Menjadikan Bagian Ilmu Penyakit Dalam fakultas Kedokteran Universitas Hasanuddin sebagai pusat pendidikan yang unggul, mandiri dan bermatabat untuk menghasilkan dokter penyakit dalam yang berkualitas dan mampu bersaing secara regional, nasional maupun global dengan didukkung oleh sumber daya manusia yang profesional dan bertanggung jawab. Menyelenggarakan pendidikan di bidang Ilmu Penyakit Dalam berbasis evidance based medicine dan riset Memberikan pelayanan kesehatan di bidang Ilmu Penyakit Dalam dengan pendekatan kultural dan budaya secara paripurna dan bermutu Meningkatkan kuantitas dan kualitas penelitian dasar dan aplikatif ilmu penyakit dalam yang bertaraf internasional Menciptakan sistim manajement departemen Ilmu Penyakit Dalam yang transparan, akuntabel, responsibel, independen, terintegrasi, dan berkeadilan Suriana Dwi Sartika Soraya Name : Mrs. E Age : 48 yo Address : Makassar Occupation : Civil officer Religion : Moslem Ethnic : Bugis Marital status : Married Hospital : Hasanuddin University Room : 4th floor/ 409 Register No. : 007597 Date of admission : 24 / 04/ 2015 Date of death : 8/ 05/ 2015 Room physician : dr. Suriana Dwi Sartika Chief physician : dr. Soraya Chief complaint : shortness of breath Experienced since 4 months ago and was advancing since 1 last week. Shortness of breath is felt constantly, not aggravated by the weather, activity, or position. Patient feel comfortable lie down to the left side. Shortness of breath accompanied by cough slimy white, There was no blood and hard to be removed, so that shortness of breath became worse. This patient was an Oncologic surgery’s patient and was consulted to Internal Department, because of her shortness of breath. There was no complaint of chest pain and febrile, sometimes nausea, but didnt vomit. Her weight was lossing about 10 kgs in last 4 months.. According to the child patient, the patient's eating and drinking less, especially 1 last week. Defecation: watery since 1 week ago, frequency of defecation was more than 5 times a day. There was no blood or mucous in the stool. There was no complain of abdominal pain. Micturation: the volume is quite less, yellowish, no pain. because the prescription was dissapear. but she didnt know the name. There is no history if consuming other drugs. There is no history of chemotherapy or radiotherapy There is a history of kidney disease 3 month ago whern she went to policlinic and got oral medicine. because of her Ca mammae and she consume tamoxifen 20 mg 2x1 but she didnt consume it in last month.PREVIOUS ILLNESS There is a history of modified radical mastectomy dextra on January. There is no history if diabetes There is no histroy of hypertension There is no history of cardiovasculer disease . Brothers in a healthy state. healthy Children: 2 people. Husband: living.FAMILY HISTORY Father: Died at the age of 65 years with unknown cause Mother: Died at the age of 70 years with no known cause Siblings: The patient is first child of three siblings. healthy PERSONAL HISTORY No history of allergy Immunization history is not clear Eating habits nothing special Patient works in the office and rarely walking outside the office everyday . strong lift Breathing : 28x/mnt Temperature : 36.3° C . regular.Impression : Nutritional Status : Awareness : BW : HW : BMI : Severe ill Malnutrition GCS 15 (E4M6V5) 40 kg 155 cm 16.67 kg / m2 Vital Sign Blood pressure : 110/80 mmHg Heart rate : 105x/mnt. Eye : Conjungtiva anemic (+). light reflex (+/+) Secret (-) Normal shape. discharge (-). Head : normocephal. hiperemic (-) JVP R+2cmH2O . sclera icteric (-) Pupil isocor. short black hair. diameter 2mm/2mm. enlargement of lymp nodes (-). epistaktis (-) Tonsil T1-T1. is not easily to removed. enlargement of thyroid gland (-) Ears: Nose: Oral Cavity: Neck: . cardiac border of normal impression Auscultation : heart sound I and II pure. regular. chest wall movement sinistra left behind Palpation : tactile fremitus hemithorax sinistra decrease as high as costae VII Percussion : percussion dimmed on the left hemithorax as high as costa VII Auscultation : breathing sound bronchovesiculer. no additional sound . decreased respiratory sounds on the left hemithorax. Wheezing on left hemithorax. there is right and left median basal hemithorax rhonki heart: Inspection : Ictus cordis seen on ICS V line on the left midclavicularis Palpation : Ictus cordis palpable at ICS V linea left midclavicularis Percussion : dullness.Thorax lung: Inspection : asymmetrical. following breathing motion. blunt edge. Auscultation : peristaltic sound increase Palpation : Palpable liver 8 cm below arcus costa.Abdomen: Inspection : Convex. warm extremity . oedem pretibial (-). hard consistency. bumpy surface Percussion : Tympani (+) . ascites (-) Extremity: erithema palmaris (-). 6 g/dl Albumin : 2.1 pg SGPT : 27 U/L MCHC : 33.9% .000/ul NEUT : 80.500 /ul GDS : 101 mg/dl HGB : 7.0 % Creatinine : 2.50 mg/dl MCV : 87 fl SGOT : 44 U/L MCH : 29.4 g/dl Ureum : 156 mg/dl HCT : 22. Pelamonia Blood Chemistry WBC : 25.8 gr/dl PLT : 195.LABORATORY TEST (23/04/2015) from RS. 1% LYMPH : 7.(100mg/dl) pH : 5.9 g/dl HCT : 23.0 % Blood Chemistry SGOT : 36 U/l SGPT : 19 U/l GDS : 79 mg/dl Ureum : 116 mg/dl Creatinin : 2.000/ul NEUT : 88.020 Leukocyte : Negatif Vit C : + (10 mg/dl) .5 (MDRD : 21.190/ul HGB : 7.94) Total Cholesterol : 125 mg/dl Albumin : 2.Routine Haematology WBC : 29.9 g/dl PLT : 289.9 fl MCH : 26.3 % MCV : 76.0 SG : 1.1 mmol/L Cloride: 111 mmol/L Urinalysis Color : Kuning Blood : Negatif Bilirubin : Negatif Urobilinogen : +Keton : Negatif Protein: Negatif Nitrit : Negatif Glucose : +.8 Electrolyte Natrium : 129 mmol/L Kalium : 5.1 pg MCHC : 33. normoaxis . HR: 108x/i.ECG : Rhytme Sinus . RADIOLOGY Thorax PA from RS.Pelamonia (14/04/2015) Hepar Metastase Renal Insuficience OTHER TEST Histopatology Test (19/01/2013) : Invasive ductal carsinoma mammae (moderate grade malignancy) which metastase to lymphe .Pelamonia (13/04/2015) Pulmo Metastase with pneumonia Fracture costa V-VI with costa IV sinistra suggest bone metastase USG Abdomen dari RS. Community Acquired Pneumoni Suspek Efusi Pleura Sinistra Adenocarsinoma mammae dextra stadium IVB post MRM metastase paru dan hepar Acute diarrhea mild-moderate dehydration Acute on CKD dd / CKD stage IV ec. renal dd / pre renal Hyponatremia Anemia of chronic disease dd / renal anemia Hypoalbuminemia malnutrition . Patients had malignant disease that decreases immunity and are prone to infection. it was found the median basal hemithorax.1%). 3x sputum smear examination. In the laboratory tests. From the examination. Blood gas analysis . Thorax photo control Examination of sputum culture and antibiotic sensitivity Ceftriaxon 1gram / 12h / intravenous (continue previous treatment of TS Surgery) N-Acetylsistein tablet 200mg / 8 hours / oral Advice: consul pulmonology Community acquired pneumonia based on: Complaints of shortness of breath that was advancing since 1 last week with a cough with purulent mucus. gram. showed leukocytosis (29190) and neutrophils were increased (88.yeast.No Problem Plan Therapy & Management 1. Exudative pleural effusions usually occur in cancer patients.a Problem Plan 2. tactile fremitus decreased and percussion dullness in the left hemithorax high as costa VII. Obtained from physical examination. Therapy & Management Evacuate the pleural fluid . Pleural effusions may be exudates or transudates. Suspek pleural effusion Thorax photo Sinsitra based on: control Thought on the main of complaints of shortness of breath that was advancing since last one week. a Problem Plan Therapy & Management 3. Shortness of breath since four months ago can be suspected as a symptom of the process of tumor metastases in the lung or pleural effusion On physical examination found left pleural effusion. Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases based on: Thought on the basic of the patient has a history of modified radical mastectomy and histopathological examination: invasive ductal breast carcinoma (moderate grade malignancy) that has metastasized to the lymph nodes. AFP O2 4 liters / minute via nasal cannula Chemotherapy plan from TS. Oncology Surgery Avoid hepatotoxic drugs . hepatomegaly with Thorax MSCT scan Abdomen MSCT scan CEA. ureum. and tachycardia with a score of dehydration 3. turgor less. On physical examination found increased peristalstic. creatinin MSCT Scan Abdomen IVFD NaCl 0. Acute diarrhea mildmoderate dehydration based on Watery defecation complaints since 1 last week with the frequency of bowel> 5x each day. not accompanied by mucus or blood.9% loading 500 cc in the first 2 hours further maintanance 20 drops / minute Attapulgite given initial 2tab and 1tab every watery defecation (maximum of 12 tablets) Positive fluid balance . These patients suspected metastases of the gastrointestinal tract that can give symptoms of digestive system disorders or immune conditions decreased due to malignancy so easily happen Analyse faeces CEA Electrolyte. Urinating less from diarrhea impression.a Problem Plan Therapy & Management 4. 94). Hyponatremia is based on: Thought on the basis of patients with malignancies and drink intake eat less. Of the laboratory tests obtained ureum 116 and creatinine 2. Acute on CKD dd / CKD stage IV ec Prerenal dd / rena lbased on l Patients experiencing watery defecation that can trigger acute in these patients. Patients already been said renal impairment three months ago at the time control at the PCC RSWS so that suspected patients had chronic kidney disease. Control the ureum/creatini ne per 3 days Adequate rehydration Amino acids 250cc / 24h / drips balance fluid 6.a Problem Plan Therapy & Management 5. Of - IVFD NaCl 0.5 (MDRD: 21.9% 20tpm Correction sodium from dietary intake Advice : consult clinical nutrition . surgery) Advice : consult clinical nutrition . Hypoalbuminemia based on Thought on the basis of Therapy & Management VIP Albumin 3x2 (therapy from TS.9. and MCH: 26. TIBC. Anemia can also be caused by renal anemia patients given once said renal impairment three months earlier and now with 116 urea and creatinine 2. Serum fe.94). nefrovit Fe APTT Analysis of peripheral blood 8.5 (MDRD: 21. Anemia in patients thought of as a chronic disease anemia dd / iron deficiency anemia patients given malignant disease and intake less.a Problem Plan 7. Anemia of Chronic Disease dd / Renal Anemia based on Obtained conjunctival pallor. epoetin alfa dan Ferritine. pT.1.9. obtained from laboratory tests Hb: 7. MCV: 76. - Therapy Plan : .67.a Problem Plan Therapy & Management 9. BMI obtained from physical examination: 16. Malnutrition based on the patient is a malignancy patients with less intake.Clinimix 1bag /hari .Advice : consult to clinical nutrition . . .Consul Renal Hypertension 4/04/15 18.Karnofsky .Amino acids 250 cc / 24 hours / drips .VIP albumin 3x2 . .Fix the general state Oncology Surgery 50% .Advice: .Low-purine diet.consul Clinical Nutrition . TIBC.PRC transfusion of 2 units .Ca Mammae post MRM metastazing to .O2 3-4 liter / minute via NK .Fe.15 Renal Hipertension A : -Acute on CKD dd / CKD stage IV ec.Date Follow up Instruction 24/04/2015 A : .9% 20 dpm .O2 4 liters / minute via NK 14.IVFD NaCl 0. salt.Ceftriaxon 1 g / 12h / iv . potassium. protein 0.renal dd / pre renal -Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases -CAP -Acute diarrhea with moderate-mild dehydration -hypoalbuminemia -Anemia of chronic disease dd / renal anemia .N-acetylsistein tablet 200mg / 8 hours / oral .Ceftriaxone 1gram / 12h / intravenous (continued therapy Surgery TS) .Infusion of NaCl 20 dpm .Ketorolac 30 mg / 8 hours / iv .Attapulgite tablet 2x2 (maximum of 12 tablets) .8 g / kg / day .30 lung and hepar (TxN0M1) .balance liquid . ferritine.consul Pulmonology .Plan: .Plan of epoetin alfa and iron capsules. N-acetylsistein tablet 200mg / 8 hours / oral . AFP .Plan of epoetin alfa and iron capsules.Fe.Analysis of peripheral blood. TIBC.30C Day Care II S: shortness of breath accompanied by cough mucus. Heart: S1 / S2 regular. feces (+).Low-purine diet. potassium. mucus (-).Thorax CT scan .Blood gas analysis and stool analysis .8 g / kg / day . Wheezing in hemithorax left.X-Ray thoracic control .9% 20 dpm . salt.IVFD NaCl 0.Amino acids 250 cc / 24 hours / drips . Lung: decreased respiratory sounds on the left hemithorax.Control routine blood and electrolytes .Date Follow up Instruction 25/04/15 BP: 110/80 HR: 100x / minute. Rhonki on hemithorax median basal right and left. Extremity edema . regular. RR: 28x / min T: 36. sputum culture and antibiotic sensitivity ./ A: Community acquired pneumonia Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases Suspek Pleural effusion Sinistra Acute diarrhea mild-moderate dehydration Acute on CKD dd / CKD stage IV renal ec dd / pre renal hyponatremia Anemia of chronic disease dd / renal anemia hypoalbuminemia Malnutrition . Liver palpable 8 cm below the surface of the arch costa nodul with hard consistency. ferritine. . Watery dfefecation 3x frequency. CEA.Plan: . protein 0.consul Pulmonology and consul Clinical Nutrition . blood (-) O: severe pain / malnutrition / composmentis Head: pale conjunctiva (+).balance liquid The advice: .Attapulgite tablet 2x2 (maximum of 12 tablets) . Less food intake. murmur (-) Abdomen: increased peristaltic impression.O2 3-4 liter / minute via NK .CT Abdomen Input: 1100cc / 24h UO: 650cc / 24h IWL: 400cc BC: + 50cc / 24h . DVS R + 2 cmH2O. gram Yeast. . jaundice (-) Neck: tumor mass (-).3x sputum smear examination.Ceftriaxone 1gram / 12h / intravenous (continued therapy Surgery TS) H-2 . .IVFD NaCl 0. 25/04/2015 Bedah Onkologi Ca mammae dextra post MRM metastasis to the lung and liver - O2 4 liters / minute via NK Infusion of NaCl 0.N-acetylsistein tablet 200mg / 8 hours / oral . TIBC. ferritine (wait for results).9% 20 dpm .Plan: .Date Follow up Instruction 25/04/2015 Renal Hipertension A: Acute on CKD dd / CKD stage IV ec. potassium. .renal dd / pre renal Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases CAP Acute diarrhea were mild dehydration hypoalbuminemia Anemia of chronic disease dd / renal anemia .TS consul Clinical Nutrition (wait The main DPJP confirmation) .O2 3-4 liter / minute via NK .Plan of epoetin alfa and iron capsules.9% 20 dpm Ceftriaxon 1 g / 12h / iv Ketorolac 30 mg / 8 hours / iv VIP albumin 3x2 Plan: routine hematology control transfusion post .balance liquid .Attapulgite tablet 2x2 (maximum of 12 tablets) .Control routine blood and electrolytes.Ceftriaxone 1gram / 12h / intravenous .8 g / kg / day .Amino acids 250 cc / 24 hours / drips . salt.Fe. protein 0.The advice: Consul Pulmonology (wait for The main DPJP confirmation) .Low-purine diet. Ca dextra post MRM mammary metastasis to the lung and liver The left pleural effusion 26/04/2015 A: 19.00 Oncology surgery Follow up Instruction Control chest x-ray results: Suggestive of pleural effusion with atelectasis of -Konsul BTKV the left Suspect metastatic nodules dd / pneumonia Fractures costa V and VI rear right A: .Date 26/04/2015 19.The left pleural effusion Insert chest tube dan WSD .30 Ca mammae dextra post MRM metastasis Thorrax and to the lung and liver Vascular surgery . . gram. salt. Wheezing no. potassium.PLT: 283000 289000 .65 ug / dl .Sodium: 132 129 .balance liquid .Neutrophils: 88. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 5.Fe tablet / 12 hours / oral . jaundice (-) Neck: tumor mass (-).Date Follow up Instruction 27 – 28 /04/2015 BP: 120/80 HR: 68x / minute. Anemia of chronic disease dd / renal anemia 7.WBC: 27860 29190 .9 . and strong lift RR: 24x / min T: 36.Fe (Iron): 51.50C Input: 850cc / 24h UO: 600cc / 24h IWL: 400 cc BC: -150cc / 24h WSD production: 650 cc since installation Day Care III . Yeast (no samples) Examination of sputum culture And antibiotic sensitivity (no samples) CT ScanAbdomen and CT Scan Thorax and (not approved by the Main DPJP) . murmur (-) Abdomen: normal peristaltic impression. Heart: S1 / S2 regular. Cough (+) slimy sometimes.N-acetylsistein 1 ampoule / 24h / drips (pro-chemotherapy) .Epoetin alfa 3000 IU / 2x a week / subcutan . Malnutrition 9. Watery defecation never since two days ago./ Lab .O2 3-4 liter / minute via NK . regular.Amino acids 250 cc / 24 hours / drips .8 g / kg / day .IVFD NaCl 0.Transferrin saturation: 33.1% . Liver palpable 8 cm below the surface of the arch costa nodule with hard consistency. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 3. Community acquired pneumonia 2.Hb: 9. Hyponatremia 6. Hypoalbuminemia 8. protein 0. Rhonki no. Acute diarrhea mild-moderate dehydration (repair) 4.1 .4 5.IV S: shortness of breath decrease.Low-purine diet.TIBC: 156 ug / dl .7 88. Extremity edema .9% 20 dpm .Advice Consul Pulmonology (not approved by the main DPJP) Consul Clinical Nutrition (wait for confirmation of the main DPJP) Plan: CEA. AFP (not approved by main DPJP) Blood gas analysis 3x sputum smear examination. O: severe pain / malnutrition / composmentis Head: pale conjunctiva (-).1 .9 7.Chloride: 113 111 A: 1.Ceftriaxone 1gram / 12h / intravenous H-4 & 5 .Potassium: 4. Lung: Chest tube on left hemithorax. DVS R + 2 cmH2O. The left pleural effusion on WSD . Femara 1x2.renal dd / Hipertension pre renal -Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases -CAP -Acute diarrhea with mild 0moderate dehydration -Hypoalbuminemia -Anemia of chronic disease dd / renal anemia Instruction .8 g / kg / day .Amino acids 250 cc / 24 hours / drips .N-acetylsistein 1 ampoule / 24h / drips (pro chemotherapy) .O2 4 liters / minute via NK Oncology lung and hepar .IVFD NaCl 0.5 mg (drugs are not administered) .Ceftriaxon 1 g / 12h / iv .O2 3-4 liter / minute via NK .VIP albumin 3x2 .Advice : Consul Pulmonology (not approved by the main DPJP) Consul Clinical Nutrition (wait for The DPJP confirmation) 27-28 /04/2015 A : Ca Mammae dextra post MRM metastase to .9% 20 dpm .Ceftriaxone 1gram / 12h / intravenous .Low-purine diet.Infusion of NaCl 0. salt. protein 0.Date Follow up 27-28 /04/2015 A : Renal -Acute on CKD dd / CKD stage IV ec.Fe tablet / 12 hours / oral .Epoetin alfa 3000 IU / 2x a week / subcutan .balance liquid .Tamoxifen 1x 20 mg (drug are not administered . potassium.9% 20 dpm Surgery . Production WSD: 50cc Extremity edema .5 C Neck: tumor mass (-). sputum culture and antibiotic sensitivity (no samples) Blood cultures and antibiotic sensitivity (wait for the result) Control routine blood. No Input: 850 cc / 24h rhonkhi UO: 650cc / 24h Heart: S1 / S2 regular.Ceftriaxone 1gram / 12h / intravenous H-6 . mid 1700 kcal diet upper arm circumference weight : 35 kg . gram.5 cm . Community acquired pneumonia 2. potassium. Malnutrition 8. protein 0. Less food intake lift. salt. Lung: chest tuber on hemithorax sinistra. hyponatremia 5. electrolytes.Date 28/04/2015 Clinical Nutrition Follow up Instruction Height : 147 cm . DVS R + 2 cmH2O./ / 24h A: 1. strong difficult to remove. No wheezing . and creatinine The advice: : chest x-ray control post chest tube insertion . Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 3. Coughing occasionally slimy and HR: 84x / min.9% 20 dpm .Fe tablet / 12 hours / oral . murmur (-) IWL: 400cc Abdomen: normal peristaltic impression. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 4. Anemia of chronic disease dd / renal anemia 6. regular O: severe pain / malnutrition / composmentis RR: 24x / min Head: pale conjunctiva (-).Plan : Blood gas analysis 3x sputum smear examination.Amino acids 250 cc / 24 hours / drips .N-acetylsistein 1 ampoule / 24h / drips (H-1) .O2 3-4 liter / minute via NK .Fluid balance . The left pleural effusion on WSD . urea.Epoetin alfa 3000 IU / 2x a week / subcutan (drugs are not logged in) . BBI : 47 kg SF Nephrisol 6 x ½ tsp Nutitional Status : Severe PEM Avcol 3x1 tbsp fruit juices 50 cal supp: Zinc 1 x 20 mg Vit. Hypoalbuminemia 7. yeast. B Comp 1x1 Vit C 1x1 Folic acid 1x400 mg 29/04/2015 IV Day Care BP: 120/80 S: shortness of breath (+). Liver palpable 8 cm BC: -200cc / 24h below the surface of the arch costa nodule with hard consistency.Low-purine diet.IVFD NaCl 0. mid upper arm circumference : 19. jaundice (-) T : 36.8 g / kg / day . potassium.5 cm . BBI : 47 kg Nutritional status: Severe PEM 1700 kcal diet SF Nephrisol 6 x ½ tsp Avcol 3x1 tbsp fruit juices 50 cal supp: Zinc 1 x 20 mg pujimin 3x2 cap Insertion NGT size 14 .Epoetin alfa 3000 IU / 2x a week / subcutan (drugs are not logged in) .renal dd / pre renal -Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases -CAP -hypoalbuminemia -Anemia of chronic disease dd / renal anemia .Fe tablet / 12 hours / oral . mid upper arm circumference weight : 35 kg .Low-purine diet.Water Balance Plan: control routine blood.IVFD NaCl 0. mid upper arm circumference : 19.N-acetylsistein 1 ampule / 24h / drips (H-1) . and electrolytes 29/04/2015 Clinical nutrition height : 147 cm . urea creatinine. salt.Date Follow up Instruction 29/04/2015 Renal Hipertension A : -Acute on CKD dd / CKD stage IV ec.8 g / kg / day .O2 3-4 liter / minute via NK .Ceftriaxone 1gram / 12h / intravenous .9% 20 dpm .Amino acids 250 cc / 24 hours / drips . protein 0. Cough mucus (+) and sputum is difficult to remove. Extremity edema .3 2.O2 3-4 liter / minute via NK .Amino acids 250 cc / 24 hours / drips .2 4.000 283.000 Neutrofil : 88.2 9.Plan : Blood gas analysis 3x sputum smear examination. Heart: S1 / S2 regular.4 Cl : 116 113 Ureum : 165 116 Creatinine : 3.Hypoalbuminemia 6.50C Input: 900cc / 24h UO: 700cc / 24h IWL: 400 cc BC: -200cc / 24h production WSD: 50 cc / 24h V Day Care S: shortness of breath (+). regular./ Laboratorium WBC : 27690 27.7 Na : 135 132 K : 4. protein 0.Malnutrition 7.Ceftriaxone 1gram / 12h / intravenous H-6 . gram.IVFD NaCl 0. O: severe pain / malnutrition / composmentis Head: pale conjunctiva (-). potassium.N-acetylsistein 1 ampoule / 24h / drips (H-2) . RR: 24x / min Q: 36.8 g / kg / day .Epoetin alfa 3000 IU / 2x a week / subcutan (1) .Community Acquired Pneumoni 2.2 88.9 PLT : 247. sputum culture and antibiotic sensitivity (samples not yet complete) Blood cultures and antibiotic sensitivity (wait for the result) The advice: chest x-ray control post chest tube insertion.Fe tablet / 12 hours / oral .Date Follow up Instruction 30/04/2015 BP: 110/70 HR: 80x / minute.860 Hb : 9. murmur (-) Abdomen: normal peristaltic.balance liquid .Anemia chronic disease dd/ anemia renal 5.Adenocarsinoma mammae dextra stadium IVB post MRM metastase lung and hepar 3.5 A: 1.Nebulilzer N-acetylsistein / 8 hours / inhalation (if sputum is difficult to remove) ..9% 20 dpm .Acute on CKD dd/ CKD stage IV ec renal dd/pre renal 4. salt.Low-purine diet. Liver palpable 8 cm below the surface of the arch costa berbenjol with hard consistency. No wheezing no rhonkhii. yeast.Efusi pleura sinistra on WSD . jaundice (-) Lung: chest tube on hemithorax sinistra. . 9% 20 dpm Ceftriaxon 1 g / 12h / iv Dexamethasone 1 amp/ iv (premedication before chemotherapy) Ranitidine 1 amp / iv VIP albumin 3x2 Femara 1x2.9% 20 dpm .IVFD NaCl 0.Ceftriaxone 1gram / 12h / intravenous .Fe tablet / 12 hours / oral .5 mg (drugs are not administered) Tamoxifen 1x20 mg (drug are not administered) . potassium.Amino acids 250 cc / 24 hours / drips .N-acetylsistein 1 ampoule / 24h / drips (H-2) .8 g / kg / day .O2 3-4 liter / minute via NK .Low-purine diet.renal dd / pre renal -Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases -CAP -hypoalbuminemia -Anemia of chronic disease dd / renal anemia .Water Balance 29-30/04/2015 A : Ca Mammae dextra post MRM metastase Oncology Surgery to lung and hepar - O2 4 liters / minute via NK Infusion of NaCl 0.Epoetin alfa 3000 IU / 2x a week / subcutan (1) . salt. protein 0.Date 30/04/2015 Renal Hipertension Follow up Instruction A : -Acute on CKD dd / CKD stage IV ec. DVS R + 2 cmH2O.Plan : Blood gas analysis 3x sputum smear examination.Date 30/04/2015 Clinical Nutrition Follow up Instruction Height : 147 cm . Hypoalbuminemia 8. Malnutrition 9. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 6. Anemia of chronic disease dd / renal anemia 7. mid upper arm 1700 kcal diet circumference weight : 35 kg . regular.Nebulizer N-Ace / 8 hours / inhalation stop . check GDS 15 minutes later continue with maintenance D10% 28 dpm. Decrease Awareness et causa suspected intracranial tumor metastasis 3. mid upper arm circumference : 19. Hypoglycemia 2.O2 3-4 liter / minute via NK .40C VI Day Care S: loss of consciousness (+).Low-purine diet. O: severe pain / malnutrition / delirium GCS E4MxV1 Head: pale conjunctiva (-). Heart: S1 / S2 regular.D40% 2 flacon / intravenous. No wheezing no rhonkhi. protein 0.Epoetin alfa 300 IU / 2x a week / subcutan . jaundice (-) Neck: tumor mass (-). murmur (-) Abdomen: normal peristaltic impression. shortness of breath (+).Fe tablet / 12 hours / oral . gram.Give sugar water via NGT .Amino acids 250 cc / 24 hours / drips . The left pleural effusion on WSD Input: 850cc / 24 hours UO: 720cc / 24h IWL: 400 cc BC: -250cc / 24h WSD production: - .5 cm . sputum culture and antibiotic sensitivity (samples not yet complete) The advice: Control chest xray post chesttube insertion Head MSCT scan . .N-acetylsistein 1 ampoule / 24h / drips stop (had been given for 3 days) . Liver palpable 8 cm below the surface of the arch costa nodule l with hard consistency. Lung: chest tube on left hemithorax. BBI : 47 kg Via NGT: Porridge sonde 3x100 Nutrition Status: Severe PEM Ensure SF +100 cc 3x2 sdt water Avcol 3x1 sdm Supp: Zinc 1 x 20 mg pujimin 3x2 capp 02/05/2015 BP: 130/80 HR: 92x / minute./ Lab GDS: 49 mg / dl. Community Acquired pneumonia 4. GDS 15 minutes after administration D40%: 81 mg / dl Blood culture: no growth A: 1.Ceftriaxon 1gram / 12h / iv H-9 . Extremity edema . yeast. potassium.8 g / kg / day . the patient was restless. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 5. salt.Monitoring GDS / 30 min . RR: 20x / min ST: 36. Cough mucus (+) sputum is difficult to remove. Fluid balance 02/05/2015 Oncology Surgery A : Ca Mammae dextra post MRM lung and hepar metastase - 02/05/2015 Clinical Nutrition Height: 147 cm .5 mg H-2 tamoxifen 1x20 mg H-2 . 1700 kcal diet mid upper arm circumference weight: 35 kg .renal dd / pre renal -Adenocarsinoma mammaae dextra post MRM IVB stage lung and liver metastases -CAP -hypoalbuminemia -Anemia of chronic disease dd / renal anemia -hypoglycemia -Loss of consciousness suspicious tumor metastases to the brain . potassium.Fe tablet / 12 hours / oral . salt.Epoetin alfa 3000 IU / 2x a week / subcutan .IVFD D10% 20 dpm .Amino acids 250 cc / 24 hours / drips .Date Follow up Instruction 02/05/2015 Renal Hipertension A : -Acute on CKD dd / CKD stage IV ec.8 g / kg / day . mid upper arm circumference : 19. protein 0.O2 3-4 liter / minute via NK .5 cm .N-acetylsistein 1 ampoule / 24h / drips (has been given for 3 days) stop .Low-purine diet. BBI : 47 kg Via NGT: Nutritional Status: Severe PEM MLP 3x150 Milk Nefrisol 3 x 135 kcal (3x2 tsp) olive oil 3x80 kcal (3x1sdm) Low potassium juice 100 kcal Honey 3x64 kcal (3x1 tablespoons) supplementation: Zinc 1 x 20 mg pujimin 3x2 cap O2 4 liters / minute via NK Ceftriaxon 1 g / 12h / iv VIP albumin 3x2 Femara 1x2.Ceftriaxone 1gram / 12h / intravenous . Amino acids 250 cc / 24 hours / drips . Input : 900cc/ 24 jam Heart: S1 / S2 regular. Anemia of chronic disease dd / renal anemia 7. urea creatinine.00 Interna S: patient was agitated O: GCS: E4MxV1. Hypoalbuminemia 8. Cough mucus (+) sometimes. the patient was agitated and disorientation. sputum culture and antibiotic sensitivity (samples not yet complete) Blood gas analysis Control routine blood. yeast.Epoetin alfa 3000 IU / 2x a week / subcutan (2) . protein 0. potassium. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 6.8 g / kg / day .Plan : 3x sputum smear examination. SO2 : 97% Lung: chest tube on left hemithorax. murmur (-) UO :850cc/24jam Abdomen: normal peristaltic impression.Fe tablet / 12h / oral . N : 92x/menit. salt. TD : 130/80 shortness of breath (+). O: severe pain / malnutrition / delirium kuat angkat GCS E4MxV1 P : 20x/menit Head: pale conjunctiva (-).Ceftriaxon 1gram / 12h / iv H-11 . Decrease Awareness et causa suspected intracranial tumor metastasis 3. Liver palpable 8 cm below the IWL : 400 cc surface of the arch costa nodule with hard consistency. reguler . CT scan of the head (not done since general condition does not allow) The advice: Consul neurology Consul HOM .Post hypoglycemia Loss of consciousness suspect tumor metastases to the brain IVFD D10% 28 dpm Head MSCT scan (not successful because of patient agitated) 03/05/2015 Oncology Surgery General state: patient was agitated O: GCS E4MxV1 A: Ca mammaae post MRM hepatic and pulmonary metastases Observation on the general condition and vital signs Consul ICU 04/05/2015 VII Day Care ICU H-1 S: loss of consciousness (+). DVS R + 2 cmH2O. No wheezing no rhonkhi. and electrolytes. gram. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 5. The left pleural effusion on WSD ./ Lab GDS (06:00): 96 mg / dl A: 1. Post Hypoglycemia 2.IVFD D10% 28 dpm . jaundice (-) 0 S : 36. Malnutrition 9. GDS: 116 mg / dl A: .Low-purine diet.4 C Neck: tumor mass (-).O2 8-10 liters / minute via NRM . BC :-350/24jam Extremity edema .Date Follow up Instruction 02/05/15 16. Community Acquired pneumonia 4.Monitoring GDS / 30 min . Loss of consciousness suspicious tumor metastases to the brain dd / DIC .balance liquid .Epoetin alfa 3000 IU / 2x a week / subcutan (2) .IVFD D10% 20 dpm .8 g / kg / day .Ca mammae post MRM metastasis to the lung and liver Omeprazole 40mg / 24h / iv .Amino acids 250 cc / 24 hours / drips .Acute on CKD dd / CKD stage IV ec.5 cm .Impairment of consciousness suspect tumor metastases to the Head Up 300 brain Measure urine / h . salt.Low-purine diet. protein 0.5 mg H-4 Tamoxifen 1x20 mg H-4 . mid upper KET: 1700kkal arm circumference weight : 35 kg .hypoalbuminemia .Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases . urea creatinine.Acute on CKD dd / CKD stage IV Other therapies according TS Interna and Surgery 04/05/2015 Renal hypertension A : . mid upper arm circumference : 19.Ceftriaxone 1gram / 12h / intravenous . and . BBI : 47 kg Diet today 50% of kcal requirements 850 Nutritional status: Severe PEM kcal Via NGT: Honey 3x64 kcal (3x1 tablespoons) Supplementasi : zink 1 x 20 mg delay pujimin 3x2 cap delay O2 4 liter/meinutes via NK Ceftriaxon 1 gr/12hours/iv VIP albumin 3x2 Femara 1x2.Anemia of chronic disease dd / renal anemia . 04/05/2015 Oncology Surgery A : Ca Mammae dextra post MRM lung and hepar metastase - 04/05/2015 Clinical Nutrition Height : 147 cm .electrolyte.Date Follow up Instruction 04/05/2015 Anestesi ICU Day-1 O2 8-10 l / min via NRM A: .O2 8-10 liters / minute via NRM .Fe tablet / 12 hours / oral . potassium.renal dd / pre renal .Plan: routine blood test control.CAP .Post Hypoglycemia . Education for hemodialysa .O2 8-10 liters / minute via NRM .8 4. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 7. No wheezing no rhonkhi.IVFD D10% 28 dpm . Cough mucus (+) sometimes.9 BE: -13. shortness of breath (+).6 88./ Laboratoy Result GDS (06. The left pleural effusion on WSD Instruction . Community Acquired pneumonia 5.0 to 100.000 283. Abdomen: normal peristaltic impression.0 SO2: 98. yeast. Extremity edema . Liver palpable 8 cm below the surface of the arch costa berbenjol with hard consistency.3 2.000 Neutrofil : 72.2 88.Fe tablet / 12h / oral delay . Anemia of chronic disease dd / renal anemia 8. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 6. Decrease Awareness et causa suspected intracranial tumor metastasis dd / DIC 3. salt. Hb : 9. RR: 20x / min Q: 36. the patient was restless and disorientation. APTT. protein 0.IX S: loss of consciousness (+). Thrombocytopenia suspicious DIC 4. regular.Amino acids 250 cc / 24 hours / drips .2 pO2: 113.0 ctCO2: 12. Anti HIV.00 tgl 06/06/2015 ) 121 mg/dl WBC : 12220 27690 27. Malnutrition 10. Post Hypoglycemia 2. jaundice (-) Lung: hemithorax Mounted on the left chest tube.3 (22-26) ctO2: 13. fibrinogen.000 247. HBsAg.4 Cl : 107 116 113 Ureum : 201 165 116 . sputum culture and antibiotic sensitivity (samples aren’t complete yet) CT scan of the head (not done since General state does not allow to) The advice Consul neurology and HOM (not approved by the Main DPJP) .3 (80.Date 05 – 06 /05/2015 ICU D-2 BP: 144/90 HR: 101X / minute. potassium.9 PLT : 99.5 Ferritine : > 1200 A: 1.0) HCO 3: 12.2 9.8 3. O: severe pain / malnutrition / delirium GCS E4V1Mx Head: pale conjunctiva (-).Low-purine diet. gram.2 4.Ceftriaxon 1gram / 12h / iv H12 .8 g / kg / day .40C SO2: 99% Input: 900 cc / 24 hours UO: 850cc / 24h IWL: 400cc BC: -350cc / 24h WSD minimal production Blood Gas Analysis pH: 7. Anti-HCV.860 . Hypoalbuminemia 9.7 Na : 129 135 132 K : 4.Epoetin alfa 3000 IU / 2x a week / subcutan . 3x sputum smear examination.35 to 7. Kreatinin : 3.372 (7.Monitoring GDS / 3 hours . D-dimer.00 tgl 05/06/2015 ) : 84 mg/dl GDS (06.Plan : Check pT.9 9.2 (-2 s / d +2) Result: metabolic acidosis complete compensated Follow up Day Care VIII .45) pCO2: 21. 05 – 06 /05/2015 Oncology Surgery A : Ca Mammae dextra post MRM lung and hepar . salt.Epoetin alfa 3000 IU / 2x a week / subcutan .Ceftriaxone 1gram / 12h / IV .Amino acids 250 cc / 24 hours / drips .Date Follow up Instruction 05 – 06 /05/2015 Anestesi ICU Hari-2 & 3 A : .Tamoxifen 1x20 mg stop Hegight : 147 cm .Ceftriaxon 1 gr/12hours/iv metastase .balance liquid. protein 0.Penurunan kesadaran curiga metastase tumor ke otak .8 g / kg / day .IVFD D10% 20 dpm .Femara 1x2.VIP albumin 3x2 .O2 8-10 liters / minute via NRM .renal dd / pre renal Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases CAP Hypoalbuminemia Anemia of chronic disease dd / renal anemia Post Hypoglycemia Loss of consciousness suspicious tumor metastases to the brain dd / DIC . potassium. mid upper arm circumference weight : 35 kg . Diet today 80% of KET 1360 kcal BBI : 47 kg Via NGT: Nutritional status: Severe PEM Milk Nefrisol 6x135 kcal (2 tbsp) VCO 2x80 kcal (1sdm) supplementation: B1 100 mg / 24 hours B6 10 mg / 24 hours Vitamin C 50 mg / 24 hours 05 – 06 /05/2015 Clinical Nutrition .Low-purine diet.5 mg stop . mid upper arm circumference : 19.5 KET: 1700kkal cm .Ca Mammae post MRM metastase ke paru dan hepar -Akut on CKD dd/CKD stage IV O2 8-10 l / min via NRM Head Up 300 Measure urine / h omeprazole 40mg / 24h / iv Other therapies according TS Interna and Surgery 05 – 06 /05/2015 Renal Hypertension A: Acute on CKD dd / CKD stage IV ec. Anemia of chronic disease dd / renal anemia 8. Hypoalbuminemia 9. Adenocarsinoma mammary dextra post MRM IVB stage lung and liver metastases 6. Decrease Awareness et causa suspected intracranial tumor metastasis dd / DIC 3. Pulmonary: chest tube on the left hemithorax.renal dd / pre renal Adenocarsinoma mammae dextra post MRM IVB stage lung and liver metastases CAP hypoalbuminemia Anemia of chronic disease dd / renal anemia Post Hypoglycemia Loss of consciousness suspicious tumor metastases to the brain - Low-purine diet. Malnutrition 10. gram. potassium. the patient appears apathy. salt.Amino acids 250 cc / 24 hours / drips . and creatinine MSCT scan head (wait for the results) Chest x ray (wait for the result) Acute on CKD dd / CKD stage IV ec. CT. albumin.Plan : 3x sputum smear. mushrooms. jaundice (-) Neck: tumor mass (-). fibrinogen. Anti-HIV (wait for the results). The left pleural effusion on WSD 07/05/2015 Renal Hipertension - . Acute on CKD dd / CKD stage IV renal ec dd / pre renal 7. HBsAg (ELISA). Anti-HCV (ELISA). sputum culture and antibiotic sensitivity (not examined because the sample is not yet complete) Check pT. Community Acquired pneumonia 5.Follow up the signs of bleeding . O: serious illness / malnutrition / apathy GCS E3M3V1 Head: pale conjunctiva (-). Liver palpable 8 cm below the surface of the arch costa nodule with hard consistency. murmur (-) Abdomen: normal peristaltic impression./ Laboratory result: GDS (06:00) = 99 mg / dl A: 1. urea.Ceftriaxon 1gram / 12h / iv H-14 . salt. Wheezing no. BT. regular RR: 24x / min Q: 37. Heart: S1 / S2 regular.Low-purine diet.20C Input: 950 cc / 24 hours UO: 850cc / 24h IWL: 400 cc BC: -300cc / 24h WSD production: minimal Day care X S: loss of consciousness (+). protein 0. protein 0.IVFD D10% 28tpm . Post Hypoglycemia 2.07/05/2015 BP: 140/90 HR: 84x / minute.8 g / kg / day O2 8-10 liters / minute via NRM IVFD D10% 20 dpm Amino acids 250 cc / 24 hours / drips Ceftriaxone 1gram / 12h / IV Epoetin alfa 3000 IU / 2x a week / subcutan Fluid Balance . Control routine blood.8 g / kg / day .O2 8-10 liters / minute via NRM . Extremity edema . Thrombocytopenia suspicious DIC 4. DVS R + 2 cmH2O. APTT.Monitor GDS / 3 hours . shortness of breath (+). Rhonki no. D-dimer.Epoetin alfa 3000 IU / 2x a week / subcutan . potassium. 08/05/2015 A : Ca Mammae dextra post MRM lung and hepar Oncology Surgery metastase 07 – 08 /05/2015 Height : 147 cm . BBI : 47 kg Nutritional status: Severe PEM .07 . mid upper arm circumference : 19. mid upper arm circumference weight : 35 kg .Ceftriaxon 1 gr/12hours/iv .VIP albumin 3x2 KET : 1700kkal Via NGT : Nefrisol 3x 3 tablespoon (202.5 kkal) VCO 4x80 kkal (1 tablespoon) Honey 3x64 kkal (1tablespoon Fruti juice 50 kkal .5 Gizi Klinik cm . 1 3.8 g / kg / day .Low-purine diet. murmur (-) Abdomen: normal peristaltic impression. Anemia of chronic disease dd / renal anemia 8. Decrease Awareness et causa suspected cerebral toxoplasma dd / DIC 3. Hypoalbuminemia 9.Amino acids 250 cc / 24 hours / drips .9C Input: 1000 cc / 24 hours UO: 950 cc / 24 hours IWL: 400cc BC: -350 cc / 24h WSD production: minimal Day care XI S: loss of consciousness (+). The left pleural effusion on WSD . sputum culture and antibiotic sensitivity (not examined because the sample is not yet complete) Blood routine control (waiting result) Advice : Consul dr. potassium.Plan : 3x sputum smear. protein 0. Wheezing no. and liver 6 .8 HBsAg : non reaktif Albumin : 2. shortness of breath (+). the patient appears apathy. Pulmonary: chest tube on left hemithorax. salt.08/05/2015 BP: 140/90 HR: 109x / min RR: 24x / min Q: 36.IVFD D10% 28 dpm . Heart: S1 / S2 regular. jaundice (-) Neck: tumor mass (-). O: serious illness / malnutrition / apathy GCS E3M3V1 Head: pale conjunctiva (-).29 CT Scan Head (06/05/2015) : Falx cerebri calcification and occipital region of the cerebral parenchyma bilateral.00 : 116 D-dimer : 3490 (<585) Fibrinogen : 545 pT : 15.O2 8-10 liters / minute via NRM . DIC score: 4 A: 1.Satriawan Abadi. mushrooms. Acute on CKD dd / CKD stage IV renal ec dd / pre renal 7. Liver palpable 8 cm below the surface of the arch costa nodule with hard consistency. KIC Advice: The Consul Tropical Infections Advice examination Toxoplasma IgG and IgM Educate for HD .Follow up on the signs of bleeding . Malnutrition 10.8 3. apTT : 23.Ceftriaxon 1gram / 12h / iv H-15 .8 anti HCV : non reaktif Ureum : 243 201 165 116 anti HIV : non reaktif Creatinine : 4.5 GDS 07. Extremity edema . Adenocarsinoma mammary dextra post MRM IVB stage lung metastases. gram. Rhonki no.Epoetin alfa 300 IU / 2x a week / subcutan .3 . Sp.Monitor GDS / 6 hours .PD./ Laboratorium result Total Protein : 6.9 2. DVS R + 2 cmH2O. Thrombocytopenia suspicious DIC 4.3 2. Community Acquired pneumonia 5. INR : 1.8 .. Post Hypoglycemia 2. . . KIC S: shortness of breath (+) O: saturation 94% A: . blood pressure could not measured.410 08/05/2015 21.2 PLT : 232.3 ANC : 71210 .45 mcg / kg 15.00 S: seixure generalisata 1x.7 cc / hour / sp apnea.410 Hb : 9.6 cc / hour / sp 08/05/2015 Interna 20.9% Vascon 0.15 Increased titration of dose inotropic Vascon 0.25 mcg / hour / sp 7cc / h / sp Dobutamine 3 mcg / kg 1.5 cc / hour / sp 5mcg dobutamine / kg 2.respiratory failure cardiogenic shock End Stage Renal Disease Priority III to ICU O2 8-10 lpm via NRM Loading 250cc NaCl 0.PD.30 S : Loss of conciousness (+) O : BP : 70/40 HR : 110x/i T: 38.Satriawan Abadi.00 BP : 80/50 HR : 110x/i RR : 36 x/i T : 37.000 Neutrofil : 83.70C RR : 36x/i Leukosit via tphone : 85. fever (+) O: BP: 100/60 HR: 110x / i RR: 36x / i T: 38. Pupills were total mydriasis Result Blood Routine: WBC : 85. Sp.5 Visite dr.08/05/2015 19.50C Diazepam injection ampoules iv bolus extra ½ Paracetamol drips 1 g / 12h / drips 08/05/2015 Interna 20. the pulse Pastient was death was not palpable. not accompanied by mucus or blood. tactile fremitus decreased hemithorax the left height costa VII. HR: 105x / min strong lift. wheezing on left hemithorax. History modified radical mastectomy surgery mammary dextra in January 2013 and a history of renal impairment three months ago when the controls in the clinic. a cough with purulent mucus.Woman. it was found BP: 110/80 mmHg. There is a weight loss of approximately 10 kg in 4 months and nutrient intake less. sunken eyes. rhonki on both the median basal lung. Micturition impression less from diarrhea patients. surface nodule and blunt edges. From the examination. Watery bowel movement since the first week. the sound of breathing decreased in left hemithorax.30C axilla. . peristaltic impression increased. from TS Surgical Oncology counsulted with complaints of shortness of breath that was advancing since 1 last week. and T: 36. hepatomegaly 8 cm below the arcus costa. the movement of the chest wall of the left behind. Conjunctival pallor. hard consistency. RR: 28x / min. percussion dullness in hemithorax the left height costa VII. 48 years old. the frequency is 5 times a day. Based on history. and hypoalbuminemia (albumin 2. anemia (Hb: 7. anemia of chronic disease dd / renal anemia. and malnutrition. .94).9 g / dl). GFR: 21. adenocarcinoma mammae dextra stage IVB post MRM metastases of lung and liver. and investigations. On chest x ray dated 13 April 2015 of lung metastases impression with pneumonia.5. fractures V-VI costa costa IV right and left suggestive of bone metastases. patients diagnosed with community acquired pneumonia.8 g / dl). acute diarrhea mild dehydration moderate.In the investigations obtained leukocytosis (WBC: 29190 / UL). hyponatremia. physical examination. creatinine: 2. hyponatremia (sodium : 129 mmol / L). acute on CKD dd / CKD stage IV ec renal dd / prerenal. azotemia (urea: 116 mg / dl. hypoalbuminemia. On Abdominal ultrasound image dated 14 April 2015 and the hepatic metastases of renal insufficiency. the occurrence of seizures can be caused by a process that is suspected intracranial brain tumor metastases. Eventually the patient is declared dead after no improvement with administration of inotropic and vasoactive. the patient experienced a suspected septic shock due to CAP infection and exacerbated by suspicious Toxoplasma infection.On day 11 of treatment. . and due uremikum syndrome. Seizures that occur can lead to cerebral hypoxia. cerebral toxoplasma suspicious. In addition. infections and neoplasms .Diarrhea GI infection Pulmonary infection Immunocompromize Less intake Carsinoma Mammae CAP Shortness of breath Dehidration metastase Acute on CKD Brain? sepsis Hepar Septic Shock Uremicum enchephalopaty seizure Toxoplasma Cerebral ? Lung Cerebral hypoxia Death Calcification on CT scan of the head picture can be caused by: age.