Death Report March 7,2013

7/27/2019 Death Report March 7,2013

1/16

Team :

dr.Susi Andriani, dr.Rahmilna,

dr.Seri Amni Siregar, dr.Rinni Andriani

dr.Edo Yudistira, dr.Farah S Effendi,

dr.Rangga Lunesia

Death ReportMarch 7th,2013


2/16

Yuliarti, female, 52 y.o

Patient was admitted to ward (7th day

hospitalized)with:

WD : - Decrease of consciousness cb uremic

encephalopathy

cb CKD stg V cb nephropathy DM

- Septic shock cb BP Duplex

- Type 2 DM controlled by diet normoweight- Cirrhosis Hepatic post necrotic std

Decompensate

- Suspect Relapse Lung TB


3/16

March 7th, 2013, 15.20 WIB

Patient was assisted to duty team in condition :S : Decrease of consciousness

O : GA : Severe, Consc : Sopor, BP: 80/pols,

Heart rate: soft and rapid

Respiration rate : 14x Temp : 37,8C

Eyes : Pupil isochors, Light reflex +/+ decrease,

conj anemic -/-, icteric -/-

Lung: Bronchovesicular, Rales +/+

Cor : Sinus rhythm , regular, murmur (-)

Abdomen : Shifting dullness (+)

Ext Sup- Inf- or : Oedem +/+, RF +/+, RP -/-


4/16

Lab :

March 2nd, 2013 : Analysis of Fluid Acites:

Hemoglobin : 13,8 LDH : 190

Hematocrite : 39,8 cell : 25

Leucosite : 9400 Protein : 3,9

Trombosit : 215.000 Glucose: 157

Rivalta : (-) ->A:Transudat

Na/K : 132/4,5 urinalisa : protein ++

Ur/Cr : 179/5,2

Albumin : 1,9

Globulin : 5,7

GDS : 139

HbsAg : (+)


5/16

March 7th, 2013 :

pH : 7,24 HCO3 : 14,6

pCO2 : 34 BE : -12,8

pO2 : 141 SO2 : 99%

Therapy :

Rest/NGT/Diabetic Diet 1500 kkal,RG II RP gr, DH 1

IVFD Eas Primer:NaCl 0,9% 12 hours/kolf Drip Dopamin 20gtt/I

Inj Ceftriaxon 1x2gr iv

Inj Levofloxacin 1x500mg

Inj Dexametason 3x5mg Inj Ca Gluconas 3x1amp

Lactulose syr 3xC1

Spironolactan 1x100gr


6/16

Curcuma 1x40mg

As folat 1x5mg

Bic Nat 3x500mh

Correction Meylon 100mEg on 100cc NaCl

March 7th, 2013, 16.00 WIB

S : Decrease of Consciousness (+)

O : GA : Severe, Consc : Sopor, BP : 80/pulse,Heart rate : soft and rapid

Respiration rate : 18x Temp : 37,8

A : Septic shock cb Bronchopneumonia (HAP) (no resolveyet)

Decrease of consciousness cb uremic encepalopathy

P : - Combination with Dobutamin drip 2 ampul on500cc NaCl 0,9% start from 5 gtt until blood pressure100

- KI /15 minutes


7/16

March 7th, 2013, 16.30 WIB

S : Decrease of Consciousness (+)

O : GA : Severe, Consc : Sopor, BP : 70/pulse,

Heart rate : soft and rapidRespiration rate : 16x Temp : 37,8

A : Septic shock cb Bronchopneumonia (no resolve

yet)

P : - Dobutamin drip 10 gtt/ (increase the titrasi)

- KI /15 minutes


8/16

March 7th, 2013, 17.20 WIB

Patient was apnea

Blood pressure : unmeasurable

Heart rate : unmeasurable

Pupil : maximal dilatation

ECG : FlatPatient was sentenced die in front of family and

friends,

with COD : MODS


9/16

Sutiani, Female, 66 y.o

Patient was admitted to ward (11st day

hospitalized)with:

WD :

Septic cb Bilateral Bronchopneumonia with

respiratory failure type II

Type 2 Diabetic Melitus controlled with insulin,

underweight

CHF fc II LVH RVH sinus rhythm cb ASHD

SOPT


10/16

March 7th, 2013, 16.30 WIB

Patient was assisted to duty team in condition :S : Breathlessness (+), Fever (-)

O : GA :Moderate , Consc :CMC , BP : 130/80 ,

Heart rate : 102x

Respiration rate : 28 Temp : 36,5

Eyes : anemia (-), sclera icteric (-)

Lung: bronchovesicular, Rales +/+, wh -/-

Cor : cardiomegali, murmur(-)Abdomen : Hepar palpable 1 finger BAC

Ext Sup- Inf- or : Oedem -/- , RF +/+, RP -/-


11/16

Lab :

March 2nd, 2013 :

Hb : 10,5 -Total Cholesterol : 146

Ht : 37,1 -LDL : 91,6

Leucosite : 4.240 -HDL : 40

Trombosit : 206.000 -Trigliserida : 72

Na/K : 140/2,6 March 7th, 2013 :

February 25th,2013 -pH : 7,27

- Ur/Cr : 29/0,7 -pCO2 : 101

- SGOT/SGPT : 22/15 -pO2 : 54

- Alb/Glo : 3,2/4,4 -HCO3 : 46,4-BE : 19,5

March 7th, 2013 : -SO2 : 83%

Fasting Glucose : 114

2hours Post Prandial Glucose :162


12/16

Consult to Pulmonology Consultant :

Impression : Type II Respiratory FailureAdvice :

Optimalization nebu

Aminophylin drip

Corticosteroid inj

Blood gas analyse

Not necessary to consult the patient to ICU yet

because patient was conscious


13/16

Therapy :

Rest/DJ II DD 1700kkal

IVFD NaCl 0,9% 8hours/kolf Farbivent nebu /4hours

Inj Methyl Prednisolon 2x62,5

Inj Ceftriaxon 1x2gr

Inj Lasix 1x1amp

Ramipril 1x2,5

Ascardia 1x80mh

Ambroxol 3xc1

Dulcolax 1x2tab

KSR 2x1 tab Inj Novorapid 3x6iu

Urine Catheter (Fluid Balance)


14/16

17.30 WIB

S : Breathlessness (+), Fever (-)

O : GA :moderate, Consc :aphatic , BP : 120/80,Heart rate : 110x/

Respiration rate : 34x/ Temp : 37,8

A : Septic cb Bronchopneumonia duplex with SOPT

P : Continue the therapy

Blood Gas Analyze

18.00 WIBRepeat Blood Gas Analyze had been sent but the

sample return because it was not enough


15/16

18.30 WIB

S : Breathlessness (+)

Fever (+)

O : GA : severe, Consc :sopor, BP : 110/80, Heart

rate :120

Respiration rate : 38, Temp : 37,8Eyes : Pupil isochors, Light reflex +/+ decrease,

Ext Sup- Inf- or : Lateralisation (-) , RF +/+, RP

-/-

A : Decrease of Consciousness cb type 2

respiratory failure cb SOPT

P : Blood Gas Analyze

Intensive control /15 minutes


16/16

19.15 WIB

Patient was apneaBlood pressure : unmeasurable

Heart rate : unmeasurable

Pupil : maximal dilatationECG : Flat

Patient was sentenced die in front of family and

friends,

with COD : Type 2 Respiratory Failure

Documents

Death Report March 7,2013