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  • Follow Up Harian

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    Fikri Ananda
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    The patient presented with acute inferior ST elevation myocardial infarction with late onset of chest pain. On examination, the patient was afebrile with stable vital signs and no abnormalities found. The electrocardiogram showed acute inferior ST elevation. Treatment included medications, oxygen therapy via nasal cannula, diet modifications, and monitoring of vital signs. The chest pain was gradually decreasing and the patient remained stable.

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    The patient presented with acute inferior ST elevation myocardial infarction with late onset of chest pain. On examination, the patient was afebrile with stable vital signs and no abnormalities found. The electrocardiogram showed acute inferior ST elevation. Treatment included medications, oxygen therapy via nasal cannula, diet modifications, and monitoring of vital signs. The chest pain was gradually decreasing and the patient remained stable.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    16 views5 pages

    Follow Up Harian

    Uploaded by

    Fikri Ananda
    The patient presented with acute inferior ST elevation myocardial infarction with late onset of chest pain. On examination, the patient was afebrile with stable vital signs and no abnormalities found. The electrocardiogram showed acute inferior ST elevation. Treatment included medications, oxygen therapy via nasal cannula, diet modifications, and monitoring of vital signs. The chest pain was gradually decreasing and the patient remained stable.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    of 5

    Tanggal

    27/11/2012 H1 (03 00!

    Subyektif
    "yeri #a#a berkurang $es T( H* ** Su-u .ata

    Objektif
    % &'mp's mentis % 120/)0mmHg % )2 +/menit % 2,+/ menit % Afebris % &ekung (///! $'nj p0t (///! Sklera ikt (///! Telinga % Serumen (/! Hi#ung % Sekret (/! "&H (/! .ulut % 1ibir% pu0at(/! sian'sis (/! le-er % T23 */20mH2O T-'ra+ % Simetris (4! *etraksi (/! s'n'r (454! r'nki basal (4! 2esikuler (454! 6- (///!5 3antung % 13 1 7 13 885 reguler5 bising (/!

    Assessment
    A0ute ST9.8 anter'inferi'r T-/

    Terapi/Planning

    :ate 'nset T8.8 s0're ;/1, / 1e# rest semi f'?ler $8:8P 88 <ra0e s0're 10= / (iet jantung 2 tanpa re>askularisasi /O2 2/, liter (nasal kanul! /82@( *: )gtt/i /8njeksi Ari+tra 1+052;00/2, jam /8nj .'rfin 2 mg /&l'pi#'grel 1+7; mg /Tablet Sim>astatin ,0 mg 1+1 'ral (malam! /(ul0'la+ syrup 3+&8 /Tablet Aspilet )0 mg 1+1 'ral / &apt'pril 3+A52; mg /AlpraB'lam 1+052; mg / (rip &e#'0ar# Clasi+ 2 amp(e+tra! pukul 12 305 selanjutnya 2+1 amp

    P/

    #ara-

    rutin/ureum/

    0reatinin/$<("/23PP / Drinalisa / @'t' t'raks AP (menunggu -asil!

    3,

    Ab#'men % simetris (4! (istensi (/! Peristaltik (4! -epar/lien/renal ti#ak teraba 9kstremitas% D#em (///! Sian'sis (///!

    HbA10

    (jika

    Hb7105

    kreatininE2! / Pasang 0ateter

    2)/11/2012 Hr/2

    "yeri #a#a mulai berkurang

    $es T( "a#i ** Su-u .ata

    % 0'mp'smentis % =0/A0mmHg % 10, +/menit % 27+/ menit % 3A5;0& % &ekung (///! $'nj p0t (///! Sklera ikt (///!

    A0ute ST9.8 anter'inferi'r T-/ late 'nset T8.8 s0're A5 / 1e# rest semi f'?ler / O2 2/, liter (nasal kanul! / 82@( *: )gtt/i /8njeksi Ari+tra 1+052;00/2, jam / &l'pi#'grel 1+7; mg / Tablet Sim>astatin ,0 mg 1+1 'ral (malam! / (ul0'la+ syrup 3+&8 /Tablet Aspilet )0 mg 1+1 'ral / &apt'pril 3+A52; mg /AlpraB'lam 1+052; mg / 8S(" 3+; mg / 8nj "'>'rapi# )/)/) 82 (sebelum makan! $8::8P 885 <ra0e s0're 10= / (iet 3antung 2 tanpa re>askulasirasi 4 (. tipe 2

    H*% +/menit

    Telinga % Serumen (/! Hi#ung % Sekret (/! "&H (/! .ulut % 1ibir pu0at(/! sian'sis (/! :e-er % T23 */20mH2O T-'ra+ % Simetris (4!

    3;

    *etraksi (/! S'n'r #i ke#ua lapangan paru5 2esikuler #i ke#ua lapangan paru5 r'nki basa- basal5 6- (///!5

    / (rip 8nsulin 200/jam C &ek <(S tiap 2 jam C Perta-ankan <( 1=0/1)0 mmHg

    P/ 3antung % 13 1 7 13 885 reguler5 bising (/! Ab#'men % simetris (4! (istensi (/! Peristaltik (4! nyeri tekan (/! H/:/* % Ti#ak teraba 9kstremitas% D#em (///! Sian'sis (/! / 9arly P&8 / $'nsul P'li en#'krin (Su#a-! / 90-' (su#a-! / &ek elektr'lit/ 3 -ari

    3A

    2=/11/ 2012 H/3

    /$etika batuk terasa se#ikit sakit /"yeri berkurang #a#a

    $es T(

    % 0'mp'smentis % 120/70mmHg % 11= +/menit % 30 +/ menit % afebris % &ekung (///! $'nj p0t ( ! Sklera ikt (///!
    ///

    A0ute

    ST9.8

    anter'inferi'r late 'nset T-/ T8.8 s0're ;/1,5 $8::8P / 1e# rest semi f'?ler 885 <ra0e s0're 10= tanpa / (iet 3antung 2 re>askulasirasi 4 (. tipe / O2 2/, liter (nasal kanul! 2 / 82@( *: )gtt/i /8njeksi Ari+tra 1+052;00/2, jam / &l'pi#'grel 1+7; mg / Tablet Sim>astatin ,0 mg 1+1 'ral (malam! / (ul0'la+ syrup 3+&8 /Tablet Aspilet )0 mg 1+1 'ral / &apt'pril 3+A52; mg /AlpraB'lam 1+052; mg (jika perlu! / 8nj "'>'rapi# )/)/) 82 (sebelum makan! / 8nj :'>emir 0/0/1, C Perta-ankan <( 1=0/1)0 mmHg

    sangat "a#i ** Su-u .ata

    H*% +/menit

    Telinga % Serumen (/! Hi#ung % Sekret (/! "&H (/! .ulut % 1ibir pu0at(/! sian'sis (/! :e-er % T23 */20mH2O T-'ra+ % Simetris (4! *etraksi (/! S'n'r #i ke#ua lapangan paru5 2esikuler #i ke#ua lapangan paru5 r'nki basa- basal5 6- (///!5 3antung % 13 1 7 13 885

    37

    reguler5 bising (/! Ab#'men % simetris (4! (istensi (/! Peristaltik (4! nyeri tekan (/! H/:/* % Ti#ak teraba 9kstremitas% D#em (///! Sian'sis (///!

    P/ / &ek <(S tiap 2 jam

    3)

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