MAPPING DR. dr. HERRY PRIYANTO SP.

P(K)
10-12-2022
Raudah 3 HCU MEDICAL
ISO 2 B8
DPJP : BV Dpjp : Anastesi
RABER : dr. Herry Priyanto,SP.P(K) Raber : DR. dr. HERRY P SP.P(K)
DIRMA BINTI ALWI MUSLINA BINTI ABDULLAH
CM : 1-32-40-75 Umur : 52 thn
Tanggal lahir : 10-08-1953 CM: 0869983

S/ sesak napas sejak 4 hari Lab 07-12-2022 s/ Lab 7-12-2022

Hb/Ht/L/T 8.9/26/8.80/386 sesak napas PT/APTT 16.50/30.00
Dx/ E/B/NB/NS/L/M 0/0/1/83/6/10 Ca/Mg 8.0/2.0
- PPOK eksaserbasi akut derajat Sedang Protein total 5.90 Dx/ Na/K/Cl 138/2.00/90
- Pneumonia CAP PSI 79 Alb 2.80 - Acute lung oedema
- DVT a.r cruris dextra et sinistra Globulin 3.10 - DM tipe 2
- hipoalbumnemia - HT gr 2
- anemia berat perbaikan
Th/
TH/ - O2 NRM 15lpm
- Drip Levofloxacin 750mg/24jam (2/12) -IVFD NaCl 0,9% 10gtt/i
H9 - Inj. Tygacil 100mg/24jam (8/12)H 3
-PO.Spironollakton 25 mg 1x1 - Inj. Mycacin 100mg/24jam (8/12) H3
-PO Amlodipin 20mg 1x1 - Drip Furosemide dosis titrasii>>
-Vit c 3x1 pantau TD ketat
- SC heparin 5000/12 jam - Drip. Novorapid/jam
- Inj. Furosemide 1x 20 mg - Drip Resfar 8-8-9/24 jam (26/11)
- candensartan 1x 8 mg H14
- Atorvastatin 1x40 mg -Iv. Omeprazole 40 mg/12 jam
- nebul.Combivent 1 respul /8 jam - Sc heparin 5000 iu/ 12 jam
- nebul pulmicort 1 resp/12 jam - Amlodipin 1 x10 mg
- Naletal 2x 100 mg - valsartan 1x1
-Curcuma 3x1
P/ - Diamox 250 mg/ 8 jam
-Evaluasi ku dan saturasi -Nebul ventolin 1 respul/ 8 jam
-Cek Dr 3 hari post antibiotic - Nebul pulmicort 1 respul/ 8 jam
-Kultur dahak mo gram (TAD)
-Foto thorak evaluasi 5 hari post Antibiotik p/
- SARAN: DR dan Foto Thorax ulang -Evaluasi ku dan saturasi
(9/12) Ur Cr KGDS Elektrolit PT APTT
Ddimer/3 Hari
Laboratorium tgl 24/11/2022 : - Kultur Sputum MO gram (K/R)
Hb/Ht/E/T/L : 7,3/19/2,6/510/10,32 Staphylococcus, Saran AB :
E/B/NB/NS/L/M : 1/0/1/85/6/7 Vancomicin
Albumin: 2,1
KGDS: 94 Lab 27/11/2022
cr : 0,6 D-dimer : >4000
Na/K/Cl: 134/4,2/114 HbsAg : non reaktif
D-dimer : > 4000 Sgot/sgpt : 69/45
Mg/ca : 1,8/8,7
Lab 28/11/2022 Ur/cr : 48/0,70
Hb/Ht/E/T/L : 10,4/29/3,6/6,17/523 Na/k/cl : 142/4,00/106
E/B/NB/NS/L/M : 0/0/1/79/9/11
Alb : 2,50 Lab 28/11/2022
Hb/HT/E/Leu/Trom:
Lab 02/12/2022 17,5/57/6,4/13,81/216
Hb/Ht/Erit/L/T : 10.9/32/4,0/13,80/244 E/B/NB/NS/L/M : 0/0/1/87/6/6
E/B/NB/NS/L/M : 0/0/0/84/2/4
Pt/aptt : 21,20/40,60 02/12/2022
d-dimer : 2540 Hb/Ht/E/Trom/Leu :
sgot/sgpt : 51/20 19,0/61/6,9/162/13,02
alb : 2,50 E/B/NB/NS/L/M : 0/0/0/91/5/4
ur/cr : 26/0,50 Pt/aptt : 17,90/33,90
na/k/cl : 134/4,00/109
Lab 03/12/2022
Lab 05-12-2022 Mg/ca : 2,2/8,0
Hb/Ht/L/T 9.3/27/8.07/401 Na/k/cl : 140/3,40/99
E/B/NB/NS/L/M 0/0/0/79/8/13
PT/APTT 23.80/31.30 Lab 05/12/2022
Hb/Ht/Erit/L/T :
AGDA 6-12-2022 15,9/5,3/4,0/12,80/322
pH 7.507 E/B/NB/NS/L/M : 0/0/0/76/2/6
pCO2 46.70 sgot/sgpt : 51/20
pO2 64 alb : 3,0
HCO3 37.4 ur/cr : 22/0,45
Total CO2 38.8 na/k/cl : 132/3,00/102
BE +13.8
SpO2 99.9
Kesan: Alkalosis metabolic terkompensasi
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