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Menjadikan Bagian Ilmu Penyakit Dalamfakultas Kedokteran UniversitasHasanuddin sebagai pusat pendidikan yang
unggul, mandiri dan bermatabat untukmenghasilkan dokter penyakit dalam yangberkualitas dan mampu bersaing seararegional, nasional maupun global dengan
didukkung oleh sumber daya manusia yangprofesional dan bertanggung ja!ab"
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Menyelenggarakan pendidikan di bidang Ilmu Penyakit
Dalam berbasis evidane based mediine dan riset
Memberikan pelayanan kesehatan di bidang Ilmu
Penyakit Dalam dengan pendekatan kultural dan budaya
seara paripurna dan bermutu
Meningkatkan kuantitas dan kualitas penelitian dasar dan
aplikatif ilmu penyakit dalam yang bertaraf internasional
Meniptakan sistim manajement departemen Ilmu
Penyakit Dalam yang transparan, akuntabel, responsibel,
independen, terintegrasi, dan berkeadilan
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#uriana D!i #artika
#oraya
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$ame % Mrs" & 'ge % () yo 'ddress % Makassar *upation % +ivil oer
-eligion % Moslem &thni % Bugis Marital status % Married Hospital % Hasanuddin University -oom % (th .oor/ (01
-egister $o" % 002312 Date of admission % 4( / 0(/ 4053 Date of death % )/ 03/ 4053 -oom physiian % dr" #uriana D!i #artika +hief physiian % dr" #oraya
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+hief omplaint % shortness of breath
&6periened sine ( months ago and !as advaning sine 5last !eek" #hortness of breath is felt onstantly, notaggravated by the !eather, ativity, or position" Patient feelomfortable lie do!n to the left side" #hortness of breathaompanied by ough slimy !hite, 7here !as no blood andhard to be removed, so that shortness of breath beame!orse" 7his patient !as an *nologi surgery8s patient and!as onsulted to Internal Department, beause of hershortness of breath" 7here !as no omplaint of hest pain andfebrile, sometimes nausea, but didnt vomit" Her !eight !aslossing about 50 kgs in last ( months"" 'ording to the hild
patient, the patient9s eating and drinking less, espeially 5 last!eek"Defeation% !atery sine 5 !eek ago, fre:ueny of defeation!as more than 3 times a day" 7here !as no blood or muousin the stool" 7here !as no omplain of abdominal pain"Mituration% the volume is :uite less, yello!ish, no pain"
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PREVIOUS ILLNESS 7here is a history of modifed radical mastectomy de6tra
on ;anuary, beause of her +a mammae and sheonsume tamo6ifen 40 mg 465 but she didnt onsume itin last month, beause the presription !as dissapear"
7here is no history of hemotherapy or radiotherapy 7here is a history of kidney disease < month ago !hern
she !ent to polilini and got oral mediine, but she didntkno! the name"
7here is no history if onsuming other drugs"
7here is no history if diabetes 7here is no histroy of hypertension 7here is no history of ardiovasuler disease
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FAMILY HISTORY=ather% Died at the age of >3 years !ith unkno!n auseMother% Died at the age of 20 years !ith no kno!n ause#iblings% 7he patient is ?rst hild of three siblings" Brothers
in a healthy state"Husband% living, healthy+hildren% 4 people, healthy
PERSONAL HISTORY
$o history of allergyImmuni@ation history is not lear&ating habits nothing speialPatient !orks in the oe and rarely !alking outside the
oe everyday
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Impression % #evere ill$utritional #tatus % Malnutrition'!areness % A+# 53 &(M>C3BE % (0 kg
HE % 533 mBMI % 5>,>2 kg / m4
Cital #ign
Blood pressure % 550/)0 mmHg Heart rate % 5036/mnt, regular,
strong lift Breathing % 4)6/mnt
7emperature % ,
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Head : normoephal, short blak hair, is not easily to
removed" Eye :
+onjungtiva anemi G, slera iteri Pupil isoor, diameter 4mm/4mm, light re.e6 G/G Ears: #eret
Nose: $ormal shape, disharge , epistaktis
Oral Cavity: 7onsil 7575, hiperemi
Nec: ;CP -G4mH4* , enlargement of lymp nodes ,
enlargement of thyroid gland
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T!ora"lung% Inspetion % asymmetrial, hest !all movement
sinistra left behind Palpation % tatile fremitus hemithora6 sinistraderease as high as ostae CII
Perussion % perussion dimmed on the lefthemithora6 as high as osta CII
'usultation % breathing sound bronhovesiuler,
dereased respiratory sounds on the left hemithora6"Ehee@ing on left hemithora6, there is right and leftmedian basal hemithora6 rhonki
heart% Inspetion % Itus ordis seen on I+# C line on the
left midlaviularis Palpation % Itus ordis palpable at I+# C linea leftmidlaviularis
Perussion % dullness, ardia border of normalimpression
'usultation % heart sound I and II pure, regular, no
additional sound
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'bdomen% Inspetion % +onve6, follo!ing breathing
motion, 'usultation % peristalti sound inrease Palpation % Palpable liver ) m belo! arus
osta, hard onsisteny, blunt edge, bumpysurfae
Perussion % 7ympani G , asites
&6tremity% erithema palmaris , oedempretibial , !arm e6tremity
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LA#ORATORY TEST $%&'()'%(*+, -ro. RS/Pela.o0ia
EB+ % 43"300 /ul
HAB % 2,( g/dl
H+7 % 44,0 J
M+C % )2 .
M+H % 41,5 pg
M+H+ %
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Ro1ti0e Hae.atolo2y
EB+ % 41"510/ulHAB % 2,1 g/dlH+7 % 4,1 .M+H % 4>,5 pg
M+H+ %
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&+A % -hytme #inus , H-% 50)6/i, normoa6is
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RA4IOLO5Y
7hora6 P' from -#"Pelamonia 5
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+ommunity ':uired Pneumoni #uspek &fusi Pleura #inistra 'denoarsinoma mammae de6tra stadium ICB
post M-M metastase paru dan hepar 'ute diarrhea mildmoderate dehydration 'ute on +KD dd / +KD stage IC e" renal dd / pre
renal Hyponatremia 'nemia of hroni disease dd / renal anemia Hypoalbuminemia malnutrition
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No Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
5" Co..10ity ac91ired
70e1.o0ia 6ased o0:+omplaints of shortness ofbreath that !as advaningsine 5 last !eek !ith a ough!ith purulent muus" =rom thee6amination, it !as found the
median basal hemithora6"Patients had malignantdisease that dereasesimmunity and are prone toinfetion" In the laboratorytests, sho!ed leukoytosis41510 and neutrophils !ereinreased ))"5J"
7hora6 photo
ontrol&6amination ofsputum ultureand antibiotisensitivity
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
4" S1s7e 7le1ral e1sio0
Si0sitra 6ased o0:7hought on the main ofomplaints of shortness ofbreath that !as advaningsine last one !eek" *btainedfrom physial e6amination,
tatile fremitus dereased andperussion dullness in the lefthemithora6 high as osta CII"Pleural eusions may bee6udates or transudates"&6udative pleural eusions
usually our in anerpatients"
7hora6 photo
ontrol
&vauate the pleural
.uid
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
(" Ac1te diarr!ea .ild;
.oderate de!ydratio06ased o0Eatery defeation omplaintssine 5 last !eek !ith thefre:ueny of bo!elN 36 eahday, not aompanied by
muus or blood" Urinating lessfrom diarrhea impression" *nphysial e6amination foundinreased peristalsti, turgorless, and tahyardia !ith asore of dehydration
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
3"
>"
Ac1te o0 C and reatinine 4"3MD-D% 45"1("Hy7o0atre.ia is 6ased o0:7hought on the basis ofpatients !ith malignanies
and drink intake eat less" *f
+ontrol the
ureum/reatinine per < days
'de:uate rehydration
'mino aids 430 /4(h / dripsbalane .uid
IC=D $a+l 0"1J 40tpm+orretion sodium fromdietary intake'dvie % onsult linialnutrition
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
2"
)"
A0e.ia o- C!ro0ic 4iseasedd ' Re0al A0e.ia 6asedo0*btained onjuntival pallor,obtained from laboratory testsHb% 2"1, M+C% 2>"1, and M+H%4>"5" 'nemia in patientsthought of as a hroni
disease anemia dd / ironde?ieny anemia patientsgiven malignant disease andintake less" 'nemia an alsobe aused by renal anemiapatients given one said renal
impairment three monthsearlier and no! !ith 55> ureaand reatinine 4"3 MD-D%45"1("
Hy7oal61.i0e.ia 6ased
o07hought on the basis of
#erum fe, 7IB+,=erritine, p7,'P77'nalysis ofperipheralblood
epoetin alfa dannefrovit =e
CIP 'lbumin
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a Pro6le. Pla0 T!era7y 8Ma0a2e.e0t
1" Mal01tritio0 6ased o0the patient is a malignanypatients !ith less intake" BMIobtained from physiale6amination% 5>">2"
7herapy Plan % +linimi6 5bag /hari 'dvie % onsult tolinial nutrition
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4ate Follo= 17 I0str1ctio024/04/201514.30Oncology Surgery
A : - Ca Mammae post MRM metasta!ng tolung an" #epar $%&'0M1( )*arno+s,y50
- O2 4 l!ters / m!nute !a '*- !& t#e general state- n+us!on o+ 'aCl 20 "pm- Ce+tr!a&on 1 g / 12# / !- *etorolac 30 mg / #ours / !
- alum!n 3&2- RC trans+us!on o+ 2 un!ts- Consul Renal ypertens!on
4/04/151.15Renal
!pertens!on
A :-Acute on C*6 "" / C*6 stage ec.renal ""/ pre renal
-A"enocars!noma mammae "e&tra post MRM7 stage lung an" l!er metastases-CA-Acute "!arr#ea 8!t# mo"erate-m!l""e#y"rat!on-#ypoalum!nem!a-Anem!a o+ c#ron!c "!sease "" / renal anem!a
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*
- 6 'aCl 0. 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps- Ce+tr!a&one 1gram / 12# / !ntraenous
$cont!nue" t#erapy Surgery %S(- '-acetyls!ste!n talet 200mg /
#ours / oral- Attapulg!te talet 2&2 $ma&!mum o+ 12
talets(- lan o+ epoet!n al+a an" !ron capsules.- alance l!;u!"- A"!ce:- consul ulmonology- consul Cl!n!cal 'utr!t!on- lan:- e) %7C) +err!t!ne.
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4ate Follo= 17 I0str1ctio0
25/04/157: 110/0R: 100& / m!nute)regular)RR: 2& / m!n
%: 3atery "+e+ecat!on 3&+re;uency) +eces $?() mucus $-() loo" $-(O: seere pa!n / malnutr!t!on / composment!s
ea": pale con@unct!a $?() @aun"!ce $-('ec,: tumor mass $-() 6S R ? 2 cm2O.9ung: "ecrease" resp!ratory soun"s on t#e le+t#em!t#ora&. >#ee!ng !n #em!t#ora& le+t.R#on,! on #em!t#ora& me"!an asal r!g#t an"le+t.eart: S1 / S2 regular) murmur $-(A"omen: !ncrease" per!stalt!c !mpress!on.
9!er palpale cm elo8 t#e sur+ace o+ t#earc# costa no"ul 8!t# #ar" cons!stency.&trem!ty e"ema - / -A:Commun!ty ac;u!re" pneumon!aA"enocars!noma mammary "e&tra post MRM7 stage lung an" l!er metastases
Suspe, leural e++us!on S!n!straAcute "!arr#ea m!l"-mo"erate "e#y"rat!onAcute on C*6 "" / C*6 stage renal ec "" /
pre renal#yponatrem!aAnem!a o+ c#ron!c "!sease "" / renal anem!a#ypoalum!nem!aMalnutr!t!on
- 9o8-pur!ne "!et) potass!um) salt) prote!n0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 'aCl 0. 20 "pm
- Am!no ac!"s 250 cc / 24 #ours / "r!ps- Ce+tr!a&one 1gram / 12# / !ntraenous$cont!nue" t#erapy Surgery %S( -2
- '-acetyls!ste!n talet 200mg / #ours /oral
- Attapulg!te talet 2&2 $ma&!mum o+ 12talets(
- lan o+ epoet!n al+a an" !ron capsules.
- alance l!;u!"%#e a"!ce:- consul ulmonology an" consul Cl!n!cal
'utr!t!on- lan:- Control rout!ne loo" an" electrolytes- e) %7C) +err!t!ne.
- Analys!s o+ per!p#eral loo") CA) A- 7loo" gas analys!s an" stool analys!s- 3& sputum smear e&am!nat!on) gram Beast) sputum culture an" ant!!ot!c
sens!t!!ty- -Ray t#orac!c control- %#ora& C% scan- C% A"omen
4ate Follo= 17 I0str1ctio0
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4ate Follo= 17 I0str1ctio025/04/2015Renal!pertens!on
A:Acute on C*6 "" / C*6 stage ec.renal "" / pre renalA"enocars!noma mammae "e&tra postMRM 7 stage lung an" l!er
metastasesCAAcute "!arr#ea 8ere m!l" "e#y"rat!on#ypoalum!nem!aAnem!a o+ c#ron!c "!sease "" / renalanem!a
- 9o8-pur!ne "!et) potass!um) salt) prote!n 0.g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 'aCl 0. 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps
- Ce+tr!a&one 1gram / 12# / !ntraenous- '-acetyls!ste!n talet 200mg / #ours / oral- Attapulg!te talet 2&2 $ma&!mum o+ 12
talets(- lan o+ epoet!n al+a an" !ron capsules.- alance l!;u!"- %#e a"!ce:
Consul ulmonology $8a!t +or %#e ma!n 6Dcon+!rmat!on(
- %S consul Cl!n!cal 'utr!t!on $8a!t %#e ma!n6D con+!rmat!on(
- lan:- e) %7C) +err!t!ne $8a!t +or results(.- Control rout!ne loo" an" electrolytes.
25/04/20157e"a# On,olog!
Ca mammae "e&tra post MRMmetastas!s to t#e lung an" l!er
- O2 4 l!ters / m!nute !a '*- n+us!on o+ 'aCl 0. 20 "pm- Ce+tr!a&on 1 g / 12# / !- *etorolac 30 mg / #ours / !- alum!n 3&2- lan: rout!ne #ematology control post
trans+us!on
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4ate Follo= 17 I0str1ctio02E F 2 /04/20157: 120/0R:
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4ate Follo= 17 I0str1ctio02E-2 /04/2015Renal!pertens!on
A :-Acute on C*6 "" / C*6 stage ec.renal "" /pre renal-A"enocars!noma mammae "e&tra post MRM7 stage lung an" l!er metastases
-CA-Acute "!arr#ea 8!t# m!l" 0mo"erate"e#y"rat!on-ypoalum!nem!a-Anem!a o+ c#ron!c "!sease "" / renal anem!a
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 'aCl 0. 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps
- Ce+tr!a&one 1gram / 12# / !ntraenous- '-acetyls!ste!n 1 ampoule / 24# / "r!ps
$pro c#emot#erapy(- poet!n al+a 3000 = / 2& a 8ee, /
sucutan- e talet / 12 #ours / oral- alance l!;u!"
- A"!ce :Consul ulmonology $not approe" y
t#e ma!n 6D(Consul Cl!n!cal 'utr!t!on $8a!t +or %#e6D con+!rmat!on(
2E-2 /04/2015OncologySurgery
A : Ca Mammae "e&tra post MRM metastase tolung an" #epar
- O2 4 l!ters / m!nute !a '*- n+us!on o+ 'aCl 0. 20 "pm- Ce+tr!a&on 1 g / 12# / !- alum!n 3&2- emara 1&2)5 mg $"rugs are not
a"m!n!stere"(- %amo&!+en 1& 20 mg $"rug are not
a"m!n!stere"
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2/04/2015Cl!n!cal 'utr!t!on
e!g#t : 14E cm H m!" upper arm c!rcum+erence : 1)5 cm H m!"upper arm c!rcum+erence 8e!g#t : 35 ,g H 77 : 4E ,g
'ut!t!onal Status : Seere M
1E00 ,cal "!etS 'ep#r!sol < & I tspAcol 3&1 tsp+ru!t @u!ces 50 calsupp: J!nc 1 & 20 mg!t. 7 Comp 1&1!t C 1&1
ol!c ac!" 1&400 mg
2/04/20157: 120/0R: 4& / m!n) strongl!+t) regularRR: 24& / m!n% : 3
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4ate Follo= 17 I0str1ctio02/04/2015Renal!pertens!on
A :-Acute on C*6 "" / C*6 stage ec.renal "" /pre renal-A"enocars!noma mammae "e&tra post MRM 7stage lung an" l!er metastases
-CA-#ypoalum!nem!a-Anem!a o+ c#ron!c "!sease "" / renal anem!a
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 'aCl 0. 20 "pm- Am!no ac!"s 250 cc / 24 #ours /
"r!ps- Ce+tr!a&one 1gram / 12# /
!ntraenous- '-acetyls!ste!n 1 ampule / 24# /
"r!ps $-1(- poet!n al+a 3000 = / 2& a 8ee, /
sucutan $"rugs are not logge" !n(
- e talet / 12 #ours / oral- >ater 7alancelan: control rout!ne loo") urea
creat!n!ne) an" electrolytes
2/04/2015Cl!n!cal nutr!t!on
#e!g#t : 14E cm H m!" upper arm c!rcum+erence :1)5 cm H m!" upper arm c!rcum+erence 8e!g#t : 35
,g H 77 : 4E ,g'utr!t!onal status: Seere M
1E00 ,cal "!etS 'ep#r!sol < & I tsp
Acol 3&1 tsp+ru!t @u!ces 50 calsupp:J!nc 1 & 20 mgpu@!m!n 3&2 capnsert!on 'K% s!e 14
4ate Follo= 17 I0str1ctio0
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30/04/20157: 110/E0R: 0& / m!nute)regular)RR: 24& / m!nL: 39: 400 cc7C: -200cc / 24#
pro"uct!on >S6: 50cc / 24#
6ay CareS: s#ortness o+ reat# $?(. Coug# mucus $?( an" sputum !s "!++!cultto remoe.O: seere pa!n / malnutr!t!on / composment!sea": pale con@unct!a $-() @aun"!ce $-(9ung: c#est tue on #em!t#ora& s!n!stra. 'o 8#ee!ng no r#on,#!!..
eart: S1 / S2 regular) murmur $-(A"omen: normal per!stalt!c. 9!er palpale cm elo8 t#e sur+aceo+ t#e arc# costa eren@ol 8!t# #ar" cons!stency.&trem!ty e"ema - / -9aorator!um>7C : 2E
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4ate Follo= 17 I0str1ctio0
30/04/2015Renal!pertens!on
A :-Acute on C*6 "" / C*6 stage ec.renal"" / pre renal-A"enocars!noma mammary "e&tra postMRM 7 stage lung an" l!er metastases
-CA-#ypoalum!nem!a-Anem!a o+ c#ron!c "!sease "" / renal anem!a
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 'aCl 0. 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps
- Ce+tr!a&one 1gram / 12# / !ntraenous- '-acetyls!ste!n 1 ampoule / 24# / "r!ps
$-2(- poet!n al+a 3000 = / 2& a 8ee, /
sucutan $1(- e talet / 12 #ours / oral- >ater 7alance
2-30/04/2015Oncology Surgery
A : Ca Mammae "e&tra post MRM metastaseto lung an" #epar
- O2 4 l!ters / m!nute !a '*- n+us!on o+ 'aCl 0. 20 "pm- Ce+tr!a&on 1 g / 12# / !- 6e&amet#asone 1 amp/ !
$preme"!cat!on e+ore c#emot#erapy(
- Ran!t!"!ne 1 amp / !- alum!n 3&2- emara 1&2)5 mg $"rugs are not
a"m!n!stere"(- %amo&!+en 1&20 mg $"rug are not
a"m!n!stere"(
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30/04/2015Cl!n!cal 'utr!t!on
e!g#t : 14E cm H m!" upper arm c!rcum+erence : 1)5 cm H m!" upper armc!rcum+erence 8e!g#t : 35 ,g H 77 : 4E ,g
'utr!t!on Status: Seere M
1E00 ,cal "!et!a 'K%: orr!"ge son"e 3&100nsure S ?100 cc 3&2 s"t 8aterAcol 3&1 s"mSupp: J!nc 1 & 20 mg
pu@!m!n 3&2 capp
02/05/2015
7: 130/0R: 2& / m!nute)regular) RR: 20& / m!nS%: 39: 400 cc7C: -250cc / 24#
>S6 pro"uct!on: -
6ay Care
S: loss o+ consc!ousness $?() t#e pat!ent 8as restless) s#ortness o+ reat#$?(. Coug# mucus $?( sputum !s "!++!cult to remoe.O: seere pa!n / malnutr!t!on / "el!r!umKCS 4M&1ea": pale con@unct!a $-() @aun"!ce $-(
'ec,: tumor mass $-() 6S R ? 2 cm2O.9ung: c#est tue on le+t #em!t#ora&. 'o 8#ee!ng no r#on,#!.eart: S1 / S2 regular) murmur $-(A"omen: normal per!stalt!c !mpress!on. 9!er palpale cm elo8 t#e
sur+ace o+ t#e arc# costa no"ule l 8!t# #ar" cons!stency.&trem!ty e"ema - / -9aK6S: 4 mg / "l) K6S 15 m!nutes a+ter a"m!n!strat!on 640: 1 mg / "l7loo" culture: no gro8t#A:1. ypoglycem!a2. 6ecrease A8areness et causa suspecte" !ntracran!al tumor metastas!s3. Commun!ty Ac;u!re" pneumon!a4. A"enocars!noma mammary "e&tra post MRM 7 stage lung an" l!ermetastases5. Acute on C*6 "" / C*6 stage renal ec "" / pre renal
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4ate Follo= 17 I0str1ctio002/05/2015Renal !pertens!on
A :-Acute on C*6 "" / C*6 stage ec.renal "" / pre renal-A"enocars!noma mammaae "e&tra post MRM 7 stagelung an" l!er metastases-CA-#ypoalum!nem!a-Anem!a o+ c#ron!c "!sease "" / renal anem!a-#ypoglycem!a-9oss o+ consc!ousness susp!c!ous tumor metastases to t#e
ra!n
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 3-4 l!ter / m!nute !a '*- 6 610 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps- Ce+tr!a&one 1gram / 12# / !ntraenous- '-acetyls!ste!n 1 ampoule / 24# / "r!ps
$#as een g!en +or 3 "ays( stop
- poet!n al+a 3000 = / 2& a 8ee, /sucutan
- e talet / 12 #ours / oral- lu!" alance
02/05/2015Oncology Surgery
A : Ca Mammae "e&tra post MRM lung an" #eparmetastase
- O2 4 l!ters / m!nute !a '*- Ce+tr!a&on 1 g / 12# / !- alum!n 3&2
- emara 1&2)5 mg -2
- tamo&!+en 1&20 mg-2
02/05/2015Cl!n!cal 'utr!t!on
e!g#t: 14E cm H m!" upper arm c!rcum+erence : 1)5 cm Hm!" upper arm c!rcum+erence 8e!g#t: 35 ,g H 77 : 4E ,g
'utr!t!onal Status: Seere M
1E00 ,cal "!et!a 'K%:
M9 3&150M!l, 'e+r!sol 3 & 135 ,cal $3&2 tsp(ol!e o!l 3&0 ,cal $3&1s"m(9o8 potass!um @u!ce 100 ,caloney 3&
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702/05/151S6
- 9o8-pur!ne "!et) potass!um) salt)prote!n 0. g / ,g / "ay
- O2 -10 l!ters / m!nute !a 'RM- 6 610 2 "pm- Ce+tr!a&on 1gram / 12# / ! -11- Am!no ac!"s 250 cc / 24 #ours / "r!ps- poet!n al+a 3000 = / 2& a 8ee, /
sucutan $2(- e talet / 12# / oral- Mon!tor!ng K6S / 30 m!n- lan :3& sputum smear e&am!nat!on) gram)
yeast) sputum culture an" ant!!ot!csens!t!!ty $samples not yet complete(
7loo" gas analys!sControl rout!ne loo") urea creat!n!ne) an"
electrolytes.C% scan o+ t#e #ea" $not "one s!ncegeneral con"!t!on "oes not allo8(
%#e a"!ce:Consul neurologyConsul OM
4ate Follo= 17 I0str1ctio0
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4ate Follo= 17 I0str1ctio004/05/2015Anestes!
C= 6ay-1A: - mpa!rment o+ consc!ousness suspect tumor metastases to t#e
ra!n- Ca mammae post MRM metastas!s to t#e lung an" l!er- Acute on C*6 "" / C*6 stage
O2 -10 l / m!n !a 'RMea" =p 300
Measure ur!ne / #Omepraole 40mg / 24# / !Ot#er t#erap!es accor"!ng %S nterna an"Surgery
04/05/2015Renal #ypertens!on
A :- Acute on C*6 "" / C*6 stage ec.renal "" / pre renal- A"enocars!noma mammary "e&tra post MRM 7 stage lung an"l!er metastases- CA- #ypoalum!nem!a- Anem!a o+ c#ron!c "!sease "" / renal anem!a- ost ypoglycem!a- 9oss o+ consc!ousness susp!c!ous tumor metastases to t#e ra!n "" /
6C
- 9o8-pur!ne "!et) potass!um) salt) prote!n0. g / ,g / "ay
- O2 -10 l!ters / m!nute !a 'RM- 6 610 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps- Ce+tr!a&one 1gram / 12# / !ntraenous- poet!n al+a 3000 = / 2& a 8ee, / sucutan
$2(- e talet / 12 #ours / oral
- alance l!;u!"- lan: rout!ne loo" test control) ureacreat!n!ne) an"
- electrolyte.
04/05/2015Oncology Surgery
A : Ca Mammae "e&tra post MRM lung an" #epar metastase - O2 4 l!ter/me!nutes !a '*- Ce+tr!a&on 1 gr/12#ours/!- alum!n 3&2
- emara 1&2)5 mg -4
- %amo&!+en 1&20 mg
-4
04/05/2015Cl!n!cal 'utr!t!on
e!g#t : 14E cm H m!" upper arm c!rcum+erence : 1)5 cm H m!" upperarm c!rcum+erence 8e!g#t : 35 ,g H 77 : 4E ,g
'utr!t!onal status: Seere M
*%: 1E00,,al6!et to"ay 50 o+ ,cal re;u!rements 50,cal!a 'K%:oney 3&
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05 F 0< /05/2015C= 6-27: 144/0R: 101 / m!nute)regular)RR: 20& / m!nL: 39: 400cc7C: -350cc / 24#>S6 m!n!mal
pro"uct!on
7loo" Kas Analys!sp: E.3E2 $E.35 to E.45(pCO2: 21.0SO2: .2
pO2: 113.3 $0.0 to100.0(CO 3: 12.3 $22-2
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705 F 0< /05/2015Anestes!
C= ar!-2 G 3A : - enurunan ,esa"aran cur!ga metastase tumor ,eota,- Ca Mammae post MRM metastase ,e paru "an #epar-A,ut on C*6 ""/C*6 stage
O2 -10 l / m!n !a 'RMea" =p 300Measure ur!ne / #omepraole 40mg / 24# / !Ot#er t#erap!es accor"!ng %S nterna an"Surgery
05 F 0< /05/2015Renal ypertens!on
A:Acute on C*6 "" / C*6 stage ec.renal "" / prerenalA"enocars!noma mammae "e&tra post MRM 7 stagelung an" l!er metastasesCAypoalum!nem!aAnem!a o+ c#ron!c "!sease "" / renal anem!aost ypoglycem!a9oss o+ consc!ousness susp!c!ous tumor metastases tot#e ra!n "" / 6C
- 9o8-pur!ne "!et) potass!um) salt) prote!n0. g / ,g / "ay
- O2 -10 l!ters / m!nute !a 'RM- 6 610 20 "pm- Am!no ac!"s 250 cc / 24 #ours / "r!ps- Ce+tr!a&one 1gram / 12# / - poet!n al+a 3000 = / 2& a 8ee, /
sucutan- alance l!;u!".
05 F 0< /05/2015Oncology Surgery
A : Ca Mammae "e&tra post MRM lung an" #eparmetastase
- Ce+tr!a&on 1 gr/12#ours/!- alum!n 3&2
- emara 1&2)5 mg stop
- %amo&!+en 1&20 mgstop
05 F 0< /05/2015Cl!n!cal 'utr!t!on
eg!g#t : 14E cm H m!" upper arm c!rcum+erence : 1)5cm H m!" upper arm c!rcum+erence 8e!g#t : 35 ,g H77 : 4E ,g
'utr!t!onal status: Seere M
*%: 1E00,,al6!et to"ay 0 o+ *% 13
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0E/05/20157: 140/0R: 4& / m!nute)regularRR: 24& / m!nL: 3E)20Cnput: 50 cc / 24 #ours=O: 50cc / 24#
>9: 400 cc7C: -300cc / 24#>S6 pro"uct!on:m!n!mal
6ay care S: loss o+ consc!ousness $?() t#e pat!ent appears apat#y) s#ortness o+ reat#$?(.O: ser!ous !llness / malnutr!t!on / apat#yKCS 3M31ea": pale con@unct!a $-() @aun"!ce $-(
'ec,: tumor mass $-() 6S R ? 2 cm2O.ulmonary: c#est tue on t#e le+t #em!t#ora&. >#ee!ng no. R#on,! no.
eart: S1 / S2 regular) murmur $-(A"omen: normal per!stalt!c !mpress!on. 9!er palpale cm elo8 t#esur+ace o+ t#e arc# costa no"ule 8!t# #ar" cons!stency.&trem!ty e"ema - / -9aoratory result: K6S $0
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0E - 0/05/2015Oncology Surgery
A : Ca Mammae "e&tra post MRM lung an" #eparmetastase
- Ce+tr!a&on 1 gr/12#ours/!- alum!n 3&2
0E F 0 /05/2015K!! *l!n!,
e!g#t : 14E cm H m!" upper arm c!rcum+erence : 1)5cm H m!" upper arm c!rcum+erence 8e!g#t : 35 ,g H77 : 4E ,g'utr!t!onal status: Seere M
*% : 1E00,,al!a 'K% :'e+r!sol 3& 3 talespoon $202)5,,al(CO 4&0 ,,al $1 talespoon(oney 3&
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0/05/20157: 140/0R: 10& / m!nRR: 24& / m!nL: 39: 400cc
7C: -350 cc / 24#>S6 pro"uct!on:m!n!mal
6ay care S: loss o+ consc!ousness $?() t#e pat!ent appears apat#y) s#ortness o+ reat#$?(.O: ser!ous !llness / malnutr!t!on / apat#yKCS 3M31ea": pale con@unct!a $-() @aun"!ce $-(
'ec,: tumor mass $-() 6S R ? 2 cm2O.ulmonary: c#est tue on le+t #em!t#ora&. >#ee!ng no. R#on,! no.
eart: S1 / S2 regular) murmur $-(A"omen: normal per!stalt!c !mpress!on. 9!er palpale cm elo8 t#esur+ace o+ t#e arc# costa no"ule 8!t# #ar" cons!stency.&trem!ty e"ema - / -9aorator!um result%otal rote!n :
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0/05/2015 !s!te "r Satr!a8an Aa"! Sp 6 *C O2 10 lpm !a 'RM
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0/05/20151.007 : 0/50R : 110&/!RR : 3< &/!% : 3E)5
!s!te "r.Satr!a8an Aa"!) Sp.6) *CS: s#ortness o+ reat# $?(O: saturat!on 4A: - resp!ratory +a!lurecar"!ogen!c s#oc,n" Stage Renal 6!sease
r!or!ty to C=
O2 -10 lpm !a 'RM9oa"!ng 250cc 'aCl 0.ascon 0.25 mcg / #our / spEcc / # / sp
6outam!ne 3 mcg / ,g 1. mg / dl,reatinine% 4"3, A=-% 45"1(, hyponatremia sodium % 541 mmol /, and hypoalbuminemia albumin 4") g / dl" *n hest 6 raydated 5< 'pril 4053 of lung metastases impression !ithpneumonia, fratures CCI osta osta IC right and left suggestiveof bone metastases" *n 'bdominal ultrasound image dated 5(
'pril 4053 and the hepati metastases of renal insuieny"
Based on history, physial e6amination, and investigations,patients diagnosed !ith ommunity a:uired pneumonia,adenoarinoma mammae de6tra stage ICB post M-Mmetastases of lung and liver, aute diarrhea mild dehydration
moderate, aute on +KD dd / +KD stage IC e renal dd / prerenal,hyponatremia, anemia of hroni disease dd / renal anemia,hypoalbuminemia, and malnutrition"
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*n day 55 of treatment, the patiente6periened a suspeted septi shok due to+'P infetion and e6aerbated by suspiious
7o6oplasma infetion" In addition, the
ourrene of sei@ures an be aused by aproess that is suspeted intraranial braintumor metastases, erebral to6oplasmasuspiious, and due uremikum syndrome"
#ei@ures that our an lead to erebralhypo6ia" &ventually the patient is delareddead after no improvement !ithadministration of inotropi and vasoative"
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Carsinoma Mammae
mmunocomprom!eK !n+ect!onDiarrhea
9ess !nta,e
6e#!"rat!on
Acute on C*6
=rem!cum
enc#ep#alopaty
se!ure
ulmonary
!n+ect!onCA
metastase
7ra!nQepar
9ung
Shortness of breath
Cereral
#ypo&!aDeath
seps!s
%o&oplasma
Cereral Q
Sept!c S#oc,
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