Death Case

Acute Lung Oedem

Community Acquired Pneumonia
Diabetes Melitus II
Hipertensi
Dr. Samsirun, SpPD (KIC)
Dr. Fuad, SpJp
Identitas Pasien
Nama: Tn. M
Umur: 68 Tahun
Alamat : Kuala Tungkal
MRS : 7 Juni 2019 (20.25)
Anamnesis (7-6-2019)
Selama 4 hari
diberikan
paracetamol tetapi
4 hari smrs, pasien
keluhan demam
mengeluh demam
masih ada. Lalu
naik turun,
dibawa ke SHJB
menggigil, mual,
nafsu makan
kurang, pusing

1
Riwayat Penyakit Dahulu

Hipertensi Diabetes Melitus tipe II

Amlodipin 1 x 5 mg Metformin 3 x 500mg

2
 Pemeriksaan Fisik
(7-6-2019)
o Mata : Konjungtiva anemis -, pupil Tanda-Tanda Vital
isokor, 5mm/5 mm, RC +/+ • TD : 170/90
menurun • HR : 110 x/m
o Leher : JVP 5-2 cmH20
• RR : 20x/m
o Jantung : BJ 1&2 reguler, murmur -, gallop –
o Paru : Vesikuler normal, Rh +/+, wh-/- •S : 37,9
o Perut : Supel, NT + epigastrik, timpani,
BU + normal
o Ekstrimitas : Edema-, Deformitas-
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 Pemeriksaan Penunjang EKG (7-6-2019)

SINUS TAKIKARDIA
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 Diagnosis

Febris H4 + Dispepsia + Hipertensi + DM II

5
 Futrolit 20 x/m

Flunarizin 2x10mg

Pantoprazol 2x40mg

Domperidon 3x10mg
PENATALAKSANAAN
Glimepiride 1x2mg
(7-6-2019)
Amlodipin 1x10mg

Mecobalamin 3x500mg

Diet diabetasol 6x200cc

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Cek GDN, GDPP, Elektrolit, Ur, Cr,
HbA1C
 Pemeriksaan Penunjang

Laboratorium (7-6-2019)
• Hb: 13,9 • Ur: 31.8 • GDN: 172
• Ht: 37,00 • Cr: 1.46 • GD2PP: 234
• WBC: 7.580 • Na: 129 • HbA1C: 7.7
• Tro: 156.000 • K: 4.9
• TUBEX 0 • Cl: 98
• GDS 163 (ETC)
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 FOLLOW UP
7 Juni 2019 – 11 Juni 2019

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 S : Kadang-kadang demam P:
O : TD: 130/80 RR: 18x/m E4M6V5 • Futrolit 20 x/m
• Flunarizin 2x10mg
HR: 80x/m S: 38,0 0C
• Pantoprazole 2x40mg
GDS:172
8 Juni 2019 (07.30) BC (7/6/19): +25/3 jam
• Domperidone 3x10mg
• Glimepiride 1x2mg
Kepala : CA-/-, SI-/- Pupil isokor, • Amlodipin 1x10mg
2/2, RC +/+ • Mecobalamin 3x500mg
Thorax : Cor: Murmur-, Gallop- • Diet diabetasol 6x 200cc
Pulmo: Wh-/-, Rh-/- • Cek UL, Ro Thorax
Abd: Supel, NT(-), BU normal
Ext : Edema -/-
9 A : Febris H5 + Hipertensi + DM II
 Rontgen Thorax
(8 Juni 2019)

• Kardiomegali
• Infiltrat di parakardial kanan, suspek
pneumonia

10
 S : Sesak+ P:
O : TD: 150/80 RR: 30x/m E4M6V5 Advis dr. Samsirun, SpPD:
• Furosemide 3x1amp
HR: 130x/m S: 38,0 0C
• Pasang DC
BC: + 160cc/11 jam
• Turun ICU
Kepala : CA-/-, SI-/- Pupil isokor,
Advis dr. Patra, SpAn:
8 Juni 2019 (11.30) 2/2, RC +/+ • CPAP ( PEEP 8, PS 14, FiO2
Thorax : Cor: Murmur-, Gallop- 90%, trigger 2
Pulmo: Rh+/+, Wh-/- • Futrolit 500cc/24 jam

Abd: Supel, NT(-), BU normal

Ext : Edema -/-, akral hangat
A : Dispnea ec Impending ALO dd/ CAP +
Hipertensi + DM II

10
 S : Sesak+ P:
O : TD: 190/90 RR: 40x/m S: 37,0 Advis dr. Samsirun, SpPD:
• Furosemid 5mg/jam
HR: 154x/m E4M6V5
• Ekstra Amiodaron 1 ampul
Kepala : CA-/-, SI-/- Pupil isokor,
8 Juni 2019 (13.20)
2/2, RC +/+
Advis dr. Samsirun, SpPD Saat visit
Thorax : Cor: Murmur-, Gallop- sore (15.20):
Pulmo: Rh+/+, Wh-/- • NTG 10mg/jam
Abd: Supel, NT(-), BU normal • Digoxin 2x1amp
• Drip insulin 2 IU/jam (sesuai
Ext : Edema -/-, akral hangat
protap)
A : ALO dd/ CAP + SVT + Hipertensi + • Cek GDS /3 jam
DM II

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 EKG (8 Juni 2019)

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 Hasil UL (19.07 WIB)
Protein 1+
S : Sesak+ Glukosa 1+
O : TD: 120/70 RR: 40x/m S: 37,0 Occult Blood +3
HR: 104x/m GDS: 248 E4M6V5 Eritrosit 39-40
8 Juni 2019 (20.50) Bacteria +
Kepala : CA-/-, SI-/- Pupil isokor,
2/2, RC +/+
Thorax : Cor: Murmur-, Gallop- P:
Advis dr. Patra, SpAn
Pulmo: Rh+/+, Wh-/-
• Levofloxacin 1x750mg
Abd: Supel, NT(-), BU normal
• Ceftazidime 3x2gr
Ext : Edema -/-, akral hangat • Nebu Salbutamol 4x/hari
A : ALO dd/ CAP + Hipertensi + DM II
12
 P:
• Futrolit 500cc/24 jam
S : TD cenderung turun, Sesak+, gelisah • Nitrogliserin 10mg/jam
O : TD: 80/50 RR: 40x/m S: 37,0 • Furosemid 5mg/jam
• Drip insulin 2 IU/jam (sesuai protap)
HR: 142x/m SpO2: 93% E4M6V5
• Flunarizin 2x10mg
BC: -1032,5cc/12 jam GDS: 164 • Pantoprazole 2x40mg
Kepala : CA-/-, SI-/- Pupil isokor, • Domperidone 3x10mg
9 Juni 2019 (10.00) 2/2, RC +/+
• Glimepiride 1x2mg
• Amlodipin 1x10mg
Thorax : Cor: Murmur-, Gallop- • Mecobalamin 3x500mg
• Digoxin 2x1
Pulmo: Rh+/+, Wh-/-
• Levofloxacin 1x750mg
Abd: Supel, NT(-), BU normal • Ceftazidime 3x2gr
• Nebu Salbutamol 4x/hari
Ext : Edema -/-, akral hangat
• Diet Diabetasol 6x200cc
A : Hipotensi + ALO dd/ CAP + Hipertensi Advis dr. Samsirun, SpPD:
+ DM II • Nitrogliserin dan furosemid stop
• Jika Sistolik >100 dan MAP >70,
13 jalankan lagi
• Bolus Amiodaron1 ampul
• Konsul SpJPCuti
 S : Sesak+, gelisah P:
O : TD: 112/73 RR: 45x/m S: 37,1 Advis dr. Patra, SpAn:
• Saran Intubasipasien di
HR: 128x/m SpO2: 93% E4M6V5
intubasi pkl 18.50 WIB
GDS 232 • Pasang NGT
Kepala : CA-/-, SI-/- Pupil isokor, • Konsul Fisioterapi
9 Juni 2019 (18.30) 2/2, RC +/+ • Kultur sputum
Thorax : Cor: Murmur-, Gallop- • Midazolam 1mg/jam
Pulmo: Rh+/+, Wh-/- • Morfin 0,5mg/jam
• Furosemide drip stop ganti
Abd: Supel, NT(-), BU normal
Furosemide 3x1amp
Ext : Edema -/-, akral hangat
A : Hipotensi + ALO dd/ CAP + Hipertensi
+ DM II
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 S : TD cenderung turun, Sesak+, Gelisah+ P:
O : TD: 83/54 RR: 26x/m S: 37,2 Advis dr. Samsirun, SpAPD
• Dobutamin 5mcg/jam
HR: 142/m SpO2: 92% E4M6Vt
• Norepinefrin 0,3mcg/jam
PSIMV (PEEP 8, FiO2 80%, PS 16)
titrasi
9 Juni 2019 (22.10) Kepala : CA-/-, SI-/- Pupil isokor, • Target MAP 80
2/2, RC +/+
Thorax : Cor: Murmur-, Gallop-
Pulmo: Rh+/+, Wh-/-
Abd: Supel, NT(-), BU normal
Ext : Edema -/-, akral hangat
A : Hipotensi + ALO dd/ CAP + Hipertensi +
DM II
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S : Sesak+, gelisah+
O : TD: 130/80 RR: 40x/m S: 36,2
HR: 140x/m SpO2: 95% E4M6Vt
BC: -1485,5cc/24 jam GDS: 221
Kepala : CA-/-, SI-/- Pupil isokor,
10 Juni 2019 (07.05) 2/2, RC +/+
Thorax : Cor: Murmur-, Gallop-
Pulmo: Rh+/+, Wh-/-
Abd: Supel, NT(-), BU normal
Ext : Edema -/-, akral hangat
A : Hipotensi + ALO dd/ CAP + Hipertensi
+ DM II
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P:
• Futrolit 500cc/24 jam
• Drip insulin 2 IU/jam (sesuai protap)
• Dobutamin 5mcg/jam
• Norepinefrin 0,2mcg/jam titrasi
• Midazolam 1mg/jam
• Morfin 0,5mg/jam
• Pantoprazole 2x40mg
• Domperidone 3x10mg
• Glimepiride 1x2mg
• Mecobalamin 3x500mg
• Digoxin 2x1
• Levofloxacin 1x750mg
• Ceftazidime 3x2gr
• Nebu Salbutamol 4x/hari
• Diet Diabetasol 6x200cc
Advis dr. Samsirun, SpPD:
• Midazolam 3mg/jam
• Diabetasol 6x100cc
Advis dr. Patra, SPAn:
• Midazolam 1mg/jam
 P:
S : Sesak+, kesadaran semakin turun
Advis dr Patra, SpAn
O : TD: 127/56 RR: 50x/m S: 36,2
• Stop Midazolam
HR: 136x/m SpO2: 95% E2M2Vt • Dobutamin titrasi max
GDS: 112 10mcg/jam
10 Juni 2019 (12.00) PSIMV (PEEP 8,FiO2 80, Pins 16) • Target SpO2 92%
Kepala : CA-/-, SI-/- Pupil isokor,
2/2, RC +/+
Thorax : Cor: Murmur-, Gallop-
Pulmo: Rh+/+, Wh-/-
Abd: Supel, NT(-), BU normal
Ext : Edema -/-, akral dingin+/+
A : Hipotensi + ALO dd/ CAP + Hipertensi
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+ DM II
 Rontgen Thorax
(10-6-2019)

• Infiltrat kedua paru cenderung

bertambah, DD/ edema paru,
pneumonia
• ETT dengan ujung setinggi T4/5

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 P:
S : (-)
Advis dr Hadi
O : TD: 68/50 RR: 25x/m S: 36,2
• Ekstra SA 2 amp
HR: 50 x/m SpO2: 68% E1M1Vt • FiO2 90%
GDS: 112 • Titrasi naik Norepinefrin (0,5
10 Juni 2019 (17.00) PSIMV (PEEP 8,FiO2 80, Pins 16) mcg/jam)
Kepala : CA-/-, SI-/- Pupil isokor, • Stop Furosemide 3mg/jam
2/2, RC -/- • IC keluargapenurunan
Thorax : Cor: Murmur-, Gallop-
Pulmo: Rh+/+, Wh-/-
Abd: Supel, NT(-), BU normal
Ext : Edema -/-, akral dingin+/+
A : Hipotensi + ALO dd/ CAP + Hipertensi
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+ DM II
 P:
Advis dr Fuad, SpJP:
• Echocardiografi
S : (-)
• Titrasi naik Norepinefrin (0,5
O : TD: 94/57 RR: 16x/m S: 36,2 mcg/jam)
HR: 122x/m SpO2: 94% E1M1Vt • Naikkan Dobutamin sampai 15
mcg/jam
GDS: 112
10 Juni 2019 (21.00) PSIMV (PEEP 8,FiO2 80, Pins 16)
• Cek CKMB, Trop T
• Extra RL 500cc + Norepinefrin 1
Kepala : CA-/-, SI-/- Pupil isokor, amp masukkan 200cc (pukul
21.05)
2/2, RC -/-
• Hydrocortisone 200mg + Nacl
Thorax : Cor: Murmur-, Gallop- 0,9% 500 cc/24 jam (pukul
Pulmo: Rh+/+, Wh-/- 23.00)
• Fondaparinux 1x2.5 mg SC
Abd: Supel, NT(-), BU normal (pukul 01.00)
Ext : Edema -/-, akral dingin+/+
A : Hipotensi + ALO dd/ CAP + Hipertensi Trop T: >2.000
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+ DM II + Paroxysmal AF CK MB: 100
 ECHOCARDIOGRAFI

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 11 Juni 2019

●
S : Nadi (-)
●
O : TD: 41/28 RR: 16x/m HR: 40x/m E1M1Vt
●
A : Cardiac Arrest
●
P : RJP  Epinefrin  RJP  ROSC (03.50 WIB)

03.45 WIB

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THANK YOU!