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Tutorial stase iccu
Agung Ambara Putra
13430/J.13.1
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identitas
• Nama : Bp. NH• J. elamin : !a"i#la"i• Tanggal la$ir : 1% April &014•
Alamat : Bausaran' (anure)an' *og+a"arta• Agama : ,slam• Pendidi"an :•
Pe"er)aan : Pensiunan• -tatus : eni"a$• Tgl. asu" : (esember &014• No.: 1%%22
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elu$an tama
• N+eri dada ru)u"an - Bet$esda!empu+ang5angi
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i5a+at pen+a"it se"arang
• 13 )am -- os mengelu$ n+eri ulu$ati' dada terasa tida" n+amandengan s"ala n+eri 4#%' tida"men)alar' terdapat "eringat dingin'terdapat mual' tida" munta$' tida"terdapat sesa" napas' sesa" +g
diperberat a"ti6tas' sesa" saat tidurterlentang' sesa" dan batu" saatsedang tidur malam' "a"i beng"a"
disang"al' terdapat nggli+er
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• & )am -- "elu$an sema"inmemberat' masi$ terdapat n+eridada' asa mual dan munta$ 12'terdapat "eringat dingin' tida"terdapat ge)ala sesa" napas dan "a"ibeng"a"' os diba5a "e - bet$esda
lempu+ang5angi didiagnosis -T7,in8erior dan bradi"ardia' os diberi"anaspilet 3&0 mg' dan clopidogrel 300
mg lalu diru)u" "e -P (r -ard)ito
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• asu" -' os masi$ mengelu$"ann+eri dada dengan s"ala 1#&' masi$terdapat mual tapi tida" munta$'terdapat "eringat dingin dan merasalemas
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i5a+at pen+a"it da$ulu
• 9s menderita $ipertensi' namuntida" rutin minum obat
• (' dislipidemia disang"al
• 9- merupa"an be"as pero"o"
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i5a+at pen+a"it "eluarga
• i5a+at "elu$an serupa di "eluargadisang"al
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esume anamnesis
• ardioas"ular: palpitasi;#
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(iagnosis banding
• A- -T7,
• A- N-T7,
•
A- AP
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Pemeri"saan 6si"
• : lema$' somnolen
• BB: ??"g TB:??cm B,:??
•
Tanda @ital – Nadi : 4& 2/menit
– re"uensi Napas: &0 2/menit
– Te"anan dara$: 11/C mmHg
– -u$u: a8ebris
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• epala: A ;#< -, ;#<
• !e$er: J@P %=3 cmH&0' !im8onodi ta"
teraba• Tora"s paru
– ,nspe"si: dada simetris' "etinggalangera" ;#<
– Palpasi:8remitus ta"til "anan D ta"til "iri
– Per"usi: sonor
– Aus"ultasi: esi"uler ;=/=< ron"$i ;#/#<
5$eeEing ;#/#<
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• Jantung: – ,nspe"si: ictus cordis ta" tampa"
–Palpasi: ictus cordis ta" teraba
– Per"usi: "ardiomegali ;#<
– Aus"ultasi: -1 -& murni' bising ;#
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• 7"stremitas: – A"ral $angat
– -p9& 100F
– 7dema
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(iagnosis er)a
• Acute coronar+ s+ndrome -T7, ddN-T7, dd AP
• Hipertensi stage ,,
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7>
• 7> ,: )unctional r$+t$m' $ 4&2/menit' -T eleasi lead ,,' ,,,' a@'atrial Gutter
• TA@B' - rate 40 2/menit' -Teleasi lead ,,' ,,,' a@
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laboratorium
• Hb 14'%
• A! C'%
• AT &C&
• A7 %'1C
• Hct 44'C
• Bun &%
• reat &'%
•A '
• >(- 1
• ->9T 14&
• ->PT %
• Na 13C
• 3'
• ! 10&
• APTT &C ;3&'3<
• PPT 1%' ;14'&<
• ,N 1'1
• 3C
• B 3
• Trop , '%
• Alb 3'4
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(iagnosis "linis
• -T7, in8erior et de"stra onset 13 )am illip ,' T /14' >- 11
• Hipertensi stage ,,
• Acute enal ailure dd acute onc$ronic renal 8ailure
• 7lectrical instabilit+ ;)unctionalr$+tm< atrial Gutter dengan TA@B
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ana)emen
• 9& 3 !pm N
,@( Nal 0'CF &0 tpm
•
Aspilet 0 mg/&4 )am• lopidogrel % mg/&4 )am
• Atorastatin 40 mg/&4 )am
•
AlpraEolam 0'% gr/&4 )am• !a2adin ,,/ &4 )am
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planning
• a5at ,
• Primar+ P, = TP
• o t$ora"s
• 7"o"ardiogra6
• 7aluasi 7>' HbA1c' pro6l lipid' >(P'>&JPP
• Target cairan &000 cc/&4 )am• Target urin output 0'%#1 cc/"g/)am
• 7aluasi Bun/nat post tinda"an
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