Lapkas Ika

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    CHF ec DILATED RA-RV + OBESITAS

    Presenter : Ika Diamanda Apriano

    Amalia P Dewi

    Day/Date : Monday/ June 17th 2013

    Supervisor in charge : Dr. Hj. Melda Deliana Sp.A(K)

    INTRODUCTION

    Obesity is the most prevalent nutritional disorder among children and adolescents in

    the United States. Approximately 21-24% of American children and adolescents are

    overweight, and another 16-18% is obese; the prevalence of obesity is highest among specific

    ethnic groups.1

    Using body mass index (BMI) criteria, the most recent national surveys demonstrate

    that 21-24% of American children and adolescents are overweight and that another 16-18%

    are obese. A 2012 study noted a 16.9% prevalence of obesity in children and adolescents in

    2009-2010, which is comparable to the prevalence rates reported in 2007-2008

    12

    .Thesefindings, indicate that the prevalence of overweight (BMI 85th percentile) children and

    adolescents in the US has increased by 50-60% in a single generation, and the prevalence of

    obesity has doubled. The prevalence of obesity in American Indians, Hawaiians, Hispanics,

    and blacks is 10-40% higher than in whites.

    International data reporting regarding childhood obesity varies, and accuracy may be

    less than optimal; however, Eneli and Dele Davies reported that in 77% of the countries

    analyzed, the prevalence rate for children who were overweight was at least 10%13

    . Notably,

    the highest rates for children at risk for obesity were found in Malta (25.4%) and the United

    States (25.1%). Lithuania (5.1%) and Latvia (5.9%) had the lowest rates. A recent European

    Youth Heart Study suggests Swedish children have a lower risk of becoming overweight or

    obese in adolescence compared with Estonian children14.

    Race and ethnicity are associated with increased rates of obesity in children and

    adolescents. Puerto Rican, Cuban American, and Native American preschoolers have an

    increased incidence of obesity; black, Native American, Puerto Rican, Mexican, and native

    http://emedicine.medscape.com/article/123702-overviewhttp://emedicine.medscape.com/article/123702-overview
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    Hawaiian school-aged children have the highest rates of obesity in this age group.

    Approximately 25% of black adolescents are obese. Rosen reported thatobstructive sleep

    apnea hypoventilation (OSA/H) is more commonly seen in black children than in Hispanic or

    white children.14 Tonsils and adenoids are at their peak size, relative to the size of the

    oropharynx, when children are aged 2-7 years.

    During the second decade of life, females are more likely to be obese than males,

    except for black teenagers, among whom males are more likely to be obese than females.

    Although the male sex is associated with an increased incidence of OSA in adults, no

    differences have been identified in children before puberty.

    Adolescent obesity is predictive of adult obesity, with 80% of teenagers who are

    obese continuing on to be obese as adults. Obesity is more likely to occur during specific

    periods of life, such as when children are aged 5-7 years and during adolescence. A recent

    European Youth Heart Study suggests male sex confers a higher risk of obesity in

    adolescence13.

    CASE

    http://emedicine.medscape.com/article/1002703-overviewhttp://emedicine.medscape.com/article/1002703-overviewhttp://emedicine.medscape.com/article/1002703-overviewhttp://emedicine.medscape.com/article/1002703-overview
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    Follow up on May 22th

    - 9th

    June 2013

    May 22t 2013

    S Dyspnoe (+), fever (+), oedem (+),

    O Sensorium: compos mentis

    Temperature: 37,6C

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-, oedema(+/+)

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpable

    Chest : Simmetrical fusiformis, no retraction

    HR : 100 bpm, reguler, no murmur

    RR : 22 breathes/minute, reguler, no ronkhi

    Abdomen : Soepel, peristaltic (+) normal, hepar palpable mass in right hipocondria, size 6

    x 5x 4 cm, immobile, venectation (+). Spleen indeterminate.

    Extremities : pulse 100 bpm, reguler, pressure and volume were adequate, warm acral, CRT

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    Lymph Absolute 10 /L 2,09 1,7-5,1

    Mono Absolute 10 /L 1,03 0,2-0,6

    Eos Absolute 10 /L 0,33 0,10-0,30

    Baso Absolute 10 /L 0,05 0-0,1

    Conclusion :

    Clinical Chemistry

    AGDA

    pH 7,474 7,35 - 7,45

    pCO2 mmHg 36,6 3842

    pO2 mmHg 182,9 85100

    HCO3 Mmol/l 26,2 2226

    Total CO2 Mmol/l 27,4 1925

    BE Mmol/l 2,8 (-2)(+2)

    Saturation O2 % 99,4 95100

    Liver

    Albumin gr/dl 3,6 3,85,4

    Carbohydrate Metabolism

    Glucose ad random mg/dl 80,00

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    P Treatment

    1. O2 1 l/I nasal kanul2. Furosemide 2x40 mg3. Spironolacton 2x2,5mg

    4. Digoxin 2x0,3mg5. Diet MB 2000 kcal + 60 gr protein

    Laboratory result : May 23th

    2013

    Maret 23t

    2013

    Test Unit Result Reference

    URINALYSIS

    Complete Urine Analysis

    Colour Clear yellow Yellow

    Glucose Negative Negative

    Bilirubin Negative Negative

    Keton Negative Negative

    SG 1.015 1.0051.030

    Ph 8,0 5 - 8

    Protein Negative Negative

    Urobillinogen Negative

    Nitrit Positive Negative

    Blood Negative Negative

    Urine Sedimented

    Eritrocyte LPB 01

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    Temperature: 37,0C

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-,

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpable

    Chest : Simmetrical fusiformis, no retraction

    HR : 96 bpm, reguler, no murmurRR : 26 breathes/minute, reguler, no ronkhi

    Abdomen : Soepel, peristaltic (+) normal, hepar palpable mass in right hipocondria,

    size 6 x 5x 4 cm, immobile, venectation (+). Spleen indeterminate.

    Extremities : pulse 100 bpm, reguler, pressure and volume were adequate, warm acral,

    CRT

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    1. O2 1 l/I nasal kanul2. Furosemide 2x40 mg3. Spironolacton 2x2,5mg4. Digoxin 2x0,3mg5. Diet MB 2000 kcal + 60 gr protein

    Dipstick Urine 15.00 WIBLeu / Nit/ Uro/ Pro/ pH / Blo / SG / Ket / Bil / Glu

    / - / 0,2 / + / 6,0 / - / 1,010/ / + / -

    Planning

    Kultur Urine to Microbiology

    Follow up on May 27th

    2013

    May 27t -20t 2013

    S Dyspnoe (+), fever (-),

    O Sensorium: compos mentis

    Temperature: 37,0C, weight 66 kg

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-,

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpable

    Chest : Simmetrical fusiformis, no retraction

    HR : 98 bpm, reguler, no murmur

    RR : 32 breathes/minute, reguler, no ronkhi

    Abdomen : Soepel, peristaltic (+) normal, hepar palpable mass in right hipocondria,

    size 6 x 5x 4 cm, immobile, venectation (+). Spleen indeterminate.

    Extremities : pulse 100 bpm, reguler, pressure and volume were adequate, warm acral,

    CRT

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    O Sensorium: compos mentis

    Temperature: 36,9C, weight 65 kg

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-,

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpable

    Chest : Simmetrical fusiformis, no retractionHR : 98 bpm, reguler, no murmur

    RR : 30 breathes/minute, reguler, no ronkhi

    Abdomen : Soepel, peristaltic (+) normal, hepar palpable mass in right hipocondria,

    size 6 x 5x 4 cm, immobile, venectation (+). Spleen indeterminate.

    Extremities : pulse 98 bpm, reguler, pressure and volume were adequate, warm acral,

    CRT

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    2. Furosemide 2x40 mg3. Spironolacton 2x2,5mg4. Digoxin 2x0,3mg5. Diet MB 2000 kcal + 60 gr protein

    Planning : CT Scan intraabdomen

    Follow up on May 30th

    2013

    May 30t 2013

    S Dyspnoe (+), fever (-),

    O Sensorium: compos mentis

    Temperature: 36,1C, weight 65 kg

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-,

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpable

    Chest : Simmetrical fusiformis, no retraction

    HR : 98 bpm, reguler, no murmur

    RR : 30 breathes/minute, reguler, no ronkhi

    Abdomen : Soepel, peristaltic (+) normal, hepar palpable mass in right hipocondria,

    size 6 x 5x 4 cm, immobile, venectation (+). Spleen indeterminate.

    Extremities : pulse 98 bpm, reguler, pressure and volume were adequate, warm acral,

    CRT

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    CHF ec dilated RA-RV + moderated PI +n moderated TI + obesitas + suspect

    abdominal tumor

    P Treatment

    1. O2 1 l/I nasal kanul

    2. Furosemide 2x40 mg3. Spironolacton 2x2,5mg4. Digoxin 2x0,3mg5. Diet MB 2000 kcal + 60 gr protein

    Balance fluids 18.00 WIB

    Input : IVFD = 50 Output : IWL = 1300

    Diet = 500 cc UOP = 50

    Total : 550 cc 1350

    Balance : InputOutput = 5501350 = 800

    Needs of fluids on 6 hours= Holiday segar Balance

    = 1600 + 800

    = 2400 cc

    Follow up on June 1th

    2013

    June 1t 2013

    S Dyspnoe (+), fever (-),

    O Sensorium: compos mentis

    Temperature: 36,9C, weight 66 kg

    Head : Eyes : Light reflexes : +/+, isocoric, conjunctiva palpebra pale -/-,

    Ear, nose, and mouth : normal

    Neck : lymph node was not palpa