Case Report Enchephalopathy

Presentators: Dewi Putri Rejekinta Berutu Azmeilia Syafitri Lubis Supervisor: Prof. dr. H. Munar Lubis, Sp.A (K) DEPARTMENT OF PEDIATRIC HAJI ADAM MALIK GENERAL HOSPITAL FACULTY OF MEDICINE UNIVERSITY OF NORTH SUMATERA 2012

Introduction
Enchephalopathy

is a general term for a disease that alters a persons brain function and mental state.
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Introduction There are many possible precipitants of encephalopathy. Symptomps of enchephalopathy can generalized causing decreased level of conciousness from minimal lethargy to coma.
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Objective
The aim of this study is to explore more about the theoritical aspects on metabolic enchephalopathy, and to integrate the theory and application of hepatic enchephalopathy case in daily life.
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Defenition

Encephalopathy is an acute confusional state that is accompanied by an alterations in cortical function and disturbances of consciousness may range from mild confusional states to coma

Some types of enchephalopathy : Glycine enchephalopathy : caused by a metabolic disorder Hepatic enchephalopathy : caused by disorders that affect the liver Hypoxic enchephalopathy : caused by reduce oxygen to brain Static enchephalopathy : permanent brain damage Uremic enchephalopathy : caused by toxins remaining in the body Wernickes enchephalopathy : caused by a thiamine deficiency, usually due to alcoholism. Hashimotos enchephalopathy : an autoimmune disorder Hypertensive enchehalophaty : caused by very high blood pressure Toxic-metabolic enchephalopathy : general term to describe enchephalopathies caused by infections, toxins or organ failure.
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Etiology

Infections Trauma, Tumor/Paraneoplastic Seizures, Stroke, (P)Sychiatric Drugs (intoxication withdrawal), dementia (Decompensated Dementia) Electrolytes Low glucose, Leukoencephalopathy Inflammatory Rheumatologic Intracranial Pressure Uremia Metabolic, Malnutrition, Mitochondrial

Over 5.5 million people in the United States have been diagnosed with cirrhosis. One of this population, 3045 % of patients develop overt encephalopathy during the course of their disease. This debilitating condition can negatively impact quality of life for patients and their families. Epidemiology The frequency of hospitalization for enchephalopathy has nearly doubled over the last decade, with lengths of stay between 5 and 7 days.

Dehydration Hyponatremia Hypokalemia Excessive dietary protein

Renal Failure Urinary Obstruction Gastrointerstinal bleeding Constipation

RISK FACTOR

Hepatocellular carcinoma Terminal liver disease Superimposed liver injury Transjugular intrahepatic portalsystemic shunt

Surgery Central nervous system acting drugs Infections

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Some types of enchephalopathy :

Glycine enchephalopathy : caused by a metabolic disorder Hepatic enchephalopathy : caused by disorders that affect the liver Hypoxic enchephalopathy : caused by reduce oxygen to brain Static enchephalopathy : permanent brain damage Uremic enchephalopathy : caused by toxins remaining in the body Wernickes enchephalopathy : caused by a thiamine deficiency, usually due to alcoholism. Hashimotos enchephalopathy : an autoimmune disorder Hypertensive enchehalophaty : caused by very high blood pressure Toxic-metabolic enchephalopathy : general term to describe enchephalopathies caused by infections, toxins or organ failure. Metabolic enchephalopathy : broad category that describes abnormalities of the water, electrolytes, vitamins and other chemicals that adversely affect brain function
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The pathogenesis of encephalopathy is incompletely understood, and the discussion that follows represents a collection of ideas and concepts that have emerged from recent research. There is probably no single pathophysiology. Rather, many different perturbations of brain function may produce the same clinical syndrome. Potential mechanisms include a deficiency of substrates for oxidative metabolism, impaired synaptic transmission, and gross alterations in the water and electrolyte composition of the internal milieu. These mechanisms may be interrelated. For example, Hyponatraemia is defined as a serum sodium <135mEq/l. Under normal circumstances, the human body is able to maintain the plasma sodium within the normal range (135 145mEq/l) despite wide fluctuations in fluid intake. The bodys primary defence against developing hyponatraemia is the kidneys ability to generate a dilute urine and excrete free water. Hyponatraemia usually develops when there are underlying conditions that impair the kidneys ability to excrete free water. There are a few clinical settings where patients most often develop hyponatraemic encephalopathy.

Pathophysiology
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DIAGNOSIS
Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Patients with hepatic encephalopathy can become unconscious, unresponsive, and possibly enter a coma. Mild Change in sleep patterns Changes in thinking Confusion that is mild Forgetfulness Mental fogginess Personality or mood changes Poor concentration Poor judgment Worsening of handwriting or loss of other small hand movements Severe Abnormal movements or shaking of hands or arms Agitation, excitement, or seizures (occur rarely) Disorientation Drowsiness or confusion Inappropriate behavior or severe personality changes Slurred speech Slowed or sluggish movement
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PHYSICAL EXAMINATION

Jaundice, petechial hemorrhages, gastrointestinal bleeding, ascites, or hypothermia may indicate hepatic dysfunction. A coarse facies, dry hair, or bradycardia suggests hypothyroidism. Acne, obesity, and hypertension are common in Cushing syndrome. Needle tracks in the skin raise the possibility of a toxic encephalopathy. Hypertension suggests that the encephalopathy is caused by a metabolic disorder (e.g., a renal or endocrinologic disorder) or an ischemic disorder (e.g., a cerebrovascularor cardiovascular condition), and Hepar enlargement, lead to cirrhosis hepatic. Hypothermia suggests a metabolic or toxic cause. Neurologic examination
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Tests may include:

Blood test CT Scan of the head or MRI

EEG
Lumbar Puncture Arterial blood gases

Electrolyte
Chest radiograph

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Management & Treatment

Dehydration : diuretics, intravenous infusion of physiologic saline, and therapy for the underlying cause of increased fluid and electrolyte losses. Gastrointestinal bleeding is identified and treated appropriately. Hypokalemia : vigorously corrected with parenteral potassium in enchephalopathy. Severe hyponatremia : Limited infusions of hypertonic saline (3% NaCl, 150 mL intravenous) may be needed for very severe hyponatremia.

Correction Precipating Factors

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Management & Treatment

Dietary protein : Restriction of dietary protein to 40 g/day or less used to be advocated for patients with enchephalopathy because of excessive dietary protein. The current recommended protein diet for patients is 0.8 to 1.5 g/kg/d. Tranplantation Adjuvant (antibiotics & dissacharides) Symptomatic

Correction Precipating Factors

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Complication

Brain herniation Brain swelling Increased risk of: Cardiovascular collapse Kidney failure Respiratory failure Sepsis Permanent nervous system damage (to movement, sensation, or mental state) Progressive, irreversible coma Side effects of medications

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Prognosis

Acute encephalopathy may be treatable. Chronic forms of the disorder often keep getting worse or continue to come back.
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Name : AIP Age : 4 months Sex : Female Date of Admission: May, 7th 2012

Case Report
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3 days ago

Precipated by fever

Seizure

Tonic clonic

Frek 10 times/day; 5

Main Complain
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Diarrhoea (+)
3 days before fever Frequency >10 times /day especially after having milk Volume = 10-20 cc/ diarrhoea Watery

Impairment of consciousness (+)

weak cry with moan impression (+) 2 days ago after seizure.

Urine output(+)
Colour : yellow (+) Volume : less Vomit (-) history of melena (+) since 2 days ago dyspnoe (-).
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History of Birth

Spontaneous and cried immediately Help by midwives in clinic. BW =3 Kg and BBL =48 cm Injection of vitamin K (+) hypertension , DM, using herbal medicine (-). Early fetal membrane broken (+) From birth to 3 months : Breast milk From 3 months to now : Breast milk + formula milk

Historyof Pregnancy

Feeding History

History of Growth and Development History of Immunisation

Patient has been able to face downward

Hep B, BCG, Polio, DPT

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Consciousness:
Alert (GCS 12: E:4, C=3, M=5) Temperature: 38oC. Body length: 63 cm. Head circumferences: 38 cm. Upper Arm Circumferences: 9,5 cm.

Anemic (-). Icteric (-). Cyanosis (-). Oedema (-). Dyspnoe (+). BB/U = 5,3/6,2 x 100 % = 85,48 % TB/U = 63/62 x 100 % = 101,6 BB/TB = 5,3/6,6 x 100 % = 80,3 % Impression: Mild malnutrition

Sensorium
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Head
Fontanella : Large open flat, concave (+) Hair: black, rarely, easily removed (-) Head circumference: 38 cm Eye: light reflex (+/+), isochoric pupillary, palpebra inferior conjunctival pallor (-/-), icteric sclera (-) Nose: nostrils in breathing (+). Ear and mouth: within normal limit

Neck
Lymph node enlargement (-) Stiff neck (-)

Thorax
Simetris fusiformis. Retraction (+) epigastrial, intercostal, and suprasternal. HR: 158 bpm, regular, murmur () RR: 30 bpm, reguler, rales (-), wheezing (-).

Localized Status
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Abdomen
Soepel Peristaltik (+) normal Hepar/Lien within normal limit

Urogenital
Female, Diapper rash (+)

Exremities
Ptechiae (-) Pulse 158 bpm, regular, adequate pressure and volume Warm acral Capillary refill time < 3.

Localized Status
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Parameters Complete Blood Count Hemoglobin Erithrocyte

Value

Normal Value 11,5 16,5 gr% 4,2 5,4 x 106 /mm3

10,5 gr% 4,05 x 106 /mm3

Leucocyte
Hematocrite Platelet

13,7 x 103 /mm3

31,6% 80.000 /mm3

4- 11 x 103 /mm3
37 47% 150000 440000 /mm3

MCV
MCH MCHC

77,8 fL
25,9 pg 33,3 gr%

80 95 fL
27 32 pg 32 36 gr%

RDW
MPV PCT LED Laboratory

12,7 %
9,90 fL 0,079%

11,6 15,5 %
6,5 12.0 fL 0,100- 0,500
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8 mm/hours < 15 mm/hours Findings (7th May 2012):

Diftel

Neutrophil
Limfosit Monosit Eosinophil

78,0 %
16 % 4% 2%

55 70 %
20 40 % 28% 16%

Basophil

0.100 %
ELECTROLYTE

01%

Natrium Kalium

148 mEq/l 5,8 mEq/l

135- 155 mEq 3,6- 5,5 mEq/l

Chloride

10/l2 mEq

96-106 mEq/l
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Management
Head elevation 30 O2 - 1 L/i nasal canule IVFD RL 99 gtt/i micro (rehydration from 19.30 to 23.30) Inj. Ampicilin 250 mg/6 hours/iv Inj. Cefotaxim 350 mg/8 hours/iv Inj. Dexamethasone 1 mg/8 hours/ iv Paracetamol 3x 100 mg (if need) Diet based milk or complementbased milk 60 cc/ 2 hours/ NGT

Diagnostic Planning
Consult to neurology Consult to respirology Mantoux test Lumbal Punction EEG Head CT-Scan Check electrolyte (Ca, Mg), LFT, RFT, blood culture, urine culture, AGDA, CRP, Blood Glucose Level Chest X-Ray

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Follow Up

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May 7th 2012 S O Seizure (-), fever (-) Sens: GCS:12 (E=4, V=3, M=5), Temp: 36,1C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5,3 kg. Head Eye: Light reflex (+)/(+). Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (+). Prominent fontanella (- ) Ear-mouth: within normal limit. Nose: nostrils in breathing (+) Neck Lymph node enlargement (-). Stiff neck (-).

Thorax

Symmetrical fusiformis. Retraction (+) epigastrial and suprasternal.

HR: 160 bpm, reguler, murmur (-). RR: 65 bpm, regular, rales (-/-). Snoring (-).

Abdomen
Extremities

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Palpable 1 cm under arcus costae, blunt.
Pulse 160 bpm, regular, adequate p/v, warm, CRT < 3. Physiology reflex (APR + Normal, KPR +Normal). Patologic reflex (Babinsky +, Meningeal -)

Genital A

Female. Eritematous lesion in anal area. Enchephalitis + bronchopneumony + mild moderate dehydration Meningoenchephalitis + bronchopneumony + mild moderate dehydration Meningoenchephalitis + bronchopneumony + Mild - moderate dehydration

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Management: Head elevation 30 O2 - l L/i nasal canule Rehydration RL 99 gtt/I since 19.30 pm - 23.30 pm Injection of Ampicillin 250 mg/6 hr/iv (Skin Test) Injection of Cefotaxim 350 mg/8 hr/iv (Skin Test) Injection of dexamethasone 1mg/8 hr/iv Paracetamol 3 x 100 mg (if needed) Diet breast milk/ PASI 60 cc/2 hr/NGT 10.00 pm Injection Phenytoin 100 mg in 20 cc NaCl 0,9 % out in 20 minutes, after 12 hours 25 mg/12 hr in 20 cc NaCl 0.9 %.

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Laboratory Findings on 7th May 2012

Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite 10,5 gr% 4,05 x 106 /mm3 13,7 x 103 /mm3 31,6% 11,5 16,5 gr% 4,2 5,4 x 106 /mm3 4- 11 x 103 /mm3 37 47%

Platelet
MCV MCH MCHC RDW MPV PCT LED Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil

80.000 /mm3
77,8 fL 25,9 pg 33,3 gr% 12,7 % 9,90 fL 0,079% 8 mm/hours

150000 440000 /mm3

80 95 fL 27 32 pg 32 36 gr% 11,6 15,5 % 6,5 12.0 fL 0,100- 0,500 < 15 mm/hours 55 70 % 20 40 % 28% 16% 01%
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78,0 % 16 % 4% 2% 0.100 % ELECTROLYTE

Natrium

148 mEq/l

135- 155 mEq

Kalium

5,8 mEq/l

3,6- 5,5 mEq/l

May 8 th 2012 S O Seizure (-), fever (-). Sens: GCS:12 (E=4, V=3, M=5), Temp: 36,1C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5,3 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (+). Prominent fontanella (-) Ear-mouth: within normal limit.. Nose: nostrils in breathing (+)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Simetrical fusiformis. Retraction (+) epigastrial and suprasternal. HR: 140 bpm, reguler, murmur (-). RR: 52 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Palpable 1 cm under arcus costae, blunt. Pulse 140 bpm, regular, adequate p/v, warm, CRT < 3. Physiology reflex (APR + Normal, KPR +Normal). Patologic reflex (Babinsky +, Meningeal -)

Genital A

Female. Eritematous lesion in anal area. Enchephalitis

Meningoenchephalitis + Bronkhopneumonia
Meningoenchephalitis + Mild to moderate dehydration
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Management: Head elevation 30 O2 - l L/i nasal canule IVFD D5 restriction 25 % 16 gtt/i Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes Injection of Ampicillin 250 mg/6 hr/iv (H1) Injection of Cefotaxim 350 mg/8 hr/iv (H1) Injection of dexamethasone 1mg/8 hr/iv (H1) Paracetamol 3 x 100 mg (if needed) Diet breast milk/ PASI 70 cc/3 hr/NGT. (10.30 am) : Phenytoin 10 mg/kgBW in 6cc NaCl 0,9% out in 20 minutes (05.00 pm): Correction of hipocalsemy (Ca= 6,6 mg/dl) 0,5 mg/kg BB= 0,5 x 5,3= 2,65 mg in 3 cc out in 20 minutes

Consult to neurology Consult to respirology Mantoux test Lumbal punction Electroenchepalograph Head CT-Scan Electrolyte test: LFT, RFT, blood culture, urine culture, AGDA, CRP, procalcitonin, lactate acid, LED
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Dipstic Results: Leu/Nit/Uro/Pro/pH/Blo/SG/Ket/Bil/Glu: /- /- /++ /6 /1,030 /- /- /- /Blood Glucose Test: 46 mg/dl Blood Culture: Bacteria was not found

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Result of Consult to Radiology: - The heart, sinus & diaphragma are normal. - The lung: consolidation upper right lung field. There is triangle opaque shadow at lower right lung field. -Impression: a. Pneumonia b. Atelectasis segmental at posterior right lung

Chest Radiograph

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Laboratory finding on 8th May 2012

Parameters Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite Platelet MCV MCH MCHC 10,3 gr% 3,72 x 106 /mm3 11,12 x 103 /mm3 30,80 % 103.00 /mm3 82,80 fL 27,70 pg 33,4 gr% 10,7 17,1 gr% 3,75 4,95 x 106 /mm3 6,0- 17,5 x 103 /mm3 38 52% 217000 497000 /mm3 93 -115 fL 29 35 pg 28 34 gr% Value Normal Value

RDW
MPV PCT Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil Kesan: normocrom normositter anemia+ trombositopenia

13,5 %
10,40 fL 0,011 %

14,9 18,7 %
7,2 10,00 fL

94,10 % 4,20 % 1,70 % 0.00 % 0,000 %

37 80 % 20 40 % 28% 16% 01%

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BLOOD GASES ANALYSIS pH pCO2 pO2 HCO3 CO2 total BE O2 saturation 7,40 23,0 173,3 14,20 14,90 -9,3 99,3 % 7,35- 7,45 38- 42 mmHg 85- 100 mmHg 22- 26 mmol/l 19- 25 mmol/l -2 2 95- 100

ELECTROLYTE Calsium Natrium Kalium Phospor Cloride Magnesium 6,6 134 3,7 3,2 110 1,61 8,4- 10,8 mg/dl 135- 155 mEq 3,6- 5,5 mEq 5,0- 10,8 mEq 96- 106 mEq 1,4- 1,8 mEq

Procalcitonin

79,03

<0.05 ng/ mL

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9th May 2012 S Seizure (-), fever (-), Conciousness: increase (this patient crying more loudly).

Sens: GCS:14 (E=4, V=4, M=5), Temp: 37,5C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5,5 kg.

Head

Eye: Light reflex (+)/(+) Conjunctiva palpebra inferior anemic (-/-) Isochoric pupil Sunken eye (-) Prominent fontanella (-) Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 140 bpm, reguler, murmur (-). RR: 48 bpm, regular, rales (-/-). Snoring (-).

Abdomen

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Not palpable

Extremities

Pulse 140 bpm, regular, adequate p/v, warm, CRT < 3.

Genital A

Female. Within normal linit

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Enchephalopathy

Management:

Head elevation 30
O2 - l L/i nasal canule IVFD D5 Na Cl 0,9 % 16 gtt/i micro Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes Injection of Ampicillin 250 mg/6 hr/iv (H2) Injection of Cefotaxim 350 mg/8 hr/iv (H2) Injection of dexamethasone 1mg/8 hr/iv (H2) Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam

Diet breast milk/ PASI 70 cc/3 hr/NGT.

Waiting for the answer neurology consult Consult to respirology Mantoux test Check electrolyte

The Result of Consult Respirology: Clinically, symptom of respirology was not found.
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Parameters Function of hemostatic PT +INR Protombine Time INR Control Patient

Value

Normal Value

12,50 sec 18,0 sec 1,36

APTT
Control Patient 29,50 29,70 Electrolyte Calcium Natrium Kalium Chloride Magnesium 6,9 136 3,3 103 1,77 8,4- 10,8 mg/dl 135-155 mEq 3,6- 5,5 mEq 95- 106 mEq 1,4- 1,8 meq

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10th May 2012 S O Seizure (-), fever (-), diarrhoea (+) Sens: GCS:15 (E=5, V=4, M=5), Temp: 37,1C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5,5 kg. Head Eye: Light reflex (+)/(+). Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-) Neck Lymph node enlargement (-). Stiff neck (-).

Thorax

Symmetrical fusiformis. Retraction (-)

HR: 135 bpm, reguler, murmur (-). RR: 42 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 135 bpm, regular, adequate p/v, warm, CRT < 3. Female. Within normal limit. Enchephalopathy ec electrolyte imbalance + GE without dehydration

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Management:

IVFD D5 Na Cl 0,25 % 16 gtt/i2

Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes Injection of Cefotaxim 350 mg/8 hr/iv (H3)

Injection of dexamethasone 1mg/8 hr/iv (H3)

Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI 70 cc/3 hr/NGT. Zink 1 x 10 mg Consult to gastroenterohepatology

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11th May 2012

S
O

Seizure (-), fever (+), diarrhoea (+)

Sens: GCS:13 (E=4, V=4, M=5), Temp: 37,8C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5,5 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-).

Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-)

HR: 132 bpm, reguler, murmur (-).

RR: 40 bpm, regular, rales (-/-). Snoring (-). Abdomen Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable

Extremities
Genital A

Pulse 132 bpm, regular, adequate p/v, warm, CRT < 3.

Female. Within normal limit. Enchephalopathy + Gastroenteritis without dehydration
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Management: IVFD D5 Na Cl 0,25 % 16 gtt/i Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes Injection of Cefotaxim 350 mg/8 hr/iv (H4) Injection of dexamethasone 1mg/8 hr/iv (H4) Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI 70 cc/3 hr/NGT. Zink 1 x 10 mg

R Give low lactose milk Check routine feces

Feces culture

Parameters

Value ELECTROLYTE

Normal Value

Calcium (Ca) Natrium (N) Kalium (K) Phospor Chloride (Cl) Magnesium (Mg)

7,2 158 3,3 2,9 108 1,71

8,4 10,8 mg/dL 135 155 mEq/L 3,6 5,5 mEq/L 5,0 10,8 mEq/ L 96 106 mEq/L 1,4 1,8 mEq/L
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12th May 2012 S O Seizure (-), fever (-), diarrhoea (+) Sens: Compos mentis Temp: 36,8C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg. Head Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-).

Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-) Neck Thorax Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 104 bpm, reguler, murmur (-). RR: 42 bpm, regular, rales (-/-). Snoring (-).

Abdomen
Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable

Pulse 104 bpm, regular, adequate p/v, warm, CRT < 3. Female. Enchephalopathy + Gastroenteritis without dehydration + suspect cows milk allergy 51

Management:

IVFD D5 Na Cl 0,25 % 16 gtt/i

Injection of Phenytoin 2x 25 mg Injection of Cefotaxim 350 mg/8 hr/iv (H5) Zink 1 x 10 mg Lacto B Sach 2 x 1 Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI low lactose 70 cc/3 hr/NGT.

Check routine feces Feces culture

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13th May 2012 S O Seizure (-), fever (-), diarrhoea (+) Sens: Compos mentis Temp: 36,8. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 100 bpm, reguler, murmur (-). RR: 40 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 100 bpm, regular, adequate p/v, warm, CRT < 3. Female. Enchephalopathy ec electrolyte imbalance+ Gastroenteritis without dehydration + suspect cows milk allergy
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Management: IVFD D5 Na Cl 0,25 % 16 gtt/i Injection of Phenytoin 2x 25 mg Injection of Cefotaxim 350 mg/8 hr/iv (H6) Zink 1 x 10 mg Lacto B Sach 2 x 1 Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI low lactose 70 cc/3 hr/NGT.

R Check routine feces

Feces culture
Blood culture

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14th May 2012 S O Seizure (-), fever (-), diarrhoea (+) Sens: Compos mentis Temp: 36,8. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 104 bpm, reguler, murmur (-). RR: 38 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 104 bpm, regular, adequate p/v, warm, CRT < 3. Female. Enchephalopathy ec electrolyte imbalance+ Gastroenteritis without dehydration + suspect cows milk allergy
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Management: IVFD D5 Na Cl 0,25 % 16 gtt/i Injection of Phenytoin 2x 25 mg Injection of Cefotaxim 350 mg/8 hr/iv (H7) Zink 1 x 10 mg Lacto B Sach 2 x 1 Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI low lactose 75 cc/3 hr/NGT.

R Check electrolyte (Ca, Mg)

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15th May 2012 S O Seizure (-), fever (-), diarrhoea (-) Sens: Compos mentis Temp: 37. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 116 bpm, reguler, murmur (-). RR: 42 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 116 bpm, regular, adequate p/v, warm, CRT < 3. Female. Enchephalopathy ec electrolyte imbalance + Gastroenteritis without dehydration + suspect cows milk allergy
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Management: IVFD D5 Na Cl 0,25 % 16 gtt/i Injection of Phenytoin 2x 25 mg Injection of Cefotaxim 350 mg/8 hr/iv (H8) Zink 1 x 10 mg Lacto B Sach 2 x 1 Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI low lactose 75 cc/3 hr/NGT.

Waiting for blood electrolyte result

Result of bactery culture: negative

Laboratory Finding on 15th May 2012

Parameters Value ELECTROLYTE Normal Value

Calcium (Ca)
Natrium (N) Kalium (K) Phospor Chloride (Cl) Magnesium (Mg)

8,4
136 3,7 109 1,62

8,4 10,8 mg/dL

135 155 mEq/L 3,6 5,5 mEq/L 5,0 10,8 mEq/ L 96 106 mEq/L 1,4 1,8 mEq/L
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16th May 2012 S O Seizure (-), fever (-), diarrhoea (-) Sens: Compos mentis Temp: 37 C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg.

Head

Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-)

Neck Thorax

Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 106 bpm, reguler, murmur (-). RR: 36 bpm, regular, rales (-/-). Snoring (-).

Abdomen Extremities Genital A

Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 106 bpm, regular, adequate p/v, warm, CRT < 3. Female. Enchephalopathy ec electrolyte imbalance
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Management: IVFD D5 Na Cl 0,25 % 16 gtt/i Injection of Phenytoin 2x 25 mg Injection of Cefotaxim 350 mg/8 hr/iv (H9) Zink 1 x 10 mg Lacto B Sach 2 x 1 Paracetamol 3 x 100 mg (if needed) Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam Diet breast milk/ PASI low lactose 75 cc/3 hr/NGT.

Waitng for blood electrolyte result

This patient may go home

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HOME VISIT 25th May 2012 S O Seizure (-), fever (-), diarrhoea (-) Sens: Compos mentis Temp: 36,2C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg. Head circumference= 38 cm, Upper arm

circumference= 9,5 cm.

Head Eye: Light reflex (+)/(+). Conjunctiva palpebra inferior anemic (-/-). Isochoric pupil. Sunken eye (-). Prominent fontanella (-). Ear-mouth: within normal limit. Nose: nostrils in breathing (-) Neck Thorax Lymph node enlargement (-). Stiff neck (-). Symmetrical fusiformis. Retraction (-) HR: 158 bpm, reguler, murmur (-). RR: 26 bpm, regular, rales (-/-). Snoring (-). Abdomen Extremities Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable Pulse 158 bpm, regular, adequate p/v, warm, CRT < 3.

Genital
A

Female.
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Management: Amoxycillin syrup 3 x 1 cth Ambroxol pulv 3 x 1 Control to General Hospital Of Haji Adam Malik Medan

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SKETCH OF HOUSE

Bathroom, Toilet & Location to wash

Kitchen

Guest room+ Family room+ Making cake room

Bed room

Jen dela

Pintu

Jen dela

Size of house 4 x 5 meter

Impression: Bad ventilasion, small house but crowded people, bad sanitation.
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Address: Pasar 11, Gg.Rejeki, Kec. Percut, Sei Tuan

Impression : Bad Sanitation

Home Visit (25th May 2012)

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THEORY Definition Encephalopathy is an acute confusional state that is accompanied by an alterations in cortical function and disturbances Dehydration Electrolyte imbalance Excessive dietary protein Renal Failure Urinary Obstruction Gastrointerstinal bleeding Surgery Infections Drugs Hypoxia, intravascular disease etc Static, Uremic, Wernicke. Hashimotos. Hypertensive, Toxic & Metabolic

PATIENT In this patient, mental status changes and conciousness impairment was found

Causes

In this patient, the precipitating factor is dehydration (electrolyte imbalance)

Types

Discussion Glycine. Hepatic, Hypoxic,

This patient is metabolic enchephalopathy

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THEORY Clinical Manifestation Change in sleep patterns Changes in thinking Confussion impairment Mental fogginess Personality or mood changes Poor concentration Abnormal movements or shaking of hands or arms Agitation, excitement, or seizures (occur rarely) Disorientation Drowsiness or confusion Inappropriate behavior or severe personality changes Slurred speech Slowed or sluggish movement

PATIENT In this patient, seizure and conciousness impairment was found

Supporting Examination

Blood test In this patient, supporting CT Scan of the head or MRI examinations are: EEG -Complete blood count 66 Lumbar Puncture -Chest radiograph

THEORY Manageme nt Correction by Precipating Factors, adjuvant therapy (antibiotics and dissacharides), transplantation and symptomatic.

PATIENT Treatment of this patients are: - RL 99 gtt/i micro (rehydration from 19.30 to 23.30) Head elevation 30 O2 - l L/i nasal canule IVFD D5 Nacl 25 % 16 gtt/i Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes Injection of Ampicillin 250 mg/6 hr/iv (H1) Injection of Cefotaxim 350 mg/8 hr/iv (H1) Injection of dexamethasone 1mg/8 hr/iv (H1) Paracetamol 3 x 100 mg (if needed) Diet breast milk/ PASI 70 cc/3 hr/NGT. (10.30 am) : Phenytoin 10 mg/kgBW in 6cc NaCl 0,9% out in 20 minutes (05.00 pm): Correction of hipocalsemy (Ca= 6,6 mg/dl) 0,5 mg/kg BB= 0,5 x 5,3= 2,65 mg in 3 67 cc out in 20 minutes

THANK YOU

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Camara-Chua, Pia Teresa A, MD., Enchephalopathies. 2010. Available from: NEJM.org\ Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 156. K. Lin , Chou-Ching. EEG Manifestations in Metabolic Encephalopathy.2005. Acta Neurologica Taiwanica Vol 14 No 3 September 2005 Kaplan PW, Fisher RS, Pathophysiology of Encephalopathy. 2005. New York: Demos Medical Publishing. Munos, J.S., Hepatic Enchephalopathy. Available from: http://www.med.upenn.edu/gastro/documents/MedClinNAencephalopathy2008.pdf Myer, Edwin, MD., Acute toxic-metabolic encephalopathy in children.2010. Available from: file:///E:/Print/acute-toxic-metabolic-encephalopathy-in-children.htm Riordhan, M.S., Treatment of hepatic enchepalophaty. 2012. Available from: http://www.nejm.org/action/showImage?doi=10.1056%2FNEJM199708143370707& iid=t01 Spundorfer, Phillip., Electrolyte and Fluids. Comprehensive Pediatric Hospital Medicine. 2007. Philadhelpia: Mosby Elsevier. Swaiman, K.F., Pediatric Neurology Principles & Practise. 1999. Missouri: A Hartcourt Health Sciences Company. Wright, W.L., Current Clinical Neurology: Handbook of Neurocritical Care. 2004. Totowa NJ: Humana Press Inc.

References
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