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  • MR 12 Juni Death Case Edit-1

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    jeffry boike
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    This document contains medical records for a 4-day-old female infant admitted on June 8, 2021. She was diagnosed with respiratory distress syndrome, multiple congenital anomalies including omphalocele and spinal bifida, suspected early onset neonatal sepsis, and other issues. Her vital signs and oxygen levels fluctuated significantly over the course of treatment before she passed away. A second patient, a 19-day-old male infant, was also discussed. He was admitted on June 12, 2021 and diagnosed with respiratory distress syndrome, septic shock, late onset neonatal sepsis, suspected necrotizing enterocolitis, and other conditions. Despite treatment attempts including increased respiratory support, his condition deteriorated and he died on June

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    This document contains medical records for a 4-day-old female infant admitted on June 8, 2021. She was diagnosed with respiratory distress syndrome, multiple congenital anomalies including omphalocele and spinal bifida, suspected early onset neonatal sepsis, and other issues. Her vital signs and oxygen levels fluctuated significantly over the course of treatment before she passed away. A second patient, a 19-day-old male infant, was also discussed. He was admitted on June 12, 2021 and diagnosed with respiratory distress syndrome, septic shock, late onset neonatal sepsis, suspected necrotizing enterocolitis, and other conditions. Despite treatment attempts including increased respiratory support, his condition deteriorated and he died on June

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    4 views10 pages

    MR 12 Juni Death Case Edit-1

    Uploaded by

    jeffry boike
    This document contains medical records for a 4-day-old female infant admitted on June 8, 2021. She was diagnosed with respiratory distress syndrome, multiple congenital anomalies including omphalocele and spinal bifida, suspected early onset neonatal sepsis, and other issues. Her vital signs and oxygen levels fluctuated significantly over the course of treatment before she passed away. A second patient, a 19-day-old male infant, was also discussed. He was admitted on June 12, 2021 and diagnosed with respiratory distress syndrome, septic shock, late onset neonatal sepsis, suspected necrotizing enterocolitis, and other conditions. Despite treatment attempts including increased respiratory support, his condition deteriorated and he died on June

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 10

    Identity

    Name : Baby. Mrs. Siti Aulia


    Age : 4 days
    Gender : female
    No. RM : 1-47-45-22
    Tanggal masuk : 08-6-2021

    Diagnosis:
    • Respiratory distress syndrome
    • Multiple congenital anomaly (Omphalocele, Atresia Ani,
    Dextrocardia, Spina bipida)
    • Susp. EONS
    • Post colostomy ec Atresia Ani
    • Icteric neonatal
    • Hypoalbuminemia
    • Hyponatremia
    • hypokalemia
    1
    Respiratory distress 15 hours

    Early onset neonatus sepsis 2 days

    Multicongenital anomali
    Omphalocele 4 days
    Icteric neonatal

    Multiple congenital anomaly


    (Omphalocele, Atresia Ani,
    Dextrocardia, Spina bipida)
    Susp. EONS
    Post colostomy ec Atresia Ani
    Icteric neonatal
    Hypoalbuminemia
    Hyponatremia
    hypokalemia

    2
    Vital sign graphic
    250 160

    168 140
    162 164
    200
    148
    138 120
    132 128
    112 112 100
    150

    80
    68
    100
    52 54 48 60
    46 48 49 48
    44 45 44
    35 22
    40
    50 37 37.1 37.1 36.9 36.8 36.9 37.3 37.2 37.2 37 37 36.9
    21
    12 20

    0 0
    14.00 15.00 16.00 17.00 18.00 19.00 19.30 20.00 20.30 21.00 21.10 21.20

    T HR RR SpO2
    Follow Up
    12/06
    Patient has ROSC in 06.30, Ventilator was full
    14.00
    HR: 112x/m, RR: 44 x/m, T: 37 C, 96 % on VTP,
    Desaturated (+), SD: 4

    12/06
    19.00 HR: 164x/m, RR: 45 x/m, T: 36.6 C, 95 % on VTP

    12/06
    20.00 Education the family about condition
    Family ask to DNR

    12/06 maximal mydriatic pupil (+), HR (-), RR (-)


    21.45 Declare of death in front of family and team

    4
    4
    Follow up
     Hour T HR RR SpO2
    14.00 37,0 112 44 96
    15.00 37,1 138 46 99
    16.00 37,1 148 52 98
    17.00 36,9 162 54 98
    18.00 36,8 168 48 97
    19.00 36,9 164 45 95
    19.30 37,3 132 49 98
    20.00 37,2 128 44 90
    20.30 37,2 112 48 88
    21.00 37 68 35 73
    21.10 37 48 21 69
    21.20 36,9 22 12 54
    21.30 36,8 18 8 32
    21.45 36,8 0 0 0
    5
    Identity
    Name : Baby. Mrs. Istikomah
    Age : 19 days
    Gender : Male
    No. RM : 1-47-47-11
    Tanggal masuk : 12-6-2021

    Diagnosis:
    • Respiratory distress syndrome
    • Septic Shock
    • Late Onset Neonatal Sepsis
    • Susp. NEC
    • AKI stage failure
    • thrombocytopenia
    • Hypoalbuminemia
    • Anemia
    6
    Respiratory distress 24 hours

    Septic shock 2 days

    Late onset neonatus sepsis 8 days

    Respiratory distress syndrome


    Septic Shock
    Late Onset Neonatal Sepsis
    Susp. NEC
    AKI stage failure
    thrombocytopenia
    Hypoalbuminemia
    Anemia

    7
    Vital sign graphic
    200 180
    147
    180 160
    127
    120 122
    160 112
    108 140
    140
    120
    120
    100
    100 52
    80
    67 66 40
    80 62
    56 60
    60
    37 34
    36.6 36.7 37.2 36.9 36.5 36.6 36.4 36.3 36.2
    0 40
    40
    18 17
    20 20
    0
    0 0
    14:00 17:45 22:00 1:00 5:00 6:00 6:10 6:20 6:30

    T HR RR SpO2
    Follow Up
    12/06
    HR: 120x/m, RR: 67 x/m, T: 36,6 C, 90-95 % CPAP 6/21, CRT 4 sec, SD: 4
    14.00

    12/06
    Defecation (+) Whithis mucous, crying (-), tones (<)
    17.45
    HR: 147x/m, RR: 56 x/m, T: 36,7 C, 90-93 % CPAP 6/21, CRT 4 sec

    12/06 Desaturated (+), instab (-)


    22.00 HR: 112x/m, RR: 37 x/m, T: 37,2 C, 88 % CPAP 6/30, CRT 4 sec

    13/06 Re- Desaturated (+), instab (-)


    01.00 HR: 122x/m, RR: 66 x/m, T: 36,9 C, 84 % CPAP 7/40, CRT 4 sec
    Education the family about condition

    13/06 Re- Desaturated (+), instab (-)


    05.00 HR: 127x/m, RR: 62 x/m, T: 36,5 C, 84 % CPAP 7/50, CRT 4 sec
    Pro intubation if ventilator ready, Education the family about condition

    13/06 Re- Desaturated (+), instab (-)


    06.00 HR: 108x/m, RR: 34 x/m, T: 36,6 C, 60 % CPAP 7/60, CRT 4 sec
    Pro VTP (+) Bagging (+) Inj epineprine (+), respone (-)
    Education the family about condition

    13/06 maximal mydriatic pupil (+), HR (-), RR (-)


    06.30 Declare of death in front of family and team
    9
    9
    Follow up
     Hour T HR RR SpO2
    14.00 36,6 120 67 90
    17.45 36,7 147 56 93
    22.00 37,2 112 37 88
    01.00 36,9 122 66 84
    05.00 36,5 127 62 84
    06.00 36,6 108 34 60
    06.10 36,4 52 18 53
    06.20 36,3 40 17 45
    06.30 36,2 0 0 0

    10

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