24 Year Old Male With Hemoptoe Massive

Recurrent

No SUBJECTIVE OBJECTIVES ASSESSMENT TREATMENT1 Mr E / 24 yo

Hemoptoe 200-300 cc /day

Physic Diagnostic :GCS 456BP 120/110; PR 102 x/min, RR: 28x/min; SaO2: 99% (10 lpm NRBM)

Hemoptoe gr IV

--Trendelenberg position to the left side-- Inj Tranexamic acid 3 x 500 mg iv

No SUBJECTIVE OBJECTIVES ASSESMNT TREATMENT2.

Admitted ER (Dec 7th) 14.00

RHCU 20.00

Mr E/24 yoHemoptoe ½-1 glass since 8 days ago, red-black color, intermittent chest pain especially when cough. Low grade fever (+), night sweating (+), decreased of appetite (+), decreased of body weight (+) (?kg)History of lung TB 3 years ago, got OAT 1st cath from Kepanjen Hospital for 6 month, until declared cured.History of recurrent hemoptoe 2 years ago, hospitalized in Wava hospital for 1 week (Dx?, Tx?)Patient was referred from Wava Hospital. He had been hospitalized there wicne Dec 1st, referred to RSSA because the condition is not getting better. History of HT (-), DM (-).Smoking (+) 6 pieces/dayOccupation Pedicab driverDrugs: + History of using Ganja 10 years ago

Physic Diagnostic :Look moderately ill GCS 456BP 120/110; PR 102x/mnt; RR: 28x/mnt; sat 99% 10 lpm NRBM; An -/- Ict -/- Cy -/- JVP R+3 cmH2OCor: RHM SL DLHM ICS V MCL Sin, S1S2 normalPulmo :St D>S, Dy D>SFS N Pc S D BS V V N S D V V N S D V VRh - - wh - - - - - - - - - -leg swelling -/-Warm acralECG:sinus rhythm HR 92 x/minCXR:Lung tb Lab BGA: mild hypoxemia (pO2 52.8 – O2 10 lpm NRBM)

2. Hemoptoe gr IV massive 2.1 Pneumonia CAP2.2 Lung TB inative dd active

-Trendelenberg position to the left side- IVFD NS 0.9 % + Carbazochrome (not covered by BPJS)- Inj Tranexamic acid 3 x 500 mg iv- Inj Vit K 3 x 1 amp iv- codein 3 x 10 mg po

-Admitted to RHCU

1.ADHF prec fator infection

1.1 CAD2.HF st C fc

IV dt DCM, CAD

3.MR sever / PH mild

4. Septic cond

5. Pneumonia CAP

Bed rest, Semifowler positionO2 2-4 lpm NC-total fluid intake 1500cc/24h--500 IVFD NS-1000 poFluid balance zero-DJ I 6x150 cc

-sc-inj. furosemide 10mg iv/hour-Po. -Loading ASA 80-0-Simvastatin 1x40mg-Captopril 3x12,5 mg-ISDN 3x5 mg-Bisoprolol withhold

admitted to CVCU

CXR 15/5/2015PA position, symetris KV EnoughSoft tissue: NBone N, costae D: mallunion costae 7 posterior S: NICS D/S:NTrachea : in the middleHillus D/S: thickeningCor site: NSize: CTR 67%Apex: Rounded, embededHemidiaphragma D/S: domeshapeCostophrenicus sinus: sharpPulmo D: infiltrate para hilar D, air bronchogram (+)S: infiltrate para hilar S, air bronchogram (+)Conclusion:Old Fracture Costae 7 D Posterior CardiomegalyPneumonia

CXR 24/5/2015AP position, symetris, KV to lowSoft tissue: NBone N, costae D: mallunion costae 7 posterior S: NICS D/S:NTrachea : in the middleHillus D/S: thickeningCor site: NSize: CTR 72%Apex: Rounded, embededHemidiaphragma D/S: domeshapeCostophrenicus sinus: sharpPulmo D: infiltrate para hilar D, air bronchogram (+)S: infiltrate (-)Conclusion: Old Fracture Costae VII D PosteriorCardiomegalyPneumonia

ER/ may 24th /9 pmECG

Echo September ‘14

AnamnesisMr.S/59yo / CVCU / BPJS insurance

• CC : shortness of breathSOB for 3 days at rest, dyspneu increase with mild activity (walk >10m), OP (+), hardly sleep at night because of SOB, PND (+), cough with sputum for 2 weeks , accompanied with subfebril fever.Last drugs at outpatient clinic at RSSA (22/5) aspilet, ISDN, spironolacton, diovan History of admission at hospital bcause same complain 2008 & 2013• History of HTN (+) , DM (-)

PHYSICAL EXAMINATIONGeneral appearance

Well nourished, GCS 456

Vital sign BP 131/63 mmHg HR 100 regular RR 28tpmHead Pale conjungtiva -,Icteric-, nostril breath +Neck JVP R +4 cmH2O at 30o

Thorax :Heart &Lung

Ictus visible palpable at ICS V AAL sinistraRHM SL D LHM as ictus S1 S2 normal, gallop (-)murmur systolic 3/6 PM at apexSimetric, Rh - - W h - - - - - - + + - -

Abdomen Flat,Soft,Liver Spleen unpalpable,Non tender,BS (+) N, epigastric pain (+)

Extremities Edema - - warm acral - - + + - -

CVCU / may 24th /11 pmECG

Laboratory Finding may 24th 2015 Value

Leucocyte 25.280 /µL 4.700 – 11,300

Hb 15,50 gr/dL 11,4 – 15,1

Hematokrit 45,00 % 38 – 42

Plt 258.000 /µL 142.000 – 424.000

CRP kuantitatif 12,28 mg/dL <0,3

Procalcitonin 13,71 ng/dL >2 high risk for septic

Eosinofil 0,0 % 0 – 4

Basofil 0,1 % 0 – 1

Neutrofil 89,8 % 51 – 67

Limfosit 4,7 % 25 – 33

Monosit 5,4 % 2 – 5

Limfosit count:

Laboratory Finding may 24th 2014 Value

RBS 73 mg/dL < 200

Ureum 29,60 mg/dL 16,6-48,5

Creatinine 1,49 mg/dL <1,2

SGOT 32 U/L 0 – 32

SGPT 15 U/L 0 – 33

Natrium 130 mmol/L 136 – 145

Kalium 3,39 mmol/L 3,5 – 5,0

Chloride 111 mmol/L 98 – 106

Cardiac Enzime

Lab Value Normal value

CPK 670 u/L 30-190

CKMB 70 u/L <25

Trop I 1.00 Ng/ml Neg

Hemostatic Physiologic

Lab Patien t Normal value

PPT 21,0 sec 11,5-11,88

INR 1,75 0,8 – 1,30

APTT 33,60 sec 27,4 – 28,6

Concl. PPT lengthened, APTT normal

Conclusion :• Metabolic acidosis partially compensated

BGA7 LPM

PH 7,28 7.35-7.45 Fi02 0,7PCO2 23,2 mmHg 35-45 PAO2 ((760-47)*0,7)-(23,2/0,8)PO2 94,5 mmHg 80-100 470,1HCO3 13,8 m mol/l 21-28 A-a DO2 (470,1-94,5)BE -14,1 28,35 m mol/l -3 - +3 375,6

Sat O2

96,5 Severe Hypoxemia

% >95FiO2 need (375,6+150)/760

0,691578947

BGA with O2 L/m;

Original PO2

CUE AND CLUE PROBLEM LIST

INITIAL DIAGNOSE

PLANINGDIAGNOSE PLANING THERAPY PLANING

MONITORING

1. Mr.S/59yoSOB for a week related with hard activity, worsening after she had shocked and run, OP.History of Leg swelling and PNDHistory of HT 12 years with in adequately drugs, hospitalized >5 times as jantung bengkakHistory of ACS (SOB+epigastric pain) 2 months ago, outpatient clinic with nitrat, bisoproplol, dimenhidrinat, vastigoBP 165/ 80 HR 120 RR 24x/mnt, nostrill breath, basal rales, cardiomegali with ictus displacement

ECG: ST, incomplete LBBB, LAE, LVH

1.ADHFPrecip factor-infection

3.1. ischemic CM3.2 CAD3.3. HHD

EchocardiographyCoronary AngiographyLipid profileUric acidECG serial

O2 4 lpm nasal canuleBed rest , semi fowler positionFluid intake 1200 cc dailyNegatif fluid balanced 500 cc/daySoft heart diet 1700 kcalFurosemide 40 mg--0-0 ivPO:Captopril 3x12.5mgSpironolactone 0-25mg-0Simvastatin 0-0-10mgAsa 1x80mg

Subjective, VSUrine productionECG serial

CUE AND CLUE PROBLEM LIST

INITIAL DIAGNOSE

PLANINGDIAGNOSE PLANING THERAPY PLANING

MONITORING

2. Mr.S/59yoCough, whitish sputum, subfebrileInfiltrate at CxR, leukocytosis

2. Pneumonia

Sputum culture, gram, sensitivity

As Pulmonology Dept(O2 10 lpm NRBM,Inf. Levofloxacin 1x750 mg i.v,N. Acetyl cystein 3x200 mg)

3. Mr.S/59yoHistory dispneu, orthopneu, PND, leg swelling

3. HF dt ischemic cardiomyopathy

Echocardiography

Subjective

4. Mr. S/59 yoHR 120 bpm, febrile (38.2 C), RR 40 tpm, pneumoni

4. Septic condition

Inj. Levofloxacin 1x750 mg i.v.

Subjective

5. Mr. S/59 yoUreum/Creat: 49.6/1.4

5. Renal azotemia

Treat underlying disease

Subjective

CXR 10/6/2015AP position, symetris, KV enoughSoft tissue: NBone N, costae D: mallunion costae 7 posterior S: NICS D/S:NTrachea : in the middleHillus D/S: thickeningCor site: NSize: CTR 70%Apex: Rounded, embededHemidiaphragma D/S: domeshapeCostophrenicus sinus D: bluntPulmo D: infiltrate para hilar D, air bronchogram (+)S: infiltrate (-)Conclusion: Old Fracture Costae VII D PosteriorCardiomegalyPneumonia

Kultur Sputum 27/5/15

Kultur Darah 29/5/15

Kultur sputum 12/6/15

PROGRESS NOTEDATE SUBJ OBJ PLAN

25/5/15CVCU

Dispneu , productive

cough

BP 100/59 Hr 104 bpm, SaO2 96%

Rh+ + + - + -

Negative balance 500 cc

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc /24 hrs•Inj Furosemide 40-20-0 mg i.v.•Inj Cefoperazone 2x1 gram•Inj Levofloxacin 1x750 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-25-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener

28/5/15CVCU

Dispneu , productive

cough

BP 105/69 Hr 100 bpm, SaO2 96%

Rh+ + + - + -

Negative balance 750 cc

Sputum culture: fungi

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc /24 hrs•Inj Furosemide 40-20-0 mg i.v.•Inj Cefoperazone 2x1 gram•Inj Levofloxacin 1x250 mg•Inj Fluconazole 1x400 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-25-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol 2.5-0-0 mg

DATE SUBJ OBJ PLAN

30/5/15Dispneu , productive

cough

BP 96/59 Hr 96 bpm, SaO2 97%

Rh+ + + - + -

Negative balance 750 cc

Blood culture: gentamycin sensitive

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc /24 hrs•Inj Furosemide 40-20-0 mg i.v.•Inj Cefoperazone 2x1 gram STOP inj Gentamycin 2x80 mg•Inj Levofloxacin 1x250 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-25-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol 2.5-0-2.5 mg•Digoxin 0.25-0-0 mg

3/6/15CVCU

Dispneu , productive

cough

BP 105/69 Hr 88 bpm, SaO2 96%

Rh+ + + + + -

Negative balance 750 cc

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc /24 hrs•Inj Furosemide 40-0-0 mg i.v.•Inj Gentamycin 2x80 mg•Inj Levofloxacin 1x250 mg STOP•Inj Fluconazole 1x400 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol 2.5-0-2.5 mg•Digoxin 0.25-0-0 mg

DATE SUBJ OBJ PLAN

4/6/15WARD

Dispneu subsided, productive

cough

LAB:Leukocyte:

8,850Ur/cr: 27.3/1.22

BP 100/60 Hr 88 bpm,

Rh - - + - + -

Negative balance 500 cc

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1500 cc/24 hrs, negative fluid balance 750 cc /24 hrs•Inj Furosemide 40-0-0 mg i.v.•Iinj Gentamycin 2x80 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol 2.5-0-2.5 mg•Digoxin 0.25-0-0 mg

8/6/15WARD

Dispneu after walking to rest

room , productive

cough

BP 100/60 Hr 82 bpm,

Rh - - + + + -

Negative balance 500 cc

Target fluid balance: neg 2000 cc/24 hrs

•semifowler position•O2 4 lpm NC•Total fluid 1000 cc/24 hrs, target negative fluid balance 2000 cc /24 hrs•Inj Furosemide 40-40-40 mg i.v.•Inj Cefoperazone 2x1 gram•Inj Fluconazole 1x400 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol ↓ 2.5-0-0 mg•Digoxin 0.25-0-0 mg

DATE SUBJ OBJ PLAN

10/6/15

Dispneu , productive

cough

-CxR

BP 100/70 Hr 80 bpm,

Rh - - + - + -

Negative balance 800 cc/24 hrs

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1000 cc/24 hrs, target negative fluid balance 1500 cc /24 hrs•Inj Furosemide 60-60-60 mg i.v.•Iinj Gentamycin 2x80 mg•Inj Fluconazole 1x200 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-25-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol 2.5-0-0 mg•Digoxin 0.25-0-0 mg

12/6/15

Dispneu , productive cough ↓

LABLekocyte 9.650

Ur/Cr : 60.5/2.35Sputum culture:

Pseudomonas Aeruginosa

BP 100/60 Hr 77 bpm,

Rh - - - - + -

Negative balance 1000 cc

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1000 cc/24 hrs, target negative fluid balance 1500 cc /24 hrs •Inj Furosemide 40-40-40 mg i.v.•Inj Gentamycin 2x80 mg STOP•Inj Fluconazole 1x200 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x25 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Bisoprolol STOP•Digoxin 0.25-0-0 mg

DATE SUBJ OBJ PLAN

15/6/2015

Dispneu subside ,

productive cough ↓

BP 110/70 Hr 64 bpm,

Rh - - - - + -

Negative balance 800 cc/24 hrs

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1200 cc/24 hrs, target negative fluid balance 1000 cc /24 hrs•Inj Furosemide 40-40-0mg i.v.•Iinj Gentamycin 2x80 mg•Inj Fluconazole 1x200 mg•Nebu farbivent++flixotide 3 times/day•Captopril 3x50 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Digoxin 0.25-0-0 mg

17/6/15

Dispneu subsided , productive cough ↓

LABUr/Cr : 70/3.8

BP 120/60 Hr 60 bpm,

Rh - - - - - -

Negative balance 1000 cc

•Bed rest, semifowler position•O2 4 lpm NC•Total fluid 1250 cc/24 hrs, target negative fluid balance 1000 cc /24 hrs •Inj Furosemide 40-40-0 mg i.v.•Inj Fluconazole 1x200 mg (DAY 21)•Nebu farbivent++flixotide 3 times/day•Captopril 3x50 mg•Spironolacton 0-50-0 mg•ISDN 3x5 mg•N Acetyl Cystein 3x200 mg•Stool softener•Digoxin 0.25-0-0 mg

TIMELINE May 24

May 28

May 30

June 3

June 10

June 12

June 18• Inj.

Levofloxacin

1x750 mg

• Inj. Cefoperazone 2x1

g

• Inj. Levo

1x750 mg

• Inj. Cefoperazone 2x1

g• Inj.

Fluconazole

1x400 mg

• Inj. Levo

1x250 mg

•Cefoperazone STOP

• Inj. Gentamycin 2x80• Inj.

Fluconazole

• Inj. Levo STOP• Inj

Gentamycin 2x80 mg

• Inj. Flucona

zole

• Inj Gentamycin 2x80

mg• Inj.

Fluconazole

• Inj Gentamycin 2x80 mg STOP• Inj.

Fluconazole

UNTIL June 17

• STOP ALL

ANTIBIOTICS

THANK YOU

Discussion

• Incidence cardiac complications are common in patients with CAP and are associated with increased mortality.

• Older age, nursing home residence, pre-existing cardiac disease and pneumonia severity are associated with their occurence.

• Several mechanism, related largely to the systemic response to infection can account for development of incidence cardiac complication in px with CAP

Discussion

• Acute systemic inflammation can directly depress myocardial function and increase LV afterload

• Hypoxemia decreases myocardial oxygen delivery , raise pulmonary arterial pressure, RV afterload.

• Tachycardia increases myocardial oxygen needs, shorten diastole

• Net effect: negative shift of cardiac metabolic supply-demand ratio and further myocard dysfunction.

Discussion

• Acute infections promote inflammatory activity within coronary atherosclerotic plaques and induce prothrombotic changes in blood and endothelium, resulting in plaque instability and facilitating coronary thrombosis

• Pre-existing CAD that is insufficient to produce myocard ischemia under baseline condtions can also result in significant ischemia in the state of increased myocardial oxygen demand