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DUTY REPORTJuly 8th 2015GP on duty: dr. Indri dan dr.HusnahCo-Assistant on duty:Melissa and Fitriano
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PATIENT RECAPITULATIONMr. Waluyo 70 y.o Low intake, Ca nasopharynxMr. Harwin 40 y.o Respiratory tract infectionMr. Yoga 27 y.o prolonged febrisMrs.Yuniar 65 y.o Obs. FebrisMr. Atirin 61 y.o Hematemesis
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PATIENTS IDENTITYName: Mr. Waluyo BasukiAge: 70 years oldJob: RetiredReligion: MuslimsMarital Status: MarriedRace: JavaneseAddress: Pondok kopi
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Anamnesis
Chief complain: Patient came with nausea and vomiting (1-2 times) 4 days before admission
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HISTORY OF PRESENT ILLNESSPatient came with chief complain nausea and vomiting since 4 days before admission. Vomit 1-2 times/day, contains liquid and little bit of food excess, the volume was around aqua glass. Vomit no affected by meal time. After vomit, patient felt bitter taste on his tongue and only drink water.
5 days before admission, patient felt dizziness also pain on forehead area and cheek. Patient admitted there was diffulty of swallowing food and liquid so he lost his appetite. Weight lose 10 kg in 6 mounths
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1 day before admission, suddenly he noticed swelling in four extremities, present at the same time. Urinary decrease as much as 1 aqua glass and constipated for 2 days. Patient had been admitted for 3 days in RSI Pondok Kopi, the CT scan was done, and the ENT specialist diagnosed him with nasopharynx carcinoma then the patient was referred to RSPAD.Hypertension (-), DM (-), Heart disease (-)
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Past IllnessNo history of past illnesses
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History of Family IllnessHT (-)Lung disease (-)Allergy (-)Similar complaint with patient (-)
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HabitSmoking Alkohol
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Threatment historyPujimin 3x1Cefixime 2x1Ambroxol 3x1Omeprazole 2x1
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Physical ExaminationGeneral State:Moderately sickConsciousness: GCS E4M6V5
Vital SignsBlood Pressure:130/80 mmHgHeart rate:76 bpm (regular)Respiratory Rate:24 times/minuteTemperature:36,7 oC
Body Weight:40 kgBody Height:165 cmBMI:14,69 (Underweight)
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General ExaminationHead: NormocephalEye: i.K (+/+), i.S (-/-), asimetris (+)Ears: discharge (-)Nose: septum deviation (-), discharge (+)Mouth: coated tongue (-), hyperemic pharynx (-), normal T1-T1, pale mouth mucosa (-), dried mucosa (+)Neck : JVP 5 2 cmH2O, palpable soft mass sized 1,5 cm on the left of the neck
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Thorax: symmetric, intercostals retraction (-)CORInspection: Ictus cordis (-)Palpation: heave (-), lift (-), thrill (-)Percussion:Right border: ICS V, linea parasternal dekstraLeft border : ICS V, linea midclavicularis sinistraHeart waist: ICS III, linea parasternal sinistraAuscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-)
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PULMOInspection : chest within normal shape, symmetries on static and dynamic statePalpation : tactile vocal fremitus both lungs were symmetries, chest expansion symmetriesPercussion : resonant both lungsAuscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)
Abdomen: flat, not distended, Murphy Sign (-), timpani, no enlargement of liver & spleen
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Abdomen: flat, not distended, timpani, no enlargement of liver & spleenExtremitiesPitting edema ++/++Cyanotic - - / - -
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LABORATORY RESULTS
ExaminationResultNormal labHematologi rutin:Hb13*13 - 18 g/dlHt37*40 52 %Erythrocyte4.74.3 - 6.0 mil /ulLeukocyte15.150*4800 - 10800/ulThrombocyte421.000*150000 - 400000/ulMCV8080 96 fLMCH3027 - 32 pgMCHC3332 36 g/dL
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ExaminationResultNormal labUreum16*20 - 50 mg/dlCreatinin1,00.5 1.5 mg/dlRandom Blood Glucose108*< 140 mg/dlNatrium120*135 147 mmol/LKalium3.53.5 5.0 mmol/LChloride88*95 105 mmol/LAlbumin3.0*3.0 5.0 g/dL
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CT-ScanNasofaring mass in the left and spread to left sinus maxilaris, echmoid, frontalis, and sfenoid bilateral with destruction of sinus wall, left orbita wall and basis cranii stadium V., no lymph node enlargement.
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ResumePatient, male, 70 years old come with NFC. The chief complain was nausea and vomit since 4 days before admission, cephalgia, pain in sinuses area, dysphagia, anorexia, lose of appetite and lose weight, pitting edema. 1 day before admission low urinary output. History of medicine consumption pujimin, ambroxol, omeprazol. Nutritional states under weight. In physical examination there were conjungtiva injection, asimetric eyes, rhinorea, mass on faring, mass on left neck, pitting edema in extremities. The lab results showed lekositosis, trombositosis, hiponatremi, hipoalbuminemia
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Problem ListCarcinoma nasopharynx stage V with low intakeElectrolite imbalanceHipoalbuminemiaVomitus
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AssesementCNT with low intakeBased on: -Patients complains vomitus 4 days frek 1-2 times/day, volume aqua glass, low appetite and drink, lose of weight, difficult to swallowDiagnostic: IMT ; underweightTherapy: Fluid treatment 1900 cc/2 hoursCalori needed 1950 kkal
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2. Electrolite imbalance Based on: Vomitus and difficult intakeDiagnostic : HiponatremiTherapy: natrium replacement 480 meq/L corection given in 4 hours
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HipoalbuminemiaBased on the :Patient feel weekness and pitting edema ++/++Diagnosis : Albumin 3.0Teraphy : Given albumin 32 gram
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VomitusGet from : vomit 1-2 times/day, contain liquid and cast-off, and the volue aqua glassTherapy:Ondansentron IV 1x4 mgRanitidin 1x50 mg IV
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Prognosis Quo ad vitamdubia ad malamQuo ad functionamdubia ad malamQuo ad sanationamdubia ad malam
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