MR pneumonia sepsis KAD asidosis copy.pptx

MR pneumonia sepsis KAD asidosis copy.pptx
MORNING REPORT IMC ward September, 26th 2022
Patient Identity • Name : Mrs. HM • Age : 40 years old • Sex : Female • Occupation : House Wife • Education : Senior High School
A 40 year-old Woman was admitted to R.D. Kandou Hospital at IMC ward on September, 26th 2022 Chief complaint: shortness of breath
Present Medical History • The patient was referred from Wahyu Slamet Bitung Navy hospital and was admitted this morning with complaints of shortness of breath since last night, which initially along with cough and fever. • Cough was felt 3 days ago without any sputum and bloody strep • Also, the patient has felta fever three days ago before hospitalised. The fever went down with an antipyretic drug and went up again • Nausea (+), vomit (-) • Currently, there was no complaints of urine and defecation
Past Medical History • The patient and family has denied a history of T2DM, hypertension, renal disease, heart disease
Family History • None experienced the same illness
Physical Examination • GC: Severe ill . Sens : CM • Vital sign : BP: 128/80 mmHg, PR 88 x/m, RR 20 x/m, T 36.7 oC SpO2 98% via nasal canule 2-3 lpm • Head : conj. Anemic (-), scl. Icteric(-) • Neck : JVP 5+0 cmH2O, lymph nodes enlargement (-), trachea midline, thyroid impalpable • Thorax : • Heart : – Insp : IC not visible – Palp : IC not palpable – Perc : left border: ICS VI left anterior axillar line right border: ICS IV right parasternalis line – Ausc : SI-II regular, murmur (-), gallop (-)
Physical Examination • Lung : Insp : Symmetric R = L Palp : Stem fremitus R = L Perc : Dull on 1/3 basal of lung Ausc : Vesicular +/+, ronchi -/-, wheezing -/- • Abdomen Insp : Convex Ausc : Normal bowel sound Palp : Tender, no liver & spleen enlargement, Epigastric pain (+) Perc : Timpanic, shifting dullness (-) • Extr : warm, CRT <2 secs, edema -/-, cyanosis (-), • RT : not evaluated
CHEST RADIOGRAPH
RONTGEN INTERPRETATION Rontgen components Interpretation Identity, Name, Diagnosis Same Side Marker (right/left) Correct Film Type (AP/PA/Lateral/Erect) Anteroposterior (AP) Film Quality: • Adequate Inspiration? • Thoracal vertebrae? • Clavicula and Sternum symetric in middle Adequate Adequate Symetric Tube/Cable No Cor + CTR 61% Pulmo (Trachea position, bronchi, hilar, vascular pattern, infiltrate, cavity, fibrosis, nodul, Pleural thickening Normal
RONTGEN INTERPRETATION Rontgen components Interpretation Soft tissue and Bone • Neck, supraclavicula, axilla, chest, mammae, upper abdomen, gastric gas, shoulder joint, scapula, clavicula, vertebrae, costae, and sternum Intact Diaphragma Normal Mediastinum (Shape, diapraghm height, free air, tenting, elevation, Flattening) Normal Sinus Costovertebrae Sharp Sinus Cardiophrenicus Normal CONCLUSION :there was no significantly disorder in this photo
Lab Result (25/09/2022) [Wahyu Slamet Bitung Hospital] • WBC 29.300 • Hemoglobin 15.1 • Platelet 205.000 • Antigen SARS CoV-2 negative
Lab Result (25/09/2022) [Kandou] • WBC 25.900 • Hemoglobin 14.2 • Platelet 214.000 • RBG 976 • Ureum Serum 68 • Creatinine Serum 1.6 • Natrium Serum 119 • Kalium Serum 5.8 • Klorida Serum 84 • Osm 292
BGA Result (25/09/2022) • pH 7.058 • PCO2 13.7 • PO2 123 • BE -26 • HCO3 3.9 • TCO2 < 5 • sO2 97% • Lactat 1.10 • FiO2 36 • P/F ratio : 342
Urinalysis Result (25/09/2022) • Yellow • Slightly cloudy • Erythrocyte > 50 • Leukocyte 15-20 • Epithel 8-10 • Bacteria – • Fungi - • Amoeba - • SG 1015 • pH 5 • Leukocyte +2 • Nitrit – • Protein +3 • Glucose +4 • Ketone +4 • Urobilinogen - • Bilirubin - • Blood +5 • Cylinder – • Crystal -
Lab Result (25/09/2022) 21.05 • Sodium 133 • Potassium 7.1 • Chloride 71
Urinalysis Result (25/09/2022) 21.05 • Yellow • Slightly cloudy • Erythrocyte > 50 • Leukocyte 5-15 • Epithel 2-6 • Bacteria – • Fungi - • Amoeba - • SG 1010 • pH 5 • Leukocyte +1 • Nitrit – • Protein +2 • Glucose +4 • Ketone +3 • Urobilinogen - • Bilirubin - • Blood +5 • Cylinder – • Crystal -
BGA Result (25/09/2022) 21.30 • pH 7.278 • PCO2 18.5 • PO2 91 • BE -18 • HCO3 8.6 • TCO2 9 • sO2 96 • Lac. 0.88 • P/F ratio : 98
BGA Result (26/09/2022) 03.00 • pH 7.233 • PCO2 14.5 • PO2 122 • BE -21 • HCO3 6.1 • TCO2 7 • sO2 98% • Lac. 0.86 • FiO2 100% • P/F ratio : 122 (Moderate)
Urinalysis Result (26/09/2022) 03.00 • Yellow • Slightly cloudy • Erythrocyte > 50 • Leukocyte 5-10 • Epithel 2-5 • Bacteria – • Fungi - • Amoeba - • SG 1015 • pH 5 • Leukocyte +1 • Nitrit – • Protein +2 • Glucose +4 • Ketone +3 • Urobilinogen - • Bilirubin - • Blood +5 • Cylinder – • Crystal -
BGA Result (26/09/2022) 09.00 • pH 7.189 • pCO2 16.2 • pO2 245 • BEcf -22 • HCO3 6.2 • pCO2 7 • SO2 100 • Lac 0.59
BGA Result (26/09/2022) 15.00 • pH 7.21 • pCO2 16.4 • pO2 241 • FiO2 32 • PF rasio 753 • BEcf -21 • HCO3 6.6 • pCO2 7 • SO2 100% • Lac 0.77
Monitoring Blood Glucose Time RBG Tx 14.00 High 15.00 High 10 unit IV extra 16.00 High 5 unit/hour 17.00 513 5 unit/hour 18.00 489 5 unit/hour 19.00 High 5 unit/hour 20.00 570 6 unit/hour 21.00 481 6 unit/hour 22.00 530 6 unit/hour 23.00 528 6 unit/hour 00.00 412 6 unit/hour 01.00 312 6 unit/hour Time Glucose Tx 02.00 452 6 unit/hour 03.00 389 6 unit/hour 04.00 412 5 unit/hour 05.00 395 5 unit/hour 06.00 425 7 unit/hour 07.00 378 7 unit/hour 08.00 414 8 unit/hour 09.00 375 8 hour/hour 10.00 454 8 unit/hour (change to insulin) 11.00 259 4 unit/hour 12.00 379 5 unit/hour 13.00 410 6 unit/hour 14.00 452 7unit/hour
Monitoring Blood Glucose Time RBG Tx 15.00 444 N7 15.40 350 N6 16.10 320 N5 17.00 302 N3 18.00 297 N3 19.00 199 N3
Problem List • DKA • Septic shock ec pneumonia • Pneumonia with ARDS recovery • Partly compensated metabolic acidosis • Hyponatremia • AKI dd/ CKD
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 1. DKA IVFD NaCl 0.9% 500 ml/8 hours, change D5% 500cc / 8 hours if RBG <200. IVFD Novorapid 50 unit in NaCl 0.9% 50 ml (titrasi doses) IVFD KCL 50 meq drips in NaCl 0.9% 500 ml/6 hours  KCL 25 meq drips in NaCl 0.9% 500 ml/6 hours Monitoring urine output/24 bours Monitoring blood glucose/hour Check Na/K/Cl, BGA, urinalysis/6 hours Check HbA1C, lipid profile Consult ICU —> the patient and family were refusing to intubate Titrate with target decrease 50- 75 mg/dl per hour. Target 140- 200 mg/dl Diagnostic Care Plan
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 2. Septic shock ec pneumonia IVFD Norepinefrin 80 mg in NaCl 0.9% 100 ml, doses titrasi according BP (STOP) MAP <65 mmHg Care Plan
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 3. Pneumonia with ARDS improved Oxygen adequate Levofloxacin 1x750 mg IV ST Paracetamol 3x500 mg via NGT SpO2 >96% WBC 4000-10000 Fever (-) T 36.0-37.5 Care Plan
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 4. Partly Compensated Metabolic acidosis BGA/6 hours PH 7.35-7.45 HCO3 22-26 PCO2 35-45 Diagnostic Care Plan
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 5. Hyponatremia IVFD NaCl 0.9% 500cc/8 hours Check Na, K, Cl control/6 hours Na 135-153 Diagnostic Care Plan
Natrium Correction – Na deficit: (135-119)x0.5x50 = 400 meq – Na daily: 2-3 meq/kgBB = 100 -150 meq – Total Na = 500 – 550 meq – Max Na / day = 8x0.5x50 = 200 meq – NaCl 0,9% = 200/154 *1000 = 1.298 ml/day – Duration = 550/200 x 24 hours = 66 hours – Osmolality = 2 x 119 + (976/18) + (68/6) = 292
Hiponatremia
no Problem list Pharmacological and Non Pharmacological Intervention Output and Outcome 6. AKI dd/ CKD. IVFD NaCl 0.9% 500 ml/8 hours Monitoring urine output/24 hours Urinalysis/6 hours Rehydrate UO 0.5-1cc/kgbw/day Diagnostic Care plan
Conclusion • Has been reported the case of a 40-year-old woman who was admitted to R. D. Kandou Hospital at IMC ward with the chief complaint of shortness of breath. After a thorough history-taking, physical examination, and laboratory-radiology workup, patient was diagnosed with DKA, Septic shock ec pneumonia, Pneumonia with ARDS recovery, Partly compensated metabolic acidosis, Hyponatremia, AKI dd/ CKD
Prognosis • Ad vitam: malam • Ad functionam: malam • Ad sanationam:malam

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