Friday, November 30, 2018

CAUSE OF DEATH REPORT - 4

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE
UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK
GENERAL HOSPITAL
MEDAN

Presenter : dr. Andre Lona

Moderator : dr. Muhammad Yusuf, Sp.S FINS
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PERSONAL IDENTIFICATION PERSONAL IDENTIFICATION

▪ Name : Mrs. DS ▪ Medical Record No. : 00.76.25.52

▪ Age : 68 years old ▪ Date of admission : November 13th , 2018

▪ Sex : female ▪ Time of admission : 21.45 pm

▪ Nationality : Indonesian ▪ Date of death : November 17th, 2018

▪ Address : LabuhanBatu ▪ Time of death : 11.30 am

▪ Doctor in Charge : dr. Andre
▪ Marital status : Married
▪ Supervisor : dr. Cut Aria Arina, Sp.S
HISTORY TAKING

Main Complaint : Decreased level of consciousness

History of Present Illness :
▪ She had been suffered the declining level of consciousness approximately 3
days prior to admission to Adam Malik General Hospital, which occurred
slowly. Previously before it, she had looked drowsiness. History of headache
was found since 2 weeks ago, characterized by pain all over the head and
didn’t reduce by using painkiller. History of seizures was not found. History of
projectile vomit was not found.
▪ History of hypertension, hypercholesterolemia, diabetes mellitus, and heart
disease were denied.
▪ History of head trauma was not found. History of prolonged coughwas found
since 4 weeks ago. History of weight loss was denied. History of night sweats
was found. History of fever was found for 2 weeks.
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GENERAL PHYSICAL EXAMINATION

▪ Alertness : Somnolen ▪ Respiratory rate : 28 x/ minute
▪ Blood pressure : 110/80 mmHg ▪ Temperature : 38,9o C
▪ Heart rate : 100 bpm Irreguler

NEUROLOGIC EXAMINATION
Level of consciousness
Signs of increased ICP
Signs of meningeal irritation
: Apatis
: Headache (+), Projectile Vomiting (-), Seizures (-)
: Nuchal Rigidity (+), Kernig Sign (-), Brudzinski I (-),
Brudzinski II(-)
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CRANIAL NERVES
1st nerve : Difficult to examine
2nd and 3rd nerves : Pupillary light reflexes (+/+)
Pupil isocoria, OD Ø 3 mm, OS Ø 3 mm
Ophthalmoscope examination : Papil oedem bilateral
3rd,4th and 6th nerves : Doll’s Eye Phenomenon (+/+)
7th nerve : Mouth was rest laid symmetrically
8th nerve : Difficult to examine
9th and 10th nerves : Gag reflex (+)
11th nerve : Difficult to examine
12th nerve : Tongue at rest laid medial
REFLEXES
Physiologic reflexes Right extremity Left extremity

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

Pathologique reflexes

Hoffman/ Tromner : -/- -/-

Babinski : - -
MOTOR EXAMINATION
Strength of muscle : Difficult to examine
Lateralization (-)

DIAGNOSIS
Functional Diagnosis : Apatis
Anatomical Diagnosis : Meningens
Etiological Diagnosis : Infection
Working Diagnosis : Apatis ec due to dd 1. Meningitis TB 2.
Meningitis Bakterial
 FURTHER EXAMINATION
TREATMENT 1.Complete Blood Count (CBC)
 Bed rest, head elevation 30° 2.Random Blood Sugar Level
 NGT and urinary catheter in use
3.Renal Function Test
 Oxygen by nasal canule 2-4 l/minute
 IVFD Ringer Solution 20 drips/minute 4.Electrolyte
 IVFD Paracetamol 1000 mg/ 8 hours 5.Imuneserology
6.Blood Gas Analysis
7.Chest X-ray
8.Head CT – Scan
9.ECG
 LABORATORY FINDING (November 13th, 2018)

Blood gas analysis:

Hemoglobin : 13,00 g/dL
 PH : 7.442 mmHg ( 7.35 - 7.45)
WBC : 18.190 / mm3
 pCO2 : 32,1 mmHg (38-42)
Thrombocyte : 238.000 / mm3
 pO2 : 191.5 mmHg (85-100)
Hematocrite : 39.00 %
 Bicarbonate : 27.0 mmol/L (22-26)
 Total CO2 : 27.9 mmol/L (19–25)
Diff. Telling
 Base Excess : 2.0 ( -2)- (+2)
Neutrofil : 88,30 (37-80)
 O2 saturation : 99.5 ( 95- 100)
Lymphocyte : 7,70 (20-40)
Monocyte : 5,90 (2-8)
Eosinofil : 0,00 (1-6) Blood Sugar Level ( random) : 129 mg/dL
Basofil : 0.100 (0-1)
Renal Function Test:
 Ureum : 40 (<50)
 Creatinine : 0,52 (0.70-1.20)
Electrolytes:
 Natrium : 140 mEq/L (135-155)
 Kalium : 3,4 mEq/L (3.6-5.5)
 Chloride : 102 mEq/L (96-106)
HEAD CT-SCAN (November 13 th, 2018)
Impression: Early hidrocefalus
CHEST X-RAY (November 13 th, 2018)
Impression: left pleural effusion
ECG finding :
Normal Sinus Rhytm

Working diagnosis Apatis due to DD: 1.Meningitis Tuberculosis

2.Meningitis Bakterialis
TREATMENT
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv  skin test
• Dexamethason inj 10 mg/bolus/iv  then 5 mg/6 hrs/iv (tapp. off every 3 days)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips
• KSR 1 x 600 mg
• B complex 3 x 1
 Follow-up November 14th, 2018
FURTHER EXAMINATION Chief complain : Declined level of consciousness
1. Consult to Pulmonalogy
Department Vital sign
2. Lumbal puncture Alertness : Apatis
Blood pressure : 110/80 mmHg
Heart Rate : 88 bpm
Resp. rate : 30 x/ min
Temperature : 38,2 ° C

Working Diagnosis : Apatis + due to DD. 1.

Meningitis TB 2. Meningitis
Bakterial
TREATMENT
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4 l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv  skin test
• Dexamethason inj 5 mg/6 hrs/iv (Day 1)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips
• KSR 1 x 600 mg
• B complex 3 x 1
Consult to Pulmonology Department LABORATORY FINDING (November 14th,2018)
November 14th,2018 :
Fasting Glucose Level : 121 mg/dL(70-120)
2 Hours Post Prandial Glucose Level : 160 mg/dL( < 200 )
Diagnosis : Hb-A1C : 5.2 % (4.8-5.9)

Suspect Mild Left Efusi Pleural due to Lipid Profile :

Pneumonia DD. 1.TBC Pulmonal
Therapy : - Total Cholesterol : 140 (˂ 200 )
Trigliserida : 77 (˂ 150 )
Sugestion: HDL Cholesterol : 24 (≥ 60 )
LDL Cholesterol : 109 (˂ 100 )
- Blood cultur
- Urine cultur
- BTA direct smear 3 x
- Sputum cultur
Working diagnosis:
Apatis due to DD: 1.Meningitis Tuberculosis 2.Meningitis Bakterialis + Suspect Mild Left Efusi Pleural due to
Pneumonia DD 1.TBC pulmonal
• Treatment :
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4 l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv
• Dexamethason inj 5 mg/6 hrs/iv (Day 1)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips
• KSR 1 x 600 mg
• B complex 3 x 1
Follow up November 15th, 2018
Chief complain : declined level of consciousness

Vital sign
Alertness : Somnolence
Blood pressure : 120/80 mmHg
Heart Rate : 112 bpm
Resp. rate : 30 x/ min
Temperature : 38,9 ° C

Working Diagnosis : Somnolence due to DD: 1.Meningitis Tuberculosis 2.Meningitis

Bakterialis + Suspect Mild Left Efusi Pleural due to Pneumonia DD
1.TBC pulmonal
Therapy :
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use Lumbal puncture :
• Oxygen by nasal canule 2-4 l/minute Nonne (-), Pandy (-)
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv
• Dexamethason inj 5 mg/6 hrs/iv(Day-2) Working diagnosis : Somnolence due to
• Ranitidine inj 50mg/12 hrs/iv Meningitis TB + Suspect Mild Left Efusi
• Paracetamol infusion 1 gr/8 hrs/drips Pleural due to Pneumonia DD 1.TBC
• KSR 1 x 600 mg pulmonal
• B complex 3 x 1
Follow up November 16th, 2018

Chief complain : declined level of consciousness, Fever (+)

Vital sign
Alertness : Somnolence
Blood pressure : 110/70 mmHg
Heart Rate : 101 bpm
Resp. rate : 28 x/ min
Temperature : 38,9° C

Working Diagnosis : Somnolence due to Meningitis Tuberculosis + Suspect

Mild Left Efusi Pleural due to Pneumonia DD 1.TBC
pulmonal
Therapy :
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4 l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv
• Dexamethason inj 5 mg/6 hrs/iv(Day-3)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips
• Rifampicin 600 mg
• Isoniazid 300 mg
• Pirazinamid 1000 mg
• Etambutol 1000 mg
• KSR 1 x 600 mg
• B complex 3 x 1
Follow up November 17th, 2018

Chief complain : declined level of consciousness, Fever (+)

Vital sign
Alertness : Sopor
Blood pressure : 90/70 mmHg
Heart Rate : 132 bpm
Resp. rate : 34 x/ min
Temperature : 39,3° C

Working Diagnosis : Sopor due to Meningitis Tuberculosis + Suspect

Mild Left Efusi Pleural due to Pneumonia DD 1.TBC
pulmonal
Therapy :
• Bed rest + Head elevation 300
• Nasogastric tube and urinary catheter in use
• Oxygen by nasal canule 2-4 l/minute
• IVFD R-Sol 20 drips/minute
• Ceftriaxone inj 2gr/12 hrs/iv
• Dexamethason inj 5 mg/8 hrs/iv(Day-1)
• Ranitidine inj 50mg/12 hrs/iv
• Paracetamol infusion 1 gr/8 hrs/drips
• Inj. Levosol 1 amp + NaCl 0,9% 40 cc 3 cc/hour (via syringe pump) up titration until
SBP ≥ 100 mmHg or MAP ≥ 65
• Rifampicin 600 mg
• Isoniazid 300 mg
• Pirazinamid 1000 mg
• Etambutol 1000 mg
• KSR 1 x 600 mg
• B complex 3 x 1
Sugestion: CSF analysis :
Random Blood Sugar Level Color clear (Clear)
Electrolyte LDH 68 U/L (< 200)
Blood Gas Analysis Protein total 102,00 mg/dL (< 45)
Leucocyte count 0,180 (<0,03)
Eritrocyte count 0,000
Glucose 28 mg/dL (40 – 75)
pH 9,0 (7 – 8)
MN cell 80,9
PMN cell 19,1
 LEVEL
TIME BP/mmHg PULSE x/minute RR x/minute T oC EXPLANATION
OF CONSCIOUSNESS

Light reflex (-↓/-↓),

10.00 am Coma 80/40 134 10 39,0
pupil isocory Ø R=4 mm,L=4mm

Light reflex (-↓/-↓),

10.30 am Coma 70/- 100 8 38,9
Pupil isocory R Ø= 4mm,L=4mm

Light reflex (-↓/-↓),

10.45 am Coma 60/- 82 8 38,9
pupil isocory R Ø =4 mm,L =4mm

Light reflex (-/-),

11.00 am Coma 60/- 64 6 38,8
pupil isocory R Ø =4 mm,L =4mm

Maximal dilatation
11.15 am Coma 40/- 40 - 37,8 of pupil
corneal reflexes(-)

11.30 am EXITUS

COD : Shock septic

Thank You…