CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

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

PERSONAL IDENTIFICATION
Name : Mrs. S Medical Record No. : 00.77.89.93
Age : 69 years old Date of admission : April, 07th , 2019
Sex : Female Time of admission : 18.00 PM
Nationality : Indonesian Date of death : April, 09th, 2019
Address : Asam Peutik Street, Langsa Time of death : 04.15 am
Marital status : Married Doctor in Charge : dr. Oriza Novita
Supervisor : dr. Alfansuri Kadri, Sp.S

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :

She had been suffered the declining level of consciousness approximately 4 days prior to admission to
Adam Malik General Hospital, which occurred suddenly when she had activity. History of headache was not
found. History of seizure was not found. History of projectile vomit was found. History of hypertension was
found since 1 year ago, but uncontrolled. History of diabetes mellitus was not found. History of
hypercholesterolemia was not found. History of heart disease was found since 1 month ago but
uncontrolled. History of previous stroke was not found. History of head trauma was not found. History of
fever found 4 days before, decreased with antipyretic drug.
History of previous disease : Hypertension, Heart Disease.
History of previous medication : Unknown

GENERAL PHYSICAL EXAMINATION

Alertness : Somnolen
Blood pressure : 180/100 mmHg Respiratory rate : 32 x/ minute
Heart rate : 58 bpm reguler Temperature : 39,4 oC

NEUROLOGIC EXAMINATION
Level of consciousness : Somnolen
Signs of increased ICP : Headache (-), Projectile Vomiting (+), History of 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 anisocoria, OD Ø 4 mm, OS Ø 2 mm
 Ophthalmoscope examination :
Optic disc Right Eye Left Eye
Color : hiperemis orange
Boundary : blurred clear
Excavatio : vanished vanished
A/V : 1/3 2/3
Impression : Papil edema dextra

P1
3rd,4th and 6th nerves : Doll’s Eye Phenomenon (+/+)
5th nerve : Corneal reflex (+)
7th nerve : Simetric
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 exam, left lateralization.

DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Differential Diagnosis
: Somnolen + Left Hemiparesis
: Subcortex
: Cardioembolic
: Ischemic Stroke
Haemorrhagic Stroke

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by rebreathing mask 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 6 hrs
 IVFD Paracetamol drips 1000mg 1 fl/ 8 hours
 Vitamin B Complex 3 x 1 tablet

FURTHER EXAMINATION
1. Complete Blood Count (CBC)
2. Random Blood Sugar Level
3. Renal Function Test
4. Electrolyte
5. Blood Gas Analysis
6. Procalcitonin
7. ECG
8. Chest X-ray
9. Head CT – Scan

LABORATORY FINDING (April 7th, 2019)

P2
 Hemoglobin : 14.5 g/dL
WBC : 18.030 / mm3
Thrombocyte : 234.000 / mm3
Hematocrite : 45.00 %
Diff. Telling :
 Neutrophyl : 87.70 (50-70)
 Lymphocyte : 8.20 (20-40)
 Monocyte : 3.60 (2-8)
 Eosinophyl : 0.20 (1-3)
 Basophyl : 0.30 (0-1)
Protrombine Time : 12,6 (control: 13.30)
INR : 0,87 (0,8-1,30)
APTT : 29.4 (27-39)

Blood Sugar Level ( random) : 135 mg/dL

Renal Function Test:

 Ureum : 51 (18-55)
 Creatinine : 1,07 (0.70-1.30)

Electrolytes:
 Natrium : 139 mEq/L (135-155)
 Kalium : 3.7 mEq/L (3.6-5.5)
 Chloride : 99 mEq/L (96-106)

Procalcitonin : 1.52 ng/mL (<0.05)

Blood gas analysis:

 PH : 7.460 mmHg ( 7.35 - 7.45)
 pCO2 : 37,0 mmHg (38-42)
 pO2 : 218.0 mmHg (85-100)
 Bicarbonate : 23.2 mmol/L (22-26)
 Total CO2 : 24.9 mmol/L (19–25)
 Base Excess : 0.8 (-2) - (+2)
 O2 saturation : 100.0 ( 95- 100)

Planning : consult to pulmonology, cardiology

Consult to Pulmonology Departement on April 7th, 2019

Assesment : Sepsis ec Pneumonia
Treatment : Inj. Ceftriaxon 1 gr/ 12 hours
Inj. Metilprednisolon 62,5 mg/ 12 hours
Ventolin Nebule 2,5 mg/ 8 hours
Planning : blood culture

Consult to Cardiology Departement on April 7th, 2019

Assesment : CHF Fc II ec HHD
Treatment : Inj.Furosemid 20mg / 12 hours
Ramipril 1 x 5 mg
Bisoprolol 1 x 1,25 mg
P3
 Simvastatin 1 x 20 mg

Planning : echocardiography if the condition of patient was stable

HEAD CT-SCAN (April 7th, 2019)

Impression: Large infarct at right temporoparietooccipital lobe

CHEST X-RAY (April 7th, 2019)

Impression: Cardiomegaly

ECG finding :
Normal rhytm

Working Diagnosis: Somnolen + Left Hemiparesis due to Ischemic Stroke + Sepsis ec Pneumonia + CHF fc
II ec HHD

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by Rebreathing Mask 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 6 hrs
 IVFD Paracetamol drips 1000mg 1 fl/ 8 hours
 Inj. Ranitidin 50 mg/12 hours
 Aspilet 1 x 320 mg
 Inj. Ceftriaxon 1 gr/ 12 hours
 Inj. Metilprednisolon 62,5 mg/ 12 hours
 Inj.Furosemid 20mg / 12 hours
 Ventolin Nebule 2,5 mg/ 8 hours
 Ramipril 1 x 5 mg
 Bisoprolol 1 x 1,25 mg
 Simvastatin 1 x 20 mg
 B complex 3 x 1 tablet

Planning : Fasting Glucose, 2 Hours Post Prandial Glucose Level, Hb-A1c, Uric Acid, Lipid Profile,

Follow-up April 8th, 2019

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

Vital sign
Alertness : Sopor
Blood pressure : 150/90 mmHg
Heart Rate : 57 bpm, reguler
Resp. rate : 29x/ min
Temperature : 38,9 ° C

Working Diagnosis : Sopor + Left Hemiparesis due to Ischemic Stroke + Sepsis ec Pneumonia + CHF fc II
ec HHD
P4
Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by non-rebreathing mask 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 8 hrs
 IVFD Paracetamol drips 1000mg 1 fl/ 8 hours
 Inj. Ranitidine 50 mg/ 12 hours
 Aspilet 1 x 320 mg
 Vitamin B Complex 3 x 1 tablet
Planning : recheck electrolyte, blood gas analyses

Follow-up Pulmonology April 8th, 2019

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

Vital sign
Alertness : Sopor
Thorax : Respiratory breath : vesicular
Abnormal respiratory breath : Ronchi (+/+), wheezing (-/-)
Working diagnosis : Sepsis ec Pneumonia
Treatment : Inj. Ceftriaxon 1 gr/ 12 hours
Inj. Metilprednisolon 62,5 mg/ 12 hours
Ventolin Nebule 2,5 mg/ 8 hours

Follow-up Cardiology April 8th, 2019

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

Working diagnosis : CHF Fc II ec HHD

Treatment : Inj.Furosemid 20mg / 12 hours
Ramipril 1 x 5 mg
Bisoprolol 1 x 1,25 mg
Simvastatin 1 x 20 mg

LABORATORY FINDING (April 8th, 2019)

Electrolytes:
 Natrium : 136 mEq/L (135-155)
 Kalium : 3.6 mEq/L (3.6-5.5)
 Chloride : 97 mEq/L (96-106)

Blood gas analysis:

 PH : 7.360 mmHg ( 7.35 - 7.45)
 pCO2 : 36,0 mmHg (38-42)
 pO2 : 199.0 mmHg (85-100)
 Bicarbonate : 23.5 mmol/L (22-26)
 Total CO2 : 25.1 mmol/L (19–25)
 Base Excess : 0.8 (-2) - (+2)
P5
  O2 saturation : 100.0 ( 95- 100)

Glucose nuchter : 88 (70-105 mg/dl)

Glucose 2 hrs post prandial : 127 (76-140 mg/dl)
Hb-A1c : 4.3 (4.0-6.0)
AST/ SGOT : 30 (5-32 U/L)
SGPT : 13 (0-55U/L)
Total Cholesterol : 147 mg/dl
Trigliseride : 57 mg/dl
Cholesterol HDL : 41mg/dl
Cholesterol LDL : 81 mg/dl
Uric Acid : 5,0 mg/dl

Follow-up April 9, 2019

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

Vital sign
Alertness : Sopor
Blood pressure : 140/80 mmHg
Heart Rate : 61 bpm, reguler
Resp. rate : 30 x/ min
Temperature : 38.8° C

Working Diagnosis : Sopor + Left Hemiparesis due to Ischemic Stroke + Sepsis ec Pneumonia + CHF fc II
ec HHD

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by non-rebreathing mask 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 6 hrs
 IVFD Paracetamol drips 1000mg 1 fl/ 8 hours
 Inj. Ranitidine 50 mg/ 12 hours
 Aspilet 1 x 320 mg
 Vitamin B Complex 3 x 1 tablet

Follow-up Pulmonology April, 9th, 2019

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

Vital sign
Alertness : Sopor
Thorax : Respiratory breath : vesicular
Abnormal respiratory breath : Ronchi (+/+), wheezing (-/-)
Working diagnosis : Sepsis ec Pneumonia
Treatment : Inj. Ceftriaxon 1 gr/ 12 hours
Inj. Metilprednisolon 62,5 mg/ 12 hours
Ventolin Nebule 2,5 mg/ 8 hours
Follow-up Cardiology April 9th, 2019

P6
Chief complain : Declined level of consciousness, breathless (+)

Working diagnosis : CHF Fc II ec HHD

Treatment : Inj.Furosemid 20mg / 12 hours
Ramipril 1 x 5 mg
Bisoprolol 1 x 1,25 mg
Simvastatin 1 x 20 mg

Follow-up Follow-up April 9 th, 2019 20.55 pm

Chief complain : Declined level of consciousness, decrease of blood pressure

Vital sign
Alertness : Sopor
Blood pressure : 80/40 mmHg
Heart Rate : 78 bpm, eguler
Resp. rate : 32 x/ min
Temperature : 38.5 ° C

Working Diagnosis : Sopor + Left Hemiparesis due to Ischemic Stroke + Sepsis ec Pneumonia + CHF fc II
ec HHD
Treatment : IVFD Nacl 0.9% 2 fls
IVFD Levosol 8 mg/ 50 cc NaCl 0,9% starting 2 cc/ hours up titration

Follow up before Death April 9th, 2018

TIME LEVEL OF BP/mmHg PULSE RR x/ T oC EXPLANATION RESPIRATORY

CONSCIOUSNESS bpm minute TYPE
03.30 Light reflex (+/
am +)↓,
Sopor 80/50 55 32 37.8 pupil anisocoria Hiperventilation
R Ø=4 mm, L= 2
mm
03.45 Light reflex (+/
pm +)↓,
Sopor 80/50 49 28 36.8 Pupil anisocoria Hiperventilation
R Ø= 4 mm, L= 2
mm
04.00 Light reflex (+/
am +)↓,
Coma 60/40 51 24 36.5 pupil anisocoria Ataxic
R Ø = 4 mm, L = 3
mm
04.06 Light reflex (-/-),
am coma 50/palpate 44 4 36.0 R= Ø 5 mm, L= 5 Ataxic
mm
04.15 Light reflex (-/-),
am Corneal reflex (-/-) Respiratory
absent absent - -
Passed away Both pupils were arrest
maximally dilated

Cause of Death : Brain Herniation

P7
ECG

P8
CHEST X RAY

HEAD CT SCAN

P9
P10