Professional Documents
Culture Documents
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
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
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
Head
Neck
Thorax :
Heart &Lung
Abdomen
Extremities
ECG
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
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.
0,8 1,30
se
c
27,4 28,6
BGA
Conclusion :
Metabolic acidosis partially compensated
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
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