identitas Dpjp Diagnosis Radiografi Swab PCR Terapi saat ini

iati
Ny. 63th
The Kiat covid
dr. Dini, SpPCKD pro HD
19 + dr. dini rb dr.
COVID-19 Fu CT thorax 11/3 SHLL
Multifocal groundglass opacity dengan konsolidasi dan 28/05/21 pukul 00.05 avigan
Inj Azitromycin 1x500mg TPK 1 14/3
h1 2x1600mg
Hua dr. Andry, SpN HT penebalan septa interlobuler pada posterior paru kanan kiri Positive CT value 36 Inj Dexamethasone 3x5mg
60th dr. Adrian Masno, SpJP Vertigo mengarah pada pneumonia typical C-19 (severe). Resfar drip 1x5gr
27.03.32 Tak tampak efusi pleura. rencana swab selanjutnya: Inj Vitamin C 1x1000mg
Prove D3 1x1000mg
Aortosklerosis thorakoabdominalis. Betaserc 2x24mg
Spondyloarthrosis thorakalis dengan osteoporosis. Sanmol 3x1
Diazepam 1x2mg
Novomix 2x8iu
Candesartan 1x8mg
Spironolactone 1x12,5mg

Follow up
2705/21 28/05/21 29/05/21 30/05/21
TD 130/80 TD 145/72 TD 180/110 TD 200/110
HR 90 HR 88 HR 73 HR 78
RR 20 RR 24 RR 20 RR 24
T 36,8 T 36,6 T 36,2 T 36,5
SpO2 99% room air SpO2 98% NRM 15 lpm SpO2 95% NRM 15 lpm SpO2 96% NRM 15lpm

Pusing berputar, mual
muntah
dr. Andry SpN
Betaserc 2x6mg PO
Inj Ondansentron 2x4mg IV
Inj Ondansentron 8mg IV ekstra
Hexium 1gr IV ekstra
Sanmol 1gr IV ekstra
Pusing berputar berkurang
Raber dr. Dini, SpP
Azitromycin 1x500mg
Inj Dexamethasone 3x5mg IV
Resfar drip 1x5mg
Inj Vitamin C 1x1000mg IV
Zegavit 1x1 PO
Prove D3 1x1000m
dr. Adrian Masno SpJP
Candesartan 21x8mg
Inj Lovenox 1x0,4mg sc
Pusing (-) sesak (-) nyeri
dada (-)
dr. Adrian Masno
Candesartan 8mg ekstra
Amlodipin 1x5mg
Spironolactone 1x12,5mg
dr. Andry SpN
Ondansentron stop
Betaserc stop
TDS sempat mencapai
125mmHg, naum naik
kembali mjd 170
Pusing (-) sesak (-) nyeri dada
(-)
dr. Adrian Masno, SpJP (07.00)
drip nicardipin 5cc/jam, titrasi per 15
menit, dosis max 15mg/jam
target TDS 140mmHg
dr. Anjab SpPD (09.50)
novomix 2x8iu
cek BSS tiap pagi
dr. Dini, SpP (10.15)
cek keton urin sore ini
saran pindah ICU

dr. Andry SpN

Betaserc 24 2x1
Diazepam 1x2mg
Sanmol 3x1 IV
Lab
28/05/21 29/05/21 30/9/21