CAUSE OF DEATH REPORT

DEPARTMENT OF NEUROLOGY MEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARA H. ADAM MALIK GENERAL HOSPITAL
MEDAN
PERSONAL IDENTIFICATION
Name
: Surya Darma
Age
: 23 years old
Sex
: Male
Nationality : Indonesian
Adress
: Simpang Selayang
Marital status : Not married

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

: 00.63.89.95
: May,11th2015
: 11.00pm
: May, 14th2015
: 17.00pm
: dr. Mira Arianti
: dr. Khairul P Surbakti, Sp.S

HISTORY TAKING
Main Complain

: Decreased level of consciousness

History of Present Illness :

He had suffered declining level of consciousness approximately 3 days prior to admission to
Adam Malik General Hospital, which occurred gradually.
History of headache (+) since 2 weeks ago, characterized by pain all over the head and not
reduced by painkiller. History of projectile vomit was not found. History of seizure (-).
History of head trauma was not found.
History of fever was found since 5 days prior to admission
History of prolonged cough (+) from 5 month ago, and found blood at the sputum, history of
weight loss (+) since 1 month ago, history of night sweats (+), history of using TB drug (-),
history of ear discharge (-), history of carries (-).
History of hypertension (-), history of diabetes mellitus (-), hypercholesterollemia and heart
disease (-).
History of previous disease and the use of medications were unclear.
History of Previous Disease
: Unknown
History of Previous Medication
: Unknown
GENERAL PHYSICAL EXAMINATION
Sensorium
: Apatis
Blood pressure
: 120/80 mmHg
Heart rate
: 102x/minute

Respiratory rate
Temperature

: 30x/minute
: 38,2oC

NEUROLOGIC EXAMINATION
Level of consciousness
: Apatis
Sign of increased ICP
: Headache (+), Projectile Vomiting (- ), Seizures (-)
Sign of meningeal irritation
: Nuchal Rigidity (+), Kernig Sign (-), Brudzinski I-II (-)
CRANIAL NERVES
1st nerve
2nd and 3rd nerves
Opthalmoscopic examination

: Difficult to examine
: Pupillary light reflexes (+/+), pupil isokor 3 mm/3mm
:
P1

Optic disc
Color
Boundary
Excavatio
A/V
Impression
3rd,4th and 6th nerves
5th nerve
7th nerve
8th nerve
9th and 10th nerves
11th nerve
12th nerve

Right Eye
Left Eye
:
hiperemis
hiperemis
:
blurred
blurred
:
vanished
vanished
:
2/3
2/3
:
Papil oedembilateral
: Dolls eye phenomen (+)
: Corneal reflex (+)
: Mouth was laid symetrically
: Difficult to examine
: Gag reflex (+)
: Difficult to examine
: Tounge at rest was laid symmetrically

REFLEXES
Physiological reflexes
Biceps/Triceps
KPR/APR

Pathological reflexes
Hoffman/ Tromner
Babinski

:
:

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

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

MOTOR EXAMINATION
Strenght of muscle was difficult to examine and lateralization was not found
DIAGNOSIS
Functional Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Differential Diagnosis
Working Diagnosis

: Apatis
: Meningens
: Infection
: 1.Meningitis TB
2.Meningitis Bacterial
: Apatis due to DD 1. Meningitis TB
2.Meningitis Bacterial

TREATMENT
Head elevation 300
Nasogastric tube and urinary catheter in use
Oxygen by rebreathing mask 6-8 l/minute
IVFD R Solution 20 gtt/i
Ceftriaxone inj 2gr/12 hrs/iv skin test
Dexametasone inj 2amp/bolus/iv 1amp/6 hrs (tapp. off every 3 days)
Ranitidine inj 50mg/12 hrs/iv
Paracetamol 3x500mg tab
FURTHER EXAMINATION
1. Lumbal puncture
2. Blood Gas Analysis
3. Consult to Pulmonologi department
P2

4. Consult to Gastroenterohepatologi
5. Consult to Special Service Centre for HIV/AIDS
LABORATORY FINDING (May 12th, 2015)
Haemoglobin
WBC
Thrombocyte
Haematocrite
Diff. Telling
Neutrofil
Lymphocyte
Monocyte
Eosinofil
Basofil

: 13.20g/dL
: 12.75/ mm3
: 374.000/mm3
: 36,90 %
:
: 64,40
: 23,60
: 11,80
: 0,00
: 0.200

Blood Sugar Level (ad random)

: 153 mg/dL

Renal Function Test

Ureum
Creatinine

: 24,70
: 0,54

(<50)
(0.70-1.20)

: 123 mEq/L
: 3,8 mEq/L
: 95 mEq/L

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

Electrolytes

Natrium
Kalium
Chloride

Blood Gas Analysis:

PH
: 7.453mmHg
pCO2
: 30.0 mmHg
pO2
: 191.2 mmHg
Bicarbonate
: 23.9 mmol/L
Total CO2
: 25.0mmol/L
Base Excess
: -3.0
O2 Saturation
: 99.2%
Impressions : Respiratoric Alkalosis

(37-80)
(20-40)
(2-8)
(1-6)
(0-1)

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

Chest X-Ray( may,11th 2015): normal cor and pulmo

Head CT-Scan + iv Contrast( may,11th 2015) : Hidrocephalus communicans with meningitis
ECG FINDING (may, 11th 2015) : Sinus Tachycardi
Follow-up 12 May th, 2015
Chief complain
: decreased level of consciousness
Vital sign
Sensorium
: Apatis
Blood pressure
: 130/80 mmHg
P3

Heart rate
Resp. rate
Temperature

: 112 bpm
: 30 times/minute
: 38,40C

SGOT : 12 (<38)
SGPT : 10 (<41)
Working diagnosis

: Apatis due to DD. 1.Meningitis TB 2. Meningitis bacterial

Consult to GEH Departement May 12 2015 :

Diagnosis : Upper gastrointestinal bleeding
Therapy : Ozid inj 40mg/12 hrs
Transamin inj 500mg/8 hrs
Sucralfat Syr 3dd CII
Sugestion : Gastroscopy
Consult to Pulmonologi Departement May 12 2015 :
Diagnosis : Lung Tuberculosis (Millier Type)
Therapi : Met.Prednisolon inj 125mg/8 hrs/iv
Ceftriaxon inj 2gr/12 jam/iv
INH 1x300mg
RIF 1x450mg
PRZ 1x1000mg
ETA 1x750mg
Treatment :
Head elevation 30
Oxygen by rebreathing mask 6-8 l/minute
Nasogastric tube and urinary catheter in use
IVFD NaCL 3% 8gtt/I (1 Flash) + IVFD NaCL 0,9% 20gtt/I (1 Flash)
Ceftriaxone inj 2gr/12 hrs/iv
Dexametason inj 1amp/6 hrs/iv(day-1)
Transamin inj 500mg/8 hrs/iv
Ozid inj 40mg/12 hrs/iv
Paracetamol 3x500mg tab
Sucralfat Syr 3DD CII
R/H/Z/E
Follow-up May 13th, 2015
Chief complain
Vital sign
Sensorium
Blood pressure
Heart rate
Resp. rate
Temperature

: decreased level of consciousness

: Somnolen
: 140/80 mmHg
: 112 bpm
: 30 times/minute
: 38,90C
P4

LABORATORY FINDING (13 May 2015) :

Haemoglobin
: 12.90g/dL
WBC
: 14.58/ mm3
Thrombocyte
: 332.000/mm3
Haematocrite
: 37.70 %
Diff. Telling
:
Neutrofil
: 85.60
Lymphocyte
: 4.10
Monocyte
: 10.20
Eosinofil
: 0,00
Basofil
: 0.100

(37-80)
(20-40)
(2-8)
(1-6)
(0-1)

Blood Sugar Level (ad random)

: 150 mg/dL

Renal Function Test

Ureum
Creatinine

: 19,70
: 0,54

(<50)
(0.70-1.20)

: 129 mEq/L
: 3,9 mEq/L
: 105 mEq/L

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

Electrolytes

Natrium
Kalium
Chloride

Blood Gas Analysis:

PH
pCO2
pO2
Bicarbonate
Total CO2
Base Excess
O2 Saturation

: 7.393mmHg
: 32.9 mmHg
: 178.3 mmHg
: 19.6 mmol/L
: 25.0 mmol/L
: -4.6
: 99.5%

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

Working diagnosis : Somnolen e.c Meningitis TB + Upper gastrointestinal bleeding

CSF Analyze
Colour
LDH
Protein
Leukocyte
Erytrocyte
Glukosa
pH
MN cell
PMN cell

: Colourless
: 223 U/L
: 0.36 mg/dl
: 0,079 103/uL
: 0,000 106/uL
: 14
mg/dl
: 8.0
: 92,7 %
: 7,6 %

P5

Treatment
Head elevation 30
Oxygen by rebreathing mask 6-8 l/minute
Nasogastric tube and urinary catheter in use
IVFD R Solution 20 gtt/i---IVFD NaCL 0,9% 20 gtt/i
Ceftriaxone inj 2gr/12 hrs/iv
Dexametason inj 1amp/6 hrs/iv (day 2)
Paracetamol infusion 1gr/8 hrs/iv
Ozid inj 40mg/12 hrs/iv
Transamin inj 500mg/8 hrs/iv
Sucralfat Syr 3dd CII
R/H/Z/E
Follow-up May 14th, 2015
Chief complain
Vital sign
Sensorium
Blood pressure
Heart rate
Resp. rate
Temperature
Working diagnosis

: decreased level of consciousness

: Sopor
: 100/50 mmHg
: 120 bpm
: 38 times/minute
: 39,40C

Sopor e.c meningitis TB + Upper gastrointestinal bleeding

Treatment :
Head elevation 30
Oxygen by rebreathing mask 6-8 l/minute
Nasogastric tube and urinary catheter in use
IVFD R Solution 20 gtt/i---IVFD NaCL 0,9% 20 gtt/i
Ceftriaxone inj 2gr/12 hrs/iv
Dexametason 1amp/6 hrs(day 3)
Paracetamol infusion 1gr/8 hrs/drips
Ozid inj 40mg/12 hrs/iv
Transamin inj 500mg/8 hrs/iv
Sucralfat syr 3dd CII
R/H/Z/E
Follow up before Death May, 14th 2015
TIME

LEVEL
OF
CONSCIOUS
NESS

BP/mmHg

PULSE
x/minute

RR
x/minute

T oC

15.45 pm

Coma

80/40

134

12

39,0

16.00 pm

Coma

70/-

105

10

38,9

EXPLANATION
Light reflex (-/-),
pupil isocoria
R=3mm,L=3mm
Light reflex (-/-),
P6

16.15pm

Coma

60/-

82

38,9

16.30 pm

Coma

60/-

64

38,8

16.50 pm

Coma

40/-

40

38,7

17.05 pm
Cause of Death :Meningitis

Pupil isocoria R =
3mm,L=3mm
Light reflex (-/-),
pupil isocory R =5 mm,L
5mm
Light reflex (-/-),
pupilanisocory R =6 mm,L
=6mm
Maximal dilatation
of pupil
corneal reflexes(-)

EXITUS

P7

P8

P9