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PERSONAL IDENTIFICATION
HISTORY TAKING
History of Present Illness : She had been suffering from declining of consciousness
approximately 1 day prior to admission to Adam Malik General
Hospital, which occurred suddenly when she was resting. History of
headache, seizure and projectile vomiting were not found. History of
hypertension was found since several years ago, uncontrolled. History
of diabetes mellitus was also found since several years ago,
uncontrolled. History heart disease was not found. History of stroke
was found one year ago with left hemiparalysis. History of trauma and
fever were not found.
NEUROLOGIC EXAMINATION
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 : Yellowish Yellowish
Boundary : Clear Clear
Excavatio : Concave Concave
A/V : 2/3 2/3
Impression : Normal papil
1
3rd, 4th and 6th Nerves : Doll’s eye phenomen (+)
5th Nerve : Corneal reflex (+)
7th Nerve : Droopy mouth to the right side
8th Nerve : Difficult to examine
9th and 10th Nerves : Gag reflex (+)
11th Nerve : Difficult to examine
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 was difficult to examine and lateralization was not found
DIAGNOSIS
2
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. Cithicoline injection 250 mg 1 amp/12 hours
7. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
8. Paracetamol 500 mg 3 x 1
FURTHER EXAMINATION
3
HEAD CT SCAN (September 28th 2012)
Infratentorial 4th ventricle and cerebellum were normal.
There were multiple hypodense lesion in bilateral ganglia basalis and right periventricular.
There were no mass effect or midline shift.
Impression :
Multiple infarct in bilateral ganglia basalis and right periventricular.
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
6. Cithicoline injection 250 mg 1 amp/12 hours
7. Xyllo : Della injection = 2 : 1 (temperature > 39 oC)
8. Humulin R 6 – 6 – 6 IU
9. Paracetamol 500 mg 3 x 1
10. Aspilet 300 mg 1 x 1
11. Simvastatin 10 mg 1 x 1
4
CAUSE OF DEATH REPORT
DEPARTEMENT OF NEUROLOGY
SCHOOL OF MEDICINE
UNIVERSITY OF NORTH SUMATERA
ADAM MALIK GENERAL HOSPITAL MEDAN