LAPORAN KASUS 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 ^ Encephalitis is generally caused by a viruses ^ Encephalitis viruses are divided into 3 groups: 1. Primary encephalitis can be caused by the herpes simplex virus infection, influenzavirus, ECHO, Coxsackie and arbovi rus 2. Primary encephalitis of unknown cause 3. Para-infectious encephalitis, namely encephalitis arising as a complication of a viral disease that is known as rubella, varicella, herpes zoster, parotitis epidemika,i nfectious mononucleosis and vaccination.

Retrovirus.Streptococcus. Fumagatus dan Mucor mycosis . sitomegalivirus.tuberculosa 2.Coccidiodis. Encephalitis Parasites caused by: Plasmodium falsifarum .CLASSIFICATION 1. Encephalitis Due to fungus caused by: candida albicans.etc 4.Encephalitis Supurativa Staphylococcus aureus. Ensefalitis Virus caused by: herpes simplex. Toxoplasma gondii . E. Amuba 5. Epstein-Barr virus. poxviruses . Encephalitis Siphylis Caused by Treponema pallidum 3. Cryptococcus neoformans. Coli and M. Aspergillus.

CLINICAL MANIFESTATIONS TRIASSIC ENCEPHALITIS a Fever b Seizures c Awareness of decreased .

vomiting.  Tremor.myalgia.  Stiff neck.sudden fever .headache.  problems with pronunciation  Changed mental status and / or perso nality changes  Focal symptoms.Nausea . and autonomic dysfunction  Movement disorders  Cranial nerve paralysis  Dysphagia  Unilateral sensorimotor dysfunction .lethargy.Prodormal Symptoms : . . suchas hemiparesis . focal seizures. Other manifestations:  Confused and disoriented. . .

Photos x-ray head .Stool Examination .complete blood examination .EXAMINATION SUPPORT .CT-Scan .Checking fluid serobrospinal .EEG .

therapy depends on etiology * supportive therapy: . .Fluid and electrolyte balance.Hiperpireksia .THERAPY * there is no specific therapy. .increased intracranial pressure. can be consulted to rehabilitation medic . * If the patient's general condition is stable.treatment of seizures. * Patients should be treated in intensive care.

Damai-Palas Date of entry : 20 February 2011 Alloanamnesis Awarded by : Parents of patients The main complain t : Impairment of consciousness 2 days SMRS .Illustration case: PATIENT IDENTITY Name / No. MR : Fransisca Marita / 70 47 19 Age : 5 years Father / mother : Osmar Gultom / Suriani Butar-Butar Tribe : batak Address : Jl.

Patients also had seizures. then the patient was referred to hospitals AA . high fever(tem perature unknown). Then the patient was taken to hospital and treated in the PICU SM but due to cost reasons. sudden fever. duration of 1015 minutes. initially the patient's eyes opened wide up.then followed by spasms in the arms and legs. no nausea & vomiting . looking sleepy and looked very weak Previously. patients have fevers. patients experienced decreased consciousness. when called patient did not answer or no response.Seizures as much as 2 times. no chills. and entire body.DISEASE HISTORY NOW: .2 days SMRS.patients stop seizures about 2 minutes later the patient backspasms.

NOTICE DISEASE HISTORY .Ever treated in hospital for 1 week due to lung infection FAMILY HISTORY OF DISEASE .Patients often experience fever .No family members of patients who experienced the same pain .

Pregnancy: Pregnancy single. helped midwife. smoking (-) Birth: Children born spontaneously. During pregnancy the mother regularly check her pregnancy to the midwife. mature. started to cry. no drinking herbs.PREGNANCY AND BIRTH HISTORY . no blue. . alcohol (-). no congenital abnormalityies BBL 3000grams.

HISTORY OF EATING AND DRINKING .Not drinking milk formula IMMUNIZATION HISTORY .Age 7 months: the child can sit .breastfeeding until age 6 months .age 14 months: children can walk .Age 6 months the child began to be given porridge .Immunizations complete HISTORY OF PHYSICAL growth .

20 C : 104 x / i : 24 x / I : E3V2M3 = 8 : less : 101 cm : 15 kg : 15 cm : 48 cm .PHYSICAL EXAMINATION General impression : severely ill Consciousness : somnolen Vital signs: BP Temperature HR RR GCS Nutrition TB BB LILA Head circumference : 131/83 mmHg : 37.

Black. not easy to pull Neck . 94% (underweight) Skin .hematoma on the left inguinal Head .mikrosefal (-).KGB: no enlargement .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.Stiff neck: (+) .miliary in the neck . makrosefal (-) Hair: .

Inspection : symmetrical ka = ki.Auscultation: BU (+) N Genitals . heart noise (-) Abdomen: . ronkhi (-/-).Auscultation: vesicular.Palpation : Liver and spleen not palpable .Palpation : fremitus ka = ki .Inspection : flat stomach .Percussion : sonor . rib retraction (-) . .Palpation .Inspection . wh (-/-) Heart .Percussion : timpani .No abnormalities Extremity .Auscultation : ictus cordis is not visible : deaf : ictus cordis palpable in RIC V LMCS : regular heart rhythm.Percussion .Akral warm.RCT <2µ .thorax Lung: .

Hb : 12 g / dL . 2010 .6% .Leukocytes : 11.LABORATORY EXAMINATION Blood Date 20/02/2011 .Platelets : 435 000 u/L .Ht : 36.Erythrocytes : 4.75 million / uL .ESR : 25 mm / hr Radiology February 16.860 u/L .Impression: pre infarction cerebri partial DS / S .

general impression: severely ill .GCS : E3V2M3 = 8 .Lab : Leukocytes increased Elongated erythrocyte sedimentation rate .BP : 131/83 mmHg IMPORTANT THINGS OF EXAMINATION SUPPORT .Awareness : somnolen .Radiology : pre infarction cerebri partial D / S WORK DIAGNOSIS: Encephalitis .IMPORTANT THINGS FROM PHYSICAL EXAMINATION .

Meningitis .DIFFRENTIAL DIAGNOSE : .Hematoma serebri EXAMINATION advice Punksi lumbal .Kejang demam .

Zovira (acyclovir) 3x 125 mg o Inj. Ceftriakson IV 2x500 mg o Inj.Therapy: MEDICA MENTOSA o 02 2 L/i o IVFD 2A 10 cc/i + RL 10 cc/i 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 PROGNOSIS Quo at vitam : dubia at bonam Quo at functionam: dubia at malam .

Ceftazidin Kes: apatis 3x350 mg TTV: PF: Kaku kuduk (+) Reflex patologis (+) GCS: E5V1M3 T : 37.5 mg .50 C RR:23 x/i HR: 92 x/i TD: 120/80 mmHg Captopril 2x12.FOLLOW UP PASIEN TANGGAL 3/3/2011 SUBJEKTIF Demam (-) Kejang (-) OBJEKTIF ASSESMENT TERAPI KU: tampak sakit Statik ensefalitis IVFD 2A 24 tpm sedang Inj.

Ceftazidin 3x350 mg Captopril 2x12.5 mg Parasetamol 3 cth I .Demam (+) Kejang (-) KU: tampak sakit berat Kes: apatis TTV: PF: Kaku kuduk (+) Reflex patologis (+) GCS: E5V1M3 T : 38.90 C RR:48 x/i HR: 100 x/i TD: 120/80 mmHg Statik ensefalitis IVFD 2A 24 tpm Inj.

7/3/2011 Demam (-) Kejang (-) KU: tampak sakit sedang Kes: apatis TTV: PF T : 37. Ceftazidin 3x350 mg Captopril 2x12.5 mg fisioterapi - - - Kaku kuduk (+) Reflex babinsky (-/-) Reflex fisiologis bicep dan triceps meningkat Reflex patella meningkat Bibir mencong ke kiri kelumpuhan N VII sentral Tremor pada1/3 distal ekstremitas atas dextra GCS: E5V1M3 .80 C RR:44 x/i HR: 108 x/i TD: 120/80 mmHg Statik ensefalitis IVFD 2A 24 tpm Inj.

Ceftazidin 3x350 mg Captopril 2x12.8/3/2011 Demam (-) Kejang (-) KU: tampak sakit sedang Kes: apatis TTV: PF: Kaku kuduk (+) Reflex babinsky (-/-) Reflex fisiologis bicep dan triceps meningkat Reflex patella meningkat Bibir mencong ke kiri kelumpuhan N VII sentral Tremor pada1/3 distal ekstremitas atas dextra GCS: E5V1M3 T : 36.80 C RR:42 x/i HR: 110 x/i TD: 110/75 mmHg Statik ensefalitis IVFD 2A 24 tpm Inj.5 mg Roboransia B complex 1x1/2 Fisioterapi - - - .

5 mg Roboransia B complex 1x1/2 Fisioterapi - - - .9/3/2011 Demam (-) Kejang (-) KU: tampak sakit sedang Kes: apatis TTV: PF: Kaku kuduk (+) Reflex babinsky (-/-) Reflex fisiologis bicep dan triceps meningkat Reflex patella meningkat Bibir mencong ke kiri kelumpuhan N VII sentral Tremor pada1/3 distal ekstremitas atas dextra GCS: E5V1M3 T : 37.50 C RR:46 x/i HR: 114x/i TD: 110/80 mmHg Statik ensefalitis IVFD 2A 24 tpm Inj. Ceftazidin 3x350 mg Captopril 2x12.

TERIMA KASIH .

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