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  • Mapping Dr. Shilvanna SP.P 10-12-2022

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    nina purnamasari
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    A 49-year-old female patient from Aceh Selatan presented with cough, chronic progressive chest pain, left hemiparesis, and an intra cranial mass suspected to be a tumor. She was diagnosed with pneumonia possibly due to mass in the mediastinum or lungs. Her treatment plan included insulin titration, intravenous antibiotics, steroids, and monitoring of vital signs, labs, and imaging studies.

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    Mapping Dr. Shilvanna Sp.p 10-12-2022

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    A 49-year-old female patient from Aceh Selatan presented with cough, chronic progressive chest pain, left hemiparesis, and an intra cranial mass suspected to be a tumor. She was diagnosed with pneumonia possibly due to mass in the mediastinum or lungs. Her treatment plan included insulin titration, intravenous antibiotics, steroids, and monitoring of vital signs, labs, and imaging studies.

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    8 views1 page

    Mapping Dr. Shilvanna SP.P 10-12-2022

    Uploaded by

    nina purnamasari
    A 49-year-old female patient from Aceh Selatan presented with cough, chronic progressive chest pain, left hemiparesis, and an intra cranial mass suspected to be a tumor. She was diagnosed with pneumonia possibly due to mass in the mediastinum or lungs. Her treatment plan included insulin titration, intravenous antibiotics, steroids, and monitoring of vital signs, labs, and imaging studies.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    MAPPING DR. SHILVANA SP.

    P(K)
    10-12-2022
    ICU 1
    B4
    DPJP : NEURO
    RABER : DR. SHILVANA SP.P
    RATNA ARLIS
    Umur : 49 tahun
    Alamat :Aceh selatan
    RM : 1-32-44-27
    s/
    batuk sesekali

    dx/
    - Pneumonia dd 1. Massa
    mediastinum
    2. Massa paru
    -Chepalgia kronik progresif
    - Hemiparesis sinistra ec SOL
    intrakranial
    - Pro removal tumor

    Th/
    -Titrasi insulin
    - Iv. Ceftriaxon 2gr/24 jam (07/12) H4
    - Iv. Omeprazole 40mg/12 jam
    - iv Dexamethason 10mg/8 jam
    Saran:
    - Drip Levofloxacin 750mg/24jam

    p/
    - Evaluasi KU, TTV, Saturasi
    - Cek DR evaluasi 3 hari post AB
    - Foto Thorak evaluasi 5 hari post AB
    - Kultur sputum mo gram K/R (TAD)
    - CT-Scan thorax k/nk (-)

    Lab 28/11/22
    Hb/Ht/L/T : 13,1/38/10,32/259
    E/B/Nb/Ns/L/M : 2/0/0/70/20/8
    Ur/Cr : 32/0,56
    Na/K/Cl : 141/3,60/111
    Gds : 120

    Lab 06/12/2022
    Hb/Ht/E/Leu/Trom :
    15,9/46/5,2/27,34/190
    E/B/Nb/Ns/L/M : 0/1/0/87/6/5
    Pt/aptt : 14,10/22,70
    d-dimer : >4000
    Gds : 141
    Sgot/sgpt : 38/96
    Na/k/cl : 133/4,10/115
    Ur/cr : 48/0,60

    Lab 08/12/2022
    Mg/ca : 2,1/8,2
    Na/k/cl : 142/4,00/112

    Lab 09/12/2022
    Hb/Ht/E/Leu/Trom :
    13,3/32,3/5,1/17,34/130
    E/B/Nb/Ns/L/M : 0/1/0/87/6/2

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