Upload
fajri-aan
View
214
Download
0
Embed Size (px)
Citation preview
8/13/2019 Death Report 12 Th Januari 2013
1/35
DUTY TEAM
Dr. Wahyudi
Dr. Seri Amni Siregar
Dr. Yostila
Dr. Riko JumatullahDr. Fajriansyah, dr. Yanrike
8/13/2019 Death Report 12 Th Januari 2013
2/35
1. Muchni Luthan, M, 60 YO
A man was admitted since 47 days ago withWD/
Septic shock Cb Bronchopneumonia
Non small cell lung Carcinoma effusion bilatreral Cb malignancy
COPD acut exacerbation
Melena Cb Gastropathy Steroid Hyponatremia Cb Low intake
Post GEA
8/13/2019 Death Report 12 Th Januari 2013
3/35
Therapy
Rest/ flow NGT, fasting 8 hours continue gastric diet / O25 L/1
Prosogan Drip 2 amp in 500 cc NaCl 0,9 % for 10 hours
IVFD NaCl 0,9 % 12 hours/kolf
Ciprofloxacin inf. 2 x 200 mg Dopamin drip 5 microgram/KgBW/hours
Vit. K inj. 3 x 1 amp
Transamin inj. 3 x 1 amp
Sucralfat syr 3 x C1
PCT 3 x 500 mg Ambroxol syr. 3 x C1
Fluid Balanceapplay chateter
8/13/2019 Death Report 12 Th Januari 2013
4/35
8/13/2019 Death Report 12 Th Januari 2013
5/35
Physical Examination
Skin : Decrease of turgor
Eyes : Anemic (+) ikteric (-)
Lung : Broncovesiculer , rales +/+ , Wh-/-
Heart : mur mur (-), reguler
Abdomen : liver and spleen unpalpable
Ext : Oedema -/-
8/13/2019 Death Report 12 Th Januari 2013
6/35
LAB
Hb : 7,4 gr/dl Ht : 41 %
Tr : 626000/mm Leu : 18.200 /mm3
Ur : 34 mg/dL Cr : 1 mg/dL
Na/K/Cl : 123/2,6/98 mmol/dL
RBG : 162 mg/dL
Blood gas analysis
pH : 7,34 pCO2 : 22 mmHg
pO2 : 92 mmHg HCO3- : 11,9 mmol/L
BE ecf : -13,9 mmol/L SO2 : 97 %
8/13/2019 Death Report 12 Th Januari 2013
7/35
Investigation
21/11/2013 : Result of Lung X-ray : Right LungTB
Result of pleural fluid analysis
Impression : Excudate, PMN 85 %, MN 15 %,Rivalta (+)
Pleural fluid cytology : impression : malignancyeffusion (metastase)
CT-Scan ThoraxSugestif Ca. Bronchogenicsegment of the right lung
8/13/2019 Death Report 12 Th Januari 2013
8/35
8/13/2019 Death Report 12 Th Januari 2013
9/35
Consul of consultant hematologist
Impression :
- Non small cell Bronchogenic carcinoma
Advice :
- Prepare of chemotherapy- Chemotherapy with Sindaxel and Actoplatin
Stool cultures of E. Colli sensitive to ciprofloxacin andgentamicin
Sputum cultur : Streptococcus and Hemolyticus, sensitiveCiprofloxacin and Meropenem
8/13/2019 Death Report 12 Th Januari 2013
10/35
Therapy Rest /Gastric diet I/O2 3 L/
Prosogan Drip 2 amp in 500 cc NaCl 0,9 %for 10 hours
Dopamin drip 5 microgram/KgBW/hours
Correction NaCl 3 % 12 Hours/kolf (1 kolf)
Ciprofloxacin inf. 2 x 200 mg
KSR 1 x 1 tab
Sucralfat syr 3 x C1
PCT 3 x 500 mg Ambroxol syr. 3 x C1
Fluid Balanceapplay chateter
Intensive control every 15 minute
8/13/2019 Death Report 12 Th Januari 2013
11/35
Follow up, 10.50 AmS/ Breathlessness (+) Black stool (+)
O/ :GA : Severe Sens : cmc
BP : 70/p HR : fast and smooth
RR : 26 x/min T : 35 C
Impression : Septic shock not resolved
Attitute :
- Intensive control every 15 minute
- Dopamin drip maximal dose continue- Norepinefrin 1 amp in 50 cc NaCl 0,9 % (syringe
pump) star 0,01 microgram/KgBW/hours, up titrationevery 15 minute until Blood presure >= 100 mmHg
8/13/2019 Death Report 12 Th Januari 2013
12/35
At. 22.30 wib
Patient apnue, BP unmeasure, pulselessness,
pupil midriatic, ECG flat, patient state death in
front of doctor, co-ass, nurse and family with
COD septic shock
8/13/2019 Death Report 12 Th Januari 2013
13/35
2. Marzuki, Male, 80 yo,MW
Patient a man was admitted since 1 day
ago wd/:
Septic shock Cb BP bilateral (CAP)
Left antebrachii cellulitis
AKI rifle I Cb pre renal Cb dehidration
8/13/2019 Death Report 12 Th Januari 2013
14/35
Condition of the patient at
admission
S/ Fever (+) , cought (+)
Breathlessness (+)
O/
GA : severe Sens : apathy
BP : unmeasuremen HR : 104x /min
Rr : 32x/min Temp : 36,7 C
8/13/2019 Death Report 12 Th Januari 2013
15/35
Physical examination
Skin : Tugor back later
Eyes : anemic (+), icteric (-)
Lung : Bronchovesiculer , rales +/+
Wheezing -/-
Heart : pure heart rhythm, murmur (-),M1>M2,
A2 > P2
Abd : soepel, Liver and spleen unpalpable
8/13/2019 Death Report 12 Th Januari 2013
16/35
Laboratory :
Hb : 11,8 gr/dl
Ht : 38 %
Tr : 168000/mm
Leu : 3400 /mm
BG : 81 mg/dl
8/13/2019 Death Report 12 Th Januari 2013
17/35
Therapy that has been awarded
Rest / soft diet high calory high protein/O2 L/1
Loading NaCl 0,9 % until urine output >= 0,5 -1 cc/kgbw/hor BP > 100mmHg
Ceftriaxone inj. 1x2 gr (iv)
Ciprofloxacine 2x100 mg Methylprednisolon inj. 2x 30 mg
Ambroxol syr 3x 30 mg
Pct 3x500 mg
Liquid balanceApplay chateter
if the shock is not resolved further norepineprin drip uptitration every 15 minute, maximal 0,5 mg/kgBW/hour
NB : Syring pump is no available, patients fitted drip dopamin
8/13/2019 Death Report 12 Th Januari 2013
18/35
Condition when reffered to duty team
S/ Breathlessness (+), cough (+)
O/ Sens : Apathy BP : 60/palpation
HR : 120 x/min RR : 30 x/min
T : 35,4 C
Eyes : anemic (-), Icteric (-)
Neck : JVP 5-2 cmH2o
Lung : Bronchovesiculer , rales +/+ smooth wet loud,
Wheezing : -/-
Heart : Cardiomegaly (-)
Abd : Liver and spleen unpalpable
Extremitas : oedema -/+
Left Arm : selulitis(+), abses size10x5x0,5cm,pus (+), edema(+)
8/13/2019 Death Report 12 Th Januari 2013
19/35
Impression :
Septic shock Cb Celulitis left antebrachii
(Vascon attached 0,05 microgram/KgBW/hours) BP Bilateral (CAP)
AKI RIFLE I ec prerenal Cb dehydration Cbseptic
Action :
o Intensive controll/15 min
o Norepinefrin up titration
o Another therapy is continued
o Wound care 2x/days
8/13/2019 Death Report 12 Th Januari 2013
20/35
At 11.15 Am
Patient apnue, BP unmeasure, pulselessness,
pupil midriatic, ECG flat, patient state death in
front of doctor, co-ass, nurse and family with
COD Septic Shock
8/13/2019 Death Report 12 Th Januari 2013
21/35
8/13/2019 Death Report 12 Th Januari 2013
22/35
The patient's condition at admission HCU, January 10 th
2014
S/ - Decrease of consioussness (+)
- Breathlessness (+), Fever (+)
O/
Sens : Severa Sensorium : Soupor
BP : 130/80 mmHg HR : 110 x/min
RR : 29 x/min T : 35,8 C
Eyes : anemic (+), Icteric (-)
Neck : JVP 5-2 cmH2o, stiff neck (-)
Lung : Bronchovesiculer , rales +/+ smooth wet loud,
Wheezing : -/-
Heart : Cardiomegaly (-)Abd : Liver and spleen unpalpable
Extremitas : oedema +/+
8/13/2019 Death Report 12 Th Januari 2013
23/35
LAB Hb : 7,9 gr/dl Ht : 41 %
Tr : 126.000/mm Leu : 18.200 /m Ur : 42 mg/dL Cr : 0,7 mg/dL
Na/K/Cl : 122/4,8/97 mmol/dL
RBG : 132 mg/dLAlb/Globulin : 2,8/2,2 gr/dL
Blood gas analysis pH : 7,31 pCO2 : 42 mmHg
pO2 : 56 mmHg HCO3- : 21 mmol/L
BE ecf : -5,2 mmol/L SO2 : 86 %
8/13/2019 Death Report 12 Th Januari 2013
24/35
Therapy that has been awarded
Rest/ Fluid diet via NGT/DD 1700 Kcal
Correction NaCl 3 % 12 hours/kolf and three way with IVFD NaCl0,9 % 12 hours/kolf
Ceftazidin 2 x 1 gr (IV)
Levofloxacin inf. 1x500 mg
Nebulizer Ventolin : fulmicort = 1:1 (if needed) Phyllocontin 2 x tab 1
Brain act inj. 2 x 500 mg
Methyl prednisolon inj. 2 x 30 mg
Neptin tab 2 x 1
Aspilet 2 x 80 mg PCT 3 x 500 mg (if needed)
Fluid BalanceApplay Chateter
Transfusion PRC until Hb >= 10 gr/dL
8/13/2019 Death Report 12 Th Januari 2013
25/35
Visite of duty consultant
Impression : Septic Cb HAP
Advice :
- Applay CVP line
- Fluid balance
- Decubitus ulcer treatment
- Cultur of pus
- Passive mobilization
8/13/2019 Death Report 12 Th Januari 2013
26/35
Condition when reffered to duty team, January 12 th
2014, 08.10 AM
S/ Decrease of consioussnes (+)
Brethlessness (+), Cough (+)O/
Sens : Severe Sens : Souporcomatous
BP : 120/80 mmHg HR : 110 x/min
RR : 29 x/min T : 37,4 o C
Eyes : anemic (+), Icteric (-), pupils ishokor,Light reflex (+)Neck : JVP 5-2 cmH2o, stiff neck (-)
Lung : Bronchovesiculer , rales +/+ smooth wet loud,
Wheezing : -/-
Heart : Cardiomegaly (-), pure rhythm
Abd : Liver and spleen unpalpableExtremitas : oedema +/+
8/13/2019 Death Report 12 Th Januari 2013
27/35
A/
Decrease of Conscioussness Cb hipoxia
Septic Cb HAP
Multiple infark cerebri stroke Type 2 DM controll by insulin with ulcus Right
pedis
Ulcus decubitus grade II-III Hipoalbuminemia Cb Low intake
Hiponatremia Cb Low intake
8/13/2019 Death Report 12 Th Januari 2013
28/35
Impression :
- Intensive control / hours
- Repeat BGA
- Therapy Continue
Planing : Apply CVP line emergency
Consult of cosultant vasculer surgery for
apply CVP lineagree for apply CVP
line
8/13/2019 Death Report 12 Th Januari 2013
29/35
13.00 Wib
out result BGApH : 7,21 pO2 : 49 mmHg
pCO2 : 44 mmHg HCO3- : 22,2 mmol/L
BE ecf : - 4 SO2 : 80 % mmol/LImpression :
- Type 1 Respiratory failure with respiratory Acidosis
Attitude :
- Containment NRM 10 L/1 for 6 Hours
- Check BGA 6 hours post correction
8/13/2019 Death Report 12 Th Januari 2013
30/35
19.00 WIB
S/ the patient still unconsciousBreathlessness (+)
O/
Sens : Severe Sens : Suporocomatus
BP : 110/70 mmHg HR : 120 x/min
RR : 24 x/min T : 37,2 o CEyes : Pupils ishokor,Light reflex (+)
Neck : stiff neck (-)
Lung : Bronchovesiculer , rales +/+ smooth wet loud,
Wheezing : -/-
Laboratory :Out result BGA : pH : 7,2 pCO2 : 54 mmHg pO2 : 141 mmHg
HCO3- : 21,1 mmol/L BE ecf : -6,9 mmol/L
S O2 : 99 % Na/K : 124/4,4 mmol/L
8/13/2019 Death Report 12 Th Januari 2013
31/35
Impression : Respiratory acidosis
Attitude :
- O2 : 2 L/1
- Intensive Controll every hour
8/13/2019 Death Report 12 Th Januari 2013
32/35
23. 00 Wib
Finish to apply CVP Line in OK, The condition patient :S/ the patient still unconscious
Breathlessness (+), Fever (-)O/
Sens : Severe Sens : Suporocomatus
BP : 110/80 mmHg HR : 110 x/minRR : 25 x/min T : 37 o C
Eyes : Pupils ishokor,Light reflex (+)
Neck : stiff neck (-)
Thorax : CVP line inserted eitherLung : Bronchovesiculer , rales +/+ smooth wet loud,
Wheezing : -/-
8/13/2019 Death Report 12 Th Januari 2013
33/35
A/
Decrease of Conscioussness Cb Multiple infarkcerebri
Septic Cb HAP
Type 2 DM controll by insulin with ulcus Right pedis
Ulcus decubitus grade II-III
Attitude :- Intensive Controll every hour
- Therapy continue
04 50 AM J 13 th 2014
8/13/2019 Death Report 12 Th Januari 2013
34/35
04.50 AM , January 13 th 2014 Patient apnue, BP unmeasure, pulselessness,
pupil midriatic, ECG flat, patient state death in
front of doctor, co-ass, nurse and family with
COD pulmonary embolism
8/13/2019 Death Report 12 Th Januari 2013
35/35
THANK YOU