CASE OF DEATH REPORT

DEPARTMENT OF NEUROLOGY MEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARA H. ADAM MALIK GENERAL HOSPITAL
MEDAN

PERSONAL IDENTIFICATION
Name
: Siangkan Barus
Age
: 52 years old
Sex
: Male
Nationality
: Indonesian
Adress
: Cingkes Dolok Silau
Marital status : Married

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

: 62.79.78
: December, 25th 2014
: 05.00 pm
: December, 28th 2014
: 02.00 pm
: dr. M. Taufiq Regia Arnaz
: dr. Kiki M. Iqbal, Sp.S

HISTORY TAKING
Main Complain
: Decreassed level of conciousness
History of Present Illness :
He had suffered the declining level of conciousness approximately 6 days prior to
admission to Adam Malik General Hospital which occured suddenly when he was resting.
History of headache, projectile vomit, and seizure were not found. History of head trauma was
not found. Previously, he was treated in other hospital for 6 days dan he referred to Adam Malik
General Hospital. History of hypertension was found since 5 years ago with controlled
medication with amlodipine. History of diabetes mellitus, hypercolesterolemia, and heart disease
were denied.
History of stroke was found since 2 months ago and based on information from his family, he
have operated because of brain haemorrhage on left brain 2 months ago.
History of Previous Disease
History of Previous Medication

: Hypertension
: Amlodipine

GENERAL PHYSICAL EXAMINATION

Alertness
: Somnolent
Blood pressure
: 100/60 mmHg
Heart rate
: 104 bpm

Respiratory rate
Temperature

: 28 x/minute
: 37,4 oC

NEUROLOGIC EXAMINATION
Level of consciousness
: Somnolent
Sign of increased ICP
: Headache (-), Projectile Vomiting (-), Seizures (-)
Sign of meningeal irritation
: Nuchal Rigidity (-), Kernig Sign (-), Brudzinski I (-),
Brudzinsky II (-)
CRANIAL NERVES
1st nerve
2nd and 3rd nerves
Opthalmoscopic examination
Optic disc
Color
Boundary
Excavatio
A/V
Impression
rd th
3 ,4 and 6th nerves
5th nerve
7th nerve
8th nerve
9th and 10th nerves
11th nerve
12th nerve

: Difficulty to examine
: Pupillary light reflexes (+/+), pupil isochors : 3 mm
:
Right Eye
Left Eye
:
yellowish
yellowish
:
clear
clear
:
concave
concave
:
2/3
2/3
:
Normal Papil
: Dolls eye phenomenon (+)
: Corneal reflex (+)
: Droopy mouth to the right
: Difficult to examine
: Gag reflex (+)
: Difficult to examine
: Tongue at rest laid symetrically

REFLEXES
Physiological reflexes
Biceps/Triceps
KPR/APR

Right extremity
:
+/+
+/+

Pathologique reflexes
Hoffman/ Tromner
Babinski

:
:

-/-

Left extremity
+/+
+/+
-/-

MOTOR EXAMINATION
Difficulty to examine. There is no lateralization.
DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Working Diagnosis

: Somnolent + Duplex Hemiparalysis + Right 7th nerve paralysis UMN

Type
: Subcortex
: Thrombus
: Somnolent + Duplex Hemiparalysis + Right 7th nerve paralysis UMN
Type due to :
1. Ischemic Stroke
2. Recurrent Stroke

TREATMENT
Bed rest
Nasogastric tube and urinary catheter in use
Oxygen by nasal canule 2-4 L/minute
IVFD Ringer Solution 20 drips/minute
Inj. Citicholin 1amp/12 hours
B Complex 3x1
FURTHER EXAMINATION
1. Complete Blood Count (CBC)
2. Ad Random Blood Sugar Level
3. Fasting Blood Glucose and 2 Hours Post Prandial Glucose Level
4. Renal Function Test
5. Liver Function Test
6. Lipid Profile
7. Electrolyte
8. Blood Gas Analysis
9. ECG
10. Chest X-Ray
11. Head CT-Scan
Follow-up December 26th, 2014
Chief complain
: Declined level of consciousness
Vital sign
Sensorium
Blood pressure
Heart rate
Resp. rate
Temperature

: Sopor
: 110/60 mmHg
: 104 bpm
: 32 x/ min
: 39,3 0C

LABORATORY FINDING (December 26th, 2014)

Haemoglobin
WBC
Thrombocyte
Haematocrite

: 8,50 g %
: 18.310/mm3
: 145.000/mm3
: 27,6 %
2

Diff. Telling
Neutrofil
Lymphocyte
Monocyte
Eosinofil
Basofil

:
: 95,00
: 3,80
: 1,00
: 0,10
: 0.100

Blood Sugar Level (ad random )

: 57 mg/dL

Renal Function Test

Ureum
Creatinine

: 63,10
: 0,33

(<71)
(0.70-1.20)

Electrolytes
Natrium
Kalium
Chloride

: 140 mEq/L
: 2,8 mEq/L
: 109 mEq/L

(135-155)
(3.6-5.5)
(96-106)

Blood Gas Analysis:

PH
pCO2
pO2
Bicarbonate
Total CO2
Base Excess
O2 Saturation
Liver Function Test
Albumin

(37-80)
(20-40)
(2-8)
(1-6)
(0-1)

: 7.436 mmHg
: 24,8 mmHg
: 127,2 mmHg
: 16,3 mmol/L
: 17,0 mmol/L
: -7,1
: 98,1%

( 7.35 - 7.45)
(38-42)
(85-100)
(22-26)
(1925)
( -2)- (+2)
( 95- 100)

: 1,7

Procalcitonin : 1,42 ng/ml

ECG FINDING (December 26th, 2014)

: Sinus Rhytme + Tachicardy + VES

CHEST X-RAY (December 26th, 2014)

Impression : Cardiomegaly + Elongation Aorta + Bronchopneumonia
HEAD CT-Scan (December 26th, 2014)
Impression
: Multiple infarct on periventricular and left interna Capsula and right interna
capsula
Consult to Pulmonology Department December 26th , 2014 :
Diagnosis : Nosocomial Pneumonia. DD: - Aspiration Pneumonia
- Tuberculosis
Therapy :
- Inj. Meropenem 1 gr/8 hours
- Inj. Ceftriaxone 2 gr/12 hours
- Inj. Gentamycin 80 mg/12 hours
- Inf. Ciprofloxacin 400 mg/12 hours
- Nebule Ventolin/ 8 hours
- Nebule Flixotide/ 12 hours
Sugesstion :
- Sputum analysis
- Sputum culture

Consult to Cardiology Department December 26th , 2014 :

Diagnosis : Hypertension Heart Disease
Therapy :
- Furosemide 1x40 mg tab
- Simvastatin 1x20 mg tab
- Aspillet 1x80 mg tab
Working diagnosis

: Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by

Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

Treatment :
Bed rest
Nasogastric tube and urinary catheter in use
Oxygen by rebreathing mask 8-10 L/minute
IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
0,9 % 20 drips/minute
IVFD Albumin 20 % 20 drips/minute/day
Inj. Citicholin 1amp/12 hours
Inj. Meropenem 1 gr/8 hours
Furosemide 1 x 40 mg tab
Simvastatin 1 x 20 mg tab
Aspillet 1 x 80 mg tab
Paracetamol 3x500 mg
B.complex 3x1tab
KSR 3x1 tab
Nebule Ventolin/8 hours
Nebule Flixotide/8 hours
Inj. Novalgin 1 amp (Temp 39 oC)

IVFD Nacl

Follow-up December 27th, 2014

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

: Sopor
: 110/60 mmHg
: 96 bpm
: 32 x/ min
: 38,5 0C

LABORATORY FINDING (December 27th, 2014)

Blood Gas Analysis:
PH
pCO2
pO2
Bicarbonate
Total CO2
Base Excess
O2 Saturation

: 7.543 mmHg
: 17,2 mmHg
: 176,9 mmHg
: 14,5 mmol/L
: 15,0 mmol/L
: -7,2
: 98,1%

( 7.35 - 7.45)
(38-42)
(85-100)
(22-26)
(1925)
( -2)- (+2)
( 95- 100)

Blood Sugar Level (ad random) : 124 mg/dl

Working diagnosis

: Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by

Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

Treatment :
Bed rest
Nasogastric tube and urinary catheter in use
Oxygen by rebreathing mask 8-10 L/minute
IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
0,9 % 20 drips/minute
IVFD Albumin 20 % 20 drips/minute/day
Inj. Citicholin 1amp/12 hours
Inj. Meropenem 1 gr/8 hours
Furosemide 1 x 40 mg tab
Simvastatin 1 x 20 mg tab
Aspillet 1 x 80 mg tab
Paracetamol drips 500 mg/8 hours
B.complex 3x1tab
KSR 3x1 tab
Nebule Ventolin/8 hours
Nebule Flixotide/8 hours

IVFD Nacl

Follow-up December 28th, 2014

Chief complain
: Declined level of consciousness
Vital sign
Alertness
Blood pressure
Heart rate
Resp. rate
Temperature
Working diagnosis

: Sopor
: 130/80 mmHg
: 96 bpm
: 32 x/ min
: 38,6 0C

: Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by

Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

Treatment :
Bed rest
Nasogastric tube and urinary catheter in use
Oxygen by rebreathing mask 8-10 L/minute
IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
0,9 % 20 drips/minute
IVFD Albumin 20 % 20 drips/minute/day
Inj. Citicholin 1amp/12 hours
Inj. Meropenem 1 gr/8 hours
Furosemide 1 x 40 mg tab
Simvastatin 1 x 20 mg tab
Aspillet 1 x 80 mg tab
Paracetamol drips 500 mg/8 hours
B.complex 3x1tab
KSR 3x1 tab
Nebule Ventolin/8 hours
Nebule Flixotide/8 hours

IVFD Nacl

Follow Up Before Death December, 28th 2014

TIME

LEVEL
OF
CONSCIOUS
NESS

BP/mm
Hg

PULSE
bpm

RR
x/minute

T oC

01.00 pm

Sopor

80/60

126

38

40,5

01.15 pm

Coma

70/50

128

36

40,0

01.30 pm

Coma

60/40

110

32

40,0

01.45 pm

Coma

50/-

40

39,0

Light reflex (+/+),

pupil isocory =5 mm

Light reflex (-/-),

Corneal reflex (-/-)
Both pupils were maximally
dilated

02.00 pm

Passed away

absent

absent

EXPLANATION
Light reflex (+/+),
Pupil isocory =4mm
Light reflex (+/+),
pupil isocory =4mm
Light reflex (+/+),
pupil isocory R=5mm

Cause of Death : Sepsis caused by Pneumonia