MAPPING PINERE 1
30 Juli 2021
Pinere 4 K8
Dpjp : dr. Reza Febriliant,
SpPD
Nama : Ilyas Ismail
CM : 0977499
TTL : 25/10/1948 (72)
TM : 27/07/21
ASS :
1. Confirmed case
Covid 19
2. Dyspepsia tipe like
ulcer
3. Hipokalemia ec dd
1.low intake 2. GI
loss
4. Hiponatremia
normoosmolar
hipovolemik
5. Trombositopeni ec
viral infection
Th/
-Bedrest
- O2 4 liter/menit
- IVFD Nacl 0,9 % 20 tpm
- Diet MII 1700 kkal/hari
- IV Omeprazole
40mg/12jam
- KSR 1x600mg
- Amlodipin 1x10mg
- Domperidone 3x10 mg
- Curcuma 3x1
Lab 27/7/2021
Prot Total : 6,2
Alb/ Glo : 3, 09/ 3,11
Lab 26/ 7/ 2021
Hb/ L/ Tr : 14,2/ 5,6/
79000
MCV/ MCH/ MCHC :
76/28/37
Diftel : 0/0/0/80/11/9
Ratio PT/ APTT : 1, 07/ 1,2
D dimer : 760
SGOT/ SGPT : 94/30
Ca : 7,8
GDS: 117
Ur/ Cr : 36/ 1,2
Na/ K/ Cl : 123/ 3,4/ 90
Pinere 1 K5 Pinere 1 K8B
DPJP : dr. M Reza Febriliant, SpPD DPJP : dr. Suheir Muzakkir, Sp.PD
Nama : Abd. Rahman Nama : Sulaiman
TTL : 13/06/1957 (64 th) TTL : 02/10/19961 (59 Tthn)
CM : 1280029 CM :1280212
Tgl Masuk : 20/7/21
Tgl Masuk : 23/07/2021
Ass/ Ass/
1.1.CHF FC NYHA II-III ec dd/ 1. Probable covid 19 dengan
-HHD gejala ringan
-IHD
2. diare kronik ec dd
-DCM
2.Pneumonia geriatri dd/ infeksi 1) kolitis Infeksi
paru spesifik 2) kolitis ulseratif
3.Hipertensi terkontrol
4.Dyspepsia tipe mixed
5.High Risk trombosis 3) chron disease
6.Geriatri Problem Th/
7.Post Stroke Iskemik - Bed rest semifowler position
 
- Diet MB 1700 kkal/hari
Th/
- Bedrest - IVFD rl 20 gtt/i
- Diet MII 1700 kkal/hari + rendah - IV Lansoprazole 30 mg/12 jam
garam - Attapulgit 1 tab/mencret
- IVFD NaCl 0,9% 10 tpm Zink 1x20 mg
- IV Ceftriaxone 2 g/24 jam (H1) Vit d 2x400 mcg
- IV Lansoprazole 30 mg/24 jam Vit c 2x500 mg
- IV Furosemide amp/12 jam Favipiraviw 2x1600mg H1
- Domperidone 3 x 10 mg
Favipiravir 2x600 tgl 27/7/21
- CPG 1 x 75 mg
- ISDN 3 x 5 mg (tunda)
- Atorvastatin 1 x 20 mg Lab 25/7/21
- Ramipril 1 x 2,5 mg Hb/L/Tr : 6,2/8,3/441
- alprazolam 1x0,25 MCV/MCH/MCHC : 66/20/31
- heparin 5000unit/12j Diftel : 1/0/11/75/15/8
- fosen K/p PT/APTT : 1,06/1,0
- favipiravir 2x1600mg H1 Fibrinogen : 458
- favipiravir 2x600mg mulai tgl
D-Dimer : 840
22/7
SGOT/SGPT : 17/9
Lab 26/ 7/ 2021 Ca : 8,6
Hb/ L/ Tr : 13,4/ 5,1/ 185 GDS : 105
Diftel : 15/1/0/50/26/8 Ur/Cr : 22/0,6
SI: 100 Na/K/Cl : 132/3,5/99
GDS: 113
Ur/ Cr : 23/ 0,87 Swab + tgl 23/7/21
PT/ APTT : 1,07/ 0,9
D dimer: >4000
Lab 21/7/21
Hb/K/Cl : 13,1/5,3/221
Na/K/Cl : 144/3,3/107
Ca : 8,8
D-Dimer : 1610
PT/APTT : 1,01/1,0
Ferritin : 238
Ur/cr : 14/0,83
 
Lab 20/07/2021
Hb/L/T : 13,6/5,1/237
MCV/MCH/MCHC
83/31/37
Diftel: 7/1/0/53/28/11
Ca:8,8
Albumin :3,70
GDS : 108
Ur/Cr: 19/1,00
Na/K/Cl: 144/3,20/111
Ro : cardiomegaly pulmo dbn