LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019

Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

Kamar Identitas Diagnosis Terapi Pem. Penunjang Keterangan

1 M.Alvin Ramadhan / Large VSD PMO + pulmonal - Pro open heart 21-01-19 Echo 21-01-2019
Lt 3 lk/ 7 bulan hipertensi + gagal jantung - Captoptril 2 x 12,5 mg - Atrial situs solitus
po Hb 13.1 Erit 5.18 leu 12.01 Ht 39 Trb 395 MCV
Kamar 1 661532/
- Furosemide 2 x 20 mg 75.7 MCH 25 MCHC 33 RDW CV 14.10 LED - AV-VA concordance
L : 3 September 2013
MRS : 21 Januari 2019
po 13 DC 0/738//48/7 PT INR 14.70 (K) / 14.3 (P) - Normal systemic and
INR 1.07 APTT 32.8 (K) / 34.1 (P) Besi 31.9
TIBC 356 SGOT 21 SGPT 13 Pro tot 7.7 Alb pulmonary venous
Pedamaran , OKI 4.5 Globulin 2.1 GDS 98 Ur 17 As Ur 5.7 Cr drainage
0.59 Ca 10 Phospor 5.8 Mg 2.10 Na 145 K 4.1
Cl 109 HbsAg Non reaktif Anti HCV non - Dilatated LA-LV
BB 33 kg
PB 132 m reactive Anti HCV Non Reactive - Mild Aorta Regurgitation
BB/U -3<Z-2 - Prolapse anterior aorta
PB/U -3<Z<-2 valve
BB/PB -2<Z<-1
- Mild Pulmonal
regurgitation
Balance Diuresis - No ASD seen
I - Large VSD PMO high type
O
IWL 70
8 mm L to R shunt
B - No PDA seen
D - Well contracting
ventricles, no paradoxical
A: rudi
I: yastati
movements
Hp : 085273677175 - LV systolic function EF
77.5 % FS 45.9 %
- Left aortic arch, no
coarctation of aorta seen
- No pericardial effusion
seen
Conlusion :
Large Ventricular Septal Defect
Perimembrane Outlet High Type +
Mild Aorta Regurgitation +
Prolapse anterior aorta valve +
Mild Pulmonal regurgitation

1
 LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019
Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

2 Adreena Naira Malika /PR/ PDA besar pro Ligasi PDA - Ampicilin 3x 400 mg (4) 18-01-19 11 Januari 2019
Lt 3 7 bulan - Ceftazidime 3x150mg (4)
Kamar 1 1091384/ RI 19001922 - Carbogliserin 4x1 tts AS Hb 10.5 Erit 4.49 leu 12.62 Ht 32 Trb 353 MCV - Atrial situs solitus
- Furosemide 2x5mg 71.9 MCH 23 MCHC 33 RDW CV 14.60 LED - AV-VA concordance
TL : 30 Juni 2018
- Captopril 2x2.5 mg 5 DC 0/5/14/75/6 PT INR 13.50 (K) / 15.3 (P) - Normal systemic and pulmonary
MRS : 18 Januari 2019 INR 1.17 APTT 31.6 (K) / 40 (P) Besi 39 TIBC venous drainage
357 SGOT 36 SGPT 12 Pro tot 6.5 Alb 4.5 - Dilated LA-LV
Pedamaran , OKI Globulin 2.1 GDS 72 Ur 17 As Ur 4.3 Cr 0.44 - AV and semilunar valves are normal
Ca 11 Phospor 5.5 Mg 2.4 Na 141 K 5.3 Cl 109 - No ASD seen
BB 5,6kg ferritin 15.60 HbsAg Non reaktif Anti HCV non - No VSD seen
PB 62cm reactive Anti HCV Non Reactive - PDA 8 mm Lto R shunt
- Well contracting ventricles, no
BB/U -3<Z-2
paradoxical movements
PB/U -3<Z<-2 - LV systolic function EF 69 %
BB/PB -2<Z<-1 FS 37 %
- Left aortic arch, no coarctation of
aorta seen
Balance Diuresis - No pericardial effusion seen
I
Kesan Large Patent ductus arteriosus
O
IWL 70 18 Januari 2018
B Ro Thorax
D Kardiomegali

A: M. Apriadi
I: Nita
Hp : 085367640180
3 Pinkan ramadhan/ 10 tahun Post VSD closure H 6 ai Large VSD -IVFD 50 % Kebutuhan cairan harian 18-01-19 November 9th 2018
Lt 2 / PR PMO, Mild MR , Mild TR, Mild PR , - aff infus  perbanyak minum Hb 12.1 Erit 4.34 Le 8.61 Ht 36 Trb 163 RDW - Situs solitus
1.1 250697/ RI 19001161 Moderate AR , Prolaps aorta valve + 100% kebutuhan cairan 1600cc/24 jam CV 13.7 DC 0/2/82/10/6 - AV-VA concordance
Gizi Kurang Furosemide 2x20mg IV - Normal systemic and pulmonary
TL : 31 Agustus 2008
Cefuroxime 3x450 mg IV (7) 15-1-19 venous drainage
MRS : 11 Januari 2019 Paracetamol fl 3x500mg IV Hb 9.8 RBC 3.36 WBC 16.91 Ht 28 PLT 178 - Dilated LA-LV
Furosemide 2x25 mg po DC 0/0/95/3/2 PT 15.9(P) INR 1.22 APTT 33.7 - Mild MR
Kertapati Palembang Paracetamol 3x500mg po (P) SGOT 73 SGPT 14 Alb 3.8 Asam urat 4.6 - Mild TR
Captopril 2x12,5mg (po) Creatinin 0.63 Ureum 24 Calcium 10 Phospor - Mild pulmonal regurgitation
BB: 25 kg Digoxin 2x 1 tab 3.8 Mg 3.5 Natrium 145 Kalium 3.6 Cl 113 - Moderate AR
TB:137cm Spironolakton 2x25mg - Prolaps aorta valve seen
Renc. Transfusi PRC 1x100cc bila darah 11-1-19 - Left aortic arch, no coarctation of
BB/U : p5
jadi masuk kurang input dari infus atau Hb 13.4 RBC 4.68 WBC 8.16 Ht 38 PLT 325 aorta seen
TB/U: p50 minum - Large VSD Perimembran outlet
MCV 8.4 MCHC 16 RDW-CV 12.69 LED 12
BB/TB : 25/33 =75.7 % 13.6 mm (L to R shunt)
Gol da O Rh + DC 0/8/48/38/6 CT BT menit
Kesan : - No PDA seen
PT 14.7(k)/ 13.5(P) INR 1.00 APTT 33.4 (K)/
Gizi Baik perawakan - No PFO seen
36.6 (P) SGOT 20 SGPT 10 Prot Tot 7.5 Alb 4.5 - No ASD seen
normal
Ret 2.3 Asam urat 5 Creatinin 0.61 Ureum 26 - Well-contracting ventricles
Calcium 10 Phospor 4.7 Mg 2.2 Natrium 144 LV systolic function normal EF
2
 LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019
Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

Persentil Tensi Kalium 3.7 Clorin 110 HbSAg non reaktif Anti- 77% FS45%
HCV non reaktif CRP < 5 Anti HIV non reaktif - No pericardial effusion seen
5P 91 53 GDS 103
50P 103 63 Conclusion : Large VSD PMO, Mild MR ,
90 P 114 72 Mild TR, Mild PR , Moderate AR , Prolaps
95 P 117 74
aorta valve
99P 123 78

Balance Diuresis
18.00 – 06.00
I
O
IWL 200
B
D
Ayah; Budiman
Ibu : Islamiah
Hp :082373508946
081373552056
4 Putri Aini /PR/8 bulan Decompensatio Cordis sedang ec VSD O2 nasal 1lpm 16 Januari 2019 16 januari 2019
Lt 2 1074381 / RI 19001697 besar + RD + Severely wasted Furosemid 2x3mg IV ECHO
1.4 TL: 2 Mei 2018 Aldacton 2x3.125 mg PO Hb 10 Erit 365 Leu 8.93 Ht 29 Trb 343 - Atrial situs solitus
MRS : 16 Januari 2018 Captopril 2x2 mg RDWCV 13.80 LED 16 DC 0/0/31/61/8 CRP < - AV-VA concordance
Ampicilin 2x120mg IV (6) - Normal systemic and pulmonary
5
Kertapati Palembang Gentamicin 2x10mg IV (6) venous drainage
Paracetamol 3x 2cc - Dilated LA-LV
- Mild Pulomnal regurgitation
BB 3.8kg Raber GIZI - No ASD seen
PB 62cm F75 12x 30cc - Large doubly commited VSD 8,7
BB/U : <-3sd mm Lto R shunt
PB/U -3< z< -2sd - Well contracting ventricles, no
BB/PB 3.8/ 6.4 = 59 % paradoxical movements
Kesan Gizi buruk - Left aortic arch, no coarctation of
perawakan pendek aorta seen
- No pericardial effusion seen
A Budi Cahyono Conclusion : Large VSD DCSA
I Nurlela
HP 085367640180 Mild Pumonal regurgitation

Balance Diuresis
I
O
IWL 47,5
B
D
5 Aidel Fitri / Perempuan / 13 Decomp Cordis NYHA IV ec TR - O2 NRM 10 lpm 18-01-19 15 Januari 2019
Lt 2 tahun moderate + PR moderate ec PDA besar - O2 2lpm nasal canule ECHO

3
 LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019
Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

1.5 1019313/RI 19001349 + Hipertensi Pulmonal + Gizi buruk + - Stopper Bt 1 Ct 9 PT 13.5 (K)/16.2 (P) INR 1.25 APTT - Atrial situs solitus
TL : 13 November 2005 delayed puberty + poor contractility + - Furosemid 2x20mg iv 31.6 (K) / 32.6 (P)INR 1.25 APTT 31.6 (K)/ - AV-VA concordance
MRS 14-01-19 Susp Cholestasis intra hepatic dd - Spirunolaktone 3x12,5mg 32.6 (P) Fibrinogen 312 (K) / 253 (P) D dimer - Normal systemic and pulmonary
extrahepatik - Captopril 2x12.5mg venous drainage
1.51 Ca 8 Na 125 K 3.4 Cl 86 T3 <0.4 FT4 1.53
Lahat Cholestasis intrahepatic - Sildenafil 4x10mg - Dilated pulmonary artery
- Dobutamine 5 TSH 3.36 - Balance four chambers
BB 20kg GEH : cmg/kgbw/minute - Moderate Tricuspid Regurgitation
TB 123cm Hepar membesar uk 15.03 tepi tumpul - Dobutamine 2,5 16-1-19 PG 30,5 mmHg
BB/U <p3 berdungkul-dungkul lien 10.5 normal cmg/kgbw/minute - Pulmonal regurgitation
TB/U <p3 pleural efusi kiri (+) , ginjal - Digoksin 2x 0.125 mg po Hb 10.8 Erit 5.70 Leu 8.35 Ht 34 Trb 239 - No ASD seen
BB/TB 86.9% hidronefrosis bilateral RDWCV 19.40 DC 0/2/72/15/11 ALP 124 AST - No VSD seen
Kesan : Gizi kurang Kesimpulan : Terapi GEH 78 ALT 56 GGT 163 Pro tot 5.6 Alb 3 Glob 2.6 - Large PDA seen
perawakan sangat pendek - Kemungkinan suatu proses - Urdafalk 4x 100mg - poorl contracting ventricles, no
Koles total 82 HDL 16 LDL 64 Trigliserid 48
sirosis hepatis paradoxical movements
Balance Diuresis - Tidak ditemukan hipertensi porta Ur 21 Cr 0.53 Ca 8 Fosfor 127 Na 127 K 2.9 - LV systolic function EF 35,9 %
18.00 – 06.00 - Penyebab kelainan jantung tidak Cl92 FS 16,4 %
I dapat disingkirkan - Left aortic arch, no coarctation of
O 13- 1-19 aorta seen
IWL 187.5 NPM Hb 11.7 Erit 6.24 Leu 8.81 ht 36 Plt 352 - No pericardial effusion seen
B Gizi buruk berdasarkan LILA RDWCV 19.60 LED 2 DC 0/0/64/24/12 Bil tot Kesan : Large PDA + Severe Pulmonary
D Saran : Diet NC 1.5 5x100 = 750 kkal hypertension + decreased LV systolic function
14.7 Bildirek 5.80 SGOT 131 SGPT 76 CRP 15
Susu F100 4x 100 = 400 kkal
Total 1150 kkal /hari
A Ersen Monitoring akseptabilitas, toleransi Urinalisa
I Hervi dan efikasi
HP 081377774162 Warna kuning pH 7 protein – Ascorbic acid –
Glukosa – keton – Bil – urobilinogen 2 Nitrit –
lekosit esterase – Sedimen Urin epitel + Lekosit
2-4 Eri 0-1 Silinder silinder hyaline + Kristal –
Bakteri + mucus – jamur -

6. Aqilah bt Asnawi /PR / 2 Large VSD perimembrane outlet O2 2 lpm 16-01-2019 14-01-2019
Lt 2 tahun 8 bulan extent to inlet + Large secundum ASD Captopril 2x3 mg Hb 13.1 Erit 4.22 Leu 18.15 Ht 39 Trb 370 ECHO
1.6 1012647/ RI 19001569 + Mild pulmonal stenosis Furosemide 2x7 mg IV MCV 92,9 MCH 31 MCHC 33 RDWCV 12 - Atrial situs solitus
Ampicilin 3x30 mg IV (5) LED 29 DC 0/1/44/47/8 - AV-VA concordance
TL : 27 April 2016
Gentamicin 2x20 mg IV (5) - Normal systemic and pulmonary
MRS : 15 Januari 2019 venous drainage
- Dilated LA-LV
Bukit Kecil Palembang Renc. Pulang, echo sebelum pulang - Mild pulmonal stenosis valvular PG
20
BB 7 kg - Large VSD perimembrane outlet
PB 68cm extent to inlet 10 mm, L to R shunt
- Large secundum ASD 24 mm, L to
A: Asnawi
R shunt
I : Badiah - No PDA seen
HP : 081278796933 - Well contracting ventricles, no
paradoxical movements
BB/U :7/13.1 <-3sd - Left aortic arch, no coarctation of
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 LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019
Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

PB/U : 68/ 92.2 <-3sd aorta seen

BB/PB : 7/7.7 -2 <z<-1 - No pericardial effusion seen

Ro Thorax
Balance Diuresis
Kardiomegali dengan bendungan paru
I
O
IWL 87.5
B
D
7 Bagas Al Akbar / 4 th / LK Post op VSD Closure H5 ai VSD Stopper 16-01-19 (14.50) 17 Januari 2019
Lt 1 901452 / RI 19001421 PMO besar + mild PH Kebutuhan cairan 100% -1450cc/24 jam ECHO
HCU TL 07 Januari 2015 Paracetamol 400mg/ 8 jam po Hb 13 Erit 4.63 Leu 20.33 Ht 38 Plt 146 RDW - Atrial situs solitus
MRS 14-01-19 Captopril 2 x 12.5 mg po CV 13.20 DC 0/1/71/22/6 PT 13.40 (K) / 16.2 - AV-VA concordance
Furosemid 2x20mg po - Normal systemic and pulmonary
(P) INR 1.25 APTT 31.6 (K)/ 41.4 (P)
Palembang Cefuroxime 3x320mg IV venous drainage
Fibrinogen 320 (K) / 195 (P) D dimer 0.32 - Mild dilated LA-LV
BB 19kg SGOT 92 SGPT 50 Alb 40 GDS 282 ur 21 as.ur - Mild Tricuspid Regurgitation
TB 107cm 4.0 Cr 0.59 Ca 10.0 Phospor 5.1 Mg 2.50 Na 144 - Trivial Pulmonal Regurgitation
BB/U 1SD<Z<2SD K 4.2 Cl 112 - Trivial Aorta Regurgitation
TB/U 0 SD<Z<2SD - No ASD seen
BB/TB 1SD AGD - Large VSD PMO 12 mm PG trans
Kesan : Gizi baik VSD 63,6 mmHg
Perawakan Normal - PDA ?
FIO2 60 Ph 7,281 pCO2 45.2 pO2 271.2 SO2 - Well contracting ventricles, no
A: Sugeng Pramugari 99.9% Hct 38 Hb 12.6 Na 141.5 Ca 1.24 K 3.98 paradoxical movements
I : Dessi laktat 4.3 pHtc 7.282 pCO2tc 45 pO2tc 270.7 - LV systolic function EF 62,1 %
HP : 081368773313 TCO2 22.8 HCO3 21.5 BEecf -5.5 BEb -4.6 FS 32,6 %
SBC 20.6 O2CT 18.4 RI 0.4 O2cap 17.6 A 372.3 - Left aortic arch, no coarctation of
I aorta seen
O - No pericardial effusion seen
12.41
IWL 181.25 Conclusion : Large perimembrane outlet
B ventricular septal defect + Mild pulmonary
D Ca 12 phospor 3.9 Mg 2.60 Na 140 K 4 Cl 113 hypertension + PDA ?

15-01-19 Ro Thorax
Kardiomegali CTR >50%, corakan vascular
Hb 12 RBC 4.46 WBC 11.01 Ht 35 PLT 299 meningkat
MCV 78 MCHC 35 RDW-CV 13.10 LED 8Gol
15 November 2018
da B Rh +DC 0/4/48/40/8CT BT 1.5 menit PT
13.7(k)/ 13.6(P) INR 1.01 APTT 30.2 (K)/ 32
(P) SGOT 44 SGPT 91Prot Tot 6.7Alb 4.3 Asam - Situs solitus
urat 2.7 Creatinin 0.51 Ureum 28 Calcium 10 - AV-VA concordance
- Mild dilated LA LV
Phospor 6.2 Mg 2.10 Natrium 144 Kalium 4.7
- Normal systemic and pulmonary
Clorin 110 HbSAg non reaktif Anti-HCV non venous drainage
reaktif CRP < 5 Anti HIV non reaktif GDS 91 - Mild PR
- Mild TR (PG 25 mmHg)
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 LAPORAN HARIAN KARDIOLOGI PERIODE JANUARI 2018 Selasa 22-01-2019
Junior : dr. Nurmega Kurnia, dr. Tessa Rulianty;Madya : dr. Ari FibriantoSenior : dr. Teti Hendrayani, dr. Febrialita

ECG - No ASD seen

- Small PDA ? ( tidak tervisualisasi
HR 100 x/menit, sinus rhytm , aksis normal, dengan baik)
Kuadran II 600 P pulmonal (-), P mitral (-) , PR - Large VSD perimembranous outlet
9.5mm with MSA, (L to R shunt)
interval 0,08 sec , LVH +
- Mild Dilated pulmonary artery
- Left aortic arch, no coarctation of
aorta seen
- Well-contracting ventricles
- LV systolic function EF FS
- No pericardial effusion seen
Conclusion : Large perimembran outlet VSD
with MSA

Mild pulmonal hypertension

17 Januari 2019
8 Faiqah/ pr / 1 bulan ECHO
Lt 3 1102974 Double outlet right ventrikel + large Furosemid 2 x 20 mg 17- 1-19 - Atrial situs solitus
subaortic venrikular septal defect + Aldactone 2 x 3.125 mg Hb 8.8 eri 2.56 leu 7.93 ht 25 tro 426 mcv 96.1 - AV concordance, VA discordance
Kamar 9 TL : 18 des 2018
mild pulmonal stenosis + malposition - Normal systemic and pulmonary
Mrs : 17 jan 2019 mch 34 mchv 36 led 2 dc 0/15/20/52/13 feritin
great artery +persistent foramen ovale venous drainage
104 uibc 60 serum iron 104 tibc 164 - Aorta and pulmonary artery arise
Alamat : Palembang from right ventricle
BB : 2.1 kg Gdt : anemia normositik normokromik + - Aorta more anterior from
Pb : 43 cm tersangka proses infeksi + inflamasi + pulmonary artery
Status gizi : gizi kurang hipersensitivitas - Aorta and pulmonary artery side by
side
- Dilated RA-RV
Saran : followup fungsi hati, feces rutin, CRP
- Mild Pulmonal stenosis
- PFO 4,8 mm
- Large subaortic VSD (R to L shunt)
- No PDA seen
- Well contracting ventricles, no
paradoxical movements
- Right aortic arch, no coarctation of
aorta seen
- No pericardial effusion seen
Conclusion : Double outlet right ventricle +
large subaortic ventricular septal defect + mild
pulmonal stenosis + malposition great artery +
persistent foramen ovale