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    COD Siangkan

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    Denis Harli Siregar
    Siangkan Barus, a 52-year-old male, was admitted to the hospital with declining consciousness over 6 days. He had a history of hypertension and a stroke 2 months prior. During his hospital stay, his condition deteriorated further and he was diagnosed with recurrent stroke, pneumonia, and hypoalbuminemia. His consciousness continued to decline and vital signs became unstable until he passed away on December 28th at 2:00 pm from sepsis caused by pneumonia.

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    COD Siangkan

    Uploaded by

    Denis Harli Siregar
    27 views9 pages
    Siangkan Barus, a 52-year-old male, was admitted to the hospital with declining consciousness over 6 days. He had a history of hypertension and a stroke 2 months prior. During his hospital stay, his condition deteriorated further and he was diagnosed with recurrent stroke, pneumonia, and hypoalbuminemia. His consciousness continued to decline and vital signs became unstable until he passed away on December 28th at 2:00 pm from sepsis caused by pneumonia.

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    Siangkan Barus, a 52-year-old male, was admitted to the hospital with declining consciousness over 6 days. He had a history of hypertension and a stroke 2 months prior. During his hospital stay, his condition deteriorated further and he was diagnosed with recurrent stroke, pneumonia, and hypoalbuminemia. His consciousness continued to decline and vital signs became unstable until he passed away on December 28th at 2:00 pm from sepsis caused by pneumonia.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    27 views9 pages

    COD Siangkan

    Uploaded by

    Denis Harli Siregar
    Siangkan Barus, a 52-year-old male, was admitted to the hospital with declining consciousness over 6 days. He had a history of hypertension and a stroke 2 months prior. During his hospital stay, his condition deteriorated further and he was diagnosed with recurrent stroke, pneumonia, and hypoalbuminemia. His consciousness continued to decline and vital signs became unstable until he passed away on December 28th at 2:00 pm from sepsis caused by pneumonia.

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    of 9

    CASE OF DEATH REPORT

    DEPARTMENT OF NEUROLOGY MEDICAL FACULTY


    UNIVERSITY OF SUMATERA UTARA H. ADAM MALIK GENERAL HOSPITAL
    MEDAN

    PERSONAL IDENTIFICATION
    Name
    : Siangkan Barus
    Age
    : 52 years old
    Sex
    : Male
    Nationality
    : Indonesian
    Adress
    : Cingkes Dolok Silau
    Marital status : Married

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

    : 62.79.78
    : December, 25th 2014
    : 05.00 pm
    : December, 28th 2014
    : 02.00 pm
    : dr. M. Taufiq Regia Arnaz
    : dr. Kiki M. Iqbal, Sp.S

    HISTORY TAKING
    Main Complain
    : Decreassed level of conciousness
    History of Present Illness :
    He had suffered the declining level of conciousness approximately 6 days prior to
    admission to Adam Malik General Hospital which occured suddenly when he was resting.
    History of headache, projectile vomit, and seizure were not found. History of head trauma was
    not found. Previously, he was treated in other hospital for 6 days dan he referred to Adam Malik
    General Hospital. History of hypertension was found since 5 years ago with controlled
    medication with amlodipine. History of diabetes mellitus, hypercolesterolemia, and heart disease
    were denied.
    History of stroke was found since 2 months ago and based on information from his family, he
    have operated because of brain haemorrhage on left brain 2 months ago.
    History of Previous Disease
    History of Previous Medication

    : Hypertension
    : Amlodipine

    GENERAL PHYSICAL EXAMINATION


    Alertness
    : Somnolent
    Blood pressure
    : 100/60 mmHg
    Heart rate
    : 104 bpm

    Respiratory rate
    Temperature

    : 28 x/minute
    : 37,4 oC

    NEUROLOGIC EXAMINATION
    Level of consciousness
    : Somnolent
    Sign of increased ICP
    : Headache (-), Projectile Vomiting (-), Seizures (-)
    Sign of meningeal irritation
    : Nuchal Rigidity (-), Kernig Sign (-), Brudzinski I (-),
    Brudzinsky II (-)
    CRANIAL NERVES
    1st nerve
    2nd and 3rd nerves
    Opthalmoscopic examination
    Optic disc
    Color
    Boundary
    Excavatio
    A/V
    Impression
    rd th
    3 ,4 and 6th nerves
    5th nerve
    7th nerve
    8th nerve
    9th and 10th nerves
    11th nerve
    12th nerve

    : Difficulty to examine
    : Pupillary light reflexes (+/+), pupil isochors : 3 mm
    :
    Right Eye
    Left Eye
    :
    yellowish
    yellowish
    :
    clear
    clear
    :
    concave
    concave
    :
    2/3
    2/3
    :
    Normal Papil
    : Dolls eye phenomenon (+)
    : Corneal reflex (+)
    : Droopy mouth to the right
    : Difficult to examine
    : Gag reflex (+)
    : Difficult to examine
    : Tongue at rest laid symetrically

    REFLEXES
    Physiological reflexes
    Biceps/Triceps
    KPR/APR

    Right extremity
    :
    +/+
    +/+

    Pathologique reflexes
    Hoffman/ Tromner
    Babinski

    :
    :

    -/-

    Left extremity
    +/+
    +/+
    -/-

    MOTOR EXAMINATION
    Difficulty to examine. There is no lateralization.
    DIAGNOSIS
    Functional Diagnosis
    Anatomical Diagnosis
    Etiological Diagnosis
    Working Diagnosis

    : Somnolent + Duplex Hemiparalysis + Right 7th nerve paralysis UMN


    Type
    : Subcortex
    : Thrombus
    : Somnolent + Duplex Hemiparalysis + Right 7th nerve paralysis UMN
    Type due to :
    1. Ischemic Stroke
    2. Recurrent Stroke

    TREATMENT
    Bed rest
    Nasogastric tube and urinary catheter in use
    Oxygen by nasal canule 2-4 L/minute
    IVFD Ringer Solution 20 drips/minute
    Inj. Citicholin 1amp/12 hours
    B Complex 3x1
    FURTHER EXAMINATION
    1. Complete Blood Count (CBC)
    2. Ad Random Blood Sugar Level
    3. Fasting Blood Glucose and 2 Hours Post Prandial Glucose Level
    4. Renal Function Test
    5. Liver Function Test
    6. Lipid Profile
    7. Electrolyte
    8. Blood Gas Analysis
    9. ECG
    10. Chest X-Ray
    11. Head CT-Scan
    Follow-up December 26th, 2014
    Chief complain
    : Declined level of consciousness
    Vital sign
    Sensorium
    Blood pressure
    Heart rate
    Resp. rate
    Temperature

    : Sopor
    : 110/60 mmHg
    : 104 bpm
    : 32 x/ min
    : 39,3 0C

    LABORATORY FINDING (December 26th, 2014)


    Haemoglobin
    WBC
    Thrombocyte
    Haematocrite

    : 8,50 g %
    : 18.310/mm3
    : 145.000/mm3
    : 27,6 %
    2

    Diff. Telling
    Neutrofil
    Lymphocyte
    Monocyte
    Eosinofil
    Basofil

    :
    : 95,00
    : 3,80
    : 1,00
    : 0,10
    : 0.100

    Blood Sugar Level (ad random )

    : 57 mg/dL

    Renal Function Test


    Ureum
    Creatinine

    : 63,10
    : 0,33

    (<71)
    (0.70-1.20)

    Electrolytes
    Natrium
    Kalium
    Chloride

    : 140 mEq/L
    : 2,8 mEq/L
    : 109 mEq/L

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

    Blood Gas Analysis:


    PH
    pCO2
    pO2
    Bicarbonate
    Total CO2
    Base Excess
    O2 Saturation
    Liver Function Test
    Albumin

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

    : 7.436 mmHg
    : 24,8 mmHg
    : 127,2 mmHg
    : 16,3 mmol/L
    : 17,0 mmol/L
    : -7,1
    : 98,1%

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

    : 1,7

    Procalcitonin : 1,42 ng/ml


    ECG FINDING (December 26th, 2014)

    : Sinus Rhytme + Tachicardy + VES

    CHEST X-RAY (December 26th, 2014)


    Impression : Cardiomegaly + Elongation Aorta + Bronchopneumonia
    HEAD CT-Scan (December 26th, 2014)
    Impression
    : Multiple infarct on periventricular and left interna Capsula and right interna
    capsula
    Consult to Pulmonology Department December 26th , 2014 :
    Diagnosis : Nosocomial Pneumonia. DD: - Aspiration Pneumonia
    - Tuberculosis
    Therapy :
    - Inj. Meropenem 1 gr/8 hours
    - Inj. Ceftriaxone 2 gr/12 hours
    - Inj. Gentamycin 80 mg/12 hours
    - Inf. Ciprofloxacin 400 mg/12 hours
    - Nebule Ventolin/ 8 hours
    - Nebule Flixotide/ 12 hours
    Sugesstion :
    - Sputum analysis
    - Sputum culture

    Consult to Cardiology Department December 26th , 2014 :


    Diagnosis : Hypertension Heart Disease
    Therapy :
    - Furosemide 1x40 mg tab
    - Simvastatin 1x20 mg tab
    - Aspillet 1x80 mg tab
    Working diagnosis

    : Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by


    Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

    Treatment :
    Bed rest
    Nasogastric tube and urinary catheter in use
    Oxygen by rebreathing mask 8-10 L/minute
    IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
    0,9 % 20 drips/minute
    IVFD Albumin 20 % 20 drips/minute/day
    Inj. Citicholin 1amp/12 hours
    Inj. Meropenem 1 gr/8 hours
    Furosemide 1 x 40 mg tab
    Simvastatin 1 x 20 mg tab
    Aspillet 1 x 80 mg tab
    Paracetamol 3x500 mg
    B.complex 3x1tab
    KSR 3x1 tab
    Nebule Ventolin/8 hours
    Nebule Flixotide/8 hours
    Inj. Novalgin 1 amp (Temp 39 oC)

    IVFD Nacl

    Follow-up December 27th, 2014


    Chief complain
    : Declined level of consciousness
    Vital sign
    Alertness
    Blood pressure
    Heart rate
    Resp. rate
    Temperature

    : Sopor
    : 110/60 mmHg
    : 96 bpm
    : 32 x/ min
    : 38,5 0C

    LABORATORY FINDING (December 27th, 2014)


    Blood Gas Analysis:
    PH
    pCO2
    pO2
    Bicarbonate
    Total CO2
    Base Excess
    O2 Saturation

    : 7.543 mmHg
    : 17,2 mmHg
    : 176,9 mmHg
    : 14,5 mmol/L
    : 15,0 mmol/L
    : -7,2
    : 98,1%

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

    Blood Sugar Level (ad random) : 124 mg/dl


    Working diagnosis

    : Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by


    Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

    Treatment :
    Bed rest
    Nasogastric tube and urinary catheter in use
    Oxygen by rebreathing mask 8-10 L/minute
    IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
    0,9 % 20 drips/minute
    IVFD Albumin 20 % 20 drips/minute/day
    Inj. Citicholin 1amp/12 hours
    Inj. Meropenem 1 gr/8 hours
    Furosemide 1 x 40 mg tab
    Simvastatin 1 x 20 mg tab
    Aspillet 1 x 80 mg tab
    Paracetamol drips 500 mg/8 hours
    B.complex 3x1tab
    KSR 3x1 tab
    Nebule Ventolin/8 hours
    Nebule Flixotide/8 hours

    IVFD Nacl

    Follow-up December 28th, 2014


    Chief complain
    : Declined level of consciousness
    Vital sign
    Alertness
    Blood pressure
    Heart rate
    Resp. rate
    Temperature
    Working diagnosis

    : Sopor
    : 130/80 mmHg
    : 96 bpm
    : 32 x/ min
    : 38,6 0C

    : Sopor + Duplex Hemiparalysis + Right 7th nerve UMN Type caused by


    Recurrent Stroke + Pneumonia + HHD + Hypoalbuminemia

    Treatment :
    Bed rest
    Nasogastric tube and urinary catheter in use
    Oxygen by rebreathing mask 8-10 L/minute
    IVFD Dextrose 10 % 10 drips/minute, if blood glucose > 200 mg/dl
    0,9 % 20 drips/minute
    IVFD Albumin 20 % 20 drips/minute/day
    Inj. Citicholin 1amp/12 hours
    Inj. Meropenem 1 gr/8 hours
    Furosemide 1 x 40 mg tab
    Simvastatin 1 x 20 mg tab
    Aspillet 1 x 80 mg tab
    Paracetamol drips 500 mg/8 hours
    B.complex 3x1tab
    KSR 3x1 tab
    Nebule Ventolin/8 hours
    Nebule Flixotide/8 hours

    IVFD Nacl

    Follow Up Before Death December, 28th 2014


    TIME

    LEVEL
    OF
    CONSCIOUS
    NESS

    BP/mm
    Hg

    PULSE
    bpm

    RR
    x/minute

    T oC

    01.00 pm

    Sopor

    80/60

    126

    38

    40,5

    01.15 pm

    Coma

    70/50

    128

    36

    40,0

    01.30 pm

    Coma

    60/40

    110

    32

    40,0

    01.45 pm

    Coma

    50/-

    40

    39,0

    Light reflex (+/+),


    pupil isocory =5 mm

    Light reflex (-/-),


    Corneal reflex (-/-)
    Both pupils were maximally
    dilated

    02.00 pm

    Passed away

    absent

    absent

    EXPLANATION
    Light reflex (+/+),
    Pupil isocory =4mm
    Light reflex (+/+),
    pupil isocory =4mm
    Light reflex (+/+),
    pupil isocory R=5mm

    Cause of Death : Sepsis caused by Pneumonia

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