Case

LAPORAN KASUS

ENSEFALITIS

OLEH:RAUDHATUL JANNAH

0708120326

PEMBIMBING;dr.RIZA IRIANI NASUTION Sp.A

KEPANITRAAN KLINIK SENIOR

BAGIAN ILMU KESEHATAN ANAKFAKULTAS KEDOKTERAN UNIVERSITAS RIAU

RSUD ARIFIN ACHMAD2011

^ 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 arbovirus2. Primary encephalitis of unknown cause3. Para-infectious encephalitis, namely encephalitis arising as a complication of a viral disease that is known as rubella, varicella, herpes zoster, parotitis epidemika,infectious mononucleosis and vaccination.

CLASSIFICATION

1.Encephalitis SupurativaStaphylococcus aureus,Streptococcus, E. Coli and M.tuberculosa

2. Encephalitis SiphylisCaused by Treponema pallidum

3. Ensefalitis Virus caused by: herpes simplex, sitomegalivirus, Epstein-Barr virus, poxviruses ,Retrovirus,etc

4. Encephalitis Parasitescaused by: Plasmodium falsifarum , Toxoplasma gondii , Amuba

5. Encephalitis Due to funguscaused by: candida albicans, Cryptococcus neoformans,Coccidiodis, Aspergillus, Fumagatus dan Mucor mycosis

CLINICAL MANIFESTATIONS

TRIASSIC ENCEPHALITISa Fever

b Seizuresc Awareness of decreased

TRIASSIC ENCEPHALITISa Fever

b Seizuresc Awareness of decreased

Prodormal Symptoms :

- sudden fever

- headache,

- Nausea

- vomiting,

- lethargy,

- myalgia,

Other manifestations: Confused and disoriented, Stiff neck, Tremor, problems with pronunciation Changed mental status and / or pers

onality changes Focal symptoms, suchas hemiparesi

s, focal seizures, and autonomic dysfunction

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

* there is no specific therapy. therapy depends on etiology

* supportive therapy:

- Hiperpireksia

- Fluid and electrolyte balance,

- increased intracranial pressure,

- treatment of seizures.

* Patients should be treated in intensive care.

* If the patient's general condition is stable, can be consulted to rehabilitation medic

Illustration case:

PATIENT IDENTITYName / No. MR : Fransisca Marita / 70 47 19Age : 5 yearsFather / mother : Osmar Gultom / Suriani Butar-ButarTribe : batakAddress : Jl. Damai-PalasDate of entry : 20 February 2011

AlloanamnesisAwarded by : Parents of patientsThe main complain t : 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 unknown), 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 EXAMINATIONGeneral impression : severely illConsciousness : somnolen

Vital signs:BP : 131/83 mmHgTemperature : 37.20 CHR : 104 x / iRR : 24 x / I

GCS : E3V2M3 = 8

Nutrition : lessTB : 101 cmBB : 15 kgLILA : 15 cmHead circumference : 48 cm

Nutritional status according the weight/heigt percentileNCHS 50BB / 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: (+)

thoraxLung:- 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 EXAMINATIONBloodDate 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

RadiologyFebruary 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:

MEDICA MENTOSAo 02 2 L/io IVFD 2A 10 cc/i + RL 10 cc/io Inj. Ceftriakson IV 2x500 mgo Inj. Zovira (acyclovir) 3x 125 mgo Inj. Piracetam IV 3x500 mgo Enchepabol syrup 1x5 cco Nebulizer ventolir fulmicort/6 jamo 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

FOLLOW UP PASIENTANGGAL SUBJEKTIF OBJEKTIF ASSESMENT TERAPI

3/3/2011 Demam (-)

Kejang (-)

KU: tampak sakit sedang

Kes: apatis

TTV:

-T : 37,50 C-RR:23 x/i-HR: 92 x/i-TD: 120/80 mmHgPF:

-Kaku kuduk (+)-Reflex patologis (+)-GCS: E5V1M3

Statik ensefalitis IVFD 2A 24 tpm

Inj. Ceftazidin 3x350 mg

Captopril 2x12,5 mg

Demam (+)

Kejang (-)

KU: tampak sakit berat

Kes: apatis

TTV:


-Kaku kuduk (+)-Reflex patologis (+)-GCS: E5V1M3



Captopril 2x12,5 mg

Parasetamol 3 cth I

7/3/2011 Demam (-)

Kejang (-)


Kes: apatis

TTV:

-T : 37,80 C-RR:44 x/i-HR: 108 x/i-TD: 120/80 mmHgPF

-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



Captopril 2x12,5 mg

fisioterapi

8/3/2011 Demam (-)

Kejang (-)


Kes: apatis

TTV:





Captopril 2x12,5 mg

Roboransia B complex 1x1/2

Fisioterapi

9/3/2011 Demam (-)

Kejang (-)


Kes: apatis

TTV:

-T : 37,50 C-RR:46 x/i-HR: 114x/i-TD: 110/80 mmHgPF:


Statik ensefalitis - IVFD 2A 24 tpmInj. Ceftazidin 3x350

mg

Captopril 2x12,5 mg

Roboransia B complex 1x1/2

Fisioterapi

TERIMA KASIH

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