DEATH CASE

REPORT

dr Levina

dr Muhammad Fauzan Assegaf

History Taking
(Autoanamnesis)
– Chief complain: shortness of breath
– Shortness of breath since 1 month before admission, got worsened since 3 days
before admission. Shortness of breath was initially only felt upon activities, yet it got
worsened and felt with less than ordnary daily activities. The patient got dyspneic
only by walking to the bathroom or taking a bath.Shortness of breath improved by
rest Shortness of breath mainly felt during the night. The patient was unable to lie
flat and slept with 3 pillows. Shortness of breath improved by lying at the left side.
– Shortness of breath was accompanied by cough with white sputum since 3 days
before admission, worsened with sitting down and especially felt during the night.
The cough was also improved by lying at the left side. Prolonged cough
accompanied by bloody sputum was not present. History of previous pleural fluid
evacuation was not present. History of chest pain was denied.
History Taking -cont’d

– The complain was accompanied by general weakness felt since 1 month before
admission, got worsened during 1 week before admission. Families also
admitted that the patient look pale and weak. History of recent bleeding was
not present.
– The patient also complained of swelling of body parts, predominantly of the left
side, since 1 month before admission. It was initially appeared on both ankles,
but then also appeared on the abdomen, face, and both eyelids. The swelling
improved after hemodialysis but then reappeared afterward. Yet, during the last
1 week, since the patient was unable to do hemodialysis because of obstructed
DLC, the swelling persisted.
History Taking-cont’d

– The patient undergone hemodialysis since 3 months ago. The DLC was installed in
Wahidin Hospital at October 2017. The patient undergone 10 times HD in Wahidin
Hospital and 6 times in Bulukumba, yet the last 2 HD session was not sucessfully
carried out due to obstructed DLC (according to HD nurse at Bulukumba Hospital).
The patient was then referred to Vascular and Thoracic Surgery Outpatient Clinic for
DLC repair and AV shunt procedure, yet the patient got increasingly dyspneic and
was observed in the ER and then advised to be hospitalized.
– During HD sessions in Wahidin, the patient got injection on the right arm, yet he
didn’t get it in Bulukumba Hospital. At the time of admission, the patient consumed
furosemife 40 mg/12 hours/oral, amlodipine 10 mg/24 hours/oral and allopurinol
100 mg/24 hours/oral from Bulukumba Hospital.
History Taking-cont’d

– There was no change in bowel habit, no history of black tarry stool nor bloody red stool.
– There was a decrease in urine volume, with dark yellow colour. History of stone upon
urination was not present, painful urination was not present, blood in urine was not
present
– There was a history of hypertension since 1 year before admission, highest blood
pressure known were 180/x, did not regularly take medication, but upon admission
consumed amlodipine 10 mg/24 hours/oral. History of diabetes mellitus was not
present.
– The patient was known to be hepatitis B positive when he was prepared for hemodialysis
3 months ago. History of previous yellowish skin and eyes followed by fever was not
present. History of previous yellowish skin and eyes followed by fever in family was
denied. History of previous transfusion was not present.
History Taking-cont’d

– Past medical history: history of tuberculosis medication was not present, history of
stroke was not present
– Family history
– The patient was the only son in the family
– Both of the patient’s parent is still alive and healthy
– The patient has not been married
– History of family with same illness was not present
– History of malignancy in the family was not present
– History of diabetes mellitus, hypertension, and cardiac disease in the family was not
present
History Taking-cont’d

– Psychosocial history
– The patient was a high school student
– The patient lived with his parents
– Smoking and alcohol consumption was denied
– Intravenous drug use was denied
 PHYSICAL
EXAMINATION
Physical
Examination
– Blood pressure : 170/80 mmHg
– Pulse rate : 96
– Respiratory rate : 24
– Temperature : 37.6
– Oxygen saturation : 96%
– Body weight : 65 kg
– Body height : 160 cm
– BMI : 25.3 kg/m2
Physical
Examination-cont’d
– General condition : severely ill
– Nutrition : well nourished
– Consciousness : composmentis
– Weight : 65 kg (edematous state)
– Height :160 cm
– IMT :25.3 kg/m2
Physical
Examination-cont’d
Head : Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly
left side
Eye : isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-),
palpebral edema (+/+).
Neck : JVP R+3 cmH2O position 30o, no lymph node enlargement
Thorax :
– Inspection : Asymmetrical, bulging of the left hemithorax
– Palpation : Vocal fremitus decreased on both sides
– Percussion : Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level
– Auscultation : vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th
ICS level, rales at right basal lung field, no wheezing
Physical
Examination-cont’d
Cor
– Inspection : Ictus cordis not visible
– Palpation : Ictus cordis not palpable
– Percussion : heart border hard to evaluate
– Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
– Inspection : convex, parallel with breathing pattern
– Auscultation : apparently normal peristaltic
– Palpation : liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no
tumor
– Percussion : tympanic (+), lateral and Shifting dullness (+)
Extremities : edema on bilateral upper and lower extremities predominantly left side
 Value 6/1/2018 8/1/2018 Reference ramge
(Bulukumba)
Hb 8.2 7.4 12.00 -16.00 g/dl

MCV 83 89.8 80.0-97.0

MCH 31.1 28.0 26.5-33.5

MCHC 37.4 31.2 31.5-35.0

WBC 10000 7900 4.00 – 10.00x103 /mm3

Neutr - 66.5 52-75%

Plt 179 197 150-400x103 /mm3

 Value 6/1/2018 8/1/2018 Reference ramge
(Bulukumba)
Ur 89 137
0-53 mg/dl
Cr 10.2 17.78
0,6-1,3 mg/dl
Na 138.8 136
136-145 mmol
K 4.21 4.6
3,5-5,1 mmol
Cl 107.8 99
97-111 mmol
SGOT/SGPT 30/13 28/11 <35/<45 gr/dl

Albumin 3.2 3,3-5,0 gr/dl

Protein Total - 6 – 9 g/dl

 Value 6/1/2018 8/1/2018 Reference ramge
(Bulukumba)
PT - 10.9 10-14 detik

APTT - 28.4 22.0-30.0 detik

INR - 1.00

GDS 104 109 80-180 mg/dl

Uric acid 5.9 - 2.4-5.7 mg/dl

Total cholesterol 166 - 200 mg/dl

LDL 107 - <130 mg/dl

HDL 32 40-60 mg/dL

Triglyceride 141 - 200 mg/dl

Electrocardiography
ECG interpretation
– Rhythm : sinus rhythm
– Rate : 94 bpm, regular
– Axis : +40 degree, normoaxis
– P wave :normal duration and morphology
– PR interval : 0.18 second
– QRS complex : normal duration. S in V2+R in V6>35 mV
– ST segmen : no depression or elevation
– T wave : normal duration and morphology
– U wave : not present
– Conclusion: Sinus rhythm, 94 bpm, normoaxis, left ventricular hypertrophy
Thorax X-ray PA projection
– Homogenous opacities on left hemithoraz covering sinus,
diaphragm, and right border of the heart at anterior ICS II
level
– Capping on lateral side of left hemithorax
– Blunted right sinus, apparently normal right diaphragm
– Intact bones

– Conclusion:
Bilateral pleural effusion predominantly on left side.
MSCT scan abdomen
(17/12/2018)
– Hepatomegaly
– Ascites
– Bilateral pleural effusion
– Device on right femoral region suggestive of double lumen catheter
LIST OF PROBLEMS
1. BILATERAL PLEURAL EFFUSION
PREDOMINANTLY LEFT SIDE

– Diagnosed based on complain of shortness of breath since 1 month before

admission got worsened since 3 days before admission. The dyspnea
characteristically improved with lying at the left side.
– From physical examination at thoracic region:
– Inspection: Bulging of left hemithorax
– Palpation: Decreased vocal fremitus on both sides
– Percussion: Dullness on left ICS IV and right ICS VI (posterior)
– Auscultation:Decreased vesicular breath sound at ICS IV and right ICS VI level
(posterior)
– Diagnostic plan: USG thorax marker, analysis and cytology of pleural fluid
– Therapeutic plan: Pleural fluid evacuation
– Monitoring plan: Monitoring of clinical symptoms and vital signs, post-
evacuation control thorax x-ray
– Education plan: Education about the importance, side effects, and complication
of pleural fluid evacuation
2. CONGESTIVE HEART
FAILURE NYHA III
– Diagnosed based on the complain of shortness of breath, dyspnea on exertion,
paroxysmal nocturnal dyspnea, and orthopnea was present.
– Nocturnal cough was present
– Physical examination: increased jugular veous pressure, mediobasal rales,
bilateral pleural effusion, bilateral pitting edema on extremities
– ECG: sinus rhyhtm, normoaxis, left ventricular hypertrophy
– MSCT scan: hepatomegaly
– Fulffiling 3 major and 3 minor Framingham criteria for heart failure
– There was history of furosemide consumption.
– Diagnostic plan: Echocardiography
– Therapeutic plan:
– Oxygen 3 liter/menit nasal cannule
– Furosemide 40 mg/12 hours/oral
– Glyceryl trinitate 2.5 mg/12 hours/oral
– Monitoring plan: Monitoring of clinical symptoms and fluid balance (target
negative)
– Education plan: Education concerning heart failure as a consequence of
hypertension and kidney failure and the importance of fluid restriction
3. CHRONIC KIDNEY
DISEASE G5 ON DIALYSIS
– Diganosed based on complain of shortness of breath and swelling of body parts
since 1 month before admission. There was also a 3-month history of dialysis
– Physical examination: blood pressure 170/80 mmHg, anemic conjunctivae, signs
of fluid overload (distended jugular vein, bilateral pleural effusion, mediobasal
rales, ascites, and pitting edema of extremities)
– Lab: Hb 7.4 mg/dL (MCV 89.8 fL, MCH 28.0 pg, MCHC 31.2 g/dL), ureum 137,
dan creatinine 17.78 (eGFR 3.7 ml/min/1.73m2), and from urinalysis:
proteinuria 3+. glucosuria 2+.
– Chronic kidney disease was thought to stem from hypertension or
glomerulopathy
– Diagnostic plan: kidney biopsy
– Therapeutic plan:
– Protein <1.2 gram/day diet
– Low phosphate, potassium, phosphate, purin diet
– Regular hemodialysis
– Consult to thoracic and vascular surgery dept for AV shunt
– Monitoring plan: monitoring of clinical symptoms and fluid balance (target negative)
– Education plan: Educaton concerning diet, importance of biopsy, AV shunt, and
regulr hemodialysis
4. GRADE 2 HYPERTENSION

– Diagnosed based on histoty of hypertension since 1 year before admission

– Physical examination: initial blood pressure 170/80 mmHg with amlodipine 10
mg/24 hours/oral.
– Hypertension can be thought as a cause or complication from the chronic
kidney disease.
– Diagnostic plan: kidney biopsy
– Therapeutic plan:
– Low salt diet <2 gram/day
– Nifedipine GITS 30 mg/24 hours/oral
– Monitoring plan: monitoring of blood pressure, target <140/80
– Education plan: Educaton concerning low salt diet
4. NORMOCYTIC
NORMOCHROMIC ANEMIA
• Diagnosed based on complain of general weakness and pale since 1 month
before admission without signs of acute bleeding. According to the family, the
patient didn’t get subcutaneous injection during the last 6 dialysis.
• From laboratory examination we found Hb 7.4 g/dL, MCV 89 fL, MCH 28 pg,
MCHC 31.2 g/dL
– Diagnostic plan: iron study (Fe, TIBC, Ferritin)
– Therapeutic plan: -
– Monitoring plan: monitoring of clinical symptoms and signs of bleeding,
periodic monitoring of Hb level
– Education plan: Educaton concerning the importance and complication of blood
transfusion
5. HEPATITIS B INFECTION

– Diagnosed based on positive hepatitis B result 3 months ago upon initiation of

HD and laboratory examination shows HbSAg titer of 2.09 (reactive).
– Diagnostic plan: USG abdomen, liver function test
– Therapeutic plan: -
– Monitoring plan: -
– Education plan: education concerning natural history of the disease and
hemodialysis in hepatitis B positive machine
INITIAL MANAGEMENT

– Oksigen 3 liter/menit/nasal cannule -Pleural fluid evacuation

– Low salt diet <2 gram/hari -Pleural fluid analysis and citology
– Low protein diet <1.2 gram/hari -USG thorax marker
– Low potassium, phosphate, purin diet -Iron study, liver function test
– Furosemide 40 mg/12 jam/oral
– Glyceryl trinitrate 2,5mg/12 jam/oral
– Nifedipine GITS 30 mg/24 jam/oral
– Regular hemodialysis Senin, Rabu, Jumat
 Follow Up
Date Course of disease Therapy

10/1/2018 Treatment day 1 -Oxygen 3 liter/minutes/nasal cannule

13.00 S: Shortness of breath and weakness, cough present -Protein diet 1.2 gr/kgBB/day
INTERNA O: -Low salt diet <2 gr/day
BP: 170/90 -Low potassium, purine, phosphate diet
HR: 96 bpm, regular -Furosemide 40 mg/12 hours/oral
RR: 24 tpm
-Glyceryl trinitrate 2,5 mg/12 hours/oral
T: 37.6
SaO2 96% -Nifedipine GITS 30 mg/24 hours/oral
Head: Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly left side -Regular hemodialysis 3 times per week
Eye: isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-), palpebral edema (+/+).
Neck: JVP R+3 cmH2O position 30o, no lymph node enlargement Plan:
Thorax : Pleural fluid evacuation
Inspection: Asymmetrical, bulging of the left hemithorax
Echocardiography if clinical condition allows
Palpation: Vocal fremitus decreased on both sides
Percussion: Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level Iron study (Fe, TIBC, ferritin)
Auscultation: vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th ICS level, rales at
right basal lung field, no wheezing
Cor
Inspection: Ictus cordis not visible
Palpation: : Ictus cordis not palpable
Percussion : heart border hard to evaluate
Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
Inspection: convex, parallel with breathing pattern
Auscultation: apparently normal peristaltic
Palpation: liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no
tumor
Percussion: tympanic (+), lateral and Shifting dullness (+)
Extremities: edema on bilateral upper and lower extremities predominantly left side
 Course of disease Therapy
10/1/2018 Laboratorium (8/1/2018):
13.00 WBC 7900
INTERNA Hb 7.4
PLT 197
PT/ INR/APTT 10.9/1.00/28.4
Ur/Cr 137/17.78
HbsAg 2.09 (reactive)
Anti HCV 0.29 (non reactive)
Anti HIV non reactive
GDS 109
Na/K/Cl 136/4.8/99
CXR (9/1/2018):
Bilateral pleural effusion predominantly left side
A:
Bilateral pleural effusion predominantly left side
Congestive heart failure NYHA III
Chronic kidney disease G5D
Grade 2 hypertension
Normocytic normochromic anemia
Hepatitis B Infection

10/1/2018 S: weakness HD regular

15.00 O: BP 170/100 TD: 4 jam
HD HR 100 QB 150
RR 28 QD 350
T 37 UFG 1500
Anemic conjunctivae Cond 14.3
JVP R+3 T 37
Decreased vesicular breath sound on left side, rhonkhi +/+, wheezing -/- Akses DLC
Regular heart sound, no murmur
Pitting edema bilateral
A: CKD G5D
Date Course of disease Therapy
11/1/2018 Treatment day 2 -Oxygen 3 liter/minutes/nasal cannule
06.00 S: Shortness of breath and weakness, cough present -Protein diet 1.2 gr/kgBB/day
INTERNA O: -Low salt diet <2 gr/day
BP: 170/90 -Low potassium, purine, phosphate diet
HR: 100 bpm, regular -Furosemide 40 mg/12 hours/oral
RR: 26 tpm
-Glyceryl trinitrate 2,5 mg/12 hours/oral
T: 37.6
SaO2 97% -Nifedipine GITS 30 mg/24 hours/oral
UO 300 cc, fluid balance +100cc -Telmisartan 80 mg/24 hours/oral
Head: Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly left side -Regular hemodialysis 3 times per week
Eye: isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-), palpebral edema (+/+).
Neck: JVP R+3 cmH2O position 30o, no lymph node enlargement Plan:
Thorax :
Consultation to thoracic and vasc surgery dept for AV shunt
Inspection: Asymmetrical, bulging of the left hemithorax
Palpation: Vocal fremitus decreased on both sides Pleural fluid evacuation
Percussion: Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level Echocardiography if clinical condition allows
Auscultation: vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th ICS level, rales at Urinalysis
right basal lung field, no wheezing
Cor
Inspection: Ictus cordis not visible
Palpation: : Ictus cordis not palpable
Percussion : heart border hard to evaluate
Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
Inspection: convex, parallel with breathing pattern
Auscultation: apparently normal peristaltic
Palpation: liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no
tumor
Percussion: tympanic (+), lateral and Shifting dullness (+)
Extremities: edema on bilateral upper and lower extremities predominantly left side
A:
Bilateral pleural effusion predominantly left side
Congestive heart failure NYHA III
Chronic kidney disease G5D
Grade 2 hypertension
Normocytic normochromic anemia
Hepatitis B Infection
Date Course of disease Therapy
12/1/2018 Treatment day 3 -Oxygen 3 liter/minutes/nasal cannule
10.00 S: Shortness of breath and weakness, fever especially during the night -Protein diet 1.2 gr/kgBB/day
INTERNA O: -Low salt diet <2 gr/day
BP: 130/90 -Low potassium, purine, phosphate diet
HR: 118 bpm, regular -Furosemide 40 mg/12 hours/oral
RR: 28 tpm
-Glyceryl trinitrate 2,5 mg/12 hours/oral
T: 38.3
SaO2 96% -Nifedipine GITS 30 mg/24 hours/oral
UO 400 cc, fluid balance -50cc -Telmisartan 80 mg/24 hours/oral
Head: Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly left side -Paracetamol 500 mg/8 hours/oral
Eye: isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-), palpebral edema (+/+). -Regular hemodialysis 3 times per week
Neck: JVP R+3 cmH2O position 30o, no lymph node enlargement
Thorax :
Evacuation of 750 cc pleural fluid, hemorrhagic
Inspection: Asymmetrical, bulging of the left hemithorax
Palpation: Vocal fremitus decreased on both sides
Percussion: Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level Plan:
Auscultation: vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th ICS level, rales at Waiting for reply from consultation to surgery dept
right basal lung field, no wheezing Pleural fluid analysis and cytology
Cor Repeat routine blood examination after pleural fluid
Inspection: Ictus cordis not visible evacuation
Palpation: : Ictus cordis not palpable
Transfusion of 2 bag of PRC during HD
Percussion : heart border hard to evaluate
Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
Inspection: convex, parallel with breathing pattern
Auscultation: apparently normal peristaltic
Palpation: liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no
tumor
Percussion: tympanic (+), lateral and Shifting dullness (+)
Extremities: edema on bilateral upper and lower extremities predominantly left side

Laboratorium (11/1/2017)
WBC 9890  7900
Hb 7.1  7.4
PLT 136  197
Urinalysis (11/1/2017)
Protein 300 /+++
Glucose 250/+++
Date Course of disease Therapy
13/1/2018 Treatment day 4 -Oxygen 3 liter/minutes/nasal cannule
06.00 S: Shortness of breath improves, fever present. Pain and redness at DLC insertion site -Protein diet 1.2 gr/kgBB/day
INTERNA O: -Low salt diet <2 gr/day
BP: 130/90 -Low potassium, purine, phosphate diet
HR: 120 bpm, regular -Furosemide 40 mg/12 hours/oral
RR: 20 tpm
-Glyceryl trinitrate 2,5 mg/12 hours/oral
T: 38.5
SaO2 96% -Nifedipine GITS 30 mg/24 hours/oral
UO 350 cc, fluid balance +50 cc -Telmisartan 80 mg/24 hours/oral
Head: Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly left side -Paracetamol 500 mg/8 hours/oral
Eye: isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-), palpebral edema (+/+). -Ceftriaxone 2 gr/24 hours/oral
Neck: JVP R+3 cmH2O position 30o, no lymph node enlargement -Erythropoietin 4000 IU/subcutaneous/2 times a week
Thorax :
-Regular hemodialysis 3 times per week
Inspection: Asymmetrical, bulging of the left hemithorax
Palpation: Vocal fremitus decreased on both sides
Percussion: Dull on the left hemithorax at ICS V level and right hemithorax at ICS VI level Evacuation of 750 cc pleural fluid, hemorrhagic
Auscultation: vesicular breath sound, decreased breath sound at left 5th ICS level and right 6th ICS level, rales at
right basal lung field, no wheezing Plan:
Cor Waiting for surgery schedule for AV shunt
Inspection: Ictus cordis not visible Waiting for pleural fluid cytology result
Palpation: : Ictus cordis not palpable
Transfusion of 2 bag of PRC during HD
Percussion : heart border hard to evaluate
Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
Inspection: convex, parallel with breathing pattern
Auscultation: apparently normal peristaltic
Palpation: liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no
tumor
Percussion: tympanic (+), lateral and Shifting dullness (+)
Extremities: edema on bilateral upper and lower extremities predominantly left side

Laboratorium (12/1/2018)
WBC 8250  9890  7900
Hb 7.0  7.1  7.4
PLT 177  136  197
Fe 55, TIBC 202, Transferrin sat 27.2, ferritin >1200

Peripheral blood smear (12/1/2018)

Conclusion: Normochromic normocytic anemia with sgns of decreased renal function
13/1/2018 Pleural fluid analysis (12/1/2018)
06.00 Color: red
INTERNA Volume: 10 cc
Clot negative
Spec gravity 1.015
pH 8.0
Rivalta positive
Glucose 92
Protein 3800
LDH 523
Cell count 750, PMN 5% MN 95%
A:
Bilateral pleural effusion predominantly left side post evacuation
Congestive heart failure NYHA III
Chronic kidney disease G5D
Grade 2 hypertension
Renal anemia
Hepatitis B Infection
Infected DLC
13/1/2018 S: shortness of breath PRC transfusion 2 bags
15.00 O: BP 170/100 HD regular
HD HR 100 TD: 4 hours
RR 28 QB 150
T 37 QD 350
Anemic conjunctivae UFG 1500
JVP R+3 Cond 14.3
Decreased vesicular breath sound on left side, rhonkhi +/+, wheezing -/- T 37
Regular heart sound, no murmur Akses DLC
Pitting edema bilateral
A: CKD G5D
13/1/2018 S: weakness Therapy according to internal medicine dept
BTKV O: BP 150/90, HR 88
RR 20
A:Post DLC ec CKD
Pro AV shunt
Date Course of disease Therapy
15/1/2018 Treatment day 6 -Oxygen 3 liter/minutes/nasal cannule
06.00 S: Shortness of breath worsened after drinking 2 bottles of mineral water -Protein diet 1.2 gr/kgBB/day
INTERNA BP: 130/90 -Low salt diet <2 gr/day
HR: 120 bpm, regular -Low potassium, purine, phosphate diet
RR: 26 tpm -Furosemide 40 mg/8 hours/intravenous
T: 38
-Glyceryl trinitrate 2,5 mg/12 hours/oral
SaO2 93%
UO 400 cc, fluid balance +1200cc -Nifedipine GITS 30 mg/24 hours/oral
Head: Normocephaly, black hair, not easily plucked, facial edema (+/+) predominantly left side -Telmisartan 80 mg/24 hours/oral
Eye: isochoric pupil, light reflex (+), normal, pale conjuctivae, icteric sclerae (-/-), palpebral edema (+/+). -Paracetamol 500 mg/8 hours/oral
Neck: JVP R+3 cmH2O position 30o, no lymph node enlargement -Ceftriaxone 2 gr/24 hours/oral
Thorax : -Erythropoietin 4000 IU/subcutaneous/2 times a week
Inspection: Asymmetrical, bulging of the left hemithorax
-Regular hemodialysis 3 times per week
Palpation: Vocal fremitus decreased on both sides
Percussion: Dull on the left hemithorax at ICS V level and right hemithorax at ICS VI level
Auscultation: vesicular breath sound, decreased breath sound at left 5th ICS level and right 6th ICS level, rales at Plan:
bilateral mediobasal basal lung field, no wheezing Control routine blood exam, ureum, creatinine, electrolyte
Cor USG thorax marker followed by pleural fluid evacuation
Inspection: Ictus cordis not visible Waiting for pleural fluid cytology
Palpation: : Ictus cordis not palpable Transusion of 1 bag PRC during HD
Percussion : heart border hard to evaluate
Waiting for surgery schedule for AV shunt
Auscultation : Regular heart sound I/II, no audible murmur/gallop
Abdomen
Inspection: convex, parallel with breathing pattern
Auscultation: apparently normal peristaltic
Palpation: liver and spleen hard to evaluate, no pain on palpation, no costoverteral angle percussion pain no tumor
Percussion: tympanic (+), lateral and Shifting dullness (+)
Extremities: edema on bilateral upper and lower extremities predominantly left side
A:
Acute decompensated heart failure
Bilateral pleural effusion predominantly left side post evacuation
Chronic kidney disease G5D
Grade 2 hypertension
Normocytic normochromic anemia
Hepatitis B Infection
Infected DLC
15/1/2018 S: weakness Continue therapy according to
BTKV O: BP 130/90 internal medicine
HR 80 Wait for AV shunt schedule
RR 20
A: Post DLC ec CKD
Pro AV shunt

15/1/2018 S: shortness of breath Delay transfusion

HD O: BP 170/100 HD regular
HR 100 TD: 4 hours
RR 28 QB 200
T 37 QD 400
Anemic conjunctivae UFG 1500
JVP R+3 Cond 14.3
Decreased vesicular breath sound on left side, rhonkhi +/+, T 37
wheezing -/- Akses DLC
Regular heart sound, no murmur Normal heparin
Pitting edema bilateral
A: CKD G5D
15/1/2018 Treatment day 6 -Oxygen 4 liter/minutes/nasal cannule
15.10 S: Shortness of breath persists after hemodialysis, fever improves -Furosemide 200 mg/24 hours/syringe pump
INTERNA BP: 150/100 -ISDN 1 mg/hour/syringe pump
HR: 120 bpm, regular -Nifedipine GITS 30 mg/24 hours/oral
RR: 30 tpm -Telmisartan 80 mg/24 hours/oral  stop
T: 37.9
-Paracetamol 500 mg/8 hours/oral
SaO2 97%
UO 400 cc, fluid balance +1200cc -Ceftriaxone 2 gr/24 hours/oral
Thorax : -Erythropoietin 4000 IU/subcutaneous/2 times a week
Inspection: Asymmetrical, bulging of the left hemithorax -Kalitake 1 sach/8 hours/oral
Palpation: Vocal fremitus decreased on both sides -Regular hemodialysis 3 times per week
Percussion: Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level
Auscultation: vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th ICS level, rales at
bilateral mediobasal basal lung field, no wheezing
Extremities: edema on bilateral upper and lower extremities predominantly left side

Laboratorium (15/1/2018)
WBC 7709  8250
Hgb 5.4  7.1
PLT 159  177
Neut 73.9
Lymph 15.7
Ureum 159  137
Creatinine 13.60  17.78
Natrium 132  136
K 5.6  4.8
CL 99  99
Pleural fluid cytology: Smear consists of erythrocytes, plenty neutrophil and lymphocytes, no malignant cells
A:
Acute decompensated heart faiiure
Bilateral pleural effusion predominantly left side post evacuation
Congestive heart failure NYHA III
Chronic kidney disease G5D
Grade 2 hypertension
Normocytic normochromic anemia
Hepatitis B Infection
Infected DLC
16/1/2018 Treatment day 7 -Oxygen 10 liter/minutes/non rebreathing mask
04.00 S: Shortness of breath worsened -furosemide 200 mg/24 hours/syringe pump
INTERNA BP: 120/90 -ISDN 1 mg/hour/syringe pump
HR: 90 bpm, regular
RR: 30 tpm Plan:
SaO2 86%
Blood gas analysis
JVP R+4
Thorax :
Inspection: Asymmetrical, bulging of the left hemithorax
Palpation: Vocal fremitus decreased on both sides
Percussion: Dull on the left hemithorax at ICS IV level and right hemithorax at ICS VI level
Auscultation: vesicular breath sound, decreased breath sound at left 4th ICS level and right 6th ICS level, rales at
bilateral mediobasal basal lung field, no wheezing
Extremities: edema on bilateral upper and lower extremities predominantly left side

Laboratorium (15/1/2018)
WBC 7709  8250
Hgb 5.4  7.1
PLT 159  177
Neut 73.9
Lymph 15.7
Ureum 159  137
Creatinine 13.60  17.78
Natrium 132  136
K 5.6  4.8
CL 99  99
Pleural fluid cytology: Smear consists of erythrocytes, plenty neutrophil and lymphocytes, no malignant cells
A:
Acute decompensated heart failure
Bilateral pleural effusion predominantly left side post evacuation
Congestive heart failure NYHA III
Chronic kidney disease G5D
Grade 2 hypertension
Normocytic normochromic anemia
Hepatitis B Infection
Infected DLC
Hyperkalemia
Date Course of disease Therapy
16/1/2018 S: Apnea CPR 2 cycle
05.50 BP: not measurable Epinephrine 1 amp
INTERNA HR: not palpable 06.10: pupil maximally dilated, no light reflexes,
RR: no breathing no corneal reflexes. The patient was declared
SaO2: not measurable
death in front of nurses and families
JVP R+4
A:
Cardiac arrest
 Dyspnea

Cardiovascular
Pulmonary abnormality
abnormality

Acute Decompensated
Congestive heart failure Pleural effusion
Heart Failure

Hypertension Volume overload Respiratory failure

Chronic kidney disease

DLC

Infected DLC Sepsis

Death
THANK YOU