Laporan Jaga Ruangan September 2020

1 September 2020 Gizella (Pagi)
No Masuk Bed Nama Diagnosis TTV

1 28-Aug 1602 dr. Herdhito Dewahyu/54th COVID-19 confirmed case Kes CM
Bakrie DMT2 TD:
dr. Taufan, Sp.P HT N:
dr. Felix Sp.PD Dislipidemia RR:
S:
2 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case Kes CM

Kemkes Pneumonia TD:
dr Felix Sp.PD Cephalgia N:
dr. Taufan Sp.P HT HHD RR:
CAD S:
Hiperuricemia
3 27-Aug 1605 Tn. Imam Wahyudi /43 th COVID-19 confirmed case Kes CM
Bakrie TD:
dr. Taufan SpP N
RR
S
4 4-Aug 1606 Tn. Lilik S/ 55 th COVID-19 confirmed case Kes CM

Kemkes TB paru kasus baru TD:
dr. Taufan, Sp.P N:
RR:
S:
6 19-Aug 1608 dr. Novie Hediyani/ 40th COVID-19 confirmed case Kes CM
Kemkes Bronkitis akut TD:
dr. Taufan SpP N:
RR:
S:
7 29-Aug 16 dr. Achmad Budiarto/62 Covid 19 Confirmed Case Kes

Bakrie Hipertensi TD
dr Taufan SpP DM tipe II N
raber dr Felix Sp. PD DHF RR
Riw Asma S
observasi trombosit
8 30-Aug 16 Tn. Sabam Frando/32 th Covid 19 Confirmed Case Kes

Bakrie TD
dr. Taufan Sp.P N
RR
S
9 16-Aug 1101 Ny.Dian Purnamalia/38 th COVID-19 confirmed case Kes CM

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:
10 19-Aug 1102 Tn Faisal Firdaus/52th COVID-19 confirmed case Kes CM

Darma TD:
Henwa dr. Taufan SpP N:
RR:
S:
11 25-Aug 1103 Tn. Yan Rahmanto/52 th COVID-19 confirmed case Kes:CM

Bakrie TD;
dr. Taufan Sp.P N:
RR:
S:
12 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case Kes CM

Darma TD:
Henwa dr. Taufan Sp.P N:
RR:
S:
13 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case Kes CM

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:
14 15-Aug 1106 Ny. Reni COVID-19 confirmed case Kes CM
TD:
asuransi dr. Taufan Sp.P N:
RR:
S:
15 25-Aug 1001 Tn. Dmitry / 49th ADHF ec CAD Kes: CM
Pribadi (Advanced HF EF 17%) TD: 96/60
dr. Damba, Sp.JP AF RVR N: 91
dr. Taufan, Sp.P Pneumonia RR: 24
co dr Putri SpGK Pleuritis S 36.1
SaO2: 97
Per 24 jam
In: 1010
Out: 1300
Bal: -290
16 27-Aug 1003 Ny. Violen Helen/ 41 th AUB Kes CM

Pribadi Post shock hipovolemik TD: 111/54
dr. Felix, Sp.PD Anemia berat ec perdarahan N: 91
dr. Lucy, Sp.OG Pneumonia RR: 20
S: 37.1
18 25-Aug 1205 Tn. Bruce Gimon/ 42 th TB paru kasus baru Kes : CM

Pribadi Pneumonia TD : 127/68
dr. Taufan, Sp.P Diare kronis N: 109
Immunocompromise RR: 27
S: 36.9
BB: 65 kg SaO2: 56-94
20 21-Aug ICU Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8) Kes:

BPJS HT TD: 157/92
Pneumonia N: 69
dr. Hendri, Sp.An-KIC Electrolyte imbalance RR: 14-15
dr. Angelina, Sp.N Post PDT (27/8) S: 36
dr. Felix, Sp.PD Hipoalbuminemia SaO2: 100
Konstipasi
BB: 70 kg Per 24 jam
Intake:
Out:
Bal:
UO
Penunjang
26/8 PCR swab I +
28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12
S Typhi O/H 1/160 paratyphi 1/80. EKG NSR
Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru
29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
1/9 PT/APTT 14.9/17.0 D-dimer kuantitatif <100
Kol. Total 143, TG 127, HDL 27, LDL Direk 95, As.Urat 6.2
10/8 Hb/Ht/L/Tr 11.9/37/3.3/202 Widal S typhi H 1/320

11/8 Hb/Ht/L/Tr 12.4/38/4/205 Rapid negatif
Na/K/Cl 136/3.7/99, OT/PT 41/24; EKG SR 94x normoaxis ST elevasi -
CXR: kardiomegali + elongasi aorta; bronkopneumonia dupleks
13/8 Hb/Ht/L/Tr 11.6/34/5.1/193 LED 70 NLR 8.31 Eo 1 Neu. Segmen 82 Limf 10
PT/APTT 17.7/32.9 GDP 76 Kol Tot 149/TG101/HDL 34/LDL86
Asam urat 6.2/Ur/Cr 35/1.2
14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52
19/8 PCR Swab II +
25/8 Hb/Ht/L/Tr 11.3/33/7/409 LED 50 NLR 2.88 Diff 1/1/62/3/23/10
26/8 PCR Swab III +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
3/8 CXR: fibroinfiltrat suprahilar kanan dan kiri + paracardial kanan kiri
diafragma dan sinus baik. Kesan: KP duplex aktif.
Hb 13,2 Ht 37,9 leu 6,99 Tr 298rb LED 82 Seg/limf 62/30
4/8 Rapid SARS Cov2 + EKG NSR
5/8 PCR Swab I+
12/8 PCR swab II +
19/8 PCR swab III +
26/8 PCR swab III -
18/8 Hb/Ht/L/Tr 13.1/39.1/3.8/192 Diff 0.3/2.6/35.6/53.9/7.6 , Widal Ty H 1/40, Para BH 1/20
19/8 CXR bronkopneumonia bilateral
19/8 PCR Swab I +
26/8 PCR swab II +
28/8 CXR: GGO perburukan
29/8 PCR Swab I +

29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue -
GDS 153
CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19
blm dapat disingkirkan
30/8 Hb 15.6 Ht 46 Leu 3.6 Tr 117 eri 5.17 GDP 155 GD2PP 184 HbA1C 7.7 chol tot 100 TG 189
choles LDL hitung 39/direct 46 AU3.5 ur 24 cr 1.2 Ot/PT 66/51
UL dbn
31/8 Hb 14.9 Ht 43 Leuko 3.3 Trombo 107 Eritrosit 4,94 GDS 18:65 21:115
1/9 Hb/HT/L/Tc/E 14.3/42/2.2/117/4.77 PT/APTT 15.2/31.8 D-Dimer <100, GDS 85
26/8 PCR Swab I + CXR C/P dbn Hb/Ht/L/Tr 14.2/41.8/4.7/255 Monosit 10 OT/PT 25/38
Rapid Sars Cov2 -
30/8 CXR Susp. Gambaran GGO di paru S atypical, kemungkinan viral pneumonia Covid 19 belum
dapat disingkirkan Hb/Ht/L/Tr 14.6/42/5.7/237 LED 20 Eo 1 Limf 24 Mono 9
16/8 PCR Swab premier gene N2 positive Ct 30.67

Hb/Ht/L/Tr 12.7/38/9.2/328 MCV/MCH/MCHC 86/30/35 LED 31 NLR 0.32 Diff 3/0/65/3/22/7
CXR: cor dbn, susp GGO paru dextra
24/8 PCR swab II +
16/8 PCR Swab I +

16/8 Hb/Ht/L/Tr 14.7/41.5/4.16/190 LED 5 CRP 10 Diff 0/1/5/60/26/8,OT/PT 21/18,Ur/Cr 14/1.1
IgM anti salmonella +, NS1 -, IgG IgM dengue -, AGD normal, Na/K/Cl 135/4.2/95
CT Thorax: multinodul GGO di segmen ant lobus atas paru kiri, GGO minimal di
segmen posterobasal
24/8 PCR swab II +
31/8 PCR swab III -
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

CXR Cor dbn. Arcus aorta elongasi. Susp. Gambaran GGO halus di kedua paru (typical) kemungkinan
viral pneumonia/covid 19 belum dapat disingkirkan. PCR Swab I +
21/8 Hb/Ht/L/Tr 13.1/39/3.2/175 diff 0/0/40/3/44/13 LED 17 NLR 0.96

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
23/8 PCR Swab +

24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10
CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru
(atypical).
28/8 Swab PCR +

HB10.2 HT 31 L 6.5 Tc 306 E3.8 LED 8 NLR 1.21
Hitung Jenis 2/0/46/3/40/9/3.17/2.61

25/8 Hb/Ht/L/Tr 12.7/41/4.9/142 Diff 1/0/60/3/30/6/ LED 10 SGOT 32 SGPT 20, alb 3.5 globulin 2.9
INR 1.82 INR control 1.73
Na/K/Cl/Caion 136/2.9/101/1.02, Rapid non reaktif
Ro tho Kardiomegali sedikit meningkat,Aorta elongasi kalsifikasi. Bronkopneumonia dupleks meningkat DD/ lung edema
efusi pleura kanan meningkat, pleuritis kiri berkurang
26/8 AGD pH 7.45 pCO2 34 pO2 68 HCO3 23.7 tCO2 24.7 Actual BE 0.8 Sat 94.4
27/8 ur/cr 26/0,5 Na 145 K 3 Cl 101 pH 7,46 pCO2 34,2 pO2 120,6 HCO3 24,5 SaO2 99,3
troponin T 33
29/8 Ur/Cr 24/0.6 Na/K/Cl 136/2.7/98
Kultur sputum: M. TBC Culture negative. Microorganism Culture: Positive (Staphylococcus hominis)
31/8 Hb 13.5 Ht 41 Leuko 9 Trombo 170 Eritro 3.87 MCV 105 MCH 35 MCHC 33
Diff count 2/0/68+3/22/8/ Na K CL 138/3.3/101
17/8 Hb/Ht/L/Tr 5.7/17.6/21.74/774 Neu. Segmen 80 Limf 13 Na/K 138/ 4.26 Widal negatif
CXR pneumonia atypical (patchy opacity parakardial kanan kiri)
27/8 Hb/Ht/L/Tr 5.3/17/31.1/925 Neu. Segmen 83 Limf 8 NLR 10.3, Ur/Cr 31/0.7
UL keton+1, leuk 2-4, erit 0-1, pregnancy dipstick -, HBsAg -, antiHCV -, antiHIV -, pt/aptt 12.5/28
27/8 PCR Swab -
29/8 USG abdomen ??
29/8 DPL 6 jam post transfusi Hb/Ht/L/Tr 9.6/28/21.5/627 LED 44 NLR 19.64, diff 1/0/86/3/5/5/
30/08 Ca-125<1 U/mL
31/8 Hb/Ht/L/Tr 10.8/32/19.6/487
25/8 Hb/Ht/L/Tr 13/37/3.3/441 Duff 2/0/32/3/3/46/17 LED 121 SGOT 56/SGPT 30

bil tot 0.9, bil dir 0.59 indir 0.31
Foto thorax : Cor dbn, Susp GGO dikedu paru typical , kemungkinan pneumonia/Covid blm dapat disingkirkan
Rapid Covid Non reaktif
26/8 PCR Swab -
28/8 AGD (vena??) pH 7,35 pCO2 45,3 pO2 35,4 HCO3 25,3 BE -0,1 Sat 63,3
29/8 AGD pH 7.47 pCO2 29,6 pO2 93,6 HCO3 21,8 BE -0,2 Sat 98,2
31/8 AGD pH 7.45 pCO2 33 pO2 72.4 HCO3 23.4 BE -0,9 Sat 95.6
31/8 CD4 absolut 28 CD4% 2 Rapid +
19/8 CT brain: perdarahan intraparenkim pons dan cerebellum sisi kiri. Infark kronik basal
ganglia kiri. Microvascular ischemia basal ganglia kanan dan korona radiata kiri. Awal sinusitis
maksilaris kanan.
CXR: kardiomegali dengan elongasio aorta, pneumonia bilateral.
Hb 13,7 Ht 38 Leu 12,2 Tr 241 Bas/eos/bat/seg/lim/mo 0/2/0/35/57/6. LED 1. Ca 1,04 GDS 172
OT/PT 26/16 ur/cr 35/1,5 AU 5,2 Na 141 K 2,9 Cl 100 Rapid SARS Cov 2 - PCR Swab -
21/8 Rapid sars cov2 - GDP 147 Kol. Tot 155 TG 124 HDL 48 LDL 64 Asam urat 3.3
22/8 Hb/Ht/L/Tr 11.3/29/10.6/211 GDP 90 Hba1c 5.1 Na/K/Cl 144/4.3/104
UL Agak keruh protein +1 Darah 2+ PT/APTT 15.4/31.5
24/8 HB/HT/L/Tc/E 9.7/30/7.5/199/3.01 Diff count 4/0/73/13/10/5.49/0.94
GDS 185 Na/K/Cl 140/3.8/105
26/8 PT/APTT 15.5(13.7)/26.6(30.1)
27/8 Hb 9,7 Ht 30 Leu 8,1 Tr 422 LED 110 NLR 4,71 GDS 144 ur/cr 48/0,8 OT/PT 34/50
Alb/glob 2,9/3,1
29/8 lesi hiperdens/perdarahan dengan lesi hipodens/perdarahan yang diserp di infratentorial
pd pons yang meluas ke cerebelum kiri batas tegas, vol perdarahan +/- 6.42 cm3 (HU 58.2),
sebelumnya vol perdarahan 17.6 cc, perbaikan
lacunar infark kronik di basal ganglia bilateral dan corona radiata stqa
tak tampak lesi perdarahan EDH, SDH, ICH, atau SOL intrakranial saat ini.
Subgaleal hematoma di parietal kiri.
30/8 HB/HT/L/Tc/E 11.2/33/14.1/617/3.63 Diff count 2/0/82/7/6/12.03/0.95 GDS 131
31/8 Na K Cl 137/4.3/98
Terapi
Baquinor forte 2x500 mg PO (29/8)
Oseltamivir 2x75mg (29/8)
Hyloquine 1x400mg (29/8)
Azitromycin 1x500mg (29/8)
Becomzet 1x1 PO
Lantus 1x32 unit SC malam-->36 unit
Lapiva 1x10/160 mg PO 0-0-1
Concor 1x2,5 mg PO 1-0-0
Cardioaspirin 1x80 mg PO
Amaryl 4 mg 1-0-0 PO
Acarbose 3x100 mg PO
Januvia 100mg 1-0-0 PO
Atorvastatin 20mg 0-0-1 PO
Ondancentron 2x8 mg PO
Lapraz 1x1
O2 3 lpm via nasal canule
Venflon
Lansoprazole 1x30 mg PO
Candesartan 1x4mg PO malam bila MAP <65 tunda
Bisoprolol 1x1,25mg PO pagi
Clopidogrel 1x75mg PO
Mecobalamin 2x500 mg PO
Atorvastatin 1x20 mg PO malam
Ultracet 3x1 tab PO kp nyeri kepala
Allopurinol 1x100 mg PO (malam)
Becomzet 1x1 PO
Betadine garg 3x/ hari
liproqy 2x1

Becomzet 1x1po
Nalgestan 2xI PO
O2 3 lpm via nasal canule k/p

Venflon
RHZE 600/400/1500/1000 (6/8)
OBH 3xC1 PO
Becomzet 1xI PO
Paracetamol 500 mg PO k/p

Sumagesik 3x500mg PO
Codipront exp 3x cthI PO
Sanexon 1x4mg PO - 30/8 STOP
Lansoprazole 2x30mg PO
Amlodipin1x5 mg PO pagi
Salbutamol 2x1.5 mg po
Teofilin 2x100 mg po
Becomzet 1x1 PO
Seretide diskus 4x2 puff
Minosep garg 3x/hari
Ventolin inhaler 2 puff k/p sesak bertambah
RL 500 cc/ 24 jam IV--> NaCl 500cc/6jam
Becomzet 1x1po
Sanmol forte 3x1 tab po
Pumpicel 1x1 amp iv
Metformin 2x500 mg po
Glimepiride 1x2 mg po
Lantus 1x12 U
Amlodipin 1x 5 mg po
Candesartan 1x 8 mg po
Lesichol 1x300mg PO
Fenofibrat 100mg 0-1-0 PO
Vectrine 3x300 mg PO
Prome syr k/p batuk
Etorvel 60mg 0-1-0
Terfacef 1x2gr
Hyloquin 1x400 mg PO (30/8)

Azitromisin 1x500 mg PO (30/8)
Becomzet 1x1 PO
Codipront exp 3x cth I PO
Becomzet 1xI PO
Betadine garg 3 x/ hari
Levopront 3x1cth
Paracetamol 3x500mg PO
Becomzet 1x1 PO

Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Codipront syr 3x cth 1

Becomzet 1x1po
Codipront 3x1cth
Amlodipin 1x10 mg PO pagi
Candesartan 1x8 mg PO malam
Becomzet 1x1po
IVFD RL 500 cc + KCL 25 meq drip dalam 24 jam (2 hari)
O2 15lpm via NRM
Avelox 1x400mg IV (26/8) 7 hari
Lasix 20 mg/ jam IV drip
Uperio 2x50 mg po
Simarc 1x2mg po
Tromboaspilet 1x80 mg po
Concor 1x1.25 mg po
Atorvastatin 1x20 mg po
Spironolacton 1x25 mg po
Omeprazole 2x 40 mg IV
Ventolin expectoran 2xC I PO
Nebulisasi ventolin : pulmicort=1:1/ 12jam
IVFD NS 20tpm
Levocin 1x750mg IV (27/8)-->stop
Mezatrin 1x500mg PO (27/8)--> Azitro 1x500
Merosan 3x1g IV (28/7)--> Meropenem 3x1gr STOP
Pumpisel 1x40mg IV--> omeprazole 2x20
Becomzet 1x1tab PO
Asetin effevescent 1x600mg PO--> STOP
Drip sanmol 1 gr k/p Demam
Probiostim 1x1
O2 14 lpm NRM
Venflon
R/H/Z/E 450/400/1000/1000 mg PO (27/8)
Codipront 3x1cth po
Bcomzet 1x1 tab po
New diatab 3x2 tab po
PCT 3x 1000 mg PO k/p demam
HP pro 2xI PO
(Bronsolvon 120 mg+Salbutamol 1,5 mg) 2x1 caps PO
Medixon 1x125 mg IV (31/8)
Nebulizer Ventolin:Pulmicort 1:1 /12 jam
bactrim 2x1 (31/8) atau cotrimoxazole
IVFD NS:KAEN3B 1:1 20 tpm
Ensure 3x200 cc per NGT + Diet Saring 3x250
Meropenem 3x1 g IV (27/8)
Levofloxacin 1x750mg IV (24/8)
Citicoline 2x500 mg IV
Omeprazole 2x40 mg IV
Ibuprofen 3x400 mg per NGT
Mecobalamin 2x500 mg IV
Candesartan1x16 mg PO malam
Sucralfat syr 2xCII po
Nebulizer ventolin/pulmicort+ NaCl 0.9% 3x per hari
Acetylsistein 3x200 mg PO
Gabaxa 1x100mg IV
Prohiper 2x10 mg PO (3 hari, mulai 29/8)
Asam folat 3x1 tab PO
VIP albumin 3x2caps PO
Omega 3 2x1 g PO
Dulcolax supp 0-0-II
Lactulax 3x2 CII PO
Probiokid 1x/minggu
Spironolactone 50 mg 0-1-0 PO
Cendo lyters 4x1 gtt
polygran eye ointment 2xsehari terutama tidur
Keterangan
30/8 Trajenta, truvas, angioten stop
31/9 R/ GDP pagi, GDS pk 18
1/9 R/ swab ulang form+ PE+
*Febris sejak 6/8

co dr. Damba: candesartan 1x8mg, concor ganti bisoprolol 1x1.25mg, simvastatin 20mg malam, CPG 1x75mg
co dr. Angelina, Sp.N: cephalgia ec thypoid fever
15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
19/8 hyloquin, oseltamivir stop
2/9 R/ swab ulang, form +, PE +
* Riwayat demam 5 hari SMRS

1/9 R/ PCR swab, form+ PE+
Bila sesak bertambah/ wheezing, lapor dr. Taufan, Sp.P dan cek AGD!
13/8 Stop Oseltamivir, azitro, hyloquin
18/8 Ventolin syr STOP
24/8 Pasien minta obat kumur->sudah wa dr.. Taufan, belum dibalas
31/8 FU hasil swab
R/ cek sputum BTA 3x + kultur -> sampel -
* Demam sejak 15/8, sudah konsumsi ciprofloxacin dan azitromisin 5 hari. Riw asma +
** R/ CXR ulang sebelum pulang setelah 2x swab negatif
25/8 ondansetron 4mg kp muntah
27/8 Hyloquin, Oseltamivir, Azitromycin STOP
28/8 extra dexametasone 1 amp IV kp sesak (-), px menolak steroid, minta levofloxacin saja
2/9 R/ Swab ulang, form +, PE +
Jika sesak dan saturasi di bawah 90 % cek PT APTT DDimer
30/8 Tromboaspilet tunda

1/9 DR/24 jam , GDP, GDS jam 18.00, PT/APTT, D-dimer
1/9 Konsul Gizi
*Cek DR/hari
20//8 Hylo, azitro, oselta stop

31/8 FU hasil swab
24/8 Codipront sudah habis -> ganti levopront 3x1cth
tanya dr Taufan paracetamol k/p?
26/8 Hyloqiun, Azitromycin, Oseltamivir STOP
31/8 FU hasil swab
1/9 cek DL
26/8 Pasien mengeluhkan nyeri dada kiri, EKG ulang gambaran AF saja -> extra PCT 1 gr IV drip, NRM naik 15 lpm, Swab ditolak
Monitoring TTV /4 jam, Target MAP > 55. Intake 1500cc/24 jam, target balance -500 ds -1000cc/24 jam
27/8 Codipront stop
31/8 furosemide 15 mg/jam
1/9 furosemide 10 mg/jam ,rencana rajal Rabu
EKG per hari
dr. Damba: Cek UrCr dan elektrolit/2 hari --> next ,31; dr Taufan cek DPL UrCr, CXR ulang post Avelox 7 hari:1/9 dr. Damba cek
KIE pasien agar mau swab!!! --> titipan manajeman
*Bila post concor sesak, lasix naik 20 mg/jam. Saat memberikan concor awasi tanda sesak memberat, posisi duduk tegak
dr. Lucy Sp.OG: pro MRI abdomen dengan kontras setelah ada hasil swab, pro Tranfusi PRC 1000cc
27/8 PRC 1: 223cc; co dr. Taufan: pneumonia pd anemia berat ->kultur darah
28/8 PRC 2: 192cc, PRC 3: 220 cc
29/8 PRC 4: 203 cc, ekstra Ca glukonas 1 amp iv
MRI + BNO IVP (pasien belum bersedia)
30/8 PRC V : 200 cc , dr Felix : jika bebas demam 2 hari , SaO2 baik, HB >10 rencana rawat jalan
FU hasil kultur darah 28/7
1/9 DPL
*30/8 pk. 18 suhu 39.9
31/8 pk 18 t 38.1, sanmol tab 1000 mg
*menolak pasang venflon, ACC rajal dr. Felix terapi AB cefixime 2x200 mg,azitromisin 1x500mg, metronidazole 3x500mg -->5
kontrol poli dr. Felix bila demam, bila tidak sesuai protap dr Lucy SpOG
1/9 rencana pemberian trovas I (trovas 3-6 siklus : 28 hari/siklus)
*Awasi reaksi OAT 3 hari. AGD bila sesak bertambah!
27/8 cotrimoxazole stop
31/8 co dr. Robert -->metylprednisolon , menolak ingin fokus ke terapi dr. Taufan SpP
FU hasil anti HIV, CD4+ (kata lab 4 hari jadinya senin), edukasi dubia malam (+) dan hasil CD 4, lembar KIE (+) hasil rapid B20: b
FU sample cek sputum BTA 3x
24/8 dr. Felix: Antibiotik ganti levofloxacin 1x750mg iv, Kultur dahak dan tes sensitivitas, Azithromicin 1x500 sd hari ke-5
As tranexamat dan vit K STOP, manito stop, Ceftriaxon stop
25/8 R/ MRI Brain NK -> tidak dpt dilakukan karena pasien terintubasi, dr Angel maklum
26/8 dr. Angel: kalau bisa jangan mulai blistra kecuali MABP>= 130, coba antihipertensi oral dulu
29/8 Pro Brain CT kontrol tanpa kontras
29/8 Co ulang dr.Ichsan SpBS
30/8 dr. Ichsan: ct kontrol 1 mgg, co rehab
31/ Konsul dr Amytha, rencana home care 1/9 KIE keluarga (-) , dr angel rencana visite
IPD: R/ DPL + GDS/ 3 hari --> next 2 hari acc BPJS + (30/8 dan 2/9)
31/8 fisioterapi, cek elektrolit, form +

5/8 R/ Brain CT scan kontrol tanpa kontras
FU hasil kultur sputum
1 September 2020 Malam (Safira)

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

dr. Taufan, Sp.P N:
RR:
S:
dr. Taufan SpP N:
RR:
S:
6 29-Aug 16 dr. Achmad Budiarto/62 th Covid 19 Confirmed Case Kes

Co dr. Putri Sp.GK Riw Asma S
observasi trombosit

Bakrie TD
dr. Taufan Sp.P N
RR
S

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Bakrie TD;
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

TD:
RR:
S:
14 25-Aug 1001 Tn. Dmitry / 49th ADHF ec CAD Kes: CM

Pribadi (Advanced HF EF 17%) TD:
dr. Damba, Sp.JP AF RVR N:
dr. Taufan, Sp.P Pneumonia RR:
co dr Putri SpGK Pleuritis S
SaO2:
Per 24 jam
In:
Out:
Bal: -
15 27-Aug 1003 Ny. Violen Helen/ 41 th AUB

Pribadi Post shock hipovolemik
dr. Felix, Sp.PD Anemia berat ec perdarahan
dr. Lucy, Sp.OG Pneumonia

Pribadi Pneumonia TD :
dr. Taufan, Sp.P Diare kronis N:
Immunocompromise RR:
S: 3
BB: 65 kg SaO2: 89-93
17 21-Aug ICU Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8) Kes:

BPJS HT TD: 145/78
Pneumonia N: 72
dr. Hendri, Sp.An-KIC Electrolyte imbalance RR: 15
dr. Angelina, Sp.N Post PDT (27/8) S: 36.6
dr. Ichsan Sp.BS Konstipasi
Co dr Amytha Sp.M Per 24 jam
Intake:
BB: 70 kg Out:
Bal:
UO
Penunjang
26/8 PCR swab I +
29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
1/9 PT/APTT 14.9/17.0 D-dimer <100 Kol. Total 143, TG 127, HDL 27, LDL Direk 95, As.Urat 6.2 GDS 18: 286

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
5/8 PCR Swab I+
12/8 PCR swab II +
19/8 PCR swab III +
26/8 PCR swab III -

19/8 PCR Swab I +
26/8 PCR swab II +
29/8 PCR Swab I +

GDS 153
UL dbn
1/9 Hb/HT/L/Tc/E 14.3/42/2.2/117/4.77 PT/APTT 15.2/31.8 D-Dimer <100, GDS 06: 85 18.00: 213
Rapid Sars Cov2 -

24/8 PCR swab II +
16/8 PCR Swab I +

segmen posterobasal
24/8 PCR swab II +
31/8 PCR swab III -
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177


CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
23/8 PCR Swab +

(atypical).
28/8 Swab PCR +

1/9 Hb 10.2 Ht 31 L 6.5 Tc 306 E3.8 LED 8 NLR 1.21 Hitung Jenis 2/0/46/3/40/9/3.17/2.61
25/8 Hb/Ht/L/Tr 12.7/41/4.9/142 Diff 1/0/60/3/30/6/ LED 10 SGOT 32 SGPT 20, alb 3.5 globulin 2.9
INR 1.82 INR control 1.73
Na/K/Cl/Caion 136/2.9/101/1.02, Rapid non reaktif
CXR: Kardiomegali sedikit meningkat,Aorta elongasi kalsifikasi. BP dupleks meningkat DD/ lung edema
efusi pleura kanan meningkat, pleuritis kiri berkurang
26/8 AGD pH 7.45 pCO2 34 pO2 68 HCO3 23.7 tCO2 24.7 Actual BE 0.8 Sat 94.4
27/8 ur/cr 26/0,5 Na 145 K 3 Cl 101 pH 7,46 pCO2 34,2 pO2 120,6 HCO3 24,5 SaO2 99,3
troponin T 33
29/8 Ur/Cr 24/0.6 Na/K/Cl 136/2.7/98
Kultur sputum: M. TBC Culture negative. Microorganism Culture: Positive (Staphylococcus hominis)
31/8 Hb 13.5 Ht 41 Leuko 9 Trombo 170 Eritro 3.87 MCV 105 MCH 35 MCHC 33
Diff count 2/0/68+3/22/8/ Na K CL 138/3.3/101
1/9 CXR: Cor dbn, bronkopneumonia dx perbaikan, efusi pleura kanan perbaikan

CXR : Cor dbn, Susp GGO dikedu paru typical , kemungkinan pneumonia/Covid blm dapat disingkirkan
26/8 PCR Swab -
maksilaris kanan.
GDS 185 Na/K/Cl 140/3.8/105
26/8 PT/APTT 15.5(13.7)/26.6(30.1)
Alb/glob 2,9/3,1
31/8 Na K Cl 137/4.3/98
1/9 Kultur Sputum: positif Stenotrophomonas maltophilia
Terapi
Becomzet 1x1 PO
Lantus 1x36 unit SC malam
Lapraz 1x1 PO
HCT 25 mg 0-1/2-0 PO
Kombilyze XR 5/500 1x1 PO (siang)
Venflon
Becomzet 1x1 PO
liproqy 2x1
Becomzet 1x1 po
Nalgestan 2xI PO

Venflon
RHZE 600/400/1500/1000 (6/8)
OBH 3xC1 PO
Becomzet 1xI PO

Becomzet 1x1 PO
Hydrocortisone zalf 2x1 ue
Becomzet 1x1po
Pumpicel 1x1 amp iv
Metformin 2x500 mg po (pagi sore)
Lantus 1x12 U
Lesichol 1x300mg PO
Prome syr k/p batuk
Etorvel 60mg 0-1-0
Terfacef 1x2gr
Liproqy 1x1 PO
Probiostim 1x/seminggu
Kombiglyze XR 5/500 1x1 PO (siang)

Becomzet 1x1 PO
Becomzet 1xI PO
Levopront 3x1cth
Becomzet 1x1 PO
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Becomzet 1x1po
Codipront 3x1cth

Becomzet 1x1po
IVFD RL 500 cc + KCL 25 meq drip dalam 24 jam

O2 3lpm via Nk
Lasix 5 mg/ jam IV drip
Uperio 2x50 mg po
Simarc 1x2mg po
Tromboaspilet 1x80 mg po
Concor 1x1.25 mg po
Atorvastatin 1x20 mg po
Spironolacton 1x25 mg po
Omeprazole 2x 40 mg IV
Ventolin expectoran 2xC I PO
Nebulisasi ventolin : pulmicort=1:1/ 12jam
PULANG
O2 14 lpm NRM
Venflon
R/H/Z/E 450/400/1000/1000 mg PO (27/8)
Codipront 3x1cth po
Bcomzet 1x1 tab po
HP pro 2xI PO
bactrim 2x1 PO (31/8) atau cotrimoxazole
Gabaxa 1x100mg IV
Omega 3 2x1 g PO
Lactulax 3x2 CII PO
Probiokid 1x/minggu
polygran eye ointment 2xsehari terutama tidur
Keterangan
Follow up swab PCR 1/9
GDP dan GDS 18.00
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop

29/8 Oseltamivir hyloquin azithromycin STOP
31/8 FU hasil swab

*Cek DR/hari
GDP dan GDS 18.00

31/8 FU hasil swab
2/9 Swab PCR form (+) PE (+)
2/9 hyloquin oseltamivir azithromycin stop
31/8 FU hasil swab

26/8 Pasien mengeluhkan nyeri dada kiri, EKG ulang gambaran AF saja -> extra PCT 1 gr IV drip, NRM naik 15 lpm, Swab ditolak
Monitoring TTV /4 jam, Target MAP > 55. Intake 1500cc/24 jam, target balance -500 ds -1000cc/24 jam
27/8 Codipront stop
1/9 Avelox stop
2/9 Lasix drip stop, dr Damba Sp.JP dan dr Taufan Sp.P rencana pulang TUTD, ekstra lasix 1 amp sebelum pulang,
EKG per hari

dr. Damba: Cek UrCr dan elektrolit/2 hari
KIE pasien agar mau swab!!! --> titipan manajeman
*Bila post concor sesak, lasix naik 20 mg/jam. Saat memberikan concor awasi tanda sesak memberat, posisi duduk tegak

Hasil CD4: edukasi dubia malam (+) lembar KIE (+) hasil rapid B20: blm KIE
1/9 dr Hendri Sp.An: Homecare
2/9 DPL, GDS, Albumin Globulin, Protein total
2 September 2020 Malam (Meri)

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

dr. Taufan, Sp.P N:
RR:
S:
dr. Taufan SpP N:
RR:
S:

observasi trombosit

Wilmar TD
dr. Taufan Sp.P N
RR
S

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Bakrie TD;
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

TD:
RR:
S:
14 25-Aug 1001 Tn. Dmitry / 49th ADHF ec CAD

Pribadi (Advanced HF EF 17%)
dr. Damba, Sp.JP AF RVR
dr. Taufan, Sp.P Pneumonia
co dr Putri SpGK Pleuritis


Pribadi Pneumonia TD :
dr. Taufan, Sp.P Diare kronis N:
Immunocompromise RR:
S: 3
BB: 65 kg SaO2: 89-93
17 21-Aug 10 Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8) Kes:

BPJS HT TD: 145/78
Pneumonia N: 72
Intake:
BB: 70 kg Out:
Bal:
UO
Penunjang
26/8 PCR swab I +
29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
5/8 PCR Swab I+
12/8 PCR swab II +
19/8 PCR swab III +
26/8 PCR swab III -

19/8 PCR Swab I +
26/8 PCR swab II +
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80
Rapid Sars Cov2 -

24/8 PCR swab II +
16/8 PCR Swab I +

segmen posterobasal
24/8 PCR swab II +
31/8 PCR swab III -
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177


CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
23/8 PCR Swab +

(atypical).
28/8 Swab PCR +

CXR : Cor dbn, Susp GGO dikedu paru typical , kemungkinan pneumonia/Covid blm dapat disingkirkan
26/8 PCR Swab -
2/9 AGD pH 7.47 pCO2 38.6 pO2 64.3 HCO3 28.3 BE 5.3 Sat 92.9
maksilaris kanan.
GDS 185 Na/K/Cl 140/3.8/105
26/8 PT/APTT 15.5(13.7)/26.6(30.1)
Alb/glob 2,9/3,1
31/8 Na K Cl 137/4.3/98
2/9 Hb/Ht/L/Tr 11.7/35/13.6/771 LED 25 NLR 8.84 Neu segmen 80 Limf 9
GDS 129 Protein total 7.0 Alb 3.1 Globulin 3.9
Terapi
Becomzet 1x1 PO
Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
Venflon
Becomzet 1x1 PO
liproqy 2x1
Becomzet 1x1 po
Nalgestan 2xI PO

Venflon
RHZE 600/400/1500/1000 (6/8)
OBH 3xC1 PO
Becomzet 1xI PO

Becomzet 1x1 PO
Becomzet 1x1po
Pumpicel 1x1 amp iv
Lantus 1x10 U
Lesichol 1x300mg PO
Prome syr k/p batuk
Etorvel 60mg 0-1-0 k/p nyeri
Terfacef 1x2gr
Liproqy 1x1 PO
Kombiglyze XR 5/500 1x1 PO (siang) TUNDA

Becomzet 1x1 PO
Becomzet 1xI PO
Levopront 3x1cth
Becomzet 1x1 PO
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Becomzet 1x1po
Codipront 3x1cth

Becomzet 1x1po
PULANG
PULANG
O2 14 lpm NRM
Venflon
R/H/Z/E 450/400/1000/1000 mg PO (27/8)
Codipront 3x1cth po
Bcomzet 1x1 tab po
HP pro 2xI PO
Bactrim 2x1 PO (31/8) atau cotrimoxazole

Gabaxa 1x100mg IV
Omega 3 2x1 g PO
Lactulax 3x2 CII PO
Probiokid 1x/minggu
Polygran eye ointment 2xsehari terutama tidur
Keterangan
GDS 18.00
DPL/3hari next (3/9) Form+
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop

31/8 FU hasil swab

GDS 18.00
DPL/3hari next (4/9) Form -

31/8 FU hasil swab
31/8 FU hasil swab

Hasil CD4: edukasi dubia malam (+) lembar KIE (+) hasil rapid B20 keluarga terinfo
dr. Felix: rawat icu isolasi, bila ada gagal napas konsul sp.An, rencana pemberian ARV setelah OAT masuk 2 minggu (bila tidak t
rencana rujuk), Cotrimoksazol 480 mg 3x2 tab, Meropenem 3x1 gr, Inj. Omeprazole 40 mg 1x1, Probiostim 1x1 PO,
Fluconazole 2x150 mg IV drips, Antasida syr 3xC1, Inj. Ca Gluconas 3x1 IV pelan, MgSO4 20% 3 cc + larutan dalam syringe 10 cc
pelan (dengan NaCl atau aquades), sisanya drips MgSO4 20% dalam NaCl 0,9% 100 cc habiskan dalam 1 jam,
kultur dahak +sensitivitas & kultur darah+sensitivitas, cek ur cr, (cek ulang Na K Cl Ca total, Mg setelah 2 hari pemberian korek
*MgSO4 tunda
2/9 dr. Hendri Sp.An acc pindah ruangan, tapi wacana homecare
dr. Felix: R/ ro thorax ulang sebelum pindah ruang biasa, bila demam kultur dahak ulang
2 September 2020 Malam (Cylla)

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

dr. Taufan, Sp.P N:
RR:
S:
dr. Taufan SpP N:
RR:
S:

observasi trombosit

Wilmar TD
dr. Taufan Sp.P N
RR
S

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Bakrie TD;
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

TD:
RR:
S:
14 2-Sep 1601 Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM
TD:
dr. Taufan Sp.P N:
RR:
S:
15 25-Aug 1001 Tn. Dmitry / 49th ADHF ec CAD

Pribadi (Advanced HF EF 17%)
dr. Damba, Sp.JP AF RVR
dr. Taufan, Sp.P Pneumonia
co dr Putri SpGK Pleuritis

17 25-Aug 1205 Tn. Bruce Gimon/ 42 th TB paru kasus baru

Pribadi Pneumonia
dr. Taufan, Sp.P Diare kronis
AIDS
BB: 65 kg
BPJS HT TD: 145/78
Pneumonia N: 72
Intake:
BB: 70 kg Out:
Bal:
UO
19 2-Sep 1204 Tn. Muhammad Arisandi/ Melena + anemia Kes CM
pribadi 46th HT tidak terkontrol TD:
Gout N:
dr. Daniel, Sp.PD Kardiomegali RR:
S:
Alergi Nexium
Penunjang
26/8 PCR swab I +
29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab I +
5/8 PCR Swab I+
12/8 PCR swab II +
19/8 PCR swab III +
26/8 PCR swab III -

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
Rapid Sars Cov2 -

24/8 PCR swab II +
16/8 PCR Swab I +

segmen posterobasal
24/8 PCR swab II +
31/8 PCR swab III -
2/9 PCR swab III -
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab I +

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab I +
23/8 PCR Swab +

(atypical).
28/8 Swab PCR +

1/9 Swab PCR +
2/9 Hb 15.7 Ht 44 L 6.4 Tc 260 LED 30 NLR 2.01 Hitung Jenis 1/0/59/3/31/6/3.96/1.97 GDS 81
maksilaris kanan.
GDS 185 Na/K/Cl 140/3.8/105
26/8 PT/APTT 15.5(13.7)/26.6(30.1)
Alb/glob 2,9/3,1
31/8 Na K Cl 137/4.3/98
2/9 Hb/Ht/L/Tr 11.7/35/13.6/771 LED 25 NLR 8.84 Neu segmen 80 Limf 9 GDS 129
Protein total 7.0 Alb 3.1 Globulin 3.9
CXR: kardiomegali sedikit bertambah dengan elongasio aorta, gambaran bendungan paru dupleks STQA
1/9 Hb 6.9/ Ht 21.8/ RBC 2.62/ Lc 5.8/ Tc 351/ Diff count 0/3/2/69/15/11 ESR 85 Retikulosit 9.87%/258.600
pt/aptt 10.50 (10.30)/31.70 (36.60) , SI 12, TIBC 379, Trasnferin 3.2, Feritin 40.39; OT/PT 25/26
Cr 1.19/Egfr 70; AU 12.5; GDS 105; HBSAg non reactive; antiHCV non reactive; AFP 1.7 CEA 0.62 CRP 29.3
Goldar A+; Rapid non reaktif
2/9 EKG: SR HR 96x/min + VES?
CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta
Terapi
Becomzet 1x1 PO
Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
Venflon
Becomzet 1x1 PO
liproqy 2x1
Becomzet 1x1 po
Nalgestan 2xI PO

Venflon
RHZE 600/400/1500/1000 (6/8)
OBH 3xC1 PO
Becomzet 1xI PO

Becomzet 1x1 PO
Becomzet 1x1po
Pumpicel 1x1 amp iv
Lantus 1x10 U
Lesichol 1x300mg PO
Prome syr k/p batuk
Terfacef 1x2gr
Liproqy 1x1 PO

Becomzet 1x1 PO
Becomzet 1xI PO
Levopront 3x1cth
Becomzet 1x1 PO
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Becomzet 1x1po
Codipront 3x1cth

Becomzet 1x1po

Becomzet 1x1po
Mucopect 3xC1
Rhinos SR 2x1
PULANG
PULANG
MENINGGAL 3/9 PK 00.03

Gabaxa 1x100mg IV
Omega 3 2x1 g PO
Probiokid 1x/minggu
Venflon
Pro transfusi PRC 750cc premed lasix 1amp/bag
Episan 4xC1
Mucosta 3x1tab
Zyloric 1x300mg
Letonal 1x25mg
Pariet 2x20mg
Keterangan
GDS 18.00
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop

31/8 FU hasil swab


GDS 18.00
DPL/3hari next (5/9) Form +

2/9 Extra sanmol 500, ondan 8mg, ome 20mg
31/8 FU hasil swab
R/ Pulang FU ke dr Taufan
31/8 FU hasil swab

8/9 Swab PCR, form -, PE -
00.03
IPD: R/ DPL + GDS/ 3 hari --> next 5/9, Pribadi

2/9 Gelofusal stop, nexium stop ec alergi
Co dr Damba (ec pro echo): beliau tanya kenapa di echo? Tambahan: adalat oros 1x30mg (blm acc)
PRC belum dapat krn stock darah PMI kosong, FU lagi
3 September 2020 Pagi (Safira)

1 2-Sep 1601 Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM
TD:
Admed dr. Taufan Sp.P N:
RR:
S:

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

dr. Taufan, Sp.P N:
RR:
S:
dr. Taufan SpP N:
RR:
S:

observasi trombosit
Wilmar TD
dr. Taufan Sp.P N
RR
S

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Bakrie TD;
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

TD:
FWD dr. Taufan Sp.P N:
RR:
S:

BPJS HT TD: 145/78
Pneumonia N: 72
Intake:
BB: 70 kg Out:
Bal:
UO
16 3-Sep 1001 Putri Yasinta/ 26 th Post Faringektomi (3/9) ai Kes CM

Abses submandibula TD:
BPJS dr Robert Sp.THT-KL perluasan faring N:
R:
S:
17 2-Sep 1204 Tn. Muhammad Arisandi/ Melena + anemia Kes CM

pribadi 46th HT tidak terkontrol TD:
Gout N:
dr. Daniel, Sp.PD Kardiomegali RR:
Co dr Damba Sp.JP S:
Co dr Teguh Sp.PD
Alergi Nexium
18 3-Sep 1203 Ny Amalia Pristya Sari/36 th G3P2A0 gr 38-39 minggu Kes CM

pro induksi persalinan TD
KPN dr Lucy Sp.OG N
R
S
Penunjang
1/9 Swab PCR +
26/8 PCR swab I +

29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
3/9 DPL?

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab I +
5/8 PCR Swab I+
12/8 PCR swab II +
19/8 PCR swab III +
26/8 PCR swab III -

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
Rapid Sars Cov2 -

24/8 PCR swab II +
16/8 PCR Swab I +

segmen posterobasal
24/8 PCR swab II +
31/8 PCR swab III -
2/9 PCR swab III -
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab I +

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab I +
23/8 PCR Swab +

(atypical).
28/8 Swab PCR +
maksilaris kanan.
GDS 185 Na/K/Cl 140/3.8/105
26/8 PT/APTT 15.5(13.7)/26.6(30.1)
Alb/glob 2,9/3,1
31/8 Na K Cl 137/4.3/98
27/8 Hb/Ht/L/Tr 12.8/38/8.4/271 LED 10 Diff 4/1/51/3/35/6 BT 3/CT 12 HbsAg (-) Anti HIV (-)
GDS 89 Ur 17/Cr 0.5 OT 24/PT 24
CXR: Cor dan pulmo dbn, dextroscoliosis minimal thoracalis vertebrae
3/9 Hb 9.5/Ht 28/L 13.9/Tr 293 LED 34 Diff 1/1/78/3/12/5 Rapid test IgM IgG negatif
Terapi
Becomzet 1x1po
Mucopect 3xC1
Rhinos SR 2x1
Becomzet 1x1 PO
Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
Venflon
Becomzet 1x1 PO
liproqy 2x1
Becomzet 1x1 po
Nalgestan 2xI PO

Venflon
RHZE 600/400/1500/1000 (6/8)
OBH 3xC1 PO
Becomzet 1xI PO

Becomzet 1x1 PO
Becomzet 1x1po
Pumpicel 1x1 amp iv
Lantus 1x10 U
Lesichol 1x300mg PO
Prome syr k/p batuk
Terfacef 1x2gr
Liproqy 1x1 PO

Becomzet 1x1 PO
Becomzet 1xI PO
Levopront 3x1cth
Becomzet 1x1 PO
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Becomzet 1x1po
Codipront 3x1cth

Becomzet 1x1po
IVFD NS:KAEN3B 1:1 20 tpm/12 jam

Gabaxa 1x100mg IV
Omega 3 2x1 g PO
Probiokid 1x/minggu
IVFD RL 500cc/8 jam

Ceftriaxon 1x2gr IV (3/9)
As tranexamat 3x500mg IV
Ranitidin 2x150mg IV
Vit K 2x1amp IV
Dexamethason 2x5mg IV
Venflon
Pro transfusi PRC 750cc premed lasix 1amp/bag
Episan 4xC1
Mucosta 3x1tab
Zyloric 1x300mg
Letonal 1x25mg
Pariet 2x20mg
Pumpisel 40mg IV drip dlm NS 50cc/5 jam
IVFD RL + Oxytocin 5 IU 20 tpm -> naik 4 tpm/30 menit
Keterangan
8/9 Swab PCR, form -, PE -
8/9 Swab PCR?
GDS 18.00
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop

8/9 Swab PCR?
31/8 FU hasil swab

9/9 Swab PCR?
*Swab dikirim ke MIKRO UI


GDS 18.00
DPL/3hari next (5/9) Form +

2/9 Extra sanmol 500, ondan 8mg, ome 20mg
31/8 FU hasil swab
R/ Pulang FU ke dr Taufan
8/9 Swab PCR?
9/9 Swab PCR?
31/8 FU hasil swab

3/9 dr Angel saran konsul ulang Sp.M
4/9 R/ BLPL setelah visite dan fisioterapi 1x, dr Felix acc BLPL besok
IPD: R/ DPL + GDS/ 3 hari --> next 5/9, Pribadi

Diet lunak sejuk

* BPJS: ceftriaxon acc 2 hari, lain2 acc 1 hari

Co dr Damba (ec pro echo): beliau tanya kenapa di echo? Tambahan: adalat oros 1x30mg TUNDA
PRC belum dapat krn stock darah PMI kosong, FU lagi
3/9 dr Teguh Sp.PD pro gastroskopi Sabtu 5/9 bila Hb>9 dan Swab PCR (-)
3/9 cek UL, form + sample -
4/9 PCR Swab form (+) PE (-)
*bila pumpisel masuk, pariet STOP
3 September 2020 Malam (Meri)
No Masuk Bed Nama Diagnosis TTV Penunjang Terapi Keterangan

1 2-Sep 1601 Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM 1/9 Swab PCR + Oseltamivir 2x75mg (3/9) 8/9 R/Swab PCR, form +, PE +
TD: 2/9 Hb 15.7 Ht 44 L 6.4 Tc 260 LED 30 NLR 2.01 Hitung Jenis 1/0/59/3/31/6/3.96/1.97 GDS 81 Hyloquine 1x400mg (3/9)
Admed dr. Taufan Sp.P N: Azitromycin 1x500mg (3/9)
RR: Becomzet 1x1po
S: Mucopect 3xC1
Rhinos SR 2x1
2 28-Aug 1602 dr. Herdhito Dewahyu/54th COVID-19 confirmed case Kes CM 26/8 PCR swab I + Baquinor forte 2x500 mg PO (29/8) 30/8 Trajenta, truvas, angioten stop
Bakrie DMT2 TD: 28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12 Oseltamivir 2x75mg (29/8) 8/9 R/ Swab PCR form+, PE+
dr. Taufan, Sp.P HT N: S Typhi O/H 1/160 paratyphi 1/80. EKG NSR Hyloquine 1x400mg (29/8)
dr. Felix Sp.PD Dislipidemia RR: Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru Azitromycin 1x500mg (29/8)
S: 29/8 GDP 198 2PP 347, GDS 18.00 221 Becomzet 1x1 PO
30/8 GDP: 143 GDS pk 18:199 Lantus 1x36 unit SC malam
31/8 GDP 189 Lapiva 1x10/160 mg PO 0-0-1
1/9 PT/APTT 14.9/17.0 D-dimer <100 Kol. Total 143, TG 127, HDL 27, LDL Direk 95, As.Urat 6.2 GDS 18: 286 Concor 1x2,5 mg PO 1-0-0 GDS 18.00
2/9 GDP 123 GDS 18.00 226 Cardioaspirin 1x80 mg PO DPL/3hari next (6/9) Form+
1/9 PCR swab II + Amaryl 4 mg 1-0-0 PO
3/9 Hb/Ht/L/Tr 14.7/43/5.7/357 LED 30 Mono 10 GDS pk. 18: 163 Acarbose 3x100 mg PO
Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
3 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case Kes CM 10/8 Hb/Ht/L/Tr 11.9/37/3.3/202 Widal S typhi H 1/320 O2 3 lpm via nasal canule *Febris sejak 6/8
Kemkes Pneumonia TD: 11/8 Hb/Ht/L/Tr 12.4/38/4/205 Rapid negatif Venflon co dr. Damba: candesartan 1x8mg, concor ganti bisoprolol 1x1.25mg, simvastatin 20mg malam, CPG 1x75mg
dr Felix Sp.PD Cephalgia N: Na/K/Cl 136/3.7/99, OT/PT 41/24; EKG SR 94x normoaxis ST elevasi - Lansoprazole 1x30 mg PO co dr. Angelina, Sp.N: cephalgia ec thypoid fever
dr. Taufan Sp.P HT HHD RR: CXR: kardiomegali + elongasi aorta; bronkopneumonia dupleks Candesartan 1x4mg PO malam bila MAP <65 tunda 15/8 Ceftri stop
CAD S: 13/8 Hb/Ht/L/Tr 11.6/34/5.1/193 LED 70 NLR 8.31 Eo 1 Neu. Segmen 82 Limf 10 Bisoprolol 1x1,25mg PO pagi 16/8 Arixtra stop
Hiperuricemia PT/APTT 17.7/32.9 GDP 76 Kol Tot 149/TG101/HDL 34/LDL86 Clopidogrel 1x75mg PO 18/8 Azitro stop
Asam urat 6.2/Ur/Cr 35/1.2 Mecobalamin 2x500 mg PO 19/8 hyloquin, oseltamivir stop
14/8 d dimer 3552 Atorvastatin 1x20 mg PO malam
12/8 PCR swab I + Ultracet 3x1 tab PO kp nyeri kepala
16/8 D dimer 138 Allopurinol 1x100 mg PO (malam) 9/9 R/ Swab PCR form+ PE+
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Becomzet 1x1 PO
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 Betadine garg 3x/ hari
19/8 PCR Swab II + Liproqy 2x1
26/8 PCR Swab III +
2/9 PCR Swab IV +
4 27-Aug 1605 Tn. Imam Wahyudi /43 th COVID-19 confirmed case Kes CM 25/8 PCR swab I + Becomzet 1x1 po * Riwayat demam 5 hari SMRS
Bakrie TD: 25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252 Nalgestan 2xI PO 29/8 Oseltamivir hyloquin azithromycin STOP
dr. Taufan SpP N 1/9 PCR swab I + 8/9 R/ Swab PCR form+ PE+
RR
S
5 4-Aug 1606 Tn. Lilik S/ 55 th COVID-19 confirmed case Kes CM 3/8 CXR: fibroinfiltrat suprahilar kanan dan kiri + paracardial kanan kiri O2 3 lpm via nasal canule k/p Bila sesak bertambah/ wheezing, lapor dr. Taufan, Sp.P dan cek AGD!
Kemkes TB paru kasus baru TD: diafragma dan sinus baik. Kesan: KP duplex aktif. Venflon 13/8 Stop Oseltamivir, azitro, hyloquin
dr. Taufan, Sp.P N: Hb 13,2 Ht 37,9 leu 6,99 Tr 298rb LED 82 Seg/limf 62/30 RHZE 600/400/1500/1000 (6/8) 18/8 Ventolin syr STOP
RR: 4/8 Rapid SARS Cov2 + EKG NSR OBH 3xC1 PO 4/9 R/ rawat jalan SK+ R+ Resume+ TUTD
S: 5/8 PCR Swab I+ Becomzet 1xI PO
12/8 PCR swab II + Paracetamol 500 mg PO k/p
19/8 PCR swab III + Betadine garg 3x/ hari R/ cek sputum BTA 3x + kultur -> sampel -
26/8 PCR swab IV -
31/9 PCR swab V -
3/9 CXR C/P dbn
6 19-Aug 1608 dr. Novie Hediyani/ 40th COVID-19 confirmed case Kes CM 18/8 Hb/Ht/L/Tr 13.1/39.1/3.8/192 Diff 0.3/2.6/35.6/53.9/7.6 , Widal Ty H 1/40, Para BH 1/20 O2 2 lpm via nasal canule * Demam sejak 15/8, sudah konsumsi ciprofloxacin dan azitromisin 5 hari. Riw asma +
Kemkes Bronkitis akut TD: 19/8 CXR bronkopneumonia bilateral Sumagesik 3x500mg PO ** R/ CXR ulang sebelum pulang setelah 2x swab negatif
dr. Taufan SpP N: 19/8 PCR Swab I + Codipront exp 3x cthI PO 25/8 ondansetron 4mg kp muntah
RR: 26/8 PCR swab II + Lansoprazole 2x30mg PO 27/8 Hyloquin, Oseltamivir, Azitromycin STOP
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi 28/8 extra dexametasone 1 amp IV kp sesak (-), px menolak steroid, minta levofloxacin saja
2/9 PCR swab II + Salbutamol 2x1.5 mg po 30/8 Sanexon 1x40 mg PO STOP
Teofilin 2x100 mg po 9/9 R/ Swab PCR 7/9 form+ PE+
Becomzet 1x1 PO
Seretide diskus 4x2 puff *Swab dikirim ke MIKRO UI
Minosep garg 3x/hari Jika sesak dan saturasi di bawah 90 % cek PT APTT DDimer
Sanexon 2x125 mg IV (4/9) 3hari
7 29-Aug 16 dr. Achmad Budiarto/62 th Covid 19 Confirmed Case Kes 29/8 PCR Swab I + RL 500 cc/ 24 jam IV--> NaCl 500cc/6jam 30/8 Tromboaspilet tunda
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Oseltamivir 2x75mg (29/8) 5/9 R/ swab ulang, form +, PE +
dr Taufan SpP DM tipe II N GDS 153 Hyloquine 1x400mg (29/8)
raber dr Felix Sp. PD DHF RR CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19 Becomzet 1x1po
Co dr. Putri Sp.GK Riw Asma S blm dapat disingkirkan Sanmol forte 3x1 tab po
observasi trombosit 30/8 Hb 15.6 Ht 46 Leu 3.6 Tr 117 eri 5.17 GDP 155 GD2PP 184 HbA1C 7.7 chol tot 100 TG 189 Pumpicel 1x1 amp iv
choles LDL hitung 39/direct 46 AU3.5 ur 24 cr 1.2 Ot/PT 66/51 Metformin 2x500 mg po (pagi sore)
UL dbn Glimepiride 1x2 mg po GDS 18.00
31/8 Hb 14.9 Ht 43 Leuko 3.3 Trombo 107 Eritrosit 4,94 GDS 18:65 21:115 Lantus 1x10 U DPL/3hari next (5/9) Form +
1/9 Hb/HT/L/Tc/E 14.3/42/2.2/117/4.77 PT/APTT 15.2/31.8 D-Dimer <100, GDS 06: 85 18.00: 213 Amlodipin 1x 5 mg po
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114 Candesartan 1x 8 mg po
3/9 GDS pk. 18: 244 Lesichol 1x300mg PO
Prome syr k/p batuk
Terfacef 1x2gr IV (31/8) 5 hari
Liproqy 1x1 PO
Cerini 1x10 mg PO malam
8 30-Aug 16 Tn. Sabam Frando/32 th Covid 19 Confirmed Case Kes 26/8 PCR Swab I + CXR C/P dbn Hb/Ht/L/Tr 14.2/41.8/4.7/255 Monosit 10 OT/PT 25/38 Hyloquin 1x400 mg PO (30/8) 9/9 R/ Swab PCR PE+ form+
Wilmar TD Rapid Sars Cov2 - Oseltamivir 2x75mg (30/8)
dr. Taufan Sp.P N 30/8 CXR Susp. Gambaran GGO di paru S atypical, kemungkinan viral pneumonia Covid 19 belum Azitromisin 1x500 mg PO (30/8)
RR dapat disingkirkan Hb/Ht/L/Tr 14.6/42/5.7/237 LED 20 Eo 1 Limf 24 Mono 9 Becomzet 1x1 PO
S 2/9 PCR Swab II + Codipront exp 3x cth I PO
9 16-Aug 1101 Ny.Dian Purnamalia/38 th COVID-19 confirmed case Kes CM 16/8 PCR Swab premier gene N2 positive Ct 30.67 Becomzet 1xI PO 20//8 Hylo, azitro, oselta stop
Bakrie TD: Hb/Ht/L/Tr 12.7/38/9.2/328 MCV/MCH/MCHC 86/30/35 LED 31 NLR 0.32 Diff 3/0/65/3/22/7 Betadine garg 3 x/ hari 2/9 Extra sanmol 500, ondan 8mg, ome 20mg
dr. Taufan Sp.P N: CXR: cor dbn, susp GGO paru dextra 4/9 R/ Swab PCR form+ PE+
RR: 24/8 PCR swab II +
S: 31/8 PCR swab III -
10 19-Aug 1102 Tn Faisal Firdaus/52th COVID-19 confirmed case

Darma PULANG
Henwa dr. Taufan SpP
11 25-Aug 1103 Tn. Yan Rahmanto/52 th COVID-19 confirmed case Kes:CM 24/8 Hb/Ht/L/Tr 14.5/42/7.2/177 Becomzet 1x1 PO 2/9 hyloquin oseltamivir azithromycin stop
Bakrie TD: CXR Cor dbn. Arcus aorta elongasi. Susp. Gambaran GGO halus di kedua paru (typical) kemungkinan Mucopect 3xC1 PO 8/9 R/ Swab PCR form+ PE+
dr. Taufan Sp.P N: viral pneumonia/covid 19 belum dapat disingkirkan. PCR Swab I + Betadine garg 3 x/ hari
RR: 1/9 PCR swab I +
S:
12 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case Kes CM 21/8 Hb/Ht/L/Tr 13.1/39/3.2/175 diff 0/0/40/3/44/13 LED 17 NLR 0.96 Becomzet 1x1 PO 26/8 Hyloqiun, Azitromycin, Oseltamivir STOP
Darma TD: CXR : C/P DBN Lansoprazole 2x30 mg PO 9/9 R/ Swab PCR form+ PE+
Henwa dr. Taufan Sp.P N: 24/8 PCR Swab I + Codipront syr 3x cth 1
RR: 31/8 PCR swab II - Betadine garg 3 x/ hari
S: 2/9 PCR swab I +
13 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case Kes CM 23/8 PCR Swab I + Becomzet 1x1po 29/9 hyloquin oseltamivir azithromycin stop
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Codipront 3x1cth 7/9 R/ Swab PCR form+ PE+
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Minosep garg 3x/hari
RR: (atypical). Amlodipin 1x10 mg PO pagi
S: 31/8 PCR Swab II + Candesartan 1x8 mg PO malam
14 3-Sep 11 Ny. RA Tetty Saroso/ 63 th Covid 19 Confirmed Case Kes 31/8 PCR Swab I + Azitromisin 1x500 mg PO (4/9) 3 hari 4/9 R/ Ro thorax form+ JP+
HT TD 3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3 Hyloquin 1x400 mg PO (4/9) 3 hari 5/9 R/ Cek Profil lipid
Bakrie dr. Taufan Sp.P N Oseltamivir 2x75 mg PO (4/9) 3 hari 7/9 R/ Swab PCR form+ PE+ JP+
RR Vectrine 3x1 PO
Alergi Antalgin, Salisilat S Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Candesartan 1x8 mg PO
Mucopect 3xcth1 PO
15 15-Aug 1106 Ny. Reni COVID-19 confirmed case

RUJUK
FWD dr. Taufan Sp.P
16 21-Aug 1002 Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8) Kes: 19/8 CT brain: perdarahan intraparenkim pons dan cerebellum sisi kiri. Infark kronik basal IVFD NS:KAEN3B 1:1 20 tpm/12 jam 24/8 dr. Felix: Antibiotik ganti levofloxacin 1x750mg iv, Kultur dahak dan tes sensitivitas, Azithromicin 1x500 sd hari ke-5
BPJS HT TD: 127/68 ganglia kiri. Microvascular ischemia basal ganglia kanan dan korona radiata kiri. Awal sinusitis Ensure 3x250 cc per NGT + Diet Saring 3x250 As tranexamat dan vit K STOP, manito stop, Ceftriaxon stop
Pneumonia N: 75 maksilaris kanan. Meropenem 3x1 g IV (27/8) 25/8 R/ MRI Brain NK -> tidak dpt dilakukan karena pasien terintubasi, dr Angel maklum
dr. Hendri, Sp.An-KIC Electrolyte imbalance RR: 20 CXR: kardiomegali dengan elongasio aorta, pneumonia bilateral. Citicoline 2x500 mg IV 26/8 dr. Angel: kalau bisa jangan mulai blistra kecuali MABP>= 130, coba antihipertensi oral dulu
dr. Angelina, Sp.N Post PDT (27/8) S: 36.2 Hb 13,7 Ht 38 Leu 12,2 Tr 241 Bas/eos/bat/seg/lim/mo 0/2/0/35/57/6. LED 1. Ca 1,04 GDS 172 Omeprazole 2x40 mg IV 29/8 Pro Brain CT kontrol tanpa kontras
dr. Felix, Sp.PD Hipoalbuminemia SaO2: 98 OT/PT 26/16 ur/cr 35/1,5 AU 5,2 Na 141 K 2,9 Cl 100 Rapid SARS Cov 2 - PCR Swab - Ibuprofen 3x400 mg per NGT 29/8 Co ulang dr.Ichsan SpBS
dr. Ichsan Sp.BS Konstipasi 21/8 Rapid sars cov2 - GDP 147 Kol. Tot 155 TG 124 HDL 48 LDL 64 Asam urat 3.3 Mecobalamin 2x500 mg IV 30/8 dr. Ichsan: ct kontrol 1 mgg, co rehab
Co dr Amytha Sp.M Per 24 jam 22/8 Hb/Ht/L/Tr 11.3/29/10.6/211 GDP 90 Hba1c 5.1 Na/K/Cl 144/4.3/104 Candesartan1x16 mg PO malam 1/9 dr Hendri Sp.An: Homecare
Intake: UL Agak keruh protein +1 Darah 2+ PT/APTT 15.4/31.5 Sucralfat syr 2xCII po Prohiper stop
BB: 70 kg Out: 24/8 HB/HT/L/Tc/E 9.7/30/7.5/199/3.01 Diff count 4/0/73/13/10/5.49/0.94 Nebulizer ventolin/pulmicort+ NaCl 0.9% 2x per hari 2/9 dr. Hendri Sp.An acc pindah ruangan, tapi wacana homecare
Bal: GDS 185 Na/K/Cl 140/3.8/105 Acetylsistein 3x200 mg PO 3/9 dr Angel saran konsul ulang Sp.M
UO 26/8 PT/APTT 15.5(13.7)/26.6(30.1) Gabaxa 1x100mg IV 4/9 R/ rawat jalan setelah visite dan fisioterapi 1x, dr Felix acc rawat jalan, dr. Amytha rencana visite
27/8 Hb 9,7 Ht 30 Leu 8,1 Tr 422 LED 110 NLR 4,71 GDS 144 ur/cr 48/0,8 OT/PT 34/50 Amlodipin 1x10 mg PO pagi R/ cek DPL form+
Alb/glob 2,9/3,1 Asam folat 3x1 tab PO
29/8 lesi hiperdens/perdarahan dengan lesi hipodens/perdarahan yang diserp di infratentorial VIP albumin 3x2caps PO
pd pons yang meluas ke cerebelum kiri batas tegas, vol perdarahan +/- 6.42 cm3 (HU 58.2), Omega 3 2x1 g PO
sebelumnya vol perdarahan 17.6 cc, perbaikan Probiokid 1x/minggu
lacunar infark kronik di basal ganglia bilateral dan corona radiata stqa Spironolactone 50 mg 0-1-0 PO IPD: R/ DPL + GDS/ 3 hari --> next 5/9, Pribadi
tak tampak lesi perdarahan EDH, SDH, ICH, atau SOL intrakranial saat ini. Cendo lyters 4x1 gtt 5/9 R/ Brain CT scan kontrol tanpa kontras
Subgaleal hematoma di parietal kiri. Polygran eye ointment 2xsehari terutama tidur
31/8 Na K Cl 137/4.3/98
17 3-Sep 1001 Nn. Putri Yasinta/ 26 th Post Faringektomi (3/9) ai Kes CM 27/8 Hb/Ht/L/Tr 12.8/38/8.4/271 LED 10 Diff 4/1/51/3/35/6 BT 3/CT 12 HbsAg (-) Anti HIV (-) IVFD RL 500cc/8 jam Diet lunak sejuk
Abses submandibula TD: 104/58 GDS 89 Ur 17/Cr 0.5 OT 24/PT 24 Ceftriaxon 1x2gr IV (3/9) * BPJS: ceftriaxon acc 2 hari, lain2 acc 1 hari
BPJS dr Robert Sp.THT-KL perluasan faring N: 88 CXR: Cor dan pulmo dbn, dextroscoliosis minimal thoracalis vertebrae As tranexamat 3x500mg IV
R: 20 Ranitidin 2x150mg IV
S: 36.2 Vit K 2x1amp IV
Dexamethason 2x5mg IV
18 3-Sep 1006 Tn. Heru Suminto/81 th Batu ginjal kanan Kes CM 27/8 CXR Cor dbn, arcus aorta elongasi. Tak tampak GGO. Gambaran pleuritis D. efusi pleura ringan S Premed Ceftriaxone 1 gr IV 4/9 R/ URS Litotripsi pukul 11, dr. Sandhi Sp.An terinfo
Batu ureter kanan TD 99/60 Hb/Ht/L/Tr 14.4/41/7.5/253 BT/CT 3/12 GDS 111 Ur/Cr 23/0.8 OT/PT 11/12
BPJS N 60 31/8 PCR Swab -
dr. Adianti Sp.U RR 18
S 36.6
19 2-Sep 1204 Tn. Muhammad Arisandi/ Melena + anemia Kes CM 1/9 Hb 6.9/ Ht 21.8/ RBC 2.62/ Lc 5.8/ Tc 351/ Diff count 0/3/2/69/15/11 ESR 85 Retikulosit 9.87%/258.600 Venflon 2/9 Gelofusal stop, nexium stop ec alergi
Pribadi 46th HT tidak terkontrol TD: 124/68 pt/aptt 10.50 (10.30)/31.70 (36.60) , SI 12, TIBC 379, Trasnferin 3.2, Feritin 40.39; OT/PT 25/26 Episan 4xC1 PO Co dr Damba (ec pro echo) Tambahan: adalat oros 1x30mg TUNDA
Gout N: 96 Cr 1.19/Egfr 70; AU 12.5; GDS 105; HBSAg non reactive; antiHCV non reactive; AFP 1.7 CEA 0.62 CRP 29.3 Mucosta 3x1tab PO Pro transfusi PRC 750cc premed lasix 1amp/bag (PRC belum dapat krn stock darah PMI kosong, FU lagi)
dr. Daniel, Sp.PD Kardiomegali RR: 20 Goldar A+; Rapid non reaktif Candesartan1x16 mg PO malam 3/9 Pumpicel stop ec alergi
Co dr Damba Sp.JP S: 36.7 2/9 EKG: SR HR 96x/min + VES? Zyloric 1x300mg PO dr. Teguh Sp.PD: bila mungkin CT thorax (pastikan lagi ke dr. Daniel saat visite), analgetik injeksi, pariet ganti PPI IV, Kalnex, Vit K TUNDA
Co dr Teguh Sp.PD CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO
Alergi Nexium, Pumpicel 3/9 UL dbn Pariet 2x20mg PO 4/9 R/ PCR Swab form (+) PE (+)
5/9 R/ Gastroduodenoscopy bila Hb >9 dan Swab PCR negatif dengan dr. Teguh
F/U print echo
20 3-Sep 1205 Ny Amalia Pristya Sari/36 th G3P2A0 gr 38-39 minggu Kes CM 3/9 Hb 9.5/Ht 28/L 13.9/Tr 293 LED 34 Diff 1/1/78/3/12/5 Rapid test IgM IgG negatif IVFD RL + Oxytocin 5 IU 16 tpm 3/9 dr. Novi Sp.A terinfo
pro induksi persalinan TD 109/65 4/9 Terfacef 2 gr IV pk. 05.00, D5% 500 cc guyur sebelum drip oxytosin
KPN dr Lucy Sp.OG N 68
RR 20
S 36.4 Obs. DJJ, his, dan kemajuan persalinan
Sat 98
4 September 2020 Pagi (Lauretta)

1 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM 1/9 Swab PCR + Oseltamivir 2x75mg (3/9) 8/9 R/Swab PCR, form +, PE +
AdMed TD: 2/9 Hb 15.7 Ht 44 L 6.4 Tc 260 LED 30 NLR 2.01 Hitung Jenis 1/0/59/3/31/6/3.96/1.97 GDS 81 Hyloquine 1x400mg (3/9)
dr. Taufan Sp.P N: CXR: GGO halus paru D Azitromycin 1x500mg (3/9)
RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
Rhinos SR 2x1 caps PO
2 28-Aug 1602 dr. Herdhito Dewahyu/54th COVID-19 confirmed case Kes CM 26/8 PCR swab I + Becomzet 1x1 PO 30/8 Trajenta, truvas, angioten stop
Bakrie DMT2 TD: 28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12 Lantus 1x36 unit SC malam 6/9 Cek DPL + GDS
dr. Taufan, Sp.P HT N: S Typhi O/H 1/160 paratyphi 1/80. EKG NSR Lapiva 1x10/160 mg PO 0-0-1 8/9 R/ Swab PCR form+, PE+
dr. Felix Sp.PD Dislipidemia RR: Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru Concor 1x 5 mg PO 1-0-0
S: 29/8 GDP 198 2PP 347, GDS 18.00 221 Cardioaspirin 1x80 mg PO
30/8 GDP: 143 GDS pk 18:199 Amaryl 4 mg 1-0-0 PO
31/8 GDP 189 Acarbose 3x100 mg PO
1/9 PT/APTT 14.9/17.0 D-dimer <100 Kol. Total 143, TG 127, HDL 27, LDL Direk 95, As.Urat 6.2 GDS 18: 286 Januvia 100mg 1-0-0 PO
2/9 GDP 123 GDS 18.00 226 Atorvastatin 20mg 0-0-1 PO DPL + GDS/3hari
1/9 PCR swab II + Ondancentron 2x8 mg PO
3/9 Hb/Ht/L/Tr 14.7/43/5.7/357 LED 30 Mono 10 GDS pk. 18: 163 Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
Clonidine 2x0,15 mg PO
Asam urat 6.2/Ur/Cr 35/1.2 Atorvastatin 1x20 mg PO malam 19/8 hyloquin, oseltamivir stop
14/8 d dimer 3552 Allopurinol 1x100 mg PO (malam) 5/9 Cek DPL +D-dimer, form +
12/8 PCR swab I + Becomzet 1x1 PO 9/9 R/ Swab PCR form+ PE+
16/8 D dimer 138 Betadine garg 3x/ hari
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Liproqy 2x1
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL/ 3 hari
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
dr. Taufan SpP N 1/9 PCR swab II + 8/9 R/ Swab PCR form+ PE+
RR
S
5 4-Aug 1606 Tn. Lilik S/ 55 th COVID-19 confirmed case

Kemkes TB paru kasus baru
PULANG
dr. Taufan, Sp.P
Teofilin 2x100 mg po 9/9 R/ Swab PCR 7/9 form+ PE+
Becomzet 1x1 PO
dr. Taufan Sp.P N: CXR: cor dbn, susp GGO paru dextra
RR: 24/8 PCR swab II + FU hasil swab PCR 4/9
S:
S: 2/9 PCR swab III +
11 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case Kes CM 23/8 PCR Swab I + Becomzet 1x1 PO 29/9 hyloquin oseltamivir azithromycin stop
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Codipront 3x1cth PO 7/9 R/ Swab PCR form+ PE+
12 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Azitromisin 1x500 mg PO (4/9) 3 hari 5/9 R/ Cek Profil lipid
Bakrie HT TD 3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3 Hyloquin 1x400 mg PO (4/9) 3 hari 7/9 R/ Swab PCR form+ PE+ JP+
dr. Taufan Sp.P Dislipidemia N Oseltamivir 2x75 mg PO (4/9) 3 hari
Asma terkontrol RR Vectrine 3x1 PO
Alergi Antalgin, Salisilat S Becomzet 1x1 PO FU hasil CXR 4/9
Amlodipin 1x5 mg PO
Mucopect 3xcth1 PO
13 29-Aug 1108 dr. Achmad Budiarto/62 th COVID-19 confirmed case Kes 29/8 PCR Swab I + Becomzet 1x1po 30/8 Tromboaspilet tunda
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Sanmol forte 3x1 tab po 5/9 R/ swab ulang, form +, PE +
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO
dr Felix Sp. PD Riw. Dengue fever RR CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19 Metformin 2x500 mg po (pagi sore)
Co dr. Putri Sp.GK Hipertrigliserdemia S blm dapat disingkirkan Glimepiride 1x2 mg po
Dispepsia 30/8 Hb 15.6 Ht 46 Leu 3.6 Tr 117 eri 5.17 GDP 155 GD2PP 184 HbA1C 7.7 chol tot 100 TG 189 Lantus 1x10 U
Asma terkontrol choles LDL hitung 39/direct 46 AU3.5 ur 24 cr 1.2 Ot/PT 66/51 Amlodipin 1x 5 mg po
UL dbn Candesartan 1x 8 mg po GDS 18.00
31/8 Hb 14.9 Ht 43 Leuko 3.3 Trombo 107 Eritrosit 4,94 GDS 18:65 21:115 Lesichol 1x300mg PO DPL/3hari
1/9 Hb/HT/L/Tc/E 14.3/42/2.2/117/4.77 PT/APTT 15.2/31.8 D-Dimer <100, GDS 06: 85 18.00: 213 Fenofibrat 100mg 0-1-0 PO
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114 Vectrine 3x300 mg PO
3/9 GDS pk. 18: 244 Prome syr k/p batuk
Liproqy 1x1 PO
14 21-Aug 1002 Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8)

BPJS HT
Pneumonia
dr. Hendri, Sp.An-KIC Electrolyte imbalance
dr. Angelina, Sp.N Post PDT (27/8) PULANG
dr. Felix, Sp.PD Hipoalbuminemia
Co dr Amytha Sp.M
15 3-Sep 1001 Nn. Putri Yasinta/ 26 th Post Faringektomi (3/9) ai

BPJS Abses submandibula
PULANG
dr Robert Sp.THT-KL perluasan faring
16 3-Sep 1006 Tn. Heru Suminto/81 th Post URS (4/9) a/i Kes CM 27/8 CXR Cor dbn, arcus aorta elongasi. Tak tampak GGO. Gambaran pleuritis D. efusi pleura ringan S Ceftriaxone 2x1 g IV (4/9) Aff DC 12 jam post op
BPJS Batu ginjal+ ureter kanan TD : 135/85 Hb/Ht/L/Tr 14.4/41/7.5/253 BT/CT 3/12 GDS 111 Ur/Cr 23/0.8 OT/PT 11/12 Paracetamol 3x500 mg PO 5/9 R/ BPL TUTD
dr. Adianti Sp.U N 82 31/8 PCR Swab -
RR 18
S 36
17 4-Sep 1203 Ny. Dewi Kusumaningsih/38 Post BA (4/9) Kes CM 28/8 Hb 12,3 LED 10 Leu 4690 Ht 37 Tr 364 NLR 1,05 OT/PT 17/17 ur/cr 10/0,6 AU 3,1 HBA1c 5,3 Koltot 190 FU terapi post op
Klinik TD: 108/67 LDL 121 HDL 69 TGA 60 HBsAg non rx UL dbN BT/CT 2/12 GDP 93 anti HIV non rx PCR Swab -
dr. Ir dr. Irawan, Sp.BS N: 70
RR: 20
S: 36,7
18 2-Sep 1204 Tn. Muhammad Arisandi/ Melena (perbaikan) Kes CM 1/9 Hb 6.9/ Ht 21.8/ RBC 2.62/ Lc 5.8/ Tc 351/ Diff count 0/3/2/69/15/11 ESR 85 Retikulosit 9.87%/258.600 Venflon 2/9 Gelofusal stop, nexium stop ec alergi
Pribadi 46th Anemia TD: 124/71 pt/aptt 10.50 (10.30)/31.70 (36.60) , SI 12, TIBC 379, Trasnferin 3.2, Feritin 40.39; OT/PT 25/26 Episan 4xC1 PO Co dr Damba, Sp.JP (ec pro echo) Tambahan: adalat oros 1x30mg TUNDA
Acute heart failure N: 101 Cr 1.19/Egfr 70; AU 12.5; GDS 105; HBSAg non reactive; antiHCV non reactive; AFP 1.7 CEA 0.62 CRP 29.3 Mucosta 3x1tab PO 3/9 Pumpicel stop ec alergi
dr. Daniel, Sp.PD Ht HHD RR: 20 Goldar A+; Rapid non reaktif Candesartan1x16 mg PO malam Co dr. Teguh Sp.PD: bila mungkin CT thorax, analgetik injeksi, pariet ganti PPI IV--> DPJP tidak acc. Kalnex, Vit K TUNDA
Co dr Teguh Sp.PD Gouty arthtritis S: 36 2/9 EKG: SR HR 96x/min + VES? Zyloric 1x300mg PO 4/9 PRC I: 201 cc, PRC II: 198 cc. Pro transfusi 3 unit lalu cek DR
Nefrolith S CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO 5/9 R/ Gastroduodenoscopy bila Hb >9 dan Swab PCR negatif dengan dr. Teguh
Alergi Nexium, Pumpicel NAFLD 3/9 UL dbn. Echo: mild dilatasi LA-LV, LVH konsentrik, EF 77% TAPSE 2,7 cm global normokinetik, katup dbN Pariet 2x20mg PO
FU hasil PCR swab 4/9
19 3-Sep 1205 Ny. Amalia Pristya Sari/36 th G3P2A0 gr 38-39 minggu Kes CM 3/9 Hb 9.5/Ht 28/L 13.9/Tr 293 LED 34 Diff 1/1/78/3/12/5 Rapid test IgM IgG negatif IVFD RL + Oxytocin 5 IU 40 tpm 3/9 dr. Novi Sp.A terinfo
KPN gagal induksi TD: 108/67 4/9 Terfacef 2 g IV pk. 05.00, D5% 500 cc guyur sebelum drip oxytosin
dr Lucy Sp.OG N: 70
RR: 20 Pro SC Pk 15.00, co dr Novi +, co dr. sandhi +
S: 36,7 Obs. DJJ, his, dan kemajuan persalinan
DJJ: 150

dr. Taufan Sp.P N: CXR: GGO halus paru dextra Azitromycin 1x500mg (3/9)
RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
Ondancentron 2x8mg PO kp mual
New Diatab 3x1tab PO
2/9 GDP 123 GDS 18.00 226 Atorvastatin 20mg 0-0-1 PO DPL + GDS/3hari -> next 6/9
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
14/8 d dimer 3552 Allopurinol 1x100 mg PO (malam) 5/9 Cek DPL + D-dimer, form +
16/8 D dimer 138 Betadine garg 3x/ hari
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Liproqy 2x1 DPL/3 hari
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
dr. Taufan SpP N 1/9 PCR swab II + Minocef gargle 3x15cc 8/9 R/ Swab PCR form+ PE+
RR
S
5 4-Sep 1606 Rezka Budi/17 th COVID-19 confirmed case Kes: CM 4/9 CXR: Cor pulmo dbn, tak tampak GGO Hyloquin 1x400mg PO (5/9) 10/9 Swab PCR form+ PE+
Kemkes TD FU hasil DPL Oseltamivir 2x75mg PO (5/9)
dr. Taufan, Sp.P N Azitromycin 1x500mg PO (5/9)
R Becomzet 1x1 PO
S Rhinos SR 2x1 tab PO
Teofilin 2x100 mg po 9/9 R/ Swab PCR form+ PE+
Becomzet 1x1 PO
Dexamethason 3x0.75mg PO
S:
dr. Taufan Sp.P Dislipidemia N 4/9 CXR: Cor dbn, Gambaran GGO di kedua paru/viral pneumonia covid 19 (typical) Oseltamivir 2x75 mg PO (4/9) 3 hari
Amlodipin 1x5 mg PO
Mucopect 3xcth1 PO
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Sanmol forte 3x1 tab po
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 5/9 Cek DPL ulang
dr Felix Sp. PD Riw. Dengue fever RR CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19 Metformin 2x500 mg po (pagi sore) 5/9 R/ swab ulang, form +, PE +
4/9 GDS pk. 18: 122 Etorvel 60mg 0-1-0 k/p nyeri
Liproqy 1x1 PO
Minocef gargle 3x15cc
14 3-Sep 1001 Ny. Amalia Pristya Sari/36 th P3A0 post SC ai stenosis Kes CM 3/9 Hb 9.5/Ht 28/L 13.9/Tr 293 LED 34 Diff 1/1/78/3/12/5 Rapid test IgM IgG negatif Line I: IVFD RL + Oxytocin 10 IU 28 tpm (II) 3/9 dr. Novi Sp.A terinfo
KPN cervix + CPD + lilitan tali TD: Line II: Asering 500 cc + Pethidin 1 amp/12 jam 4/9 Terfacef 2 g IV pk. 05.00, D5% 500 cc guyur sebelum drip oxytosin
dr Lucy Sp.OG pusat N: Terfacef 2x1gr IV (4/9) 4/9 PRC I: 202 cc selesai pk 2.30
RR: 5/9 Cek DPL ulang 6 jam post transfusi (pk 8.30)
S:
15 4-Sep 1001 By Ny Amalia BCB SMK

KPN TTN
RUJUK RSUD TARAKAN
dr Novi Sp.A
16 3-Sep 1006 Tn. Heru Suminto/81 th Post URS (4/9) a/i Kes CM 27/8 CXR Cor dbn, arcus aorta elongasi. Tak tampak GGO. Gambaran pleuritis D. efusi pleura ringan S Ceftriaxone 2x1 g IV (4/9) Aff DC 12 jam post op
BPJS Batu ginjal+ ureter kanan TD : Hb/Ht/L/Tr 14.4/41/7.5/253 BT/CT 3/12 GDS 111 Ur/Cr 23/0.8 OT/PT 11/12 Paracetamol 3x500 mg PO 5/9 R/ BPL TUTD
dr. Adianti Sp.U N 31/8 PCR Swab -
RR
S
17 4-Sep 1203 Ny. Dewi Kusumaningsih/38 Post BA (4/9)

Klinik
PULANG
dr. Ir dr. Irawan, Sp.BS
Pribadi 46th Anemia TD: pt/aptt 10.50 (10.30)/31.70 (36.60) , SI 12, TIBC 379, Trasnferin 3.2, Feritin 40.39; OT/PT 25/26 Episan 4xC1 PO Co dr Damba, Sp.JP (ec pro echo) Tambahan: adalat oros 1x30mg TUNDA
Acute heart failure N: Cr 1.19/Egfr 70; AU 12.5; GDS 105; HBSAg non reactive; antiHCV non reactive; AFP 1.7 CEA 0.62 CRP 29.3 Mucosta 3x1tab PO 3/9 Pumpicel stop ec alergi
dr. Daniel, Sp.PD Ht HHD RR: Goldar A+; Rapid non reaktif Candesartan1x16 mg PO malam Co dr. Teguh Sp.PD: bila mungkin CT thorax, analgetik injeksi, pariet ganti PPI IV--> DPJP tidak acc. Kalnex, Vit K TUNDA
Co dr Teguh Sp.PD Gouty arthtritis S: 2/9 EKG: SR HR 96x/min + VES? Zyloric 1x300mg PO 4/9 PRC I: 201 cc, PRC II: 198 cc. PRC III: 389 cc
Nefrolith S CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO R/ Gastroduodenoscopy bila Hb >9 dan Swab PCR negatif dengan dr. Teguh
5/9 cek DR ulang post transfusi 3 bag, sample +
19 3-Sep 1208 Tn Muhammad Rachmani/ Hiperglikemia pd DM II Kes CM 28/8 Rapid test IgM - IgG - IVFD Nacl 0.9% 500cc/8 jam 4/9 Extra Novorapid 10 U
Pribadi 45 th Dispepsia dd GERD TD: 1/9 PCR swab - Terfacef 1x2gr IV 5/9 Mulai Novorapid drip sesuai dr Felix Sp.PD, cek GDS/4 jam (jam 7, 11, dst)
Cephalgia N: 4/9 Hb 17.5/Ht 51/L 9.5/Tr 219 LED 15 Diff 1/0/73/3/17/6 GDS 683 Ur 65/Cr 1.8 OT 25/PT 15 Amlodipin 10mg 1-0-0 PO
dr. Felix Sp.PD HT RR: 5/9 UL kuning jernih, pH 5.0 berat jenis 1.010 glukosa+3 protein - keton - leuko 1-3 eri 0-1 epitel 3-5 Spironolacton 100mg 0-1-0 PO
Dislipidemia S: GDS pk 23: 713 HbA1c 11.7 Na 128/K 4.6/Cl 89 keton darah 0.6 Sanmol forte 3x1 tab PO 5/9 Cek GDP, G2PP
Betahistin mesilat 3x6mg PO
D Acarbose 3x50mg PO
Pumpisel 1x40mg IV
Sansulin 1x18 U SC malam
Allopurinol 100mg 0-0-1 PO
Truvaz 20mg 0-0-1 PO
Kombiglyze 5/500 1-0-1 PO * bila osmolaritas >320 -> protap HONK, loading 2L 1 jam petama, 1L 1 jam kedua, 500ml jam ketiga, 500ml jam keempat
Insulin drip 3,5 unit/jam selanjutnya NaCL maintenance 20 tpm

RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
New Diatab 3x1tab PO
2/9 GDP 123 GDS 18.00 226 Atorvastatin 20mg 0-0-1 PO DPL + GDS/3hari -> next 6/9 form (+) acc (+)
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
14/8 d dimer 3552 Allopurinol 1x100 mg PO (malam) 5/9 Cek DPL + D-dimer, form + --> dr. Felix Sp.PD maklum
16/8 D dimer 138 Betadine garg 3x/ hari 5/9 dr. Felix Sp.PD --> Cetirizine 1x1 tab
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Liproqy 2x1 8/9 DPL dan D-dimer /3 hari form (+) acc
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 dr. Felix SP.PD Cetirizine 1x1 tab
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
RR
S
R Becomzet 1x1 PO
Teofilin 2x100 mg po 9/9 R/ Swab PCR form+ PE+
Becomzet 1x1 PO
S:
Amlodipin 1x5 mg PO
Mucopect 3xcth1 PO
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Sanmol forte 3x1 tab po
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 5/9 Cek DPL ulang --> dr. Felix maklum
dr Felix Sp. PD Riw. Dengue fever RR CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19 Metformin 2x500 mg po (pagi sore) 5/9 R/ swab ulang, form +, PE +
Co dr. Putri Sp.GK Hipertrigliserdemia S blm dapat disingkirkan Glimepiride 1x2 mg po 8/9 cek DPL, form (+) acc
Liproqy 1x1 PO
RR: 5/9 Cek DPL ulang 6 jam post transfusi (pk 8.30) --> dr. Lucy Sp.OG sudah mengetahui hasil
S: 5/9 dr. Lucy Sp.OG : Trichodazole 3x500mg (IV) Sanmol drip 3x1 gr (IV) sampai hari Minggu, Senin (7/9) stop
Ketorolac injek 3x30mg hari Minggu stop, jam 15.00 aff kateter dan mobilisasi
15 4-Sep 1001 By Ny Amalia BCB SMK
KPN TTN
RUJUK RSUD TARAKAN
dr Novi Sp.A
16 3-Sep 1006 Tn. Heru Suminto/81 th Post URS (4/9) a/i

BPJS Batu ginjal+ ureter kanan
dr. Adianti Sp.U
PULANG
17 4-Sep 1203 Ny. Dewi Kusumaningsih/38 Post BA (4/9)

Klinik
PULANG
dr. Ir dr. Irawan, Sp.BS
Cephalgia N: 4/9 Hb 17.5/Ht 51/L 9.5/Tr 219 LED 15 Diff 1/0/73/3/17/6 GDS 683 Ur 65/Cr 1.8 OT 25/PT 15 Amlodipin 10mg 1-0-0 PO 5/9 Cek GDP, G2PP
dr. Felix Sp.PD HT RR: 5/9 UL kuning jernih, pH 5.0 berat jenis 1.010 glukosa+3 protein - keton - leuko 1-3 eri 0-1 epitel 3-5 Spironolacton 100mg 0-1-0 PO 5/9 dr. Felix visit :
Dislipidemia S: GDS pk 23: 713 HbA1c 11.7 Na 128/K 4.6/Cl 89 keton darah 0.6 Sanmol forte 3x1 tab PO Novorapid syringe pump sesuai skema
Betahistin mesilat 3x6mg PO Sanmol forte 3x1 tab k/p
D Acarbose 3x50mg PO Betahistine 3x6mg k/p
Pumpisel 1x40mg IV Sansulin 0-0-36 unit --> TUNDA
Sansulin 1x18 U SC malam Ascarbose --> TUNDA
Allopurinol 100mg 0-0-1 PO Kombiglyze --> TUNDA
Truvaz 20mg 0-0-1 PO Cek GDS per 4 jam lapor dr. Felix Sp.PD --> jam 11.00 dan jam 15.00 belum lapor
5 September (M) Ebelline

AdMed TD: 2/9 Hb 15.7 Ht 44 L 6.4 Tc 260 LED 30 NLR 2.01 Hitung Jenis 1/0/59/3/31/6/3.96/1.97 GDS 81 Hyloquine 1x400mg (3/9) 5/9 lanso STOP, new diatab STOP
RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
Bakrie DMT2 TD: 95/67 28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12 Lantus 1x36 unit SC malam 6/9 Cek DPL + GDS
dr. Felix Sp.PD Dislipidemia RR: Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru Concor 1x 5 mg PO 1-0-0 5/9 clonidine 1x0.15 mg, 2x0.15mg bila TD >140/90
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 dr. Felix SP.PD Cetirizine 1x1 tab
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
5/9 Hb 11.0 Ht 33 Leu 7.7 Tr 257 LED 43 NLR 2.68 , diff 5/1/60/3/24/7, D dimer 572
RR
S
R Becomzet 1x1 PO
Teofilin 2x100 mg po 5/9 Sanexon 2x125 mg IV (4/9) STOP
Becomzet 1x1 PO 9/9 R/ Swab PCR form+ PE+
Ventolin inhaler 3X1 puff
S:
Asma terkontrol RR 5/9 koltot 106 TG 123 HDL 28 LDL 63 Vectrine 3x1 PO
Amlodipin 1x5 mg PO
Mucopect 3xcth1 PO
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Sanmol forte 3x1 tab po Fu hasil swab 5/9
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 8/9 cek DPL, GDS form (+) acc (-)
UL dbn Candesartan 1x 8 mg po GDS /3 hari
5/9 Hb 14.2 Ht 41 Leu 5.3 Tr 225 LED 45 NLR 3.54 , diff 1/0/68/3/20/8 , GDS 99 Liproqy 1x1 PO
RR: 5/9 Cek DPL ulang 6 jam post transfusi (pk 8.30) --> dr. Lucy Sp.OG sudah mengetahui hasil
S: 5/9 dr. Lucy Sp.OG : Trichodazole 3x500mg (IV) Sanmol drip 3x1 gr (IV) sampai hari Minggu, Senin (7/9) stop
Ketorolac injek 3x30mg hari Minggu stop, jam 15.00 aff kateter dan mobilisasi
dr. Felix Sp.PD HT RR: 5/9 UL kuning jernih, pH 5.0 berat jenis 1.010 glukosa+3 protein - keton - leuko 1-3 eri 0-1 epitel 3-5 Spironolacton 100mg 0-1-0 PO 5/9 dr. Felix visit :
Dislipidemia S: GDS pk 23: 713 HbA1c 11.7 Na 128/K 4.6/Cl 89 keton darah 0.6 Sanmol forte 3x1 tab PO Novorapid syringe pump sesuai skema
Betahistin mesilat 3x6mg PO Sanmol forte 3x1 tab k/p
D Acarbose 3x50mg PO Betahistine 3x6mg k/p
Pumpisel 1x40mg IV Sansulin 0-0-36 unit --> TUNDA
Sansulin 1x18 U SC malam Ascarbose --> TUNDA
Allopurinol 100mg 0-0-1 PO Kombiglyze --> TUNDA
Truvaz 20mg 0-0-1 PO Cek GDS per 4 jam lapor dr. Felix Sp.PD --> jam 11.00 dan jam 15.00 belum lapor
17 5-Sep 120 Nn. Azzura Khoirunnisa/ appendicitis chronic Kes CM 3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169 IVFD Asering 500 cc/ 6 jam rencana laparoscopy Cito
19 tahun exacerbasi acute TD: Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg merosan 3x1g (5/9) 5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
6 September (M) Siska

RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
6/9 Cek DPL + GDS --> DPL dr. Taufan Sp.P dan dr. Felix Sp.PD sudah terinfo. GDS tidak diperiksa, jadinya besok pagi jam 06.00 (dr. Felix
Bakrie DMT2 TD: 95/67 28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12 Lantus 1x36 unit SC malam maklum)
6/9 Hb/Ht/L/Tr 13.7/38/6.2/318 LED 29 GDS: belum dicek HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 Cetirizine 1x1 tab 9/9 Swab PCR form (+), acc (+)
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
RR
S
R Becomzet 1x1 PO
dr. Taufan Sp.P N: CXR: cor dbn, susp GGO paru dextra 6/9 Swab ke IV sudah terlapor ke dr. Taufan Sp.P, acc pulang besok pagi (7/9) sebelum pulang foto thorx dan lapor dr. Taufan Sp.P
4/9 PCR swab IV -
S:
Amlodipin 1x5 mg PO
Mucopect 3xcth1 PO
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 8/9 cek DPL, GDS form (+) acc (-)
IVFD : Nacl 0.9% 500cc/8jam Rawat ODC lt 10
14 6-Aug ODC Ny. Nurhayati/ 63 th Obs febris H-2 + Malaise Kes : CM 6/9 : Hb 13.2/Ht 38 /L 5.7/Tr 287/LED 20/NLR 8.04/ Diff : 0/0/76/3/10/11/4.5/0.56 GDS : 113/ Na 128/K 4.4/ Clo 87
BPJS dr. Felix Sp.PD Cephalgia + Susp BPPV TD 6/9 Rapid IgM&IgG sars cov-2 : Negatif Inj Ceftriaxone 1x2 gr IV Jika besok (7/9) masih sakit kepala --> pro konsul saraf
Dispepsia sindrom N CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Inj Omeprazole 1x1 amp IV
Low oral intake RR Paracetamol 4x500mg PO
S N-acetylsistein 3x200 mg PO
BB : 50 kg Cetirizine 10 mg 0-0-1
Sucralfat syrp 3x1 cth
Ondancentron IV K/P muntah
Diet lunak
Drip ketorolac 1 amp dlm NS K/P nyeri kepala
15 3-Sep 1001 Ny. Amalia Pristya Sari/36 th P3A0 post SC ai stenosis Kes CM 3/9 Hb 9.5/Ht 28/L 13.9/Tr 293 LED 34 Diff 1/1/78/3/12/5 Rapid test IgM IgG negatif Trichodazole 3x500mg IV (5/9) 3/9 dr. Novi Sp.A terinfo
KPN cervix + CPD + lilitan tali TD: 6/9 Hb 9.2/ Ht 29/L 18/ Tr 324/ Er 3.7 Terfacef 2x1gr IV (4/9) 4/9 Terfacef 2 g IV pk. 05.00, D5% 500 cc guyur sebelum drip oxytosin
dr Lucy Sp.OG pusat N: Sanmol 3x1 g IV (5/9 sampai 6/9) 4/9 PRC I: 202 cc selesai pk 2.30
RR: Ketorolac 3x30 mg IV (5/9 kemudiaan STOP) 5/9 Cek DPL ulang 6 jam post transfusi (pk 8.30) --> dr. Lucy Sp.OG sudah mengetahui hasil
S: Ranitidin 3x150 mg PO ac (6/9) 5/9 dr. Lucy Sp.OG : Trichodazole 3x500mg (IV) Sanmol drip 3x1 gr (IV) sampai hari Minggu, Senin (7/9) stop
Molluco B12 3x1 tab PO (6/9) Ketorolac injek 3x30mg hari Minggu stop, jam 15.00 aff kateter dan mobilisasi
6/9 dr. Lucy Sp.OG : cek DPL jam 19.00 --> lapor dr. Lucy Sp.OG, rencana aff venflon setelah trichodazole dan terpacef injeksi masuk malam
6/9 hasil DPL terlapordr. Lucy Sp.OG --> trichodazole dan terpacef injeksi lanjut jam 08.00 (7/9) baru kemudiaan aff venflon. Lapor dr. Lucy
Sp.OG untuk tanya boleh TUTD ? Pasien minta pulang pagi, resep pulang (+), surat kontrol (+), resume (+)
R/ Gastroduodenoscopy bila Hb >9 dan Swab PCR negatif dengan dr. Teguh -> senin 7/9 jam 10.00-10.30, puasa total 6 jam (tidak makan dan
Nefrolith S CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO minum), lapor OT (+)
Alergi Nexium, Pumpicel NAFLD 3/9 UL dbn. Echo: mild dilatasi LA-LV, LVH konsentrik, EF 77% TAPSE 2,7 cm global normokinetik, katup dbN Pariet 2x20mg PO 6/9 Pasien mau di sedasi umum saat gastroduodenoskopi, konsul anestesi (+), lembar konsul (+)
4/9 PCR swab - Tramal 3x1 iv (6/9)
5/9 HB/HT/L/TR 10.7/34/8.2/527/3.91 Ur/Cr 27/1.1 Na/K/Cl 138/3.5/95
dr. Felix Sp.PD HT RR: 5/9 UL kuning jernih, pH 5.0 berat jenis 1.010 glukosa+3 protein - keton - leuko 1-3 eri 0-1 epitel 3-5 Spironolacton 100mg 0-1-0 PO 5/9 dr. Felix visit : Betahistine k/p sanmol k/p ascarborse tunda, kombiglyze tunda
6/9 KGDH jam 12,18,21 --> dr. Felix terinfo. Advice : Novorapid naik jadi 3x16 unit SC, sansulin 0-0-38unit, besok pagi cek GDS pasien rencana
Dislipidemia S: GDS pk 23: 713 HbA1c 11.7 Na 128/K 4.6/Cl 89 keton darah 0.6 Sanmol forte 3x1 tab PO K/P pulang besok TUNGGGU DOKTER VISIT)
6/9 GDS pk 12.00: 290 18.00 : 230 21.00 : 116 Betahistin mesilat 3x6mg PO K/P
D 7/9 GDS pk 6.30 : 106 mg/dl Acarbose 3x50mg PO (TUNDA)
Pumpisel 1x40mg IV
Sansulin 1x38U SC malam
Allopurinol 100mg 0-0-1 PO
Truvaz 20mg 0-0-1 PO
Kombiglyze 5/500 1-0-1 PO (TUNDA) * bila osmolaritas >320 -> protap HONK, loading 2L 1 jam petama, 1L 1 jam kedua, 500ml jam ketiga, 500ml jam keempat
Insulin drip 3,5 unit/jam (STOP) selanjutnya NaCL maintenance 20 tpm
Novorapid 3x14 unit --> 3x16 unit
18 5-Sep 120 Nn. Azzura Khoirunnisa/ appendicitis chronic Kes CM 3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169 IVFD Asering 500 cc/ 6 jam rencana laparoscopy Cito
19 tahun exacerbasi acute TD: Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg merosan 3x1g (5/9) 5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
7 September (P) Connie

RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
7/9 GDS 145 Kombilyze XR 5/500 1x1 PO (siang)
Probiostin 1xI PO
Laxadine 2xCI PO
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Liproqy 2x1 8/9 DPL dan D-dimer /3 hari form (+) acc (+)
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
RR Codipront syr 3x 1 C
S
Kemkes TD 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Oseltamivir 2x75mg PO (5/9)
R Becomzet 1x1 PO
Polycrol 3x15 cc po ac
Polycrol 3x15 cc po
8 16-Aug 1101 Ny.Dian Purnamalia/38 th COVID-19 confirmed case

Bakrie
PULANG
dr. Taufan Sp.P
S:
Amlodipin 1x5 mg PO
Mucopect STOP --> Codipront syr 3x 1C
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 8/9 cek DPL, GDS form (+) JP (+)
IVFD : Nacl 0.9% 500cc/8jam R/ DR ulang tgl 9/9
BPJS dr. Felix Sp.PD Cephalgia + Susp BPPV TD 6/9 Rapid IgM&IgG sars cov-2 : Negatif Inj Ceftriaxone 1x2 gr IV
co dr Angel SpN Dispepsia sindrom N CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Inj Omeprazole 1x1 amp IV
Low oral intake RR 7/9 UL: dalam batas normal Paracetamol 4x500mg PO ( STOP)
Diet lunak
Mecobalamin 2x500mg PO
Betahistin 2x24mg
Tramadol 37.5mg + PCT 325mg -> 2-3x1 caps
Flunarizine 2x10mg
15 3-Sep 12 Tn. Bambang Halim/24
Prudential
dr. Daniel, Sp.PD
Gastritis erosif Ceftriaxone 1x2 gr IV ( 5/9) 5/9 cek DR ulang post transfusi 3 bag, sample +
Nefrolith S CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO STOP minum), lapor OT (+)
Pariet?, gelofusin 4/9 PCR swab - Tramal 3x100 mg iv (6/9)
5/9 HB/HT/L/TR 10.7/34/8.2/527/3.91 Ur/Cr 27/1.1 Na/K/Cl 138/3.5/95 Sanmol 3x1 gr IV
7/9 Gastrosopi : Gastritis Erosiva dan bekas ulkus , hiatus sliding hernia
7/9 HB/HT/L/TR 9.1/27/8.2/585/3.21 CRP 76.7
17 3-Sep 1208 Tn Muhammad Rachmani/ Hiperglikemia pd DM II
Pribadi 45 th Dispepsia dd GERD
Cephalgia
PULANG
dr. Felix Sp.PD HT
Dislipidemia
18 5-Sep 1203 Nn. Azzura Khoirunnisa/ Post Laparoskopi Appendektomi Kes CM 3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169 IVFD Asering 500 cc/ 6 jam rencana laparoscopy Cito
Pribadi 19 tahun ec App kronis eksaserbasi akut TD: Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg merosan 3x1g (5/9) 5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
7 September (M) Gizella

RR: Becomzet 1x1 PO
S: Mucopect 3xC1 PO
7/9 GDS 145 Kombilyze XR 5/500 1x1 PO (siang)
Probiostin 1xI PO
Laxadine 2xCI PO
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Liproqy 2x1 8/9 DPL dan D-dimer /3 hari form (+) acc (+)
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
RR Codipront syr 3x 1 C
S
Kemkes TD 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Oseltamivir 2x75mg PO (5/9)
R Becomzet 1x1 PO
Polycrol 3x15 cc po
S:
Amlodipin 1x5 mg PO
Mucopect STOP --> Codipront syr 3x 1C
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Lapraz 1x30 mg PO 8/9 cek DPL, GDS form (+) JP (+)
IVFD : Nacl 0.9% 500cc/8jam R/ DR ulang tgl 9/9
BPJS dr. Felix Sp.PD Cephalgia + Susp BPPV TD 6/9 Rapid IgM&IgG sars cov-2 : Negatif Inj Ceftriaxone 1x2 gr IV
co dr Angel SpN Dispepsia sindrom N CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Inj Omeprazole 1x1 amp IV
Low oral intake RR 7/9 UL: dalam batas normal Paracetamol 4x500mg PO ( STOP)
Diet lunak
Betahistin 2x24mg
Flunarizine 2x10mg
14 3-Sep 12 Tn. Bambang Halim/24 GEA dehidrasi ringan - sedang 7/9 Hb/HT/L/Tc/E 16.5/47/5.7/195/5.03 Hitung Jenis 2/0/55/3/31/93.34/1.77 LED 6 NLR 1.89 New diatab 3x2 tab F/u sample u/ feses lengkap
Prudential Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25 Pumpicell 2x40 mg iv
dr. Daniel, Sp.PD CRP <2.5, Na/K/Cl 140/ 3.8/102 Trovensis 3x8 mg iv
Thorax: dbn Sanmol 3x1 g iv prn
RL 500 cc/6 jam
Diet lambung3 bubur 1700 kal
Gastritis erosif Ceftriaxone 1x2 gr IV ( 5/9) 5/9 cek DR ulang post transfusi 3 bag, sample +
Nefrolith S CXR Kardiomegali dgn tanda awal bendungan paru, elongatio dan atherosklerosis aorta Letonal 1x25mg PO STOP minum), lapor OT (+)
Pariet?, gelofusin 4/9 PCR swab - Tramal 3x100 mg iv (6/9)
5/9 HB/HT/L/TR 10.7/34/8.2/527/3.91 Ur/Cr 27/1.1 Na/K/Cl 138/3.5/95 Sanmol 3x1 gr IV
7/9 HB/HT/L/TR 9.1/27/8.2/585/3.21 CRP 76.7
16 5-Sep 1203 Nn. Azzura Khoirunnisa/ Post Laparoskopi Appendektomi Kes CM 3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169 IVFD Asering 500 cc/ 6 jam rencana laparoscopy Cito
Pribadi 19 tahun ec App kronis eksaserbasi akut TD: Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg merosan 3x1g (5/9) 5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
8 September (P) Cylla

1 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM
Kemkes TD:
dr. Taufan Sp.P N:
RR:
S:
Bakrie DMT2 TD: 95/67

S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S
5 4-Sep 1606 Rezka Budi/17 th COVID-19 confirmed case Kes: CM

Kemkes TD
dr. Taufan, Sp.P N
R
S

Wilmar TD
dr. Taufan Sp.P N
RR
S
dr. Taufan SpP N:
RR:
S:

Bakrie TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:
11 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes

Bakrie HT TD
dr. Taufan Sp.P Dislipidemia N
Asma terkontrol RR
Alergi Antalgin, Salisilat S
12 29-Aug 1108 dr. Achmad Budiarto/62 th COVID-19 confirmed case Kes

dr Taufan SpP DM tipe II + pruritus N
dr Felix Sp. PD Riw. Dengue fever RR
Co dr. Putri Sp.GK Hipertrigliserdemia S
Dispepsia
Asma terkontrol
13 6-Aug ODC Ny. Nurhayati/ 63 th Obs febris H-2 + Malaise Kes : CM
BPJS dr. Felix Sp.PD Cephalgia + Susp BPPV TD

co dr Angel SpN Dispepsia sindrom N
Low oral intake RR
S
BB : 50 kg
14 3-Sep 12 Tn. Bambang Halim/24 GEA dehidrasi ringan - sedang

Prudential
dr. Daniel, Sp.PD
15 2-Sep 1204 Tn. Muhammad Arisandi/ Melena (perbaikan) Kes CM

Pribadi 46th Anemia TD:
Acute heart failure N:
dr. Daniel, Sp.PD Ht HHD RR:
Co dr Teguh Sp.PD Gouty arthtritis S:
Gastritis erosif
Nefrolith S
Alergi Nexium, Pumpicel NAFLD
Pariet?, gelofusin
16 5-Sep 1203 Nn. Azzura Khoirunnisa/ Post Laparoskopi Appendektomi Kes CM

Pribadi 19 tahun ec App kronis eksaserbasi akut TD:
N:
dr. Daniel SpPD RR:
raber dr. Minarti SpB-KBD S:
co dr. Sang SpOG
17 1006 Tn Dadang DMT2
Bronkopneumonia
dr. Taufan Sp.P AKI dd ACKD
dr. Daniel, Sp.PD
18 8-Sep 1208 Ny Fenti Puspitasari/ 43th Pro liposuction + repair
hyperthrophic scar mamae D
dr. Irawan Sp.BP
co: dr Hendri, SpAn
co: dr. Felix, Sp.PD
Penunjang
1/9 Swab PCR +
CXR: GGO halus paru dextra
26/8 PCR swab I +
29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
3/9 Hb/Ht/L/Tr 14.7/43/5.7/357 LED 30 Mono 10 GDS pk. 18: 163
6/9 Hb/Ht/L/Tr 13.7/38/6.2/318 LED 29 GDS: belum dicek
7/9 GDS 145

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
4/9 CXR: Cor pulmo dbn, tak tampak GGO

2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif
Rapid Sars Cov2 -
2/9 PCR Swab II +

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab II +

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab III +
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
31/8 PCR Swab I +

3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3
4/9 CXR: Cor dbn, Gambaran GGO di kedua paru/viral pneumonia covid 19 (typical)
5/9 koltot 106 TG 123 HDL 28 LDL 63
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
5/9 Hb 14.2 Ht 41 Leu 5.3 Tr 225 LED 45 NLR 3.54 , diff 1/0/68/3/20/8 , GDS 99
6/9 : Hb 13.2/Ht 38 /L 5.7/Tr 287/LED 20/NLR 8.04/ Diff : 0/0/76/3/10/11/4.5/0.56 GDS : 113/ Na 128/K 4.4/ Clo 87
6/9 Rapid IgM&IgG sars cov-2 : Negatif
CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini
7/9 UL: dalam batas normal
7/9 Hb/HT/L/Tc/E 16.5/47/5.7/195/5.03 Hitung Jenis 2/0/55/3/31/93.34/1.77 LED 6 NLR 1.89

Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25
CRP <2.5, Na/K/Cl 140/ 3.8/102
Thorax: dbn
3/9 UL dbn. Echo: mild dilatasi LA-LV, LVH konsentrik, EF 77% TAPSE 2,7 cm global normokinetik, katup dbN
4/9 PCR swab -
5/9 HB/HT/L/TR 10.7/34/8.2/527/3.91 Ur/Cr 27/1.1 Na/K/Cl 138/3.5/95
7/9 HB/HT/L/TR 9.1/27/8.2/585/3.21 CRP 76.7
3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169
Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg
kalsifikasi pada daerah mesenterial abdomen kanan bawah dd calcified lymphonode, organ intrabdominal
lainnya normal
5/9 Hb: 8.7 ht 27 leuko 7.2 tr 502 eri 3.8 Pt 20.1 Aptt 39.3
6/9 Hb: 8.72
7/9 Hb 10/Ht 31/L 7.9/Tr 469 LED 15 Diff 1/0/81/3/10/5 CRP 18.7, albumin 3.5, PT 16.9
Terapi
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO

Concor 1x 5 mg PO 1-0-0
Lapraz 1x1 PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO

Venflon
Becomzet 1x1 PO
Liproqy 2x1
Cetirizine 1x1 tab
Becomzet 1x1 po
Nalgestan 2xI PO
Codipront syr 3x 1 C
Hyloquin 1x400mg PO (5/9)

Oseltamivir 2x75mg PO (5/9)
Azitromycin 1x500mg PO (5/9)
Becomzet 1x1 PO
Rhinos SR 2x1 tab PO
Becomzet 1x1 PO

Becomzet 1x1 PO
Polycrol 3x15 cc po
Becomzet 1x1 PO
Mucopect 3xC1 PO
Becomzet 1x1 PO
Becomzet 1x1 PO
Codipront 3x1cth PO
Azitromisin 1x500 mg PO (4/9) 3 hari

Hyloquin 1x400 mg PO (4/9) 3 hari
Oseltamivir 2x75 mg PO (4/9) 3 hari
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Prome syr k/p batuk
Liproqy 1x1 PO
IVFD : Nacl 0.9% 500cc/8jam
Nacl 3% 500cc/24jam
Inj Ceftriaxone 1x2 gr IV
Omeprazole 2x20 mg PO
N-acetylsistein 3x200 mg PO
Cetirizine 10 mg 0-0-1
Diet lunak
Betahistin 2x24mg
Flunarizine 2x10mg
New diatab 3x2 tab

Pumpicell 2x40 mg iv
Trovensis 3x8 mg iv
Sanmol 3x1 g iv prn
RL 500 cc/6 jam
Episan syr 4xC1
Vometa FT 3x1tab kunyah
Buscopan 3x1amp
Venflon
Episan 4xC1 PO
Mucosta 3x1tab PO
Zyloric 1x300mg PO
Ceftriaxone 1x2 gr IV ( 5/9)
Pariet 2x20mg PO
Tramal 3x100 mg iv (6/9)
Sanmol 3x1 gr IV
Venofer 2amp dlm NS 100cc drip 4jam
IVFD Asering 500 cc/ 6 jam

merosan 3x1g (5/9)
Sanmol 3x1 g IV
Levopron 3x2 cth
Ketorolac 3x30 mg IV (6/9)
Ondancentron 1x1amp K/P
Betadin gargle 3x/ hari
Ketorolac kp nyeri
Cernevit 1x1vial
PULANG
FU terapi post op
Keterangan
8/9 R/Swab PCR, form +, PE +
5/9 lanso STOP, new diatab STOP

6/9 Cek DPL + GDS --> DPL dr. Taufan Sp.P dan dr. Felix Sp.PD sudah terinfo. GDS tidak diperiksa, jadinya besok pagi jam 06.00
maklum)
8/9 R/ Swab PCR form+, PE+
5/9 clonidine 1x0.15 mg, 2x0.15mg bila TD >140/90
DPL + GDS/3hari -> next 9/9 form (+) acc (+)
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
5/9 Cek DPL + D-dimer, form + --> dr. Felix Sp.PD maklum
9/9 R/ Swab PCR form+ PE+
5/9 dr. Felix Sp.PD --> Cetirizine 1x1 tab
8/9 DPL dan D-dimer /3 hari form (+) acc (+)
9/9 Swab PCR form (+), acc (+)
10/9 Swab PCR form+ PE+
9/9 R/ Swab PCR PE+ form+
30/8 Sanexon 1x40 mg PO STOP
5/9 Sanexon 2x125 mg IV (4/9) STOP

8/9 12.00 TD 183/103 extra Captopril 12.5 mg sedang konfirmasi dr Taufan apa boleh konsul IPD

FU hasil swab 7/9
5/9 R/ Cek Profil lipid

FU hasil swab 7/9

Fu hasil swab 5/9
8/9 cek DPL, GDS form (+) JP (+)
GDS /3 hari
DPL/3hari
R/ DR + OT/PT tgl 9/9, form +, acc +
elektrolit belum acc
FU hasil feses lengkap

Lembar medis lanjutan

Co dr Damba, Sp.JP (ec pro echo) Tambahan: adalat oros 1x30mg TUNDA
3/9 Pumpicel stop ec alergi
Co dr. Teguh Sp.PD: bila mungkin CT thorax, analgetik injeksi, pariet ganti PPI IV--> DPJP tidak acc. Kalnex, Vit K TUNDA
4/9 PRC I: 201 cc, PRC II: 198 cc. PRC III: 389 cc
R/ Gastroduodenoscopy bila Hb >9 dan Swab PCR negatif dengan dr. Teguh -> senin 7/9 jam 10.00-10.30, puasa total 6 jam (ti
minum), lapor OT (+)
6/9 Pasien mau di sedasi umum saat gastroduodenoskopi, konsul anestesi (+), lembar konsul (+)
PULANG SETELAH VENOFER HABIS; Resume belum
rencana laparoscopy Cito

5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
anest terinfo : dr. Linda SpAn
dr Min SpBKBD pro op bila: obg terkonsul, darah tersedia, asuransi acc, anest acc; JP pribadi +
6/9 Laparoscopy app pk 14.00, prc 1 labu, FFP 1 labu, dr. Daniel terinfo, dr. Sang terinfo, dr. Linda terinfo
6/9 instuksi dr. Min Sp.BKBD post op : tidak jadi transfusi di OT, cek DPL dan albumin besok pagi (7/9) form (+) JP (+),
6/9 instruksi dr. Linda Sp.An post op : ketorolac 3x30 mg IV rutin 2 hari, tamoliv 1x1gr k/p
6/9 instuksi dr. Daniel Sp.PD post op : transfusi PRC 1 bag dan FFP 1 bag di ruangan tanpa premedikasi, cek DPL, PT, CRP, acc c
albumin sesuai TS bedah (7/9) form (+) JP (+), tambahan terapi Levopron 3x2 cth, tamoliv tidak usah krn sdh dpt sanmol rutin
6/9 Transfusi PRC 1 bag dan FFP 1 bag
7/9 dr Min: alinamin f stop, pro GV jika pulang tolong disiapkan set GV; dr Daniel: R/ pulang besok
IPD: toleransi sedang

8 September Malam (Lauretta)

Kemkes TD:
dr. Taufan Sp.P N:
RR:
S:

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S
5 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case Kes: CM

Kemkes TD
dr. Taufan, Sp.P N
R
S
6 30-Aug 1607 Tn. Sabam Frando/32 th COVID-19 confirmed case Kes

Wilmar TD
dr. Taufan Sp.P N
RR
S
dr. Taufan SpP N:
RR:
S:
8 8-Sep 1102 Ny. Zuhairiah/ 36 COVID-19 confirmed case Kes CM

Kemkes TD:
dr. Taufan SpP N:
RR:
S:
9 8-Sep 1102 Nn. Windri/23 th COVID-19 confirmed case Kes CM
Kemkes TD:
dr. Taufan SpP N:
RR:
S:

Bakrie HT TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

Bakrie HT TD
Asma terkontrol RR

Dispepsia
Asma terkontrol
15 6-Aug ODC10 Ny. Nurhayati/ 63 th Obs febris (4/9) ec susp. Viral inf Kes : CM
BPJS BBPV + TTH TD: 138/83
dr. Felix Sp.PD HipoNaCl N: 89
RR: 16
S: 36,6
16 2-Sep 1204 Tn. Muhammad Arisandi/ Melena ec gastritis erosif

Pribadi 46th Anemia
Acute heart failure
dr. Daniel, Sp.PD Ht HHD
Gouty arthtritis
Nefrolith S
17 5-Sep 1203 Nn. Azzura Khoirunnisa/ Post Laparoskopi Appendektomi Kes CM

Pribadi 19 tahun (6/9) a/i App kronis eks. akut TD:
N:
dr. Daniel SpPD RR:
dr. Minarti SpB-KBD S:
18 3-Sep 1206 Tn. Bambang Halim/24th GEA dehidrasi ringan - sedang Kes : CM
AA TD
dr. Daniel, Sp.PD N
RR
S
19 8-Sep 1208 Ny Fenti Puspitasari/ 43th Pro liposuction + repair (8/9) Kes CM
Klinik hyperthrophic scar mamae D TD:
dr.Irawan dr. Irawan Sp.BP N:
RR:
S:
Penunjang
1/9 Swab PCR +
26/8 PCR swab I +

29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
7/9 GDS 145

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
3/9 PCR swab I +
Rapid Sars Cov2 -
2/9 PCR Swab II +

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5
CXR: bronchitis, tak tampak GGO.
8/9 CXR: dextroscoliosis
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab II +

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab III +
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
31/8 PCR Swab I +

29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
Rapid IgM&IgG sars cov-2 : Negatif
3/9 Hb 9.6/Ht 32/L 4.4/Tr 535 LED 45 Diff 0/1/0/77/16/6 MCV/MCH/MCHC 72/21/30, OT/PT 9/7, ur/cr 0.5/169
Na 138 K4.7 Cl 102 widal : -, CXR: normal, CT abd :Appendicitis acute curiga perforasi, soft tissue density dg
kalsifikasi pada daerah mesenterial abdomen kanan bawah dd calcified lymphonode, organ intrabdominal
lainnya normal
5/9 Hb: 8.7 ht 27 leuko 7.2 tr 502 eri 3.8 Pt 20.1 Aptt 39.3
6/9 Hb: 8.72
7/9 Hb 10/Ht 31/L 7.9/Tr 469 LED 15 Diff 1/0/81/3/10/5 CRP 18.7, albumin 3.5, PT 16.9
CRP <2.5, Na/K/Cl 140/ 3.8/102
Thorax: dbn
8/9 FL:kuning cair darah samar +
4/9 CXR dbN Hb 10,9 ht 34 leu 5,8 Tr 237 BT/CT 2,5/8 HBsAg non rx anti HIV non rx OT/PT 13/ 13 ur/cr 25/0,54
GDS 87
5/9 Swab PCR -
Terapi
Becomzet 1x1 PO
Mucopect 3xC1 PO
Ondancetron 2x8mg PO kp mual
Becomzet 1x1 PO
Lapiva 1x10/160 mg PO malam
Concor 1x 5 mg PO pagi
Amaryl 1x4 mg PO pagi
Januvia 1x 100mg PO pagi
Atorvastatin 1x20mg PO malam
Ondancetron 2x8 mg PO
Lapraz 1x30 mg PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Laxadine 2xCI PO
Clonidine 1x0,15 mg PO (siang)

Venflon
Becomzet 1x1 PO
Liproqy 2x1
Cetirizine 1x10 mg PO
Becomzet 1x1 po
Nalgestan 2xI PO
Codipront syr 3x 1 C

Becomzet 1x1 PO
Polysilane 3x15 cc po ac*
Becomzet 1x1 PO

Becomzet 1x1 PO
Polysilane 3x15 cc po

Becomzet 1x1 PO
Becomzet 1x1 PO
Becomzet 1x1 PO
Mucopect 3xC1 PO
Exforge 1x5/80 mg PO
Becomzet 1x1 PO
Becomzet 1x1 PO
Codipront 3x1cth PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO
Minosep gargle 3x15cc
IVFD : Nacl 0.9% 500cc/8jam
Diet lunak
Nacl 3% 500cc/24jam
Ceftriaxone 1x2 g IV (6/9)
Ondancetron 8 mg IV K/P muntah
Drip ketorolac 30 mg dlm NS K/P nyeri kepala
Betahistin 2x24mg PO
Flunarizine 2x10mg PO
PULANG
IVFD Asering 500 cc/ 6 jam

Merosan 3x1g (5/9)
Sanmol 3x1 g IV
Levopron 3x2 cth
Ketorolac 3x30 mg IV k/p
Ondancetron 1x1amp K/P
Betadin gargle 3x/ hari
Cernevit 1x1vial
IVFD RL 500 cc/6 jam
Taxegram 3x1 g IV (8/9)
L Bio 3x2 sach PO
New diatab 3x2 tab
Trovensis 3x8 mg iv
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
IVFD Aminofluid 500 mL/6 jam

Ethanyl 200 mcg/ 24 jam IV
Tamoliv 4 x1 g IV
Gabaxa 1xI IV
Keterangan
8/9 hyloquin, oseltamivir, azitro stop
8/9--> 9/9 R/ Swab PCR form+ PE+
Pasien minta pulang karena takut Kemenkes tdk tanggung biaya--> sampaikan ke DPJP

8/9--> 9/9 R/ Swab PCR form+ PE+
DPL + GDS/3hari -> next 9/9 form (+) acc (+)
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
9/9 Swab PCR form (+), acc (+)
DPL dan D-dimer /3 hari--> next 11/9, form -

*R/ stop 10/9

9/9 R/ Swab PCR PE+ form+
10/9 R/ Swab PCR PE- form+

FU hasil lab

8/9 12.00 TD 183/103 extra Captopril 12.5 mg sedang konfirmasi dr Taufan apa boleh konsul IPD
8/9-->9/9 R/ Swab PCR form+ PE+
Co dr. Daniel, Sp.PD: Cek EKG, elektrolit, cr--> form +


FU hasil swab 7/9
FU hasil swab 7/9
Fu hasil swab 5/9

GDS+DPL /3 hari
Co dr. Angel, Sp.N: BPPV + TTH
9/9 R/ DR + OT/PT, elektrolit , form +, acc +
5/9 hasil konsul :USG dr. Sang SpOG : bidang Obg aman, bersedia konsul intra OP
anest terinfo : dr. Linda SpAn
dr Min SpBKBD pro op bila: obg terkonsul, darah tersedia, asuransi acc, anest acc; JP pribadi +
6/9 Laparoscopy app pk 14.00, prc 1 labu, FFP 1 labu, dr. Daniel terinfo, dr. Sang terinfo, dr. Linda terinfo
instuksi dr. Min Sp.BKBD post op : tidak jadi transfusi di OT, cek DPL dan albumin besok pagi (7/9) form (+) JP (+),
instruksi dr. Linda Sp.An post op : ketorolac 3x30 mg IV rutin 2 hari, tamoliv 1x1gr k/p
instuksi dr. Daniel Sp.PD post op : transfusi PRC 1 bag dan FFP 1 bag di ruangan tanpa premedikasi, cek DPL, PT, CRP, acc cek
albumin sesuai TS bedah (7/9) form (+) JP (+), tambahan terapi Levopron 3x2 cth, tamoliv tidak usah krn sdh dpt sanmol rutin
Transfusi PRC 1 bag dan FFP 1 bag
8/9 dr Min: alinamin f stop, pro GV jika pulang tolong disiapkan set GV; dr Daniel: R/ pulang 9/9
8 September Pagi (Cylla)

Kemkes TD:
dr. Taufan Sp.P N:
RR:
S:

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

Kemkes TD
dr. Taufan, Sp.P N
R
S

Wilmar TD
dr. Taufan Sp.P N
RR
S
dr. Taufan SpP N:
RR:
S:
8 8-Sep 1102 Ny. Zuhairiah/ 36 COVID-19 confirmed case Kes CM

Kemkes TD:
dr. Taufan SpP N:
RR:
S:

Kemkes TD:
dr. Taufan SpP N:
RR:
S:

Bakrie HT TD:
dr. Taufan Sp.P N:
RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

Bakrie HT TD
Asma terkontrol RR

Dispepsia
Asma terkontrol
dr. Felix Sp.PD HipoNaCl + HipoK N: 89
Low intake RR: 16
S: 36,6
17 5-Sep 1203 Nn. Azzura Khoirunnisa/ Post Laparoskopi Appendektomi

Pribadi 19 tahun (6/9) a/i App kronis eks. akut
dr. Daniel SpPD

dr. Minarti SpB-KBD
AA TD
dr. Daniel, Sp.PD N
RR
S
19 8-Sep 1208 Ny Fenti Puspitasari/ 43th Pro liposuction + repair (8/9)

Klinik hyperthrophic scar mamae D
dr.Irawan dr. Irawan Sp.BP
Penunjang
1/9 Swab PCR +
26/8 PCR swab I +

29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
7/9 GDS 145

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
3/9 PCR swab I +
Rapid Sars Cov2 -
2/9 PCR Swab II +

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +

Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab II +
9/9 EKG sinus rhythm

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab III +
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
31/8 PCR Swab I +

29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97

CRP <2.5, Na/K/Cl 140/ 3.8/102
Thorax: dbn
Terapi
Becomzet 1x1 PO
Mucopect 3xC1 PO
Rhinos SR k/p
Becomzet 1x1 PO
Lapraz 1x30 mg PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Becomzet 1x1 PO
Liproqy 2x1
Becomzet 1x1 po
Nalgestan 2xI PO k/p
Codipront syr 3x 1 C k/p

Becomzet 1x1 PO
Polysilane 3x15 cc po ac*
Becomzet 1x1 PO
Minosep garg 3x

Sumagesik 3x500mg PO k/p
Codipront exp 3x cthI PO k/p
Amlodipin1x5 mg PO pagi k/p (sudah tdk minum)
Becomzet 1x1 PO

Becomzet 1x1 PO

Becomzet 1x1 PO
Minosep garg 3x
Prome syr 3xc1
Becomzet 1x1 PO
Mucopect 3xC1 PO
BecomC 2x1 PO
Becomzet 1x1 PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO
IVFD : Nacl 0.9% + KCl 25meq 500cc/8jam
Diet lunak
PULANG

L Bio 3x2 sach PO
Imodium 3x2 tab
Trovensis 3x8 mg iv
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
PULANG
Keterangan
FU hasil swab 9/9

FU hasil swab 9/9, DPL+ GDS
DPL + GDS/3hari -> next 12/9 form (-) acc (+)
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
FU hasil swab 9/9, DPL + Ddimer

** Infokan ke dr. Taufan minta foto evaluasi sudah 1 bulan belum foto ulang
FU hasil swab 9/9
*R/ stop 10/9

FU hasil swab 9/9

*Swab reguler
FU hasil swab 9/9

8/9 12.00 TD 183/103 extra Captopril 12.5 mg
FU hasil swab 9/9
Co dr. Daniel, Sp.PD: FU hasil elektrolit, cr

FU hasil swab 9/9

FU hasil swab 7/9
FU hasil swab 7/9

Belum ada obat kumur

FU hasil DPL + GDS 9/9
Fu hasil swab 5/9

GDS+DPL /3 hari
FU hasil swab 9/9, FU hasil Ro thorak evaluasi 9/9
Nacl 3% stop
*konfirmasi kak gebby apakah obat saraf boleh lanjut
*MENOLAK PEMASANGAN NGT
9/9 New diatab stop

9 September M (Connie)

Kemkes TD:
dr. Taufan Sp.P N:
RR:
S:

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

Kemkes TD
dr. Taufan, Sp.P N
R
S

Wilmar TD
dr. Taufan Sp.P N
RR
S
dr. Taufan SpP N:
RR:
S:
8 8-Sep ODC 11 Ny. Zuhairiah/ 36 COVID-19 confirmed case Kes CM

Kemkes TD:
dr. Taufan SpP N:
RR:
S:
9 8-Sep ODC 11 Ny. Lisa Septiana Covid 19 Confirmed Case Kes : CM
TD
N
RR
S

Kemkes TD:
dr. Taufan SpP N:
RR:
S:

Bakrie HT TD:
dr. Taufan Sp.P N:
co dr. Daniel Sp.PD RR:
S:

Darma TD:
RR:
S:

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

Bakrie HT TD
Asma terkontrol RR

Dispepsia
Asma terkontrol
Low intake RR: 16
Pneumonia S: 36,6
AA TD
dr. Daniel, Sp.PD N
RR
S
Penunjang
1/9 Swab PCR +
26/8 PCR swab I +

29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
7/9 GDS 145
9/9 Hb/Ht/L/Tr 14.9/44/9.2/364 LED 35 NLR 2.45 diff 1/0/60/3/26/10
9/9 PCR Swab III -

14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 Hb/Ht/L/Tr 11.1/32/7.1/259 LED 34 NLR 3.1 diff 4/1/63/3/22/7 , D-dimer 559
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
9/9 PCR swab III persumtif
3/9 PCR swab I +
Rapid Sars Cov2 -
2/9 PCR Swab II +

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7
8/9 CXR cor dan pulmo tak tampak kelainan, tak tampak GGO
3/9 PCR Swab I +

24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab II +
9/9 Cr 0.9 , Na 140/K 3.3/Cl 98
9/9 PCR Swab III -

CXR : C/P DBN
24/8 PCR Swab I +
31/8 PCR swab II -
2/9 PCR swab III +
9/9 PCR swab IV -
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
31/8 PCR Swab I +

29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
9/9 PCR swab II +
9/9 Ro Thorax Pneumonia bacterial bilateral

CRP <2.5, Na/K/Cl 140/ 3.8/102
Thorax: dbn
Terapi
Becomzet 1x1 PO
Mucopect 3xC1 PO
Rhinos SR k/p
Becomzet 1x1 PO
Lapraz 1x30 mg PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Becomzet 1x1 PO
Liproqy 2x1
Becomzet 1x1 po
Tremenza 2xI PO k/p

Becomzet 1x1 PO
Polysilane 3x15 cc po ac* STOP
Becomzet 1x1 PO
Minosep garg 3x

Becomzet 1x1 PO
N-asetilsistein 3x200 mg po
Becomzet 1x1 PO

Becomzet 1x1 PO

Becomzet 1x1 PO
Minosep garg 3x
Prome syr 3xc1
Becomzet 1x1 PO
Mucopect 3xC1 PO
KSR 2x1 tab pc
BecomC 2x1 PO
Becomzet 1x1 PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO
IVFD : Nacl 0.9% + KCl 25meq 500cc/8jam
Diet lunak
Azitromicin 1x500 mg po (9/9) ( ACC 3 hari)
L Bio 3x2 sach PO
Imodium 3x2 tab
Trovensis 3x8 mg iv
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
Keterangan
FU hasil swab 9/9

10/9 GDS form + ACC +
DPL + GDS/3hari -> next 12/9 form (-) acc (+)
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop

*R/ stop 10/9

FU hasil swab 9/9

*Swab reguler
FU hasil swab 9/9
*Dexametason 3x0.75 sampai 7 hari --> tgl 12/9 dexametason 2x0.75


FU hasil swab 9/9

FU hasil swab 9/9

FU hasil swab 7/9
FU hasil swab 7/9

Belum ada obat kumur --> dr Taufan : belum perlu

GDS+DPL /3 hari -- next 12/9 form -

FU hasil swab 9/9, FU hasil Ro thorak evaluasi 9/9
Nacl 3% stop
*konfirmasi kak gebby apakah obat saraf boleh lanjut
*MENOLAK PEMASANGAN NGT
9/9 New diatab stop

10/9 Cek FL, Form +, JP +, ACC -
10 September 2020 P (Meri)

1 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM 1/9 Swab PCR + Becomzet 1x1 PO 5/9 lanso STOP, new diatab STOP
Kemkes TD: 2/9 Hb 15.7 Ht 44 L 6.4 Tc 260 LED 30 NLR 2.01 Hitung Jenis 1/0/59/3/31/6/3.96/1.97 GDS 81 Mucopect 3xC1 PO 8/9 hyloquin, oseltamivir, azitro stop
dr. Taufan Sp.P N: CXR: GGO halus paru dextra Minosep garg 3x/hari FU hasil swab 9/9
RR: Rhinos SR k/p
S: Ondancetron 2x8mg PO kp mual
Bakrie DMT2 TD: 28/8 Lab luar Hb 14,8 Ht 42 Leu 3,8 Tr 183 OT/PT 27/29 GDS lab luar 312. HbA1c 12 Lantus 1x36 unit SC malam 5/9 clonidine 1x0.15 mg, 2x0.15mg bila TD >140/90
dr. Taufan, Sp.P HT N: S Typhi O/H 1/160 paratyphi 1/80. EKG NSR Lapiva 1x10/160 mg PO malam 10/9 GDS pk. 18 form+ JP+
dr. Felix Sp.PD Dislipidemia RR: Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru Concor 1x 5 mg PO pagi 11/9 R/ PCR Swab form+ JP+ PE-
30/8 GDP: 143 GDS pk 18:199 Amaryl 1x4 mg PO pagi
1/9 PT/APTT 14.9/17.0 D-dimer <100 Kol. Total 143, TG 127, HDL 27, LDL Direk 95, As.Urat 6.2 GDS 18: 286 Januvia 1x 100mg PO pagi
2/9 GDP 123 GDS 18.00 226 Atorvastatin 1x20mg PO malam DPL + GDS/3hari -> next 12/9 form+ JP+
1/9 PCR swab II + Lapraz 1x30 mg PO
3/9 Hb/Ht/L/Tr 14.7/43/5.7/357 LED 30 Mono 10 GDS pk. 18: 163 HCT 25 mg 0-1-0 PO
6/9 Hb/Ht/L/Tr 13.7/38/6.2/318 LED 29 GDS: belum dicek Kombiglyze XR 5/500 1x1 PO (siang)
7/9 GDS 145 Probiostin 1xI PO
9/9 Hb/Ht/L/Tr 14.9/44/9.2/364 LED 35 NLR 2.45 diff 1/0/60/3/26/10 Clonidine 1x0,15 mg PO (siang)
9/9 PCR Swab III -
3 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case Kes CM 10/8 Hb/Ht/L/Tr 11.9/37/3.3/202 Widal S typhi H 1/320 Lansoprazole 1x30 mg PO *Febris sejak 6/8
Kemkes Pneumonia TD: 11/8 Hb/Ht/L/Tr 12.4/38/4/205 Rapid negatif Candesartan 1x4mg PO malam bila MAP <65 tunda co dr. Damba: candesartan 1x8mg, concor ganti bisoprolol 1x1.25mg, simvastatin 20mg malam, CPG 1x75mg
dr Felix Sp.PD Cephalgia N: Na/K/Cl 136/3.7/99, OT/PT 41/24; EKG SR 94x normoaxis ST elevasi - Bisoprolol 1x1,25mg PO pagi co dr. Angelina, Sp.N: cephalgia ec thypoid fever
dr. Taufan Sp.P HT HHD RR: CXR: kardiomegali + elongasi aorta; bronkopneumonia dupleks Clopidogrel 1x75mg PO 15/8 Ceftri stop
CAD S: 13/8 Hb/Ht/L/Tr 11.6/34/5.1/193 LED 70 NLR 8.31 Eo 1 Neu. Segmen 82 Limf 10 Atorvastatin 1x20 mg PO malam 16/8 Arixtra stop
Hiperuricemia PT/APTT 17.7/32.9 GDP 76 Kol Tot 149/TG101/HDL 34/LDL86 Allopurinol 1x100 mg PO (malam) 18/8 Azitro stop
Asam urat 6.2/Ur/Cr 35/1.2 Becomzet 1x1 PO 19/8 hyloquin, oseltamivir stop
14/8 d dimer 3552 Betadine garg 3x/ hari
12/8 PCR swab I + Liproqy 2x1 F/U hasil swab 9/9
16/8 D dimer 138 Cetirizine 1x10 mg PO
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL dan D-dimer /3 hari--> next 12/9, form+ acc+
19/8 PCR Swab II + ** Infokan ke dr. Taufan minta foto evaluasi sudah 1 bulan belum foto ulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
Bakrie TD: 25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252 Tremenza 2xI PO k/p 29/8 Oseltamivir hyloquin azithromycin STOP
dr. Taufan SpP N 1/9 PCR swab II + Minocef gargle 3x15cc
RR 9/9 PCR swab III persumtif Codipront syr 3x 1 C k/p
S
5 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case Kes: CM 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Hyloquin 1x400mg PO (5/9) *R/ stop 10/9
Kemkes TD 3/9 PCR swab I + Oseltamivir 2x75mg PO (5/9) 10/9 Swab PCR form+ PE+
dr. Taufan, Sp.P N 4/9 CXR: Cor pulmo dbn, tak tampak GGO Azitromycin 1x500mg PO (5/9)
R Becomzet 1x1 PO
6 30-Aug 1607 Tn. Sabam Frando/32 th COVID-19 confirmed case Kes 26/8 PCR Swab I + CXR C/P dbn Hb/Ht/L/Tr 14.2/41.8/4.7/255 Monosit 10 OT/PT 25/38 Becomzet 1x1 PO FU hasil swab 9/9
Wilmar TD Rapid Sars Cov2 - Codipront exp 3x cth I PO *Swab reguler
dr. Taufan Sp.P N 30/8 CXR Susp. Gambaran GGO di paru S atypical, kemungkinan viral pneumonia Covid 19 belum Ondancetron 2x8 mg PO
RR dapat disingkirkan Hb/Ht/L/Tr 14.6/42/5.7/237 LED 20 Eo 1 Limf 24 Mono 9 Sumagesik 2x500mg PO
S 2/9 PCR Swab II + Minosep garg 3x
7 19-Aug 1608 dr. Novie Hediyani/ 40th COVID-19 confirmed case Kes CM 18/8 Hb/Ht/L/Tr 13.1/39.1/3.8/192 Diff 0.3/2.6/35.6/53.9/7.6 , Widal Ty H 1/40, Para BH 1/20 O2 2 lpm via nasal canule k/p * Demam sejak 15/8, sudah konsumsi ciprofloxacin dan azitromisin 5 hari. Riw asma +
Kemkes Bronkitis akut TD: 19/8 CXR bronkopneumonia bilateral Sumagesik 3x500mg PO k/p ** R/ CXR ulang sebelum pulang setelah 2x swab negatif
dr. Taufan SpP N: 19/8 PCR Swab I + Codipront exp 3x cthI PO k/p 27/8 Hyloquin, Oseltamivir, Azitromycin STOP
RR: 26/8 PCR swab II + Lansoprazole 2x30mg PO 28/8 extra dexametasone 1 amp IV kp sesak (-), px menolak steroid, minta levofloxacin saja
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) FU hasil swab 9/9
2/9 PCR swab II + Salbutamol 2x1.5 mg po *Swab dikirim ke MIKRO UI
Becomzet 1x1 PO
Ventolin inhaler 3X1 puff *Dexametason 3x0.75 sampai 7 hari --> tgl 12/9 dexametason 2x0.75
8 8-Sep ODC 11 Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM 8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5 Oseltamivir 2x75mg (9/9) F/U hasil swab 10/9
Kemkes TD: CXR: bronchitis, tak tampak GGO. Hyloquine 1x400mg (9/9)
dr. Taufan SpP N: 4/9 PCR Swab I + Azitromycin 1x500mg (9/9)
RR: Becomzet 1x1 PO
S:
9 8-Sep ODC 11 Ny. Lisa Septiana/22 th Covid 19 Confirmed Case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Oseltamivir 2x75mg (10/9)
TD 8/9 CXR cor dan pulmo tak tampak kelainan, tak tampak GGO Hyloquine 1x400mg (10/9)
N 3/9 PCR Swab I + Azitromycin 1x500mg (10/9)
RR Becomzet 1x1 PO
S
10 8-Sep 1102 Nn. Windri/23 th COVID-19 confirmed case Kes CM 8/9 CXR: dextroscoliosis Oseltamivir 2x75mg (9/9) F/U hasil swab 10/9
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Hyloquine 1x400mg (9/9)
RR: Becomzet 1x1 PO
S: Minosep garg 3x
Prome syr 3xc1
Bakrie HT TD: CXR Cor dbn. Arcus aorta elongasi. Susp. Gambaran GGO halus di kedua paru (typical) kemungkinan Mucopect 3xC1 PO 8/9 12.00 TD 183/103 extra Captopril 12.5 mg
dr. Taufan Sp.P N: viral pneumonia/covid 19 belum dapat disingkirkan. PCR Swab I + Betadine garg 3 x/ hari 11/9 R/ PCR Swab Form+ JP+ PE-
co dr. Daniel Sp.PD RR: 1/9 PCR swab II + Exforge 1x10/160 mg PO
S: 9/9 EKG sinus rhythm KSR 2x1 tab pc
9/9 Cr 0.9 , Na 140/K 3.3/Cl 98
9/9 PCR Swab III -
12 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case Kes CM 21/8 Hb/Ht/L/Tr 13.1/39/3.2/175 diff 0/0/40/3/44/13 LED 17 NLR 0.96 BecomC 2x1 PO 26/8 Hyloqiun, Azitromycin, Oseltamivir STOP
Darma TD: CXR : C/P DBN Lansoprazole 2x30 mg PO
9/9 PCR swab IV -
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Minosep garg 3x/hari FU hasil swab 7/9
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi
RR: (atypical). Candesartan 1x8 mg PO malam
S: 31/8 PCR Swab II +
14 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO FU hasil swab 7/9
Bakrie HT TD 3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3 Becomzet 1x1 PO Belum ada obat kumur --> dr Taufan : belum perlu
dr. Taufan Sp.P Dislipidemia N 4/9 CXR: Cor dbn, Gambaran GGO di kedua paru/viral pneumonia covid 19 (typical) Amlodipin 1x5 mg PO
Asma terkontrol RR 5/9 koltot 106 TG 123 HDL 28 LDL 63 Candesartan 1x8 mg PO
Alergi Antalgin, Salisilat S Codipront syr 3x 1C
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Lapraz 1x30 mg PO 12/9 R/ PCR Swab Form+ JP+ PE-
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore)
dr Felix Sp. PD Riw. Dengue fever RR CXR : sup gambaran GGO di paru dextra (Atypical), kemungkinan vial pneumonia /Covid 19 Glimepiride 1x2 mg po
Co dr. Putri Sp.GK Hipertrigliserdemia S blm dapat disingkirkan Lantus 1x10 U
Dispepsia 30/8 Hb 15.6 Ht 46 Leu 3.6 Tr 117 eri 5.17 GDP 155 GD2PP 184 HbA1C 7.7 chol tot 100 TG 189 Amlodipin 1x 10 mg po
Asma terkontrol choles LDL hitung 39/direct 46 AU3.5 ur 24 cr 1.2 Ot/PT 66/51 Candesartan 1x 8 mg po
UL dbn Lesichol 1x300mg PO GDS+DPL /3 hari -- next 12/9 form+ JP+
31/8 Hb 14.9 Ht 43 Leuko 3.3 Trombo 107 Eritrosit 4,94 GDS 18:65 21:115 Fenofibrat 100mg 0-1-0 PO
1/9 Hb/HT/L/Tc/E 14.3/42/2.2/117/4.77 PT/APTT 15.2/31.8 D-Dimer <100, GDS 06: 85 18.00: 213 Vectrine 3x300 mg PO
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114 Codipront 3xcthI PO
4/9 GDS pk. 18: 122 Liproqy 1x1 PO
5/9 Hb 14.2 Ht 41 Leu 5.3 Tr 225 LED 45 NLR 3.54 , diff 1/0/68/3/20/8 , GDS 99 Probiostim 1x/seminggu
9/9 Hb 13.3 Ht 40 Leu 7.5 Tr 415 LED 60 NLR 2.91 , diff 5/1/57/3/21/13 , GDS 187 Kombiglyze XR 5/500 1x1 PO (siang)
5/9 PCR swab II + Cerini 1x10 mg PO malam
16 6-Aug ODC10 Ny. Nurhayati/ 63 th Obs febris (4/9) ec susp. Viral inf Kes : CM 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 adekuatm elevasi 30 derajat Co dr. Angel, Sp.N: BPPV + TTH
BPJS BBPV + TTH TD: 138/83 Rapid IgM&IgG sars cov-2 : Negatif Line I IVFD NaCl 0.9% 14 tpm Nacl 3% stop
dr. Felix Sp.PD HipoNaCl + HipoK N: 89 CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Line II IVFD : Nacl 0.9% + KCl 25meq 500cc/8jam 10/9 Ceftriaxone naik 2x2 gr IV. Cetirizine, drip ketorolac, betahistin, capsul racik, flunarizin STOP
Low intake RR: 16 7/9 UL: dalam batas normal Diet lunak R/ Cek PT, APTT, Anti HIV rapid, UL
Pneumonia S: 36,6 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Ceftriaxone 2x2 g IV (6/9) F/U hasil swab 9/9
Penkes Susp. Meningoensefa 9/9 Ro Thorax Pneumonia bacterial bilateral Omeprazole 2x20 mg PO
litis 10/9 GDS 119 N-acetylsistein 3x200 mg PO
Sucralfat syrp 3x1 cth DPL/3 hari --> next 12/9 form+ acc+
Mecobalamin 2x500mg PO *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Paracetamol 4x1gr IV *MENOLAK PEMASANGAN NGT
Asam Traneksamat3x500 mg IV
17 3-Sep 1206 Tn. Bambang Halim/24th GEA dehidrasi ringan - sedang Kes : CM 7/9 Hb/HT/L/Tc/E 16.5/47/5.7/195/5.03 Hitung Jenis 2/0/55/3/31/93.34/1.77 LED 6 NLR 1.89 IVFD RL 500 cc/6 jam 9/9 New diatab stop
AA TD Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25 Diet lambung3 bubur 1700 kal 10/9 Cek FL, Form+ JP+
dr. Daniel, Sp.PD N CRP <2.5, Na/K/Cl 140/ 3.8/102 Taxegram 3x1 g IV (8/9)
RR Thorax: dbn L Bio 3x2 sach PO
S 8/9 FL:kuning cair darah samar + Imodium 3x2 tab
Trovensis 3x8 mg iv k/p mual
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
Salofalk 3x500 mg PO
10 September 2020 M (Cylla)

Kemkes TD:
dr. Taufan Sp.P N:
RR:
S:

Bakrie DMT2 TD:
S:

CAD S:
Hiperuricemia
Bakrie TD:
dr. Taufan SpP N
RR
S

Kemkes TD
dr. Taufan, Sp.P N
R
S

Wilmar TD
dr. Taufan Sp.P N
RR
S
dr. Taufan SpP N:
RR:
S:
8 8-Sep ODC 11 Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM

Kemkes TD:
dr. Taufan SpP N:
RR:
S:
9 8-Sep ODC 11 Ny. Lisa Septiana/22 th Covid 19 Confirmed Case Kes : CM
TD
N
RR
S

Kemkes TD:
dr. Taufan SpP N:
RR:
S:

Bakrie HT TD:
dr. Taufan Sp.P N:
co dr. Daniel Sp.PD RR:
S:
12 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case

Darma
Henwa dr. Taufan Sp.P

Kemkes HT TD:
dr.Taufan Sp.P N:
RR:
S:

Bakrie HT TD
Asma terkontrol RR

Dispepsia
Asma terkontrol
Low intake RR: 16
Pneumonia S: 36,6
Penkes Susp. Meningoensefa
litis
AA Typhoid fever TD
dr. Daniel, Sp.PD susp Colitis N
RR
S
18 10-Sep 1003 Ny Sumanti Bong/ 55th Pro kranioplasty 11/9 Kes : CM

BPJS hipoK/Cl TD
dr. Adolf Sp.BS Leukositosis N
Co: dr. Felix, Sp.PD HT tdk terkontrol RR
Co: dr. Linda, Sp.An S
Co: dr. Damba, Sp.JP
Co: dr. Taufan Sp.P
Penunjang
1/9 Swab PCR +
26/8 PCR swab I +

29/8 GDP 198 2PP 347, GDS 18.00 221
30/8 GDP: 143 GDS pk 18:199
31/8 GDP 189
2/9 GDP 123 GDS 18.00 226
1/9 PCR swab II +
7/9 GDS 145
9/9 PCR Swab III -
10/9 GDS 155
14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
3/9 PCR swab I +
Rapid Sars Cov2 -
2/9 PCR Swab II +

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
4/9 PCR Swab I +
3/9 PCR Swab I +

3/9 PCR Swab I +
24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

1/9 PCR swab II +
9/9 Cr 0.9 , Na 140/K 3.3/Cl 98
9/9 PCR Swab III -
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
31/8 PCR Swab I +

29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
5/9 PCR swab II +
6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87

9/9 Ro Thorax Pneumonia bacterial bilateral
10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+

CRP <2.5, Na/K/Cl 140/ 3.8/102
Thorax: dbn
10/9 FL: cokelat tua cair; darah samar+ jamur+
24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine
ke kiri 1.5cm+ edema cerebi ec metastasis
4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis
10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12
Na/K/Cl 139/2.75/92
Terapi
Becomzet 1x1 PO
Mucopect 3xC1 PO
Rhinos SR k/p
Becomzet 1x1 PO
Lapraz 1x30 mg PO
HCT 25 mg 0-1-0 PO
Probiostin 1xI PO
Becomzet 1x1 PO
Liproqy 2x1
Becomzet 1x1 po
Tremenza 2xI PO k/p

Becomzet 1x1 PO
Becomzet 1x1 PO
Minosep garg 3x

Becomzet 1x1 PO
Dexamethason 3x0.75mg PO (5/9)
Becomzet 1x1 PO

Becomzet 1x1 PO

Becomzet 1x1 PO
Minosep garg 3x
Prome syr 3xc1
Becomzet 1x1 PO
Mucopect 3xC1 PO
KSR 2x1 tab pc
PULANG
Becomzet 1x1 PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO
O2 adekuatm elevasi 30 derajat

Line I IVFD NaCl 0.9% 14 tpm
Line II IVFD : Nacl 0.9% + KCl 25meq 500cc/8jam
Total 2500cc/24jam
Diet cair 6x100cc
L Bio 3x2 sach PO
Imodium 3x2 tab
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
Diflucan caps 1x150mg
Venflon
Keterangan
FU hasil swab 9/9

11/9 R/ PCR Swab form+ JP+ PE-
DPL + GDS/3hari -> next 12/9 form+ JP+
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
F/U hasil swab 9/9
DPL dan D-dimer /3 hari--> next 12/9, form+ acc+

16/9 R/ swab ulang, form +, JP +
*R/ stop 10/9

FU hasil swab 10/9
FU hasil swab 9/9

*Swab reguler
FU hasil swab 9/9

*Dexametason 3x0.75 sampai 7 hari --> tgl 12/9 dexametason 2x0.75 (KONFIRMASI ULANG KE DR. TAUFAN SAAT VISITE)
F/U hasil swab 10/9
11/9 R/ swab ulang, form+, PE+

F/U hasil swab 10/9

11/9 R/ PCR Swab Form+ JP+ PE-

FU hasil swab 7/9
FU hasil swab 7/9

12/9 R/ PCR Swab Form+ JP+ PE-
GDS+DPL /3 hari -- next 12/9 form+ JP+

Nacl 3% stop
10/9 Ceftriaxone naik 2x2 gr IV. Cetirizine, drip ketorolac, betahistin, capsul racik, flunarizin STOP
*Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
F/U hasil swab 9/9, rencana konsul paru jk sudah ada hasil swab
FU hasil elektrolit 11/9
DPL/3 hari --> next 14/9 form+ acc+ (terakhir)
9/9 New diatab stop
Co dr Linda: pro co ipd, cek DPL PT/APTT elektrolit ur/cr ot/pt faal tiroid --> tolong infokan ke beliau hasil lab, hasil konsul, jam
Co dr Felix: koreksi kalium RL+KCL 25meq/8jam, KSR 3x1, Ceftriaxone 1x2g, tunggu faal tiroid (IPD Toleransi sedang)
Ramipril 10mg malam (sudah masuk), jk TD >140/90 pro Amlodipin 10mg pagi ini
Co dr Taufan: beliau tdk bs dtg pagi ke MTSJ, tidak ada advis --> FU lg ke DPJP/ anestesi
Co dr Damba: belum ada balasan
dr Adolf sudah terinfo hasil lab & usul IPD (belum ada balasan), tanya kebutuhan ICU -> info ke dr. Hendri Sp.An-KIC
FU hasil faal tiroid T3 T4 TSH
* darah sudah ada 1 bag di lab +/- 216cc
11 September 2020 M (Siska)

1 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM 1/9 Swab PCR + Becomzet 1x1 PO 5/9 lanso STOP, new diatab STOP
RR: Rhinos SR k/p
dr. Taufan, Sp.P HT N: S Typhi O/H 1/160 paratyphi 1/80. EKG NSR Lapiva 1x10/160 mg PO malam FU swab 11/9
dr. Felix Sp.PD Dislipidemia RR: Lab RSMT Hb 14,9 Ht 43 Leu 4,8 Tr 214 GDS 251 ur/cr 37/0,9 CXR: GGO kedua paru Concor 1x 5 mg PO pagi
9/9 Hb/Ht/L/Tr 14.9/44/9.2/364 LED 35 NLR 2.45 diff 1/0/60/3/26/10 Clonidine 1x0,15 mg PO (siang)
9/9 PCR Swab III -
10/9 GDS 155
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL dan D-dimer /3 hari--> next 12/9, form+ acc+
** Infokan ke dr. Taufan minta foto evaluasi sudah 1 bulan belum foto ulang --> dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat
19/8 PCR Swab II + pulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
dr. Taufan SpP N 1/9 PCR swab II + Minocef gargle 3x15cc 16/9 R/ swab ulang, form +, JP +
RR 9/9 PCR swab III persumtif 11/9 dr. Taufan Sp.P Codipront syr --> STOP
S
Kemkes TD 3/9 PCR swab I + Oseltamivir 2x75mg PO (5/9) FU hasil swab 10/9
R Becomzet 1x1 PO
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) 16/9 R/ swab ulang, form +, JP +
9/9 PCR swab III + Teofilin 2x100 mg po 11/09 dr. Taufan Sp.P --> Dexametason tapp off jadi 2x0.75 dan Ventolin inhaler 3x2 puff
Becomzet 1x1 PO
RR: Becomzet 1x1 PO
S:
9 8-Sep ODC 11 Ny. Lisa Septiana/22 th Covid 19 Confirmed Case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Oseltamivir 2x75mg (10/9) F/U hasil swab 11/9
RR Becomzet 1x1 PO
S
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Hyloquine 1x400mg (9/9) 11/9 dr. Taufan Sp.P tambah polysilan 3x1cth
RR: Becomzet 1x1 PO
S: Minosep garg 3x
Polisilan 3x1 cth
Prome syr 3xc1
dr. Taufan Sp.P N: viral pneumonia/covid 19 belum dapat disingkirkan. PCR Swab I + Betadine garg 3 x/ hari F/U hasil swab 11/9
co dr. Daniel Sp.PD RR: 1/9 PCR swab II + Exforge 1x10/160 mg PO 11/9 dr. Daniel Sp.PD --> Alprazolam 1x0.5mg
9/9 Cr 0.9 , Na 140/K 3.3/Cl 98 Alprazolam 1x0.5mg
9/9 PCR Swab III -
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Minosep garg 3x/hari FU hasil swab 7/9
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi 11/9 nyeri uuhati --> ekstra omeprazole 40mg po belum lap dr Taufan
13 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 14/9 --> Rencana swab selanjutnya form (+) acc(+)
Bakrie HT TD 3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3 Becomzet 1x1 PO 11/9 dr. Taufan Sp.P --> N-asetilsistein 3x200mg
Alergi Antalgin, Salisilat S 7/9 PCR Swab II presumtif Codipront syr 3x 1C
HP pro 3x1 tab PO
N-asetil sistein 3x200mg
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore) FU EKG ? -- Lapor dr Felix SpPD -- saran Bisoprolol 2.5 mg 1/2-0-0 -- dr taufan --> acc
11/9 EKG Sinus Takikardia Minosep gargle 3x15cc
Bisoprolol 1.25mg-0-0
15 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis Kes : CM 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 adekuatm elevasi 30 derajat Co dr. Angel, Sp.N: BPPV + TTH
BPJS dd infeksi SSP dd CVD TD: 138/83 Rapid IgM&IgG sars cov-2 : Negatif Line I IVFD NaCl 0.9% 14 tpm Nacl 3% stop
Low intake RR: 16 7/9 UL: dalam batas normal Total 2500cc/24jam *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Pneumonia S: 36,6 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Diet cair 6x100cc F/U hasil swab 9/9, rencana konsul paru jk sudah ada hasil swab
Anemia chronic disease 9/9 Ro Thorax Pneumonia bacterial bilateral Ceftriaxone 2x2 g IV (6/9) 11/9 Omeprazole IV tidak acc BPJS --> ganti oral
Sistitis 10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1 Omeprazole 2x40 mg PO
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO DPL/3 hari, Na K CL / 2 hari --> next 13/9 form+ acc+ (terakhir)
10/9 Na/K/Cl 134/3.1/97 Sucralfat syrp 3x1 cth
Mecobalamin 2x500mg PO dr Felix SPPD : kultur darah urin + te sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau rujuk RS lain
Azitromicin 1x500 mg po (9/9) ( ACC 3 hari) - 5 hari dr Angel N : Pro MRI kepala + kontras , saran rawat ICU /rujuk
Paracetamol 3x1000mg PO Follow up keluarga pasien, rencana APS (dr. Felix Sp.PD dan dr. Angel Sp.S belum terinfo)
KSR 3x1 tab po
Loading dexametason 2 amp IV
lanjut dexametason 4x1 amp iv (12/9 3x1 amp iv)
Amlodipin 10 mg 1-0-0
AA Typhoid fever TD Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25 Diet lambung3 bubur 1700 kal
dr. Daniel, Sp.PD susp Colitis N CRP <2.5, Na/K/Cl 140/ 3.8/102 Taxegram 3x1 g IV (8/9)
10/9 FL: cokelat tua cair; darah samar+ jamur+ Pumpicell 2x40 mg iv
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
11/9 Hb 15.5/Ht 46/ Leu 4.9/ Tr 220/ Eri 5.32 / Pt 14.6 / Aptt 35.4/ Ur 27/Cr 1.1/ SGOT 33 / SGPT 45 / Na 143/ K 3.8 Cl IVFD : RL 500cc 24 tpm
17 11-Sep 1002 Tn. Muhammad Farhan Pranata Appendisitis kronis eksaserbasi akut Kes : CM 103
BPJS post apendiktomi H-1 TD 11/9 Rapid IgG dan IgM covid-19 negatif Ceftriaxone 2x1 gr
dr. Ade Sp.B N 28/8 Swab negatif Ranitidin 2x1 amp
RR Ketorolac 3x1 amp
S As Traneksamat 2x1 amp
18 10-Sep 1003 Ny Sumanti Bong/ 55th Pro kranioplasty 11/9 Kes : CM 24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine Venflon Co dr Linda: ACC operasi
BPJS hipoK hipo Cl TD ke kiri 1.5cm+ edema cerebi ec metastasis RL+KCL 25meq/8jam Co dr Felix: koreksi kalium RL+KCL 25meq/8jam, KSR 3x1, Ceftriaxone 1x2g, amlodipin 1x10 mg pagi, ramipril 1x10 mg malam,
leukositosis ec bacterial dd KSR 3x2 tab po cek DPL / 3 hari, Na K CL /2 hari (BPJS acc DR saja 1x), kultur dahak dan CT thorax evaluasi ( BPJS tdk ACC) dr Adolf ?,
dr. Adolf Sp.BS pneumonia dd ISPA N 4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis Omeprazole 2x20 mg PO target TD < 140/90, target K >3.5, asetilsistein 3x200 mg po ,
Co: dr. Felix, Sp.PD HT gr II , malnutrition RR 10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12 Acetilsistein 3x200 mg po Co dr Taufan: beliau tdk bs dtg pagi ke MTSJ, tidak ada advis --> FU lg ke DPJP/ anestesi
Co: dr. Linda, Sp.An riw Ca mamae S Na/K/Cl 139/2.75/92 Ceftriaxone 1x2g IV (saat sebelum insisi) Co dr Damba: Amlodipin 10 mg pagi, ramipril 10 mg malam, koreksi kalium sesuai TS IPD, tolop sedang jika TD <140/90
Co: dr. Damba, Sp.JP riw pasca tiroidektomi 11/9 Ca Total 4.4 Na 140 K 3,3 Cl 98 Ca glukonas 3x1 amp IV dr Adolf sudah terinfo hasil lab & usul IPD
11/9 dr. Adolf Sp.BS instruksi post op : IVFD Nacl 2000cc/24 jam, Ceftriaxone 1x2gr, Ketorolac 2x1 amp, Omeprazole 2x1 amp, Kalnec 3x1amp, Vit
Co: dr. Taufan Sp.P T3 94, T4 3.79 TSH 2.05 diet rendah garam III, tinggi kalium K 3x1 amp, Phenitoin 3x100 saat SOAP perhatikan GCS dan pupil
* darah hanya ada 1 bag di lab +/- 216cc -- dr Adolf Sp. BS terinfo
19 6-Sep 1006 David Jaya Putra/ 29th Riw Febris + ISPA Kes CM 6/9 HB/HT/L/TC/ 14.6/43/7.1/213 LED 70 NLR 5 Rapid Test (-) Dexamethason 2x0.75mg PO (12/9) 6/9 BAB cair 1x
Wilmar Tonsilofaringitis kronik eks akut TD CXR: cor dbn arkus aorta elongasi. GGO di kedua lap paru (typical) Nacetylsistein 3x200mg PO 11/9 dr. Taufan Sp.P : rencana ro thorax ulang (12/9) form (+) JP (+), Dexametason 2x0.75 mg PO, mucopect ganti codiproont, PCT stop
dr. Taufan Sp.P N 7/9 Swab : Negatif Codipront 3x1c (12/9)
RR Levofloxacin 1x500mg PO (6/9)
S
12 September 2020 P(Ebel)

1 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case Kes CM 1/9 Swab I PCR + Becomzet 1x1 PO 5/9 lanso STOP, new diatab STOP
RR: 9/9 Swab II PCR - Rhinos SR k/p
9/9 Hb/Ht/L/Tr 14.9/44/9.2/364 LED 35 NLR 2.45 diff 1/0/60/3/26/10 Clonidine(Catapress) 1x0,15 mg PO (siang)
9/9 PCR Swab III -
10/9 GDS 155
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL /4 hari--> next 16/9
** Infokan ke dr. Taufan minta foto evaluasi sudah 1 bulan belum foto ulang --> dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat
19/8 PCR Swab II + pulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
12/99/9 Hb/Ht/L/Tr 11/33/6.1/285 LED 60 NLR 2.72 diff 4//62/3/24/7 d-Dimer 354
9/9 PCR Swab V -
dr. Taufan SpP N 1/9 PCR swab II + Minocef gargle 3x15cc 16/9 R/ swab ulang, form +, JP +
RR 9/9 PCR swab III persumtif 11/9 dr. Taufan Sp.P Codipront syr --> STOP
S 12/9 extra Microlax
R Becomzet 1x1 PO
9/9 PCR Swab III -
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) 16/9 R/ swab ulang, form +, JP +
9/9 PCR swab III + Teofilin 2x100 mg po 11/09 dr. Taufan Sp.P --> Dexametason tapp off jadi 2x0.75 dan Ventolin inhaler 3x2 puff
Becomzet 1x1 PO
RR: Becomzet 1x1 PO
S:
9 8-Sep ODC 11 Ny. Lisa Septiana/22 th Covid 19 Confirmed Case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Oseltamivir 2x75mg (10/9) F/U hasil swab 11/9
RR Becomzet 1x1 PO
S
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Hyloquine 1x400mg (9/9) 11/9 dr. Taufan Sp.P tambah polysilan 3x1cth
RR: Becomzet 1x1 PO
S: Minosep garg 3x
Polisilan 3x1 cth
Prome syr 3xc1
co dr. Daniel Sp.PD RR: 1/9 PCR swab II + Exforge 1x10/160 mg PO 11/9 dr. Daniel Sp.PD --> Alprazolam 1x0.5mg
9/9 PCR Swab III -
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Minosep garg 3x/hari r/ swab 14/9 form + Pe+
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi 11/9 nyeri uuhati --> ekstra omeprazole 40mg po belum lap dr Taufan
7/9 PCR Swab III -
13 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 14/9 --> Rencana swab selanjutnya form (+) acc(+)
Bakrie HT TD 3/9 Hb/Ht/L/Tr 15.4/45/3.4/126 LED 26 Mono 15 OT/PT 181/78 Ur/Cr 23/0.7 Asam urat 5.3 Becomzet 1x1 PO
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore) FU EKG ? -- Lapor dr Felix SpPD -- saran Bisoprolol 2.5 mg 1/2-0-0 -- dr taufan --> acc
12/9 Hb 14.3 Ht 43 Leu 5.7 Tr 484 LED 95 NLR 1.46 , diff 6/1/45/3/33/12 Bisoprolol 1.25mg-0-0
15 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis Kes : CM 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 adekuatm elevasi 30 derajat Co dr. Angel, Sp.N: BPPV + TTH
Low intake RR: 16 7/9 UL: dalam batas normal Total 2500cc/24jam *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Pneumonia S: 36,6 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Diet cair 6x100cc F/U hasil swab 9/9, rencana konsul paru jk sudah ada hasil swab
Anemia chronic disease 9/9 Ro Thorax Pneumonia bacterial bilateral Ceftriaxone 2x2 g IV (6/9) 11/9 Omeprazole IV tidak acc BPJS --> ganti oral
Sistitis 10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1 Omeprazole 2x40 mg PO
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO DPL/3 hari, Na K CL / 2 hari --> next 13/9 form+ acc+ (terakhir)
Mecobalamin 2x500mg PO dr Felix SPPD : kultur darah urin + te sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau rujuk RS lain
Paracetamol 3x1000mg PO Follow up keluarga pasien, rencana APS (dr. Felix Sp.PD dan dr. Angel Sp.S belum terinfo)
KSR 3x1 tab po
Loading dexametason 2 amp IV
lanjut dexametason 4x1 amp iv (12/9 3x1 amp iv)
Amlodipin 10 mg 1-0-0
AA Typhoid fever TD Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25 Diet lambung3 bubur 1700 kal
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
11/9 Hb 15.5/Ht 46/ Leu 4.9/ Tr 220/ Eri 5.32 / Pt 14.6 / Aptt 35.4/ Ur 27/Cr 1.1/ SGOT 33 / SGPT 45 / Na 143/ K 3.8 Cl IVFD : RL 500cc 24 tpm
17 11-Sep 1002 Tn. Muhammad Farhan Pranata Appendisitis kronis eksaserbasi akut Kes : CM 103
BPJS post apendiktomi H-1 TD 11/9 Rapid IgG dan IgM covid-19 negatif Ceftriaxone 2x1 gr
dr. Ade Sp.B N 28/8 Swab negatif Ranitidin 2x1 amp
RR Ketorolac 3x1 amp
18 10-Sep 1003 Ny Sumanti Bong/ 55th Pro kranioplasty 11/9 Kes : CM 24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine Venflon Co dr Linda: ACC operasi
BPJS hipoK hipo Cl TD ke kiri 1.5cm+ edema cerebi ec metastasis RL+KCL 25meq/8jam Co dr Felix: koreksi kalium RL+KCL 25meq/8jam, KSR 3x1, Ceftriaxone 1x2g, amlodipin 1x10 mg pagi, ramipril 1x10 mg malam,
leukositosis ec bacterial dd KSR 3x2 tab po cek DPL / 3 hari, Na K CL /2 hari (BPJS acc DR saja 1x), kultur dahak dan CT thorax evaluasi ( BPJS tdk ACC) dr Adolf ?,
dr. Adolf Sp.BS pneumonia dd ISPA N 4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis Omeprazole 2x20 mg PO target TD < 140/90, target K >3.5, asetilsistein 3x200 mg po ,
Co: dr. Felix, Sp.PD HT gr II , malnutrition RR 10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12 Acetilsistein 3x200 mg po Co dr Taufan: beliau tdk bs dtg pagi ke MTSJ, tidak ada advis --> FU lg ke DPJP/ anestesi
Co: dr. Linda, Sp.An riw Ca mamae S Na/K/Cl 139/2.75/92 Ceftriaxone 1x2g IV (saat sebelum insisi) Co dr Damba: Amlodipin 10 mg pagi, ramipril 10 mg malam, koreksi kalium sesuai TS IPD, tolop sedang jika TD <140/90
Co: dr. Damba, Sp.JP riw pasca tiroidektomi 11/9 Ca Total 4.4 Na 140 K 3,3 Cl 98 Ca glukonas 3x1 amp IV dr Adolf sudah terinfo hasil lab & usul IPD
11/9 dr. Adolf Sp.BS instruksi post op : IVFD Nacl 2000cc/24 jam, Ceftriaxone 1x2gr, Ketorolac 2x1 amp, Omeprazole 2x1 amp, Kalnec 3x1amp, Vit
Co: dr. Taufan Sp.P T3 94, T4 3.79 TSH 2.05 diet rendah garam III, tinggi kalium K 3x1 amp, Phenitoin 3x100 saat SOAP perhatikan GCS dan pupil
19 6-Sep 1006 David Jaya Putra/ 29th Riw Febris + ISPA Kes CM 6/9 HB/HT/L/TC/ 14.6/43/7.1/213 LED 70 NLR 5 Rapid Test (-) Dexamethason 2x0.75mg PO (12/9) 6/9 BAB cair 1x
Wilmar Tonsilofaringitis kronik eks akut TD CXR: cor dbn arkus aorta elongasi. GGO di kedua lap paru (typical) Nacetylsistein 3x200mg PO 11/9 dr. Taufan Sp.P : rencana ro thorax ulang (12/9) form (+) JP (+), Dexametason 2x0.75 mg PO, mucopect ganti codiproont, PCT stop
dr. Taufan Sp.P N 7/9 Swab : Negatif Codipront 3x1c (12/9)
RR Levofloxacin 1x500mg PO (6/9)
S
20 12-Sep 1002 Herman Sitepu/24 th pro radikal mastoidectomy s Kes CM 10/9 Hb 17/Ht 50/ Leu 8.5/ Tr 212/ Eri 5.57 / Ur 27/Cr 0.9/ OT/PT 21/22
TD
dr. Robert SpTHT N
RR
S
21 12-Sep 1204 Monika Siska /32 pro BA Kes CM 10/9 Hb 14.5/Ht 42/ Leu 5.5/ Tr 416/ Eri 4.39 / Ur 17/Cr 0.8/ OT/PT 19/10
TD
dr. Irawan SpBP N
RR
S
12 September 2020 M (Safira)

1 8-Sep Pres Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM 8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5 Oseltamivir 2x75mg (9/9) FU instruksi dr Taufan Sp.P
dr. Taufan Sp.P N: 4/9 PCR Swab I + Azitromycin 1x500mg (9/9)
RR: 10/9 PCR Swab II - Becomzet 1x1 PO
S:
2 8-Sep Pres Nn. Lisa Septiana/22 th Covid 19 Confirmed Case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Oseltamivir 2x75mg (10/9) F/U hasil swab 11/9
Kemkes TD 8/9 CXR cor dan pulmo tak tampak kelainan, tak tampak GGO Hyloquine 1x400mg (10/9)
dr. Taufan Sp.P N 3/9 PCR Swab I + Azitromycin 1x500mg (10/9)
RR Becomzet 1x1 PO
S
3 12-Sep Pres Nn Debby/23 th Covid 19 Confirmed Case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) R/ PCR Swab 16/9
TD 12/9 Hb 12.7/Ht 38/L 5.5/Tr 241 LED 16 Diff 2/0/52/3/35/8 Hyloquine 1x400mg (12/9)
Kemkes dr Taufan Sp.P N CXR: Cor dan pulmo dbn Azitromycin 1x500mg (12/9)
RR Becomzet 1x1 PO
S
4 8-Sep Executive Nn. Windri/23 th COVID-19 confirmed case Kes CM 8/9 CXR: dextroscoliosis Oseltamivir 2x75mg (9/9) FU instruksi dr Taufan Sp.P
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Hyloquine 1x400mg (9/9)
S: Minosep garg 3x15cc
Polisilan 3x1 cth
Prome syr 3xc1
5 12-Sep Executive Tn Junardi/ 31 th Covid 19 Confirmed Case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) R/ PCR Swab 16/9
TD: 12/9 Hb 14.2/Ht 43/L 4.8/Tr 225 LED 20 Diff 5/0/45/3/37/10 Hyloquine 1x400mg (12/9)
Kemkes dr Taufan Sp.P N: Azitromycin 1x500mg (12/9)
RR: Becomzet 1x1 PO
Minocep gargle 3x/hari
S: Mucopect syr 3xCI
6 12-Sep Executive Tn Dedi Gunawan/ 41 th Covid 19 Confirmed Case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) R/ PCR Swab 16/9
HT TD: 12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10 Hyloquine 1x400mg (12/9)
RR: Becomzet 1x1 PO
S: Ramipril 1x5mg PO
Amlodipin 1x5mg PO
7 12-Sep Executive Tn M Eggy/33 th Covid 19 Confirmed Case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) R/ PCR Swab 16/9
RR: Becomzet 1x1 PO
2/9 GDP 123 GDS 18.00 226 Atorvastatin 1x20mg PO malam DPL + GDS/3hari -> next 15/9 form -
1/9 PCR swab II + Lapraz 1x30 mg PO *Bila TD>140/90 Clonidin 2x0.15 mg PO
9/9 PCR Swab III -
10/9 GDS 155
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL /4 hari--> next 16/9
19/8 PCR Swab II + ** Infokan ke dr. Taufan minta foto evaluasi sudah 1 bulan belum foto ulang --> dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti
25/8 Hb/Ht/L/Tr 11.3/33/7/409 LED 50 NLR 2.88 Diff 1/1/62/3/23/10 saja saat pulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
dr. Taufan SpP N 1/9 PCR swab II + Minocef gargle 3x15cc 11/9 dr. Taufan Sp.P Codipront syr --> STOP
RR 9/9 PCR swab III persumtif 12/9 extra Microlax
S 16/9 R/ swab ulang, form +, JP +
R Becomzet 1x1 PO
9/9 PCR Swab III -
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum)
2/9 PCR swab II + Salbutamol 2x1.5 mg po
9/9 PCR swab III + Teofilin 2x100 mg po
Becomzet 1x1 PO 16/9 R/ swab ulang, form +, JP +
9/9 PCR Swab III -
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Minosep garg 3x/hari 11/9 ekstra omeprazole 40mg po
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi
S: 31/8 PCR Swab II + R/ swab 14/9 form + Pe+
7/9 PCR Swab III -
16 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO R/ PCR Swab 14/7
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Lapraz 1x30 mg PO FU PCR Swab 12/9
UL dbn Lesichol 1x300mg PO GDS+DPL /3 hari -- next 15/9 form -
18 12-Sep 1204 Monika Siska /32 th Post Breast Augmentation (12/9) Kes CM 10/9 Hb 14.5/Ht 42/ Leu 5.5/ Tr 416/ Eri 4.39 / Ur 17/Cr 0.8/ OT/PT 19/10 Ceftriaxon 1x1gr IV (1x sebelum pulang) 13/9 R/ BLPL TUTD
TD Ketorolac 30mg IV kp nyeri
Pribadi dr. Irawan SpBP N Ondancentron 8mg IV kp mual
RR Duragesic
S
AA Typhoid fever TD Widal: negatif, Rapid negatif, GDS 82, Cr 0.9, OT/PT 26/25 Diet lambung3 bubur 1700 kal 13/9 R/ BLPL TUTD Resume + Resep + Surat kontrol +
Sanmol 3x1 g iv prn
Episan syr 4xC1 PO
Buscopan 3x1amp IV
20 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis E4M5V3 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 adekuatm elevasi 30 derajat Co dr. Angel, Sp.N: BPPV + TTH
dr. Felix Sp.PD HipoNaCl + HipoK N: CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Line II IVFD : Nacl 3% 500cc/24 jam 10/9 Ceftriaxone naik 2x2 gr IV. Cetirizine, drip ketorolac, betahistin, capsul racik, flunarizin STOP
dr. Angel Sp.N Low intake RR: 7/9 UL: dalam batas normal Total 2500cc/24jam *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Pneumonia S: 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Diet cair 6x100cc perNGT 11/9 Omeprazole IV tidak acc BPJS --> ganti oral
Anemia chronic disease 9/9 Ro Thorax Pneumonia bacterial bilateral, PCR Swab - Ceftriaxone 2x2 g IV (6/9) 12/9 KSR dan KCl STOP
Sistitis 10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1 Omeprazole 2x20 mg PO 13/9 Cek DR Na K Cl
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO 13/9 As tranexamat STOP bila tidak hematuria
12/9 pH 7.5/pCO2 28/pO2 130/HCO3 21/tCO2 22/Actual BE -1/Standar BE 3/Sat 100 Mg ion 0.35 Ca ion 0.66 Ondancetron 8 mg IV K/P muntah DPL/3 hari, Na K CL / 2 hari --> next 13/9 form+ acc+ (terakhir)
As laktat 1.0 Na 124/K 5.1/Cl 93 Mecobalamin 2x500mg PO dr Felix SpPD : kultur darah urin + tes sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau rujuk RS lain
Ca gluconas 3x1fls
Dexametason tapp off 3x1amp IV -> 13/9 2x1amp
Amlodipin 10 mg 1-0-0 PO
MgSo4 20% 3 cc + aquades 7cc bolus IV pelan
sisanya drip dlm NaCL 100cc habis dlm 1 jam (2 hari)
21 11-Sep 1002 Tn. Muhammad Farhan Pranata Post Appendectomy (11/9) Kes : CM 11/9 Hb 15.5/Ht 46/ Leu 4.9/ Tr 220/ Eri 5.32 / Pt 14.6 / Aptt 35.4/ Ur 27/Cr 1.1/ SGOT 33 / SGPT 45 / Na 143/ K 3.8 IVFD : RL 500cc 24 tpm 13/9 R/ BLPL TUTD
BPJS TD Cl 103 Ceftriaxone 2x1 gr
dr. Ade Sp.B N 11/9 Rapid IgG dan IgM covid-19 negatif Ranitidin 2x1 amp
RR 28/8 Swab negatif Ketorolac 3x1 amp
22 12-Sep 1002 Herman Sitepu/24 th Post Radical Mastoidectomy S (12/9) Kes CM 10/9 Hb 17/Ht 50/ Leu 8.5/ Tr 212/ Eri 5.57 / Ur 27/Cr 0.9/ OT/PT 21/22 IVFD RL 500cc/12 jam Telinga jangan kemasukan air, ganti verban bila kassa rembes darah
TD Ceftriaxon 1x2gr IV (12/9)
BPJS dr. Robert SpTHT N As tranexamat 3x500mg IV
RR Dexametason 2x5mg IV
S Ranitidin 2x1 amp
Ketorolac 3x30mg IV
23 10-Sep 1003 Ny Sumanti Bong/ 55th Post kranioplasty 11/9 Kes : CM 24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine Venflon 11/9 dr. Adolf Sp.BS instruksi post op: saat SOAP perhatikan GCS dan pupil, bila Hb<10 transfusi PRC
BPJS hipoK hipo Cl TD ke kiri 1.5cm+ edema cerebi ec metastasis IVFD Nacl 0.9% 2000cc/24 jam 13/9 Rencana GV, cek DR Na K Cl
dr. Adolf Sp.BS leukositosis ec bacterial dd N 4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis KSR 3x2 tab po 16/9 R/ BLPL bila ku baik
Co: dr. Felix, Sp.PD pneumonia dd ISPA RR 10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12 Omeprazole 2x40mg IV
Co: dr. Linda, Sp.An HT gr II , malnutrition S Na/K/Cl 139/2.75/92 Acetilsistein 3x200 mg po
Co: dr. Damba, Sp.JP riw Ca mamae 11/9 Ca Total 4.4 Na 140 K 3,3 Cl 98 T3 94, T4 3.79 TSH 2.05 Ceftriaxone 1x2g IV (11/9)
Co: dr. Taufan Sp.P riw pasca tiroidektomi Ca glukonas 3x1 amp IV
Ketorolac 2x30mg IV Cek DPL/3 hari, Na K Cl/2 hari (BPJS acc DR dan elekrolit 1x) -> next 13/9
As tranexamat 3x500mg IV *dr Felix Sp.PD saran CT Thorax untuk evaluasi, BPJS tdk acc, JP pribadi +
Vit K 3x1amp IV
Phenitoin 3x100mg IV
Amlodipin 1x10mg PO pagi
Ramipril 1x10mg PO malam
diet rendah garam III, tinggi kalium
24 6-Sep 1006 David Jaya Putra/ 29th Riw Febris + ISPA
Wilmar Tonsilofaringitis kronik eks akut
dr. Taufan Sp.P PULANG
13 September 2020 Pagi (Lauretta)

1 8-Sep Pres Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM 8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5 Oseltamivir 2x75mg (9/9) FU instruksi dr Taufan Sp.P
S:
2 8-Sep Pres Nn. Lisa Septiana/22 th COVID-19 confirmed case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Oseltamivir 2x75mg (10/9) F/U hasil swab 11/9
RR Becomzet 1x1 PO
S
3 12-Sep Pres Nn. Debby/23 th COVID-19 confirmed case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR Becomzet 1x1 PO
S
4 13-Sep Executive Ny. Destina/ COVID-19 confirmed case Kes CM Oseltamivir 2x75mg (13/9) 14/9 R/ swab PCR ulang, form +, PE +
Kemkes TD: Hyloquine 1x400mg (13/9)
dr. Taufan, Sp.P N: Azitromycin 1x500mg (13/9)
RR: Becomzet 1x1 PO
S: Paracetamol 3x500 mg PO
Mucopect 3xCI
5 8-Sep Executive Nn. Windri/23 th COVID-19 confirmed case Kes CM 8/9 CXR: dextroscoliosis Becomzet 1x1 PO 13/9 Triple therapy hari terakhir lalu stop
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Minosep garg 3x15cc FU instruksi dr Taufan Sp.P
dr. Taufan SpP N: 3/9 PCR Swab I + Polisilan 3x1 cth
RR: 10/9 PCR Swab II - Prome syr 3xc1
S:
6 12-Sep Executive Tn. Junardi/ 31 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
Mucopect syr 3xCI
S:
7 12-Sep Executive Tn. Dedi Gunawan/ 41 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
Amlodipin 1x5mg PO
8 12-Sep Executive Tn. M Eggy/33 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) R/ PCR Swab 16/9
RR: Becomzet 1x1 PO
dr. Taufan, Sp.P HT N: S Typhi O/H 1/160 paratyphi 1/80. EKG NSR Lapiva 1x10/160 mg PO malam FU hasil swab 11/9
2/9 GDP 123 GDS 18.00 226 Atorvastatin 1x20mg PO malam DPL + GDS/3hari -> next 15/9 form +
9/9 PCR Swab III -
10/9 GDS 155
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL /4 hari--> next 16/9 form +
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
RR 9/9 PCR swab III persumtif 12/9 extra Microlax
S 16/9 R/ swab PCR ulang, form +, PE +
13 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case Kes: CM 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Becomzet 1x1 PO FU hasil swab 10/9
Kemkes TD 3/9 PCR swab I + Rhinos SR 2x1 tab PO
dr. Taufan, Sp.P N 4/9 CXR: Cor pulmo dbn, tak tampak GGO
R
S
9/9 PCR Swab III -
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) 16/9 R/ swab PCR ulang, form +, PE +*
Becomzet 1x1 PO
9/9 PCR Swab III -
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi 14/9 R/ swab PCR ulang, form +, PE +*
7/9 PCR Swab III -
18 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 14/9 R/ swab PCR ulang, form +, PE +*
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Lapraz 1x30 mg PO FU hasil PCR Swab 12/9
UL dbn Lesichol 1x300mg PO GDS+DPL /3 hari -- next 15/9 form +
20 12-Sep 1204 Monika Siska /32 th
Pribadi
PULANG
dr. Irawan SpBP PULANG
21 3-Sep 1206 Tn. Bambang Halim/24th
AA
dr. Daniel, Sp.PD
PULANG
22 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis E4M5V3 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 8 lpm via NRM Co dr. Angel, Sp.N: BPPV + TTH
dr. Felix Sp.PD HipoNaCl + HipoK N: 88 CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Line II IVFD : Nacl 3% 500cc/24 jam 10/9 Ceftriaxone naik 2x2 gr IV. Cetirizine, drip ketorolac, betahistin, capsul racik, flunarizin STOP
dr. Angel Sp.N Low intake RR: 21 7/9 UL: dalam batas normal Total 2500cc/24jam *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Pneumonia S: 36 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Diet cair 6x100cc perNGT 11/9 Omeprazole IV tidak acc BPJS --> ganti oral
Sistitis 10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1 Omeprazole 2x20 mg PO 13/9 As tranexamat STOP bila tidak hematuria, azitro terakhir lalu stop
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO
12/9 pH 7.5/pCO2 28/pO2 130/HCO3 21/tCO2 22/Actual BE -1/Standar BE 3/Sat 100 Mg ion 0.35 Ca ion 0.66 Ondancetron 8 mg IV K/P muntah DPL/3 hari, Na K CL / 2 hari
13/9 Hb 11,8 Ht 35 Leu 6,6 Tr 236 Paracetamol 3x1000mg PO dr Angel N : Pro MRI kepala + kontras , saran rawat ICU /rujuk
Ca gluconas 3x1fls
Amlodipin 10 mg 1-0-0 PO bila TDS >100
sisanya drip dlm NaCL 100cc habis dlm 1 jam (2 hari)
23 11-Sep 1002 Tn. Muhammad Farhan Pranata

BPJS
dr. Ade Sp.B PULANG
24 12-Sep 1002 Tn. Herman Sitepu/24 th Post Radical Mastoidectomy S (12/9) Kes CM 10/9 Hb 17/Ht 50/ Leu 8.5/ Tr 212/ Eri 5.57 / Ur 27/Cr 0.9/ OT/PT 21/22 IVFD RL 500cc/12 jam Telinga jangan kemasukan air, ganti verban bila kassa rembes darah
a/I OMSK AS TD 132/89 Ceftriaxon 1x2g IV (12/9) 13/9 Extra adona 1 amp IV drip
BPJS dr. Robert SpTHT N 85 As tranexamat 3x500mg IV 14/9 R/ BPL tunggu visite
RR 20 Dexametason 2x5mg IV
Alergi seafood S 36 Ranitidin 2x1 amp
Ketorolac 3x30mg IV
25 10-Sep 1003 Ny Sumanti Bong/ 55th Post kranioplasty (11/9) Kes : CM 24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine Venflon 11/9 dr. Adolf Sp.BS instruksi post op: saat SOAP perhatikan GCS dan pupil, bila Hb<10 transfusi PRC
BPJS hipoK hipo Cl TD: 120/80 ke kiri 1.5cm+ edema cerebi ec metastasis IVFD Nacl 0.9% 2000cc/24 jam 14/9 Rencana GV-aff drain
dr. Adolf Sp.BS leukositosis ec bacterial dd N 82 4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis KSR 3x2 tab po 16/9 R/ BLPL bila ku baik
pneumonia dd ISPA RR 20 10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12 Omeprazole 2x40mg IV
HT gr II , malnutrition S 36,2 Na/K/Cl 139/2.75/92 Acetilsistein 3x200 mg po
riw Ca mamae 11/9 Ca Total 4.4 Na 140 K 3,3 Cl 98 T3 94, T4 3.79 TSH 2.05 Ceftriaxone 1x2g IV (11/9)
riw pasca tiroidektomi Drain: 500 cc 13/9 Hb 12 Ht 36 Leu 11 Tr 359 Na 143 K 3,4 Cl 99 Ca glukonas 3x1 amp IV
per 24 jam Ketorolac 2x30mg IV Cek DPL/3 hari, Na K Cl/2 hari (BPJS acc DR dan elekrolit 1x)
Vit K 3x1amp IV
13 September 2020 Malam (Ebelline)

1 8-Sep Pres Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM 8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5 Oseltamivir 2x75mg (9/9) 14/9 R/ swab PCR ulang, form +, PE +
S:
RR Becomzet 1x1 PO
S
3 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case Kes CM Oseltamivir 2x75mg (13/9) 14/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
Mucopect 3xCI
4 13-Sep pres nn. Adinda Angelica /26 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
kemkes TD: Hyloquine 1x400mg (13/9)
RR: Becomzet 1x1 PO
S:
5 12-Sep executive Nn. Debby Fauziah/23 th COVID-19 confirmed case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR Becomzet 1x1 PO
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Minosep garg 3x15cc 14/9 R/ swab PCR ulang, form +, PE +
S:
7 13-Sep executive nn. Rizki Amelia/23th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
kemkes TD: 12/9 Hb 10.6/Ht 34/L 6.4/Tr 286 LED 20 Diff 1/0/43/3/48/5 Hyloquine 1x400mg (13/9)
dr. Taufan SpP N: CXR: Cor dan pulmo dbn Azitromycin 1x500mg (13/9)
RR: Becomzet 1x1 PO
S:
8 13-Sep Executive tn. Hendra Kurniawan/42 COVID-19 confirmed case Kes CM Oseltamivir 2x75mg (13/9)
N: Azitromycin 1x500mg (13/9)
dr. Taufan SpP RR: Becomzet 1x1 PO
S: ondanecentrone 2x 8mg
9 12-Sep Executive Tn. Junardi Juliansyah/ 31 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
Mucopect syr 3xCI
S:
RR: Becomzet 1x1 PO
Amlodipin 1x5mg PO
11 12-Sep Executive Tn. M Eggy/33 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
9/9 PCR Swab III -
10/9 GDS 155
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
RR 9/9 PCR swab III persumtif n acetylsistein 3x1 12/9 extra Microlax
R
S
9/9 PCR Swab III -
Becomzet 1x1 PO
9/9 PCR Swab III -
7/9 PCR Swab III -
21 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 14/9 R/ swab PCR ulang, form +, PE +*
HP pro 3x1 tab PO
23 13-Sep 11 Tn. Edy Rosadi COVID-19 confirmed case Kes 10/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 17/9 R/ swab PCR ulang, form +, PE +
Pribadi TD Hyloquine 1x400mg (13/9)
dr. Taufan SpP N Azitromycin 1x500mg (13/9)
RR Becomzet 1x1 PO
S
Sistitis 10/9 GDS 119; Hb11.9/Ht 34/L6.1/Tr 226/LED 50/NLR ?/ Diff: 0/0/77/3/9/11/1.92/6.02 PT12.2/APTT36.1 Omeprazole 2x20 mg PO 13/9 As tranexamat STOP bila tidak hematuria, azitro terakhir lalu stop, NE mulai 0,03micro/kgbb/menit target 100
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO
Ca gluconas 3x1fls
sisanya drip dlm NaCL 100cc habis dlm 1 jam (2 hari:13-14/9)
25 12-Sep 1002 Tn. Herman Sitepu/24 th Post Radical Mastoidectomy S (12/9) Kes CM 10/9 Hb 17/Ht 50/ Leu 8.5/ Tr 212/ Eri 5.57 / Ur 27/Cr 0.9/ OT/PT 21/22 IVFD RL 500cc/12 jam Telinga jangan kemasukan air, ganti verban bila kassa rembes darah
a/I OMSK AS TD 132/89 Ceftriaxon 1x2g IV (12/9) 13/9 Extra adona 1 amp IV drip
BPJS dr. Robert SpTHT N 85 As tranexamat 3x500mg IV 14/9 R/ BPL tunggu visite
RR 20 Dexametason 2x5mg IV
Alergi seafood S 36 Ranitidin 2x1 amp
Ketorolac 3x30mg IV
Vit K 3x1amp IV
14 September 2020 Pagi (Gizella)

1 8-Sep Pres Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM 8/9 Hb 14,4 Ht 43 Leu 9,7 Tr 299 LED 20 NLR 2,82 eos/bas/seg/bat/lim/mo 1/0/67/3/24/5 Oseltamivir 2x75mg (9/9) 14/9 R/ swab PCR ulang, form +, PE +
S:
RR Becomzet 1x1 PO
S
3 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case Kes CM 1/9 PCR Swab I + Oseltamivir 2x75mg (13/9) F/U hasil swab PCR 14/9
RR: Becomzet 1x1 PO
Mucopect 3xCI
Lactulac 3x1cth
4 13-Sep pres nn. Adinda Angelica /26 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
S:
5 12-Sep executive Nn. Debby Fauziah/23 th COVID-19 confirmed case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
RR Becomzet 1x1 PO
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Minosep garg 3x15cc 14/9 R/ swab PCR ulang, form +, PE +
S:
7 13-Sep executive nn. Rizki Amelia/23th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
kemkes TD: 12/9 Hb 10.6/Ht 34/L 6.4/Tr 286 LED 20 Diff 1/0/43/3/48/5 Hyloquine 1x400mg (13/9)
RR: Becomzet 1x1 PO
S: Omeprazole 2x1 tab
ondansentron 4mg 2x1 tab
8 13-Sep Executive tn. Hendra Kurniawan/42 COVID-19 confirmed case Kes CM Oseltamivir 2x75mg (13/9) R/ Swab 16/09
N: Azitromycin 1x500mg (13/9)
S: ondanecentrone 2x 8mg
minocef 3x1
polysilane 3x1
RR: Becomzet 1x1 PO
Mucopect syr 3xCI
S:
RR: Becomzet 1x1 PO
S: Ramipril 1x5mg PO STOP
Amlodipin 1x5mg PO
Mucopect 3x1
Omz 2x1
RR: Becomzet 1x1 PO
S: Minocef 3x1
9/9 Hb/Ht/L/Tr 14.9/44/9.2/364 LED 35 NLR 2.45 diff 1/0/60/3/26/10 Clonidine(Catapress) 1-0-1 0,15 mg PO
9/9 PCR Swab III -
10/9 GDS 155
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
R
S
9/9 PCR Swab III -
Becomzet 1x1 PO
9/9 PCR Swab III -
7/9 PCR Swab III -
21 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 14/9 R/ swab PCR ulang, form +, PE +* -> tidak jadi hari ini jadinya 15/9 karena mau sameday
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore) 14/9 Bisoprolol tunda
12/9 Hb 14.3 Ht 43 Leu 5.7 Tr 484 LED 95 NLR 1.46 , diff 6/1/45/3/33/12 Bisoprolol 1.25mg-0-0 TUNDA
Pribadi TD Hyloquine 1x400mg (13/9)
dr. Taufan SpP N Azitromycin 1x500mg (13/9)
RR Becomzet 1x1 PO
S
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO 14/9 Levofloxacin 1x 500mg tab (5 hari), Azithromicin stop,
Ca gluconas 3x1fls
sisanya drip dlm NaCL 100cc habis dlm 1 jam (2 hari:13-14/9)
Levofloxacin 1x500mg tab PO (5hr)
25 12-Sep 1002 Tn. Herman Sitepu/24 th Post Radical Mastoidectomy S (12/9) Kes CM 10/9 Hb 17/Ht 50/ Leu 8.5/ Tr 212/ Eri 5.57 / Ur 27/Cr 0.9/ OT/PT 21/22
a/I OMSK AS TD 132/89
BPJS dr. Robert SpTHT N 85
Alergi seafood
RR 20
S 36
PULANG
Vit K 3x1amp IV
14 September 2020 Malam (Cylla)
No Masuk Bed Nama Diagnosis

1 8-Sep Exe B Ny. Zuhairiah/ 36 th COVID-19 confirmed case
Kemkes
dr. Taufan Sp.P
2 8-Sep Exe B Nn. Lisa Septiana/22 th COVID-19 confirmed case

Kemkes
dr. Taufan Sp.P
3 8-Sep Exe B Nn. Windri/23 th COVID-19 confirmed case

Kemkes
dr. Taufan SpP
4 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case

Kemkes
dr. Taufan, Sp.P
5 13-Sep Pres Nn. Adinda Angelica /26 th COVID-19 confirmed case

kemkes
dr. Taufan, Sp.P
6 12-Sep Pres Nn. Debby Fauziah/23 th COVID-19 confirmed case
Kemkes dr Taufan Sp.P
7 13-Sep Pres Nn. Rosalia Pasaribu/th COVID-19 confirmed case

kemkes
dr. Taufan SpP
8 13-Sep Pres Nn. Rizki Amelia/23th COVID-19 confirmed case

kemkes
dr. Taufan SpP
9 14-Sep Pres Nn. Ion Sintesa/th COVID-19 confirmed case
kemkes
dr. Taufan SpP
10 13-Sep Executive tn. Hendra Kurniawan/42 COVID-19 confirmed case

kemkes
dr. Taufan SpP
11 12-Sep Executive Tn. Junardi Juliansyah/ 31 th COVID-19 confirmed case
12 12-Sep Executive Tn. Dedi Gunawan/ 41 th COVID-19 confirmed case

HT
13 12-Sep Executive Tn. M Eggy/33 th COVID-19 confirmed case
14 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case
Kemkes
dr. Taufan Sp.P
15 28-Aug 1602 dr. Herdhito Dewahyu/54th COVID-19 confirmed case

Bakrie DMT2
dr. Taufan, Sp.P HT
dr. Felix Sp.PD Dislipidemia
16 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case
Kemkes Pneumonia
dr Felix Sp.PD Cephalgia
dr. Taufan Sp.P HT HHD
CAD
Hiperuricemia
17 27-Aug 1605 Tn. Imam Wahyudi /43 th COVID-19 confirmed case

Bakrie
dr. Taufan SpP
18 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case

Kemkes
dr. Taufan, Sp.P
19 30-Aug 1607 Tn. Sabam Frando/32 th COVID-19 confirmed case

Wilmar
dr. Taufan Sp.P
20 19-Aug 1608 dr. Novie Hediyani/ 40th COVID-19 confirmed case

Kemkes Bronkitis akut
dr. Taufan SpP
21 25-Aug 1103 Tn. Yan Rahmanto/52 th COVID-19 confirmed case
Bakrie HT
dr. Taufan Sp.P
co dr. Daniel Sp.PD
22 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case

Kemkes HT
dr.Taufan Sp.P
23 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case

Bakrie HT
dr. Taufan Sp.P Dislipidemia
Asma terkontrol
Alergi Antalgin, Salisilat
24 29-Aug 1108 dr. Achmad Budiarto/62 th COVID-19 confirmed case

Bakrie Hipertensi
dr Taufan SpP DM tipe II + pruritus
dr Felix Sp. PD Riw. Dengue fever
Co dr. Putri Sp.GK Hipertrigliserdemia
Dispepsia
Asma terkontrol
25 13-Sep 11 Tn. Edy Rosadi COVID-19 confirmed case
Pribadi
dr. Taufan SpP
26 13-Sep 11 Tn. Marsuddin/ 45th COVID-19 confirmed case

Pribadi
dr. Taufan SpP
27 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis

BPJS dd infeksi SSP dd CVD
dr. Felix Sp.PD HipoNaCl + HipoK
dr. Angel Sp.N Low intake
Pneumonia
Anemia chronic disease
Sistitis
28 12-Sep 1002 Tn. Herman Sitepu/24 th Post Radical Mastoidectomy S (12/9)

a/I OMSK AS
BPJS dr. Robert SpTHT
Alergi seafood
29 10-Sep 1003 Ny Sumanti Bong/ 55th Post kranioplasty (11/9)
BPJS hipoK hipo Cl
dr. Adolf Sp.BS leukositosis ec bacterial dd
pneumonia dd ISPA
HT gr II , malnutrition
riw Ca mamae
riw pasca tiroidektomi
30 14-Sep 1003 Ny Dalasih/ 62th Reattack CVD SNH

Pribadi DMT2
dr. Felix, Sp.PD Hipertensi
dr. Angelina, Sp.N Dislipidemia
Cholecystitis
TTV
Kes CM
TD:
N:
RR:
S:
Kes : CM
TD
N
RR
S
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes : CM
TD
N
RR
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N
RR
S
Kes: CM
TD
N
R
S
Kes
TD
N
RR
S
Kes CM
TD:
N:
RR:
S:
Kes:CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes
TD
N
RR
S
Kes
TD
N
RR
S
Kes
TD
N
RR
S
Kes
TD
N
RR
S
E4M5V4-5
TD:
N:
RR:
S:
Kes
TD
N
RR
S
Kes : CM
TD:
N
RR
S
Drain:
per 24 jam
Kes : CM
TD:
N
RR
S
Penunjang
4/9 PCR Swab I +
10/9 PCR Swab II -
3/9 PCR Swab I +
11/9 PCR Swab II -

3/9 PCR Swab I +
10/9 PCR Swab II -
1/9 PCR Swab I +
9/9 Swab PCR +

12/9 Hb 11.6/Ht 35/L 6.4/Tr 185 LED 18 Diff 2/0/61/3/29/5
CXR: Bronkhitis
9/9 Swab PCR +

12/9 Hb 12.7/Ht 38/L 5.5/Tr 241 LED 16 Diff 2/0/52/3/35/8
CXR: Cor dan pulmo dbn
9/9 Swab PCR +

12/9 Hb 13.4/Ht 40/L 6.2/Tr 342 LED 14 Diff 3/0/59/3/28/7
9/9 Swab PCR +

12/9 Hb 10.6/Ht 34/L 6.4/Tr 286 LED 20 Diff 1/0/43/3/48/5
10/9 Swab PCR +
12/9 Hb 13.1/Ht 39/L 6.4/Tr 293 LED 17 Diff 1/0/48/3/39/9
9/9 Swab PCR +
9/9 Swab PCR +

12/9 Hb 14.2/Ht 43/L 4.8/Tr 225 LED 20 Diff 5/0/45/3/37/10
9/9 Swab PCR +

12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10
9/9 Swab PCR +

12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10
1/9 Swab I PCR +

9/9 Swab II PCR -
14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
3/9 PCR swab I +
10/9 PCR swab 2 +
Rapid Sars Cov2 -
2/9 PCR Swab II +
9/9 PCR Swab III -

19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
9/9 PCR swab III +
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
7/9 PCR Swab III -
31/8 PCR Swab I +

7/9 PCR Swab II presumtif
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
5/9 PCR swab II +
11/9 EKG Sinus Takikardia
12/9 Hb 14.3 Ht 43 Leu 5.7 Tr 484 LED 95 NLR 1.46 , diff 6/1/45/3/33/12
10/9 PCR Swab I +
13/9 Hb 16.9/Ht 49/L 7.5/Tr 261 LED 8 Diff 4/0/47/3/40/6
CXR: Cor dbn, arkus aorta elongasi. Gambaran bronkhitis. Dextroskoliosis min
10/9 PCR Swab I +

13/9 Hb 15.6/Ht 46/L 9.3/Tr 396 LED 9 Diff 1/1/63/3/28/4
CXR: Cor paru normal

9/9 Ro Thorax Pneumonia bacterial bilateral, PCR Swab -
10/9 Na/K/Cl 134/3.1/97
12/9 pH 7.5/pCO2 28/pO2 130/HCO3 21/tCO2 22/Actual BE -1/Standar BE 3/Sat 100 Mg ion 0.35 Ca ion 0.66
As laktat 1.0 Na 124/K 5.1/Cl 93
13/9 Hb 11,8 Ht 35 Leu 6,6 Tr 236
24/6 CT: nodul kistik + solid dgn perdarahan 7x5cc + perifokal edema yg menyebabkan herniasi subfalcine
ke kiri 1.5cm+ edema cerebi ec metastasis
4/8 CXR: Multipel nodul di kedua paru dd/ tuberkuloma, metastasis
10/9 Hb11.8/Ht 34/L13.8/Tr 350/LED 71/NLR ?/ Diff: 1/0/78/3/11/7 PT18.6/APTT28.9; Ur/cr 16/1.0; ot/pt 29/12
Na/K/Cl 139/2.75/92
11/9 Ca Total 4.4 Na 140 K 3,3 Cl 98 T3 94, T4 3.79 TSH 2.05
13/9 Hb 12 Ht 36 Leu 11 Tr 359 Na 143 K 3,4 Cl 99
14/9 Rapid test -, GDP 192, EKG: VES infrequent

MRI brain non contrast: infark hemorrhage pons S, lacunar infark lama periventrikel lat cornu ant D
leukoariosis, atrofi cerebri senilis, rhinitis
15/9 GDS 56 (D40 1fl) -> GDS 77 (D40 1fl) -> GDS 136 (D10) -> GDS 06 179
Terapi
Becomzet 1x1 PO
Becomzet 1x1 PO
Becomzet 1x1 PO
Minosep garg 3x15cc
Polisilan 3x1 cth
Prome syr 3xc1

Becomzet 1x1 PO
Paracetamol 3x500 mg PO
Mucopect 3xCI
Lactulac 3x1cth
Becomzet 1x1 PO
Ondansentron 2x4mg k/p mual
Becomzet 1x1 PO

Becomzet 1x1 PO

Becomzet 1x1 PO
Omeprazole 2x1 tab
Becomzet 1x1 PO

Becomzet 1x1 PO
ondansentron 2x 8mg
Amlodipin 1x5mg PO
Minocef 3x1
Polysilane 3x1 cth
Becomzet 1x1 PO
Mucopect syr 3xCI

Becomzet 1x1 PO
Amlodipin 1x5mg PO
Mucopect 3x1
Omeprazole 2x1

Becomzet 1x1 PO
Minocef 3x1
Becomzet 1x1 PO
Mucopect 3xC1 PO
Rhinos SR k/p
PULANG
PULANG
Becomzet 1x1 PO
Liproqy 2x1
Becomzet 1x1 po
Tremenza 2xI PO k/p
n acetylsistein 3x1
Becomzet 1x1 PO
Becomzet 1x1 PO
Minosep garg 3x

Becomzet 1x1 PO
PULANG
Becomzet 1x1 PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO
Becomzet 1x1 PO
Mucopect 3xc1
Rhinos SR 2x1
Becomzet 1x1 PO
Amlodipin 1x5mg
Omeprazole 1x20mg
O2 8 lpm via NRM
Line II IVFD : Nacl 3% 500cc/24 jam
Total 2500cc/24jam
Diet cair 6x100cc perNGT
Ca gluconas 3x1fls
Levofloxacin 1x500mg tab PO (14/9)
PULANG
cefixime 3x200mg (14/9)

Omeprazole 2x20mg
Ketorolac 2x30mg
Fenitoin 3x100mg
Amlodipin 1x10mg pagi
Ramiprol 1x10mg malam
N asetilsistein 3x200mg
KSR 3x2tab
IVFD D5 14tpm
Cernevit 1x1amp
Novomix 30-0-30 IU
Terfacef 1x2g (14/9)
Amlodipin 10mg 1-0-0
Candesartan 8mg 0-0-1
Allupurinol 100 0-0-1
Lansoprazol 30 1x1
Urlicon 2x250mg
Truvaz 20 0-0-1
Citicolin 2x500mg
Mecobalamin 2x500mg
Keterangan
14/9 stop oseltamivir hyloquine azitro
FU hasil swab 14/9

15/9 R/ swab PCR ulang, form +, PE +
13/9 Triple therapy stop

FU hasil swab 14/9
F/U hasil swab PCR 14/9
FU hasil lab + thorak (status belum ada)


FU hasil swab 12/9
*Febris sejak 6/8
15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
F/U hasil swab 12/9
DPL /4 hari--> next 16/9 form +

** dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat pulang

11/9 dr. Taufan Sp.P Codipront syr --> STOP
12/9 extra Microlax
17/9 R/ swab PCR ulang, form -, PE - (Belum konfirmasi dr Taufan)
FU hasil swab 12/9

*Swab reguler

11/9 ekstra omeprazole 40mg po
15/9 R/ swab PCR ulang, form +, PE + (same day)

FU hasil PCR Swab 12/9
14/9 Bisoprolol 1.25-0-0 tunda
GDS+DPL /3 hari -- next 15/9 form +

Pantau TD , obat sudah masuk belum

Nacl 3% stop
11/9 Omeprazole IV tidak acc BPJS --> ganti oral
12/9 KSR dan KCl STOP
13/9 As tranexamat STOP bila tidak hematuria, azitro terakhir lalu stop, NE mulai 0,03micro/kgbb/menit target 100
14/9 Levofloxacin 1x 500mg tab (5 hari), Azithromicin stop,
15/9 Dexa, MgSO4 stop
DPL/3 hari, Na K CL / 2 hari

dr Felix SpPD : kultur darah urin + tes sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau r
dr Angel N : Pro MRI kepala + kontras , saran rawat ICU /rujuk
11/9 dr. Adolf Sp.BS instruksi post op: saat SOAP perhatikan GCS dan pupil, bila Hb<10 transfusi PRC
15/9 R/ BLPL sesudah aff drain bila ku baik (dr Adolf visit pagi/siang)
Cek DPL/3 hari, Na K Cl/2 hari (BPJS acc DR dan elekrolit 1x)
*dr Felix Sp.PD saran CT Thorax untuk evaluasi, BPJS tdk acc, JP pribadi +
GDP- GDS (06-18)

15/9 DPL, Na/K/Cl/Ca total
14/9 Thromboaspilet 80 0-1-0, CPG 75 1-0-0 tunda
15/9 Hipoglikemia -> bolus D40 2fl, IVFD ganti D10 14tpm; dr. Felix: D10 habis ganti D5, Novomix 30-0-30
15 September 2020 M Gizella
No Masuk Bed Nama Diagnosis

1 8-Sep Exe B Ny. Zuhairiah/ 36 th COVID-19 confirmed case
Kemkes
dr. Taufan Sp.P
2 8-Sep Exe B Nn. Lisa Septiana/22 th COVID-19 confirmed case

Kemkes
dr. Taufan Sp.P
3 8-Sep Exe B Nn. Windri/23 th COVID-19 confirmed case

Kemkes
dr. Taufan SpP
4 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case

Kemkes
dr. Taufan, Sp.P
5 13-Sep Pres Nn. Adinda Angelica /26 th COVID-19 confirmed case

kemkes
dr. Taufan, Sp.P
6 12-Sep Pres Nn. Debby Fauziah/23 th COVID-19 confirmed case
7 13-Sep Pres Nn. Rosalia Pasaribu/th COVID-19 confirmed case

kemkes
dr. Taufan SpP
8 13-Sep Pres Nn. Rizki Amelia/23th COVID-19 confirmed case

kemkes
dr. Taufan SpP
9 14-Sep Pres Nn. Ion Sintesa/th COVID-19 confirmed case

kemkes
dr. Taufan SpP
10 13-Sep Executive tn. Hendra Kurniawan/42 COVID-19 confirmed case

kemkes
dr. Taufan SpP
11 12-Sep Executive Tn. Junardi Juliansyah/ 31 th COVID-19 confirmed case
12 12-Sep Executive Tn. Dedi Gunawan/ 41 th COVID-19 confirmed case

HT
13 12-Sep Executive Tn. M Eggy/33 th COVID-19 confirmed case
14 2-Sep 1601 Ny. Tyta Lilin Nuha/ 30th COVID-19 confirmed case
Kemkes
dr. Taufan Sp.P
15 15-Sep 1602 dr. Rina Safrina COVID-19 confirmed case
dr. Taufan, Sp.P
16 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case

Kemkes Pneumonia
dr Felix Sp.PD Cephalgia
dr. Taufan Sp.P HT HHD
CAD
Hiperuricemia
17 27-Aug 1605 Tn. Imam Wahyudi /43 th COVID-19 confirmed case

Bakrie
dr. Taufan SpP
18 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case

Kemkes
dr. Taufan, Sp.P
19 30-Aug 1607 Tn. Sabam Frando/32 th COVID-19 confirmed case

Wilmar
dr. Taufan Sp.P
20 19-Aug 1608 dr. Novie Hediyani/ 40th COVID-19 confirmed case
Kemkes Bronkitis akut
dr. Taufan SpP
21 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case

Kemkes HT
dr.Taufan Sp.P
22 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case

Bakrie HT
dr. Taufan Sp.P Dislipidemia
Asma terkontrol
Alergi Antalgin, Salisilat
23 29-Aug 1108 dr. Achmad Budiarto/62 th COVID-19 confirmed case

Bakrie Hipertensi
dr Taufan SpP DM tipe II + pruritus
dr Felix Sp. PD Riw. Dengue fever
Co dr. Putri Sp.GK Hipertrigliserdemia
Dispepsia
Asma terkontrol
24 13-Sep 11 Tn. Edy Rosadi COVID-19 confirmed case
Pribadi
dr. Taufan SpP
25 13-Sep 11 Tn. Marsuddin/ 45th COVID-19 confirmed case

Pribadi
dr. Taufan SpP

Pneumonia
Sistitis
27 10-Sep 1003 Muhammad Faishal Gerd

Asuransi ileitis
dr. Felix, Sp.PD Haemorrhoid interna
28 14-Sep 1003 Ny Dalasih/ 62th Reattack CVD SNH
Pribadi DMT2
dr. Felix, Sp.PD Hipertensi
dr. Angelina, Sp.N Dislipidemia
Cholecystitis
29 15-Sep Susilawati /50th Covid-19 Confirmed case
dr. Taufan, Sp.P

TTV
Kes CM
TD:
N:
RR:
S:
Kes : CM
TD
N
RR
S
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes : CM
TD
N
RR
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N
RR
S
Kes: CM
TD
N
R
S
Kes
TD
N
RR
S
Kes CM
TD:
N:
RR:
S:
Kes CM
TD:
N:
RR:
S:
Kes
TD
N
RR
S
Kes
TD
N
RR
S
Kes
TD
N
RR
S
Kes
TD
N
RR
S
E4M5V4-5
TD:
N:
RR:
S:
Kes : CM
TD:
N
RR
S
Kes : CM
TD:
N
RR
S
Kes : CM
TD:
N
RR
S
Penunjang
4/9 PCR Swab I +
10/9 PCR Swab II -
14/9 PCR swab III -
3/9 PCR Swab I +
11/9 PCR Swab II -

3/9 PCR Swab I +
10/9 PCR Swab II -
14/9 PCR swab III +
1/9 PCR Swab I +

14/9 PCR swab II +
9/9 Swab PCR +

12/9 Hb 11.6/Ht 35/L 6.4/Tr 185 LED 18 Diff 2/0/61/3/29/5
CXR: Bronkhitis
9/9 Swab PCR +

12/9 Hb 12.7/Ht 38/L 5.5/Tr 241 LED 16 Diff 2/0/52/3/35/8
9/9 Swab PCR +

12/9 Hb 13.4/Ht 40/L 6.2/Tr 342 LED 14 Diff 3/0/59/3/28/7
9/9 Swab PCR +

12/9 Hb 10.6/Ht 34/L 6.4/Tr 286 LED 20 Diff 1/0/43/3/48/5
10/9 Swab PCR +

12/9 Hb 13.1/Ht 39/L 6.4/Tr 293 LED 17 Diff 1/0/48/3/39/9
9/9 Swab PCR +
9/9 Swab PCR +

12/9 Hb 14.2/Ht 43/L 4.8/Tr 225 LED 20 Diff 5/0/45/3/37/10
9/9 Swab PCR +

12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10
9/9 Swab PCR +

12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10
1/9 Swab I PCR +

9/9 Swab II PCR -
14/8 d dimer 3552
12/8 PCR swab I +
16/8 D dimer 138
19/8 PCR Swab II +
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
15/9 Hb/Ht/L/Tr 11.4/35/7.3/316 LED 33 NLR 2.09 diff 4/0/58/3/29/6/4.41/2.11 d-Dimer 6942
25/8 PCR swab I +

25/8 Hb/Ht/L/Tr 15.1/42.9/4.1/252
1/9 PCR swab II +
3/9 PCR swab I +
10/9 PCR swab 2 +
Rapid Sars Cov2 -
2/9 PCR Swab II +
9/9 PCR Swab III -
19/8 PCR Swab I +
26/8 PCR swab II +
2/9 PCR swab II +
9/9 PCR swab III +
23/8 PCR Swab I +

(atypical).
31/8 PCR Swab II +
7/9 PCR Swab III -
14/9 PCR swab IV +
31/8 PCR Swab I +

7/9 PCR Swab II presumtif
29/8 PCR Swab I +

GDS 153
UL dbn
2/9 Hb/Ht/L/Tr 13.5/40/2.5/122 GDP 80 GDS 18.00 114
3/9 GDS pk. 18: 244
4/9 GDS pk. 18: 122
5/9 PCR swab II +
11/9 EKG Sinus Takikardia
15/9 Hb 13.8 Ht 40 L 8.8 Tr 494, LED 40 NLR 2.38 Diff 1/0/61/3/27/8/5.58/2.34
10/9 PCR Swab I +

13/9 Hb 16.9/Ht 49/L 7.5/Tr 261 LED 8 Diff 4/0/47/3/40/6
CXR: Cor dbn, arkus aorta elongasi. Gambaran bronkhitis. Dextroskoliosis min
10/9 PCR Swab I +

13/9 Hb 15.6/Ht 46/L 9.3/Tr 396 LED 9 Diff 1/1/63/3/28/4
CXR: Cor paru normal

9/9 Ro Thorax Pneumonia bacterial bilateral, PCR Swab -
10/9 Na/K/Cl 134/3.1/97
12/9 pH 7.5/pCO2 28/pO2 130/HCO3 21/tCO2 22/Actual BE -1/Standar BE 3/Sat 100 Mg ion 0.35 Ca ion 0.66
As laktat 1.0 Na 124/K 5.1/Cl 93
13/9 Hb 11,8 Ht 35 Leu 6,6 Tr 236
11/09 Hb/Ht/L/Tr 16.6/47/6.2/177 LED 40 NLR 1.86 Diff 1/0/53/3/31/12/3.51/1.89

11/09 widal -, SGOT/SGPT 73/53 FL dbn
14/9 Rapid test di tempat lain -
15/9 Thorax PA-> Pneumonia
14/9 Rapid test -, GDP 192, EKG: VES infrequent
MRI brain non contrast: infark hemorrhage pons S, lacunar infark lama periventrikel lat cornu ant D
leukoariosis, atrofi cerebri senilis, rhinitis
15/9 GDS 56 (D40 1fl) -> GDS 77 (D40 1fl) -> GDS 136 (D10) -> GDS 06 179
15/9 Magnesium 1.44
15/9 UL-> bakteri +, jamur +
15/9 DPL 14.3/42/11.1/344 LED 48 Diff count 1/0/73/3/16/5/8.57/1.83
15/9 Na/K/CL/Ca Total 140/4.17/99/9.52
15/9 GDS 18 399 22 201
16/9 GDS 06.00: 140
15/09 D-dimer 971

11/9 Swab PCR I +
12/09 DPL-> Hb/Ht/L/Tr 11/35/4.7/224 LED 55 Diff 0/0/65/28/7 hs-CRP 24.19
Terapi
Becomzet 1x1 PO
Becomzet 1x1 PO
Becomzet 1x1 PO
Minosep garg 3x15cc
Polisilan 3x1 cth
Prome syr 3xc1

Becomzet 1x1 PO
Mucopect 3xCI
Lactulac 3x1cth
Becomzet 1x1 PO
Ondansentron 2x4mg k/p mual
Becomzet 1x1 PO

Becomzet 1x1 PO

Becomzet 1x1 PO
Omeprazole 2x1 tab
Becomzet 1x1 PO
New diatab 3x2 tab

Becomzet 1x1 PO
ondansentron 2x 8mg
Amlodipin 1x5mg PO
Minocef 3x1
Polysilane 3x1 cth
Becomzet 1x1 PO
Mucopect syr 3xCI

Becomzet 1x1 PO
Amlodipin 1x5mg PO
Mucopect 3x1
Omeprazole 2x1

Becomzet 1x1 PO
New diatab 3x1
Minocef 3x1
Becomzet 1x1 PO
Mucopect 3xC1 PO
Rhinos SR k/p
Polysilane 3xc1
Omeprazole 2x1
Becomzet 1x1 PO
Becomzet 1x1 PO
Liproqy 2x1
Arixtra 2.5mg SC sehari 1x sd 3 hari (15/9)
Becomzet 1x1 po
Tremenza 2xI PO k/p
n acetylsistein 3x1
Becomzet 1x1 PO
Becomzet 1x1 PO
Minosep garg 3x
Becomzet 1x1 PO
Becomzet 1x1 PO
Vectrine 3x1 PO
Becomzet 1x1 PO
Amlodipin 1x5 mg PO
Codipront syr 3x 1C
HP pro 3x1 tab PO
Becomzet 1x1po
Lapraz 1x30 mg PO
Lantus 1x10 U
Lesichol 1x300mg PO
Codipront 3xcthI PO
Liproqy 1x1 PO

Becomzet 1x1 PO
Mucopect 3xc1
Rhinos SR 2x1
Becomzet 1x1 PO
Amlodipin 1x5mg
Omeprazole 1x20mg
O2 8 lpm via NRM
Line II IVFD : Nacl 3% 500cc/24 jam
Total 2500cc/24jam
Diet cair 6x100cc perNGT
Ceftriaxone 2x2 g IV (6/9) -> Stop 15/9
Ca gluconas 3x1fls -> Tunda
IVFD NS:Futrolit 20tpm

Terfacef 1x2gr (15/9)
Sanmol 3x500mg PO
Pumpisel 2x40 mg iv
Probiostim 1x1
Plasminex 3x500mg iv
Buscopan 3x1 po
vosedon 3x10mg po
Episan syr 4xc1
Lesichol 300mg 1x1 po
Mezatrin 1x500mg po
lodia 2mg kp diare
Acetin effervescent 1x1
IVFD D5 14tpm
Cernevit 1x1amp
Novomix 32-0-32 IU
Terfacef 1x2g (14/9)
Amlodipin 10mg 1-0-0
Candesartan 8mg 0-0-1
Allupurinol 100 0-0-1
Lansoprazol 30 1x1
Urlicon 2x250mg
Truvaz 20 0-0-1
Citicolin 2x500mg
Mecobalamin 2x500mg
Antasida syr 3xC1
Keterangan
15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
F/u hasil swab 15/09
13/9 Triple therapy stop










FU hasil swab 12/9
R/ swab 17/09
*Febris sejak 6/8

15/8 Ceftri stop
16/8 Arixtra stop
18/8 Azitro stop
F/U hasil swab 12/9
DPL /4 hari--> next 19/9 form -

** dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat pulang

11/9 dr. Taufan Sp.P Codipront syr --> STOP
12/9 extra Microlax
17/9 R/ swab PCR ulang, form -, PE - (Belum konfirmasi dr Taufan)

15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn (KONFIRMASI LAGI)
FU hasil swab 12/9

*Swab reguler


11/9 ekstra omeprazole 40mg po
15/9 R/ swab PCR ulang, form +, PE + (same day)

FU hasil PCR Swab 12/9
14/9 Bisoprolol 1.25-0-0 tunda
GDS+DPL /3 hari -- next 18/9 form -

Pantau TD , obat sudah masuk belum


Nacl 3% stop
11/9 Omeprazole IV tidak acc BPJS --> ganti oral
12/9 KSR dan KCl STOP
13/9 As tranexamat STOP bila tidak hematuria, azitro terakhir lalu stop, NE mulai 0,03micro/kgbb/menit target 100
14/9 Levofloxacin 1x 500mg tab (5 hari), Azithromicin stop,
15/9 Dexa, MgSO4 stop, Ceftriaxone stop, infus bengkak aff, Ca glukonas tunda ganti CaCo3 3x1
DPL/3 hari, Na K CL / 2 hari

dr Felix SpPD : kultur darah urin + tes sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau r
dr Angel N : Pro MRI kepala + kontras , saran rawat ICU /rujuk
Pasien mau APS 16/9
15/9 puasa 8 jam lalu diet cair dingin 4x150cc, USG upper abdomen, saran swab 16/09
GDP- GDS (06-18)
15/9 DPL, Na/K/Cl/Ca total
14/9 Thromboaspilet 80 0-1-0, CPG 75 1-0-0 tunda
15/9 Hipoglikemia -> bolus D40 2fl, IVFD ganti D10 14tpm; dr. Felix: D10 habis ganti D5, Novomix 30-0-30
15/9 cek KGDH -> 06, 12, 18, 22
15/9 dr. Taufan terinfo, balasan -

16 September 2020 p Ebell

1 8-Sep Exe B Ny. Zuhairiah/ 36 th COVID-19 confirmed case Kes CM
Kemkes TD:
dr. Taufan Sp.P N:
pulang
RR:
S:
2 8-Sep Exe B Nn. Lisa Septiana/22 th COVID-19 confirmed case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Becomzet 1x1 PO 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
Kemkes TD 8/9 CXR cor dan pulmo tak tampak kelainan, tak tampak GGO F/u hasil swab 15/09
dr. Taufan Sp.P N 3/9 PCR Swab I +
RR 11/9 PCR Swab II -
S
3 8-Sep Exe B Nn. Windri/23 th COVID-19 confirmed case Kes CM 8/9 CXR: dextroscoliosis Becomzet 1x1 PO 13/9 Triple therapy stop
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Minosep garg 3x15cc 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
dr. Taufan SpP N: 3/9 PCR Swab I + Polisilan 3x1 cth 21/9 Swab ulang
4 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case Kes CM 1/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
Kemkes TD: 14/9 PCR swab II + Hyloquine 1x400mg (13/9) 21/9 Swab ulang
dr. Taufan, Sp.P N: Azitromycin 1x500mg (13/9) FU hasil lab + thorak (status belum ada)
RR: Becomzet 1x1 PO
Mucopect 3xCI
Lactulac 3x1cth
5 13-Sep Pres Nn. Adinda Angelica /26 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
kemkes TD: 12/9 Hb 11.6/Ht 35/L 6.4/Tr 185 LED 18 Diff 2/0/61/3/29/5 Hyloquine 1x400mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
dr. Taufan, Sp.P N: CXR: Bronkhitis Azitromycin 1x500mg (13/9)
RR: Becomzet 1x1 PO
S: Ondansentron 2x4mg k/p mual
6 12-Sep Pres Nn. Debby Fauziah/23 th COVID-19 confirmed case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (12/9) 16/9 R/ swab PCR ulang, form +, PE +
TD 12/9 Hb 12.7/Ht 38/L 5.5/Tr 241 LED 16 Diff 2/0/52/3/35/8 Hyloquine 1x400mg (12/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
RR Becomzet 1x1 PO
7 13-Sep Pres Nn. Rosalia Pasaribu/th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
S:
8 13-Sep Pres Nn. Rizki Amelia/23th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 16/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
9 14-Sep Pres Nn. Ion Sintesa/th COVID-19 confirmed case Kes CM 10/9 Swab PCR + Oseltamivir 2x75mg (14/9) 17/9 R/ swab PCR ulang, form +, PE +
RR: Becomzet 1x1 PO
S: Minosep garg 3x/hari
New diatab 3x2 tab
10 13-Sep Executive tn. Hendra Kurniawan/42 COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (14/9) 16/9 R/ swab PCR ulang, form +, PE +
kemkes TD: Hyloquine 1x400mg (14/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
N: Azitromycin 1x500mg (14/9) FU hasil lab + thorak (status belum ada)
S: ondansentron 2x 8mg
Amlodipin 1x5mg PO
Minocef 3x1
Polysilane 3x1 cth
TD: 12/9 Hb 14.2/Ht 43/L 4.8/Tr 225 LED 20 Diff 5/0/45/3/37/10 Hyloquine 1x400mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
RR: Becomzet 1x1 PO
Mucopect syr 3xCI
S:
HT TD: 12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10 Hyloquine 1x400mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
RR: Becomzet 1x1 PO
Amlodipin 1x5mg PO
Mucopect 3x1
Omeprazole 2x1
TD: 12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10 Hyloquine 1x400mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
RR: Becomzet 1x1 PO
New diatab 3x1
S: Minocef 3x1
15 15-Sep 1602 dr. Rina Safrina COVID-19 confirmed case Kes CM Oseltamivir 2x75mg (15/9) R/ swab 17/09
TD: Hyloquine 1x400mg (15/9)
Polysilane 3xc1
Omeprazole 2x1
RR: Becomzet 1x1 PO
S:
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Arixtra 2.5mg SC sehari 1x sd 3 hari (15/9)
22/8 Hb/Ht/L/Tr 11.4/33/5.5/449 RDW 15.5 LED 60 NLR 2.10 diff 1/1/55/3/28/12/3.19/1.52 DPL /4 hari--> next 19/9 form -
19/8 PCR Swab II + ** dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat pulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
18 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case Kes: CM 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Becomzet 1x1 PO 17/9 R/ swab PCR ulang, form -, PE - (Belum konfirmasi dr Taufan)
Kemkes TD 3/9 PCR swab I + Rhinos SR 2x1 tab PO 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn tambah 2 hari 16-17/9
R 10/9 PCR swab 2 +
S
Wilmar TD Rapid Sars Cov2 - Codipront exp 3x cth I PO *Swab 1.5
9/9 PCR Swab III -
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) 16/9 R/ swab PCR ulang, form +, PE +
Becomzet 1x1 PO
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi 21/9 Swab ulang
7/9 PCR Swab III -
14/9 PCR swab IV +
22 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO 15/9 R/ swab PCR ulang, form +, PE + (same day)
HP pro 3x1 tab PO
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore) 14/9 Bisoprolol 1.25-0-0 tunda
UL dbn Lesichol 1x300mg PO GDS+DPL /3 hari -- next 18/9 form -
15/9 Hb 13.8 Ht 40 L 8.8 Tr 494, LED 40 NLR 2.38 Diff 1/0/61/3/27/8/5.58/2.34
kemkes TD 13/9 Hb 16.9/Ht 49/L 7.5/Tr 261 LED 8 Diff 4/0/47/3/40/6 Hyloquine 1x400mg (13/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
dr. Taufan SpP N CXR: Cor dbn, arkus aorta elongasi. Gambaran bronkhitis. Dextroskoliosis min Azitromycin 1x500mg (13/9) Pantau TD , obat sudah masuk belum
RR Becomzet 1x1 PO
S Mucopect 3xc1
Rhinos SR 2x1
25 13-Sep 11 Tn. Marsuddin/ 45th COVID-19 confirmed case Kes 10/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 17/9 R/ swab PCR ulang, form +, PE +
Pribadi TD 13/9 Hb 15.6/Ht 46/L 9.3/Tr 396 LED 9 Diff 1/1/63/3/28/4 Hyloquine 1x400mg (14/9) 15/9 Th/ covid lanjut s/d 7 hari -> Hyloquin, Oseltamivir, Azithromicyn
dr. Taufan SpP N CXR: Cor paru normal Azitromycin 1x500mg (13/9)
RR Becomzet 1x1 PO
S Amlodipin 1x5mg
Omeprazole 1x20mg
26 6-Aug ODC10 Ny. Nurhayati/ 63 th Penkes ec susp meningoensefalitis E4M5V4-5 6/9 Hb13.2/Ht 38/L5.7/Tr 287/LED 20/NLR 8.04/ Diff: 0/0/76/3/10/11/4.5/0.56 GDS:113/Na128/K4.4/Clo87 O2 8 lpm via NRM Co dr. Angel, Sp.N: BPPV + TTH
BPJS dd infeksi SSP dd CVD TD: Rapid IgM&IgG sars cov-2 : Negatif Line I IVFD NaCl 0.9% 20 tpm Nacl 3% stop
dr. Felix Sp.PD HipoNaCl + HipoK N: CXR : Tidak tampak kelainan COR dan Pulmo saat ini, Tak tampak gambaran GGO di kedua paru saat ini Line II IVFD : Nacl 3% 500cc/24 jam 10/9 Ceftriaxone naik 2x2 gr IV. Cetirizine, drip ketorolac, betahistin, capsul racik, flunarizin STOP
dr. Angel Sp.N Low intake RR: 7/9 UL: dalam batas normal Total 2500cc/24jam *Paracetamol acc 2 fl saja, lanjut Paracetamol 3x1000 mg PO
Pneumonia S: 9/9 Hb11.2/ Ht 22/ Lc 6/ Tc 240; OT/PT 24/3; Na/K/Cl 133/3.1/97 Diet cair 6x100cc perNGT 11/9 Omeprazole IV tidak acc BPJS --> ganti oral
Anemia chronic disease 9/9 Ro Thorax Pneumonia bacterial bilateral, PCR Swab - Ceftriaxone 2x2 g IV (6/9) -> Stop 15/9 12/9 KSR dan KCl STOP
Anti HIV non reaktif, ur/cr 20/1.1, UL Keton+2/Leu+1/Darah+1; Leu5-7/Eri 10-12/Bakteri+ N-acetylsistein 3x200 mg PO 14/9 Levofloxacin 1x 500mg tab (5 hari), Azithromicin stop,
10/9 Na/K/Cl 134/3.1/97 Sucralfat syrp 3x1 cth 15/9 Dexa, MgSO4 stop, Ceftriaxone stop, infus bengkak aff, Ca glukonas tunda ganti CaCo3 3x1
12/9 pH 7.5/pCO2 28/pO2 130/HCO3 21/tCO2 22/Actual BE -1/Standar BE 3/Sat 100 Mg ion 0.35 Ca ion 0.66 Ondancetron 8 mg IV K/P muntah 16/9 APS terapi tambahan pct 1g, omporazole 1 vial, as tranexamat 1 vial
As laktat 1.0 Na 124/K 5.1/Cl 93 Mecobalamin 2x500mg PO DPL/3 hari, Na K CL / 2 hari
13/9 Hb 11,8 Ht 35 Leu 6,6 Tr 236 Paracetamol 3x1000mg PO dr Felix SpPD : kultur darah urin + tes sensitivitas , AGD ( tidak acc BPJS dr Felix sudah terinfo), pro ICU jika swab neg atau rujuk RS lain
Ca gluconas 3x1fls -> Tunda dr Angel N : Pro MRI kepala + kontras , saran rawat ICU /rujuk
Amlodipin 10 mg 1-0-0 PO bila TDS >100 Pasien mau APS 16/9
27 10-Sep 1003 Muhammad Faishal Gerd Kes : CM 11/09 Hb/Ht/L/Tr 16.6/47/6.2/177 LED 40 NLR 1.86 Diff 1/0/53/3/31/12/3.51/1.89 IVFD NS:Futrolit 20tpm 15/9 puasa 8 jam lalu diet cair dingin 4x150cc, USG upper abdomen, saran swab 16/09
Asuransi ileitis TD: 11/09 widal -, SGOT/SGPT 73/53 FL dbn Terfacef 1x2gr (15/9) 16/9 jam 17, makan sore bubur
dr. Felix, Sp.PD Haemorrhoid interna N 14/9 Rapid test di tempat lain - Sanmol 3x500mg PO
GE kronis RR 15/9 Thorax PA-> Pneumonia Pumpisel 2x40 mg iv
hepatopati S Probiostim 1x1
Plasminex 3x500mg iv
Buscopan 3x1 po
vosedon 3x10mg po
Episan syr 4xc1
Lesichol 300mg 1x1 po
Mezatrin 1x500mg po
lodia 2mg kp diare
Acetin effervescent 1x1
etorvel 1x60 mg
esilgan 1x2,mg malam
28 14-Sep 1003 Ny Dalasih/ 62th Reattack CVD SNH Kes : CM 14/9 Rapid test -, GDP 192, EKG: VES infrequent IVFD D5 14tpm GDP- GDS (06-18)
Pribadi DMT2 TD: MRI brain non contrast: infark hemorrhage pons S, lacunar infark lama periventrikel lat cornu ant D Cernevit 1x1amp 15/9 DPL, Na/K/Cl/Ca total
dr. Felix, Sp.PD Hipertensi N leukoariosis, atrofi cerebri senilis, rhinitis Novomix 32-0-32 IU 14/9 Thromboaspilet 80 0-1-0, CPG 75 1-0-0 tunda
dr. Angelina, Sp.N Dislipidemia RR 15/9 GDS 56 (D40 1fl) -> GDS 77 (D40 1fl) -> GDS 136 (D10) -> GDS 06 179 Terfacef 1x2g (14/9) 15/9 Hipoglikemia -> bolus D40 2fl, IVFD ganti D10 14tpm; dr. Felix: D10 habis ganti D5, Novomix 30-0-30
Cholecystitis S 15/9 Magnesium 1.44 Amlodipin 10mg 1-0-0 15/9 cek KGDH -> 06, 12, 18, 22
15/9 UL-> bakteri +, jamur + Candesartan 8mg 0-0-1
15/9 DPL 14.3/42/11.1/344 LED 48 Diff count 1/0/73/3/16/5/8.57/1.83 Allupurinol 100 0-0-1
15/9 Na/K/CL/Ca Total 140/4.17/99/9.52 Lansoprazol 30 1x1
15/9 GDS 18 399 22 201 Urlicon 2x250mg
16/9 GDS 06.00: 140 Truvaz 20 0-0-1
Citicolin 2x500mg
Mecobalamin 2x500mg
Antasida syr 3xC1
levepiracetam 2x250mg
cenfres 3-4x gtt 1 OD
29 15-Sep Susilawati /50th Covid-19 Confirmed case Kes : CM 15/09 D-dimer 971 15/9 dr. Taufan terinfo, balasan -
TD: 11/9 Swab PCR I +
dr. Taufan, Sp.P N 12/09 DPL-> Hb/Ht/L/Tr 11/35/4.7/224 LED 55 Diff 0/0/65/28/7 hs-CRP 24.19
RR
S
30 16/9 ny. Mamah /48 Covid-19 Confirmed case 9/9 cxr: dextroscoliosis ringan Oseltamivir 2x75mg (16/9) fu hasil swab 15/9
vertigo HT 11/09 Hb/Ht/L/Tr 13/38/5.7/220 LED 25 NLR 2.32 Diff 2/0/59/3/27/9/3.52/1.52 Hyloquine 1x400mg (16/9)
dr .Taufan SpP 5/9 Swab PCR I + Azitromycin 1x500mg (16/9)
becomzet 1x1
mucopect 3xc1
pct 3x1 kp
betahistine 2x8mg
ondane 2x8mg
#NAME?
17 September 2020 P (Siska)

1 8-Sep Exe B Nn. Lisa Septiana/22 th COVID-19 confirmed case Kes : CM 8/9 Hb 10,8 Ht 32 Leu 7.8 Tr 292 LED 25 NLR 2.23 , diff 0/0/61/3/29/7 Becomzet 1x1 PO 17/9 R/ Oseltamivir --> STOP (7 hari)
Kemkes TD 8/9 CXR cor dan pulmo tak tampak kelainan, tak tampak GGO N Acetyl sistein 3x200 mg PO 18/9 R/ Hyloquin, Azitromisin --> STOP (7 hari)
dr. Taufan Sp.P N 3/9 PCR Swab I + 22/9 Swab PCR ke IV form (+) PE (+) , acc (+)
RR 11/9 PCR Swab II -
S 15/9 PCR Swab III -
2 8-Sep Exe B Nn. Windri/23 th COVID-19 confirmed case Kes CM 8/9 CXR: dextroscoliosis Becomzet 1x1 PO 13/9 Triple therapy stop
Kemkes TD: Hb 15.9 Ht 44 Leu 8.2 Tr 246 LED 15 NLR 3.14 eos/bas/seg/bat/lim/mo 0/0/68/3/22/7 Minosep garg 3x15cc 18/9 R/ Hyloquin, Oseltamivir, Azithromicyn --> STOP (7 hari)
dr. Taufan SpP N: 3/9 PCR Swab I + Polisilan 3x1 cth 21/9 R/ Swab PCR Form+ PE+
S: 14/9 PCR swab III + N Acetyl sistein 3x200 mg PO
3 13-Sep Pres Ny. Destina Ayu/23th COVID-19 confirmed case Kes CM 1/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 7 hari 21/9 R/ Swab PCR Form+ PE+
Kemkes TD: 14/9 PCR swab II + Hyloquine 1x400mg (13/9) 7 hari FU hasil lab + thorak (status belum ada) --> sudah diingetin ke perawat lt 16
dr. Taufan, Sp.P N: 17/9 Hb 12,4 / Ht 37/ Leu 12,2 / Trom 377 / Eritro 4.18/ MVC 87 / MCH 30/ MCHC 34 / LED 80 / NLR 3.09 Azitromycin 1x500mg (13/9) 7 hari
RR: 17/9 Diff count 6/0/63/3/21/7/ Becomzet 1x1 PO
Mucopect 3xCI
N Acetyl sistein 3x200 mg PO
Lactulac 3x1cth
4 13-Sep Pres Nn. Adinda Angelica /26 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
kemkes TD: 12/9 Hb 11.6/Ht 35/L 6.4/Tr 185 LED 18 Diff 2/0/61/3/29/5 Hyloquine 1x400mg (13/9) 7 hari
dr. Taufan, Sp.P N: CXR: Bronkhitis Azitromycin 1x500mg (13/9) 7 hari
RR: Becomzet 1x1 PO
S: Ondansentron 2x4mg k/p mual
5 12-Sep Pres Nn. Debby Fauziah/23 th COVID-19 confirmed case Kes : CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
TD 12/9 Hb 12.7/Ht 38/L 5.5/Tr 241 LED 16 Diff 2/0/52/3/35/8 Hyloquine 1x400mg (13/9) 7 hari
Kemkes dr Taufan Sp.P N CXR: Cor dan pulmo dbn Azitromycin 1x500mg (13/9) 7 hari
RR Becomzet 1x1 PO
6 13-Sep Pres Nn. Rosalia Pasaribu/31th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
dr. Taufan SpP N: CXR: Cor dan pulmo dbn Azitromycin 1x500mg (13/9) 7 hari
RR: Becomzet 1x1 PO
S: N Acetyl sistein 3x200 mg PO
7 13-Sep Pres Nn. Rizki Amelia/23th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
RR: Becomzet 1x1 PO
Ondansentron 4mg 2x1 tab
8 14-Sep Pres Nn. Ion Sintesa/24 th COVID-19 confirmed case Kes CM 10/9 Swab PCR + Oseltamivir 2x75mg (14/9) 7 hari 17/9 R/ Swab PCR, form +, PE +
RR: Becomzet 1x1 PO
S: Minosep garg 3x/hari
Ondansentron 4mg 2x1 tab
9 13-Sep Executive Tn. Hendra Kurniawan/42 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (14/9) 7 hari F/U Hasil swab (16/9)
kemkes TD: Hyloquine 1x400mg (14/9) 7 hari
N: Azitromycin 1x500mg (14/9) 7 hari
S: Ondansentron 2x 8mg FU hasil lab + thorak (status belum ada)
Amlodipin 1x5mg PO
Minocef garg 3/hari
Polysilane 3x1 cth
10 12-Sep Executive Tn. Junardi Juliansyah/ 31 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
TD: 12/9 Hb 14.2/Ht 43/L 4.8/Tr 225 LED 20 Diff 5/0/45/3/37/10 Hyloquine 1x400mg (13/9) 7 hari
Kemkes dr Taufan Sp.P N: Azitromycin 1x500mg (13/9) 7 hari
RR: Becomzet 1x1 PO
Mucopect syr 3xCI
S:
11 12-Sep Executive Tn. Dedi Gunawan/ 41 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
HT TD: 12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10 Hyloquine 1x400mg (13/9) 7 hari
RR: Becomzet 1x1 PO
Amlodipin 1x5mg PO
Mucopect 3x1
Omeprazole 2x1
12 12-Sep Executive Tn. M Eggy/33 th COVID-19 confirmed case Kes CM 9/9 Swab PCR + Oseltamivir 2x75mg (13/9) 7 hari F/U Hasil swab (16/9)
TD: 12/9 Hb 14.2/Ht 42/L 7.4/Tr 301 LED 36 Diff 7/1/38/3/41/10 Hyloquine 1x400mg (13/9) 7 hari
RR: Becomzet 1x1 PO
S: Minocef 3x1
dr. Taufan Sp.P N: CXR: GGO halus paru dextra Minosep garg 3x/hari R/ Rencana swab tgl 19/9 Form (+) PE (+) acc (+) --> konfirmasi ulang ke dr. Taufan Sp.P krn pasien ga mau diswab weekend
S: 12/9 Swab III PCR + Ondancetron 2x8mg PO kp mual
14 15-Sep 1602 dr. Rina Safrina/51 th COVID-19 confirmed case Kes CM 15/9 CXR C/P dbn Oseltamivir 2x75mg (15/9) 7 hari 17/9 R/ Swab PCR Form+ PE+
TD: Hyloquine 1x400mg (15/9) 7 hari FU hasil lab (di status belum ada) --> udah diingetin ke perawat di lt 16
dr. Taufan, Sp.P N: Azitromycin 1x500mg (15/9) 7 hari
RR: Polysilane 3xc1
S: Omeprazole 2x1
Becomzet 1x1 PO
Motilium 2x1 PO
14/8 d dimer 3552 Betadine garg 3x/ hari F/U hasil swab (12/9) Jika hasil swab negatif, rencana rawat jalan. Jika positif, rencana swab ulang tanggal 19/9
12/8 PCR swab I + Liproqy 2x1 19/9 Rencana swab ke VII form (+), PE (+) acc (+)
16/8 D dimer 138 Cetirizine 1x10 mg PO DPL /4 hari--> next 19/9 form (+)
19/8 Hb 11,4 Ht 34 Leu 5,2 Tr 400 LED 125 NLR 2,73 Arixtra 1x2.5mg SC (15/9) 3 hari
19/8 PCR Swab II +
25/8 Hb/Ht/L/Tr 11.3/33/7/409 LED 50 NLR 2.88 Diff 1/1/62/3/23/10 ** dari dr. Taufan Sp.P tidak perlu foto thorax lagi nanti saja saat pulang
26/8 PCR Swab III +
2/9 PCR Swab IV +
9/9 PCR Swab V -
12/9 PCR swab VI +
16 27-Aug 1605 Tn. Imam Wahyudi /43 th COVID-19 confirmed case Kes CM 25/8 PCR swab I + Becomzet 1x1 PO * Riwayat demam 5 hari SMRS
RR 9/9 PCR swab III persumtif N acetylsistein 3x200 mg PO 12/9 extra Microlax
S F/U Hasil swab (16/9)
17 4-Sep 1606 An. Reska Budi/17 th COVID-19 confirmed case Kes: CM 2/9 Hb/ht/L/Tr 13.9/42/6.4/291 diff count 1/3/63/24/9 LED 6 CRP 0.7, Rapid covid IGG Non reaktif IGM Reaktif Becomzet 1x1 PO F/U hasil swab tgl 17/9
Kemkes TD 3/9 PCR swab I + Rhinos SR 2x1 tab PO 18/9 R/ Hyloquin, Oseltamivir, Azithromicyn --> STOP (7 hari)
dr. Taufan, Sp.P N 4/9 CXR: Cor pulmo dbn, tak tampak GGO N acetylsistein 3x200 mg PO
R 10/9 PCR swab 2 +
S
18 15-Sep 1606 Susilawati /50th COVID-19 confirmed case Kes 15/09 D-dimer 971 Hyloquin 1x400 mg PO (17/9) 3 hari 17/9 R/ Swab PCR Form+ PE+
TD 11/9 Swab PCR I + Tamiflu 2x75 mg PO (17/9) 3 hari Zegavit diganti Becomzet sudah dilapor ke dr. Taufan dari farmasi
dr. Taufan Sp.P N 12/09 DPL-> Hb/Ht/L/Tr 11/35/4.7/224 LED 55 Diff 0/0/65/28/7 hs-CRP 24.19 Azitromisin 1x500 mg PO (17/9) 3 hari
RR 16/9 CXR Cor dbn. Susp. Gambaran GGO halus di subpleura paru S. Reaksi pleura S dd/ pleuritis Becomzet 1x1 PO
S Interzinc 3x1 PO
Cavit D3 1x1 PO
Codipront syr 3xC1 PO

Wilmar TD
dr. Taufan Sp.P N
RR
PULANG
S
S: 28/8 CXR: GGO perburukan Amlodipin1x5 mg PO pagi k/p (sudah tdk minum) F/U Hasil swab (16/9)
2/9 PCR swab II + Salbutamol 2x1.5 mg po 17/9 Dexametason tapp off 1x0.75 (start 19/9)
Becomzet 1x1 PO
Kemkes HT TD: 24/8 Hb/Ht/L/Tr 122.6/38/5.8/191 LED 20 NLR 1.61 Diff 2/1/50/3/34/10 Minosep garg 3x/hari 11/9 Extra omeprazole 40mg po
dr.Taufan Sp.P N: CXR: kardiomegali dengan arcus aorta elongasi (HHD?), susp gambaran GGO halus di paru Amlodipin 1x10 mg PO pagi 21/9 R/ Swab PCR Form+ PE+
7/9 PCR Swab III -
14/9 PCR swab IV +
22 3-Sep 1106 Ny. RA Tetty Saroso/ 63 th COVID-19 confirmed case Kes 31/8 PCR Swab I + Vectrine 3x1 PO F/U Hasil swab (15/9)
HP pro 3x1 tab PO
Bakrie Hipertensi TD 29/8 Hb 16.0 Ht 47 Leu 3.4 Tr 104 LED 10 NLR 1.22 , diff 2/0/44/3/38/13, NS1 +, IGG IGM Dengue - Lapraz 1x30 mg PO 14/9 Bisoprolol 1.25-0-0 tunda
dr Taufan SpP DM tipe II + pruritus N GDS 153 Metformin 2x500 mg po (pagi sore) 18/9 R/ PCR Swab Form+ PE+
UL dbn Lesichol 1x300mg PO Cek GDS+DPL /3 hari --> next 18/9 form+
3/9 GDS pk. 18: 244 Etorvel 60mg 0-1-0 k/p nyeri dr. Taufan minta diinfokan nilai normal CT Value di genetic
12/9 Hb 14.3 Ht 43 Leu 5.7 Tr 484 LED 95 NLR 1.46 , diff 6/1/45/3/33/12 Tromboaspilet 1x80 mg PO siang
15/9 Hb 13.8 Ht 40 L 8.8 Tr 494, LED 40 NLR 2.38 Diff 1/0/61/3/27/8/5.58/2.34 N Acetyl sistein 3x200 mg PO
12/9 PCR Swab III +
24 13-Sep 11 Tn. Edy Rosadi COVID-19 confirmed case Kes 10/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 7 hari 17/9 R/ swab PCR, form +, PE +
kemkes TD 13/9 Hb 16.9/Ht 49/L 7.5/Tr 261 LED 8 Diff 4/0/47/3/40/6 Hyloquine 1x400mg (13/9) 7 hari
dr. Taufan SpP N CXR: Cor dbn, arkus aorta elongasi. Gambaran bronkhitis. Dextroskoliosis min Azitromycin 1x500mg (13/9) 7 hari Pantau TD , obat sudah masuk belum
RR Becomzet 1x1 PO
S Mucopect 3xc1
Rhinos SR 2x1
25 13-Sep 11 Tn. Marsuddin/ 45th COVID-19 confirmed case Kes 10/9 PCR Swab I + Oseltamivir 2x75mg (13/9) 7 hari F/U hasil swab tgl 17/9
Kemkes TD 13/9 Hb 15.6/Ht 46/L 9.3/Tr 396 LED 9 Diff 1/1/63/3/28/4 Hyloquine 1x400mg (14/9) 7 hari
dr. Taufan SpP N CXR: Cor paru normal Azitromycin 1x500mg (13/9) 7 hari
RR Becomzet 1x1 PO
S Amlodipin 1x5mg
Omeprazole 1x20mg
26 11 Ny. Mamah /48 th COVID-19 confirmed case Kes 9/9 cxr: dextroscoliosis ringan Oseltamivir 2x75mg PO (16/9) F/U Hasil swab 15/9
Kemkes TD 11/09 Hb/Ht/L/Tr 13/38/5.7/220 LED 25 NLR 2.32 Diff 2/0/59/3/27/9/3.52/1.52 Hyloquine 1x400mg PO (16/9)
dr. Taufan Sp.P N 5/9 Swab PCR I + Azitromycin 1x500mg PO (16/9)
RR Becomzet 1x1 PO
S Mucopect 3xc1 PO
Paracetamol 3x500 mg PO kp
Betahistine 2x8mg PO
Ondancentron 2x8mg PO

APS
Pneumonia
Sistitis
28 10-Sep 1003 Muhammad Faishal Gerd Kes : CM 11/09 Hb/Ht/L/Tr 16.6/47/6.2/177 LED 40 NLR 1.86 Diff 1/0/53/3/31/12/3.51/1.89 IVFD NS:Futrolit 20tpm 15/9 puasa 8 jam lalu diet cair dingin 4x150cc
Asuransi ileitis TD: 113/53 11/09 widal -, SGOT/SGPT 73/53 FL dbn Terfacef 1x2gr IV (15/9) 16/9 sore mulai diet bubur/lunak
dr. Felix, Sp.PD Haemorrhoid interna N 65 14/9 Rapid test di tempat lain - Sanmol 3x500mg PO 17/9 R/ Cek fecal cal protectin
GE kronis RR 20 15/9 Thorax PA-> Pneumonia Pumpisel 2x40 mg iv F/U Hasil swab 16/9
hepatopati S 36.3 Probiostim 1x1 PO 17/9 dr. Felix Sp.PD : Plasminex stop, buscopan k/p, etrovel k/p
Sat 98 Plasminex 3x500mg iv --> STOP F/U hasil feca cal protein tgl 17/9
Buscopan 3x10 po --> K/P
Vosedon 3x10mg po R/ USG Upper Abdomen setelah ada hasil swab
Episan syr 4xc1 po
Lesichol 1x300 mg po
Mezatrin 1x500mg po
Lodia 2mg PO kp diare
Acetin effervescent 1x600 mg PO
Etorvel 1x60 mg PO --> K/P jika nyeri kepala
Esilgan 2 mg 0-0-1/2 PO kp sulit tidur
29 14-Sep 1003 Ny Dalasih/ 62th Reattack CVD SNH Kes : CM 14/9 Rapid test -, GDP 192, EKG: VES infrequent IVFD D5 14tpm 14/9 Thromboaspilet 80 0-1-0, CPG 75 1-0-0 tunda
Pribadi DMT2 TD: 117/81 MRI brain non contrast: infark hemorrhage pons S, lacunar infark lama periventrikel lat cornu ant D Cernevit 1x1amp IV 15/9 Hipoglikemia -> bolus D40 2fl, IVFD ganti D10 14tpm; dr. Felix: D10 habis ganti D5, Novomix 30-0-30
dr. Felix, Sp.PD Hipertensi N 73 leukoariosis, atrofi cerebri senilis, rhinitis Terfacef 1x2g IV (14/9) 17/9 R/ dari neuro rawat jalan, menyesuaikan DPJP
17/9 dr. Felix Sp.PD : acc pulang hari ini, resume (+) resep pulang (+) surat kontrol (+), jika pasien menolak pulang terapi lanjutkan Novorapid
dr. Angelina, Sp.N Dislipidemia RR 15/9 GDS 56 (D40 1fl) -> GDS 77 (D40 1fl) -> GDS 136 (D10) -> GDS 06 179 Amlodipin 10mg 1-0-0 3x10 ui sc, Sansulin 1x32 ui sc lainnya lanjtkan
17/9 dr. Angel Sp.S : acc pulang hari ini, resume (+), resep pulang (+), surat kontrol (+), jika pasin menolak pulang, jika pasien menolak pulang
Cholecystitis S 36.1 15/9 Magnesium 1.44 Candesartan 8mg 0-0-1 obat lanjut jadi oral lihat di cppt, provilen stop,levetiracetam stop
Sat 95 15/9 UL-> bakteri +, jamur + Allupurinol 100 mg 0-0-1 Pasien minta pulang besok (18/9) lapor ke dr. Felix Sp.PD dan dr. Angel Sp.S keluarga minta ketemu DPJP besok
15/9 DPL 14.3/42/11.1/344 LED 48 Diff count 1/0/73/3/16/5/8.57/1.83 Lansoprazol 30 1x1 Cek KGDH -> 06, 12, 18, 22
15/9 Na/K/CL/Ca Total 140/4.17/99/9.52 Urlicon 2x250mg
15/9 GDS 18 399 22 201 Truvaz 20 0-0-1
16/9 GDS pk 06: 140, pk 12: 115, pk 18: 248, pk 22: 184 Citicolin 2x500mg PO
17/9 GDS pk 06: 112 pk 12 : 151 Mecobalamin 2x500mg PO
Antasida syr 3xC1
Pregabalin --> STOP
Levetiracetam 2x250mg PO --> STOP
Cenfres 3-4x gtt 1 OD
Novorapid 3x10 ui
Sansulin 1x32 ui
Betahistine 6mg 3x1 tab PO
Flunarizin 2x5 mg PO
Thromboaspilet 1x80 mg tab PO
CPG 1x75 mg tab PO
THP 2x2mg PO
30 17-Sep 1006 Tn. Arwan Wirawan/ 35th Suspek demam tifoid Kes : CM 17/9 Hb 14.7/Ht 42/ Leu 7.5/Trom 340/ Erit 5.05/ MCV 84/ MCH 29/ MCHC 35/ LED 21/ NLR 1.89 IVFD NS 0,9% : Futrolit 2:1 20tpm 17/9 EKG di ruangan hasil sudah dilapor ke dr. Felix Sp.PD

Laporan Jaga Ruangan September 2020

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Laporan Jaga Ruangan September 2020

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1 September 2020 Gizella (Pagi)

No Masuk Bed Nama Diagnosis TTV

2 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case Kes CM

4 4-Aug 1606 Tn. Lilik S/ 55 th COVID-19 confirmed case Kes CM

7 29-Aug 16 dr. Achmad Budiarto/62 Covid 19 Confirmed Case Kes

8 30-Aug 16 Tn. Sabam Frando/32 th Covid 19 Confirmed Case Kes

9 16-Aug 1101 Ny.Dian Purnamalia/38 th COVID-19 confirmed case Kes CM

10 19-Aug 1102 Tn Faisal Firdaus/52th COVID-19 confirmed case Kes CM

11 25-Aug 1103 Tn. Yan Rahmanto/52 th COVID-19 confirmed case Kes:CM

12 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case Kes CM

13 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case Kes CM

14 15-Aug 1106 Ny. Reni COVID-19 confirmed case Kes CM

asuransi dr. Taufan Sp.P N:

16 27-Aug 1003 Ny. Violen Helen/ 41 th AUB Kes CM

18 25-Aug 1205 Tn. Bruce Gimon/ 42 th TB paru kasus baru Kes : CM

20 21-Aug ICU Tn. Sugeng Purwanto/63th SH cerebellum-pons (19/8) Kes:

10/8 Hb/Ht/L/Tr 11.9/37/3.3/202 Widal S typhi H 1/320

25/8 PCR swab I +

29/8 PCR Swab I +

16/8 PCR Swab premier gene N2 positive Ct 30.67

16/8 PCR Swab I +

24/8 Hb/Ht/L/Tr 14.5/42/7.2/177

21/8 Hb/Ht/L/Tr 13.1/39/3.2/175 diff 0/0/40/3/44/13 LED 17 NLR 0.96

23/8 PCR Swab +

28/8 Swab PCR +

Hitung Jenis 2/0/46/3/40/9/3.17/2.61

25/8 Hb/Ht/L/Tr 13/37/3.3/441 Duff 2/0/32/3/3/46/17 LED 121 SGOT 56/SGPT 30

Oseltamivir 2x75mg (24/8)

O2 3 lpm via nasal canule k/p

O2 2 lpm via nasal canule

Hyloquin 1x400 mg PO (30/8)

Oseltamivir 2x75mg (28/8)

Oseltamivir 2x75mg (24/8)

Oseltamivir 2x75mg (1/9)

Hyloquine 1x400mg (1/9)

Azitromycin 1x500mg (1/9)

*Febris sejak 6/8

2/9 R/ swab ulang, form +, PE +

* Riwayat demam 5 hari SMRS

R/ cek sputum BTA 3x + kultur -> sampel -

Jika sesak dan saturasi di bawah 90 % cek PT APTT DDimer

30/8 Tromboaspilet tunda

2/9 R/ swab ulang, form +, PE +

20//8 Hylo, azitro, oselta stop

tanya dr Taufan paracetamol k/p?

1/9 R/ swab ulang, form +, PE +

26/8 Hyloqiun, Azitromycin, Oseltamivir STOP

31/8 FU hasil swab

31/8 fisioterapi, cek elektrolit, form +

No Masuk Bed Nama Diagnosis TTV

2 11-Aug 1603 Ny. Zulhermis/ 58th COVID-19 confirmed case Kes CM

4 4-Aug 1606 Tn. Lilik S/ 55 th COVID-19 confirmed case Kes CM

6 29-Aug 16 dr. Achmad Budiarto/62 th Covid 19 Confirmed Case Kes

7 30-Aug 16 Tn. Sabam Frando/32 th Covid 19 Confirmed Case Kes

8 16-Aug 1101 Ny.Dian Purnamalia/38 th COVID-19 confirmed case Kes CM

9 19-Aug 1102 Tn Faisal Firdaus/52th COVID-19 confirmed case Kes CM

10 25-Aug 1103 Tn. Yan Rahmanto/52 th COVID-19 confirmed case Kes:CM

11 21-Aug 1104 Ny. Fera Melia/ 49 th COVID-19 confirmed case Kes CM

12 25-Aug 1105 Ny.Prihatin/ 58 th COVID-19 confirmed case Kes CM

13 15-Aug 1106 Ny. Reni COVID-19 confirmed case Kes CM

14 25-Aug 1001 Tn. Dmitry / 49th ADHF ec CAD Kes: CM

15 27-Aug 1003 Ny. Violen Helen/ 41 th AUB