Laporan Jaga Icu 23 02 2015 (Bed 1)

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN

TANDA VITALTD Sistolik

TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD

20/2/2015BALANS CAIRAN

CMCK

UrineUo (cc/kg/jam)

BalansBalans kumulatif

PEMERIK. PENUNJANGLABORATORIUM

Hb/Hct/Leu/TrNa/K/Cl

Ureum/CreatininSGOT/SGPT

GDP

Bilirubin T/D/IPT/APTT

Protein T/A/GCK/CK-MB

Ca/MgFib

D-dimer/FibrinogenAlbuminKulturLaktat

CD3 (%/absolut)/CD4 (%/absolut)INRLEDPCT

Px Penunjang lainCxrEcho

Ctscan thoraxMRI

analisa cairan asitesHbA1c/Beta hidroksi butirat (Keton)

KulturCT Scan Kepala

USGMASALAH

TERAPI

OL/P/44 thn/Efusi pleura post sternotomi

Dr.Eka y Lantang, SpARizal, Roy, Ilham, Shirby, Tanti, Nia

105-16560-8385-13036- 36,518-24

95- 99%E4V5M6

Konj. Anemis -/- Sklera ikterik -/-SI-II n regular, bising -, murmur -

Sp. Vesikuler, Rh-/-, Wh-/-I : datar, A : BU(+), Pal: lemas

PO2/FIO2 343,3

cc/kg/jam

20 Februari 2015 (Hari Perawatan ke 25)

pH 7,481/pCO2 48,5/pO2 137,3/HCO3- 36,5/BEecf 12,8/SO2 98,1/Hb 11,0/Hct 33

cefexime 3x100 mgkalnex 3x 100 tab

As. Mefenamat K/PSildemafil 3x12,5 mgcaptopril 2x12,5 mg

nebulizer 4x/hari

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN


TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD


CMCK

UrineUo (cc/kg/jam)





GDPBilirubin T/D/I

PT/APTTProtein T/A/G

CK/CK-MBCa/Mg

FibD-dimer/Fibrinogen

AlbuminKulturLaktat


Px Penunjang lainCxr

EchoCtscan thorax

MRIanalisa cairan asites

HbA1c/Beta hidroksi butirat (Keton)Kultur

CT Scan KepalaUSG

MASALAH

TERAPI

ER/L/67 thnLimphadenopathy colly bilateral + mediastinal ec. Susp limphoma + sindrom vena cava superior

Dr. Lucky Kumaat Sp AnRoy,Billy, Ester, Cristie

71-20041-120121-15336 - 38.3

87-100%E2VxM5



pH 7,490/Pco2 61,2/pO2 77,6/HCO3 31,2/BEecf -4,8/SO2 %/ 92,1/Hb 13,4/Hct40 PO2/FIO265,2

550

5000,30cc/kg/jam

50

13,4 / 40 135,9 / 3,74 / 101,6

23 Februari 2015 (Hari Perawatan 2)

Ceftriaxone 2x1 grRanitidin 2x50 mg

Dexamethasone 3x1 grMetilprednisolon 2x 125 mg

Furosemid 20 mg 1x1 amp

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN


TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD


CMCK

UrineUo (cc/kg/jam)





GDP



Ca/MgFib




EchoCtscan thorax



CT Scan KepalaUSG

MASALAH

TERAPI

AT/L/52 thnobstruksi usus mekanik total ec susp. Tumor colon sinistra, CKD + sepsis ec pneumonia post laparatomi

Dr. Lucky Kumaat Sp AnRoy,Billy, Ester, Cristie

110 - 15272- 80

105-11535-36,518-33

86-96%E4V5M6



pH 7,489/Pco33,2/pO2 106,8/HCO3 25,5/BEecf -2/SO2 97,7%/Hb 13,8/Hct 41% PO2/FIO2 292,7

200

3000,92cc/kg/jam

100

23 Februari 2015 HP 4

Asam folat 3x1amlodipin 1-0-0

ceftriaxone 3x1grMethylprednisolon 3x500 mg

Ranitidin 250 mg

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN


TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD


CMCK

UrineUo (cc/kg/jam)





GDP



Ca/MgFib




EchoCtscan thorax



CT Scan KepalaUSG

MASALAH

TERAPI

YW/P/50 thn/h2Penurunan Kesadaran ec CVD SH (ICH ganglia basalis S 170 cc +ivh, prerenal azotemia)

Dr. Lucky Kumaat, Sp.AnRizal, Roy, Ilham, Shirby, Tanti, Nia

125-13985-11095-12537,8- 3824-26

94- 99%E2V1M4



PO2/FIO2 26,3

350

3000,47cc/kg/jam

50


pH 7,443/pCO2 37,8/pO2 72,7/HCO3 26,1/BEecf 1,8/SO2 93,5/Hb 13,1/Hct 39

Valsartan 80 mgCeftriaxone 2x2 gCiticoline 2x50 mgRanitidin 2x 50 mg

PCT drips 3x1

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN


TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD


CMCK

UrineUo (cc/kg/jam)





GDP



Ca/MgFib




EchoCtscan thorax



CT Scan KepalaUSG

MASALAH

TERAPI

LM/L/52 thn/H4Miastenia gravis + gagal napas

Dr. Lucky Kumaat, Sp.AnRizal, Roy, Ilham, Shirby, Tanti, Nia

125-13985-11095-12537,8- 3824-26

94- 99%dalam pengaruh Midazolam



PO2/FIO2 142,6

350

3000,47cc/kg/jam

50

22 Februari 2015

pH 7,251/pCO2 82,1/pO2 83,5/HCO3 36,7/BEecf 9,3/SO2 92,8/Hb 16,8/Hct 50

ij. Prostigmin 3x1Mestimun 4x600 mg

Valsartan 40 mg 1-0-0Prostigmin 3xkapCeftriaxone 2x1 gr

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATAN


TD DiastolikNSP

SPO2Kesadaran

MataJantung

ParuAbdomen

VENTILASIMOV

AGD


CMCK

UrineUo (cc/kg/jam)





GDP



Ca/MgFib



Px Penunjang lainCxrEcho

Ctscan thoraxMRI

analisa cairan asitesHbA1c/Beta hidroksi butirat (Keton)

KulturCT Scan Kepala

USGMASALAH

TERAPI

TM/P/48 thnMultiple fr. Costae Segmental + cliping costae post torakotomy

Dr. Lucky Kumaat, Sp.Ancristie , ilham

102- 12269-7874-90

36,1- 36,516-22

97- 99%E1VxM1



PO2/FIO2 85,3

462500500

20,8 cc/kg/jam38

2/5/201511,8/ 32,6/ 9600/192.000

22/ 0,4


pH 7,335/pCO2 41,1/pO2 260,4/HCO3 22,1/Beecf -3,9/SO2 98,5/Hb 12,6/Hct 38

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Laporan Jaga Icu 23 02 2015 (Bed 1)

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Transcript of Laporan Jaga Icu 23 02 2015 (Bed 1)