MAPPING HCU ASTER IV

30/05/2022
BED PASIEN DPJP DIAGNOSIS DPH RESIDEN TERAPI PLAN

B Ny. Wuryani Dr. Adi Bestara SpJP Ax: Efusi Perikard Masif (Rekuren), Post 7 NR/AF Colchisine 1x0.5 mg Pungsi pericard/24
01568502 Pericardiocentesis H-1 Lansoprazole 1x30 mg jam
49 tahun Fx: NYHA IV, impending tamponade Amlodipine 1x 5 mg
E: Malignansi
23/5/2022 P:
Cylothorax Dextra, tumor mediastinum
Efusi pleura
C Ny. Sumarni Dr. Niniek SpJP(K) Ax : MR severe, PR moderate, TR moderate 3 NR/AF Bedrest total ½ duduk Cek lab melengkapi
01575012 Fx: ADHF, EF 40% O2 3lpm nk senin
61 tahun Ex : PJR DJ II 1700kkal
P: IVFD RL 20cc/jam
CKD on HD SP furosemide 200mg murni dosis
Efusi Pleura 5mg/jam
Dyspepsia Inj Ranitidin 50mg/12jam
Amlodipine 1x10mg
Inf. D40% 2fl + Inj. Insulin
Novorapid 10 iu (3x)
VIP Albumin 3x1
Nebulizer Salbutamol 3x1 respule
D Ny. Nurmala Wiiastuti Dr. Trisulo SpJP(K) Ax : VSD L to R shunt, MR Mild, TR Severe, PR 1 NR/AF - Bedrest total Cek lab melengkapi
01578775 Moderate - DJ II 1700kkal Echocardiography
20 tahun Fx : NYHA II LVEF 49.55% ( RS Perujuk) - 02 nasal canul 3lpm
Ex : konginetal - Inj. Furosemide k/p
29/5/2022 P:
1. G1P0A0 UK 34 Minggu

E Tn. Lalu Adijaya Dr. Niniek SpJP(K)  Ax : CAD 2VD post PCI 1 DES osteal-distal LAD, 1 DES 4 NR/AF Bedrest total -
01578530 osteal-distal LCx, pada STEMI anteroseptal late onset O2 3lpm NK k/p
50 tahun tanpa fibrinolitik, OMI inferior DJ II 1700kkal + diet DM
Fx : Killip I --> Killip IV, AHF, EF 35% (bedside) IVFD RL 40cc/jam
Ex : PJK, FR : DM, smoker, laki-laki >45 th Atorvastatin 1x40mg
26/5/2022 P: Ramipril 1x2.5mg
DM tipe II Bisoprolol tunda ec on Dobutamin
lekositosis (AL 17.6) ec infeksi dd reaktif Aspilet 1x80mg
susp. Pneumonia Ticagrelor 2x90 mg
Inj Lovenox 60 mg/12 jam SC (IV-V)
Spironolakton 1x25mg
inj SP Dobutamin 3 mcg/kg/menit
Coralan 2x2.5mg
Inj. Furosemide 20mg/8jam

Terapi IPD
1. Inj Apidra 5-5-5 unit
2. Inj Lantus 0-0-0-10 unit
F Tn. Agus sapto Dr. Trisulo SpJP(K) Ax : CAD3VD PCI 1 DES prox mid LAD, mild ISR di RPL 1 NR/AF Bedrest total 1/2 duduk Cek lab melengkapi
01460374 (Juni 2021), stent lama LCx patent IVFD RL 10cc/jam
37 Ttahun Fx : ADHF, EF 33%-35% DJ II 1700 kkal
Ex : PJK O2 3lpm NK
29/5/2022 P: Aspilet 1x80mg
 - Efusi Pleura Sinistra Clopidogrel 1x75mg
- DM tipe II Atorvastatin 1x40mg
- Hiperurisemia (AU 11.8) Spironolakton 1x25mg
Valsartan 1x160mg
Bisoprolol tunda
SP Inj. Furosemide 200mg murni dosis
5mg/jam
G Tn. Suparman Dr.pramadya SpJP  Ax: CAD 1VD CTO Prox RCA, DCM dd iskemik 6 NR/AF Bedrest total CEK UR/CR hari ini
01220617 cardiomyopati dd chronic myocarditis, MR Inf NS 0.9% 20cc/jam --> 60 cc/jam Cek kultur sputum
63 tahun Moderate e.c. Restricted PML DJ I 6x200cc --> DJ II 1700 kkal
Aspilet 1x80mg
Fx: ADHF, Forrester Class II, EF 13% (Teich),
24/5/2022 Atorvastatin 1x 40 mg
16% (Simpson), Post ROSC (VT/VF-->TAVB-- Uperio tunda
>sinus rhythm dengan PVC Occasional) Bisoprolol tunda
Ex : PJK Spironolakton 1 x 25 mg
P: SP Dobutamine tapp down 10 --> 7.5
- Hiperkalemia ( K 5.6 --> 3.9 --> 4.2) mcg/kgbb/menit (5.4 cc/jam)
- Riwayat Hipoglikemia (GDS 49 --> 111 --> 54 SP Norepinephrine 0.1 mcg/kgbb/min
--> 156) (4.5cc/jam) --> stop
Acetazolamide stop
- Azotemia (Cr 1.3)
SP Lansoprazole 6mg/jam (5 cc/jam)
- Cardiac arrest survivor (VT/VF post defibrilasi)
- Stress ulcer
- Hematemesis perbaikan
- alkalosis metabolik perbaikan
H Tn. Ilham C Dr. Niniek SpJP(K) Ax: DCM, MR PR TR mild 4 NR/AF 1. Bedrest ½ duduk Konfirmasi TS IPD
01578540 Fx: ADHF, EF 23%, Intermediet prob of PH 2. O2 3lpm NK untuk kepentingan
21 tahun Ex: Myopathy dd Infeksi dd Autoimun 3. DJ II 1700 kkal rendah protein, HD
tanpa kaldu, rendah garam
26/5/2022 P:
1. Azotemia (Cr 4.7, Ur 319, eGFR 13 ml/min) e.c 4. IVFD RL 10 cc/jam
ACKD dd CKD 5. SP Furosemide 200mg murni 5
2. Lekositosis (AL 13.0 10.1) mg/jam kec 0.5 cc/jam
3. Hipoalbuminemia (Alb 2.9) 6. SP Dopamin 200 mg/50 cc NS,
4. Hiperbilirubinemia (Bil Tot 6.55) dosis 3 mcg/kgbb/menit,
5. Susp. Pneumonia kecepatan 4.5 cc/jam (single
6. Hiperkalemia (6.3) dose)
7. peningkatan Enzim Transaminase e.c Susp
7. Ramipril --> Tunda e.c
Congestive Liver DIsease (SGOT: 58 SGPT: 123)
8. obesitas gr II hiperkalemia
9. Alkalosis respiratorik terkompensasi tidak 8. Spironolakton tunda e.c eGFR
sempurna <30 ml/min
9. Carvedilol inisiasi 2x 3,125mg
10. Ivabradine 2x5mg
11. Inj. ranitdin 1A/12 jam
12. lactulose Syr 3xC1
13. VIP Albumin 3x1
 MAPPING ASTER V
30/05/2022
BED PASIEN DPJP DIAGNOSIS DPH RESIDEN TERAPI PLAN
1A Ny. DR. Hasil Kateterisasi (26/5/22) : MR Grade 2+, LVEF 32.4%, Global Hipokinetik, 5 NR/AF P : 1. Bedrest 1/2 duduk Cek INR / 3 hari
Nurul’ain Triadhy Normal Coroangiography, ---> Saran : Konservatif 2. O2 3lpm nk (selanjutnya
Paiman SpJP(K) Echo 25/4 : Dilataso seluruh ruang jantung dgn kontraktilitas LV turun EF 3. DJ II 1700 kkal 31/05)
01177319
14% simpson 20% 4. IVFD RL 20cc/jam Cek UR/CR/ 3 hari
61 tahun
Disfungsi diastolik gr II, MR severe ec restricted PML, TR mild. 5. Inj Furosemid 20mg/12 jam (selanjutnya
25/05/2022 A : Ax : MR severe, TR mild, dilated all chamber 6. Warfarin 0-0-2mg 31/05)
Fx : ADHF (Perbaikan), EF 20%, PVC trigemini RVOT origin 7. Atorvastatin 1x 40mg BC/UO
Ex : Restricted PML 8. Ramipril 1x5mg EKG pagi evaluasi
P: 9. Carvedilol 2x3.125mg PVC
1. Hipertensi 10. Spironolakton 1x25mg
2. Azotemia (Cr 1.8, eGFR 32 ml/min/1.73 m2) 11. Digoxin 1x0.25mg
3. hiperuricemia (AU 16.2) 12. Asam Amino Keto 1fl/24 jam (IPD)
4. Hipomagnesemia (Mg 0.39 --> 0.29 - 0,59) 13. Prorenal 3x1 (IPD)
14. Asam Folat 1x800mcg (IPD)
15. CacO3 3x1 tab (TS IPD)
2A 01574213 Dr. Ax : CCS pada OMI Inferior, Riw ACS (Maret dan Februari 2022) 1 NR/AF 1. Bedrest total 1. Pro DCA/PCI
HARYADI Triadhy, Fx : CCS III, LVEF 37-40% 2. DJ III 1700kkal 2. cek lab
46 tahun Sp.JP Ex : PJK 3. IVFD RL 60cc/jam melengkapi
FR : Laki2 >45th, Riw ACS ( Maret dan Februari 2022), Hipertensi 4. Bisoprolol 5mg 1-0-0
29/5/22
P: 5. Nitrokaf 2x1
1. Hipertensi 6. Aspilet 1x80mg
2. Riw ACS (Maret dan februari 2022) 7. CLopidogrel 1x75mg
8. Rosuvastatin 1x20mg
Echo 19/4/22 : LVH ekcentrik RWMA ef 37 % simpson 40%, MR mild, Disfungsi 9. Ramipril 1x10mg
diastolik gr II 10. Spironolactone 25mg 1-0-0
2B 01555580 Dr. A : Ax : CCS pada OMI Anterior 1 NR/AF 1. Bedrest total 1. Pro DCA/PCI
DARTO Triadhy, Fx : CCS III, LVEF 42% 2. DJ III 1700kkal 2. cek lab
60 tahhun Sp.JP Ex : PJK 3. IVFD RL 60cc/jam melengkapi
FR : Laki2 >45th Hipertensi 4. Bisoprolol 5mg 1-0-0 3. Echocardiografi
29/5/22
P: 5. ISDN 5mg k/p
1. Hipertensi 6. Aspilet 1x80mg
2. TMT (+) 7. Atorvastatin 40mg 0-0-1
8. Candesartan 8mg 0-1-0
Echo 26/10/21 : LVH ekcentrik fungsi sistolik LV turun, ggn kimetik segmental, Fungsi 9. Spironolactone 25mg 1-0-0
Sistolik RV normal, AR MR mild
2H 01578511 Dr. Ax : CAD2 VD PCI 1 DES prox-mid RCA pd STEMI inferior RV onset 10 jam post 4 NR/AF - Bedrest total
ARIF Indah, successfull fibrinolitik, OMI anterior - DJ 1700 kkal
GUNAWAN Sp.JP Fx : Killip I--> Killip IV--> perbaikan,EF 33-37%, TAPSE 1.3 cm - IVFD RL 80 cc/jam
44 tahun Ex : PJK - O2 3 lpm/menit jika SpO2 < 90%
FR : laki-laki, smoker, Hipertensi - Inj. Enoxaparin 60 mg/12 jam SC (9-10)
P: - Aspilet 1x80 mg
26/5/22 Leukositosis (AL 15900) ec reaktif dd infeksi - Clopidogrel 1x75 mg
- Atorvastatin 1x40 mg
Echo 27/5 : LVH ekcentrik dengn RWMA EF 33% sipmson 37% - Bisoprolol naik 1x 2.5 mg
MR moderate, AR TR PR Mild, Disfungsi diastolik gr II - Ramipril 1x 2.5 mg
 - Spironolactone 1 x 25mg
5 Ny. Sularmi Dr.Niniek Ax : ASD II, R to L Shunt, HHD, AR-TR-PR Moderate, MR Mild 4 NR/AF 1. Bedrest total 1/2 duduk
01578538 SpJP(K) Fx : ADHF perbaikan, AFRVR --> AFNVR, High Probability of PH, EF 55-56% 2. DJ II 1700 kkal+ diet rendah garam
72 tahun Ex: HT 3. O2 NK 3 lpm k/p
P: 4. IVFD NS 0.9% 500cc 30 cc/jam
26/5/2022 1. Aneurisma Aorta Asenden 5. Inj. Furosemide 40mg/8 jam
2. Hematuria Perbaikan 6. Warfarin 0-0-2mg
3. HAP 7. Ramipril 2x 2.5mg
4. DM tipe II 9HbA1C 7.0) 8. Bisoprolol 1x1.25 mg
5. Hiperurisemia (AU 8.6) 9. Spironolacton 1x100mg
6. Hipokalemia (K 3.1 - 4) 10. Inf paracetamol 1gram /8jam
11. Atorvastatin 1x20mg
Echo 27/5 : ASD II R to L shunt, LVH eksentrik dgn kontraktilitas LV baik EF 55% 12. Inj. Digoxin 0.25mg jk HR >110 bpm
simpson 56% 13. Sildenafil 3x20mg inisiasi
TR PR moderate, AR moderate ec aneurism aorta asc, MR Mild, High prob of PH 14. Ampiciln 4x 1 gr (TS Paru)
15. Levofloxacin 1x750 mg (TS Paru)
6 01347734 Dr, Heru, Ax : CCS pada CAD 3VD PCI 2 DES Osteal Distal LAD Timi Flow III, Stent lama di osteal 1 NR/AF 1. Bedrest total Pro DCA besok tgl 30
BAMBANG Sp.JP (K) Prox RCA Patent, Stent lama di Distal Lcx Patent ( 13 januari 2022) 2. DJ III 1700kkal Mei 2022, urutan ke
NATUR Fx : CCS III, LVEF 55-63% 3. IVFD RL 60cc/jam 3
RAHADI Ex : PJK 4. Bisoprolol 5mg 1-0-0 Cek lab melengkapi
FR : Laki2 >45th Hipertensi 5. Nitrokaf (k/p) Echocardiografi
56 tahun P: 6. Aspilet 1x80mg
1. Hipertensi 7. Clopidogrel 1x75mg
29/5/22 2. TMT (+) 8. Atorvastatin 40mg 0-0-1
3. Azotemia (Cr 1.5 eGFR 46ml/min) 9. Ramipril 5mg 0-0-1

Echo 13/1/22 : LV concentric remodeling gn kontraktilitas LV baik EF 55 simpson 63%

Fungsi diastolik baik, katup normal