NAME: LAKIM BIN GALONGAN M/61 YRS/DUSUN

IC :550620-12-5367

RN :082267

DOA :2/9/2016 @9 AM

ADDRESS:NO 29, FLAT TAMAN PUBLIC JAYA,

LIKAS, SABAH.

31/8/16 @5.30 PM

Patient went to ETD QEH 11. c/o fever, chills and rigor and generalised body
weakness x 4/7. Diarrhoea loose stool 2-3/day. Vital sign on arrival: BP 74/42
mmhg, PR: 82/min. SPO2: 87%. RR: 24/min. Noted pt tachypnoiec . Up grade
from yellow zone to red zone @ 7 pm.

Ixs: RSVC x3 taken on 31/8, 1/9 and 2/9/2016. Denggue serology on 31/8/2016.
ZIKA PCR taken on 1/9/2016.

1/9/2016 @ 4.35 pm

Patient intubated in ETD due to respiratory distress. Refer icu but no bed
available. To admit MHDU.

2/9/16 @ 10 am.

Patient admitted to MHDU. Continue ventilator support. On triple inotrope.

At 1.45pm. Noted pt asystole. CPR commenced for 15 minutes. Pt revive. Vital

sign: BP 88/58 mmhg. PR: 136/ min. SPO2: 97%. BP supported with triple
inotropes. Refer to cardio for AF with NSTEMI.

2/9/2016 @2.30 pm.

Inform by MLT lab that urine and serum for zika both positive. {verbally
informed}. Formal result pending. Case inform and update to Dr Giri [ID
Physcian]. Notification for dengue and zika virus all done via ETD and MHDU.

2/9/2016 @ 8.10 pm.

Patient transfer in to icu from MHDU. Patient still continue on ventilator support.
GCS 2T/15 [ E1, VT, M1]. BP supported with 4 th inotrope. Shortly after arrival,
patient developed AF. HR 175/min. IV Amiodarone given. Plan: to start CVVHD.

2/9/2016 @ 10.40 pm.

Case seen by Datuk Jayaram and case discuss with Dr. Giri. Noted
haemodynamic unstable.

Vital sign: BP ranging Systolic BP 70-100 mmhg. Diastolic BP:40-60 mmhg.

Persistent tachycardia.

3/9/2016 @ 12.10 am.

Family conference done by :

Consultant physician- Datuk Jayaram

Consultant cardiologist- Dr Liew Houng Bang

Consultant Anaesthesiologist Dr Lily Ng.

Attended by patient wife and son. Family members understood.

3/9/2016 @ 3.45 pm.

Case seenby Dr Giri.

General condition patient critically ill. Impression: Septic shock with multi organ
failure.

3/9/2016 @ 3 pm

Noted patient HR 180/min. Subsequently went into asystole. CPR commemcedfor

15 minutes.

Defibrillation x 2 given. Subsequent revive after 15 minutes.

3/9/2016 @ 4pm

Noted BP 50/40 mmhg. HR 45/Min. Cardioversion with 200 joule. HR pick up to

110 / min.

After 5 minutes , noted ECG on monitoring asystole, no pulse palpable.

CPR commenced from 5.05 pm- 5.40 pm. Total drug given. IV Adrenaline 1 mg
x 5.

Pronounced death @ 5.40 pm.

Cause of death: Pending

Body sent to mortuary QEH for post mortem @ 8 pm.

IK Ricky noted.