VVIP.

LH/L/51thn
Hari Perawatan ke
Diagnosis : Sepsis ec pneumonia + Pneumonia lobaris + Efusi pleura bilateral + Hipertensi Grade II + CHF IV ec
HHD dd CAD + Anemia renal + CKD 5 on HD ec HNS dd OKD + DM Tipe 2

S = Sesak
O = KU : Sedang , Kes : CM
B1: RR: 36x/m, SpO2: 98%
Sp: Bronkovesikuler, Rh:-/-, Wh:-/-
B2: TD: 155/90mmHg, Nadi: 101x/m, BJ I-I reguler, bising(-),
Sb:36,0oC
B3: GCS E5M6V4, pupil bulat isokor 3mm/3mm
B4: kateter (-)
B5: Abdomen datar, lemas, BU (+) N
B6: akral hangat, edema (-)
Hasil Laboratorium
01 Oktober 2017
Leukosit 8700/uL Ureum Darah 95mg/dL
Eritrosit 2.92 10^6/uL Creatinin Darah 4.6mg/dL
Fosfor 2.5mg/dL
Hemoglobin 8.7g/dL
Magnesium 2.30mg/dL
Hematokrit 25.9% Chlorida DaraH TAP
Trombosit 228 10^3/uL Kalium Darah 3.80mEq/L
MCH 29.8pg Natrium Darah 141mEq/L
Calsium 7.94mg/dL
MCHC 33.6g/dL
MCV 88.7fL
Medikasi
Asam Folat 400mcg/12jam
Atorvastatin 20mg/24jam
Telmisartan 20mg/24jam
Bisoprolol 1.25mg/24jam
Gliseril triniloat 2.5mg/12jam
Tromboaspilet 80mg/24jam
Carvedilol 6.25mg/12jam
Levofloxacin 500mg/48jam
Ranitidin 50mg/12jam
Nebulisasi combivent+pulmioost/8jam
 Bed 19. NT/P/73thn
Hari Perawatan ke-24
Diagnosis: Penurunan Kesadaran ec Sepsis + Hipotensi + AKI Superimposed CKD + CHF ec Suspek VHD
+ Hipoalbuminemia + HipoNa+ Hipo K Ringan

S : kontak (+) Batuk (+)

O : KU berat, Kesadaran apatis
B1: RR 20x/m, SpO2 100% dengan NRM 18lpm
Sp: Vesikuler, Rh +/+, Whz -/-
B2: TD 117/72mmHg (dengan Norepinephrine, Vasopresin, dan Dobutamin),
Nadi 95x/m, Isi Cukup, BJ I-II reguler, Sb 36,9oC
B3: GCS , pupil bulat isokor
B4: Kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (+)
Medikasi
KSR 600mg/12jam
Atorvastatin 20mg/24jam
Digoxin 0.25mg/24jam
Dobutamin 5mcg/kgBB/menit
Zinc 20mg/24jam
Levofloxacin 500mg/48jam
Fluoconazole 400mg/24jam
Rilus 2x1tab
New Diatatis 2 tab tiap BAB cair
 Bed 20. LS/P/66thn
Hari Perawatan ke 2
Diagnosis: Gagal napas on ventilator + penurunan kesadaran ec CVD SH (ICH Temporoparietal Dextra) + SAH Non
Trauma onset H2 + HVH Bilateral + Hipertensi Emergency + Hiperglikemia ec Stress Metabolik

S: penurunan kesadaran
O: Ku berat, Kesadaran Koma
B1: RR 20x/m, SpO2 100% dengan Ventilator VC-AC
Sp Vesikuler, Rh -/-, Wh -/-
B2: TD 90/53mmHg (dengan norepinephrine, dobutami , dan
vasopresin), Nadi 56x/m, BJ I-II reguler, Bising(-), Sb 37oC
B3: GCS E1M1Vx, Pupil midriasis bilateral
B4: Kateter(+)
B5: NGT Terpasang, Abdomen datar lemas, BU(+)
B6: Akral hangat
Analisis Gas Darah
1 Oktober 2017
pH: 7.417
pCO2: 40.7
pO2: 241.1
SO2: 99.2
HCT: 34
Hb: 11.2
HCO3: 26.4
BEecf: 1.7
BEB: 2.4
PO2/FiO2: 241.1
Medikasi
Sucralfat Syrup 10mL/6jam
Nimodipin 60mg/6jam bila TD 136/86
Lactukosa Syrup 7mg/24jam
Manitol 20% loading 300mL lanjut 150mL/6jam
Asam Tranexamat 1gr/6jam
Omeprazole 40mg/12jam
Paracetamol 1gr/8jam
Norepinefrin 0,05-1,5mcg/kgBB/jam
Vasopresin 1.8unit/jam
Nebulisasi NaCl 0.9/8jam
 Bed 5. YM/P/75thn. BB: 65kg
Hari Perawatan ke
Diagnosis: Gagal Napas Terpasang Ventilator + Penurunan Kesadaran ec Stroke Iskemik Emboli Luas Onset
H13 + AF NVR + CHF fc.II + Hematemesis ec Stress Ulcer + Hipokalemia

S: penurunan kesadaran
O: KU berat, Kesadaran: Coma
B1: RR 20x/m terpasang Ventilator VC-AC, Sp Vesikuler, Rh -/-, Whz -/-
B2: TD 90/50mmHg (dengan norepinefrin dan vasopresin), BJ I -II
reguler, bising (-), Sb 37oC
B3: GCS E1M1Vx, pupil midriasis bilateral
B4: Kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (+)
Aanalisis Gas Darah
1 Oktober 2017
pH 7.501
pCO2 36.1
pO2 58.7
SO2 91.9
SpO2 97%
HCT 33
Hb 11.1
HCO3 28.5
pO2/FiO2 83.8
 Medikasi
Sucralfat Syrup 1gr/6jam
Atorvastatin 20mg/24jam
Bisoprolol 2.5mg/24jam
Simarc 2mg/24jam
Furisemide 20mg/24jam
Spirondakton 20mg/12jam
Meropenen 1gr/8jam
Omeprazole 40mg/12jam
Paracetamol 1gr/8jam
Novorapid drips 0.5 unit
Norepinefrin dosis titrasi
Vasopresin dosis titrasi
 Bed 4. PC/L/17thn. BB: 70kg
Hari Perawatan ke
Diagnosis: Gagal napas terpasang ventilator melalui trakeokanul + penurunan kesadaran ec
edema serebri + Fr. Basis Kranii + Pneumonia HAP + Post hematemesis

S: penurunan kesadaran
O: KU sedang, Kesadaran somnolen
B1: RR 14x/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 132/83mmHg, Nadi 69x/m, BJ I-II reguler, bising (-), Sb 35,8oC
B3: GCS E3M5V1, pupil bulat isokor d:3mm/3mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral dingin, edema (-)
Analisis Gas Darah
1 Oktober 2017
pH 7.540
pCO2 35.1
pO2 96.2
HCO3 33.8
TCO2 35
BEecf 11
BEb 11.1
pO2/FiO2 594.1
Medikasi
Zinc 20mg/12jam
Vit C 200mg/12jam
Sucralfat syrup 10mL/6jam
N-asetilsistein 200mg/8jam
B1B6B12 1 tab/8jam
Nebulisasi NaCl 0.9%/8jam
Tygesiklin 50mg/12jam
Omeprazole 40mg/12jam
Paracetamol 1gr/8jam
 Bed 24. SL/P/60th
Hari Perawatan ke 10
Diagnosis : post gagal napas terpasang ventilator, post kraniotomi dekompresi ec EDH + ICH + , DM
tipe 2, anemia ec perdarahan akut.

S: penurunan kesadaran
O: KU berat, Kesadaran delirium
B1: RR 14x/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 107/54mmHg, Nadi 112x/m, BJ I-II reguler, bising (-), Sb 35,8oC
B3: GCS E4M6V2, pupil bulat isokor d:3mm/3mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
01 Oktober 2017
pH 7.592
pCO2 37,0
pO2 81,3
HCO3 86
BEecf 14,1
Hb 9,8
Beb 13,9
HCT 29
PO2/F1O2 354,5
Medikasi
Amlodipin 10 mg/24 jam
Valsartan 80 mg/24 jam
Paracetamol 500 mg/8 jam
Sucralfat syr 10 ml(1 gr)/6 jam
Ceftriaxone 1 gr/24 jam
Ranitidin 50 mg /12 jam
Novorapid 10 unit/ 6 jam
Levemir 14 unit pada 22.00
Nebursasi NaCl 0,9%/8 jam
Omeprazole 40 mg/12 jam
Asam tareksamat 500 mg/8 jam
 Bed 9. MM/P/60 thn
Hari Perawatan Ke 14
Diagnosis : post gagal napas dengan NIV, post penurunan kesadaran ec metabolik dd sepsis, NSTEMI +
hipertensi terkontrol + CHF Fc III + hiperu , hiperkolestrolemia + hiperalbumin

S: sesak
O: KU berat, Kesadaran cm
B1: RR 20x/m, SpO2 100% tanpa Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 128/72mmHg, Nadi 92x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E4M6V5, pupil isokor 3 mm/3 mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Medikasi
Allopurinol 100 mg/24 jam
Atorvastatin 20 mg/24 jam
Bisoprolol 2,5 mg/24 jam
Amlodipine 10 mg/24 jam
Telmisartan 80 mg/24 jam
Gliseril trinitlat 2,5 mg/12 jam
Asam x 80 mg/24 jam
Clopidogrel 75 mg/24 jam
Asam folat 400 mg/12 jam
FSR 600 mg/12 jam
Sucralfat 10 ml/6 jam
Levofloxacin 750 mg/24 jam
Furosemid 5-20 mg
Miconazole zalf kulit-gosok/12 jam
Nebulisasi NaCl 0,9%/8 jam
Levemir 18 unit
Novorapid 10 unit
 Bed 8. BS/L/50 th
Hari Perawatan ke
Diagnosis : gagal napas terpasang ventilator, penurunan kesadaran ec CVD SH (ICH ganglia basalis), post
hematemesis ec stress ulcer+ DM tipe 2 + hipertensi, epilepsi fokal + penumonia + hiperalbuminemia

S: penurunan kesadaran
O: KU berat, Kesadaran coma
B1: RR 24/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/-, Whz -/-
B2: TD 164/58mmHg, Nadi 117x/m, BJ I-II reguler, bising (-), Sb 36,5oC
B3: GCS E1M1Vx, pupil midriasis bilateral d:
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
01 Oktober 2017
pH 7.483 PO2/F1O2 354,5
pCO2 36,5
pO2 212,7
HCO3 27,6
BEecf 3,9
Hb 13,3
Beb 4,7
HCT 40
Medikasi
Sucralfat syr 10 ml/6 jam
Amlodipin 10 mg/24 jam
Fenitoin 100 mg/8 jam
Asam folat 400 mg/12 jam
B1B6B12 1 tab/8 jamMerspenem
1 gr/8 jam
Omeprazole 40 mg/12 jam
As. traneksamat 1000 mg/6 jam
Paracetamol1 gr/8 jam
Fentanyl 12,5 mg/ jam
Novorapid 6 unit
Levemir 12 unit
Nebulisasi NaCl 0,9% / 8 jam
GDS 4 porsi
 Bed 7. JK/L/62 th
Perawatan Hari ke 12
Diagnosis : post gagal napas terpasang ventilator, penurunan kesadaran ec CVD SH (ICH pons 15,
hipertensi + hipoalbumin +'hipoNa + hipoCa, post hematemesis ec stress ulcer

S: Penurunan kesadaran
O: KU berat, Kesadaran somnolen
B1: RR 17/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 116/72mmHg, Nadi 97x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E2M2Vx, pupil midriasis bilateral
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
01 Oktober 2017
pH 7.576
pCO2 47,2
pO2 143,5
HCO3 44,3
BEecf 22,2
Hb 11,6
502/0 98,7
HCT 35
PO2/F1O2 177,2
Medikasi
N-asetilsistein 200 mg/8 jam
Amlodipin 10 mg/24 jam
Valsartan 160 mg/24 jam
Lactulosa syr 10 ml/24 jam
Sucralfat 10 ml/6 jam
Tigesiklin 50 mg/12 jam
Omeprazole 40 mg/12 jam
Asam traneksamat 500 mg/8 jam
Paracetamol 1 gr/8 jam
Fentanyl 25 mg/
 Bed 6.FK/L/68 th
Perawatan Hari ke 3
Diagnosis : gagal napas terpasang ventilator, sepsis ec pneumonia+ penumonia aspirasi, CKD 5 on HD
ec HNS dd urate nephropathy, anemia renal + hiperkalemia + hiponatremia, asidosis metabolik

S: penurunan kesadaran
O: KU berat, Kesadaran delirium
B1: RR 37/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh -/+, Whz -/-
B2: TD 130/58mmHg, Nadi 82x/m, BJ I-II reguler, bising (-), Sb 37oC
B3: GCS E3M4Vx,
B4: kateter (+)
B5: NGT terpasang, abdomen cembung, BU(+)
B6: akral hangat, edema (+)
Analisa Gas Darah
01 Oktober 2017
Ph 7.168
PcO2 36
PO2 67
SO2 86,6
HCT 20
Hb 6.7
BEeCF -15,6
HCO3 13,2
PO2/FiO2 83,7
Medikasi
Asam Folat 400 mg/12 jam Kalitake 3x1 sach/oral
Amlodipin 5 mg/24 jam Norepinefrine dosis titrasi
Micardis 80 mg/24 jam Vasopresin dosis titrasi
Allopurinol 100 mg/24 jam Furosemide 5-20mg
Omeprazole 40 mg/12 jam Fentanyl12,5-50 mg
Paracetamol 500 mg/8 jam Midazolan 1-5 mg
Nebulisasi ventolin + NaCl 0,9%/8 Meropenen loading 1gr
jam