2
7/25/2019 CATATAN KEMAJUAN http://slidepdf.com/reader/full/catatan-kemajuan 1/2 CATATAN KEMAJUAN TGL PROBLEM SUBYEKTIF OBYEKTIF PX PENUNJANG TERAPI 0 6- 01 -2 01 6 1.CHF NYHA III 2. Ischaemic whole wall 3.Pneumonia CURB 6! 0 ". #$ us i %l eu &a 'u%le(s .Hi%o(alsemi 6.)assa %a&u *. +us%e( P,I i'a( +esa( i'a( ne&i 'a'a BAB su'ah /U lemah /esa'a&an Com%osmenis 120 40 mmH5  N *0 meni7 &e57 i cu(u% RR 20 meni 367 °  C Peme&i(saan Fisi( 8ehe& ,P R92cm Co& (on$i5u&asi :anun5 ;e&5ese& (e (au'olae&al Pulmo +< menu&un %a'a ;asal  %a&u A;'omen ';n #(s&imias in$e&io& oe'em =--> Hematologi 2!2"!# $ H; 1174 5&? @ H 372? #&i&osi 716 :mm( )CH 2370 %5 @ )C *70 $l @ <+ 160 m5'l U&eum 30 /&eainin 074 La%o&at'&i'm #!2"!# <12 4126 EKG "#!2"!#$ Ischaemic whole wall 1. 2 le%as %asan5 2 lie&meni 2. <ie luna( 100 ((al7 )P 1ha&i 3. IF< <? 10 eesmeni ". Fu&osemi'e 20m512 :am iD . 8isino%&il 27 m52" :am %o 6. I+<N 10 m54 :am %o *. Clo%i'o5&el * m52" :am %o 4. <i5oin 07123 m52" :am %o . +%ino&ola(on 2 m52" :am %o 10. In:.ce$&iaon 1 2 5& i.D. 11. Ca C3 00 m52" :am 12. Asam $ola 1000m512 :am P&o5&am Ra;e& /a&'iolo5i #choca&'io5&a%h #/ %a5i +%uum BA 3. 57 :amu& Usul ele(&oli7 Ca7 )5 U&in &uin 0 * - 01 -2 01 6 1.CHF NYHA II- III 2.Ischaemic whole wall 3.Pneumonia CURB 6!0 ". #$ us i %l eu &a 'u%le(s .hi%o(alsemi 6..massa %a&u *.sus%e( P,I i'a( +esa(  i'a( Ne&i  %e&u /U lemah /esa'a&an Com%osmenis 120 60 mmH5  N *2 meni7 &e57 i cu(u% RR 20 meni 367 °  C Peme&i(saan Fisi( 8ehe& ,P R92cm Co& (on$i5u&asi :anun5 ;e&5ese& (e (au'olae&al Pulmo +< menu&un %a'a ;asal  %a&u A;'omen';n #(s&imias in$e&io& oe'em =--> EKG (!2"!# $ Ischaemic whole wall elah 'ila(u(an  %eme&i(saan echoca&'io5&a%h %u(ul 1".00 1. <ie luna( 100 ((al7 )P 1ha&i 2. IF< <? 10 eesmeni 3. Fu&osemi'e 20m512 :am iD ". 8isino%&il 27 m52" :am %o . I+<N 10 m54 :am %o 6. Clo%i'o5&el * m52" :am %o *. <i5oin 07123 m52" :am %o 4. +%ino&ola(on 2 m52" :am %o . In:.ce$&iaon 1 2 5& i.D. 10. Ca C3 00 m52" :am 11. Asam $ola 1000m512 :am P&o5&am un55u hasil echoca&'io5&a%h7 #/ %a5i7 +%uum BA 37 5&7 :amu&7 u&in &uin

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Page 1: CATATAN  KEMAJUAN

7/25/2019 CATATAN KEMAJUAN

http://slidepdf.com/reader/full/catatan-kemajuan 1/2

CATATAN KEMAJUAN

TGL PROBLEM SUBYEKTIF OBYEKTIF PX PENUNJANG TERAPI

06-01-2016 1.CHF NYHA III

2. Ischaemic wholewall

3.Pneumonia

CURB 6! 0

".#$usi %leu&a

'u%le(s

.Hi%o(alsemi

6.)assa %a&u

*. +us%e( P,I

i'a( +esa( 

i'a( ne&i'a'a

BAB su'ah

/U lemah

/esa'a&anCom%osmenis

120 40 mmH5

 N *0 meni7 &e57 i cu(u%

RR 20 meni

367 ° C

Peme&i(saan Fisi(

8ehe& ,P R92cm

Co& (on$i5u&asi :anun5 ;e&5ese& 

(e (au'olae&al

Pulmo +< menu&un %a'a ;asal

 %a&u

A;'omen ';n

#(s&imias in$e&io& oe'em =-->

Hematologi 2!2"!# $

H; 1174 5&? @H 372?

#&i&osi 716 :mm(

)CH 2370 %5 @

)C *70 $l @<+ 160 m5'l

U&eum 30

/&eainin 074

La%o&at'&i'm #!2"!#

<12 4126

EKG "#!2"!#$

Ischaemic whole wall

1. 2 le%as %asan5 2 lie&meni2. <ie luna( 100 ((al7 )P 1ha&i

3. IF< <? 10 eesmeni

". Fu&osemi'e 20m512 :am iD

. 8isino%&il 27 m52" :am %o

6. I+<N 10 m54 :am %o

*. Clo%i'o5&el * m52" :am %o

4. <i5oin 07123 m52" :am %o

. +%ino&ola(on 2 m52" :am %o

10. In:.ce$&iaon 1 2 5& i.D.

11. Ca C3 00 m52" :am

12. Asam $ola 1000m512 :am

P&o5&am Ra;e& /a&'iolo5i#choca&'io5&a%h

#/ %a5i

+%uum BA 3. 57 :amu& 

Usul ele(&oli7 Ca7 )5

U&in &uin

0* -01-2016 1.CHF NYHA II-

III

2.Ischaemic whole

wall

3.Pneumonia

CURB 6!0".#$usi %leu&a

'u%le(s

.hi%o(alsemi

6..massa %a&u

*.sus%e( P,I

i'a( +esa( 

  i'a( Ne&i

 %e&u

/U lemah

/esa'a&an

Com%osmenis

120 60 mmH5

 N *2 meni7 &e57 i cu(u%RR 20 meni

367 ° C

Peme&i(saan Fisi(

8ehe& ,P R92cm

Co& (on$i5u&asi :anun5 ;e&5ese& 

(e (au'olae&al

Pulmo +< menu&un %a'a ;asal

 %a&u

A;'omen';n

#(s&imias in$e&io& oe'em =-->

EKG (!2"!# $ Ischaemic

whole wall

elah 'ila(u(an

 %eme&i(saan

echoca&'io5&a%h %u(ul1".00

1. <ie luna( 100 ((al7 )P 1ha&i

2. IF< <? 10 eesmeni

3. Fu&osemi'e 20m512 :am iD

". 8isino%&il 27 m52" :am %o

. I+<N 10 m54 :am %o6. Clo%i'o5&el * m52" :am %o

*. <i5oin 07123 m52" :am %o

4. +%ino&ola(on 2 m52" :am %o

. In:.ce$&iaon 1 2 5& i.D.

10. Ca C3 00 m52" :am

11. Asam $ola 1000m512 :am

P&o5&am un55u hasil echoca&'io5&a%h7

#/ %a5i7 +%uum BA 37 5&7 :amu&7 u&in

&uin

Page 2: CATATAN  KEMAJUAN

7/25/2019 CATATAN KEMAJUAN

http://slidepdf.com/reader/full/catatan-kemajuan 2/2

TGL PROBLEM SUBYEKTIF OBYEKTIF PX PENUNJANG TERAPI

04 -01-2016 1.CHF NYHA II-

III

2.Ischaemic whole

wall

3.PneumoniaCURB 6!0

".#$usi %leu&a

'u%le(s

.hi%o(alsemi

6..massa %a&u

*.sus%e( P,I

i'a( sesa( 

i'a( ne&i

'a'a

/U lemah

/esa'a&an Com%osmenis

12060 mmH5

 N *0 meniRR 20 meni

3674° C

Peme&i(saan Fisi(

8ehe& ,P R92cm

Co& (on$i5u&asi :anun5 ;e&5ese& 

(e (au'olae&al

Pulmo +< menu&un %a'a ;asal

 %a&u

A;'omen';n

#(s&imias in$e&io& oe'em =-->

U&i) R'ti) (!2"!# $

+e'imen e%iel u;ulus 9

oDal $a; ;o'ies

#&i&osi "0-" =9>

Ca oalae =9>

1. <ie luna( 100 ((al7 )P 1ha&i

2. IF< <? 10 eesmeni

3. Fu&osemi'e 20m512 :am iDEusul 5ani

o&al "0 m52" :am

". 8isino%&il 27 m52" :am %o. I+<N 10 m54 :am %o

6. Clo%i'o5&el * m52" :am %o

*. <i5oin 07123 m52" :am %o

4. +%ino&ola(on 2 m52" :am %o

. In:.ce$&iaon 1 2 5& i.D.E usul so%

10. Ca C3 00 m52" :am

11. Asam $ola 1000m52" :am

0 -01-2016 1.CHF NYHA II-III

2.Ischaemic whole

wall

3.Pneumonia

CURB 6!0

".#$usi %leu&a

'u%le(s

.hi%o(alsemi

6..massa %a&u

*.sus%e( P,I

i'a( sesa( i'a( ne&i

'a'a

/U ;ai( /esa'a&an Com%osmenis

12060 mmH5

 N *0 meni

RR 22 meni

3674° C

Peme&i(saan Fisi(

8ehe& ,P R92cm

Co& (on$i5u&asi :anun5 ;e&5ese& 

(e (au'olae&al

Pulmo +< menu&un %a'a ;asal %a&u

A;'omen';n

#(s&imias in$e&io& oe'em =-->

ACC PU8AN