You are on page 1of 21

Morning Report

August, 13th 2014


COASS INCHARGE:
Nooryuliana Sari Asmarina
Manjula Alagari
Supervisor:
dr. Bogi Pratomo, SpPD-KGEH

Summary of Data Base


Mr. Hasyim/ 45yo/ W.25
Chief complaint: Pain on the neck tumor
(Autoanamnesa and Heteroanamnesa)
Patient suffered from pain on the neck of tumor since 3 months ago but
getting worse in the last 2 weeks. The pain was stabbing like sensation,
intermittently, localized on the neck and didnt radiate.
There was a tumor on the right neck since 3 years ago. First, the size was
equal with telur puyuh but gets bigger til now.
Last January 2014 (8months ago) the patient was diagnosed as carcinoma
nasopharing and had been chemotherapy on Private Hospital.
Chemotherapy just 1 time because the patient didnt have enough money.
Since that he just took medicine from alternatif medicine. On Mei 2014
(3months ago) he went to alternative medicine and made the mass had
broken. The mass eject the blood from there until now.

Blurred vision accompanied with juling left eye since 8


months ago
History of pass illness:
He didnt had Diabetess Mellitus and Hypertension
History of private and social:
He used to worke at Bentoel Factory, as a Antikarat division
that contact with tiner for 4 years but already retired in this
last 3 months.
He is married, have 2 children

Physical examination
BP = 120/80 mmHg

PR = 80 regular strong RR =20 on ER--20


tpm,

Tax : 36,7 C

General appearance looked moderately ill


O2 2-4 lpm

GCS 456

Head

Pale conjunctiva +
Icterus Sclera -

Pupil isocor 3 mm/3 mm, strabismus left eye

Neck

JVP R + 0 cmH2O 30 degree, Mass at regio colli D,hard consistency,


irregular margin, size 7cmx7cm,with ulcer and pus, blood from the
wound, tender,
R/ left submandibula s: Multiple nodul, diameter 1-3cm, fixed, non
tender, irregular margin, with ulcer or pus

Chest

Heart:

Ictus invisible and palpable at ICS V, MCL Sinistra


LHM ictus,
RHM: SL D
S1, S2 single, murmur (-), gallop (-)

Lung:

Symetric, SF D= S v v
v v
v v

Rh - ---

Wh

- ---

Abdomen and Genital

Flat, Soefl, liver span 8 cm, traube space tympani,


bowel sound (+) normal

Extremities

Oedema -/-, motoric 4 4 ,reflex pathologic negative, reflex physiologic n

Laboratory finding (12 August 2014)


Lab

Value

Lab

Value

Leukocyte

14.300

3.50010.000/L

Natrium

128

136-145 mmol / L

Haemoglobine
MCV

3.9
63.90

11,0-16,5 g/dl
80-97

Kalium

4.01

3,5-5,0 mmol / L

MCH

18.10

26,5-33,5

Chlorida

101

98-106 mmol / L

PCV

13.80

35-50%

Osmolarity

280.59

Trombocyte

686.000

100.000390.000/L

Eo/Ba/Neu/Ly/
Mo

2.5/0.3/82.
3/6.7/8.2

SGOT

14

11-41U/L

Ureum

41.3

10-50 mg/dL

SGPT

10-41U/L

Creatinine

0.91

0,7-1,5 mg/dL

RBS

134

<200

Albumin

3.2

3.5-5,5 g/dL

PPT

17.00

APTT

29.30

ECG

Sinus Takikardi, Heart rate 115 bpm


Frontal Axis
: normal
Horizontal Axis
: normal
PR interval
: 0,16
QRS complex
: 0.04
QT interval
: 0.28
Conclusion : sinus tachycardia with HR 115 bpm

CXR August, 12rd 2014

AP position, asymetric, enough inspiration


soft tissue thin, bone normal
Trachea in the middle
Hemidiaphragma D/S domeshape
Sinus costophrenicus D/S sharp
Pulmo D/S within normal limit
Cor : site normal, shape normal, size CTR 48 %
Conclusion : normal Xray

CUE AND CLUE


Male/ 45 yo/W. 25
A
Pale
bloody loss from mass
for 3 months
Neck tumor since 3 years
PE
GCS : 456
BP : 120/80 mmHg
PR : 80
RR : 20
Tax : 36,7
Head : Pale conjugtiva
Neck: Mass at regio colli
D,hard,7cmx7cmx7c
m,with ulcer, bloody,
tender
R/ submandibula s:
multiple nodul,
diameter 1-3cm, fixed,
non tender, irregular
margin, no ulcer bor
pus
LAB
Hb : 6,5
MCV : 63,9
MCHC : 18.1

PL
1. Anemia
Gravis
(hipokrom
mikrositer)

IDx

PDx

1.1.Deff. Fe
due to
chronic
blood loss

SI,TIBC,ferritin

1.2 Chronic
disease
due to
malignan
ncy

PTx
O2 2-4 lpm Nasal
Canule
Transfussion PRC 2
kolf/day until Hb >10
g/dl

PMo
S, VS, urine
production
P Edu:
Planning
diagnostic,
Prognosis, and
therapy

CUE AND CLUE

PL

Male/ 45 yo/W. 25
A
tunor at regio colli D
and S
The last chemotherapy
on January
PE
GCS : 456
BP : 120/80 mmHg
PR : 80
RR : 20
Tax : 36,7
Mass at regio colli
D,hard,7cmx7cmx7c
m,with ulcer, bloody,
tender
R/ submandibula s:
multiple nodul,
diameter 1-3cm, fixed,
non tender, irregular
margin, no ulcer bor
pus
Male/ 45 yo/W. 25
PE
Ulcer at mass
No pus
Lab :
Leucocyte : 14.300
Neutrofil : 82.3%

IDx

PDx

PTx

2. Carcinoma
Nasofaryng
T4N1Mx,
drop out
chemothera
py

Re-staging:
Brain CT scan
Abdominal
USG

Diet HCHP 2100


kkal/day
. Plan for chemotherapy
after re staging

3. Infected
Tumor Colli D

Gram, culture
pus, sensitivity
Ab wound

Oral ; Clindamycin 4x300


mg
Wound hygiene

PMo
S, VS,
P Edu:
Planning
diagnostic,
Prognosis, and
therapy

Wound
Complete
blood count

CUE AND CLUE


Male/ 45 yo/W. 25
A
nausea
vomit

PL

IDx

PDx

PTx

PMo

4.Hiponatremia
euosmolar
euvolemik

4.1 GI loss
4.2 SIADH

UNa

IVFD NaCl 0.9% 1360cc in


14 hours continue with
maintenance IVFD NaCl
0.9% 20dpm

SE

5. Strabismus

5.1 Metastatic
Process

Brain CT
scan with
contras

Treat underlying disease

S, VS,
urine
productio
n

Lab :
Na 128
Osm 280.65
Male/ 45 yo/W. 25
A
Left eye strabismus
PE :
Strabismus left eye

P Edu:
Planning
diagnosti
c,
Prognosis
, and
therapy

CUE AND CLUE


Male/ 45 yo/W. 25
PE
Oedema ekstremity
Inferior minimal
Lab :
Albumin : 3.2

PL

IDx

6.Mild
Hypoalbumine
mia

7.1
hypercatabolic
state
7.2 low intake

PDx

PTx
Diet protein 1 1,2
g/kg/day

PMo
Albumin

Problem analysa
Worked
Contact with
Tinner

Ca
Nasopharyng

Alternative
Medicine

Chronic Bloody
Mass

Anemia

Infected Mass

Risk Factor Analysis


Ca Nasopharnx
1. Ras
2. Gender
3. Diet
4. Epstein Barr Virus
5. genetic
6. Family history
7. Workplace exposure

Management analysis

bed rest
O2 NC 2 -4 L/minutes
Diet HCHP 2100 kkal/day

Diet protein 1 1,2 g/kg/day


IVFD NaCl 0.9% 1360cc in 14 hours
continue with maintenance IVFD
NaCl 0.9% 20dpm
Tranfusion PRC 2 kolf/day
Oral : Clindamycin 4x300 mg

Condition this morning

GCS : 456
BP : 110/70 mmHg
HR : 84 bpm
RR : 22 tpm
Tax 36,7

Thank you