DEATH CASE REPORT

Name : Tn. A.H.K Hospital : RSUH

Room : ICU,2nd bed Age : 71 years old

Address : Makassar
Reg number :113275
Occupation : Retired
Admission date : 03/02/2019 (22:40)
Religion : Islam
Death Date : 02/26/2019 (12.50)
Ethnic : Bugis
Physician : dr. Irfhana Husa
Marriage Status : Married
Chief : dr. Ardan Mirasz

HISTORY

Chief complaint : Shortness of breath

Current Medical History:

Shortness of breath experienced by patients since 1 week before hospital admission, felt
increasingly worse last few days. Shortness of breath is not affected by activity. Patient have
history of being treated with COPD 6 months ago, and treated by symbicort. Smoking history
more than 20 years ago, ± 26 cigarettes a day. Coughing since 1 day ago, mucus is present, blood
is absent. A history of long coughing and cough mixed with blood is absent, there is no history of
ATD (Anti Tuberculosis Drugs) consumption. Fever is not present, history of fever is absent.
History of headache and seizure absent. weakness was experienced 2 months ago, and worsen
last 3 days. Since last 2 months, patient eats a little less than 10 spoons a day, drinking enough
water. Patients experienced weight loss in the past 6 months, estimated at more than 10 kg.
Currently the patient cannot walk again since 6 months ago. Urination tend to be decrease in
volume, and yellow in colour. There’s history of urination mixed with blood 1 day ago. There
was no pain during urination, no history of sandy urination. There’s no complaint about
defecation, last defecation 1 day ago. Currently, there is no history of defecation mixed with
blood, or black defecation. But patient have a history of black defecation 2 years ago, for 2 days.
There is no history of nausea, vomiting, or black vomiting.

Past Medical History:

 Nine years ago at RSWS, complained of chest pain and treated with stent. Patients were
given medication 1x80mg Miniaspi.
 Stroke 1 year ago, complaining half of the left body and mouth suddenly paralyzed, not
accompanied by nausea and vomiting, previous headaches did not exist.
 Two years ago at RSWS, patient undergo an endoscopy with an indication of a history of
melena and was told that the endoscopy results were normal.
 There’s a history of hypertension that has only been known for 6 months. No routine
control.
 There’s no history of kidney disease.
 There’s no history of diabetes.

Biopsychososial and Family History:

• The patient is married and has 5 children, in good health.

• There is no family history of hypertension.
• There is no family history of diabetes mellitus.
• Smoking more than 20 years ago and has stopped since 10 years ago.
• Herbal medicine consumption 2 years ago, consumed it for 1 week.
• There is no history of alcohol consumption

PHYSICAL EXAMINATION

General description

• General appearance : Moderately ill

• Nutritional status : Malnutrition

• Awareness : Compos mentis

Vital sign

• Blood pressure :150/90 mmHg

• Heart rate : 85 x/minute, reguller,

• Respiratory rate : 28 x/minute

• SpO2 : 99%

• Temperature : 36,5oC, axilla

• Height : 152 cm

• Weight: 32 kg

• BMI : 13,85 kg/m2

• UAC 16 cm, KH 45 cm

à Height : 64,19 + (2,02 x KH) – (0,04 x age)

: 64,19 + 90,9 – 2,8

: 152, 29 cm

à Weight : (current UAC /26,3) x BBI

: (16/26,3) x ((152-100)x100%)

: 0,61 x 48 = 31,7 kg

Head: normocephalic, gray hair, not easily removed.

Eyes: isocoric pupils, 2.5 mm / 2.5 mm in diameter, normal direct and indirect light reflexes,
anemic conjunctiva is absent, sclera is not jaundiced.

Ears: no secretions appear.

Nose: normal shape, no secretions, no epistaxis.

Mouth: tongue atrophy is absent, tonsils and pharynx are not hyperemic,

Neck: DVS R + 1cmH2O (30O), thyroid isn’t enlarge, tracheal not deviated.

Thorax

 Inspection: symmetric left and right when dynamic or static.

 Palpation: no tenderness, no palpable mass tactile fremitus is difficult to assess.

 Percussion: Sonor, equal at both side.

 Auscultation: vesicular breathing, no ronkhi, no wheezing, pulmonary-hepatic border at
6th intercostal space.

Heart

 Inspection: Ictus cordis is not visible.

 Palpation: Ictus cordis is not palpable.

 Percussion: dullness, right side heart border at the right parasternal line, the left side
heart border in the left midclavicular line.

 Auscultation: normal SI and SIIsound, regular, gallop absent, no murmur.

Abdomen

 Inspection: Concave, following breath movement, no sicatric.

 Auscultation: Normal bowel sound.

 Palpation: The liver is not palpable, the spleen is not palpable, abdominal tenderness is
absent

 Percussion: timpanic sound

Extremities

 Superior et inferior dextra: strength 5, normal tone, warm, CRT < 2 seconds, no edema.

 Superior et inferior sinistra: left lateralisation, decrease tone, warm, CRT < 2 seconds, no
edema.

SUPPORTING INVESTIGATION

ECG 03/02/2019

Figure 1: Patient’s ECG

 • Sinus rhythm, heart rate 79 x / min, normoaxis, P wave 0.06 second, PR interval 0.14
second, Scomplex QR 0.12 seconds, normal ST segment, pathological Q, normal T wave
leads.

• Conclusion: rhythm sinus, heart rate 79 times / minute, normoaxis, inferior OMI.

LABORATORIES 03/02/2019

Table 1. Laboratories 03/02/2019

PARAMETER RESULTS UNIT NORMAL RANGE

WBC 5660 103/mm3 4-10 x 103/mm3

Neut. 64,5% % 52.0 – 75.0

Lymph. 46,5 % 20.0 – 40.0

Mono. 18,9% % 2.00 – 8.00

Eo. 2,1 % 1.00 – 3.00

Baso. 0,5 % 0.00 – 1.00

HB 12,8 g/dl 14-18

HCT 38,8 % 37,0-48,0

MCV 91,9 pl 80.0 – 97.0

MCH 30,3 pg 26.5 – 33.5

MCHC 33 g/dl 31.5 – 35.0

PLT 27.000 103/mm3 150-400 x 103/mm3

CHEST X-RAY 03/02/2019

 Figure 2: Patient’s chest x-ray

• Prominent lungs.

• There is no specific active process in both lungs

• Heart: normal impression, normal aorta

• Both the sinus and diaphragm are good

• Bones are intact.

Conclusion : Bronchitis, normal heart.

ABDOMINAL USG 07/02/2019

Figure 3: Patient’s abdominal USG.

• Prostate hypertrophy, volume ± 52,67 ml

 • Bilateral mild hydronefrosis

• Cystitis

HEAD CT-SCAN 29/09/2017

• Cerebral atrophy

• There’s no hyperdensed or hypodensed lesion

NCV-EMG 25/01/2018

• Severe axonal motoric neuropathy multiplex predominant left peroneal

EARLY ASSESSMENT AND PLAN

List of Problems

1. COPD
2. Malnutrition
3. Hyponatremia
4. Hypoalbuminemia
5. Uncontrolled hypertension
6. Total dependence
7. CAD Post PCI
8. Immobilization

1. COPD
Based onshortness of breath complaints since 1 week before entering the hospital, it felt
increasingly and worsen last few days.Shortness of breath is not affected by
activity.History of smoking for more than 20 years, ± 26 cigarettes per dayPatients had
history of being treated with COPD 6 months ago and received symbicort therapy.On
lung examination, examination of the chest X-ray shows an aspect of bronchitis.
Diagnostic plan: spirometry
Therapy plan : oxygen 1-2 liters / minute
Monitoring plan : observation of shortness of breath and signs of distress respiratory.
 Education plan: Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.

2. Malnutrition
Based on loss of appetite complaints since 6 months, worsen 2 days ago, patients ate only
10 spoons every day. On physical examination obtained BMI 13.85 kg / m2, LILA 16 cm
and score MNA 4.
Diagnostic Plan: -
Therapy Plan : Consul to Nutritionist
Monitoring plan : -
Educationplan : Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.

3. Hyponatremia
Hyponatremia is diagnosed based on the results of a laboratory examination dated
03/02/2019 that found sodium levels: 128 mmol
Diagnostic plan: -
Therapy plan : correction of sodium via IVFD
line 1: 3% NaCl 500 cc / 24 hours
line 2: 0.9% NaCl 12 tpm
Monitoring plan : check electrolytes 6 hours after correction of sodium.
Education plan: Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.

4. Hypoalbuminemia
According to the results of 2.5 albumin laboratory tests.
Therapy plan : sachet albumin every 12 hour via oral

5. Uncontrolled hypertension
 According to a history of hypertension that known since the last 6 months, and
uncontrolled hypertension, on physical examination blood pressure is 150/90 mmHg.
Diagnostic Plan: Blood Pressure Measurement / day
Therapy Plan : Amlodipin 10 mg 0-0-1
Monitoring Plan :
• Blood pressure/day
• ECG

6. Total dependence
Based of history by using the Barthel Index obtained Score 2
Diagnostic Plan : -
Therapy Plan : left and right tilt mobilization every 2 hoursand pressure sores
Monitoring Plan : -
Education Plan : Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.

7. Coronary Artery Disease

According to history of heart disease and stent management 9 years ago and consumption
of 80 mg Miniaspi drugs.
• Diagnostics Plan : -
• Therapy plan: Aspilet / 24hours / via oral
• Monitoringplan: ECG
• Education plan : Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.

8. Immobilization
According to the history of post stroke with the symptoms of internal hemiparese so that
the patient's activities are confined to the bed and aggravated by inadequate intakes that
make weakness, decreased muscle tone and muscle atrophy.
Diagnostic plan: -
Therapy plan : left and right tilt mobilization every 2 hours
Monitoring plan : signs of infection
Education plan : Educate about the medical condition, the patient’s disease, the
examination that will be test and the management plan.