210 S: sesak berkurang.

Pasien Diet: Plan: 14/2-14/2NIV-15/2-16/2-17

Roma Ida Br Siregar sudah bisa tidur. Mobilisasi Peptisol 6x250cc (@250 kkal) -> - Cek GDS pagi-siang 18/2-19/2-20/2
Tgl lahir/usia : 04-07- aktif Batuk kering sesekali diet lunak - Fisioterapi mobilisasi ph 7,418-7,513-7,49-7.48-7
1958/62thn - Swab per 3 hari (15/3) 7,54-7,48
DPJP: dr. Lucas Sp.PD O: Oral: - Rawat luka 2x1 p02 52-30-125-81-76-79-10
Raber : dr ketty spB Kes : CM, E4M6V5 -co-amoxiclav 3x625mg po H4 - acc dpjp pindah modular pco2 23-30-28-34-28-33-39
TD : 129/83 (11/2) hco3 18-24-21-25-22-28-29
Tanggal di rawat di HR :75 -clindamycin 3x300mg po H4 GDS BE 18/1,9/-1/1.3/-1.5/6/+5
ICU RSPJ : 14/02/21 RR : 20x/ menit (11/2) 11/3: 192 Sa 88-96-99-97-96-97/98
Onset : 11/02/21 S : 36,5 - Isoprinosin 4x500mg H8 (7/3) 12/3: 99
Masuk HCU Sat: 99% on NK 3 lpm k/p RA - Lansoprazole 2x30mg 13/3: 136, 140 21/2-23/2-24/2-25/2-26/2-
02/03/2021 97-99% - NAC 3x200mg 14/3: 124, 198 28/2
PH: 27 - Vit C 2x500mg Ph 7.56-7.56-7,51-7.51-7.49
onset: 30 - Vit D3 1x1000 u Debridement 11/3 oleh dr Ketty, SpB 7.47-7.48
A: - Zinc 2x20mg PO2 148-60-75-181-135-11
Bb : 64 kg - Confirmed Covid 19 - Atorvastatin 1x20mg Instruksi dr.ketty Sp.B 13/3: PCO2 41-41-38-30-32-29-37
Tb : 165 cm - ARDS severe ec pneumonia - Melatonin 2x16mg Debri sore HCO3 36-7.7-30-23-24-21-2
- Hipokalemia - Yakult 3 x 1 botol Siapkan lidocaine, sufratule, bisturi BE 13/93/+7,3/-.4/1/-2/3.7
RS asal: RS Omni - Hipertensi + cetirizine 1x10mg Rawat luka 3x1 dengan salep SaO2 99-93-96-99-99-99-94
Pekayon - Peningkatan enzim - Kolkisin 1x0,5mg burnazin
Tanggal dirawat: transaminase - Burnazin salep 01/3-2/3
09/02/2021 - Hipoalbuminemia - Candesartan 1x8mg po Visite dr pasha sppd 14/3 : (adv ph 7,38-7.46
perbaikan - Amlodipine 1x5mg po dpjp tdk perlu pantau aptt) p02 159-79
Status Covid19 -Ulkus Pedis dextra (post - Alprazolam 1x0.25mg bila tidak ada tindak lanjut dari pco2 26-39
PCR test : di RS Omni debridement) bedah acc pindah modular hco3 15-27
Pekayon Lain: krn d-dimer 2.02 (tgl 12/3) saran BE -9/3.4
09/02/2021 Nebulizer 3x sehari heparin 2x7500 sc Sa 99-96
Hasil : POSITIF pulmicort+Combivent pantau aptt/24 jam, selama aptt
(Ct:26,29/26,54) Burnazin zalf masih <2.5x kontrol heparin sc tetap 14/2-15/2-16/2-17/2-17/2s
4/3: Positif CT Heparin 2x7500 sc lanjut 18/2-19/2-20/2
30.06/30.85 Hb 10,8-8,8-8.7-9.3-11.2-11
6/3 : Positif CT RPO: adv dr ketty SpB 14/3: 10,3-10
27.54/28.56 Plasmanate 1 fl/12 jam 1hari acc pindah modular Ht 35,1-28,1-28.9-30.6-36.3
9/3: Positif KCL 50meq/24 jam (15/2) perawatan luka 2x1 dengan burnazin 36.5-34,1-32,8
34.48/36.06 Terapi RS Omni Pekayon : Leu 19,8-15-13.7-15-15.8-1
12/3: Positif Levofloxacin 1x750 mg 11-9,8
35.1/35.59 Azithromycin 1x500 mg Trom 345-305-284-347-319
Methopi 4x500 mg 245
Radiologi Oseltamivir 2x75 mg NLR 38,96-20,9-14.2-14.0-1
Ro thorax di RS KCL 30 meq dalam 3 jam lanjut 75 9,2-14,9-19
sebelumnya: (9/2) meq dalam 24 jam 16/2 LED 112
kesan pneumonia, cor -PRC 2 bag 17/2
dalam batas normal - Kokreksi KCL 75 meq/24 jam 21/2-22/2-23/2-24/2-24/2s
(start 20.30 17/2) 25/2-26/2-27/2-28/2
RO Thorax 14/2 - Kolkisin 2x0,5mg Hb 12.1-10,8-6.2-8,4-9.7-10
Severe Pneumonia - Ivermectin 0,4 mg/kg (24mg) utk 9.5-9.3-8.8
H1 (14/2) ,H3 (16/2) dan H5 (18/2) Ht 39.3-33,5-19.3-26,9-30.5
RO Thorax 15/2 -> Besok STOP 19/2 32.2-30.5-29.1-27.7
Sugestif pneumonia ec - Doxycycline 1 x 100 mg 5 hr Leu 11.1-15,7-13.5-12,7-17-
viral. (15/2-18/2) -> besok STOP 19/2 14.3-9-6.3
Pasca intubasi, posisi + Albumin 20% (start 19/2-20/2) Trom 294-222-141-122-123
tip distal ETT setinggi -> STOP 129-148-142
2 korpus vertebra di - Meropenem 3 x 1 gr (14/2) NLR 22.2-x-11.91-20.2-15.3
atas karina, Tidak - Moxifloxacin 1 x 400 mg 7.3-7
tampak komplikasi. (14/2)STOP
- Miloz 5 mg/jam stop 01/3-2/3
Ro thorax 16/2 - Propofol 50 mg/jamstop Hb 10,1-10.1
Pneumonia -Icunes 0,2mg STOP Ht 32,3-31.7
perburukan - Remdesivir 1x200 mg-> 1x100 Leu 7,4-5.4
dibandingkan dengan mg (15/2) -> stop Trom 163-170
foto tanggal - Heparin 20.000 u/24jam -> NLR 7,09-4
15.02.2021 10.000u/24 jam  tunda
- Lasix drip 3 mg/jam -> STOP 14/2-15/2-15/2u-16/2-17/2
Ro thorax 20/2 -Nicardipin titrasi -> STOP 18/2-19/2-20/2-21/2-24/2-
Status pneumonia, - bisolvon syrup 3 x C1 26/2-27/2-28/2-01/3-2
dibandingkan - KSR 3x4  STOP PT 0,976x
sebelumnya saat ini - Ascardia 1x80  tunda APTT 1,42x->2 menit-0,8x-0
perbaikan. - MP 2x125 mg 3 hari,(14/2-16/2) 3.4x-1,2x-2,9-0,77-1.1x-0,78
-> 2x80 mg (17/2) MP 2 x 40 mg 0,81x-1.4x-1.3x-1.1x-0,9x-1x
RO Thorax 25/2 (23/2)  1 x 40 mg (24/2)  lalu
Status pneumonia, STOP ganti oral 14/2-20/2-22/2-5/3-12/3
dibandingkan - rencana medixon tab 2 x 8 mg D-dimer 3.80- 10.15-4,71-3,
sebelumnya saat ini (25/2-26/2)  2x4mg (27/2-28/2) 2.02
relatif stqa. lalu stop
- SNMC 1 X 2 amp (14/2) -> naik 14/2-20/2-23/2
Ro Thorax 6/3 2x2 A (19/2 s/d 21/2) -> lanjut Ferritin 1666-982.80-937.10
Status pneumonia, 22/2-26/2 CRP 102-8-5
dibandingkan - CPG 1x75 mgSTOP
sebelumnya saat ini - Tygacil 100 mg, lanjut 2 x 50 mg 15/2-23/2
perbaikan. (23/2)->STOP PCT 3.19-0,09
- Fluconazole 1 x 400 mg (14/2)->
CT-scan thorax 15/2 STOP 14/2-18/2-22/2-26/2
Severe Pneumonia, - Colchicine 2 x 0,5 mg  STOP OT 92-99-85-45
sugestif Viral Infection - CPG STOP PT 123-118-99-69
- Tygacil dan Xarelto ijin habis
USG Abdomen dr -Rencana SWAB 01/03. Jika 14/2-15/2-18/2-25/2
Sutrisno SpRad (24/2) Negatif rujuk Mayapada Ureum 16-30-72-55
- Riwayat -Fluco dan Moxi STOP Cr x-0,6-0,7-0.5
hysterectomy - rencana medixon tab 2 x 8 mg
- Sonografi tak tampak (25/2-26/2)  2x4mg (27/2-28/2) 14/2
kelainan pada organ- lalu stop As laktat 4,6
organ intra-abdominal - ekstra dulcolax supp
lain nya saat ini - ekstra ketorolac 30 mg 14/2-16/2-17/2-18/2-24/2-
+ Xarelto 1x15mgSTOP 27/2
ICON 15/2 - Novorapid drip titrasi Na 136-144-143-141-146-14
SV cukup, CO cukup, - Cefosulbac 2x2gr (23/2-3/3) 140
FTC cukup, ICON - RL 500 ml/ 12 jam  Standby K 2,4-2.8-3.3-4.0-4,6-3.8-3.5
kurang, TFC - Lactulac syr 3x10 ml Cl 96-92-103-104-100-92-92
cukup,SVR cukup - Omeprazole 2 x 40 mg
- Resfar 1 x 5 gr 27/2-8/3
Icon 20/2 - + Codein tab 3x10mg Ca serum 12.1-10.7
SV,ftc, cukup TFC SVR - Vip albumin 3x2caps STOP Magnesium 3-x
lebih co icon kurang - Cefixime 2x200mg (3/3) H7
- Lixiana 1x30mg H7 s/d H7 (8/3) 15/2-24/2
GDS: 225-175

TPK 1 16/2 start 04.00-07.00 15/2-18/2-21/2-24/2-8/3

TPK 2 17/2 start 05.45-08.45 Albumin 3.3-3,1-3.9-3,2-3.6
TPK 3 19/2 start 00.30-02.30
TPK 4 22/2 start 11.00 – 13.30 16/2
HbA1c 5.4
PRC 1 16/2
PRC 2 17/2 12.00 – 15.00 17/2
PRC 3 23/2 12.00 IL-6 4.8 (n=<7)
PRC 4 23/2 16.00
PRC 5 24/2 21.00 18/2
PRC 6 01/3 00.30 Biltot 0,8

Gamarass 1 18/2 start 05.00 Kultur Sputum 15/2

Gamarass 2 20/2 start 05.00 Biakan negatif
Gamarass 3 21/2 start 12.20
Gamaras 4 FU dpjp -> TIDAK 24/2
LANJUT, CUKUP 3 Feses Rutin
Makroskopik: Konsisten: lem
Warna: coklatLendir: Negati
Darah: negative

Mikroskopik: Eritrosit: 0-1,

Leukosit: 0-1
Telur cacing: - Cacing: - Amo
- Kista: -
Lemak: - Jamur: -
24/2
MDT normositik, normokro

Kultur sputum 15/2

Biakan negatif