Case Conference

Friday Shift, June 30th 2017

Izni MD/Eddy MD/Lubna MD/Rekno MD/Patra MD/Putri MD
Debby MD?Tatag MD
Hamid MD/Mire MD
 PATIENT ADMISSION
Melati 2 ward
1.

HCU Melati 2
1. R/17 y.o./girl/meningoencephalitis due to viral dd bacteri dd TB, prolonged
fever due to dd meningitis, encephalitis, meningoencephalitis, TB,
undernourished
PICU
HCU Neonatus
 PATIENT IDENTITY

Name : R
Age/W/L : 17 years old/ 36 kg / 168
cm
Sex : girl
Address : Sragen, Central Java
Medical Record : 013837744
 CHIEF COMPLAINT
Loss of consciousness
(refferal from private hospital)
 CURRENT MEDICAL HISTORY

3 months before admission

Headache
Double vision and blurry
No fever
No seizure
There were no nausea and vomit
No balance disorder
Patient tooth had cavities until swollen but no
medication
 CURRENT MEDICAL HISTORY

2 weeks before admission

Patient had fever

Patient was having a seizure, which involving whole
body.
Patient brought to public health, and got seizure
medication and resolved,after having the seizure
patient was awake
Before seizure, patient fully alert. after seizure patient
was alert, seizure follow with fever, patient had
dizziness before seizure. No liquor got out from ears,
no difficulty on swallowing
 CURRENT MEDICAL HISTORY

18 days before admission

Patient hospitalized in Sragen Public Hospital

Still has fever and headache
No seizure
Vomit 3x
During hospitalized patient was having loss of
consciousness, talking raved, then got head ct scan
(normal) then repatried
 CURRENT MEDICAL HISTORY

10 days before admission

At home patient still fever

No seizure
hard to talk and communicate
Patient take to Amal Sehat Hospital
 CURRENT MEDICAL HISTORY

4 days before admission

patient still had fever

No seizure
patient was having loss of consciousness
Patient unable to communicate
Vomit
Patient got ct scan for the second time and the result is
meningoenchephalitis with hydrocephalus obstructive sign
Patient reffered to RSDM
 CURRENT MEDICAL HISTORY

Ar Emergency Room

Patient no fully alert,

No fever and seizure
No vomit
Defecation and urination 1 hours before admission
 PAST MEDICAL HISTORY

History of previous seizure : +

History of familial seizure : -
History of hospitalization : +, admission into public
health due to seizure
 HISTORY OF PREGNANCY AND DELIVERY

Conclusion: pregnancy was normal, delivery history was normal

 VACCINATION HISTORY

BCG : 1 month
Hepatitis B1 : 0 month
DPT-HB : 2,3,4 months
Polio : 1,2,3,4 months
Measles : 9, 24 months

Conclusion : Complete Immunization,

apropriate with Ministry Of Health 2013

13
 PEDIGREE

II

III

R, 17 y.o., 36 kgs
 NUTRITIONAL HISTORY

Patient eats 2-3 times a day, rice with tahu, tempe, also with meat,
fish, vegetables. the portion of meal is 3/4 1 portion. Patient has
no difficulty in feeding due to his condition. He sometimes drinks
milk 1-2 glasses a day.
Conclusion: nutrition status is adequate

Growth DEVELOPMENT HISTORY

and Development History
She is now 17 years old, can communicate and interract with family
and his friends. She study in second class in Senior High School
Her weight is 36 kg with body height 168 cm.
Conclusion: not appropriate for her age
15
 NUTRITIONAL STATUS

BW/A : 36/65 x 100% = 55.4 % (p25<BW/A< p10)

severe underweight
BH/A : 168/176 x 100% = 95.5% (BH/A < p3)
Normoheight
BW/BH: 36/57 x 100% = 63.2% (p10<BW/BH <p3)
undernourished

Conclusion : Under-nourished, severe underweight,

normoheight (CDC)
Physical examination
General appearance : moderate illness, apatis,
E3M5V4
Vital sign :
Heart Rate = 85 bpm
Respiration rate = 24 bpm
Temperature = 36.5 0 C (axillary)
O2 saturation =99%
Blood Pressure=120/80mmHg

17
 Head : mesocephal
Eyes : pale conjunctiva (+/+), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 2 mm/2mm, tears (+/+)
Nose : nostril flares (-/-)
Mouth : wet lips (+), lips and tongue cyanotic
Neck :nodul 2cm submandibula dextra, mobile, tenderness (-)
Thorax : symmetric (+), retraction (-)
LUNG:
I: normal, symmetric,
P: fremitus equal on both sides of hemithorax
P: sonor in both lung
A: normal vesicular breath sound, pathological sound (-/-)

18
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement difficulties to evaluated
A: 1st 2nd Heart sound normal intensity, regular
ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strongly palpable, cyanotic , clubbing finger
- -
- - - -
GENITALIA : , no abnormality - -

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 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky -/- Neck spasm +

Triceps +2/+2 Chaddock -/- Kernig -

Patella +2/+2 Oppenheim -/- Brudzinsky I/II -/-
Achilles +2/+2 Schaffner -/-

Spastic
Clonic
- -
- -
- -
CRANIAL NERVES Examinations
N. Olfaktory Nerve (I) : cannot be evaluated yet.
N. Optikus Nerve (II) : isochoric pupil (2mm/2mm), light
reflex +/+, funduscopy was not performed
N. Okulomotorius Nerve (III), N. Troklearis (IV), N.
Abduscens (VI)
Normal movement of eyes, pupils at center, no strabismus
-
N. Trigeminus Nerve : corneal reflex (+/+), able to be
breastfed with normal suck motion
N. Fasialis (VII) : symmetric face
N. Akustikus (VIII) : hearing dan balance test, not performed,
N. Glossofaringeus (IX) : no tongue deviation
N. Vagus : cry vigorous
N. Aksesorius (XI) : no shoulder paralyzed found
N. Hypoglossus : suck and swallowing normally

21
 LABORATORY RESULTS (30/6/17)

Hemoglobin = 10.3 g/dl

Hematocyrte = 31 %
Leucocyte count = 8.400 /uL
Thrombocyte count = 552.000 /uL
Erythrocytes count = 4.19 million /uL
MCV = 74.6 / um
MCH = 24.6 pg
MCHC = 32.9 g/dL
RDW = 13.4 %
MPV = 6.9 FL
PDW = 16 %
Eos/Bas/Neut/Limf/Mono = 0.7%/0.6%/82.1%/8.3%/8.3%
 LABORATORY RESULTS (30/6/17)

Blood Glucose = 99 mg/dL

Albumin = 2.8 g/dL
Sodium = 131 mmol/L
Potassium = 4.7 mmol/L
Calcium = 1.13 mmol/L
SGOT = 52 u/L
SGPT = 174 u/L
Ureum = 16 mg/dL
Creatinine = 0.4 mg/dL
Meningoencephalitis with obstructive hydrochepalus signs
 LIST OF PROBLEMS

R,a girl, 17 years old, 36 kgs, with :

1. fever
2. Headache,
3. Having seizures, duration was unknown, tonic clonic
(whole body)
4. Patient was unconscious during seizure
5. Seizures resolved with medication
6. Patient was fully awake after seizure
7. There were blurry vision
8. There were no nausea and vomit
9. Defecation and urination were within normal limit
 LIST OF PROBLEMS

11. There were history of previous seizure

12. There were history of hospitalization due to seizure
13. There were no history of familial seizure
14. GCS E3V4M5 apatis
15. Colli: nodul 2cm submandibula dextra, mobile,
tenderness (-)
16.Neck Spasm (+)
17. Under- nourished, severe underweight, normoheight
 DIFFERENTIAL DIAGNOSIS

1. Loss of consciousness due to meningoencephalitis

et causa viral dd bacteri dd TB
2. prolonged fever due to dd
meningitis,encephalitis, meningoencephalitis,
TB
3. Under-nourished, severe underweight
normoheight
 WORKING DIAGNOSIS

1. Loss of consciousness due to meningoencephalitis et causa viral dd

bacteri dd TB
2. prolonged fever due to dd meningitis,encephalitis, meningoencephalitis,
TB
3. Under-nourished, severe underweight normoheight
 THERAPIES

1. Admitted to HCU Melati 2

2. Diet sonde 2000 kkal/via NGT
3. IVFD D5 1/2 NS 79mL/days i.v.
4. Inj. Ceftriaxone (50mg/kgBw/12hr) 1gr/12hr i.v.
(I)
5. Inj. dexamethason (0,6mg/kgBw/day)
3mg/6hours i.v.
6. Inj. parasetamol (10 mg/kg/hr) 400mg/8hr i.v.
 THERAPIES

10. IV Manitol 20% (0.5mL/kg/day) 120/8hr i.v.

11. IV Metoclopramide (0.2mg/kg/12hr) 9mg/days
12. Zinc tab. 20mg/24hr (I)
 PLANNING

1. Blood analysis, blood sugar, electrolyte, OT/PT,

Ur/Cr
2. Peripheral blood smear
3. Lumbal puncture (CSF analysis and culture)

MONITORING

General appearance/vital sign/3hours

Fluid balance / 8 hours
Observation recurrence of seizure
FOLLOW UP
May 19th 2017
 FOLLOW UP (19/5/17)
Issues Loss of consciousness, seizure, fever
CNS Severe illness. GCS : E4V4M6, apatis. Pupil isocor 2mm/2mm,
light reflex Direct +/+, Indirect +/+
I
Cardiovascular Heart rate : 110x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strongly palpable
Assessment: within normal limit
Respiratory Respiratory rate : 20x/minute , SiO2 : 98% preductal
System Retraction (-), crackles -/- Air entry (+)
Assessment : within normal limit
GIT Hepatal Distended(-), peristaltic sound (+) within normal, vomit (-), icteric (-)
System Liver and spleen were not palpable
Assessment : within normal limit
II
Genitourinaria Urination (+) yellowish color
System 39thAssessment: within normal limit 34th
Infection Thermoregulation System 36.2- Respiratory System (+)
System 39.10C Gastrointestinal System (-)
III Central nervous system (+) Hematology System (-)
Cardiovascular
8 thnSystem (-) Hemodynamic System(-)
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +4/+4 Babinsky -/- Kaku Kuduk -/-
Triceps +4/+4 Chaddock -/- Kernig -
Patella +4/+4 Gordon +/+ Brudzinsky I/II -/-
Achilles +4/+4 Oppenheim -/-
Schaffer -/-
Spastic
Clonic
- -
+ +
- -
 NEUROLOGICAL EXAMINATION

N I : can not be evaluated yet

N II : light reflex D +/+ I +/+
N III,IV,VI : eye movement are within normal
N V : jaw movement is within normal
N VII : symetric face
N VIII : can no be evaluated yet
N IX : gag reflex (+)
N X : gag reflex (+), uvula deviation (-)
N XI : head movement (+)
NXII : tounge movement (+)
 BRAIN CT SCAN
WITH CONTRAST
Conclusion:
1. Sinusitis maxilaris,
ethmoidalis, and
sphenoidalis
bilateral
2. Encephalitis
3. Cystic benign lession
in left retroareola,
there are no sign of
malignancies
4. Nasal septum
deviation to the left
 WORKING DIAGNOSIS

1. Status epilepticus
2. Encephalitis dd/ meningitis
3. History of hematuria
4. History of GIT bleeding
5. Lymphopenia
6. Hyponatremia
7. Well-nourished, normoweight normoheight
 THERAPIES

1. O2 via nasal canule

2. Diet sonde 2000 kkal/via NGT
3. IVFD D5 1/2 NS 92mL/days i.v.
4. Inj. Meropenem (30mg/kg/8hr) 1gr/8hr i.v. (II)
5. Inj. Paracetamol (10mg/kg/8hr) 500mg/8hr i.v.
6. Inj. Midazolam (0,1 mg/kg/hr) 108mg + NaCl up to
24ml 1 mL/hr i.v.
7. Inj. Phenytoin (5mg/kg/hr) 125mg/12hr i.v.
8. Inj. Phenobarbital (5mg/kg/hr) 125mg/12hr i.v.
 THERAPIES

9. IV Manitol 20% (0.5mL/kg/day) 120/8hr i.v. (II)

10. IV Metoclopramide (0.2mg/kg/12hr) 9mg/days
11. Zinc tab. 20mg/24hr (I)
 PLANNING

MONITORING

General appearance/vital sign/SiO2/hour

Fluid balance / 8 hour
Observation recurrence of seizure
FOLLOW UP
May 20th 2017
 FOLLOW UP (20/5/17)
Issues Loss of consciousness, seizure, fever
CNS Severe illness. GCS : E4V4M6, apatis. Pupil isocor 2mm/2mm,
light reflex Direct +/+, Indirect +/+
I
Cardiovascular Heart rate : 110x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strongly palpable
Assessment: within normal limit
Respiratory Respiratory rate : 20x/minute , SiO2 : 98% preductal
System Retraction (-), crackles -/- Air entry (+)
Assessment : within normal limit
GIT Hepatal Distended(-), peristaltic sound (+) within normal, vomit (-), icteric (-)
System Liver and spleen were not palpable
Assessment : within normal limit
II
Genitourinaria Urination (+) yellowish color
System 39thAssessment: within normal limit 34th
Infection Thermoregulation System 36.2- Respiratory System (+)
System 39.10C Gastrointestinal System (-)
III Central nervous system (+) Hematology System (-)
Cardiovascular
8 thnSystem (-) Hemodynamic System(-)
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +4/+4 Babinsky -/- Kaku Kuduk -/-
Triceps +4/+4 Chaddock -/- Kernig -
Patella +4/+4 Gordon +/+ Brudzinsky I/II -/-
Achilles +4/+4 Oppenheim -/-
Schaffer -/-
Spastic
Clonic
- -
+ +
- -
 NEUROLOGICAL EXAMINATION

N I : can not be evaluated yet

N II : light reflex D +/+ I +/+
N III,IV,VI : eye movement are within normal
N V : jaw movement is within normal
N VII : symetric face
N VIII : can no be evaluated yet
N IX : gag reflex (+)
N X : gag reflex (+), uvula deviation (-)
N XI : head movement (+)
NXII : tounge movement (+)
 WORKING DIAGNOSIS

1. Status epilepticus
2. Encephalitis dd/ meningitis
3. History of hematuria
4. History of GIT bleeding
5. Lymphopenia
6. Hyponatremia
7. Well-nourished, normoweight normoheight
 THERAPIES

1. O2 via nasal canule

2. Diet sonde 2000 kkal/via NGT
3. IVFD D5 1/2 NS 92mL/days i.v.
4. Inj. Meropenem (30mg/kg/8hr) 1gr/8hr i.v. (III)
5. Inj. Paracetamol (10mg/kg/8hr) 500mg/8hr i.v.
6. Inj. Midazolam (0,1 mg/kg/hr) 108mg + NaCl up to
24ml 1 mL/hr i.v.
7. Inj. Phenytoin (5mg/kg/hr) 125mg/12hr i.v.
8. Inj. Phenobarbital (5mg/kg/hr) 125mg/12hr i.v.
 THERAPIES

9. IV Manitol 20% (0.5mL/kg/day) 120/8hr i.v.

(III)
10. IV Metoclopramide (0.2mg/kg/12hr) 9mg/days
11. Zinc tab. 20mg/24hr (I)
 PLANNING

1. Head CT Scan with Contrast

2. Lumbal puncture (CSF analysis and culture)
3. Consult to Eye Department
4. Blood culture

MONITORING

General appearance/vital sign/SiO2/hour

Fluid balance / 8 hour
Observation recurrence of seizure
49