CASE

A, Male, Age 5 months 23 days, BB = 6630 gr, PB = 67 cm, Address in Desa Bukit Satu Securai
Utara Subdistrict Babalan Langkat came to RSUP Haji Adam Malik Medan on 01 June 2017 the
main complaint of decreasing awareness.

It is experienced by the patient since 1 week before hospital admission, decreased consciousness
begins with diarrhea, since 8 days, frequency> 3 x / day, more water from dregs, mucus (+),
blood (-) and accompanied by fever since 7 days before admission to hospital, fever is up and
down with febrifuge. When in the ER patient in a state of fever.
• Seizures (+) are experienced by patients 7 days before hospital admission, frequency 5 x / day,
duration <15 min / x seizure, when the seizures are wide-eyed, hands and feet clasped, after the
patient's seizures are unconscious.
• Cough (+) since 7 days before admission
• BAK (+) is normal

Pregnancy history: maternal age at 30 years of pregnancy, the patient is the first child.
History of fever during pregnancy (+), history of taking medication (+)
That is procold and bodrex, history of drinking herbs (+).
Birth History: The patient is the first child, born spontaneously in the midwife
With BBL = 2000 gr, PBL = 50 cm.
Immunization history: BCG (+), DPT 2 times (incomplete impression)
History Growth: The patient is biased face down
Feeding history:
0-3 months: breast milk ± 8 x / day
3 months - present: cerelac 2 x / day and formula milk 8 times / day
RPO: O2 1-2 l / min, IVFD RL 36 gtt / min macro, Inj. Rititidine
8 mg / 8 hours, Paracetamol drips 70 mg / 8 hours
RPT: The patient is a referral from Tanjung Pura Hospital by SpA with
Diagnosis: Ensefalolapati Dengue
Physical examination
Presence Status: Sensoryum: GCS 9 (E5V3M4) Temperature: 40 ⁰C
Anemis (-), dyspnoe (-), cyanosis (-), edema (-)
Localization Status:
Head: Eye: Light Reflex (+ / +), Pupil isokor, Conjunctiva Palpebra
Pale Inferior (- / -), Ear / Nose / Mouth: dbn / O2 nasal kanul /
NGT attached greenness (+)
Thorax: Symmetrical Fusiformis, retraction (-)
HR: 152 x / min, regular, sigh (-)
RR: 42 x / min, regular, ronchi (- / -)
Abdomen: soepel, peristaltic (+) N, liver / lien: not palpable
Extremities: Pulse: 152 x / min, regular, T / V enough, warm acral , CRT <3 sec
Anogenital: Male, within normal limits

Diagnosis: Meningitis

Laboratory Results (01 June 2017)

Types of Checking Results Normal value

Blood Complete
Hemoglobin 10.8 g / dL 10.5-13.1 g / dL
Erythrocyte 4.08 x 106 / mm3 3.60 - 5.20 x106 / mm3
Leukocyte 3.150 / mm3 6000-17.500 / mm3
Hematocrit 33% 35-43%
Calculate Type
Neutrophil 45.20% 25.00 - 60.00%
Lymphocytes 32.90% 25.00 - 50.00%
Monocyte 16.50% 1.00 - 6.00%
Eosinophils 5.40% 1.00 - 5.00%
Basofil 0.00% 0.00 - 1.00%
Blood gas analysis
PH 7,360 7,35 - 7,45
 PCO2 30 mmHg 36- 42 mmHg
PO2 191,0 mmHg 85 - 100 mmHg
Bicarbonate (HCO3) 16.9 U / L 22- 26 U / L
Total CO2 17.8 U / L 19 - 25 U / L
Excess Bases (BE) -7.4 U / L (-2) - (+2)
O2 Saturation 100% 95 - 100%
Carbohydrate metabolism
Blood glucose When 469 mg / dL 40 - 60 mg / dL
Electrolyte
Sodium 144 mEq / L 135- 156 mEq / l
Potassium 2.4 mEq / L 3,6 - 5,5 mEq / L
Chloride 106 mEq / L 95 - 106 mEq / L

Differential Diagnosis:
• Meningoencephalitis
• Encephalitis

Temporary Diagnosis:
• Meningitis

Therapy :
• O2 1-2 l / min
• IVFD RL 36 gtt / min macro
• Inj. Ranitidine 8 mg / 8 hours
• Paracetamol drips 70 mg / 8 hours

Plan:
- CT scan
- Complete blood check, AGDA, Re-electrolyte check
- Lumbal punction
 FOLLOW UP

June 2, 2017
S: Decreased Awareness (+), fever (+), diarrhea (+)
O: Sens GCS 10 (E2M5V3) T = 37.5 ⁰C
Head = UUB open flat
Eyes = RC + / +, pale inferior palpebral conjunctiva - / -
T / H / M = dbn / PCH (-), O2 nasal canule (+) / dbn
Chest = Symmetrical Fusiformis, retraction (-), HR: 104x / min, regular, wheeze (-)
RR: 24x / min, regular, ronchi (- / -)
Stomach = Soepel, peristaltic (+) N, H / L: ttb
Extremities = warmer acral, T / V enough, CRT <3 "
A: DD / CNS infection ec - Meningitis + GE without dehydration
- Meningoencephalitis
- Dengue encephalopathy
P: O2 nasal kanul 0.5 lpm
Head Elevation 30⁰ midline position
IVFD NaCl 0.9% tpm micro
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. Paracetamol 80 mg / 8 hours / IV
Diet Milk SGM = 80 cc / 3 hour / NGT

Laboratory Results (June 2, 2017)

Types of Checking Results Normal Value

Blood Complete
Hemoglobin 10.6 g / dL 10.5 - 13.1 g / dL
Erythrocyte 4.01x106 / mm3 3.60 -5.20 x106 / mm3
Leukocyte 8.430 / mm3 6000 - 17.500 / mm3
Haematocrit 32% 35 - 43%
Platelets 184,000 229,000 - 553,000
Calculate Type
 Neutrophils 41.60% 25.00 - 60.00%
Lymphocytes 38.0% 25.00 - 50.00%
Monocyte 15.50% 1.00 - 6.00%
Eosinophils 4,70% 1,00 - 5,00%
Basofil 0.20% 0.00 - 1.00%
Absolute neutrophil 3.50x103 / mm3 1.9 - 5.4x103 / mm3
Absolute lymphocyte 3.20x103 / mm3 3.7-10,7x103 / mm3
Absolute monocyte 1.31x103 / mm3 0,1-0,8x103 / mm3
Eosinophil absolute 0.40x103 / mm3 0.20-0,50x103 / mm3
Absolute basophil 0,02x103 / mm3 0-0,1x103 / mm3
Carbohydrate metabolism
Blood glucose During 69 mg / dL 40 - 60 mg / dL
Electrolyte
Calcium 7.20 mg / dl 8.4-10.2 mg / dl
Sodium 140 mEq / L 135- 156 mEq / l
Potassium 2.8 mEq / L 3,6 - 5,5 mEq / L
Chloride 103 mEq / L 95 - 106 mEq / L

Immunoserology
Virus
IgM Anti Dengue Negative
Anti Dengue IgG Negative
Autoimmune
Quantitative CRP 0.7 mg / dl <0.7
Another test

Procalcitonin 4,65 ng/dl <0,05

June 3, 2017
S: fever (+), decreased awareness (+)
O: Sens GCS 13 (E4V4M5) T = 38⁰C BB = 7.7 kg
Head = Ubun the large crown open flat. Eyes RC + / +, isokor pupils,
 Conjuncral palpebral inferior pale - / -
Chest = Symmetrical fusiformis, retraction (-)
HR: 120x / minute, regular, murmur (-)
RR: 28x / min, regular, ronchi - / -
Stomach = Soepel, peristaltic (+) N, H / L: ttb
Extremities = pulse: 120x / min, regular, T / V enough, warm acral , CRT <3 "
A: CNS infection ec DD / Meningitis + GE without dehydration
Meningoencephalitis
P: O2 nasal kanul 1 lpm
IVFD kaen 38 32 cc / hr
Inj. Ceftriaxone 400 mg / 12hour / IV
Inj. PCT 10 cc / 6 hour / IV
Diet SGM / ASI 50 cc / 3jam / OGT

June 4, 2017
S: fever (+), decreased awareness (+)
O: Sens GCS 13 (E4V4M5) T = 35⁰C
Head = UUB open flat. RC + / + eye, isokor pupil, inferior papular conjunctiva
pale -/-
Chest = Symmetrical Fusiformis, retraction (-)
HR: 122x / minute, regular, sigh (-)
RR: 22x / min, regular, ronchi (-)
Stomach = Soepel, peristaltic (+) N, H / L: ttb
Extremities = pulse: 122x / min, regular, T / V enough, warm acral
A: CNS infection ec DD / Meningitis + GE without dehydration
Meningoencephalitis
P: O2 nasal canule 1 lpm
IVFD Kaen 38 32 cc / hr
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. PCT 10cc / 6 hours / IV
 Diet SGM / ASI 80 cc / 3 hours / OGT

Laboratory Results (June 4, 2017)

Types of Checking Results Normal Value

Liver
Albumin 2.4 g / dl 3.5-5.0 g / dl

5 June 2017
S: Fever (+), decreased awareness (+)
O: Sens GCS 13 (E4M5V4) T = 37.5⁰C
Head = UUB open flat. RC + / + eye, isokor pupil, inferior papular conjunctiva
pale -/-
Chest = Symmetrical Fusiformis, retraction (-)
HR: 122x / minute, regular, sigh (-)
RR: 20x / min, regular, ronchi (-)
Stomach = Soepel, peristaltic (+) N, H / L: ttb
Extremities = pulse: 122x / min, regular, T / V enough, warm acral
A: CNS infection ec DD / Meningitis + GE without dehydration
Meningoencephalitis
P: O2 nasal canule 1 lpm
IVFD Kaen 38 32 cc / hr
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. PCT 10cc / 6 hours / IV
Diet SGM / ASI 80 cc / 3 hours / OGT

Laboratory Results (5 June 2017)

Types of Checking Results Normal Value

Blood Complete
Hemoglobin 10.7 g / dL 10.5 - 13.1 g / dL
 Erythrocyte 4,04x106 / mm3 3,60 -5,20 x106 / mm3
Leucocytes 14.600 / mm3 6000 - 17.500 / mm3
Haematocrit 32% 35 - 43%
Platelets 466.000 229.000 - 553.000
Calculate Type
Neutrophils 20.50% 25.00 - 60.00%
Lymphocytes 58.70% 25.00 - 50.00%
Monocyte 16.40% 1.00 - 6.00%
Eosinophils 2.20% 1.00 - 5.00%
Basofil 0.20% 0.00 - 1.00%
Neutrophil absolute 2.99x103 / mm3 1.9 - 5.4x103 / mm3
Absolute lymphocyte 8.57x103 / mm3 3,7-10,7x103 / mm3
Absolute monocyte 2.69x103 / mm3 0.1-0,8x103 / mm3
Eosinophil absolute 0.32x103 / mm3 0.20-0,50x103 / mm3
Absolute basophil 0,03x103 / mm3 0-0,1x103 / mm3
Liver
Albumin 3.3 g / dl 3.5-5.0 g / dl
Electrolyte
Calcium 7.90 mg / dl 8.4-10,2 mg / dl
Sodium 139 mEq / L 135- 156 mEq / l
Potassium 3.3 mEq / L 3,6 - 5,5 mEq / L
Chloride 107 mEq / L 95 - 106 mEq / L

June 6, 2017
S: Fever (+), decreased awareness (+)
O: Sens GCS 13 (E4M5V4) T = 37.5⁰C
Head = UUB open flat. RC + / + eye, isokor pupil, inferior papular conjunctiva
pale -/-
Chest = Symmetrical Fusiformis, retraction (-)
HR: 102x / min, regular, wheeze (-)
RR: 22x / min, regular, ronchi (-)
 Stomach = Soepel, peristaltic (+) N, H / L: ttb
Extremities = pulse: 102x / min, regular, T / V enough, warm acral
A: CNS infection ec DD / Meningitis + GE without dehydration
Meningoencephalitis
P: O2 nasal canule 1 lpm
IVFD Kaen 38 32 cc / hr
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. PCT 10cc / 6 hours / IV
Diet SGM / ASI 80 cc / 3 hours/ OGT