laporan pasien cvcu
TRANSCRIPT
![Page 1: Laporan Pasien CVCU](https://reader035.vdocuments.pub/reader035/viewer/2022062222/55cf949e550346f57ba33f7d/html5/thumbnails/1.jpg)
Pasien CVCU
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Tn. PS / 63 thKU: nyeri dada kiri
RPS: mengeluh nyeri dada kiri dirasa memberat kurang lebih 14 jam SMRS terasa seperti ditusuk-tusuk, terasa menjalar ke lengan kiri dan punggung, tidak berkurang dengan istirahat, tidak dipengaruhi aktivitas, dirasakan lebih dari 20menit, keringat dingin (-), sesak nafas (-), BAK t.a.k, BAB t.a.k.
RPD: HT (+) tidak terkontrol
AU (+)
kolesterol (+)
DM, paru, ginjal disangkal
RPSos: alkohol (+) sesekalimerokok (-)
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PF T 120/90 N 57x/mnt SaO2 97%
Kepala CA (-/-) SI (-/-)
Thoraks C Ictus cordis tidak tampak
Tidak teraba thrill, ictus cordis tidak kuat angkat
S1-2 reg, m(-), g(-)
P vesikuler Rh (-/-), Wz (-/-)
Abdomen Datar, supel, BU (+), H/L t.t.b
Ekstremitas Akral hangat Oedem (-)
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Lab 7/4/2014
CK 266 CKMB 24 TC 159 HDL 32 LDL 92 TG 52
8/4/2014 CK 1137 CKMB 84 Hb 15.6 Hct 45.4% Trombosit 168.000 Leukosit 10.500 Ur 18.2 Cr 0.91
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EKG
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Foto thoraks
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TIMI Risk NSTEMI Umur ≥65th (-)
3 Faktor risiko CAD (1) Stenosis koroner 50% atau lebih (-) Deviasi ST segmen EKG ≥0.5mm (1) Penggunaan aspirin 7 hari (-) Setidaknya 2 kejadian angina dalam 24 jam (-) Peningkatan biomarker jantung (1)
Total : 3/7
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Diagnosa STEMI anteroekstensif TIMI 3/7
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Terapi CVCU IVFD NS 500 cc 7 gtt/menit Inj Fondaparinux 2.5mg 1 x 1 SC (H2) Aspilet 80 mg 0-1-0 CPG 75 mg 0-1-0 ISDN 3x 5 mg Miozidin 2 x 1 Captopril 3 x 12.5 mg Simvastatin 20 mg 0–0–1 Ubi Q 3x 100 mg Nattokinase 3 x 1 Inj. Ranitidin 2 x 1 amp Bisoprolol ¼-0-0
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Pasien CVCU
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Tn. MJ / 65 th KU: nyeri dada RPS: nyeri dada kiri memberat sejak 2 hari SMRS, terasa seperti
tertusuk tidak menjalar ke lengan/ punggung, dirasakan terus-menerus sampai masuk RS, tidak hilang dengan istirahat. Sesak nafas (-), keringat dingin (-). Sebelumnya 3 hari yll pasien merasa tidak enak di dada saat habis menghadiri acara pesta, menghilang dengan istirahat. Pasien biasa tidur dengan satu bantal BAK t.a.k, BAB t.a.k.
RPD: HT (-) RPSos Merokok (+) 2 bks/hr
DM (-) Alkohol (-)
Kolesterol (-)
ginjal (-)
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PF T 120/80 N: 74x/mnt SaO2 97%
Kepala CA (-/-) SI (-/-)
Thoraks C: I: Ictus cordis tidak tampak
Pa: Tidak teraba thrill, ictus cordis tidak kuat angkat
Pe: Kiri bawah ICS V-VI LMCSKanan bawah ICS IV-V L.parasternal dextra
Au: S1-2 n, reg, m(-), g(-)
P SN vesikuler Rh (-/-) Wz (-/-)
Abdomen Datar, supel, BU (+), H/L t.t.b
Ekstremitas Akral hangat Oedem (-)
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Lab 7/4/2014
CK 3483 CKMB 259 Hb 15.1 Hct 43.2% Trombosit 184.000 Leukosit 12.500 Ur 28 Cr 0.8
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EKG
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Foto thoraks
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TIMI Risk STEMI Umur <65 th/ 65-74th/ ≥75th (2) DM/ HT/ Angina (0) SBP < 100mmHg (0) HR > 100x/menit (0) Killip class II-IV (0) Berat badan <67kg (0) ST elevasi anterior/ LBBB (1) Time to treatment > 4 jam (0)
3/14
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Diagnosa Recent MCI anteroekstensif (TIMI 3/14) HT terkontrol
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Terapi CVCU IVFD NS 500 cc 7 gtt/menit Inj Fondaparinux 2.5mg 1 x 1 SC (H1) Aspilet 80 mg 0-1-0 CPG 75 mg 0-1-0 Bisoprolol 5 mg 1/2- 0- 0 Miozidin 2 x 1 Captopril 3 x 25mg Amlodipin 5mg 1-0-0 Simvastatin 20 mg 0–0–1 Ubi Q 3x 100 mg Nattokinase 3 x 1 Inj. Ranitidin 2 x 1 amp Inj Ceftriaxone 2x1gr (H1)