Visite Isolasi Covid 11 April 2021

Visite isolasi covid minggu, 11/04/2021
Dr. Erisanti, SpPD
assalaamu’alaykum, mohon izin lapor pasien isolasi dokter di rsud pandega dok:
1. tn. Refangga Aditya

masuk 09/04/2021
swab antigen 05/04/2021
swab pcr 06/04/2021
S
Penciuman mulai terasa tapi belum total, sesekali batuk ringan
O
KU cukup, Kes CM
TD 132/88
N 106
Rr
20
T 37C
SpO2 98% room air
Pulmo sdv +/+, rh -/-, wh -/-
A
Covid 19 kasus konfirmasi dengan gejala ringan
Terapi berjalan
Oseltamivir 2x75 mg po (H3)
Azithromicin 1x500mg po (H3)
Astaplus 2x1 po
Sancoidan 2x1 po
Sivit zinc 2x1 po
Vit D3 1000, 1x1 po
2. ny. Dwi Atmawati

masuk 07/04/2021
swab PCR 07/04/2021
penunggu pasien an. Nadya kamila
S
Batuk hampir tidak ada. Keluhan lain –
O
KU cukup, kes CM
TD 140/84
N 91
Rr 22
T 36.2
Spo2 97% room air
Pulmo sdv +/+, rh -/-, wh -/-
A
Covid 19 kasus konfirmasi dengan gejala ringan
Terapi berjalan
Oseltamivir 2x75 mg po (H5)
Azithromicin 1x500mg po (H5)
Sivit zinc 2x1 po
Lansoprazole 1x30 mg po
Vit D3 1000, 1x1 po
Vit E 1x300 iu po
NAC 3x200mg po
Levofloxacin 1x500 mg po
3. ny. Iyan sugiarti

masuk 08/04/2021
swab antigen 08/04/2021 mandiri di labkesda
swab pcr 08/04/2021 mandiri di labkesda, menunggu hasil ke BLK
S
Sesak + berkurang, batuk berkurang, diare 15x seharian kemarin, pagi ini belum
O
KU sesak ringan, kes CM
TD 143/98
N 98
Rr 22
T 36.2c
SPO2 98% (O2 4lpm nc)
Cor S1-S2 reg

Pulmo sdv +/+, rh
abd: BU +, NT epigastium +
ext: crt <2, akral hangat
A
covid 19 (swab antigen dengan gejala berat)
DM tipe 2
Terapi berjalan
O2 4lpm nc
Inf asering 2000cc/ 24 jam
Inj remdesivir 1x100mg iv (H3)
resfar 1x1 fls iv drip
inj omeprazole 2x40 mg iv
inj ondansetron 3x4 mg iv
azithromicin 1x500mg iv drip (H4)
sivit zinc 2x1 po
vit D3 1000, 1x1 po
paracetamol 3x500mg po
metformin 3x500mg dc
KSR 1x600mg po
interlac 2x1 po
4. ny. Hoeriyah
Masuk 8/4/21
Swab Antigen , 7/4/21
S
sesak + namun berkurang
O
KU sesak ringan
kes CM
TD 127/77
N 73
RR 22
T 36.7C
SpO2 99% room air
pulomo sdv +/+, rh -/-, wh -/-
A
covid 19 gejala ringaninf nacl 0.9 1500cc/ 24jam
inj esomeprazole 2x40 mg iv
sucralfate susp 4x10mL ac
sivit zinc 2x1 po
vit D3 1000, 1x1 po
oseltamiir 2x75 mg po (H4)
azithromicin 1x500mg iv (H4)
5. tn. Syahman Dinar

Masuk 6/4/21
Swab PCR :30/3/21
S
batuk <, sesak <
O
KU sesak ringan, kes CM
TD 147/85
N 60
RR 22
T 36.5C
SpO2 97% (O2 3lpm NC)
pulmo sdv +/+, rh -/-, wh -/-
A
covid 19 gejala sedang
terapi berjalan
inf asering 1000cc/ 24 jam
ij ondansetron 2x4 mg iv
inf paracetamol 3x500mg iv
vit E 1x300iu po
sivit zinc 2x1 po
vit D3 1000, 1x1 po
movibet 1x400mg iv (H5)
remdesivir 1x100mg iv (H%)
inj dexamethasone 1x6 mg iv
inj diviti 1x2.5 mg sc
6. ny. Sutiawati (ICU)

Masuk 2/4/2021
Swab antigen 30/3/2021 positif
Swab pcr 05/04/2021
S
sesak berkurang, cemas malam hari, batuk berkurang
O
KU sesak, kes CM
TD 125/72
N 83
RR 23
T 36.2C
SpO2 98% HFNC
pulmo sdv +/+, rh +/+, wh -/-
A
covid 19 kasus konfirmasi gejala berat
terapi berjalan
vit E 1x300 iu po
vit D3 1000, 1x1 po
sivit sinc 2x1 po
tironem 2x500mg iv (H9)
remdesivir 1x100mg iv (H9)
lovenox 1x0.4mL sc
paracetamol 3x1
vit C drip 1 gr iv 1x1
7. ny. Enung (ICU)

Masuk 08/04/2021
Swab antigen 07/04/2021
S
sesak dirasa berkurang
O
Ku tampak sesak, kes CM
TD 118/76
N 107
RR 24
T 36
SpO2 97% HFNC
A
covid 19 gejala berat
terapi berjalan
HFNC
inj pantoprazole 1x1 iv
paracetamol 3x1 gr iv
tironem 3x1 gr iv (H2)
inj remdesivir 1x100mg iv (H2)
sivit ainc 2x1 po
vit D3 1x1000 po
vit E 1x300 iu po
novorapid 3x10 unit sc
lantus 0-0-8 unit sc
vit C iv drip 1x1000mg
8. tn. Upen (HCU)
Masuk 2/4/2021
Swab antigen 30/3/2021
Swab pcr 5/4/2021
S
sesak berkurang, batuk jarang
O
KU tampak sesak ringan, kes CM
TD 147/74
n 102
rr 20
t 36.2
SpO2 96% (O2 15 lpm NRM)
cor S1-S2 reg

A
terapi berjalan
O2 15 lpm NRM
inf NaCl 0.9 1000cc/ 24 jam
inj remdesivir 1x100mg iv (H 10)
inj lovenox 1x0.4 cc sc
gabaxa 1x1
sivit 2x1 po
vit D3 1x1000
amlodipine 0-0-5 mg po
tironem 3x1 gr iv (H3)
9. tn. Asep taufik

Masuk RRK 08/04/21
Swab Antigen 08/04/21
S
sesak +, batuk +
O
Ku sesak, kes Cm
TD 114/67
N 71
RR 22
T 36
SpO2 97% (O2 15 lpm nrm)
cor S1-S2 reg

abd: BU +, NT epigastrium +
ext: crt <2s, akral hangat
A
terapi berjalan
O2 15 lpm NRM
inf NaCl 0.9% 1500cc/ 24 jam
tironem 3x500mg iv (H 4)
gabaxa 1x1
sivit zinc 2x1 po
vit D3 1x1000
vit E 1x300 iu po
NAC 3x200mg po
diviti 1x2.5 mg sc
VIT c 1X1GR IV DRIP
10. ny. Oti

Masuk 1/4/2021
Swab pcr tgl 5/4/2021 positif
S
sesak -, nyeri ulu hati +, muyal +, batuk sedikit
O
KU sedang, kes CM
TD 146/81
n 80
rr 20
t 36C
SpO2 96% room air
cor S1-S2 reg

A
terapi berjalan
inf RL 1000cc/ 24 jam
inj omeprazoloe 2x40 mg iv
tironem 3x500mg iv (H9)gabaxa 1x1
sivit sinc 2x1 po
vit D3 1x1000 Lacys 2x600mg po
alodipine 0-0-10 mg po
inj diviti 1x2.5 mg sc
peinloss 3x1 iv
codein 2x10 mg po
11. tn. Dudih Elang

masuk 07/04/2021
Swab PCR 07/4/21
S
batuk berkurang
O
KU sedang, kes CM
TD 122/78
n 84
rr 20
t36.5C
SpO2 98% room air
A
covid 19 kasus konfirmasi dengan gejala sedang
terapi berjalan
peinlos 3x1 iv
gabaxa 1x1
lansoprazole 1x30 mg
favipiravir 2x600mg po
sivit zinc 2x1 po
vit D3 1x1000
vit E 1x300 iu po
12. ny. Eny
Masuk RRK 08/04/21
Swab PCR 07/04/21
S
keluhan –
O
KU cukup, kes Cm
TD120/82
N 88
RR 20
T 36.2C
SpO2 98% room air
cor S1-S2 reg

A
terapi berjalan
inf RL 1000 cc/ 24 jam
neurobion drip 2x1
vivena 1x1
as folat 1x1
vit D3 1x1000
oseltamivir 12x75 mg po (H4)
azithromicin 1x500mg po (H4)
13. tn. yana

Masuk 1/4/2021
Swab pcr 31/3/2021 positif
S
demam sudah tidak terasa, batuk tidak ada, makan lancar
O
KU cukup, kes CM
TD 128/78
N 84
RR 20
T36.4C
SpO2 98% room air
cor S1-S2 reg,

A
covid 19 kasus konfirmasi dengan gejala sedang
terpi berjalan
lansoprazole 1x30 mg po
sivit aonc 2x1 po
vit D3 1x1000
Lacys 2x600mg po
LBio 2x1 po
remdesivir 1x100mg iv (h4)
movibet 1x400mg iv (H4)
mohon advise selanjutnya dok, hatur nuhun dokter
Dr. Irfan, SpPD
assalaamu’alaykum, mohon izin lapor pasien dokter di isolasi covid rsud pandega dokter.
sebelumnya mohon maaf atas keterlambatan laporannya dokter.
1. tn. Siswo utomo

Masuk 10/04/21
Swab Antigen 9/04/21
S
sakit kepala+, sulit tidur+, mual berkurang, batuk -, sesak –
O
KU cukup, kes CM
TD 121/70
N 83
RR 20
T 36.5C
SpO2 97% room air
cor S1-S2 reg

abd: BU +, NT epigastrium +
A
covid 19 gejala ringan
terapi berjalan
Ivfd NaCl 0,9 2000cc/24 jam
Inj Omeprazole 2x40mg
Inj Ondansentron 3x4mg
Caps Oseltamivir 2x75 (H2)
Tab Azitromisin 1x500 (H2)
Tab Paracetamol 3x500
Tab NAC 3x200
Tab Sivit Zinc 2x1
Tab Vit D3 1000 1x1
Tab Vit E 1x1
2. tn. Ismail Elyas

masuk 10/04/2021
RDT Ag 10/4/2021 POSITIF
S
sesak masih tetap sama
O
KU sesak, kes CM
TD 134/75
N 85x/m
RR 24x/ m
T 36.2C
SpO2 97% (O2 4lpm NC)
cor S1-S2 reg

A
terapi berjalan
O2 NK 4lpm
IVFD NaCl 1500cc/24jam
Inj remdesivir 2x100mg, lanjut 1x100mg
Inj OMZ 1x40mg
Inj ondansetron 3x4mg
Inf resfar 1x1
Inj levofloxacin 1x750mg
Inj dexametason 1x6mg
Inj pct 3x500mg
Sivit zink 2x1 po
VitD 1x1 po
3. tn. Sujono
masuk RRK 05/04/2021
PCR 05/04/2021
S
sesak +
O
KU jelek, sesak berat, kes CM
TD 116/79
N 117
RR 26
T 36.4C
SpO2 93% HFNC
cor S1-S2 reg

A
covid 19 kasus konfirmasi gejala berat
terapi berjalan
HFNC
inf RL 1000cc/ hari
caproliv 3x1 po
B6 1x1
OAT 4-0-0
LBio 2x1
zinc 1x1
nebu combivent/ 8 jam
remdesivir 1x100 mg iv (H7)
peinlos 3x1 iv
tironem 3x1 gr iv drip (H3)
inj lovenox 2x0.4cc sc
movibet 1x400mg iv
KSR 1x1200mg po
4. ny. Oop sopiah

Masuk 10/4/2021
Rdt Ag 10/4/2021 positif
S
sesak +, batuk +
O
KU sesak, kes CM
TD 135/82
N 100
RR 24x/ m
T 36C
SpO2 98% (O2 15 lpm NRM)
pulmo sdv ++, rh +/+, wh -/-
A
terapi berjalan
O2 15 lpm NRM
IVFD NaCl 1500cc/24jam
Inj OMZ 1x40mg
Inf resfar 1x1
Inj pct 3x500mg
Sivit zink 2x1 po
VitD 1x1 po
Furosemid 2x40mg iv
amlodipin 1x10mg po
Nacl 1000cc
5. ny. Anis
masuk 31/3/2021
Swab pcr 1/4/21 positif
S
keluhan –
O
KU cukup, kes CM
TD 124/82
N 84
RR 20
T 36.7C
SpO2 98% room air
cor S1-S12 reg

A
covid 19 gejala sedang perbaikan
terapi berjalan
vit E 1x300iu po
vit D3 1x1000
sivit zinc 2x1 po
astaplus 2x1 po
levofloxacin 1x750 mg iv (H 5)
6. tn. Miskanda
Masuk 27/03/2021
Swab PCR 29/03/2021 positif
S
sesak berkurang
O
KU sesak berkurang, kes CM
TD 121/78
N 84x/ m
RR 22
T 36.7C
SpO2 98%
cor S1-S2 reg

A
covid 19 kasus konfirmasi dengan gejala sedang – berat
terapi berjalan
O2 3lpm nc
inj pantoprazole 1x1 iv
sivit zinc 2x1 po
amlodipine 0-0-10 mg po
betahistine 3x6 mg po
Lacys 2x600mg po
vit D3 1x1000
tironem 3x500mg iv (H 5)
gabaxa 1x1
7. ny. Iwi
Masuk 28/03/2021
Swab PCR 29/03/2021 positif
S
keluhan –
O
KU cukup, kes CM
TD 120/78
N 86
RR 21
T36.6C
SpO2 98% room air
A
covid 19 kasus konfirmasi gejala sedang, perbaikan
terapi berjalan
sivit zinc 1x1 po
asta plus 2x1 po
sancoidan 1x1 po
analsik 2x1 po
8. tn. Handi
Masuk RRK 07/04/21
Swab PCR 07/04/21
S
sesak -, batuk -, ada darah menetes saat BAB, benjolan di dubur –, BAB keras+
O
KU cukup, kes CM
TD 168/90
N 88
RR 21
T 36.6C
SpO2 98% room air
cor S1-S21 reg

A
terapi berjalan
tironem 3x500mg iv (H5)
gabaxa 1x1
alprazolam 0-0-0.25 mg po
LBio 3x1 po
sivit zinc 2x1 po
vit D 1x1 po
valsartan 1x160mg po
unalium 0-0-5 mg po
amlodipine 1x10 mg po
favipiravir 2x600mg po (H4)
9. tn. Robert
masuk 10/04/2021
swab PCR 08/04/2021
S
batuk + berkurang, sesak -, demam –
O
KU sedang, kes CM
TD 134/82
N 88
RR 21
T 36.8C
SpO2 98% room air
A
covid gejala sedang
terapi berjalan
O2 NK 4lpm prn
IVFD NaCl 0.9% 1000cc/24jam
Inj OMZ 1x40mg
Inf resfar 1x1
Inj dexametason 1x6mg
Inj pct 3x500mg
Sivit zink 2x1 po
VitD 1x1 po
10. ny. Ade ruminah

Masuk 10/4/2021
Pcr tgl 8/4/2021 positif
S
batuk mulai ada dahak, mulai terasa plong, anosmia masih total
O
KU sedang, kes CM
TD 124/78
N 88
RR 21
T 36.7C
SpO2 98% room air
A
covid 19 kasus konfirmasi gejala ringan
terapi berjalan
IVFD NaCl 0.9% 2000cc/24jam
Po favipiravir 2x1600mg, selanjutnya 2x600mg
Inj omz 1x40mg
Azitromicin 1x500mg iv
cefotaxime 3x1gr iv
Po PCT 3x500mg
Po sivit zinc 2x1
Po vitD 1x1
Po Lacys 2x600mg
11. nn. amelia

Masuk 10/4/2021
Pcr tgl 8/4/2021 positif
S
batuk ringan+, anosmia mulai berkurang, mulai tercium sedikit untuk bau-bauan, nyeri ulu
hati sedikit
O
KU ringan, kes CM
TD 108/70
N 80
RR 20
T 36C
SpO2 99% room air

abd: BU +,. NT epigastrioum +
A
covid 19 kasus konfirmasi dengan gejala ringan
terapi berjalan
Po Oseltamivir 2x75mg
Po Azitromisin 1x500mg
Po Sivit zinc 2x1
Po VitD 1x1
Po PCT 3x500mg prn
Po Lacys 2x600mg
usul tambah lansoprazole 1x30 mg po dok
mohon advise selanjutnya dok, hatur nuhun dokter
Dr. Irma, SpPD
assalaamu’alaykum, mohon izin lapor pasien dokter di isolasi covid rsud pandega dokter.
1. An. Nadya Kamila

masuk 04/04/2021
Swab antigen (+) 04/04/2021
swab pcr 05/04/2021
S
tidak merasa ada keluhan apa-apa, demam -, batuk -, sakit perut -, perdarahan –
O
Ku sedang, kes CM
TD 122/68
N 71
RR 22
T36.9C
SpO2 98% room air
cor S1-S2 reg

A
terapi berjalan
inf KAEN 3B 40cc/ jam
inj methylprednisolone 2x20 mg iv
oseltamivir 2x75 mg po sejak 09/04/2021 (H3)menggantikan remdesivir yang sudah
diberikan selama 5 hari s/d 08/04/2021
cefixime 1x200mg po (H3)
Nac 3x200mg po
sivit zinc 1x1 po
vit D3 1x1000
sucralfate susp 4x10mL
interlac 1x1
as folat 2x1 po
mohon advise selanjutnya dok, hyatur nuhun dokter
Dr. Alexander, SpOG
selamat malam dok, mohon izin lapor pasien dokter di isolasi covid rsud pandega dokter.
1. Ny. Euis Lisnasari

masuk 09/04/2021
swab antigen 05/04/2021
swab pcr 06/04/2021
S
gerak janin dirasa berkurang semalam, walaupun dirangsang tapi tidak merespons. tapi
mulai ada gerak janin lagi mulai pagi ini (gerak janin hilang timbul), dinding perut terasa
tegang. batuk bila nasal canul sedang dilepas, terutama bila berjalan ke kamar toilet
O
KU sedang, kes CM
TD 101/65
N 99x/ m
RR 24x/ m
T 36.9C
SpO2 98% room air (nasal canul sedang tidak dipakai)
ca -/-, si -/-
cor S1-S2 reg
abd: BU +, uterus gravid,
DJJ 141x/ m
ext: crt <2s, akral hangat, oedem tungkai -/-
A
G1P0A0 uk 33 minggu, covid 19 kasus konfirmasi PCR dengan gejala sedang
terapi berjalan
O2 3lpm NC
drip neurobion 1 amp/ 12 jam
inj dexamethasone 3x1 amp iv
inj ceftriaxone 2x1 gr iv (H3)
promavit 2x1 po
silex syr 3x10mL
L acys 2x600mg po
nebu combivent/ 8 jam (pasien ttd surat penolakan nebulisasi combivent karena dada
berdebar bila dinebulisasi dengan combivent)
O2 dinaikkan jadi 8LPM NRM bila memberat
mohon advise selanjutnya dok, terima kasih dokter

Visite Isolasi Covid 11 April 2021

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Visite isolasi covid minggu, 11/04/2021

Dr. Erisanti, SpPD

1. tn. Refangga Aditya

Pulmo sdv +/+, rh -/-, wh -/-

2. ny. Dwi Atmawati

Pulmo sdv +/+, rh -/-, wh -/-

3. ny. Iyan sugiarti

Cor S1-S2 reg

pulomo sdv +/+, rh -/-, wh -/-

5. tn. Syahman Dinar

pulmo sdv +/+, rh -/-, wh -/-

6. ny. Sutiawati (ICU)

pulmo sdv +/+, rh +/+, wh -/-

7. ny. Enung (ICU)

pulmo sdv +/+, rh -/-, wh -/-

cor S1-S2 reg

9. tn. Asep taufik

cor S1-S2 reg

10. ny. Oti

cor S1-S2 reg

11. tn. Dudih Elang

pulmo sdv +/+, rh -/-, wh -/-

cor S1-S2 reg

13. tn. yana

cor S1-S2 reg,

mohon advise selanjutnya dok, hatur nuhun dokter

Dr. Irfan, SpPD

1. tn. Siswo utomo

cor S1-S2 reg

2. tn. Ismail Elyas

cor S1-S2 reg

cor S1-S2 reg

4. ny. Oop sopiah

pulmo sdv ++, rh +/+, wh -/-

cor S1-S12 reg

cor S1-S2 reg

Swab antigen 28/03/2021 positif

Swab PCR 29/03/2021 positif

pulmo sdv +/+, rh -/-, wh -/-

cor S1-S21 reg

pulmo sdv +/+, rh -/-, wh -/-

10. ny. Ade ruminah

pulmo sdv +/+, rh -/-, wh -/-

11. nn. amelia

pulmo sdv +/+, rh -/-, wh -/-

usul tambah lansoprazole 1x30 mg po dok

mohon advise selanjutnya dok, hatur nuhun dokter

Dr. Irma, SpPD

1. An. Nadya Kamila

cor S1-S2 reg

mohon advise selanjutnya dok, hyatur nuhun dokter

Dr. Alexander, SpOG

1. Ny. Euis Lisnasari

mohon advise selanjutnya dok, terima kasih dokter

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