KETOASIDOSIS DIABETES MELLITUS PPTX.pptx

KAD

1. Internal Medicine Department Faculty of Medicine Udayana University – Sanglah Hospital Denpasar DUTY REPORT SATURDAY, 15 th FEBRUARY 2020 1

2. CONSULTANTS DR. AAA YULI GAYATRI , SP.PD -KPTI TEAM I A : DR. DEDY / DR. IFAN I B : DR. ROYKHAN/ DR. GANGGA II A : DR . SRI / DR. JEFFRY / DR. EDWIN II B : DR. JUNI / DR. EKA HANDREAN III : DR. GODFRIED / DR. TEGUH TEAM IN CHARGE

3. Resume New Patients : 9 Consultation : 8 Out patients : 1 Refused adm : 1 Death case : - 3

4. II B

5. 1 SUTIANI F 60 YO CM 19024799 JL. IMAMBONJOL GG, MAHKOTA NO; 98H DPS TC 11.10 CC: SHORTNESS OF BREATH ROOM SANJIWANI ASSESMENT THERAPY PLANNING PNEUMONIA (CAP) PSI CLASS IV CHRONIC KIDNEY DISEASE STADIUM V EC SUSPECT DIABETIK KIDNEY DISEASE MILD ANEMIA NN ON CKD METABOLIC ACIDOSIS STAGE II HYPERTENSION TYPE 2 DM POST TOTAL THYROIDECTOMY CHF FC II EC HHD ADM -> O2 NC 4 LPM IVFD NACL 0.9 8 DPM CKD DIET 35KCAL/KG/DAY + 0,8 GR PROTEIN/KG/DAY CEFOPERAZONE 1 GR VERY 12 HOUR INTRAVENOUSLY LEVOFLOXACINE 750 MG EVERY 24 HOURS INTRAVENOUSLY AMLODIPINE 10 MG EVERY 24 HOUR INTRAORALLY CANDESARTAN 16 MG EVERY 24 HOURS INTRAORALLY ALOPURINOL 100 MG EVERY 24 HOURS INTRAORALLY FOLIC ACID 2 MG EVERY 12 HOURS INTRAORALLY NATRIUM THYROXIN 100MG EVERY 24 HOURS INTRAORALLY APIDRA 8 UNIT EVERY 15 MINUTE BEFORE MEAL SUBCUTANEOUSLY LANTUS 18 UNIT EVERY 24 HOURS INTRAVENOUSLY PLANNING HEMODYLISIS URGENT ACETOSAL 80 MG EVERY 24 HOUR INTRAORALLY PDX: CONSULT TO SURGERY DEPT IN WARD TO PUT CDL URINALYSIS CA/PO4 SPUTUM CULTURE/GR/ST ECHOCARDIOGRAPHY AS CARDIOLOGY MX: VITAL SIGN, COMPLAINT FLUID BALANCE FBG/ BG 2 HOURS PP

6. ECG

7. RONTGEN

8. PICTURE OF PATIENT

9. 2 PINASTIN F 46 YO CM 20007940 DUSUN SIDOTENTREM RT/RW 001/003 DESA YOSOMULYO KEC GAMBIRAN KAB BANYUWANGI JATIM TC 11.15 CC: DECREASE OF CONCIOUSNESS ROOM MS ASSESMENT THERAPY PLANNING ADM -> O2 NC 2 LPM IVFD NACL 0.9 LOADING PDX: MX: VITAL SIGN, COMPLAINT CASE PRESENTATION

10. 3 ADE REGINA MAHESWARI F 18 YO CM 20007094 DALUNG PERMAI BLOK K 3 / 02 BR TEGAL PERMAI KEROBOKAN KAJA KUTA UTARA BADUNG TC 12.40 CC: FEVER ROOM OUTPATIENT ASSESMENT THERAPY PLANNING SYSTEMIC LUPUS ERYTHEMATOSUS MILD FLARE UP UPPER RESPIRATORY TRACT INFECTION PLEURITIS TB ON OAT CONTINUED PHASE PARACETAMOL 500 MG EVERY 6 HOURS INTRAVENOUSLY AZITHROMYCIN 500 MG EVERY 24 HOURS INTRAORALLY N-ACETYLSISTEIN 200 MG EVERY 8 HOURS INTRAORALLY METYLPREDNISOLONE 8 MG EVERY 8 HOURS INTRAORALLY HIDROCHLOROQUIN 200 MG EVERY 24 HOURS INTRAORALLY OAT KAT 1 CONTINUED PHASE 3 TABLET 3X PER WEEK PDX: - MX: VITAL SIGN, COMPLAINT

11. ECG

12. RONTGEN

13. PICTURE OF PATIENT

14. 4 AGUSTINA ENDIR F 41 YO CM 00977994 JL. PLAWA GG XIX / 7 SUMERTA K TC 13.15 CC: DIARRHEA ROOM OUTPATIENT ASSESMENT THERAPY PLANNING ACUTE GASTROENTERITIS EC SUSPECT VIRAL DD/ BACTERIAL - MOEDRATE DEHYDRATION CKD STAGE V EC. NS ON REGULAR HD 2X/WEEKD - CONTROLLED HYPERTENSION HYPONATREMIA CHRONIC ASYMPTOMATIC HYPOOSMOLAR HYPOVOLEMIC EC SUSPECT LOSS ADM -> IVFD NACL 0.9 % LOADING 250 CC THEN 8 DPM CKD DIET 35 KCAL/KG/DAY+ 1,2 GR PROTEIN/KG/DAY CIPROFLOXACINE 500 MG EVERY 12 HOURS INTRAORALLY HEMODIALYSIS ES SCHEDULE PDX: - MX: VITAL SIGN, COMPLAINT FLUID BALANCE

15. FL

16. ECG

17. RONTGEN

18. PICTURE OF PATIENT

19. 5. I PUTU SATRIA M 69 YO CM 00739378 JLN P. MISOL GG IV NO 9 TC 13.55 CC: DIARRHEA ROOM RATNA ASSESMENT THERAPY PLANNING DELIRIUM EC SUSPECT SEPTIC ENCEPHALOPATHY ACUTE DIARRHEA EC SUSPECT BACTERIAL DD/ VIRAL - SEPTIC TYPE 2 DIABETES MELITUS HYPERTENSION STAGE 2 IMPAIRMENT : VISION, HEARING DISABILITY : MODERATE DEPENDENCY HANDICAP : NEGATIVE ADM -> IVFD NACL 0.9 % LOADING 500 CC THEN 20 DPM DIET DM 1900 KCAL/DAY CIPROFLOXACINE 400 MG EVERY 12 HOURS INTRAVENOUSLY PARACETAMOL 500 MG EVERY 6 HOURS INTRAORALLY APIDRA 6 UNIT EVERY 15 MINUTES BEFORE MEAL SUBCUTANEOUSLY LANTUS 8 UNIT EVERY 24 HOURS SUBCUTANEOUSLY AMLODIPINE 10 MG EVERY 24 HOURS INTRAORALLY PDX: BLOOD CULTURE/ST URINALYSIS MX: VITAL SIGN, COMPLAINT FBG/ BG 2 HOURS PP FLUID BALANCE

20. FECES LENGKAP

21. ECG

22. RONTGEN

23. PICTURE OF PATIENT

24. 6 I KETUT SUDJANA M 71 YO CM 20007944 BR PANTI GEDE PEMOGAN DENSEL TC 13.10 CC: FEVER ROOM RATNA 214 ASSESMENT THERAPY PLANNING COPD ACUTE EXACERBATION ANTONISEN TYPE 2 ON COPD GROUP B PNEUMONIA (CAP) PSI CLASS IV IMPAIRMNET : VISI0N DISABILITY : MILD DEPENDENCY HANDICAP : NEGATIVE ADM -> O2 NC 2 LPM IVFD NACL 0.9 % 20 DPM DIET LOW CARBOHYDRATE 1800 KCAL/DAY CEFOPERAZONE 1 GRAM EVERY 12 HOURS INTRAVENOUSLY LEVOFLOXACINE 750 MG EVERY 24 HOURS INTRAVENOUSLY METILPREDNISOLONE 62,5 MG EVERY 12 HOURS INTRAVENOUSLY COMBIVENT NEBULIZER 1 RESPUL EVERY 6 HOURS PDX: SPUTUM GRAM/ CULTUURE/ST SPIROMETRI IF STABLE MX: VITAL SIGN, COMPLAINT

25. ECG

26. RONTGEN

27. PICTURE OF PATIENT

28. 7 NI KOMANG EMI MINARTI F 40 YO CM 20007956 JL KARTINI GG IV A NO 8 BR WANGAYA KELOD DAUH PURI KAJA DENUT TC 15.00 CC: COUGH ROOM FORCED TO DISCHARGE ASSESMENT THERAPY PLANNING SECONDARY IMMUNOCOMPROMISED EC SUSPECT B24 DD/ SLE SUSPECT PLEUROPNEUMONIA DEXTRA MILD ANEMIA NN EC SUSP ACD ADM -> O2 NC 4 LPM IVFD NACL 0.9 20 DPM PARACETAMOL 500 MG EVERY 8 HOURS INTRAORALLY CEFOPERAZONE 1 GR EVERY 12 HOURS INTRAORALLY LEVOFLOXACINE 750 MG EVERY 24 HOURS INTRAVENOUSLY ACETILCYSTEIN 200 MG EVERY 8 HOURS INTRAORALLY PDX: PLEURAL FLUID ANALYSIS – FAILED ANTI HIV SPUTUM GRAM/ CULTURE/ST MX: VITAL SIGN, COMPLAINT

29. ECG

30. RONTGEN

31. PICTURE OF PATIENT

32. 8 NI NENGAH JULIARTINI F 33 YO CM 20007957 BR PENGLUMBARAN KAWAN SUSUT BANGLI TC 17.00 CC: SHORTNESS OF BREATH ROOM LELY ASSESMENT THERAPY PLANNING OBS. DYSPNEA EC SUSPECT CARDIOMYOPATHY PERIPARTUM G2P1001, 34-35 WEEKS OF GESTATION SINGLE ALIVE HYPOKALEMIA EC SUSPECT LOSS DD/ SHIFT ADM -> O2 NC 2 LPM IVFD NACL 0.9 % 8 DPM DIET 1800 KCAL/DAY= EXTRA FRUIT FUROSEMID DRIP 5MG/HOUR  POSTPHONED KCL DRIP 50 MEQ IN NACL 0,9% 500 CC 20 DPM PDX: CONSULT TO OBGYN DEPT  DONE CONSULT TO CARDIOLOGY DEPT  DONE KALIUM URINE 24 HOURS MX: VITAL SIGN, COMPLAINT K EVERY 6 HOURS DURING FRIP KCL

33. ECG

34. RONTGEN

35. PICTURE OF PATIENT

36. 9 JRO MANGKU SEDANA M 45 YO CM 19043203 DUSUN BAYUNG GEDE KINTAMANI BANGLI TC 17.25 CC: GUM BLEEDING ROOM MS 2.11 ASSESMENT THERAPY PLANNING MDS MULTILINEAGE DYSPLASIA - SEVERE ANEMIA NN - TROMBOCYTOPENIA - NEUTROPENIA TYPE 2 DIABETES MELITUS ADM -> O2 NC 2 LPM IVFD NACL 0.9 20 DPM DIET 1800 KCAL/ DAY PRC TRANSFUSSION 1-2 KOLF UNTIL HB ≥ 10 GR/DL TC TRANSFUSSION 5-10 KOLF UNTIL PLT ≥ 20.000 OR GUM BLEEDING STOPPED ORAL HYGIENE NOVORAPID 8 UNIT EVERY 8 HOURS SUBCUTANEOUSLY LANTUS 24 UNIT EVERY 24 HOURS SUBCUTANEOUSLY PDX: URINALYSIS RO/THORAX MX: VITAL SIGN, COMPLAINT FBG/ BG 2HRPP

37. ECG

38. RONTGEN 23 JANUARI 2020

39. PICTURE OF PATIENT

40. CASE PRESENTATION

41. I DENTITY NAME : PNS GENDER : FEMALE AGE : 46 YEARS OLD MR : 20007940 ADDRESS : DUSUN SIDOTENTREM, DESA YOSOMULYO KEC GAMBIRAN KAB BANYUWANGI JATIM WARD : TRIAGE TC : 11.15 INSURANCE : B PJS-KIS CHIEF COMPLAIN T : DECREASE OF CONSIOUSNESS

42. PRESENT MEDICAL HISTORY PATIENT COME WITH CONDITION DECREASE OF CONSIOUSNESS SINCE 2 HOURS BEFORE ADMISSION, AFTER SHE GOT SEIZURE. PATIENT CAN NOT COMMUNICATE WITH HER FAMILIES AND LOOK CONFUSED PATIENT GOT SEIZURE 2 HOURS AGO. THE SEIZURE WAS GENERALIZED, ALL OF HER BODY BECOME NUMB, HER EYES LOOKING UP TO TOP, AND HER MOUTH WAS TURNING. DURATION OF SEIZURE ABOUT 5 MINUTES THEN AFTER SEIZURE, PATIENT LOOK CONFUSED PATIENT COMPLAINED HEADACHE BEFORE SHE GOT SEIZURE. PATIEN FREQUENTLY COMPLAINED HEADACHE AT HOME BUT SHE ONLY TOOK MEDICINE TO RELIEVED IT

43. PRESENT MEDICAL HISTORY PATIENT GOT FEVER SINCE 2 DAYS AGO, FEVER WAXE AND WANE. FEVER GETTING BETTER IF THE PATIENT TOOK MEDICINE. PATIENT ALSO GOT PRODUCTIVE COUGH SINCE 3 DAYS AGO, THERE WAS SPUTUM WITH WHITE COLOUR. PATIENT GOT SHORTNESS OF BREATH SINCE 2 DAYS AGO, WHICH BECOME WORSENING. SHORTNESS OF BREATH DID NOT RELIEVED WITH CHANGING POSITION NAUSSEA SINCE 2 DAYS AGO, BUT WITHOUT VOMMITING. HER APETITE WAS DECREASE. THERE IS NO PROBLEM WITH URINATION, HISTORY OF DIARRHEA WAS DENIED

44. PAST MEDICAL HISTORY PATIENT KNEW THE SHE GOT DIABETES SINCE 3 MONTH AGO, HER BLOOD GLUCOSE WAS 400 GR/DL. BUT SHE DIDN’T TOOK ANY MEDICATION FROM DOCTORS. SHE DRINK HERBAL MEDICINE AND HER BLOOD GLUCOSE SAID TO BE NORMAL PATIENT ALSO HAD MASS IN HER LEFT BREAST WHICH KNOWN SINCE 1 YEARS AGO. THE MASS WAS NOT PAIN, IT BECOME BIGGER SINCE 3 MONTH BUT THERE WAS NO PROCEDURE TO CONFIRMING THE DIAGNOSIS. FAMILY HISTORY THERE WAS NO FAMILY MEMBER WITH THE SAME COMPLAINTS , HISTORY OF HYPERTENSION, DIABETES MELLITUS, HEART FAILURE IN THE FAMILY WAS DENIED SOCIAL HISTORY SHE IS A HOUSEWIFE. HISTORY OF SMOKING WAS DENIED. HISTORY OF DRUG ABUSE WAS DENIED

45. LOC : E3 V3 M5 APP : MODERATELY ILL BP : 110 / 80 MMHG PR : 102 X/MNT REGULAR RR : 30 X/MIN TEMP : 36,7 º C SPO2 : 9 3 % ROOM AIR EYE : CONJUNGTIVA AN EMIS - / - , SCLERA I CT ERIC -/- NECK : JVP 4 CMH2O PHYSICAL EXAMINATION

46. THORAX : HEART INSPECTION : IC UNSEEN PALPATION : IC PALPABLE AT AXILLAR ANTERIOR ( S ), ICS VI PERCUSSION : RIGHT BORDER : PSL (D) LEFT BORDER : AXILLAR ANTERIOR S ICS VI AUSCULTATION : S1 S2 SINGLE, REGULAR, MURMUR ( -) LUNG INSPECTION : SYMMETRIC ON STATIC AND DYNAMIC , PALPATION : FOCAL FREMITUS +/+ PERCUSSION : SONOR/SONOR AUSCULTATION : V ES + / + , RHONCI -/ -, WHEEZING - / - +/+ -/ + -/- + /+ - /+ -/-

47. ABDOMEN INSPECTION : D ISTENDED ( - ), COLLATERAL VEIN (-) AUSCULTATION : B OWEL SOUND NORMAL 3-4 X/MIN PALPATION : PAIN IN PALPATION (-) LIVER : UNPALPABLE , LIVER SPAN 10 CM SPLEEN : NOT PALPABLE PERCUSSION : SHIFTING DULLNESS ( - ) EXTREMITIES WARM + / + , PITTING E DEMA - / - + / + - / - LOCAL STATE : REGIO MAMAE SINISTRA LOOK : HYPEREMYS (-) PEAU DE ORANGE (=) FEEL : MASS PALPABLE ABOUT 4X5 CM, SOLID, PAIN IN PALPATION (-) MOVE : MASS FIXED WITH SKIN.

48. LABORATORY CBC 15/2/20 REF RANGE WBC 22.54 4 . 1-11 . NE 15.86 2.5-7.5 LYM 5.17 1.0-4.00 MO 1.04 0.1-1.2 EO 0.24 . 0-0.5 BA 0.24 . 0-0 . 1 H GB 14.86 13.5-17.5 H CT 43.67 41.0-53.0 MCV 78.15 80 .0 -100 .0 MCH 26.59 26 .0 -34 .0 P L T 443.80 150-440

49. C HEMISTRY 15/02/20 REF RANGE AST /SGOT 17.7 11- 33 U/L ALT /SGPT 16.20 11- 50 U/L A LBUMIN 4,2 3.4-4.8 G/DL BUN 9,4 8 .0 -23 . MG/DL SC - .7 0- 1.2 MG/DL RANDOM BLOOD SUGAR 564 70-140 MG/DL HBA1C 11,8 4.8 - 5.9 OSM : 322 mosm /Liter

50. BGA 15/2/20 REF PH 7,32 7.35-7.45 pCO2 39,7 35-35 pO2 183.60 80-100 BEecf -6.2 -2-2 HCO3- 19.90 22-26 SO2 99.2 95-100% Natrium 134 136-145 Kalium 3,55 3.5-5.10 Chlorida 98 96-108 CORRECTED Na : 144 ANION GAP 26,1 MEQ/L

51. Berat Jenis 1.029   1.003 - 1.035   pH 6   4.5 - 8   Leukosit Negatif leuco/uL Negatif   Nitrit Negatif mg/dL Negatif   Protein Negatif mg/dL Negatif   Glukosa (4+) OVER mg/dL Negatif   Keton (2+) 40 mg/dL Negatif   Darah Negatif ery/uL Negatif   Bilirubin Negatif mg/dL Negatif   Warna Colorless   p.yellow - yellow   Urobilinogen Normal mg/dL Normal   Leukosit Sedimen 1 /LPB ? 7   Eritrosit Sedimen /LPB ? 5   Sel Epitel Sedimen :       Gepeng 1 /LPB     Lain-lain bakteri + /LPB     URINALYSIS

52. ECG SINUR RHTYM HR 100 X, REGULER AXIS: NORMAL AXIS P WAVE: 0. 12 S PR INTERVAL 0.13 S QRS COMPLEX 0.104 S ST SEGMENT: NOT ELEVATED/DEPRESSED T WAVE : NOT INVERTED CONCLUSSION : NORMAL SINUS RHYTM

53. RONTGEN CHEST X-Ray COR SHAPE AND SIZE WITHIN NORMAL LIMIT PULMO BRONCOVASCULAR NORMAL CONSOLIDATION IN PARACACARDIAL SINISTRA COSTOPHRENIC ANGLE D/S SHARP BONE WITHIN NORMAL LIMIT CONCLUSION PNEUMONIA COR WITHIN NORMAL LIMIT

54. HEAD CT SCAN 15/2/20

55. Tampak lesi hipodens dengan dinding slight hiperdens intraaxial supratentorial berbentuk bulat tepi sebagian irreguler batas tegas berukuran 2.2 x 2.5 x 2.7 cm pada cortical-subcortical lobus parietalis kiri disertai fingerlike oedema disekitarnya yang mendesak ventrikel lateralis kiri ke caudal Sulci dan gyri merapat pada lobus parietalis kiri Sistem ventrikel lateralis kanan , III, IV  dan cisterna normal Tak tampak deviasi midline struktur Tak tampak kalsifikasi abnormal Pons dan cerebellum tak tampak kelainan Orbita dan mastoid kanan kiri tak tampak kelainan Tampak penebalan mukosa sinus maksilaris kanan   Sinus maksilaris kiri , frontalis , ethmoidalis dan sphenoidalis kanan kiri tak tampak kelainan Tampak lesi litik multipel pada os parietalis kanan kiri serta os frontalis kiri SCALP tak tampak kelainan Kesan : Lesi hipodens dengan dinding slight hiperdens intraaxial supratentorial pada cortical-subcortical lobus parietalis kiri disertai fingerlike oedema disekitarnya yang mendesak ventrikel lateralis kiri ke caudal, suspek dd / 1. Metastase Proses , 2.High Grade Astrocytoma, 3. Brain AbscessLesi litik multipel pada os parietalis kanan kiri serta os frontalis kiri , suspek proses metastase Sinusitis Maksilaris kanan

56. CONSULT TO NEUROLOGY ASSESSMENT : SOL CEREBRI EC SUSPECT PRIMARY CEREBRAL TUMOR DD/ METASTASE THERAPY : DIAZEPAM 10 MG INTRAVENA IF SEIZURE DEXAMETHASONE 5 MG EVERY6 HOUS INTRAVENOUSLY OMEPRAZOLE 40 MG EVERY 12 HOURS INTRAVENOUSLY PARACETAMOL 1000MG EVERY 8 HOURS INTRAORALLY PHENYTOIN 100 MG EVERY 8 HOURS INTRAORALLY FOLIC ACID 400 MCG EVERY 12 HOURS INTRAORALLY

57. CONSULT TO INTENSIVIST ASSESSMENT : PNEUMONIA TYPE 2 DIABETES MELITUS - KAD - HHS THERAPY : PATIENT STILL STABLE RIGHT NOW. WE ADVISE TO TREAT THE PATIENT IN INTERMEDIATE MS/RATNA.

58. PICTURE OF PATIENT

59. ASSESSMENT DECREASE OF CONSIOUSNESS EC SUSPECT SEPTIC ENCEPHALOPATHY DD/ INTRACRANIAL PROCESS TYPE 2 DIABETES MELITUS - HYPEROSMOLAR HYPERGLICEMIC STATE - DIABETIC KETOACIDOSIS PNEUMONIA (CAP) PSI CLASS IV - SEPTIC TUMOR MAMMAE SINISTRA EC SUSPEK MALIGNANCY SOL CEREBRI EC SUSPECT PRIMARY CEREBRAL TUMOR DD/ METASTASE - SYMPTOMATIC SEIZURE

60. THERAPY IVFD NACL 0,9% LOADING 1500 CC IN THE FIRST HOUR, THEN 1000CC IN THE SECOND HOUR, THEN 500 CC IN THE THIRD HOUR, THEN 500 CC IN THE FOUTH HOUR, THEN 250 CC IN THE FIFTH HOUR, THEN 20 DPM SOFT DIET DM 1900 KCL/DAY CEFOPERAZONE 1 GRAM EVERY 12 HOURS INTRAVENOUSLY LEVOFLOXACINE 750 MG EVERY 24 HOURS INTRAVENOUSLY INSULIN BOLUS 4 UNIT INTRAVENOUSLY THEN DRIP INSULIN START FROM 4 UNIT/HOUR AS PROTOCOL  IF BLOOD GLUCOSE DECREASE ≤ 50 GR/DL, UPTITRATE DOSE 1 UNIT FROM THE LAST DOSE  IF BLOOD GLUCOSE DECREASE ≥ 75 GR/DL, DOWNTITRATE DOSE 1 UNIT FROM THE LAST DOSE  TARGET BG 250-300 GR/DL THEN INSULIN DOSE 1 UNIT/HOUR WITH IVFD D5% 20 DPM

61. THERAPY THEN AFTER PATIENT CAN EAT, ADD APIDRA 4 UNIT EVERY 15 MINUTES BEFORE MEALS SUBCUTANEOUSLY DRIP INSULIN STOPPED 1 HOURS AFTER INJECTION LANTUS 8 UNIT SUBCUTANEOUSLY DIAZEPAM 10 MG INTRAVENA IF SEIZURE DEXAMETHASONE 5 MG EVERY6 HOUS INTRAVENOUSLY OMEPRAZOLE 40 MG EVERY 12 HOURS INTRAVENOUSLY PARACETAMOL 1000MG EVERY 8 HOURS INTRAORALLY PHENYTOIN 100 MG EVERY 8 HOURS INTRAORALLY FOLIC ACID 400 MCG EVERY 12 HOURS INTRAORALLY

62. P lanning Dx / SPUTUM GRAM/ CULTURE/ST BLOOD CULTURE/ST CONSULT TO NEUROLOGY DEPT  DONE CONSULT TO INTENSIVIST  DONE CONSULT TO ONCOLOGY DEPT IN WARD BIOPSI MAMMAE AS ONCOLOGY IF PATIENT STABLE MX/ VITAL SIGN , COMPLAINT BLOOD GLUCOSE EVERY HOUR KALIUM EVERY 6 HOUR DURING INSULIN DRIP FLUID BALANCE POC 7 DAYS

63. PROBLEM I NTERVENTION T ARGET DECREASE OF CONSIOUSNESS EC SUSPECT SEPTIC ENCEPHALOPATHY DD/ INTRACRANIAL PROCESS CORECCTION FOR PRECIPITATING CAUSE CONSULT TO NEUROLOGY DEPT GCS 15 WITHIN 24 HOURS CONSULT ANSWERED IN 24 HOUR DIABETES MELITUS TYPE 2 - HYPEROSMOLAR HYPERGLICEMIC STATE+ DIABETIC +KETOACIDOSIS GIVING REHYDRATION WITH NORMAL SALINE INSULIN DRIP URINE OUTPUT 0,5-1 CC/KG/HOUR BG 250-300 GR/DL PLANNING OF CARE

64. PROBLEM I NTERVENTION T ARGET PNEUMONIA (CAP) PSI CLASS IV - SEPTIC GIVING ANTIOBIOTIC WBC ≤ 10.000 WITHIN 72 HOURS TUMOR MAMMAE SINISTRA EC SUSPECT MALIGNANCY CONSULT TO ONCOLOGY SURGERY DEPT CONSULT ANSWERED IN WARD SOL CEREBRI EC SUSPECT PRIMARY CEREBRAL TUMOR DD/ METASTASE - SYMPTOMATIC SEIZURE CONSULT TO NEUROLOGY DEPT CONSULT ANSWERED IN 24 HOUR PLANNING OF CARE

65. LAST CONDITION S: PATIENT ALERT, SHORTNESS OF BREATH (+) DECREASE O: MODERATELY ILL / E 4 V 5 M 6 TD 110 / 8 /; N 8 8 REGULER; S 36. 8 ; RR 18 X / MIN BS 07 236 EYE : AN - / - , ICT - / - COR: S1S2 SINGLE RE GULAR , MURMUR ( - ) PO : VES +/+, RH -/-, WH -/- +/+ - /+ -/- +/+ - /+ -/- ABD: DISTENDED ( - ), BOWEL SOUND (+) 3 -4x/min EXT : WARM + / + EDEMA - / - + / + - / -

66. TIME BG INSULIN DOSAGE HYDRATION URINE OUTPUT 11.15 564 - 1500 CC 300 CC 13.00 520 4 UNIT 2500 CC 500CC 14.00 495 4 UNIT 3500CC 700CC 15.00 456 4 UNIT 4000 CC 1000 CC 16.00 402 4 UNIT 4500 CC 1100CC 17.00 380 4 UNIT 5000 CC 1300 CC 18.00 345 3 UNIT 5000 CC 1300 CC 19.00 228 1 UNIT 5000 CC 1500 CC 23.00 161 1 UNIT 5000 CC 1700 CC 03.00 250 1 UNIT 5000 CC 1700 CC 07.00 256 1 UNIT 5300 CC 2000 CC 11.00 220 1 UNIT 5500 CC 2200 CC ADD PRANDIAL INSULIN 4 UNIT 15.00 180 1 UNIT 5500CC 2300 CC 19.00 143 1 UNIT 5500 CC 2500 CC 22.00 279 STOP ADD BASAL INSULIN 8 UNIT 06.00 236 STOP

67. THANK YOU

68. H yperglycemic Crises in Adult Patients With Diabetes : Abbas E. Kitabchi , [email protected]. Diabetes Care 2009 Jul; 32(7): 1335-1343.

69. EFFECTIVE SERUM OSMOLARITY: 326