mapping bl 25 apr
TRANSCRIPT
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016
No Nama & RM Ruangan Anamnesa
PF Diagnosis DX TS Terapi Perubahan terapi Plan
1. Ny. Sudarmi Melati 11 B
S :B :N :
TD :HR :N :RR :
Ax : CPC, TR moderate, massa IntracardiacFx : FC Nyha IV, EF 80%Ex : cronisitas paru
1. azotemia2. hematemesis3. melena4.
Furosemide 20mg/24 jam i.vSpironolakton 1 x 25 mg POValsartan 1x80 mg PO
Echo +Ur/Cr/elektrolit/3 hari
2. Nartowiyono01254162
Melati 11 D
S :B :N :
TD :HR :N :RR :
Ax : OMI anteroseptalFx :Ex :
1.2.3.4.
Simvastatin 1x20mgAspilet 1x80mg
Echo (21/4/16)Hasil ?
3. Tn Sukimin Melati 12 H
S :B :N :
TD :HR :N :RR :
Ax : OMI inferiorFx : Nyha IIEx : PJK
1 CHF NYHA III2.chronic liver disease3.4.
Atorvastatin 20mg/24 jam POAspilet 80mg/24jam POValsartan 80mg/24jam POCarvedilol 3,125mg/12jam
Echo 21/4/16Hasil ?
4. Tukiyo Melati 12 F
S :B :N :
TD :HR :N :RR :
Ax : Iskemik AnteriorFx : Nyha IIEx: PJK
1. CKD stg V2.DM type II3.4.
Atorvastatin 1x20mgAspilet 1x80mg (Ts.Interna)Ramipal 1x5mg (Ts.Interna)Carvedirol 2x3.125 mg
Echo 24.4.16
5. Tn Suharno Melati 13 F
S :B :N :
TD :HR :N :RR :
Ax : DCMFx : NYHA II, AF rapid VREx : myopathi
1 GGA dehidrasi sedang2.3.4.
Warfarin 0-0-IIAmiodaron 150 mg/8 jam iv jika HR >100 stopJika HR <100 diberikan carvedilol 3,125mg/24jamLidocaon bolus 60 mg dalam 10cc Nacl SP. 1mg/menit
Cek PT/APTT/INR/3 harUr/cr/ei
6. Sudarmi Melati 15D
S :B :N :
TD :HR :N :RR :
Ax : TR, AR mildFx : CLBBBEx :
1 CHF NYHA IV2.DM tipe 23.Hipoalbumin4. Anemia
Inj Furosemid 1 amp/24 jamSpironolacton 25mg/24 jamNitrokaf 2x1Telmisartan 80 mg/24 jamSimvastatin 280mg/24 jamAspilet 1x80 mgConcor 1x1.25 mgClonidin 2x0.3 mg
ekg
7. Temu Melati 1??
S :B :N :
TD :HR :N :RR :
Ax : HHDFx : NYHA IIEx : HT
1. susp. Perporasi gaster2.3.4.
Valsartan 1x80mgConcor 1x2,5mg
Echo (jk KU post op memungkinkan)
8. Siti Lestari Melati 16j
S :B :N :
TD :HR :N :
Ax : HT Stage IIFx :Ex :
12.3.
Valsartan 1x80 mg
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016
RR : 4.9.
10. Ny. Ngadinah Mawar 13 B
S :B :N :
TD :HR :N :RR :
Ax : HHDFx : FC Nyha III, EF 80 %Ex : HT
1. DM type II2.3.4.
Furosemide (interna)Clopidogrel 75mg/24 jam POCarvedilol 6,25mg/12 jam POCaptopril 50mg/ 8jam POAmlodipine 1x10mg POClonidin 2x0.5 mg
Echo +Ur/Cr/Elektrolit
11. Ny. Darmi01284707
Mawar 17A
S:B:N:
TD:HR:N:RR:
Ax: HT urgencyFx: -Ex: HT
1.2.3.4.
Valsartan 80mg/12 jamAdalat oros 30mg/24 jam
12. Ny munjiyah01336751
Mawar 1 HCU
S :B :N :
TD :HR :N :RR :
Ax : susp ASD IIFx :Ex :
1 kista ovarium2.3.4.
echo
13. Ny Suyati01922799
Mawar 1 S:B:N:
TD:HR:N:RR:
Ax: dextrocardia, HT stg IFx:Ex:
1 Ca mamae234
echo
14. S Tinet Setyo Budi74 tahun01262298
Ang 11 F
S :B :N :
TD :HR :N :RR :
Ax : Aneurisma aorta abdominalisFx :Ex :
1. Pneumonia komuniti KR III (perbaikan)2.3.4.
Echo (22.4.16)Hasil ?
15. Ny Sumini Ang 11 i
S :B :N :
TD :HR :N :RR :
Ax : HT urgencyFx :-Ex : HT
1 HCAP2. Asthma eksaserbasi akut3.4.
Adalat oros 30mg/24jamValsartan 160mg/12jam
16. Tn. Rajikun77 thn01329940
Ang 12 A
S :B :N :
TD :HR :N :RR :
Ax : HT stage II dengan wandering atrial pace makerFx : CorcompensatedEx : HT
1 Tumor paru2.3.4.
Adalat oros 30 mg/24jam PO Echo (21.4.16) hasil ?
17. Tn Tjokro pawiro74 thn01336924
Ang 14D
S :B :N :
TD :HR :N :RR :
Ax : OMI anteriorFx : FC NYHAEx : PJK
1 Susp pneumonia2.3.4.
Miniaspi 80mg/24jamAtorvastatin 20mg/24jam POValsartan 80mg/24jam PO
Echo (jika KU memungkinkan)Rontgen thorax
18. Ny. Mulyani Ang 14 F
S :B :
TD :HR :
Ax : Efusi pericardFx : corcompensated
1 Tumor paru2.
Metylprednison 62,5mg/12 i.v Evakuasi cairan pericard ,
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016
N : N :RR :
Ex : 3.4.
Medikasi luka/ 2 hariEcho evaluasi 25.4.16
19. Ny. Ngadiyem Ang 1 7 A
S :B :N :
TD :HR :N :RR :
Ax : Efusi pericard (teratasi)Fx : corcompensatedEx :
1 TB paru2.3.4.
Metylprednison 62,5mg/12 i.v Cek albumin (2,5)
20. Tn. Jukaeri Ang 15 i
S :B :N :
TD :HR :N :RR :
Ax :HT urgencyFx : cor compensatedEx : HT
1 ca paru2.3.4.
Adalat oros 30 mg/ 24 jam POValsartan 80mg/ 12 jam PO
Echo 25.4.16
21. Budianto01323662
Ang 15A
S :B :N :
TD :HR :N :RR :
Ax : iskhemik anteriorFx :Ex :
1 tumor paru dextra2.3.4.
Atorvastatin 1x80 mgMiniaspi 1x80 mgDiovan 1x80 mgFasorbid 3x5 mg
22. Budi Darmanto
Ang 11D
S :B :N :
TD :HR :N :RR :
Ax : ASD R to L shuntFx :Ex :
12.3.4.
Dorner 3x20 mgValsartan 1x80 mg
23. Tn Agus Ang 2 S :B :N :
TD :HR :N :RR :
Ax : OMI anteriorFx : bradikardiEx : PJK
12.3.4.
Digoxin 1x1/2 tabAspilet 1x80 mg (jika ts neuro setuju)Simvastatin 1x20 mgRamipril 1x 5 mgNitrokaf 2x1 tab
24. Sri Widodo01334659
Ang 2 S :B :N :
TD :HR :N :RR :
Ax : OMI anterior, HFFx : FC nyha IIEx :
12.3.4.
Apilet 1x80 mg’clopidogrel 1x75 mgValsartan 1x80 mg tundaISDn 3x5 mg tundaSimvastatin 1x20 mgBisoprolol 1x2.5 mg tunda
25. Tn. Manto Diarjo75 thn01336473
Maw 25 F
S :B :N :
TD :HR :N :RR :
Ax : iskemi anteroseptalFx : Nyha II, EF 75 %Ex : PJK stabil
1 CF subtrochanter femur (S) + CF tibia fibula (D)2.3.4.
Ramipril 1x10 mg POAtorvastatin 20mg/24 jam POAmlodipin 5mg/24jam POConcor 1,25mg/24jam POAspilet 80mg/24jam (setelah operasi)
Echo +LVH kon dgn kontraktilitas LV baik, EF 75 %Katup baik
26. Tn. Paino Mawar 27D
S :B :N :
TD :HR :N :RR :
Ax : -Fx : Cor compensated, VES frequentEx : -
1. CF tibial plantar dextra2.3.
Bisoprolol 5mg/ 24 jam PO EKG/pagi
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016
4.27. Surati Mawar 3
15AS:B:N:
TD:HR:N:RR
Ax: HT stage IIFx:Cor compensatedEx:HT
1. Ca Sinonasal2. DM tipe 23.4.
Adalat oros 30mg/24 jam POClonidine 2x0,3 (Ts Interna)Telmisartan 1x80 (Ts Interna)Amlodipin 1x10 (Ts Interna)Concor 2.5/24 jam
28. Kasnadi01336324
Melati 35 A
S :B :N :
TD :HR :N :RR :
Ax : OMI inferiorFx :Ex :
1. DM type II2.azotemia dd aki dd ckd3.penumonia KR III4.BPH
Valsartan 80 mg/24jam Echo 25.4.16
29. Suwandana00971816
Melati 36C
S :B :N :
TD:HR :N :RR
Ax : HHDFx : NYHA sdeEx : HT terkontrol
1. PPOK eksaserbasi akut2. CHF NYHA III3. HT grade I4. Anoreksia
Echo 25.4.16
30. Sutarno Melati 37B
S :B :N :
TD :HR :N :RR :
Ax : OMI anteroseptalFx :Ex :
12.3.4.
Bisoprolol 2,5mg/24 jamSimvastatin 20mg/24 jamAspilet 1x80 mg
31. Mardiyah51 tahun01300446
Melati 3 12 A
S :B :N :
TD :HR :N :RR :
Ax : iskemik anteroseptalFx :Ex :
1 GEA ec drug induce (perbaikan)2. Massa intraabdomen ec intralumen dd extralumen3. Riw hematoschezia4.
Atorvastatin 1x20mg POAspilet 1x80mg POValsartan 1x80mg POConcor 1x2.5 mg
Echo (22.4.16)Hasil ?
32. Sengkorini01032679
Melati 317 C
S :B :N :
TD :HR :N :RR :
Ax : DCM, MR & TR mildFx : NYHA sde, EF 19%Ex :
1. Ulkus DM2. HAP late onset3. DM tipe II4.
Aspilet 80 mg/24 jamSimvastatin 20mg/24 jamCaptopril 25 mg/ 8jamSp dobutamin 5mg/mnt
Echo(Dilatasi seluruh ruang jantung kontraktilitas LV rendah, EF 19%, MR & TR mild)
33. Suminem01337266
Melati 313A
S :B :N :
TD :HR :N :RR :
Ax : HHDFx :Ex :
1 Hipertensi grade 12. HHD3.azotemia4.
Echo
34. Mujiono00747920
11B S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
1 hipertiroid2.3.4.
Simarc 0-0-2mgSpironolakton 1x25 mg PO
35. Sarju 12B S : TD : Ax : HHD , MR 1 nefrolithiasis kiri Captopril 3x6.25 mg PO echo
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016
01336818 B :N :
HR :N :RR :
Fx :Ex :
2. cystitis kronis3.cholesystitis4. hepatomegali
Spironolakton 1x25 mg
36. Wasiyem01337582
S :B :N :
TD :HR :N :RR :
Ax : HT grade II, PAC multipleFx :Ex :
1 TB paru2.3.4.
Amlodipin 1x5 mg
37. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
38. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
39. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
40. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
41. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
42. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
43. S :B :N :
TD :HR :N :RR :
Ax :Fx :Ex :
12.3.4.
44.
45.
Daftar Pasien Bangsal Luar SMF Kardiologi & KVMinggu 24 April 2016