DEATH CASE REPORT

PATIENTS IDENTITY
Name: Mr. S
Hospital : Wahidin Sudirohusodo
Age: 19 Year
Room : No. 1 Bed 5 Third Class
Gender: Male
No. MR: 00-71-96-20
Address: Soppeng
Date of Entry: 04-05-16
Occupation: Farmer
Death Date: 05-05-16
Religion: Islam
Room Doctor : dr. Riswan Idris
Tribe: Makassar
Chief Doctor: dr. Gina Medica S.
Marital status: Unmarried

HISTORY TAKING
(HETEROANAMNESIS)
Main complaints: Gum Bleeding
Guided Anamnesis:
Patients admitted to hospital with complaints of bleeding gums was advancing from one day before entering the hospital,
bleeding gums have experienced since three days ago but increasingly become heavy, bleeding gums initially experienced
a little-bit and stops by itself and then bleed again, but since the last 1 day gums continue to bleed and can not stop even if
sometimes the patient pressed by using a cotton swab. Patients previously treated at area hospitals for bloody gums
treated for 1 day only no improvement finally the patient was referred to Wahidin Sudirohusodo Hospital.Initially 10 days
before admission to Wahidin Sudirohusodo hospital, the patient complained of sudden fever, high, continuous, not relieved
by medication for fever and there is shivering. Fever with pain in all parts of the head and pain throughout the body,
especially the legs, disrupting the patient and does not improve with rest, feeling like tingling and become heavy when
pressed.
The patient also complained appear bruises on the thigh area, since 1 last week, there was no history of trauma, not
accompanied by pain
there is a history Patients diagnosed with ITP since last 3 years and patients had received treatment with
methylprednisolone and celcept but the drug is not taken since last 1 year.
The patient did not complain of fever, often no history of fever.
No history of long cough before
No Nausea no, no vomiting, and no heartburn.
URINATE: Fluent, enough, yellowish
DEFECATE: Normal

PAST MEDICAL HISTORY

Past medical history :
History of ITP diagnosed was exist
Family history of bleeding disease does not exist.

Family History
Father: alive, healthy
Mother: alive, healthy
Siblings: alive, healthy

Personal History
Work as farmer
history of smoking and drinking alcohol does not exist
history of travel to malaria-endemic areas do not exist.
no allergy history
no specific Hobby

Physical Examination
Impression: intermediete pain
Nutrition: enough
Height: 160 cm
Weight: 63 kg
BMI: 24.60 kg / m2
Vital signs:
Awareness: GCS13 E4M5V4
Blood pressure: 130/70 mmHg
Pulse : 80 x / min, strong lift, regular, equitable.
Breathing: 20 x / min, thoracoabdominal
Temperature: 36.8 C (axilla)

 Head: normocephal, straight black hair, is not easily removed,

no edema of the face
Eyes: isochoric pupil, normal light reflex, no pale conjunctiva,
no sclera icteric, no exopthalmus
Ears: normal shape, no otorrhea
Nose: normal shape, no rhinorrhea, no epistaxis
Lips: not dry and no cyanosis
Mouth Surface : gum bleeding exist and no hypertropic ginggiva
Neck : JVP R + 1 cm H2O, no enlarged lymph nodes, no neck
stiffness
Skin : LEMBAB

Thorax:
I: Symmetrical left = right, no petechie
P: no tenderness, no tumor mass, vocal fremitus left = right
P: Sonor, liver lung boundary ICS VI front right
A: The sound of breath: vesicular. Additional sound: no ronchi and wheezing
Heart:
I: Ictus cordis does not appear
P: Ictus cordis was not palpated
P: Dull
The upper limit: ICS II
Right Border : linea parasternalis dextra
Left Border: linea midclavicularis the left.
A: heart sound I / II regular pure, no heart murmur

Abdomen:
I: Convex, follow the motion of breath
A: no impression normal peristalsis
P: no tenderness, no mass tumor, liver and spleen not
palpated
P: Tympani (+), no ascites
Extremity:
No edema, no petechie, hematome at both thighs, no palmar
erythema

LAB
Blood Routine (11-01-2016)

WBC : 13.800 / ul
RBC : 4.50 x 106
Hb : 12,3 gr/dL
PLT : 1000 /ul
Natrium : 136
Kalium : 3,9
Chloride : 100
GDS : 186
SGOT : 23
SGPT : 14
Ureum : 29
Creatinine: 0,88

ECG
Sinus Rhytm
QRS rate : 74 times/ minute
Regularity: Regular
Interval PR : 0,16 secs
Axis : Normoaxis

P wave : (0,08 sec) Normal

QRS complex : (0,12 sec) Normal
ST Segment : Normal
T wave : Normal

Interpretate : Sinus rhytm, HR 74x/min, Normal ECG

LIST OF ISSUE AND DISCUSSION

1. ITP
Based on the complaints bleeding gums experienced
since three days before entering the hospital, bleeding
gums experienced continuously and was advancing from
the first day, the complaint bruises on both thighs
experienced since 1 week before admission, a history of
being diagnosed with ITP since 3 years ago as well as a
history of consuming celcept and methylprednisolone
earlier. and the laboratory examination obtained PLT
1000.

 Diagnostic Plan : BMP

Therapy Plan : Thrombocyte transfusion 6 bags
Methylprednisolone 1 gr/ 24 hours/ IV
Omeprazole 40 gr/ 24 hours/ IV

FOLLOW UP
05/05/16

1st Day Treatment

treatment:

04.00

S: Agitated (+), headache (+), gum bleeding (+), shortness of IVFD NaCl 0.9% 28 drops / minute

BP: 140/90 mmHg

breath (-), cough (-), nausea (+), vomit (+)

HR: 80 times/minute

O: CC: intermediate pain / nutrition enough / delirium GCS15 Omeprazole 40 mg/ 24 hours / iv

RR: 21 times/minute

E4M6V4

T: 36,50C

Head : Anemic (-), Icterus (-), Cyanotic (-)

Methylprednisolone 1 gr/ 24 hours/ iv

Post Thrombocyte Transfusion 6 bags

Neck : Tumor mass (-), Pain (-), DVS R - 1 cmH2O

Plan:

Respiratory sounds: vesicular, no ronchi and wheezing

Head CT-Scan (CITO)

Heart sound I / II, regular pure, no murmur

Blood Routine Controlled Post Transfusion

Peristaltic in normal impression, no hepatomegaly, no epigastric Consult Neurology dept. after the result of head CT-Scan
pain
Extremity: no edema, Hematoma at region femoral dextra (+)
size 3cm x 2cm, sinistra 2cm x 5cm
A:
Immune Thrombocytopenic Purpura
Suspect Intracranial Bleeding

05/05/16

2nd DAY TREATMENT

treatment:

07.00

S: Decreased consciousness, gum bleeding, shortness of breath, No

IVFD NaCl 0.9% 28 drops / minute

BP: 140/90 mmHg

Cough, No Nausea, No vomiting, convulsion (+)

Methylprednisolone 1 gr/ 12 hours/ iv

HR : 80 times/minute

O: CC: Intermediate pain / nutrition enough / GCS6 E1M1V4

Omeprazole 40 mg/ 24 hours / iv

RR : 21 times/minute

Head : Anemia (-), Icterus (-), pupil anisocoric 2,5 mm/ 3,5mm

Vital Signs monitoring

T : 36,50C

DVS R - 1cmH2O

Apply Urine Catheter

Respiratory sounds: vesicular, no ronchi and wheezing

Waiting for head CT-Scan result

Heart sound I / II, regular pure, no murmur

Peristaltic in normal impression, no epigastric pain

Extremitas: no edema, hematoma region femoral dextra (+) size Plan:
3cm x 2cm, sinistra 2 cm x 5 cm

Check Electrolyte, GDS, AGD

A:

CITO Referral to Neurology Dept

Transfer to HCU ward (full)

Decreased consciousness ec suspect hemorrhagic stroke

Immune Thrombocytopenia purpura

24/07/15

HEAD CT-Scan

07:00
BP: 150/90 mmHg
HR: 92 times / min
RR: 30 beats / min
T: 37,50C
SpO2: 96%
GDS: 111
I: 2650cc / 24h
O: 400cc / 24h
IWL: 900 cc / 24h
BC: + 1350cc / 24h

- Artifacts motion at some slides

- Hiperdense Lesions (69 HU) at left frontotemporal region which push and
narrowing left lateral ventricle and cause midline shift with bleeding 44,68 cc
- Normal sulcus and gyrus
- Other ventricle system and subharachnoid in normal limit
- Pons and cerebellum in normal limit

- Both bulbus oculi and retrobulber structure in normal limit

- Paranasalis sinuses and mastoid cell air in normal limit
- Bones in normal limit
Interpret :
- Left Intracerebral Bleeding
- Subfalcin herniated

Therapy

NEUROLOGY
05/05/16

08.00

shortness of breath (-), cough (-), nausea (-), vomit (+), - Oxygen 10 lpm via NRM

BP:

Decreased

consciousness

(+),

gum

bleeding

(+), - Head Up 30o

130/70 convulsion (+), fever (-)

mmHg

O : Decreased consciousness GCS 6 (E1M1V4)

HR:

90 Cortical Sublime Function : Difficult to interpretation

times/min

Meninges Reflex : neck stiff (-), KS :-/-

- Citicholine 500mg/ 12 hours/ iv

- Mannitol 20% loading 200 cc then continue 6 x 100
cc
- Sohobion 1 amp/ 24 hours/ im

RR:

28 Craniales Nerve : anisocoric pupil 2,5 mm/4 mm, Direct Light Diazepam 1 amp/ iv slow, every convulsions, interval
times/min
Reflex +/+, indirect Light Reflex +/+ (slowing)

15 minute maksimum 3 times

T: 37,5 C
0

Other Craniales Nerve : Difficult to interpretation

Motoric : Motion and Power hard to interpretation without
lateralization, Tonus : Normal, Physiologic Reflex : normal,
pathologic reflex : (-)
Sensoric : Difficult to interpretation
Otonom : Urinate : Unbillated bladder
A:
Decreased consciousness without lateralization Ec.
hemorrhagic stroke
Immune Thrombocytopenia Purpure

Planning
- Transferring to Special Ward (full)

INTERNIST

S : Decreased Consciousness GCS 6

15.00

O : TD : 60/palpate
HR : 21 x/m
RR : 8 x/m
T : 37,9 C

INTERNIST
15.15

S : Decreased Consciousness GCS 6

- Family of patient reject resuscitation perform

O : TD : Not measured
HR : No palpable
RR : Apneu
T : 37,9 C
- The patient declared death in front of the
patients family

Resume
Male - 19 years old admitted to hospital with complaints of bleeding gums was
advancing from one day before entering the hospital, bleeding gums have
experienced since 3 days ago increasingly become heavy, bleeding gums
initially experienced a little-bit and stops by itself and then bleed again but
since the first day of the last gums continue to bleed and can not stop even if
the patient has been pressed by using a cotton swab. Patients previously there
was a history of being diagnosed with ITP since three years ago, but patients
do not seek treatment regularly and rarely checked himself into the doctor,
the patient's history of treatment with methylprednisolone and celcept history
last 1 year, but the drugs are not taken by patient, the examination found sick
moderate / adequate nutrition / compos mentis, the extremities obtained
hematoma femoral region dextra size 3cm x 2 cm and the left region of 5 cm x
3 cm, in laboratory tests found WBC 13800, HB 12.3, PLT 1000.
Based on the anamnesis and physical examination and laboratory results of
this patient upon admission at the assessment as IMMUNE TROMBOSTIPONIA
PURPURA. In the mean time of the disease the patient's condition deteriorated
and lost consciousness as a result of intracranial bleeding suspected to be the
cause of death in these patients.

STRUCTURAL CONCEPT
ITP

Thrombocytopenia

Intracranial bleeding

Herniated Brainstem

Decreased
consciousness

Death