MORNING REPORTOct 10th 2014

PHYSICIAN IN CHARGENP : IA. dr. Aria DC : 1 IB. dr. AdrianneC : - II. dr. siskaIII. dr. Astuti, Sp.P (K)

LAPORAN KEMATIANIDENTITAS Nama : Tn eko Apriyanto Umur : 34 tahun Alamat : Jl Kolonel sugiono Gadang

MRS : 8 -11-2014 Meninggal : 10-11-2014

IDx1. Lung Tb far advance lession2. Pneumonia CAP + Septic condition dt 2.1 Bacterial 2.2 PCP3. Imunocomprommised 3.1 B24 3.2 Chronic disease4. Electrolite imbalance 4.1 hiponatremia5. Reflux (?)6. Oral trush

Dx Akhir1. Shock sepsis2. Severe PCP3. TB far advanced lesion4. Hipoalbuminemia5. Oral thrush

Terapi 7/09/2014Ptx: O2 4 lpm NC IVFD NS 0,9% : aminofluid 2:1 30 dpm Inj Ceftriaxon 2x1 gr iv Inf Levofloxacine 1x750 mg Ranitidin 2x1 amp iv Metoclopromide 3x1 amp iv Farbivent nebulizer 3x1/hari Cotrimoxazole 1x960mg

Laboratory Finding Nov 8th 2014 Value

Leucocyte 10850 /µL 4.700 – 11,300Hb 11.30 gr/dL 11,4 – 15,1Hematokrit 34.30 % 38 – 42 Plt 318.000 /µL 142.000 – 424.000MCV 80.30 fL 80 – 93 MCH 26.50 pg 27 – 31 MCHC 32.90 g% 32 – 36 Eosinofil 0,2 % 0 – 4 Basofil 0.3 % 0 – 1 Neutrofil 82.8 % 51 – 67 Limfosit 7.8 % 25 – 33 Monosit 8.9 % 2 – 5 Lymfosit count 846.3

Laboratory Finding Nov 8st 2014 Value

RBS 86 mg/dL < 200Ureum 23.90 mg/dL 16,6-48,5Creatinine 0.58 mg/dL <1,2SGOT 143 U/L 0 – 32SGPT 44 U/L 0 – 33Bil Total 0.41 mg/dL <1.10Bil Direct 0.28 mg/dL <0.25Bil Indirect 0.13 mg/dl <0.75Albumine 3.61 g/dL 3.5 – 5.5Natrium 124 mmol/L 136 – 145Kalium 3.76 mmol/L 3,5 – 5,0Chloride 103 mmol/L 98 – 106

UrinalysisBJ 1,030PH 6.0Leukocyte Neg Nitrite Neg Prot/Alb +1Glucose Neg Ketones Neg Urobilinogen Neg Bilirubin Neg Erythrocyte Trace-

intactSedimentLpf: Silinder Neg Hpf:Erythrocyte 2.7

Leukocyte 6.7Bacteria 21.4

ECG (Nov 8th 2014) HR 118 x/mnt Axis frontal : N Axis horizontal : NConclusion : Rhytm HR118 x/mnt

CXR Nov 8th 2014

Conclusion: Lung TB far advanced

lession Pneumonia

AP position, asymmetrySoft tissue : thinBone : costa D/S: normal

ICS : D/S: normalTrachea : in the middleHillus : D: thickening

S : thickeningCor : site : normal

Size : ctr 50%Shape : normal

Hemidiaphragm : D :domeshape S :domeshape

Sinus costophrenicus : D/S: sharp Pulmo D : fibroinfiltrates on the

upper,middle area, multiple cavities in upper area Ø 0,1x0,5 cm, air bronchogram +

Pulmo S : fibroinfiltrates on upper, middle, lower area. Cavities 2x3m m in the upper area.

Blood Gas Analysis (Nov 8th 2014)

4 lpm NCpH 7.42 7.35-7.45 FiO2 0.36PCO2 26.1 mmHg 35-45 ((760-47)*0.36)-(26.1/0,8)PO2 56.3 mmHg 80-100 224.055HCO3 17 m mol/l 21-28 A-a DO2 (224.055-56.3)BE -7.6 32.841667 m mol/l -3 - +3 167.755Sat O2 90.1 % >95 FiO2 needed (167.755+150)/760

41.80986842

with O2 4 lpm NC

Original PO2

Conclusion:• Hypooxemia• Hypocarbia• Acidosis metabolic fully compensated• Vein Blood

FiO2 needed : 4-5 lpm NC

PROGRESS NOTEWAKTU GCS TD N RR SO2 % PDX PTX

10-11-201401.00 456 110/60 108 32 99 •O2 4lpm NC

•Nebule farbivent 3x hari

03.00 456 - 70 32 45•O2 4 lpm NC ganti 10 lpm NRBM •Loading NaCl 200cc

03.15 111 70/palp 120 28 72Ganti Tight mask 15 lpm Drip NE 4tpm/jam

03.30 111 - - 10 3703.40 111 - - apnoe - KIE keluarga. Resusitasi

Jantung :paru 30:2

03.45 Pupil midriasis maksimal. Refleks kornea (-). KIE keluarga. Pasien dinyatakan meninggal di depan keluarga dan perawat

Penyebab Kematian Penyebab langsung

Septic shock Akibat penyakit:

Severe PCPLung TB Pneumonia CAP

Penyakit Penyerta:Susp B24Oral thrushhipoalbuminemia

MORNING REPORTFriday Night, Nov 7th 2014

PHYSICIANS INCHARGE:

New Inpatient : 3Consultation : - I.A. dr. AriaDeathcase : - I.B dr. Aziz

II. dr. DewiIII. dr. Suryanti, Sp.P

ANAMNESISMr.EkoApriyanto/39 y.o/R.HCU/JKNChief complaint : CoughHe has been suffering from cough since 1 months,

worsening in 2 week with yellowish sputum. Bloody cough (-), Night sweating (+)

He has been suffering from shortnesss of breath since 2 week ago just if cough.its getting worse 3 days ago, he sleeps on 1 pillow. PND(-),Leg edema(-).

He has been fever 1 month ago but didn’t until high fever. He feel fever began afternoon until evening. Fever didn’t until cold sweat dan thrill.

He complained of difficulty in swallowing food and drink water since 3 weeks ago. He also complained Every drink water always back out of the nose through. It suffering has been since 3 days ago.

He also complained injuries the mouth,the tongue has long been difficult to heal since 3 weeks ago

History of previous disease: DM(-) Ht(-), asthma (-), lung TB (-)

Anamnesis cont’……. History of family disease: HT (-),DM (-), TB

(-). History of smoking: 12 pieces/day for 15

years. Occupation : Freelance Risk factor : tattoo(+), free sex (?), alcohol

(-) drugs (-)

PHYSICAL EXAMINATIONSGeneral appearance: looks severely illLevel of consciousness: GCS 456BP : 90/70 mmHgHR : 105x/mnt RR : 20 x/mnt T ax : 36.2 ⁰C

Head : anemis +/+, icterus -/-Neck : JVP: R + 0 cmH2O at 300, enlargement of lymphnodes

(-)Thorax : COR : Insp: ictus invisible

Palp: ictus palpable at 2 cm lateral MCL S ICS VPerc: RHM : SL D LHM : ictus Ausc: S1 S2 single, murmur (-), reguler

BW : kgBH : cmBMI : kg/m2

50168

17.72

PULMO: I St D=S Au V/V Dy D=S V/V V/V P SF N/ N Rh - / - N/ N -/ - N/ N - / -Pc S/ S Wh -/ - S/ S - /- S/ S - /-

Abdomen : flat, soefle, met(-), BS (+) H/L unpalpableExtremities : edema - -

- -

Laboratory Finding Nov 8th 2014 Value

Leucocyte 10850 /µL 4.700 – 11,300Hb 11.30 gr/dL 11,4 – 15,1Hematokrit 34.30 % 38 – 42 Plt 318.000 /µL 142.000 – 424.000MCV 80.30 fL 80 – 93 MCH 26.50 pg 27 – 31 MCHC 32.90 g% 32 – 36 Eosinofil 0,2 % 0 – 4 Basofil 0.3 % 0 – 1 Neutrofil 82.8 % 51 – 67 Limfosit 7.8 % 25 – 33 Monosit 8.9 % 2 – 5 Lymfosit count 846.3

Laboratory Finding Nov 8st 2014 Value

RBS 86 mg/dL < 200Ureum 23.90 mg/dL 16,6-48,5Creatinine 0.58 mg/dL <1,2SGOT 143 U/L 0 – 32SGPT 44 U/L 0 – 33Bil Total 0.41 mg/dL <1.10Bil Direct 0.28 mg/dL <0.25Bil Indirect 0.13 mg/dl <0.75Albumine 3.61 g/dL 3.5 – 5.5Natrium 124 mmol/L 136 – 145Kalium 3.76 mmol/L 3,5 – 5,0Chloride 103 mmol/L 98 – 106

UrinalysisBJ 1,030PH 6.0Leukocyte Neg Nitrite Neg Prot/Alb +1Glucose Neg Ketones Neg Urobilinogen Neg Bilirubin Neg Erythrocyte Trace-

intactSedimentLpf: Silinder Neg Hpf:Erythrocyte 2.7

Leukocyte 6.7Bacteria 21.4

ECG (Nov 8th 2014) HR 118 x/mnt Axis frontal : N Axis horizontal : NConclusion : Rhytm HR118 x/mnt

CXR Nov 8th 2014

Conclusion: Lung TB far advanced

lession Pneumonia

AP position, asymmetrySoft tissue : thinBone : costa D/S: normal

ICS : D/S: normalTrachea : in the middleHillus : D: thickening

S : thickeningCor : site : normal

Size : ctr 50%Shape : normal

Hemidiaphragm : D :domeshape S :domeshape

Sinus costophrenicus : D/S: sharp Pulmo D : fibroinfiltrates on the

upper,middle area, multiple cavities in upper area Ø 0,1x0,5 cm, air bronchogram +

Pulmo S : fibroinfiltrates on upper, middle, lower area. Cavities 2x3m m in the upper area.

Blood Gas Analysis (May 28th 2014)

4 lpm NCpH 7.42 7.35-7.45 FiO2 0.36PCO2 26.1 mmHg 35-45 ((760-47)*0.36)-(26.1/0,8)PO2 56.3 mmHg 80-100 224.055HCO3 17 m mol/l 21-28 A-a DO2 (224.055-56.3)BE -7.6 32.841667 m mol/l -3 - +3 167.755Sat O2 90.1 % >95 FiO2 needed (167.755+150)/760

41.80986842

with O2 4 lpm NC

Original PO2

Conclusion:• Hypooxemia• Hypocarbia• Acidosis metabolic fully compensated• Vein Blood

FiO2 needed : 4-5 lpm NC

IDx1. Lung Tb far advance lession2. Pneumonia CAP + Septic condition dt 2.1 Bacterial 2.2 PCP3. Imunocomprommised 3.1 B24 3.2 Chronic disease4. Electrolite imbalance 4.1 hiponatremia5. Reflux (?)6. Oral trush

PDx Sputum gram,culture,

sensitivity test Sputum AFB 3 times Blood culture Determinant test LDH,recheck SE

PTx O2 : 4-6 lpm NC IVFD NaCl 0.9%: D5% 1:1 20 tpm Inj. Ceftriaxon 2x1 gr IV Inj Gentamycin 1x160 mg IV Inj. Ranitidine 2x1amp N Acetyl Sistein 3x200mg OAT kat I R/H/Z/E 450/300/1000/1000 B6 1x10mg Cotrimoxazole 1x960 mg Nystatin drop 4x1cc Pasang NGT

Consultation result from Interna dept. Diagnosis: 1. Septic dt lung infection 1.1 Pneumonia CAP+septic condition 1.2 Lung TB far advanced lesion + secondary infection2. Dyspepsia syndrome 2.1 GERD 2.2 FUD3. Hiponatremia Hiposmolar hipovolemik 3.1 low intake4. Limfopeni +oral thrush 4.1 Imunocompromised state 4.1.1 B24 4.1.2 TB5. Increase transaminase 5.1 dt no 1 5.2 dt drug induced 5.3 Hepatitis viral6. Anuria 11 jam 6.1 AKI

PDx Bil T/D/I,ur/cr, SE,Bj

Plasma HBsAg,anti HCV,

determinant test di ruangan

Endoskopi jika perlu

PTx Diet cair 6x200cc per NGT Loading NS 0,9% 1000cc diikuti

dengan IVFD NS 0,9% :aminofluid 2:1 30 tpm

Metoclopromide 3x10mg iv Injeksi ranitidine 2x50mg Lain sesuai ts ParuPasien akan kami raber dengan Sie Gastro + tropmed jika keluarga & TS setuju.Atas perhatiannya kami ucapkan terima kasih Dr.Dikara/dr.Amel/dr Sri,Sp.PD

THANK YOU