20231019_Ca_gaster_post_kemoterapi_metastase_hepar,_Anemia_dr_Ninis.pptx

MORNING REPORT
October 19th, 2023
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

VISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT
Menjadi Institusi Program Pendidikan Dokter Spesialis
Penyakit Dalam yang unggul dan berdaya saing nasional,
dalam menyelenggarakan Tri Dharma perguruan tinggi
dengan mengembangkan IPTEKDOK khususnya berwawasan
penyakit di lingkungan lahan basah.

MISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT
1. Menyelenggarakan program pendidikan dokter spesialis Penyakit Dalam yang menghasilkan SDM
berkualitas sebagai pendukung pembangunan nasional terutama permasalahan kesehatan berwawasan
penyakit di lingkungan lahan basah
2. Menyelenggarakan penelitian yang menghasilkan IPTEKDOK sesuai dengan kebutuhan prioritas
pembangunan nasional terutama permasalahan kesehatan berwawasan penyakit di lingkungan lahan
basah.
3. Menyelenggarakan pengabdian kepada masyarakat dan menyebarluaskan IPTEKDOK untuk
meningkatkan kualitas hidup masyarakat terutama permasalahan kesehatan berwawasan penyakit di
lingkungan lahan basah.
4. Memantapkan kerjasama dengan pemerintah daerah diwilayah Kalimantan, perguruan tinggi dalam dan
luar negeri, pengusaha dan para pihak lainnya untuk peningkatan pelaksanaan Tridharma Perguruan
Tinggi dan Pengadaan sumber dana (Income generating).
5. Meningkatkan transparansi dan akuntabilitas dalam manajemen pengelolaan Program Pendidikan Dokter
Spesialis Penyakit Dalam

MORNING REPORT
Wednesday, October 19th 2023
MR Facilitator : dr. Sigit Prasetia Kurniawan, SpPD, K-HOM, FINASIM
Co-Facilitator I : dr. Nurul Aina, SpPD, FINASIM
Co-Facilitator II : dr. Lingga Suryakusumah, SpPD
Supervisor on Duty : dr. Diah Sukmawati Hidayah, MMR, SpPD
Duty Team
Chief/III : dr. Adlan
R6 : dr. Rudex
R5 : dr. Anna
IIB : dr. Ninis, dr. Coni
IIA : dr. Topan
IB : dr. Kevin, dr. Fadil
IA : dr. Syaidy, dr. Alex

ER PATIENTS

No Name/Age Diagnosis Info
1. Mr. R/48 yo
Severe Anemia, Hematemesis Melena, Hypoalbuminemia,
Hyponatremia
Tulip lt. 3
2. Mrs. T/56 yo
Severe Anemia, Adenocarcinoma gaster metastase liver,
Pulmonary nodule, AKI, Esophagitis
Tulip lt. 3
3. Mr. AS/83 yo
Acute Gout, ACKD, TB on treatment, Hypoalbumin, Prostate
hyperplasia
Mawar 2b
4. Mr. A/65 yo ACKD, Anemia, Chronic cough, hyperuricemia, Ht. st.2 Mawar 2a
5. Mr. Is/62 yo
Severe Anemia, CKD st. 5 on HD, HT, Polycystic kidney
disease
Tulip lt.3
6. Mrs. TY/38 yo
DoC, severe Anemia, Melena, CKD st. 5 on HD, HT
Tulip lt.3
7. Mr. JH/58 yo
DoC, HCC CTP C BCLD D, with cancer pain, Melena, AKI,
Hyperkalemia
ER
New Patient at ER (12/01/2022)
New Patient at ER (18/10/2023)

1. Mr. JH/58 yo
DoC, HCC CTP C BCLD D, with cancer pain, Melena, AKI,
Hyperkalemia
Consult to
Nephrologist
Stagnant at ER < 24h (18/10/2023)

1. - - -
Stagnant at ER > 24h (18/10/2023)

-
Dead Patients at ER (18/10/2023)

-
New Patients at ICU (18/10/2023)

1. Mr. Ef/66 yo
Syok Cardiogenic, Melena non variceal, Anorexia Geriatric,
AKI dd ACKD, HF, OMI, Geriatric Problem
From Mawar
New Patients at ICCU (18/10/2023)

No
Identity
(Name/Age/MR/
Department)
Problem Diagnosed Answered
1. Mrs. RS/ 42 yo/
RMK 01532470
Leukopenia
treatment, upgrade
LFT, HT stage 2, Ca
cervix stage 3B susp
pulmo metastasis
post chemotherapy
5x
1. Leukopenia with neutropenia
1.1 chemotherapy induced
(paclitaxel, carboplatin)
1.2 Bone marrow infiltration
2. Ca cervix stadium 3B dg pulmo
metastasis on chemotherapy
3. Elevated liver enzyme
3.1 metastasis?
3.2 reactive rt chemotherapy
induced
4. HT on normotension
Therapy
• Diet TKTP 1600 kkal
• RG < 5 gram/day
• Leucogen, same as Ts DPJP
• Po Curcuma 3x1 caps
• Indication and chemotherapy eligibility
from TS DPJP
Plan IPD:
• Evaluate SGOT/SGPT 72 hours later
• USG Abdomen
• We do not join care this patient
Consult To IPD ( 18/10/2023)

No
Identity
(Name/Age/MR/
Department)
2. Mrs. FE/59 yo/
RMK 01534478
Treatment 1. AIHA warm type with severe Anemia
Makrositer
2. T inverted lead I,II,AVL,V1
2.1 normal variant
2.2 related anemia
3. Low Back Pain dt Fraktur
Compression VL1-L2 +
Spondylolisthesis VL5-S1 Asia
Impairment Scale E
4. Ulkus decubitus grade 1
5. Colitis improved
Acc change leader
Therapy:
• Soft diet TKTP 1500 kkal/day
• PRC transfusion (8-7.2)× 4 × 50= 160
cc,1 kolf PRC Leukodepleted
IV
• IVFD NaCl 0.9% 1500 cc/24 hours
• Inj. Methylprednisolone 62.5mg/12
hours
• Inj. Omeprazole 40mg/24 hours
Po
• Po Imuran (Azathioprine) 2x50mg
Plan:
• Check DR post correction
• Aware of transfusion reaction
• Repeat EKG post transfusion
• Compress decubitus wound
• Join care with HOM division at ward

No
Identity
(Name/Age/MR/
Department)
3. Mrs. S/54 yo/
RMK 01536742
AKI Treatment 1. Rentensio Urine + Hydronephrosis
bilateral Dt obstructive uropathy
2. AKI stage III dd ACKD
Acute insult : volume depletion
Chronic insult : PNC
3. Severe Hypoalbumin
4. Ischemic anterior + Prolonged QT
4.1 ACS
4.2 CCS
5. Non Keratizing Squamous Cell
Carcinoma Cervix
• Avoid nephrotoxic drugs
• Monitor urine output and equal fluid
balance everyday
• Check UL
• Check Ureum/Creatinin per 48 hours
Saran:
• Transfusion albumin 20% 100cc
• Stop antrain
• Co Cardiology
• Join care with nephrology division IPD

WARD PATIENTS
TEAM PATIENTS
PDP 23
PDW 22
ISO/TB 0/0

1. Mr. R/ 26 yo
Hyperleukocytosis with Low Risk TLS, Anemia NN,
Hepatosplenomegaly, Thrombocytosis, Asymptomatic
Hyperuricemia, Hypokalemia
Polyclinic HOM
2. Mrs. N/ 54 yo
CLL RAI 1 BINET A, Neutropenia without Febrile,
Thrombocytopenia
Polyclinic HOM
3. Mrs. E/ 24 yo
AFI Day 7, Leukopenia, Coated Tongue dt Thypoid Fever dd Dengue
fever, Other viral infection, hypokalemia
From ER
4. Mrs. WB / 30 yo
Adenocarcinoma colon with cancer pain, Febrile neutropenia, SLE
with mild disease activity, Multiple Colon Polyposis, T inverted
without chest pain on V1
From ER
5. Mrs. F/ 62 yo DOC, SOB, AKI st 3 dd ACKD stge V newly diagnostic, HT, HNP
From Alamanda,
Passed away 18.52
6. Mr. RE/48 yo
Anemia MH, Hematemesis Melena (Non variceal Bleeding), Mild
hyponatremia hypoosmolar euvolemia
From ER
7. Mrs.T /57 yo
Anemia NN, Adenocarcinoma gaster st IV, Pulmonary Nodule rt
Metastasis Process T3bN2M13. AKI stage 4, Esofagitis LA grd B,
Asymptomatic moderate hyponatremia hipoosmolar hypovolemia,
Cancer Cachexia
Polyclinic
8. Mr. I/62 yo
Anemia MH, CKD stg 5 on HD (1x per minggu) HT. Polycystic
Kidney Disease
From ER
New Patients at WARD (18/10/2023)

1. - - -
2.
3.
4.
5.
6.
7.
8.
Dead Patients at WARD (18/10/2023)

1. Mrs. F / 62 yo
DOC, AKI st 3 dd ACKD stge V newly, Anemia NN,
HT, HNP
Dead at18.52 WITA
2. Mr. K/51 yo
COC, Syok sepsis Qsofa 3 with SOI DFU Wagner,
DOC dt hipoglikemik, anemia MH, DM tipe 2, DFU
Wagner 4 pedis dextra, Wagner 2 maleolus sinistra,
HT, Hiponatremia hipoosmolar euvolume, Severe
hypoalbuminemia Malnutrisi11. Deformitas of upper
ekstremitas dextra dt trauma.
Dead at 02.05
Dead Patients at WARD (18/10/2023)

CASE PRESENTATION
Mrs. T/ 56 YO
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat / RSUD Ulin Banjarmasin

• Name/Age : Mrs. T/ 56 y.o
• Birth of date : 3th June 1966
• Medical Record : 01513257
• Occupation : Housewife
• Marital status : Had Married
• Last Education : Senior High School
• Adresses : Brigend Hasan Basry gg Rahim 2
Identity

Identity : Mrs. T / 56 y.o
Chief complaint : Weakness
HISTORY OF PRESENT ILLNESS :
• Patient came to the emergency room with complaint of weakness since 1
week ago. complaint did not improve with rest, food cannot enter. The
patient looks pale.
• Patient also had nausea and vomited 1 time per day, also complaint of
decreased appetite.
• 1 year ago patient complained about decreased of appetite for 1 month,
nausea, and black tarry stools, and went to RS Islam for treatment, and
went to RS Ulin for diagnosis and treatment. The patient was diagnosed
with tumor in the stomach based on endoscopy and the biopsy result in
Adenocarcinoma gaster and has chemotherapy for 5 times.
• Patient felt a hard lump on the right side of her stomach that has been
getting bigger since 4 months ago, getting bigger since 2 weeks ago.
She also complained of heartburn. Complaint of abdominal pain was
Anamnesis

• History of black stools and black vomit 2 weeks ago, but now there are no
black stools or black vomit
• History of Gastric cancer with liver metastases by digestive surgery planned
surgery but refused by patient
• The patient complained about the decrease in her appetite because her
stomach felt full quickly.
• Urination decreased 2 times/day, approximately 300cc/24 hours, pain
when urinate (-), blood (-)
• History of first chemotherapy in March 2023 with a regimen of cisplatin, 5
FU, and leucovurin completed in 6 cycles in July 2023.
• No complaints about urination, frequency 4-5 times, normal amount. Pain
when urination was denied.
• History of repeated transfusions since the start of chemotherapy due to
anemia, most recently last month 6 bags of red blood transfusion.
• Patient was scheduled for a contrast abdominal CT scan on 10/23/23 due
to restaging post-first chemotherapy
• Hypertension was denied, Diabetes mellitus was denied
Anamnesis

HISTORY OF PAST ILLNESS
Liver disease (-), kidney disease (-), Heart disease (-), Stroke (-), Tuberculosis (-)
HISTORY OF MEDICATION
The first chemotherapy was in March 2023 with a regimen of cisplatin, 5 FU, and
leucovorin completed in 6 cycles in July 2023
FAMILY MEDICAL HISTORY
HT (-), DM (-), Malignancy (-), heart disease (-), kidney disease(-)
PERSONAL AND SOCIAL HISTORY
- Patient did not have history of consuming alcohol
- Patient did not have history of herbal
- Patient did not have history of drug abuse
Anamnesis

Physical Examination
General appearance: looked moderate ill
GCS : E4 V5 M6
Weight : 42 Kg
Height : 155 Cm
BMI : 17.5 (Underweight)
UOP : 500 cc/24 hours
Diuresis : 0.4 cc/kgBB/hours
VAS 5
BP: 110/80mmHg
HR: 109 bpm  98
bpm
RR: 20 bpm Tax: 36.3 oC SpO2: 98 on RA
Head
Eye
Mouth
Tongue
Etc
: Pale conjunctiva (+/+), sclera icteric (-), palpebra oedema (-), moon face (-)
: Pale (-), cyanosis (-), dry mucosa (-), ulcer (-)
: Papilla atrophy (-)
: Atrophy M. Temporalis (-), hair loss (-), Moon face (-), buffalo hump (-)
Neck
JVP
Lymph node
Thyroid
: 5+2 cm H2O, hepatojugular reflux (-)
: Lymph node enlargement (-)
: mass (-), bruit (-), pain (-/-)
Axilla : Lymph node enlargement (-)
Thorax Heart
Inspection
Palpation
Percussion
Auscultation
: Ictus cordis seen
: Ictus palpable at ICS V midclavicula line sinistra, thrill (-)
: LMH (Left Margin of Heart) ictus cordis at ICS V midclavicularis line sinistra
: RHM (Right Margin of Heart) : sternalis line dextra
 ICS II Parasternalis line dextra: aortic valve murmur (-)
 ICS II Parasternalis line sinistra: pulmonal valve murmur (-)
 ICS IV-V Parasternalis line sinistra: tricuspid valve murmur (-)
 ICS IV-V midclavicularis line sinistra: mitral valve murmur (-)

Thorax
Lung
(Anterior)
Inspection: symmetrical thoracal expansion, intercostal retraction (-)
Vocal
Fremitus
Percussion Breath Sound Ronchi Wheezing Egophony
D = S Sonor Sonor Vesicular Vesicular - - - - - -

Thorax
Lung
(Posterior)
Inspection: symmetrical thoracal expansion, intercostal retraction (-)
Vocal
Fremitus
Percussion Breath Sound Ronchi Wheezing Egophony
D = S sonor sonor Vesicular Vesicular - - - - - -

Abdomen
Inspection : Soefl (+), striae (+), venectation (-), protrude umbilicus (-), no pulsation was seen.
Auscultation : Bowel sounds (+) 10 bpminute, other sounds (-)
Percussion : tympanic sound Inferior border of right rib --> dullness (liver)
Inferior border of left rib -> tympani (gastric)
Traube space timpani
Palpation : Abdominal tenderness (+) epigastric
Defensive muscular (-)
Superficial mass (-)
Intra-abdominal mass (-)
The patient's face doesn’t look painful when the abdomen is palpated
Blast (-)
Free fluid examination : Shifting dullness (-)
Right hypochondriacal : mass palpable, humped, hard, immobile, uk. 7x7 cm
Liver palpation : not palpable liver
Palpation of the spleen : Schuffner method: spleen difficult to evaluate
Palpation of McBurney's point: Tenderness (-), pain relief (-), Local muscular defans (-)
Ballotement : Impression was not felt on right/left
CVA tap pain : Right (-/-) left (-/-)
Inguinal Lymphadenopathy (-)
Extremity
Spoon nails (-/-), clubbing fingers (-/-), petechiae (-)
Edema superior (-/-), Oedema inferior ext edema (-/-), pitting edema (-)
CRT < 2”, cold (-/-)
Enlarged lymph nodes (-/-), flapping tremor (-), palmar erythema (-)
Motoric (5/5/5/5), sensorics normal
Rectal
Toucher:
Anal sphincter clamps tightly, rectal ampulla does not collapse, mass (-), blood (-), feces (-), melena (-
)

Lab 18/10/23 Normal
Haemoglobin 5.1 14.0 – 18.0
Leukocyte 9.3 4.0 – 10.5
Erythrocyte 1.71 4.10 – 6.00
Haematocrit 16.3 56.0 – 56.0
Platelet 451 150 – 450
RDW-CV 15.7 12.1 – 14.0
MCV 95.3 75.0 – 96.0
MCH 29.8 28.0 – 56.0
MCHC 31.3 33.0 – 37.0
Laboratory Results
Lab 18/10/23 Normal
Basophil% 0.2 0.0 – 1.0
Eosinophil % 0.6 1.0 – 3.0
Neutrophil% 85.7 50.0 – 81.0
Lymphocyte% 7.6 20.0 – 40.0
Monocyte % 5.9 2.0 – 8.0
Basophil# 0.02 < 1.00
Eosinophil# 0.06 <3.00
Neutrophil# 7.94 2.50-7.00
Limfosit# 0.70 1.25-4.00
Monosit# 0.55 0.30-1.00

Laboratory Results
Lab 9/9/23 18/10/23 Normal
RGB - 108 >200
Albumin - 3.5 3.5-5.2
SGOT - 70 5 - 34
SGPT - 37 0 - 55
Ureum 45 0-50
Creatinine 1.21 1.63 0.46 – 1.25
Natrium - 128 136-145
Kalium - 4.8 3.5-5.1
Chlorida - 104 98-107
LDH 174 - -
CEA 5.04 - -

Lab
15/10/20
23
Normal Lab 15/10/2023 Normal
Urinalysis Sediment
Color Yellow Yellow Leucocyte 1-3 2-4
Clearly Clear Clear Erythrocyte 0-2 0-1
Specific
Gravity
1.025 1.005 – 1030 Epithel 1+ Negative
pH 6.0 5,0 – 6,5 Crystal Negative Negative
Keton Negative Negative Silinder Negative Negative
Protein 1+ Negative Bacteria Negative Negative
Glucose Negative Negative Etc Negative Negative
Bilirubin Negative Negative
Occult blood Negative Negative
Nitrite Negative Negative
Urobilinogen 0.2 0.1-1.0
Leukocytes Trace Negative
Urinalysis

Identity Mrs. T/ 56 yo
Position PA
Density Enough
Inspiration Enough
Soft Tissue Normal
Bone Intact
Trachea Normal
Hilus D/S Normal
Mediastinum Wide
Cor CTR 48%
Hemidiaphragm Sinistra (normal)
Dextra ( normal)
Costophrenicus
Sinus
Sinistra : sharp
Dextra : sharp
Parenchym Infiltrate (-)
Conclusion Expertise(-)
Opaque nodule with other small opaque nodules around it 7th
intercostal right posterior soft tissue mass
Chest X-ray
A B
A B
C
C
Opaque nodule with other small opaque nodules around it 6th
intercostal right posterior soft tissue mass

ECG Interpretations 18/10/2023

sinus rhythm Q wave : pathological Q (-)
Regular QRS Complex : 0.08 s, RBBB -, LBBB -
Heart Rate 98 bpm
ST segment : isoelectric, ST elevation (-), ST
depression (-)
Normal Axis T inverted (-) peak tall T (-), U wave (-)
Horizontal Axis: no rotation
R/S <1
R V5/6 + S V1 <56  RVH (-), LVH (-)
P wave : 0.08 s, P mitral (-), P pulmonal (-
)
PR interval : 0.12 s
Conclusion :
Sinus rhytm, 98 bpm, LAE
ECG Interpretations 18/10/2023

Endoscopy (05/11/2022 Pre Chemotherapy)
Results
Esophagitis LA grade B
The mass from the lesser
curvature of the corpus to the
gastric antrum is suspiciously
malignant

Abdominal CT Scan 06/01/2023 (Pre Kemo)
Results
- Susp gastric mass.
malignancy
- Multiple liver nodules
suggestive of liver
metastases
- No visible enlargement
of the abdominal para
aorta lymph nodes

PA Biopsy (11/07/2022)
Results
Gastric adenocarcinoma

USG Abdominal 02/08/2023 Post Chemotherhapy
Results
There is no obvious gastric mass
No intrahepatal metastases were seen
There was no visible enlargement of the
paraaortic/parailiac lymph nodes
Radiologically, the liver, gallbladder,
spleen, pancreas, bilateral kidneys and
urinary bladder are within normal limits.

• Liver size 12 cm, multiple
nodules
USG Bedside

7 months ago
Weight loss
Gastric cancer
with liver
metastases
First
chemotherapy
2 months ago
Mass right
hypochondrium
2 weeks ago
History of Black
stools and black
vomitting
1 week ago
Weakness
Nause
Vomitting
Enlargement
Mass right
hypochondrium
TIMELINE

Summary of Database
RESUME OF DATABASE
ANAMNESIS PHYSICAL EXAMINATION OTHER EXAMINATION
• Weaknesses
• Looks pale
• Nausea and vomit,
Heartburn
• History of black vomiting
• Stomach felt full quickly
• Decrease of body weight
• Mass in the abdomen
dextra and the middle of
the stomach
• History of repeated
hospitalization due to
anemia
• Diagnosed with
Adenocarcinoma gaster
• planned abdominal CT
scan for restagging
Objective
KU: looks moderately ill
GCS: E4 V5 M6
BP : 110/80mmHg
Pulse: 98x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
VAS 5
BW: 42 Kg / TB: 155cm/ IMT: 17.5
(Underweight)
WHO dehidration score 8 (mild moderate
dehydration)
Head/neck : pale conjunctiva (+)
Abdomen: Distended (-), BS (+), soefl,
tenderness (+) a/r epigastric
Status location a/r right hipocondriaca:
palpable hard mass, diameter 7 cm, uneven
surface, unclear boundaries, mobile,
tenderness (+)
Rectal Toucher: melena (-), blood (-)
Laboratory 18/10/23
Hb 5.1/MCV 95.3/ MCH 29.8
Leukosit 9.300/N% 85.7/L% 7.6
Tromb 451.000/Eritrosit 1.71
RDW 15.7
SGOT 70/ SGPT 37
GDS 108
Ur 45/Cr 1.63
Na 128/K 4.8/ Cl 104
Osm 267 (hipoosmolar)
Laboratorium 4/9/23 RS Ulin
LDH 174
CEA 5.04
EKG 18/10/23
Rontgen thorax 18/10/23
Impression:
Opaque nodule with other small
opaque nodules around it 6th
intercostal right posterior soft tissue
mass
Urinalysis 19/10/23
Yellow clear
pH 6.0, Spesific gravity 1.025
Prot +1
Gastric Biopsy Results 07/11/22
Gastric biopsy: Adenocarcinoma
of the stomach
Endoscopy results 05/11/22 Ulin
Hospital
Mass curvatura minor corpus to
gastric antrum suspected
malignant
CT scan abdoment Ulin Hospital
06/1/23
- gastric mass susp. malignancy
- multiple Hepar nodules
suggestive of liver metastases
- no visible KGB enlargement
paraaourta abdominalis
USG abdomen 2/8/23 after
chemotherapy
No obvious gastric mass
No visible intrahepatal
metastases
No visible paraaortic/parailiac
KGB enlargement
Radiologically Hepar, Gallbladder,
Spleen, Pancreas, bilateral Kidney
and Vesica Urinaria within normal
limits.
Regimen kemoterapi March
2023 six cycle
Cisplatin
5FU
leucovurin

1. Severe anemia NN
2. Nausea vomite with mild moderate dehydration
3. AKI stage 1
4. Adenocarcinoma gaster st IV post kemoterapi with cancer
pain
5. Esofagitis LA grd B
6. Asymptomatic moderate hiponatremia hipoosmolar
hipovolemia
PROBLEM LIST

CUE AND CLUE Problem List
Diagnosis
Planning Diagnosis
Therapy monitoring
Mrs.T/ 56 yo
• Weaknesses, Looks pale
• Nausea and vomite, low intake
• Post chemotherapy 6 cycle dt adenocarcinoma gaster
• History of black vomiting and black stool continuously 2 weeks ago
• History of repeated hospitalization due to anemia and got
transfusion
1. Severe Anemia NN 1.1 Chronic
Blood loss
1.2 Chronic
disease
Benzidine test
Peripheral blood
smear
Reticulocyte
Non-pharmacology
O2 NC 3 lpm
Pharmacology
PRC transfusion:
(10 – 5.1) x 42 x 4 = 823 cc =
4bags PRC
Given 1 bag /12hours
+ Ca gluconas 1amp there after
Planning monitoring
- Weakness, signs of
O2 hunger, bleeding,
transfusion reaction
- Vital sign
- CBC evaluation after
transfusion
Planning education
- Complain might be
related to the
underlying
malignancy &
complication
(bleeding,
inadequate nutrition
intake)
- Report if there is
bleeding
manifestations
Physical examination
RR 20 bpm
SpO2 : 98 % on RA
Pale conjunctiva (+)
Abd: palpable mass (+) a/r right
hipocondriaca
RT: melena (-), blood (-)
Laboratory 18/10/23
Hb 5.1/MCV 95.3/ MCH 29.8
Eritrosit 1.71
RDW 15.7
EKG 18/10/23
Gastric biopsy 07/11/22:

CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis
Therapy monitoring
Mrs.T/ 56 yo
• Nausea and vomite
• Decreased of appetite
• Adenocarcinoma gaster, post chemotherapy 6 cycle (cisplatin,5FU,
leucovorin), 3 months ago
2. Nausea vomite with
mild moderate
dehydration
2.1 related to
malignancy +
esofagitis
2.2 PUD
Endoscopy if needed Non-pharmacology
Drink water 1500cc/day
Pharmacology
Rehydration: 109/100x42 x30 =
1373.4 cc
Maintenance = 2000 cc
Total 3373.4 cc
 IVFD Nacl 0.9%: 1500cc in the
1st 8hours, 1500cc in the next
16 hours
Maintenance IVFD Nacl 0.9%
1500cc/24h
IV:
- Omeprazole 40mg/24h
- Ondancentron 4 mg/8 h
PO:
Sucralfat syr 4x10 ml
Planning monitoring
- Nausea vomite, sign of
dehydration
- Fluid balance
- Urine output/day
- Vital sign
Planning education
- Complain might be
related to the
underlying malignancy
- Nutriton intake, small
portion and regularly
Pulse: 109 bpm  post rehydration,
Pulse 96 bpm
sunkend eye (+) dry turgor (+) dry lips
(+)
tenderness (+) a/r epigastric, mass (+)
a/r right hipocondriaca
WHO dehydration score = 8
Laboratory 18/10/23
Na 128/K 4.8/ Cl 104
Ur 45/ Cr 1.63
Endoscopy results 05/11/22
Mass curvatura minor corpus to
gastric antrum suspected malignant

Planning
Therapy
Planning
monitoring
Mrs. T/56 yo
• Weaknesses
• Decreased appetite
• HT (-) DM (-)
3. AKI st 1 ec volume
depletion
Non-Farmakologi
- Avoid Nephrotoxic drug
- Drink water 1500cc/day
Pharmacology
Rehydration: 109/100x42 x30 = 1373.4
cc
Total 3373.4 cc
 IVFD Nacl 0.9%: 1500cc in the 1st
8hours, 1500cc in the next 16 hours
Maintenance IVFD Nacl 0.9% 1500 cc/
24h
Planning Monitoring :
- UO, Balance fluid
- Ur Cr 48 h
Planning Education
- Avoid dehydration
- Avoid nephrotoxic
drug
Phy. Exam:
BP : 110/80mmHg
Head: sunkend eye (+)
dry turgor (+) dry lips
(+)
Abd: tenderness (+) a/r
epigastric, mass (+) a/r
right hipocondriaca
UOP : 500 cc/24
hours
Diuresis : 0.4
cc/kgBB/hours
WHO dehydration
score = 8
Lab 18/10/23
Hb 5.1 MCV 95.3 MCH 29.8
Ur 45/ Cr 1.63 eGFR 37
BUN: Cr 12.9:1
Lab 9/9/23
Cr 1.21
Urinalysis 19/10/23
Yellow clear
pH 6.0, Spesific gravity 1.025
Prot +1
USG abdomen 2/8/23 after
chemotherapy
bilateral Kidney and Vesica
Urinaria within normal limits
INITIAL PLAN

Therapy monitoring
Mrs.T/ 56 yo
• Mass in the abdomen dextra and the middle of the stomach
• Stomach felt full quickly
• Decrease of body weight
• Post chemotherapy 6 cycle (cisplatin,5FU, leucovorin)
• Diagnosed with tumor in the stomach based on endoscopy and the biopsy
result Adenocarcinoma gaster
4. Gastric
adenocarcinoma
stage IV post
chemotherapy
with cancer pain
And cancer
cachexia
Non-pharmacology
- Basal Callory x 25 = 1237 kkal
- Age (-10%), ill (+20%), activity
(+10%) = 1703 kcal /day
- Carbohydrate 60%= 1022 kcal/day =
255.5 g/day
- Protein 1gr/kg/day = 49 gr = 196
kcal/day
- Fat = 485 kcal/day = 53.8 g/day
Diet High Calorie High Protein 1703
kcal/day
Pharmacology
Tramadol 100mg in Nacl 0.9%
100cc/8 h
Consider consult HOM division for
restaging
Consult Nutrisionist in ward
Planning monitoring
- Diet/intake
- Ecog and karnofsky
score
- BW, mass
enlargement
- CBC, comprehensive
chemistry profile
- CT scan abdomen
contras
- HER 2, PD-L1
Planning education
- Staging is required to
allow planning of
definitive therapy
- Nutriton intake, small
ECOG 2
Karnofsky 60
VAS 5
BW: 42 Kg / TB: 155cm/ IMT:
17.5 (Underweight)
Status lokalis a/r right
hipocondriaca:
palpable hard mass, diameter
7 cm, uneven surface, unclear
boundaries, mobile,
tenderness (+)
Laboratory 18/10/23
SGOT 70/ SGPT 37
Rontgen thorax 18/10/23 post chemotherapy
Opaque nodule with other small opaque
nodules around it 6th intercostal right posterior
soft tissue mass (enlargement)
CT scan abdoment Ulin Hospital 06/1/23
- multiple Hepar nodules suggestive of liver
metastases
- no visible KGB enlargement paraaourta
abdominalis
USG abdomen 2/8/23 after chemotherapy
Normal limits

Therapy monitoring
Mrs.T/ 56 yo
• Weight loss 60 Kg  42Kg in 7 month
• Dysphagia (-), odynophagia (-), heart burn (-)
5. Esofagitis
(LA gr B)
Non-pharmacology
Diet High Calorie High Protein 1703
kcal/day
Pharmacology
IV :
Omeprazole 40mg/24h
PO:
Planning monitoring
- Nausea, vomite
Planning education
- Nutrion intake small
Abd: tenderness (+) a/r
epigastric,
Endoscopy results 05/11/22
Mass curvatura minor corpus to gastric
antrum suspected malignant

Therapy monitoring
Mrs.T/ 56 yo
• Weaknesses
• Urination was decreased
6. Asymptomatic
moderate
hyponatremia
hypoosmolar
hypovolemia
6.1. Ekstra renal
loss
6.1.1 GI loss
6.1.2 Low intake
6.2 Renal loss
Sodium urine if
needed
Non-pharmacology
Drink water 1500cc/day
Pharmacology
Rehydration: 109/100x42 x30 =
1373.4 cc
Total 3373.4 cc
 IVFD NS 0.9%: 1500cc in the
1st 8hours, 1500cc in the next
16 hours
Maintenance IVFD Nacl 0.9%
1500 cc/24h
Planning monitoring
- Weakness, nausea and
vomite
- UO, fluid balance
- Vital signs, signs of
dehydration, SE
Planning education
- Balanced nutrition &
adequate fluid intake
Pulse: 109 bpm  post
rehydration, Pulse 96 bpm
Head: sunkend eye (+) dry
turgor (+) dry lips (+)
Diuresis : 0.4
cc/kgBB/hours
WHO dehydration score = 8
Laboratory 18/10/23
RBG 108
Na 128/K 4.8/ Cl 104
CT scan abdoment Ulin Hospital 06/2/23
- multiple Hepar nodules suggestive of liver
metastases
- no visible KGB enlargement paraaourta
abdominalis

No Date PROBLEM SOAP TTD PPDS TTD DPJP
1 19/10/23 Severe anemia NN Subjective:
Weakness +, melena -
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
Assessment:
Severe anemia NN
Therapy :
O2 NC 3 lpm
PRC transfusion:
(10 – 5.1) x 42 x 4 = 823 cc = 4bags PRC
Given 1 bag /12hours
+ Ca gluconas 1amp there after
Plans:
CBC evaluation after transfusion
Dr. Firdinia Dr. Yulia,SpPD
Progress Note

2. 19/10/23 Nausea vomite with mild
moderate dehydration
Subjective:
Nausea -, Vomite –
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
WHO dehydration score 6
Assessment:
Nausea vomite with mild moderate dehydration
Therapy :
Maintenance IVFD Nacl 0.9% 1500cc/24h
IV:
- Omeprazole 40mg/24h
- Ondancentron 4 mg/8 h
PO:
Plans:
- Monitoring sign of dehydration
Progress Note

3 19/10/23 AKI st 1 ec volume depletion Subjective:
Weaknesses -, Nausea -, vomite -
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
UO
Assessment:
AKI st 1 ec volume depletion
Therapy :
Maintenance IVFD Nacl 0.9% 1500cc/24h
Plans:
- Fluid balance
- Urine output/day
Progress Note

4 19/10/23 Gastric adenocarcinoma stage
IV post chemotherapy
(progression disease)
with cancer pain
And cancer cachexia
Subjective:
Epigastric pain decreased,
Feel full
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
Assessment:
Gastric adenocarcinoma stage IV post chemotherapy
(progression disease)
with cancer pain
And cancer cachexia
Therapy :
Diet High Calorie High Protein 1703 kcal/day
Pharmacology
Tramadol 100mg in Nacl 0.9%
100cc/8 h
Plan:
Evaluasion Ecog and karnofsky score
CT scan abdomen contras
Check HER 2
Progress Note

5 19/10/23 Esophagitis
(LA gr B)
Subjective:
Nausea -, vomite –
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
Assessment:
Esophagitis (LA gr B)
Therapy :
IV :
Omeprazole 40mg/24h
PO:
Progress Note

6. 19/10/23 Asymptomatic moderate
hyponatremia hypoosmolar
hypovolemia
Subjective:
Nausea -, vomite –
Objective:
BP : 100/70mmHg
Pulse: 99x/menit
RR : 22x/menit
T : 36.3⁰C
SpO2 : 98 % on RA
UO : 300cc/9 h
Diur: 0.8 cc/kg/h
Assessment:
AKI st 1 ec volume depletion
Therapy :
Maintenance IVFD Nacl 0.9% 1500 cc/24h
Plans
- Fluid balance
- Urine output/day
Progress Note

THEORY AND GUIDELINE

Gastric adenocarcinoma

ANEMIA

MELENA

DEHIDRASI

HIPONATREMIA

ESOFAGITIS

COLITIS

PULMONARY NODULE

TROMBOCYTOSIS

THANK YOU

20231019_Ca_gaster_post_kemoterapi_metastase_hepar,_Anemia_dr_Ninis.pptx

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