CASE REPORT 4

PNEUMONIA DEXTRA SUSPECT

COVID-19 + ACUTE GASTRITIS
By : Fenda Khafidhotenty

Supervisor :
M Diana Rahim, MD
Patient Identity

■ Name : Mrs. P
■ Age : 68 years old
■ Gender : Female
■ No. RM : 150674
■ Admission Date : 12 March 2021
■ Address : Kp. Randu Kurung, Limbangan, Kab. Garut
Course of Disease

12 March
10 March
9 March 2021
2021
2021 Epigastrium
Epigastrium tenderness,
Diarrhea
tenderness Dyspnea
History Taking

■ Chief complain : epigastrium tenderness

■ The patient came to emergency unit of Guntur Hospital with complaint of pain in the
gut since 3 days before admission, which accompanied by shortness of breath,
nausea and vomiting, so that she could not eat. The patient also complained of
diarrhea 4 days ago, liquid stool, no pulp, blood (-), mucus (-), brown stool. The
patient claimed to have a history of gastritis, HT (-), DM (-), TB (-). Fever, cough and
runny nose are prevented by the patient. Out-of-town travel history (-), contact history
with confirmed covid-19 (-).
Physical Examination

■ General condition : mild pain

■ Awareness : composmentis
■ GCS : E4M6V5
■ TTV :
– Heart Rate : 100/80 mmHg
– Pulse Rate : 78 bpm
– Respiratory Rate : 22 bpm
– Temperature : 36,5 oC
– SpO2 : 98% free air
■ Head : normochepal
– Eyes : sclera icteric (-/-), conjunctiva anemic (-/-)
– Nose : septum deviation (-), secret (-)
– Ears: secret (-), edema (-)
– Mouth : wet oral mucosa
■ Neck : lymph node enlargement (-)
■ Thorax : symmetrical chest movements
– Cor : S1S2 regular, gallop (-), murmur (-)
– Pulmo : VBS right/left, crackle (-/-), wheezing (-/-)
■ Abdomen : flat, supple, BU (+) normal, epigastrium tenderness (+)
– Liver : within normal limits
– Spleen : within normal limits
■ Extremities : warm, CRT < 2 sec
Supporting Examination
■ LABORATORY EXAMINATION • NLR : 4.93
RESULT
Blood Chemistry:
Blood Routine:
• Random Blood sugar :125 mg/dL
• Hemoglobin : 13.4 gr/dl
• Ureum : 35 mg/dL
• Leucocyte : 10,400 /mm3
• Creatinin :1.06 mg/dL
• Hematocrite : 39 %
• SGOT : 47 U/L
• Thrombocyte : 337.000/mm3
• SGPT : 32 U/L
• Diff Count : 0/2/3/74/15/6
Supporting Examination

■ LABORATORY EXAMINATION RESULT

– Immunology :
• Rapid antibody Covid-19 IgG : Reactive

• Rapid antibody Covid-19 IgM : Reactive

■ Rontgen thorax
■ EKG
Diagnostic

■ Pneumonia dextra ec. suspect Covid-19

■ CHF fc IV ec. CAD OMI Inferior
■ Acute Gastritis
Management
■ IVFD Asering 30 tpm
■ Inj. Omeprazole 1 x 40 mg IV
■ Inj. Ondansetron 2 x 4 mg IV
■ Braxidin 3 x 1 PO
■ Sucralfat 3x 1 cth PO
■ Advice dr. Yanti Sp.PD
– Dx : Pneumonia dextra ec. suspect
Covid-19, CHF fc IV ec. CAD OMI
Inferior
– Swab PCR
– IVFD Asering 1000 cc/24 hours
– Inj. MP 2 x 62,5 mg IV
– Spironolactone 1 x 100 mg PO
– Digoxin 1 x ½ tab PO
 Follow Up
16 March 2021
■ S : Dyspnea (+), epigastric pain (+), vomitus (+),
diarrhea (+)
■ O : BP: 90/80 mmHg, PR: 70 bpm, RR: 24 bpm,
S: 36,2 OC, epigastric tenderness (+), SpO2: 91 %
free air, 96 % O2 5 Lpm Nasal Cannula
■ A : Confirmed covid-19, dyspepsia syndrome,
CHF fc IV ec. CAD OMI Inferior
■ P : IVFD Asering 20 tpm, Omeprazole 1x40mg
IV, Ondansetron 2x4mg IV, Levofloxacin 1x750mg,
Braxidin 3x1 PO, Sucralfat 3x1cth PO, MP 2 x 62,5
mg IV, Spironolactone 1 x 100 mg PO, Digoxin 1 x
½ tab PO, Oseltamivir 2x75mg PO, Becom-C 2x1
PO, Zinc 1x1 PO
Swab PCR (+)
22 March 2021
■ S : Dyspnea (+), epigastric pain (+)
■ O : BP: 130/80 mmHg, PR: 80 bpm, RR: 21 bpm,
S: 36,5 OC, epigastric tenderness (+), SpO2: 91-92 %
free air, 96-97 % O2 3 Lpm Nasal Cannula
■ A : Confirmed covid-19, dyspepsia syndrome,
CHF fc IV ec. CAD OMI Inferior
■ P : IVFD Asering 20 tpm, Omeprazole 1x40mg
IV, Ondansetron 2x4mg IV, Levofloxacin 1x750mg,
Braxidin 3x1 PO, Sucralfat 3x1cth PO, MP 2 x 62,5
mg IV, Spironolactone 1 x 100 mg PO, Digoxin 1 x ½
tab PO, Oseltamivir 2x75mg PO, Becom-C 2x1 PO,
Zinc 1x1 PO
 Follow Up
26 March 2021
■ S : Dyspnea (-), epigastric pain (+)
■ O : BP: 100/70 mmHg, PR: 80 bpm, RR: 20
bpm, S: 36,8 OC, epigastric tenderness (+), SpO2
: 96 % free air, 98% O2 3 lpm Nasal Cannula
■ A : Confirmed covid-19, dyspepsia syndrome,
CHF fc IV ec. CAD OMI Inferior
■ P : IVFD Asering 20 tpm, Omeprazole
1x40mg IV, Ondansetron 2x4mg IV,
Levofloxacin 1x750mg, Braxidin 3x1 PO,
Sucralfat 3x1cth PO, MP 2 x 62,5 mg IV,
Spironolactone 1 x 100 mg PO, Digoxin 1 x ½
tab PO, Oseltamivir 2x75mg PO, Becom-C 2x1
PO, Zinc 1x1 PO
Finished isolation, improvement condition