Tanggal S O A P

1. H1 24/05/2018 Sesak nafas T:120/70 mmHg CHF Planning therapy

MRS (+), kaki dan N : 132 x/mnt  O2 NC 2lpm
perut S : 38,0oC  Parenteral
membengkak RR: 42x/mnt • Furosemid 1 amp
, BAB cair 4x K/L: dyspneu + • Antrain 1 ampl
Thorax:  Oral:
Cor: irama Irreguler • Ramipril 1,25mg
Pulmo: Rh : +/+ • Lodia 2 tab
Abdo: shifting
dullness + Co- dr. Wiwit.,
Extremitas: Sp.PD:
Edema - - IVFD RL 15tpm
+ + Inj. Ceftriaxone 2x1gr
Inj.
Ondancetron/8jam
Inj. Ranitidin /12jam
PO.Lodia 2 tab
2. H2 25/05/2018 Sesak T:110/70 mmHg CHF Planning therapy
MRS nafas (+), N : 94 x/mnt  Infus D5% 7 tpm
kaki masih S : 36,6oC  Parenteral
bengkak, RR: 24x/mnt • Furosemid 2-2-0
diare 2x K/L: JVP me↑ amp
Thorax: • Inj. Ceftriaxone
Cor: irama Irreguler 2x1gr
Pulmo: Rh : +/+ • Inj. Ondancetron
Abdo: shifting k/p
dullness + • Inj. Ranitidin k/p
Extremitas:  Oral:
Edema + + • KSR 1-0-1
+ + • Valsartan 80mg 0-
0-1
3. H3 26/5/2018 Sesak nafas TD:100/70mmHg Planning therapy
MRS (+), kedua N : 90 x/mnt  venflon
Hasil Lab: kaki masih RR: 28x/menit  Parenteral
Albumin: bengkak, S : 36,0 oC • Furosemid 2-2-0
1.1 gr/dl K/L: JVP me↑ amp
Thorax: • Inj. Ceftriaxone
Cor:irama Irreguler 2x1gr
M(-) G(-) • Inj. Ondancetron
Pulmo: Rh : + /+ k/p
Abdo: shifting • Inj. Ranitidin k/p
dullness +  Oral:
Extremitas: • KSR 1-0-1
Edema + + • Valsartan 80mg 0-
+ + 0-1
Berkurang  Konsul Jantung

4. H4 27/5/2018 Sesak nafas TD:100/60mmHg CHF Planning therapy

MRS berkurang, N : 92 x/mnt  venflon
kedua kaki RR: 24 x/mnt  Parenteral
masih S : 36,5 oC • Furosemid 2-2-0
bengkak, K/L: JVP me↑ amp
Thorax: • Inj. Ceftriaxone
Cor: irama Irreguler 2x1gr
Pulmo: Rh : + /+ • Inj. Ondancetron
Abdo: shifting k/p
dullness + • Inj. Ranitidin k/p
Extremitas:  Oral:
Edema - - • KSR 1-0-1
+ + • Valsartan 80mg 0-
0-1
 Konsul Jantung

5. H5 28/5/2018 Sesak nafas TD:110/60mmHg 1.CHF e.c Planning therapy

MRS (+), kedua N : 96 x/mnt HHD  venflon
kaki masih RR: 28 x/mnt 2.AF  Parenteral
bengkak, S : 36,8 oC paroksis • Inj. Ceftriaxone
K/L: mal 2x1gr
exopthalmus+/+ 3. • Inj. Ondancetron
Struma: + Hipoalbu k/p
JVP me↑ min • Inj. Ranitidin k/p
Thorax: • Furosemide 5 amp
Cor: :irama +NaCl 0,9%
Irreguler, M(-) G(-) 50cc/24 jam SP
Pulmo: Rh : + /+  Oral:
15.11 Abdo: shifting • KSR 1-0-1
WITA dullness • Valsartan 80mg 0-
+Extremitas: 0-1
Edema - - • Bisoprolol 5mg
+ + 1x1

 Cek Lab. FT4 dan

TSHs

 Advice dr. Putri.,

Sp.JP: (15.11
WITA)
• Inj. Furosemide
extra 2 amp IV
maintenance
5mg/jam SP
• PO.Spironolacton
25mg 0-1-0
• PO Digoxin
0.25mg 0-1/2-0

• Transfusi Albumin
 20% 50cc
• Diet ekstra putih
telur 3x3 biji
• Pro echo 2/6/2018

 Advice dr.Wiwit,
Sp.PD :
Hari ini 5 amp
lasix/24jam lanjut
3amp/24jam.
Terapi lain Acc
6. H6 29/05/2018 Sesak (+) TD:120/80mmHg 1.CHF e.c  Planning therapy
MRS berkurang N : 90 x/mnt HHD venflon
RR: 22 x/mnt 2.AF  Parenteral
S : 36,8 oC paroksis • Inj. Ceftriaxone
K/L: mal 2x1gr
exopthalmus+/+ 3. • Inj. Ondancetron
Struma: + Hipoalbu k/p
Thorax: min • Inj. Ranitidin k/p
Cor: • Furosemide 5 amp
Pulmo: Rh : +↓ /+↓ +NaCl 0,9%
Abdo: shifting 50cc/24 jam SP
dullness + ↓  Oral:
Extremitas: • KSR 1-0-1
Edema - - • Valsartan 80mg 0-
+↓ +↓ 0-1
• Bisoprolol 5mg
1x1
• Spironolacton
25mg 0-1-0
• Digoxin 0.25mg 0-
1/2-0
7. H7 30/05/2018 Sesak TD:110/70mmHg THD Planning therapy
MRS berkurang N : 96 x/mnt  venflon
RR: 22 x/mnt  Parenteral
S : 36,8 oC • Inj. Ceftriaxone
K/L: 2x1gr
exopthalmus+/+ • Inj. Ondancetron
Struma: + stop
JVP me↑ • Inj. Ranitidin stop
Thorax: • Furosemide 5 amp
Cor: :irama +NaCl 0,9%
Irreguler, M(-) G(-) 50cc/24 jam SP
Pulmo: Rh : +↓ /+↓  Oral:
Abdo: shifting • KSR 1-0-1
dullness +↓ • Valsartan 80mg 0-
Extremitas: 0-1
Edema - - • Bisoprolol 5mg
+↓ +↓ 1x1
• Spironolacton
25mg 0-1-0
• Digoxin 0.25mg 0-
1/2-0
8. H8 31/05/2018 Tidak ada TD:110/60mmHg THD Planning therapy
MRS sesak N : 102 x/mnt  venflon
RR: 20 x/mnt  Parenteral
Hasil Lab: S : 36,5 oC • Inj. Ceftriaxone
Albumin K/L: 2x1gr
2.0 exopthalmus+/+ • Inj.Furosemide
Struma: + 20mg/24 jam
JVP me↑ • Tranf.
Thorax: Albumin20%
Cor: :irama 100cc (+
Irreguler, M(-) G(-) inj.Furosemid 1
Pulmo: Rbh : +↓ /+↓ amp)
Abdo: shifting  Oral:
 dullness - • KSR 1-0-1
Extremitas: • Valsartan 80mg 0-
Edema - - 0-1
+↓ +↓ • Bisoprolol 5mg
1x1
• Spironolacton
25mg 0-1-0
• Digoxin 0.25mg 0-
1/2-0
• Simarc 2mg 0-0-
2tab
• VipAlbumin 3x2
tab
 Diet Putih telur
 Pro echo tgl.2/6/18
9. H9 1/06/2018 Tidak ada TD:110/70mmHg THD Planning therapy
MRS sesak N : 102 x/mnt  venflon
RR: 20 x/mnt  Parenteral
S : 36,5 oC • Inj.Furosemide
K/L: 20mg/24 jam
exopthalmus+/+  Oral:
Struma: + • KSR 1-0-1
JVP me↑ • Valsartan 80mg 0-
Thorax: 0-1
Cor:irama Irreguler, • Bisoprolol 5mg
M(-) G(-) 1x1
Pulmo: Rbh : -/- • Spironolacton
Abdo: shifting 25mg 0-1-0
dullness (-) • Digoxin 0.25mg 0-
Extremitas: 1/2-0
Edema - - • Simarc 2mg 0-0-
- - 2tab
• VipAlbumin 3x2
 tab
 Diet Putih telur
 Pro echo tgl.2/6/18
10. 2/06/2018 Tidak ada TD:110/70mmHg THD Planning therapy
H10 keluhan N : 101 x/mnt  BLPL
MRS RR: 20 x/mnt  Oral:
Hasil Lab: S : 36,2 oC • Thyrozol 10mg
Albumin: K/L: 3x1
2.3 g/dl exopthalmus+/+ • Furosemide 40mg
fT4 : 93.26 Struma: + 1-0-0
TSH: <0.05 JVP me↑ • Spironolacton
Thorax: 25mg 0-1-0
Echo(+) Cor: :irama • Digoxin 0.25mg 0-
Irreguler, M(-) G(-) 1-0
Pulmo: Rbh : -/- • Simarc 2mg 0-0-
Abdo: shifting 1tab
dullness (-) • VipAlbumin 3x1
Extremitas: tab
Edema - -
- -  Cek INR saat
kontrol ke poli