CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF NORTH SUMATERA – ADAM MALIK GENERAL HOSPITAL MEDAN

PERSONAL IDENTIFICATION

Name : Ahmad Kaharuddin MR : 49.16.00

Age : 70 years old Date of admission : October 25th 2011
Sex : Male Time of admission : 11.35 am
Nationality : Indonesian Date of death : October 30 2011
Adress : Pattimura Street 3 Langkat Time of death : 10.50 pm
Marital Status : Married Doctor in Charge : dr. Anyta Prisca Dormida
Supervisor : dr. Puji Pinta O. S, SpS

HISTORY TAKING

Main Complain : Decreased level of consciousness

History of Present Illness : He had been suffering from declining of consciousness

approximately 5 hours prior to admission to Adam Malik General
Hospital, which occurred suddenly when he was resting. History
of headache, seizure and projectile vomiting were not found.
History of hypertension was found since 1 year ago,
uncontrolled. History of diabetes mellitus and heart disease were
not found. History of trauma and fever were not found.

History of Previous Disease : Hypertension

History of Previous Medication : Unknown

GENERAL PHYSICAL EXAMINATION

Level of Consciousness : Sopor

Blood Pressure : 180/100 mmHg
Heart Rate : 92 bpm
Respiratory Rate : 24 x/minute
Temperature : 37.5 oC

NEUROLOGIC EXAMINATION

Level of Consciousness : Sopor

Sign of ICP Increased : Headache (-), Projectile vomite (-), Seizure (-)
Sign of Meningeal Irritation : Nuchal rigidity (-), Kernig sign (-), Brudzinski (-), Brudzinski II (-)

Cranial Nerves
1st Nerve : Difficult to examine
2nd and 3rd Nerves : Pupillary light reflexes (+)/(+), isocoria ∅ 3 mm

Ophtalmoscopic Examination
Optic Disc Right Eye Left Eye
Color : Yellowish Yellowish
Boundary : Clear Clear

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 Excavatio : Concave Concave
A/V : 2/3 2/3
Impression : Normal papil

3rd, 4th and 6th Nerves : Doll’s eye phenomen (+)

5th Nerve : Corneal reflex (+)
7th Nerve : Droopy mouth to the right side
8th Nerve : Difficult to examine
9th and 10th Nerves : Gag reflex (+)
11th Nerve : Difficult to examine
12th Nerve : Tounge at rest was laid symmetrically

Reflexes
Right Extremity Left Extremity
Physiologic Reflexes
Biceps/Triceps : (+) / (+) (+) / (+)
KPR/APR : (+) / (+) (+) / (+)
Pathologic Reflexes
Hoffman/Tromner : (-) / (-) (-) / (-)
Babinsky : - -

Motor Examination
Strength of muscle was difficult to examine and right lateralization was found

DIAGNOSIS

Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Differential Diagnosis
Working of Diagnosis
: Sopor + Right Hemiparalysis + Right 7th Nerve Paralysis UMN type
: Subcortex
: Thrombus
: 1. Ischemic Stroke
2. Hemorrhagic Stroke
: Sopor + Right Hemiparalysis + Right 7th Nerve Paralysis UMN type ec
Ischemic Stroke

LABORATORY FINDING (October 25th 2011)

Cell Blood Count
Hemoglobin 16.20 g% (11.7-15.5)
Eritrocyte 6.06 x 106 /mm3 (4.20-4.87)
Leucocyte 21.76 x 103 /mm3 (4.5-11.0)
Trombocyte 248 x 103 /mm3 (150-450)
Hematocryte 50.40 % (38-44)
Liver Function Test
SGOT 56 U/L (<32)
SGPT 20 U/L (<31)
Blood Sugar Level 116.90 mg/dL (<200)
Renal Function Test
Ureum 33.1 mg/dL (<50)
Creatinine 1.17 mg/dL (0.50-0.90)
Serum Electrolytes
Sodium 141 mEq/L (135-155)

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 Potassium 4.5 mEq/L (3.6-5.5)
Chlorida 105 mEq/L (96-106)
Blood Gas Analysis
pH 7.483 (7.35-7.45)
pCO2 24.90 mmHg (38-42)
pO2 174.40 mmHg (85-100)
HCO3 18.2 mmol/L (22-26)
Total CO2 19 mmol/L (19-25)
BE -5.2 mmol/L (-2) - (+2)
Saturasi O2 99.3 % 95-100

TREATMENT

1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 1 gr/12 hours (skin test)
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Ranitidin injection 1 amp/12 hours
8. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
9. Paracetamol 500 mg 3 x 1

FURTHER EXAMINATION

1. Complete Blood Count

2. Ad Random/Nuchter/2 hours pp Blood Sugar Level
3. Renal Function Test
4. Liver Function Test
5. Electrolyte
6. Lipid Profile
7. Blood Gas Analysis
8. Chest X-Ray
9. ECG
10. Head CT Scan

FOLLOW UP October 26th - 27th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 140 – 150 / 90 mmHg
Heart Rate : 100 – 148 bpm
Respiratory Rate : 24 x/minute
Temperature : 37.5 – 38 oC

LABORATORY FINDING (October 26th 2011)

Blood Sugar Level
Nuchter 139 mg/dl (70-120)
2 hours pp 175 mg/dl (<200)

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Lipid Profile
Total Cholesterol 161 mg/dl (<200)
Trigliserida 87 mg/dl (40-200)
HDL 31 mg/dl (>65)
LDL 109 mg/dl (<150)

CHEST X-RAY (October 26th 2011)

Impression : cardiomegaly with pulmo edema

ECG (October 26th 2011)

Sinus Rhytme, Anteroseptal OMI + LVH
Treatment :
- Amlodipin 10 mg 1 x 1
- Valsartan 80 mg 1 x 1
- Captopril 12.5 mg 3 x 1
- Bisoprolol 1.25 mg 1 x 1

Working Diagnosis : Sopor + Right Hemiparalysis + Right 7th Nerve Paralysis UMN type ec
Ischemic Stroke

Treatment
1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 1 gr/12 hours  2 gr/12 hours
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Ranitidin injection 1 amp/12 hours
8. IVFD Mannitol 125 cc/6 hours
9. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
10. Paracetamol 500 mg 3 x 1

FOLLOW UP October 28th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 140/80 mmHg
Heart Rate : 138 bpm
Respiratory Rate : 28 x/minute
Temperature : 37.3 oC

HEAD CT SCAN (October 28th 2011)

Infratentorial 4th ventricle and cerebellum were normal.
There were hypodense lesion in left ganglia basalis and left parietal.
There were no mass effect or midline shift.
Ventricular system and cortical sulci were normal.
Impression :
Infarct in left ganglia basalis and left parietal.

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LABORATORY FINDING (October 28th 2011)
Blood Gas Analysis
pH 7.545 (7.35-7.45)
pCO2 19.8 mmHg (38-42)
pO2 68.9 mmHg (85-100)
HCO3 16.7 mmol/L (22-26)
Total CO2 17.3 mmol/L (19-25)
BE -3.2 mmol/L (-2) - (+2)
Saturasi O2 95.5 % 95-100

Working Diagnosis : Sopor + Right Hemiparalysis + Right 7th Nerve Paralysis UMN type ec
Ischemic Stroke
Treatment
1. Bed rest
2. O2 3-4 L/minute by rebreathing mask
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 1 gr/12 hours  2 gr/12 hours
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Ranitidin injection 1 amp/12 hours
8. IVFD Mannitol 125 cc/6 hours
9. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
10. Paracetamol 500 mg 3 x 1
11. Aspilet 80 mg 1 x 1

FOLLOW UP October 29th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 160/100 mmHg
Heart Rate : 142 bpm
Respiratory Rate : 28 x/minute
Temperature : 38.3 oC

LABORATORY FINDING (October 29th 2011)

Blood Gas Analysis
pH 7.498 (7.35-7.45)
pCO2 28.2 mmHg (38-42)
pO2 61.5 mmHg (85-100)
HCO3 21.4 mmol/L (22-26)
Total CO2 22.3 mmol/L (19-25)
BE -0.6 mmol/L (-2) - (+2)
Saturasi O2 90.3 % 95-100

Consult to Pulmonary Departement (October 29th 2011)

Diagnosis : Pneumonia
Treatment :
- O2 5 – 7 L/minute (rebreathing mask)
- Ceftriaxone injection 2 gr/12 hours

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 - Gentamycin injection 80 mg/8 hours
- Chest physiotherapy
Advise : Sputum analysis and sputum cytology

Working Diagnosis : Sopor + Right Hemiparalysis + Right 7th Nerve Paralysis UMN type ec
Ischemic Stroke + Pneumonia

Treatment
1. Bed rest
2. O2 3-4 L/minute by rebreathing mask
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 2 gr/12 hours
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Ranitidin injection 1 amp/12 hours
8. IVFD Mannitol 125 cc/6 hours
9. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
10. Gentamycin injection 80 mg/8 hours
11. Paracetamol 500 mg 3 x 1
12. Aspilet 80 mg 1 x 1

FOLLOW UP BEFORE DEATH October 30 2011

Time Level of Blood Pulse Resp. Temp. Explanation

Consciousness Pressure (bpm) Rate (0C)
(mmHg) (x/minute)
09.00 pm Sopor 100/70 124 44 40.2 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
09.30 pm Sopor 90/60 126 36 40.9 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
10.00 pm Coma 80/60 120 36 41 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
10.30 pm Coma 70/40 110 32 41 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
11.00 pm Coma 70/40 88 24 41 Light reflex (+)/(+)
pupil isokor ф ODS
4mm
11.30 pm Coma 60/40 36 6 41 Light reflex (+)/(+)
pupil isokor ф ODS
4mm
11.55 pm Both pupil were
EXITUS maximally dilated
Light reflex (-)/(-)
Corneal reflex (-)/(-)

Cause of Death : Sepsis ec Pneumonia

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 CAUSE OF DEATH REPORT
DEPARTEMENT OF NEUROLOGY
SCHOOL OF MEDICINE
UNIVERSITY OF NORTH SUMATERA
ADAM MALIK GENERAL HOSPITAL MEDAN

Presenter : dr. Anyta Prisca Dormida

Moderator : dr. Kiki M. Iqbal, SpS

Day/Date : Friday/December 16th 2011