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2/5/17 Sesak napas Sensorium: Compos -Congenital -Tirah baring
Mentis Heart Failure -O2 2-4l/I via nasal
TD: 110/60 mmHg FC III/IV ec kanul
HR: 92x/i Coronary -Diet Jantung III
RR: 24x/i Artery Disease -IVFD Nacl 0,9% 10
T: 36,4oC -Coronary gtt/ml mikro
UOP: 750 mL Artery Disease -Inj. Furosemide 20
Balance: ±100 mL Anterior mg/ 12 jam/ IV
Kepala -Hipertensi -Aptor 1x100 mg
Mata anemis (-) Terkontrol -Amlodipin 1x5 gr
Telinga/ Hidung/ -Hipokalemia -Bisoprolol 1x2,5 gr
Mulut (3,0)
Dalam Batas Normal
Leher
TVJ R+3 cmH2O
Thoraks
Suara pernafasan
vesikuler tanpa suara
tambahan
Abdomen
Soepel
Hati/ Limpa/ Ginjal
Dalam Batas Normal
Ekstremitas
Edema (-)
46
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Laboratorium
Na/ K/ Cl: 137/ 3/ 100
3/5/17 Sesak napas Sensorium: Compos - Congenital -Tirah baring
Mentis Heart Failure -O2 2-4l/I via nasal
TD: 130/60 mmHg FC III/IV ec kanul
HR: 88x/i Coronary -Diet Jantung III
RR: 24x/i Artery Disease -IVFD Nacl 0,9% 10
T: 36,3oC -Coronary gtt/ml mikro
UOP: 700 mL Artery Disease -Inj. Furosemide 20
Balance: ±50 mL Anterior mg/ 12 jam/ IV
Kepala -Hipertensi -Aptor 1x100 mg
Mata anemis (-) Terkontrol -Amlodipin 1x5 gr
Telinga/ Hidung/ -Hipokalemia -Bisoprolol 1x2,5 gr
Mulut (3,0) -KSR 1x600 mg
Dalam Batas Normal
Leher
TVJ R+3 cmH2O
Thoraks
Suara pernafasan
vesikuler tanpa suara
tambahan
Abdomen
Soepel
Hati/ Limpa/ Ginjal
Dalam Batas Normal
Ekstremitas
Edema (-)
4/5/17 Sesak napas Sensorium: Compos - Congenital -Tirah baring
(07.00) berkurang Mentis Heart Failure -O2 2-4l/I via nasal
TD: 110/60 mmHg FC III/IV ec kanul
HR: 76x/i Coronary -Diet Jantung III
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