DEATH CASE

A 58 years old woman was admitted to R.D.

Kandou Hospital at IRDM ward on
3 Desember 2016 at 23.30 and
C1 ward on 4 Desember 2016 at 01.30

And passed away on 10 Desember 2016

at 15.45
A 58 year-old female was admitted to R.D.
Kandou Hospital at IMC ward on 10 December,
2016 at 01.30

With main complaint:

Abdominal enlargement
 Patient’s identity
Name : Mrs AA
Age : 58 yrs
Sex : Female
Occupation : Housewife
Education : elementary School
Ethnicity : Minahasa
Religion : Christian
 Present Medical History
• Abdominal enlargement since 3 days b.a
• Abdominal discomfort, especially after meal
• Jaundice since 2 week ago.
• Nausea (+), Vomiting (-). Epigastric pain (+)
• Itchy skin (-)
• General weakness (+)
• Breathlessness (+)
• Fever (+) since 2 days b.a all day long
• Defecating (-) 1 week
• Urinating tea color
 Past Medical History
• History of hypertension (+) 7 years
• History of heart, liver, kidney, High uric acid, was denied
 Family History
• None experienced the same illness
History of allergy :
Unknown

History of immunization :
Unknown

Habit history :
Alkoholism (-)
Smoking (-)
General anamnesis ( review of system )
General : general weakness
Skin : jaundice
Head and neck : -
Eye : jaundice
Ear :-
Nose :-
Mouth and throat: -
Respiratory : -
Chest :-
Heart :-
Abdomen : abdominal enlargement
Genitalia :-
Kidney :-
Hematology :-
Endocrine :-
Musculosceletal : -
Neurology :-
Psychology :-
 Physical Examination
• GC: Moderate ill . Sens : compos mentis
• C1 :BP: 130/80, PR 90x/m, RR 22x/m,T 36.9ºC SpO2 98%
• ER :BP: 130/70mmHg, PR 92x/m, RR 24x/m, T 36,3 C
• BW 55 kg, BH 160 cm
• Head : conj. anemic (-), scl. icteric(+)
• Neck : JVP 5+0 cmH20, lymph nodes enlargement (-)
• Thorax : spider naevi (-),
• Heart :
– Insp : IC not visible
– Palp : IC palpable
– Perc : left border: ICS V midclavicularis sinistra
right border: ICS IV parasternalis dextra
– Ausc : SI-II regular, murmur (-), gallop (-)
 Physical examination
• Lung : Insp : Symmetric R = L,
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
• Abd :
Insp : caput medusae - ,
Palp : soepel, liver / spleen not enlarged,
Perc : Shifting dullness (+), undulasi (-)
Ausc : Bowel sound (+)

• Waist : Pain on CVA exam (-/-)

• Extr : warm, eritema palmaris (-), edema (-/-), tophi -/-,
CRT < 2”, flapping tremor -
Genital : not evaluated (no complain)

Rektum : normal

Neurology : normal
 Lab Result
03/12/2016
• Leucocyte 7300
• Erythrocyte 3,02x106
• Hb 10,9
• Ht 31,4
• Platelet 41.000
• Ureum 40
• Creatinine 0,6
• SGOT 90
• SGPT 105
• Na 135
• K 3,8
• Cl 108
HbsAg Reaktif
Anti HCV –
 Roentgen INTERPRETATION
Roentgen Componen Interpretation
Identity Same
KV Normal
Symmetric asymmetric
Trachea to the right
Diaphragma Normal
Sinus Costophrenicus Sharp
Sinus Cardiophrenicus Sharp
Bone Intact
COR - CTR 55%
Pulmo Parenchym
CONCLUSION : normal
ECG
 Interpretation of ECG
ECG components Interpretation Value
Rhythm Sinus rhythm Sinus Rhythm
Speed / HR (times/mnt) 80x/min 1500/R-R’
Axis normal Normal / RAD / LAD
Morphology P wave 0,06 sec Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,16 sec 0,12” – 0,20”
QRS complex duration 0,11 sec 0,05” – 0,11”``
ST segmen Isoelectric Normal / Elevated / Depressed
T wave Inverted V1-3 Normal / abnormal
QT Interval 0,36 sec cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION sinus rhytm 80x/m
USG:
Sirosis Hepatis
Ascites
 Problem List
No CM : 45.21.23 Age : 58 y.o
1. Main complain:
• Abdominal enlargement
2. Anamnesis:
• Jaundice
• Fever
• Urine tea colored
• Rash
• Black ground vomit
3. Physical examination:
• GC: Moderate ill . Sens : compos mentis
• C1 :BP: 130/80, PR 90x/m, RR 22x/m,T 36.9ºC SpO2 98%
• ER :BP: 130/70mmHg, PR 92x/m, RR 24x/m, T 36,3 C
• Head : conj. anemic (-), scl. icteric(+)
• Neck : JVP 5+0 cmH20, lymph nodes enlargement (-)
• Thorax : spider naevi (-),
• Abd :
Insp : caput medusae -
Palp : soepel, liver not enlarged,
Perc : Shifting dullness (+), undulasi (-)
Ausc : Bowel sound (+)
• Extr : warm, eritema palmaris (-), edema (-/-), tophi -/-,
, CRT < 2”, flapping tremor -
4.Laboratorium :
Erythrocyte 3,02x106
Hb 10,9
Ht 31,4
Platelet 41.000
SGOT 90
SGPT 105
HbsAg Reaktif
 Treatment
• O2 4 lpm
• IVFD NaCl 0.9% : Aminofusin Hepar = 1 : 1 =
20 gtt/min
• Cefotaxime 3 x 2 gr IV
• Ranitidine 2x50 mg IV
• Ondansentron 3 x 1 IV
• Furosemide 1 – 1 – 0 IV
• Spironolaktone 1 – 1 – 0 PO
• Propanolol 2 x 10 mg
• Lactulosa syr 4 x c2
Working Diagnosis
- Susp. Sirosis hepatis dekompensata
- susp. SBP
- Hepatitis B
- hypoalbumin
 FOLLOW UP
05-12-2016
S : Abdominal enlargement, pain (+)
ikterik, defecating (-) P:
O: VS : severe ill, somnolen • O2 4 lpm
BP=130/70 mmhg • IVFD NaCl 0.9% : Aminofusin Hepar
PR=96x/m reguler (comafusin hepar TAP)
RR=22x/m SpO2 99% = 1 : 1 = 20 gtt/min
• Cefotaxime 3 x 2 gr IV
BT 36.8 ºC • metronidazole 3 x 500 mg PO
Head: Conj.An -, sclera ikterik + • Ranitidine 2x50 mg IV
Thorax: Rh -/-, wh – • Ondansentron 3 x 1 IV
Abdomen: convex, pain + • Furosemide 1 – 1 – 0 IV
Ext : odem – • Spironolaktone 1 – 1 – 0 PO
• Propanolol 2 x 10 mg
A: decrease of consiousness ec. • Lactulosa syr 4 x c2
encephalopathy hepaticum • human albumin 20 % 100cc
Susp. Sirosis hepatis dekompensata
susp. SBP
Hep.B
Hypoalbuinemia
 FOLLOW UP
06-12-2016
S : Abdominal enlargement, pain (+)
ikterik, defecating (-) P:
O: VS : severe ill, delirium • O2 4 lpm
BP=130/80 mmhg • IVFD NaCl 0.9% : Comafusin Hepar
PR=86x/m reguler = 1 : 1 = 20 gtt/min
RR=22x/m SpO2 99% • Cefotaxime 3 x 2 gr IV
• metronidazole 3 x 500 mg PO
BT 36.8 ºC • Ranitidine 2x50 mg IV
Head: Conj.An -, sclera ikterik + • Ondansentron 3 x 1 IV
Thorax: Rh -/-, wh – • Furosemide 1 – 1 – 0 IV
Abdomen: convex, pain + • Spironolaktone 1 – 1 – 0 PO
Ext : odem – • Propanolol 2 x 10 mg
• Lactulosa syr 4 x c2
A: decrease of consiousness ec. • hepatosol lola 3 x 200cc
encephalopathy hepaticum •human albumin 20 % 100cc
Susp. Sirosis hepatis dekompensata
susp. SBP •Monitor urine output
Hep.B
Hypoalbuinemia - Lab control: bill tot, bill.direk indirek, ALP,
GGT, Albumin, Globulin, PT, APTT, INR
 Lab Result
• Leucocyte 14220
• Erythrocyte 2,65x106
• Hb 10,6
• Ht 30,5
• Platelet 58.000
• SGOT 82
• SGPT 62
• Bill tot 24,55
• Bill dir 15,47

• PT >70 (12,7)
• INR >5 (1,01)
• APTT 107,3 (28,9)
 FOLLOW UP
07-12-2016
S : Abdominal enlargement, pain (+)
ikterik P:
O: VS : severe ill, delirium • O2 8 lpm via N RM
BP=130/80 mmhg • IVFD NaCl 0.9% : Comafusin Hepar
PR=80x/m reguler = 1 : 1 = 20 gtt/min
RR=24x/m SpO2 99% • Cefotaxime 3 x 2 gr IV
• metronidazole 3 x 500 mg PO
BT 36.8 ºC • Ranitidine 2x50 mg IV
Head: Conj.An -, sclera ikterik + • Ondansentron 3 x 1 IV
Thorax: Rh -/-, wh – • Furosemide 1 – 1 – 0 IV
Abdomen: convex + • Spironolaktone 1 – 1 – 0 PO
Ext : odem – • Propanolol 2 x 10 mg
• Lactulosa syr 4 x c2
A: decrease of consiousness ec. • hepatosol lola 3 x 200cc
encephalopathy hepaticum • human albumin 20 % 100cc
Sirosis hepatis dekompensata
susp. SBP
Hep.B
Hypoalbuinemia
08-12-2016
FOLLOW UP
S : Abdominal enlargement,
ikterik
O: VS : severe ill, sopor P:
• O2 8 lpm via NRM
BP=110/80 mmhg
• IVFD NaCl 0.9% : Comafusin Hepar
PR=76x/m reguler = 1 : 1 = 20 gtt/min
RR=24x/m SpO2 99% • Cefotaxime 3 x 2 gr IV
BT 36.2 ºC • metronidazole 3 x 500 mg PO
Head: Conj.An -, sclera ikterik + • Ranitidine 2x50 mg IV
• Ondansentron 3 x 1 IV
Thorax: Rh +/+, wh –
• Furosemide 1 – 1 – 0 IV
Abdomen: pain - • Spironolaktone 1 – 1 – 0 PO
Ext : odem – • Propanolol 2 x 10 mg
A: decrease of consiousness ec. • Lactulosa syr 4 x c2
encephalopathy hepaticum • hepatosol lola 3 x 200cc
Sirosis hepatis dekompensata • human albumin 20 % 100cc
susp. SBP
•CXR Cito
Hep.B •Blood Culture + ST
Hypoalbuinemia
susp. HAP
 FOLLOW UP
09-12-2016
S : Abdominal enlargement,
ikterik
P:
O: VS : severe ill, sopor
• O2 8 lpm via NRM
BP=130/90 mmhg • IVFD NaCl 0.9% : Comafusin Hepar
PR=88x/m reguler = 1 : 1 = 20 gtt/min
RR=20x/m SpO2 98% • Cefotaxime 3 x 2 gr IV  Meropemen
BT 37,4 ºC (TAP)
• metronidazole 3 x 500 mg PO
Head: Conj.An -, sclera ikterik +
• Ranitidine 2x50 mg IV
Thorax: Rh -/-, wh – • Ondansentron 3 x 1 IV
Abdomen: pain - • Furosemide 1 – 1 – 0 IV
Ext : odem – • Spironolaktone 1 – 1 – 0 PO
A: decrease of consiousness ec. • Propanolol 2 x 10 mg
encephalopathy hepaticum • Lactulosa syr 4 x c2
• hepatosol lola 3 x 200cc
Sirosis hepatis dekompensata
• human albumin 20 % 100cc
susp. SBP
Hep.B •Plan : DL, Ur, Cr, GDS, Na, K, Cl
Hypoalbuinemia
Susp. HAP
 FOLLOW UP
10- 12-2016
S : Abdominal enlargement,
ikterik
P:
O: VS : severe ill, sopor
• O2 8 lpm via NRM
BP=130/80 mmhg • IVFD NaCl 0.9% : Comafusin Hepar
PR=82x/m reguler = 1 : 1 = 20 gtt/min
RR=26x/m SpO2 98% • Cefotaxime 3 x 2 gr IV
BT 36,8ºC • metronidazole 3 x 500 mg PO
• Ranitidine 2x50 mg IV
Head: Conj.An -, sclera ikterik +
• Ondansentron 3 x 1 IV
Thorax: Rh -/-, wh – • Furosemide 1 – 1 – 0 IV
Abdomen: pain - • Spironolaktone 1 – 1 – 0 PO
Ext : odem – • Propanolol 2 x 10 mg
A: decrease of consiousness ec. • Lactulosa syr 4 x c2
encephalopathy hepaticum • hepatosol lola 3 x 200cc
• human albumin 20 % 100cc
Sirosis hepatis dekompensata
susp. SBP
Hep.B
Hypoalbuinemia
susp. HAP
 FOLLOW UP
S O A P
14.15 decrease of VS : severe ill, decrease of •O2 8 lpm via NRM
consiousness E1V1M1 consiousness ec. • IVFD NaCl 0.9% : Comafusin
BP=130/80 mmhg encephalopathy Hepar
PR=82x/m reguler hepaticum = 1 : 1 = 20 gtt/min
RR=24x/m • Cefotaxime 3 x 2 gr IV
BT 36,8ºC Sirosis hepatis • metronidazole 3 x 500 mg
SpO2 93% dekompensata PO
• Ranitidine 2x50 mg IV
Head: Conj.An -, susp. SBP • Ondansentron 3 x 1 IV
sclera ikterik + • Furosemide 1 – 1 – 0 IV
Thorax: Rh +/+, Hep.B • Spironolaktone 1 – 1 – 0 PO
wh – • Propanolol 2 x 10 mg
Abdomen: Hypoalbuinemia • Lactulosa syr 4 x c2
convex, • hepatosol lola 3 x 200cc
Ext : odem – • human albumin 20 % 100cc

•NGT
UO 250cc/8jam •kateter
 FOLLOW UP
S O A P
15.00 decrease of VS : severe ill, decrease of •O2 10 lpm via NRM
consiousness E1V1M1 consiousness ec. • IVFD NaCl 0.9% : Comafusin
BP=110/70 mmhg encephalopathy Hepar
PR=82x/m reguler hepaticum = 1 : 1 = 20 gtt/min
RR=24x/m • Cefotaxime 3 x 2 gr IV
BT 36,8ºC Sirosis hepatis • metronidazole 3 x 500 mg
SpO2 86% dekompensata PO
• Ranitidine 2x50 mg IV
Head: Conj.An -, susp. SBP • Ondansentron 3 x 1 IV
sclera ikterik + • Furosemide 1 – 1 – 0 IV
Thorax: Rh +/+, Hep.B • Spironolaktone 1 – 1 – 0 PO
wh – • Propanolol 2 x 10 mg
Abdomen: Hypoalbuinemia • Lactulosa syr 4 x c2
convex, • hepatosol lola 3 x 200cc
Ext : odem – • human albumin 20 % 100cc

•NGT
•kateter
Thank You