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HCU

Bed 6
Tanggal : 3 Mei 2020
Masuk RS : 27 April 2020
Hari Rawat :7
Nama pasien : Tn Irwan / 33 th
Diagnosis : Respiratory failure ec CAP (Swab PCR negative) + Edema Paru + ESRD on
CAPD dan HD + Decomp Cordis FC 4 + HT stg 2 + Konjungtivitis Hemoragic ec viral infection
DPJP : Dr.dr. Erwin Pradian, Sp.An-KIC,KAR,MKes

CNS : DPO ( Midazolam 3 mg/jam )


CVS :
TD : 141/68 mmHg
HR : 96 kali/menit
PSIMV Pins 18 PS 18 PEEP 8 Rate 6 FiO2 50% I : E rasio 1:3
Vt PIns 540-600 ml
MV 5-5.6 Ppeak 28-29
RR : 8-10 kali/menit
SpO2: 99%
Suhu : 37 C
GIT
Retensi (-) NGT bening
GUT
Urin Output : -
Balance : - 400/24 jam
Lab 3/5/2020
(19.00)
Laktat 1,1
pH 7,402 pCO2 33,7 pO2 188,8 HCO3 21,2 tCO2 22,2 BE -2,6 SO2 96,6
(04.18)
Hb 7,7 Ht 23,6 Leu 5.680 Tr 223.000
PT 11.7 INR 1.05 aPTT 29,6 CRP 21,71 Ur 82,7 Cr 8,29
Na 133 K 2,9 Cl 96 Ca 4.53 MG 1.8
pH 7.317 pCO2 49,0 pO2 54,7 HCO3 25,3 BE -0.3 SaO2 83,7

2/5/2020
(13.06)
Hb 8,1 Ht 24,6 Leuko 8260 Tr 223.000
PT 11,4 INR 1,02 aPTT 27,70
Ur 66,7 Kr 6,64
Na 134 K 3,0 Ca 4,53
pH 7,371 pCO2 44,1 pO2 170,1 HCO3 25,8 BE 1,3 SpO2 96,9

1/5/2020
(19.00)
Laktat 1,0
pH 7,342 pCO2 45,1 pO2 137 HCO3 24,6 tCO2 26 BE -0,4 SO2 98,6
(06.00)
Hb 9.0 Ht 27.8 Leu 9370 Tr 230000
PT 11.7 INR 1.04 aPTT 51.8 CRP 19.8 Ur 98.7 Cr 9.75
Na 131 K 3.4 Cl 96 CA 4.28 MG 1.8
Laktat 0.5 pH 7.271 pCO2 55.0 pO2 113.0 HCO3 25.5 BE -0.5 SaO2 95.9

30/4/2020
Na 137 K 4,0 Cl 99 Ca 4,44
pH 7,166 pCO2 77,3 pO2 84,1 HCO3 28,2 tCO2 30,5 BE - 1,2 SO2 92,2
PF ratio 120
PT 10,3 INR 0,92 APTT 28,2
Bilirubin total 0,327 Bilirubin direk 0,103
Albumin 2,44
Fibrinogen 750,2 D-dimer 2,51
Hb 10,3 Ht 32,2 L 9.840 Tr 220.000
Ureum 60,3 Creat 5,89 Na 135 K 3,6 Cl 98 Ca 4,12 Mg 1,6 GDS 107
pH 7,255 pCO2 61,7 pO2 103,7 HCO3 27,6 be 0,4 SpO2 96,8

29/04/2020
Hb 6.8 Ht 21.1 Leu 10.760 Trombosit 171.000 PT 10.9 INR 0.97 aPTT 30.1 CRP Kuantitatif
17.32 GDS 147 Albumin 2,02 Ureum 108 Cr 9.98 Na 137 K 3.3 Cl 99 Ca 3.85 Mg 1.8
pH 7.216 pCO2 105.7 HCO3 28 Be 1.3 SaO2 90.2
AGD Jam 9.30
pH 7.186 pCO2 74.5 pO2 137 HCO3 28.2 Be 0 SaO2 98 %

28/4/2020
(20.00)
Hb 7,8 Ht 23,1 L 14.720 Tr 230.000
Ureum 70,1 Creat 6,36 Na 133 K 3,4 Cl 100 Ca 5,43 Mg 1,8 GDS 93
pH 7,258 pCO2 59,9 pO2 224,8 HCO3 27,0 be 0,2 SpO2 99,6
(10.18)
Hb 8,0 Ht 24,6 L 19.880 Tr 243.000 Basosil 0 Eosi 0 Batang 0 Segmen 88 Limfosit 6 Monosit 5
PT 16,9 aPTT 32,1 INR 1,22 CRP 23,79 GDS 119 SGOT 31 SGPT 22 Albumin 2,57
Ureum 169,8 Creat 15,84 Na 131 K 4,8 Cl 91 Ca 3,61 D Dimer 1,69
PH 7,161 pCO2 79,4 pO2 88,2 HCO3 28,6 be -0,2 SpO2 92,6
(03.00)
Hb 8.2 Ht 24.6 Leukosit 23780 Trombosit 311.000
CRP Kuantitatif 18.87 LDH 636
pH 7,183 pCO2 78.1 pO2 80.0 HCO3 29.6 BE 1.3 SatO2 90.5
27/4/2020 (pre intubasi)
Hb 8.7 Ht 25.2 Leukosit 17120 Trombosit 286000
GDS 139 Ur 156.0 Cr 15.5
K 3.0
pH 7,484 pCO2 29.0 pO2 61.7 HCO3 22.0 BE -0.1 SatO2 92.8

Kultur darah (28/4) dan sputum (29/4) : menunggu hasil


Rapid test & Swab : Swab Negatif

Ro thorax (3/5/20)
Ro thorax (2/5/20)

Ro. Thorax (1/5/20)

Ro. Thorax (30/4/20)


Pneumonia bilateral
Kardiomegali tanpa bendungan paru

28/04/2020

Pneumonia bilateral belum jelas perbaikan


Kardiomegali tanpa bendungan paru
29/4/2020

Pneumonia bilateral belum jelas perbaikan


Kardiomegali tanpa bendungan paru
Terapi :
F : Test feeding.
A : Paracetamol 1gr/6 jam.
S : Midazolam 3 mg/jam.
T:-
H : Head up 30o
U : Omeprazole 2x40 mg iv
G:-

Terapi lain:
- Ceftriaxon 2x1 gr iv (7)
- Levofloxacin 500mg/48 jam iv (6)
- Oseltamivir 30 mg/minggu per ngt
- Bicnat 3x500 mg per NGT
- Caco3 3x500 mg per NGT
- KSR 1x600 mg per NGT
- as folat 1x5 mg per NGT
- N asetil sistein 3x200 mg oer NGT
- Cendo lyteers ed 6xgtt
- Amlodipine 10 mg/24 jam per ngt
- Mycamin 1x100 mg iv

Permasalahan:
- Nafas spontan masih sedikit apabila pasien tertidur.

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