CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

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

PERSONAL IDENTIFICATION
Name : Mrs. HJ Medical Record No. : 00.75.92.80
Age : 75 years old Date of admission : October 12th , 2018
Sex : Male Time of admission : 21.38 pm
Nationality : Indonesian Date of death : October 15th, 2018
Address : Labuhan Batu Time of death : 09.40 am
Marital status : Married Doctor in Charge : dr. M.Ibnu Sina
Supervisor : Dr.dr. Puji Pinta O Sinurat, SpS(K)

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :

She had been suffered the declining level of consciousness approximately 3 day prior to admission to Adam
Malik General Hospital, which occurred suddenly when she is resting. 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 3 years ago, but uncontrolled. History of diabetes mellitus and Hypercholesterolemia was not
found. History of heart disease was not found. History of previous stroke was not found. History of trauma
was found approximately 2 weeks ago. The patient fell from his bed and complained of pain in the upper left
arm and has not been repaired. patients received treatment for 1 week from another hospital and then
referred.

History of previous disease : Hypertension, Fracture

Hystory of previous medication : Unknown

GENERAL PHYSICAL EXAMINATION

Alertness : somnolence
Blood pressure : 160/90 mmHg Respiratory rate : 28x/ minute
Heart rate : 98 bpm reguler Temperature : 37,8 o C

NEUROLOGIC EXAMINATION
Level of consciousness : Somnolence
Signs of increased ICP : Headache (-), Projectile Vomiting (-), Seizures (-)
Signs of meningeal irritation : Nuchal Rigidity (-), Kernig Sign (-), Brudzinski I (-),
Brudzinski II(-)

CRANIAL NERVES
1st nerve : Difficult 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
olor : orange orange
Boundary : clear clear
P1
 Excavatio : vanished vanished
A/V : 2/3 2/3
Impression : normal Papil bilateral

3rd,4th and 6th nerves : Doll’s Eye Phenomenon (+/+)

7th nerve : Symmetrical nasolabial folding

8th nerve : Difficult 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 : Difficult to exam, left lateralization.

DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Differential Diagnosis
: Somnolence + left Hemiparesis
: Subcortex
: Trombus
: 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
 Paracetamol tab 3x500 mg
 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. ECG
7. Chest X-ray
8. Head CT – Scan

P2
 LABORATORY FINDING (October 12th, 2018)

Hemoglobin : 8,7 g/dL

WBC : 12.790 / mm3
Thrombocyte : 170.000 / mm3
Hematocrite : 29.00 %
Diff. Telling :
 Neutrophyl : 78.70 (37-80)
 Lymphocyte : 9 (20-40)
 Monocyte : 10.20 (2-8)
 Eosinophyl : 1.90 (1-6)
 Basophyl : 0.20 (0-1)

INR : 1,06 (0,80-1,30)

D-Dimer : 3200

Blood Sugar Level ( random) : 76 mg/dL

Renal Function Test:

 Ureum : 34 (<50)
 Creatinine : 0,51 (0.70-1.20)

Albumin : 1,5 (3,5-5,0)

Electrolytes:
 Natrium : 122 mEq/L (135-155)
 Kalium : 4,9 mEq/L (3.6-5.5)
 Chloride : 198 mEq/L (96-106)

Blood gas analysis:

 PH : 7.340 mmHg ( 7.35 - 7.45)
 pCO2 : 49,0 mmHg (38-42)
 pO2 : 196.0 mmHg (85-100)
 Bicarbonate : 26,4 mmol/L (22-26)
 Total CO2 : 27,9 mmol/L (19–25)
 Base Excess : 0,1 ( -2 )- (+2)
 O2 saturation : 100.0 ( 95- 100)

HEAD CT-SCAN (October 12th, 2018)

Impression: Infarct in right and left frontal lobe, right temporal lobe, right occipito-parietal lobe and left
occipito lobe

CHEST X-RAY (October 12th, 2018)

Impression: Suspect Cardiomegaly with LVH + Pulmonal hypertension and pulmonal edema, DD infection
Bilateral pulmonary effusion

ECG finding :
Non specific T inverted in inferior lead + Slow R wave in V1-V3

Working Diagnosis : Somnolence + left Hemiparesis due to ischemic stroke + hyponatremia + Anemia
P3
TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal NRM 6-8 l/minute
 IVFD NaCl 0,9% 20 drips/minute + IVFD NaCl 3 % 8 drips/minute
 IVFD Mannitol 20 % 250 cc loading dose 125 cc/6 h
 Inj. Ceftriaxone 1 gr/ 12 h  Skin Test
 Paracetamol tab 3x500 mg
 Inj Ranitidin 1 amp/12 hrs
 Aspilet 1 x 80 mg
 B complex 3 x 1 tablet

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

Consult to Orthopedic Departement on October 13th 2018

Assesment : Proximal Fracture of the left Humerus
Treatment : ORIF elective

Planning : X-rays Left Humerus (AP/L)

Consult to Internal Departement on October 13th 2018

Assesment : Upper Gastrointestinal Bleeding due to stress ulcer + Anemia due to Chronic disease +
Hyponatremia + Ishemic stroke + hypoalbumin

Treatment : Inj. Omeprazole 2 amp 1 amp (40 mg)/12 h

Sucralfat Syr 3x 1 cth
(2,5-1,5)x70x0,8 =56% (3 fls Albumin 20%) IVFD Albumin 20% 1 fls/days
IVFD NaCl 0,9% 20 drips/minute + IVFD NaCl 3 % 8 drips/minute

Planning : Urinalysis

Consult to Pulmonology Departement on October 13th 2018

Assesment :.Pnemonia + Left Hemiparesis due to Ischemic stroke
Treatment : In.Levofloxacin 750 mg/24 jam,
Paracetamol tab 3x500

Planning : blood culture, sputum culture

Consult to Cardiology Departement on October 13th 2018

Assesment : Until now there were no signs of cardioembolism

Planning : Echocardiogram

Follow-up October 13th, 2018

Chief complain : Declined level of consciousness, Upper Gastrointestinal Bleeding
P4
Vital sign
Alertness : Somnolence
Blood pressure : 140/80 mmHg
Heart Rate : 108 bpm
Resp. rate : 16 x/ min
Temperature : 37,6 ° C

Working Diagnosis : Somnolence + left Hemiparesis due to ischemic stroke + hyponatremia +

hypoalbumin+ Anemia + Upper Gastrointestinal Bleeding

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal NRM 6-8 l/minute
 IVFD NaCl 0,9% 20 drips/minute + IVFD NaCl 3 % 8 drips/minute
 IVFD Mannitol 20 % 125 cc/8 h
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 Paracetamol Tab 3x500 mg
 Aspilet 1 x 80 mg  Stop
 B complex 3 x 1 tablet
 IVFD Albumin 20% 1 fls/day (d1)
 Inj. Omeprazole 1 amp (40 mg)/12 h
 Sucralfat Syr 3x 1 cth
 Inj Levofloxacin 750 mg/24 jam

LABORATORY FINDING October 13th , 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 : 208 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)

Follow up Oktober 14th, 2018

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

Vital sign
Alertness : Sopor
Blood pressure : 110/80 mmHg
Heart Rate : 88 bpm
Resp. rate : 30 x/ min
Temperature : 38,3 ° C
P5
 Working Diagnosis : Sopor + left Hemiparesis due to ischemic stroke+ hyponatremia + Anemia +
Upper Gastrointestinal Bleeding + Pnemonia

Treatment
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by nasal NRM 6-8 l/minute
 IVFD NaCl 0,9% 20 drips/minute
 IVFD Mannitol 20 % 125 cc/12 h
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 Paracetamol Tab 3x500 mg
 B complex 3 x 1 tablet
 IVFD Albumin 20% 1 fls/day (d2)
 Inj. Omeprazole 1 amp (40 mg)/12 h
 Sucralfat Syr 3x 1 cth
 Inj Levofloxacin 750 mg/24 jam

Planning : Complete Blood Count ,Blood Gas Analysis, electrolyte recheck, Procalcitonin, Consult to ICU

LABORATORY FINDING (October 14th, 2018)

Hemoglobin : 8.3 g/dL

WBC : 16.840 / mm3
Thrombocyte : 254.000 / mm3
Hematocrite : 29.00 %
Diff. Telling :
 Neutrophyl : 82.60 (37-80)
 Lymphocyte : 6.40 (20-40)
 Monocyte : 10.30 (2-8)
 Eosinophyl : 0.30 (1-6)
 Basophyl : 0.40 (0-1)

Electrolytes:
 Natrium : 136 mEq/L (135-155)
 Kalium : 4,6 mEq/L (3.6-5.5)
 Chloride : 106 mEq/L (96-106)

Blood gas analysis:

 PH : 7.22 mmHg ( 7.35 - 7.45)
 pCO2 : 58 mmHg (38-42)
 pO2 : 178 mmHg (85-100)
 Bicarbonate : 23,7 mmol/L (22-26)
 Total CO2 : 25.5 mmol/L (19–25)
 Base Excess : -4,7 ( -2)- (+2)
 O2 saturation : 99.0 ( 95- 100)

Procalcitonin : 0,42 (< 0,05)

P6
Urinalysis

Color Dark yellow

Glucose Negative
Bilirubin Negative
Keton Negative
Spesific gravity 1.020
PH 5.0
Protein Positive 2
Urobilinogen Positive
Nitrit Negative
Leukosit Positive
Blood Positive

FCM
Erythrocyte 35-50
Leukocyte 50-65
Epithel 0-1
Cests Negative
Crystal Negative

Planning : Consult to Nephrologist Division

Follow up Oktober 14th, 2018 (22.40 pm)

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

Vital sign
Alertness : Sopor
Blood pressure : 60/40 mmHg
Heart Rate : 58 bpm
Resp. rate : 28 x/ min
Temperature : 38,8 ° C

Asessment : Sopor + left Hemiparesis due to ischemic stroke + Anemia +Acidosis Respiratoric
+ Severe Sepsis

Treatment

 IVFD NaCl 0,9% 20 cc/kgbw in 30-60 minute  MAP up to > 70 mmhg

 IVFD Mannitol 20 % 125 cc/12 hStop
 IVFD Paracetamol 1000 mg/8 h
 if the target is not reached planning, Give levosol 8 mg in 50 cc Nacl 0,9%
 Start dose 1,15 cc/h increase the titration according to the levosol dose table

Follow up Oktober 15th, 2018

P7
Chief complain : Declined level of consciousness,

Vital sign
Alertness : Coma
Blood pressure : 100/80 mmHg
Heart Rate : 120 bpm
Resp. rate : 30 x/ min
Temperature : 38,1 ° C

Working Diagnosis : Coma + left Hemiparesis due to ischemic stroke + Anemia +Acidosis Respiratoric
+ Severe Sepsis
Treatment

 Bed rest, head elevation 30°

 NGT and urinary catheter in use
 Oxygen by nasal NRM 6-8 l/minute
 IVFD NaCl 0,9% 20 drips/minute
 IVFD Mannitol 20 % 125 cc/12 hStop
 Inj. Ceftriaxone 1 gr/ 12 h
 Inj Ranitidin 1 amp/12 hrs
 IVFD Paracetamol 1000 mg/8 h
 B complex 3 x 1 tablet
 IVFD Albumin 20% 1 fls/day (d3)
 Inj. Omeprazole 1 amp (40 mg)/12 h
 Sucralfat Syr 3x 1 cth
 Inj Levofloxacin 750 mg/24 jam
 levosol 8 mg in 50 cc Nacl 0,9% in syringe pump 5,3 cc/h

Follow up before Death October 15th, 2018

TIME LEVEL OF BP/mmHg PULSE RR T EXPLANATION RESPIRATORY

CONSCIOUSNESS bpm x/minu oC TYPE
Te
09.00 Coma 100/70 98 30 37.2 Light reflex (+/ Hiperventilation
am +)↓,
Pupil isocoria
R Ø= 4 mm, L=
4 mm
09.10 Coma 90/40 78 24 36.8 Light reflex (+/ Ataxic
am +)↓,
Pupil isocoria
R Ø= 5 mm, L=
5 mm
09.25 Coma 70/palpate 58 8 36.4 Light reflex (+/ Ataxic
am +)↓,
pupil isocoria
R= Ø 5 mm, L=
5 mm
09.40 Coma 60/palpate 12 4 36.0 Light reflex (-/-), Ataxic

P8
am R= Ø 5 mm, L=
5 mm
09.55 Passed away Absent absent - - Light reflex (-/-), Respiratory
am Corneal reflex arrest
(-/-)
Both pupils were
maximally
dilated

Cause of Death : Septic Shock

ECG

Chest X-rays

P9
Head CT scan

P10