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COVID 27 Februari 2021 Pagi
COVID 27 Februari 2021 Pagi
HCU Kemuning
Bed 1. Ny. Pipit Sofia/P/ 61 tahun / BB 60 kg/ 0001565185/HS 43/ HP 10
Objectives Assessment Planning
CNS : E4M6V5 Confirmed COVID-19 Severe Case dengan koinfeksi bakteri + DM 2, uncontrolled hyperglycemia + Hipertensi F : Diet DM 1500 kkal
dalam terapi
A : Paracetamol 500 mg/8 jam
CVS 27/02/21 S:-
Hb 11.1 Ht 31,7 Leu 9430 Tr 494.000 E3,79 TLC 850 NLCR 9,54 GDS 254 Ur 34.0 Cr 0.60 Na 135 K 4.1 Ca 5,13
T : 125/60 mmHg T : Fondaparinux 2.5 mg/24 jam SC
Mg 1.9 Cl 110 PT 10.90 APTT 21.00 INR 0.99 Alb 2.32 CRP 1.70 LDH 314 D-dimer 1.36 SGOT 23 SGPT 28
pH 7.414 pCO2 28.7 pO2 77.7 HCO3 18.5 tC02 19.4 BE -4.6 SatO2 94.4 P/F ratio 86,3 P/F ration 86,3 ROX H : Head up 30O
N : 71 kali per menit, reguler index 3,2-6,3 Diff.count 0/0/0/86/9/5 MCHC 35 MCH 29,3 MCV 83,6
U : Omeprazole 40 mg/ 12 jam
26/02/21 G : Insulin basal 1x18 IU SC, Insulin rapid 3x10
Hb 11.6 Ht 33.4 Leu 11.270 Tr 390.000 TLC 9.92 NLCR 12.56 GDS 315 Ur 30 Cr 0.66 Na 135 K 4.4 Ca 4.65 Mg IU SC
1.8 Cl 110 PT 13.0 APTT 30.1 INR 0.91 Alb 2.36 CRP 5.55 As.laktat 2.36
Respirasi pH 7.356 pCO2 25.1 pO2 77.6 HCO3 14.2 BE -9.0 SatO2 94.8 P/F ratio 77.6 Terapi :
16-30x/menit, WOB (-) - Remdesivir 100 mg/24 jam IV (6)
HFNC 60 lpm,FiO2 100% 25/02/21 - Dexamethasone 1x6mg IV (6)
SpO2 94-97% Hb 11.6 ht 33.4 Leu 11.270 Trom 390.000 DC 0/0/1/87/7/5 NLR 12.56 - Ceftriaxone 1 gram/ 12 jam IV (9)
ROX 3,2-6,3 PT 13.0 INR 0.91 APTT 30.10 CRP 5.55 alb 2.36 laktat 1.8 ur 30 cr 0.66 - Levofloxacin 1x750mg IV (3)
Na 135 K 4.4 Cl 110 Ca 4.65 Mg 1.8 - Vitamin C 1x1000mg IV
GIT
pH 7.356 pCO2 25.1 pO2 56.2 HCO3 14.2 BE -9.0 SaO2 94.8% - Vitamin D 1x5000IU PO
Datar, supel
- Omega 3 1x1caps PO
24/02/21 - N-asetilsistein 400mg/8jam PO
Hb 11.8 ht 34.1 Leu 11.600 Trom 337.000 DC 0/0/0/78/17/5 NLR 4,59 - Amlodipin 1x10 mg PO
PT 12,1 INR 0,85 APTT 25,8 CRP 1.24 LDH 301 SGOT 27 SGPT 45 - Zinc 20mg/12jam PO
Bil.tot 0.377 Bil.direk 0.137 Bil.indirek 0.24 alb 2,33 laktat 1.4 ur 43 cr 0.64 - TPK labu pertama telah selesai
Na 134 K 4,5 Cl 111 Ca 3,55 Mg 1,7 Fibrinogen 561 Ddimer - Actemra kedua telah selesai
pH 7.392 pCO2 28.3 pO2 56.2 HCO3 17.4 BE -5,7 SaO2 88,3% (P/F ratio 56,2)
23/02/21
Hb 11.9 Hct 34,6 Leu 5440 Tr 298.000 GD2PP 337 AGD: pH 7.411 pCO2 27.7 pO2 71.1 HCO3 17.7 tCo2 18.6
SB-b -5.5 SpO2 91.9
GUT : PCR swab 18/02/21: positif. Ct: 15.44 Kultur darah (24/2/21): Belum ada hasil
PCR swab 24/2/21: positif Ct : 23.39
UOP:1615/24 jam
Diuresis:1,12 cc/kgBB/jam
19/2/21
Hb 10.5 Ht 30.2 Leu 18600 Tr 286.000 HBA1C 11.0 AGD: pH 7.361 pCO2 36.0 pO2 149.5 HCO3 20.6 tCO2
21.7 SBE-b -3.7 SpO2 99.0
18/02/21
Hb 13.1 Hct 37.3 Leu 7730 Tr 273.000 PT 12.2 INR 0.85 APTT 25.6 Kolesterol total 160, HDL 52 LDL85 TR 109
CRP kuantitatif 2,27 GDS 465 LDH 170 SGOT 33 SGPT 58 Bil total 0.431 Bil direk 0.157 Bil indirek 0.274 Prot
total 3.62 Globulin 4.0 Ureum 44.5 Crea 1.12 Na 128 K 4,4 Ca Ion 4,21 Mg 2.0 Fibrinogen 373.0 D-Dimer
kuantitatif 0.63 Tropo I < 0.01 Ferritin 572.7 Procalcitonin 0.13
Ro thorax 26 Februari 2021
A : paracetamol 3 x 500mg po
CVS 26/02/2021 S:-
Hb 13.9 Ht 40.0 Leu 5.100 Tr 323.000 PT 15.6 INR 1.10 CRP 9.28 APTT 22.60 GDS 421 LDH 612
T : 151/78 mmHg SGOT 47 SGPT 19 Alb 1.88 As.laktat 2.8 Ur 32 Cr 0.43 Na 133 K 4.5 Cl 113 Ca 4.55 Mg 1.6 T : Arixtra 1 x 2.5 SC
N : 95-97 kali per menit, reguler Fibrinogen 550 D-dimer 4.41
H : Head up 30O
25/2/2021
Hb 14,3 Ht 42.3 Leu 4.700 Tr 264.000 TLC 0.28 NLR 15.43 U : Omeprazole 40 mg/ 12 jam
PT 15.9 INR 1.13 APTT 27.4 G : Insulin rapid 3 x 5 unit SC
pH 7.433 pCO2 26.2 pO2 55.4 tCO2 18.4 HCO3 17.6 be -4.3 SpO2 89.1
Respirasi Terapi :
24-25 x/menit 24/2/2021 - Levofloxacin 750mg/24 jam IV (6)
(WOB minimal) Hb 13,4 Ht 39,8 Leu 3.570 Tr 292.000 TLC 0.29 NLR 10.97 - Azithromicin 1x500mg/24 jam (5)
SpO2 94-95% HFNC 60lpm/95% PT 16,6 INR 1,17 APTT 31,2 D-dimer 4,48 Fibrinogen 738,0 - Ceftazidime 3x2gr IV (3)
Rox index 3.76-3.95 pH 7,420 pCO2 24,1 pO2 60,5 tCO2 16,5 HCO3 15,8 be -6,4 SpO2 90,9 PF rasio 63,68 - Remdesivir 200mg/24 jam (6)
- Methylprednisolone 3x125mg (3)
23/02/2021 - Vitamin C 1000mg/24 jam PO
GIT Hb 12.7 Hct 38.3 Leu 6540 Tr 294000 PT 13.00 APTT 20.8 INR 1.19 GDP 234 SGOT 234 SGPT 25 Bil - Vitamin D 5000 iu/ 24 jam PO
supel, datar total 0.497 Bil direk 0.220 Bil indirek 0.277 Protein total 5.2 Albumin 1.74 Asam laktat 1.8 Ureum 24.0 - Zinc 20mg /12jam PO
Crea 0.53 Na 133 K 4.7 Cl 112 Ca ion 4.49 Mg 1.3. AGD. pH 7.441 pCO2 25.0 pO2 50.SB-b –5.0 - NAC 3 x 400 mg PO
SpO2 85.9 - Ondansentron 4mg/8jam IV
- TPK sudah diberikan (24/2/21)
- Actemra sudah pemberian 2 kali
• Pneumonia bilateral
• Kardiomegali dd/posisi
• Atherosclerosis aorta
Bed 5. Budy Setiabudi Zakaria, drg /L/ 57 tahun /0001902120/ BB 60 kg/ HS 23/ HP 15/HV 13
22/2/21
Hb 12.24 Hct 38.8 Leu 22.070 Tr 99.000 Ur 112 Cr 0,89
PT 12,9 APTT 51,29 INR 1313 NLCR 97.2 TLC 0.22 .
pH 7231 pCO2 93,5 pO2 108,6 HCO3 39,6 BE 9,3 SaO2 96,4 p/f ratio 98,42
21/2/21
Hb 13,34 Hct 40,6 Leu 22.050 Tr 128.000
Ur 112 Cr 0,89
PT 16,0 APTT 51.6 INR
pH7,298 pCO2 70,5 pO2 71,8 HCO3 39.6 BE 9.02 SaO2 90,3
20/2/2021 Kultur darah 14/2/2021
Hb 12.6 Ht 38.4 Leu 17.060 Tromb 105.000Total neutrofil 16.72Total limfosit 0.17 Neutrofil limfosit ratio 98.35
PT: 13,4 inr: 1.23 aptt: 30.3CRP : 0.59 Gds: 238 Ur: 93.6 Cr: 0.96. Na: 144 K: 4.4 Cl: 112 Ca: 4.33 Mg: 26 D-Dimer :
Isolate 1: staphylococcus
8.57 epirdermidis susceptibility
AGD 7.396/53.6/64,1/33,2/7.5/91.2% Troponon I : 0.04 Resisten: Ampiscilin/sulbactam,
ceftriaxone, gentamycin, amox+
19/02/21
Hb 12.8 Ht 38.5 L14.880 Tr 151.000 TLC 150 NLR97.20 CRP 1.16 clavulanic acid ,
Na 138 K 4.5 Ur 78.0 Cr 0.89 GDS 208 piperacillin/tazobactam,
PT 13.20 APTT 20.10 INR 1.21 Fib 221.1 D-Dimer 12.16 cefazolin, cefuroxime, cefadroxil,
pH 7.370 pCO2 61.2 pO2 84.4 HCO3 35.7 BE 8.8 SaO2 95.4
cefoperazone, cefotaxime,
18/02/21 ceftazidime, cefepime, cefixime,
Hb 13.3 Ht 39.8 L 19.040 Tr 179.000 TLC 0.38 NLR 48.61 CRP 6.97 ciprofloxacin, levofloxacin,
Na 143 K 3,9 UR 75 Cr 0.99 SGOT 41 SGPT 61 Alb 3.14 GDS 154 CRP 2.27 maxifloxacin, co-trimoxazole,
PT 14.7 APTT 25.90 INR 1.04 Fib 304.0
pH 7.4432 pCO2 63.4 pO2 69.1 HCO3 43.7 BE 17.1 SaO2 94.0 clindamycin, erythromycin
Sensitive : Tigecycline,
17/02/21 vancomycin
Hb 11.4 Ht 33.8 L 16.190 Tr 164.000 TLC 0.16 NLR 99.19 CRP 6.97
Na 134 K 4,2 Cl 105 Ca 4.50 UR 60.0 Cr 0.78 SGOT 25 SGPT 42 Alb 2.28 GDS 148
PT 16,0APTT 50.20 INR 1.13 Fib 335.0 D-dimer 8.17 Asam laktat 2,2 Procalcitonin 0.11
pH 7,382 pCO2 63.2 pO2 101.6 HCO3 37.9 BE 12.1 SaO2 96.3
AGD istat 18:09
pH 7.416 pCO2 62,2 pO2 56,9 HCO3 40 BE 15 Sat 88
16/02/21
Hb 11.4 Ht 33.8 L 16.190 Tr 164.000 TLC 0.16 NLR 99.19 CRP 6.97
Na 134 K 4,2 Cl 105 Ca 4.50 UR 60.0 Cr 0.78 SGOT 25 SGPT 42 Alb 2.28 GDS 148
PT 16,0APTT 50.20 INR 1.13 Fib 335.0 D-dimer 8.17 Asam laktat 2,2 Procalcitonin 0.11
pH 7,382 pCO2 63.2 pO2 101.6 HCO3 37.9 BE 12.1 SaO2 96.3
13/02/21
Hb 12,8 Ht 36,7 L 19.350 Tr 215.000 TLC 0,19 NLR 99,79 PT 13,6 APTT 22,2 INR 1,25 Kolesterol total 87 HDL
24 LDL 49 Trigliserida 121 HbA1c 6,1 CRP 2,29 GDS 135 LDH 675 SGOT 58 SGPT 53 GT 148 Biltot 0,528
Bildir 0,139 Bilindir 0,389 Alb 1,66 Laktat 2,5 Ur 82,0 Cr 1,20 AsUrat 5,8 Na 133 K 3,4 Cl 108 Ca 4,29 Mg 2,3
Fib 140,5 D-dimer 35,04
pH 7,506 pCO2 28,1 pO2 54,8 HCO3 22,4 BE 0,8 SaO2 90,0
13/02/21
Hb 12,8 Ht 36,7 L 19.350 Tr 215.000 TLC 0,19 NLR 99,79 PT 13,6 APTT 22,2 INR 1,25 Kolesterol total 87 HDL
24 LDL 49 Trigliserida 121 HbA1c 6,1 CRP 2,29 GDS 135 LDH 675 SGOT 58 SGPT 53 GT 148 Biltot 0,528
Bildir 0,139 Bilindir 0,389 Alb 1,66 Laktat 2,5 Ur 82,0 Cr 1,20 As. Urat 5,8 Na 133 K 3,4 Cl 108 Ca 4,29 Mg 2,3
Fib 140,5 D-dimer 35,04
pH 7,506 pCO2 28,1 pO2 54,8 HCO3 22,4 BE 0,8 SaO2 90,0
Ro Thorax 26/02/2021
- Efusi pleura kiri belum berkurang
- Pneumonia bilateral belum perbaikan.
- Kardiomegali tanpa bendungan paru.
- Atherosklerosis aorta
Ro Thorax 25/02/2021
- Pneumonia bilateral belum perbaikan.
- Kardiomegali tanpa bendungan paru.
- Atherosklerosis aorta
Ro Thorax 24/02/2021
- Pneumonia bilateral belum perbaikan.
- Kardiomegali tanpa bendungan paru.
- Atherosklerosis aorta
Rontgen Thoraks 23/2/2021
Rontgen Thoraks 22/2/2021
Ro.Thorax 21/2/21
Ro.Thorax 20/2/21
Ro.Thorax 18/2/21
Ro.Thorax 17/2/21
Ro. Thorax 15/2/2021
Ro thorax 14/02/2021
Bed 6. Ny, Tuti/P/ 63 tahun / BB 60 kg/0000614446/ HS 25/ HP 11
Objectives Assessment Planning
CNS : compos mentis CAP ec Confirmed COVID-19 severe case + Hipertensi F : Diet lunak 3x/24 jam
A:-
CVS 26/2/2021 S:-
Hb 11.8 Ht 34.5 Leu 13.100 PT 12.4 APTT 26.60 INR 0.87 Laktat 3.7 Fibrinogen 307 D-Dimer 0.75
TD : 100/55 mmHg pH 7,453 pCO2 35.5 pO2 195.5 HCO3 25.0 tCO2 26.1 BE 2.0 SaO2 99.7 IL 6 16.6 T : Fondaparinux 1x5mg sc
N : 80-88 x /menit
25/2/2021 H : Head up 30O
Hb 12,3 Ht 36,9 Leu 11.320 Tromb 279.000
NLR 14.6 PT 12.2 INR 0.92 APTT 22.30 CRP 0,06 Alb 3.00 ur 37.0 cr 0.60 U : Lansoprazol 30mg/12 jam po
Na 131 k 5.3 Cl 102 Ca 4.75 Mg 2.2 G:-
Respirasi 24/2/2021 Terapi :
22 kali per menit, WOB (-), SpO2 98- - Meropenem 1gr/8 jam (10)
99% on NRM 10 lpm Hb 12,4 Ht 36,5 Leu 12.880 Tromb 279.000 DC 0/0/2/85/6/7
NLR 14,56PT 12.2 INR 0,86 APTT 27,3 CRP 0,02 GDS 120 LDH 429 - Vitamin C 1 x 1000 mg iv
ROX 5.5-5.6 - Vitamin D 1 x 5000 iu po
SGOT 15 SGPT 37 Alb 2,93 laktat 3,5 ur 36 cr 0,58 fibrinogen 410 Ddimer 1.23
Na 132 k 4,4 Cl 100 Ca 5.09 Mg 2,3 - Omega 3 1x1 PO
pH 7,438 pCO2 38,0 pO2 127,3 tCO2 27,1 HCO3 25,9 BE 2.4 SatO2 98,9 pf ratio 159,1 - Dexamethasone 1x6 mg IV (10)
Procalcitonin: 0,01feritin: 2053 - N-Asetilsistein 3x400 mg po
GIT - Cernevit 1 amp/24 jam
distensi (-) 23/02/2021 - Lisinopril 100 mg/24 jam po
Hb 11.7 Ht 34.6 Leu 11.170 Tr 272.000 TLC 0.56 NLRC 17.75 GDS 92 SGOT 13 SGPT 38 Na 129 K - Zinc 20 mg/12 jam po
4.4 Ca 4.56 Mg 2.1 Cl 104 PT 112.8 APTT 24.00 INR 0.90 D-dimer 3.00 Fibrinogen 397 Alb 2.71 - Amlodipin 1x10 mg
- Rencana :
- Prone position berkala
GUT : PCR swab 16/2/21 (RS Al-Islam) positif CT 1.6
PCR Swab 17/2/21 (RSHS) : Positif Ct gen: 34,74
Diuresis: 2435 cc/23 jam (1,3 PCR Swab 24/2/21 (RSHS) : Positif Ct 28.45
cc/kgBB/jam)
Balans: -695 cc/23 jam
22/02/21
Hb 11.9 Ht 33.9 Leu 16.550 Tr 282.000 TLC 510 NLCR 23.04 GDS 184
PT 13.60 APTT 30.0 INR 0.95 Ur 39.0 Cr 0.66 Alb 2.54 Laktat 5.2
Na 131 K 4.2 Ca 4.29 Mg 2.2 Cl 104
PH 7.403 PCO2 38.6 PO2 177.2 HCO3 24.3 BE 0.3 SPO2 99.5 Procalcitonin 0.02 Ferritin 1822
21/2/21
Hb 11,8 Hct 34,9 Leu 11.470 Tr 306.000 TLC 0.34 NLR 31.71 PT 11.0 INR 1.00 aPTT 20.70Gds 145 sgot 21 sgpt 49 alb 2.42 laktat 3.7 Ur 41 Cr 0.61 Na 130 / K 4.3/ Cl
103/ Ca 4.47 / Mg 2.0 CRP kuantitatif 0.34Fibrinogen 377.0 D-dimer 3.65
20/2/2021
Hb 11.8/Ht 34.9/Lc 14.740 /Tc 307.000 TLC 1030 ( kemarin 410)NLR 12.74 ( kemarin 31.95)PT 11.0 INR 1.00 aPTT 20.10Gds 90 sgot 19 sgpt 33 alb 2.42 laktat 2.4 Ur
40.3 Cr 0.91Na 136 / K 4.1/ Cl 106/ Ca 4.61 / Mg 2.1 CRP kuantitatif 0.68Fibrinogen 444.0 D-dimer 4.40
19/02/21
Hb 11.80 Ht 34.50 Leu 13.650 Tr 315.000 TLC 410 NLCR 31.95 GDS 178
PT 14.7 APTT 30.70 INR 1.03 Laktat 3.6
Na 131 K 3.9 Ca 4.28 Mg 1.9 Cl 104
PH 7.439 PCO2 36.4 PO2 163.0 HCO3 24.9 BE 1.6 SpO2 99.5
18/02/21
Hb 11.40 Ht 33.1 Leu 16.550 Tr 305.000 TLC 500 NLCR 30.78 GDS 121
PT 14.60 APTT 28.20 INR 1.03 Ur 37.2 Cr 0.87 Alb 2.67 Laktat 1.8
Na 133 K 4.0 Ca 4.68 Mg 1.9 Cl 106
PH 7.464 PCO2 35.4 PO2 81.8 HCO3 25.7 BE 2.7 SPO2 96.3
Rontgen Thoraks 26/2/2021
Rontgen Thoraks 25/2/2021
Ro. Thorax 24/2/21
Rontgen Thoraks 23/2/2021
Rontgen Thoraks 22/2/2021
Ro. Thorax 21/2/21
Ro. Thorax 20/2/21
Ro. Thorax 19/2/21
Ro. Thorax 18/2/21
Ro. Thorax 17/2/21
Ro. Thorax 16/2/2021 (RS Al-Islam)
Kesan :
Bronkopneumonia bilateral tampak perbaikan.
Kardiomegali tanpa bendungan paru
Atherosclerosis aorta
RIKK
2. Tn. Ahmad Rifai Shalahudin/ 46 tahun / 70 kg /0001904600/ H Sakit 9/ HP 2
Objectives Assessment Planning
CNS : E4M6V5 Confirmed COVID-19 Severe Case + Suspek meningitis TB + Suspek TB paru + DM F : Diet DM 6 x 200 cc
Tipe II + Anemia + ITP Sekunder dd/Primer
A : Paracetamol 1gr/ 8 jam IV
CVS 26/02/21 S:
Hb 12,7 Ht 36.9 Leu 11.300 Tr 66.000 TLC 0.68 NLR 15.49 PT 15,2 INR 1,07 aPTT 39.2 CRP 6,95
T : 101/72 mmHg GDS 348 LDH 625 SGOT 128 SGPT 119 Ur 42 Cr 0.79 Na 137 K 5.3 Cl 101 Ca 1,16 Mg 2,3 Fibrinogen T : Heparin 2 x 5000 IU
N : 120-130 x/m,reguler 614 d-dimer 3.48
pH 7.347 pCO2 31.0 pO2 107,8 HCO3 18,2 BE -5.3 SaO2 97.9 H : Head up 30O
25/02/21 U : Omeprazole 40mg/12 jam
Hb 11,6 Ht 32,8 Leu 8.850 Tr 50.000 G : Insulin rapid 6x3 unit sc
Na 124 k 4,3
Respirasi pH 7.475 pCO2 22,7 pO2 122,2 hco3 16,9 BE -4,4 satO2 98,6 Terapi :
30-40 x/menit (WOB minimal) • Ceftriaxone1gr/12 jam IV (3)
SpO2 94-95% % HFNC 50lpm/90% 24/02/21 • Levofloxacin 750mg/24 jam IV (3)
Rox index 3.1-3.3 Hb 10,7 Ht 30,2 Leu 9.940 Tr 48.000 • Remdesivir 100mg/24 jam (3)
ur 26 cr 0.75 Na 126 k 3.9 • Dexamethasone 4x5mg (3) selama 7 hari
pH 7,507 pCO2 23,6 pO2 70,4 hco3 18,9 BE -2,3 satO2 94,8 • Vitamin C 1000mg/24 jam PO
GIT • Vitamin D 5000 iu/ 24 jam PO
Datar, supel • Zinc 20 mg/12 jam PO
• Cernevit 1amp
• NAC 3 x 400 mg PO
• Zegavit 1x1 tab PO
• OAT kategori 1x1tab (2)
GUT : PCR Swab (20/2/21): positif CT 32,71 Pewarnaan sputum 20/2/2021 : batang gram
positif : negatif, batang gram negative :
Balans:
negatif, coccus gram positif : +1, coccus
diuresis: gram negative : negative , Jamur : Hifa (+)
23/2/21
Hb 11.3 Ht 36.6 Leu 17.780 Tr 288.000 TKC 0.36 NLCR 46.92 Ur 92.0 Cr 1.87 OT 25 PT 35 Na 139 K 6.1 Ca 4.57 Mg 2.1 Cl 114 PT 14.60 APTT >180 INR 1.35 D-Dimer 3.45
Fibrinogen 269.4 Fe 3114.6
pH 7.382 pCO2 63.2 pO2 42.1 HCO3 38.0 tCO2 40.0 BE 11.2 SaO2 72.7
22/2/21
Hb 11.4 Ht 36.3 Leu 17.860 Tr 418.000 TLC 0.18 Ur 83.58.0 Cr 1.94 Na 143 K 5.0
Ca 4.92 Mg 2.1 Cl 120 PT 17.4 APTT 41.5 INR 1.24 D-dimer 4.08 Fibrinogen 329
pH 7,297 pCO2 56.9 pO2 88.7 HCO3 28.1 BE 29.8 SaO2 95.2
21/2/21
Hb 12.2 Ht 39.2 Leu 27.140 Tr 422.000 TLC 26.33 NLCR 97.52 GDS 242 Ur 88.0 Cr 1.84 Na 138 K 6.9
Ca 4.98 Mg 1.9 Cl 114 PT 12.60 APTT 56.70 INR 1.15 D-dimer 13.26 Fibrinogen 298.2
pH 7,308 pCO2 62,9 pO2 88,2VHCO3 31,8 BE 4.7 SaO2 95.4
20/02/2021
Hb 12,4 Ht 37,1 Leu 22.560 Tromb 356.000TLC 0.45 NLR 48.13
19/2/21
Hb 12.7 Ht 37.9 Leu 21.180 Tr 413.000 TLC 640 NLCR 31.44 GDS 134 Ur 88.3 Cr 1.65 Na 138 K 5.6
Ca 5.01 Mg 2.3 Cl 111 PT 14.50 APTT 24.00 INR 1.34 D-dimer 13.36 Fibrinogen 377.1
pH 7,448 pCO2 29.9 pO2 49 HCO3 20.7 BE -3.0 SaO2 86.0
Ro. Thorax 25/2/21
Ro. Thorax 24/2/21
Ro Thorax 24/2/2021
-Pneumonia bilateral perbaikan
-Kardiomegali dd/ posisi
Rontgen Thorax 23/2/2021
Rontgen Thorax 22/2/2021
Ro. Thorax 21/02/2021
Ro. Thorax 20/02/2021
GICU 2
1. dr. Mulya A. Hasjym SP.B/ 69 tahun / 70 kg /0001383056/ H Sakit 23/ HP 9
GUT : PCR swab (19-2-2021) :Positif CT 20,32 Pewarnaan gram 22/2/21: Yeast (-)
Diuresis : 3810 cc/24 jam (1.98 PCR swab (22-2-2021) :positif CT 22,78 batang gr positif (-)
cc/kg/jam) batang gr negatif (+1)
coccus gram positif (+2)
Balance : -4335 cc/24 jam coccus gram negatif (-)
23/2/2021
Hb 13.3 Ht 38.1 Leu 8.710 Tr 310.000 TLC 0.78 NLCR 10.05 GDS
277 Ur 43 Cr 0.80 OT 35 PT 44 Na 134 K 3.7 Ca 4.73 Mg 2.1 Cl 113
PT 14.1 APTT 31.10 INR 0.99 D-Dimer 0.66 Fibrinogen 468.0
pH 7.401 pCO2 29.7 pO2 85.0 HCO3 18.6 tCO2 19. BE -4.4 SaO2
96.3
22/2/2021
Hb 13.2 Ht 37.4 Leu 6.660 Tr 298.000 Tot.limfosit 0.73 Tot.netrofil
5.73 NLR 7.85 CRP 64.26 GDS 136 LDH 429 SGOT 35 SGPT 50 alb
2,78 ur 45 cr 0,81 Na 141 K 4.0 Cl 109 Ca 5.0 Mg 2,4
pH 7,382 pCO2 40.2 pO2 41.3 HCO3 24.1 tCO2 25.4 BE -0.2 SatO2
72.1 (vena)
21/2/2021
Hb 12,9 Ht 36,4 Leu 3.990 Tr 231.000 Tot.limfosit 0.76Tot.netrofil
3.38 NLR 4.04 PT 10,9 INR 0,99 APTT 28,4 CRP 6,47 GDS 345 LDH
396 SGOT 40 SGPT 50 alb 2,73 ur 50 cr 0,87 Na 133 K 4,3 Cl 109 Ca
4,40 Mg 2,0 D-dimer 0.26 Fibrinogen 512,9
pH 7,475 pCO2 26,4 pO2 74,7 HCO3 19,6 tCO2 20,4 BE -2,7 SatO2
95,9
20/2/2021
Hb 13,3 Ht 37,4 Leu 3.980 Tr 200.000 Tot.limfosit 0.48Tot.netrofil
3.38 NLR 7,04 PT 10,4 INR 0,94 APTT 27,8 CRP 8,33 GDS 289 LDH
481 SGOT 60 SGPT 47 alb 2,64 ur 38 cr 0,78 Na 135 K 4,7 Cl 110 Ca
4,61 Mg 2,0 D-dimer 0.38 Fibrinogen 586,0 Procalcitonin 0,16
pH 7,386 pCO2 27,7 pO2 106,6 HCO3 16,8 tCO2 17,7 BE -6,6 SatO2
97,3
Ro thorax 26/02/2021
Ro. Thorax 25/2/21
Ro. Thorax 24/2/21
Ro Thorax 24/02/2021
20/02/21
Hb 15,2 Ht 43.4 Leu 13.360 Tromb 239.000Hitung Jenis Leu: 0/0/1/95/3/1TNC: 12.83 TLC: 0,40 NLR: 32.08Pt 11.9 inr 1.09 aPTT 25.8
pH 7.442 pCO2 32 PO2 77.1 HcO3 22 BE 23 Sat O2 95.8
19/2/21
Hb 15.3 Ht 44.2 Leu 14.240 Tr 239.000 TLC 430 NLRC 31.14 GDS 134 Ur 55 Cr 1.03 Na 134 K 4.2
PT 12.00 APTT 25.20 INR 1.10 D-dimer 1.09 Alb 2.74 LDH 537
CRP 4.79
18/2/21
Hb 15.3 Ht 43.4 Leu 10.830 Tr 205.000 TLC 540 NLRC 18.44 GDS 150 Ur 57 Cr 0,93 Na 134 K 4.0
Cl 112 PT 13.00 APTT 27.10 INR 1.19 D-dimer 0.31 Fibrinogen 435.9 Alb 2.55 Laktat 1.77 LDH 414
CRP 8.95 Feritin 3077,1 pH 7.408 pCO2 27.0 pO2 79.1 HCO3 17.2 BE -5.3 SaO2 95.8 PCT 0,61
17/2/21
Hb 15.9 Ht 46.4 Leu 4.990 Tr 180.000 TLC 500 NLRC 8.78 GDS 132 Ur 45.6 Cr 1.01 Na 128 K 4.2
Ca 4.81 Mg 2.3 Cl 107 PT 13.00 APTT 27.10 INR 1.19 D-dimer 0.42 Fibrinogen 339.9 Albumin 2.67
CRP 20.74 Laktat 1.6 Feritin 1802,1 pH 7.417 pCO2 26.4 pO2 63.7 HCO3 17.2 BE -5.5 SaO2 92.5
16/2/21
Hb 14.7 Ht 42.7 Leu 6.450 Tr 164.000 TLC 0.84 NLRC 6.37 GDS 92 Ur 50.5 Cr 1.28 Na 127 K 4,0
Ca 4.93 Mg 2.1 Cl 106 PT 11.50 APTT 30.80 INR 1.05 D-dimer 0.45 Fibrinogen 444.0 Albumin 2.77
CRP 15.74 Laktat 1.4 pH 7.456 pCO2 24.4 pO2 82.3 HCO3 17.4 BE -4.5 SaO2 96.5
15/2/21
Hb 14.9 Ht 43,6 Leu 6.680 Tr 161.000 TLC 1.110 NLRC 4.95 GDS 98 Ur 57,0 Cr 1,28 Na 131 K 4,2
Ca 4.97 Mg 1,9 Cl 110 PT 11,70 APTT 29.30 INR 1,06 D-dimer < 0.19 Fibrinogen 303,9 Albumin 2.88
LDH 191 CRP 8.37 Laktat 1.1 pH 7.458 pCO2 24.3 pO2 70.7 HCO3 13.3 BE -4.1 SaO2 95.0
14/2/21
Hb 15,6 Ht 45,2 Leu 8.610 Tr 161.000 TLC 1.120 NLRC 6,38 Ur 54,0 Cr 1,27 Na 136 K 4,3 Ca 5,08 Mg 1,8 Cl 111 PT 16,70 APTT 27,INR 1,55 D-
dimer 0,24 Fibrinogen 273,9 LDH 179 CRP 2,47
13/2/21
Hb 16,3 Ht 48,7 Leu 4.990 Tr 162.000 TLC 1.150 NLRC 3,08 Ur 59,3 Cr 1,23 Na 131 K 4,3 Ca 4,97 Mg 2,1 Cl 110 PT 11,10 APTT 28,2 INR 1,01 D-
dimer <0,19 Fibrinogen 228,2 LDH 179 CRP 3,40 HDL 34 LDL 116 Kolesterol total 159 Trigliserida 74
pH 7,338 pCO2 28,6 pO2 101,6 HCO3 17,4 BE -5,5 SaO2 98s
12/2/21
Hb 17.5 ht 51.8 Leu 7.410 Tro 170.000 Total Neutrofil 4.00 Total Limfosit 2.52 NLR 1.59
PT 11,3 INR 1,03 APTT 25.3 GDS 85 Ur 47.0 Cr 1,37 Fibrinogen 283.1 Na 134 K 3,8 D-Dimer 0,24 pH 7.394 pCO2 31,9 pO2 66.2 HCO3 19,6 tCO2
20.6 BE -3,5 Sat O2 92.7%
11/2/21
Hb 16,6/ht 48,7/Leu 7.110/Tro 153.000 Total Neutrofil 4.91 Total Limfosit 1.49 NLR 3,3
PT 11,5/INR 1,05/APTT 24,4 GDS 107 Ur 53,7/Cr 1,36 Fibrinogen 214,4 Na 135/K 4,1 D-Dimer 0,21 pH 7.410/pCO2 36,9/pO2 35,3/HCO3
23,6/tCO2 24,7/ BE -0.1/66,4%
Ro. Thorax 26/2/21
Ro Thorax 26/02/2021
- Pneumonia bilateral perbaikan
-Tidak tampak kardiomegali
Ro. Thorax 25/2/21
Ro. Thorax 24/2/21
Ro Thorax 24/02/2021
GUT : Swab di RSUD Kota Bandung 15/2/21 dan 16/2/21 Ro thorax 22/2/21 Pneumonia bilateral
Poaitif
Balans:
Swab tanggal (22/2/21) Ct 29.55
diuresis: Sputum 22/2 : jamur yeast +, coccus gram positif 3+
Kultur darah dan sputum 22/2 belum ada hasil
23/2/21
Hb 10.1 Hct 30.9 Leu 9380 Tr 417000 PT11.3 INR 1.03 APTT
22.3 GDS 181 LDH 454 SGOT 26 SGPT 32 Alb 2.45 As laktat
1.3 Ureum 72.0 crea 0.81Na 138 K 4.1 Cl 113 Ca ion 4.17 Mg
2.5 TIBC 129 Fibrinogen 512.9 D-dimer 3.78 Trop I 0.20. AGD
pH 7.485 pCO2 36.7 pO2 53.9 HCO3 27.9 tCO2 29.1 SB-b 5.1
SpO2 90.0 Procalcitonin 042
22/2/21
Hb 10,7 Ht 33.7 Leu 16.590 Tr 486.000 TLC 0,66 NLCR 23.12
GDS 213 Ur 60 Cr 0,61 Na 138 K 4.3
Ca 4,67 Mg 2,3 Cl PT 13,70 APTT 23,7 INR 1,26 D-dimer
1.09 Fibrinogen 538.9
pH 7,380 pCO2 50,1 pO2 69,8 HCO3 29.9 BE 4,5 SaO2 92.1
LDH 510 Albumin 1,96
Ro. Thorax 26/2/21
Ro Thorax 26/02/2021
- Pneumonia bilateral bertambah
- Tidak tampak kardiomegali
Ro. Thorax 25/2/21
Ro. Thorax 24/2/21
Ro Thorax 24/02/2021
22/2/21
Hb 10,7 Ht 30,7 Leu 17.560 Tr 230.000 TLC 2.11NLCR 6.57 GDS 176 Ur 29,9 Cr 0.87 Na 141 K 3.4
Ca 5.33 Mg 2.3 Cl 117 PT 14.10 APTT 19.10 INR 1.30 D-dimer 3.49 Fibrinogen 256.4 SGOT 49 SGPT 42
pH 7,418 pCO2 32.2 pO2 96,5 HCO3 21.0 BE -2.4 SaO2 96.5
21/2/21
Hb 13,2 Ht 37.3 Leu 18.050 Tr 328.000 TLC 2.53NLCR 5.57 GDPS 207 Ur 34 Cr 0.84 Na 145 K 3.5
Ca 4.81 Mg 2.0 Cl 118 PT APTT INR D-dimer Fibrinogen SGOT 48 SGPT 45 LDH 339
pH 7,447 pCO2 28.9 pO2 83,8 HCO3 20.2 BE -2.1 SaO2 96.6
Ro. Thorax 26/2/21
Ro Thorax 26/02/2021
- Pneumonia kanan
- Tidak tampak lagi efusi pleura
- Kardiomegali tanpa bendungan paru
Rontgen Thorax 23/2/2021
Rontgen Thorax 22/2/2021
Ro. Thorax 19/02/2021
TERIMA KASIH
7. Dadi/ 61 tahun / 80 kg /0001302941/ H Sakit 17/ HP 7
Objectives Assessment Planning
CNS : Compos Mentis Confirmed COVID-19 moderate case + Hipertensi F : Diet biasa 1500kkal
A: -
CVS 26/02/2021 S:-
Hb11.1 Ht 35.5 Leu 6.79 Tr 495.000 PT 15.6 APTT 30.30 INR 1.10 GDS 97 LDH 236 SGOT 32 SGPT
T :103/57 mmHg 86 Alb 3.14 Laktat 1.7 Ur 34.5 Cr 0.75 Na 137 K 4.2 Cl 107 Ca 5.25 Mg 2.3 Fibrinogen 353 D-Dimer T : Fondaparinux 1 x 2,5 mg
N : 76 x/m,regular 0.70
pH 7.440 pCO2 33.2 pO2 70.7 HCO3 22.8 tCO2 23.8 BE -0.2 SaO2 93.8 Procalcitonin 0.02 Feritin 1070 H : Head up 30O
S : 36 ,4
25/2/2021 U : Lansoprazole 1x30mg
Hb 11,2 Ht 35,5 Leu 6.080 Tr 544.000 G :-
NLR 2.86 PT 16.2 INR 1.14 APTT 32.4 Laktat 2.1 ur 34.0 cr 0.69
Respirasi Na 135 K 4.4 Ca 4.92 Mg 2.2 Terapi :
RR: 18-20 x/menit pH 7,421 pCO2 34.9 pO2 86.9 tCO2 24.0 HCO3 22.9 be -0.4 SaO2 98.6 • Remdesivir 1x200mg (6)
SpO2: 99% dengan nasal kanul 2 pm • Dexamethasone 6 mg/24 ham iv (8)
Rox Index: 16,5 • Vit D 1x500 IU
24/2/2021 (15.03)
pH 7,442 pCO2 38,7 pO2 84,0 tCO2 28 HCO3 26,4 BE 2 SatO2 97% • Cernevit 1 ampul dalam RL 500 cc/24 jam
• N-acetylsistein 3x400mg IV
24/2/2021 • Zinc 2x20mg PO
GIT
Hb 11,8 Ht 37,5 Leu 6.710 Tr 559.000 • Amlodipin 5 mg/24 jam po
Datar, distensi (-)
NLR 3.7PT 15,5 INR 1,09 APTT 33,1 CRP 0,7 GDS 119 • Candesartan 8mg/24jam po
LDH 190 SGOT 30 SGPT 114 Laktat 3,0 ur 36 cr 0,79 • Atorvastatin 10mg/24jam po
Na 137 K 4,3 Cl 107 Ca 5,33 Mg 2,3 Fibrinogen 449,0 D-dimer 0,44 • Aspilet 1x80 mg po
pH 7,409 pCO2 32,8 pO2 134,3 tCO2 21,9 HCO3 20,9 be -2,4 SaO2 98,8
22/2/2021
Hb 10.8 Ht 35.2 Leu 5.770 Tr 512.000 Tot.limfosit 0.81 Tot.netrofil 4.44 NLR 5.48
GDS 94 LDH 241 SGOT 23 SGPT 31 alb 3.31 ur 43 cr 0.66 Na 137 K 4.9 Cl 110 Ca 5.0 Mg 2.3
pH 7,407 pCO2 36.9 pO2 169.2 HCO3 23.4 tCO2 24.5 BE -0.3 SatO2 99,2
21/2/2021
Hb 12,2 Ht 39,2 Leu 27.140 Tr 422.000 Tot.limfosit 0.27Tot.netrofil 26.33 NLR 97,6 PT 12,6 INR 1,15 APTT 56,70 GDS
242LDH 590 SGOT 23 SGPT 31 alb 2,84 ur 88 cr 1,84 Na 138 K 6,9 Cl 114 Ca 4,98 Mg 2,0 D-dimer 0.26 Fibrinogen
512,9
pH 7,308 pCO2 62,9 pO2 88,2,7 HCO3 31,8 tCO2 33,7 BE 4,7 SatO2 95,4
Ro. Thorax 26/2/21
Ro Thorax 26/02/2021
- Bronkopneumonia belum perbaikan
- Tidak tampak kardiomegali
Ro. Thorax 25/2/21
Ro. Thorax 24/2/21
Ro Thorax 24/2/2021
• Pneumonia bilateral perbaikan
• Kardiomegali DD/ posisi
Ro. Thorax 23/02/2021
Ro. Thorax 22/02/2021
Ro. Thorax 21/02/2021