Professional Documents
Culture Documents
ENSEFALITIS
OLEH:
RAUDHATUL JANNAH
0708120326
PEMBIMBING;
dr.RIZA IRIANI NASUTION Sp.A
KEPANITRAAN KLINIK SENIOR
BAGIAN ILMU KESEHATAN ANAK
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
RSUD ARIFIN ACHMAD
2011
^ Encephalitis is inflammation of the brain
tissue caused by bacteria, worms, protozoa,fungi, viruses or rickets
1.Encephalitis Supurativa
Staphylococcus aureus,Streptococcus, E. Coli and M.tuberculosa
2. Encephalitis Siphylis
Caused by Treponema pallidum
3. Ensefalitis Virus
caused by: herpes simplex, sitomegalivirus, Epstein-Barr
virus, poxviruses ,Retrovirus,etc
4. Encephalitis Parasites
caused by: Plasmodium falsifarum , Toxoplasma gondii , Amuba
5. Encephalitis Due to fungus
caused by: candida albicans, Cryptococcus
neoformans,Coccidiodis, Aspergillus, Fumagatus dan Mucor
mycosis
CLINICAL MANIFESTATIONS
TRIASSIC ENCEPHALITIS
a Fever
b Seizures
c Awareness of decreased
Other manifestations:
Confused and disoriented,
Stiff neck,
Tremor,
Prodormal Symptoms : problems with pronunciation
- sudden fever
Changed mental status and / or pers
- headache, onality changes
- Nausea Focal symptoms, suchas hemiparesi
- vomiting, s, focal seizures, and autonomic
- lethargy, dysfunction
- myalgia, Movement disorders
Cranial nerve paralysis
Dysphagia
Unilateral sensorimotor dysfunction
EXAMINATION SUPPORT
- complete blood examination
- Checking fluid serobrospinal
- Stool Examination
- EEG
- Photos x-ray head
- CT-Scan
THERAPY
PATIENT IDENTITY
Name / No. MR : Fransisca Marita / 70 47 19
Age : 5 years
Father / mother : Osmar Gultom / Suriani Butar-Butar
Tribe : batak
Address : Jl. Damai-Palas
Date of entry : 20 February 2011
Alloanamnesis
Awarded by : Parents of patients
The main complaint : Impairment of
consciousness 2 days SMRS
DISEASE HISTORY NOW:
- 2 days SMRS, patients experienced decreased
consciousness, looking sleepy and looked very weak
Previously,
patients have fevers, sudden fever, high fever(temperature unkn
own), no chills, no nausea & vomiting
- Patients also had seizures, initially the patient's eyes opened
wide up, when called patient did not answer or no
response,then followed by spasms in the arms and legs,
and entire body.Seizures as much as 2 times, duration of 10-
15 minutes,patients stop seizures about 2 minutes later the
patient backspasms. Then the patient was
taken to hospital and treated in the PICU SM but due
to cost reasons, then the patient was referred to hospitals AA
NOTICE DISEASE HISTORY
- Patients often experience fever
- Ever treated in hospital for 1 week due to lung infection
FAMILY HISTORY OF DISEASE
- No family members of
patients who experienced the same pain
PREGNANCY AND BIRTH HISTORY
- Pregnancy: Pregnancy single. During pregnancy the mother
regularly check her pregnancy to the midwife,
no drinking herbs, alcohol (-), smoking (-)
Birth: Children born spontaneously, helped midwife, mature,
started to cry, no blue, no congenital abnormalityies
BBL 3000grams,
HISTORY OF EATING AND DRINKING
- breastfeeding until age 6 months
- Age 6 months the child began to be given porridge
- Not drinking milk formula
IMMUNIZATION HISTORY
- Immunizations complete
HISTORY OF PHYSICAL growth
- Age 7 months: the child can sit
- age 14 months: children can walk
PHYSICAL EXAMINATION
General impression : severely ill
Consciousness : somnolen
Vital signs:
BP : 131/83 mmHg
Temperature : 37.20 C
HR : 104 x / i
RR : 24 x / I
GCS : E3V2M3 = 8
Nutrition : less
TB : 101 cm
BB : 15 kg
LILA : 15 cm
Head circumference : 48 cm
Nutritional status according the weight/heigt percentileNCHS 50
BB / TB (%) = (BB measured current) / (BB measurable
standards for TB according to NCHS) x 100%
15/19 x 100% = 78, 94% (underweight)
Skin
- miliary in the neck
- hematoma on the left inguinal
Head
- mikrosefal (-), makrosefal (-)
Hair:
- Black, not easy to pull
Neck
- KGB: no enlargement
- Stiff neck: (+)
thorax
Lung:
- Inspection : symmetrical ka = ki, rib retraction (-)
- Percussion : sonor
- Palpation : fremitus ka = ki
- Auscultation: vesicular, ronkhi (-/-), wh (-/-)
Heart
- Inspection : ictus cordis is not visible
- Percussion : deaf
- Palpation : ictus cordis palpable in RIC V LMCS
- Auscultation : regular heart rhythm, heart noise (-)
Abdomen:
- Inspection : flat stomach
- Percussion : timpani
- Palpation : Liver and spleen not palpable
- Auscultation: BU (+) N
Genitals
- No abnormalities
Extremity
- Akral warm,
- RCT <2‘
LABORATORY EXAMINATION
Blood
Date 20/02/2011
- Erythrocytes : 4.75 million / uL
- Leukocytes : 11,860 u/L
- Hb : 12 g / dL
- Ht : 36.6%
- Platelets : 435 000 u/L
- ESR : 25 mm / hr
Radiology
February 16, 2010
- Impression: pre infarction cerebri partial DS / S
IMPORTANT THINGS FROM PHYSICAL EXAMINATION
- general impression: severely ill
- Awareness : somnolen
- GCS : E3V2M3 = 8
- BP : 131/83 mmHg
IMPORTANT THINGS OF EXAMINATION SUPPORT
- Lab :
Leukocytes increased
Elongated erythrocyte sedimentation rate
- Radiology : pre infarction cerebri partial D / S
WORK DIAGNOSIS: Encephalitis
DIFFRENTIAL DIAGNOSE :
- Meningitis
- Kejang demam
- Hematoma serebri
EXAMINATION advice
Punksi lumbal
Therapy:
PROGNOSIS
MEDICA MENTOSA
o 02 2 L/i Quo at vitam : dubia at bonam
o IVFD 2A 10 cc/i + RL 10 cc/i Quo at functionam: dubia at
malam
o Inj. Ceftriakson IV 2x500 mg
o Inj. Zovira (acyclovir) 3x 125 mg
o Inj. Piracetam IV 3x500 mg
o Enchepabol syrup 1x5 cc
o Nebulizer ventolir fulmicort/6 jam
o Fladex IVFD 3x125 mg
DIIT
MC 150 cc/3-4 jam via NGT
FOLLOW UP PASIEN
TANGGAL SUBJEKTIF OBJEKTIF ASSESMENT TERAPI
3/3/2011 Demam (-) KU: tampak sakit Statik ensefalitis IVFD 2A 24 tpm
sedang
Kejang (-) Inj. Ceftazidin
Kes: apatis 3x350 mg
TTV: Captopril 2x12,5
-T : 37,50 C mg
-RR:23 x/i
-HR: 92 x/i
-TD: 120/80
mmHg
PF:
-Kaku kuduk (+)
-Reflex patologis
(+)
-GCS: E5V1M3
Demam (+) KU: tampak sakit Statik ensefalitis IVFD 2A 24 tpm
berat
Kejang (-) Inj. Ceftazidin
Kes: apatis 3x350 mg
TTV: Captopril 2x12,5
mg
-T : 38,90 C
-RR:48 x/i Parasetamol 3 cth
-HR: 100 x/i I
-TD: 120/80
mmHg
PF:
-Kaku kuduk (+)
-Reflex patologis
(+)
-GCS: E5V1M3
7/3/2011 Demam (-) KU: tampak sakit sedang Statik ensefalitis IVFD 2A 24 tpm
-T : 37,80 C fisioterapi
-RR:44 x/i
-HR: 108 x/i
-TD: 120/80 mmHg
PF