Susi MD/Ifa MD/Delfia MD/Rini MD/Putri MD

Sekar MD/ Karmono MD

Ida MD/ Mire MD
 PATIENT ADMISSION
 Melati 2 ward
1. A/13 months / 5,5 kgBW / Tuberculosis on theraphy, acute
pharyngitis with feeding difficulty, undernourished
 Wing Mawar
C/5 y.o/19 kg with ALL L2 Standard risk in 1st week induction phase
chemotherapy , epistaxis, gum bleeding, severe nethrophenia, 3rd
grade mucositis, under-nourished
 Pediatric High Care Unit (HCU)
1. A/8 y.o./girl/Meningitis dd encephalitis, Acute
Pharyngitis , caries dentis, under-nourished
 NICU : (-)
 Neonatal HCU :
 PATIENT IDENTITY

Name :A
Age/W/L : 8 years old
BW/H : 21 kgs/125 cm
Sex : Female
Address : Karanganyar, Central
Java
Medical Record : 01385365
Admission : July, 13th 2017
 CHIEF COMPLAINT
Altered of conscioussness
(referred from Private Hospital)
 CURRENT MEDICAL HISTORY

2 days before admission

 Rash appears all over the body

 High fever, intermittent
 No headache, cough, cold, vomiting and seizure
 Patients still can eat and drink
 She neither complain about Urination nor defecation
 CURRENT MEDICAL HISTORY

At The day before admission

 Patient had a seizure, which involved whole body,
once, for less than 5 minutes, stopped without anti
seizure medication and conscious after seizure.
 She vomitted 3 times, contain of gastric juice and
excess food and than the Patient became drowsy and
could not communicate.
 Family took patient to private hospital and reffered to
Moewardi hospital because of limited facility
 CURRENT MEDICAL HISTORY

At Emergency Room

 Patient still unconsciuos

 Continuous high fever
 Vomit (-), seizure (-), rigidity (-), dyspnea (-)
 The last defecation and urination 1 hours before
admission
 PAST MEDICAL HISTORY

 History of previous seizure :-

 History of familial seizure : (+) on her sister
 History of hospitalization : (-)
 History of prolong cough :-
 History of prolong antipyretic therapy : -
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy

• she is second child of his family. Gestational age was 39 weeks. The
mother consumed vitamins and pills routinely from a midwife.
According to the family member from his mother, she had routine
check up to the midwife monthly. There was no history of
hospitallization during pregnancy.

Delivery
• She was delivered spontaneously. There was no complication
during procedure. No history of cyanotic or icteric.

Conclusion: pregnancy and delivery history were normal

 VACCINATION HISTORY

BCG : 1 month
Hepatitis B1 : 0 month
DPT-HB : 2,3,4 months
Polio : 1,2,3,4 months
Measles : 9 months
Conclusion : complete Immunization,
apropriate to Ministry Of Health

10
 PEDIGREE

II

III

A, 8 y.o., 21 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
difficulty in feeding due to his condition. She sometimes drinks
milk 1-2 glasses a day.
Conclusion: nutrition status inadequate while she was sick

Growth DEVELOPMENT HISTORY

and Development History
She is now 8 years old, can communicate and interract with family
and his friends. She studied in second class in Elementary School
Her weight is 21 kg with body height 125 cm.
Conclusion: appropriate for her age
12
 NUTRITIONAL STATUS

BW/A : 21/25 x 100% = 84 % (p10<BW/A< p50)

underweight
BH/A : 125/128 x 100% = 97.6% (p25<BH/A < p75)
normoheight
BW/BH: 21/24 x 100% = 87.5% (p25<BW/BH <50)
undernourished

Conclusion : undernourished, underweight, normoheight

(CDC 2000)
Physical examination
 General appearance : severe ill, somnolen E2M5V2
 Vital sign :
 Heart Rate = 88 bpm
 Respiration rate = 22 bpm
 Temperature = 38 0 C (per axillary)
 O2 saturation =99%
 Blood Pressure=110/70 mmHg

14
 Head : mesocephal
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm, tears (+/+)
 Nose : nostril flares (-/-)
 Mouth : wet lips (+), lips and tongue no cyanotic
 Neck : There is a lymph node enlargement in submandibula dextra,
with 1,5 cm x 1,5 cm diameter,mobile, eritema, soft
consistency, pain (+)
 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 (-/-)

15
 CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: no cardiac enlargement
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 (-)
 Baggy pants -/-
- -
 Wasting -/-
 -/-
- - - -
- -
GENITALIA : M1P1
16
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky +/+ Nuchal rigidity +
Triceps +2/+2 Chaddock -/- Kernig +
Patella +2/+2 Oppenheim -/- Brudzinsky I/II +/ +
Achilles +2/+2 Schaeffner -/-

Spastic
Clonus Sensoric and motoric
examination: - -
- - difficult to assess
- -
CRANIAL NERVES Examinations

N. Olfactory Nerve (I) : cannot be evaluated

N. Opticus Nerve (II) : isochoric pupil (2mm/2mm), light reflex
+/+, funduscopy was not performed
N. Occulomotorius Nerve (III), N. Trochlearis (IV), N. Abduscens (VI)
Normal movement of eyes, pupils at center, no strabismus -
N. Trigeminus Nerve (V) : corneal reflex (+/+)
N. Facialis (VII) : symmetric face
N. Acusticus (VIII) : hearing dan balance test, not performed,
N. Glossofaringeus (IX) : cannot be evaluated
N. Vagus (X) : gag refleks (+)
N. Accesorius (XI) : no shoulder paralyzed found
N. Hypoglossus (XII) : cannot be evaluated

18
 LABORATORY RESULTS (13/7/17)

 Hemoglobin = 10.6 g/dl

 Hematocyrte = 34%
 Leucocyte count = 7.600 /uL
 Thrombocyte count = 194.000 /uL
 Erythrocytes count = 4.10 x 106 /uL
 MCV = 82.7 / um
 MCH = 25.8 pg
 MCHC = 31.2 g/dL
 RDW = 12.4 %
 MPV = 8.1 FL
 PDW = 15 %
 Eos/Bas/Neut/Limf/Mono = 0.2%/0.1%/82.6%/10.9%/4.4%
 LABORATORY RESULTS (13/7/17)

 Blood Glucose = 161 mg/dL

 Sodium = 134 mmol/L
 Chloride = 100 mmol/L
Conclusions:
 Potassium = 4.7 mmol/L Absolut Limfopeni (ALC 884)
 Calcium = 1.22 mmol/L Mild Hiponatremia
 AST = 41 u/L
 ALT = 22 u/L
 Ureum = 24 mg/dL
 Creatinine = 0.6 mg/dL
 LIST OF PROBLEMS

A, girl, 8 years old, 21 kgs, with :

1. High fever
2. Nausea and vomit
3. General seizure, 1 times, 5 minutes
4. Unconscious after seizures
5. No cough, no runny nose, no bleeding
6. Defecation and urination were within normal limit
7. There was no history of previous seizure
8. There was no history of prolong cough
9. There was history of familial seizure
10. Somnlen, GCS E2V2M4
11. Under nourished, underweight, normoheight
12. Nuchal rigidity
13. Absolute lymfopeni
14. Mild Hyponatremia
 DIFFERENTIAL DIAGNOSIS

1. Meningitis dd enchepalitis
2. Acute Pharyngitis
3. Dental caries
4. Under-nourished, underweight, normoheight
 THERAPIES

1. Admitted to Pediatric HCU

2. O2 2 lpm via nasal canule
3. Liquid diet 800 Kcal/day  via nasogastric tube
4. IVFD D5 1/2 NS 51 mL/hour iv
5. Inj Ceftriaxone (50mg/kgBw/12hr)  1g/12hours
i.v.
6. Dexamethason (0,6mg/kgBW/day)  3 mg/6
hours i.v.
6. Paracetamol (10 mg/kgBw/8hours)  200mg/8
hours i.v. (if temperature >380C)
 PLAN
1. Electrolyte , ALT, AST, Ureum, Creatinine
2. Urinalysis, feces examination
3. Peripheral blood smear examination
4. Lumbal puncture (CSF analysis and culture)
5. Consult to neurology department

MONITORING

 General appearance/vital signs/3hours

 Fluid balance / 8 hours
 Observation recurrence of seizure
July 14th 2017
 FOLLOW UP (14/7/17)
Issues Altered of consciousness, high fever , no seizure

CNS Severe illness. GCS : E3V3M5, apatis, isocoric pupil 4 mm/4 mm,
I light reflex Direct +/+, Indirect +/+, nuchal rigidity (+)
Cardiovascular Heart rate : 110 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strongly palpable
Assessment: within normal limit
Respiratory Respiratory rate : 25x/minute , SiO2 : 95% preductal
System Retraction (-), crackles -/- Air entry (+)
Assessment : within normal limit
GIT
II Hepatal Distended(-), peristaltic sound (+) within normal, vomit (-), icteric (-)
System Liver and spleen were not palpable
39thAssessment : within normal limit 34th
Genitourinaria Urination (+) yellowish color
System Assessment: within normal limit
III
Infection Thermoregulation System 38 – 39 Respiratory System (-)
System 0C 8 thn Gastrointestinal System (-)
Central nervous system (+) Hematology System (-)
Cardiovascular System (-) Hemodynamic System(-)
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky +/+ Nuchal rigidity +
Triceps +2/+2 Chaddock -/- Kernig +
Patella +2/+2 Oppenheim -/- Brudzinsky I/II +/+
Achilles +2/+2 Schaffner -/-

Spastic
Clonic Sensoric and motoric
examination: difficulty - -
- - to assessment
- -
CRANIAL NERVES Examinations

N. Olfactory Nerve (I) : cannot be evaluated

N. Opticus Nerve (II) : isochoric pupil (2mm/2mm), light reflex
+/+, funduscopy was not performed
N. Occulomotorius Nerve (III), N. Trochlearis (IV), N. Abduscens (VI)
Normal movement of eyes, pupils at center, no strabismus -
N. Trigeminus Nerve (V) : corneal reflex (+/+)
N. Facialis (VII) : symmetric face
N. Acusticus (VIII) : hearing dan balance test, not performed,
N. Glossofaringeus (IX) : gag refleks (+)
N. Vagus (X) : gag refleks (+)
N. Accesorius (XI) : no shoulder paralyzed found
N. Hypoglossus (XII) : cannot be evaluated

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 DIFFERENTIAL DIAGNOSIS

1. Meningitis dd enchepalitis
2. Dental caries
3. Acute Pharyngitis
4. Under-nourished, underweight, normoheightc
 THERAPIES

1. Diet sonde 900 Kcal/day  via feeding tube ( 8 x

80 – 100 ml )
2. IVFD D1/2 NS 36cc/jam
3. Ceftriaxone (50mg/kgBw/12hr)  1gr/12hr i.v.
4. Dexamethason (0,6mg/kgBW/day)  3
mg/6hours i.v.
6. Paracetamol (10 mg/kg/times)  500mg/times i.v.
(if t>380C)
7. Metoclopramide (0.1 mg/kgBW/x) = 2 mg/8hr i.v.
8. Zinc 20mg/24 hour i.v.
 PLAN
1. Electrolyte , ALT, AST, Ureum, Creatinine
2. Urinalysis, feces examination
3. Peripheral blood smear examination
4. Lumbal puncture (CSF analysis and culture)
5. Consult to neurology department

MONITORING

 General appearance/vital signs/3hours

 Fluid balance / 8 hours
 Observation recurrence of seizure
 FOLLOW UP (15/7/17)
Issues Loss of consciousness, no fever , no seizure

CNS Severe illness. GCS : E2V5M6, apatis, pupil isocor 3 mm/3 mm,
I light reflex Direct +/+, Indirect +/+
Cardiovascular Heart rate : 92x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strongly palpable
Assessment: within normal limit
Respiratory Respiratory rate : 20x/minute , SiO2 : 95% preductal
System Retraction (-), crackles -/- Air entry (+)
Assessment : within normal limit
GIT
II Hepatal Distended(-), peristaltic sound (+) within normal, vomit (-), icteric (-)
System Liver and spleen were not palpable
39thAssessment : within normal limit 34th
Genitourinaria Urination (+) yellowish color
System Assessment: within normal limit
III
Infection Thermoregulation System 37 – 376 Respiratory System (-)
System oC 8 thn Gastrointestinal System (-)
Central nervous system (+) Hematology System (-)
Cardiovascular System (-) Hemodynamic System(-)
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky -/- Nucal rigidity +
Triceps +2/+2 Chaddock -/-
Kernig -
Patella +2/+2 Oppenheim -/-
Brudzinsky I/II -/-
Achilles +2/+2 Schaffner -/-

Spastic
Clonic Motor
power - -
- -
5555 5555 - -
5555 5555
CRANIAL NERVES Examinations

N. Olfactory Nerve (I) : cannot be evaluated

N. Opticus Nerve (II) : isochoric pupil (2mm/2mm), light reflex
+/+, funduscopy was not performed
N. Occulomotorius Nerve (III), N. Trochlearis (IV), N. Abduscens (VI)
Normal movement of eyes, pupils at center, no strabismus -
N. Trigeminus Nerve (V) : corneal reflex (+/+)
N. Facialis (VII) : symmetric face
N. Acusticus (VIII) : hearing dan balance test, not performed,
N. Glossofaringeus (IX) : gag refleks (+)
N. Vagus (X) : gag refleks (+)
N. Accesorius (XI) : no shoulder paralyzed found
N. Hypoglossus (XII) : swallow refleks (+)

34
 WORKING DIAGNOSIS

1. Meningitis
2. Caries dentis
3. Acute Pharyngitis
4. Under- nourished
 THERAPIES

1. Diet sonde 900 Kcal/day  via feeding tube ( 8 x

80 – 100 ml )
2. IVFD D1/2 NS 36cc/jam
3. Ceftriaxone (50mg/kgBw/12hr)  1gr/12hr i.v.
4. Dexamethason (0,6mg/kgBW/day)  3
mg/6hours i.v.
6. Paracetamol (10 mg/kg/times)  500mg/times i.v.
(if t>380C)
7. Metoclopramide (0.1 mg/kgBW/x) = 2 mg/8hr i.v.
8. Zinc 20mg/24 hour i.v.
 PLAN
1. Electrolyte
2. Urinalysis, feces examination
3. Peripheral blood smear
4. Lumbal puncture (CSF analysis and culture)

MONITORING

 General appearance/vital sign/3hours

 Fluid balance / 8 hours
 Observation recurrence of seizure
What is the respone of metoclopropamide
therapy in children with limfopenia
P: children with limfopenia
I : metoclopropamide
C:-
O : laboratory improvement
40