lapsus pneumonia-shock sepsis, diti.pptx

Pasien dengan keluhan sesak disertai demam tinggi

1. LAPORAN KASUS Oleh : d r. Dwi Arditi Dewi Pendamping Internship: Lettu Kes . dr. Amelia Lucky Ragil DPJP: dr. Mirza Thaariq Haspito , Sp. JP PNEUMONIA SUSP. COVID + SHOCK SEPTIC

2. IDENTITAS PASIEN Name: Tn. S Patient ID: 0-11-25-36 Age : 68 tahun (31-12-1952) Sex : Male Religion: Islam Address: Sapen , Majasem , Kendal, Kab . Ngawi Occupation: Petani Room : Mars Isolasi Date of Examination: 4-11-2021 Class: BPJS

3. History taking (anamnesis) Pasien datang ke IGD RSAU dengan keluhan lemas +- 2mg SMRS. Makan minum menurun seminggu terakhir , mual muntah setiap kali makan . BB dirasa menurun . 1mg SMRS pasien juga mengeluhkan demam nggreges , demam dirasa sepanjang hari . Pasien juga mengeluh batuk kering , dada terasa ampeg setiap batuk , dan disertai sesak . Pasien tidak mengeluhkan sesak jika jalan jauh / aktivitas berat , menggunakan bantal tinggi saat tidur disangkal . Keluhan nyeri dada (-). Sakit kepala cekot2 (+) bebarengan dengan demam . Batuk (-), pilek (-), nyeri tenggorokan (-). Belum dibawa berobat sejak muncul keluhan 2mg SMRS. Alergi (-) BAB (-) 1mg BAK (+) N. pasien post jatuh (-). Lemes Chief Complain RPS

4. HISTORY OF ILLNESS HISTORY OF PREVIOUS ILLNESS Heart disease ( - ) Hypertension history (-) DM history (-) Smooking (-) terakhir tahun 1965 Alcohol (-) FAMILY’S HISTORY OF DISEASE Hypertension history ( - ) DM history (-) Heart Disease History (-) SOSIO-ECONOMIC HISTORY : Hospital cost certified by “BPJS”

5. General : tampak lemas Awareness : E4M6V5 (GCS : 15) Vital Sign Blood Pressure : 80/53 mm H g (MAP=62 mmHg) Pulse : 100 x/m inute , regular Breath Frequency : 25 x/minute Temp : 38 o C SpO2 : 91% tanpa tambahan O2 : 95% dengan nasal canule 5lpm Intepretation : H y potensi on, takipneu , hipertermi , desaturasi O2

6. Head : Mesocephal, alopesia (-) Eyes : Anemic Conjun g tiva ( + / +) , Icteric sclera ( - / -), mata cowong (-/-) Nose : symmetric , secret (-), Nostril Breath (-) Ears : Normal Shape , discharge (-/-) M outh : Cyanosis (-) Neck : Trakhea deviation (-), Lymph Hypertropy (-) , increasing JVP (-) Weight : +- 50kg Intepretation : Anemic Conjunctiva GENERAL EXAMINATION

7. THORAX EXAMINATION INSPEKSI ANTERIOR POSTERIOR Stati c RR : 25x/min , H y per pigment (-), spider nevi (-) , atrophy Pectoral Muscle (-) , Ginekomastia (-) Hemit h oraks D=S, ICS Normal , Diameter AP < LL RR : 25 x/min , Hyper pigment (-) , Hemit h oraks D=S, ICS Normal , Diameter AP < LL Dynami c Up and down of hemitoraks D=S, abdominothorakal breathing, (-), muscle retraction of breathing ( - ), retraction ICS (-) Palpa tion Percution Palpable pain(-), tumor (-) , Ste r m fremitus normal Sonor D=S Palpable pain (-), tumor (-) , Ste r m fremitus normal Auskul tation Vesicular (-) , Whezzing (-), Ronchi ( - ) Intepretation : Increased RR

8. Inspe ct i on : I c tus cordis tidak terlihat Palpation : Ictus cordis is palpable at ICS VI linea midclavicularis sinistra, thrill ( - ) , epigastric pulse (-), parasternal pulse ( - ), s ternal lift (-) . Per c us s i on   : dull sound Upper borderline : ICS II linea sternalis sinistra Waist borderline : ICS III linea parasternalis sinistra Lower right borderline : ICS V linea sternalis dextra Lower left borderline : ICS VI, 2cm lateral from linea mid calvicula sinistra CARDIAC EXAMINATION Intepretation : NORMAL

9. CARDIAC Auscultation Aortal valve : S1 < S2 standard , additional sound (-) Pulmonary valve: S1 < S2 standard , additional sound (-) Tricuspid valve : S1 > S2 standard , additional sound ( - ) Mitral valve : S1 > S2 standard , additional sound (-) Intepretation : Normal

10. ABDOMEN EXAMINATION Inspection : Soepel , Distantion (-) , sycatric (-), striae (-) , caput medusa ( - ) . Aus c ulta tion : peristaltic (+) 20x/m (N) Percussion : tympani , side of dullness (-), shifting dullness (-) Liver : redup (+) , right liver span 8 cm , left liver span 4 cm Spleen : Throbe space percussion (+)  tympani Palpation : Superfisia l : tight (-) , mass (-) , epigastrial pain ( - ) Deep : epigastric pain ( - ) , liver , kidney, and spleen weren ’ t palpable Intepretation : NORMAL

11. EXTREMITY EXAMINATION Ekstremitas S uper i or I nferior Oedema -/- -/- Cold -/- -/- Jaundice -/- -/- Capillary <2 second <2 second refill Intepretation : NORMAL

12. Laboratorium Examination

13. HAEMATOLOGY & BLOOD CHEMICAL TEST TEST RESULT NORMAL RESULT Hematology Hb 8.0 (-) 13-18 MCV 77.9(-) 80-100 Hematocrit 22.9 (-) 40-54% Leukocyte 12.960 (+) 5.000-10.000/mm3 Trombocyte 301.000 150-450 ribu /mm3 Diff count Neutrofil 87.6 (+) 50-70% Lymphosit 6.6 (-) 20-40% Monofil 5.6 2-8% Eosinofil 0.0 1-3% Basofil 0.2 0-1% Interpretation : ↓ Hb ↓ Hematokrit Leukositosis Neutrofilia L imfositopeni 4-11-2021

14. HAEMATOLOGY & BLOOD CHEMICAL TEST TEST RESULT NORMAL RESULT Kimia darah SGOT 35 0-35 U/L SGPT 18 0-40 U/L Ureum 35 <50mg/dl Creatinine 1.1 <1.5mg/dl Cholesterol 125 <200mg/dl Trigliserida 75 <200mg/dl Gula darah acak 137 <200mg/dl Antigen Rapid Test C-19 Negatif Negatif Interpretation : NORMAL 4-11-2021

15. ECG

16. 4/11/2021

17. Interpretation R hy tm : Sinus Regularitas : Regular Frekuensi : 100 x/ menit (300:3kotak sedang ) Axis : lead avf (+), lead I (+)  NAD Zona Transisi : V2/V3 Gelombang P : + di lead II, - di AVR, P pulmonal (-), P mitral (-) Interval PR : 0,16dt Komplek QRS : 0.08dt Gelombang Q : Q patologis (-) Segmen ST : ST depressed (-), ST elevation (-) Gelombang T : T tall (-), T inverted (-) Interpretation : NSR

18. Chest X-Ray X-Foto Thorax COR = besar dan bentuk normal Pulmo = infiltrat diffuse kedua lapang paru sinus phrenicocostalis kanan kiri tajam hemidiafragma kanan kiri tampak baik sistema tulang tampak baik Intepretation : Pneumonia bilateral (typical type)

19. Abnormal Data History Taking Lemas Demam Batuk Sesak Mual Muntah Vital sign : 6. Hipotensi 7 . Hipertermi 8 . Desaturasi 9. Takipneu Physical Examinatio n General examination 10. Konjungtiva anemis Chest X-Ray : 15. Pneumonia Bilateral Lab 11. Anemia 12. Leukositosis 13. Neutrofilia 14. Limfositopenia

20. DIFFERENTIAL DIAGNOSIS Pneumonia ec bacterial Pneumonia ec corona virus Shock condition: - Cardiogenik shock -Septic shock -Hypovolemic shock

21. Problem List PNEUMONIA, SUSP COVID Anemia SHOCK CONDITION, DD SEPTIC

22. ADVIS DPJP P: Inf RL 1000cc loading Inj Metamizol sodium 500mg/2ml 1 amp Konsul dr. Mirza , Sp. JP TERAPI IGD P: - Infs RL + neurobion 1500cc/ hari Drip norepinefrin 50-200 nano Inj levofloxacin 1x750mg Inj pantoprazole 2x40mg Inj ondansentron 3x1 kp Inj bromhexine 3x1 Inj heparin 2x7500 unit SC Inf acetylsycteine 1200mg 1x1 Cholecalciferol 1x1 Zinc 1x1 Glutamine 2x1

23. Shock Septic Ass : emergency condition  to prevent cardiac arrest IP Dx : blood ga s analysis, kultur darah Ip Tx : Airway = intubation Breathing = NRM 10 lpm Circulation = loading cairan 30cc/ kgBB Injeksi NE 0.15-0.20 mg/ kgbb ( 4mg/4mL) Ip Mx : Vital Sign, ECG, Diuresis

24. Pneumonia Assessment : Pneumonia ec bacterialis pneumonia ec viral (covid-19) IP diagnosis : Diff count Swab PCR IP Therapy levofloxacin 1x750mg IP Monitoring Vital sign Complete blood count ( Hb , Ht ) IP Education menggunakan masker

25. Anemia Assessment : Anemia microcytic hypochromic Anemia normocytic normochromic IP diagnosis : Eritrocyte index (MCV, MCH, MCHC), IP Therapy FeSO4 3x100 mg Vit C 1x100 mg IP Monitoring Vital sign Complete blood count ( Hb , Ht ) IP Education Explain about anemia and the treatment high iron diet (Spinach, broccoli, bean) High vitamin C diet

26. FOLLOW UP PASIEN

27. Hari, tanggal S O P 5/11/2021 H 2 Batuk (+) KU: cm, sakit sedang TD : 101/57 Hr : 100x/m RR : 21x/m S:37,1 SpO2: 99% terpasang NRM 10lpm A: susp. Covid + pneumonia + shock condition dd septic P: Tx lanjut 6/11/2021 H 3 Batuk (+), sesak berkurang KU: CM TD: 88/50 HR: 108x/m RR: 22x/m S: 37 SpO2: 99% terpasang NRM 10lpm Swab PCR (-) A: susp. Covid + pneumonia + shock condition dd septic P: Tx lanjut 7/11/2021 H 4 Batuk berkurang KU: CM TD: 75/48 HR: 75x/m RR: 20x/m S=36 SpO2: 99% terpasang NRM 15lpm A: susp. Covid + pneumonia + shock septic P: drip NE 150nano Inj. Dexamethasone 3x1 amp Tx lain lanjut 8/11/2021 H 5 Batuk berkurang KU: CM TD: 84/58 HR: 69x/m RR: 22x/m S=36.5 SpO2: 99% terpasang NRM 10lpm A: susp. Covid + pneumonia + shock septic P: drip NE 100nano Inj. Dexamethasone 3x1 amp Tx lain lanjut

28. 9/11/2021 H 6 Sesak berkurang KU: CM TD: 115/76 HR: 83x/m RR: 20x/m S=36.6 SpO2: 99% terpasang NRM 10lpm Swab PCR ke 2 (-) A: susp. Covid + pneumonia + shock septic P: drip NE 100nano Inj. Dexamethasone 3x1 amp Tx lain lanjut 11/11/2021 H 8 Sesak berkurang KU: CM TD: 127/78 HR: 89x/m RR: 20x/m S=36.1 SpO2: 98% terpasang nasal canule 5lpm A: susp. Covid discarded + pneumonia + shock septic P: drip NE 50nano Inj. Dexamethasone 3x1 amp Inj levofloxacin 1x750mg Inj pantoprazole 2x40mg Inj ondansentron 3x1 kp Cholecalciferol 1x1 Zinc 1x1 Glutamine 2x1 Heparin, bromhexine, acetylsistein  STOP 12/11/2021 H 9 Lemas berkurang KU: CM TD: 1 10 /7 4 HR: 98 x/m RR: 20x/m S=36. 4 SpO2: 9 7 % terpasang nasal canule 5lpm A: susp. Covid discarded + pneumonia + shock septic P: Inf RL + neurobion Drip NE stop Tx lain lanjut

29. SEPTIC SHOCK

30. Decisions to titrate vasopressors to achieve mean arterial pressure goals should be balanced against potential adverse effects, including arrhythmias, cardiovascular events, and ischemia . Norepinephrine is the first-line vasopressor Vasopressin .  Septic shock involves relative vasopressin deficiency. Adding vasopressin as a replacement hormone has been shown to have a sparing effect on norepinephrine, resulting in a lower dose needed. Epinephrine   as a second-line vasopressor. It has potent alpha-and beta-adrenergic activity, which increases mean arterial pressure by increasing cardiac output and vasomotor tone. Use of epinephrine is limited by significant risk of tachycardia, arrhythmia, and transient lactic acidosis . Phenylephrine  is a pure alpha-adrenergic agonist that is routinely used in septic shock, albeit with limited data on its efficacy and safety. Angiotensin II  was recently approved as a vasopressor for use in septic shock. It activates angiotensin type 1a and 1b receptors to increase intracellular calcium in smooth muscle, promoting vasoconstriction. Inotropic agents   : epinephrine and dobutamine .The response to use of inotropes should be monitored by measuring changes in cardiac output, central venous oxygen saturation, or other indices of tissue perfusion

31. PNEUMONIA

32. Pneumonia yang disebabkan oleh mycobacterium tuberculosis tidak termasuk . Peradangan paru yang disebabkanoleh non mikroorganisme ( bahankimia , radiasi , aspirasi , obat-obatanlain ) disebut pneumonitis . Bronkopneumonia . Ditandai dengan bercak bercak infiltrate pada lapangan paru . Dapat disebabkan oleh bakteria maupun virus. Sering pada bayidan orangtua . Pneumonialobaris. Pneumania bakterial , jarang pada bayi dan orangtua . Mengenai pada satu lobus paru . PneumoniaInterstitial PNEUMONIA JENIS PNEUMONIA

33. ANEMIA