MAPPING ASTER IV

Senin, 3 Juni 2019

BED IDENTITAS DIAGNOSIS TERAPI PLAN

B Ny Unik S Ax: MSI post MVR, TR moderate post TV repair 1. Bedrest total 1. Aspirasi cairan pericard per 8 jam
37 tahun Fx: AF RVR, NYHA III 2. DJ III 1700kkal 2. Rawat luka per 2 hari
01140392 Ex: PJK 3. O2 3 lpm NK 3. Pro pericardioctomy setelah lebaran
Dr. Heru SpJP P: Efusi pericardial post pericordocenthesis hari kedua 4. IVFD NaCl 0.9% 60cc/jam 4. Cek INR per 3 hari (6/6/19)
DPH II Leukositosis (19,4) 5. Inj Lanoxan 0.25 (jika HR >110bpm) 5. Cek DR 3 Ur Cr (6/6/19)
Azotemia (Cr 1.6, EGFR 41) 6. Candesartan 4mg/24jam (TUNDA)
Hiponatremi (125) 7. Concor 5mg/24jam
Overshoot INR (16.9-9.4) 8. PMR 250mg/12jam
9. Warfarin 4mg/24 jam (TUNDA) II
10. Kolkisin 0,5mg/24 jam
11. Metilprednisolon 8mg/12jam
12. Inj Ranitidin 50mg/12jam
13. Sucralfat syr 3 cth 1
14. Inj ampisilin sulbactam 1.5g/8jam
15. Vit K tab 1 tab/24jam
C Tn. Joko Riyanto Ax : OMI anteroseptal, MR mild, thrombus dextra 1. Bedrest setengah duduk
52 tahun apikal LV 2. O2 3 lpm nasal kanul 1. EKG pagi
01234690 Fx : ADHF perbaikan , EF 19% -20 % 3. DJ III 1700 kkal
Dr.Alfin sp. JP Ex : CAD, FR : Laki-laki, >45 tahun, merokok 4. Infus RL 30ml/jam
DPH VI P : melena perbaikan, hypokalemia, efusi pleura 5. Injeksi furosemide 20mg/24 jam
transudatif, trombus besar di apikal LV 6. Ramipril 2,5 mg/24 jam
7. Atorvastatin 40mg/24jam
8. Injeksi omeprazole sp 80mg/50cc dosis
8mg/jam kecepatan 5cc/jam
9. Bisoprolol 1,25mg/24 jam
10. Sucralfat 3 cth 2
11. KSR 3x1
12. Usul inisiasi heparin
F Tn. Widada Ax: STEMI anterior luas onset 4 jam post failed 1. Mobilisasi duduk
51 tahun fibrinolitik, post PCI IDES proksimal LAD 2. IVFD NaCl 0,9% 40cc/jam 1. BLPL hari ini
01462748 Fx : Killip I, EF 31-39% 3. O2 3 lpm NK
Dr Alfin SpJp Ex : PJK 4. DJ I 1700kkal
DPH VIII P : Hipertensi 5. Aspilet 1x80 mg
ISPA 6. Clopidogrel 1x75mg
7. Ramipril 1x10mg
8. Atorvastatin 40mg/24 jam
9. Bisoprolol 10mg/24jam
10. Amlodipine 1x10mg po
11. NAC 200mg/8jam
G Darso, Ny Ax: OMI anteroseptal 1. Bedrest total ½ duduk 1. Cek lab melengkapi
69 tahun Fx: ADHF, AFNVR 2. IVFD NaCl 0.9% 20cc/jam 2. Cek fungsi jantung
01463357 Ex: PJK 3. DJ III 1700 kkal 3. Cek INR/3 hari (6/6/19)
Dr. Heru SpJP P: Pneumonia, efusi pleura bilateral 4. O2 3 lpm NK 4. Balance cairan
DPH II 5. Ramipril 2,5mg/24jam 5. EKG pagi
6. Inj lanoxin 0,25mg jika HR>110bpm
7. Bisoprolol 1,25mg jika HR<110bpm
8. Warfarin 0-0-2mg
9. Inj furosemid 40mg-40mg-0
10. Atorvastatin 0-0-40mg
11. Spironolakton 25mg-0-0
12. NAC 200mg/8jam
13. Inj Ampisilin sulbactam 1,5g/8jam (TS
Paru)