Belajar_kasusStrumaNodular_Rumahsakit.pptx

Kasus struma sering dikenal dengan penyakit gondok yang banyak terjadi di Indonesia.

1. Patient Identity . 993503 MR number July 23 th , 1974 Date of birth November 09 th , 2022 Admission Date Consultation Date November 10 th , 2022 M s . A, 48 y.o . ( Fem ale ) Medical diagnosis Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44) Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5 Vertebral Lumbal I-II , lumbal II-III EMD : Struma multinodular suspect malignancy

2. Chief Complaint Decreased of oral intake Fever and Seizure No history Nausea & Vomiting Cough and Shortness of Breath No history Subjective (History taking) Swallowing Disorders No History Epigastric Pain No History No history Headache No history Weight loss There was history of unintentional weight loss approximately ± 4 kg ( 8.3 % of initial weight, 48 kg) since 3 months ago since 3 months ago due to lower back pain that has been getting worse since 5 days ago due to severe back pain Nasogastric Tube No History

3. Toilet, normal concistency yell owish color Defecation Last defecation was 4 days ago via Via Toilet, 3 times/day, yellowish color, seems to be normal Urination Subjective (History taking)

4. Patient Family No history Cerebrovascular disease No history Cardiovascular disease, DM No History Kidney and urinary disease No History Cerebrovascular disease Cardiovascular disease, DM No history Kidney and urinary disease No history Hyperuricemia, hypercholesterolemia Others ( Hypothiroid ) Others No history No History There was lump on the neck since 20 years ago, never checked and never treated,just found out as hypothyroid No history Hyperuricemia, hypercholesterolemia

5. History of PRESENT Illness 3 months ago 2 years ago She complains of intermittent low back pain, there was history of slipped and fall in sit position but only taking pain killer medicine the pain was worsened and went to primary health care. She then referred for MRI examination. She diagnosed with spine tumor and nerve impingement. She referred to orthopedics polyclinic , routine control and physiotherapy. There was plan for surgery but waiting for schedule She brought to ED because the pain worsened since 5 days before admitted to hospital and being treated at L4 Orthopedics and planned for surgery but waiting for the schedule and consulted to Endocrine colleagues for hypothyroid management yesterday

6. 01 02 03 Occupation and Habit Psychosocial history Smoking Drugs and alcohol No History She is housewife No History

7. Dietary History Typical intake and usual amount of food: (before admitted to the hospital) Intake: Via oral Quantity: She eats regularly 3 times/day, 1 cups of white rice with 1 medium chunck of varied of animal side dishes,and 1 small bowl of vegetables, 1 portion of fruit Quality: She likes almost every food 3 months ago , s he ate ¾ cup of white rice with ¾ medium chunk of varied of animal side dishes and ¾ small bowl of vegetables 5 day ago , s he ate ¼ cup of white rice with ¼ medium chunk of varied of animal side dishes and ¼ small bowl of vegetables 24 hours, She eat once a day, ¼ cup of rice, with ¼ medium chunk of varied of animal and vegetable side dishes and ¼ small bowl of vegetables, 1 piece of bread Neither food allergies nor lactose intolerance 9

8. Intake Analysis Last intake Energy (kcal) Protein (g) Carbohydrate(g) Fat (g) Intake before sick 1785 (105 %) 73.59 331.85 27.18 3 month ago 1300 (76.47%) 54.25 231 17.38 5 days ago 462.50 (27.21%) 19.25 81 6.63 24 hours 201.25(11.83%) 7.75 (15.40%) 29 (57.64%) 5.88 (26.27%)

9. GCS E4M6V5 Actual Body Weight : 44 kg Body Height : 145 cm IBM : 22.4 Kg/M² IBW : 45 kg MUAC : 24.5 cm Estimated MUAC B W : 42.89 kg Anthropometry Blood pressure : 129/87 mmHg Pulse : 60 beats/minute Respiratory rate : 18 times/minute Temperature : 36.5 °C Vital signs 01 02 OBJECTIVE MODERATE ILLNESS Handgrip Strength: 7.0 Kg (weak) Functional Status : 03

10. Physical examination HEAD AND NECK Conjunctiva was not anemic, Sclera was not icteric Oxygen support was not supported , Nasogastric tube was not inserted There was enlargement of lymph nodes estimated mass size 10 x 10 cm CHEST Inspection : Symmetric ,there was no loss of subcutaneous fat Palpation : No tenderness Percussion : Sonor Auscultation : Vesicular breathing sound. There was No Rhonchi and wheezing, Regular heart sounds and no murmurs ABDOMEN Inspection : Flat Appearance. Auscultation : Normal Bowel Sound Palpation : Hepar not palpable and lien not palpable Percussion : Tympanic

11. Physical examination EXTREMITY There was minimal wasting in all exterimities There was no edema

12. MEDICATION FROM OTHER DIVISION 16 Orthopedic (November 11 st , 2022) IVFD RL 20 dpm / 24 hours / Intravenous Ranitidin 50 mg/ 12 hours / Intravenous Ketorolac 30 mg/24 hours/ Intravenous Gabapentin 300mg/ 24 hours / Intravenous

13. LABORATORY FINDINGS Laboratory November 09 th, 2022 Normal Value WBC 10.0 4,0 - 10,0 x 10 3 / μ L TLC 1770 1.5 - 4 x 10 3 / μ L PLT 346.000 150-400 x 10 3 / μ L HGB 13.3 12.0 -16.0 gr/dl MCV 80 80 – 100 μ m 3 MCH 27 27.0 – 32.0 pg MCHC 34 32.0-36.0 g/dl Neutrofil 75.6 52.0-75.0% Lymfosit 17.7 20.0-40.0% Random Plasma Glucose 119 < 200 mg/dl Urea 22 10- 50 mg/dl Creatinine 0.60 M:(<1.3) ; F:(<1.1) mg/dL Sodium 142 135 – 145 mmol/L Potassium 3.5 3.5 – 5.0 mmol /L Chloride 106 97 – 111 mmol/L NLR 4.27 < 3.13

14. LABORATORY FINDINGS Laboratory October 31 st, 2022 November 09 th, 2022 Normal Value FT4 0.85 0.93 – 1.71 ng/dl TSHS <0.05 0.27 – 4.20 mlU /ml AST 16 <38 U/L ALT 0.60 <41 U/L PT 10.8 10-14 INR 1.0 0.8-1.1 APTT 28.3 22-30

15. Thorax Photo PA/AP (November 10 th 2022) Normal cardio and pulmo Elevation of the right diaphragm MRI Lumbosacral (September 27 th 2022 ) Extramedullar intradural mass as high as CV L1-L3 suggestive schwannoma differential diagnosis of meningioma Bulging disc levels L3-L4, L4-L5 and L5-S1 pressing thecal sac MR Myelography : visible stenosis canalis spinal level L1-L3 MRI Servical (September 27 th 2022 ) Bulging disc levels C3-C4, C4-C5, C5-C6 and C6-C7 pressing thecal sac MR Myelography :does not appear cervical level spinal canalis stenosis USG thyroid : - Bilateral thyroid mass ( TIRADS 5 ) RADIOLOGIC FINDINGS

16. November 09 th , 2022 Increased NLR 4.2 October 31 st , 2022 Decreased of FT4 0,85 Decreased of TSHs < 0,05 Metabolical status Functional GI- Tract status Functional Status Handgrip Strength 7.0 kg HYDRATION STATUS Normovolemic Assesment

17. Diagnosis & Prognosis Prognosis Vitam : Dubia ad bonam Functionam : Dubia ad bonam Sanactionam : Dubia ad bonam 22 Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44) Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5 Vertebral Lumbal I-II , lumbal II-III EMD : Struma multinodular suspect malignancy

18. B asal E nergy E xpenditure : 1119 Kcal T otal E nergy E xpenditure : 1700 Kcal Macronutrient Composition: Protein 1.5 g/ kgBW /day : 66 g (15.7%) Carbohydrate 50% : 212 g Fat 30.5% : 65.1 g Medical Nutrition therapy is given 40% TEE (680 Kcal) via oral : Standard food 331 Kcal ONS Peptisol 250 Kcal EVOO 160 Kcal F luid requirements 1700 cc/24 hours Planning 23

19. Supplementation via oral : B. Complex 2 tabs/8 hours Zinc 20mg/ 24 hours Curcuma 400mg/8 hours Monitoring and evaluation Haemodynamic Daily intake Gastrointestinal tolerance Nutritional education: Follow the meal according to the schedule Lab : UUN, Albumin Agree to join multidisciplinary care Planning 24

20. FOLLOW UP

21. LABORATORY FINDINGS Laboratory November 10 th, 2022 Normal Value Albumin 4.7 3.5 – 5.0 gr/dl PNI 55.85 > 45

22. Subjective Objective Assessment Planning Intake via oral, There was no nausea and Vomiting. There was low back pain Defecation was 2 days ago Urination : Via toilet, seems to be normal 1st day Follow Up (November 11 th , 20 2 2 ) General Condition :MODERATE ILLNESS GCS E4M6V5 Vital sign : Blood pressure : 130/80 mmHg Pulse : 70 beats/minute Respiratory rate : 22 times/minute Temperature : 36.5°C Anhtropometry Body Length : 145 cm Actual Body Weight : 44 kg Ideal Body Weight : 45 kg Estimated MUAC B W : 42.89 kg MUAC : 24.5 cm IBM : 22.4 kg/M² Food Recall 24 hours via Oral Energy : 842 Kcal (49%) Protein : 30.5 gr (14%) Carbohydrate : 154 gr (73%) Fat : 11 gr (11.7%) Physical Examination: HEAD AND NECK Conjunctiva was not anemic, Sclera was not icteric Oxygen was not supported Nasogastric tube was not inserted There was enlargement of lymph nodes estimated mass size 12 x 10 cm CHEST Inspection : S ymmetric, There was loss of subcutaneous fat Palpation : No tenderness Percussion : Sonor Auscultation : V esicular breathing sound. T here was rhonchi, There was not wheezing , regular heart sounds and no murmurs ABDOMEN Inspection : Flate Appearance Auscultation : Normal Bowel Sound Palpation : Liver and spleen was not pappable Percussion : Tympanic EXTREMITY There was wasting in all extremities There was no edema November 09 th , 2022 Increased NLR 4.2 October 31 st , 2022 Decreased of FT4 0,85 Decreased of TSHs < 0,05 Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44) Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5 Vertebral Lumbal I-II , lumbal II-III EMD : Struma multinodular suspect malignancy BEE : 1119 Kcal TEE : 1700 Kcal (1.2/1.3) Macronutrient Composition: Protein 1.5 g/ kgBW /day : 66 g (15.7%) Carbohydrate 50% : 212 g Fat 30.5% : 65.1 g Medical Nutrition therapy is given 60% TEE (1020 kcal), via oral : - Standart food 662 Kcal -ONS Peptisol 250 kcal -EVOO 160 Kcal Fluid requirements 1700 cc/24 hours Supplementation via oral : - Zinc 20mg/24jam/oral - B comp 2 tab/8 hours -Curcuma 400mg/8 hours -Vitamin D 1000 IU/ 24 jam Monitoring and evaluation - Haemodynamic -Daily intake -Gastrointestinal tolerance Nutritional education: Follow the meal according to the schedule Lab : Waiting for UUN, Albumin result

23. Subjective Objective Assessment Planning Intake via oral, There was no nausea and Vomiting. There was low back pain Defecation was yesterday Urination : Via toilet, seems to be normal 2nd day Follow Up (November 12 th , 20 2 2 ) General Condition :MODERATE ILLNESS GCS E4M6V5 Vital sign : Blood pressure : 130/70 mmHg Pulse : 80 beats/minute Respiratory rate : 22 times/minute Temperature : 36.5°C Food Recall 24 hours via Oral Energy : 1075 Kcal (63%) Protein : 43.5 gr (16.2%) Carbohydrate : 160 gr (59%) Fat : 28.5 gr (23%) Physical Examination: HEAD AND NECK Conjunctiva was not anemic, Sclera was not icteric Oxygen was not supported Nasogastric tube was not inserted There was enlargement of lymph nodes estimated mass size 12 x 10 cm CHEST Inspection : S ymmetric, There was loss of subcutaneous fat Palpation : No tenderness Percussion : Sonor Auscultation : V esicular breathing sound. T here was rhonchi, There was not wheezing , regular heart sounds and no murmurs ABDOMEN Inspection : Flate Appearance Auscultation : Normal Bowel Sound Palpation : Liver and spleen was not pappable Percussion : Tympanic EXTREMITY There was wasting in all extremities There was no edema November 09 th , 2022 Increased NLR 4.2 October 31 st , 2022 Decreased of FT4 0,85 Decreased of TSHs < 0,05 Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44) Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5 Vertebral Lumbal I-II , lumbal II-III EMD : Struma multinodular suspect malignancy BEE : 1119 Kcal TEE : 1700 Kcal (1.2/1.3) Macronutrient Composition: Protein 1.5 g/ kgBW /day : 66 g (15.7%) Carbohydrate 50% : 212 g Fat 30.5% : 65.1 g Medical Nutrition therapy is given 80% TEE (1360 kcal), via oral : - Standart food 662 Kcal -ONS Peptisol 300 kcal - Fruit Juice 100 Kcal -EVOO 240 Kcal Fluid requirements 1700 cc/24 hours Supplementation via oral : - Zinc 20mg/24jam/oral - B comp 2 tab/8 hours -Curcuma 400mg/8 hours -Vitamin D 1000 IU/24 jam Monitoring and evaluation - Haemodynamic -Daily intake -Gastrointestinal tolerance Nutritional education: Follow the meal according to the schedule Lab : Waiting for UUN result

24. Thank you