Slide DC

Menjadikan Bagian Ilmu Penyakit Dalam
fakultas Kedokteran Universitas

Hasanuddin sebagai pusat pendidikan yang
unggul, mandiri dan bermatabat untuk
menghasilkan dokter penyakit dalam yang
berkualitas dan mampu bersaing secara
regional, nasional maupun global dengan
didukkung oleh sumber daya manusia yang
profesional dan bertanggung jawab.
Menyelenggarakan pendidikan di bidang Ilmu Penyakit

Dalam berbasis evidance based medicine dan riset
Memberikan pelayanan kesehatan di bidang Ilmu

Penyakit Dalam dengan pendekatan kultural dan budaya
secara paripurna dan bermutu
Meningkatkan kuantitas dan kualitas penelitian dasar dan

aplikatif ilmu penyakit dalam yang bertaraf internasional
Menciptakan sistim manajement departemen Ilmu

Penyakit Dalam yang transparan, akuntabel, responsibel,
independen, terintegrasi, dan berkeadilan
Suriana Dwi Sartika

Soraya
Name
: Mrs. E
Age
: 48 yo
Address
: Makassar
Occupation
: Civil officer
Religion
: Moslem
Ethnic
: Bugis
Marital status
: Married
Hospital
: Hasanuddin University
Room
: 4th floor/ 409
Register No.
: 007597
Date of admission
: 24 / 04/ 2015
Date of death
: 8/ 05/ 2015
Room physician : dr. Suriana Dwi Sartika
Chief physician : dr. Soraya
Chief complaint : shortness of breath

Experienced since 4 months ago and was advancing since 1
last week. Shortness of breath is felt constantly, not
aggravated by the weather, activity, or position. Patient feel
comfortable lie down to the left side. Shortness of breath
accompanied by cough slimy white, There was no blood and
hard to be removed, so that shortness of breath became
worse. This patient was an Oncologic surgerys patient and
was consulted to Internal Department, because of her
shortness of breath. There was no complaint of chest pain and
febrile, sometimes nausea, but didnt vomit. Her weight was
lossing about 10 kgs in last 4 months.. According to the child
patient, the patient's eating and drinking less, especially 1 last
week.
Defecation: watery since 1 week ago, frequency of defecation
was more than 5 times a day. There was no blood or mucous
in the stool. There was no complain of abdominal pain.
Micturation: the volume is quite less, yellowish, no pain.
PREVIOUS ILLNESS
There is a history of modified radical mastectomy dextra
on January, because of her Ca mammae and she
consume tamoxifen 20 mg 2x1 but she didnt consume it
in last month, because the prescription was dissapear.
There is no history of chemotherapy or radiotherapy
There is a history of kidney disease 3 month ago whern
she went to policlinic and got oral medicine, but she didnt
know the name.
There is no history if consuming other drugs.
There is no history if diabetes
There is no histroy of hypertension
There is no history of cardiovasculer disease
FAMILY HISTORY
Father: Died at the age of 65 years with unknown cause
Mother: Died at the age of 70 years with no known cause
Siblings: The patient is first child of three siblings. Brothers
in a healthy state.
Husband: living, healthy
Children: 2 people, healthy
PERSONAL HISTORY
No history of allergy
Immunization history is not clear
Eating habits nothing special
Patient works in the office and rarely walking outside the
office everyday
Impression
:
Nutritional Status :
Awareness
:
BW
:
HW
:
BMI
:
Severe ill
Malnutrition
GCS 15 (E4M6V5)
40 kg
155 cm
16,67 kg / m2
Vital Sign
Blood pressure : 110/80 mmHg
Heart rate
: 105x/mnt, regular,
strong lift
Breathing
: 28x/mnt
Temperature
: 36,3 C
Head :
normocephal, short black hair, is not easily to

removed.
Eye :
Conjungtiva anemic (+), sclera icteric (-)

Pupil isocor, diameter 2mm/2mm, light reflex (+/+)
Secret (-)
Normal shape, discharge (-), epistaktis (-)
Tonsil T1-T1, hiperemic (-)
JVP R+2cmH2O , enlargement of lymp nodes (-),

enlargement of thyroid gland (-)
Ears:
Nose:
Oral Cavity:
Neck:
Thorax
lung:
Inspection : asymmetrical, chest wall movement
sinistra left behind
Palpation
: tactile fremitus hemithorax sinistra
decrease as high as costae VII
Percussion : percussion dimmed on the left
hemithorax as high as costa VII
Auscultation : breathing sound bronchovesiculer,
decreased respiratory sounds on the left hemithorax.
Wheezing on left hemithorax, there is right and left
median basal hemithorax rhonki
heart:
Inspection : Ictus cordis seen on ICS V line on the
left midclavicularis
Palpation
: Ictus cordis palpable at ICS V linea left
midclavicularis
Percussion
: dullness, cardiac border of normal
impression
Auscultation : heart sound I and II pure, regular, no
additional sound
Abdomen:
Inspection
: Convex, following breathing
motion,
Auscultation : peristaltic sound increase
Palpation
: Palpable liver 8 cm below arcus
costa, hard consistency, blunt edge, bumpy
surface
Percussion
: Tympani (+) , ascites (-)
Extremity: erithema palmaris (-), oedem
pretibial (-), warm extremity
LABORATORY TEST (23/04/2015) from RS.

Pelamonia
Blood Chemistry
WBC
: 25.500 /ul
GDS : 101 mg/dl
HGB
: 7,4 g/dl
Ureum
: 156 mg/dl
HCT
: 22,0 %
Creatinine : 2,50 mg/dl
MCV
: 87 fl
SGOT : 44 U/L
MCH
: 29,1 pg
SGPT : 27 U/L
MCHC : 33,6 g/dl
Albumin : 2,8 gr/dl
PLT : 195.000/ul
NEUT : 80,9%
Routine Haematology
WBC : 29.190/ul
HGB : 7,9 g/dl
HCT
: 23,3 %
MCV : 76,9 fl
MCH : 26,1 pg
MCHC : 33,9 g/dl
PLT
: 289.000/ul
NEUT : 88,1%
LYMPH : 7,0 %
Blood Chemistry
SGOT : 36 U/l
SGPT : 19 U/l
GDS : 79 mg/dl
Ureum : 116 mg/dl
Creatinin : 2,5 (MDRD : 21,94)
Total Cholesterol : 125 mg/dl
Albumin : 2,8
Electrolyte
Natrium
: 129 mmol/L
Kalium : 5,1 mmol/L
Cloride: 111 mmol/L
Urinalysis
Color : Kuning
Blood : Negatif
Bilirubin
: Negatif
Urobilinogen : +Keton : Negatif
Protein: Negatif
Nitrit : Negatif
Glucose
: +- (100mg/dl)
pH
: 5,0
SG
: 1.020
Leukocyte : Negatif
Vit C : + (10 mg/dl)
ECG : Rhytme Sinus , HR: 108x/i, normoaxis
RADIOLOGY
Thorax PA from RS.Pelamonia (13/04/2015)
Pulmo Metastase with pneumonia
Fracture costa V-VI with costa IV sinistra suggest bone
metastase
USG Abdomen dari RS.Pelamonia (14/04/2015)
Hepar Metastase
Renal Insuficience
OTHER TEST
Histopatology Test (19/01/2013) :
Invasive ductal carsinoma mammae (moderate grade
malignancy) which metastase to lymphe
Community Acquired Pneumoni

Suspek Efusi Pleura Sinistra
Adenocarsinoma mammae dextra stadium IVB
post MRM metastase paru dan hepar
Acute diarrhea mild-moderate dehydration
Acute on CKD dd / CKD stage IV ec. renal dd / pre
renal
Hyponatremia
Anemia of chronic disease dd / renal anemia
Hypoalbuminemia
malnutrition
No Problem
Plan
Therapy &
Management
1.
Thorax photo
control
Examination of
sputum culture
and antibiotic
sensitivity
Ceftriaxon 1gram / 12h

/ intravenous (continue
previous treatment of
TS Surgery)
N-Acetylsistein tablet
200mg / 8 hours / oral
Advice: consul
pulmonology
Community acquired
pneumonia based on:
Complaints of shortness of
breath that was advancing
since 1 last week with a cough
with purulent mucus. From the
examination, it was found the
median
basal
hemithorax.
Patients
had
malignant
disease
that
decreases
immunity and are prone to
infection. In the laboratory
tests, showed leukocytosis
(29190) and neutrophils were
increased (88.1%).
3x sputum
smear
examination,
gram,yeast.
Blood gas
analysis
Problem
Plan
2.
Suspek pleural effusion

Thorax photo
Sinsitra based on:
control
Thought on the main of
complaints of shortness of
breath that was advancing
since last one week. Obtained
from physical examination,
tactile fremitus decreased and
percussion dullness in the left
hemithorax high as costa VII.
Pleural effusions may be
exudates
or
transudates.
Exudative pleural effusions
usually
occur
in
cancer
patients.
Therapy &
Management
Evacuate the pleural
fluid
Problem
Plan
Therapy &
Management
3.
Adenocarsinoma mammae
dextra post MRM IVB stage
lung and liver metastases
based on:
Thought on the basic of the
patient has a history of
modified radical mastectomy
and
histopathological
examination: invasive ductal
breast carcinoma (moderate
grade malignancy) that has
metastasized to the lymph
nodes. Shortness of breath
since four months ago can be
suspected as a symptom of
the
process
of
tumor
metastases in the lung or
pleural effusion On physical
examination found left pleural
effusion, hepatomegaly with
Thorax MSCT
scan
Abdomen
MSCT scan
CEA, AFP
O2 4 liters / minute via

nasal cannula
Chemotherapy plan
from TS. Oncology
Surgery
Avoid hepatotoxic
drugs
Problem
Plan
Therapy &
Management
4.
Acute diarrhea mildmoderate dehydration

based on
Watery defecation complaints
since 1 last week with the
frequency of bowel> 5x each
day, not accompanied by
mucus or blood. Urinating less
from diarrhea impression. On
physical examination found
increased peristalstic, turgor
less, and tachycardia with a
score of dehydration 3. These
patients
suspected
metastases
of
the
gastrointestinal tract that can
give symptoms of digestive
system disorders or immune
conditions decreased due to
malignancy so easily happen
Analyse faeces
CEA
Electrolyte,
ureum,
creatinin
MSCT Scan
Abdomen
IVFD NaCl 0.9% loading

500 cc in the first 2
hours further
maintanance 20
drops / minute
Attapulgite given initial
2tab and 1tab every
watery defecation
(maximum of 12
tablets)
Positive fluid balance
Problem
Plan
Therapy &
Management
5.
Acute on CKD dd / CKD

stage IV ec Prerenal dd /
rena lbased on l
Patients experiencing watery
defecation that can trigger
acute
in
these
patients.
Patients already been said
renal
impairment
three
months ago at the time
control at the PCC RSWS so
that suspected patients had
chronic kidney disease. Of the
laboratory
tests
obtained
ureum 116 and creatinine 2.5
(MDRD: 21.94).
Control the
ureum/creatini
ne per 3 days
Adequate rehydration
Amino acids 250cc /
24h / drips
balance fluid
6.
Hyponatremia is based on:

Thought on the basis of
patients with malignancies
and drink intake eat less. Of
IVFD NaCl 0.9% 20tpm

Correction sodium from
dietary intake
Advice : consult clinical
nutrition
Problem
Plan
7.
Anemia of Chronic Disease

dd / Renal Anemia based
on
Obtained conjunctival pallor,
obtained from laboratory tests
Hb: 7.9, MCV: 76.9, and MCH:
26.1. Anemia in patients
thought of as a chronic
disease anemia dd / iron
deficiency anemia patients
given malignant disease and
intake less. Anemia can also
be caused by renal anemia
patients given once said renal
impairment
three
months
earlier and now with 116 urea
and creatinine 2.5 (MDRD:
21.94).
Serum fe, TIBC, epoetin alfa dan

Ferritine, pT,
nefrovit Fe
APTT
Analysis of
peripheral
blood
8.
Hypoalbuminemia based
on
Thought on the basis of
Therapy &
Management
VIP Albumin 3x2

(therapy from
TS.surgery)
Advice : consult
clinical nutrition
Problem
Plan
Therapy &
Management
9.
Malnutrition based on
the patient is a malignancy
patients with less intake. BMI
obtained from physical
examination: 16.67.
Therapy Plan :
- Clinimix 1bag /hari
- Advice : consult to
clinical nutrition
Date
Follow up
Instruction
24/04/2015
A : - Ca Mammae post MRM metastazing to - O2 4 liters / minute via NK
14.30
lung and hepar (TxN0M1) ,Karnofsky - Fix the general state
Oncology Surgery
50%
- Infusion of NaCl 20 dpm
- Ceftriaxon 1 g / 12h / iv
- Ketorolac 30 mg / 8 hours / iv
- VIP albumin 3x2
- PRC transfusion of 2 units
- Consul Renal Hypertension
4/04/15
18.15
Renal
Hipertension
A :
-Acute on CKD dd / CKD stage IV ec.renal dd
/ pre renal
-Adenocarsinoma mammae dextra post MRM
IVB stage lung and liver metastases
-CAP
-Acute diarrhea
with moderate-mild
dehydration
-hypoalbuminemia
-Anemia of chronic disease dd / renal anemia
- Low-purine diet, potassium, salt,

protein 0.8 g / kg / day
- O2 3-4 liter / minute via NK
- IVFD NaCl 0.9% 20 dpm
- Amino acids 250 cc / 24 hours / drips
- Ceftriaxone 1gram / 12h / intravenous
(continued therapy Surgery TS)
- N-acetylsistein tablet 200mg / 8
hours / oral
- Attapulgite tablet 2x2 (maximum of 12
tablets)
- Plan of epoetin alfa and iron capsules.
- balance liquid
- Advice:
- consul Pulmonology
- consul Clinical Nutrition
- Plan:
- Fe, TIBC, ferritine.
Date
Follow up
Instruction
25/04/15
BP: 110/80
HR: 100x / minute,
regular,
RR: 28x / min
T: 36,30C
Day Care II
S: shortness of breath accompanied by cough
mucus. Less food intake. Watery dfefecation 3x
frequency, feces (+), mucus (-), blood (-)
O: severe pain / malnutrition / composmentis
Head: pale conjunctiva (+), jaundice (-)
Neck: tumor mass (-), DVS R + 2 cmH2O.
Lung: decreased respiratory sounds on the left
hemithorax. Wheezing in hemithorax left.
Rhonki on hemithorax median basal right and
left.
Heart: S1 / S2 regular, murmur (-)
Abdomen: increased peristaltic impression.
Liver palpable 8 cm below the surface of the
arch costa nodul with hard consistency.
Extremity edema - / A:
Community acquired pneumonia
Adenocarsinoma mammary dextra post MRM
Suspek Pleural effusion Sinistra
Acute diarrhea mild-moderate dehydration
Acute on CKD dd / CKD stage IV renal ec dd /
pre renal
hyponatremia
hypoalbuminemia
Malnutrition
- Low-purine diet, potassium, salt, protein

0.8 g / kg / day
(continued therapy Surgery TS) H-2
- N-acetylsistein tablet 200mg / 8 hours /
oral
tablets)
- balance liquid
The advice:
- consul Pulmonology and consul Clinical
Nutrition
- Plan:
- Control routine blood and electrolytes
- Fe, TIBC, ferritine.
- Analysis of peripheral blood, CEA, AFP
- Blood gas analysis and stool analysis
- 3x sputum smear examination, gram
Yeast, sputum culture and antibiotic
sensitivity
- X-Ray thoracic control
- Thorax CT scan
- CT Abdomen
Input: 1100cc / 24h

UO: 650cc / 24h
IWL: 400cc
BC: + 50cc / 24h
Date
Follow up
Instruction
25/04/2015
Renal
Hipertension
A:
Acute on CKD dd / CKD stage IV
ec.renal dd / pre renal
Adenocarsinoma mammae dextra post
MRM IVB stage lung and liver
metastases
CAP
Acute diarrhea were mild dehydration
hypoalbuminemia
Anemia of chronic disease dd / renal
anemia
- Low-purine diet, potassium, salt, protein 0.8

g / kg / day
- N-acetylsistein tablet 200mg / 8 hours / oral
tablets)
- balance liquid
- The advice:
Consul Pulmonology (wait for The main DPJP
confirmation)
- TS consul Clinical Nutrition (wait The main
DPJP confirmation)
- Plan:
- Fe, TIBC, ferritine (wait for results).
- Control routine blood and electrolytes.
25/04/2015
Bedah Onkologi
Ca mammae dextra post MRM

metastasis to the lung and liver
O2 4 liters / minute via NK

Infusion of NaCl 0.9% 20 dpm
Ceftriaxon 1 g / 12h / iv
Ketorolac 30 mg / 8 hours / iv
VIP albumin 3x2
Plan: routine hematology control
transfusion
post
Date
26/04/2015
19.00
Oncology
surgery
Follow up
Instruction
Control chest x-ray results:

Suggestive of pleural effusion with atelectasis of -Konsul BTKV
the left
Suspect metastatic nodules dd / pneumonia
Fractures costa V and VI rear right
A: - Ca dextra post MRM mammary metastasis to
the lung and liver
The left pleural effusion
26/04/2015
A:
19.30
Ca mammae dextra post MRM metastasis
Thorrax
and
to the lung and liver
Vascular surgery - The left pleural effusion
Insert chest tube dan

WSD
Date
Follow up
Instruction
27 28 /04/2015
BP: 120/80
HR: 68x / minute,
regular, and strong lift
RR: 24x / min
T: 36,50C
Input: 850cc / 24h
UO: 600cc / 24h
IWL: 400 cc
BC: -150cc / 24h
WSD production: 650
cc since installation
Day Care III - IV

S: shortness of breath decrease. Cough (+) slimy sometimes. Watery
defecation never since two days ago.
Head: pale conjunctiva (-), jaundice (-)
Lung: Chest tube on left hemithorax. Wheezing no. Rhonki no.
Abdomen: normal peristaltic impression. Liver palpable 8 cm below
the surface of the arch costa nodule with hard consistency.
Extremity edema - / Lab
- Fe (Iron): 51.65 ug / dl
- TIBC: 156 ug / dl
- Transferrin saturation: 33.1%
- WBC: 27860 29190
- Hb: 9.9 7.9
- PLT: 283000 289000
- Neutrophils: 88.7 88.1
- Sodium: 132 129
- Potassium: 4.4 5.1
- Chloride: 113 111
A:
1. Community acquired pneumonia
2. Adenocarsinoma mammary dextra post MRM IVB stage lung and
liver metastases
3. Acute diarrhea mild-moderate dehydration (repair)
4. Acute on CKD dd / CKD stage IV renal ec dd / pre renal
5. Hyponatremia
6. Anemia of chronic disease dd / renal anemia
7. Hypoalbuminemia
8. Malnutrition
9. The left pleural effusion on WSD

- Ceftriaxone 1gram / 12h /
intravenous H-4 & 5
- Amino acids 250 cc / 24 hours /
drips
- N-acetylsistein 1 ampoule / 24h /
drips (pro-chemotherapy)
- Epoetin alfa 3000 IU / 2x a week /
subcutan
- Fe tablet / 12 hours / oral
- balance liquid
- Advice
Consul Pulmonology (not
approved by the main DPJP)
Consul Clinical Nutrition (wait
for confirmation of the main
DPJP)
Plan:
CEA, AFP (not approved by
main DPJP)
Blood gas analysis
3x sputum smear examination,
gram, Yeast (no samples)
Examination of sputum culture
And antibiotic sensitivity (no
samples)
CT ScanAbdomen and
CT Scan
Thorax and (not
approved by the Main DPJP)
Date
Follow up
27-28 /04/2015 A :
Renal
-Acute on CKD dd / CKD stage IV ec.renal dd /
Hipertension
pre renal
-Adenocarsinoma mammae dextra post MRM
-CAP
-Acute diarrhea with mild 0moderate
dehydration
-Hypoalbuminemia
Instruction
- N-acetylsistein 1 ampoule / 24h / drips
(pro chemotherapy)
subcutan
- balance liquid
- Advice :
Consul Pulmonology (not approved by
the main DPJP)
Consul Clinical Nutrition (wait for The
DPJP confirmation)
27-28 /04/2015 A : Ca Mammae dextra post MRM metastase to - O2 4 liters / minute via NK
Oncology
lung and hepar
- Infusion of NaCl 0.9% 20 dpm
Surgery
- Ceftriaxon 1 g / 12h / iv
- VIP albumin 3x2
- Femara 1x2,5 mg (drugs are not
administered)
- Tamoxifen 1x 20 mg (drug are not
administered
Date
28/04/2015
Clinical Nutrition
Follow up
Instruction
Height : 147 cm ; mid upper arm circumference : 19,5 cm ; mid 1700 kcal diet
upper arm circumference weight : 35 kg ; BBI : 47 kg
SF Nephrisol 6 x tsp
Nutitional Status : Severe PEM
Avcol 3x1 tbsp
fruit juices 50 cal
supp: Zinc 1 x 20 mg
Vit. B Comp 1x1
Vit C 1x1
Folic acid 1x400 mg
29/04/2015
IV Day Care
BP: 120/80
S: shortness of breath (+). Coughing occasionally slimy and
HR: 84x / min, strong difficult to remove. Less food intake
lift, regular
RR: 24x / min
T : 36,5 C
Lung: chest tuber on hemithorax sinistra. No wheezing . No
Input: 850 cc / 24h
rhonkhi
UO: 650cc / 24h
IWL: 400cc
Abdomen: normal peristaltic impression. Liver palpable 8 cm
BC: -200cc / 24h
below the surface of the arch costa nodule with hard consistency.
Production WSD: 50cc Extremity edema - / / 24h
A:
1. Community acquired pneumonia
2. Adenocarsinoma mammary dextra post MRM IVB stage lung
and liver metastases
4. hyponatremia
6. Hypoalbuminemia
7. Malnutrition

H-6
drips (H-1)
subcutan (drugs are not logged in)
- Fluid balance
- Plan :
Blood gas analysis
3x sputum smear examination, gram,
yeast, sputum culture and antibiotic
sensitivity (no samples)
Blood cultures and antibiotic sensitivity
(wait for the result)
Control routine blood, electrolytes, urea,
and creatinine
The advice: : chest x-ray control post
chest tube insertion
Date
Follow up
Instruction
29/04/2015
Renal
Hipertension
A :
-Acute on CKD dd / CKD stage IV ec.renal dd /
pre renal
-Adenocarsinoma mammae dextra post MRM IVB
stage lung and liver metastases
-CAP
-hypoalbuminemia

drips
intravenous
- N-acetylsistein 1 ampule / 24h /
drips (H-1)
subcutan (drugs are not logged in)
- Water Balance
Plan: control routine blood, urea
creatinine, and electrolytes
29/04/2015
Clinical nutrition
height : 147 cm ; mid upper arm circumference :

19,5 cm ; mid upper arm circumference weight : 35
kg ; BBI : 47 kg
Nutritional status: Severe PEM
1700 kcal diet

SF Nephrisol 6 x tsp
Avcol 3x1 tbsp
fruit juices 50 cal
supp:
Zinc 1 x 20 mg
pujimin 3x2 cap
Insertion NGT size 14
Date
Follow up
Instruction
30/04/2015
BP: 110/70
HR: 80x / minute,
regular,
RR: 24x / min
Q: 36,50C
Input: 900cc / 24h
UO: 700cc / 24h
IWL: 400 cc
BC: -200cc / 24h
production WSD: 50
cc / 24h
V Day Care
S: shortness of breath (+). Cough mucus (+) and sputum is difficult
to remove.
Lung: chest tube on hemithorax sinistra. No wheezing no rhonkhii..
Abdomen: normal peristaltic. Liver palpable 8 cm below the surface
of the arch costa berbenjol with hard consistency.
Extremity edema - / Laboratorium
WBC : 27690 27.860
Hb : 9,2 9,9
PLT : 247.000 283.000
Neutrofil : 88,2 88,7
Na : 135 132
K : 4,2 4,4
Cl : 116 113
Ureum : 165 116
Creatinine : 3,3 2,5
A:
1.Community Acquired Pneumoni
2.Adenocarsinoma mammae dextra stadium IVB post MRM
metastase lung and hepar
3.Acute on CKD dd/ CKD stage IV ec renal dd/pre renal
4.Anemia chronic disease dd/ anemia renal
5.Hypoalbuminemia
6.Malnutrition
7.Efusi pleura sinistra on WSD

intravenous H-6
drips
drips (H-2)
subcutan (1)
- Nebulilzer N-acetylsistein / 8
hours / inhalation (if sputum is
difficult to remove)
- balance liquid
- Plan :
Blood gas analysis
sensitivity (samples
not
yet
complete)
Blood
cultures
and
antibiotic
sensitivity (wait for the result)
The advice: chest x-ray control post
chest tube insertion.
Date
30/04/2015
Renal
Hipertension
Follow up
Instruction
A :
-Acute on CKD dd / CKD stage IV ec.renal
dd / pre renal
-Adenocarsinoma mammary dextra post
MRM IVB stage lung and liver metastases
-CAP
-hypoalbuminemia

(H-2)
subcutan (1)
- Water Balance
29-30/04/2015
A : Ca Mammae dextra post MRM metastase Oncology Surgery
to lung and hepar
-

Infusion of NaCl 0.9% 20 dpm
Dexamethasone
1
amp/
iv
(premedication before chemotherapy)
Ranitidine 1 amp / iv
VIP albumin 3x2
Femara 1x2,5 mg (drugs are not
administered)
Tamoxifen 1x20 mg (drug are not
administered)
Date
30/04/2015
Clinical Nutrition
Follow up
Instruction
Height : 147 cm ; mid upper arm circumference : 19,5 cm ; mid upper arm 1700 kcal diet
circumference weight : 35 kg ; BBI : 47 kg
Via NGT: Porridge sonde 3x100
Nutrition Status: Severe PEM
Ensure SF +100 cc 3x2 sdt water
Avcol 3x1 sdm
Supp: Zinc 1 x 20 mg
pujimin 3x2 capp
02/05/2015
BP: 130/80
HR: 92x / minute,
regular, RR: 20x / min
ST: 36,40C
VI Day Care
S: loss of consciousness (+), the patient was restless, shortness of breath
(+). Cough mucus (+) sputum is difficult to remove.
O: severe pain / malnutrition / delirium
GCS E4MxV1
Lung: chest tube on left hemithorax. No wheezing no rhonkhi.
Abdomen: normal peristaltic impression. Liver palpable 8 cm below the
surface of the arch costa nodule l with hard consistency.
GDS: 49 mg / dl, GDS 15 minutes after administration D40%: 81 mg / dl
Blood culture: no growth
A:
1. Hypoglycemia
2. Decrease Awareness et causa suspected intracranial tumor metastasis
3. Community Acquired pneumonia
4. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver
metastases
7. Hypoalbuminemia
8. Malnutrition
Input: 850cc / 24 hours

UO: 720cc / 24h
IWL: 400 cc
BC: -250cc / 24h
WSD production: -
- Give sugar water via NGT

- D40% 2 flacon / intravenous, check
GDS 15 minutes later continue with
maintenance D10% 28 dpm.
- Ceftriaxon 1gram / 12h / iv H-9
stop (had been given for 3 days)
- Nebulizer N-Ace / 8 hours / inhalation
stop
subcutan
- Monitoring GDS / 30 min
- Plan :
Blood gas analysis
sensitivity (samples not yet complete)
The advice: Control chest xray post
chesttube insertion
Head MSCT scan
Date
Follow up
Instruction
02/05/2015
Renal Hipertension
A :
-Acute on CKD dd / CKD stage IV ec.renal dd / pre renal
-Adenocarsinoma mammaae dextra post MRM IVB stage
-CAP
-hypoalbuminemia
-hypoglycemia
-Loss of consciousness suspicious tumor metastases to the
brain

- IVFD D10% 20 dpm
(has been given for 3 days) stop
subcutan
- Fluid balance
02/05/2015
Oncology Surgery
A : Ca Mammae dextra post MRM lung and hepar metastase

-
02/05/2015
Clinical Nutrition
Height: 147 cm ; mid upper arm circumference : 19,5 cm ; 1700 kcal diet
mid upper arm circumference weight: 35 kg ; BBI : 47 kg Via NGT:
Nutritional Status: Severe PEM
MLP 3x150
Milk Nefrisol 3 x 135 kcal (3x2 tsp)
olive oil 3x80 kcal (3x1sdm)
Low potassium juice 100 kcal
Honey 3x64 kcal (3x1 tablespoons)
supplementation:
Zinc 1 x 20 mg
pujimin 3x2 cap

VIP albumin 3x2
Femara 1x2,5 mg H-2
tamoxifen 1x20 mg H-2
Date
Follow up
Instruction
02/05/15
16.00
Interna
S: patient was agitated

O: GCS: E4MxV1, GDS: 116 mg / dl
A: - Post hypoglycemia
Loss of consciousness suspect tumor metastases to the brain
IVFD D10% 28 dpm

Head MSCT scan (not successful because
of patient agitated)
03/05/2015
Oncology Surgery
General state: patient was agitated

O: GCS E4MxV1
A: Ca mammaae post MRM hepatic and pulmonary metastases
Observation on the general condition and

vital signs
Consul ICU
04/05/2015
VII Day Care
ICU H-1
S: loss of consciousness (+), the patient was agitated and disorientation,
TD : 130/80
shortness of breath (+). Cough mucus (+) sometimes.
N : 92x/menit, reguler , O: severe pain / malnutrition / delirium
kuat angkat
GCS E4MxV1
P : 20x/menit
0
S : 36,4 C
SO2 : 97%
Lung: chest tube on left hemithorax. No wheezing no rhonkhi.
Input : 900cc/ 24 jam
UO :850cc/24jam
IWL : 400 cc
surface of the arch costa nodule with hard consistency.
BC :-350/24jam
GDS (06:00): 96 mg / dl
A:
1. Post Hypoglycemia
metastases
7. Hypoalbuminemia
8. Malnutrition

- O2 8-10 liters / minute via NRM
- IVFD D10% 28 dpm
subcutan (2)
- Fe tablet / 12h / oral
- Monitoring GDS / 30 min
- Plan :
sensitivity (samples not yet complete)
Blood gas analysis
Control routine blood, urea creatinine, and
electrolytes.
CT scan of the head (not done since
general condition does not allow)
The advice:
Consul neurology
Consul HOM
Date
Follow up
Instruction
04/05/2015
Anestesi
ICU Day-1
O2 8-10 l / min via NRM
A: - Impairment of consciousness suspect tumor metastases to the Head Up 300
brain
Measure urine / h
- Ca mammae post MRM metastasis to the lung and liver
Omeprazole 40mg / 24h / iv
- Acute on CKD dd / CKD stage IV
Other therapies according TS Interna and
Surgery
04/05/2015
Renal hypertension
A :
- Acute on CKD dd / CKD stage IV ec.renal dd / pre renal
- Adenocarsinoma mammary dextra post MRM IVB stage lung and
liver metastases
- CAP
- hypoalbuminemia
- Anemia of chronic disease dd / renal anemia
- Post Hypoglycemia
- Loss of consciousness suspicious tumor metastases to the brain dd /
DIC

0.8 g / kg / day
- IVFD D10% 20 dpm
- Epoetin alfa 3000 IU / 2x a week / subcutan
(2)
- balance liquid
- Plan: routine blood test control, urea
creatinine, and
- electrolyte.
04/05/2015
Oncology Surgery
A : Ca Mammae dextra post MRM lung and hepar metastase
04/05/2015
Clinical Nutrition
Height : 147 cm ; mid upper arm circumference : 19,5 cm ; mid upper KET: 1700kkal
arm circumference weight : 35 kg ; BBI : 47 kg
Diet today 50% of kcal requirements 850
kcal
Via NGT:
Honey 3x64 kcal (3x1 tablespoons)
Supplementasi :
zink 1 x 20 mg delay
pujimin 3x2 cap delay
O2 4 liter/meinutes via NK
Ceftriaxon 1 gr/12hours/iv
VIP albumin 3x2
Femara 1x2,5 mg H-4
Tamoxifen 1x20 mg H-4
Date
05 06 /05/2015
ICU D-2
BP: 144/90
HR: 101X / minute,
regular,
RR: 20x / min
Q: 36,40C
SO2: 99%
Input: 900 cc / 24 hours
UO: 850cc / 24h
IWL: 400cc
BC: -350cc / 24h
WSD
minimal
production
Blood Gas Analysis
pH: 7.372 (7.35 to 7.45)
pCO2: 21.0
SO2: 98.2
pO2: 113.3 (80.0 to
100.0)
HCO 3: 12.3 (22-26)
ctO2: 13.0
ctCO2: 12.9
BE: -13.2 (-2 s / d +2)
Result:
metabolic
acidosis
complete
compensated
Follow up
Day Care VIII - IX
S: loss of consciousness (+), the patient was restless and disorientation,
shortness of breath (+). Cough mucus (+) sometimes.
O: severe pain / malnutrition / delirium
GCS E4V1Mx
Lung: hemithorax Mounted on the left chest tube. No wheezing no rhonkhi.
surface of the arch costa berbenjol with hard consistency.
Extremity edema - / Laboratoy Result
GDS (06.00 tgl 05/06/2015 ) : 84 mg/dl
GDS (06.00 tgl 06/06/2015 ) 121 mg/dl
WBC : 12220 27690 27.860 ,
Hb : 9,9 9,2 9,9
PLT : 99.000 247.000 283.000
Neutrofil : 72,6 88,2 88,7
Na : 129 135 132
K : 4,8 4,2 4,4
Cl : 107 116 113
Ureum : 201 165 116 , Kreatinin : 3,8 3,3 2,5
Ferritine : > 1200
A:
2. Decrease Awareness et causa suspected intracranial tumor metastasis dd /
DIC
3. Thrombocytopenia suspicious DIC
metastases
8. Hypoalbuminemia
9. Malnutrition
Instruction
- IVFD D10% 28 dpm
- Ceftriaxon 1gram / 12h / iv H12
drips
subcutan
- Fe tablet / 12h / oral delay
- Monitoring GDS / 3 hours
- Education for hemodialysa
- Plan :
Check pT, APTT, D-dimer, fibrinogen,
HBsAg, Anti-HCV, Anti HIV.
sensitivity
(samples
arent
complete yet)
CT scan of the head (not done since
General state does not allow to)
The advice
Consul neurology and HOM (not
approved by the Main DPJP)
Date
Follow up
Instruction
05 06 /05/2015
Anestesi
ICU Hari-2 & 3

A : - Penurunan kesadaran curiga metastase tumor ke
otak
- Ca Mammae post MRM metastase ke paru dan hepar
-Akut on CKD dd/CKD stage IV
O2 8-10 l / min via NRM

Head Up 300
Measure urine / h
omeprazole 40mg / 24h / iv
Other therapies according TS Interna and
Surgery
05 06 /05/2015
Renal Hypertension
A:
Acute on CKD dd / CKD stage IV ec.renal dd / pre
renal
Adenocarsinoma mammae dextra post MRM IVB stage
CAP
Hypoalbuminemia
Post Hypoglycemia
Loss of consciousness suspicious tumor metastases to
the brain dd / DIC

0.8 g / kg / day
- IVFD D10% 20 dpm
- Ceftriaxone 1gram / 12h / IV
subcutan
- balance liquid.
05 06 /05/2015
Oncology Surgery
A : Ca Mammae dextra post MRM lung and hepar - Ceftriaxon 1 gr/12hours/iv

metastase
- VIP albumin 3x2
- Femara 1x2,5 mg stop
- Tamoxifen 1x20 mg stop
Hegight : 147 cm ; mid upper arm circumference : 19,5 KET: 1700kkal
cm ; mid upper arm circumference weight : 35 kg ; Diet today 80% of KET 1360 kcal
BBI : 47 kg
Via NGT:
Milk Nefrisol 6x135 kcal (2 tbsp)
VCO 2x80 kcal (1sdm)
supplementation:
B1 100 mg / 24 hours
B6 10 mg / 24 hours
Vitamin C 50 mg / 24 hours
05 06 /05/2015
Clinical Nutrition
07/05/2015
BP: 140/90
HR: 84x / minute,
regular
RR: 24x / min
Q: 37,20C
UO: 850cc / 24h
IWL: 400 cc
BC: -300cc / 24h
WSD
production:
minimal
Day care X
S: loss of consciousness (+), the patient appears apathy, shortness of breath
(+).
O: serious illness / malnutrition / apathy
GCS E3M3V1
Pulmonary: chest tube on the left hemithorax. Wheezing no. Rhonki no.
Extremity edema - / Laboratory result: GDS (06:00) = 99 mg / dl
A:
dd / DIC
metastases
8. Hypoalbuminemia
9. Malnutrition
07/05/2015
Renal Hipertension

- IVFD D10% 28tpm
subcutan
- Monitor GDS / 3 hours
- Follow up the signs of bleeding
- Plan :
3x sputum smear, gram, mushrooms,
sputum culture and antibiotic sensitivity
(not examined because the sample is not
yet complete)
Check pT, APTT, CT, BT, D-dimer,
fibrinogen, HBsAg (ELISA), Anti-HCV
(ELISA), Anti-HIV (wait for the
results).
Control routine blood, albumin, urea, and
creatinine
MSCT scan head (wait for the results)
Chest x ray (wait for the result)
Acute on CKD dd / CKD stage IV ec.renal dd / pre renal

Adenocarsinoma mammae dextra post MRM IVB stage lung and
liver metastases
CAP
hypoalbuminemia
Post Hypoglycemia
Loss of consciousness suspicious tumor metastases to the brain
-
Low-purine diet, potassium, salt,

O2 8-10 liters / minute via NRM
IVFD D10% 20 dpm
Amino acids 250 cc / 24 hours /
drips
Ceftriaxone 1gram / 12h / IV
Epoetin alfa 3000 IU / 2x a week /
subcutan
Fluid Balance
07 - 08/05/2015
A : Ca Mammae dextra post MRM lung and hepar
Oncology Surgery
metastase
07 08 /05/2015 Height : 147 cm ; mid upper arm circumference : 19,5
Gizi Klinik
cm ; mid upper arm circumference weight : 35 kg ;
BBI : 47 kg
- Ceftriaxon 1 gr/12hours/iv
- VIP albumin 3x2
KET : 1700kkal
Via NGT :
Nefrisol 3x 3 tablespoon (202,5
kkal)
VCO 4x80 kkal (1 tablespoon)
Honey 3x64 kkal (1tablespoon
Fruti juice 50 kkal
08/05/2015
BP: 140/90
HR: 109x / min
RR: 24x / min
Q: 36,9C
UO: 950 cc / 24 hours
IWL: 400cc
BC: -350 cc / 24h
WSD
production:
minimal
Day care XI
S: loss of consciousness (+), the patient appears apathy, shortness of breath
(+).
O: serious illness / malnutrition / apathy
GCS E3M3V1
Pulmonary: chest tube on left hemithorax. Wheezing no. Rhonki no.
Extremity edema - / Laboratorium result
Total Protein : 6,8
HBsAg : non reaktif
Albumin : 2,9 2,8
anti HCV : non reaktif
Ureum : 243 201 165 116
anti HIV : non reaktif
Creatinine : 4,1 3,8 3,3 2,5
GDS 07.00 : 116
D-dimer : 3490 (<585)
Fibrinogen : 545
pT : 15,3 , apTT : 23,8 , INR : 1,29
CT Scan Head (06/05/2015) :
Falx cerebri calcification and occipital region of the cerebral parenchyma
bilateral.
DIC score: 4
A:
2. Decrease Awareness et causa suspected cerebral toxoplasma dd / DIC
5. Adenocarsinoma mammary dextra post MRM IVB stage lung
metastases. and liver
6 .. Acute on CKD dd / CKD stage IV renal ec dd / pre renal
8. Hypoalbuminemia
9. Malnutrition

- IVFD D10% 28 dpm
subcutan
- Monitor GDS / 6 hours
- Follow up on the signs of bleeding
- Plan :
3x sputum smear, gram, mushrooms,
sputum
culture
and
antibiotic
sensitivity (not examined because the
sample is not yet complete)
Blood routine control (waiting result)
Advice : Consul dr.Satriawan Abadi,
Sp.PD, KIC
Advice: The Consul Tropical Infections
Advice examination Toxoplasma IgG and
IgM
Educate for HD
08/05/2015
19.00
BP : 80/50
HR : 110x/i
RR : 36 x/i
T : 37,5
Visite dr.Satriawan Abadi, Sp.PD, KIC

S: shortness of breath (+)
O: saturation 94%
A: - respiratory failure
cardiogenic shock
End Stage Renal Disease
Priority III to ICU
O2 8-10 lpm via NRM

Loading 250cc NaCl 0.9%
Vascon 0.25 mcg / hour / sp
7cc / h / sp
Dobutamine 3 mcg / kg 1.6
cc / hour / sp
08/05/2015
Interna
20.00
S: seixure generalisata 1x, fever (+)

O: BP: 100/60
HR: 110x / i
RR: 36x / i
T: 38,50C
Diazepam injection ampoules iv

bolus extra
Paracetamol drips 1 g / 12h /
drips
08/05/2015
Interna
20.30
S : Loss of conciousness (+)

O : BP : 70/40
HR : 110x/i
T: 38,70C
RR : 36x/i
Leukosit via tphone : 85.410
08/05/2015
21.15
Increased titration of dose

inotropic
Vascon 0.45 mcg / kg 15.5 cc /
hour / sp
5mcg dobutamine / kg 2.7 cc /
hour / sp
apnea, blood pressure could not measured, the pulse Pastient was death
was not palpable. Pupills were total mydriasis
Result Blood Routine:
WBC : 85.410
Hb : 9,2
PLT : 232.000
Neutrofil : 83,3
ANC : 71210
Woman, 48 years old, from TS Surgical Oncology counsulted

with complaints of shortness of breath that was advancing since 1
last week, a cough with purulent mucus. There is a weight loss of
approximately 10 kg in 4 months and nutrient intake less. Watery
bowel movement since the first week, the frequency is 5 times a
day, not accompanied by mucus or blood. Micturition impression
less from diarrhea patients. History modified radical mastectomy
surgery mammary dextra in January 2013 and a history of renal
impairment three months ago when the controls in the clinic.
From the examination, it was found BP: 110/80 mmHg, HR: 105x /
min strong lift, RR: 28x / min, and T: 36,30C axilla. Conjunctival
pallor, sunken eyes, the movement of the chest wall of the left
behind, tactile fremitus decreased hemithorax the left height costa
VII, percussion dullness in hemithorax the left height costa VII, the
sound of breathing decreased in left hemithorax, wheezing on left
hemithorax, rhonki on both the median basal lung, peristaltic
impression increased, hepatomegaly 8 cm below the arcus costa,
hard consistency, surface nodule and blunt edges.
In the investigations obtained leukocytosis (WBC: 29190 /

UL), anemia (Hb: 7.9 g / dl), azotemia (urea: 116 mg / dl,
creatinine: 2.5, GFR: 21.94), hyponatremia (sodium : 129 mmol /
L), and hypoalbuminemia (albumin 2.8 g / dl). On chest x ray
dated 13 April 2015 of lung metastases impression with
pneumonia, fractures V-VI costa costa IV right and left suggestive
of bone metastases. On Abdominal ultrasound image dated 14
April 2015 and the hepatic metastases of renal insufficiency.
Based on history, physical examination, and investigations,
patients diagnosed with community acquired pneumonia,
adenocarcinoma mammae dextra stage IVB post MRM
metastases of lung and liver, acute diarrhea mild dehydration
moderate, acute on CKD dd / CKD stage IV ec renal dd / prerenal,
hyponatremia, anemia of chronic disease dd / renal anemia,
hypoalbuminemia, and malnutrition.
On day 11 of treatment, the patient

experienced a suspected septic shock due to
CAP infection and exacerbated by suspicious
Toxoplasma infection. In addition, the
occurrence of seizures can be caused by a
process that is suspected intracranial brain
tumor metastases, cerebral toxoplasma
suspicious, and due uremikum syndrome.
Seizures that occur can lead to cerebral
hypoxia. Eventually the patient is declared
dead
after
no
improvement
with
administration of inotropic and vasoactive.
Diarrhea
GI infection
Pulmonary
infection
Immunocompromize
Less intake
Carsinoma Mammae
CAP
Shortness of breath
Dehidration
metastase
Acute on CKD
Brain?
sepsis
Hepar
Septic Shock
Uremicum
enchephalopaty
seizure
Toxoplasma
Cerebral ?
Lung
Cerebral
hypoxia
Death
Calcification on CT scan of the head picture can be

caused by: age, infections and neoplasms

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Menjadikan Bagian Ilmu Penyakit Dalam

fakultas Kedokteran Universitas

Menyelenggarakan pendidikan di bidang Ilmu Penyakit

Memberikan pelayanan kesehatan di bidang Ilmu

Meningkatkan kuantitas dan kualitas penelitian dasar dan

Menciptakan sistim manajement departemen Ilmu

Suriana Dwi Sartika

Chief complaint : shortness of breath

normocephal, short black hair, is not easily to

Conjungtiva anemic (+), sclera icteric (-)

Normal shape, discharge (-), epistaktis (-)

Tonsil T1-T1, hiperemic (-)

JVP R+2cmH2O , enlargement of lymp nodes (-),

LABORATORY TEST (23/04/2015) from RS.

ECG : Rhytme Sinus , HR: 108x/i, normoaxis

Community Acquired Pneumoni

Ceftriaxon 1gram / 12h

Suspek pleural effusion

O2 4 liters / minute via

Acute diarrhea mildmoderate dehydration

IVFD NaCl 0.9% loading

Acute on CKD dd / CKD

Hyponatremia is based on:

IVFD NaCl 0.9% 20tpm

Anemia of Chronic Disease

Serum fe, TIBC, epoetin alfa dan

VIP Albumin 3x2

- Low-purine diet, potassium, salt,

- Low-purine diet, potassium, salt, protein

Input: 1100cc / 24h

- Low-purine diet, potassium, salt, protein 0.8

Ca mammae dextra post MRM

O2 4 liters / minute via NK

Control chest x-ray results:

Insert chest tube dan

Day Care III - IV

- Low-purine diet, potassium, salt,

- Low-purine diet, potassium, salt,

- Low-purine diet, potassium, salt,

height : 147 cm ; mid upper arm circumference :

1700 kcal diet

- Low-purine diet, potassium, salt,

- Low-purine diet, potassium, salt,

O2 4 liters / minute via NK

Input: 850cc / 24 hours

- Give sugar water via NGT

- Low-purine diet, potassium, salt,

A : Ca Mammae dextra post MRM lung and hepar metastase

O2 4 liters / minute via NK

S: patient was agitated

IVFD D10% 28 dpm

General state: patient was agitated

Observation on the general condition and

- Low-purine diet, potassium, salt,

- Low-purine diet, potassium, salt, protein

A : Ca Mammae dextra post MRM lung and hepar metastase

ICU Hari-2 & 3

O2 8-10 l / min via NRM

- Low-purine diet, potassium, salt, protein

A : Ca Mammae dextra post MRM lung and hepar - Ceftriaxon 1 gr/12hours/iv

- Low-purine diet, potassium, salt,

Acute on CKD dd / CKD stage IV ec.renal dd / pre renal

Low-purine diet, potassium, salt,