CAUSE OF DEATH REPORT

DEPARTMENT OF NEUROLOGY – MEDICAL FACULTY

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

PERSONAL IDENTIFICATION
Name : Mr K.A MR : 00.72.13.33
Age : 79 years old Date of admission : April, 11th 2018
Sex : Male Time of admission : 22.44 pm
Nationality : Indonesian Date of death : April, 19th 2018
Adress : Lingk IX Langkat Time of death : 13.50 pm
Marital status : Married Doctor in Charge : dr. Erni Br. Purba
Supervisor : Dr.dr.Khairul, Sp.S(K)

HISTORY TAKING

Main Complain : Decreased level of consciousness

History of Present Illness :

 He had been suffered the declining level of consciousness approximately 1 day prior to
admission to Adam Malik General Hospital, which occurred suddenly when he was resting.
 History of hypertension (+) since 8 years ago, but uncontrolled. History of headache was
denied. History of vomitting was not found. History of seizure was not found.
 History of stroke (+) was 8 years ago with the complaint was right hemiparalysis, but after
that the patient could walk as usual.
 History of diabetes mellitus, hypercholesterolemia, heart disease, smoking were not found.
 History of fever (+) 4 days ago, history of cough (+) 1 week ago.

History of Previous Disease : hypertension, stroke

History of Previous Medication : unknown

GENERAL PHYSICAL EXAMINATION

Sensorium : Somnolence
Blood pressure : 170/100 mmHg Respiratory rate : 30 times/minute
Heart rate : 121 beats/minute Temperature : 38.1oC

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

CRANIAL NERVES
1st nerve : Difficult to examine
2nd and 3rd nerves : Pupil isocoria, OD Ø 3 mm, OS Ø 3 mm
 Opthalmoscopic examination :
Optic disc Right Eye Left Eye
Color : yellowish yellowish
Boundary : not clear not clear
Excavatio : convex convex

P1
 A/V : 2/3 2/3
Impression : normal papil
3rd,4th and 19th nerves : Doll’s eye phenomen (+)
5th nerve : Corneal reflex (+)
7th nerve : Mouth was laid symetrically
8th nerve : Difficult to examine
9th and 10th nerves : Gag reflex (+)
11th nerve : Difficult to examine
12th nerve : Tongue at rest was laid symmetrically

REFLEXES
Physiological reflexes Right extremity Left extremity
Biceps/Triceps : ++ / ++ ++ / ++
KPR/APR : ++ /++ ++ / ++

Pathological reflexes
Hoffman/ Tromner : -/- -/-
Babinski : - -

MOTOR EXAMINATION
Strength of muscle was difficult to examine and there was lateralization to the right.

LABORATORY FINDING (April 11th, 2018)

Haemoglobin : 15.80 g/dL

WBC : 17.820 / mm3
Thrombocyte : 262.000/mm3
Haematocrite : 45.7 %
Diff. Telling :
 Neutrofil : 87.80 (37-80)
 Lymphocyte : 4.00 (20-40)
 Monocyte : 8.1 (2-8)
 Eosinofil : 0.00 (1-6)
 Basofil : 0.1 (0-1)

Blood Sugar Level (ad random) : 144.00 mg/dL

Renal Function Test

 Ureum : 54 (<50)
 Creatinine : 1.26 (0.70-1.20)

Electrolytes
 Natrium : 148 mEq/L (135-155)
 Kalium : 4.2 mEq/L (3.6-5.5)
 Chloride : 109 mEq/L (96-106)

Blood Gas Analysis:

 PH : 7.38 mmHg ( 7.35 - 7.45)
 pCO2 : 29,0 mmHg (38-42)

P2
  pO2 : 187,0 mmHg (85-100)
 Bicarbonate : 17,2 mmol/L (22-26)
 Total CO2 : 18.1 mmol/L (19–25)
 Base Excess : -6,6 ( -2)- (+2)
 O2 Saturation : 100% ( 95- 100)

Head CT Scan non contrast (April, 11th 2018 ) :

Infratentorial cerebellum and ventrikel IV was normal.
Supratentorial had seen lesion hypodens on left basal ganglia and left insular.
There were no mass affect or midline shift.
Ventricular system and cortical sulci were normal.
Impression : Infarct on the left basal ganglia and left insular.

ECG FINDING (April, 11th 2018) :

Sinus Tachycardia

Chest X ray (April, 11th 2018)

Cardiomegaly

DIAGNOSIS
Functional Diagnosis : Somnolence + Right Hemiparalysis
Anatomical Diagnosis : Subcortex
Etiological Diagnosis : Thombus
Working Diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke

TREATMENT
 Bed rest + Head elevation 300
 Nasogastric tube and urinary catheter in use
 Oxygen 6-8 l/minute by RM
 IVFD Ringer Solution 20 drips/minute
 Ceftriaxone inj 1 g/12 hrs skin test
 Aptor 1 x 300mg
 Paracetamol 3x500mg
 B.complex 3 x 1

FURTHER EXAMINATION
Consult to Department of Pulmonology Medicine

Follow-up April, 12th 2018

Chief complain : Decreased level of consciousness
Vital sign
Sensorium : Somnolence
Blood pressure : 200/110 mmHg
Heart rate : 95 beats/minute
Resp. rate : 30 times/minute
Temperature : 38,1 0C
Working diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke

Treatment :
P3
  Bed rest + Head elevation 300
 Oxygen 6-8 l/minute by RM
 Nasogastric tube and urinary catheter in use
 IVFD Ringer Solution 20 drips/minute
 Inj. Ceftriaxone 1 g/12 hrs
 Inj. Furosemid 1 amp/12 hrs
 Aptor 1 x 300mg
 Captopril 25 mg 3x1
 Paracetamol 3x500mg
 B.complex 3 x 1

Consult to Department of Pulmonology Medicine :

Working diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke +
Pneumoniae
- O2 6-8 l/minute by RM
- Nebule ventolin/8 hrs
- Sugesstions :
- Sputum analysis
- Sputum culture
- Blood culture

Follow-up April, 13th 2018

Chief complain : Decreased level of conciousness
Vital sign
Sensorium : Somnolence
Blood pressure : 130/70 mmHg
Heart rate : 117 beats/minute
Resp. rate : 35 times/minute
Temperature : 38,8 0C

Working diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumoniae

Treatment :
 Bed rest + Head elevation 300
 Nasogastric tube and urinary catheter in use
 Oxygen 6-8 l/minute by RM
 IVFD Ringer Solution 20 drips/minute
 Inj. Ceftriaxone 1 g/12 hrs
 Inj. Furosemid 1 amp/12 hrs
 Inf. Paracetamol drip 1 Fls/8 hrs (if Temp > 38,8 0C)
 Aptor 1 x 300mg
 Captopril 25 mg 3x1
 Paracetamol 3x500mg
 B.complex 3 x 1
 Nebule ventolin/8 hrs (pulmonology)

P4
Follow-up April, 14th-15th 2018
Chief complain : Decreased level of conciousness
Vital sign
Sensorium : Somnolence
Blood pressure : 130/90 mmHg
Heart rate : 108 beats/minute
Resp. rate : 42 times/minute
Temperature : 38,8 0C

Working diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumoniae

Treatment :
 Bed rest + Head elevation 300
 Nasogastric tube and urinary catheter in use
 Oxygen 6-8 l/minute by RM
 IVFD Ringer Solution 20 drips/minute
 Inj. Ceftriaxone 1 g/12 hrs
 Inj. Furosemid 1 amp/12 hrs (aff)
 Inf. Paracetamol drip 1 Fls/8 hrs (if Temp > 38,5 0C)
 Aptor 1 x 300mg
 Captopril 25 mg 3x1
 Paracetamol 3x500mg
 B.complex 3 x 1
 Nebule ventolin/8 hrs (pulmonology)

Follow-up April, 16th-17th 2018

Chief complain : Decreased level of conciousness
Vital sign
Sensorium : Somnolence
Blood pressure : 110/60 mmHg
Heart rate : 90 beats/minute
Resp. rate : 34 times/minute
Temperature : 38 0C

Working diagnosis : Somnolence + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumoniae

Treatment :
 Bed rest + Head elevation 300
 Nasogastric tube and urinary catheter in use
 Oxygen 6-8 l/minute by RM
 IVFD Ringer Solution 20 drips/minute
 Inj. Ceftriaxone 2 g/12 hrs
 Aptor 1 x 300mg
 Captopril 25 mg 3x1 (aff)
 Paracetamol 3x500mg
 B.complex 3 x 1
 Nebule ventolin/8 hrs (pulmonology)

P5
  Methyl prednisolon 125 mg/24 hrs (pulmonology)
 N-asetil systein 3x1 (pulmonology)
 Chest fisiotherapy (pulmonology)

Follow-up April, 18th-19th 2018

Chief complain : Decreased level of conciousness
Vital sign
Sensorium : Sopor
Blood pressure : 100/60 mmHg
Heart rate : 102 beats/minute
Resp. rate : 44 times/minute
Temperature : 38.8 0C

Working diagnosis : Sopor + Right Hemiparalysis due to Recurrent Ischemic Stroke + Pneumoniae

Treatment :
 Bed rest + Head elevation 300
 Nasogastric tube and urinary catheter in use
 Oxygen 6-8 l/minute by RM
 IVFD Ringer Solution 20 drips/minute
 Inj. Ceftriaxone 2 g/12 hrs
 Inf. Paracetamol drip 1 Fls/8 hrs (if Temp > 38,5 0C)
 Aptor 1 x 100mg
 Paracetamol 3x500mg
 B.complex 3 x 1
 Inj. Ciprofloxacin 400 mg/12 hrs (pulmonology)
 Inj. Methyl prednisolon 125 mg/24 hrs (pulmonology)
 Nebule ventolin/8 hrs (pulmonology)
 N-asetil systein 3x1 (pulmonology)
 Chest fisiotherapy (pulmonology)

Follow up before Death April, 19th 2018

LEVEL
OF PULSE RR
TIME CONSCIOUS
BP/mmHg T oC EXPLANATION
x/minute x/minute
NESS
Light reflex (-/-),
12.00 pm Coma 80/40 134 10 40,0 pupil isocory Ø R=4
mm,L=4mm
Light reflex (-/-),
12.30 pm Coma 80/40 100 8 40,5 Pupil isocory R Ø=
4mm,L=4mm
Light reflex (-/-),
13.00 pm Coma 70/palpate 82 7 40,0 pupil isocory R Ø =4 mm,L
=4mm
Light reflex (-/-),
13.15 pm Coma 60/palpate 64 5 39,8 pupil isocory R Ø =4 mm,L
=4mm

P6
 Maximal dilatation
13.30 pm Coma -/- 40 4 39,7 of pupil
corneal reflexes(-)
13.50 pm EXITUS

Cause of Death : Sepsis

P7
P8