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. : 00.74.61.63
Age : 67 years old Date of admission : June 14th , 2018
Sex : Male Time of admission : 09.55 am
Nationality : Indonesian Date of death : June 18th, 2018
Address : Pagar Pisang village Time of death : 06.30 am
Marital status : Married Doctor in Charge : dr. M.Ibnu Sina
Supervisor : dr. Cut Aria Arina, SpS

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :

She had been suffered the declining level of consciousness approximately 1 day prior to admission to Adam
Malik General Hospital, which occurred suddenly when she want go to the bathroom. History of headache
was not found. History of seizure was not found. History of projectile vomit was not found. History of
hypertension was found since 4 years ago, but uncontrolled. History of diabetes mellitus and
Hypercholesterolemia was found since 3 month ago, but uncontrolled. History of heart disease was not
found. History of previous stroke was not found..

History of previous disease : Hypertension, Hypercholesterol, Diabetes mellitus

Hystory of previous medication : Unknown

GENERAL PHYSICAL EXAMINATION

Alertness : Apatis,
Blood pressure : 169/83 mmHg Respiratory rate : 28x/ minute
Heart rate : 61 bpm reguler Temperature : 37 o 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 : Difficulty to examine
2nd and 3rd nerves : Pupillary light reflexes (+/+)
Pupil isocoria, OD Ø 3 mm, OS Ø 3 mm
 Ophthalmoscope examination :
Optic disc Right Eye Left Eye
Color : orange orange
Boundary : clear clear
Excavatio : vanished vanished
A/V : 2/3 2/3
Impression : normal Papil bilateral
P1
3rd,4th and 6th nerves : Doll’s Eye Phenomenon (+/+)
7th nerve : Deviation to the left
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
: Apatis +Paresis N VII sinistra UMN+ left Hemiparesis
: subcortex
: Embolus
: Ischemic Stroke
Hemmorhagic Stroke

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by Nasal canule 4-6 l/minute
 IVFD Ringer Solution 20 drips/minute
 B complex 3 x 1 tablet

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 (June 14th, 2018)

P2
 Hemoglobin : 12 g/dL
WBC : 14.470 / mm3
Thrombocyte : 155.000 / mm3
Hematocrite : 36.00 %
Diff. Telling :
 Neutrophyl : 87.50 (37-80)
 Lymphocyte : 7.40 (20-40)
 Monocyte : 4.80 (2-8)
 Eosinophyl : 0.20 (1-6)
 Basophyl : 0.10 (0-1)

INR : 0,80 (0,80-1,30)

Blood Sugar Level ( random) : 100 mg/dL

Renal Function Test:

 Ureum : 17 (<50)
 Creatinine : 0,72 (0.70-1.20)

Electrolytes:
 Natrium : 138 mEq/L (135-155)
 Kalium : 3,7 mEq/L (3.6-5.5)
 Chloride : 106 mEq/L (96-106)

Blood gas analysis:

 PH : 7.330 mmHg ( 7.35 - 7.45)
 pCO2 : 23,0 mmHg (38-42)
 pO2 : 124.0 mmHg (85-100)
 Bicarbonate : 12.1 mmol/L (22-26)
 Total CO2 : 12.8 mmol/L (19–25)
 Base Excess : -12 ( -2 )- (+2)
 O2 saturation : 98.0 ( 95- 100)

Consult to Cardiology Departement on June 14th 2018

Assesment : CHF Fc II ec HHD + HT stage II + Ischemic Stroke
Treatment : Inj. Furosemide 40 mg/24 h
Valsartan tablets 1x 80 mg

HEAD CT-SCAN (June 14st, 2018)

Impression: Large infarct in right hemisfer according to distribution right media cerebral artery

CHEST X-RAY (June 14st, 2018)

Impression: Cardiomegaly with aorta elongasio

ECG finding :
Sinus bradycardia

P3
Working Diagnosis : Apatis +Paresis N VII sinistra UMN + left Hemiparesis
due to ischemic stroke

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal RM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20 % 250 cc loading dose 125 cc/6 h
 Inj. Ceftriaxone 1 gr/ 12 h  Skin Test
 Inj Ranitidin 1 amp/12 hrs
 Aspilet 1 x 320 mg
 B complex 3 x 1 tablet
 Inj. Meylon 6 Fls @ 25 meq in 250 cc Nacl 0,9 % 10 gtt/minute
 Inj. Furosemide 40 mg/24 h
 Valsartan tablets 1x 80 mg

Planning : Fasting Glucose, 2 Hours Post Prandial Glucose Level, Hb-A1c, uric acid, Lipid profile check,
Blood gas analysis recheck

Follow-up June 15th, 2018

Chief complain : Declined level of consciousness,

Vital sign
Alertness : Apatis
Blood pressure : 175/80 mmHg
Heart Rate : 68 bpm
Resp. rate : 20 x/ min
Temperature : 37 ° C

Working Diagnosis : Apatis +Pharesis N VII sinistra UMN + left Hemiparesis

due to ischemic stroke

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal RM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20 % 125 cc/8 h
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 Aspilet 1 x 320 mg
 B complex 3 x 1 tablet
 Inj. Meylon 6 Fls @ 25 meq in 250 cc Nacl 0,9 % 10 gtt/minute stop
 Inj. Furosemide 40 mg/24 h
 Valsartan tablets 1x 80 mg
P4
LABORATORY FINDING June 15th , 2018)

Fasting Glucose Level : 93 mg/dL (70-120)

2 Hours Post Prandial Glucose Level : 120 mg/dL ( < 200 )
Hb-A1C : 6,9 % (4.8-5.9)

Lipid Profile :
Total Cholesterol : 230 mg/dL ( < 200 )
Trigliserida : 67 mg/dL ( <150 )
HDL-Cholesterol : 57 mg/dL ( >=60 )
LDL-Cholesterol : 153 mg/dL ( <100 )
Uric Acid : 6,8 (2,6-6,0)

Blood gas analysis:

 PH : 7.410 mmHg ( 7.35 - 7.45)
 pCO2 : 43,0 mmHg (38-42)
 pO2 : 191.0 mmHg (85-100)
 Bicarbonate : 27.0 mmol/L (22-26)
 Total CO2 : 28.6 mmol/L (19–25)
 Base Excess : 2.3 ( -2)- (+2)
 O2 saturation : 100.0 ( 95- 100)

Follow up June 16st, 2018

Chief complain : Declined level of consciousness,

Vital sign
Alertness : Apatis
Blood pressure : 160/80 mmHg
Heart Rate : 88 bpm
Resp. rate : 20 x/ min
Temperature : 37,3 ° C

Working Diagnosis : Apatis +Paresis N VII sinistra UMN + left Hemiparesis

due to ischemic stroke

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal RM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20 % 125 cc/12 h
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 Aspilet 1 x 320 mg
 B complex 3 x 1 tablet
 Inj. Furosemide 40 mg/24 h
 Valsartan tablets 1x 80 mg

P5
 Follow up June 17st, 2018
Chief complain : Declined level of consciousness,

Vital sign
Alertness : somnolen
Blood pressure : 150/60 mmHg
Heart Rate : 52 bpm
Resp. rate : 18 x/ min
Temperature : 36,8 ° C

Working Diagnosis : Somnolen +Paresis N VII sinistra UMN + left Hemiparesis

due to ischemic stroke

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal RM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20 % 125 cc/24 h
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 Aspilet 1 x 320 mg
 B complex 3 x 1 tablet
 Inj. Furosemide 40 mg/24 h
 Valsartan tablets 1x 80 mg

Planning : Complete blood count, electrolyte, and Blood gas analysis recheck, Consult to
Neurosurgery depaartement

LABORATORY FINDING (June 17th, 2018)

Hemoglobin : 12 g/dL
WBC : 13.330 / mm3
Thrombocyte : 220.000 / mm3
Hematocrite : 36.00 %
Diff. Telling :
 Neutrophyl : 75.30 (37-80)
 Lymphocyte : 13.10 (20-40)
 Monocyte : 10.30 (2-8)
 Eosinophyl : 1.10 (1-6)
 Basophyl : 0.20 (0-1)

Electrolytes:
 Natrium : 138 mEq/L (135-155)
 Kalium : 3,7 mEq/L (3.6-5.5)
 Chloride : 108 mEq/L (96-106)

Blood gas analysis:

 PH : 7.458 mmHg ( 7.35 - 7.45)
 pCO2 : 30.7 mmHg (38-42)
P6
  pO2 : 165 mmHg (85-100)
 Bicarbonate : 21.2 mmol/L (22-26)
 Total CO2 : 22.2 mmol/L (19–25)
 Base Excess : -1,5 ( -2)- (+2)
 O2 saturation : 99.2 ( 95- 100)

Follow up before Death June 18th, 2018

TIME LEVEL OF BP/mmHg PULSE RR T EXPLANATION RESPIRATORY

CONSCIOUSNESS bpm x/minu oC TYPE
Te
05.15 Sopor 150/70 82 32 37.8 Light reflex (+/ Hiperventilation
am +)↓,
pupil isocoria
R Ø=3 mm, L= 4
mm
05.30 coma 110/50 62 28 37.8 Light reflex (+/ Hiperventilation
am +)↓,
Pupil anisocoria
R Ø= 2 mm, L=
4 mm
05.45 Coma 90/40 78 24 37.5 Light reflex (+/ Ataxic
am +)↓,
Pupil anisocoria
R Ø= 2 mm, L=
4 mm
06.00 coma 70/palpate 58 8 37.4 Light reflex (+/ Ataxic
am +)↓,
pupil isocoria
R= Ø 4 mm, L=
4 mm
06.15 coma 60/palpate 12 4 37.0 Light reflex (-/-), Ataxic
am R= Ø 5 mm, L=
5 mm
06.30 Passed away absent absent - - Light reflex (-/-), Respiratory
am Corneal reflex arrest
(-/-)
Both pupils were
maximally
dilated

Cause of Death : Brain Herniation

P7
ECG

Chest X-rays

P8
Head CT scan

P9