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DAFTAR PASIEN RAWAT INAP KARDIOLOGI 8 JANUARI 2015

Lontara 1 Bawah Depan Ruang Perawatan Khusus


1 RPK BAWAH Perawatan hari ke 49 - Oksigen 4 liter per Laboratorium 31/12/2014
BED 1 A : Post syok menit WBC 10.31
Paulus Lande Batara Kardiogenik - Dobutamin 5 RBC 4,96
TTL : 02/05/1972 - Congestive mcg/kgBB/menit/via HB 14.9
689765 heart failure syringe pump HCT 44.5
MRS 20/11/2014 NYHA III et - Vascon 0.03 PLT 368
DPJP : dr. Pendrik causa coronary mcg/kgBB/menit/via UR/CR 27 /0.8
Tandean,Sp.PD artery disease syringe pump
- Thrombus di - Clopidogrel 75 mg/24 Albumin 3.3
ventrikel kiri jam/oral Na/k/Cl : 137/3.8/101
- Haemoptosis - Digoxin 0.25 mg/24
jam/oral Echocardigram 24/11/14
- Codein 10 mg/12 - Disfungsi sistolik dan diastolik
jam/oral ventrikel kiri
- Spironolakton 25 - Ejeksi fraksi 27%
mg/24 jam/oral - Atrium kiri dan ventrikel kiri
- Adona tab/12 dilatasi
jam/oral - STOP - Akinetik anterior,anterolateral,
- Cefixime 100 mg/12 segmen lain hipokinetik
jam/oral ( hari ke 3) - Mitral regurgitasi sedang
- Paracetamol 500 mg - Fungsi sistolik ventrikel kanan
tab/8 jam/oral menurun
- Trombopob zalf - Trombus di ventrikel kiri
- Carbamazokrom Foto thorax 20/11/2014
inj.50 mg/12 jam/iv - Bronchitis kronik
- TB paru dextra suspek tenang
Tambahan: - Cardiomegaly dengan bendungan
Fagoxin 1 amp dalam 100 paru
cc NaCl habis dalam 1 - Efusi pleura minimal sinistra
jam/EXTRA/iv

Dobutamin 7.5
mcg/KgBB/menit syringe
pump
2 RPK BAWAH Perawatan hari ke 9 - Oksigen 4 Laboratorium 30/12/2014
BED 2 A : recent ST elevasi liter/menit WBC 7.2
Mappajari miokard infark KILLIP - NaCl 0.9% 500 RBC 3.40
TTL : 07/05/1955 II cc/24 jam HB 10.6
694428 - Congestive heart - Furosemide 40 HCT 30.2
MRS 26/12/2014 failure et causa mg/12 jam/IV PLT 490
DPJP : dr. Pendrik coronary arteri - Farsorbid 0.5 PT/APTT : 12.4’/32.3’
Tandean,Sp.PD disease mg/jam.syringe GDS 327
- DM tipe II pump UR/CR 36 /1.30
- Hipertensi on - Aspilet 80 mg/24 SGOT/SGPT 19/22
treatment jam/oral Troponin T : 1.1
- Clopidogrel 75 CK/CK-MB : 77/8.9
mg/24 jam/oral
- Simvastatin 20 Laboratorium 6/1/2015
mg/24 jam/oral GDP: 50
- Novorapid 8 GD2PP: 152
unit/8 HBA1c: 8.6
jam/subkutan Albumin: 3.0
- Levemir 12 Kolesterol total: 158
unit/24 LDL/HDL/Trigliserida: 102/28/88
jam/subkutan As.Urat: 7.5
- Alprazolam 0.5 Na/K/Cl: 143/3.7/106
mg/24 jam/oral
- GDS strip: 272
- Diet 1500 kalori
DAFTAR PASIEN RAWAT INAP KARDIOLOGI 8 JANUARI 2015

3 RPK BAWAH Perawatan hari ke 8 - Oksigen 4 Pemeriksaan Dopler vaskuler


BED 3 A : ST elevasi miokard liter/menit ekstremitas inferior sinistra 5/1/2015
Hamsinah infark whole anterior - NaCl 0.9% 500 Kesan :
TTL : 17/07/1971 onset > 2 hari KILLIP II cc/24 jam - aliran arteri ekstremitas inferior
694921 -Ulkus dekubitus pada - Furosemide 20 kiri kurang lancar dari proximal
MRS 30/12/2014 midaxilla dextra mg/12 ke distal hingga setinggi 1/3
DPJP : dr. Pendrik -DM tipe non obese jam/Intravena distal A. Tibialis Anterior
Tandean,Sp.PD -Dispepsia organik - Aspilet 80 mg/24 - Aliran vena kurang lancar dari
jam/oral distal ke proximal, tampak SEC
- Clopidogrel 75 namun tidak didapatkan trombus
mg/24 jam/oral - Kesimpulan : Severe stenosis
- Farsorbid 10 peripheral artery disease
mg/24 jam/oral
- Isosorbit dinitrat Laboratorium 1/1/2015
sublingual/jika GDP 272
nyeri dada GD2PP 224
- Miostazol 100 Kolesterol total 130
mg/12 jam/oral Kolesterol HDL 35
- Simarc 2 mg/12 Kolesterol LDL 82
jam/oral Trigliserida 71
- GDS trip: 269
- Terapi lain sesuai Analisis Gas darah 31/12/2014
TS interna Alkalosis respiratorik dan metabolik

Pemeriksaan Hematologi 6/1/2015


- Leukositosis dengan tanda tanda infeksi
- Trombositosis reaktif

Pemeriksaan Laboratorium 6/1/2015


Bilirubin total/direk: 0.37/0.19
Protein total: 6.1
Albumin: 2.9
Globulin: 3.2
D dimer: 1.90
Na/K/Cl: 137/4.2/93
PT/APTT/INR: 12.8/29.7/1.09

WBC: 21.71
RBC: 3.92
HGB: 10.8
HCT: 33.6
PLT: 1634 +

4 RPK BAWAH Perawatan hari ke 6 - Oksigen 2-4 liter/menit EKG 6/1/2015


BED 4 A: Congestive Heart nasal AF rapid ventrikular response, HR 130
Tn. Ismail Nganro Failure NYHA III et - Na Klorida 0.9% kali/menit, Normal axix
TTL: 07/07/1947 causa atrial fibrilasi rapid 500cc/24 jam
695179 ventrikular response - Bisoprolol 2.5 mg/24 Pemerisaan Laboratorium 5/1/2015
MRS 02/01/2015 jam/oral RBC: 5.48
DPJP: dr. Pendrik - Fasorbid 10 mg/8 HGB: 16.7
Tandean,Sp.PD jam/oral HCT: 47.1
- Maxiliv Tab/12 jam/oral PLT: 1021
- Cefixime 100 mg/24 PCT: 0.0951
jam/oral (Penggunaan hari WBC 17.3
ke 1)
- Furosemide 40 mg/12 GDS: 186
jam/oral Ureum/kreatinin: 161/4.30
SGOT/SGPT: 1237/4890
Na/K/Cl: 137/3.6/102
Lontara 1 Bawah Depan Kamar 2 kelas II
DAFTAR PASIEN RAWAT INAP KARDIOLOGI 8 JANUARI 2015

1 BED 1 Perawatan hari ke 22 - Oksigen 2-4 liter per Laboratorim 5/1/2014


H. Ramli Pareo A : Congestive Heart menit jika sesak WBC 5.24
TTL : 05/05/1961 Failure NYHA I et causa - Furosemide 20 mg/24 RBC 3.84
656399 coronary artery disease jam/oral HB 11.3
MRS 15/12/2014 - Observasi abdominal - Omeprazole 40 mg/24 HCT 33.9
DPJP : dr.Idar pain dd abses mesenteric jam/oral PLT 363
Mappangara,Sp.JP - Efusi pleura bilateral - Aspilet 80 mg/24 Na/K/Cl : 138/3.0/96
jam/oral
- Trizedon MR 35 Echocardiography 23/12/2014
mg/12 jam/oral - Disfungsi sistolik dan diastolik
- ventrikel kiri
Rencana alih rawat ke - Global hipokinetik
Bedah Digestif - Ejeksi fraksi 37%
Tidak ada penanganan
khusus dari kardiologi
2 BED 2 Perawatan hari ke 4 - Aspilet 80 mg/24 Laboratorium 5/1/2015
Muhammad Natsir A : Coronary Artery jam/oral PT: 11.6
TTL : 12/05/1970 Disease ( 2 vessel - Clopidogrel 75 mg/24 INR: 1.02
615520 disease) jam/oral APTT: 34.3
MRS 05/1/2015 - Simvastatin 20 mg/24 GDS: 114
DPJP : dr.Idar jam/oral Ureum/Kreatinin: 25/1.10
Mappangara,Sp.JP - Nitrokaf R 2.5 mg/24 SGOT/SGPT: 41/62
jam/oral CK/CK-MB: 83.00/11.5
- Captopril 12.5 mg/12 Troponin I: <0.01
jam/oral Na/K/Cl: 144/3.6/106
- Alprazolam 0.5 mg/24
jam/oral WBC: 6.74
RBC: 5.94
HGB: 16.3
HCT: 47.6
PLT: 241

Lontara 1 Bawah Depan kamar 3 kelas II


1 BED 1 Perawatan hari ke 27 - Oksigen 4 Laboratorium 3/1/2015
Suriani A : Infected liter/menit/jika WBC 8.6
TTL : 11/10/1967 Bronchiectasis sesak RBC 4.16
652392 Pulmonary Hypertension - Dorner 20 mcg/12 HB 12.7
MRS 12/12/2014 jam/oral HCT 38.7
DPJP : - Nebu Farbivent 1 PLT 293
Prof.dr.Peter amp/12 Na/K/Cl : 141/3.8/88
Kabo,Sp.JP jam/inhalasi
- Domperidone/8 Echocardiography 19/12/2014
jam/oral - Fungsi diastolik ventrikel kiri
- Pasien rencana baik
pulang hari ini - Ejeksi fraksi 69%
- Disfungsi diastolik ventrikel kiri
- Atrium & Ventrikel kanan
dilatasi, Ventrikel kiri D-Shaped
- Trikuspid regusrgitasi sedang,
pulmonal hipertensi berat
- Pulmonal regurgitasi ringan

EKG
Sinus rhythm, HR 100 kali/menit, P
pulmonal, RAD, RVH

2 BED 2 Perawatan hari ke 5 - Furosemide 40 mg/24 Analisis Cairan Perikard 5/1/2015


DAFTAR PASIEN RAWAT INAP KARDIOLOGI 8 JANUARI 2015

Reeta Kombong A : Efusi Perikard Masif jam/intravena Hasil: Eksudat


TTL : 31/12/1947 - Spironolakton 25
693884 mg/24 jam/oral
MRS 02/01/2015 - Corsel tab/24 jam/oral
DPJP : dr.Abd. - Miozidine 25 mg/12
Hakim A,Sp.JP jam/oral
- Ceftriaxone 2 mg/24
jam/oral (Penggunaan
Hari 1)
- Pepsol 40 mg/24
jam/oral

- dilakukan aspirasi
cairan haemorragic
pericard 370 cc
- Inj.heparin 5000
unit diencerkan
menjadi 10 cc dengan
NaCl intrapericard

3 BED 3 Perawatan hari ke 5 - Pro reparasi Laboratorium 31/12/2014


Andi Haderah A : Hipertensi Heart pacemaker WBC 6.8
TTL : 31/12/1928 Disease Permanent - Amlodipine 10 RBC 3.70
674347 Pacemaker mg/24 jam/oral HB 10.6
MRS 03/01/2015 HCT 33.0
DPJP : Prof.dr.Peter PLT 254
Kabo,Sp.JP CT/BT 7.30/2.00
PT/APTT : 10.1’/30.3’
INR 0.89
GDS 152
UR/CR 71 /1.70
SGOT/SGPT 32/13

Na/k/Cl : 139/4.5/107