v 2. Tn.

Eddy - Cendana 9 YBG U

lemas
Objective:

Hemodinamik
VAS : 0/10
TD 110/54
HR 72 x/i
RR 20 x/i
Sp.O2 99 % RA

Pfisik : dalam batas normal

Hasil lab rs cpl 14/01/23
Hb/Ht/Leu/Plt :
7,8/22,9/3.400/227.000
Na/K/Cl : 135/4,22/99
GDS : 289

hasil MSCT Scan (06/Oktober/2022) 

CCTA (Coronary CT Angiography)
LM : Dijumpai stent di proximal - distal, kesan patent
LAD : Dijumpai stent di proximal – distal, In-stent restenosis di proximal. Dijumpai 
Multiple Calcified Plaque di distal dengan stenosis 70-80 %
LCx : Dijumpai stent di proximal, kesan patent. Dijumpai Multiple Calcified Plaque di 
distal dengan stenosis 30-40%
OM1 : Dijumpai Multiple Calcified Plaque di proximal dengan stenosis 60-70%
OM2 : Dijumpai Calcified Plaque di proximal dengan stenosis 60-70%
RCA : Dijumpai Multiple Calcified Plaque di proximal – distal dengan stenosis 80-90%
Lain-Lain:
SVG-Distal LAD : Graft Patent, Distal Anastomosis baik
LIMA-LAD : Difus Calcified plaque di proximal dengan stenosis 80-90%.
SVG-OM1 : Total stenosis di osteal
SVG-PDA : Graft Patent, Distal Anastomosis baik
Kesimpulan:
Severe stenosis di distal LAD, proximal – distal RCA (CAD RADS 4a)
Moderate stenosis di proximal OM1, proximal OM2 (CAD RADS 3)
Mild stenosis di distal LCx (CAD RADS 2)
In-stent restenosis di proximal LAD
Graft Patent di SVG-Distal LAD, SVG-PDA
Graft tidak patent di SVG-OM1, LIMA-LAD

Suggestion:
Optimal Medikamentosa
Risk Factor Modifications
 
Assessment:
CAD post CABG (2017) 
Anemia e.c penyakit kronis (Hb:7,8)
AKI dd CKD (CrCl: 47 ml/i)
DM tipe 2
 
Planning:

Terapi kardio
Bisoprolol 2x2.5mg
Candesartan 1x8mg
Nitrokaf 2 x 2,5 mg
Clopidogrel 1x75mg
Aspilet 1 x 80 mg
Atorvastatin 1x40mg
Novorapid 3 x 12 IU
 

R/ Konsul gizi klinik unutk diet dan nutrisi pasien

R/Echo

--------------
Subjective:

BTK atas konsulnya

Penurunan berat badan 5 kg dalam 1 bulan, nafsu makan baik, semua makanan habis
Objective:

BB: 60 kg (berat badan turun 7,7% dalam 1 bulan)

TB : 160 cm
IMT : 23, 43 kg/m2
Assessment:

Overweight, CAD post CABG (2017), AKI dd CKD, DM tipe 2

Planning:

MB DM 1800 kkal, protein 60 gr

--------
Novomix 2x12 unit
Inj. Omeprazole 40mg/12 jam
R/cek feses rutin, benzidin test
R/Transfusi PRC 1 bag -> menunggu acc pengendali
R/ cek profil besi 

==================
3. Tn. Tulus - Cendana 10 YBG U
Subjective:

nyeri dada (-), sesak (-) kaki bengkak berkurang

Objective:

Sens CM
TD 110/70
HR 88 x/i
RR 20 x/i
Sp.O2 97 % RA 
 

Pemeriksaan Fisik
Thorax:
Pulmo : vesikuler (+/+), rhales (+) 1/3 basal, rhonki (-/-), wheezing (-/-)
Extremitas : edema pretibial (+/+)

Hasil lab
Hb/ht/leu/plt 14/44.8/9780/157000
GDS 120
PT/INR 12.5(19.3)
Aptt 33.6
Ur/Cr 47.6/1.14
Na/K/Cl 140/4.05/101
Assessment:

CHF fc III ec MR severe (EF 63%)

Post MV repair 2021
AF NVR
Planning:

Inj. Furosemide 40 mg / 8 jam

Simarc 1x2 mg
Candesartan 1x8 mg
Digoxin 1 x 0,25 mg
Spironolacton 1x50mg
 

R/Rujuk ke HAM untuk penanganan lebih lanjut hari ini

susul hasil GDP/2PP, bilirubin

==============
8. Tn. Zulkarnaen - Mahoni 18 YBG U
Subjective:

nyeri dada (-), sesak nafas (-)

Objective:
Sens: CM
VAS = 0/10 
TD 140/70
HR 74x
RR 20x
SpO2 98%

mata : ca (-/-), si (-/-)

Jantung: s1s2 reguler, murmur dan gallop tidak ada
Paru: Vesikuler +/+, rhonki (-/-), wheezing -/-, rhales (-/-)
abd : BU(+)
ext : edema pretibial (-/-)
Assessment:

STEMI inferior onset 1 jam KILLIP 1 TIMI RISK 1/14

HT stage 1
Planning:

IVFD NS 0.9 % 25 tpm mikro

Inj. Lovenox 0.6 mg/12 jam (H3) rencana 3 hari
Aspilet 1x80 mg
CPG 1 x 75 mg
Atorvastatin 1x40 mg
NKR 2x

2,5mg
Bisoprolol 1x2,5mg
Laxadin syr 1x1 cth
Insulin novorapid 3 x 14 IU
Insulin Lantus 1x10 IU

======================
10. Tn. Supriyono - Mahoni 19 YBG

Subjective:

sesak nafas (-)

Objective:

Sens : CM 
TD 170/90 mmHg 
HR 86 x/i 
RR 22 x/i 
SaO2 96% room air -> 98% Nasal Kanul 3Lpm

UOP 2100cc/24jam
BC -500cc/24jam
Mata : anemis -/- ikterik +/+
TVJ 5+3 cm H2O 
Cor : S1S2 reguler, murmur - gallop -
Pulmo : Vesikuler +/+ Ronki -/- Rales +/+ minimal basal paru, Wheezing -/-
Abdomen : Soepel, normoperistaltik, ascites (+), 
Extremitas : edema +/+ akral hangat

Lab RS CPL (16/01/2023)

Hb/Ht/Leu/Plt : 7.7/23.5/12.800/235.000
MCV/MCH/MCHC: 93.6/30.7/32.8 
Kesan : Makrositik Normokrom 
GDS : 78
Rapid antigen : Negative
Ur/Cr : 108/6.72 (CrCl : 9)
Na/K/Cl : 139/5.14/113 
Assessment:

ADHF Wet and Warm ec Overvolume 

HFrEF 32%
HHD dengan HT stage II
Jaundice d/t Liver Congestion 
AKI dd CKD (CrCl : 6)
Anemia (Hb 7.7)
Planning:

IVFD NaCl 0,9% 10 tpm

Inj. Ceftriaxon 1 gr/12 jam
Inj. Furosemid 40mg/8jam
Inj.Ondansentron 8mg/12jam
Inj. Ranitidin 50mg/12jam
Adalat oros 1x30mg
Bicnat 3x1 tab
NAC 3x1 tab
Vitamin B comp 3x1 tab
Nitrokaf retard 2x2.5mg 
Simvastatin 1x20mg

TS Nefro
-cek urinalisa ( susul )
-cek RFT/3 hari ( 19/01/23)
-pantau UOP per 3 hari (19/01/23)
-hindari obat-obatan nefrotoxic

===============
v 11. Tn Hendra ICU YBG
Subjective:

KU : Penurunan kesadaran
Objective:

Sens : DPO
TD 90/60 mmHg 
HR 109 x/i 
RR 20 x/i 
SaO2 98% terintubasi on venti

UOP: 614cc/6jam, BC: +314cc/26am

Mata : anemis -/- ikterik -/-

TVJ 5+2 cm H2O 
Cor : S1S2 reguler, murmur - gallop -
Pulmo : Vesikuler +/+ Ronki -/- Rales -/-, Wheezing -/-
Abdomen : Soepel, normoperistaltik
Extremitas : edema -/- akral hangat

Lab RS Royal Prima (16/01/2023)

Hb/Ht/Leu/Plt : 18/52,2/14.970/257.000
GDS : 139
Rapid antigen : Negative

Lab RS CPL (16/01/2023)

Ur/Cr : 46/1,64
Na/K/Cl : 147/-/105
pH/pO2/pCO2/HCO3/BE/TCO2/SatO2
7,59/184/20,2/24/-2,8/15,9/99
PT/INR 13(12,5)/0,88
APTT 25,9 (33,6)

Head CT Scan Royal Prima (16/01/2023)

ICH di hemisfer cerebri kanan dengan vol 35cc
IVH luas dengan hidrosefalus
Midline shift ke kiri 2cm
Assessment:

HT emergensi (target organ otak)

HHD
Spontaneous ICH (R) basal ganglia
IVH
Planning:

Drips Nicardipin dilanjutkan (titrasi sesuai TD) -→ STOP

Inj. Furosemide 20mg/12jam
Kandesartan 1x16mg -→ tunda
Atorvastatin 1x20mg
===================
v 1. Tn, Syamsul Bahri - Cendana 8 YBG

Subjective:
sesak (-)

Objective:
Sens : CM
TD : 110/70 mmHg
HR : 88 x/i
RR 22 x/i
SaO2 97%

Mata : anemis -/- ikterik -/-

TVJ : R+2 cmH2O
Cor : S1 S2 reguler, murmur -, gallop -
Pulmo : Vesikuler +/+ Ronki +/- Rales -/- Wheezing -/-
Abdomen : Soepel, normoperistaltik
Extremitas : edema -/- akral hangat

Lab RS CPL 15/1/23

Hb/Ht/Leu/Plt : 11.2/32.0/11.200/215.000
GDS 120
Rapid antigen : negatif
Ur/Cr : 33.2/1.05
Na/K/Cl : 136/3.0/98
AGD : pH/pCO2/pO2/HCO3/BE/TCO2/SaO2 : 7.45/30.9/159.5/21.0/-2.9/18.1/99%
SGOT/SGPT : 67/58

EKG RS USU
Kesan : Normo sinus ritme

Foto thoraks RSU Mitra Medika Tanjung Mulia 15/1/23

Kesan : Kardiomegali + dilatasi aorta (Susp. Aneurisma aorta)

Assessment:
- CHF ec CAD
- Pneumonia komunitas
- CAD post PCI tahun 2016
-Hepatomegali

Planning:
Terapi kardio
- Clopidogrel 1x75mg
- Candesartan 1x8mg
- Bisoprolol 1x5mg
- Amlodipin 1x5mg
- Simvastatin 1x20mg

Terapi paru
- IVFD NaCl 0.9% 20tpm
- Inj Ranitidin 150mg/12jam
- Inj Levofloxacin 750mg/24jam
- NAC 3x200mg
- Vit B Comp 3x1

Terapi GEH

KSR 1x600
curcuma 3x1
cek hbsag, anti hcv, usg whole abdomen