DEATH CASE

A 54 years old man admitted to C2 ward on May

1st and passed away on 8th May 2019
•A 54 years old man admitted to C2 Ward on
May 1st 2019

•With main complain : passing of bloody

stool
Patient’s Identity
• Name : Mr. JWK
• Age : 54 years old
• Sex : Male
• Adress : Manado
• Occupation : others
• Education : High school
• Ethnic : Minahasa
• Religion : Christian
History of Present Illness
• Patient came to ER because of passage of bloody stool
since 3 days before admissions. He had 2 watery
bloody stool over 24 hours.
• He also complained of fever since one day before
admissions, malaise, nausea , pain in the middle of
upper abdomen and shortness of breath
• There was no history of vomitus, cough
Past Medical History
• History of hypertension since 10 years ago. Routinely,
taking amlodipine 10 mg
• History of stroke in 2015
Family history
• Family history was negative for the same illness
• History of allergy :-
• Histroy of immunization :-
• Habit history
• Alcoholism :-
• Smoking :-
Physical Examination
• GC : moderately ill. Consciousness : CM
• BP : 127/80 mmHg, PR : 84 bpm , RR : 24 x/m , T : 38,2°C , SatO2: 97 %
• BW : 70 kg , BH: 165 cm , BMI : 25,71
• Head : Conj. Anemic (+/+), Scl. Icteric (-)
• Neck : JVP 4+1 cmH2O, lymph node enlargemenet (-)
• Heart
• Insp : IC not visible
• Palp : IC palpable
• Perc : left border : ICS V midclavicular line sinistra
right border : ICS IV parasternal line dextra
• Ausc : SI- II, regular, murmur (-), gallop (-)
• Lung
• Insp : symmetric
• Palp : stem fremitus R=L
• Perc : sonor
• Ausc : vesicular, Ronchi -/- , Wheezing -/-

• Abdomen
• Insp : Flat
• Ausc : Bowel sound (+)
• Palp : soft, epigastric tenderness(+), hepar and lien not palpable
• Perc : tympanic, shifting dullness (-)

• Extremity : warm, oedema (-)

Lab Result
• Leu : 17.400/µL • SGOT : 22 U/L
• Eri : 245.000/µL • SGPT : 14 U/L
• Hb : 5,0 g/dL • Ureum : 94 mg/dL
• Ht :18,2 % • Creatinin : 4.3 mg/dL
• Plt : 553.000/µL • Sodium : 138 mEq/L
• MCH : 20,4 pg • Potassium : 3,74 mEq/L
• MCHC : 27,5 g/dL • Chloride : 120 mEq/L
• MCV :74,3 fl • Random Blood sugar : 120 mg/dL
Working diagnosis
• Hematochezia ec susp. Malignancy dd/ hemorrhoid
• Anemia ec GI bleeding
• Dyspeptic syndrome
• Susp. Electrolite imbalance
• Susp. Ckd
• Hypertension
Therapy
• IVFD NaCl 0,9 % 20 drops per min
• Tranexamic acid 3 x 500 mg (IV)
• Ranitidine 2 x 50 mg (IV)
• Micardis 80 mg (0-0-1) (PO)
• Metoclopramide 3 x 10 mg (IV)
 Follow up
S O A P
02- 05- Passing GA : moderate , • Hematochezia ec • Plan : check urinalysis, stool
2019 bloody Consciousness: CM susp. Malignancy analysis, faecal occult blood, SI,
stool BP : 140/90 mmHg , HR: 88 dd/ hemorrhoid TIBC, Feritin, Albumin, Globulin,
07.10 bpm, RR : 20 , T:36,8°C • Anemia ec GI abdomen and kidney ultrasound
Head : CA(+) SI (-) bleeding
Cor : SI-II regular, • CKD stage 5 ND ec • Monitor : vital sign per 12 hours
murmur (-), gallop (-) Hypertensive and urine output per 24 hours
Pulmo : vesicular, Rhonci - Nephrosclerosis
/-, wheezing -/- • Stage 1 • Therapy :
Abdomen : soft, epigastric hypertension  IVFD NS 0,9% 500 cc 20 drops
pain (+) per min
Extremity : warm, oedema  Ceftriaxone 2 x 1 gram (IV)
(-)  Tranexamic acid 3 x 1 (IV)
 Ranitidine 2 x 50 mg (IV)
 Micardis 80 mg (0-0-1) (PO)
 Metoklopramide 3 x 10 mg (IV)
 Follow up
S O A P
03- 05- Had 6 GA : moderate , • Acute • Plan : check urinalysis, stool
2019 Watery Consciousness: CM gastroenteritis analysis, faecal occult blood, SI,
bloody BP : 140/90 mmHg , HR: 88 • Hematochezia ec TIBC, Feritin, Albumin, Globulin,
07.10 stool in bpm, RR : 20 , T:36,8°C susp. Malignancy abdomen and kidney ultrasound
24 hours Head : CA(+) SI (-) dd/ hemorrhoid
Cor : SI-II regular, • Anemia ec GI • Monitor : vital sign per 12 hours
murmur (-), gallop (-) bleeding and urine output per 24 hours
Pulmo : vesicular, Rhonci - • CKD stage 5 ND
/-, wheezing -/- • Stage 1 • Therapy :
Abdomen : soft, epigastric hypertension  IVFD NS 0,9% 500 cc 20 drops
pain (+) per min
Extremity : warm, oedema  Ceftriaxone 2 x 1 gram (IV)
(-)  Tranexamic acid 3 x 1 (IV)
 Ranitidine 2 x 50 mg (IV)
 Micardis 80 mg (0-0-1) (PO)
 Metoklopramide 3 x 10 mg (IV)
 New diatab 3 x 2 tab
 Follow up
S O A P
04- 05- Passing GA : moderate , • Acute • Plan : complete blood count, PT/
2019 watery Consciousness: CM gastroenteritis INR/ APTT, ureum creatinine,
stool, BP : 120/80 mmHg , HR: 88 • Anemia ec GI Sodium, Potassium, Chloride, SI,
06.00 one time bpm, RR : 20 , T:36,3°C bleeding TIBC, Ferritin
Head : CA(+) SI (-) • Acute on chronic
Cor : SI-II regular, kidney disease • Therapy :
murmur (-), gallop (-)  IVFD NS 0,9% 500 cc 20 drops per
Pulmo : vesicular, Rhonci - min
/-, wheezing -/-  PRC transfusion 230 cc with Hb
Abdomen : soft, epigastric target > 9 mg/dL
pain (-) premedication : furosemide 1
Extremity : warm, oedema ampoule with target systolic BP >
(-) 100 mmHg
 Ceftriaxone 2 x 1 gram (IV)
 Tranexamic acid 3 x 1 (IV)
 Micardis 80 mg (0-0-1) (PO)
 Metoklopramide 3 x 10 mg (IV)
 New diatab 3 x 2 tab
Laboratorium ( 04-05-2019
• Leu : 6.000/µL • Ureum : 197 mg/dL
• Eri : 234.000/µL • Creatinin : 11,9 mg/dL
• Hb : 4.8 g/dL • Chloride : 89,2 meq/L
• Ht : 16,6 % • Potassium : 5,15 meq/L
• Plt : 368.000 /µL • Sodium : 131 meq/L
• MCH : 20,5 pg • PT : 19.0 sec
• MCHC : 289 g/dL • INR : 1.52 sec
• MCV : 70,9 fL • APTT : 61, 8 sec
 Follow up
S O A P
05- 05- Loss of GA : severe , • Acute on CKD dd/ • Blood gas analysis
2019 cons- Consciousness: delirium CKD stage 5 ND ec • Consul nephrology department
cious- BP : 150/80 mmHg , HR: 84 nephrosclerosis
12.00 ness bpm, RR : 22 , T:37°C hypertension
Urine Output: 0 cc/kg/hour
Head : CA(+) SI (-)
Cor : SI-II regular,
murmur (-), gallop (-)
Pulmo : vesicular, Rhonci -
/-, wheezing -/-
Abdomen : soft, epigastric
pain (-)
Extremity : warm, oedema
(-)
BGA ( May 5th 2019)
37°C 37,2°C
• pH : 7.174 • pH : 7,172
• pCo2 : 12.7 mmHg • pCO2 : 12,8 mmHg
• pO2 : 118 mmHg • pO2 : 119 mmHg
• BE ect : -24 mmol/L
• HCO3 : 4.7 mmol/L
• sO2 : 98%
• Lac : 1,89 mmol/L
Lab (may 5th 2019)
• Leu : 4.600/µL • Ureum : 177 mg/dL
• Eri : 260.000/µL • Creatinin : 12,3 mg/dL
• Hb : 5.8 g/dL
• Ht : 18,5 %
• Plt : 290.000 /µL • Qualitative anti- HCV : Non reactive
• HBsAg Elisa : Non reactive
• MCH : 22,5 pg
• Anti HIV (ELISA) : Non reactive
• MCHC : 31,4 g/dL
• MCV : 71,2 fL
Nephrology department
• Plan
• Hemodialysis if Hb > 6,59
• Vascular access insertion (DLC) on
Jugularis Interna Dekstra vein by vascular
surgeon
• Control BP by giving micardis 1 x 80 mg
• PRC transfusion 230 cc per 48 hours or
durante HD
• Kidney non dialysis diet ( protein 0,8
gr/kg/ hr; calories 30 kkal/kg/hr)
• Positive fluid balance
• Monitor urine output
• Kidney ultrasound
Follow up
S O
06- 05- Patient GA : moderate ,
2019 looks Consciousness: delirium
irritable, BP : 150/90 mmHg , HR: 96
06.00 passing bpm, RR : 20 , T:36,8°C
watery Head : CA(+) SI (-)
stool (-) Cor : SI-II regular,
murmur (-), gallop (-)
Pulmo : vesicular, Rhonci -
/-, wheezing -/-
Abdomen : soft, epigastric
pain (+)
Extremity : warm, oedema
(-)
A P
• CKD V ND ec • Plan : Sodium, Potassium,
nephrosclerosis Chloride, SI, TIBC
hypertension • Therapy :
• Anemia ec GI  IVFD NS 0,9% 500 cc 20 drops per
bleeding dd/ renal min
• Metabolic acidosis  Ceftriaxone 2 x 1 gram (IV)
• Hypertension  Micardis 80 mg (0-0-1) (PO)
 Metoklopramide 3 x 10 mg (IV)
 Folic acid 2 x 0,4 mg (PO)
 Vitamin B complex 3 x 1 (PO)
 Lanzoprazole 2 x 1 vial (IV)
 Follow up
S O A P
07- 05- Patient GA : severe , • CKD V ND ec • Therapy :
2019 looks Consciousness: delirium nephrosclerosis  IVFD NS 0,9% 500 cc 20 drops per
irritable, HR: 96 bpm, RR : 20 , hypertension min
06.00 short- T:36,8°C • Renal anemia  Kidmin 200 cc, 10 drops per min
ness of Head : CA(+) SI (-) • Metabolic acidosis  Ceftriaxone 2 x 1 gram (IV)
breath Cor : SI-II regular, • Hypertension  Micardis 80 mg (0-0-1) (PO)
murmur (-), gallop (-)  Metoklopramide 3 x 10 mg (IV)
Pulmo : vesicular, Rhonci -  Folic acid 2 x 0,4 mg (PO)
/-, wheezing -/-  Vitamin B complex 3 x 1 (PO)
Abdomen : soft, epigastric  Lanzoprazole 2 x 1 vial (IV)
pain (+)  PRC transfusion 230 cc durante
Extremity : warm, oedema HD
(-)
• Insertion double
lumen catheter in
may 7th 2019 ) on
Jugularis Interna
Dekstra vein by
vascular surgeon
Hemodialysis
• Time : 5 hours
• QB : 200 ml
• QD : 500
• UFG : 500 cc

Free Heparin
PRC transfusion durante HD
 Follow up
S O A P
08- 05- Loss of GA : severe , • CKD V ND ec • Plan : complete blood count,
2019 consciou Consciousness: coma nephrosclerosis ureum, creatinine, Sodium,
sness, BP : 150/90 mmHg , HR: hypertension Potassium, Chloride, magnesium,
06.00 HD bpm, RR : 24 , T:36,6°C • Renal anemia phosphate, calcium, random
initiation Head : CA(+) SI (-) • Metabolic acidosis blood sugar
may 7th Cor : SI-II regular, • Hypertension • Therapy :
2019 murmur (-), gallop (-)  IVFD NS 0,9% 500 cc 20 drops per
Pulmo : vesicular, Rhonci - min
/-, wheezing -/-  Kidmin 200cc / 24 hours
Abdomen : soft, epigastric  Oxygen 8-10 L per min (NRM)
pain (-)  Ceftriaxone 2 x 1 gram (IV)
Extremity : warm, oedema  Micardis 80 mg (0-0-1) (PO)
(-)  Metoklopramide 3 x 10 mg (IV)
 Folic acid 2 x 0,4 mg (PO)
 Vitamin B complex 3 x 1 (PO)
 Lanzoprazole 2 x 1 vial (IV)
 PRC transfusion 230 cc
Follow up

S O A P
08- 05- apneu Heart rate cant palpated • COD : organ failure • Patient confirmed dead 14.00
2019 Jugular vein pulse cant WITA, May 7th 2019
palpated
14.00 Blood pressure cant
measured

Pupil : totally mydriatic

Pupillary light reflex (-/-) O
5 mm
Corneal Reflex (-)