CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF NORTH SUMATERA – ADAM MALIK GENERAL HOSPITAL MEDAN

PERSONAL IDENTIFICATION

Name : Sutiara MR : 53.19.05

Age : 50 years old Date of admission : September 28th 2012
Sex : Female Time of admission : 07.39 am
Nationality : Indonesian Date of death : September 29th 2012
Adress : Kuala Langkat Time of death : 05.45 am
Marital Status : Married Doctor in Charge : dr. Anyta Prisca Dormida
Supervisor : dr. Kiki M. Iqbal, SpS

HISTORY TAKING

Main Complain : Decreased level of consciousness

History of Present Illness
: She had been suffering from declining of consciousness
approximately 1 day prior to admission to Adam Malik General
Hospital, which occurred suddenly when she was resting. History of
headache, seizure and projectile vomiting were not found. History of
hypertension was found since several years ago, uncontrolled. History
of diabetes mellitus was also found since several years ago,
uncontrolled. History heart disease was not found. History of stroke
was found one year ago with left hemiparalysis. History of trauma and
fever were not found.

History of Previous Disease : Hypertension, diabetes mellitus, stroke

History of Previous Medication : Unknown

GENERAL PHYSICAL EXAMINATION

Level of Consciousness : Somnolence

Blood Pressure : 180/90 mmHg
Heart Rate : 116 bpm
Respiratory Rate : 24 x/minute
Temperature : 38.5 oC

NEUROLOGIC EXAMINATION

Level of Consciousness : Somnolence

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

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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 lateralization was not found

DIAGNOSIS

Functional Diagnosis : Somnolence + Duplex Hemiparalysis + Right 7th Nerve Paralysis

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

LABORATORY FINDING (September 28th 2012)

Cell Blood Count
Hemoglobin 14.4 g% (11.7-15.5)
6 3
Eritrocyte 4.74 x 10 /mm (4.20-4.87)
Leucocyte 3
28.18 x 10 /mm 3 (4.5-11.0)
3 3
Trombocyte 313 x 10 /mm (150-450)
Hematocryte 41.30 % (38-44)
Blood Sugar Level 277 mg/dL (<200)
Renal Function Test
Ureum 42.0 mg/dL (<50)
Creatinine 0.77 mg/dL (0.50-0.90)
Serum Electrolytes
Sodium 140 mEq/L (135-155)
Potassium 3.7 mEq/L (3.6-5.5)
Chlorida 105 mEq/L (96-106)
Blood Gas Analysis
pH 7.365 (7.35-7.45)
pCO2 39.1 mmHg (38-42)
pO2 139.5 mmHg (85-100)
HCO3 21.9 mmol/L (22-26)
Total CO2 23.1 mmol/L (19-25)
BE -3.2 mmol/L (-2) - (+2)
Saturasi O2 98.9 % 95-100

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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 2 gr/12 hours (skin test)
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
8. 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 September 28th 2012

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Somnolence
Blood Pressure : 170 / 90 mmHg
Heart Rate : 120 bpm
Respiratory Rate : 26 x/minute
Temperature : 38 oC

LABORATORY FINDING (September 28th 2011)

Blood Gas Analysis
pH 7.435 (7.35-7.45)
pCO2 34.7 mmHg (38-42)
pO2 112.8 mmHg (85-100)
HCO3 22.8 mmol/L (22-26)
Total CO2 23.8 mmol/L (19-25)
BE -0.9 mmol/L (-2) - (+2)
Saturasi O2 98.3 % 95-100
Blood Sugar Level
Nuchter 258 mg/dl (70-120)
2 hours pp 265 mg/dl (<200)
Lipid Profile
Total Cholesterol 258 mg/dl (<200)
Trigliserida 127 mg/dl (40-200)
HDL 53 mg/dl (>65)
LDL 188 mg/dl (<150)

ECG (September 28th 2012)

Sinus Rhytme + LVH

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HEAD CT SCAN (September 28th 2012)
Infratentorial 4th ventricle and cerebellum were normal.
There were multiple hypodense lesion in bilateral ganglia basalis and right periventricular.
There were no mass effect or midline shift.
Impression :
Multiple infarct in bilateral ganglia basalis and right periventricular.

Working Diagnosis : Somnolence + Duplex 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 2 gr/12 hours
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
8. Humulin R 6 – 6 – 6 IU
9. Paracetamol 500 mg 3 x 1
10. Aspilet 300 mg 1 x 1
11. Simvastatin 10 mg 1 x 1

FOLLOW UP BEFORE DEATH September 29th 2012

Time Level of Blood Pulse Resp. Temp. Explanation

Consciousness Pressure (bpm) Rate (0C)
(mmHg) (x/minute)
03.15 am Sopor 100/70 124 44 40.2 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
03.45 am Sopor 90/60 126 36 40.9 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
04.15 am Coma 80/60 120 36 41 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
04.45 am Coma 70/40 110 32 41 Light reflex (+)/(+)
pupil isokor ф ODS
3mm
05.15 am Coma 70/40 88 24 41 Light reflex (+)/(+)
pupil isokor ф ODS
4mm
05.30 am Coma 60/40 36 6 41 Light reflex (+)/(+)
pupil isokor ф ODS
4mm
05.45 am PASSED Both pupil were
AWAY maximally dilated
Light reflex (-)/(-)
Corneal reflex (-)/(-)

Cause of Death : Sepsis caused by 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. Haflin S. Hutagalung, SpS

Day/Date : Friday/October 19th 2012