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Kronologis Tn Darsono - Tim jaga Jumat malam.pptx
- 3. Time Subjective Objective Issue Action
Friday, 29 Jul
2022
15.00
Handover from
morning duty to
night shift
Shortness of breath was
reduced.
No chest pain nor
palpitation
History of shortness of
breath the day before
Patient looks moderately ill
GCS 456
BP: 120/80 mmHg
HR 80 bpm regular
RR 22 tpm
Temp 36.0 C
SaO2 99% on 3 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
ECG:
Sinus Rhytm, 95 bpm, FA LAD, HA CWR, PR Int. 120ms, QRS 80 ms,
QTc 394ms. Q patologis II, III, aVF, V3-V6 poor R wave progression.
UOP : 750cc/10 hr
IWL : 375 cc/10 hr
Intake : 1000/10 hr
BC : -125cc/10 hr
1. STEMI Inferoposterior Killip IV post PPCI with acute stent
thrombosis at distal RCA, implanted 2 DES at proximal-
distal RCA (overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
2. HF mr EF St.C FCIi dt. CAD HHD
3. Pneumonia CAP
4. History of VT with pulse
5. Moderate hypoalbuminemia (2.47->2.75)
6. Mild hypokalemia (perbaikan 2.74->3.87->3.68)
Planning
PDx:
ECG/24jam or acute event
PTx :
O2 NC 3-4 lpm
IV plug
Total fluid 1500cc / 24hr on oral route
Equal fluid balance
DJ II 2000kkal/24hr, high protein diet
Inj. Meropenem 3x1 gr (H4)
PO:
ASA 0-0-80mg
Ticagrelor 2 x 90 mg
Atorvastatin 0-0-40mg
Valsartan 2x80mg
Bisoprolol 1,25mg-0-0
ISDN 3x5mg k/p
Laxadyn syr 0-0-CI
Lansoprazole 1x30mg
Alprazolam 0-0-0,5mg
NAC 3x200mg
Nebul Combivent 3x1 respule
P.Mo: S, VS, UOP
18.00 Mild SOB (+). No chest
pain nor palpitation.
Patient looks moderately ill
GCS 456
TD: 118 /78 mmHg
HR 90 bpm
RR 22 tpm
Temp 36.0 C
SaO2 97% on 3 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
1. STEMI Inferoposterior Killip IV post PPCI with acute stent
thrombosis at distal RCA, implanted 2 DES at proximal-
distal RCA (overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
2. HF mr EF St.C FCIi dt. CAD HHD
3. Pneumonia CAP
4. History of VT with pulse
5. Moderate hypoalbuminemia (2.9 -> 2.4 -> 2.7--> 2.8)
6. Mild hypokalemia (perbaikan 3.0 -> 2.7 -> 2.6 -> 3.8 -> 3.7)
Continue observation and medication
- 4. Time Subjective Objective Issue Action
19.00 No chest pain nor
palpitation.
Patient in supine
position at 15 degree.
Patient looks moderately ill
GCS 456
TD: 118 /78 mmHg
HR 90 bpm
RR 22 tpm
Temp 36.0 C
SaO2 97% on 3 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
Oral intak 1350 cc/14jam
UOP 1100 cc/14 jam
IWL 525 cc/14 jam
BC -275 cc/14 jam
1. STEMI Inferoposterior Killip IV post PPCI with
acute stent thrombosis at distal RCA, implanted 2
DES at proximal-distal RCA (overlapped) and 2
DES at osteal-distal LAD (overlapped) on 3VDCAD
2. HF mr EF St.C FCIi dt. CAD HHD
3. Pneumonia CAP
4. History of VT with pulse
5. Moderate hypoalbuminemia (2.9 -> 2.4 -> 2.7-->
2.8)
6. Mild hypokalemia (perbaikan 3.0 -> 2.7 -> 2.6 ->
3.8 -> 3.7)
Continue observation and medication
24.00 Patient can sleep at
flat position.
No chest pain nor
palpitation.
Patient looks moderately ill
GCS 456
TD: 110 / 70 mmHg
HR: 92 bpm
RR 22 tpm
Temp 36.0 C
SaO2 97% on 4 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
1. STEMI Inferoposterior Killip IV post PPCI with
acute stent thrombosis at distal RCA, implanted 2
DES at proximal-distal RCA (overlapped) and 2
DES at osteal-distal LAD (overlapped) on 3VDCAD
2. HF mr EF St.C FCIi dt. CAD HHD
3. Pneumonia CAP
4. History of VT with pulse
5. Moderate hypoalbuminemia (2.9 -> 2.4 -> 2.7-->
2.8)
6. Mild hypokalemia (perbaikan 3.0 -> 2.7 -> 2.6 ->
3.8 -> 3.7)
Continue observation and medication
- 5. Time Subjective Objective Issue Action
04.00 Intermitent mild SOB
(+). Patient complain
of bloating and
epigastric discomfort.
Defecation (+) twice
for last 24 hours.
No chest pain nor
palpitation.
Patient looks moderately ill
GCS 456
TD: 110 / 70 mmHg
HR 98 bpm
RR 22 tpm
Temp 36.0 C
SaO2 99% on 4 lpm NC
K/L anaemic (+), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/--+, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, no edema
ECG:
Sinus Rhytm, 95 bpm, FA N, HA CWR, PR Int. 120ms, QRS 80
ms, QTc 394ms. Q patologis II, III, aVF,V6. QS pattern V3-V4,
poor R wave progression (same as morning ECG)
1. STEMI Inferoposterior Killip IV post PPCI with
acute stent thrombosis at distal RCA,
implanted 2 DES at proximal-distal RCA
(overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
2. HF mr EF St.C FCIi dt. CAD HHD
3. Pneumonia CAP
4. History of VT with pulse
5. Moderate hypoalbuminemia (2.9 -> 2.4 ->
2.7--> 2.8)
6. Mild hypokalemia (perbaikan 3.0 -> 2.7 -> 2.6
-> 3.8 -> 3.7)
Drink warm water
Continue observation and medication
- 6. Time Subjective Objective Issue Action
06.50
Handover
from night
shift to
morning Duty
Patient complaint of
shortness of breath
felt worsen than last
night.
No chest pain nor
palpitation
bloating and
epigastric discomfort
still persist few
watery defecation (+)
Patient looks moderately ill
GCS 456
TD: 140 / 86 mmHg
HR 122 bpm
RR 30 tpm
Temp 36.0 C
SaO2 97% on 4 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
ECG:
Sinus Rhytm, 95 bpm, FA N, HA CWR, PR Int. 120ms, QRS 80
ms, QTc 394ms. Q patologis II, III, aVF,V6. QS pattern V3-V4,
poor R wave progression (same as morning ECG)
UOP : 1700cc/24 hr
Intake : 2000cc/24 hr
IWL 525
BC : -225cc/24 hr
1. Impeding ALO
2. STEMI Inferoposterior Killip IV post PPCI with
acute stent thrombosis at distal RCA,
implanted 2 DES at proximal-distal RCA
(overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
3. HF mr EF St.C FCIi dt. CAD HHD
4. Pneumonia CAP
5. History of VT with pulse
6. Moderate hypoalbuminemia (2.9 -> 2.4 ->
2.7--> 2.8)
7. Mild hypokalemia (perbaikan 3.0 -> 2.7 -> 2.6
-> 3.8 -> 3.7)
8. Dyspepsia
PO ISDN 5mg SL
Lanzoprazole 3omg PO extra
BGA evaluation
Consult to Pulmonology depart.
- 7. Time Subjective Objective Issue Action
07.00 Shortness of breath
decrease
No chest pain nor
palpitation
bloating and
epigastric discomfort
relieve
Patient looks moderately ill
GCS 456
TD: 120 / 81 mmHg (post ISDN SL)
HR 114 bpm
RR 30 tpm
Temp 36.0 C
SaO2 97% on 4 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
1. Impending ALO
2. Inferoposterior STEMI Killip IV post PPCI with
acute stent thrombosis at distal RCA,
implanted 2 DES at proximal-distal RCA
(overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
3. History of VT with pulse
4. Pneumonia CAP
5. Moderate hypoalbuminemia (2.47->2.75)
6. Mild hypokalemia (perbaikan 2.74->3.87-
>3.68)
7. Dyspepsia
Continue observation and medication
07.10 Shortness of breath
(+)
No chest pain nor
palpitation
Patient looks moderately ill
GCS 456
TD: 140 / 84 mmHg 113/76 mmHg (post Morphine IV)
HR 122 108 bpm
RR 30 25 tpm
Temp 36.0 C
SaO2 99% on 5 lpm NC
Pale (-), icteric (-), cyanosis (-)
JVP R+0 cmH2O
Cor: S1S2 regular, murmur (-) gallop (-)
Pulmo: ves +++/+++, ronchi --+/---, wheezing --/--
Abd: soefl, bowel sound normal
Ext: warm acral, edema arm +/-
1. Impending ALO
2. Inferoposterior STEMI Killip IV post PPCI with
acute stent thrombosis at distal RCA,
implanted 2 DES at proximal-distal RCA
(overlapped) and 2 DES at osteal-distal LAD
(overlapped) on 3VDCAD
3. History of VT with pulse
4. Pneumonia CAP
5. Moderate hypoalbuminemia (2.47->2.75)
6. Mild hypokalemia (perbaikan 2.74->3.87-
>3.68)
7. Dyspepsia
Inj Morphine 1 mg IV
- 8. BP HR
Sp
O2
RR
200 200 100 50
180 180 90 45
160 160 80 40
140 140 70 35
120 120 60 30
100 100 50 25
80 80 40 20
60 60 30 15
40 40 20 10
20 20 10 5
0 0 0 0
Urine output (cc)
15.00
GCS 456
BP: 12/80 mmHg
HR 80 bpm regular
RR 22 tpm
Temp 36.0 C
SaO2 99% on 3 lpm NC
UOP : 750cc/10 hr
IWL : 375 cc/10 hr
Intake : 1000/10 hr
BC : -125cc/10 hr
BP HR
19.00
GCS 456
TD: 118 /78 mmHg
HR 90 bpm
RR 22 tpm
Temp 36.0 C
SaO2 97% on 3 lpm NC
Oral intak 1350
cc/14jam
UOP 1100 cc/14 jam
IWL 525 cc/14 jam
BC -275 cc/14 jam
15.00 18.00 19.00 24.00 12.00
04.00 06.50
24.00
GCS 456
TD: 110 / 70 mmHg
HR: 92 bpm
RR 22 tpm
Temp 36.0 C
SaO2 97% on 4 lpm NC
UOP 270cc/5 jam
04.00
GCS 456
TD: 110 / 70 mmHg
HR 98 bpm
RR 22 tpm
Temp 36.0 C
SaO2 99% on 4 lpm NC
UOP 500cc/ 9 jam
1700cc/24 hs
Friday, 29 July 2022
06.50
GCS 456
TD: 140 / 86 mmHg
HR 122 bpm
RR 30 tpm
Temp 36.0 C
SaO2 97% on 4 lpm NC
UOP : 1700cc/24 hr
Intake : 2000cc/24 hr
IWL 525
BC : -225cc/24 hr
18.00
GCS 456
TD: 101 / 60 mmHg
HR 75 bpm
RR 21 tpm
Temp 36.0 C
SaO2 99% on 4 lpm NC
UOP : 250 cc/3 h
