CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF SUMATERA UTARA H. ADAM MALIK GENERAL HOSPITAL
MEDAN
PERSONAL IDENTIFICATION
Name
: Sofyan H. Siregar
Age
: 48 years old
Sex
: Male
Nationality : Indonesian
Address
: Siregar Kel Dolok
Marlawan
Marital status : Married

Medical Record No.

Date of admission
Time of admission
Date of death
Time of death
Doctor in Charge
Supervisor

: 64.04.00
: April 24th , 2015
: 11.55 am
: April 27th, 2015
: 12.55 pm
: dr. Mira Arianti
: dr. Aida Fitri, Sp.S

HISTORY TAKING
Main Complaint

: 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 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 not found.
History of hypertension was found since 5 years ago, but uncontrolled. History of diabetes
mellitus was found since 5 years ago and the use of medications were unclear. History of
hypercholesterolemia and heart disease were denied.
GENERAL PHYSICAL EXAMINATION
Alertness
: Apatis
Blood pressure
: 170/100 mmHg
Heart rate
: 100 bpm

Respiratory rate
Temperature

: 20 x/ minute
: 37o C

NEUROLOGIC EXAMINATION
Level of consciousness
: Apatis
Signs of increased ICP
: Headache (-), Projectile Vomiting (-), Seizures (-)
Signs of meningeal irritation
: Nuchal Rigidity (-), Kernig Sign (-), Brudzinski I (-),
Brudzinski II(-)
CRANIAL NERVES
1st nerve
2nd and 3rd nerves

Ophthalmoscope examination
Optic disc
Color
Boundary

: Difficulty to examine
: Pupillary light reflexes (+/+)
Pupil isocoria, OD 3 mm, OS 3 mm
:
Right Eye
Left Eye
:
yellowish
yellowish
:
clear
clear
1

Excavation
A/V
Impression
rd th
3 ,4 and 6th nerves
7th nerve
8th nerve
9th and 10th nerves
11th nerve
12th nerve

:
convex
:
2/3
: Normal papil
: Dolls Eye Phenomenon (+)
: Mouth was laid to the right
: Difficulty to examine
: Gag reflex (+)
: Difficulty to examine
: Tongue at rest laid symmetrically

REFLEXES
Physiologic reflexes
Biceps/triceps
KPR/APR

Right extremity
:
:

++ / ++
++ / ++

convex
2/3

Left extremity
++ / ++
++ / ++

Pathologique reflexes
Hoffman/ Tromner
Babinski
MOTOR EXAMINATION
Strength of muscle
DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Working Diagnosis

:
:

-/-

-/-

: Difficulty to examine
Right Lateralization was found.
: Apatis + Right Hemiparalysis + Parese Nerve VII
Right UMN
: Sub cortex
: Thrombus
: Apatis + Right Hemiparalysis + Parese Nerve VII
UMN due to :
1. Ischemic Stroke
2. Hemorrhagic 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
Inj Ceftriaxon 1 gr/12 hrs
Inj. Citicholine 1 amp/12 hrs
Inj Ranitidin 1 amp/12 hrs
Aptor 1 x 300 mg
B complex 3 x 1 tablet
2

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. ECG
8. Chest X-ray
9. Head CT Scan
LABORATORY FINDING (April 25th, 2015)
Hemoglobin
: 15.70 g/dL
WBC
: 19.100 / mm3
Thrombocyte
: 348.000 / mm3
Hematocrite
: 46.00 %
Diff. Telling
:
Neutrophyl
: 77.20 (37-80)
Lymphocyte
: 14.90 (20-40)
Monocyte
: 6.80 (2-8)
Eosinophyl
: 0.60 (1-6)
Basophyl
: 0.500 (0-1)
Blood Sugar Level ( random)

: 208.40 mg/dL

Renal Function Test:

Ureum
Creatinine

: 42.90
: 0.74

Electrolytes:

Natrium
Kalium
Chloride

Blood gas analysis:

PH
pCO2
pO2
Bicarbonate
Total CO2
Base Excess
O2 saturation

(<50)
(0.50-0.90)

: 137 mEq/L (135-155)

: 4.0 mEq/L (3.6-5.5)
: 101 mEq/L (96-106)
: 7.430 mmHg
( 7.35 - 7.45)
: 31 mmHg (38-42)
: 115.6 mmHg
(85-100)
: 20.6 mmol/L (22-26)
: 21.6 mmol/L (1925)
: -2.8
( -2)- (+2)
: 96.9
( 95- 100)

HEAD CT-SCAN (April 25th, 2015)

Impression: There are no infarct or cerebral hemorrhage or space occupying lesion in
cerebral. Suggest MRI brain.
3

CHEST X-RAY (April 25th, 2015)

Impression: normal cor and pulmo
ECG finding : Sinus Rythm (Normal ECG)
Working Diagnosis
Ischemic Stroke

: Apatis + Right Hemiparalysis + parese Nerve VII right UMN due to

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
Inj Ceftriaxon 1 gr/12 hrs
Inj. Citicholine 1 amp/12 hrs
Inj Ranitidin 1 amp/12 hrs
Aptor 1 x 300 mg
B complex 3 x 1 tablet
Follow-up April 25th, 2015
Chief complain
: Declined level of consciousness
Vital sign
Alertness
Blood pressure
Heart Rate
Resp. rate
Temperature

: Somnolent
: 190/110 mmHg
: 100 bpm
: 30 x/ min
: 38.8 C

LABORATORY FINDING (April 25th, 2015)

Fasting Glucose Level
: 268 mg/dL
2 Hours Post Prandial Glucose Level : 330 mg/dL
Hb-A1C
: 12.8 %

(70-120)
( < 200 )
(4.8-5.9)

Lipid Profile :
Total Cholesterol
Trigliserida
HDL-Cholesterol
LDL-Cholesterol

( < 200 )
( 40 200 )
( >65 )
( <150 )

: 331 mg/dL
: 278 mg/dL
: 51 mg/dL
: 245 mg/dL

Consult to Endocrinology :
Assesment : DM type II + Dyslipidemia
Planning
: Diet for DM type II
Inj Novorapid 8 8 8 IU
Inj Levemir 8 IU (night at 10 PM)
Simvastatin 1 x 20 mg (night)
4

Working Diagnosis : Somnolent + Right Hemiparalysis + parese Nerve VII right UMN due
to Ischemic Stroke + DM type II

Therapy

:
Diet for DM type II
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
Inj Ceftriaxon 1 gr/12 hrs
Inj. Citicholine 1 amp/12 hrs
Inj Ranitidin 1 amp/12 hrs
Inj Furosemide 1 amp/12 hrs
Aptor 1 x 300 mg
Simvastatin 1 x 20 mg (night)
Paracetamol 3 x 500 mg
B complex 3 x 1 tablet
Inj Novorapid 8 8 8 IU
Inj Levemir 8 IU (night at 10 PM)

Follow up April 26th, 2015

Chief complain
: declined level of consciousness
Vital sign
Alertness
Blood pressure
Heart Rate
Resp. rate
Temperature

: Somnolent
: 180/100 mmHg
: 110 bpm
: 32 x/ min
: 39 C

Working Diagnosis : Somnolent + Right Hemiparalysis + parese Nerve VII right UMN due
to Ischemic Stroke + DM type II
Therapy

:
Diet for DM type II
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
Inj Ceftriaxon 1 gr/12 hrs
Inj. Citicholine 1 amp/12 hrs
Inj Ranitidin 1 amp/12 hrs
Inj Furosemide 1 amp/12 hrs
Aptor 1 x 300 mg
5

Captopril 2 x 25 mg
Paracetamol 3 x 500 mg
Simvastatin 1 x 20 mg (night)
B complex 3 x 1 tablet
Inj Novorapid 8 8 8 IU
Inj Levemir 8 IU (night at 10 PM)

Planning : Consult to Department Pulmonology with Pneumonia

Blood culture
Blood gas analysis:
PH
pCO2
pO2
Bicarbonate
Total CO2
Base Excess
O2 saturation

: 7.50 mmHg ( 7.35 - 7.45)

: 27 mmHg (38-42)
: 194.0 mmHg
(85-100)
: 21.1 mmol/L (22-26)
: 21.9 mmol/L (1925)
: -0.3
( -2)- (+2)
: 100
( 95- 100)

Follow up April 27th, 2015

Chief complain
: declined level of consciousness
Vital sign
Alertness
Blood pressure
Heart Rate
Resp. rate
Temperature

: Sopor
: 140/90 mmHg
: 110 bpm
: 30 x/ min
: 39 C

Working Diagnosis : Sopor due to sepsis due to pneumonia + Right Hemiparalysis + Parese Nerve
VII Right UMN due to Ischemic Stroke + DM type II
Therapy

:
Diet for DM type II
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
Inj Ceftriaxon 2 gr/12 hrs
Inj. Citicholine 1 amp/12 hrs
Inj Ranitidin 1 amp/12 hrs
Inj Furosemide 1 amp/12 hrs
Captopril 2 x 25 mg
Aptor 1 x 300 mg
Paracetamol 3 x 500 mg
Simvastatin 1 x 20 mg (night)
6

B complex 3 x 1 tablet
Inj Novorapid 8 8 8 IU
Inj Levemir 8 IU (night at 10 PM)
Inj. Novalgin 1 amp/iv if T > 39 C

Follow up before Death April 27th, 2015

TIME
LEVEL OF BP/mmHg PULSE
CONSCIO
bpm
USNESS
11.45 am
sopor
90/50
142

RR
x/minu
Te
46

T oC

EXPLANATION

41.0

Light reflex (+/+),

pupil isocoria
R =3 mm, L= 3 mm
Light reflex (+/+),
Pupil isocoria
R = 3mm, L= 3 mm
Light reflex (+/+),
pupil isocoria
R = 3 mm, L = 3 mm
Light reflex (+/+),
pupil anisocoria
R= 4 mm, L= 4 mm
Light reflex (-/-),
R= 5 mm, L= 5 mm
Light reflex (-/-),
Corneal reflex (-/-)
Both pupils were
maximally dilated

12.00 am

coma

90/50

122

38

41.0

12.15 am

coma

80/40

78

32

40.0

12.30 am

coma

70/40

58

40.0

12.45 am

coma

50/palpate

12

39.8

12.55 am

Passed
away

absent

absent

Cause of Death : Sepsis