CASE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

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

PERSONAL IDENTIFICATION
Name : Mrs. D Medical Record No. : 72.14.28
Age : 66 years old Date of admission : May 21th , 2018
Sex : Female Time of admission : 13.00 pm
Nationality : Indonesian Date of death : May 21th, 2018
Address : Medan Sunggal Time of death : 14.35 am
Doctor in Charge : dr. Pratiwi
Marital status: Married Supervisor : dr. Chairil Amin
Batubara, M.Ked (Neu),
Sp.S

HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :

She had been suffered the declining level of consciousness approximately 4 days prior
to admission to Adam Malik General Hospital, which occurred suddenly when she
was doing her daily routine. 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 these last 5 years, but uncontrolled. History
of diabetes mellitus was found since these last 5 years, but uncontrolled and the use of
medications were unclear. History of hypercholesterolemia were denied. History of
fever was found since 3 days ago. History of head trauma was not found.
History of previous stroke was found with weakness of the right left and arm since 1
year ago.

GENERAL PHYSICAL EXAMINATION

Alertness : Somnolent
Blood pressure : 150/90 mmHg Respiratory rate : 24 x/ minute
Heart rate : 95 bpm Temperature : 37.1o 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 : Difficulty to examine
2nd and 3rd nerves : Pupillary light reflexes (+/+)
Pupil isocoria, OD Ø 3 mm, OS Ø 3 mm

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 Ophthalmoscope examination :
Optic disc Right Eye Left Eye
Color : yellowish yellowish
Boundary : clear clear
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 symmetrically

REFLEXES
Physiologic reflexes Right extremity Left extremity

Biceps/triceps : ++ / ++ ++ / ++
KPR/APR : ++ / ++ ++ / ++

Pathologique reflexes

Hoffman/ Tromner : -/- -/-

Babinski : - -

MOTOR EXAMINATION
Strength of muscle : Difficulty to examine.
Right Lateralization was found.

DIAGNOSIS
Functional Diagnosis : Somnolent + Right Hemiparalysis
Anatomical Diagnosis : Sub cortex
Etiological Diagnosis : Thrombus
Working Diagnosis : Somnolent + Right Hemiparalysis due to:
1. Recurrent Ischemic Stroke
2. Hemorrhagic Stroke

TREATMENT
 Bed rest, head elevation 30°
 Nasogastric tube and urinary catheter in use
 Oxygen by nasal canule 2-4 l/minute
 IVFD Ringer Solution 20 drips/minute

FURTHER EXAMINATION
1. Complete Blood Count (CBC)
2. Random Blood Sugar Level
3. Renal Function Test
4. Electrolyte
5. Blood Gas Analysis
6. ECG

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 7. Chest X-ray
8. Head CT – Scan

LABORATORY FINDING (March 12th, 2018)

Hemoglobin : 10.80 g/dL
WBC : 13.490 / mm3
Thrombocyte : 310.000 / mm3
Hematocrite : 31.80 %
Diff. Telling :
 Neutrophyl : 87.80 (37-80)
 Lymphocyte : 6.90 (20-40)
 Monocyte : 3.80 (2-8)
 Eosinophyl : 1.40 (1-6)
 Basophyl : 0.100 (0-1)

Blood Sugar Level ( random) : 180.0 mg/dL

Renal Function Test:
 Ureum : 27.20 (<50)
 Creatinine : 1.06 (0.50-0.90)

Electrolytes:
 Natrium : 134 mEq/L (135-155)
 Kalium : 3.9 mEq/L (3.6-5.5)
 Chloride : 106 mEq/L (96-106)

Blood gas analysis:

 PH : 7.445 mmHg (7.35-7.45)
 pCO2 : 28.2 mmHg (38-42)
 pO2 : 176.6 mmHg (85-100)
 Bicarbonate : 18.9 mmol/L (22-26)
 Total CO2 : 19.8 mmol/L (19–25)
 Base Excess : -4.5 ( (-2) - (+2)
 O2 saturation : 99.5 ( 95- 100)

HEAD CT-SCAN (March 12th, 2018)

Impression: Old infarct that is quite widely on the left temporo occipital lobe with retraction
on the left posterior horn of lateral ventricel and new infarct on the pons with senile cerebri
atrophy.

CHEST X-RAY (March 12th, 2018)

Impression: Cardiomegaly with aorta calcification and elongation

ECG finding : Sinus Rythm (Normal ECG)

Working Diagnosis : Somnolent + Right Hemiparalysis due to Recurrent Ischemic Stroke

TREATMENT
 Bed rest, head elevation 30°

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  Nasogastric Tube and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD R Sol 20 drips/minute
 Inj. Ceftriaxone 1 gr/12 hours (skin test)
 Aptor tab 1 x 300 mg
 PCT tab 3 x 500 mg
 B comp tab 3 x 1

Consult to Pulmonology Department, March 12th , 2018 :

Diagnosis : Pneumonia + Somnolent + Right Hemiparalysis due to Recurrent Ischemic Stroke
Therapy :
- O2 8-10 L/minute
- Inj. Ceftriaxone 1gr/12 hours
Sugesstions :
- Sputum analysis
- Sputum culture
- Blood culture

Follow-up March 13-14th, 2018

Chief complain : Declined level of consciousness

Vital sign
Alertness : Somnolent
Blood pressure : 160/90 mmHg
Heart Rate : 120 bpm
Resp. rate : 32 x/ min
Temperature : 38.8° C

LABORATORY FINDING (March 14th, 2018)

Fasting Glucose Level : 163 mg/dL (70-120)

2 Hours Post Prandial Glucose Level : 179 mg/dL ( < 200 )
Hb-A1C : 5.2 % (4.8-5.9)

Lipid Profile :
Total Cholesterol : 184 mg/dL ( < 200 )
Trigliserida : 126 mg/dL ( 40 – 200 )
HDL-Cholesterol : 46 mg/dL ( >65 )
LDL-Cholesterol : 95 mg/dL ( <150 )

Uric acid : 4.5 mg/dL (<5.7)

Follow up March 15th, 2018

Chief complain : declined level of consciousness

Vital sign
Alertness : Somnolent
Blood pressure : 150/100 mmHg
Heart Rate : 120 bpm
Resp. rate : 32 x/ min

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Temperature : 39° C

Working Diagnosis : Somnolent + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumonia
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD R Sol 20 drips/minute
 Inj. Ceftriaxone 1 gr/12 hours (skin test)
 Inj. Paracetamol Drip 1 flash/8 hours (if Temp > 39oC)
 Aptor tab 1 x 300 mg
 PCT 500 mg 3x1
 B comp 3x1

Follow up March 16th, 2018

Chief complain : declined level of consciousness

Vital sign
Alertness : Somnolent
Blood pressure : 120/70 mmHg
Heart Rate : 110 bpm
Resp. rate : 30 x/ min
Temperature : 37.8° C

Working Diagnosis : Somnolent + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumonia
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD R Sol 20 drips/minute
 Inj. Ceftriaxone 1 gr/12 hrs (skin test)
 Inj. Paracetamol Drip 1 flash/8 hrs (if Temp > 39oC)
 Aptor tab 1 x 300 mg
 PCT 500 mg 3x1
 B comp 3x1

Follow up March 17th, 2018

Chief complain : declined level of consciousness

Vital sign
Alertness : Somnolent
Blood pressure : 110/70 mmHg
Heart Rate : 130 bpm
Resp. rate : 34 x/ min
Temperature : 39.5° C

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 LABORATORY FINDING (March 17th, 2018)
Hemoglobin : 10.80 g/dL
WBC : 15.250 / mm3
Thrombocyte : 356.000 / mm3
Hematocrite : 31.30 %

Electrolytes:
 Natrium : 132 mEq/L (135-155)
 Kalium : 3.2 mEq/L (3.6-5.5)
 Chloride : 108 mEq/L (96-106)

Blood gas analysis:

 PH : 7.488 mmHg ( 7.35 - 7.45)
 pCO2 : 32.6 mmHg (38-42)
 pO2 : 155.1 mmHg (85-100)
 Bicarbonate : 24.1 mmol/L (22-26)
 Total CO2 : 25.1 mmol/L (19–25)
 Base Excess : 1.0 ( -2)- (+2)
 O2 saturation : 99.5 ( 95- 100)

Working Diagnosis : Somnolent + Right Hemiparalysis due to Recurrent Ischemic Stroke +

Pneumonia
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD R Sol 20 drips/minute
 Inj. Ceftriaxone 1 gr/12 hrs (skin test)
 Inj. Paracetamol Drip 1 flash/8 hrs (if Temp > 39oC)
 Aptor tab 1 x 300 mg
 PCT 500 mg 3x1
 B comp 3x1

Follow up March 18th, 2018

Chief complain : declined level of consciousness

Vital sign
Alertness : Somnolent
Blood pressure : 90/60 mmHg
Heart Rate : 140 bpm
Resp. rate : 32 x/ min
Temperature : 39.4° C

Working Diagnosis : Somnolent due to sepsis due to pneumonia + Right Hemiparalysis due to
Recurrent Ischemic Stroke
Therapy :

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  Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD NaCl 0.9% 20 drips/minute
 Inj. Ceftriaxone 2 gr/12 hours (skin test)
 Inj. Paracetamol Drip 1 flash/8 hours (if Temp > 39oC)
 Aptor tab 1 x 300 mg
 PCT 500 mg 3x1
 B comp 3x1

Follow up March 19th, 2018

Chief complain : declined level of consciousness

Vital sign
Alertness : Sopor
Blood pressure : 90/60 mmHg
Heart Rate : 138 bpm
Resp. rate : 33 x/ min
Temperature : 40.2° C

LABORATORY FINDING (March 19th, 2018)

Hemoglobin : 9.80 g/dL
WBC : 27.060 / mm3
Thrombocyte : 302.000 / mm3
Hematocrite : 29.40 %
Blood gas analysis:
 PH : 7.517 mmHg ( 7.35 - 7.45)
 pCO2 : 12.6 mmHg (38-42)
 pO2 : 155.8 mmHg (85-100)
 Bicarbonate : 10.0 mmol/L (22-26)
 Total CO2 : 10.4 mmol/L (19–25)
 Base Excess : -11.9 ( -2)- (+2)
 O2 saturation : 98.7 ( 95- 100)

Working Diagnosis : Sopor due to sepsis due to pneumonia + Right Hemiparalysis due to
Recurrent Ischemic Stroke
Therapy :
 Bed rest, head elevation 30°
 NGT and urinary catheter in use
 Oxygen by face mask 8-10 l/minute
 IVFD NaCl 0.9% 20 drips/minute
 Inj. Ceftriaxone 2 gr/12 hrs
 Inj. Ciprofloxacin 200 mg/12 hours
 Inj. Paracetamol Drip 1 flash/8 hours (if Temp > 39oC)
 Aptor tab 1 x 300 mg
 PCT 500 mg 3x1
 B comp 3x1

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Follow up before Death March 20th, 2018
TIME LEVEL OF BP/mmHg PULSE RR T oC EXPLANATION
CONSCIO bpm x/minu
USNESS te
13.15 am Sopor 90/50 142 46 41.0 Light reflex (+/+)↓,
pupil isocoria
R Ø=3 mm, L= 3 mm
13.30 am Coma 90/50 122 38 41.0 Light reflex (+/+)↓,
Pupil isocoria
R Ø= 3mm, L= 3 mm
13.45 am Coma 80/40 78 32 40.0 Light reflex (+/+)↓,
pupil isocoria
R Ø = 3 mm, L = 3 mm
14.00 am Coma 70/40 58 8 40.0 Light reflex (+/+)↓,
pupil anisocoria
R= Ø 4 mm, L= 4 mm
14.15 am Coma 50/palpate 12 4 39.8 Light reflex (-/-),
R= Ø 5 mm, L= 5 mm
14.35 am Passed away Absent absent - - Light reflex (-/-),
Corneal reflex (-/-)
Both pupils were
maximally dilated

Cause of Death : Sepsis

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