Follow Up IMC

Minggu, 1 Agustus 2021

NO Identitas Diagnosis LAB LAB CXR Terapi Lain-Lain
1 Ny. Femmy Wowor, DM Tipe 2 (post HHS) Swab Antigen dari RS Siloam 25/7/2021 : UL 27/7/2021 : X-Foto Thorax IVFD NaCl 0.9% 500 cc / 8 jam KU berat
57 tahun Penurunan kesadaran ec Eritrosit 23-25 26/7/2021 Meropenem 3x1 gr iv (H2) Kes sopor
metabolic dd sepsis dd reattack Negatif Leukosit 6-7/+2 Simvastatin 1x20 mg po TD
RM 098984 CVD SI Nitrit neg Cor dan pulmo normal Human albumin 25% 100 cc/24 jam HR x/ menit
Sepsis ec ulkus decubitus dd Lab dari RS Siloam 25/7/2021 : Protein +1 Dilatasio aorta Aspilet 80 mg 1x1 RR 22 (nasal kanul
DOB 02/02/1964 Urosepsis Hb 17,2 Keton +2 Paracetamol 3x1 gram iv 4 lpm)
Bed 6 Ulkus decubitus grade II Hct 49,1 Novorapid 3x4 iu SC T
Leukositosis reaktif dd bacterial Leukosit 16.040 Lab 27/7/2021: Lantus 1x12 iu SC
Hari ke 6 infection n. segmen 87.0 Natrium 155 Ekspertisi EKG dari Swab PCR TCM
Hipernatremia terkoreksi Natrium 152 Kalium 3,58 IRDM sinus ritme , HR GDS/jam
DPJP : Dislipidemia Kalium 2,9 Kolesterol 335 90x/menit, normoaxis Terapi TS Neuro :
Dr. Harlinda Hipoalbuminemia Chlorida 113 HDL 28 dengan global ST-T Bromokriptin 3x2,5 mg 26/7/2021:
Haroen, SpPD, ISK LDL 277 depresi dan flat T ec Diazepam 10 mg k/p bila kejang 23.00 272 (N
KHOM Tg 149 electrolit imbalance dd Deksametazone 10mg loading dose 4U/jam)
Lab dari RS Siloam 26/7/2021 : HbA1C 12,1 iskemik Lanjut deksametazone 5mg tiap 6 jam
GDS 553 Calcium 8,01 27/7/2021:
SWAB TCM Natrium 160 Albumin 3,12 Plan GD 4 porsi 00.00 223
SARSCOV II Kalium 2,3 Ca Corrected 8.7
Cl 120 Jawaban konsul Neuro (novorapid 2
Negatif 31/7/21 Fosfor 1.8 27/7/2021 : unit/jam)
CK 694 Penurunan kesadaran 01.00 237
Lab 26/7/2021 di RSUP Prof Kandou :
CKMB 21 ec metabolic dd sepsis 12.00 416 (novorapid 7.0 unit/jam) (novorapid 2
Leukosit 21.900
dd reattack CVD 13.00 360 (novorapid 7.0 unit/jam)
Hb 16.2 unit/jam)
AGD 27/7/2021 : Rencana Brain CT scan 14.00 327 (novorapid 7.0 unit/jam)
Trombosit 205.000 02.00 265
pH 7.499 kepala polos 15.00 309 (novorapid 7.0 unit/jam)
MCV 90.2 (novorapid 2
PCO2 37.2 mmHg 16.00 320 (novorapid 7.0 unit/jam)
MCH 29.1 unit/jam)
PO2 78 mmHg 17.00 307 (novorapid 7.0 unit/jam)
Diffcount 0/0/19/69/9/3 04.00 227
BEecf 6 mmol/L 18.00 298 (novorapid 7.0 unit/ jam)
SGOT 13 (novorapid 1
HCO3 29.0 mmol/L 28/7/2021 Jam 01:30 19.00 312 (novorapid 7.0 unit/jam)
SGPT 8
TCO2 30 mmol/L Konsul TS Bedah Cito 20.00 287 (novorapid 6.0 unit/jam) unit/jam)
Ureum 114
SO2 97% mmol/L untuk pemasangan 21.00 269 (novorapid 5.0 unit/jam) 05.00 191
Creatinine 1,0
Lac 1.74 mmol/L CVC  Acc pasang 22.00 270 (novorapid 5.0 unit/jam) (novorapid 0.5
GDS 566
CVC 23.00 23.00 255 (novorapid 4.0 unit/jam)
Kalium 3,52
Lab 27/7/2021 : unit/jam) 06.00 187
Natrium 153
Cek Na/K/Cl ulang 29/07/2021 (novorapid 0.5
Anti HCV non reaktif
Na 161 00.00 240 (novorapid 3.0 unit/jam) unit/jam)
HbsAg non reaktif
K 2,67 01.00 235 (novorapid 2.0 unit/jam)
Anti HIV non reaktif 07.00 210
Cl 122,3 02.00 230 (novorapid 1.0 unit/jam)
PT 16,6/13,4 (novorapid 0.5
03.00 231 (novorapid 1.0 unit/jam)
INR 1,44/1,09 unit/jam)
04.00 220 (novorapid 0.5 unit/jam)
APTT 24,9/32,8 Jam 22:30 08.00 260
05.00 202 (novorapid 0.5 unit/jam)
Na 155 (novorapid 1.0
UL 26/7/2021 : 06.00 227 (novorapid 0.5 unit/jam)
K 2,24 unit/jam)
Leukosit 4-5/negative 07.00 242 (novorapid 1.0 unit/jam)
Cl 114,5
Nitrit neg 08.00 356 (novorapid 2.0 unit/jam) 09.00 316
Keton +4 09.00 304 (novorapid 2.0 unit/jam) (novorapid 1.5
Lab 28/7/2021
Glukosa +4 10.00 231 (novorapid 1.5 unit/jam) unit/jam)
06.00
Bilirubin +1 11.00 243 (novorapid 1.5 unit/jam) 10.00 355
Na 154
12.00 246 (novorapid 1.5 unit/jam) (novorapid 2.0
K 3,14
 Follow Up IMC
Minggu, 1 Agustus 2021
Hasi AGD 26/7/2021 jam 21.51: Cl 114,9 13.00 270 (novorapid 2.0 unit/jam) unit/jam)
pH 7,411 14.00 268 (novorapid 2.0 unit/jam) 11.00 390
pCO2 25,2 Jam 13:11 15.00 221 (novorapid 1.0 unit/jam) (novorapid 3.0
pO2 145 Hb 13,7 16.00 201 (novorapid 1.0 unit/jam) unit/jam)
BEecf -9 Leuko 13.300 17.00 218 (novorapid 1.0 unit/jam) 12.00 383
HCO3 16.0 Trombo 103.000 18.00 248 (novorapid 1.0 unit/jam) (novorapid 4.0
TCO2 17 Diff.count : 0/0/30/56/10/4 19.00 244 (novorapid 1.0 unit/jam)
unit/jam)
SO2 99% MCH 29,4 20.00 220 (novorapid 1.0 unit/jam)
13.00 373
Lac 1.64 MCHC 32,4 21.00 238 (novorapid 1.0 unit/jam)
pO2 : fiO2 = 140 : 28 = 500 MCV 90,8 22.00 203 (novorapid 0.5 unit/jam) (novorapid 5.0
Ureum 34 23.00 217 (novorapid 0.5 unit/jam) unit/jam)
Creatinin 0,6 24.00 247 (novorapid 1.0 unit/jam) 14.00 317
Na 158 30/07/2021 (novorapid 4.0
Lab 29/7/2021 jam 11.00 K 3,38 01.00 266 (novorapid 1.5 unit/jam unit/jam)
Cl 116,5 02.00 203 (novorapid 1 unit/jam) 15.00 304
Natrium 150 03.00 232 (novorapid 1 unit/jam) (novorapid 3.0
Kalium 4,19 UL 28/7/21 J.12:12 04.00 312 (novorapid 1,5 unit/jam) unit/jam)
Clorida 109,4 Eri 11-15 05.00 226 (novorapid 1.0 unit/jam) 16.00 245
Leuko 3-5 06.00 199 (novorapid 0.5 unit/jam) (novorapid 2.0
AGD 29/7/2021 08.30
Epitel 2-3 07.00 212 (novorapid 0.5 unit/jam) unit/jam)
pH 7.542
pH 5 08.33 231 (novorapid 0.5 unit/jam)
PO2 60 17.00 194
Leuko +1 09.30 219 (novorapid 0.5 unit/jam,
PCO2 31.6 (novorapid 0,5
Protein +1 Levemir 12 iu SC
HCO3 27.2 unit/jam+ D5%)
Glukosa +4 10.30 293 (novorapid 1.0 unit/jam)
SO2 94% 18.00 218
Keton +3 12.00 279 Novorapid 4iu SC
Lac 1.83 (novorapid 0,5
Eri +3 14.00 214
FiO2 28 unit/jam)
18.00 208 Novorapid 4iu SC
Jam 18.00 22.00 160 Lantus 12iu SC 19.00 268
UL 29/7/2021 jam 11.00:
eritrosit >50 ?+5 Na 153 (novorapid 0.5
Leukosit 7-9 / +2 K 4,19 31 Juli 2021: unit/jam)
Keton +3 Cl 116,6 06.00 130 20.00 270
12.00 179 4 unit novorapid (novorapid 1,0
29/07/2021 Jam 18:57 AGD 18.00 191 4 unit novorapid unit/jam)
Na 141 pH 7,473 20.00 deksametashon 5mg iv 21.00 300
K 4,06 PCO2 34,1 22.00 197 Lantus 12 iu (novorapid 2,0
Cl 107,3 PO2 56 Instruksi dr BS-> GDS per 4 jam lapor
dr BS unit/jam)
BEecf 1
HCO3 25,0 03.00 22.00 330
Jam 23.30
TCO2 26 07.00 (novorapid 3,0 unit
Na 128 (NS 0.9% 500 cc / 6 jam)
SpO2 91% jam)
K 3,58
Cl 98,7 Lac 3,42 23.00 304
Lab 28/7/2021 jam 18.00 (novorapid 3,0 unit
Na 153 jam)
30/07/2021 K 4,19
Leuko 14.700 Cl 116,6
Hb 11,9 28/7/2021:
Hct 35,0 00:00 295
Trombo 112.000
(novorapid tunda,
 Follow Up IMC
Minggu, 1 Agustus 2021
MCH 30,2 kalium 2,24
MCHC 34,0 dikarenakan drips
MCV 88,9 KCl salah setting
GDP 234 01.00 356
Ureum 17 (novorapid tunda),
Creatinin 0,4 konsul TS Bedah
Kolesterol total 209
u/ pasang CVC
HDL 24
02.00 372
LDL 161
TG 119 novorapid tunda
Ca 7,79 03.00 400
Mg 1,87 novorapid tunda
Ph 1,7 04.00 423 Pasang
CVC Femoral
dextra
05.00 421 NS
0.9%+KCl 75 meq
28 TPM
06.00 389
(novorapid tunda
untuk sementara
waktu)
07.00 401 (K 3.14
- insulin drip mulai
5 unit/jam)
08.00 377
(novorapid 4.0
unit/jam)
09.00 374
(novorapid 5.0
unit/jam)
10.00 419
(novorapid 5.0
unit/jam)
11.00 420
(novorapid 6.0
unit/jam)