Cardiac Resume Adreena.docx

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