CAUSE OF DEATH REPORT

DEPARTMENT OF NEUROLOGY MEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARA H. ADAM MALIK GENERAL HOSPITAL
MEDAN
PERSONAL IDENTIFICATION
Name
: Imelda Sari Gulo
Age
: 23 years old
Sex
: Female
Nationality : Indonesian
Adress
: Kec. Banjarmasin Barat, Langkat
Marital status : Married

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

: 00.60.67.28
: July 9th 2014
: 10.00 pm
: Mei 31st 2013
: 11.20 am
: dr. M. Gandhi S
: dr. Kiki M. Iqbal, Sp.S

HISTORY TAKING
Main Complain
: Headache
History of Present Illness :
She had been suffered headache approximately since 4 months prior to admission to Adam Malik
General Hospital and worsening in the last 2 weeks. It was not reduce with analgetic drug. History of
projectile vomit and seizure was not found. History of decrease of consciousness was not found.
History of fever was found in the last 4 months. History of chronic cough was not found. History of
bloody cough was not found, history of losing body weight was not found. The patient has already
scanned with brain MRI and the result was meningitis + hidrocephalus.
History of Previous Disease
History of Previous Medication

: not clear
: not clear

GENERAL PHYSICAL EXAMINATION

Alertness
: Compos mentis
Blood pressure
: 140/70 mmHg
Heart rate
: 86 bpm

Respiratory rate
Temperature

: 22 x/minute
: 38,3 oC

NEUROLOGIC EXAMINATION
Level of consciousness
: Somnolen
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
3rd,4th and 6th nerves
5th nerve
7th nerve
8th nerve
9th and 10th nerves
11th nerve

: normosmia
: Pupillary light reflexes (+/+), pupil isochors : 3 mm
: Eye movement (+)
: Open and close mouth (+)
: Mouth corner symetrical
: Hearing normal
: Uvula in medial position
: Shoulder elevation (+)
1

12th nerve

: Tongue at rest laid symetrically

REFLEXES
Physiological reflexes
Biceps/Triceps
KPR/APR

Pathologique reflexes
Hoffman/ Tromner
Babinski

:
:

MOTOR EXAMINATION
ESD : 55555/55555
ESS

: 55555/55555

EIS

: 55555/55555

: 55555/55555

DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Working Diagnosis

EIS

Right extremity
:
++/ ++
+ +/++

Left extremity
++ / + +
++ / + +

-/-

-/-

: Secondary headache
: Meningens
: Infection
: Secondary headache due to :
1. meningitis viral
2. meningitis bacterial

TREATMENT
Bed rest, head elevation 300
IFVFD Ringer Solution 20 drips/minute
Inj. Dexamethason 2 amp bolus i.v 1 amp / 6 hours (tapp off/ 3 days)
Inj. Ranitidin 1 amp / 12 hours
Inj. Ceftriaxone 2 gr / 12 hours skin test
Paracetamol 3 x 500 mg
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 Tet
6. Lipid Profile
7. Electrolyte
8. Blood Gas Analysis
9. ECG
10. Chest X-Ray
Follow-up July 10th, 2014
Chief complain
Vital sign
Sensorium
Blood pressure

: Headache, decrease level of consciousness, fever

: Apatis
: 130/80 mmHg
2

Heart rate
Resp. rate
Temperature
Working Diagnosis

: 86 bpm
: 24 x/ min
: 38,5 0C
: Secondary headache due to DD :
1. meningitis viral
2. meningitis bacterial

Treatment
Bed rest, head elevation 300
IFVFD Ringer Solution 20 drips/minute
Inj. Dexamethason 1 amp / 6 hours Day 1 (tapp off/ 3 days)
Inj. Ranitidin 1 amp / 12 hours
Inj. Ceftriaxone 2 gr / 12 hours Day 1
Paracetamol 3 x 500 mg
LABORATORY FINDING (July 9th, 2014)
Haemoglobin
WBC
Thrombocyte
Haematocrite

: 10,10 g/dL
: 6.780/mm3
: 320.000/mm3
: 31,70 %

Blood Glucose Level (ad random)

: 112 mg/dL

Electrolytes
Natrium
Kalium
Chloride

: 129 mEq/L
: 4,1 mEq/L
: 99 mEq/L

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

Renal Function Test

Ureum
Creatinine

: 15,7
: 0.34

(< 50)
(0.50 0,90)

mmHg
mmHg
mmHg
mmol/L
mmol/L

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

Blood Gas Analysis:

PH
pCO2
paO2
Bicarbonate
Total CO2
Base Excess
O2 Saturation

: 7,525
: 21
: 130,1
: 17
: 17,6
: - 3,3
: 97 %

ECG FINDING (July 9th, 2014)

Impression : normal sinus rythm
CHEST X-RAY (July 9th, 2014)
Impression : Impression : normal lung and cardiac.
3

Follow-up July 11th, 2014

Chief complain
Vital sign
Sensorium
Blood pressure
Heart rate
Resp. rate
Temperature
Working Diagnosis

: Headache, decrease level of consciousness, fever

: Apatis
: 140/80 mmHg
: 86 bpm
: 28 x/ min
: 38,4 0C
: Secondary headache due to DD :
1. meningitis viral
2. meningitis bacterial

Treatment
Bed rest, head elevation 300
IFVFD Ringer Solution 20 drips/minute
Inj. Dexamethason 1 amp / 6 hours Day 2 (tapp off/ 3 days)
Inj. Ranitidin 1 amp / 12 hours
Inj. Ceftriaxone 2 gr / 12 hours Day 2
Paracetamol 3 x 500 mg
LABORATORY FINDING (July 12nd, 2014)
Blood Sugar Level Nuchter : 104 mg/dL
Blood Sugar Level 2 h pp
: 120 mg/dL
Hb-A1c
: 5,2 %
Lipid Profile :
Total Cholesterol
Trigliserida
HDL-Cholesterol
LDL-Cholesterol
Uric Acid

: 185 mg/dL
: 119 mg/dL
: 29 mg/dL
: 112 mg/dL
: 3,2 mg/dL

( < 200 )
( 40 200 )
( >65 )
( <150 )

Liver Function Test

SGOT
: 38 U/L
SGPT
: 31 U/L

< 32
< 31

Renal Function Test

Ureum
Creatinine
Uric Acid

: 21.30
: 0.87
: 3,2 mg/dL

(< 50)
(0.50 0,90)

Follow-up July 11th, 2014 at 10.30 pm

Chief complain
: Decrease level of consciousness, fever, dyspneu
Vital sign
Sensorium
: Somnolen
Blood pressure
: 140/80 mmHg
4

Heart rate
Resp. rate
Temperature
Working Diagnosis

: 86 bpm
: 32 x/ min
: 38,4 0C
: Secondary headache due to DD :
1. meningitis viral
2. meningitis bacterial

Treatment
Bed rest, head elevation 300
IFVFD Ringer Solution 20 drips/minute
Inj. Dexamethason 1 amp / 6 hours Day 2 (tapp off/ 3 days)
Inj. Ranitidin 1 amp / 12 hours
Inj. Ceftriaxone 2 gr / 12 hours Day 2
Paracetamol 3 x 500 mg
Check Blood Gas Analysis cito
Consult to pulmonolgy departement
Result A : Aspiration pneumonia
P : - Inj. Metronidazole 500 mg/8 hours
- Inj. Gentamycin 80 mg / 8 hours
- Inj. Ceftriaxione 1 gr / 12 hours
- Suggest : Check Complete Blood Count, Elektrolite, Blood Gass Analysis
LABORATORY FINDING (July 12nd, 2014)
Haemoglobin
WBC
Thrombocyte
Haematocrite

: 10,90 g/dL
: 7.850/mm3
: 382.000/mm3
: 33,30 %

Electrolytes
Natrium
Kalium
Chloride

: 119 mEq/L
: 4,9 mEq/L
: 94 mEq/L

Blood Gas Analysis:

PH
pCO2
paO2
Bicarbonate
Total CO2
Base Excess
O2 Saturation

: 7,2154 mmHg
: 31,3 mmHg
: 124,6 mmHg
: 12,4 mmol/L
: 13,3 mmol/L
: - 14,2
: 100 %

(135-155)
(3.6-5.5)
(96-106)
( 7.35 - 7.45)
(38-42)
(85-100)
(22-26)
(1925)
( -2)- (+2)
( 95- 100)

Follow Up Before Death July, 12nd 2014

TIME

LEVEL
OF
CONSCIOUS

BP/mm
Hg

PULSE
bpm

RR
x/minute

T oC

EXPLANATION

NESS

12.50 am

Coma

80/40

56

16

38,5

12.55 am

Coma

80/40

48

16

38,5

01.00 am

Coma

70/40

40

12

38,5

01.05 am

Coma

50/-

40

38,5

01.10 am

Passed away

Absent

absent

Light reflex (+/+),

Pupil isocory =4mm
Light reflex (+/+),
Pupil isocory =4mm
Light reflex (+/+),
pupil isocory =4mm
Light reflex (+/+),
pupil isocory =5mm
Light reflex (-/-),
Corneal reflex (-/-)
Both pupils were maximally dilated

Cause of Death : Sepsis ec Pneumonia