Death Case 7 AGUSTUS 2020 RSU MANADO MEDICAL CENTER Identitas Pasien Nama : Tn. M. P Usia : 41 tahun Jenis Kelamin : Laki- Laki Alamat : Lingkungan 1, Tuminting MRS : 26 Juni 2020 jam 23.00 Keluhan Utama : Lemah Badan sejak beberapa hari SMRS disertai dengan penurunan nafsu makan Pasien rujukan dari Dr. Inggrit Lontoh, SpPD dgn dx : TB paru aktif bilateral Anemia on chronic disease Hepatopati Susp CKD dd AKI Physical Examination TD = 107/66 mmHg HR = 99 bpm, teratur, kuat angkat RR = 20 tpm, teratur Keadaan umum tampak sakit sedang GCS 4-5-6 Kepala Konjungtiva pucat(+/+), Sklera ikterik (-/-) Kulit Turgor cepat kembali, pigmentasi kulit kuning langsat Chest Jantung: S1, S2 tunggal, murmur (-), gallop (-) Paru: Inspeksi : Simetris Palpasi : FV D = S Perkusi : Sonor Auskultasi : Suara Napas Vesikuler Rh -/Wh - / +/+ +/+ Abdomen Datar, (+), BU (+) Normal, Nyeri tekan episgastrium (+) Extremities Akral hangat, CRT <2” T : 36 °C Laboratory Result 27/06/2020 Items Result Normal Value Unit Hemoglobine 7,1 12.00 - 16.00 g/dl Leukocyte 10,9 4.0 – 10.5 thousand/ul Eritrocyte 4,12 4.50 – 6.00 million/ul Hematocrit 20,3 42.00 – 52.00 Vol% Trombocyte 458 150 – 450 Ribu/ul RDW-CV 14,7 11,5-14,7 % MCV 78 80.0 – 97.0 Fl MCH 28,5 27.0 – 32.0 Pg MCHC 34,9 32.0 – 38.0 % Hematology Laboratory Result 27/06/2020 Items Result Normal Value Unit Natrium 123 135 - 150 Mmol / L Kalium 2,8 3,5 – 5,5 Mmol / L Chlorida 81,3 96,0 – 108,0 Mmol / L Ureum 41,4 20 - 40 Mg / dL Creatinin 1,5 0,5 - 1,1 Mg / dL SGOT 120,8 0-46 U/I SGPT 29,1 0-45 U/I R NR Anti HIV 1 / 2 Follow Up IGD tgl. 26/06/2020 Jam 23.00 Subjek Objective Assessment P.Tx 1. VS BP: 107/66 mmHg HR: 99 x/m RR: 22x/m T: 36°C - - Lemah Badan - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI renal dd susp CKD Susp Immunocompro mised Efusi Pleura Dextra Susp Electrolyte Imbalance - IVFD NS 09% + Biocombin 10 gtt/m Injeksi ranitidin 1 ampul extra lanjut lansoprazole 2x 30 mg caps Injeksi Ceftriaxone 2x1gr IV Omegtamine 2x1 tab Curcuma 2x1 tab Ketokonazole 1x 200mg (P) Gentian violet 2x2 tetes Clindamycin 2x1 Pro transfusi PRC sampai HB 10 gr/dl Follow Up IGD tgl. 27/06/2020 Jam 21.15 Subjek Objective Assessment P.Tx 1. VS BP: 107/66 mmHg HR: 99 x/m RR: 22x/m T: 36°C - - Lemah Badan - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI pre renal Immunocompro mised Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) - IVFD NS 09% + Biocombin 10 gtt/m (HOLD) IVFD NS 3% 10 tpm IVFD NS 0.9% + KCL 25 meq 8 tpm Follow Up Ruangan tgl. 30/06/2020 Jam 07.35 Subjek Objective Assessment P.Tx 1. VS BP: 108/67 mmHg HR: 95 x/m RR: 22x/m T: 36°C - + codein 3x1 Batuk dahak - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI pre renal Immunocompro mised Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Follow Up Ruangan tgl. 30/06/2020 Jam 19.00 Subjek Objective Assessment P.Tx 1. VS BP: 108/67 mmHg HR: 95 x/m RR: 22x/m T: 36°C - - Batuk - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI pre renal Immunocompro mised Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Terapi lanjut Follow Up Ruangan tgl. 01/07/2020 Jam 11.00 Subjek Objective Assessment P.Tx 1. VS BP: 105/65 mmHg HR: 90 x/m RR: 22x/m T: 36°C - - Batuk - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI pre renal Immunocompro mised Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Terapi lanjut Follow Up Ruangan tgl. 01/07/2020 Jam 18.30 Subjek Objective Assessment P.Tx 1. VS BP: 115/65 mmHg HR: 88 x/m RR: 22x/m T: 36°C - - Batuk - TB paru + infeksi sekunder Anemia on chronic disease ; hepatopati AKI pre renal Immunocompro mised Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Terapi lanjut Follow Up Ruangan tgl. 02/07/2020 Jam 09.48 Subjek Objective Assessment P.Tx 1. VS BP: 111/61 mmHg HR: 84 x/m RR: 22x/m T: 36°C - - Demam - - TB paru aktif bilateral Anemia on chronic disease AKI pre renal RVD stage 1 Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Guyur NS 0.9% 500cc Injeksi dexamethasone 1 ampul extra Paracetamol drips per 8 jam jika SB> 38 Atarax 1x1tab (M) PRO DL ulang Laboratory Result 02/07/2020 Items Result Normal Value Unit Hemoglobine 9,6 12.00 - 16.00 g/dl Leukocyte 27,6 4.0 – 10.5 thousand/ul Eritrocyte 4,12 4.50 – 6.00 million/ul Hematocrit 26,9 42.00 – 52.00 Vol% Trombocyte 291 150 – 450 Ribu/ul RDW-CV 16,2 11,5-14,7 % MCV 83,3 80.0 – 97.0 Fl MCH 29,7 27.0 – 32.0 Pg MCHC 35,9 32.0 – 38.0 % Hematology Follow Up Ruangan tgl. 02/07/2020 Jam 17.00 Subjek Objective Assessment P.Tx 1. VS TD : 115/560 N : 96 R : 26 SB : 36.8 - - Muntah 2x isi makanan Conj anemis +/+ Rhonki +/+ CRT <2 - - TB paru aktif bilateral Anemia on chronic disease AKI pre renal RVD stage 1 Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Injeksi omeprazole 1 ampul extra Injeksi ondasentron 2 ampul extra Follow Up Ruangan tgl. 02/07/2020 Jam 18.50 Subjek Objective Assessment P.Tx 1. VS TD : 110/55 N : 114 R : 26 SB : 36.8 - - Muntah 2x isi makanan Conj anemis +/+ Rhonki +/+ CRT <2” - - TB paru aktif bilateral Anemia on chronic disease RVD stage 1 AKI pre renal Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Terapi lanjut Follow Up Ruangan tgl. 03/07/2020 Jam 08.10 Subjek Objective Assessment P.Tx 1. 2. 3. VS TD : 110/70 N : 110 R : 26 SB : 36.8 - - Terapi lanjut + Grantusif 3x1 tab + injeksi meropenem 2x1 gr IV - DC injeksi ceftriaxone Demam (-) Muntah (-) Batuk lendiri (+) Conj anemis +/+ Rhonki +/+ CRT <2” - - TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 2 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Follow Up Ruangan tgl. 04/07/2020 Jam 08.40 Subjek Objective Assessment P.Tx 1. VS TD : 105/70 N : 100 R : 30 SB : 36.8 - - Nyeri perut Conj anemis +/+ Rhonki +/+ CRT <2” - - TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 2 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Terapi lanjut Sucralfat syr 3x c2 Follow Up Ruangan tgl. 04/07/2020 Jam 19.00 Subjek Objective Assessment P.Tx 1. VS TD : 115/80 N : 110 R : 24 SB : 36.8 - - Nyeri perut Conj anemis +/+ Rhonki +/+ CRT <2” - - TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 2 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Terapi lanjut Injeksi ondasentron 1 ampul extra Injeksi ranitidin 1 ampul extra Follow Up Ruangan tgl. 05/07/2020 Jam 08.30 Subjek Objective Assessment P.Tx 1. GCS E2 M5 V2 - - Penurunan kesadaran VS TD : 99/55 N : 144 R : 37 SB : 36.8 - Conj anemis +/+ Rhonki +/+ CRT <2” - - - - Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 2 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Terapi lanjut Injeksi Cefotaxime 2x1 gr IV Injeksi meropenem TAP Injeksi dexamethasone 1 amp extra Inj recodryl 2,5 cc extra Kotrimoksazole 2x2 tab Edukasi pemasangan ETT dan NGT Follow Up Ruangan tgl. 05/07/2020 Jam 08.30 Subjek Objective Assessment P.Tx 1. GCS E2 M5 V2 - - Penurunan kesadaran VS TD : 71/38 N : 144 R : 37 SB : 36.8 - Conj anemis +/+ Rhonki +/+ CRT >2” - - - - Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Terapi lanjut Bubur halus 50cc per 6 jam via NGT Pro ARV jika keadaan membaik Follow Up Ruangan tgl. 05/07/2020 Jam 18.00 Subjek Objective Assessment P.Tx 1. GCS E2 M5 V2 - - Instruksi DPJP : Intubasi : ETT 7.5 level 22 cm Hubungkan ke MV TV 360 RR 16 I:E 1:3 Fi02 100% PEEP 5 - Suction Pasang kateter Transfusi prc 1 kantong sekarang Penurunan kesadaran VS TD : 74/55 N : 110 R : 16 SB : 36.8 SpO2 90% Conj anemis +/+ Rhonki +/+ CRT >2” - - - ARDS Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Follow Up Ruangan tgl. 05/07/2020 Jam 20.00 Subjek Objective Assessment P.Tx 1. GCS E1 M3 V2 - - Penurunan kesadaran VS TD : 80/45 N : 100 R : 26 (MV) SB : 36.8 SpO2 80% Conj anemis +/+ Rhonki +/+ CRT >2” - - - ARDS Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Suction -> SpO2 turun ke 60% Stop MV Lanjut BVM SpO2 -> 88% Follow Up Ruangan tgl. 05/07/2020 Jam 21.00 Subjek Objective Assessment P.Tx 1. GCS E1 M3 V2 - - Penurunan kesadaran VS TD : 82/40 N : 80 R : 26 (MV) SB : 36.8 SpO2 70% Conj anemis +/+ Rhonki +/+ CRT >2” - - ARDS Sepsis ec TB paru aktif bilateral + secondary bacterial infection infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Suction -> SpO2 turun ke 50% Stop MV Lanjut BVM SpO2 -> 77% Follow Up Ruangan tgl. 05/07/2020 Jam 23.00 Subjek Objective Assessment P.Tx 1. GCS E1 M3 V2 - - Penurunan kesadaran VS TD : 80/50 N : 77 R : 22 (MV) SB : 36.4 SpO2 60% Conj anemis +/+ Rhonki +/+ CRT >2” - - - ARDS Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Suction -> SpO2 turun ke 50% Stop MV Lanjut BVM SpO2 -> 70% Follow Up Ruangan tgl. 05/07/2020 Jam 23.15 Subjek Objective Assessment P.Tx 1. GCS E1 M1 V1 - - RESPONS (-) VS TD : N:R:SB : 35.8 SpO2 40% Conj anemis +/+ CRT >2” - - - Acute Respiratory failure tipe 1 on MV Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Start RJP 5 siklus Injeksi epinefrin 1 ampul Follow Up Ruangan tgl. 05/07/2020 Jam 23.25 Subjek Objective Assessment P.Tx 1. GCS E1 M1 V1 - - RESPONS (-) VS TD : N:R:SB : 35.7 SpO2 30% Conj anemis +/+ CRT >2” - - - Acute Respiratory failure tipe 1 on MV Sepsis ec TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis Start RJP 5 siklus Injeksi epinefrin 1 ampul Follow Up Ruangan tgl. 05/07/2020 Jam 23.35 Subjek Objective Assessment P.Tx 1. GCS E1 M1 V1 - Acute Respiratory failure tipe 1 on MV - - TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis RESPONS (-) VS TD : N:R:SB : 35.7 SpO2 30% Conj anemis +/+ CRT >2” - - Start RJP 5 siklus Follow Up Ruangan tgl. 05/07/2020 Jam 23.45 Subjek Objective Assessment P.Tx 1. GCS E1 M1 V1 - - RESPONS (-) VS TD : N:R:SB : 35.7 SpO2 0% Pupil midriasis maksimal Conj anemis +/+ CRT >2” - - - Acute Respiratory failure tipe 1 on MV TB paru aktif bilateral + secondary bacterial infection Anemia on chronic disease RVD stage 3 AKI renal dd CKD Efusi Pleura Dextra Electrolyte Imbalance (Hipo Natremia, Hipo Kalemia, Hipo Chlorida) Oral candidiasis - Pasien dinyatakan meninggal EKG flat Thank you