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  • MORNING REPORT ICU 22 September

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    Thaharatin Giza
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    Mrs. Muntiasih, a 47-year-old female patient in bed 5 of the ICU, underwent craniotomy for a suspected high-grade astrocytoma in the left temporoparietal lobe. Her vital signs were stable but she had an elevated white blood cell count and signs of right lower lobe pneumonia on chest x-ray. Her treatment plan included antibiotics, anticonvulsants, steroids, and supportive care to address her neurological condition and infections while closely monitoring her respiratory status on ventilator support.

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    Mrs. Muntiasih, a 47-year-old female patient in bed 5 of the ICU, underwent craniotomy for a suspected high-grade astrocytoma in the left temporoparietal lobe. Her vital signs were stable but she had an elevated white blood cell count and signs of right lower lobe pneumonia on chest x-ray. Her treatment plan included antibiotics, anticonvulsants, steroids, and supportive care to address her neurological condition and infections while closely monitoring her respiratory status on ventilator support.

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    7 views5 pages

    MORNING REPORT ICU 22 September

    Uploaded by

    Thaharatin Giza
    Mrs. Muntiasih, a 47-year-old female patient in bed 5 of the ICU, underwent craniotomy for a suspected high-grade astrocytoma in the left temporoparietal lobe. Her vital signs were stable but she had an elevated white blood cell count and signs of right lower lobe pneumonia on chest x-ray. Her treatment plan included antibiotics, anticonvulsants, steroids, and supportive care to address her neurological condition and infections while closely monitoring her respiratory status on ventilator support.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 5

    MORNING REPORT

    ICU (22/09/2022)
    Thaharatin Giza W
    Irma Liani
    BED 5
    Mrs. Muntiasih/ 47 years old / 00.68.91.66
    Objective Assesment Planning

    CNS : E3 Vtube M1 Post op Craniotomy a.i SOL F : Parenteral


    A : Phenitoin 100mg/12h

    CVS 14/09/2022 16.25 WIB S : Midazolam drip 1,5 gr/h


    BP : 114/79 mmHg Hb: 13,7 g/dL
    HR : 94 x/mnt Leukocyte: 11,800 /uL * T : Kalnex 500mg/8h
    T : 36,9 º C Erythrocyte: 5.3 million/uL
    Thrombocyte: 228.000 /uL H : Head up 30
    Ht: 40 % U : Omeprazole 40mg/12h,
    Antibody SARS-COVID 19: IgM (-), IgG (-)

    20/09/2022 G:-
    T: 38,5 C
    Respiration Th/
    RR : 18 x/m with ventilator mode
    pH: 7,39 APACHE Score : 18 points
    pCO2 : 36,6 mmHg
    VC-PAP, VT 480, PEEP 5, FiO 2 pO2 : 169 mmHg * (Estimated mortalitiy 29,1%) Parenteral:
    70% HCO3 : 22,3 mmol/L * Ceftriaxone 1gr/12h
    SpO2 : 99% TCO2 : 23 mmol/L Citicoline 250mg/12h
    SOFA score : 8 points (Initial Phenitoin 100mg/12h
    20/09/2022 Omeprazole 40mg/12h
    Hb: 14,2 g/dL SOFA Scores ≤9 predict ≤ 33.3%
    Mannitol 125cc/6h
    GIT Leukocyte: 26.000 /uL * mortality Kalnex 500mg/8h
    Erythrocyte: 5,2 million/uL
    NGT (+), bowel sound (-) Thrombocyte: 144.000 /uL* Dexametahoson 1 amp/8h
    Ht: 41 % qSOFA : 1 points (Not High Risk) Drip:
    Ureum: 15 mg/dL
    Creatinine: 0,46 mg/dL Midazolam 1,5 gr/h
    Na: 134 mmol/L* Dobutamin 5
    GUT K: 3.0 mmol/L* Norepinefrin 0,05
    UO : 2500 cc/24 hour Ca: 19.2 mg/L *
    Cl: 108 mmol/L *
    Albumin : 2,8 g/dl
    Thorax X-ray 13/09/22

    Thorax AP

    Kesan:
    • Opasitas ground glass di basal pulmo dextra aspek
    medial sugestif pneumonia segmental lobus inferior
    dextra
    • Besar cor normal
    Head CT-Scan Kepala Tanpa Kontras 06/09/22

    Kesan:
    • massa di lobus temporoparietalis
    sinistra disertai herniasi subfalcine,
    suggestive high grade astrocytoma
    • Defect di tabula interna os frontal

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