death case tn. k
DESCRIPTION
death caseTRANSCRIPT
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DEATH CASEPRESENTATION
!!!!!!
by: Anastasia Tjan
25 / 03 / 2015
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IDENTITAS
Nama : Tn. K
Usia : 78 th
Alamat : Jl. Empunala no 272 RT 3/1
No MR : 00106349
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Sesak 1 minggu
Sesak membaik dengan posisi duduk
Batuk 1 bulan
Makan dan Minum menurun
Riw HT +, tidak berobat rutin
1
22 / 3 / 2015 (IGD)
TD :150/90
N : 88X/M
S: 37
RR: 24x/M
Keadaan umum/Kesadaran : SS/CM
Kepala : CA-/-, SI-/-
Leher : JVP meningkat
Thorax : Cor S1,S2 tunggal, regular, M-, G-
Paru Sn ves menurun, RH +/+, WZ +/+
ABD: Supel, DBN
Ex: Akral hangat, Edema -/-
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Thorax xray: Pleuropneumoniae D-S
DIAGNOSIS: PJK + DECOM CORDIS + PNEUMONIA + TB PARU
! TREATMENT : O2 nasal canule 3 LPM IVFD PZ 10 tpm Inj Ceftri 2x1 g Inj Ranitidin 2x1 Inj furosemid 1 A ISDN 3x 5 mg Captopril 2x12.5 mg
Leukosit 11.900 LED/BBS 55/89 Asam Urat 6.7 SGOT/SGPT 77/50
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23 / 3 / 2015 24/ 3 / 2015
2! 3
S: Sesak +, Demam + O: CM Td 120/60 N 88x/m RR 28xm S 38.9 C Cor s1,s2, tgl-reg,M-, G- Paru Rh+/+, wz+/+! Abd dbn, Ex Akral Hangat !A : PJK +Decom cordis +Pneumonia + TB Paru + Sepsis !P : Tambahan Inj Antrain 3x1A Curcuma sputum BTA !
S: Sesak +, Demam + Penurunan kesadaran O: GCS 1-1-1 Td 100/50 N 90x/m RR 30xm S 38.4 C Cor s1,s2, tgl-reg,M-, G- Paru Rh+/+, wz+/+! Abd dbn, Ex Akral Hangat !A : PJK +Decom cordis +Pneumonia + TB Paru !P :Captopril stop Co. Saraf - Ceftri 2x2g - Vit C 2x1 - Pasang NGT-puasa !
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25/3/2015
4
S: Sesak +, Demam + Penurunan kesadaran O: GCS 1-1-1 Td 110/70 N 100x/m RR 30xm S 38.7 C Cor s1,s2, tgl-reg,M-, G- Paru Rh+/+, wz+/+ Ex Akral Hangat !A : PJK +Decom cordis +Pneumonia + TB Paru + Sepsis !P :Inj Ceftriaxon 2x2 g Inj Antrain 2x1 Inj Dexa 2x 5mg Inj Ranitidin 2x1 Pct 4x500 mg Diet 6 x200 cc IVFD Futrolit : PZ 2:1 !
S: Henti jantung O: GCS 1-1-1 Td tidak teraba N -x/m RR apneutic S - C Cor s1,s2, tgl-reg,M-, G- Paru Rh+/+, ! Abd dbn, Ex Akral Hangat !A : PJK +Decom cordis +Pneumonia +TB Paru + Shok sepsis dd Shok cardiogenic !P :RJP 3 x 5 siklus Epinephrin 2x1 A !
02.00 11.30
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25/3/2015
S: Henti jantung + Henti nafas O: GCS 1-1-1 Td tidak teraba N -x/m RR - S - C Cor - Paru Suara nafas - Ex Akral dingin, kaku !A : Meninggal, et. causa shok sepsis dd shok cardiogenic !!!
11.45