Tn. Bambang /55 years old dr. iqbal, Sp.

jp
Diagnose: NSTEMI, HHD, Atrial Flutter

On September 25th, the patient was admitted to emergency room with shortness of breath and
cold sweat. The previous past illness were Coronary Artery Disease and uncontrolled
Hypertension. From the physical examination : The vital sign : Blood pressure was 180/120
mmHg, heart rate was 92 beats per-minute, respiratory rate was 18 breaths per-minute,
temperature was 35oC, Spo2 was 98%. Based on ECG result, Atrial Flutter. Blood test result:
creatinin was 2.0, Troponin T was high 0.106. From the chest xray result :
Today the GCS is E4 M6 V5 , _15_____.
Vital signs are:
BP:
HR:
RR:
Temperature:
Oxygen saturation:

The fluid balance is:

The input:
The urine output:

The patient theraphy :

- IVFD RL 5 drops perminute
- Cedocard drips 8mg/hour
- Tromboaspilet 80mg once daily
- Clopidogrel 75mg once daily
- Lasix tab once daily
- Digoxin twice daily
- Amlodipine 10mg once daily
- Captopril 25mg twice daily
- V-Block (B-blocker) 6,25mg once daily
Todays plan is :
Tn. Nazaruddin/57 years old dr. iqbal, Sp.jp
Diagnose: CAD, HHD, Post PCI

On September 25th, the patient was admitted to ICU with post Primary Coronary Intervention.
The previous past illness were Coronary Artery Disease and Dislipidemia. From the physical
examination : The vital sign : Blood pressure was 140/80 mmHg, heart rate was 84 beats per-
minute, respiratory rate was 18 breaths per-minute, temperature was 36.3oC. Based on ECG
result (before the patient got PCI) there was ST elevation on lead II, lead V2-V4. Blood test
result: the thrombocyte level 134, calcium level slightly decrease 1.096. From the chest xray
result :
Today the GCS is E4 M6 V5 , _15_____.
Vital signs are:
BP:
HR:
RR:
Temperature:
Oxygen saturation:
The ECG :
The fluid balance is :
The input :
The urine output :

The patient theraphy :

- IVFD RL 5 drops perminute
- Aspilet 80mg once daily
- Vaclo 75mg once daily
- Nevodio (B-Blocker>> Nebivolol) half dosage once daily
- Miozidine (trimetazidine) twice daily
- Stator 20mg once daily
- Car-Q once daily
- Tensivask (CCB-Amlodipine) 15mg once daily
Todays plan is :
Tn. Ki Agus/58 years old dr. iqbal, Sp.jp
Diagnose: STEMI Anteroseptal

On September 26th, the patient was admitted to emergency room with chest pain during
inspiration. The patient also complained about bloated and cold sweat. The patient was reffered
from RS PKT Bontang with STEMI Anteroseptal post Failed Fibrinolytic. There is no history of
previous past ilness. From the physical examination : The vital sign : Blood pressure was 129/62
mmHg, heart rate was 95 beats per-minute, respiratory rate was 20 breaths per-minute,
temperature was 36.5oC. Based on ECG result, there is ST elevation on lead V1-V5. Blood test
result: Leucosyte is high 15.89, LFT (SGPT 71, SGOT 355), CK-MB is high 137.3, Troponin T
is positif 4.79. From the chest xray result : Enlargement of the heart.
Today the GCS is E4 M6 V5 , _15_____.
Vital signs are:
BP:
HR:
RR:
Temperature:
Oxygen saturation:
The fluid balance is:
The input:
The urine output:

The patient theraphy :

- IVFD RL 5 drops perminute
- Lovenox 0.6 cc twice daily/subcutan
- Tromboaspilet 80mg once daily
- Clopidogrel 75mg once daily
- Captopril 25mg twice daily
- Furosemide tab once daily
- Amlodipine 10mg once daily
- Concor 2.5mg once daily (B-Blocker >>> Bisoprolol)
- ISDN 5mg
Todays plan is :
By. M. Aqeel/23 days old dr. Bambang, sp.A and dr. Subagyo, sp.P
Diagnosis: Bronchopneumonia, Pulmonary Tuberculosis

On September 20th, the patient was admitted to emergency room with fever and sound grook if
the baby was breathing. Physical examination result: there was nostril breath with sign of chest
retraction, there was ronchi in both lungs. Vital sign was HR 140 beats per minute, RR 50
breaths per minute, temperature 38.5oC, SpO2 57%.
Blood test result 26 th: Hb decrease 13.3, Leukosit decrease 8.73 from (20/9), trombocyt high
615
Blood gas analysis : respiratory acidosis
From the chest xray result : Bilateral bronchopneumonia

Today the vital signs are:

HR:
RR:
Temperature:
Oxygen saturation:
The fluid balance is:
The input:
The urine output:

The patient theraphy :

- IVFD D5% NS 16cc/hour
- Sanmol drips 1cc/hour
- Garamycin injection 7.5mg twice daily
- Meropenem injection 87.5mg twice daily
- Fluconazole injection 20mg once daily
- Cortidex injection 4 times daily
- Inhalation : Pumicort + NaCl 4 times daily
- Pro TB Paed once daily
- Breast milk mg/hour

Todays plan : wait for the blood culture result