nlghL ShlfL 8eporL

LncephallLls
Aldo lM
Clndy W 0103800197
8ebecca Ayesha 0103800081
denLlLy
An kela !enl 8ahayu
lemale
9 monLhs old
kelapa nunggal 8ogor
3383200
Chlef complalnL
uecrease of consclousness slnce 1 day before
hosplLal admlsslon
9resenL llness PlsLory
4 days 8A1P mencreL faeces seperLl bubur yellowlsh
3x/d [ Z glass of Aqua mucus + blood vomlL
fever selzure urlnaLlon normal sLlll acLlve
1 day 8A1P waLery dlarrhoea xZ glass yellowlsh
13x/d mucus + blood hlgh fever vomlL 2x (mllk)
mldwlfe gave orallL panas
nlghL Llme selzure maLa Lonlc 2 mlns 9osL
selzure consclous buL weak cllnlc aL Clleungsl 8S
1hamrln severe dehydraLlon (could noL lnfuse) 8S
Pusada lnfused 1he baby had selzures agaln (2x 1013
mlns lnLerval 10 mlns) sLopped wlLh medlcaLlon from
recLal I (sLesollL phenobarblLal) 9osL selzure Lhe
baby ls unconsclous pro Cu (full) 8SCM (full)
1he paLlenL came wlLhouL ambulance CCS 7 (L2I1M4) She
has noL defecaLe slnce mornlng urlnaLlon ?? LasL Llme
changed Lhe dlaper ls 6 hours ago
8W before lll 7 kg
9asL have noL have any lllness before
lamlly selzure 18C epllepsy
9arLus flrsL chlld sponLaneous mldwlfe 3200 gram lengLh
was noL measured dlrecLly crylng cyanosls selzure
mmunlsaLlon compleLe excepL campak
CrowLh developmenL prone 6 mo sLlll cannoL slL
ngoceh2 +
nuLrlLlon AS + SCM 90cc 3x/d 8ubur susu 3x/d small
amounL (few spoons)
9resenL hlsLory of lllness
4 days ago Lhe paLlenL suffers from dlarrhea
uefecaLlon 3x/day mucus (+) faeces (+) blood () 1he
dlarrhea lasLs for 2 days
2 days ago Lhe paLlenL suddenly have a hlgh fever 1he
moLher broughL Lhe paLlenL Lo 8S Clleungsl Powever
Lhe hosplLal referred Lhe paLlenL Lo 8S 1hamrln
because Lhey have no vacanL room avallable n 8S
1hamrln Lhe paLlenL was planned Lo geL I llne
aLLached buL falled 1he paLlenL was Lhen referred
agaln Lo 8S Pusada whlch Lhen referred her Lo 8SCM
9revlous medlcaLlon 9henobarblLal ln[ecLlon
9l
Ceneral condlLlon paLlenL was unconsclous
CCS L1M3I1
IlLal slgn
89 90/30
P8 120x
1emperaLure 394C
88 40 kusmaul breaLhlng
Pead bulglng fonLanele () deformlLy () head
clrcumference 43cm
Lye anemlc / lcLerlc /
pupll lsochor 1mm/1mm
dlrecL llghL reflex decreased/decreased
lndlrecL llghL reflex decreased / decreased
Ln1 funcLlon dlfflculL Lo be assessed oLhers wlLhln
normal llmlL
Cor S/S n M () g ()
9ulmo kusmaul breaLhlng symmeLrlc
veslcular 8h/ wh /
Abdo flaL paln could noL be assessed
PearL and llen was noL palpable
LxLr edema / warm accral
neurologlc sLaLus
Menlngeal slgns ()
MoLorlc rlghL hemlparesls (hypoacLlve)
Sensorlc can noL be assessed
AuLonomlc on caLheLer
ulagnosls
lnfecLlLncephallLls
PlsLory of acuLe dlarrhea wlLh severe
dehydraLlon
Anemla dd/ le defflclency dd/ lnfecLlon
SupporLlng dlagnosls
CompleLe blood counL
LlecLrolyLe
8lood glucose
8CA
L9
Laboratory kesu|t
nb 86
nt 26
Leu 18800
1hrombo 349000
,I S4
,n 18
MCPC 34
18S
na 138
k 42
| 123
pn 7211
p2 272
p2 4SS
2 736
8L 170
8eb 147
8 127
n3 110
12 118
Acidosis Metabolic
Mixed with vein
Anemia microcytic
hypoxia
1herapy
C2 nasal canule 1 L/mln
CeLrlaxone 1x173mg
Sodlum blcarbonaLe
ManlLol