Morning Report

August, 13th 2014

COASS INCHARGE:Nooryuliana Sari Asmarina

Manjula Alagari

Supervisor: dr. Bogi Pratomo, SpPD-KGEH

Summary of Data BaseMr. 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 didn’t 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 didn’t 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 didn’t 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 examinationBP = 120/80 mmHg PR = 80 regular strong RR =20 on ER--20

tpm, Tax : 36,7 °C

General appearance looked moderately illO2 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 SinistraLHM ≈ ictus, RHM: SL DS1, S2 single, murmur (-), gallop (-)

Lung: Symetric, SF D= S v v Rh - - Wh - - v v - - - - v v - - - -

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 4 4

Laboratory finding (12 August 2014)Lab Value Lab Value

Leukocyte 14.300 3.500-10.000/µL

Natrium 128 136-145 mmol / L

HaemoglobineMCV

3.963.90

11,0-16,5 g/dl80-97

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 686.000 100.000-390.000/µL

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 3 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 PL IDx PDx PTx PMo

Male/ 45 yo/W. 25A• Pale• bloody loss from mass for 3 months •Neck tumor since 3 years

PEGCS : 456•BP : 120/80 mmHg•PR : 80•RR : 20•Tax : 36,7Head : Pale conjugtivaNeck: Mass at regio colli D,hard,7cmx7cmx7cm,with ulcer, bloody, tenderR/ 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

1. Anemia Gravis (hipokrom mikrositer)

1.1.Deff. Fe due to chronic blood loss

1.2 Chronic disease due to malignanncy

SI,TIBC,ferritin • O2 2-4 lpm Nasal Canule

• Transfussion PRC 2 kolf/day until Hb >10 g/dl

S, VS, urine production

P Edu: Planning diagnostic, Prognosis, and therapy

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/W. 25A• tunor at regio colli D and S• The last chemotherapy on JanuaryPEGCS : 456•BP : 120/80 mmHg•PR : 80•RR : 20•Tax : 36,7Mass at regio colli D,hard,7cmx7cmx7cm,with ulcer, bloody, tenderR/ submandibula s: multiple nodul, diameter 1-3cm, fixed, non tender, irregular margin, no ulcer bor pus

2. Carcinoma Nasofaryng T4N1Mx, drop out chemotherapy

Re-staging:Brain CT scan Abdominal USG

• Diet HCHP 2100 kkal/day

. Plan for chemotherapy after re staging

S, VS,

P Edu: Planning diagnostic, Prognosis, and therapy

Male/ 45 yo/W. 25PEUlcer at massNo pusLab :Leucocyte : 14.300Neutrofil : 82.3%

3. Infected Tumor Colli D

Gram, culture pus, sensitivity Ab wound

Oral ; Clindamycin 4x300 mg

Wound hygiene

WoundComplete blood count

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/W. 25A• nausea• vomit

Lab :Na 128Osm 280.65

4.Hiponatremia euosmolar euvolemik

4.1 GI loss4.2 SIADH

UNa IVFD NaCl 0.9% 1360cc in 14 hours continue with maintenance IVFD NaCl 0.9% 20dpm

SE

Male/ 45 yo/W. 25ALeft eye strabismus

PE :Strabismus left eye

5. Strabismus 5.1 Metastatic Process

Brain CT scan with contras

Treat underlying disease S, VS, urine production

P Edu: Planning diagnostic, Prognosis, and therapy

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 45 yo/W. 25PEOedema ekstremity Inferior minimalLab :Albumin : 3.2

6.Mild Hypoalbuminemia

7.1 hypercatabolic state

7.2 low intake

Diet protein 1 – 1,2 g/kg/day

Albumin

Problem analysa

Ca Nasopharyng

Alternative Medicine

Chronic Bloody Mass

Worked Contact with

“Tinner”

Anemia

Infected Mass

Risk Factor AnalysisCa Nasopharnx1.Ras2.Gender3.Diet4.Epstein Barr Virus5.genetic6.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