )up

Pa!pa$% # $o p ! t r)apat p "* $aran !% n S-hu


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asil a 7rat7rium

emeriksaan "ilai "7rmal asil8 "og!o*%n

LEDL u(o$%t

8%tung J n%$

8 "ato(r%t Tro"*o$%t

11.4 > 14.4? 24

@.4 > 1 .4? @/? 1/ 4/4@ 2/24

/24 > @414? > @4?

C C

11 11/ / / ?/ @/4

21 @11


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Kumpulan ata ia!n7sis ia!n7sis+andin!

encanaa!n7sis

L !ah )an ! "a$ 0An "%a pu-at 0P rut " "* $ar 0P ra&a(an p n) ( 0R%&a'at tran$3u$%* ru!ang 0

Tha!a$ "%a Darah L ng(ap8apu$an Daraht p%6 rr%tr%n $ ru"

Tran3u6 rr'pA$a" F%ta"F%ta"


10/16

D%agno$%$ K r,a

Tha!a$ "%a


11/16

P!ann%ng D%agno$t%(

Darah ! ng(ap

8apu$an )arah t p%

6 rr%tr%n $ ru"


12/16

P!ann%ng Mon%tor%ng

Tan)a tan)a +%ta! r a($% tran3u$% (o"p!%(a$%


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K *utuhan -a%ran # 144? --/har%

K *utuhan (a!or% # 12G2 ((a!/har%

K *utuhan prot %n # 2C 4 gra"/har%


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P!ann%ng T rap%

Tran3u$% PR5 2??--

6 rr'pro 2 1

A$a" 3o!at 1 1

F%ta"%n E 1 1

F%ta"%n 5 1 1


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P!ann%ng E)u(a$%

P n, !a$an ( pa)a ( !uarga t ntang (on)%$% pa$% n $aat %n% 'ang" " r!u(an tran3u$%

M n, !a$(an ( pa)a ( !uarga pa$% n " ng na% ( "ung(%nan t r,a)%n'ar a($% tran3u$%

M n, !a$(an ( pa)a ( !uarga " ng na% (o"p!%(a$% )ar% p "* r%antran3u$% ,ang(a pan,ang


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T r%"a Ka$%h

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MR Thalasemia Baru