CUE AND CLUE Male/50 yo Decrease of consciousness Consume alcohol since 1520years GCS= 1-3-5 (somnolence) BP=80/40(ER)100/60 Tax:

35.9 PR: 120 bpm RR: 36 tpm hepatomegaly Splenomegali Shifting dullness Tr: 18.000 SGOT: 132/62 Alb: 2.58 Bil.T/D/I: 1.1/0.43/0.73

PL 1. Decrease of conscious ness

IDx 1.1.Hepatic encephalopathy

PDx EEG serum ammonia

PTx O2 6-8lpm Mask Rehidration 3liter/3 hours ( ER ) NS 0.9% 30 tpm fasting BCAA 2x 500cc Lactulosa

PMo Subjective, Vital signs, Urine production

CUE AND CLUE Male/50 yo Ax: DOC Blacktarrystool , Hematemesis (NGT) pale PE: NGT fluid: black Anemic conjunctiva, Defance muscular (+) Involuntary spasm Liver span 14cm, traube space dullness, shifting dullness +. RT: melena + Lab: WBC: 18000

PL 2. Septic shock

IDx 2.1 spontaneou s bacterial peritonitis

PDx Culture and sensitivit y ascites fluid

PTx Drip NE 0.05-2 microgram /kgBW/menit in 100 cc NS 0.9%, increased 3tpm micro/15 menits until MAP 70 Inj cefotaxim 2x2gram

PMo Subj ectiv e, bleed ing, VS, CBC

CUE AND CLUE Male/50 yo Ax: Coffee Ground Vomitus Blacktarrystool , Hematemesis (NGT) pale PE: NGT fluid: black Anemic conjunctiva, Liver span 14cm, traube space dullness, shifting dullness +. RT: melena + Lab: Hb: 5.5 MCV= 77 MCH: 24.7 Alb: 2.58 OT/PT: 132/62 PTT= 17.1 aPTT: 25.3

PL 3.Hemat emesis melena

IDx 3.1 Rupture varises esophagus dt cirrhosis hepatis 3.2 PUD

PDx

PTx

PMo Subj ectiv e, bleed ing, VS, CBC

endosco Fasting NGTGL/8h3x (-) py start fluid diet 6x200cc (1cc=1kcal) IVFD NS 0,9% 30 tpm Inj. Metoclopramide 3x10mg (iv) Inj. Omeprazole 80 mg IV bolus Omeprazole 8 mg/jam Somatostatin 250 microgram bolus 250 microgram/hour Lactulosa 3x 15 ml

CUE AND CLUE Male/ 50 yo Blacktarrystool , Hematemesis (NGT) pale PE: NGT fluid: black Anemic conjunctiva, Liver span 14cm, traube space dullness, shifting dullness +. RT: melena + Lab: Hb: 5.5 MCV= 77 MCH: 24.7 Alb: 2.58 OT/PT: 132/62 PTT= 17.1 aPTT: 25.3

PL 4. Cirrhosis hepatis

IDx 4.1 alcoholism 4.2post necrotic hepatitis B infection 4.2 post necrotic hepatitis C infection

PDx

PTx

PMo Subjective VS

Albumin/g As above lobuline, alkali fosfatase, gamma GT USG abdomen AFP

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/50 yo Anemic conjunctiva Extrimity pale Hb: 5.5 MCV= 77 MCH: 24.7

5.Ane mia hypoc hrom microc yter

5.1 Profuse Bleeding

Blood Transfussion PRC smear, 2packs/day untill SI/TIBC PCV>30%

Bleeding, VS,CBC

Male/ 52 yo Ax: Passing urine was decreased Ureum= 101.7 Creatinin=1.06

6. Azote mia

6.1 dt blood loss 6.2 dt septic condition

IVFD NS 1500cc/3 hours 30 dpm

Urine productio n, ur/cr, vs

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male /44 yo Mass at neck Mass at inguinal fold Mass at armpit Decrease body weight,nausea General weakness Decrease appetite Conj anemis +/+ Neck: multiple mass, d 3-5 cm, rubbery const, mobile Liver span 13 cm Inginal: bilateral multiple mass, d 36 cm Leuco 1500 Hb 9.5 SGOT/SGPT 89/75 FNAB: lymphoma malignant

1. Lymphoma 1.1 Non malignant hodgkin lymphoma 1.2 Hodgkin lymphoma

Blood smear

Diet 1900 kcal/day Transfusion of PRC 1 pack & leukogen Chemotheraphy Radiotheraphy

Subj Mass VS Bleeding

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male /44 yo Mass at neck Mass at inguinal fold Mass at armpit Decrease body weight,nausea Bloating sensation Decrease appetite Conj anemis +/+ Neck: multiple mass, d 3-5 cm, rubbery const, mobile Inginal: bilateral multiple mass, d 36 cm FNAB: lymphoma malignant

2. Dyspepsia syndrome

2.1 dt no 1 2.2 Peptic Ulcer disease

endoscopy inj. metoclopramide 3x10 mg IV

Subj

3. Pancytopenia 4. Transaminitis

3.1 True hepatitis 3.2 Reactive Hepatitis

FH Biopsy marrow Biopsy

CUE AND CLUE

Male/69 yo Coffee ground vomit since morning the day before admission about 5 times Consumed various kind of drugs, but the patients wife didnt remember all the names, she just remembered piroxicam and natrium diclofenac Since he was young he was heavy smoker having about 2 packs/days BP: 150/100 PR: 90 RR: 30 Lym: 700 Male/69 yo BP: 150/100 PR: 90 RR: 30 Ur: 24.7 Cr: 1.23

PL
1. Hematemesis

IDx
1.1 Gastritis erosive 1.2 Gastric ulcer 1.3 Duodenal ulcer 1.4 Gastric malignancy

PDx
Endoscopy Urea Breath Test

PTx
NGTGC/8h1x (-) Liquid diet 6x200cc IVFD NS 30 dpm Omeprazole 80mg (iv bolus) Omeprazole 8mg/h (until 72 hours)

PMo
Subjec tive Vital sign

2.HT St. 2

2.1 Renoparenchym al HT 2.2 Essential HT

Funduscopy

Lisinopril 1x10mg (po) HCT 1x12.5mg (po)

Subjec tive Vital sign

CUE AND CLUE

Male/69 yo Cough about 1 week ago Fever since yesterday PR: 90 RR: 30 Lym: 700 Leu: 10,200 Gra: 88.6% Male/69 yo Patient had CVA 3 times 1 months ago, his wife said that the patient had CVA for third times but didnt want to be admitted and since that time patient couldnt speak and moved his left arm and leg BP: 150/100 PR: 90 RR: 30

PL
3.Acute lung infection

IDx
3.1 Pneumonia CAP with PORT score 109 3.2 Acute bronchitis

PDx
Sputum culture and sensitivity test

PTx
Ceftriaxone 2x1g (iv) Ciprofloxacine 2x400mg (iv)

PMo
Subjec tive Vital sign

4.CVA sequele

Subjec tive Vital sign

CUE AND CLUE

Male/69 yo No symptoms ECG: OMI anteroseptal

PL
5.Heart Failure stage B

IDx
5.1.CAD 5.2.HHD

PDx
Echocardiog raphy

PTx
Lisinopril 1x10mg (po)

PMo
Subjec tive Vital sign

Problem analysis
HF stage B DM Gastropathy CKD stage V DM type 2 Dyspepsia syndrome

Hypertension

Erythropoetin I Anemia N-N

Proteinuria

Hyponatremia
Hypokalemia

Uremic Gastropathy

Renal loss

Low intake Hypoalbuminemia

Risk Factor analysis

Chronic Kidney disease 1. Diabetes 2. High blood pressure(hypertension) 3. Heart disease 4. Smoking 5. Obesity 6. High cholesterol 7. African-American, American Indian or Asian-American race 8. A family history of kidney disease 9. Age 65 or older

Management analysis
1. 2. 3. 4. Hypertensive therapy use ACE inhibitor or ARB (A) Diabetes : glycemic control (A) Dyslipidemia : control lipid profile, measured serial total cholesterol, HDL, LDL, TG (A) Lifestyle management : smoking cessation (B), weight reduction (B), protein dietary control (D), alcohol intake (B), exercise (D), dietary salt intake (B) Anemia : use Erythropoetin (D), Iron suplement (D) Mineral metabolism abnormalities : both Calcium, phosphate, parathyroid hormonal check (D), treat if there was symptoms (D) Proteinuria : should check the loss of protein and if treated use ACE inhibitor (A) hemodialise Renal Replacement therapy and

5. 6. 7. 8.

CUE AND CLUE Female/65 yo Swollen eye lids suddenly after dust slipped into both of her eyes Shortness of breath Had the same experience before, a few times. History of allergic to eggs Cilliary injection Edema of palpebra inferior

PL 1. Anaphylactic reaction

IDx

PDx Ig E

PTx Epinephrine 0,3mg (sc) Dexamethasone 3x10 mg (iv) Diphenhydramine 3x50 mg(iv) Salbutamol nebule

PMo Subjective BP HR RR

Female/65 yo History of hypertension since years ago, not routinely took medicine BP: 160/80 HR: 88 bpm

2. Hypertension stage 2

2.1.Renopar enchymal hypertension 2.2.Essential hypertension

Fundus copy

Captopril 3x12,5 mg (po) Spironolactone 025mg-0 (po)

Subjective BP HR

Female/65 yo Cardiomegaly BP: 160/80 HR: 88 bpm RR: 20 tpm

3. Heart Failure stage B

3.1.HHD

Captopril 3x12,5 mg (po)

Subjective BP HR RR

CUE AND CLUE Female/65 yo SGOT: 175 SGPT: 100

PL 4. Transaminitis

IDx 4.1.Chronic viral hepatitis 4.2.Reactive

PDx HBsAg Anti HCV

PTx Confirm diagnose

PMo Subjective

CUE AND CLUE Female/36 yo Shortness of breath since 5 months ago and was getting worse in this last 1 week Orthopneu Paroxysmal nocturnal dyspneu Swollen leg in this last 1 week Nocturnal cough with whitish sputum and bubbles Skin papules Joint pain and stiffness Photophobia Hair loss BP: 110/70 PR: 150, irregularly-irregular RR: 32 Icteric sclera Malar rash Increase JVP Cardiomegali Basal rales +/+ Hepato-jugular reflux Hepatosplenomegali AscitesRivalta (-) Pitting leg edema Discoid rash Vasculitis CRP: 0,73 Bil.T/D/I:5,85 / 3,08 / 2,77 SAAG > 1,1 ECG: AF RVR

PL 1. Heart Failure Stage C fc IV

IDx 1.1.RHD (Mitral valve) 1.2.Miocarditis (due to SLE)

PDx Echocardi ography ANA Anti dsDNA Blood culture and sensitivity test

PTx Bed rest Semi-fowler position O2 2-4 Lpm via NC Negative fluid balance Soft diet Venflon Furosemide 40mg-0-0 (iv) Captopril 3x6,25 mg (po)

PMo Subjective BP HR RR Urine production Body weight

CUE AND CLUE Female/36 yo Skin papules Joint pain and stiffness Photophobia Hair loss Malar rash Discoid rash Vasculitis CRP: 0,73

PL 2.SLE

IDx

PDx ANA Anti dsDNA

PTx

PMo Subjective BP HR RR

Female/36 yo ECG: AF RVR

3.AF RVR

3.1.Pericarditis 3.2.RHD (Mitral valve)

Echocardi ography

Bed rest Semi-fowler position O2 2-4 Lpm via NC Soft diet Venflon Rapid digitalization: Digoxin with maximum dose: 0,03mg/kgBW/day, continue with digoxin 2x0,25 mg (po) ASA 1x80 mg (po)

Subjective BP HR RR ECG

 Rheumatic (roo-MAT'ik) heart disease is a condition in which the heart valves are damaged by rheumatic fever. Rheumatic fever begins with a strep throat (also called strep pharyngitis). Strep throat is caused by Group A Streptococcusbacteria. It is the most common bacterial infection of the throat. Rheumatic fever is an inflammatory disease. It can affect many of the body's connective tissues especially those of the heart, joints, brain or skin. Anyone can get acute rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic heart disease that results can last for life. The incidence of rheumatic fever/rheumatic heart disease is low in the United States and most other developed countries. However, it continues to be the leading cause of cardiovascular death during the first five decades of life in the developing world.

What are the symptoms of strep throat? Symptoms include (but are not limited to): sudden onset of sore throat pain on swallowing fever, usually 101104F headache red throat/tonsils abdominal pain, nausea and vomiting may also occur, especially in children In some people, strep throat is very mild with just a few symptoms. Also, sore throats are caused more often by viruses than by a strep infection. Viral throat infections dont raise the risk of rheumatic fever and are not treatable with antibiotics.

What are the symptoms of rheumatic fever? Symptoms may include: fever painful, tender, red swollen joints pain in one joint that migrates to another one heart palpitations chest pain shortness of breath skin rashes fatigue small, painless nodules under the skin The symptoms of rheumatic fever usually appear about three weeks after the strep throat.

 Modified Jones criteria were first published in 1944 by T. Duckett Jones, MD.[3] They have been periodically revised by the American Heart Association in collaboration with other groups.[4] According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection. Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.

Major criteria Migratory polyarthritis: a temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards. Carditis: inflammation of the heart muscle which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur. Subcutaneous nodules: painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees. Erythema marginatum: a long lasting rash that begins on the trunk or arms as macules and spreads outward to form a snake like ring while clearing in the middle. This rash never starts on the face and it is made worse with heat. Sydenham's chorea (St. Vitus' dance): a characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease.

Minor criteria Fever Arthralgia: Joint pain without swelling Raised Erythrocyte sedimentation rate or C reactive protein Leukocytosis ECG showing features of heart block, such as a prolonged PR interval[8] Supporting evidence of Streptococcal infection: elevated or rising Antistreptolysin O titre or DNAase.[1]

 The management of acute rheumatic fever is geared toward the reduction of inflammation with antiinflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for strep throat should also be treated with antibiotics. Aspirin is the drug of choice and should be given at high doses of 100 mg/kg/day. One should watch for side effects like gastritis and salicylate poisoning. In children and teenagers, the use of aspirin and aspirin-containing products can be associated with Reye's syndrome, a serious and potentially deadly condition. The risks, benefits and alternative treatments must always be considered when administering aspirin and aspirin-containing products in children and teenagers. Ibuprofen for pain and discomfort and corticosteroids for moderate to severe inflammatory reactions manifested by rheumatic fever should be considered in children and teenagers. Steroids are reserved for cases where there is evidence of involvement of heart. The use of steroids may prevent further scarring of tissue and may prevent development of sequelae such as mitral

CUE AND CLUE

PL

IDx 1.1.Pancreatic carcinoma 1.2.Hepatoma 1.3.Chronic viral hepatitis

PDx Ca 19-9 Alkali phosphat ase GGT Alpha feto protein USG abdomen Liver biopsy (if needed) HBsAg Anti HCV

PTx Soft diet IVFD NS 0,9% 20 dpm Metoclopramide 3x10mg (iv)

PMo Subje ctive BP HR RR

Male/60 yo 1. Yellowish eyes for 3 Jaun weeks dice Sleep disturbance Nausea and loss of appetite Decrease of body weight (10kg in a month) Tea-like urine Sclera icteric Liver span 6 cm, palpable nodule when inspiration, hard, mobile, no pain Courvoisiers sign + Lymphocyte: 1.000 Thrombocyte: 112.000 SGOT: 91 SGPT: 159 Albumin: 3,17 Bilirubin T/D/I: 15,19/8,72/6,47 LDH: 886 UA: urobilinogen 2+, bilirubin 3+

CUE AND CLUE Male/60 yo History of stroke at 1997, not routinely control, and took medicine BP: 150/110

PL 2.Hype rtensio n stage 2

IDx 2.1.Essential hypertension 2.2.Atheroscl erosis hypertension

PDx USG Duplex

PTx Captopril 3x25mg (po) Nifedipine 3x10mg (po)

PMo Subje ctive BP

Male/60 yo History of stroke at 1997, not routinely control, and took medicine Motoric: 5 5 / 4 4

3.CVA sequel

Physiotherapy

Subje ctive

Jaundice
1) Too much bilirubin being produced for the liver to remove from the blood. (For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood), A defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile, or Blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. (For example, the bile ducts can be blocked by cancers, gallstones, or inflammation of the bile ducts). The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

2) 3)

Signs and symptoms of Pancreatic Carcinoma

Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms,[6] and the later symptoms are usually nonspecific and varied.[6] Therefore, pancreatic cancer is often not diagnosed until it is advanced.[6] Common symptoms include: Pain in the upper abdomen that typically radiates to the back[6] (seen in carcinoma of the body or tail of the pancreas) Loss of appetite and/or nausea and vomiting[6] Significant weight loss Painless jaundice (yellow skin/eyes, dark urine)[6] when a cancer of the head of the pancreas (about 60% of cases) obstructs the common bile duct as it runs through the pancreas. This may also cause pale-colored stool and steatorrhea. Trousseau sign, in which blood clots form spontaneously in the portal blood vessels, the deep veins of the extremities, or the superficial veins anywhere on the body, is sometimes associated with pancreatic cancer. Diabetes mellitus, or elevated blood sugar levels. Many patients with pancreatic cancer develop diabetes months to even years before they are diagnosed with pancreatic cancer, suggesting new onset diabetes in an elderly individual may be an early warning sign of pancreatic cancer.[7] Clinical depression has been reported in association with pancreatic cancer, sometimes presenting before the cancer is diagnosed. However, the mechanism for this association is not known.[8]

Risk factors of Pancreatic Carcinoma

Age (particularly over 60)[6] Male sex (likelihood up to 30% greater than females) Smoking. Cigarette smoking has a risk ratio of 1.74 with regard to pancreatic cancer; a decade of nonsmoking after heavy smoking is associated with a risk ratio of 1.2.[10] Diets low in vegetables and fruits[11] Diets high in red meat[12] Diets high in sugar-sweetened drinks (soft drinks) - risk ratio 1.87.[13] In particular, the common soft drink sweetener fructose has been linked to growth of pancreatic cancer cells.[14] Obesity[15] Diabetes mellitus is both risk factor for pancreatic cancer, and, as noted earlier, new onset diabetes can be an early sign of the disease. Chronic pancreatitis has been linked, but is not known to be causal. The risk of pancreatic cancer in individuals with familial pancreatitis is particularly high. Helicobacter pylori infection Family history, 510% of pancreatic cancer patients have a family history of pancreatic cancer. The genes responsible for most of this clustering in families have yet to be identified. Pancreatic cancer has been associated with the following syndromes; autosomal recessive ataxia-telangiectasia

 The Trousseau sign of malignancy is a medical sign found in certain cancers that is associated with venous thrombosis[1] and hypercoagulability. Some malignancies, especially adenocarcinomas of the pancreas and lung, are associated with hypercoagulability (the tendency to form blood clots) for reasons that are incompletely understood, but may be related to factors secreted by the tumors, in particular a circulating pool of cell-derived tissue factor-containing microvesicles.[4] In patients with malignancy-associated hypercoagulable states, the blood may spontaneously form clots in the portal vessels, the deep veins of the extremities (such as the leg), or the superficial veins anywhere on the body. These clots present as visibly swollen blood

Courvoisier's sign
Enlargement of the gallbladder with jaundice is likely to result from carcinoma of the head of the pancreas and not from a stone in the common duct, because in the latter the gallbladder is usually scarred from infection and does not distend.

Blumer's shelf
Description: A shelf-like tumor of the anterior rectal wall felt on rectal examination indicating implantation metastases in Douglas' pouch as in gastric carcinoma or tuberculous peritonitis.

 Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle). It takes its supply from lymph vessels in the abdominal cavity. The finding of an enlarged, hard node (also referred to as Troisier's sign) has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels. It is sometimes called the signal node or sentinel node for the same reason. Despite this, the concept is not directly related to the sentinel node procedure sometimes used in cancer surgery, and it is also unrelated to the "sentinel gland" of the greater omentum.[1]

CUE AND CLUE Female/41 yo General weakness for 1 month Pale Anemic conjunctiva Hb: 2,6 MCV: 108 MCH: 39,9 Bil.T/D/I: 3,78/0,54/3,24 LDH: 1427

PL 1. Macrocy ter anemia + hyperbili rubinemi a indirect

IDx 1.1.Hemolytic anemia 1.1.1.AIHA 1.1.2.SLE 1.2.Folic acid deficiency 1.3.B12 deficiency

PDx Direct coombs test Blood smear Reticuloc yte count ANA test Anti dsDNA

PTx

PMo

Postpone PRC transfusion Subje Venflon ctive Dexamethasone 3x5 mg CBC (iv) Ranitidine 2x50 mg (iv) Folic acid 1x3tab (po) B12 3x1tab (po)

Female/41 yo Shortness of breath even on lying down position Paroxysmal Nocturnal Dyspneu Cardiomegaly CXR:cardiomegaly

2.HF stage C fc IV

2.1.Anemia Echocardi Treat underlying disease Heart Disease ography

Subje ctive

CUE AND CLUE Male/52 yo Anasarca edema Uncontrolled diabetes mellitus since 3 years ago Uncontrolled hypertension since 2 years ago Shortness of breath BP:160/90mHg RR:28tpm Bilateral pleural effusion Ascites Hydrocele testicles Ur:89,3 Cr:4,29 Alb:2,25 Proteiunuria Erythrocyturia Male/52 yo Shortness of breath if walked>100m, relieved by rest BP:160/90mHg RR:28tpm Bilateral pleural effusion Ascites

PL 1. Nephritic syndrom e (Acute Glomerul onephriti s)

IDx 1.1.Post streptococcal infection 1.2.Post hepatitis infection 1.3.Membranopr oliferative Glomerulonephri tis 1.4.Ig A Nephropathy 1.5.Thin basement membrane disease

PDx ASTO HBsAg Anti HCV Kidney biopsy

PTx O2 10 Lpm NRBM Venflon DM diet 1700 kcal/day, low salt (1-2g/day) Negative fluid balance Furosemide 40-40-40mg (iv) Captopril 3x25mg (po)

Pmo Subjec tive BP HR RR Urine produc tion Body weight

2.Shortn ess of breath

2.1.due to No.1 2.2.Heart Failure Stage C fc II

Echocard iography

Same as above O2 10 Lpm NRBM Negative fluid balance Furosemide 40-40-40mg (iv) Captopril 3x25mg (po)

Subjec tive BP HR RR

CUE AND CLUE Male/52 yo Shortness of breath if walked>100m Uncontrolled diabetes mellitus since 3 years ago Uncontrolled hypertension since 2 years ago BP:160/90mHg RR:28tpm

PL 3.Heart Failure Stage C fc II

IDx 3.1.Diabetic cardiomyopathy 3.2.Hypertensiv e heart disease

PDx Echocard iography

PTx Same as above O2 10 Lpm NRBM Negative fluid balance Furosemide 40-40-40mg (iv) Captopril 3x25mg (po)

Pmo Subjec tive BP HR RR

Male/52 yo Uncontrolled diabetes mellitus since 3 years ago Family history of DM RBG:325 UA:proteinuria, glucosuria Male/52 yo Uncontrolled hypertension since 2 years ago BP:160/90mHg

4.Hyperg lycemia

4.1.DM type 2

DM diet 1700 kcal/day, low salt (1-2g/day) Insulatard 0-10 iu (sc)

FBG 2hPPB G

5.HT stage 2

5.1.Renoparenc hymatous HT 5.2.Essential HT

Repeat USG Abdome n

DM diet 1700 kcal/day, low salt (1-2g/day) Furosemide 40-40-40mg (iv) Captopril 3x25mg (po)

Subjec tive BP HR

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Male/52 yo Ur:89,3 Cr:4,29 BUN/Cr:9,73 GFR:14,25 UA:proteinuria, erythrocyturia

6.Azote mia renal

6.1.due to No.1 6.2.CKD stage 5

Repeat USG Abdome n

DM diet 1700 kcal/day, low salt (1-2g/day) Captopril 3x25mg (po)

Subjec tive Repea t Ur/Cr

Male/52 yo Hb:8,9 MCV:82 MCH:27,4

7.Anemi a normoch romnormocyt er

7.1.due to No.1

Blood smear Reticuloc yte count

Subjec tive

CUE AND CLUE 1.F/55 yo Ax: SOB, DOE, PND, cough with whitish sputum, , PE: RR: 26 tpm JVP R+7 cm,, Cardiomegaly (+) Rh: basal area of the lung D and S, Extr : oedem +/+ CXR: Cardiomegaly , bilateral pleural effusion

PROBLEM LIST 1. SOB

INITIAL DIAGNOSE 1.1 HF st C Fc IV 1.2 Pleural Effusion

PLANNING DIAGNOSE Sputum culture, gram, and sensitivity test

PLANNING THERAPY -. 02 8-10l/minute NRBM -. Venflon -. Semi fowler position -. Negative fluid balance 500 cc/day -.inj: Furosemid 40mg0-0 -Captoprile 3x 12,5 mg -

PLANNING MONITORING Subyektif, BP, HR, RR, urine production

2.F/55 yo Ax: SOB, Dypsneu On effort , orthopneu, PE: T: 100/70 RR: 26 tpm JVP R+7 cm, Cardiomegaly (+) CXR: Cardiomegaly , ECG: QS in V3 ,mutifocal PVC

2. HF st C Fc IV

2.1 CAD 2.2 HHD 2.3 ASHD

Echocardi ography

Same as above

Same as above

CUE AND CLUE

PROBLE M LIST

INITIAL DIAGNOSE

PLANNING DIAGNOSE

PLANNING THERAPY

PLANNING MONITORIN G

3. F/ 55 yo ECG : QRS bizzare, multiple & multifocal, QS in V3

3. Multifocal PVC

3.1 post MI

Holter -Amiodarone 3x 200 monitoring mg (po) - ASA 1x 80 mg

ECG

4. F/55 yo Ax: Cough with whitish sputum, for 1 weeks PE: Rh: basal area of the lung D and S,
CXR: bilateral pleural effusion

4. Pleural effusion

4.1 due to HF 4.2. pneumonia CAP

Sputum culture, gram, and sensitivity test

Inj: ceftriaxon 2x 1 gr complain iv Oral: ambroxol 3 x 30 mg

CUE AND CLUE Female/56 yo Dyspneu on exertion Orthopneu Paroxysmal nocturnal dyspneu Nausea and vomiting Lose of appetite Hypertension since 1 year ago (190/) Took captopril 1x1tab BP:180/80 PR:92 RR:32 Anemic Cardiomegaly Rales +/+ Edema anasarca Hb:8,3 MCV:76 MCH:24,5 Ur:134,7 Cr:8,21 eGFR:6,04 K:6,4 Albumin:2,69 UA:erythrocyturia and proteinuria CXR:increase of bronchovascular pattern with

PL 1. Shortnes s of breath

IDx 1.1.Uremic lung 1.2.Heart Failure stage C fc IV

PDx

PTx O2 2-4 Lpm via NC Venflon High calory, 1900 kcal/day, protein (30g/day), low salt (12g/day) Fluid restriction Drip Furosemide 10mg/hour Metoclopramide 3x10mg (iv) Ca gluconas 1amp (slow iv) D40% 50mL (iv) Actrapid 10iu (iv) Amlodipine 1x5mg (po) Clonidine 3x0,15mg (po) HD elective

PMo Subjec tive BP HR RR Urine produc tion Body weight

CUE AND CLUE Female/56 yo Shotness of breath Nausea and vomiting Lose of appetite Hypertension since 1 year ago (190/) Took captopril 1x1tab BP:180/80 PR:92 RR:32 Anemic Cardiomegaly Rales +/+ Edema anasarca Hb:8,3 MCV:76 MCH:24,5 Ur:134,7 Cr:8,21 eGFR:6,04 K:6,4 Albumin:2,69 UA:erythrocyturia and proteinuria CXR:increase of bronchovascular pattern with cephalization

PL 2.Chroni c Kidney Disease stage 5

Idx 2.1.Hypertensive nephrosclerosis 2.2.GNC 2.3.PNC

PDx USG Abdomen Doppler Urine Esbach

PTx Same as above: O2 2-4 Lpm via NC High calory, 1900 kcal/day, protein (30g/day), low salt (12g/day) Fluid restriction Drip Furosemide 10mg/hour Metoclopramide 3x10mg (iv) D40% 50mL (iv) Actrapid 10iu (iv) Amlodipine 1x5mg (po) Clonidine 3x0,15mg (po) HD elective

Pmo Subjec tive BP HR RR Urine produc tion Body weight

CUE AND CLUE

PL

Idx

PDx

PTx O2 2-4 Lpm via NC Drip Furosemide 10mg/hour Amlodipine 1x5mg (po) Clonidine 3x0,15mg (po)

PMo

Female/56 yo Dyspneu on exertion Orthopneu Paroxysmal nocturnal dyspneu Hypertension since 1 year ago (190/) Took captopril 1x1tab BP:180/80 PR:92 Cardiomegaly Rales +/+ ECG:OMI inferior and anteroseptal

3.Heart Failure stage C fc IV

3.1.HHD Echocar 3.2.CAD diograp 3.3.Uremic hy cardiomyopat hy

Subje ctive BP HR

Female/56 yo BP:180/80

4.Hyperte 4.1.Essential nsion hypertension stage II 4.2.Atheroscl erosis

5.Anemia hypochro mic micocyter 5.1.Due to No.2 5.2.Low intake

Fundus copy

Amlodipine 1x5mg (po) Clonidine 3x0,15mg (po)

Subje ctive BP
Hb

Female/56 yo Hb:8,3 MCV:76 MCH:24,5

SI/TIBC Ferritin serum

Plan to give erythropietin

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Female/56 yo K:6,4

6.Moderat e hyperkale mia

6.1.due to No.2

Ca gluconas 1 amp (slow iv) D40% 50mL (iv) Actrapid 10iu (iv)

Reche ck kalium

Female/56 yo Nausea and vomiting Lose of appetite

7.Dyspep sia syndrome

7.1.due to No.2

Same as above: Metoclopramide 3x10mg (iv)

Subje ctive

Female/56 yo pH:7,266 HCO3:16,3 BE:-10,4

8.Metaboli c acidosis

8.1.due to No.2

NaBic 75 mEq (iv bolus) NaBic 75 mEq drip in 100 ml D5%

Reche ck BGA

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/53 yo Tenderness in the right hypochondrium, with radiation around to the infracapular area for 1 month Nausea Decrease of appetite Fever Icteric Murphy sign (+) Hyperbilirubinem ia (Direct>>) USG Abdomen:thickeni ng of the gall bladders wall

1. Chroni c cholec ystitis

ERCP MRCP

Liver diet with low fat 1500 kcal/day IVFD NS 0,9% 20 dpm Ranitidine 2x50 mg (iv) Metoclopramide 3x10 mg (iv) Ursodeoxycholic acid 2x250 mg (po)

Sym ptom s BP HR RR

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/53 yo Icteric Tea-like colored urine SGOT: 731 SGPT: 725 UA: bilirubin +

2.Tran samini tis

2.1.Acute viral hepatitis

HBsAg Anti HCV

Subj ectiv e

Female/53 yo Nausea Decrease of appetite

3.Dysp 3.1.due to epsia No.1 syndro me

Metoclopramide 3x10 mg (iv) Ranitidine 2x50 mg (iv)

Subj ectiv e

CUE AND CLUE Male/34 yo Shortness of breath for a week, even at rest Nausea and vomiting since a month ago Decreased of appetite Consumed Extra Joss, Kratindaeng, and Kuku Bima for more than 10 years, 2-3 times/day BP:120/70 HR:94bpm RR:24tpm Pulmo:Rh +/+ Hb:4,9 Na:122 K:7,73 Ur:398,8 Cr:29,48 CXR:cardiomegaly and uremic lung

PL 1. Shortnes s of breath

IDx 1.1.CKD st V 1.2.HF st C fc IV

PDx

PTx O2 2-4 Lpm (NC) HD cito Venflon Diet 1900 kcal/day, protein 40g/day, and low salt Furosemide 40mg-40mg-40mg (iv)

PMo Subjective BP HR RR Urine production

CUE AND CLUE Male/34 yo Shortness of breath for a week, even at rest Nausea and vomiting since a month ago Decreased of appetite Consumed Extra Joss, Kratindaeng, and Kuku Bima for more than 10 years, 2-3 times/day BP:120/70 HR:94bpm RR:24tpm Pulmo:Rh +/+ Hb:4,9 Na:122 K:7,73 Ur:398,8 Cr:29,48 CXR:cardiomegaly and uremic lung

PL 2.CKD stage V

IDx 2.1.NSAI D nephrop athy 2.2.Ig A nephrop athy 2.3.PNC

PDx

PTx O2 2-4 Lpm (NC) HD cito Venflon Diet 1900 kcal/day, protein 40g/day, and low salt Furosemide 40mg-40mg-40mg (iv)

PMo Subjective BP HR RR Urine production

CUE AND CLUE Male/34 yo Shortness of breath for a week, even at rest BP:120/70 HR:94bpm RR:24tpm Ur:398,8 Cr:29,48 CXR:cardiomegaly and uremic lung

PL 3.Heart failure stage C fc IV

IDx 3.1.Ure mic cardiom yopathy

PDx

PTx Furosemide 40mg-40mg-40mg (iv)

PMo Subjective BP HR RR Urine production

Male/34 yo Hb: 4,9 MCV:80 MCH:26,5

4.Anemia 4.1.due normoch to No.2 rom normocyt er

Transfussion PRC durante HD

Subjective Recheck Hb

CUE AND CLUE Female/78 yo General weakness, could not walk and speak after she woke up from sleep in the morning 20 days agoBP:230/. Hypertension for 7 years, not routinely took medicine BP:180/100mmHg PR:68bpm, irregular RR:28tpm Pathologic reflex +/L:15.900 UA:Leu:10-18/hpf Female/78 yo General weakness, could not walk and speak after she woke up from sleep in the morning 20 days agoBP:230/. Hypertension for 7 years, not routinely took medicine BP:180/100mmHg PR:68bpm, irregular RR:28tpm Pathologic reflex +/-

PL 1. General weakness

IDx 1.1.CVA 1.2.Septi c conditio n 1.3.Low intake

PDx CT Scan Brain Urine culture Blood culture

PTx O2 2-4 Lpm (NC) Liquid diet 6x150cc Bed rest Semifowler position IVFD NS 0,9% 20 dpm Ceftriaxone 2x1g (iv) Metoclopramide 3x10mg (iv) Azithromycin 1x500mg (po) Captopril 3x25mg (po) Consult to Neurologic Department: Citicholin 2x500mg (po) Aspillet 1x80mg (po)

PMo Subjective BP HR RR

2.CVA

2.1.CVA thrombo sis 2.2.CVA Emboly

CT Scan Brain

Consult to Neurologic Department: Citicholin 2x500mg (po) Aspillet 1x80mg (po) Captopril 3x25mg (po)

Subjective BP HR RR

CUE AND CLUE Female/78 yo General weakness PR:68bpm, irregular RR:28tpm L:15.900 UA:Leu:10-18/hpf Female/78 yo General weakness Shortness of breath at rest Hypertension for 7 years, not routinely took medicine BP:180/100mmHg PR:68bpm, irregular RR:28tpm Female/78 yo Hypertension for 7 years, not routinely took medicine BP:180/100mmHg PR:68bpm, irregular RR:28tpm

PL 3.Septic condition

Idx 3.1.UTI 3.2.CAP

PDx CXR PA Urine culture Blood culture

PTx Ceftriaxone 2x1g (iv) Azithromycin 1x500mg (po)

PMo Subjective BP HR RR

4.Heart failure stage C fc IV

4.1.HHD 4.2.CAD

Echocardi ography

Captopril 3x25mg (po)

Subjective BP HR RR

5.HT stage 5.1.Essen Fundusco II tial HT py 5.2.Seco ndary HT

Captopril 3x25mg (po)

Subjective BP HR RR

CUE AND CLUE Female/78 yo General weakness PR:68bpm, irregular RR:28tpm ECG:atrial fibrillation, HR:62-107bpm

PL 6.Atrial fibrillation slow to rapid ventricula r response

Idx

PDx

PTx Aspillet 1x80mg (po)

PMo Subjective BP HR RR ECG/24 hours

Female/78 yo Low intake Alb:2,94

7.Hypoalb uminemia

7.1.due to low intake

Total Albumin 20% protein/al bumin/glo bulin

Recheck albumin

CUE AND CLUE Male/55 yo Vomit of coffee ground appearance, 3 times, volume: a quarter of glass History of consuming coffee and eating spicy food since young NGT: slightly dark liquid-yellowish liquid RT: melena Male/55 yo Dysarthria Right hemiparese Sudden onset BP: 170/110 Pupil isokor, pin point, no light reflex CT Scan Brain: haemorrhagic at left pons (2,9cc) Male/55 yo History of Diabetes Mellitus since 2 years Routinely control Using Insulin BMI: 25,71 RBS: 383 UA: glucose +4

PL 1.Hemat emesis

IDx 1.1.PUD 1.1.1.Gastric ulcer 1.1.2.Duodenal ulcer 1.2.Rupture Varices Oesophagus

PDx Endosco py

PTx Fasting NGTGastric lavage3 times negative/cleanstart liquid diet 6x150cc (1cc=1kcal) IVFD NaCl 0,9% 20 dpm Omeprazole 80 mg (iv bolus)continue with drip Omeprazole 8mg/hour (for 3 days)

PMo Subjec tive BP HR

2.CVA haemorr hagic

Consult to Neurologic Department: Citicholin 3x250mg Forneuro 2x1tab (po)

Subjec tive BP HR

3.Diabet es Mellitus type 2

DM diet, 1900 kcal/day Insulatard 0-10iu (sc)

Subjec tive FPG 2hPPB G

CUE AND CLUE Male/55 yo History of consuming Extra Joss 1-2 sachets/day for 10 years BP: 170/110 Ur: 47,8 Cr: 1,88 eGFR: 43,96 Male/55 yo Nausea and vomiting History of consuming coffee and eating spicy food History of DM for 2 years Male/55 yo No history of HT History of DM BMI: 25,71 BP: 170/110

PL 4.Azote mia renal

IDx 4.1.Acute Kidney Injury 4.2.CKD stage III

PDx

PTx

PMo Subje ctive

Clearan Confirm diagnosis ce creatinin e USG Abdome n

5.Dyspe psia syndro me

5.1.due to No.1 5.2.Diabetic gastroparese

Gastric emptyin g test

Metoclopramide 3x10mg (iv)

Subje ctive

6.HT stage II

6.1.due to No.2 6.2.Renoparen chymal HT 6.3.Essential HT

Captopril 2x25 mg (postponed)

Subje ctive BP

CUE AND CLUE

PL

IDx 7.1.Lipoma 7.2.Fibroma

PDx FNAB

PTx Confirm diagnosis

PMo Subje ctive

Male/55 yo 7.Benig Swelling on the n tumor right side neck since about 8 months Not getting bigger No pain History of biopsy: benign Single mass, at right side, bellow the right ear, rubbery consistency, mobile, not move when swallowing, painless, 4x5cm Male/55 yo Blurred vision for more than 1 year Iris shadow +/+ History of Diabetes Mellitus 8.Senile cataract

Consult to Opthalmologic Department

Subje ctive

CUE AND CLUE Female/72 yo Headache at the back 3 months, continuously Cervical spine photo: Lipping process at corpus vertebrae C 4,5,6,7 Female/72 yo Struma diffusa, at front neck, moved when swallowing, rubbery in consistency, soft surface, 20cm x 10cm, no bruit Decreased appetite PR:120bpm Exopthalmus Fine tremor TSHs 0,16 FT4 1,65 Newcastle index: 32 (probably hyperthyroid)

PL 1.Spon dyloarth rosis cervicali s

IDx

PDx

PTx Paracetamol 3x500mg

Pmo Subje ctive

2.Strum a uninodu sa with subclini cal hyperth yroidis m

2.1. Plummer disease 2.2.Graves disease 2.3.Adenoma thyroid

USG Thyroid FNAB Thyroid

Propanolol 2x10mg (po)

Subje ctive BP HR RR

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Female/72 yo Shortness of breath Dyspneu deffort BP:110/70 HR:120bpm Cardiomegaly Hb:7,4

3.Heart Failure stage C fc III

3.1.HHD 3.2.Thyroid Heart Disease 3.3.Anemia Heart Disease

-Propanolol 2x10mg (po)

Subje ctive BP HR RR

Female/72 yo Hb:7,4 MCV:78 MCH:25,6

4.Anemi a hypochr om microcy ter

5.Hypo albumin emia

4.1.Low intake (Fe deff) 4.2.Chronic disease

Blood smear SI TIBC

PRC transfusion 1 pack/day

Reche ck Hb

Female/72 yo Alb:2,26

5.1.Hypercata bolic state 5.2.Low intake

Total Protein/ Albumin /Globuli n

Albumin 20% transfusion

Alb

CUE AND CLUE Male/65 yo Shortness of breath Nausea Lose of appetite Uncontrolled hypertension > 2 years Routinely HD Swollen leg BP:140/90 RR:24 Hb:7,5 Ur:149,8 Cr:10,57 eGFR:6,40 K:5,6 Albumin:2,66 ECG:LVH CXR:left pleural effusion, uremic lung, and looks cardiomegaly

PL 1. CKD stage V with overloa d syndro me on routine HD

IDx 1.1.Hypertensi ve nephrosclerosi s 1.2.NSAID Nephropathy

PDx

PTx

Pmo Subje ctive BP HR RR

O2 2-4 Lpm via NC USG Abdome Venflon High calory, 1900 kcal/day, n

protein (50g/day), low salt (<2g/day) Fluid restriction Drip Furosemide 10mg/hour Metoclopramide 3x10mg (iv) Captopril 2x12,5 mg (po) Ca gluconas 1amp (slow iv) D40% 50mL (iv) Actrapid 10iu (iv) HD Cito

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Male/65 yo Shortness of breath even at rest BP:140/90 RR:24 ECG:LVH CXR:left pleural effusion, uremic lung, and looks cardiomegaly Male/65 yo K: 5,6

2.SOB

2.1.Uremic lung 2.2.Left pleural effusion 2.3.Heart Failure stage C fc IV

O2 2-4 Lpm via NC Drip Furosemide 10mg/hour

Subje ctive BP HR RR

3.Hyper kalemia

3.1.due to No.1

Ca gluconas 1amp (slow iv) D40% 50mL (iv) Actrapid 10iu (iv) SI/TIBC Ferritin PRC transfussion during HD Plan to give erythropietin

Reche ck Kaliu m Hb

Male/65 yo Hb:7,5 MCV:83 MCH:28,0

4.Anemi 4.1.due to a No.1 normoc hromnormoc yter

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Male/65 yo History of hypertension Dyspneu deffort Paroxysmal nocturnal dyspneu BP:140/70 JVP raised ECG:LVH CXR:cardiomegaly

5.Heart Failure st.C fc IV

5.1.HHD 5.2.Uremic cardiomyopath y

Captopril 2x12,5mg (po)

Subje ctive BP HR RR

CUE AND CLUE

PL

IDx 1.1.Ulcus decubitus 1.2.Uroseps is 1.3.CAP

PDx Blood, wound, urine, and sputum culture

PTx
O2 10 Lpm via NRBM IVFD RL 30dpm Liquid diet via NGT Ceftriaxone 2x1g (iv) Metronidazole 3x500mg (iv) Clindamycin 2x300mg (po) Wound toilet and dressing

Pmo Subje ctive BP HR RR

Male/63 yo 1. Septic Cough 1 month condition Turbid urine Fever 1 month 3 ulcus decubitus BP:90/60 PR:102bpm RR:24tpm Rh+ L:8800 with lymphopenia (700) Bacteriuria and leucocyte 4-8/hpf CXR:fibro-infiltrate in all area of the lung Male/63 yo 2.Lung Cough 1 month infection Fever 1 month Decrease of body weight RR:24tpm Rh+ L:8800 with lymphopenia (700) CXR:fibro-infiltrate in all area of the lung

2.1.CAP 2.2.Lung TB

Gram staining Acidfast bacilli staining

Ceftriaxone 2x1g (iv) Consult to Pulmonology Department

Subje ctive

CUE AND CLUE Male/63 yo GCS: 4-X-X Cough 1 month Turbid urine Fever 1 month 3 ulcus decubitus L:8800 with lymphopenia (700)

PL

Idx

PDx Ig G, M Toxopla sma Consult to Neurolo gy Depart ment CT Brain Consult VCT Consult Pulmon ology Depart ment FBG 2hPPB G

PTx

PMo Subje ctive

3.Altered 3.1.due to Mental No.1 State 3.2.Toxoplas mosis cerebri 3.3.Encephalit is 3.3.1.Bacterial 3.3.2.Viral 3.4.Brain atrophy 4.Immun ocompro mised state 4.1.Lung TB 4.2.HIV

Male/63 yo Cough 1 month Fever 1 month Decrease of body weight L:8800 with lymphopenia (700) Alb:2,34 Male/63 yo RBG:309

Subje ctive

5.Hyper 5.1.DM type 2 glycemia 5.2.Reactive

Insulatard 0-8iu (sc)

Subje ctive

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Male/63 yo Immobilize for 5 years Contracture History of trauma

6.Immob ilization

6.1.Spinal cord injury 6.2.Malunion of long bone fracture

Cervical Thoraco -LumboSacral X-ray Pelvis AP-Lat X-ray

Subje ctive

Male/63 yo Incontinent of urine and alvi since 5 years ago RBG:309

7.Inconti nent of urine and alvi

7.1.Diabetic autonomic neuropathy 7.2.Spinal cord injury

Same as above

Subje ctive

CUE AND CLUE

PL

IDx

PDx

PTx
O2 2-4 Lpm via NC Venflon High calory, low protein (3040g/day), low salt (<2g/day) Fluid restriction Metoclopramide 3x10mg (iv) Furosemide 40mg-0-0 (iv) Omeprazole 2x20mg (po) Captopril 2x12,5mg (po) Fluid balance Acid-base and electrolyte balance Cito HD CaCO3 3x2tabs (po)

Pmo

Female/55 yo Nausea and vomiting Lose of appetite BP:130/90 Hb:5,7 Ur:351,6 Cr:21,6 eGFR:2,09 Phosphor:8,85
Female/55 yo Rigidity since 16 hours before admission The first time Unconscious during the attack Calcium:6,0 Phosphor:8,85 Female/55 yo Nausea and vomiting Lose of appetite

1. CKD stage V

1.1.GNC 1.2.PNC

USG Abdome n

Subje ctive BP HR RR

2.Seizure+ hypocalce mia+hyper phosphate mia

2.1.due to No.1

Subje ctive Calciu m

3.Dyspepsi a syndrome

3.1.Uremic gastropath y 3.2.Gastriti s

Metoclopramide 3x10mg (iv) Omeprazole 2x20mg (po)

Subje ctive

CUE AND CLUE Female/55 yo Hb:5,7 MCV:85 MCH:28,4

PL

Idx

PDx SI/TIBC Ferritin

PTx PRC transfussion during HD Plan to give erythropietin

PMo Hb

4.Anemi 3.1.due to a No.1 normoc hromnormoc yter 5.HT stage 1 5.1.Essential HT 5.2.Secondary HT 6.1.Hypertensi ve Heart Disease

Female/55 yo BP:130/90 PR:88bpm Female/55 yo No history of shortness of breath BP:130/90 Cardiomegaly Female/55 yo No history of DM RBS:216

Captopril 2x12,5mg (po)

Subje ctive BP PR Subje ctive

6.Heart Failure stage B

Furosemide 40mg-0-0 (iv) Captopril 2x12,5mg (po)

7.Hyper glycemi a

7.1.DM type 2 7.2.Reactive

FPG 2hPPB G

 Hypocalcemia and hyperphosphatemia Hyperphosphatemia has an extensive list of causes and may be due to an increased intake of phosphorus, decreased excretion, or translocation from tissue breakdown into the extracellular fluid. Renal insufficiency is probably the most common cause of hyperphosphatemia. The use of phosphatecontaining enemas or zealous use of oral phosphate may also lead to hyperphosphatemia. Vitamin D administration may be responsible for the development of hyperphosphatemia. The transcellular shift of phosphorus from cells into the extracellular fluid compartment is seen in tissue destruction or increased metabolism. Examples of this include acute leukemias or lymphomas that received effective chemotherapy for large bulky tumors. Rapid release of cellular phosphorus may occur causing a "tumor-lysis-syndrome." In rhabdomyolysis due to crush injury, hypocalcemia and hyperphosphatemia may occur. Severe intravascular hemolysis may lead to a similar syndrome. In diabetic ketoacidosis, ketoneinduced urinary losses of phosphorus deplete total body stores, but patients may present with hyperphosphatemia. When the volume shifts during the correction of hyperglycemia and acidosis, the shift of phosphorus back into cells can result in mild transient hypophosphatemia.

 Hypocalcemia and tetany may occur if serum phosphorus rises rapidly. Hyperphosphatemia alters calcium and phosphate ion solubility products, and calcium deposition in soft tissue may occur. Hyperphosphatemia inhibits la-hydroxylase activity in the kidney. The lower circulating concentrations of 1,25(OH)2D may further aggravate the hypocalcemia by impairing intestinal absorption of calcium. Hyperphosphatemic-induced hypocalcemia inhibits vitamin D synthesis and results in an increase in PTH secretion. Secondary hyperparathyroidism from long-term hyperphosphatemia has been well described and is usually associated with renal insufficiency. Ectopic calcification in tissues may occur, including blood vessels, skin, periarticular tissues, and cornea (band keratopathy). Treatment should be directed towards the hyperphosphatemia in order to correct the hypocalcemia. Ingestion of phosphoric acid-containing soft drinks has been suggested to be a cause of hypocalcemia. It is debatable as to whether this actually occurs. It is likely that the hypocalcemia is the result of reduced calcium intake, as individuals are replacing milk, a common source of calcium, with soft drinks. A low calcium diet in itself does not cause hypocalcemia if all the normal homeostatic mechanisms are functional.

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Female/67 yo Nausea and vomiting Anorexia Low intake Dehidration Polyuria Thrist History of DM since 59 yo BP:130/70 PR:80 RR:20 RBG: 1122 mg/dL Serum osmolality: 388,53 Ketonuria (4+) pH:7,203 Serum bicarbonate: 11,7mmol/L Anion Gap:41,3 Typical mental status: Alert

1. Hyp ergli cemi a crisi s

1.1.M oderat e KAD mix with HHS 1.2.H HS 1.3.Mil d KAD

Plas ma keton

Rehidration 1 L of 0,9% NaCl per hour (15-20ml/kgBW/hr) Serum Na high/normal0,45% NaCl 250-500ml/hr Serum Na low0,9% NaCl 250-500ml/hr When serum glucose reaches 200mg/dl change to 5% Dextrose with 0,45% NaCl at 150-250ml/hr

Bicarbonate, if pH<6,9100mmol in 400ml H2O + 20mEq KCl, infuse for 2 hoursRepeat every 2 hours until pH7 (Check K/2h)
Actrapid 0,15iu/kgBW as IV bolusActrapid 0,1iu/kgBW/hr IV infusionif serum glucose does not fall by 50-70mg/dl in first hour then double actrapid infusion hourly until glucose fall by 50-70mg/dlWhen serum glucose reaches 200 mg/dlActrapid 0,05-0,1iu/kgBW/hr IV infusion to keep the serum glucose between 150200mg/dl until metabolic correction is achievedInsulatard 0-10iu (sc) and Actrapid 4-4-4iu (sc,before meal)continue iv actrapid infusion for 1-2 hours after sc insulin is begun If initial K<3,3hold insulin and drip KCl 40mEq/h until K3,3 If initial 3,3<K<5drip KCl 20-30mEq/h If initial K5do not give KCl drip, but check K/2h

Subj ectiv e BP HR RR RBG /h SE/4 h BGA /6h Urin e prod uctio n

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Female/67 yo History of DM for 8 years (since 59 yo) BMI: 20,20 RBG:1122

2. DM type II normo weight

Same as above

Subje ctive RBG

Female/67 yo No history of shortness of breath Cardiomegaly

3.Heart 3.1.Diabetic Failure cardiomyopa stage thy B

Captopril 3x6,25mg (po)

Subje ctive

Female/67 yo Ur:84 Cr:1,47 Proteinuria: -

4.Azot emia prerenal

4.1.Dehidrati on

Same as above

Ur/Cr UL

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Female/67 yo Nausea and vomiting

5.Disp epsia syndro me

5.1.due to No.1 5.2. DM gastropathy 5.3.Gastritis

Ranitidine 2x50mg (iv) Metoclopramide 3x10mg (iv)

Subje ctive

MORNING REPORT
Wednesday, September 1st 2010
PHYSICIAN INCHARGE: IA : dr. Nicholas dr. Meci IB : dr. Nurike, dr. Dewi II : dr. Hendarto III : dr. Hariadi, SpPD-KGEH MODERATOR: dr. Budi Darmawan M, Sp.PD-KHOM

CUE AND CLUE Female/45 yo Lose of apetite for 1 week RBS: 469 Normal BGA Normal Osmolarity

PL 1.Hyper glycemi a state

IDx 1.1.DM type 2 uncontrolled 1.2.Reactive due to Septic condition and superimposed with dehidration

PDx

PTx Rehidration: 2-3 L NaCl 0,9% over first 1-3 hours Actrapid 0,1iu/kgBW (iv bolus)Actrapid drip 0,1 iu/kgBW/hour until GDA<250 Actrapid drip 0,05 iu/kgBW/hour until GDA<140 Insulatard 10 iu stop Actrapid drp after 2 hours

Pmo Subje ctive BP HR RR RBS/h our SE/4 hours BGA/ 6 hours Subje ctive BP HR RR

Female/45 yo Suprapubic pain 1 week Fluor albus 2 months Disuria Poliuria Fever BP:160/90 PR:108bpm Tax:37,8C Leucocyte:20.100 UL:nitrite(+), bacteria(+)

2.Septic 2.1.Cystitis conditio 2.2.Pelvic n Inflammatory Disease

Urine culture Blood culture Consult gynecol ogy departm ent

Ceftriaxone 2x1g (iv) Ciprofloxacine 2x400mg (iv)

CUE AND CLUE Female/45 yo No history of SOB BP: 160/90 JVP R + 2 cm; 30 Cardiomegali CXR: cardiomegaly

PL 3.Heart Failure stage B

IDx 3.1.HHD 3.2.DM cardiomyopath y

PDx

PTx Captopril 3x25 mg

Pmo Subje ctive BP HR RR

Female/45 yo BP: 160/90

4.Hyper tension stage 2

Same as above

Subje ctive BP

Faecal Smear
No leukocyte No erythrocyte

CUE AND CLUE

PL

IDx

PDx

PTx Low fiber diet Rehidration: RL 1.000 mL in 2 hours Maintainance: RL 20 dpm Attapulgite 2tabs/diarrhea (max:12tabs/day)

PMo

Female/14 yo Diarrhea since yesterday, liquid, yellowish, 12 times, after eating a bowl of Es Campur Her older sister had the same complain after taking the same meal Abdominal pain sometimes relieve after passing stool Weak and just lying on her bed BP:90/50120/80 PR:8878bpm Tax:37, Trect:37,4 Sunken eyes Dry oral mucous PCV:48,540,1 Ur:50,347,4 Cr:1,781,09 PSG:1,027

1. Acute waterry diarrhea with mild dehidrat ion

1.1.Food poisoning 1.2.ETEC 1.3.Rotavirus 1.4.Irritable Bowel Syndrome

Kultur faeces

Subje ctive BP HR RR

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/14 yo Nausea and vomiting Epigastria pain Decreased of appetite Female/14 yo Ur:50,347,4 Cr:1,781,09

2.Dyspe 2.1.due to psia No.1 syndro me

Metoclopramide 3x10mg (iv)

Subje ctive

3.Azote 3.1.due to mia pre- No.1 renal

Same as above(rehydration)

Ur/Cr

CUE AND CLUE Male/55 yo Wound on the 5th digit of the left foot for 1 week and getting worse

PL 1. Diabetic foot Wagner grade 2

IDx

PDx Pus culture

PTx Wound treatment Metronidazole 3x500mg (iv) Clindamycin 3x300mg (po)

PMo Subje ctive Woun d

Male/55 yo 2.Hyper History of DM for 14 glycemi years c state Never routinely check his blood glucose BMI: 27,68 GDA: 474-248

2.1.Diabetes Mellitus type 2 overweight uncontrolled

Rehidration NS 0,9% 1L/1 hour NS 0,9% 20 dpm Insulatard 0-10iu (sc)

Subje ctive FPG 2hPP BG

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/55 yo 3.Heart History of DM for 14 Failure years stage B Never routinely check his blood glucose BP: 130/80 BMI: 27,68 GDA: 474-248 Cardiomegaly Male/55 yo Albumin:3,14 4.Hypo albumin emia

3.1.Diabetic cardiomyopath y 3.2. Hypertensive heart disease

Echocar diograp hy

Captopril 3x6,25mg

Subje ctive BP HR RR

4.1.Renal loss 4.2.due to chronic disease

Total protein/ Albumin /Globuli n

High calories high protein diet

Album in

CUE AND CLUE Male/67 yo Haematemesis Black-tarry stool History of routinely taking analgetics for 5 years Epigastria pain, not relieved with meal Nausea Vomiting Rectal touch: melena NGT:black liquid Male/67 yo History of heart disease History of DM and HT, but nor routinelly took medicine Smoking Consuming alcohol BP: 160/100mmHg HR:irregular, 64 bpm RR: 22x/mnt Cardiomegaly

PL 1. Haemat emesis melena

IDx 1.1.NSAID gastropathy 1.2.Gastritis erosiva

PDx Endosc opy

PTx NGTGastric lavageif ()start liquid diet 6x200cc IVFD NS 0,9% 20 dpm Omeprazole 80mg (iv bolus) Omeprazole drip 8mg/hour (for 3 days) Metoclopramide 3x10mg Lactulosa 3x30ml (until diarrhea or 4 times passing stool/day

PMo Subje ctive BP HR RR

2.Heart Failure stage C fc. II

2.1.Hypertensi ve Heart Disease 2.2.Diabetic cardiomyopath y

Echocar diograp hy

Captopril 2x25mg Furosemide 20mg-20mg-0 Digoxin 1x0,125mg ASA postponed

Subje ctive BP HR RR

CUE AND CLUE Male/67 yo BP:160/100mmHg

PL 3.Hyper tension stage 2 4.Diabe tes Mellitus type 2 5.Azote mia

IDx

PDx

PTx Captopril 2x25mg (po) Furosemide 20mg-20mg-0 (po) Insulatard 0-4iu (sc)

PMo Subje ctive BP HR FPG 2hPP BG

3.1.Essential Fundus HT copy 3.2.Renoparen chymatous HT

Male/67 yo History of DM since > 1 year RBS: 244 Male/67 yo Ureum:113,3 Creatinine: 2,71

5.1.Pre-renal 5.1.1.due to No.1 5.2.Renal 6.1.Spondylosi s 6.2.Spondylitis 6.3.Myalgia 6.4.HNP 7.1.Low intake 7.2.due to chronic disease

Rechec k Ur/Cr

Male/67 yo Low back pain

6.Low back pain

Lumbos acral AP/Late ral Total protein/ Albumin /Globuli n

Subje ctive

Male/67 yo Albumin: 2,91

7.Hypo albumin emia

High calories high protein diet Album in

CUE AND CLUE Female/27 yo Diarrhea since yesterday, liquid, yellowish after eating chili food Sunken eyes Dry oral mucous L:20.200 Hb:17,1 PCV:51,2

PL 1. Acute waterry diarrhea with moderat e dehidrat ion

IDx 1.1.Food poisoning 1.2.Rotavirus 1.3.ETEC

PDx Kultur faeces

PTx Low fiber diet IVFD RL 1500ml in 2 hours NS 0,9% 30dpm Attapulgite 2tabs/diarrhea (max:12tabs/day)

PMo Subje ctive BP HR RR

Female/27 yo Nausea and vomiting Epigastria pain Decreased of appetite

Female/27 yo Ur:33,1 Cr:1,79

2.Dyspe 2.1.due to psia No.1 syndro me

Metoclopramide 3x10mg (iv) Ranitidine 2x50mg (iv)

Subje ctive

3.Azote mia

3.1.due to No.1

Same as above(rehydration)

Ur/Cr

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/26 yo SOB especially on exertion Non-productive cough for 3 months Weight loss Night sweats Atypical chest pain RR:28tpm BMI:14,57 Lower vesicular sound at basal Rales at both lung CXR:Pneumonia with minimal pleural effusion of both lung

1. Chronic lung infectio n

1.1.CAP 1.2.Lung TB 1.3.PCP

CXR PA Sputum culture Gram staining

O2 2-4 Lpm (NC) Confirm diagnosis

Subje ctive BP HR RR

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/26 yo General weakness Weight loss Fever Night sweats BP:95/80mmHg BMI:14,57 Hb:7,2gr/dL

2.Immu nocomp romised state

2.1.HIV

Anti HIV CD4

High calory high protein diet IVFD NS 0,9%:D5% 1:1 Cotrimoxazole 1x960mg

Subje ctive BP HR RR Viral load

Female/26 yo Hb:7,2 MCV:72 MCH:24,8

3.Anemi a hypochr ome microcy ter 4.Hypo albumin emia

3.1.Chronic disease 3.2.Fe deficiency

Blood smear SI/TIBC

PRC transfusion 2 packs/day until PCV30%

Subje ctive Hb

Female/26 yo Alb:2,47g/dL

4.1.Chronic disease

Protein Diet: extract of stripedtotal/Glo snakehead fish (ikan kutuk) bulin

Album in serum

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Female/65 yo Decrease of consciousness History of hypertension and diabetes mellitus for 5 years uncontrolled Nausea and vomiting Anuria for 4 days BP: 190/100 Rales at lower of both lung Ur: 122,1 Cr: 10,55 Na: 114 UA: prot 4+

1. DOC

1.1.Uremic encephalopath y 1.2.Hyponatre mia

O2 2-4 Lpm (NC) Bed rest Semifowler position HD citofamily refused Low protein diet 0,6-0,8 g/kg BW/day NaCl 3% 10 dpm Furosemide 40mg-40mg-0 (iv) Metoclopramide 3x10mg (iv) Ranitidine 2x50mg (iv) Captopril 2x25mg (po) Nifedipine 2x10mg (po)

Subje ctive BP HR RR

CUE AND CLUE Female/65 yo History of hypertension and diabetes mellitus for 5 years uncontrolled Nausea and vomiting Anuria for 4 days BP: 190/100 Rales at lower of both lung Ur: 122,1 Cr: 10,55 UA: prot 4+ Female/65 yo BP: 190/100 mmHg HR: 100 bpm Female/65 yo Nausea and vomiting

PL 2. CKD stage V

IDx 2.1.Diabetic nephropathy 2.2. Hypertensive nephrosclerosi s

PDx Kidney biopsy

PTx Same as above

Pmo Subje ctive BP HR RR

3.Urgen cy HT

3.1.Renoparen chymatous HT 3.2.Essential HT 4.1.Uremic gastropathy 4.2.Peptic ulcer disease Endosc opy

Captopril 2x25mg (po) Nifedipine 2x10mg (po)

Subje ctive BP HR Subje ctive

4.Dyspe psia syndro me

Metoclopramide 3x10mg (iv) Ranitidine 2x50mg (iv)

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Male/59 yo General weakness Diarrhea of blacktarry stool BP: 50/palp PR:102 bpm RR: 32 tpm Tax:38C Cold extremities RT: melena Leucocyte: 13.800 Azotemia

1.Shock 1.1.Septic Blood conditio shock culture n 1.2.Hypovolem ic shock

O2 10 Lpm (NRM) Bed rest Semi-fowler position Fluid diet 6x200cc (1cc=1kcal) RL loading 1-3L in 1-3hours Drip NE start 0,5g/kgBW/hour Ciprofloxacin 2x400mg (iv)

Subje ctive BP HR RR

Male/59 yo Diarrhea of blacktarry stool RT: melena

2.UGIB

2.1.Gastric ulcer 2.2.Duodenal ulcer

Endosc opy

Omeprazole 80 mg (iv bolus) Subje Drip Omeprazole 8mg/hour ctive for 72 hours

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Male/59 yo Ur:55,1 Cr:2,31

3.Azote mia renal

3.1.Acute Kidney Injury

Rechec k Ur/Cr

Same as above

Subje ctive BP HR RR Ur Cr

Male/59 yo aPTT:45,7 (C: 28,7)

4.Prolo nged FH

FFP transfussion 4 packs

FH

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Male/24 yo Waterry diarrhea for 3 days Nausea and vomiting for 3 days Loss of appetite Before, ps ate yoghurt

1. Acute 1.1.Food Waterry poisoning diarrhea 1.2.ETEC 1.3.Lactose intollerance

Faecal culture

IVFD 40 dpm Low fiber diet Ranitidine 2x50mg (iv) Metoclopramide 3x10mg (iv) Magnesium Alluminium Phyllosilicate (Attapulgite) 2 tabs after diarrhea

Subje ctive BP HR RR

CUE AND CLUE

PL

IDx

PDx

PTx

Pmo

Female/16 yo SOB/dyspneu Bloody sputum Poor weight gain & slow growth Low tolerance for extra exertion Fainting/syncope Central cyanosis Clubbing fingers Sistolic murmur, gr III/ p.m at tricuspidalis valve Polycythemia BGA:severe hypoxemia Echocardiography: Ebstein anomaly, DDx: Double inlet left ventricle ECG:sinus tachicardia with right atrium enlargement

1. Cyanoti c congeni tal heart disease

1.1.Ebstein anomaly 1.2.Double inlet left ventricle

Cathete rization

O2 10 Lpm (NRBM) Bed rest semi-fowler ASA 1x 80 mg po Plan for Surgery (valve repair)

Subje ctive BP HR RR BGA

CUE AND CLUE Female/16 yo Bloody-sputum cough for 2 days

PL

Idx

PDx Sputu m Gram Sputu m culture Blood culture

PTx Confirm diagnose

PMo Subje ctive

2. 2.1.due to Hemop no.1 toe 2.2.CAP

Female/ 16 yo Hb:23,3 PCV 71.4 PaO2 : 35,1

3.Seco 3.Due to no ndary 1 polycyt hemia

Phlebotomy

Hb

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/40 yo Abdominal pain Nausea and vomiting Weight loss History of liver disease Alcoholism Jaundice Ascites Thrombocytopeni a Modest elevation of SGOT & SGPT (SGOT/SGPT >1) Elevation of bilirubin Low serum albumin SAAG > 1,1 Prolonged

1. Cirrhos is Hepati s ChildPugh class A

1.1.Post necrotic Hepatitis B virus infection 1.2.Post necrotic Hepatitis C virus infection 1.3 Alcoholic liver disease

HBSA g Anti HCV USG Abd Liver Biopsi

Venflon Inj Vit K 3 x 1 Amp i.v Inj.Furosemide 40mg-0-0 iv Po: Spironolacton 1x100mg Propranolol 2x20mg

Subje ctive BP HR RR BW SE

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Male/40 yo Nausea and vomiting

2. 2.1 due to Dispep no.1 sia syndro me

Inj: Metoclopramide 3x10 mg (iv)

Subje ctive

Male/40 yo Ascites Albumin serum 2,13

3. 3.1 Due to Hypoal no.1 bumine mia

Total Protein / Globuli n

Diet: extract of stripedsnakehead fish (ikan kutuk)

Albu min seru m

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Mrs. R/50 yo Cephalgia Perspiring Loss of body weight Palpitations Blurred vision Nausea Hematuria History of hypertension for 1 year (200-250/) BP:265/150mmH g HR: 100 bpm Ur/Cr:214,9/8,34 UA: erytrocyturia, proteinuria

1. Emerg ency Hypert ension

1.1. Secondary HT 1.1.1. Pheochromo cytoma 1.1.2. Renoparenc hymatous HT 1.2. Essential HT

USG Abd CT Whole Abd VMA (vanillyl mandel ic acid test)

Diet: Low salt <2g/day, BP low protein 30g/day, HR 1700kcal/day Glyceryl trinitrate drip start 5g/mntup-titration every 15 mnt until MAP:140Clonidine 0,15mg; captopril 25mg; nifedipine 10mgStop Glyceryl trinitrate drip after 30 minutesMaintainance: Clonidine 3x0,15mg; Captopril 2x25mg; Nifedipine 3x10mg

CUE AND CLUE Mrs. R/50 yo Nausea BP:265/150mmHg Anemia N-N Azotemia Renal GFR:6,37 UA: erytrocyturia, proteinuria

PL 2. CKD St. V

IDx 2.1.GNC 2.2. Nephroscler osis HT

PDx USG Abd

PTx Fluid balance Diet low protein 30 g/day Control blood pressure (as above) HD elective

PMo BP Hb Ur Cr

Mrs. R/50 yo Anemic conjunctiva Hb: 6,7 MCV, MCH: normal

Mrs. R/50 yo No symptoms of HF LHM: ICS VI -

3. Anemia N-N

3.1. due to No. 2

Reticulo cyte count SI/TIBC

Erytropeitin 2000 iu (sc) 2x/week

Hb post corr ectio n

4. HF St. B

4.1 HHD

CXR PA

Furosemide 40 mg-0-0 i.v Control blood pressure (as

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Mrs. R/50 yo Blurred vision BP: 265/150mmHg

5. Hypert ensive Retino pathy

Fund uscop y

Control blood pressure (as above) Consult to Opthalmology Departement Confirm diagnose

Visus BP

Mrs. R/50 yo UA: Trichomonas sp (+)

6. 1. Tricho monia sis 6.2. Conta minate d urine

Rech eck UA

CUE AND CLUE Female/19 yo Fever, acute, intermittent, 5 days Myalgia and arthralgia Tax: 38 C BP: 110/70 PR: 80 RR: 20 Lab: Hb:13.30 Hct: 38.2 L: 1.56 Tr: 51,000 Anti dengue IgM (+) Rumple Leed test + Female/19 yo Nausea and vomiting Lose appetite Female/19 yo Abdominal pain SGOT : 198 SGPT : 73

PL 1. AFI + bisitopeni a

IDx 1.1.Dengue hemmorhag ic fever grd II 1.2. Chikunguny a fever 1.4. Ricketsiosis 1.2.Other Arboviral infection

PDx WeilFelix

PTx Bed rest HCHP diet 2100 kcal/day Surface cooling IVFD RL 30 dpm Paracetamol 3 x 500 mg (prn)

PMo Subjective BP HR RR Tax CBC/6 hour

2.Dyspeps ia syndrome 3.Increase of Transamin ase

2.1.due to No.1 3.1 Reactive 3.2 acute viral Hepatitis HbSAg Anti HCV

Inj. metoclopramide 3x10 mg (iv) Confirmed diagnose

Subjective

Subjective

CUE & CLUE

PL

Idx

PDx

PTx

PMo

Female/68YO
Anamnesis : -SOB since four days before admision - occurred especially during activities (walking more than 10 meters), accompanied with chest discomfort and radiated to the back. -sleep with more than two pillows, woke up suddenly in the night due to SOB -history of both leg swelling. - productive cough since 10 days ago, whitish sputum, history of low grade fever since one day before admission.

1.SOB

1.1 Cardiogenic 1.1.1 HF Stg. C FC III 1.1.1.1 Thyroid Heart Disease 1.1.1.2 CAD
1.2 Noncardiogenic 1.2.1 Pneumonia CAP

NT pro BNP

-O2 2-4 lpm N.C -Bedrest and Semifowler position -Heart diet: 1700 kcal/day, low sodium <2 gr/day -Fluid balance ()500cc/day -Inj. Furosemide 40mg 0 0 (IV)

S VS UOP

PF : edema + pitting CXR : cardiomegaly

CUE & CLUE Female/68 YO

Anamnesis : -SOB since four days before admision - occurred especially during activities (walking more than 10 meters), accompanied with chest discomfort and radiated to the back. -sleep with more than two pillows, woke up suddenly in the night due to SOB -history of both leg swelling. PF : edema + pitting CXR : cardiomegaly

PL 2. HF Stg. C FC 3

IDx 2.1 Thyroid Heart Disease 2.2 CAD

PDx Echocardiography -Coronagiography -Lipid profile

PTx -as above

PMo Suj VS TSH FT4 T3

Female/68 YO 3. Struma Anamnesis : diffusa on The patient had treatment been diagnosed with thyroid disease since two years ago

TSH ,and FT4

-PTU 2x100mg -Propranolol 2x10 mg

Subj VS TSH FT4

CUE & CLUE Female/68 YO Anamnesis : productive cough since 10 days ago, whitish sputum, - history of low grade fever since one day before admission. PF : Rh + di semua lapangan
Female/68 YO Anamnesis : decreased of appetite, nausea and epigastric pain since several days ago. PF : epigastric pain +, tenderness +

PL 4.Acute Lung Infection

IDx 4.1 Pneumoni a CAP

PDx Sputum culture and sensitivity test

PTx -Inj. ceftriaxone 2x1 gr (IV)

PMo S VS

5. Dyspepsia 5.1 Endoscopy syndrome Diabetic gastropath y 5.2 PUD 5.3 Gastritis erosiva

-Inj. Ranitidin 2x50 mg (IV) -Inj. metochlopramid 3x10 mg (IV

Subj VS

CUE & CLUE Female/68 YO Anamnesis : History of DM (+) known since five months ago

PL 6. DM type 2 overweight controlled

IDx

PDx GD1/GDII

PTx -Inj. actrapid 4-44 IU (SC) - Inj insulatard 010 IU (SC)

PMo FBG 2HPPB G

Female/68 Lab : SGOT :141 SGPT :79

7. Increased transaminase

7.1 due to no 2

Subj VS OT/PT

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/43yo 1. ALO SOB Dyspneu of effort Orthopneu PND Cough with non producive sputum since 1 year, worsening in this last 1 week Ht since 1 year ago PE: GCS 456 BP: 160/100 PR : 111 irreg RR : 24tpm tachypnea JVP R+2cm H20, 45 degree, Hepatojugular reflexes + Rhonki at middle and lower area of

1.1 cardiogenic 1.1.1 HF st C FC IV 1.2 noncardiogenic 1.2.1 Pneumonia CAP

O2 8-10 lpm via NRBM Insert catheter Bed rest, semifowler Sputum position culture n inj. furosemide 40-40-0 sensitivit mg iv y test NT pro BNP

Subje ctive BP HR RR Urine produ ction

CUE AND CLUE Female/43yo SOB Dyspneu of effort Orthopneu PND Ht since 2 year DM since 1 year PE: GCS 456 BP: 160/100 PR: 111 irreg Pulsus alternans RR : 24tpm tachypnea JVP R+2cm H20, 45 degree, Hepatojugular reflexes + Rhonki at middle and lower area of lung D/S Bilateral pitting edema on lower extremities Lab : K 2.74mmol/l

PL 2. Heart failure stage C fc IV

IDx 2.1 Cardimyopathy 2.2 CAD 2.3 HHD

PDx Echoc ardiogr aphy

PTx O2 8-10 Lpm via NRBM Bed rest , semifowler position Heart Diet II 1600kcal/day Low salt <2gr/day Low cholesterol <300gr/day Inj. furosemide 40-40-o mg (iv) (as above) po. captopril 3x12.5mg Spironolactone 0-25mg-0

PMo Subje ctive BP HR RR Urine produ ction

CUE AND CLUE

PL

IDx 3.1 Lung TB with 2nd infection 3.2 Malignancy

PDx

PTx

PMo Subj BGA

Female/43yo 3.Chronic SOB lung Cough with non infection producive sputum since 1 year, worsening in this last 1 week PE: RR : 24tpm tachypnea Hepatojugular reflexes + Rhonki at middle and lower area of lung D/S Lab: Leuco 25.040/l Neutrofil 90.5% ESR 99mm/h ECG: RVH CXR: lung infection BGA : alcalosis metabolic, severe hypoxemia

Sputum O2 8-10lpm NRBM culture n Inj. Ceftriaxone 2x2 gr (iv) sensitivity Inf. Ciprofloxacine 2x400mg Ab AFB NSE LDH

CUE AND CLUE Female/43yo Hypertension since 2 year , not routinely consumed nifedipine 3x10mg PE: GCS 456 BP: 160/100 mmHg Lab: UL prot 2+, ery 3+ Female/43yo Nause, vomiting Lab: K 2.74 ECG: PVC quadrigemini PVC occational

PL 4. Hypertens ion stage 2

IDx 4.1 Secondary 4.1.1 Renopharench ymatous HT 4.1.2 Renovascular HT 4.2 Primary

PDx Fundusco py

PTx Inj. furosemide as above po. captopril 3x12.5mg spironolactone 0-25mg-0

PMo BP

5. Hypokale mia

5.1 GI loss 5.2 Renal loss

Kalium urine

Drip KCL 25mEq in NaCl 0.9% 100cc Inj. metoclopramide 3x10mg po.omeprazole 2x20mg

Serum kalium

Female/43yo Palpitation in this last 4 days after did hard activity PE: PR 111 bpm irreg ECG: PVC quadrigemini -- PVC occational

6. PVC occational

6.1 due to Heart Failure 6.2 due to hypokalemia

Treat underlying disease

Serial ECG

CUE AND CLUE Female/43yo DM since 1 year ago, got glibenclamide 3x1tab butnot routinelly consumed Lab: GDA 203mg/dl

PL 7. DM tyoe 2 overweigh t not routinelly controlled

IDx

PDx

PTx Inj. insulatard 0-10iu sc

PMo FBG2hP PBG

Female/43yo DM since 1 year ago, got glibenclamide 3x1tab butnot routinelly consumed Lab: GDA 203mg/dl UL: prot 3+ Alb 4.2mg/dl

8. Diabetic nephropa thy

Protein esbach

Terat underlying disease

UL Alb