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    DEVI SETYA ARIANI
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    This document summarizes the medical history and treatment of a 68-year-old female patient (AS) with non-small cell lung cancer stage 2b and hypertension who presented with respiratory failure, shortness of breath, fever, and oxygen saturation of 95% requiring ventilation. Laboratory tests on February 24th showed elevated white blood cell count, normal hemoglobin and kidney function. Chest x-rays showed infiltrates consistent with pneumonia. The patient received various medications from February 20th to 25th for her symptoms and pneumonia.

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    This document summarizes the medical history and treatment of a 68-year-old female patient (AS) with non-small cell lung cancer stage 2b and hypertension who presented with respiratory failure, shortness of breath, fever, and oxygen saturation of 95% requiring ventilation. Laboratory tests on February 24th showed elevated white blood cell count, normal hemoglobin and kidney function. Chest x-rays showed infiltrates consistent with pneumonia. The patient received various medications from February 20th to 25th for her symptoms and pneumonia.

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    25 views1 page

    VAP Mindmap

    Uploaded by

    DEVI SETYA ARIANI
    This document summarizes the medical history and treatment of a 68-year-old female patient (AS) with non-small cell lung cancer stage 2b and hypertension who presented with respiratory failure, shortness of breath, fever, and oxygen saturation of 95% requiring ventilation. Laboratory tests on February 24th showed elevated white blood cell count, normal hemoglobin and kidney function. Chest x-rays showed infiltrates consistent with pneumonia. The patient received various medications from February 20th to 25th for her symptoms and pneumonia.

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    of 1

    Ny.

    AS (68 tahun)

    Faktor Resiko
    VAP Hipertensi
    Kanker paru
    NSCLC stage 2b

    Tgl 24

    Leukosit: tgl 24 18500 cel/mm3


    Gagal nafas, sesak nafas, Hb: 12mg/dL
    menggunakan ventilator, SrCr: -
    demam, SpO2 Neutrofil BAN: 10%
    Neutrofil segment: 55% Tgl 20-24 feb 2021:
    Trombosit 100.000 cel/mm3 Xeloda oral 1dd1
    BUN: 18 mg/dL
    OT/PT: normal
    Tanggal 20/21/22/23/24 Toraks: nampak infiltrat dan
    gambaran khas pneumonia
    Suhu: 37,1/36,8/36,9/37,9/38,9
    SpO2: 95%/95%/95%/94%/95% Tangga 20/2/21 21/2/21 22/2/21 23/2/21 24/2/21
    l
    Sesak: tgl 20: +++ SpO2 95% 95% 95% 94% 95%
    TD 130/100mmHg 130/100mmHg 130/100mmHg 130/100mmHg 130/100mmHg
    Ronki/wheezing: Tgl 20-21: +/+
    RR 25 25 25 27 20
    Toraks: tgl 24: nampak infiltrat dan HR 90 90 93 90 92
    gambaran khas pneumonia
    Tgl 20-21 feb 2021: Fluimucil
    PCT: 0,8 ng/L Tgl 20-21 feb 2021:
    200mg oral 2dd1
    CRP: 35 mg/L Amlodipine 10 mg oral 1dd1
    Tgl 22-24 feb 2021: Fluimucil
    600mg effervecent 1dd1

    Tgl 22-25 feb 2021: Ventolin


    nebule 3dd1

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