Sie sind auf Seite 1von 7

CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE


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

PERSONAL IDENTIFICATION
Name : Mrs. DMS Medical Record No. : 00.75.13.31
Age : 36 years old Date of admission : July 30th , 2018
Sex : female Time of admission : 19.26 pm
Nationality : Indonesian Date of death : August 1st, 2018
Address : Bagun Sari Village Time of death : 11.00 am
Marital status : Married Doctor in Charge : dr. M.Ibnu Sina
Supervisor : dr. Kiki M Iqbal, SpS

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 occurs slowly when the patient is resting. According to the family, the
patient also suffered from right limb weakness about a week ago History of headache was found, headache
is felt for approximately 4 months, the pain felt on the left side of the head is continuous and throbbing.
History of seizure was not found. History of projectile vomit was not found. History of hypertension was not
found. History of diabetes mellitus was not found. History of Hypercholesterolemia was not found.. History
of heart disease was not found. History of previous stroke was not found. history of weight loss was not
found. history of fever was not found. history of traumatic brain injury was not found.
History of previous disease : Unknown
Hystory of previous medication : Unknown

GENERAL PHYSICAL EXAMINATION


Alertness : Somnolent
Blood pressure : 130/80 mmHg Respiratory rate : 24x/ minute
Heart rate : 52 bpm reguler Temperature : 36,5o C

NEUROLOGIC EXAMINATION
Level of consciousness : Somnolent
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
Color : orange orange
Boundary : clear clear
Excavatio : vanished vanished
A/V : 2/3 2/3
P1
Impression : normal Papil bilateral

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


7th nerve : The nasolabial angle rests symmetrically
8th nerve : Difficult to examine
9th and 10th nerves : Gag reflex (+)
11th nerve : Difficult 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,Right lateralization.

DIAGNOSIS
Functional Diagnosis : Somnolent + Secondary Headache + Right Hemiparesis
Anatomical Diagnosis : subcortex
Etiological Diagnosis : Neoplasma
Differential Diagnosis : Intracranial SOL

TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by Nasal canule 4 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

P2
LABORATORY FINDING (July 30th, 2018)

Hemoglobin : 11 g/dL
WBC : 8.240 / mm3
Thrombocyte : 404.000 / mm3
Hematocrite : 32.00 %
Diff. Telling :
 Neutrophyl : 89.90 (37-80)
 Lymphocyte : 4.10 (20-40)
 Monocyte : 5.90 (2-8)
 Eosinophyl : 0.00 (1-6)
 Basophyl : 0.10 (0-1)

Blood Sugar Level ( random) : 160 mg/dL

Renal Function Test:


 Ureum : 79 (<50)
 Creatinine : 0,80 (0.70-1.20)

Electrolytes:
 Natrium : 140 mEq/L (135-155)
 Kalium : 4.1 mEq/L (3.6-5.5)
 Chloride : 106 mEq/L (96-106)

Blood gas analysis:


 PH : 7.469 mmHg ( 7.35 - 7.45)
 pCO2 : 21,3 mmHg (38-42)
 pO2 : 191.2 mmHg (85-100)
 Bicarbonate : 15.1 mmol/L (22-26)
 Total CO2 : 15.8 mmol/L (19–25)
 Base Excess : -6.1 ( -2 )- (+2)
 O2 saturation : 99.4 ( 95- 100)

HEAD CT-SCAN (July 30th, 2018)


Impression: Brain tumor

CHEST X-RAY (July 30th, 2018)


Impression: Normal Cor and Pulmo

ECG finding :
Sinus Bradychardia

Working Diagnosis : Somnolent + Secondary Headache + Right Hemiparesis


due to primary brain tumor dd brain metastasis

P3
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
 Inj.dexamethasone 2 amp loading dose 1 amp/6 h
 Inj Ranitidin 1 amp/12 hrs
 Paracetamol tablets 3 x 500 mg
 B complex 3 x 1 tablet

Planning : Fasting Glucose, 2 Hours Post Prandial Glucose Level, Hb-A1c, uric acid, Lipid profile check,
Tumor markers check, MRI brain IV contrast

Follow-up July 31th, 2018


Chief complain : Declined level of consciousness,

Vital sign
Alertness : Somnolent
Blood pressure : 140/80 mmHg
Heart Rate : 66 bpm
Resp. rate : 22 x/ min
Temperature : 37,7 ° C

Working Diagnosis : Somnolent + Secondary Headache + Right Hemiparesis


due to primary brain tumor dd brain metastasis

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
 Inj.dexamethasone 1 amp/6 h (d-2)
 Inj Ranitidin 1 amp/12 hrs
 Paracetamol tablets 3 x 500 mg
 B complex 3 x 1 tablet

LABORATORY FINDING July 31th, 2018

Fasting Glucose Level : 248 mg/dL (70-120)


2 Hours Post Prandial Glucose Level : - ( < 200 )
Hb-A1C : 7,4 % (4.8-5.9)

Lipid Profile :
Total Cholesterol : 333 mg/dL ( < 200 )
Trigliserida : 297 mg/dL ( <150 )
HDL-Cholesterol : 47 mg/dL ( >=60 )
LDL-Cholesterol : 299 mg/dL ( <100 )
Uric Acid : 3,4 (2,6-6,0)
P4
Tumor Marker:
 CEA : 5.69 ng/mL ( ≤ 5)
 CA 125 : 41.6 U/mL (< 35)
 CA 19-9 : 33.9 U/mL (< 37)
 Cyfra 21-1 : 2.63 ng/mL (≤ 2.08)
 CA 15-3 : 10.4 U/mL (≤ 31.3)
 SCC : 1 ng/mL (< 1.5)

Planning : consult with the neurosurgery department

Follow-up August 1st, 2018


Chief complain : Declined level of consciousness,

Vital sign
Alertness : Somnolent
Blood pressure : 120/80 mmHg
Heart Rate : 72 bpm
Resp. rate : 20 x/ min
Temperature : 37,2 ° C

Working Diagnosis : Somnolent + Secondary Headache + Right Hemiparesis


due to primary brain tumor dd brain metastasis

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
 Inj.dexamethasone 1 amp/6 h (d-3)
 Inj Ranitidin 1 amp/12 hrs
 Paracetamol tablets 3 x 500 mg
 B complex 3 x 1 tablet

Follow up before Death August 1st, 2018

TIME LEVEL OF BP/mmHg PULSE RR T EXPLANATION RESPIRATORY


o
CONSCIOUSNESS bpm x/minu C TYPE
Te
09.45 Sopor 150/70 82 38 37.8 Light reflex Hiperventilation
am (+/+)↓,
pupil isocoria
R Ø=2 mm, L=
4 mm
10.00 coma 110/50 62 34 37.8 Light reflex Hiperventilation
am (+/+)↓,
Pupil anisocoria
R Ø= 2 mm, L=
4 mm

P5
10.15 Coma 90/40 78 24 37.5 Light reflex Ataxic
am (+/+)↓,
Pupil anisocoria
R Ø= 2 mm, L=
5 mm
10.30 Coma 70/palpate 58 8 37.4 Light reflex Ataxic
am (+/+)↓,
pupil isocoria
R= Ø 4 mm, L=
5 mm
10.45 Coma 60/palpate 12 4 37.0 Light reflex (-/-), Ataxic
am R= Ø 5 mm, L=
5 mm
11.00 Passed away Absent absent - - Light reflex (-/-), Respiratory
am Corneal reflex (- arrest
/-)
Both pupils were
maximally
dilated

Cause of Death : Brain Herniation

ECG

P6
Chest X-rays

Head CT scan

P7