LAPORAN KASUS

Pria 28 tahun dengan Suspek C

ovid-19
dr. Nadia Luthfiana Vashti

Pembimbing:
dr. Ammy Fahmy Myala
 Identitas Pasien

Nama : Tn. MH
01 TTL/ Umur : Madura, 20-08-1992/ 28 tahun
Jenis Kelamin : Laki-laki
Alamat : Jl. Kampung Baru RT.14/RW.10, Kel. Pulogadung, Kec. Pulogadung
Agama : Islam
Pendidikan Terakhir : S1
Status : Menikah
Pekerjaan : Karyawan Swasta
Tanggal Kunjungan : 14 Januari 2021
Anamnesis
Keluahan Utama
Demam, batuk berdahak, pilek sejak 1 minggu lalu

Keluhan Tambahan
Nyeri kepala, mudah lelah

Riwayat Penyakit Sekarang

Pasien datang ke puskesmas dengan keluhan demam yang
dirasakan sepanjang hari sejak 1 minggu lalu. Gejala tersebut
dirasakan bersamaan dengan batuk berdahak dan pilek. Pasien
juga merasa nyeri kepala dan kelelahan. Pasien mengatakan
belum mengkonsumsi obat apapun. Riwayat bepergian keluar kota
dalam 14 hari terakhir disangkal, Riwayat kontak dengan pasien
terkonfirmasi/probable Covid-19 juga disangkal
 Anamnesis
Riwayat Penyakit Dahulu
Riwayat keluhan yang sama sebelumnya disangkal. Riwayat darah tinggi, kencing manis
disangkal. Riwayat asma disangkal. Riwayat alergi obat dan makanan disangkal.

Riwayat Penyakit Keluarga

Keluhan yang sama juga ada pada istri pasien.
Riwayat kontak dengan keluarga dan lingkungan yang terkonfirmasi/probable Covid-
19 disangkal. Riwayat alergi, asma, darah tinggi dan kecing manis disangkal

Riwayat Psikososial
Pasien tinggal di lingkungan yang cukup padat penduduk. Kebersihan dalam rumah cukup
diperhatikan. Pasien dan keluarga juga selalu memakai masker ketika keluar rumah. Pasien
tinggal bersama istri dan 2 anak pasien.
 Pemeriksaan Fisik
Keadaan umum: tampak sakit ringan Status Generalis

Kesadaran: compos mentis Kepala: normocephal, rambut warna

hitam, distribusi merata, tidak mudah
Tanda vital: rontok.
TD : 120/80 mmHg Mata: konjungtiva anemis -/-,
HR : 80 x/menit sklera ikterik -/-, reflek cahaya (+/+),
pupil isokor.
RR : 20 x/menit
THT-KL : T1-T1, faring hiperemis (-)
Suhu : 36,7o C
Paru : SNV +/+, wh -/-, rh -/-
SpO2 : 99%
Jantung : S1/S2 regular, murmur -, gallop
Antropometri :
–
BB : 80 kg, TB : 167 cm
Abdomen: supel, datar, BU (+) normal,
IMT : 21.51 (Ideal) nyeri tekan epigastrium (-)
Ekstremitas : akral hangat, CRT < 2 detik,
edema -/-/-/-
DIAGNOSIS SEMENTARA DIAGNOSIS BANDING
Suspek Covid-19 • Infeksi Saluran Pernapasan Akut
• Common Cold
Pemeriksaan Penunjang

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DIAGNOSIS KERJA PENATALAKSANAAN

Infeksi Pernapasan Akut  Pro rawat jalan

 Obat:
- Paracetamol 500mg tab 3x1
- Gliseril guaikolat 100mg tab 3x1
- Loratadin 10mg tab 1x1
- Vitamin C 50mg tab 3x1

 Edukasi:
- Edukasi cara pemberian obat dan
kepatuhan meminum obat
- Kontrol kembali jika gejala memberat
- Anjuran untuk memakai masker,
mencuci tangan dan menjaga jarak
 Perjalanan Penyakit
Kamis Jumat Sabtu Minggu Senin

14/01/21 15/01/21 16/01/21 17/01/21 18/01/21

S: Demam, batuk S: Batuk berdahak, S: Batuk berdahak, S: Batuk berdahak, S: Batuk, Hasil
berdahak, pilek, pilek, meriang sore pilek, meriang, pilek, penciuman PCR negatif
nyeri kepala hari penciuman berkurang O: afebris
O: febris O: febris berkurang, hambar O: afebris A: ISPA
A: ISPA A: ISPA O: febris A: ISPA P: GG100mg tab
P: PCT 500mg tab P: Swab PCR A: ISPA P: GG100mg tab 3x1, Loratadin
3x1, GG100mg PCT 500mg tab P: PCT 500mg tab 3x1, Loratadin 10mg tab 1x1,
tab 3x1, 3x1, GG100mg 3x1, GG100mg 10mg tab 1x1, Vitamin C 50mg
Loratadin 10mg tab 3x1, tab 3x1, Vitamin C 50mg tab 3x1
tab 1x1, Vitamin Loratadin 10mg Loratadin 10mg tab 3x1
C 50mg tab 3x1 tab 1x1, Vitamin tab 1x1, Vitamin .
C 50mg tab 3x1 C 50mg tab 3x1
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