Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan...
-
Upload
morris-mcdowell -
Category
Documents
-
view
216 -
download
0
Transcript of Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan...
![Page 1: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/1.jpg)
CASE DISCUSSION:DECREASE CONSCIOUSNESS
Pratama Wicaksana Narissa Dewi MaulanyMona JamtaniKing HansNurul LarasatiMargaretha GunawanSupervisors: Prof. Sarwono & Prof
![Page 2: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/2.jpg)
Case Illustration
![Page 3: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/3.jpg)
Patient Identity
Name: Mr. R Gender: Male Age: 47 years old Religion: Islam Address: Jl. Mardani Raya Gg. T/41 RT
003/005, Johar Baru, Jakarta Pusat Medical record number: 345-94-82 Date of admission: December 27th 2010.
![Page 4: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/4.jpg)
Chief Complaint
Decrease of consciousness since 14 hours prior to hospital admission.
![Page 5: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/5.jpg)
History of Present Illness
3days
PTH
A general weaknesses, pt can’t walk thus needed help to mobilize. The weaknesses was felt at the same intensity on the four extremities. There was also decrease of appetite (pt only drink and eat a bit of porridge), no mouth deviation and no slurred speech was noticed. Pt also complained of shortness of breath, on exertion and at rest. There was no chest pain.
14H
PTH
A patient started to talk unaccordingly, not being able to communicated with, and looked drowsy as if he was going on a sleep, then pt. was brought to the hospital. There was a complain of headache and nausea, patient vomited 2 times which were consisted of food and water. There was no problem with voiding, and the last defecation was 4 days ago.
Oth
er
Com
pla
ints
Symptoms of frequent eating, urinating, and sleepiness has been noticed by his wife daily, but there was no numbness, tingling sensation, nor persistent wound complained by the patient.
![Page 6: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/6.jpg)
Past history of illness
History of type II DM since 5 years ago: does not take medicine regularly and does not know the type of drugs
Hypertension since 3 years ago: was on captopril-taken regularly and regular visit to the physician
no asthma, no history of lung disease or Anti TB drugs, no history of previous stroke, and no history of drug allergy
![Page 7: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/7.jpg)
Family history of illness There was no familial history of
hypertension, asthma, heart disease, lung disease, and allergy
Social and working history Patient smoked for 30 years, but has
stopped smoking since 4 months ago
![Page 8: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/8.jpg)
on admission to the Emergency Department (27/12/2010)
Physical Examination
![Page 9: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/9.jpg)
Physical Examination
Vital signs
Consciousness: spoor, GCS: E2M4V2 = 8
General condition: look severely ill
Blood pressure: 80/60 mmHg
Pulse: 110x/minute, weak Temperature: 36.70C
(axilla temperature) Respiratory rate:
32x/minute, fast and deep
Skin : Not pale, not cyanotic, not icteric Head : Normochepal. Hair : Black, not easily pulled Eyes : Pale conjunctiva (-/-), icteric
sclera (-/-), Round pupil, isochor, diameter 3mm, direct light reflex +/+, indirect light reflex +/+.
Ears : Auricula N/N, tymphanic membrane intact, no cerumen.
Nose: No deviation of septum Throat : Tonsil T1/T1 calm,
pharyngeal arch symmetrical, uvula in the middle, pharynx not hyperemic.
Teeth and mouth: no caries, no oral thrust
Neck: Trachea in the middle, JVP 5-2 cmH2O, lymph node was not palpable, no mass, Meningeal signs: neck stiffness (-), Laseque >70o />70o, Kernig >135o/>135
![Page 10: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/10.jpg)
Physical Examination
Lungs Inspection :
symmetrical, static and dynamic.
Palpation : fremitus are same in both lungs
Percussion : sonor on all lung fields.
Auscultation : Vesicular (+/+), no rhales, no wheezing.
Back : symmetric in static and dynamic movement, sonor, vesicular, no rhales and no wheezing
Heart Inspection: Ictus cordis is not
visible Palpation : ictus cordis is
palpable at ICS 5, on the mid clavicular line
Percussion : right heart border at linea sternalis dextra, upper heart border at ICS III linea para sternalis sinistra, and left heart border at 3 fingers lateral from linea mid clavicularis sinistra.
Auscultation : Normal first and second heart sound, no murmur, no gallop.
![Page 11: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/11.jpg)
Physical Examination
Abdomen Inspection : flat,
supple. Palpation : hepar and
spleen is not palpable Percussion :
tymphanic (+) Auscultation : Bowel
sound (+), normal. Genitals: not performed.Rectal touché: not
performed.
Extremities: warm, CRT >2”, no edema,
Motoric reflex: no hemiparesis, physiological reflex: +2/+2, +2/+2 pathological reflex: none
Sensoric reflex: can’t be assessed
Autonomic reflex: no urinary or defecation incontinence
Lymph nodes: There was no palpable lymph node enlargement
![Page 12: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/12.jpg)
Summary
Patient a gentleman aged 47yo came with chief complaint of decrease consciousness since 14hours prior to hospital admission. Since 3 days before hospital admission, patient has been complaining of general weaknesses which was felt at the same intensity on the four extremities. There was also decrease of appetite. Pt also complained of shortness of breath, on exertion and at rest. 14 hours prior to hospital admission, patient started to talk inaccordingly, not being able to communicated with, and looked drowsy as if he was going on a sleep, then pt. was brought to the hospital. There was a complain of headache and nausea, patient vomitted 2 times which were consisted of food and water. Symptoms of frequent eating, urinating, and sleepiness was noticed by his wife. Patient has history of type II DM since 5 years ago: does not take medicine regularly and does not know the type of drugs, hypertension since 3 years ago: was on captopril-taken regularly and regular visit to the physician. Patient smoked for 30 years, but has stopped smoking since 4 months ago. Laboratory results showed leukocytosis, increase plasma ureum and creatinine, very high level of blood glucose, hypokalemia, metabolic acidosis, and positive plasma ketone 3-hydroxybutyrate.
![Page 13: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/13.jpg)
Problem list: Decrease of consciousness ec hypovolemic shock ec
Diabetic Ketoacidosis Diabetic Ketoacidosis on DM Type II with history of
uncontrolled blood glucose Dyspepsia with difficulty of intake
Plan Diagnosis plan: ECG, chest x-ray CBC, diff count, electrolytes, arterial blood gas
analysis, keton 3Hb, blood chemistry, urinalysis, Brain CT
![Page 14: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/14.jpg)
Laboratory ExaminationPeripheral blood test (28/12/2010):
Result Normal range
Routine hematology
Haemoglobin 12.6 (↓) 12-14 g/dL
Haematocryte 37 40-46 %
Leukocyte 14.300 (↑) 5.000-10.000 /uL
Thrombocyte 167.000 150.000-400.000 /uL
MCV 85 82-92 fL
MCH 29 27-31 pq
MCHC 34 32-36 10^3/uL
Blood chemistry
Blood Ureum 179 (↑) <50 Mg/dL
Blood Creatinine 1.7 (↑) 0,6-1,2 Mg/dL
Blood Glucose Stick High 70-200 Mg/dL
![Page 15: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/15.jpg)
Laboratory ExaminationPeripheral blood test (28/12/2010):
Electrolytes
Natrium 131 135-147
Kalium 6.2(↑) 3.5-5.5
Chloride 106 100-106
Arterial Blood Gas Analysis
pH 7.091() 7.320-7.450
PCO2 19.7() 35-45
PO2 154(↑) 75-100
SO2 98.6
HCO3 6.1 21-25
Keton 3Hb 2.8 <0.5
![Page 16: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/16.jpg)
Treatment plan: O2 2 litre/ minute per nasal cannule Loading NaCl 0.9% up to 3000cc, MAP target >65
Followed by NaCl 0.9% in 8hour Haemacel in 12hour
Insulin: 10IU IV followed by 5IU/hour drip HCO3 50meq/6H Folley Catheter: Fluid Balance in 24H Omeprazole 1x40mg IV Prognosis: Quo ad vitam: Dubia ad bonam Quo ad functionam: dubia ad bonam Quo ad sanactionam: Dubia ad malam
![Page 17: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/17.jpg)
CASE DISCUSSION
![Page 18: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/18.jpg)
Decreased consciousness et causa Hypovolemic Shock et causa Diabetic Ketoacidosis
![Page 19: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/19.jpg)
Decreased consciousness et causa hypovolemic shock
Decreased conciousnessGCS 8Hemiparesis (-)
Shock80/60 mmHg, 110x/minute inadequate
volume , 32x/minute ,d
eep, (kussmaul)T: 36,7OC
Fever (-), focus of infection (-) sepsis
excluded. hemorrhage (-),
dehydration, diarrhea (-)
excluded History of heart
disease (-) excluded
Fluid resuscitation
good response shock
hypovolemia, suspect metabolic
condition.
![Page 20: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/20.jpg)
Diabetes Mellitus History
History of diabetes mellitus type 2,
didn’t take medication regularly
Polyuria(+), polydipsy (+), polyfagi (+),
weight loss (+)
Recent history: general weakness, anorexia, lethargy, and decreased of consciousness
Suspect Diabetic
Ketoacidosis
Planing: blood
glucose test, urinalysis, blood gas
analysis, and ketone
![Page 21: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/21.jpg)
Working Diagnosis
Glycemia > 500mg/dl, ketone
3HB 2.8 mg ↑. blood PH is 7,09↓, PCO2 19.7↓, PO2
154 ↓, HCO3 6,6↓,
Decreased consciousness et
causa Hypovolemic
Shock et causa Diabetic
Ketoacidosis
![Page 22: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/22.jpg)
Pathophysiology DKA
Glukagon↑Insulin↓↓
Fat tissue
lipolysis↑↑
Liver ketogene
sis
Liver glukoneogen
esis
Peripheral tissue glucose
consumption ↓↓
osmolarity↑↑Acidosis (ketosis)
![Page 23: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/23.jpg)
Hypovolemic Shock in Ketoacidosis DM
hyperglycemia and ketone
vascular osmolarity ↑↑
(Osmotic ) Diuresis ↑↑
polyuria, electrolyte losses, dehydration,
and eventually hypovolemia shock
![Page 24: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/24.jpg)
Metabolic Acidosis
Lipolysis & ketogenesis
ketone 3HB & acetoacetate in
circulation ↑
Unable to buffer PH↓↓
Ion exchange across cell membranes intracellular acidosis alter abnormal
celular metabolism
Metabolic acidosis
![Page 25: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/25.jpg)
Encephalopathy Metabolic
acidity↑↑ PCO2↓↓
Vasodilatation of vascular
brain
Leakage of vascular volume
increase Intracranial Pressure
Decrease of consciousness
![Page 26: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/26.jpg)
Management of Fluid Resucitation fluid resuscitation 3000cc in 3hour
to reach the MAP of >65 (in 3h BP of 90/65 was achieved fluid replacement was then continued for another 1000cc in 4 hours reaching BP of 120/80 (MAP:120), continue with maintenance fluid
![Page 27: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/27.jpg)
Management of Hyperglicemia Insulin IV initially 10IU for the very
high blood glucose concentration (>500g/dL) then followed by continuous IV 5IU/hour. In 7hours, blood glucose level of 178g/dL was achieved patient consciousness developed to delirium.
![Page 28: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/28.jpg)
Management of abdominal dyscomfort
abdominal discomfort & prevent recurrent vomit omeprazole 2x40mg IV was given.
![Page 29: Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof.](https://reader031.fdocuments.in/reader031/viewer/2022032204/56649e555503460f94b4bc6d/html5/thumbnails/29.jpg)
References
1. Faucy, et al. Harrison’s principle of internal medicine. 17th ed. USA: McGraw-Hill Company Inc; 2008. P: 721-780.
2. Warrel, et al. Oxford Textbook of Medicine. 4th ed. USA: Oxford Press; 2003. P: 220-225
3. Rucker, Donald. Diabetic ketoacidosis. Emergency medicine. www.emedicine.medscape.com. 2009.
4. Sudoyo AW, Setiyohadi B, Alwi I et al. Buku Ajar Ilmu Penyakit dalam. Jilid III Edisi V. Interna Publishing. 2009. P: 1849-1882.
5. Ronco, Claudio, Et al. Acute kidney injury. Pittsburgh: Karger. 2007. P: 89-92.