slide dc

7/24/2019 slide DC

1/51

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"

7/24/2019 slide DC

2/51

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

7/24/2019 slide DC

3/51

#uriana D!i #artika

#oraya

7/24/2019 slide DC

4/51

$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

7/24/2019 slide DC

5/51

+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"

7/24/2019 slide DC

6/51

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

7/24/2019 slide DC

7/51

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

7/24/2019 slide DC

8/51

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 % ,

7/24/2019 slide DC

9/51

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

7/24/2019 slide DC

10/51

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

7/24/2019 slide DC

11/51

'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

7/24/2019 slide DC

12/51

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+ %

7/24/2019 slide DC

13/51

Ro1ti0e Hae.atolo2y

EB+ % 41"510/ulHAB % 2,1 g/dlH+7 % 4,1 .M+H % 4>,5 pg

M+H+ %

7/24/2019 slide DC

14/51

&+A % -hytme #inus , H-% 50)6/i, normoa6is

7/24/2019 slide DC

15/51

RA4IOLO5Y

7hora6 P' from -#"Pelamonia 5

7/24/2019 slide DC

16/51

+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

7/24/2019 slide DC

17/51

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

7/24/2019 slide DC

18/51

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

7/24/2019 slide DC

19/51


7/24/2019 slide DC

20/51


(" 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

7/24/2019 slide DC

21/51


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

7/24/2019 slide DC

22/51


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

7/24/2019 slide DC

23/51


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

7/24/2019 slide DC

24/51

4ate Follo= 17 I0str1ctio0

7/24/2019 slide DC

25/51

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.


7/24/2019 slide DC

26/51


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


7/24/2019 slide DC

27/51

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

7/24/2019 slide DC

28/51

4ate Follo= 17 I0str1ctio02S6

7/24/2019 slide DC

29/51


7/24/2019 slide DC

30/51

4ate Follo= 17 I0str1ctio02E F 2 /04/20157: 120/0R:

7/24/2019 slide DC

31/51

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



- 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"


7/24/2019 slide DC

32/51

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

7/24/2019 slide DC

33/51

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


- 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


7/24/2019 slide DC

34/51

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

7/24/2019 slide DC

35/51


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



- 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"(


7/24/2019 slide DC

36/51


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

7/24/2019 slide DC

37/51

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


- 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


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&

7/24/2019 slide DC

38/51

702/05/151S6


- 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


7/24/2019 slide DC

39/51

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


- 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


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&

7/24/2019 slide DC

40/51

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

7/24/2019 slide DC

41/51

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


- 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


- 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

7/24/2019 slide DC

42/51

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

7/24/2019 slide DC

43/51

0E - 0/05/2015Oncology Surgery


- 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&

7/24/2019 slide DC

44/51

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 :

7/24/2019 slide DC

45/51

7/24/2019 slide DC

46/51

0/05/2015 !s!te "r Satr!a8an Aa"! Sp 6 *C O2 10 lpm !a 'RM

7/24/2019 slide DC

47/51

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"

7/24/2019 slide DC

50/51

*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"

7/24/2019 slide DC

51/51

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,

slide dc

Documents