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24 Year Old Male With

Hemoptoe Massive
Recurrent

No

SUBJECTIVE

OBJECTIVES

Mr E / 24 yo

Physic Diagnostic :
Hemoptoe
GCS 456
gr IV
BP 120/110; PR 102
x/min,
RR:
28x/min;
SaO2: 99% (10 lpm
NRBM)

Hemoptoe
200-300
cc /day

ASSESSME
NT

TREATMENT
--Trendelenberg

position to the left


side
-- Inj Tranexamic
acid 3 x 500 mg iv

No
2.

SUBJECTIVE

Mr E/24 yo
Hemoptoe -1
Admi glass
since 8
tted
days ago, redER
color,
(Dec black
7th) intermittent
pain
14.0 chest
0
especially when
cough.
Low
RHC grade fever (+),
U
night sweating
20.0
(+), decreased
0
of appetite (+),
decreased
of
body weight (+)
(?kg)
History of lung
TB 3 years ago,
got OAT 1st cath
from
Kepanjen
Hospital for 6
month,
until
declared cured.

OBJECTIVES

ASSESM
NT

TREATMENT

Physic Diagnostic :
Look moderately ill
GCS 456
BP
120/110;
PR
102x/mnt;
RR:
28x/mnt; sat 99% 10
lpm NRBM;
An -/- Ict -/- Cy -/JVP R+3 cmH2O
Cor:
RHM SL D
LHM ICS V MCL Sin,
S1S2 normal
Pulmo :
St D>S, Dy D>S
FS N Pc S D BS V
V
N
SD
V
V
N
SD
V
V
Rh - - wh - -

2.
Hemopto
e gr IV
massive
2.1
Pneumo
nia CAP
2.2 Lung
TB
inative
dd active

-Trendelenberg
position to the left
side
- IVFD NS 0.9 % +
Carbazochrome
(not covered by
BPJS)
- Inj Tranexamic
acid 3 x 500 mg iv
- Inj Vit K 3 x 1
amp iv
- codein 3 x 10 mg
po
-Admitted to RHCU

CXR 15/5/2015
PA position, symetris KV Enough
Soft tissue: N
Bone N, costae D: mallunion costae
7 posterior S: N
ICS D/S:N
Trachea : in the middle
Hillus D/S: thickening
Cor site: N
Size: CTR 67%
Apex: Rounded, embeded
Hemidiaphragma D/S: domeshape
Costophrenicus sinus: sharp
Pulmo D: infiltrate para hilar D, air
bronchogram (+)
S: infiltrate para hilar S, air
bronchogram (+)
Conclusion:
Old Fracture Costae 7 D Posterior
Cardiomegaly

CXR 24/5/2015
AP position, symetris, KV to low
Soft tissue: N
Bone N, costae D: mallunion costae
7 posterior S: N
ICS D/S:N
Trachea : in the middle
Hillus D/S: thickening
Cor site: N
Size: CTR 72%
Apex: Rounded, embeded
Hemidiaphragma D/S: domeshape
Costophrenicus sinus: sharp
Pulmo D: infiltrate para hilar D, air
bronchogram (+)
S: infiltrate (-)
Conclusion:
Old Fracture Costae VII D Posterior
Cardiomegaly
Pneumonia

ECG

ER/ may 24th /9 pm

Echo
September 14

Anamnesis
Mr.S/59yo / CVCU / BPJS insurance

CC : shortness of breath
SOB for 3 days at rest, dyspneu increase with
mild activity (walk >10m), OP (+), hardly sleep
at night because of SOB, PND (+), cough with
sputum for 2 weeks , accompanied with
subfebril fever.
Last drugs at outpatient clinic at RSSA (22/5)
aspilet, ISDN, spironolacton, diovan History of
admission at hospital bcause same complain
2008 & 2013
History of HTN (+) , DM (-)

PHYSICAL
EXAMINATION
Well nourished, GCS 456

General
appearance
Vital sign

BP 131/63 mmHg HR 100 regular RR 28tpm

Head

Pale conjungtiva -,Icteric-, nostril breath +

Neck

JVP R +4 cmH2O at 30o

Thorax :
Heart &Lung

Ictus visible palpable at ICS V AAL sinistra


RHM SL D LHM as ictus
S1 S2 normal, gallop (-)murmur systolic 3/6 PM
at apex
Simetric,
Rh - Wh ---++
--

Abdomen

Flat,Soft,Liver Spleen unpalpable,Non tender,BS


(+) N, epigastric pain (+)

Extremities

Edema - - warm acral - + +


- -

ECG

CVCU / may 24th /11 pm

Laboratory Finding
may 24th 2015
Leucocyte

Value

25.280

/L

4.700 11,300

Hb

15,50

gr/dL

11,4 15,1

Hematokrit

45,00

38 42

258.000

/L

142.000 424.000

CRP kuantitatif

12,28

mg/dL

<0,3

Procalcitonin

13,71

ng/dL

>2 high risk for septic

Eosinofil

0,0

04

Basofil

0,1

01

Neutrofil

89,8

51 67

Limfosit

4,7

25 33

Monosit

5,4

25

Plt

Limfosit count:

Laboratory
Finding
may 24th 2014
RBS

Value

73

mg/dL

< 200

29,60

mg/dL

16,6-48,5

1,49

mg/dL

<1,2

SGOT

32

U/L

0 32

SGPT

15

U/L

0 33

Natrium

130

mmol/L

136 145

Kalium

3,39

mmol/L

3,5 5,0

Chloride

111

mmol/L

98 106

Ureum
Creatinine

Cardiac Enzime
Lab

Value

Norm
al
value

CPK

670

u/L

30190

CKMB

70

u/L

<25

Trop I

1.00

Ng/m Neg
l

Hemostatic Physiologic
Lab

Patien
t

Normal value

PPT

21,0

se
c

11,5-11,88

INR

1,75

APTT

33,60

Concl.

PPT lengthened, APTT


normal

0,8 1,30
se
c

27,4 28,6

BGA

Conclusion :
Metabolic acidosis partially compensated

CUE AND CLUE

1. Mr.S/59yo
SOB for a week related with
hard activity, worsening after
she had shocked and run, OP.
History of Leg swelling and
PND
History of HT 12 years with in
adequately drugs,
hospitalized >5 times as
jantung bengkak
History of ACS
(SOB+epigastric pain) 2
months ago, outpatient clinic
with nitrat, bisoproplol,
dimenhidrinat, vastigo
BP 165/ 80 HR 120 RR
24x/mnt, nostrill breath, basal
rales, cardiomegali with ictus
displacement
ECG: ST, incomplete LBBB,
LAE, LVH

PROBLE
M LIST

1.ADHF
Precip
factor
-infectio
n

INITIAL
DIAGNO
SE

3.1.
ischemi
c CM
3.2
CAD
3.3.
HHD

PLANING
DIAGNOSE

Echocardi
ography
Coronary
Angiograp
hy
Lipid
profile
Uric acid
ECG serial

PLANING THERAPY

O2 4 lpm nasal
canule
Bed rest , semi
fowler position
Fluid intake 1200 cc
daily
Negatif fluid
balanced 500
cc/day
Soft heart diet 1700
kcal
Furosemide 40 mg-0-0 iv
PO:
Captopril 3x12.5mg
Spironolactone 025mg-0
Simvastatin 0-010mg
Asa 1x80mg

PLANING
MONITORI
NG

Subjective
, VS
Urine
production
ECG serial

CUE AND CLUE

PROBLE
M LIST

INITIAL
DIAGNOS
E

PLANING
DIAGNOSE

PLANING THERAPY

PLANING
MONITORI
NG

2. Mr.S/59yo
Cough, whitish sputum,
subfebrile
Infiltrate at CxR,
leukocytosis

2.
Pneumo
nia

Sputum
culture,
gram,
sensitivity

3. Mr.S/59yo
History dispneu,
orthopneu, PND, leg
swelling

3. HF dt
ischemic
cardiom
yopathy

Echocardi
ography

4. Mr. S/59 yo
HR 120 bpm, febrile (38.2
C), RR 40 tpm, pneumoni

4. Septic
conditio
n

Inj. Levofloxacin
1x750 mg i.v.

Subjective

5. Mr. S/59 yo
Ureum/Creat: 49.6/1.4

5. Renal
azotemi
a

Treat underlying
disease

Subjective

As Pulmonology
Dept
(O2 10 lpm NRBM,
Inf. Levofloxacin
1x750 mg i.v,
N. Acetyl cystein
3x200 mg)

Subjective

CXR 10/6/2015
AP position, symetris, KV enough
Soft tissue: N
Bone N, costae D: mallunion costae
7 posterior S: N
ICS D/S:N
Trachea : in the middle
Hillus D/S: thickening
Cor site: N
Size: CTR 70%
Apex: Rounded, embeded
Hemidiaphragma D/S: domeshape
Costophrenicus sinus D: blunt
Pulmo D: infiltrate para hilar D, air
bronchogram (+)
S: infiltrate (-)
Conclusion:
Old Fracture Costae VII D Posterior
Cardiomegaly
Pneumonia

Kultur
Sputum 27/5/15

Kultur
Darah 29/5/15

Kultur sputum
12/6/15

PROGRESS NOTE
DATE

25/5/15
CVCU

28/5/15
CVCU

SUBJ

Dispneu ,
productive
cough

Dispneu ,
productive
cough

OBJ
BP 100/59 Hr 104
bpm, SaO2 96%
Rh+ +
++Negative balance
500 cc

BP 105/69 Hr 100
bpm, SaO2 96%
Rh+ +
++Negative balance
750 cc
Sputum culture: fungi

PLAN
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1500 cc/24 hrs, negative fluid balance
750 cc /24 hrs
Inj Furosemide 40-20-0 mg i.v.
Inj Cefoperazone 2x1 gram
Inj Levofloxacin 1x750 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-25-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc
/24 hrs
Inj Furosemide 40-20-0 mg i.v.
Inj Cefoperazone 2x1 gram
Inj Levofloxacin 1x250 mg
Inj Fluconazole 1x400 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-25-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-0 mg

DATE

30/5/15

3/6/15
CVCU

SUBJ

Dispneu ,
productive
cough

Dispneu ,
productive
cough

OBJ
BP 96/59 Hr 96 bpm,
SaO2 97%
Rh+ +
++Negative balance
750 cc
Blood culture:
gentamycin sensitive

BP 105/69 Hr 88
bpm, SaO2 96%
Rh+ +
++
+Negative balance
750 cc

PLAN
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1500 cc/24 hrs, negative fluid balance
750 cc /24 hrs
Inj Furosemide 40-20-0 mg i.v.
Inj Cefoperazone 2x1 gram STOP inj
Gentamycin 2x80 mg
Inj Levofloxacin 1x250 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-25-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-2.5 mg
Digoxin 0.25-0-0 mg
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc
/24 hrs
Inj Furosemide 40-0-0 mg i.v.
Inj Gentamycin 2x80 mg
Inj Levofloxacin 1x250 mg STOP
Inj Fluconazole 1x400 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-2.5 mg
Digoxin 0.25-0-0 mg

DATE

SUBJ
Dispneu
subsided,
productive
cough

4/6/15
WARD

8/6/15
WARD

LAB:
Leukocyte:
8,850
Ur/cr: 27.3/1.22

Dispneu after
walking to rest
room ,
productive
cough

OBJ
BP 100/60 Hr 88
bpm,
Rh - ++Negative balance
500 cc

BP 100/60 Hr 82
bpm,
Rh - ++
+Negative balance
500 cc
Target fluid balance:
neg 2000 cc/24 hrs

PLAN
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1500 cc/24 hrs, negative fluid balance
750 cc /24 hrs
Inj Furosemide 40-0-0 mg i.v.
Iinj Gentamycin 2x80 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-2.5 mg
Digoxin 0.25-0-0 mg
semifowler position
O2 4 lpm NC
Total fluid 1000 cc/24 hrs, target negative fluid balance
2000 cc /24 hrs
Inj Furosemide 40-40-40 mg i.v.
Inj Cefoperazone 2x1 gram
Inj Fluconazole 1x400 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-0 mg
Digoxin 0.25-0-0 mg

DATE

10/6/15

SUBJ

Dispneu ,
productive
cough
-CxR

Dispneu ,
productive
cough

12/6/15

LAB
Lekocyte 9.650
Ur/Cr :
60.5/2.35
Sputum
culture:
Pseudomonas
Aeruginosa

OBJ

BP 100/70 Hr 80
bpm,
Rh - ++Negative balance
800 cc/24 hrs

BP 100/60 Hr 77
bpm,
Rh - -+Negative balance
1000 cc

PLAN
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1000 cc/24 hrs, target negative fluid
balance 1500 cc /24 hrs
Inj Furosemide 60-60-60 mg i.v.
Iinj Gentamycin 2x80 mg
Inj Fluconazole 1x200 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-25-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol 2.5-0-0 mg
Digoxin 0.25-0-0 mg
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1000 cc/24 hrs, target negative fluid balance
1500 cc /24 hrs
Inj Furosemide 40-40-40 mg i.v.
Inj Gentamycin 2x80 mg STOP
Inj Fluconazole 1x200 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x25 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Bisoprolol STOP
Digoxin 0.25-0-0 mg

DATE

15/6/2015

17/6/15

SUBJ

Dispneu
subside ,
productive
cough

Dispneu
subsided ,
productive
cough
LAB
Ur/Cr : 70/3.8

OBJ
BP 110/70 Hr 64
bpm,
Rh - -+Negative balance
800 cc/24 hrs

BP 120/60 Hr 60
bpm,
Rh - --Negative balance
1000 cc

PLAN
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1200 cc/24 hrs, target negative fluid
balance 1000 cc /24 hrs
Inj Furosemide 40-40-0mg i.v.
Iinj Gentamycin 2x80 mg
Inj Fluconazole 1x200 mg
Nebu farbivent++flixotide 3 times/day
Captopril 3x50 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Digoxin 0.25-0-0 mg
Bed rest, semifowler position
O2 4 lpm NC
Total fluid 1250 cc/24 hrs, target negative fluid balance
1000 cc /24 hrs
Inj Furosemide 40-40-0 mg i.v.
Inj Fluconazole 1x200 mg (DAY 21)
Nebu farbivent++flixotide 3 times/day
Captopril 3x50 mg
Spironolacton 0-50-0 mg
ISDN 3x5 mg
N Acetyl Cystein 3x200 mg
Stool softener
Digoxin 0.25-0-0 mg

TIMELINE

Inj.
Levoflo
xacin
1x750
mg
Inj.
Cefope
razone
2x1 g

Inj.
Levo
1x750
mg
Inj.
Cefope
razone
2x1 g
Inj.
Flucon
azole
1x400
mg

Inj.
Levo
1x250
mg
Cefop
erazon
e
STOP
Inj.
Genta
mycin
2x80
Inj.
Flucon
azole

Inj.
Levo
STOP
Inj
Genta
mycin
2x80
mg
Inj.
Flucon
azole

Inj
Genta
mycin
2x80
mg
Inj.
Flucon
azole

Inj
Genta
mycin
2x80
mg
STOP
Inj.
Flucon
azole
UNTIL
June
17

STOP
ALL
ANTIBI
OTICS

THANK YOU

Discussion
Incidence cardiac complications are
common in patients with CAP and are
associated with increased mortality.
Older age, nursing home residence, preexisting cardiac disease and pneumonia
severity are associated with their occurence.
Several mechanism, related largely to the
systemic response to infection can account
for development of incidence cardiac
complication in px with CAP

Discussion
Acute systemic inflammation can directly
depress myocardial function and increase LV
afterload
Hypoxemia decreases myocardial oxygen
delivery , raise pulmonary arterial pressure, RV
afterload.
Tachycardia increases myocardial oxygen
needs, shorten diastole
Net effect: negative shift of cardiac metabolic
supply-demand ratio and further myocard
dysfunction.

Discussion
Acute infections promote inflammatory
activity within coronary atherosclerotic
plaques and induce prothrombotic changes in
blood and endothelium, resulting in plaque
instability and facilitating coronary thrombosis
Pre-existing CAD that is insufficient to produce
myocard ischemia under baseline condtions
can also result in significant ischemia in the
state of increased myocardial oxygen demand

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