CAUSE OF DEATH REPORT - 4

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

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

Presenter : dr. Andre Lona

Moderator : dr. Muhammad Yusuf, Sp.S
FINS
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PERSONAL IDENTIFICATION PERSONAL IDENTIFICATION

▪ Name : Mrs. DS ▪ Medical Record No. : 00.76.25.52
▪ Age : 68 years old ▪ Date of admission : November 13th , 2018
▪ Sex : female ▪ Time of admission : 21.45 pm
▪ Nationality : Indonesian ▪ Date of death : November 18th, 2018
▪ Address : LabuhanBatu ▪ Time of death: 11.30 am
▪ Marital status : Married ▪ Doctor in Charge : dr. Andre

▪ Supervisor : dr. Cut Aria Arina, Sp.S

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :
▪ She had been suffered the declining level of consciousness approximately 3 days
prior to admission to Adam Malik General Hospital, which occurred slowly.
Previously before it, she had looked drowsiness. History of headache was found
since 2 weeks ago, characterized by pain all over the head and didn’t reduce by
using painkiller. History of seizures was not found. History of projectile vomit was
not found.
▪ History of hypertension, hypercholesterolemia, diabetes mellitus, and heart disease
were denied.
▪ History of head trauma was not found. History of prolonged coughwas found since 4
weeks ago. History of weight loss was denied. History of night sweats was found.
History of fever was found for 2 weeks.
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GENERAL PHYSICAL
EXAMINATION
▪ Alertness : Somnolen ▪ Respiratory rate : 28 x/ minute
▪ Blood pressure : 110/80 mmHg ▪ Temperature : 38,9o C
▪ Heart rate : 84 bpm Irreguler

NEUROLOGIC EXAMINATION
Level of consciousness
Signs of increased ICP
Signs of meningeal irritation
: Apatis
: Headache (+), Projectile Vomiting (-), Seizures (-)
: Nuchal Rigidity (+), Kernig Sign (-), Brudzinski I (-),
Brudzinski II(-)
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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 : Papil oedem bilateral
3rd,4th and 6th nerves : Doll’s Eye Phenomenon (+/+)
7th nerve : Mouth was rest laid 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 examine
Lateralization (-)

DIAGNOSIS
Functional Diagnosis : Apatis
Anatomical Diagnosis : Meningens
Etiological Diagnosis : Infection
Working Diagnosis : Apatis ec due to dd 1. Meningitis TB 2.
Meningitis Bakterial
 FURTHER EXAMINATION
1.Complete Blood Count (CBC)
TREATMENT 2.Random Blood Sugar Level
 Bed rest, head elevation 30° 3.Renal Function Test
 NGT and urinary catheter in use
4.Liver Function Test
 Oxygen by nasal canule 2-4 l/minute
 IVFD Ringer Solution 20 drips/minute 5.Electrolyte
 IVFD Paracetamol 1000 mg/ 8 hours, if 6.Imuneserology
Temp. > 39°C 7.Blood Gas Analysis
 Paracetamol 3 x 500 mg
8.Chest X-ray
9.Head CT – Scan
10.ECG
 LABORATORY FINDING (November 13th, 2018)

Blood gas analysis:

Hemoglobin : 13,00 g/dL  PH : 7.442 mmHg ( 7.35 - 7.45)
 pCO2 : 32,1 mmHg (38-42)
WBC : 18.190 / mm3
Thrombocyte : 238.000 / mm3  pO2 : 191.5 mmHg (85-100)
Hematocrite : 39.00 %  Bicarbonate : 27.0 mmol/L (22-26)
 Total CO2 : 27.9 mmol/L (19–25)
Diff. Telling  Base Excess : 2.0 ( -2)- (+2)
Neutrofil : 88,30 (37-80)  O2 saturation : 99.5 ( 95- 100)
Lymphocyte : 7,70 (20-40)
Monocyte : 5,90 (2-8) Blood Sugar Level ( random) : 129 mg/dL
Eosinofil : 0,00 (1-6)
Basofil : 0.100 (0-1) Renal Function Test:
 Ureum : 40 (<50)
 Creatinine : 0,52 (0.70-1.20)
Electrolytes:
 Natrium : 140 mEq/L (135-155)
 Kalium : 3,4 mEq/L (3.6-5.5)
 Chloride : 102 mEq/L (96-106)
HEAD CT-SCAN (November 13 th, 2018)
Impression: Early hidrocefalus
CHEST X-RAY (November 13 th, 2018)
Impression: left pleural effusion
ECG finding :
Normal Sinus Rhytm

Working diagnosis Apatis due to DD: 1.Meningitis Tuberculosis

2.Meningitis Bakterialis
TREATMENT
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv  skin test
• Methyl Prednisolon inj 250 mg/bolus/iv  then 125mg/6 hrs/iv (tapp. off every 3 days)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips (If the temperature > 39C)
• Paracetamol 3 x 500 mg
• KSR 1 x 600 mg
• B complex 3 x 1
 
 Follow-up November 14th, 2018
FURTHER EXAMINATION Chief complain : Declined level of consciousness
1. Consult to Pulmonalogy Department
2. Lumbal puncture Vital sign
  Alertness : Apatis
Blood pressure : 150/80 mmHg
Heart Rate : 74 bpm
Resp. rate : 26 x/ min
Temperature : 37,2 ° C

Working Diagnosis : Somnolen + Hemiparesis Sinistra

due to Ischemic Stroke + CHF Fc II
due to HHD + AF NVR
TREATMENT
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by NRM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 6 hrs
 Inj Ranitidin 1 amp/12 hr
 Aspilet 1 x 320 mg
 B complex 3 x 1 tablet
 inj. Furosemid 20 mg/ 12 hrs
 Concor 1 x 2,5 mg
 Ramipril 1 x 2,5 mg
Follow up October 7th, 2018
Chief complain : declined level of consciousness

Vital sign
Alertness : Sopor
Blood pressure : 150/100 mmHg
Heart Rate : 64 bpm
Resp. rate : 24 x/ min
Temperature : 38,2 ° C

Working Diagnosis : Sopor + Hemiparesis Sinistra due to Ischemic Stroke + CHF

Fc II due to HHD + AF NVR
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by NRM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 8 hrs
 Aspilet 1 x 320 mg
 Paracetamol 3 x 500 mg
 B complex 3 x 1 tablet
 inj. Furosemid 20 mg/ 12 hrs
 Concor 1 x 2,5 mg
 Ramipril 1 x 2,5 mg
Follow up October 7th, 2018 (18.00)

Chief complain : declined level of consciousness,

Vital sign
Alertness : Sopor
Blood pressure : 130/70 mmHg
Heart Rate : 80 bpm
Resp. rate : 20 x/ min
Temperature : 37,8° C

Working Diagnosis : Sopor + Hemiparesis Sinistra due to Ischemic Stroke +

CHF Fc II due to HHD + AF NVR
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by RM 6-8 l/minute
 IVFD Ringer Solution 20 drips/minute
 IVFD Mannitol 20% Loading dose 250 cc →125 cc/ 8 hrs
 Inj Ranitidin 1 amp/12 hr
 Aspilet 1 x 320 mg
 Paracetamol 3 x 500 mg
 B complex 3 x 1 tablet
 inj. Furosemid 20 mg/ 12 hrs
 Concor 1 x 2,5 mg
 Ramipril 1 x 2,5 mg
TIME LEVEL OF BP/mmHg PULSE bpm RR x/minu T oC EXPLANATION RESPIRATORY
CONSCIOUSNESS Te TYPE

22.3 Sopor 80/60 70 32 37.8 Light reflex (+/+)↓, Hiperventilation

0 pm pupil anisocoria
R Ø=4 mm, L= 2 mm

22.4 Coma 80/50 70 34 37.8 Light reflex (+/+)↓, Hiperventilation

5 pm   Pupil anisocoria
R Ø= 4 mm, L= 2 mm

23.0 Coma 60/40 60 24 37.5 Light reflex (+/+)↓, Ataxic

0 pm pupil isocoria
R Ø = 5 mm, L = 3 mm

23.1 Coma 60/palpa 58 8 37.4 Light reflex (+/+)↓, Ataxic

5 pm te pupil isocoria
  R= Ø 5 mm, L= 3 mm

23.4 Passed away Absent absent - - Light reflex (-/-), Respiratory

0 pm Corneal reflex (-/-) arrest
Both pupils were
maximally dilated
Thank You…