MORNING REPORT

Oct 10th 2014

IA. dr. Aria

DC :

IB. dr. Adrianne

II. dr. siska

III. dr. Astuti, Sp.P (K)

LAPORAN KEMATIAN
IDENTITAS

Nama

: Tn eko Apriyanto

Umur

: 34 tahun

Alamat

MRS

Meninggal : 10-11-2014

: Jl Kolonel sugiono Gadang

IDx
1.

Lung Tb far advance lession

2.

Pneumonia CAP + Septic condition dt

3.

Imunocomprommised
3.1 B24
3.2 Chronic disease

4.

Electrolite imbalance
4.1 hiponatremia

5.

Reflux (?)

6.

Oral trush

Dx Akhir
1. Shock sepsis
2. Severe PCP
3. TB far advanced lesion
4. Hipoalbuminemia
5. Oral thrush

Terapi 7/09/2014
Ptx:

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

/L

4.700 11,300

Hb

11.30

gr/dL

11,4 15,1

Hematokrit

34.30

38 42

318.000

/L

142.000 424.000

MCV

80.30

fL

80 93

MCH

26.50

pg

27 31

MCHC

32.90

g%

32 36

Eosinofil

0,2

04

Basofil

0.3

01

Neutrofil

82.8

51 67

Limfosit

7.8

25 33

Monosit

8.9

25

Plt

Lymfosit count 846.3

Laboratory
Finding
Nov 8st 2014
RBS

Urinalysis

Value

BJ

1,030

PH

6.0

Leukocyte

Neg

Nitrite

Neg

86

mg/dL

< 200

23.90

mg/dL

16,6-48,5

Creatinine

0.58

mg/dL

<1,2

Prot/Alb

+1

SGOT

143

U/L

0 32

Glucose

Neg

SGPT

44

U/L

0 33

Ketones

Neg

Bil Total

0.41

mg/dL

<1.10

Urobilinogen

Neg

Bil Direct

0.28

mg/dL

<0.25

Bilirubin

Neg

Erythrocyte

Bil
Indirect

0.13

mg/dl

<0.75

Traceintact

Albumine

3.61

g/dL

3.5 5.5

Lpf: Silinder

Neg

Natrium

124

mmol/L

136 145

2.7

Kalium

3.76

mmol/L

3,5 5,0

Hpf:
Erythrocyte

Chloride

103

mmol/L

98 106

Leukocyte

6.7

Bacteria

21.4

Ureum

Sediment

ECG (Nov 8th 2014)

HR 118 x/mnt

Axis frontal : N
Axis horizontal : N
Conclusion :

Rhytm HR118 x/mnt

CXR Nov 8th 2014

Conclusion:

Lung TB far advanced

Pneumonia

AP position, asymmetry
Soft tissue : thin
Bone : costa D/S: normal
ICS : D/S: normal
Trachea : in the middle
Hillus : D: thickening
S : thickening
Cor : 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 0,1x0,5 cm, air
bronchogram +
Pulmo S : fibroinfiltrates on upper,
middle, lower area. Cavities 2x3m m
in the upper area.

Blood Gas Analysis

Conclusion:
Hypooxemia
Hypocarbia
Acidosis metabolic fully compensated
Vein Blood

FiO2 needed : 4-5 lpm NC

PROGRESS NOTE
WAKTU

GCS

TD

RR

SO2 %

10-11-2014
01.00

456

110/60

108

32

99

O2 4lpm NC
Nebule farbivent 3x hari

45

O2 4 lpm NC ganti 10 lpm

Ganti Tight mask 15 lpm

03.00

456

70

32

03.15

111

70/palp

120

28

72

03.30

111

10

37

03.40

111

apnoe

03.45

PDX

PTX

KIE keluarga. Resusitasi

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

Penyebab Kematian
Penyebab langsung

Septic shock

Akibat penyakit:
Severe PCP
Lung TB
Pneumonia CAP
Penyakit Penyerta:
Susp B24
Oral thrush
hipoalbuminemia

MORNING REPORT
Friday Night, Nov 7th 2014
PHYSICIANS INCHARGE:

New Inpatient : 3
Consultation

:-

I.A. dr. Aria

Deathcase

:-

I.B dr. Aziz

II. dr. Dewi

ANAMNESIS
Mr.EkoApriyanto/39 y.o/R.HCU/JKN
Chief complaint : Cough
He 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 didnt until high
fever. He feel fever began afternoon until evening. Fever
didnt 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.

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 EXAMINATIONS
General appearance: looks severely ill
Level of consciousness: GCS 456
BP : 90/70 mmHg
HR : 105x/mnt
RR : 20 x/mnt
T ax : 36.2 C

BW :
BH :
BMI

kg
cm
:

kg/m2

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 V
Perc: RHM : SL D
LHM : ictus
Ausc: S1 S2 single, murmur (-), reguler

PULMO: I St D=S

Au

Dy D=S

V/V

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 unpalpable

: edema - - -

Laboratory Finding
Nov 8th 2014

Value

Leucocyte

10850

/L

4.700 11,300

Hb

11.30

gr/dL

11,4 15,1

Hematokrit

34.30

38 42

318.000

/L

142.000 424.000

MCV

80.30

fL

80 93

MCH

26.50

pg

27 31

MCHC

32.90

g%

32 36

Eosinofil

0,2

04

Basofil

0.3

01

Neutrofil

82.8

51 67

Limfosit

7.8

25 33

Monosit

8.9

25

Plt

Lymfosit count 846.3

Laboratory
Finding
Nov 8st 2014
RBS

Urinalysis

Value

BJ

1,030

PH

6.0

Leukocyte

Neg

Nitrite

Neg

86

mg/dL

< 200

23.90

mg/dL

16,6-48,5

Creatinine

0.58

mg/dL

<1,2

Prot/Alb

+1

SGOT

143

U/L

0 32

Glucose

Neg

SGPT

44

U/L

0 33

Ketones

Neg

Bil Total

0.41

mg/dL

<1.10

Urobilinogen

Neg

Bil Direct

0.28

mg/dL

<0.25

Bilirubin

Neg

Erythrocyte

Bil
Indirect

0.13

mg/dl

<0.75

Traceintact

Albumine

3.61

g/dL

3.5 5.5

Lpf: Silinder

Neg

Natrium

124

mmol/L

136 145

2.7

Kalium

3.76

mmol/L

3,5 5,0

Hpf:
Erythrocyte

Chloride

103

mmol/L

98 106

Leukocyte

6.7

Bacteria

21.4

Ureum

Sediment

ECG (Nov 8th 2014)

HR 118 x/mnt

Axis frontal : N
Axis horizontal : N
Conclusion :

Rhytm HR118 x/mnt

CXR Nov 8th 2014

Conclusion:

Lung TB far advanced

Pneumonia

AP position, asymmetry
Soft tissue : thin
Bone : costa D/S: normal
ICS : D/S: normal
Trachea : in the middle
Hillus : D: thickening
S : thickening
Cor : 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 0,1x0,5 cm, air
bronchogram +
Pulmo S : fibroinfiltrates on upper,
middle, lower area. Cavities 2x3m m
in the upper area.

Blood Gas Analysis

Conclusion:
Hypooxemia
Hypocarbia
Acidosis metabolic fully compensated
Vein Blood

FiO2 needed : 4-5 lpm NC

IDx
1.

Lung Tb far advance lession

2.

Pneumonia CAP + Septic condition dt

3.

Imunocomprommised
3.1 B24
3.2 Chronic disease

4.

Electrolite imbalance
4.1 hiponatremia

5.

Reflux (?)

6.

Oral trush

PTx

PDx

O2 : 4-6 lpm NC

IVFD NaCl 0.9%: D5% 1:1

20 tpm

Sputum gram,culture, sensitivity test

Inj Gentamycin 1x160 mg IV

LDH,recheck SE

Inj. Ranitidine 2x1amp

Blood culture

N Acetyl Sistein 3x200mg

Determinant test

Inj. Ceftriaxon 2x1 gr IV

OAT kat I R/H/Z/E 450/300/1000/1000

B6 1x10mg
Cotrimoxazole 1x960 mg

Nystatin drop 4x1cc

Pasang NGT

Consultation result from

1.

Diagnosis:
Septic dt lung infection
1.1 Pneumonia CAP+septic condition
1.2 Lung TB far advanced lesion + secondary infection

2.

Dyspepsia syndrome
2.1 GERD
2.2 FUD

3. Hiponatremia Hiposmolar hipovolemik

Increase transaminase
5.1 dt no 1
5.2 dt drug induced
5.3 Hepatitis viral

6. Anuria 11 jam
6.1 AKI

PTx

PDx

Diet cair 6x200cc per NGT

Loading NS 0,9% 1000cc diikuti

Metoclopromide 3x10mg iv

HBsAg,anti HCV, determinant test di ruangan

Endoskopi jika perlu

Injeksi ranitidine 2x50mg

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

Lain sesuai ts Paru

Pasien akan kami raber dengan Sie

Dr.Dikara/dr.Amel/dr Sri,Sp.PD

THANK YOU