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    Tanggal Subyektif Objektif Assessment Terapi/Planning

    Uploaded by

    Melia Tiarani
    - The patient presented with decreasing chest pain. On examination, the patient was alert and oriented with a blood pressure of 120/70 mmHg, heart rate of 119 beats/minute, and respiratory rate of 30 breaths/minute. - The patient was diagnosed with an acute anteroinferior STEMI, late onset, TIMI score of 5/14, KILLIP class II, Grace score of 109 without revascularization and type 2 diabetes. - Treatment included bed rest, oxygen supplementation, medications, insulin therapy, and monitoring of glucose and vital signs. The patient's chest pain had greatly decreased and cough was mildly painful.

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    Tanggal Subyektif Objektif Assessment Terapi/Planning

    Uploaded by

    Melia Tiarani
    15 views5 pages
    - The patient presented with decreasing chest pain. On examination, the patient was alert and oriented with a blood pressure of 120/70 mmHg, heart rate of 119 beats/minute, and respiratory rate of 30 breaths/minute. - The patient was diagnosed with an acute anteroinferior STEMI, late onset, TIMI score of 5/14, KILLIP class II, Grace score of 109 without revascularization and type 2 diabetes. - Treatment included bed rest, oxygen supplementation, medications, insulin therapy, and monitoring of glucose and vital signs. The patient's chest pain had greatly decreased and cough was mildly painful.

    Original Description:

    follow up

    Original Title

    Follow Up Harian

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    - The patient presented with decreasing chest pain. On examination, the patient was alert and oriented with a blood pressure of 120/70 mmHg, heart rate of 119 beats/minute, and respiratory rate of 30 breaths/minute. - The patient was diagnosed with an acute anteroinferior STEMI, late onset, TIMI score of 5/14, KILLIP class II, Grace score of 109 without revascularization and type 2 diabetes. - Treatment included bed rest, oxygen supplementation, medications, insulin therapy, and monitoring of glucose and vital signs. The patient's chest pain had greatly decreased and cough was mildly painful.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    15 views5 pages

    Tanggal Subyektif Objektif Assessment Terapi/Planning

    Uploaded by

    Melia Tiarani
    - The patient presented with decreasing chest pain. On examination, the patient was alert and oriented with a blood pressure of 120/70 mmHg, heart rate of 119 beats/minute, and respiratory rate of 30 breaths/minute. - The patient was diagnosed with an acute anteroinferior STEMI, late onset, TIMI score of 5/14, KILLIP class II, Grace score of 109 without revascularization and type 2 diabetes. - Treatment included bed rest, oxygen supplementation, medications, insulin therapy, and monitoring of glucose and vital signs. The patient's chest pain had greatly decreased and cough was mildly painful.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 5

    Tanggal

    27/11/2012

    Subyektif
    Nyeri dada berkurang

    Objektif

    Assessment

    Terapi/Planning

    Kes

    : Compos mentis

    Acute STEMI anteroinferior Th/

    H1

    TD

    : 120/80mmHg

    Late onset TIMI score 5/14 - Bed rest semi fowler

    (03.00)

    HR

    : 82 x/menit

    KILIP II Grace score 109 - Diet jantung 2

    RR

    : 24x/ menit

    tanpa revaskularisasi

    Suhu
    Mata

    : Afebris
    : Cekung (-/-)
    Konj.pct (-/-)
    Sklera ikt (-/-)

    -O2 2-4 liter (nasal kanul)


    -IVFD RL 8gtt/i
    -Injeksi Arixtra 1x0,25cc/24 jam
    -Inj. Morfin 2 mg
    -Clopidogrel 1x75 mg
    -Tablet Simvastatin 40 mg 1x1

    Telinga : Serumen (-)

    oral (malam)

    Hidung : Sekret (-)

    -Dulcolax syrup 3xCI

    NCH (-)
    Mulut : Bibir: pucat(-)
    sianosis (-)

    -Tablet Aspilet 80 mg 1x1 oral


    - Captopril 3x6,25 mg
    -Alprazolam 1x0,25 mg

    leher : TVJ R-2cmH2O

    - Drip Cedocard

    Thorax : Simetris (+)

    *lasix 2 amp(extra) pukul 12.30,

    Retraksi (-)

    selanjutnya 2x1 amp

    sonor (+,+)
    ronki basal (+)
    Vesikuler (+,+)

    P/

    Wh (-/-),

    creatinin/KGDN/2JPP

    Jantung : BJ 1 > BJ II,


    reguler, bising (-)

    darah

    rutin/ureum-

    - Urinalisa
    - Foto toraks AP (menunggu
    hasil)

    34

    Abdomen : simetris (+)

    Distensi (-)

    kreatinin<2)

    Peristaltik (+)

    - Pasang cateter

    HbA1c

    (jika

    Hb>10,

    hepar/lien/renal tidak teraba.


    Ekstremitas: Udem (-/-)
    Sianosis (-/-)

    28/11/2012
    Hr-2

    Nyeri dada mulai berkurang

    Kes

    : composmentis

    Acute STEMI anteroinferior Th/

    TD

    : 90/60mmHg

    late onset

    Nadi

    : 104 x/menit

    KILLIP II, Grace score 109 - Diet Jantung 2

    TIMI score 6, - Bed rest semi fowler

    HR: x/menit

    tanpa revaskulasirasi.

    - O2 2-4 liter (nasal kanul)

    RR

    + DM tipe 2

    - IVFD RL 8gtt/i

    : 27x/ menit
    : 36,50C

    Suhu
    Mata

    : Cekung (-/-)
    Konj.pct (-/-)
    Sklera ikt (-/-)

    -Injeksi Arixtra 1x0,25cc/24 jam


    - Clopidogrel 1x75 mg
    - Tablet Simvastatin 40 mg 1x1
    oral (malam)

    Telinga : Serumen (-)

    - Dulcolax syrup 3xCI

    Hidung : Sekret (-)

    -Tablet Aspilet 80 mg 1x1 oral

    NCH (-)

    - Captopril 3x6,25 mg

    Mulut : Bibir pucat(-)

    -Alprazolam 1x0,25 mg

    sianosis (-)

    - ISDN 3x5 mg

    Leher : TVJ R-2cmH2O

    Thorax : Simetris (+)

    (sebelum makan)

    Inj.

    Novorapid

    8-8-8

    IV

    35

    Retraksi (-)

    - Drip Insulin 2cc/jam

    Sonor di kedua lapangan

    * Cek GDS tiap 2 jam

    paru,

    Vesikuler di kedua lapangan

    mmHg

    Pertahankan GD

    190-180

    paru, ronki basah basal,


    Wh (-/-),
    P/
    Jantung : BJ 1 > BJ II,
    reguler, bising (-)

    Early PCI
    Konsul Poli endokrin (Sudah)
    Echo (sudah)
    Cek elektrolit/ 3 hari

    Abdomen : simetris (+)


    Distensi (-)
    Peristaltik (+)
    nyeri tekan (-)
    H/L/R : Tidak teraba
    Ekstremitas: Udem (-/-)
    Sianosis (-)

    36

    29/11/ 2012

    -Ketika batuk terasa sedikit

    Kes

    : composmentis

    Acute

    H-3

    sakit

    TD

    : 120/70mmHg

    anteroinferior late onset Th/

    : 119 x/menit

    TIMI score 5/14, KILLIP - Bed rest semi fowler

    -Nyeri
    berkurang

    dada

    sangat Nadi

    STEMI

    HR: x/menit

    II, Grace score 109 tanpa - Diet Jantung 2

    RR

    revaskulasirasi + DM tipe - O2 2-4 liter (nasal kanul)

    : 30 x/ menit

    Suhu
    Mata

    : afebris

    : Cekung (-/-)
    -/-

    Konj.pct ( )
    Sklera ikt (-/-)

    - IVFD RL 8gtt/i
    -Injeksi Arixtra 1x0,25cc/24
    jam
    - Clopidogrel 1x75 mg

    Telinga : Serumen (-)

    - Tablet Simvastatin 40 mg

    Hidung : Sekret (-)

    1x1 oral (malam)

    NCH (-)

    - Dulcolax syrup 3xCI

    Mulut : Bibir pucat(-)

    -Tablet Aspilet 80 mg 1x1

    sianosis (-)

    oral

    Leher : TVJ R-2cmH2O

    - Captopril 3x6,25 mg

    Thorax : Simetris (+)

    -Alprazolam 1x0,25 mg (jika

    Retraksi (-)

    perlu)

    Sonor di kedua lapangan

    - Inj. Novorapid 8-8-8 IV

    paru,

    (sebelum makan)

    Vesikuler di kedua lapangan

    - Inj. Lovemir 0-0-14

    paru, ronki basah basal,

    * Pertahankan GD 190-180

    Wh (-/-),

    mmHg

    Jantung : BJ 1 > BJ II,

    37

    reguler, bising (-)

    P/
    - Cek GDS tiap 2 jam

    Abdomen : simetris (+)


    Distensi (-)
    Peristaltik (+)
    nyeri tekan (-)
    H/L/R : Tidak teraba
    Ekstremitas: Udem (-/-)
    Sianosis (-/-)

    38

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