89.

08 Visite Dokter Dan Perawat

89.61 Pengukuran Tanda Vital
99.18 Pemasangan Dan Aff Infus
90.59 Pemeriksaan Laboratorium
87.44 Pemeriksaan Foto Thoraks
89.52 Pemeriksaan Elektrokardiogram
88.72 Pemeriksaan Echocardiogram
99.22 Pemberian Obat Oral Dan Injeksi
88.55. Coronary arteriography using a single catheter
36.07 Insertion DES PCI Insertion of drug-eluting coronary artery stent(s)
00.46 Pemasangan 2 stent
00.24 Coronary Angiography
00.66 PTCA : balloning
00.40 adjunct vascular procedure
00.45 adjunct vascular (satu stent)
99.21 injection of antibiotic

00.45 Pemasangan 1 stent

00.66 PCI Percutaneous transluminal coronary angioplasty
00.40 PCI 1 Vessel
00.42 PCI 2 Vessel
00.46 Pemasangan 2 stent
37.34 Ablasi Excision or destruction of lesion or tissue of heart, other approach
Icd 9 Cardiac retraining
37.80 PPM Insertion of permanent pacemaker
89.41 Treadmill test Cardiovascular stress test using treadmill
37.26: EP STUDY

N17 Acute Kidney Injury

N18.5 Chronic Kidney Injury
I21.4 NSTEMI Acute subendocardial myocardial infaction
I25.1 Coronary Artery Disease Atherosclerosis Heart Disease
I21.2 STEMI Acute transmural myocardial infaction
I20.0 Unstable Angina Pectoris
I25.2 Old Myocardial infarction
I11.9 Hypertensive Heart Disease without CHF
I11.0 Hypertensive Heart Disease with CHF
I50.9 Heart Failure, unspecified
I50.0 Congestive Heart Failure
I34.0 Mitral (valve) insufficiency
I36.1 Nonrheumatic tricuspid (valve) insufficiency
I37.1 Nonrheumatic pulmonary valve insufficiency
I48.9 Atrial fibrillation and flutter
I49.3 Ventricular Premature Depolarization
I44.2 TAVB Atrioventricular black, complete
Z50 Cardiac retraining functional capacity class
Z72.3 Low cardiopulmonary endurance
E87.1 Hyponatremia
E87.6 Hypokalemia
E11 - Non-insulin-dependent diabetes mellitus
I25.9 Chronic Coronary Syndrom
I08.3 : multivalvular heart disease
I20.9: angina pectoris
K30. Dyspepsia
D64.9 Anemia unspecified
I23.6 - Thrombosis of atrium, auricular appendage, and ventricle as current
complications following acute myocardial infarction

Kontrol rutin poli jantung

Minum obat teratur sesau dosis dan waktu yang tepat
Tetapkan pola hidup sehat
Jangan merokok dan hindari asap rokok
Tidur cukup 6-8 jam sehari
Makan makanan rendah lemak, kurangi garam, banyak sayuran dan buah-buahan
Olahraga atau exercise secara teratur
Hindari faktor pencetus seperti stress dan emosional

Jika keluhan nyeri dada atau sesak napas yang tidak berkurang selama 20 menit
atau tidak membaik dengan istirahat dan obat.

Diet rendah garam, diet rendah lemak, diet rendah serat

Divisi Kardiologi Rehabilitasi

Six Minute Walking Test
Walking distance 240 meter
VO2max 15.79
METS 4.51
Fitness Classification : Low
Functional Class III
Fitnes Reccomendation :
- Walking : 2.4 kilometer/30menit (3-5 kali/minggu)
- Bicycling : 4.85 kilometer/30menit (3-5 kali/minggu)
- Other Sports : Badminton (Social double)

- Aktivitas lain : Tennis (double), Table Tennis

Laboratorium (9/4/23) : aPTT 53.2

Laboratorium (6/4/2023)
HbA1c 9.5
Kolesterol total 246
LDL/HDL/Trigliserida : 139/47/375

Laboratorium (5/4/2023)
Leukosit : 10.500 (Neutrofil/Limfosit : 84.4/12.0)
Hemoglobin : 12.9
Platelet : 271.000
PT/INR/aPTT: 9.7/0.89/21.6
Ureum/Creatinin : 25/0.53 --> 31/0.63 (post tindakan)
SGOT/SGPT : 68 / 34
Natrium/Kreatinin/Clorida : 133/ 4.2 / 101
HBsAg/Anti HCV(Elisa) : NR
hs Troponin : 5688.8

Elektrokardiogram di Pusat Jantung lantai 5 (8/4/2023)

Sinus rhythm, HR 68 bpm, reguler, normoaxis, P wave 0,06 sec, PR interval 0.16 sec, QRS
duration 0,06 sec, Q wave II, III, aVF, T Inverted II, III, aVF. V5-V6, Low voltage di limb
lead

Elektrokardiogram di Cardiovarcular Care Unit Pusat Jantung lantai (8/4/2023)

Sinus rhythm, HR 68 bpm, reguler, normoaxis, P wave 0,06 sec, PR interval 0.16 sec, QRS
duration 0,06 sec, Q wave II, III, aVF, T Inverted II, III, aVF.

Compos mentis
Tensi: 117/74 mmHg
Nadi : 73 x/menit, regular
Nafas : 20 x /menit
Suhu :  36.5 C
SpO2 98% on air room 

Anemis tidak ada, ikterus tidak ada

JVP R+2 cmH20
BJ I/II murni reguler, murmur tidak terdengar
BP Vesikuler, ronkhi dan wheezing tidak ada
Edema ekstremitas tidak ada, akral teraba hangat

Left Main : Normal

Left Anterior Descending : Stenosis 50% di mid.
Left Circumflex : Normal
Right Coronary Artery : Normal
Kesimpulan : Moderate Coronary Artery Disease
Anjuran : Optimal Medical Therapy

Unstable Angina Pectoris (Grace Score 68 points ; 1.4 % probability of death from admission to 6
months)

Diet rendah garam, diet tinggi serat dan diet rendah kolesterol

EKG di PJT lantai 5 (28/4/2023)

Sinus rhythm HR 75 bpm, normoaxis, reguler, P wave 0,06 sec, PR interval 0,16 sec, QRS duration
0,06 sec, No ST-T changes

Laboratorium 27/4/2023
APTT 42.3

Laboratorium 24/4/2023
Kolesterol total 212
HDL / LDL 43 /128
Trigliserida 385

Laboratorium RS PJT (22/4/2023)

WBC 9.800
HGB 14,6
MCV 82
MCH 29
PLT 311.000
GDS 135 mg/dl
Neutrophyl/Lymphocyte 62,2/25,2
Ur/Cr 30/1,05
Ot/Pt  16/21
PT/APTT/INR 10,0/30,2/0,92
Na/K/Cl 141/4,0/105
Hs Troponin I 8,0

CT thoraco-abdominal 26/04/2023
- Aneurisma saccular arcus aorta disertai thrombus
- Circumferential thrombus disertai atherosklerosis aorta descendens hingga arteri iliaca communis
bilateral

CT thorax 26/04/2023
- Aneurisma saccular arcus aorta disertai thrombus
- TB Paru lama aktif lesi minimal
- Multiple lymphadenopaty regio axilla bilateral

CT Scan Thorax di Balai Paru (31/5/2022)

- Aneurisma Aorta Tipe Sacculer
- Aterosclerosis Aortae
- Bronchitis

Foto Thorax di Balai Paru (31/5/2022)

- Massa paru sinistra ukuran sekitar 4x2,5 cm
- Cardiomegaly

Riwayat pasien berobat jalan di Poli PJT mendapatkan terapi Ramipril 2,5 mg, Amlodipin 10 mg,
bisoprolol 2,5 mg, ISDN tab 5 mg
Faktor Risiko Koroner:
- Riwayat Hipertensi ada, berobat teratur dengan amlodipin 10 mg
- Riwayat Diabetes mellitus ada minum metformin tidak teratur
-Riwayat merokok ada, kurang lebih 20 tahun, 1 bungkus per hari
- Riwayat penyakit jantung dalam keluarga tidak ada

Compos mentis
Tensi : 103/75mmHg
Nadi : 85x/menit irreguler
Nafas : 20 x /menit
Suhu : 36.5 C
SpO2: 98 % with NC 3 lpm

Mata: Anemis tidak ada, ikterus tidak ada

JVP R+2 cmH20
BJ I/II murni, irreguler, murmur tidak ada
BP vesikuler, ronkhi tidak ada, wheezing tidak ada
Edema ekstremitas tidak ada, akral teraba hangat

Elektrokardiografi di Perawatan lantai 5 (6-5-23)

Sinus rhythm, HR 82 bpm, reguler, LAD, P wave 0.06sec, PR interval 0.16 sec, QRS complex
0.06sec. qST elevasi di II, III, aVF, ST depresi I,aVL, V5,V6, LVH

Elektrokardiografi di UGD PJT (30-04-2023)

Sinus rhythm, HR 100bpm, reguler, LAD, P wave 0.06sec, PR interval 0.16sec, QRS complex
0.06sec. qST elevasi di II, III, aVF

Elektrokardiografi Right-Poterior di PJT (30-04-2023)

Sinus rhythm, HR 100bpm, reguler, LAD, P wave 0.06sec, PR interval 0.16sec, QRS complex
0.06sec. qST elevasi di II, III, aVF, V4R, V8, V9. T inverted di V2R, V3R

Laboratorium (05/05/2023)
APTT 32.3

Laboratorium (04/05/2023)
APTT : 64.2
Ureum/Creatinin : 38/0.64

Laboratorium (02/05/2023)
APTT 26.1
Kolesterol Total 207
LDL/HDL/TG 147/48/106

Laboratorium (30-04-2023)
Leukosit 12400
Hemoglobin 13.5
Platelet 241000
NEUT/LYMPH 62.4/21.1 GDS 135
Natrium/Kalium/Clorida 141/3.9/106
Ureum/Creatinin 53/0.87
GOT/GPT 143/41
PT/INR/APTT 11.2/1.04/21.7
HS Troponin I >40000

Gula Darah Puasa 05/05/23 : 103

Laboratorium 4/5/23
Gula Darah Puasa 93
HbA1c 6.8
Kolesterol Total 194
LDL/HDL/TG 139/54/107

Urinalisa 03/05/2023
Warna kuning tua
pH 6.0
BJ 1.025
Protein, Glukosa, Bilirubin, urobilinogen, keton, nitrit, Blood, Lekosit : negatif
Sed eritrosit : 4
Sedimen kristal : 0
Sedimen torak : 1
Sedimen epitel sel : 1
Sed lain-lain BAC =15
Sed lekosit 0

Laboratorium (2-5-2023)
Leukosit: 9.500
Hemoglobin : 11.5
Platelet : 251.000
Neutrofil/Lymphosit : 52.1/33.4
PT/INR/aPTT 10.9/1.01/26.5
Ureum/ Creatinin : 35/ 1.11
SGOT/SGPT : 30/64
GDS : 123
Natrium/Kalium/Clorida : 136/3.7/106

Compos mentis
Tensi : 92/62 mmHg
Nadi : 100 x/menit
Nafas : 24x /menit
Suhu : 38 C
SpO2 97% air room
Mata: Anemis tidak ada, ikterus tidak ada
JVP R+2 cmH20
Bunyi jantung I/II murni reguler, murmur tidak terdengar
Napas Vesikuler, ronkhi minimal dibasal bilateral ada, wheezing tidak ada
Edema ekstremitas tidak ada, akral teraba hangat