MORNING REPORT on August4th 2011

PHYSICIANS INCHARGE New in Patient : 2 IA. Dr. Zainudin Aziz Consultation : IB. Dr. Didit TS Death Case :II. Dr. RA Siti Juhariyah III. Dr. Suryanti DP, SpP

ANAMNESA
F. / y.o/w. Chief complaint : SOB He has been suffering from cough since 1 week ago. The cough relieves and relapses and accompanied whitish sputum. Bloody cough (-). He has been suffering from SOB since a week ago, relieves and relapses. SOB has been getting worse since last night. First time she suffered from SOB when she was 20 age year. SOB usually is triggered by cold weather, and dust. He sleeps on a pillow. History of leg edema (-). She suffered SOB 3 times in this month,

Decrease of appetite (+), decrease of BW (-) Nausea (-), vomiting (-) History of previous disease : HT(-) . Asthma (-) DM (-) History of contact with TB patient (-), OAT treatment (-) History of treatment : He went to GP 2 days ago because of cough and left chest pain. The doctor performed CXR and diagnosed him as pleural effusion S. The doctor reffered him to SA Hospital. On march 2010, he had been hospitalized for 3 days because of SOB in SA Hospital. The doctor performed sputum AFB and CXR with result (?). The doctor diagnosed him Lung TB. The doctor gave him ...pills (?) History of smoking: pieces/day for years Occupation:

PHYSICAL EXAMINATION
General app.: looks ly ill Level of consciousness : compos mentis, GCS 456 BP : 110/80 mmHg BW : Kg PR : 88 x/mnt BH : cm RR : 20 x/mnt BMI : kg/m2 T ax : 37,6 C

Head : an -/-, ict -/Neck : JVP (R + 0 cmH2O), enlargement of lymphnodes (-) Thorax : COR : ictus invisible ictus palpable ICS V MCL S RHM : SL D LHM : ictus S1, S2, single, mur-mur (-)

PULMO: I St D=S Dy D=S P SF N N N Pc S S S Abdomen Extremities N N S S S

Au V V V V V V Rh - - - Wh - - - -

: flat, soefle, met(-), BS (+), H/L unpalpable : edema - --

LABORATORY FINDING Dec 13th 2010

Leuco Hb PCV Thrombo RBS Ur/Cr SGOT/SGPT Albumin SE Na: K : Cl : Bil T/D/I : : : : : : : :
Urinanalysis (without catheter)

SG/BJ PH Leuco Prot/alb Nitrit Sedimen LPF : epitel HPF : eri leko

glucose keton bilirubin urobilinogen eri

ECG (December 14th 2010)

Sinus tachycardia HR x/mnt Axis frontal : N Axis horizontal : N Conclusion : Sinus tachycardia HR x/m

FOTO THORAX

CXR was taken on December 13th 2010 PA position, asimetry Soft tissue : thin Bone : costae ICS : D: S : Trachea: Hillus : D: S : Thick Cor : site: Size : Shape : Hemidiaphragm : D : S: sinus costophrenicus : D : S : Sharp Pulmo D : - Schwarte (+) - FibroInfiltrate in upper and middle area of the lung with multiple cavities diameter 0,2-0,5 cm and air bronchogram

CXR con..
Pulmo S : Lateral D : Conclusion : - Pneumonia - Lung TB far advanced lesion - Minimal Effusion pleural D - Emphysematous compensatoar lung S - Atelectasis lobus anterosuperior D - Schwarte pulmo D

CXR was taken on Dec 14th 2010

BGA
BGA with O2 2L/m; Oct 15th 2010

PH PCO2 PO2

7.480 29.9 120.8

mmHg
True O2 86.89 normoxemia

mmHg

7.35-7.45 35-45 80-100

HCO3 BE Sat O2

24.0 -0.6 98.7

m mol/l
m mol/l %

21-28 -3-+3 >95

Conclusion: Hypocarbia Hyperoxemia Alcalosis respiratoric

 PEFR I : 0 PEFR 2 : 200 l/m = 3,33 l/sec Delta PEFR : =(3,33-0)/6,21 x 100% = 53,67%

TPL 1.M/ y.o SOB Cough Low grade Fever BP : RR x/mnt HR x/mnt Pulmo A : Rh +/+ Leuco : CXR: infiltrate + air bronchogram 2.M/ y.o SOB Chronic cough Low grade fever, night sweating Decrease of appetite, decrease of BW CXR : fibroinfiltrate + multiple cavities History of OAT treatment

PPL 1. Acute lung infection

IDX 1.1 Pneumonia CAP PS 72 RC III+ Septic Condition

PDX Sputum gram, culture, and sensitivity test Blood culture

PTX O2 2-4 lt/mnt Inj Ceftriaxon 2x1gr iv Inj. Levofloxacin 1x500 mgciproflox acin 2x400 mg(covered by insurance) Ambroxol 3x30mg po.

PMO SOB, Clinical feature CXR

2.Chronic lung infection

2.1 Lung TB far advanced lesion active DD inactive

Sputum AFB OAT if Dx 3x confirm ESR Sputum culture AFB media LJ

Sputu m AFB

TPL

PPL

IDX 3.1 due to no 1 3.2 due to no 2

PDX

PTX

PMO VS Clinical feature

3. M/ y.o 3.1 Minimal SOB Pleural Cough effusion Low grade Fever RR x/mnt HR x/mnt Pulmo Pc : dullness CXR : Ro opaque homogen app. Proeff puncti : redish 5cc,evacuated (-) 4. M/ y.o Edema on lower ext Albumin :

USG Confirm thorax Dx promarker Analized, culture, citology pleural fluid

4. 4.1 Chronic Recheck Hypoalbumine disease. albumin mia 4.2 Low intake Total protein albumin, globulin 5. Hypoosmotic hyponatremia uevolemic 5.1 SIADH Recheck SE

Transfusion alb 20 % Diet HCHP + fish oil + white egg IVFD NS 0.9 % 20 dpm

Alb level

5. M/ y.o Na :

SE level

TPL

PPL

IDX 1.1 Ca Bronchogenic D T4N1M1 std IV A , PA: adeno ca, KS 30-40, post chemoteraphy 1 session, kx: cancer pain Paraneoplastic syndrome

PDX CXR lat D

PTX O2 8 lt/mnt NRBM Codein 3x10mg Paracetamol 3x500mg

PMO SOB, Clinical feature CXR

1.FM/67 y.o 1. SOB Lung Cough tumor Chest pain History of chemoteraphy RR 36 x/mnt Pulmo I: st D>S; dy D<S P: SF N Pc D N A: V N Leuko: 18100 CXR: ro apaque homogen app in right upper and middle area with unclear margin USG abd: pleural effusion D CT scan thorax: susp ca paru kanan tipe stenoting type, ~ T2N1Mx Cytology of pleural fluid: class V adenocarcinoma FOB: mass inside lumen of superior lobe lung D

TPL

PPL

IDX

PDX

PTX

PMO

1.M/ 80 y.o SOB Cough Chest pain Pulmo I: Dy D<S P: SF N Pc D N A: V Leuko: 42,000 CXR: ro opaque homogen app upper area, atelectase superior lobe D

1.Susp lung tumor

1.1 Ca Bronchogenic D T2aNxMx std IB , KS 50-60 Kx: atelectase of superior lobe + paraneoplastic syndrome

CEA, NSE FOB (spirometry, FH) CT scan thorax USG abdomen

Confirm diagnose

SOB, Clinical feature CXR

TPL

PPL

IDX 1.1 Near drowning with complication ARDS 1.2 Pneumonia

PDX Serial BGA/8 hours

PTX O2 10 lt/mnt NRBM Inj Ceftriaxon 2x1gr iv Inj. Gentamycin 2x80mg iv Salbutamol + ipatropium bromide 3 x 1 nebulizer. Inj bromhexin 3x1 amp iv Consult to ICU acc take care to ICU ward and furesemid 3 x20 mg iv.

PMO SOB, Level of conscou sness Signs of ARDS RFT BGA CXR

1.M/14 y.o 1. Acute SOB lung injury Cough History of drowning RR 36 x/mnt HR 100 x/mnt Pulmo A : Rh +/+ Leuco : CXR: infiltrate and air bronchogram in all area Pa O2/ Fi O2 82.52

2.M/14 y.o SOB Cough RR 36 x/mnt HR 100 x/mnt Pulmo A : Rh +/+ Leuco :

2. Acute lung infection

2 High risk of Pneumonia

Sputu m gram/c ulture/ sensitiv ity

Inj Ceftriaxon 2x1gr SOB iv Inj. Gentamycin 2x80mg iv

TPL

PPL

IDX

PDX

PTX

PMO

4.M/ 80 y.o Hb: 8.4 MCH: 33.0 MCV: 98 MCHC: 33.8

3.M/ 80 y.o Chronic SOB Chronic cough Smoker + RR 20 x/mnt Prolonged expiration CXR: hyperaerated

4. Anemia N.N

4.1 Chronic disease 4.2 Low intake

SI/TIBC Blood smear

Recheck Hb level

Clinical feature Hb level

3. 3.1 COPD AE Obstructive type 1 lung disease

Spirometry

Inj dexamethas one 3x1 amp iv Combivent neb 3x/day Chest fisioteraphy Diet LCh

SOB, Clinical feature CXR

5. M/ 62 y.o Nausea Epigastric pain

6. Dyspepsia syndrome

6.1 dyspepsia syndrome

Inj ranitidine Clinical 2x1 amp IV feature

TPL

PPL

IDX

PDX

PTX

PMO

1.FM/19 y.o Chronic cough Bloody cough 300 cc Low grade Fever Pulmo A : Rh -/+ CXR: fibroinfiltrate FH: PPT : 13.2 (c: 12.4) APTT : 25.2 (c: 29.0)
1.F/50 y.o SOB related to weather condition, dust, and common cold She suffered asthma attack everyday this week History of asthma PE: RR 30 x/mnt Wh + + ++ ++

1. 1.1 Lung TB Hemoptoe 1.2 gr IV Pneumonia

Trendelenburg position to the left side IVFD NS 0.9% + Carbazochrom1 amp 20 dpm Tranexamic acid 3x1 inj DMP 3x1 tab

Clinical feature

1.Chronic obstructiv e lung disease

1.Mild spirometr O2 2-4 lt/mnt moderate i NC persistent IVFD NS 0,9% + asthma aminophylin bronchiale drip 20 moderatedrops/mnt severe Inj. Methyl exacerbatio prednisolon n 3x125 mg Salbutamol 2,5mg + ipatropium

Vital sign (SOB)

TPL 1.M/ 22 y.o SOB Cough 1 week RR 44 x/mnt Pulmo A : Rh +/+ CXR: infiltrate PO2: 65.4 PCO2: 31.8 True O2: 13.87 PO2/FiO2: 66% 4. M/74 y.o SOB Sleep on 3 pillows History: HT BP: 160/75 RR 32x/mnt HR 105x/mnt LHM: 2 cm lat MCL S ICS VI CXR: cardiomegally

PPL 1. ARDS

IDX

PDX

PTX O2 10 L/m Ventilator c/ to anesthesia (ventilator full)

PMO SOB, Clinical feature CXR

1.1 Serial BGA/ Pneumonia 8 hours + Septic Condition

3. HF

3.1 F: HF st c/ C FC III cardiology A: Lipid profile cardiomega ly (LVH?)) E: CPC decompens ata, HHD

Inj furosemid Clinical 40mg-0-0 feature, ECG

TPL 3. FM/59 y.o dispneu deffort Sleep on 3 pillows History: HT BP: 199/114 RR 40x/mnt HR 154x/mnt LHM: 2 cm lat MCL S ECG: p pulmonal, RAE CXR: cardiomegally 4. M/74 y.o SOB Sleep on 3 pillows History: HT BP: 160/75 RR 32x/mnt HR 105x/mnt LHM: 2 cm lat MCL S ICS VI CXR: cardiomegally

PPL 3. HF

IDX

PDX

PTX

PMO

3.1 F: CPC c/ decompens cardiology ata Lipid profile A: RAE E: COPD 3.2 F: HF st C FC III-IV A: LVH? E: HHD, DM cardiomyo pathy 3.1 F: HF st c/ C FC III cardiology A: Lipid profile cardiomega ly (LVH?)) E: CPC decompens ata, HHD

Spironolacto Clinical ne 25mg - 0 - feature, 0 if BP S > ECG 100 Infus NS + drip NE 0,052,00 ug/kg/mnt

3. HF

Inj furosemid Clinical 40mg-0-0 feature, ECG

TPL
5. M/74 y.o History of Hypertension BP 160/75

PPL
5.1 HT St II

IDX
5.1 Secondary hypertension 5.2 Primary Hypertension

PDX
C/ internal dept. Lipid Profile

PTX

PMO

Inj furosemid Clinical 40mg IV feature Captopril BP 3x12.5

6. M/70 y.o RBS: 283 Glucosuri 3+

6.1 6.1 reactive FBS Hyperglycemic dt septic 2HPP BS state 6.2 DM type II

Insulatard 0- Clinical 10 iu sc feature Diet DM 1900 kcal/day, low salt < 2 mg/day Curcuma 2x1 LFH

7. M/74 y.o Ur: 76.9 Cr: 4.09

7. Azotemia pre renal

7.1 HT nephropathy 7.2 diabetic kidney disease 7.3 reactive dt septic

Recheck Ur/Cr

TPL 1.FM/38 y.o SOB Cough RR 32x/mnt HR x/mnt Pulmo I: Dy D < S Pc: HS/S A : V/V CXR: clear zone 42,18% 1.M/47 y.o SOB Cough RR 24x/mnt Pulmo P: /N c: D/S A : /V CXR: ro opaque homogen app Airfluid level (+) Proof: (+) pus

PPL

IDX

PDX

PTX Insert thorax catheter in ER dept. At 22.00, plan to connect to WSD suction with pressure 5 mmHg (all of WSD suction being use)

PMO SOB, Clinical feature CXR

1. Right Due to Secondary 1. Lung Tb Pneumothorax 2. Emfisema ventil 42.18% compensa toar

1. Piopneumothorax D

1.1 dt. No 2 1.2 dt. No 3

Culture and analysis of empiema) USG Abdomen

Insert thorax catheter pus 100 cc (plan to conect to WSD suction 5 cmH2O

SOB, Clinical feature CXR

TPL
1. FM/ 30 y.o SOB Cough RR 36x/mnt Leg edema Pulmo: Rh +/+ CXR: cephalization, infiltrate, pleural eff

PPL
1. Lung oedem

IDX
1.1. non cardiogenic 1.2.cardiogenic

PDX
Consult cardiology dept

PTX
Drip dopamin 2.5 g/KgBB/mnt in NS 100 cc

PMO
SOB, clinical feature, CXR, urine output

3. M/ 27 Y Chronic cough History of Chronic diarrhea Prolong Fever of appetite of body weight Free sex (+) Reactive result for determine HIV, Bioline HIV, Oncoprobe 1 & 2

3.Immunocompromised state

3.1. HIV/AIDS St III

C internal Confirm dx departmen t / VCT CD4,Ig G toxo,Ig M toxo,Compl ete and culture Feses.

Clinical feature