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Follow Up Pasien

Tanggal S 29 Sesak September Nafas 2012 O Sens: CM TD: 120/80 mmHg HR: 70 x/i RR: 24 x/i T: afebris Mata: Konj.palpebra inferior anemis( -/- ), Sklera ikterik( -/- ) TVJ: R+2 cmH2O Cor: S1S2 (N) irreguler, murmur (-) ,gallop (-) Pulmo : SP: Vesikuler ST: Ronki kasar di lap.atas paru kiri (+), ronki (+) Abd: Soepel, H/L: ttb BU(+) N Eks: akral hangat, edema (-/-) Sens: CM TD: 130/80 mmHg HR: 96 x/i RR: 20 x/i T: afebris Mata: Konj.palpebra inferior anemis( -/- ), Sklera ikterik( -/- ) TVJ: R+2 cmH2O Cor: S1S2 (N) irreguler, murmur (-) ,gallop (-) Pulmo : SP: Vesikuler ST: Ronki kasar di lap.atas paru kiri (+), ronki (+) Abd: Soepel, H/L: ttb BU(+) N Eks: akral hangat, edema (-/-) A AF RVR -CHF fc IIIIV ec CAD + HHD + (OMI anterosepta) -infeksi paru P Bed rest semifowler O2 4 L/i IVFD NaCl 0.9 % 10 gtt/I mikro Injeksi Furosemide 20mg/8 jam Inj Ceftriaxone 2gr/12 jam simarc 2mg 2x1 Digoxin 1x0.25mg KSR 1x600 mg ISDN 5mg 3x1 (jika TD> 100 mg) Captropil 3 x 6.25 mg (jika TD > 100 mg) Aspilet 1 x 80 mg Laxadyn syr Inj Ranitidin 1 amp/12 jam Pct 3x500 mg Ambroxol 3x1 Bed rest semifowler O2 4 L/i IVFD NaCl 0.9 % 10 gtt/I mikro Injeksi Furosemide 20mg/8 jam Inj Ceftriaxone 2gr/12 jam simarc 2mg 2x1 Digoxin 1x0.25mg KSR 1x600 mg ISDN 5mg 3x1 (jika TD> 100 mg) Captropil 3 x 6.25 mg (jika TD > 100 mg) Aspilet 1 x 80 mg Laxadyn syr Inj Ranitidin 1 amp/12 jam Pct 3x500 mg

1 oktober 2012

Lemas

AF RVR -CHF fc IIIIV ec CAD + HHD + (OMI anterosepta) -infeksi paru

2 oktober 2012

Lemas

Sens: CM TD: 120/80 mmHg HR: 72 x/i RR: 24 x/i T: afebris Mata: Konj.palpebra inferior anemis( -/- ), Sklera ikterik( -/- ) TVJ: R+2 cmH2O Cor: S1S2 (N) irreguler, murmur (-) ,gallop (-) Pulmo : SP: Vesikuler ST: Ronki kasar di lap.atas paru kiri (+), ronki (+) Abd: Soepel, H/L: ttb BU(+) N Eks: akral hangat, edema (-/-)

AF RVR -CHF fc IIIIV ec CAD + HHD +(OMI anterosepta) -infeksi paru

Ambroxol 3x1 Bed rest semifowler O2 4 L/i IVFD NaCl 0.9 % 10 gtt/I mikro Injeksi Furosemide 20mg/8 jam Inj Ceftriaxone 2gr/12 jam Simarc 2mg 2x1 Digoxin 1x0.25mg KSR 1x600 mg ISDN 5mg 3x1 (jika TD> 100 mg) Captropil 3 x 6.25 mg Aspilet 1 x 80 mg Alprazolam 1x0.5mg Laxydin syr Inj Ranitidin 1 amp/12 jam Pct 3x500 mg Ambroxol 3x1

KESIMPULAN

Pasien menderita CHF fc IV ec CAD dan Pasien ini di berikan terapi berupa: Bed rest semi fowler O2 4L/menit IVFD Nacl 0.9% 10gtt/i Inj Furosemide 20mg/8 jam Simarc 2 mg 2x1 Digoxin 1x0.25 mg KSR 1x600 mg ISDN 5mg 3x1 Captopril 3x6.25 mg Aspilet 1x80 mg