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Case of Death Report Departement of Neurology - School of Medicine University of Sumatera Utara - H. Adam Malik General Hospital Medan
Case of Death Report Departement of Neurology - School of Medicine University of Sumatera Utara - H. Adam Malik General Hospital Medan
Case of Death Report Departement of Neurology - School of Medicine University of Sumatera Utara - H. Adam Malik General Hospital Medan
PERSONAL IDENTIFICATION
Name : Ruminta Simamora Medical Record No. : 69.78.98
Age : 68 years old Date of admission : January 25th, 2017
Sex : Female Time of admission : 00.05 am
Nationality : Indonesian Date of death : January 28th, 2017
Address : Kp. Sipirok Selat Besar Time of death : 00.55 am
Hilir Labuhan Batu Doctor in Charge : dr. Laura P.S. Tambunan
Marital status: Married Supervisor : dr. Puji Pinta O.S., Sp.S
HISTORY TAKING
She had been suffered the declining level of consciousness approximately 2 day prior
to admission to Adam Malik General Hospital, which occurred suddenly when she
was resting . History of headache was not found. History of seizure was not found.
History of projectile vomit was not found. History of head trauma was not found.
History of previous stroke was found seen in 5 years ago with right arm and leg
weakness. History of hypertension and hypercholesterolemia was found since 5 years
with uncontrolled treatment. History of diabetes mellitus and heart disease were
denied. History of fever was found since 1 days prior to admission to hospital. History
of pulmonary disease was not found. History of smoke was not found.
NEUROLOGIC EXAMINATION
Level of consciousness : Sopor
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 : yellowish yellowish
Boundary : clear clear
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Excavation : convex convex
A/V : 2/3 2/3
Impression : Normal papil
3 ,4 and 6th nerves
rd th
: Doll’s Eye Phenomenon (+)
7th nerve : Mouth was laid simetrically
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
MOTOR EXAMINATION
Strength of muscle : Difficulty to examine.
Lateralization was not found
DIAGNOSIS
Functional Diagnosis : Sopor
Anatomical Diagnosis : Sub cortex
Etiological Diagnosis : Thrombus
Working Diagnosis : Sopor + Duplex hemiparesis due to:
1. Reccurent Ischemic Stroke
2. Hemorhagic Stroke
TREATMENT
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 2-4 l/minute
IVFD Ringer Solution 20 drips/minute
IVFD Paracetamol 1.000 mg / 8 hours, if Temp. > 39°C
Parasetamol 3 x 500 mg
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. Immunoserology
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8. ECG
9. Chest X-ray
10. Head CT – Scan
Electrolytes:
Natrium : 114 mEq/L (135-155)
Kalium : 4.3 mEq/L (3.6-5.5)
Chloride : 89 mEq/L (96-106)
Immunoserology :
Procalcitonin : 30.04 ng/ml (˂0.05)
HEAD CT-SCAN
Impression: Hipodens lesion on the periventrikel right and left.
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Working Diagnosis : Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke +
Electrolite imbalance
TREATMENT:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Inj. Ranitidin 1 amp/ 12 hrs
Aptor 1 x 300 mg
Parasetamol 3 x 500 mg
B. Complex 3 x 1 tab
Working Diagnosis: Sopor + Duplex Hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Electrolite imbalance
Therapy:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
Inj. Ceftazidime 1 gram / 8 hours (skin test)
Cifrofloxacine drip 400 mg / 12 hours (skin test)
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Inj. Ranitidin 1 amp/ 12 hrs
Aptor 1 x 300 mg
Parasetamol 3 x 500 mg
B. Complex 3 x 1 tab
Planning:
- Fasting Glucose Level, 2 Hours Post Prandial Glucose Level, Lipid Profile , Uric acid,
Liver Function Test
- Electrolite after substitution
- Blood cultur
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- Urine cultur
- BTA direct smear 3 x
Vital sign
Alertness : Sopor
Blood pressure : 120/90 mmHg
Heart Rate : 110 bpm
Resp. rate : 24 x/ min
Temperature : 38,3° C
Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Electrolite imbalance
Therapy:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
Inj. Ceftazidime 1 gram / 8 hours
Cifrofloxacine drip 400 mg / 12 hours
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Inj. Ranitidin 1 amp/ 12 hrs
Aptor 1 x 300 mg
Parasetamol 3 x 500 mg
B. Complex 3 x 1 tab
Lipid Profile :
Total Cholesterol : 97 (˂ 200 )
Trigliserida : 134 (˂ 150 )
HDL Cholesterol : 75 (≥ 60 )
LDL Cholesterol : 42 (˂ 100 )
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Follow-up January 27th, 2017
Chief complain : Declined level of consciousness, fever (+), black liquid out of NGT (+)
Vital sign
Alertness : Sopor
Blood pressure : 130/90 mmHg
Heart Rate : 110 bpm
Resp. rate : 28 x/ min
Temperature : 38,3° C
Therapy:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% 20 gtt/i with IVFD NaCl 3% 8 gtt/i
Inj. Ceftazidime 1 gram / 8 hours
Cifrofloxacine drip 400 mg / 12 hours
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Inj. Ranitidin 1 amp/ 12 hrs
Aptor 1 x 300 mg aff
Parasetamol 3 x 500 mg
B. Complex 3 x 1 tab
Consult to Gastroenterohepatology:
Electrolytes:
Natrium : 131 mEq/L (135-155)
Kalium : 3.8 mEq/L (3.6-5.5)
Chloride : 97 mEq/L (96-106)
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Total CO2 : 20.2 mmol/L (19–25)
Base Excess : -9,7 ( -2)- (+2)
O2 saturation : 99.0 ( 95- 100)
Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Sepsis due to
pneumonia + Upper Gastrointestinal Bleeding + Hiponatremi + Acidosis metabolic
Therapy:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% 20 gtt/i
Inj. Ceftazidime 1 gram / 8 hours
Cifrofloxacine drip 400 mg / 12 hours
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Meylon 7 fls -- First hour 4 fls + 500 cc NaCl 0,9 % 20 gtt/i
Inj. Omeprazol 40 mg / 12 hours
Inj. Traxenamate acid 500 mg / 8 hours
Inj. Vitamin K 1 amp / 24 hours
Parasetamol 3 x 500 mg
Sucraflat syr 3 x C 1
KSR 1 x 600 mg
B. Complex 3 x 1 tab
Planning:
- Check of Blood Gas Analysis after meylon subsitution
Vital sign
Alertness : Sopor
Blood pressure : 90/60 mmHg
Heart Rate : 120 bpm
Resp. rate : 32 x/ min
Temperature : 38,5° C
Working Diagnosis: Sopor + Duplex hemiparesis due to Reccurent Ischemic Stroke + Shock sepsis
due to pneumonia + Hiponatremi + Acidosis Metabolic
Therapy:
Bed rest, head elevation 30°
NGT and urinary catheter in use
Oxygen by nasal canule 3-4 l/minute
IVFD NaCl 0,9% cor 1 flash 20 gtt/i
Inj. Ceftazidime 1 gram / 8 hours
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Cifrofloxacine drip 400 mg / 12 hours
Inj. Levosol 1 amp + NaCl 0,9% 40 cc 3 cc/hour (via syringe pump) up titration until
SBP ≥ 100 mmHg or MAP ≥ 65
IVFD Paracetamol 1.000 mg/8 hours, if Temp. > 39°C
Meylon 7 fls -- First hour 4 fls + 500 cc NaCl 0,9 % 20 gtt/i
Inj. Omeprazol 40 mg / 12 hours
Inj. Traxenamate acid 500 mg / 8 hours
Inj. Vitamin K 1 amp / 24 hours
Parasetamol 3 x 500 mg
Sucraflat syr 3 x C 1
KSR 1 x 600 mg
B. Complex 3 x 1 tab
Cause of Death :
Shock sepsis
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