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Pasien CHF ec HHD, PPOK
eksaserbasi, pneumonia bilateral,
DM Tipe 2
Pasien : Tn. A
Usia : 68 tahun
MRS : 3 Feb 2022
KRS : 7 Feb 2022
Alasan MRS :
Sesak nafas, demam 3 hari, batuk 3 hari, nyeri dada, mencret
4 x,
nafsu makan menurun
Riwayat kesehatan : DM dan hipertensi 21 tahun
Riwayat pengobatan : Novomix, symbicort, candesartan 8 mg,
parasetamol 500 mg, asetilsistein 200 mg
Diagnosa awal : Pneumonia bilateral
Diagnosa akhir :
CHF ec HHD, PPOK eksaserbasi, pneumonia bilateral, DM
Tipe 2
TTV
Tanggal
3/2 4/2 5/2 6/2 7
BP (mmHg) 126/78 110/70 120/80 120/80 130/70
HR
(x/menit)
110 108 80 80 80
RR
(x/menit)
26 20-23 22 20 20
Temp (°C) 37,2 36,7 36,4 36,5 36,4
SpO2 (%) 98 98 98 99 99
Parameter Hasil Keterangan Nilai normal
Leukosit 12,6 H 4,4-11,3
Eritrosit 4,3 L 4,5-5,9
Hemoglobin 12,8 L 13-18
Hematokrit 38,1 L 40-52
Trombosit 209 150-450
MCV 88,4 85-100
MCH 29,7 26-34
MCHC 33,6 32-50
Basofil 0,2 0-1
Eosinofil 0,0 L 2-4
Neutrofil 88,7 H 40-70
Limfosit 7,6 L 22-44
Monosit 3,5 2-10
CRP kuantitatif 33,7 H <5
Ureum 37,1 18-55
Kreatinin 1,29 H 0,7-1,2
BSS 368 H 74-130
Natrium 140 135-148
Kalium 5,3 3,5-5,5
Klorida 88 L 95-108
Obat Dosis dan frekuensi Rute Indikasi
Tanggal
3 4 5 6 7
O2 5 lpm NC Respiratory √ √ √ - -
Asering 10 tpm IVFD Rehidrasi √ √ √ √ -
Ceftriaxon 1 g/ 12 jam IV Antibiotik √ √ √ √ -
Pantoprazol 40 mg/ 24 jam IV Stress ulser √ √ √ - -
Furosemid 20 mg/12 jam IV CHF √ √ /24 jam √ -
Dexametason 5 mg/12 jam IV Antiinflamasi √ √ /24 jam √ -
Salbutamol+fluticaso
n
2,5 mg + 0,5 mg/8 jam Nebu Bronkodilator
√ √ /12 jam √ -
Sansulin 12 U/ 24 jam SC Hiperglikemi - 12 U 16 U √ √
Novorapid 10 U/ 8 jam SC Hiperglikemi drip 10 U 12 U √ √
Loperamid 4 mg/8 jam PO Diare √ stop - - -
Zink 20 mg/ 24 jam PO Suplemen
diare
√ √ √ √ √
BecomC 1 tab/24 jam PO Suplemen √ √ √ √ √
Azitromisin 500 mg/ 24 ja PO Antibiotik √ √ √ √ √
Miniaspi 80 mg/24 jam PO Antiplatelet √ √ √ √ √
ISDN 5 mg/kp SL Nyeri dada √ √ √ √ √
Alprazolam 0,5 mg/24 jam PO Sedatif √ √ √ √ √
Spironolakton 25 mg/ 24 jam PO CHF √ √ √ √ √
Resfar dlm NaCl 5 g selama 3 jam Drip Mukolitik √ stop - -
Lansoprazol 30 mg/24 jam PO Profilaksis
GU
√ √
Tgl Jam BSS Terapi Novorapid
3/2
13.00 368 Bolus 4 unit
17.00 302 4 unit 4 cc/jam
18.00 453
Sansulin 1 x 12 unit
Novorapid 3 x 10 unit
22.00 435
Bolus 5 unit, lanjut drip
novorapid 4 unit 4 cc /jam
4/2
00.30 360 4 unit/jam
6.00 115
Novorapid 10 unit sc 1 jam
kemudian stop drip
11.00 215
Sansulin 1 x 12 unit
Novorapid 3 x 10 unit
17.00 352
22.00 381
5/2 6.00 281
Sansulin 1 x 16 unit
Novorapid 3 x 12 unit
7/2 6.00 226
Sansulin 1 x 16 unit
Novorapid 3 x 12 unit
Tgl S O A P
3/2 Sesak, batuk,
muntah,
mencret, nyeri
dada, tidak
nafsu makan
BSS 368, SpO2 98%, HR
110 x/m, RR 26 x/m, Swab
(-), EKG: possible
myocardial infarction, foto
thorax: pneumonia bilateral,
wbc 12,6 (H), Hb 12,8 (L),
neutrofil 88,7 (H), CRP
33,7(H), Cr 1,29 (H), Cl 88
(L), glukosa urin: +2
IO: spironolakton
+ miniaspi: K,
azitromisin +
makanan:
absorpsi
azitromisin
Azitromisin diminum 1-2
jam setelah makan,
monitoring TTV, BSS,
elektrolit, keluhan, terapi
4/2 Sesak
berkurang
BSS 6.00 115, swab (-), HR
108 x/m, RR 23x/m
Salbutamol +
azitromisin QTc
interval
Monitoring TTV, BSS,
keluhan
5/2 Sesak
berkurang
BSS 6.00 281, echo
HHD/CAD, glukosa protein
+2, RR 22 x/m
BSS 281 dosis
insulin inadekuat,
dexametason H
3
Monitoring TTV, BSS,
keluhan, konfirmasi
ulang dosis insulin
(saran novorapid 12-14
U)
6/2 Sesak (-) BSS 6.00 287, Gen xpert (-
), RR 20 x/m
BSS 287 Monitoring TTV, BSS,
keluhan
7/2 Sesak (-),
demam(-),
batuk sesekali
BSS 6.00 226, RR 20 x/m Teofilin +
furosemid:
hipokalemia
Monitoring keluhan
Studi Kasus rev(1).pptx
Studi Kasus rev(1).pptx
Studi Kasus rev(1).pptx
Studi Kasus rev(1).pptx
Studi Kasus rev(1).pptx
Studi Kasus rev(1).pptx

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Studi Kasus rev(1).pptx

  • 1. Pasien CHF ec HHD, PPOK eksaserbasi, pneumonia bilateral, DM Tipe 2
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18.
  • 19.
  • 20.
  • 21.
  • 22.
  • 23.
  • 24. Pasien : Tn. A Usia : 68 tahun MRS : 3 Feb 2022 KRS : 7 Feb 2022 Alasan MRS : Sesak nafas, demam 3 hari, batuk 3 hari, nyeri dada, mencret 4 x, nafsu makan menurun Riwayat kesehatan : DM dan hipertensi 21 tahun Riwayat pengobatan : Novomix, symbicort, candesartan 8 mg, parasetamol 500 mg, asetilsistein 200 mg Diagnosa awal : Pneumonia bilateral Diagnosa akhir : CHF ec HHD, PPOK eksaserbasi, pneumonia bilateral, DM Tipe 2
  • 25. TTV Tanggal 3/2 4/2 5/2 6/2 7 BP (mmHg) 126/78 110/70 120/80 120/80 130/70 HR (x/menit) 110 108 80 80 80 RR (x/menit) 26 20-23 22 20 20 Temp (°C) 37,2 36,7 36,4 36,5 36,4 SpO2 (%) 98 98 98 99 99
  • 26. Parameter Hasil Keterangan Nilai normal Leukosit 12,6 H 4,4-11,3 Eritrosit 4,3 L 4,5-5,9 Hemoglobin 12,8 L 13-18 Hematokrit 38,1 L 40-52 Trombosit 209 150-450 MCV 88,4 85-100 MCH 29,7 26-34 MCHC 33,6 32-50 Basofil 0,2 0-1 Eosinofil 0,0 L 2-4 Neutrofil 88,7 H 40-70 Limfosit 7,6 L 22-44 Monosit 3,5 2-10 CRP kuantitatif 33,7 H <5 Ureum 37,1 18-55 Kreatinin 1,29 H 0,7-1,2 BSS 368 H 74-130 Natrium 140 135-148 Kalium 5,3 3,5-5,5 Klorida 88 L 95-108
  • 27. Obat Dosis dan frekuensi Rute Indikasi Tanggal 3 4 5 6 7 O2 5 lpm NC Respiratory √ √ √ - - Asering 10 tpm IVFD Rehidrasi √ √ √ √ - Ceftriaxon 1 g/ 12 jam IV Antibiotik √ √ √ √ - Pantoprazol 40 mg/ 24 jam IV Stress ulser √ √ √ - - Furosemid 20 mg/12 jam IV CHF √ √ /24 jam √ - Dexametason 5 mg/12 jam IV Antiinflamasi √ √ /24 jam √ - Salbutamol+fluticaso n 2,5 mg + 0,5 mg/8 jam Nebu Bronkodilator √ √ /12 jam √ - Sansulin 12 U/ 24 jam SC Hiperglikemi - 12 U 16 U √ √ Novorapid 10 U/ 8 jam SC Hiperglikemi drip 10 U 12 U √ √ Loperamid 4 mg/8 jam PO Diare √ stop - - - Zink 20 mg/ 24 jam PO Suplemen diare √ √ √ √ √ BecomC 1 tab/24 jam PO Suplemen √ √ √ √ √ Azitromisin 500 mg/ 24 ja PO Antibiotik √ √ √ √ √ Miniaspi 80 mg/24 jam PO Antiplatelet √ √ √ √ √ ISDN 5 mg/kp SL Nyeri dada √ √ √ √ √ Alprazolam 0,5 mg/24 jam PO Sedatif √ √ √ √ √ Spironolakton 25 mg/ 24 jam PO CHF √ √ √ √ √ Resfar dlm NaCl 5 g selama 3 jam Drip Mukolitik √ stop - - Lansoprazol 30 mg/24 jam PO Profilaksis GU √ √
  • 28. Tgl Jam BSS Terapi Novorapid 3/2 13.00 368 Bolus 4 unit 17.00 302 4 unit 4 cc/jam 18.00 453 Sansulin 1 x 12 unit Novorapid 3 x 10 unit 22.00 435 Bolus 5 unit, lanjut drip novorapid 4 unit 4 cc /jam 4/2 00.30 360 4 unit/jam 6.00 115 Novorapid 10 unit sc 1 jam kemudian stop drip 11.00 215 Sansulin 1 x 12 unit Novorapid 3 x 10 unit 17.00 352 22.00 381 5/2 6.00 281 Sansulin 1 x 16 unit Novorapid 3 x 12 unit 7/2 6.00 226 Sansulin 1 x 16 unit Novorapid 3 x 12 unit
  • 29.
  • 30. Tgl S O A P 3/2 Sesak, batuk, muntah, mencret, nyeri dada, tidak nafsu makan BSS 368, SpO2 98%, HR 110 x/m, RR 26 x/m, Swab (-), EKG: possible myocardial infarction, foto thorax: pneumonia bilateral, wbc 12,6 (H), Hb 12,8 (L), neutrofil 88,7 (H), CRP 33,7(H), Cr 1,29 (H), Cl 88 (L), glukosa urin: +2 IO: spironolakton + miniaspi: K, azitromisin + makanan: absorpsi azitromisin Azitromisin diminum 1-2 jam setelah makan, monitoring TTV, BSS, elektrolit, keluhan, terapi 4/2 Sesak berkurang BSS 6.00 115, swab (-), HR 108 x/m, RR 23x/m Salbutamol + azitromisin QTc interval Monitoring TTV, BSS, keluhan 5/2 Sesak berkurang BSS 6.00 281, echo HHD/CAD, glukosa protein +2, RR 22 x/m BSS 281 dosis insulin inadekuat, dexametason H 3 Monitoring TTV, BSS, keluhan, konfirmasi ulang dosis insulin (saran novorapid 12-14 U) 6/2 Sesak (-) BSS 6.00 287, Gen xpert (- ), RR 20 x/m BSS 287 Monitoring TTV, BSS, keluhan 7/2 Sesak (-), demam(-), batuk sesekali BSS 6.00 226, RR 20 x/m Teofilin + furosemid: hipokalemia Monitoring keluhan