Laphar Add.docx
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Kamar Lantai 2 Kamar 3 Bed 4
Identitas Sheylla Zasaya Syufa/14 th / Pr 1041338/ RI 19000514 TTL : 3-04-2004 MRS : 6/1/19
Diagnosis Syok Kardiogenik + Decomp Cordis NYHA IV ec ASD Sekundum besar + Hipertensi Pulmonal
Terapi O2 simple mask 8 lpm Dobutamin 15 mg/kgBB dalam NS 50 cc kec 1cc/jam5 mcg/kg/mnt Furosemide 2x20 mg po Sildenafil 4x10 mg po Spirunolakton 2x25mg po
Pem. Penunjang
6/1/18 Hb 14.5 Erit 5.04 Leu 7.1 Ht 44 Trb 253 RDW-CV 18.10 DC 0/2/66/24/8
Kalidoni Palembang BB: 25 kg TB:143 cm BB/U:
Keterangan 30 Juli 2018 Echo Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Hipertrophy RA-RV Severe Tricuspid regurgitation Moderate pulmonary regurgitation Dilated pulmonary artery Large secundum ASD 35.3 mm, bidirectional shunt No VSD seen No PDA seen Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large secundum ASD, Pulmonary hypertension 9 Oktober 2018 Ro Thorax - Cor membesar ke kanan dan kiri, tampak gambaran dobel kontur - Tampak sefalisasi - Tidak tampak infiltrate dikedua paru - Diaphragma kanan dan kiri licin - Sinus costofrenicus kiri tumpul - Tulang dan jaringan lunak baik Kesan : Cardiomegali disertai efusi perkardial, edema paru, Efusi Pleura kiri minimal
Kamar Lantai 2 Kamar 3 Bed 6
Identitas Dewan Daru /14 th 3 bulan / Pr 1089714/ RI19002160 TTL : 22-09-2004 MRS : 4/1/19 Gg.Karya Abadi Prabumulih
Diagnosis VSD DCSA + Prolaps RCC + AR moderate + Mild PR +trivial TR + Infected Endocarditis
Terapi Furosemid 2x40mg Captopril 2x 12,5 Spironolakton 2x25mg
Pem. Penunjang 4/1/19 Hb 12,3 RBC 4.37 WBC 8.3 Ht 36 PLT 316 MCV 82.4 MCH 28 MCHC 34 RDW CV 17.50 LED 86 DC 0/2/52/38/8 Ret 2.3 Ur 13 As. Urat 6.2 Kreat 0.70 Ca 9.0 Phos3.7 Mg 1.9 Na 145 K 3.2 Cl 108 HbsAg non reaktif anti HCV non reaktif CRP <5 Golda A Anti HIV non Reaktif
Keterangan
BB: 39 kg TB: 115 cm BB/U: p5-p10 PB/U: p10-p25 BB/PB: 34/45 =75% Kesan: Gizi kurang perawakan pendek I. Muslina A. Jemaran Hp :085267229474
PT +INR 13.50(K)/13(P) INR 0.96 APTT 29.5 (K)/34.3(P) Besi (Fe/Iron) 65 TIBC 313 SGOT 32 SGPT 42 Prot. Tot 7.4 Alb 4 GDS 80
Identitas Sheylla Zasaya Syufa/14 th / Pr 1041338/ RI 19000514 TTL : 3-04-2004 MRS : 6/1/19
Diagnosis Syok Kardiogenik + Decomp Cordis NYHA IV ec ASD Sekundum besar + Hipertensi Pulmonal
Terapi O2 simple mask 8 lpm Dobutamin 15 mg/kgBB dalam NS 50 cc kec 1cc/jam5 mcg/kg/mnt Furosemide 2x20 mg po Sildenafil 4x10 mg po Spirunolakton 2x25mg po
Pem. Penunjang
6/1/18 Hb 14.5 Erit 5.04 Leu 7.1 Ht 44 Trb 253 RDW-CV 18.10 DC 0/2/66/24/8
Kalidoni Palembang BB: 25 kg TB:143 cm BB/U:
Keterangan 30 Juli 2018 Echo Atrial situs solitus AV-VA concordance Normal systemic and pulmonary venous drainage Hipertrophy RA-RV Severe Tricuspid regurgitation Moderate pulmonary regurgitation Dilated pulmonary artery Large secundum ASD 35.3 mm, bidirectional shunt No VSD seen No PDA seen Well contracting ventricles, no paradoxical movements Left aortic arch, no coarctation of aorta seen No pericardial effusion seen Conclusion : Large secundum ASD, Pulmonary hypertension 9 Oktober 2018 Ro Thorax - Cor membesar ke kanan dan kiri, tampak gambaran dobel kontur - Tampak sefalisasi - Tidak tampak infiltrate dikedua paru - Diaphragma kanan dan kiri licin - Sinus costofrenicus kiri tumpul - Tulang dan jaringan lunak baik Kesan : Cardiomegali disertai efusi perkardial, edema paru, Efusi Pleura kiri minimal
Kamar Lantai 2 Kamar 3 Bed 6
Identitas Dewan Daru /14 th 3 bulan / Pr 1089714/ RI19002160 TTL : 22-09-2004 MRS : 4/1/19 Gg.Karya Abadi Prabumulih
Diagnosis VSD DCSA + Prolaps RCC + AR moderate + Mild PR +trivial TR + Infected Endocarditis
Terapi Furosemid 2x40mg Captopril 2x 12,5 Spironolakton 2x25mg
Pem. Penunjang 4/1/19 Hb 12,3 RBC 4.37 WBC 8.3 Ht 36 PLT 316 MCV 82.4 MCH 28 MCHC 34 RDW CV 17.50 LED 86 DC 0/2/52/38/8 Ret 2.3 Ur 13 As. Urat 6.2 Kreat 0.70 Ca 9.0 Phos3.7 Mg 1.9 Na 145 K 3.2 Cl 108 HbsAg non reaktif anti HCV non reaktif CRP <5 Golda A Anti HIV non Reaktif
Keterangan
BB: 39 kg TB: 115 cm BB/U: p5-p10 PB/U: p10-p25 BB/PB: 34/45 =75% Kesan: Gizi kurang perawakan pendek I. Muslina A. Jemaran Hp :085267229474
PT +INR 13.50(K)/13(P) INR 0.96 APTT 29.5 (K)/34.3(P) Besi (Fe/Iron) 65 TIBC 313 SGOT 32 SGPT 42 Prot. Tot 7.4 Alb 4 GDS 80
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