CASE PRESENTATION:

ICU
MENINGITIS+BRONCHOPNEUMONI
A+ SUSP. SEPSIS
Supervisor: dr. Hijrinelli SY, Sp.An
IDENTITY
 Name : Widyardi Effendi
 Age : 6 year old
 Sex : Male
 Tribe : Sasak
 EduAdress: Rembiga
 Admission : 1st of December 2017
Anamnesis
 Chief Complaint:
Decrease of Consciousness
 Chronology (Alloanamnesis)

Patient reffered from Risa Mataram General Hospital with, Susp.

Sepsis + Pneumonia + Acute Upper GI bleeding. Patient experienced a
fever and chronic cough since 2 weeks ago. The patient also had
history of vomiting and bloating since 2 weeks ago more than twice a
day. The patient had an unconscious state just before he reffered to
NTB GH. Patient also had a brownish liquid coming out from his NGT.
 History of Disease:

The patient have history of chronic coughing.

History of seizure (-).

 History of Family Disease

There are no family member that have same complain like the
patient
 History of Treatment
The patient carried to RISA GH for this complain. For
the chronic cough, the parents often come to PHC.
 History of Allergy:

None
 History of social
Father is an active smoker.
General Status
General Composure : weak
GCS: E4 V5 M6
 Pulse Rate: 110 bpm,

 Respiratory Rate: 24 tpm,

 Temperature: 36,8 C.

 Spo2 : 99%
 Eye : anemic -/-, icterus -/-
 Neck : lymph node not palpable, JVP not
evaluated. Stiff neck (+)
 Thorax :
Cor : Single S1 S2, Reguler, Murmur (-), Gallop (-)
Pulmo : Ves +/+, Rh -/-, Whez -/-
 Abdomen
Inspection : distension (-)
Auscultation bowel sound (+) 10x/ minutes
Percussion: timpanic all regio of abdomen
Palpation: hepar and lien are not palpable. Pain (+) at
epigastric regio
 Extremity : warm (+), sianosis (-), edema (-/-)
LABORATORY EXAMINATION
 Complete Blood Count 3/12/2017
Hb 11,3
HCT 32,5
WBC 3,93
PLT 7
LABORATORY EXAMINATION
 Complete Blood Count 5/12/2017
Hb 9,2
HCT 32,5
WBC 5,01
PLT 463
Electrolyte 3/12/17
Na 152
K 2,4
Cl 98
Electrolyte 4/12/17
Na 132
K 2,1
Cl 100
Mg 1,8
 Blood gas Analysis 31/10/17
pH 7,45
pCO2 32
pO2 288
BE -2
Electrolyte 6/12/17
Na 129
K 4,1
Cl 101
 Faal Hemostasis 3/12/17
PPT 14,8
APTT 14,8
KPPT 13,03
KAPTT 36,1
 Liver Function and others 3/12/17
SGOT 23
SGPT 18
Albumin 4,3
WBG 88
 Blood Culture 4/12/17 : none
 Thorax Rontgen: Bronchopneumonia susp. TB
(5/12/17)
DIAGNOSE
 Meningitis
 Bronchopneumonia
 S. Sepsis
 Therapy
Fluid:
 IVFD D5 ½ NS 10 dpm micro

 Ranitidin 20 mg/ 12 hours I.V

 Omeprazole 20 mg / 24 hours IV

 Gentamicyn 120 mg/ 24 hours I.V

 Cefotaxim 250 mg / 6 hours I.V

 Milk 8 x 30cc
FOLLOW UP (7-12-2017)
General Status
S/ Seizure (+), Uncounciesness
General Composure : severe
GCS: E1 V1 M2
 Blood Pressure : 117/64 mmHg

 Pulse Rate: 80 bpm,

 Respiratory Rate: 22 tpm,

 Temperature: 36,7 C.

 Spo2 : 99%
DIAGNOSE
 Stroke Infarct Brain Stem
 Therapy
Fluid:
 IVFD D5 ½ NS 750 cc/24 hr

 Vancomycin 1 g/12 hours

 Citicolin 500 mg/ 8 hours I.V

 Prosogan 1 A / 12 hours IV

 Novorapid 3 x 4 IU

 Curcuma 3 x 1

 Folic Acid 3 1
FOLLOW UP (11-01-2018)
General Status
S/ Seizure (+), Uncounciesness
General Composure : severe
GCS: E1 V1 M2
 Blood Pressure : 117/64 mmHg

 Pulse Rate: 80 bpm,

 Respiratory Rate: 22 tpm,

 Temperature: 36,7 C.

 Spo2 : 99%
DIAGNOSE
 Stroke Infarct Brain Stem
 Therapy
Fluid:
 IVFD D5 ½ NS 750 cc/24 hr

 Vancomycin 1 g/12 hours

 Citicolin 500 mg/ 8 hours I.V

 Prosogan 1 A / 12 hours IV

 Novorapid 3 x 4 IU

 Curcuma 3 x 1

 Folic Acid 3 1
FOLLOW UP (12-01-2018)
General Status
S/ Uncounciesness
General Composure : severe
GCS: E1 V1 M1
 Blood Preassure : 120/80 mmHg

 Pulse Rate: 92 bpm,

 Respiratory Rate: 20 tpm,

 Temperature: 36,7 C.

 Spo2 : 99%
DIAGNOSE
 Stroke Infarct Brain Stem
 Pneumonia
 SVT
 Therapy
Fluid:
 IVFD D5 ½ NS 750 cc/24 hr

 Vancomycin 1 g/12 hours

 Citicolin 500 mg/ 8 hours I.V

 Prosogan 1 A / 12 hours IV

 Novorapid 3 x 4 IU

 Curcuma 3 x 1

 Folic Acid 3 1
Thank You