Kasus bu muji 11.

Diet Lunak BBS 3x100 + Susu

3x100
1. 31/8/20
S :
Pasien datang dengan keluhan sesak
nafas 2 hari smrs ,demam +,batuk
keras
Riw perjalanan –
Dilakukan swab hasilnya +

O :
KU TSB ,GCS 15
TD 165 /77
HR 63
S 36,1
RR 36
Sat 02 88-90 dengan 02 10 lpm nrm
Kepala normochepali CA-/- SI-/-
Leher dbn
Thorax :
WOB + , Retraksi +/+
Vesikuler +/+ ,Rh+/+ Wh-/- ,bj ½ reg
murmur -, Gallop –
Abdomen :
BU + ,soelf ,NT epigastrium +
Eks akral hangat ,crt < 3
A:
Covid 19 confirmed kasus sedang-berat

P:

1. IVFD Asering 1000/24 jam

2. 02 NRM 10-15 lpm
3. Inj Meropenem 3x1gr iv (H2)
4. Infimicyn drip 1x500mg iv (H2)
5. Hyloquin 2x200mg
6. Inj Sankorbin 1gr IV
7. Vit E 1x400mg
8. Pantoprazole 2x20mg IV
9. NAC 3x200mg po
10. Dexamethasone 3x1
Pemeriksaan Penunjang

Darah Lengkap:

Hb 11,5

Ht 33,0

Leukosit 18,33 Blood Gas Analisis:

Trombosit 188.000 PH 7,360

Eritrosit 3,79 BE -7,8

MCV 87,1 PCO2 29

MCH 30,3 PO2 61

MCHC 34,8 HCT 39,0

RDW 12,7 HCO3 16,3

Total CO2 17,2

Hitung Jenis : O2 sat 88

Eosinofil 0,1

Basofil 0,1

Segmen 82,3

Limfosit 11,7

Monosit 5,8

Gds 150

Ureum 96

Cr 1,8

SGOT 172

SGPT 171

Elektrolit

Natrium 135

Kalium 4,37

Clorida 90
Kasus bu muji

2. 1/9/20
S :
10. NAC 3x200mg po
Sesak Nafas dirasa semakin memberat
11. Dexamethasone 3x1
+
12. Captopril 3x25mg po
Batuk memberat +
13. Amlodipin 1x10mg po
14. Diet Lunak BBS 3x100 + Susu
3x100
O :
KU TSB ,GCS 15
INTUBASI 14.35
TD 166 /77 Mode
HR 88 SIMV
Supp 12
S 36,1 Rate 16
RR 32 I:E 1:2
Trigger 3.0
Sat 02 85 dengan 02 15 lpm nrm Peep 6
Kepala normochepali CA-/- SI-/- Fi02 90%

Leher dbn
Thorax : BGA (15.18)

WOB + , Retraksi +/+ PH 7,360

Vesikuler +/+ ,Rh+/+ Wh-/- ,bj ½ reg BE -12,1

murmur -, Gallop –
PCO2 40
Abdomen :
PO2 86
BU + ,soelf ,NT epigastrium +
HCT 45,0
Eks akral hangat ,crt < 3
HCO3 15,3
A:
Total CO2 16,15
Covid 19 confirmed kasus sedang-berat
O2 sat 94
Hipertensi Grade 2

P:

1. IVFD Asering 1000/24 jam

2. 02 NRM 10-15 lpm
3. Inj Meropenem 3x1gr iv (H3)
4. Infimicyn drip 1x500mg iv (H3)
5. Hyloquin 2x200mg
6. Inj Sankorbin 1gr IV
7. Vit E 1x400mg
8. Pantoprazole 2x20mg IV
9. Dexamethasone 3x1 ampul IV
Kasus bu muji

3. 2/9/20
S :
10. NAC 3x200mg po
Sesak Nafas dirasa semakin memberat
11. Dexamethasone 3x1
+
12. Captopril 3x25mg po
Batuk memberat +
13. Diet Lunak BBS 3x100 + Susu
3x100

O :
INTUBASI on sedasi
KU TSB ,GCS on sedasi
Midazolam 2mg /jam via sp
TD 120/78 Morphine sulfat 1mg/jam via sp
HR 60 Mode
SIMV
S 36,1 Supp 12
RR 32 Rate 16
I:E 1:2
Sat 02 96 % Trigger 3.0
Kepala normochepali CA-/- SI-/- VT 390
Peep 6
Leher dbn Fi02 80%
Thorax :
WOB , Retraksi -/- Prog :

Vesikuler +/+ ,Rh+/+ Wh-/- ,bj ½ reg P Support turun 2 tiap jam max 6
murmur -, Gallop –
FiO2 turun tiap 1 jam max 40%
Abdomen :
BU + ,soelf ,NT epigastrium +
Eks akral hangat ,crt < 3
A:
Covid 19 confirmed kasus sedang-berat

Hipertensi Grade 2

P:

1. IVFD Asering 1000/24 jam

2. 02 NRM 10-15 lpm
3. Inj Meropenem 3x1gr iv (H4)
4. Infimicyn drip 1x500mg iv (H4)
5. Hyloquin 2x200mg
6. Inj Sankorbin 1gr IV
7. Vit E 1x400mg
8. Pantoprazole 2x20mg IV
9. Dexamethasone 3x1 ampul IV
Kasus bu muji

4. 3/9/20 9. NAC 3x200mg po

S :- 10. Dexamethasone 3x1
11. Diet Lunak BBS 3x100 + Susu
O :
3x100 via ngt
KU TSB ,GCS on sedasi
TD 154/90
INTUBASI on sedasi
HR 83 Midazolam 2mg /jam via sp
Morphine sulfat 1mg/jam via sp
S 36,1
Mode
RR 32 SIMV
Supp 10
Sat 02 94 %
Rate 14
Kepala normochepali CA-/- SI-/- I:E 1:2
Trigger 2.0
Leher dbn
VT 390
Thorax : Peep 6
WOB , Retraksi -/- Fi02 60%

Vesikuler +/+ ,Rh+/+ Wh-/- ,bj ½ reg

murmur -, Gallop – Prog :

Abdomen : Check BGA pada pukul 15.00

BU + ,soelf ,NT epigastrium + PH 7,3

Eks akral hangat ,crt < 3 BE -11,6

Urine 1950cc/24 jam PCO2 28,0
Balans -1608 PO2 49
Diuresis 1,01cc/kgbb/jam HCT 37,0
A: HCO3 13,4
Covid 19 confirmed kasus sedang-berat
Total CO2 14,15
Hipertensi Grade 2 O2 sat 80
P:

1. IVFD Asering 1000/24 jam

2. Inj Meropenem 3x1gr iv (H5)
3. Infimicyn drip 1x500mg iv (H3)
4. Hyloquin 2x200mg
5. Inj Sankorbin 1gr IV
6. Vit E 1x400mg
7. Pantoprazole 2x20mg IV
8. Dexamethasone 2x1 ampul IV
Kasus bu muji

5. 4/9/20 9. NAC 3x200mg po

S :- 10. Dexamethasone 3x1
11. Diet Lunak BBS 3x100 + Susu
O :
3x100 via ngt
KU TSB ,GCS on sedasi
TD 108/80
INTUBASI on sedasi
HR 130 Midazolam 3mg /jam via sp 3cc
/jam
S 37
Mode
RR 41 SIMV
Supp 12
Sat 02 95 %
Rate 14
Kepala normochepali CA-/- SI-/- I:E 1:2
Trigger 2.0
Leher dbn
VT 390
Thorax : Peep 6
WOB , Retraksi -/- Fi02 50%

Vesikuler +/+ ,Rh+/+ Wh-/- ,bj ½ reg

murmur -, Gallop – Prog :

Abdomen : MAPturun

BU + ,soelf ,NT epigastrium + Vascon dosis 0,05 mcg/kgbb

target map>65
Eks akral hangat ,crt < 3
Furosemide extra 20 mg
Urine 1800cc/24 jam
Levofloxacin 1x750 mg IV
Balans -1301
Diuresis 0,9cc/kgbb/jam
A:
Covid 19 confirmed kasus sedang-berat

Hipertensi Grade 2

P:

1. IVFD Asering 1250/24 jam

2. Inj Meropenem 3x1gr iv (H6)
3. Infimicyn drip 1x500mg iv (H4)
4. Hyloquin 2x200mg
5. Inj Sankorbin 1gr IV
6. Vit E 1x400mg
7. Pantoprazole 2x20mg IV
8. Dexamethasone 2x1 ampul IV
Pemeriksaan Penunjang

Darah Lengkap: Blood Gas Analisis:

Hb 14,2 PH 7,23

Ht 22,5 BE -12,6

Leukosit 29,54 PCO2 35,6

Trombosit 249.000 PO2 82

Eritrosit 4,6 HCT 39,0

MCV 90,8 HCO3 14,0

MCH 30,3 Total CO2 15,1

MCHC 33,4 O2 sat 95

RDW 13,8

Absolut LIMF count 15,1

Hitung Jenis : Rasio net/limf 21,3

Eosinofil 0,0

Basofil 0,1

Segmen 91,6

Limfosit 4,3

Monosit 4,0

Gds 150

Ureum 146

Cr 1,2

SGOT 63

SGPT 83

Albumin 3,3

Elektrolit

Natrium 146

Kalium 5,80

Clorida 117
Kasus bu muji 6. Vit E 1x400mg

6. 5/9/20 7. Pantoprazole 2x20mg IV

S :- 8. Dexamethasone 2x1 ampul IV

O : 9. NAC 3x200mg po

KU TSB ,GCS E3VettM4 10. Dexamethasone 3x1

TD 141/98 11. Paracetamol 500mg/24jam iv

HR 133 12. Furosemid 20mg/24jam

S 37,7 13. Insulin 10 Unit +D40 50cc hbs

dlm 6 jam
RR ?
14. Ca Gluconas 1 ampul /12 jam
Sat 02 91,6 %
iv
Kepala normochepali CA-/- SI-/-
15. Diet Lunak BBS 3x100 + Susu
Leher dbn 3x100 via ngt

Thorax :

WOB , Retraksi -/-

Vesikuler +/+ ,Rh-/- Wh-/- ,bj ½ reg INTUBASI

murmur -, Gallop –
Mode
Abdomen :
SIMV
BU + ,soelf ,NT -,
Supp 12
Eks akral hangat ,crt < 3
Rate 14
Urine 1540cc/24 jam
I:E 1:2
Balans -220
Trigger 2.0
Diuresis 0,8cc/kgbb/jam
VT 400
A:
Peep 6
Covid 19 confirmed kasus sedang-berat
Fi02 50%
Hipertensi Grade 2

P:

1. IVFD Asering 1000/24 jam

2. Inj Meropenem 3x1gr iv (H6)

3. Levofloxacin 750mg/24 iv (H2)

4. Hyloquin 2x200mg stop

5. Inj Sankorbin 1gr IV

Kasus bu muji 4. Inj Sankorbin 1gr IV

7. 6/9/20 5. Vit E 1x400mg

S :- 6. Pantoprazole 2x20mg IV

O : 7. Dexamethasone 1 ampul
/24jam IV
KU TSB ,GCS E3VettM4
8. NAC 3x200mg po
TD 112/83
9. Dexamethasone 5mg/24 jam
HR 130
iv
S 37,
10. Paracetamol 500mg/24jam iv
RR 24
11. Furosemid 20mg/24jam
Sat 02 91,6 %
12. Insulin 10 Unit +D40 50cc hbs
Kepala normochepali CA-/- SI-/- dlm 6 jam

Leher dbn 13. Ca Gluconas 1 ampul /12 jam

iv
Thorax :
14. Vascon 0,05mg/kgbb jalan 3
WOB , Retraksi -/- cc/jam
Vesikuler +/+ ,Rh-/+ Wh-/- ,bj ½ reg 15. Diet Lunak BBS 3x100 + Susu
murmur -, Gallop – 3x100 via ngt
Abdomen :

BU + ,soelf ,NT -,

Eks akral hangat ,crt < 3 INTUBASI

Urine 1540cc/24 jam Mode
Balans -220 SIMV
Diuresis 0,8cc/kgbb/jam Supp 15
A: Rate 16
Covid 19 confirmed kasus sedang-berat I:E 1:2
ARDS Trigger 2.0
Sepsis VT 400
P: Peep 8
1. IVFD Asering 1000/24 jam Fi02 50%
2. Inj Meropenem 3x1gr iv (H8)

3. Levofloxacin 750mg/24 iv (H3)

Elektrolit :

Natrium 149

Kalium 5,38

Klorida 135

BGA :

PH 7,27

BE -9,7

PCO2 36

PO2 63

HCT 36,0

HCO3 16,4

Total CO2 17,5

O2 sat 90
Kasus bu muji

8. 7/9/20 4. Inj Sankorbin 1gr IV

S :- 5. Vit E 1x400mg

O : 6. Pantoprazole 2x20mg IV

KU TSB ,GCS E3VettM4 7. Dexamethasone 1 ampul

/24jam IV
TD 140/99
8. NAC 3x200mg po
HR 129
9. Dexamethasone 5mg/24 jam
S 37,
iv
RR 32
10. Furosemid 20mg/24jam
Sat 02 93 %
11. Insulin 10 Unit +D40 50cc hbs
Kepala normochepali CA-/- SI-/- dlm 6 jam

Leher dbn 12. Ca Gluconas 1 ampul /12 jam

iv
Thorax :
13. Diet Lunak BBS 3x100 + Susu
WOB , Retraksi -/- 3x100 via ngt
Vesikuler +/+ ,Rh-/+ Wh-/- ,bj ½ reg
murmur -, Gallop –

Abdomen :
INTUBASI
BU + ,soelf ,NT -,
Mode
Eks akral hangat ,crt < 3
SIMV
Urine 990cc/24 jam
Supp 15
Balans -405
Rate 16
Diuresis 0,8cc/kgbb/jam
I:E 1:2
A:
Trigger 2.0
Covid 19 confirmed kasus sedang-berat
VT 400
ARDS
Peep 8
Sepsis
Fi02 50%
Qt Prolongation

P:

1. IVFD Asering 1000/24 jam

2. Inj Meropenem 3x1gr iv (H9)

3. Levofloxacin 750mg/24 iv (H4)

Pemeriksaan Penunjang

Darah Lengkap:

Hb 14,6

Ht 44,1

Leukosit 27,18

Trombosit 106.000

Eritrosit 4,79

MCV 90,8

MCH 30,3

MCHC 33,4

RDW 13,8

Hitung Jenis :

Eosinofil 0,4

Basofil 0,4

Segmen 90,3

Limfosit 3,9

Monosit 5,4

Gds 150

Ureum 197

Cr 1,3

Albumin 3,2

Elektrolit

Natrium 150

Kalium 5,4

Clorida 124
Kasus bu muji 4. Vit E 1x400mg

9. 8/9/20 5. Pantoprazole 2x20mg IV

S :- 6. NAC 3x200mg po

O : 7. Dexamethasone 5mg/24 jam iv

KU TSB ,GCS E3VettM4 8. Insulin 10 Unit +D40 50cc hbs dlm 6

jam
TD 106/72
9. Ca Gluconas 1 ampul /12 jam iv
HR 88
10. Diet Lunak BBS 3x100 + Susu
S 37
3x100 via ngt
RR 15

Sat 02 95 %

Kepala normochepali CA-/- SI-/-

INTUBASI
Leher dbn
Mode
Thorax :
SIMV
WOB , Retraksi -/-
Supp 15
Vesikuler +/+ ,Rh-/- Wh-/- ,bj ½ reg
Rate 16
murmur -, Gallop –
I:E 1:2
Abdomen :
Trigger 2.0
BU + ,soelf ,NT -,
VT 400
Eks akral hangat ,crt < 3
Peep 8
Urine 510CCcc/24 jam
Fi02 45%
Balans -1110

Diuresis 0,26cc/kgbb/jam

A:

Covid 19 confirmed kasus sedang-berat

ARDS

Sepsis

Qt Prolongation

P:

1. IVFD Asering 1000/24 jam

2. Cebactam 1gr/12 jam iv (H2)

3. Inj Sankorbin 1gr IV

BGA :

PH 7,3

BE -6

PCO2 43

PO2 60

HCT 62,0

HCO3 20,3

Total CO2 21,6

O2 sat 90

Elektrolit

Natrium 159

Kalium 5,6

Clorida 127
Kasus bu muji 4. Inj Sankorbin 1gr IV

10. 9/9/20 5. Vit E 1x400mg

S :- 6. Pantoprazole 2x20mg IV

O : 7. NAC 3x200mg po

KU TSB ,GCS E3VettM6 8. Dexamethasone 5mg/24 jam iv

TD 160/102 9. Insulin 10 Unit +D40 50cc hbs dlm 6

jam
HR 88
10. Diet Lunak BBS 3x100 + Susu
S 37
3x100 via ngt
RR 19

Sat 02 90 %

Kepala normochepali CA-/- SI-/-

INTUBASI
Leher dbn
Mode
Thorax :
SIMV
WOB , Retraksi -/-
Supp 13
Vesikuler +/+ ,Rh-/- Wh-/- ,bj ½ reg
Rate 16
murmur -, Gallop –
I:E 1:2
Abdomen :
Trigger 2.0
BU + ,soelf ,NT -,
VT 385
Eks akral hangat ,crt < 3
Peep 8
Urine 1410cc/24 jam
Fi02 45%
Balans -1419

Diuresis 0,74cc/kgbb/jam

A:

Covid 19 confirmed kasus sedang-berat

ARDS

Sepsis

Qt Prolongation

P:

1. IVFD Asering 525/24 jam

2. Cebactam 1gr/12 jam iv (H3

3. Levofloxacin 750mg/24 jam IV (H5)

 3. Levofloxacin 750mg/24 jam IV (H5)
stop
Kasus bu muji
4. Inj Sankorbin 1gr IV
11. 10/9/20
5. Vit E 1x400mg
S :-
6. Pantoprazole 2x20mg IV
O :
7. NAC 3x200mg po
KU TSB ,GCS E4VettM6
8. Dexamethasone 5mg/24 jam iv
TD 153/104
9. Insulin 10 Unit +D40 50cc hbs dlm 6
HR 124
jam
S 37
10. Vascon jalan 0,05 mcg /kgbb jalan
RR 24 3 cc/jam

Sat 02 92 % 11. Dobutamin 1 ampul jalan

5mcg/kgbb/jam jalan 3cc/jam
Kepala normochepali CA-/- SI-/-
12. Diet Lunak BBS 3x100 + Susu
Leher dbn 3x100 via ngt
Thorax :

WOB , Retraksi -/-

Vesikuler +/+ ,Rh-/- Wh-/- ,bj ½ reg INTUBASI

murmur -, Gallop –
Mode
Abdomen :
SIMV
BU + ,soelf ,NT -,
Supp 12
Eks akral hangat ,crt < 3
Rate 14
Urine 1200cc/24 jam
I:E 1:2
Balans -651
Trigger 2.0
Diuresis 0,62cc/kgbb/jam
VT 440
A:
Peep 8
Covid 19 confirmed kasus sedang-berat
Fi02 50%
ARDS

Sepsis

Qt Prolongation

P:

1. IVFD Asering 525/24 jam

2. Cebactam 1gr/12 jam iv (H4)