No.

Nama/ Usia/ MRS Diagnosa Masuk Diagnosa Saat Ini Masalah/ Rencana
Jaminan/
DPJP
2703 An. Gilbert RA Tetralogy of Fallot Post TOF repair dengan BAB hitam (-), pasien
PL Giovani/ 4 thn/ 19-2-17 contegra (20/2/17) dan masih sulit berjalan
Ratna JKN/PSR TD 98/52 mmHg, HR redo RPA&LPA stenosis
ICU 128 bpm SpO2 79% (22/2/17) TD 87/54 mmHg, HR 102
BB 11 kg 20-2-17 Riwayat melena ec drug bpm,
EKG : SR, QRS rate induced SpO2 96%
IWA 128 bpm,aksis RAD, Dropfoot ec cedera nervus
28-2-17 RVH (+) peroneus Terapi saat ini:
Lasix 2x15 mg PO
RA Lab 7/3/2017 Aldactone 1x12.5 mg
4-3-17 Darah samar tinja (-) Omeprazol 2x10 mg IV
Inpepsa 3xCI
Lab 6/3/2017 Dexamethasone 2x2 mg
Hb 12.1/leuko 14610 (segmen IV
Lab 16-1-17 : 60.9)/Ht 35.9/tromb Methilcobalt 1x250 mg
Hb 15.5 / Ht 42.6/ Leuko 9790 (segmen 54.1)/ Tr 381.000/ Ur 447.000/APTT 27.4/Na 137/K IV
10.3/ Cr 0.33/GDS 87/ Na 140/ K 4.12/ CaT 2,18/ Cl 104/ Mg 3.49/Cl 93/CRP 11 Fisioterapi
1.89/LED 1/CRP 2/PT 2/INR 1.07/APTT 31.7/protein total
6.9/albumin 3.9/globulin 3/SGOT 33/SGPT 14 Lab 5/3/2017
Hb 13.1/Ht 37.8/leuko
CXR 17920/tromb 449.000
CTR 51%, segmen aorta dan pulmonal normal, apeks upward,
pinggang jantung (+), kesan oligemia.

Echo 22/2/2017:
LV fungsi sistolik baik EF 86%,RV kontraksi menurun TAPSE
0.7 cm, residual VSD (-), anastomosis RV-contegra baik
gradient 8-9 mmHg, anastomosis contegra bifurcatio PA 22-25
mmHg, bifurcatio PA stenosis severe RPA origin gradien 100
mmHg distal 30 mmHg LPA origin gradien 16 mmHg, diameter
RPA proksimal 2-3 mm distal 4-5 mm LPA proksimal 3-4 mm
distal 7-8 mm, PR mild moderate, TR moderate TVG 50-60
mmHg (systemic systolic 60-70 mmHg), pleural effusion kanan
massif, pleural effusion kiri minimal, pericardial effusion (-)
 No. Nama/ Usia/ MRS Diagnosa Masuk Diagnosa Saat Ini Masalah/ Rencana
Jaminan/
DPJP
2709 An. Alvaro RA DORV VSD muscular Post Fontan fenestrated BAB hitam (-), demam
PL Kenzie/ 3 thn/ 28-2-17 restriktif LV smallish pada DORV, VSD restriktif, (-), batuk berdahak (+)
Ratna JKN/PSR Post BCPS (2014) ASD sekundum, LV
ICU smallish TD 92/69 mmHg, HR 92
BB 11 kg 1-3-17 TD 113/61 mmHg, HR Post BCPS (2014) bpm,
115 bpm SpO2 73% Post PA banding dan SpO2 93%
IWA ligase PDA (2013)
2-3-17 EKG : SR, QRS rate Melena ec drug induced Terapi saat ini:
104 bpm,aksis RAD, Bronkopneumonia Cefotaxime 2x275 mg IV
RA RVH (+) Paracetamol 3x150 mg
7-3-17 Lab 7/3/2017 PO
PT 17.1/INR 1.51 Captopril 3x12.5 mg
Darah samar positif Lasix 2x15 mg IV
Sildenafil 3x12.5 mg
Lab 28-2-17 : Lab 6/3/2017 Aldactone 1x12.5 mg
Hb 13.2/ Ht 42.2/ Leuko 8040 / Tr 256.000/ Ur 19.4/ Cr Hb 13.4/leuko 16510 (segmen Inpepsa 3xC1/2
0.29/GDS 76/ Na 138/K 5.11/ CaT 2.49/ Cl 100/ Mg 2.07/LED 79.4)/Ht 39/tromb 189.000/PT Omeprazole 2x10 mg IV
3/CRP 0.1/PT 11.8/INR 1.04/APTT 32.3protein total 7.3/albumin 28.1/INR 2.47/Na 133/K
4.7/globulin 2.6/SGOT 22/SGPT 7 3.62/CL 87/CaT 2.27/Mg Plan :
2.02/CRP 95 Atasi bronkopneumonia
CXR dan gastrointestinal
CTR 48%, segmen aorta dan pulmonal normal, apeks upward,
Lab 4/3/2017 bleeding
pinggang jantung (+), vaskularisasi paru normal
Hb 12.7/leuko 9920/Ht
Echo 30/1/2017: 37.8/tromb 109.000
VSD muscular restriktif 4-5 mm noncommitted to aorta L-R
shunt gradien trans VSD 22 mmHg, ASD sekundum besar 16
mm bidirectional shunt, aorta dari RV, PA sudah buntu, katup-
katup tidak tebal, TR mild TVG 90 mmHg, RV dilatasi LV
smallish, kontraksi RV cukup TAPSE 1.4 cm, LV fungsis sistolik
baik EF 86% dengan disfungsi diastolic E/A<1, anastomosis
RSVC-RPA baik, PA konfluens RPA=LPA=11 mm, arkus aorta
normal.
 No. Nama/ Usia/ MRS Diagnosa Masuk Diagnosa Saat Ini Masalah/ Rencana
Jaminan/
DPJP
2713 By. Nur IGD CHF Ross criteria III CHF Ross criteria III pada Klinis masih tampak
PB Hafizah/ 6 bln/ 16-2-17 pada TGA-VSD TGA-VSD sesak napas, retraksi
Ratna JKN/ RPR intercostae (+)
RA TD 94/59 mmHg, HR Lab 27/2/2017
BB 4.2 kg 17-2-17 140 bpm SpO2 60% Hb 14.7/Ht 46.9/leuko 9080 TD 86/44 mmHg, HR 128
Paru : vesikuler, ronki +/ (segmen 48.4)/tromb bpm,
+ di basal, wheezing (-), 291.000/CRP 0.8 SpO2 73
slem +/+
Echo 27/2/2017 Terapi saat ini:
EKG : SR, QRS rate Situs solitus,AV concordance, Lasix 2x5 mg IV
140 bpm,aksis RAD, VA discordance, all PV to Aldactone 1x6.25 mg
RVH (+) LA,rongga jantung Chest fisioterapi dna
dilatasi,RVH(+) LVH (+), fungsi nebulisasi
sistolik LV baik, ASD (-), PDA 3
Lab 16-1-17 : mm bidirectional shunt,VSD Plan :
Hb 14.9 / Ht 50/ Leuko 10780 (segmen 49.9)/ Tr 247000/ Ur perimembran subpulmonaik Kateterisasi jantung
28.7/ Cr 0.24/GDS 116/ Na 140/ K 4.82/ CaT 2,3/ Cl 99/ Mg meluas ke muscular inlet 10-11
2,91/LED 1/CRP 1 mm R-L shunt,aorta keluar dari Plan jangka panjang :
AGD : pH 7.34/pCO2 46.9/pO2 49/HCO3 25.6/BE -0.1/saturasi PV,PA overriding 50%,aorta di Arterial switch operation
80%/asam laktat 2.3/Ca ion 1.2/Mg ion 0.5 kanan anterior PA (almost side
by side), AS subvalvar mild
CXR gradien 18 mmHg,katup
CTR 75%, segmen aorta dan pulmonal normal, apeks upaward,
pulmonal tidak tebal annulus
pinggang jantung (+), kesan plethora. Mendatar, kongesti (+),
infiltrate (-)
15 mm,PS (-) gradien 11
mmHg PR mild, AoA 10-11
Echo 16/2/2017: mm, arcus oarta di kiri,
Situs solitus, AV concordance, VA discordance, all PV to LA, coarctatio aorta (+) gradien 27
ASD (-), PFO (+), PDA (-), VSD besar diameter 12 mm, aorta mmHg. Kesimpulan : TGA-
keluar dari RV, PA keluar dari LV, fungsti sistolik LV dan RA VSD perimembranous besar
baik, arkus aorta di kiri, coarctatio (-), efusi pericard minimal. meluas ke muscular inlet,
PDA, SAS, coarctaio sevre
Lab 21/2/2017
Ur 27.9/Cr 0.27/Na 137/K 4.25/Cl 97