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LAPORAN LONTARA 1 BAWAH DEPAN CARDIORABU , 22 APRIL 2015
KMR/KLSJMN/BED/HARI RAWATNAMA PASIEN & DIAGNOSAASSESMENT
PLANNING
Kmr 1Kls 2
JKNBed 39 Hari
AGUSTINA MAROY 02/06/1945RM: 430892Dx: CHF ec. CAD post PCI HT on treatment
DPJP:Dr. Pendrik Tandean, Sp.PD
JKN Bed 28 HariMARWAH SANNO31/12/1961RM: 199612Dx: HHD, Hipokalemi Diastolik Heart Failure Asma Bronkhiale
DPJP:Dr. Abdul hakim, Sp.JP
Ku: sedang Kes: composmentis Keluhan : Sesak berkurang Terpasang: Conecta Dextrose 5% + Aminophylin 2 ampul drips/ 8 tts/mnt Kateter urine Oksigen binasal 3 liter/menit Diet rendah garam, rendah kalium Terapy lanjut
1. Furosemide --- Tunda2. Spironolactone 25 mg/24 jam/oral3. KSR 1 tab/12 jam/oral4. Allopurinol 100 mg/48 jam/oral5. Alprazolam 0,5 mg/24 jam/oral6. Combivent/8 jam/inhalasi7. Aminophylin 2 ampul drips dalam Dextrose 5%/intravena (habis dalam 24 jam)8. Dexamethasone 1 ampul/8 jam/ivOmeprasole 20 mg/12 jam/oral
JKNBed 37 Hari
HAWIAH. L30/11/1958RM: 708460Dx: CHF e.c CAD AFNVR Hipertensi Hipokalemia
DPJP:Dr. Pendrik Tandean, Sp.PD
Ku: sedang Kes: composmentis Keluhan: Sesak sudah berkurang Terpasang: IVFD NaCl 0,9% 500 cc/24 jam Oksigen (k/p) Terapi lanjut
1. Furosemide 20 mg/24 jam/oral (1/2TAB)2. Spironolacton 25 mg/ 24 jam/ oral3. Ramipril 2,5 mg/24 jam/oral4. Digoxin 0,25 mg/24 jam/oral5. Alprazolam 0,5 mg/24 jam/oral6. Laxadyne syrup 100 cc/24 jam/oral7. KSR 1 tab/12 jam/oral8. Lanzoprasole 30 mg/24 jam/oralDomperidon 1 tab/8 jam/oral
Kmr1 Kls 3JKNBed 15 Hari
YOTAN SIMURUKRM: 70879911/11/1968Dx: CHF ec AFNVR Efusi Pleura Bilateral
DPJP :Prof. Dr. dr. Peter Kabo
Ku: sedang Kes: composmentis Keluhan : Sesak napas Batuk Terpasang: conecta Oksigen 4 ltr/mnt Terapi lanjut R / evaluasi cairan plura Kjs : pulmo S / echo
1. Ceftriaxon 2 gr/24 jam/iv2. Fasorbid 10 mg/8 jam/oral3. Furosemid 20 mg/ 12 jam/iv4. Codein 10 mg/8 jam/oral5. Paracetamol 500 mg/8 jam/oral6. Digoxin 0,25 mg/24jam/oral7. Adona 1ampul/8jam/iv k/p
JKNBed 28 Hari
HANAFI DG SEWANG18/7/1954RM: 639508Dx: HHD Diastolik Heart Failure Non ST-Elevasi miokard Infark
DPJP:dr. Abd. Hakim Alkatiri, Sp.JP
Ku: sedang Kes: composmentis Keluhan : Nyeri dada hilang timbul Terpasang: Conecta Teraphy lanjut S /ekg
1. Furosemide 40 mg/24 jam/oral (1/2 tab)----stop2. Nitrokaf forte 5 mg/12 jam/oral3. Micardis 40 mg/24 jam/oral4. Aspilet 80mg/24 jam/oral5. Clopidogrel 75 mg/24 jam/oral6. Simvastatin 20 mg/24 jam/oral7. Laxadyne syr 10 cc/24 jam/oral8. Alprazolam 0,5 mg/ 24 jam/oral9. Bisoprolol 2,5 mg/24jam/oral10. Dulcolax supp-----jika perlu
JKNBed 38 HariISMAIL11/04/1949RM: 545424Dx: CHF NYHA III CAD Pruritus Senilis
DPJP:Prof. dr. Peter Kabo, Sp.JP
Ku: sedang Kes: composmentis Keluhan : Sesak sudah berkurang Gatal seluruh badan Terpasang: Conecta Oksigen bila perlu KJS kulit Teraphy lanjut S /ekg
1. Furosemide 40 mg/24 jam/oral2. Spironolacton 25 mg/12 jam/oral3. KSR 1 tab/8 jam/oral4. Digoxin 0,25 mg/24 jam/oral (1/2 tab)5. ISDN 5 mg/SL (K/P)6. Captopril 12,5 mg/8 jam/oral7. Clopidogrel 75 mg/24 jam/oral8. Simvastatin 20 mg/24 jam/oral9. Laxadyne syr 10 cc/24 jam/oral10. Alprazolam 0,5 mg/ 24 jam/oral11. Harnal /24 jam/oral12. Cetirizine 10 mg/24 jam/ora;l13. Cefadroxil 500 mg/12 jam/oral
JKNBed 4 2 Hr
BUCHE BOBY HANA26/7/1965RM: 702275DX; CADDPJP :Prof Ali Aspar Sp.JP
OSB dari poli jantung ,R / PCI BESOK
JKNBed 68 HariISKANDAR08/03/1976RM: 525359DX: Venrikuler Ekstra Sistole VSD Membran Septal Aneurysma
DPJP:Dr. Pendrik Tandean
Ku: sedang Kes: composmentis Keluhan : Lemah fisik Teraphy lanjutR /penyadapan jantung1. Amiodarone 200 mg/24 jam/oral2. Spironolacton 25 mg/24 jam/oral3. Dorner 1 tab/24 jam/oral
Kmr2 kls 2
JKNBed 19 Hari KAHARUDDIN15/03/1955RM: 708061Dx: Congestive heart failiure e.c HHD ISK Low Back Pain e.c Spondylosis thoracolumbal
DPJP:Prof.Dr.dr. Peter Kabo, P.hD,Sp.KP,Sp.JP
Ku sedang Kes: composmentis Kel: Nyeri punggung bawah Terpasang Conecta Terapi lanjut Pasien Cardio KJS neuro KJS rehab medic S /ekg
1. Amlodipin 5 mg/24 jam/oral2. Ramipil 5 mg/24 jam/oral3. Simvastatin 20 mg/24 jam/oral4. Meloxicam 15 mg/12 jam/oral5. Cefixime 100mg/12 jam/oral.stop6. Ranitidine 150 mg/12jam/oral7. Amitryphylin 2x1/2 tab/oral8. Alprazolam 0,5 mg/24 jam/oral9. Mecobalamin 500 mg/12 jam/oralDiazepam 2 mg/24jam/oral
JKNBed 211 Hari
IWAN PRIBADI09/06/1956RM: 698560Dx: CHF NYHA II-III e.c CAD MR severe
DPJP:Dr.Khalid Saleh.Sp.PD
Ku: sedang Kes: composmentis Keluhan : Sesak nafas berkurang Terpasang: Conecta O2 binasal 3 liter/menit Teraphy lanjut S /ekg
1. Furosemid 40 mg/12 jam/iv2. Spinolactone 25 mg/24 jam/oral3. Digoxin 0.25 mg/24 jam/oral4. Nitrokaf R 2.5 mg/12 jam/oral5. Captopril 6.25 mg/8 jam/oral6. Omeparazole 40 mg/24jam/iv7. Alprazolam 0.5 mg/24 jam/oralAllopurinol 100 mg/24 jam/oral
JKNBed 34 HariMUH.TOHA70765231-12-1945Dx:GASTROPATI
DPJP:Dr.Haerani Rasyid SPJP Ku: sedang Kes: composmentis Keluhan : Lemah fisik NYERI ULU HATI Teraphy lanjut Terpsg Prosegen 6mg/jam/syringpump Hd regular 3 kali seminggu
1.lansoprazole 6mg/jam/sp2. nefrosteril 1 botol/hari3. furosemid 40 mg/12jam /iv4. Amlodipin 10 mg/24jam/oral
Kmr 2 kls 3JKNBed 15 Hari
MARTHA DUARM: 70613701/07/1954Dx: Total AV Blok
DPJP:Prof. Dr. dr. Peter Kabo
Ku: sedang Kes: composmentis Keluhan : Nyeri dada hilang timbul Teraphy lanjut S /ekg
1. Clopidogrel 75 mg/24 jam/oral2. Trizedon MR 35 mg/12 jam/oral3. Captopril 25 mg/ 12 jam/oral4. Lanzoprasole 30 mg/24 jam/oral5. Amlodipin 10 mg/24 jam/oral6. Ceftriaxon 2 gr/24 jam/iv-----ganti oralAsamefenamat 500 mg/8 jam/oral
Bed 2 4 Hari
HASMA DG TINO31-12-1970694787RM: CHF NYHA III
DPJP:Dr.PENDRIK TANDEAN
Ku:lemah.kes :CMSesak ada,terpsg O2 3ltr/mntIVFD nacl 0.9% 10 tts/mntPlanning:-echo-konsul endokrin-konsul GHTerapi lnjt1. Furosemid 40mg/24j/iv2. Fasorbid 10mg/8j/oral3. Aspilet 80mg/243j/oral4. Amlodipine 5mg/24j/oral5. Alprazolam 0,5mg/24j/oral6. Novoramid 8-8-8Lovemir 0-0-10
JKNBed 47 Hari
HJ. TENE01/07/1962RM: 708407Dx: APS CCS III HT on TREatment AKI Hiperurisemia
DPJP:Dr. pendrik Tandean, Sp.PD Ku: sedang Kes: composmentis Keluhan : Nyeri dada hilang timbul Terpasang: Conecta Teraphy lanjut S /ekg
1. Nitrokaf R 5 mg/12 jam/oral2. ISDN 5 mg/ SL (k/p)3. Clopidogrel 75 mg/24 jam/oral4. Simvastatin 20 mg/24 jam/oral5. Amlodipin 5 mg/24 jam/oral6. Alprazolam 0,5 mg/24 jam/oral7. Nephrosteril 1 botol/24 jam8. Lansoprasole 30 mg/24 jam/oralAllopurinol 100 mg/48 jam/oral
JKN Bed 6 4 Hari
IHAMIRM: 70746327/07/1952Dx:Total AV Blok
DPJP:Dr. Abdul Hakim Ku sedang Kes: composmentis Kel : lemah fisik Terapi lanjut S / ekg
1. Aspilet 80 mg/24 jam/oral2. Clopidogrel 75 mg/24 jam/oral3. Valsartan 80 mg/24 jam/oral4. Paracetamol 500 mg/8 jam/oral5. Cefadroxil 500 mg/12 jam/oralRanitidine 150 mg/12jam/oral
Kmr 3 kls 2JKNBed 19 Hari MUTIARA05/12/1967RM: 708091Dx: CHF Nyha III Polisitemia Mitral Stenosis
DPJP :Dr. Pendrik Tandean, Sp.PD Ku sedang Kes: composmentis Kel : sesak nafas berkurang Terpasang: Conecta O2 binasal (k/p) Terapi lanjutS /ekg1. Furosemid 40 mg/24 jam/oral2. Spironolactone 25 mg/24 jam/oral3. Dorner 1 tab/12 jam4. Captopil 6.25mg/8jam/oralSimarc 2mg/24jam/oral
JKN Bed 27 HariANDI ASMY NURHIKMAH15/05/1976RM: 708283
Dx: Palpitasi pro evaluasi Bradikardi
DPJP:Dr. Pendrik Tandean, Sp.PD
Ku sedang Kes: composmentis Kel : Sesak nafas sudah berkurang Dada berdebar-debar Terpasang : Conecta Oksigen (k/p) Terapi lanjut S /ekg
1. Omeprazole 20 mg/24 jam/oral2. Amnofilin 200 mg/ tab/12jam/oral3. Alprazolam 0.5mg/24jam/oral4. Farmabes 300 mg/12 jam
JKNBed 416 Hari NATIAH10/07/1952RM: 704568Dx: CHF e.c CAD + HHD CKD on HD Reguler AF RVR
DPJP:Dr. Pendrik Tandean, Sp.PD Ku : sedang Kes: composmentis Keluhan : Lemah badan Sesak napas berkurang Terpasang Conecta Oksigen 4 liter/menit Pasien Interna KJS Cardio dan GH HD Reguler 2x seminggu Balance cairan/hari S /ekgS /pasang ulang conecta1. Furosemide 40 mg/12 jam/iv2. Farsorbid 10 mg/8 jam/oral3. Simvastatin 20 mg/24 jam/oral4. Amlodipin 10 mg/24 jam/oral5. Alprazolam 0,5 mg/24 jam/oral6. Digoxin 0,25 mg/24 jam/oral7. Nephrosteril 1 botol/hariValsartan 160 mg /24jam/0ral
Kmr 4Kls 2JKNBed 110 HariMUCHTAR15/03/1962RM: 694532Dx: CHF NYHA IV ec CAD MR PH Mild
DPJP:Dr. Pendrik Tandean, Sp.JP
Ku : lemah Kes: composmentis Keluhan : Sesak napas berkurang Lemah badan Terpasang Conecta Dobutamin 3 mg/kgBB/SP Furosemid 50 mg/jam/SP Oksigen 3 ltr/mnt Pasien Interna KJS Cardio Balance cairan Terapi lanjut S /ekg
1. Dobutamine 3 mg/kgBB/SP2. Furosemid 50 mg/jam/SP3. Spironolacton 50 mg/24 jam/oral4. Fasorbid 10 mg/ 8 jam/oral5. Omeprazole 40 mg/24 jam/iv6. Valsartan 40 mg/24 jam/oral7. Digoxin 0,25 mg/24 jam/oral8. Novalgin 1 ampul/8 jam/iv (bila nyeri perut)9. Paracetamol 500 mg/oral (k/p)10. Neurodex 1 tab/24 jamPujimin 3x2 caps
JKNBed 29 Hari
MUH.THAMRIN.T18/08/1956RM: 708210Dx: PAD Hipoalbumin
DPJP:Dr. Pendrik Tandean, Sp.PD Ku: sedang Kes: composmentis Kel: Bengkak kedua kaki kiri dan kanan Terpasang: Conecta Therapi lanjut S /ekg
1. Cilostazole 100 mg/12 jam/oral2. Lovenox 0.6/12 am/sc3. KSR 1 tab/8 jam/oral-----stop4. Allupurinol 100 mg/2ujam/oral
JKN Bed 323 HariSANOTEN29/03/1961RM: 692049Dx: APS ccs III CAD 3 VD + Left Main Disease HiperuricemiaDPJP:Dr. Khalid Saleh, SpPD, K-KV
Ku: sedang Kes: composmentis Keluhan : Nyeri dada hilang timbul Terpasang: conecta Pasien Cardio KJS BTKV Terapi lanjut Rencana CABG, tgl 21/04/2015 S/EKG Tolong lihat di status instruksi selanjutx karna status ada sama dokter btkv
1. Nitrokaf R 2,5 mg/ 12 jam/ oral2. Captopril 12,5 mg/ 8 jam/ oral3. Simvastatin 20 mg/ 24 jam/ oral4. Bisoprolol 2,5 mg/24 jam/oral5. Allopurinol 300 mg/24 jam/oral6. ISDN 5 mg/SL bila nyeri dada
HCUJKNBed 218HariLA ODE MOGANE15/02/1960705911Dx: CHF EFUSI PLEURA BILATERAL DM TYPE 2
DPJP:Dr. Abdul Hakim
Ku : Lemah Kes: composmentis Keluhan: Sesak nafas Terpasang: Infus nacl 0,9% 500 cc/24 jam Oksigen 4 ltr/mnt Catheter Therapy lanjut S /USG ABDOMENT
1. Furosemid 40 mg/ 8 jam/iv2. Fasorbid 10 mg/ 8 jam/oral3. Aspilet 80 mg/24 jm/oral4. Clopidogrel 75 mg/ 24 jam/oral5. Spironolactone 25 mg/24 jam/oral6. Ramipril 2,5 mg/12 jam/oral7. Simvastatin 20 mg/24 jam/oral8. Alprazolam 0,5 mg/24 jam/oral9. Laxadin syrup 10 cc/24 jam/oral10. Levemir 0-0-14 iu11. Novorapid 10-10-10 iuOmeprazole 40mg/24jam/intravena