CASE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK GENERAL HOSPITAL
MEDAN

PERSONAL IDENTIFICATION
Name : Ruminta Simamora Medical Record No. : 69.78.98
Age : 68 years old Date of admission : January 25th, 2017
Sex : Female Time of admission : 00.05 am
Nationality : Indonesian Date of death : January 28th, 2017
Address : Kp. Sipirok Selat Besar Time of death : 00.55 am
Hilir Labuhan Batu Doctor in Charge : dr. Laura P.S. Tambunan
Marital status: Married Supervisor : dr. Puji Pinta O.S., Sp.S

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :

She had been suffered the declining level of consciousness approximately 2 day prior
to admission to Adam Malik General Hospital, which occurred suddenly when she
was resting . History of headache was not found. History of seizure was not found.
History of projectile vomit was not found. History of head trauma was not found.
History of previous stroke was found seen in 5 years ago with right arm and leg
weakness. History of hypertension and hypercholesterolemia was found since 5 years
with uncontrolled treatment. History of diabetes mellitus and heart disease were
denied. History of fever was found since 1 days prior to admission to hospital. History
of pulmonary disease was not found. History of smoke was not found.

GENERAL PHYSICAL EXAMINATION

Alertness : Sopor
Blood pressure : 110/70 mmHg Respiratory rate : 24 x/ minute
Heart rate : 110 bpm Temperature : 39o C

NEUROLOGIC EXAMINATION
Level of consciousness : Sopor
Signs of increased ICP : Headache (-), Projectile Vomiting (-), Seizures (-)
Signs of meningeal irritation : Nuchal Rigidity (-), Kernig Sign (-), Brudzinski I (-),
Brudzinski II (-)

CRANIAL NERVES
1st nerve : Difficulty to examine
2nd and 3rd nerves : Pupillary light reflexes (+/+)
Pupil isocoria, OD Ø 3 mm, OS Ø 3 mm
 Ophthalmoscope examination :
Optic disc Right Eye Left Eye
Color : yellowish yellowish
Boundary : clear clear

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 Excavation : convex convex
A/V : 2/3 2/3
Impression : Normal papil
3 ,4 and 6th nerves
rd th
: Doll’s Eye Phenomenon (+)
7th nerve : Mouth was laid simetrically
8th nerve : Difficulty to examine
9th and 10th nerves : Gag reflex (+)
11th nerve : Difficulty to examine
12th nerve : Tongue at rest laid medial

REFLEXES
Physiologic reflexes Right extremity Left extremity

Biceps/triceps : ++ / ++ ++ / ++
KPR/APR : ++ / ++ ++ / ++

Pathologique reflexes

Hoffman/ Tromner : -/- -/-

Babinski : + -

MOTOR EXAMINATION
Strength of muscle : Difficulty to examine.
Lateralization was not found

DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Working Diagnosis
: Sopor
: Sub cortex
: Thrombus
: Sopor + Duplex hemiparesis due to:
1. Reccurent Ischemic Stroke
2. Hemorhagic Stroke

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 2-4 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Paracetamol 1.000 mg / 8 hours, if Temp. > 39°C
 Parasetamol 3 x 500 mg

FURTHER EXAMINATION
1. Complete Blood Count (CBC)
2. Random Blood Sugar Level
3. Renal Function Test
4. Liver Function Test
5. Electrolyte
6. Blood Gas Analysis
7. Immunoserology

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 8. ECG
9. Chest X-ray
10. Head CT – Scan

LABORATORY FINDING (January 25th, 2017)

Hemoglobin : 11,7 g/dL

WBC : 4.000 / mm3
Thrombocyte : 168.000 / mm3
Hematocrite : 33 %
Diff. Telling :
 Neutrophyl : 89.20 (50-70)
 Lymphocyte : 6.90 (20-40)
 Monocyte : 3.70 (2-8)
 Eosinophyl : 0.00 (1-3)
 Basophyl : 0.20 (0-1)

Blood Sugar Level ( random) : 106.0 mg/dL

Renal Function Test:

 Ureum : 43 (19-44)
 Creatinine : 0.71 (0.7-1.3)

Electrolytes:
 Natrium : 114 mEq/L (135-155)
 Kalium : 4.3 mEq/L (3.6-5.5)
 Chloride : 89 mEq/L (96-106)

Blood gas analysis:

 PH : 7.450 mmHg ( 7.35 - 7.45)
 pCO2 : 35.0 mmHg (38-42)
 pO2 : 120.0 mmHg (85-100)
 Bicarbonate : 22.8 mmol/L (22-26)
 Total CO2 : 19.6 mmol/L (19–25)
 Base Excess : -4.5 ( -2)- (+2)
 O2 saturation : 99.0 ( 95- 100)

Immunoserology :
 Procalcitonin : 30.04 ng/ml (˂0.05)

HEAD CT-SCAN
Impression: Hipodens lesion on the periventrikel right and left.

CHEST X-RAY (January 25th, 2017)

Impression: pneumonia bilateral

ECG finding : LVH

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Working Diagnosis : Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke +
Electrolite imbalance

TREATMENT:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Inj. Ranitidin 1 amp/ 12 hrs
 Aptor 1 x 300 mg
 Parasetamol 3 x 500 mg
 B. Complex 3 x 1 tab

Consult to Pulmonology Department Januari 25th , 2017 :

Diagnosis : Sepsis ec pneumonia

Therapy : Inj. Ceftazidime 1 gram / 8 hours (skin test)
Cifrofloxacine drip 400 mg / 12 hours (skin test)

Sugestion: - Sputum cultur

- Blood cultur
- Urine cultur
- BTA direct smear 3 x

Working Diagnosis: Sopor + Duplex Hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Electrolite imbalance

Therapy:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
 Inj. Ceftazidime 1 gram / 8 hours (skin test)
 Cifrofloxacine drip 400 mg / 12 hours (skin test)
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Inj. Ranitidin 1 amp/ 12 hrs
 Aptor 1 x 300 mg
 Parasetamol 3 x 500 mg
 B. Complex 3 x 1 tab

Planning:
- Fasting Glucose Level, 2 Hours Post Prandial Glucose Level, Lipid Profile , Uric acid,
Liver Function Test
- Electrolite after substitution
- Blood cultur

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 - Urine cultur
- BTA direct smear 3 x

Follow-up January 26th, 2017

Chief complain : Declined level of consciousness, fever (+)

Vital sign
Alertness : Sopor
Blood pressure : 120/90 mmHg
Heart Rate : 110 bpm
Resp. rate : 24 x/ min
Temperature : 38,3° C

Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Electrolite imbalance

Therapy:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
 Inj. Ceftazidime 1 gram / 8 hours
 Cifrofloxacine drip 400 mg / 12 hours
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Inj. Ranitidin 1 amp/ 12 hrs
 Aptor 1 x 300 mg
 Parasetamol 3 x 500 mg
 B. Complex 3 x 1 tab

LABORATORY FINDING (January 26th, 2016)

Fasting Glucose Level : 118 mg/dL (70-120)

2 Hours Post Prandial Glucose Level : 135 mg/dL ( < 200 )
Hb-A1C : 5.2 % (4.8-5.9)

Lipid Profile :
 Total Cholesterol : 97 (˂ 200 )
 Trigliserida : 134 (˂ 150 )
 HDL Cholesterol : 75 (≥ 60 )
 LDL Cholesterol : 42 (˂ 100 )

Uric acid : 4,3 mg/dL (<5.7)

Liver Function Test:

 SGOT : 25 U/L (<38)
 SGPT : 30 U/L (<41)

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Follow-up January 27th, 2017

Chief complain : Declined level of consciousness, fever (+), black liquid out of NGT (+)

Vital sign
Alertness : Sopor
Blood pressure : 130/90 mmHg
Heart Rate : 110 bpm
Resp. rate : 28 x/ min
Temperature : 38,3° C

Therapy:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
 Inj. Ceftazidime 1 gram / 8 hours
 Cifrofloxacine drip 400 mg / 12 hours
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Inj. Ranitidin 1 amp/ 12 hrs
 Aptor 1 x 300 mg  aff
 Parasetamol 3 x 500 mg
 B. Complex 3 x 1 tab

Consult to Gastroenterohepatology:

Diagnosis: Upper gastrointestinal Bleeding

Therapi: - Inj. Omeprazol 80 mg/ iv bolus  Inj. Omeprazol 40 mg / 12 hours

- Inj. Traxenamate acid 500 mg / 8 hours
- Inj. Vitamin K 1 amp / 24 hours
- Sucraflat syr 3 x C 1

Planning: Fasting in 6 – 8 hours

LABORATORY FINDING (January 27th, 2016)

Electrolytes:
 Natrium : 131 mEq/L (135-155)
 Kalium : 3.8 mEq/L (3.6-5.5)
 Chloride : 97 mEq/L (96-106)

Blood gas analysis:

 PH : 7.190 mmHg ( 7.35 - 7.45)
 pCO2 : 31.0 mmHg (38-42)
 pO2 : 125.0 mmHg (85-100)
 Bicarbonate : 18,7 mmol/L (22-26)

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  Total CO2 : 20.2 mmol/L (19–25)
 Base Excess : -9,7 ( -2)- (+2)
 O2 saturation : 99.0 ( 95- 100)

Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Upper Gastrointestinal Bleeding + Hiponatremi + Acidosis metabolic

Therapy:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% 20 gtt/i
 Inj. Ceftazidime 1 gram / 8 hours
 Cifrofloxacine drip 400 mg / 12 hours
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Meylon 7 fls -- First hour 4 fls + 500 cc NaCl 0,9 % 20 gtt/i
 Inj. Omeprazol 40 mg / 12 hours
 Inj. Traxenamate acid 500 mg / 8 hours
 Inj. Vitamin K 1 amp / 24 hours
 Parasetamol 3 x 500 mg
 Sucraflat syr 3 x C 1
 KSR 1 x 600 mg
 B. Complex 3 x 1 tab

Planning:
- Check of Blood Gas Analysis after meylon subsitution

Follow up January 28th, 2017

Chief complain : declined level of consciousness, fever (+)

Vital sign
Alertness : Sopor
Blood pressure : 90/60 mmHg
Heart Rate : 120 bpm
Resp. rate : 32 x/ min
Temperature : 38,5° C

Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Shock sepsis
due to pneumonia + Hiponatremi + Acidosis Metabolic

Therapy:
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal canule 3-4 l/minute
 IVFD NaCl 0,9% cor 1 flash 20 gtt/i
 Inj. Ceftazidime 1 gram / 8 hours

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  Cifrofloxacine drip 400 mg / 12 hours
 Inj. Levosol 1 amp + NaCl 0,9% 40 cc 3 cc/hour (via syringe pump) up titration until
SBP ≥ 100 mmHg or MAP ≥ 65
 IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
 Meylon 7 fls -- First hour 4 fls + 500 cc NaCl 0,9 % 20 gtt/i
 Inj. Omeprazol 40 mg / 12 hours
 Inj. Traxenamate acid 500 mg / 8 hours
 Inj. Vitamin K 1 amp / 24 hours
 Parasetamol 3 x 500 mg
 Sucraflat syr 3 x C 1
 KSR 1 x 600 mg
 B. Complex 3 x 1 tab

Follow up before Death January 28th, 2017

TIME LEVEL OF BP/mmHg PULSE RR T oC EXPLANATION
CONSCIO bpm x/minu
USNESS te
00.00 am Sopor 90/40 115 30 37,3 Light reflex (+/+)↓,
pupil isocoria
R Ø=3 mm, L= 3 mm
00.15 am Coma 80/40 96 38 37,2 Light reflex (+/+)↓,
Pupil isocoria
R Ø= 3mm, L= 3 mm
00.30 am coma 70/40 48 10 36,5 Light reflex (+/+)↓,
pupil isocoria
R= Ø 4 mm, L= 4 mm
00.45 am coma 50/palpate 18 6 36,5 Light reflex (-/-),
R= Ø 5 mm, L= 5 mm
00.55 am Passed away Absent absent - - Light reflex (-/-),
Corneal reflex (-/-)
Both pupils were
maximally dilated

Cause of Death :
Shock sepsis

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