Cod Kartini

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CAUSE OF DEATH REPORT

DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE

UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK GENERAL HOSPITAL

MEDAN

PERSONAL IDENTIFICATION

Name : Kartini Medical Record No. : 64.14.29

Age : 66 years old Date of admission : June 14t ! 2"1#$e% : &emale 'ime of admission : 11.4# (m

Nationality : )ndonesian Date of deat : June 2"t! 2"1#

Address :Desa $u*adame Kec. 'ana 'ime of deat : 1".+# (m

,inem Doctor in -arge : dr. -aisar RianaMarital status: Married $u(erisor : dr. -airil Amin /! $(.$

HISTORY TAKING

Main -om(laint : Decreased leel of consciousness

0istory of ,resent )llness :

$e ad een suffered te declining leel of consciousness a((ro%imately 1 day (rior toadmission to Adam Mali* eneral 0os(ital! 3ic occurred suddenly 3en se 3as

resting. 0istory of eadace 3as not found. 0istory of seiure 3as not found. 0istory of

(ro5ectile omit 3as not found.

0istory of ead trauma 3as not found. 0istory of feer 3as not found0istory of y(ertension 3as found since tese last 1 year! ut uncontrolled. 0istory of

y(ercolesterolemia 3as found since tese last # year and te use of medications 3ereunclear. 0istory of diaetes mellitus 3ere denied. 0istory of eart disease 3ere denied.

GENERAL PHYSICAL EXAMINATION

Alertness : A(atis/lood (ressure : 22"11" mm0g Res(iratory rate : +" % minute

0eart rate : 1"" (m 'em(erature : +6!7o -

NEUROLOGIC EXAMINATION

8eel of consciousness : A(atis

$igns of increased )-, : 0eadace ;! ,ro5ectile <omiting ;! $eiures ;

$igns of meningeal irritation : Nucal Rigidity ;! Kernig $ign ;! /rudins*i ) ;!/rudins*i ));

CRANIAL NERVES

1st nere : Difficulty to e%amine

2nd and +rd neres : ,u(illary ligt refle%es ==;

,u(il isocoria! >D ? + mm! >$ ? + mm

• >(talmosco(e e%amination :

>(tic disc Rigt @ye 8eft @ye

-olor : yello3is yello3is

/oundary : clear clear @%caation : cone% cone%

A< : 2+ 2+

)m(ression : Normal (a(il+rd!4t and 6t neres : Dolls @ye ,enomenon =;

Bt nere : Droo(y mout to te rigt

7t nere : Difficulty to e%amine9t and 1"t neres : ag refle% =;

11t nere : Difficulty to e%amine

12t nere : 'ongue at rest laid symmetrically

1



REFLEXES

,ysiologic refle%es Rigt e%tremity 8eft e%tremity

/ice(strice(s : == == == ==

K,RA,R : == == == ==

,atologiCue refle%es

0offman 'romner : /ains*i :

MOTOR EXAMINATION

$trengt of muscle : Difficulty to e%amine. Rigt 8ateraliation 3as found.

DIAGNOSIS

&unctional Diagnosis : A(atis = Rigt 0emi(aralysis = B

t

nere (aralysisMN ty(e

Anatomical Diagnosis : $u corte%@tiological Diagnosis : 'romus

Eor*ing Diagnosis : A(atis = Rigt 0emi(aralysis = Bt nere (aralysis

MN ty(e due to: 1. )scemic $tro*e

2. 0emoragic $tro*e

TREATMENT

− /ed rest! ead eleation +"F

−

N' and urinary cateter in use− >%ygen y nasal canule 24 lminute

− )<&D Ringer $olution 2" dri(sminute

− )n5. 1 am( Nicardi(ine = 4"cc Na-8 "!9G ia syring (um(! 1"ccours u( titration and

follo3 u( lood (ressure eery 1# minute

− )n5. -iticoline 1 am(12 rs

FURTHER EXAMINATION

1. -om(lete /lood -ount -/-;

2. Random /lood $ugar 8eel

+. Renal &unction 'est

4. 8ier &unction 'est#. @lectrolyte

6. /lood as Analysis

B. @-7. -est Hray

9. 0ead -' I $can

L

ABORATORY FINDING (June !"#$ %&'

0emogloin : 1+."" gd8

E/- ) *.!'& mm+

'romocyte ) 2#7.""" mm+

0ematocrite : 46."" GDiff. 'elling :

− Neutro(yl : 7B.B" +B7";

− 8ym(ocyte : 9.6" 2"4";

− Monocyte : 2.6" 27;

− @osino(yl : "."" 16;

− /aso(yl : ".1"" "1;

/lood $ugar 8eel random; : 1#4." mgd8

2



Ren+, Fun"/n Te0")

− reum : +B.1" #";

− -reatinine : ".7# ".B"1.2";

L1e2 Fun"/n Te0")− $>' : ++ 8 +7;

− $,' : 19 8 41;

E,e"2/,3"e0)

− Natrium : 1+# m@C8 1+#1##;

− Kalium : +.B m@C8 +.6#.#;

− -loride : 1"1 m@C8 961"6;

B,//4 5+0 +n+,300) ,0 : B.44+ mm0g B.+# B.4#;

(->2 : +B.1 mm0g +742;

(>2 : 1"2.# mm0g 7#1"";

/icaronate : 2+.B mmol8 2226;

'otal ->2 : 22.9 mmol8 19I2#;

/ase @%cess : ".2 2; =2;

>2 saturation : 99.2 9# 1"";

HEAD CT-SCAN (June !"#$ %&'

IMPRESSION )

)nfar* at left and rigt (erientri*uler and 8eft 'alamus = -ereral Atro(y

CHEST X-RAY )

)m(ression: -ardiomegaly

+



ECG 6n4n5 :

)m(ression: $inus Rytm

LABORATORY FINDING (June '"#$ %&'

&asting lucose 8eel : 14" mgd8 B"12";

2 0ours ,ost ,randial lucose 8eel : 1B7 mgd8 2"" ;

8i(id ,rofile :

'otal -olesterol : 169 mgd8 2"" ;'rigliserida : 11" mgd8 4" I 2"" ;

0D8-olesterol : #1 mgd8 6# ;

8D8-olesterol : 11" mgd8 1#" ;

F/,,/7-u8 June '"# $ %&'

-ief com(lain : Declined leel of consciousness

<ital sign

Alertness : A(atis/lood (ressure : 1B"1"" mm0g

0eart Rate : 12" (m

Res(. rate : +2 % min'em(erature : +9.BF -

Eor*ing Diagnosis : A(atis = Rigt 0emi(aralysis = Bt nere (aralysis MN ty(e due to

)scemic $tro*e.

TREATMENT


− N' and urinary cateter in use

− >%ygen y nasal canul 24 lminute

− )<&D R $ol 2" dri(sminute

− )n5. -eftria%on 2gr12 rs

− )n5. 1 am( Nicardi(ine = 4"cc Na-8 "!9G ia syring (um(! 1"ccours u( titration and

follo3 u( lood (ressure eery 1# minute

− )n5. Noalgin 1 am(7 rs


−

)n5. Ranitidine 1 am(12 rs− A(tor ta 1 % +"" mg

F/,,/7-u8 June *"# $ %&'

-ief com(lain : Declined leel of consciousness

<ital sign

Alertness : A(atis

/lood (ressure : 14"1"" mm0g

0eart Rate : 12" (mRes(. rate : +" % min

'em(erature : 4"F -

C/n0u," "/ Pu,9/n/,/53 De8+2"9en" /n June * "# $ %&' )

Eor*ing diagnosis : As(iration ,neumonia

'era(y: )<&D -i(roflo%acin 4""mg 12 rs

N.Asetil $istein +""mg +%1 ta

/lood -ulture $(utum -ulture

Eor*ing Diagnosis : A(atis = Rigt 0emi(aralysis = Bt nere (aralysis MN ty(e due to

)scemic $tro*e = As(iration ,neumonia'era(y :

4





− >%ygen y nasal canul 46 lminute

− )<&D R $ol 2" dri(sminute


− )<&D -i(roflo%acin 4""mg 12 rs

− )n5. &urosemide 1 am(12 rs

− )n5. Noalgin 1am( 7 rs


− Amlodi(in 1%1" mg ta

− -a(to(ril 2%2# mg ta

− A(tor 1% +"" mg ta

− N.asetyl sistein +""mg +%1 ta

F/,,/7 u8 :une ;"# $ %&'

-ief com(lain : declined leel of consciousness

<ital sign

Alertness : $omnolen

/lood (ressure : 1#"1"" mm0g0eart Rate : 12" (m

Res(. rate : +2 % min

'em(erature : +9.7F -

LABORATORY FINDING (June ;"#$ %&'

0emogloin : 12."" gd8E/- ) %<.'& mm+

'romocyte ) 2#7.""" mm+

0ematocrite : 46."" G

Diff. 'elling :

− Neutro(yl : 7B.B" +B7";

− 8ym(ocyte : 9.6" 2"4";

− Monocyte : 2.6" 27;

− @osino(yl : "."" 16;

− /aso(yl : ".1"" "1;

E,e"2/,3"e0)

− Natrium : 1+B m@C8 1+#1##;

− Kalium : +.6 m@C8 +.6#.#;

− -loride : 1"+ m@C8 961"6;

B,//4 5+0 +n+,30 0 ( June ;"# $ %&'

,0 : *.!!; mm0g B.+# B.4#;

(->2 : %*.& mm0g +742;

(>2 : '=.* mm0g 7#1"";

/icaronate : 17.2 mmol8 2226;

'otal ->2 : 19.1 mmol8 19I2#;

/ase @%cess : -!. 2; =2;

>2 saturation : 99.1 9# 1"";

Eor*ing Diagnosis : $omnolen = Rigt 0emi(aralysis = Bt nere (aralysis MN ty(e due to

)scemic $tro*e = As(iration ,neumonia'era(y :



− >%ygen y NRM 71" lminute

#













F/,,/7 u8 :une %&"# $ %&'

-ief com(lain : declined leel of consciousness

<ital signAlertness : $o(or /lood (ressure : 14"9" mm0g

0eart Rate : 11" (m

Res(. rate : +4 % min'em(erature : 4"!2F -

Eor*ing Diagnosis : $o(or = Rigt 0emi(aralysis = Bt nere (aralysis MN ty(e due to)scemic $tro*e = As(iration ,neumonia

'era(y :

− /ed rest! ead eleation +"F− N' and urinary cateter in use

− >%ygen y NRM 71" lminute











F/,,/7 u8 >e6/2e De+"# %& June"#$ %&'

')M@ 8@<@8 >&

->N$-)>

$N@$$

/,mm0g ,8$@

(m

RR

%minu

te

' o- @H,8ANA')>N

1".1# (m $o(or 1""6" 1+2 4# 41.4 8igt refle% ==;↓!

(u(il isocoria

R ?L+ mm! 8L + mm1".4# (m -oma 9"B" 12" 4" 41.1 8igt refle% ==;↓!

,u(il isocoria

R ?L +mm! 8L + mm

11."" (m coma 7"#" 72 +2 +9.9 8igt refle% ==;↓!

(u(il isocoriaR ? L + mm! 8 L + mm

11.1# (m coma B"4" 64 1" +9.6 8igt refle% ==;↓↓!

(u(il isocoria

RL ? 4 mm! 8L 4 mm

11.+" (m coma #"(al(ate 12 4 +9!1 8igt refle% ;!

RL ? 6 mm! 8L # mm

6



11.4# (m ,assed

a3ay

asent asent 8igt refle% ;!

-orneal refle% ;/ot (u(ils 3ere

ma%imally dilated

C+u0e /6 De+"# ) Se800

B

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