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7/27/2019 Death Report March 7,2013
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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
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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
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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 -/-
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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 : (+)
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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
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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
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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
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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
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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
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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 -/-
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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
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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
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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)
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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
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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
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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
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