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LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita
Kamar 1 Lt 3 Kamar 1
Identitas M.Alvin Ramadhan / lk/ 7 bulan 661532/ L : 3 September 2013 MRS : 21 Januari 2019 Pedamaran , OKI BB 33 kg PB 132 m BB/U -3
Balance Diuresis I O IWL 70 B D
Diagnosis Large VSD PMO + pulmonal hipertensi + gagal jantung
Terapi -
Pro open heart Captoptril 2 x 12,5 mg po Furosemide 2 x 20 mg po
Pem. Penunjang 21-01-19 Hb 13.1 Erit 5.18 leu 12.01 Ht 39 Trb 395 MCV 75.7 MCH 25 MCHC 33 RDW CV 14.10 LED 13 DC 0/738//48/7 PT INR 14.70 (K) / 14.3 (P) INR 1.07 APTT 32.8 (K) / 34.1 (P) Besi 31.9 TIBC 356 SGOT 21 SGPT 13 Pro tot 7.7 Alb 4.5 Globulin 2.1 GDS 98 Ur 17 As Ur 5.7 Cr 0.59 Ca 10 Phospor 5.8 Mg 2.10 Na 145 K 4.1 Cl 109 HbsAg Non reaktif Anti HCV non reactive Anti HCV Non Reactive
Keterangan Echo 21-01-2019
-
-
A: rudi I: yastati Hp : 085273677175
-
Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilatated LA-LV Mild Aorta Regurgitation Prolapse anterior aorta valve Mild Pulmonal regurgitation No ASD seen Large VSD PMO high type 8 mm L to R shunt No PDA seen Well contracting ventricles, no paradoxical movements - LV systolic function EF 77.5 % FS 45.9 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen
Conlusion :
Large Ventricular Septal Defect Perimembrane Outlet High Type + Mild Aorta Regurgitation + Prolapse anterior aorta valve + Mild Pulmonal regurgitation
1
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita 2 Lt 3 Kamar 1
Adreena Naira Malika /PR/ 7 bulan 1091384/ RI 19001922 TL : 30 Juni 2018 MRS : 18 Januari 2019
PDA besar pro Ligasi PDA
-
Ampicilin 3x 400 mg (4) Ceftazidime 3x150mg (4) Carbogliserin 4x1 tts AS Furosemide 2x5mg Captopril 2x2.5 mg
Pedamaran , OKI BB 5,6kg PB 62cm BB/U -3
18-01-19 Hb 10.5 Erit 4.49 leu 12.62 Ht 32 Trb 353 MCV 71.9 MCH 23 MCHC 33 RDW CV 14.60 LED 5 DC 0/5/14/75/6 PT INR 13.50 (K) / 15.3 (P) INR 1.17 APTT 31.6 (K) / 40 (P) Besi 39 TIBC 357 SGOT 36 SGPT 12 Pro tot 6.5 Alb 4.5 Globulin 2.1 GDS 72 Ur 17 As Ur 4.3 Cr 0.44 Ca 11 Phospor 5.5 Mg 2.4 Na 141 K 5.3 Cl 109 ferritin 15.60 HbsAg Non reaktif Anti HCV non reactive Anti HCV Non Reactive
11 Januari 2019 -
-
Balance Diuresis I O IWL 70 B D
3 Lt 2 1.1
A: M. Apriadi I: Nita Hp : 085367640180 Pinkan ramadhan/ 10 tahun / PR 250697/ RI 19001161 TL : 31 Agustus 2008 MRS : 11 Januari 2019 Kertapati Palembang BB: 25 kg TB:137cm BB/U : p5 TB/U: p50 BB/TB : 25/33 =75.7 % Kesan : Gizi Baik perawakan normal
Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV AV and semilunar valves are normal No ASD seen No VSD seen PDA 8 mm Lto R shunt Well contracting ventricles, no paradoxical movements LV systolic function EF 69 % FS 37 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen
Kesan Large Patent ductus arteriosus 18 Januari 2018 Ro Thorax Kardiomegali
Post VSD closure H 6 ai Large VSD PMO, Mild MR , Mild TR, Mild PR , Moderate AR , Prolaps aorta valve + Gizi Kurang
-IVFD 50 % Kebutuhan cairan harian - aff infus perbanyak minum 100% kebutuhan cairan 1600cc/24 jam Furosemide 2x20mg IV Cefuroxime 3x450 mg IV (7) Paracetamol fl 3x500mg IV Furosemide 2x25 mg po Paracetamol 3x500mg po Captopril 2x12,5mg (po) Digoxin 2x 1 tab Spironolakton 2x25mg Renc. Transfusi PRC 1x100cc bila darah jadi masuk kurang input dari infus atau minum
18-01-19 Hb 12.1 Erit 4.34 Le 8.61 Ht 36 Trb 163 RDW CV 13.7 DC 0/2/82/10/6 15-1-19 Hb 9.8 RBC 3.36 WBC 16.91 Ht 28 PLT 178 DC 0/0/95/3/2 PT 15.9(P) INR 1.22 APTT 33.7 (P) SGOT 73 SGPT 14 Alb 3.8 Asam urat 4.6 Creatinin 0.63 Ureum 24 Calcium 10 Phospor 3.8 Mg 3.5 Natrium 145 Kalium 3.6 Cl 113 11-1-19 Hb 13.4 RBC 4.68 WBC 8.16 Ht 38 PLT 325 MCV 8.4 MCHC 16 RDW-CV 12.69 LED 12 Gol da O Rh + DC 0/8/48/38/6 CT BT menit PT 14.7(k)/ 13.5(P) INR 1.00 APTT 33.4 (K)/ 36.6 (P) SGOT 20 SGPT 10 Prot Tot 7.5 Alb 4.5 Ret 2.3 Asam urat 5 Creatinin 0.61 Ureum 26 Calcium 10 Phospor 4.7 Mg 2.2 Natrium 144
November 9th 2018 Situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild MR Mild TR Mild pulmonal regurgitation Moderate AR Prolaps aorta valve seen Left aortic arch, no coarctation of aorta seen Large VSD Perimembran outlet 13.6 mm (L to R shunt) No PDA seen No PFO seen No ASD seen Well-contracting ventricles LV systolic function normal EF
2
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita Persentil Tensi 5P 50P 90 P 95 P 99P
4 Lt 2 1.4
91 103 114 117 123
Kalium 3.7 Clorin 110 HbSAg non reaktif AntiHCV non reaktif CRP < 5 Anti HIV non reaktif GDS 103
53 63 72 74 78
Balance Diuresis 18.00 – 06.00 I O IWL 200 B D Ayah; Budiman Ibu : Islamiah Hp :082373508946 081373552056 Putri Aini /PR/8 bulan 1074381 / RI 19001697 TL: 2 Mei 2018 MRS : 16 Januari 2018
Decompensatio Cordis sedang ec VSD besar + RD + Severely wasted
BB 3.8kg PB 62cm BB/U : <-3sd PB/U -3< z< -2sd BB/PB 3.8/ 6.4 = 59 % Kesan Gizi buruk perawakan pendek
O2 nasal 1lpm Furosemid 2x3mg IV Aldacton 2x3.125 mg PO Captopril 2x2 mg Ampicilin 2x120mg IV (6) Gentamicin 2x10mg IV (6) Paracetamol 3x 2cc
16 Januari 2019 Hb 10 Erit 365 Leu 8.93 Ht 29 Trb 343 RDWCV 13.80 LED 16 DC 0/0/31/61/8 CRP < 5
Raber GIZI F75 12x 30cc
A Budi Cahyono I Nurlela HP 085367640180
5 Lt 2
77% FS45% No pericardial effusion seen
Conclusion : Large VSD PMO, Mild MR , Mild TR, Mild PR , Moderate AR , Prolaps aorta valve
Kertapati Palembang
Balance Diuresis I O IWL 47,5 B D Aidel Fitri / Perempuan / 13 tahun
-
16 januari 2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild Pulomnal regurgitation No ASD seen Large doubly commited VSD 8,7 mm Lto R shunt Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large VSD DCSA Mild Pumonal regurgitation
Decomp Cordis NYHA IV ec TR moderate + PR moderate ec PDA besar
-
O2 NRM 10 lpm O2 2lpm nasal canule
18-01-19
15 Januari 2019 ECHO
3
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita 1.5
1019313/RI 19001349 TL : 13 November 2005 MRS 14-01-19 Lahat BB 20kg TB 123cm BB/U
A Ersen I Hervi
+ Hipertensi Pulmonal + Gizi buruk + delayed puberty + poor contractility + Susp Cholestasis intra hepatic dd extrahepatik Cholestasis intrahepatic GEH : Hepar membesar uk 15.03 tepi tumpul berdungkul-dungkul lien 10.5 normal pleural efusi kiri (+) , ginjal hidronefrosis bilateral Kesimpulan : - Kemungkinan suatu proses sirosis hepatis - Tidak ditemukan hipertensi porta - Penyebab kelainan jantung tidak dapat disingkirkan
-
-
Stopper Furosemid 2x20mg iv Spirunolaktone 3x12,5mg Captopril 2x12.5mg Sildenafil 4x10mg Dobutamine 5 cmg/kgbw/minute Dobutamine 2,5 cmg/kgbw/minute Digoksin 2x 0.125 mg po
-
Terapi GEH Urdafalk 4x 100mg
-
Large VSD perimembrane outlet extent to inlet + Large secundum ASD + Mild pulmonal stenosis
Bukit Kecil Palembang
Renc. Pulang, echo sebelum pulang
BB/U :7/13.1 <-3sd
Hb 10.8 Erit 5.70 Leu 8.35 Ht 34 Trb 239 RDWCV 19.40 DC 0/2/72/15/11 ALP 124 AST 78 ALT 56 GGT 163 Pro tot 5.6 Alb 3 Glob 2.6 Koles total 82 HDL 16 LDL 64 Trigliserid 48 Ur 21 Cr 0.53 Ca 8 Fosfor 127 Na 127 K 2.9 Cl92
-
Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated pulmonary artery Balance four chambers Moderate Tricuspid Regurgitation PG 30,5 mmHg Pulmonal regurgitation No ASD seen No VSD seen Large PDA seen poorl contracting ventricles, no paradoxical movements LV systolic function EF 35,9 % FS 16,4 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Kesan : Large PDA + Severe Pulmonary hypertension + decreased LV systolic function
Urinalisa Warna kuning pH 7 protein – Ascorbic acid – Glukosa – keton – Bil – urobilinogen 2 Nitrit – lekosit esterase – Sedimen Urin epitel + Lekosit 2-4 Eri 0-1 Silinder silinder hyaline + Kristal – Bakteri + mucus – jamur -
Aqilah bt Asnawi /PR / 2 tahun 8 bulan 1012647/ RI 19001569 TL : 27 April 2016 MRS : 15 Januari 2019
BB 7 kg PB 68cm A: Asnawi I : Badiah HP : 081278796933
16-1-19
13- 1-19 Hb 11.7 Erit 6.24 Leu 8.81 ht 36 Plt 352 RDWCV 19.60 LED 2 DC 0/0/64/24/12 Bil tot 14.7 Bildirek 5.80 SGOT 131 SGPT 76 CRP 15
NPM Gizi buruk berdasarkan LILA Saran : Diet NC 1.5 5x100 = 750 kkal Susu F100 4x 100 = 400 kkal Total 1150 kkal /hari Monitoring akseptabilitas, toleransi dan efikasi
HP 081377774162
6. Lt 2 1.6
Bt 1 Ct 9 PT 13.5 (K)/16.2 (P) INR 1.25 APTT 31.6 (K) / 32.6 (P)INR 1.25 APTT 31.6 (K)/ 32.6 (P) Fibrinogen 312 (K) / 253 (P) D dimer 1.51 Ca 8 Na 125 K 3.4 Cl 86 T3 <0.4 FT4 1.53 TSH 3.36
O2 2 lpm Captopril 2x3 mg Furosemide 2x7 mg IV Ampicilin 3x30 mg IV (5) Gentamicin 2x20 mg IV (5)
16-01-2019 Hb 13.1 Erit 4.22 Leu 18.15 Ht 39 Trb 370 MCV 92,9 MCH 31 MCHC 33 RDWCV 12 LED 29 DC 0/1/44/47/8
14-01-2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild pulmonal stenosis valvular PG 20 Large VSD perimembrane outlet extent to inlet 10 mm, L to R shunt Large secundum ASD 24 mm, L to R shunt No PDA seen Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of
4
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita PB/U : 68/ 92.2 <-3sd BB/PB : 7/7.7 -2
7 Lt 1 HCU
Balance Diuresis I O IWL 87.5 B D Bagas Al Akbar / 4 th / LK 901452 / RI 19001421 TL 07 Januari 2015 MRS 14-01-19 Palembang BB 19kg TB 107cm BB/U 1SD
-
aorta seen No pericardial effusion seen
Ro Thorax Kardiomegali dengan bendungan paru
Post op VSD Closure H5 ai VSD PMO besar + mild PH
Stopper Kebutuhan cairan 100% -1450cc/24 jam Paracetamol 400mg/ 8 jam po Captopril 2 x 12.5 mg po Furosemid 2x20mg po Cefuroxime 3x320mg IV
16-01-19 (14.50) Hb 13 Erit 4.63 Leu 20.33 Ht 38 Plt 146 RDW CV 13.20 DC 0/1/71/22/6 PT 13.40 (K) / 16.2 (P) INR 1.25 APTT 31.6 (K)/ 41.4 (P) Fibrinogen 320 (K) / 195 (P) D dimer 0.32 SGOT 92 SGPT 50 Alb 40 GDS 282 ur 21 as.ur 4.0 Cr 0.59 Ca 10.0 Phospor 5.1 Mg 2.50 Na 144 K 4.2 Cl 112 AGD FIO2 60 Ph 7,281 pCO2 45.2 pO2 271.2 SO2 99.9% Hct 38 Hb 12.6 Na 141.5 Ca 1.24 K 3.98 laktat 4.3 pHtc 7.282 pCO2tc 45 pO2tc 270.7 TCO2 22.8 HCO3 21.5 BEecf -5.5 BEb -4.6 SBC 20.6 O2CT 18.4 RI 0.4 O2cap 17.6 A 372.3 12.41 Ca 12 phospor 3.9 Mg 2.60 Na 140 K 4 Cl 113 15-01-19 Hb 12 RBC 4.46 WBC 11.01 Ht 35 PLT 299 MCV 78 MCHC 35 RDW-CV 13.10 LED 8Gol da B Rh +DC 0/4/48/40/8CT BT 1.5 menit PT 13.7(k)/ 13.6(P) INR 1.01 APTT 30.2 (K)/ 32 (P) SGOT 44 SGPT 91Prot Tot 6.7Alb 4.3 Asam urat 2.7 Creatinin 0.51 Ureum 28 Calcium 10 Phospor 6.2 Mg 2.10 Natrium 144 Kalium 4.7 Clorin 110 HbSAg non reaktif Anti-HCV non reaktif CRP < 5 Anti HIV non reaktif GDS 91
17 Januari 2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Mild dilated LA-LV Mild Tricuspid Regurgitation Trivial Pulmonal Regurgitation Trivial Aorta Regurgitation No ASD seen Large VSD PMO 12 mm PG trans VSD 63,6 mmHg PDA ? Well contracting ventricles, no paradoxical movements LV systolic function EF 62,1 % FS 32,6 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large perimembrane outlet ventricular septal defect + Mild pulmonary hypertension + PDA ? Ro Thorax Kardiomegali CTR >50%, corakan vascular meningkat 15 November 2018 -
Situs solitus AV-VA concordance Mild dilated LA LV Normal systemic and pulmonary venous drainage Mild PR Mild TR (PG 25 mmHg)
5
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita ECG HR 100 x/menit, sinus rhytm , aksis normal, Kuadran II 600 P pulmonal (-), P mitral (-) , PR interval 0,08 sec , LVH +
8 Lt 3 Kamar 9
Faiqah/ pr / 1 bulan 1102974 TL : 18 des 2018 Mrs : 17 jan 2019 Alamat : Palembang BB : 2.1 kg Pb : 43 cm Status gizi : gizi kurang
Double outlet right ventrikel + large subaortic venrikular septal defect + mild pulmonal stenosis + malposition great artery +persistent foramen ovale
Furosemid 2 x 20 mg Aldactone 2 x 3.125 mg
17- 1-19 Hb 8.8 eri 2.56 leu 7.93 ht 25 tro 426 mcv 96.1 mch 34 mchv 36 led 2 dc 0/15/20/52/13 feritin 104 uibc 60 serum iron 104 tibc 164 Gdt : anemia normositik normokromik + tersangka proses infeksi + inflamasi + hipersensitivitas Saran : followup fungsi hati, feces rutin, CRP
-
No ASD seen Small PDA ? ( tidak tervisualisasi dengan baik) Large VSD perimembranous outlet 9.5mm with MSA, (L to R shunt) Mild Dilated pulmonary artery Left aortic arch, no coarctation of aorta seen Well-contracting ventricles LV systolic function EF FS No pericardial effusion seen Conclusion : Large perimembran outlet VSD with MSA Mild pulmonal hypertension 17 Januari 2019 ECHO Atrial situs solitus AV concordance, VA discordance Normal systemic and pulmonary venous drainage Aorta and pulmonary artery arise from right ventricle Aorta more anterior from pulmonary artery Aorta and pulmonary artery side by side Dilated RA-RV Mild Pulmonal stenosis PFO 4,8 mm Large subaortic VSD (R to L shunt) No PDA seen Well contracting ventricles, no paradoxical movements Right aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Double outlet right ventricle + large subaortic ventricular septal defect + mild pulmonal stenosis + malposition great artery + persistent foramen ovale
6
Kamar 1 Lt 3 Kamar 1
Identitas M.Alvin Ramadhan / lk/ 7 bulan 661532/ L : 3 September 2013 MRS : 21 Januari 2019 Pedamaran , OKI BB 33 kg PB 132 m BB/U -3
Balance Diuresis I O IWL 70 B D
Diagnosis Large VSD PMO + pulmonal hipertensi + gagal jantung
Terapi -
Pro open heart Captoptril 2 x 12,5 mg po Furosemide 2 x 20 mg po
Pem. Penunjang 21-01-19 Hb 13.1 Erit 5.18 leu 12.01 Ht 39 Trb 395 MCV 75.7 MCH 25 MCHC 33 RDW CV 14.10 LED 13 DC 0/738//48/7 PT INR 14.70 (K) / 14.3 (P) INR 1.07 APTT 32.8 (K) / 34.1 (P) Besi 31.9 TIBC 356 SGOT 21 SGPT 13 Pro tot 7.7 Alb 4.5 Globulin 2.1 GDS 98 Ur 17 As Ur 5.7 Cr 0.59 Ca 10 Phospor 5.8 Mg 2.10 Na 145 K 4.1 Cl 109 HbsAg Non reaktif Anti HCV non reactive Anti HCV Non Reactive
Keterangan Echo 21-01-2019
-
-
A: rudi I: yastati Hp : 085273677175
-
Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilatated LA-LV Mild Aorta Regurgitation Prolapse anterior aorta valve Mild Pulmonal regurgitation No ASD seen Large VSD PMO high type 8 mm L to R shunt No PDA seen Well contracting ventricles, no paradoxical movements - LV systolic function EF 77.5 % FS 45.9 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen
Conlusion :
Large Ventricular Septal Defect Perimembrane Outlet High Type + Mild Aorta Regurgitation + Prolapse anterior aorta valve + Mild Pulmonal regurgitation
1
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita 2 Lt 3 Kamar 1
Adreena Naira Malika /PR/ 7 bulan 1091384/ RI 19001922 TL : 30 Juni 2018 MRS : 18 Januari 2019
PDA besar pro Ligasi PDA
-
Ampicilin 3x 400 mg (4) Ceftazidime 3x150mg (4) Carbogliserin 4x1 tts AS Furosemide 2x5mg Captopril 2x2.5 mg
Pedamaran , OKI BB 5,6kg PB 62cm BB/U -3
18-01-19 Hb 10.5 Erit 4.49 leu 12.62 Ht 32 Trb 353 MCV 71.9 MCH 23 MCHC 33 RDW CV 14.60 LED 5 DC 0/5/14/75/6 PT INR 13.50 (K) / 15.3 (P) INR 1.17 APTT 31.6 (K) / 40 (P) Besi 39 TIBC 357 SGOT 36 SGPT 12 Pro tot 6.5 Alb 4.5 Globulin 2.1 GDS 72 Ur 17 As Ur 4.3 Cr 0.44 Ca 11 Phospor 5.5 Mg 2.4 Na 141 K 5.3 Cl 109 ferritin 15.60 HbsAg Non reaktif Anti HCV non reactive Anti HCV Non Reactive
11 Januari 2019 -
-
Balance Diuresis I O IWL 70 B D
3 Lt 2 1.1
A: M. Apriadi I: Nita Hp : 085367640180 Pinkan ramadhan/ 10 tahun / PR 250697/ RI 19001161 TL : 31 Agustus 2008 MRS : 11 Januari 2019 Kertapati Palembang BB: 25 kg TB:137cm BB/U : p5 TB/U: p50 BB/TB : 25/33 =75.7 % Kesan : Gizi Baik perawakan normal
Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV AV and semilunar valves are normal No ASD seen No VSD seen PDA 8 mm Lto R shunt Well contracting ventricles, no paradoxical movements LV systolic function EF 69 % FS 37 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen
Kesan Large Patent ductus arteriosus 18 Januari 2018 Ro Thorax Kardiomegali
Post VSD closure H 6 ai Large VSD PMO, Mild MR , Mild TR, Mild PR , Moderate AR , Prolaps aorta valve + Gizi Kurang
-IVFD 50 % Kebutuhan cairan harian - aff infus perbanyak minum 100% kebutuhan cairan 1600cc/24 jam Furosemide 2x20mg IV Cefuroxime 3x450 mg IV (7) Paracetamol fl 3x500mg IV Furosemide 2x25 mg po Paracetamol 3x500mg po Captopril 2x12,5mg (po) Digoxin 2x 1 tab Spironolakton 2x25mg Renc. Transfusi PRC 1x100cc bila darah jadi masuk kurang input dari infus atau minum
18-01-19 Hb 12.1 Erit 4.34 Le 8.61 Ht 36 Trb 163 RDW CV 13.7 DC 0/2/82/10/6 15-1-19 Hb 9.8 RBC 3.36 WBC 16.91 Ht 28 PLT 178 DC 0/0/95/3/2 PT 15.9(P) INR 1.22 APTT 33.7 (P) SGOT 73 SGPT 14 Alb 3.8 Asam urat 4.6 Creatinin 0.63 Ureum 24 Calcium 10 Phospor 3.8 Mg 3.5 Natrium 145 Kalium 3.6 Cl 113 11-1-19 Hb 13.4 RBC 4.68 WBC 8.16 Ht 38 PLT 325 MCV 8.4 MCHC 16 RDW-CV 12.69 LED 12 Gol da O Rh + DC 0/8/48/38/6 CT BT menit PT 14.7(k)/ 13.5(P) INR 1.00 APTT 33.4 (K)/ 36.6 (P) SGOT 20 SGPT 10 Prot Tot 7.5 Alb 4.5 Ret 2.3 Asam urat 5 Creatinin 0.61 Ureum 26 Calcium 10 Phospor 4.7 Mg 2.2 Natrium 144
November 9th 2018 Situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild MR Mild TR Mild pulmonal regurgitation Moderate AR Prolaps aorta valve seen Left aortic arch, no coarctation of aorta seen Large VSD Perimembran outlet 13.6 mm (L to R shunt) No PDA seen No PFO seen No ASD seen Well-contracting ventricles LV systolic function normal EF
2
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita Persentil Tensi 5P 50P 90 P 95 P 99P
4 Lt 2 1.4
91 103 114 117 123
Kalium 3.7 Clorin 110 HbSAg non reaktif AntiHCV non reaktif CRP < 5 Anti HIV non reaktif GDS 103
53 63 72 74 78
Balance Diuresis 18.00 – 06.00 I O IWL 200 B D Ayah; Budiman Ibu : Islamiah Hp :082373508946 081373552056 Putri Aini /PR/8 bulan 1074381 / RI 19001697 TL: 2 Mei 2018 MRS : 16 Januari 2018
Decompensatio Cordis sedang ec VSD besar + RD + Severely wasted
BB 3.8kg PB 62cm BB/U : <-3sd PB/U -3< z< -2sd BB/PB 3.8/ 6.4 = 59 % Kesan Gizi buruk perawakan pendek
O2 nasal 1lpm Furosemid 2x3mg IV Aldacton 2x3.125 mg PO Captopril 2x2 mg Ampicilin 2x120mg IV (6) Gentamicin 2x10mg IV (6) Paracetamol 3x 2cc
16 Januari 2019 Hb 10 Erit 365 Leu 8.93 Ht 29 Trb 343 RDWCV 13.80 LED 16 DC 0/0/31/61/8 CRP < 5
Raber GIZI F75 12x 30cc
A Budi Cahyono I Nurlela HP 085367640180
5 Lt 2
77% FS45% No pericardial effusion seen
Conclusion : Large VSD PMO, Mild MR , Mild TR, Mild PR , Moderate AR , Prolaps aorta valve
Kertapati Palembang
Balance Diuresis I O IWL 47,5 B D Aidel Fitri / Perempuan / 13 tahun
-
16 januari 2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild Pulomnal regurgitation No ASD seen Large doubly commited VSD 8,7 mm Lto R shunt Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large VSD DCSA Mild Pumonal regurgitation
Decomp Cordis NYHA IV ec TR moderate + PR moderate ec PDA besar
-
O2 NRM 10 lpm O2 2lpm nasal canule
18-01-19
15 Januari 2019 ECHO
3
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita 1.5
1019313/RI 19001349 TL : 13 November 2005 MRS 14-01-19 Lahat BB 20kg TB 123cm BB/U
A Ersen I Hervi
+ Hipertensi Pulmonal + Gizi buruk + delayed puberty + poor contractility + Susp Cholestasis intra hepatic dd extrahepatik Cholestasis intrahepatic GEH : Hepar membesar uk 15.03 tepi tumpul berdungkul-dungkul lien 10.5 normal pleural efusi kiri (+) , ginjal hidronefrosis bilateral Kesimpulan : - Kemungkinan suatu proses sirosis hepatis - Tidak ditemukan hipertensi porta - Penyebab kelainan jantung tidak dapat disingkirkan
-
-
Stopper Furosemid 2x20mg iv Spirunolaktone 3x12,5mg Captopril 2x12.5mg Sildenafil 4x10mg Dobutamine 5 cmg/kgbw/minute Dobutamine 2,5 cmg/kgbw/minute Digoksin 2x 0.125 mg po
-
Terapi GEH Urdafalk 4x 100mg
-
Large VSD perimembrane outlet extent to inlet + Large secundum ASD + Mild pulmonal stenosis
Bukit Kecil Palembang
Renc. Pulang, echo sebelum pulang
BB/U :7/13.1 <-3sd
Hb 10.8 Erit 5.70 Leu 8.35 Ht 34 Trb 239 RDWCV 19.40 DC 0/2/72/15/11 ALP 124 AST 78 ALT 56 GGT 163 Pro tot 5.6 Alb 3 Glob 2.6 Koles total 82 HDL 16 LDL 64 Trigliserid 48 Ur 21 Cr 0.53 Ca 8 Fosfor 127 Na 127 K 2.9 Cl92
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Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated pulmonary artery Balance four chambers Moderate Tricuspid Regurgitation PG 30,5 mmHg Pulmonal regurgitation No ASD seen No VSD seen Large PDA seen poorl contracting ventricles, no paradoxical movements LV systolic function EF 35,9 % FS 16,4 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Kesan : Large PDA + Severe Pulmonary hypertension + decreased LV systolic function
Urinalisa Warna kuning pH 7 protein – Ascorbic acid – Glukosa – keton – Bil – urobilinogen 2 Nitrit – lekosit esterase – Sedimen Urin epitel + Lekosit 2-4 Eri 0-1 Silinder silinder hyaline + Kristal – Bakteri + mucus – jamur -
Aqilah bt Asnawi /PR / 2 tahun 8 bulan 1012647/ RI 19001569 TL : 27 April 2016 MRS : 15 Januari 2019
BB 7 kg PB 68cm A: Asnawi I : Badiah HP : 081278796933
16-1-19
13- 1-19 Hb 11.7 Erit 6.24 Leu 8.81 ht 36 Plt 352 RDWCV 19.60 LED 2 DC 0/0/64/24/12 Bil tot 14.7 Bildirek 5.80 SGOT 131 SGPT 76 CRP 15
NPM Gizi buruk berdasarkan LILA Saran : Diet NC 1.5 5x100 = 750 kkal Susu F100 4x 100 = 400 kkal Total 1150 kkal /hari Monitoring akseptabilitas, toleransi dan efikasi
HP 081377774162
6. Lt 2 1.6
Bt 1 Ct 9 PT 13.5 (K)/16.2 (P) INR 1.25 APTT 31.6 (K) / 32.6 (P)INR 1.25 APTT 31.6 (K)/ 32.6 (P) Fibrinogen 312 (K) / 253 (P) D dimer 1.51 Ca 8 Na 125 K 3.4 Cl 86 T3 <0.4 FT4 1.53 TSH 3.36
O2 2 lpm Captopril 2x3 mg Furosemide 2x7 mg IV Ampicilin 3x30 mg IV (5) Gentamicin 2x20 mg IV (5)
16-01-2019 Hb 13.1 Erit 4.22 Leu 18.15 Ht 39 Trb 370 MCV 92,9 MCH 31 MCHC 33 RDWCV 12 LED 29 DC 0/1/44/47/8
14-01-2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Dilated LA-LV Mild pulmonal stenosis valvular PG 20 Large VSD perimembrane outlet extent to inlet 10 mm, L to R shunt Large secundum ASD 24 mm, L to R shunt No PDA seen Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of
4
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita PB/U : 68/ 92.2 <-3sd BB/PB : 7/7.7 -2
7 Lt 1 HCU
Balance Diuresis I O IWL 87.5 B D Bagas Al Akbar / 4 th / LK 901452 / RI 19001421 TL 07 Januari 2015 MRS 14-01-19 Palembang BB 19kg TB 107cm BB/U 1SD
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aorta seen No pericardial effusion seen
Ro Thorax Kardiomegali dengan bendungan paru
Post op VSD Closure H5 ai VSD PMO besar + mild PH
Stopper Kebutuhan cairan 100% -1450cc/24 jam Paracetamol 400mg/ 8 jam po Captopril 2 x 12.5 mg po Furosemid 2x20mg po Cefuroxime 3x320mg IV
16-01-19 (14.50) Hb 13 Erit 4.63 Leu 20.33 Ht 38 Plt 146 RDW CV 13.20 DC 0/1/71/22/6 PT 13.40 (K) / 16.2 (P) INR 1.25 APTT 31.6 (K)/ 41.4 (P) Fibrinogen 320 (K) / 195 (P) D dimer 0.32 SGOT 92 SGPT 50 Alb 40 GDS 282 ur 21 as.ur 4.0 Cr 0.59 Ca 10.0 Phospor 5.1 Mg 2.50 Na 144 K 4.2 Cl 112 AGD FIO2 60 Ph 7,281 pCO2 45.2 pO2 271.2 SO2 99.9% Hct 38 Hb 12.6 Na 141.5 Ca 1.24 K 3.98 laktat 4.3 pHtc 7.282 pCO2tc 45 pO2tc 270.7 TCO2 22.8 HCO3 21.5 BEecf -5.5 BEb -4.6 SBC 20.6 O2CT 18.4 RI 0.4 O2cap 17.6 A 372.3 12.41 Ca 12 phospor 3.9 Mg 2.60 Na 140 K 4 Cl 113 15-01-19 Hb 12 RBC 4.46 WBC 11.01 Ht 35 PLT 299 MCV 78 MCHC 35 RDW-CV 13.10 LED 8Gol da B Rh +DC 0/4/48/40/8CT BT 1.5 menit PT 13.7(k)/ 13.6(P) INR 1.01 APTT 30.2 (K)/ 32 (P) SGOT 44 SGPT 91Prot Tot 6.7Alb 4.3 Asam urat 2.7 Creatinin 0.51 Ureum 28 Calcium 10 Phospor 6.2 Mg 2.10 Natrium 144 Kalium 4.7 Clorin 110 HbSAg non reaktif Anti-HCV non reaktif CRP < 5 Anti HIV non reaktif GDS 91
17 Januari 2019 ECHO Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Mild dilated LA-LV Mild Tricuspid Regurgitation Trivial Pulmonal Regurgitation Trivial Aorta Regurgitation No ASD seen Large VSD PMO 12 mm PG trans VSD 63,6 mmHg PDA ? Well contracting ventricles, no paradoxical movements LV systolic function EF 62,1 % FS 32,6 % Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large perimembrane outlet ventricular septal defect + Mild pulmonary hypertension + PDA ? Ro Thorax Kardiomegali CTR >50%, corakan vascular meningkat 15 November 2018 -
Situs solitus AV-VA concordance Mild dilated LA LV Normal systemic and pulmonary venous drainage Mild PR Mild TR (PG 25 mmHg)
5
LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019 Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita ECG HR 100 x/menit, sinus rhytm , aksis normal, Kuadran II 600 P pulmonal (-), P mitral (-) , PR interval 0,08 sec , LVH +
8 Lt 3 Kamar 9
Faiqah/ pr / 1 bulan 1102974 TL : 18 des 2018 Mrs : 17 jan 2019 Alamat : Palembang BB : 2.1 kg Pb : 43 cm Status gizi : gizi kurang
Double outlet right ventrikel + large subaortic venrikular septal defect + mild pulmonal stenosis + malposition great artery +persistent foramen ovale
Furosemid 2 x 20 mg Aldactone 2 x 3.125 mg
17- 1-19 Hb 8.8 eri 2.56 leu 7.93 ht 25 tro 426 mcv 96.1 mch 34 mchv 36 led 2 dc 0/15/20/52/13 feritin 104 uibc 60 serum iron 104 tibc 164 Gdt : anemia normositik normokromik + tersangka proses infeksi + inflamasi + hipersensitivitas Saran : followup fungsi hati, feces rutin, CRP
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No ASD seen Small PDA ? ( tidak tervisualisasi dengan baik) Large VSD perimembranous outlet 9.5mm with MSA, (L to R shunt) Mild Dilated pulmonary artery Left aortic arch, no coarctation of aorta seen Well-contracting ventricles LV systolic function EF FS No pericardial effusion seen Conclusion : Large perimembran outlet VSD with MSA Mild pulmonal hypertension 17 Januari 2019 ECHO Atrial situs solitus AV concordance, VA discordance Normal systemic and pulmonary venous drainage Aorta and pulmonary artery arise from right ventricle Aorta more anterior from pulmonary artery Aorta and pulmonary artery side by side Dilated RA-RV Mild Pulmonal stenosis PFO 4,8 mm Large subaortic VSD (R to L shunt) No PDA seen Well contracting ventricles, no paradoxical movements Right aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Double outlet right ventricle + large subaortic ventricular septal defect + mild pulmonal stenosis + malposition great artery + persistent foramen ovale
6
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