Anda di halaman 1dari 3

RUANG ICU RR : x/mnt

JAGA MALAM 10/03/2021 SpO2 : % INFLAMMATION


06/03 08/03
ICU / Ny. Sutiyari, 59 tahun BC selama 24 jam Fer
MRS : 05 Maret 2021 I : cc Fibr
RM : 099155 O : cc D-Dimer < 25
DPJP : dr. Reagan, SpPD BC : cc
CRP 98.2 12.5
D : cc/kgbb/jam
Laktat
Diagnosis:
PCT 1.2 0.35
- Confirmed Covid-19 gejala berat
IL-6 9.55
- Hipertensi CIRCULATION
- DM tipe 2 06/03 09/03
Hb 11.7 11.2
ELECTROLYTE
Pemeriksaan Covid-19: Ht 37 34
Swab I 04/03/2021: Positif 06/03 07/03 10/3
Leuko 7.4 10.7
Na 132 134
Tromb 216 359
Pemeriksaan Thorax di RSUD Ciracas: K 3.4 4.6
o
(05/03/2021) Cl 102 104
NLR 5 8.4
Curiga cardiomegali? Ca 1.02 1.18
Kalsifikasi arcus aorta Mg 1.45 1.54
Gambaran viral pneumonia
ELECTROLYTE

06/03 07/03 10/3 COAGULATION


S: 06/03 07/03
Na 132 134
PT 12.6 13.3
O: K 3.4 4.6
INR 0.93 0.98
TTV Cl 102 104 APTT 167.7 124.6
TD : mmHg
MAP : Ca 1.02 1.18
N : x/menit Mg 1.45 1.54 OXYGENATION
Sh : °C
AGD 06/03 06/03 06/03 06/03 PFR
pH 7.48 7.48 7.53 7.48
pO2 80.5 78.4 112.3 67.6
pCO2 27.0 28.4 32.4 26.9 NUTRITION RENAL AND CARDIO FUNCTION
HCO3 20.5 21.7 27.4 20.6 06/03 07/03 06/03 10/3
BE -3.2 -1.9 4.6 -2.9 Alb Ureum 52 69
SpO2 96.9 96.6 98.9 95.0 SGOT 24 49 Kreatinin 1.2 10
FiO2 SGPT 22 31 BUN
PFR AU eGFR
BilTot 0.4 CK
AGD 07/03 08/03 09/03 09/03 BilDir 0.2 CKMB
pH 7.48 7.506 7.487 7.489 Kol TropT
pO2 74.3 103.6 80.7 135.4 TG NTProBNP
pCO2 30.5 26.9 28.1 29.1 HDL
HCO3 23.4 21.5 21.5 22.3 LDL
THORAX
BE -0.2 -1.8 -2.1 -1.2
SpO2 96.1 98.6 96.6 99.3
GLUCOSE tanggal tanggal tanggal
FiO2
06/03 07/03 08/03 09/03 Thorax 6/3 10/3
PFR
GDS 311 134 146 114
215 95 230 169 Biakan Sputum :
AGD 10/3
235 113 124 129
pH 7.457
173 Biakan Urin:
pO2 82.1
pCO2 32.4 Biakan Darah:
10/03
HCO3 23.1
GDS 128
BE -1.0
212
SpO2 96.7 Terapi :
111 HFNC Flow 45 lpm, FiO2 45%, S 34 C
FiO2
IVFD NaCl 0.9% 500 cc/12 jam Vitamin C 1x1 gr IV H14
Cuci hidung NaCl 3x/hari
Kumur betadine 3x/hari Oral : To do list
Colchicin 3x0.5 mg PO (7 hari) (H+5) Mobilisasi bertahap
Enteral : Metformin 2x850 mg PO Latihan prone minimal 4x2 jam
Diet diabetasol 6x200 ml Valsartan 1x80 mg PO prn TDS > 160 Rencana AGD tiap hari
Amlodipin 1x10 mg PO prn TDS > 160 Rencana KGDH tiap hari
Syringe Pump : NAC 3x200 mg PO Rencana kultur sputum MO -> belum ada
Curcuma 3x1 tab PO sample
Injeksi : Vitamin D 1x5000 IU FU hasil kultur darah 06/03/2021 -> +/- 1
Levofloxacin 1x750 mg IV (H+7) lanjut New diatab 3x2 tab minggu (13/03/2021)
sampai 10 hari Zink 2x20 mg Rencana swab tanggal 14/03/21
Fluconazol 1x400 mg PO (5 hari) (H+5) lanjut Rencana cek Pt/Appt tgl 11/3
sampai hari ke7 Stop :
Meropenem 3x1 gr IV (7 hari) (H+5) Lactulac 2x10 ml PO
Remdesivir H1 1x200 mg IV, H2-H5 1x100 KSR 3x600 mg PO
mg IV (H+7)
Dexamethason H1-5 2x5 mg IV, H6-7 1x5 mg
IV (H+5)
Lantus 1x10 IU SK
Novorapid 3x/hari (pagi-siang-sore) sesuai TPK
KGDH:
GDS 170-200 : 8 IU SK Albumin 20%
GDS 201-250 : 10 IU SK
GDS 251-300 : 12 IU SK Plan:
GDS 301-350 : 14 IU SK
GDS > 350 : 16 IU SK Protokol Remdesivir:
Heparin 1x7500 IU SK Ur/Cr, OT/PT GDS, DL, BilTot, dan diff count
Ondansentron 3x4 mg IV H1
Omeprazol 2x40 mg IV H3
Paracetamol 1 gr IV prn demam/nyeri H7 …… + PCR