SENSUS CVCU – 16 September 2018

No Nama (umur) RM Diagnosis DPJP HR

301 Efusi pericard massive dg tanda tamponade post pericardial window (13/9/18), Efusi pleura bilateral post tapping efusi pleura (6/9/18), Ca Mammae D T2 N1
dr.Shanti Ika (37) 01.59.77.21 EM 1 (3)
(VIP 1) M1 post adjuvant terapi
302 VT stable (riwayat VT berulang), riwayat NSTEMI Killips I TR 5/7 GS 88 (Very High Risk) with life threatening aritmia ( VT stable), CHF CF II ec DA LVH Eksentrik,
Harun P ( 57 Th) 01.63.91.12 BYS 3(7)
(VIP 2) RWMA DE IHD, DM2 obese terkontrol,CAD 3VD Non revask (2013 dan 2014), Riw ACS 2013 pro CAG Senin 17/9/18
303 ADHF forester II ec DA Kardiomegali, AR Severe DE HHD,kalsifikasi katup aorta, AF NVR, HT st II, stress hiperglikemia, ISK membaik, AKI dd on CRF, peningkatan enzim
Prof Sunarto (62) 01.33.97.97 BYS 5(11)
(VIP 3) transaminase membaik , riwayat hematemesis, CAP, riwayat delirium tanpa lateralisasi ec susp hipoperfusi vascular dd vascular
CAD 2 VD PPCI 1 DES di LAD, STEMI Anterior ekstensif onset 15 jam killip 1 TR 5/14 GS 112, Hipertensi stage 2 terkontrol, leukositosis ec susp related iskemik, post
304 Maryanta (52) 01.73.91.66 HH 2
stroke iskemik tanpa perberatan
SND ( Junctional Bradikardi ) ec elektrolit imbalance dd degenerative on TPM, HT terkontrol, AKI dd acute on CRF, Anemia Mikrositik Hipokromik ec susp Chronic
305 Koo Lian Hwa (68 ) 01.86.21.99 EM 3
Disease, Hiponatremia normoosmolar, pemanjangan diastase perdarahan, Riw SNH tanpa pemberatan defisit neurologis pada pasien junctional bradikardi
STEMI inferior, posterior et lateral onset 3 jam killip 1 TR 4/14 GS 120 post succesfull fibrinolisis, hiperglikemia pada pasien DM2NO, AKI dd acute on CRF,
306 Sunardi priyo (67) 01.86.23.13 IA 2
hiperkalemia ringan
CAD 2 VD Primary PCI 1 DES di RCA, STEMI inferior et dextra onset 18 jam killip 1 TR 6/14 GS 107, suspek RV infarct, Doc junctional Rhythm  NSR, stress
307 Yp. Herman Siswadi (58) 01.86.22.22 HH 3
hiperglikemia d DM2O, AKI dd acute on CRF
CAD 3VD PPCI 1 DES di RCA, STEMI Inferior onset 5 jam Killip I TR 3/14 GS 99, AV Block grd I – High Degree AV Block, Riw Bell’s Palsy tanpa defisit Neurologis, DM2NO.
308 Ponirah (60 ) 01.86.20.79 ABH 4
Problem hipoalbuminemia
NSTEMI Killip I TR 2/7 GS 88 (pro CAG+standby PCI Senin 17/8/2018), CHF cf II ec DA: Kardiomegali DE: HHD/IHD, CKD st V on HD rutin (Rabu-sabtu), HT
309 Aris Winarta (48) 01.86.23.12 uncontrolled, anemia mikrositik hipokromik ec related defisiensi besi dd chronic blood loss, perdarahan saluran cerna bagian atas ec gastropati uremikum, EM 1
hipoalbumin
310 Daryo (88) 01.86.20.28 CAD 3VD PPCI2 DES di RCA, STEMI Inferior Killip I onset 13 jam TR 8/14 GS 178 dengan RV infark, TAVB ec related infark, AKI dd Acute on CRF, PETA, Hipernatremia NT 4
311 Widiyati (24) 01.86.18.73 High probability of PH ec susp. ASD dd AP window, post SC a/I PEB, HELLP syndrome, problem : leukositosis ec susp. Infeksi, anemia, trombositopenia PRG 1(6)
CAD 3 VD Primary PCI 2 DES di RCA (Overlapped), STEMI inferior et dextra onset 16 jam killip 1 TR 8/14 GS 126, Pericarditis susp Dressler Syndrome, TAVB (escape
312 Imbar (73) 01.86.16.01 BYS 9
junctional ryhtm) -> AVB grade 1, Efusi perikard mild (observasi tren), observasi febris Hari ke 3
Bradikardia simptomatis (TAVB) ec susp. Degenerative on TPM, post stroke tanpa pemberatan, Dizzines cum riw. Sinkope berulang ec susp. Insufisiensi
313 Ruriyanto (54) 01.86.23.38 ABH 1
vestibulobasiler pada pasien bradi-simptomatis, problem : hipokalemia (3.23)
314
(ISO 2)
315
(ISO 1)

SENSUS HCU PJT – 15 September 2018

No Nama (umur) RM DPJP HR
713A
713B
714A
714B DRS. Djuwandi (63) 01.85.60.64 CLTI W2I3FI, extremitas inferior dextra ec Thrombus A. Femoralis superfacialis dextra, DM2, Riw CABG 3x a/i CAD (TMT +) 2001, Foot Ulcer Pedis dextra, PAD sinistra PRG 3

SENSUS HCU IGD – 15 September 2018

No Nama (umur) RM DPJP HR
Tn. Ponijo (68) Gagal Nafas tipe II berat, HAP, PPOK dengan infeksi sekunder, CHF CF II ec HHD, AFNVR, Alkalosis metabolic ec susp furosemide induced, hypokalemia Berat,
1 01.86.16.23 UPD/BYS 7
Hipoalbuminemia ringan
Iskandar (71) Bedah
2 1.85.84.54 Syok sepsis, ICH, HT on treatment, PAF  NSR, contusio pulmo, HAP 9
Saraf/IA