KJS BAWAH 26febs
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DAFTAR PASIEN RAWAT INAP KJS BAWAH KARDIOLOGI 26 FEBRUARI2015
PALEM BAWAH
B2/7/2Muh.Yamin7023055.05.1948MRS 22/2/15DPJP:Prof. dr. Peter Kabo,SpJP
S:Nyeri msih adaO:Tensi: 130/80BJ I/II reguler, Ronki dan wheezing tdkada.Udemekstremitastidakada.A:AP CCS IIIP:-Echokardiografi
IVFD NaCl 0,9%Farsorbide 10mg/8j/iv (TUNDA)ISDN 5 mg/SL-bila nyeri dadaClopidogrel 75 mg/24j/oralSimvastatin 20mg/24j/oralValsartan 80mg/24j/oralOmeprazoll 40mg/24j/oralParacetamol Recolfar 0.6mg/12j/oralCefadroxil 500mg /12j/oral
B2/6/1Marliah08-12-1963651016KJS: Kardio: Prof.Peter,Sp.JPS :Sesak masih adaO :BP: 140/80BJ I/II reguler,.Ronki dan wheezing tidak ada.Udemekstremitastidakada.A :CHF ec HHD,CADFurosemide 40mg/12j/ivFarsorbid 10mg/8j/oralIrbersartan 300mg/24j/oral
B2/5/2Yusuf Massa12-12-1945665029DPJP: Prof. Peter Kabo S: Sesak nafas tidak ada
O:BP: 120/80, ronchi ada di basal paru, wheezing tidak ada. BJ I/II murni regular. Ascites tidak ada. Edema ekstremitas tidak ada
A: CHF ec CADNephrolithiasis Sinistra
P: EchocardiographyNaCl 0.9% 500cc/24j/IVFurosemide 20mg/12jam/IVClopidogrel 75mg/24j/oralNitrokaf 2.5mg/12j/oralSimvastatin 20mg/24j/oralAlprazolam 0.5mg/24j/oralLaxadin syr 10cc/24j/oralOmeprazole 40mg/24j/IV
B2/1Hj.Tangnga31-12-1946339090DPJP: UrologiS:Sesak, nyeri dada, jantungberdebartidakadaO:BJ1/1 reguler, tdkada murmur.Ronkidan wheezing tdkada.Udemekstremitastidakada.A:Post AF NVR ecAnxietasAlprazolam 0.25mg/12j/oralEchoDisfungsidiastolikventrikelkiriEF 61%
EKG SR, HR 65x/i
B2/10Syamsuddin70118515-5-1960DPJPS;Sesakdannyeri dada tidakada.O: TD 130/70BJ1/1 reguler.Ronkidan wheezing tdkada.Udemekstremitastidakada.A:HHDSusp CADAmlodipie 5mg/24j/oralNitrokaf 2.5mg/12j/oralClopidogrel 75mg/24jam/oralSimvastatin 20mg/24j/oralEcho-Disfungsisistolikdan diastolic ventrikelkiriec. CAD-Ejeksifraksi 54%-LVH
LONTARA 1
7/III/3Dg Lawa4-6-1946700602MRS 9-2-15DPJP: Prof. Peter
S:Sesakberkurang, berdebarberkurangO:BJ1/1 reguler.Ronkidan wheezing tdkada.Udemekstremitastidakada.A:Post AV RVRSinus Rhtym HR 84x/menit
Digoxin 0.25mg/24j/oralSimarc 2mg/24j/oral
LAB 13-2-15Alb 2.2HB 6.4WBC 14.5RBC 2.82HCT 6.4PLT 442
EKGSR HR 90x/i
7/iii/6Sawala1-7-1952701645DPJPS:SesakberkurangO:TD 160/100BJ1/1 reguler.Ronkidibasalparudan wheezing tdkada.Udemekstremitasada minimal.
Furosemide 40mg/12j/oralKsr 1 tab/12j/oralNitrokaf R 2.5mg/12j/oralAmlodipine 10mg/24j/oralClopidogrel 75mg/24j/oral10cc/24jam/oral
ECHO: -Disfungsi sistolik dan diastolic L- LVH- Segmen posterior dilatasi, segmen lain hipokinetik- Ejeksi fraction 37%
6/III/3Tundru6929831-1-1942DPJP Prof PeterS;Sesakdannyeri dada tidakada.O:BJ1/1 irreguler.Ronkidan wheezing tdkada.Udemekstremitastidakada.A:CHF ec HHDAF NVR
O2 4LPMFurosemide 20mg/24j/oralDigoxin 0.125mg/24j/oralSimarc 2mg/24j/oralAmlodipin 10mg/24j/oralEKG control tiap pagi
6/II/1Gazali Soewandi22-6-1944580985DPJPS: sesakBatuk dan lendir putihO:BP:190/100BJ I/II regulerRonki di basal paru dan wheezing tidak adaLuka dan edemaekstremitas kanan.A: Severe PADFurosemid 40/24j/oralAspilet 80mg/24j/oralClopidogrel 75mg/24j/oralNitrokaf 2,5mg/12j/oralCilostazol 100mg/24j/oralDOPLER-severe peripheral artery diseaseTHORAX-TB paru dextra lama aktif lesi luas dengan atelectasis lobus medius paru dextra.-efusi pleura dextra minimal-cardiomegaly dengan dilatation et elongation aortae
6/II/2Thayeb1-1-1946702061S: Sesak berkurangO:Tensi 140/80Ronki di basal paruWheezing tidak adaA:CHF ec. HHD, CAD-Hematochesia ec. Tumor recti.
Furosemid 40mg/12j/ivNitrokaf 2,5mg/12j/oralValsartan 80mg/24j/oralSimvastsatin 20mg/24j/oralECHO:Disfungsi diastolik LVLVHAR TriviaLVEF 55%
PAKIS
Kamar 4Syukur Marwan67969214-04-55DPJP: dr. Pendrik T.Sp.PD K-KVS:Sesak berkurangPerut membesarO:Ronki tidak adaBJ I/II regulerAscites adaEdema ekstremitas adaA:Right heart failure ecFurosemide 40mg/12j/ivSpinolactan/2j/oral
Kamar 4Abd. Majid Asjad56860914-10-1945DPJP:Prof. Peter Kabo, Sp.JPS:Sesak dan nyeri dada tidak adaO:BP:Rhonki dan wheezing tidak adaBJ I/II regulerA:Coronary Artery disease
Nitrokaf 2,5mg/12j/oralClopidogrel 75mg/24j/oralSimvastatin 20mg/24j/oral
LONTARA 2,3,4
LONTARA 2ORTHOPEDIK7B/5Rahmat Paloa23-04-1958699769MRS 10-2-15DPJP: Prof Peter,Sp.JPS:Sesakdannyeri dada tidakadaO:BP: 120/80BJ I/II reguler.Ronkidan wheezing tdkada.A:HHDPost VESBisoprolol 10mg/24j/oralAlprazolam 0.25mg/24j/oralThorax-Cardiomegaly dgn elongation aortae HHD
EchoDisfungsi diastolic ventrikelkiriEF 76%Ventrikelkiridilatasiringan
LONTARA 2 ORTOPEDIK4/II/4Aisyah Abbas45957425/12/1946mrs 14/2/15DPJP: Prof Peter,Sp.JPS:Sesakdannyeri dada tidakadaO:BP: 160/80BJ1/1 reguler.Ronkidan wheezing tdkada.A:HHDP:Amlodipin 5mg/24j/oralValsartan 80mg/24j/oralEKGSR HR 84x/I, LVH?
ECHO: Disfungsi diastolic ventrikel kiri Ejection fraction 62% LVH AR Mild
LONTARA 3NEUROK3/III/2PARNI1-7-1942700603DPJP: Prof Peter,Sp.JPS: Tidak adaO:BP: 130/60JVP R+2BJ1/1 reguler.RonkidibasalparuEdemekstremitastdkada.A:CHF ec HHD,CADP:EchocardiografiRENCANA PULANG
NaCL 0.9%Furosemide 40mg/12j/ivFarsorbid 10mg/8j/oralAspilet 80mg/24j/oralSimvastatin 20mg/24j/oralAmlodipine 5mg/24j/oralDigoxinThorax-Cardiomegalidgn dilatation et atherosclerosis aortae
LONTARA 3NEUROK5/5Marsuki7-4-1941701991DPJP: dr. Pendrik, Sp.PD K-KVS:Sesak berkurangO:BP: 130/90BJ I/II reguler.RonkidibasalparuEdemekstremitastdkada.A:CHF ec HHDGeneral weakness ec NHSP:Echocardiografi
RLFurosemide 40mg/12j/ivNitrokaf 2,5mg/12j/oralO2 4lpmNaCl 0.9%/24j/IntravenaSpironolacton 25mg/24j/oralBalance cairanOutput urine
LONTARA 4OBGYNK5/B1SarlotaManggalo7016008-9-1984DPJP: Prof Peter,Sp.JPS:SesakberkurangO:BP: 172/117BJ1/1 reguler.Ronkidan wheezing tdkadaEdemekstremitastdkada.A:HHDAKIP:Usul co GHEchocardiografiBOLEH PULANG RAWAT JALAN
Metildopa 250mg/12j/oral
ICU
Ny. Hidrawati08-06-1977627779Prof. Ali
S: Sesak dan nyeri dada tidak adaO:BP: 116/81BJ1/1 reguler.Ronki dan wheezing tdkada.BJ I/II Murni regulerUdemek stremitas ada.A: Efusi pericardium (post pericardiosintesis + sternotomi)
RL 800cc/24j/ivAwasi tanda vital dan balance cairanTerapi sesuai TS anestesi
Ny. Nurlela Umar07-09-1974691288dr. Abd. Hakim
S: Lemas, Sesak dan nyeri dada tidak adaO: BP: 110/57, HR: 75, RR: 20, SpO2 100%Ronchi dan wheezing tidak adaBJ I/II Murni regulerA: post mitral valve replacement
Awasi tanda vitalBalance cairanTerapi sesuai TS Anestesi
H. Muh. Jafar31-12-1957702019dr. Abd. HakimS: Tidak sadar, terventilator, sesak tidak adaO: BP 101/56, HR 91Ronchi dan wheezing tidak adaBJ I/II regulerLab (24/02/15): PT:19.4, INR: 1.89, APTT: 73.2Dosis heparin diturunkanLab (25/02/15): PT: 14.8, INR: 1.40, APTT: 44.3A: Susp. Emboli Paru
Heparin 500 unit/jam/syringe pumpAwasi tanda vitalBalance cairanKontrol ulang PT, APTT, INR siang ini