DEPARTEMEN/SMF ILMU KESEHATAN ANAK- BEDAH THORAKS KARDIOVASKULAR RSUP Dr. MOHAMMAD HOESIN PALEMBANG
NRM Nama Jenis Kelamin Tanggal lahir
: 1091384/ : Adreena Naira Malika : Perempuan : 30 Juni 2018
(Mohon diisi atau tempelkan stiker jika ada)
CARDIAC RESUME (03 Januari 2019) BB/TB
5.6 kg/62 cm
Jaminan
BPJS
Asal Pasien/HP
OKI/085367640180
Diagnosis
PDA besar pro Ligasi PDA
berat badan sulit naik evaluasi echo PDA besar Pemeriksaan fisis : Cor : Bunyi Jantung I dan II normal, bising pansistolik grade
Klinis
3/6 di sela iga 4 linea parasternalis sinistra menjalar sepanjang sternum,, SpO 2 99%
Foto toraks
Cardiomegali dengan peningkatan corakan vaskuler
EKG
-
11 Januari 2018
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
Hasil Diskusi
PDA Ligation
Surgical approach
Median sternotomy
Echocardiography
Laboratorium
Tingkat urgensi
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 ELEKTIF □ URGENT □ CITO Straight forward/ early extubation ( jika intra operatif tidak ada komplikasi)
Catatan DPJP BTKV
DPJP Pedcard
DPJP ERIA
Dr.Bermansyah, SpB
Dr.Ria Nova,SpA(K)
Dr. Silvia Triratna, SpAK
BTKV(K)
DSY/Des/2019