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  • Morning Conference 13 February 2017: RNH/FM/51YO

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    Maidilla Silvia
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    A 51-year-old female presented with 1 week of dyspnea. She has a history of breast cancer, diabetes, and 3 C-sections. On examination, she had decreased breath sounds on the left lung and an X-ray showed a left pleural effusion. Her blood sugar was elevated. The working diagnosis was stage 4 breast cancer that has spread to the left and right pleura. She was started on IV fluids, antibiotics, analgesics, and antipyretics. Sodium levels were corrected and she was prepared for chest tube insertion and wound site drainage.

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    RNH 51TH WSD

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    A 51-year-old female presented with 1 week of dyspnea. She has a history of breast cancer, diabetes, and 3 C-sections. On examination, she had decreased breath sounds on the left lung and an X-ray showed a left pleural effusion. Her blood sugar was elevated. The working diagnosis was stage 4 breast cancer that has spread to the left and right pleura. She was started on IV fluids, antibiotics, analgesics, and antipyretics. Sodium levels were corrected and she was prepared for chest tube insertion and wound site drainage.

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    9 views11 pages

    Morning Conference 13 February 2017: RNH/FM/51YO

    Uploaded by

    Maidilla Silvia
    A 51-year-old female presented with 1 week of dyspnea. She has a history of breast cancer, diabetes, and 3 C-sections. On examination, she had decreased breath sounds on the left lung and an X-ray showed a left pleural effusion. Her blood sugar was elevated. The working diagnosis was stage 4 breast cancer that has spread to the left and right pleura. She was started on IV fluids, antibiotics, analgesics, and antipyretics. Sodium levels were corrected and she was prepared for chest tube insertion and wound site drainage.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 11

    MORNING CONFERENCE

    13 February 2017
    RNH/FM/51YO
    Chief Complaint : Dyspnoe
    It has been experienced by the patient since 1
    weeks. Cough (+), Vomiting (-), nausea (-),
    history of fever (-), defecate (+) N. Micturition
    (+) N. history of previous surgery : sectio
    caesaria 3 times.
    Drug History : Insulin Novorapid and
    Levemir
    Medical History : Breast Cancer (L) + DM
    Tipe 2
    Present State:
    Awareness : Compos Mentis
    Blood Pressure : 120/80 mmHg
    HR : 90x/i
    RR : 30x/i
    Temp : 36.5oc
    Generalized State
    Head and neck : No abnormality was found
    Chest :In localized state
    Abdomen : No abnormality was
    foundGenitalia : Female, no abnormality was
    found
    Extremitas : No abnormality was found
    Localized State
    Chest :
    I : Simetric,
    P : Sterm Fremitus Low
    P : Sonor Shortened
    A : Respiratory sound : Vesikuler
    Clinical photos
    Laboratory

    Hb/Leu/PLT/Erit : 12,7/24.86/256/3,92
    Ur/Cr : 64 /0,87
    Na /K/CL : 112/5,4/92
    Random blood sugar level : 372
    Chest X-ray
    Working diagnose

    (L) Breast Ca T4cN3M1 Pleura kontralateral + (L)


    Efusi pleura
    Management in Emergency Room :
    Fasting
    IVFD crystaloid
    inj. Antibiotic
    inj. Analgetic
    inj. Antipyretic
    Natrium Correction
    Prepare for (L) chest tube insertion + WSD
    THANK YOU

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