Death Case

Summary of
NO PROBLEM LIST PLANING W
database
1. Mr. Sardi/ 45 years old Emergency Problem Emergency problem ER 
CC : SOB since 2 days before 1. Septic Shock O2 10 lpm NRBM passed
admission 1.1 Pneumonia HCAP Inserted NGT fluid diet 6x 200cc away
Primary survey : 2. DOC Inserted catheter
A: patent 2.1 Septic encephalopathy Line 1: Rehydration with NS
B: spontan, tachypneu 2.2 Hepatic encephalopathy 1000cc  20 dpm
C: warm acral
2.3 Hypoxic encephalopathy Line 2: Bolus D40% 50mEq 
GCS 223 BP 70/50 mmHg on
2.4 Uremic encephalopathy D10% 10 dpm
drip NE
HR 119 bpm RR 36 tpm 3. Severe hyperkalemia Line 3: Drip NE 0.05-2mcg/kg/min
Tax: 35.5 C 3.1 impaired renal excretion Infus Ciprofloxacin 2x 200 mg
Anemic +, Icteric + Urgency Problem Inj Ceftriaxone 2x1 Gr iv
Liver span 18 cm, nodulated, 4. Anemia Hipo Mikro Inj Omz 1x 40 mg iv
ascites + 4.1 Anemia on Chronic Inj BCAA 2x 500 cc
SN: BV, decreeased at disease Urgency problem:
mediobasal right lung, basal 4.2 Occult blood loss (?) Equal fluid balance
left lung. Ronchi at mediobasal 5. Azotemia Inj vit K 3x 1 amp
right lung. 5.1 Prerenal dt Hepatorenal
syndfrome per NGT: UDCA 3x 250 mg
Hb 9.0 gr/dL 5.2 Renal dt Sepsis
WBC 32000/uL 6. Prolonged FH +
Plt: 350000/uL
Hypoalbuminemia
K: 7.05
Non urgency Non urgency: -
Ur/Cre: 151/ 2.2
OT/PT: 749/189 7. Hepatoma
RBG: 90 165 7.1 Cirrhosis Hepatis Planning Monitoring: CBC
CXR: Pneumonia malignant degeneration
7.2 HCC Reference :
EIMED PAPDI
Time Condition Assesment Planning Therapy PMo

17.00 GCS 223 1. Septic Shock dt Pneumonia O2 10 lpm NRBM VS / 15

BP: 70/50 mmHg 2. DOC Inserted NGT fluid diet 6x 200cc min
PR: 119 bpm 3. Hepatoma Inserted catheter
Line 1: Rehydration with NS 1000cc
RR: 36 tpm
 20 dpm
Line 2: Drip NE 0.05-2mcg/kg/min
Infus Ciprofloxacin 2x 200 mg
Inj Ceftriaxone 2x 1 Gr iv
Inj Omz 1x 40 mg iv
Inj BCAA 2x 500 cc
CIE: DNR
18.00 GCS 111 As Above Line 3: Bolus D40% 50mEq  VS / 15
BP: 60/45 mmHg D10% 10 dpm min
PR: 100 bpm Line 1: NE uptitration
RR: 40 tpm
RBG: 90 165 mg/dl
19.00 Patient reported 1. Septic Shock dt Pneumonia Communicate, Inform, Educate the
Apneu 2. DOC family about patient condition, and
GCS 111 3. Hepatoma the bad prognose
BP: unmeasured
PR: unpalpable
RR: -
19.25 Patient passed away Cause of Death:
1.Septic Shock dt Pneumonia