cod masriana

CAUSE OF DEATH REPORTDEPARTMENT OF NEUROLOGY – MEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK GENERAL HOSPITALMEDAN

PERSONAL IDENTIFICATIONName : Masriana Aritonang MR : 00.61.33.49Age : 38 years old Date of admission : August, 21th 2014Sex : Female Time of admission : 01.25 amNationality : Indonesian Date of death : August, 25th 2014Adress : Desa lawe Loning Sepakat Time of death : 17.20 pmMarital status : Married Doctor in Charge : dr. Sheila Maria

Supervisor : dr. Fasihah Irfani Fitri, M.Ked(Neu), Sp. S

HISTORY TAKING

Main Complain : Decreased level of consciuosness

History of Present Illness : She had been suffered the declining level of consciousness approximately 2 days prior to

admission to Adam Malik General Hospital, which occurred suddenly after she had seizure. She had seizures since 2 days prior to admission to Adam Malik General Hospital,

characterized with episode of collapse followed by jerking of all over the body. Duration of the seizure is 5 times a day and the frequency is 2 until 5 minutes for one seizure. She had the first seizure 4 years ago.

History of headache (+) since 1 year ago, characterized by pain all over the head and didn’t reduce by using painkiller. History of projectile vomit is not found. History of head trauma was not found.

History of prolonged cough, weight loss, night sweats were not found. History of diabetes mellitus, hypertension, hypercholesterolemia, heart disease, smoking

were not found.

History of Previous Disease : UnknownHistory of Previous Medication : Unknown GENERAL PHYSICAL EXAMINATIONSensorium : SoporBlood pressure : 140/80 mmHg Respiratory rate : 28 times/minuteHeart rate : 120 beats/minute Temperature : 38,8 oC

NEUROLOGIC EXAMINATIONLevel of consciousness : SoporSign of increased ICP : Headache (+), Projectile Vomiting (-), Seizures (+)Sign of meningeal irritation : Nuchal Rigidity (+), Kernig Sign (+), Brudzinski I-II (-)

CRANIAL NERVES1st nerve : Difficult to examine2nd and 3rd nerves : Pupillary light reflexes (+↓/+↓), small pupil Ø 2 mm/2mm

P1

Opthalmoscopic examination :Optic disc Right Eye Left EyeColor : hiperemis hiperemisBoundary : blurred blurredExcavatio : vanished vanishedA/V : 3/2 3/2Impression : Papil oedem bilateral

3rd,4th and 6th nerves : Doll’s eye phenomen (+)5th nerve : Corneal reflex (+) 7th nerve : Mouth was laid symetrically8th nerve : Difficult to examine9th and 10th nerves : Gag reflex (+)11th nerve : Difficult to examine12th nerve : Tounge at rest was laid symmetrically

REFLEXESPhysiological reflexes Right extremity Left extremity

Biceps/Triceps : +++ / +++ ++ / ++KPR/APR : +++ /+++ ++ / ++

Pathological reflexesHoffman/ Tromner : - / - - / -Babinski : + -

MOTOR EXAMINATIONStrenght of muscle was difficult to examine and there is lateralization to the right. LABORATORY FINDING (August 21st, 2014)

Haemoglobin : 13.30 g/dL WBC : 21.15 / mm3

Thrombocyte : 340.000/mm3

Haematocrite : 38,50 %Diff. Telling :

Neutrofil : 78,80 (37-80) Lymphocyte : 11,80 (20-40) Monocyte : 9,40 (2-8) Eosinofil : 0,00 (1-6) Basofil : 0.000 (0-1)

Blood Sugar Level (ad random) : 140,00 mg/dL

Renal Function Test Ureum : 40.00 (<50) Creatinine : 0.52 (0.70-1.20)

Electrolytes

Natrium : 143 mEq/L (135-155) Kalium : 3,0 mEq/L (3.6-5.5) Chloride : 107 mEq/L (96-106)

P2

Blood Gas Analysis: PH : 7.471 mmHg ( 7.35 - 7.45) pCO2 : 24,1 mmHg (38-42) pO2 : 151,4 mmHg (85-100) Bicarbonate : 17,2 mmol/L (22-26) Total CO2 : 17,9 mmol/L (19–25) Base Excess : -5,9 ( -2)- (+2) O2 Saturation : 99.4% ( 95- 100)

Impressions : Respiratoric Alkalosis with Metabolic compensation

Consult to Obstetri and Gynecology Department August 21st, 2014 Diagnosis : Multigravida (G4P3Ab0) + Intrauterine Pregnancy (16-18 weeks?) + SeizureAdvice : - USG Abdomen for pregnancy confirmation (when patient’s condition had been stabilized)

ECG FINDING (August, 21st 2014) : Sinus Tachycardi DIAGNOSISFunctional Diagnosis : SoporAnatomical Diagnosis : CortexEtiological Diagnosis : TumorDifferential Diagnosis : 1. SOL intracranial

2. Meningitis 3. Encephalitis

Working Diagnosis : Sopor + Right Hemiparalysis + Observational Seizure due to DD: 1. SOL intracranial 2. Meningitis 3. Ensephalitis +Multigravida

TREATMENT Bed rest + Head elevation 300 Nasogastric tube and urinary catheter in use Oxygen by rebreathing mask 8-10 l/minute IVFD NaCl 0,9% 20 drips/minute Ceftriaxone inj 2 gr/12 hrs/iv skin test Dexametasone inj 10 mg/bolus/iv then 5mg/6 hrs/iv (tapp. off every 3 days) Ranitidine inj 50mg/12 hrs/iv Paracetamol infusion 1 gr/8 hrs/drips Diazepam inj 1 amp/iv/slowly injection if seizure Phenytoin inj 500 mg (5 amp) in 50cc NaCl 0,9% 10cc/hrs

If the patient doesn’t have seizure anymore, give phenytoin 100mg 3x1 B.complex 3 x 1

FURTHER EXAMINATION1. Head CT Scan + iv contrast2. EEG3. Consult to Obgyn

Follow-up August 22nd, 2014 Chief complain : Improvement on level of consciousness, seizure (+)

P3

Vital signSensorium : SomnolenBlood pressure : 134/73 mmHgHeart rate : 110 beats/minuteResp. rate : 32 times/minuteTemperature : 38,9 0C

Working diagnosis Somnolen + Right Hemiparalysis + Observational Seizure due to DD: 1. SOL intracranial 2. Meningitis 3. Ensephalitis + Multigravida

Treatment : Bed rest + Head elevation 300 Nasogastric tube and urinary catheter in use Oxygen by rebreathing mask 8-10 l/minute IVFD NaCl 0,9% 20 drips/minute Ceftriaxone inj 2 gr/12 hrs/iv skin test Dexametasone inj 10 mg/bolus/iv then 5mg/6 hrs/iv (tapp. off every 3 days) Ranitidine inj 50mg/12 hrs/iv Paracetamol infusion 1 gr/8 hrs/drips Diazepam inj 1 amp/iv if seizure Phenytoin 3x100 mg B.complex 3 x 1 EEG

Result of EEG : Abnormal EEG with epileptiform wave (sharp wave)

Follow-up August 23rd, 2014 Chief complain : Declined level of conciousness

Vital signSensorium : SoporBlood pressure : 112/66 mmHgHeart rate : 176 beats/minuteResp. rate : 32 times/minuteTemperature : 38,9 0CSpO2 : 52%

HEAD CT-Scan (August, 23rd 2014)CCT : Hiperdens lesion after contrast with hipodens area on the inside, the boundary is not

clear, irregular edge in the left parietal widen to the right, size 4.6 x 6 cm, with minimal perifokal oedem that obliterated to the left lateral ventricle. Sella and parasella was normal.

Impression : SOL intracranial on the left frontal region widen to the right DD/ Meningioma susp. Maligna

Working diagnosis Sopor + Right Hemiparalysis + Observational Seizure due to SOL intracranial DD/Meningioma Susp Maligna + Multigravida

Treatment :

P4

Bed rest + Head elevation 300 Nasogastric tube and urinary catheter in use Oxygen by rebreathing mask 8-10 l/minute IVFD NaCl 0,9% 20 drips/minute Ceftriaxone inj 2 gr/12 hrs/iv skin test IVFD Ciprofloxacine 200 mg/12 hrs Dexametasone inj 5mg/6 hrs/iv (day 2) Ranitidine inj 50mg/12 hrs/iv Paracetamol infusion 1 gr/8 hrs/drips Diazepam inj 1 amp/iv if seizure Phenytoin 3x100mg B.complex 3 x 1 Consult to Neurosurgeon Consult to Anestesiology and reanimation department (ETT no 7 in use manual bagging

because all of ventilator is in use)

Follow-up August 24th, 2014 Chief complain : Declined level of conciousness

Vital signSensorium : ComaBlood pressure : 52/29 mmHgHeart rate : 132 beats/minutteResp. rate : 16 times/minute (manual bagging)Temperature : 39,2 0CSpO2 : 95%

Working diagnosis Coma (Brain stem death) + Right Hemiparalysis + Observational Seizure due to SOL intracranial DD/Meningioma Susp Maligna + Multigravida

Treatment : Nasogastric tube and urinary catheter in use Oxygen 8-10 L/i via ETT by manual bagging IVFD NaCl 0,9% 20 drips/minute Ceftriaxone inj 2 gr/12 hrs/iv skin test IVFD Ciprofloxacine 200 mg/12 hrs Dobutamine 1 amp in 40c NaCl 0,9% 4 cc/hrs (via syringe pump) up titration until BP 110/70

mmHg Dexametasone inj 5mg/6 hrs/iv (day 3) Ranitidine inj 50mg/12 hrs/iv Paracetamol infusion 1 gr/8 hrs/drips Diazepam inj 1 amp/iv if seizure Phenytoin 3x100 mg B.complex 3 x 1

Follow-up August 25th, 2014 Chief complain : Declined level of conciousness

Vital signSensorium : ComaBlood pressure : 51/19 mmHgHeart rate : 139 beats/minute

P5

Resp. rate : 16 times/minute (manual bagging)Temperature : 38,9 0C

Working diagnosis Coma (Brain stem death) + Right Hemiparalysis + Observational Seizure due to SOL intracranial DD/Meningioma Susp Maligna + Multigravida

Treatment : Bed rest + Head elevation 300 Nasogastric tube and urinary catheter in use Oxygen 8-10L/i via ETT by manual bagging IVFD NaCl 0,9% 20 drips/minute Ceftriaxone inj 2 gr/12 hrs/iv skin test IVFD Ciprofloxacine 200 mg/12 hrs Dobutamine 1 amp in 40c NaCl 0,9% 4 cc/hrs (via syringe pump) up titration until BP 110/70

mmHg Dexametasone inj 5mg/8 hrs/iv (day 1) Ranitidine inj 50mg/12 hrs/iv Paracetamol infusion 1 gr/8 hrs/drips Diazepam inj 1 amp/iv Phenytoin 3x100 mg B.complex 3 x 1

Follow up before Death August, 25th 2014

TIME

LEVEL OF

CONSCIOUSNESS

BP/mmHgPULSE x/minute

RR x/minute

T oC EXPLANATION

16.00 pm Coma 51/19 134 10 39,0Light reflex (-/-),

pupil isocory Ø R=4 mm,L=4mm


Pupil isocory R Ø= 4mm,L=4mm


pupil isocory R Ø =4 mm,L =4mm


pupil isocory R Ø =4 mm,L =4mm

17.15 pm Coma 35/13 40 10 38,7Maximal dilatation

of pupilcorneal reflexes(-)

17.20 pm EXITUS

Cause of Death : Brain Herniation

P6

cod masriana

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