CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF NORTH SUMATERA – ADAM MALIK HOSPITAL MEDAN

PERSONAL IDENTIFICATION

Name : Mariani Lubis MR : 48.42.86

Age : 53 years old Date of admission : August 22nd 2011
Sex : Female Time of admission : 11.53 am
Nationality : Indonesian Date of death : August 26th 2011
Adress : Situngir Labuhan Batu Time of death : 03.00 pm
Marital Status : Married Doctor in Charge : dr. Anyta Prisca Dormida
Supervisor : dr. Yuneldi Anwar, SpS (K)

HISTORY TAKING

Main Complain : Decreased level of consciousness

History of Present Illness : She had been suffering from declining of consciousness approximately ……… days prior
to admission to Adam Malik General Hospital

History of Previous Disease : (-)

History of Previous Medication : (-)

GENERAL PHYSICAL EXAMINATION

Level of Consciousness : Somnolen

Blood Pressure : 150/70 mmHg
Heart Rate : 88 bpm
Respiratory Rate : 24 x/minute
Temperature : 36.8 oC

NEUROLOGIC EXAMINATION

Level of Consciousness : Somnolen

Sign of ICP Increased : Headache (-), Projectile vomite (-), Seizure (+)
Sign of Meningeal Irritation : Nuchal rigidity (-), Kernig sign (-), Brudzinski (-), Brudzinski II (-)

Cranial Nerves
1st Nerve : Difficult to examine
2nd and 3rd Nerves : Pupillary light reflexes (+)/(+), isocoria ∅ 3 mm

Ophtalmoscopic Examination

1
 Optic Disc : Right Eye Left Eye
Color : Yellowish Yellowish
Boundary : Clear Clear
Excavatio : Concave Concave
A/V : 2/3 2/3
Impression : Normal

3rd, 4th and 6th Nerves : Doll’s eye phenomen (+)

5th Nerve : Corneal reflex (+)
7th Nerve : Mouth was laid symmetrically
8th Nerve : Difficult to examine
9th and 10th Nerves : Gag reflex (+)
12th Nerve : Tounge at rest was laid symmetrically

Reflexes
Right Extremity Left Extremity
Physiologic Reflexes
Biceps/Triceps : (+)/(+) (+)/(+)
KPR/APR : (+)/(+) (+)/(+)
Pathologic Reflexes
Hoffman/Tromner : (-)/(-) (-)/(-)
Babinsky : - -

Motor Examination
Strength of muscle difficult to examine and left lateralization was found

DIAGNOSIS

Functional Diagnosis : Somnolen + Tonic Clonic Seizure

Anatomical Diagnosis :
Etiological Diagnosis :
Differential Diagnosis :
Working of Diagnosis : Somnolen + Tonic Clonic Seizure ec Subdural Hematoma
Differential Diagnosis :

TREATMENT

1. Bed rest
2. O2 3-4 L/minute
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Diazepam injection 1 amp (k/p)
6. Fenitoin 100 mg 3 x 1

FURTHER EXAMINATION

2
 1. Complete Blood Count
2. Ad Random Blood Sugar Level
3. Renal Function Test
4. Liver Function Test
5. Electrolyte
6. Chest X-Ray
7. ECG
8. Head CT Scan

HEAD CT SCAN (August 3th 2011) in Rantauprapat Hospital

Hemmorhagic contusion bilateral frontal lobe + left higroma peri interhemisfer + subarachnoid bleeding + brain swelling
diffuse

FOLLOW UP August 23th - 24th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Somnolen
Blood Pressure : 140-150 / 80 mmHg
Heart Rate : 98 – 100 bpm
Respiratory Rate : 20 x/minute
Temperature :37.3 – 38.7 0C

LABORATORY FINDING (August 22th 2011)

Cell Blood Count
Hemoglobin 13.8 g% (11.7-15.5)
Eritrocyte 4.71 x 106 /mm3 (4.20-4.87)
Leucocyte 12.14 x 103 /mm3 (4.5-11.0)
Trombocyte 287 x 103 /mm3 (150-450)
Hematocryte 39.3 % (38-44)
Liver Function Test
SGOT 17 U/L (<32)
SGPT 6 U/L (<31)
Blood Sugar Level 337.1 mg/dL (<200)
Renal Function Test
Ureum 44.4 mg/dL (<50)
Creatinine 0.65 mg/dL (0.50-0.90)
Serum Electrolytes
Sodium 128 mEq/L (135-155)
Potassium 4.5 mEq/L (3.6-5.5)
Chlorida 93 mEq/L (96-106)

ECG FINDING (August 23th 2011) : Sinus rhytme

3
Working Diagnosis : Somnolen + Tonic Clonic Seizure ec Subdural Hematoma

Treatment :
1. Bed rest
2. O2 3-4 L/minute
3. Nasogastric tube and urinary catheter in use
4. IVFD NaCl 0.9% 20 drips/minute
5. IVFD Mannitol 20% 125 cc / 6 hours
6. Ceftriaxone injection 1 gram / 12 hours (skin test)
7. Ranitidin injection 1 amp / 12 hours
8. Diazepam injection 1 amp (k/p)
9. Xyllo : Della injection 2 : 1 im (Temperature > 39 0C)
10. Fenitoin 100 mg 3 x 1
11. Karbamazepin 200 mg 2 x ½
12. Paracetamole 500 mg 3 x 1

FOLLOW UP August 25th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 150 / 90 mmHg
Heart Rate : 120 bpm
Respiratory Rate : 28 x/minute
Temperature : 38.9 0C

LABORATORY FINDING (August 25th 2011)

Serum Electrolytes
Sodium 140 mEq/L (135-155)
Potassium 4.3 mEq/L (3.6-5.5)
Chlorida 105 mEq/L (96-106)

Working Diagnosis : Sopor + Tonic Clonic Seizure ec Subdural Hematoma

Treatment :
1. Bed rest
2. O2 3-4 L/minute
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. IVFD Mannitol 20% 125 cc / 6 hours
6. Ceftriaxone injection 1 gram / 12 hours (skin test)
7. Ranitidin injection 1 amp / 12 hours
8. Diazepam injection 1 amp (k/p)
9. Xyllo : Della injection 2 : 1 im (Temperature > 39 0C)
10. Fenitoin 100 mg 3 x 1

4
 11. Karbamazepin 200 mg 2 x ½
12. Paracetamole 500 mg 3 x 1

FOLLOW UP August 26th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 90 / 60 mmHg
Heart Rate : 100 bpm
Respiratory Rate : 28 x/minute
Temperature : 39.8 0C

LABORATORY FINDING (August 26th 2011)

Blood Gas Analysis
pH 7.298 (7.35-7.45)
pCO2 30.8 mmHg (38-42)
pO2 85.1 mmHg (85-100)
HCO3 14.7 mmol/L (22-26)
Total CO2 15.7 mmol/L (19-25)
BE -10.5 mmol/L (-2) - (+2)
Saturasi O2 94.3 % 95-100

Working Diagnosis : Sopor + Tonic Clonic Seizure ec Subdural Hematoma

Treatment :
1. Bed rest
2. O2 3-4 L/minute
3. Nasogastric tube and urinary catheter in use
4. IVFD NaCl 0.9% 30 drips/minute
5. IVFD Mannitol 20% 125 cc / 6 hours
6. Ceftriaxone injection 1 gram / 12 hours (skin test)
7. Ranitidin injection 1 amp / 12 hours
8. Diazepam injection 1 amp (k/p)
9. Xyllo : Della injection 2 : 1 im (Temperature > 39 0C)
10. Fenitoin 100 mg 3 x 1
11. Karbamazepin 200 mg 2 x 1
12. Paracetamole 500 mg 3 x 1

FOLLOW UP BEFORE DEATH August 26th 2011

Time Level of Blood Pulse Resp. Rate Type of Temp. Explanation

Consciousness Pressure (bpm) (x/minute) Respiration (0C)
(mmHg)
01.30 pm Coma 90/60 130 38 Cheyne Stokes 41.8 Light reflex (+)/(+)

5
 pupil anisokor
ф D 3mm S 5mm
01.45 pm Coma 90/60 120 48 Central 41.8 Light reflex (+)/(+)
Neurogenic pupil anisokor
Hyperventilation ф D 3mm S 5mm
02.00 pm Coma 80/60 100 32 Central 41.8 Light reflex (+)/(+)
Neurogenic pupil anisokor
Hyperventilation ф D 3mm S 5mm
02.15 pm Coma 70/40 80 20 Apneustic 41.8 Light reflex (+)/(+)
pupil anisokor
ф D 3mm S 5mm
02.30 pm Coma 60/ 40 72 12 Ataxic 41.8 Light reflex (+)/(+)
pupil anisokor
ф D 4mm S 6mm
02.45 pm Coma 40/ - 40 6 Ataxic 41.8 Light reflex (+)/(+)
pupil anisokor
ф D 4mm S 6mm
03.00 pm Both pupil were
EXITUS maximally dilated
Light reflex (-)/(-)
Corneal reflex (-)

Cause of Death : Brain herniation