CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF NORTH SUMATERA – ADAM MALIK GENERAL HOSPITAL MEDAN

PERSONAL IDENTIFICATION

Name : Febri Anza MR : 00.01.87

Age : 21 years old Date of admission : August 16nd 2011
Sex : Male Time of admission : 04.24 pm
Nationality : Indonesian Date of death : August 28th 2011
Adress : Sei Deli Silalas Time of death : 02.55 am
Marital Status : Unmarried 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
: He had been suffering from declining of consciousness approximately 2 days prior to
admission to Neurology Departement, which occurred gradually (patient came from
THT Departement). History of fever was found a week before admission. History of
headache was found, which has no response to analgetic drugs. History of projectile
vomiting was not found, the history of seizures were not found. History of right ear
infection was found 3 years ago and post mastoidectomy 2 ½ years ago. History of
cough, history of loss weight and history of sweat at night was unclear. History of head
trauma was not found.

History of Previous Disease : Otitis Media

History of Previous Medication : (-)

GENERAL PHYSICAL EXAMINATION

Level of Consciousness : Apatis

Blood Pressure : 100/60 mmHg
Heart Rate : 70 bpm
Respiratory Rate : 20 x/minute
Temperature : 36.7 oC

NEUROLOGIC EXAMINATION

Level of Consciousness : Apatis

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

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

Ophtalmoscopic Examination
Optic Disc Right Eye Left Eye
Color : Reddish Reddish
Boundary : Unclear Unclear
Excavatio : Convex Convex
A/V : 2/3 2/3
Impression : Oedema papil

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 no lateralization was found

DIAGNOSIS

Functional Diagnosis : Apatis + Secondary Headache

Anatomical Diagnosis : Meningens
Etiological Diagnosis : Infection
Differential Diagnosis : 1. Meningitis
2. Encephalitis
Working of Diagnosis : Apatis + Secondary Headache ec Meningitis

LABORATORY FINDING (August 6th 2011)

Cell Blood Count
Hemoglobin 14.40 g% (11.7-15.5)
Eritrocyte 5.14 x 106 /mm3 (4.20-4.87)
Leucocyte 12.94 x 103 /mm3 (4.5-11.0)

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 Trombocyte 350 x 103 /mm3 (150-450)
Hematocryte 42 % (38-44)
Liver Function Test
SGOT 19 U/L (<32)
SGPT 27 U/L (<31)
Blood Sugar Level 107 mg/dL (<200)
Renal Function Test
Ureum 34.2 mg/dL (<50)
Creatinine 0.86 mg/dL (0.50-0.90)
Serum Electrolytes
Sodium 136 mEq/L (135-155)
Potassium 3.4 mEq/L (3.6-5.5)
Chlorida 101 mEq/L (96-106)

LABORATORY FINDING (August 8th 2011)

Serum Electrolytes
Sodium 138 mEq/L (135-155)
Potassium 4.5 mEq/L (3.6-5.5)
Chlorida 106 mEq/L (96-106)

TREATMENT

1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 2 gr/12 hours (skin test)
6. Dexamethasone injection 2 amp bolus  1 amp/6 hours, tapering off/3 days
7. Ranitidin injection 1 amp/12 hours
8. Na diclofenac 50 mg 3 x 1
9. Paracetamol 500 mg 3 x 1

FURTHER EXAMINATION

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
9. Lumbal Puncture

HEAD CT SCAN with CONTRAST (August 11th 2011)

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Infratentorial cerebellum and ventricle IV normal.
No mass effect and midline shift.
Ventricular system normal.
There are dural enhancement in right/left hemisphere and right/left sulcus lateralis.
Impression : Meningitis

FOLLOW UP August 17th - 22th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Apatis
Blood Pressure : 100 – 120 / 60 – 80 mmHg
Heart Rate : 70 – 88 bpm
Respiratory Rate : 18 – 20 x/minute
Temperature : 36.5 – 36.8 0C

LABORATORY FINDING (August 22th 2011)

Cell Blood Count
Hemoglobin 14.50 g% (11.7-15.5)
Eritrocyte 5.13 x 106 /mm3 (4.20-4.87)
Leucocyte 27.50 x 103 /mm3 (4.5-11.0)
Trombocyte 241 x 103 /mm3 (150-450)
Hematocryte 42 % (38-44)

CHEST X-RAY (August 22th 2011)

Impression : active chronic specific process DD : bronchopneumonia

IMUNODEFICIENCY PROFILE (August 22th 2011)

Anti HIV (3 Methode) non reactive

Working Diagnosis : Apatis + Secondary Headache ec Meningitis

TREATMENT

1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 2 gr/12 hours (skin test)
6. Dexamethasone injection 2 amp bolus  1 amp/6 hours, tapering off/3 days
7. Ranitidin injection 1 amp/12 hours
8. Na diclofenac 50 mg 3 x 1
9. Paracetamol 500 mg 3 x 1
10. Rifampicin
11. Isoniazide

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 12. Pyrazinamide

FOLLOW UP August 23th - 24th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Somnolence
Blood Pressure : 120 / 60 – 70 mmHg
Heart Rate : 82 – 90 bpm
Respiratory Rate : 20 – 28 x/minute
Temperature : 38.5 – 39.5 0C

Working Diagnosis : Somnolence + Secondary Headache ec Meningitis

TREATMENT

1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 2 gr/12 hours (skin test)
6. Dexamethasone injection 2 amp bolus  1 amp/6 hours, tapering off/3 days
7. Ranitidin injection 1 amp/12 hours
8. Na diclofenac 50 mg 3 x 1
9. Paracetamol 500 mg 3 x 1
10. Rifampicin
11. Isoniazide
12. Pyrazinamide

FOLLOW UP August 25th - 27th 2011

Chief Complain : Decreased level of consciousness

Vital Sign :
Level of Consciousness : Sopor
Blood Pressure : 110 – 120 / 60 mmHg
Heart Rate : 110 – 132 bpm
Respiratory Rate : 24 – 30 x/minute
Temperature : 37.8 – 39.6 0C

LABORATORY FINDING (August 26th 2011)

Blood Gas Analysis
pH 7.521 (7.35-7.45)
pCO2 30.2 mmHg (38-42)
pO2 185.4 mmHg (85-100)
HCO3 24.2 mmol/L (22-26)

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 Total CO2 25.1 mmol/L (19-25)
BE 1.3 mmol/L (-2) - (+2)
Saturasi O2 99.4 % 95-100

Working Diagnosis : Sopor + Secondary Headache ec Meningitis

TREATMENT

1. Bed rest
2. O2 3-4 L/minute by nasal canule
3. Nasogastric tube and urinary catheter in use
4. IVFD Ringer Solution 20 drips/minute
5. Ceftriaxone injection 2 gr/12 hours (skin test)
6. Dexamethasone injection 2 amp bolus  1 amp/6 hours, tapering off/3 days
7. Ranitidin injection 1 amp/12 hours
8. Na diclofenac 50 mg 3 x 1
9. Paracetamol 500 mg 3 x 1
10. Rifampicin
11. Isoniazide
12. Pyrazinamide

FOLLOW UP BEFORE DEATH August 28th 2011

Time Level of Blood Pulse Resp. Rate Temp. Explanation

Consciousness Pressure (bpm) (x/minute) (0C)
(mmHg)
01.30 pm Coma 90/60 130 38 41.8 Light reflex (+)/(+) pupil
anisokor ф D 3mm S 5mm
01.45 pm Coma 90/60 120 48 41.8 Light reflex (+)/(+) pupil
anisokor ф D 3mm S 5mm
02.00 pm Coma 80/60 100 32 41.8 Light reflex (+)/(+) pupil
anisokor ф D 3mm S 5mm
02.15 pm Coma 70/40 80 20 41.8 Light reflex (+)/(+) pupil
anisokor ф D 3mm S 5mm
02.30 pm Coma 60/ 40 72 12 41.8 Light reflex (+)/(+) pupil
anisokor ф D 4mm S 6mm
02.45 pm Coma 40/ - 40 6 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 : Sepsis + Meningitis