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201820401011131 Rafdian Janitra Hadi
• Conclusion
• Cardiomegaly
Laboratory Finding
Hematocrit 39.7 % 40 – 47 %
MCV 89.0 fL 80 – 93 fL
MCH 29.8 pg 27 – 31 pg
Planning Therapy :
Bedrest
O2 NC 2-4 lpm
Infus PZ 0.9 % 500 cc/24 hour
Inj. Diltiazem 0,25mg/kg in 2 minutes
Inj. Furosemid 3x1 ampul (10mg/ml).6cc SC
Peroral :
Telmisartan 1x80mg
Clopidogrel 1x75 mg
Spironolakton 1x25 mg
Risk factors
Physical Examination
BP 202/115 mmHg HR 100 bpm regular RR 24 tpm SpO2 97 % on O2
nasal canul 4 lpm
General appearance looked moderately ill GCS 456 VAS 1/10
Lung: Symmetric Rh - - Wh - -
- - - -
- - - -
Abdomen soefl, shifting dullness (-), epigastric tenderness (-), normal bowel
sound
Extremities Edema - -
- -
Therapy ICU
• PZ 7 TPM
• Inj. Herbesser 0,25 mg/kg in 2 minutes, continued
pump 5 mg/hr.
• Inj. Ranitidine 2 x 1 (IV)
• Inj. Furosemide inj. 3x1 (IV)
• Clopidrogel 1x75 mg (P.O)
• Spirolonacton 1x25mg (P.O)
• Micordis 1 x 80 mg (P.O)
Condition the of duty
• S: heart palpitation (-), chest discomfort subsided
• O:
• BP 186/123 mmHg
• HR 135 bpm
• RR 30 x/min
• Tax 37.1 degrees C
• SpO2 99 % NC 4 lpm
• Urine output : 100 ml/h
Condition this morning
• S: chest pain (-), chest discomfort subsided
• O:
• BP 150/85 mmHg
• HR 80 bpm
• RR 17 x/min
• Tax 36.9 degrees C
• SpO2 99 NC 4 lpm
• Urine output 1500 ml/ 24h
ECG this morning
THANKYOU
GRACE
Score 63