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Presented by :Silvia P. Tarigan
Counsellor :H. Tisna Sukarna, dr., SpA, MBA
PATIENT IDENTITY Name : M Rafif Lathif
Age : 1 month old
Sex : Male
Date of hospitalized : January, 16th 2011
Date of examination : January, 16th 2011
Father : Name : Mr. Beni H
Age :36 years old
Education : Senior High School
Occupation :Entrepreneur
Address :
Sukamukti RT 3 RW 5, Katapang Bandung.
Mother : Name : Mrs. Siti M
Age :35 years old
Education : Senior
High School
Occupation : Housewife
Address : Sukamukti RT 3 RW 5, Katapang Bandung.
Heteroanamnesis was given by his mother on January, 16 th 2011
Chief complaint: convulsion
History of present illness:
One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patient’s mother denied any historical information of falling from a baby box.
2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.
The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patient’s mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patient’s mother also said that the baby had not been given Vitamin K injection when the baby was born
Urine: the color, volume, and frequency was normal and no pain when urinate.
Defecation : the color, consistency, and frequency was normal
Medical Effort: 1 day ago went to the midwife and got some medicine.
Past Medical History: the patient never had sick like this before.
History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever
Birth History The patient is the 3rd child from 3 children. No
stillbirth and no abortus.
Birth : aterm, spontaneous, directly cry and helped by a midwife.
Birth weight : 3500 grams. Birth length : 52 cm
Physical and Intelligence Development Turn over : - Sitting down : - Standing up : - Talking : - Walking : -
Immunization
VaccineBasic Vaccination
Booster Vaccination
RecommendedVaccination
BCG - - - - HiB : none
Polio - - - - - - MMR : none
DPT - - - - - - Hep A : none
Hep B - - - - - - Varicella : none
Measles - - - - Typhim/typha : none
Influenzae : none
Nutrition and Feeding Breastmilk
Past Illnesses Cough
Family history : Convulsion
General appearance Condition : severe sickness Consciousness : somnolen Activity and position : no force position General condition : weak
Vital signs Pulse : 143 times a minute, regular, equal,
strong
Respiration : 36 times a minute, thoracoabdominal type
Temperature : 35,7 ºC, aksiler
Measuring Weight : 4,9 kg Height : 65 cm (113,95 % standard Weight/Age ) (119,04 % standard Height/Age )
Nutrition status : (standard Weight/Height ) Rumple Leede : (-)
SYSTEMATIC EXAMINATION
4.1. Skin : rash (-), pale (+), icteric (+), turgor was immediately returns to normal position
Head Hair : black, disseminated, not easy to yanked out Fontanel ² : tense Eyes : conjunctiva anemic +/+, conjungtiva
hyperemic -/-, sclera icteric +/+, pupil anisokor (diameter pupil sinistra > dextra), light reflex : -/-
Nose : nostril breathing+/+, secret -/-, epistaxis -/-
Lips : wet, cyanosis + Mouth : moist mucosa Gums : no bleeding, no hyperemic Palate : no disparity Tongue: coated tongue -, hyperemic -, tremor –,
Koplik’s spot – Pharynx and tonsil : hyperemic -, T1=T1
Neck Nuchal rigidity : (-) Lymph node : not palpable
Thorax Lungs Inspection : shape and movement was simetric, right
was equal to left, retractions supraclavicle +
Palpation : vocal fremitus right was equal to left Auscultation : vesicular breath sound +/+, ronchi
-/-, wheezing -/- Heart Inspections : ictus cordis was not seen Palpations : ictus cordis was palpable at ICS 4
linea midclavicularis sinistra
Percussions : border on top ICS 2 linea parasternalis sinistra, border on left ICS 4 linea midclavicularis sinistra, border on right ICS 3 linea sternalis dextra
Auscultations : heart sounds regular, shuffle –
Abdomen : Inspections : flat Auscultations : bowel sound (+) Percussions : tympanic, Traube’s space : tympanic Palpations : , liver 4 cm below arch costarum,
tenderness (-), skin’s turgor was immediately returns to its normal position.
Liver and spleen inpalpable
Genital : male, normal Anus & Rectal: no disparity Extremities : no disparity Upper : left: active, right : active Lower : left: active, right: active Joint : no disparity Muscle : hypertrophy -, atrophy - Neurological Examination Reflex : physiological -/-, pathological +/+
On January 16,2011 On January 17,, 2011
22
Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑
Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑
Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L ↓K : 4,6 mEq/L
Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl
Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L ↓K : 4,6 mEq/L
Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl
CT- scan
On 16 January,2011
Trail:
Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.
1 month old boy, with 4,9 kg body weight, 60m body height, nutritional status (standard Weight/Height) came to Immanuel Hospital because convulsion.
One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patient’s mother denied any historical information of falling from a baby box.
2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.
The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patient’s mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patient’s mother also said that the baby had not been given Vitamin K injection when the baby was born
Urine: the color, volume, and frequency was normal and no pain when urinate.
Defecation : the color, consistency, and frequency was normal
Medical Effort: 1 day ago went to the midwife and got some medicine.
Past Medical History: the patient never had sick like this before.
History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever.
Immunization profile: the patient haven’t receive all basic immunization.
Nutrition status : (standard Weight/Height)
General appearance Condition : severe sickness Consciousness : somnolen Activity and position : no force position General condition : weak
Vital signs Pulse : 143 times a minute, regular, equal,
strong
Respiration : 36 times a minute, thoracoabdominal type
Temperature : 35,7 ºC, aksiler
Skin : rash (-), pale (+), icteric (+), turgor was immediately returns to normal position
Head Eyes : conjungtiva anemic +/+, sklera ikteric +/+,
light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra
Fontanel ² : tense Nose :nostril breathing+/+, secret -/-, Mouth : moist mucosa Tongue : Koplik’s spot – Pharynx and tonsil : hyperemic -, T1=T1
Neck Lymph node : not palpable
Thorax Lungs retractions supraclavicle + vesicular breath sound +/+, ronchi -/-, wheezing -/-
Abdomen
Liver 4 cm below arch costarum
On January 16,2011 On January 17,, 2011
32
Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑
Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑
Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L ↓K : 4,6 mEq/L
Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl
Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L ↓K : 4,6 mEq/L
Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl
CT- scan
On 16 January,2011
Trail:
Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.
Differential Diagnosis : Intracranial hemorrhage
Increased in Intracranial Pressure
Sepsis neonatorum
Working diagnosis :Intracranial hemorrhage (subdural and intraserebral hemorrhage)
Additional diagnosis : Anemia, Hiperbilirubin neonatus, hiperglikemia neonatorum
Serial Lumbar Punctures Blood gas analysis CT Scan USG
Quo ad vitam : dubia ad bonam Quo ad functionam : dubia ad bonam
Non Medicamentous Treated in the PICU Fluid : Ringer Lactat 500cc / 24 hour O2 nasal 2Lpm Fasting
Medicamentous Amoxicillin : 3 x 500 mg iv Kalmethason : 2 x 1 mg iv Garamicine : 2 x10 mg iv Mannitol : 3 x 10 cc, drip Vit K : 2 x 1 mg, IM every day ( during 5 day) Diazepam : 1 mg prn PRC 50 cc during 3 hours FFP 50 cc during 3 hours
Jan 16 th, 2011 Subjective:
Groan (+) Convulsion (+) Pale (+)
Objective: Sklera ikteric (+/+), pupil
anisokor ( diameter pupil sinistra> dextra)
Skin : pale (+), ikteric (+) Fontanel ² : tense Bradipnoe RR:12 x/m SpO2 : 97 % Nastril breath +/+,
retraction +/+
Therapy
02 nasal 2 lpm Fluid : RL 500cc /24h Fasting Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Diazepam 1 mg Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during 5
days Transfussion PRC 50 cc
during 3 hours Plan to transfussion FFP 50
cc during 3 hours
Jan 17th, 2011 Subjective:
Groan (-) Convulsion (+) Cry (+)
Objective: Sklera ikteric (+/+),
pupil anisokor ( diameter pupil sinistra> dextra)
Skin : ikteric (+) Fontanel : tense SpO2 : 100 % Nastril breath -/-,
retraction -/-
Plan: 02 nasal 2 lpm Diet : fasting IVF : Aminofuchsin ped
100cc/hour, D5 %+ valium 15 mg 400 cc/24 hour
Transfusi WB 50 cc Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg
iv Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during
5 days
Jan 18th, 2011 Subjective:
Convulsion (+) Objective:
Sklera ikteric (+/+), pupil anisokor ( diameter pupil sinistra> dextra)
Skin : ikteric (+) Fontanel : tense SpO2 : 100
%,spontaneus breathing
Nastril breath -/-, retraction -/-
Plan: Craniotomy
Diet : fasting IVF : Aminofuchsin ped
100cc/hour, D5 % 400 cc/24 hour
Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg
iv Kalmethason 2x1 mg Mannitol 3 x 10 cc, drip Phenitoin 2x 25 mg Diazepam 1 mg prn Vit K : 1 mg IM
Jan 19th, 2011 Subjective:
Convulsion (+) Eyelash (+) General condition :
improve Objective:
Sklera ikteric (+/+), pupil isokor , light reflex +/+
Skin : ikteric (+) Fontanel : soft spontaneus breathing Nastril breath -/-,
retraction -/-
Plan : Diet : D5 % 6 x 10 cc KaEN 1 B 100 cc Aminofucsin 100 cc
Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Kalmethason 2x1 mg Phenitoin 2x 25 mg Vit K : 1 mg IM Novalgin 4x 50 mg Valium 1mg prn
The Diagnosis of based Intracranial Hemorrhage In the Newborn
on :
Anamnesis : Patient was 1 month year old Convulsion wasn’t preceded by fever never cry again since seizures vomitting ikteric had not been given Vitamin K injection when the baby was born. The big brother of patient had experience the convulsion at the
age of 6 months old
Physical Diagnostic Skin : pale (+), ikteric (+) Fontanel : Tense Eyes : conjungtiva anemic +/+, sklera ikteric +/+,
light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra
Nose : Nostril breathing (+) Thorax : retractions supraclavicle +
CT Scan :
subdural and intraserebral haemorrhage
Vitamin K is one of the essential vitamins. The letter K in vitamin K actually comes from the word
"Koagulations", that means coagulation or clotting.
Without vitamin K, blood would be unable to clot. Deficiencies in vitamin K lead to clotting disorders,
bruising, and other blood disorders.
a coagulation disturbance in newborns due to vitamin K deficiency. As a consequence of vitamin K deficiency there is an impaired production of coagulation factors II, VII, IX, X, by the liver
Causes
Newborns are relatively vitamin K deficient for a variety of reasons. They have low vitamin K stores at birth, vitamin K passes the placenta poorly, the levels of vitamin K in breast milk are low and the gut flora has not yet been developed (vitamin K is normally produced by bacteria in the intestines).
Brain tumors Bleeding (hemorrhage) or blood clots (hematomas) from
injuries (subdural hematoma or epidural hematomas) Weaknesses in blood vessels (cerebral aneurysms) Damage to tissues covering the brain (dura) Pockets of infection in the brain (brain abscesses) Epilepsy
Definition Bleeding in the cranial cavity and its contents in infants
from birth until age 4 weeks.
Intracranial Hemorrhage includes epidural, subdural, subarachnoid, intra serebral/parenkim dan intraventrikuler hemorrhage
Epidemiology from 5 to 15 %, with a mortality of from 40 to 50 % low birth weight infants, weighing less than 1500 g)
Etiology
The chief cause is trauma Breech extraction, in which rapid or forceful delivery of the
after-coming head produces the injury. Precipitate labors, where there is sudden compression of
the head. Very difficult or prolonged labors, where there is excessive
molding of the head with injury. Instrumental deliveries
Cause not trauma• Prematurity of the infant
Grade I: hemorrhage limited to the germinal matrix (subependymal hemorrhage)
Grade II: hemorrhage which has extended into the ventricular system but without dilation of the lateral ventricles
Grade III: hemorrhage extending into the ventricular system with the blood resulting in ventricular dilatation
Grade IV: hemorrhage which extends into the brain tissue (this grade is also referred to as PVH and associated with intraparenchymal echodensity (IPE) by some
Epidural hemorrhage (extradural hemorrhage) which occur between the durameter and the skull, is caused by trauma It may result from laceration of an artery, most commonly the middle meningeal artery dangerous type of injury because the bleed is from a high-pressure system and deadly increases in intracranial pressure can result rapidly
Subdural hemorrhage results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater
Subarachnoid hemorrhage which occur between the arachnoid and pia meningeal layers, can result either from trauma or from ruptures of aneurysms or arteriovenous malformations
Intraventrikuler hemorrhage↓
hypoxia ↓
vasodilatation blood vessel of the brain and venous congestion
↓increase blood flow
↓ elevated pressure of the brain blood
↓ Easily Ruptur
Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive :
Alteration in level of consciousness (approximately 50%) Nausea and vomiting (approximately 40-50%) Headache (approximately 40%) Seizures Focal neurological deficits Cephalic cry Snake like flicking of the tongue Expiratory grunting
Physical exam:
unconscious individual should quickly assess the adequacy of the airway, breathing, pulse, and blood pressure before beginning a more detailed neurological and physical exam.
The latter includes an evaluation of level of consciousness, pupil response and vital signs, motor function, reflexes, and memory.
Serial Lumbar Punctures Blood gas analysis CT Scan USG
Treated in the incubator that allows continuous observation and O2 delivery
It should be observed carefully: body temperature, degree of consciousness, pupil size and reaction, motor activity, respiratory frequency, heart frequency, pulse rate and diuresis.
Keeping the airway to remain free.The baby lies on his side
Vitamin K and blood transfusions may be considered.
Valium / luminal if convulsion, valium dose from 0.3 to 0, 5 mg / kgBB
Corticosteroids such as dexamethasone 0.5 to 1 mg/kgBB/24 hours that have good effect against hypoxia and brain edema
Antibiotics can be given to prevent secondary infection Lumbar puncture to reduce intracranial pressure,
bleeding, prevent obstruction likuor flow and reduce the effects of irritation on the surface of the cortex
Emergency surgery Craniotomy
Staging I, II : mild Staging III, IV : severe
Intracranial hemorrhage is a serious medical emergency because the build up of blood within the skull can lead to increases in intracranial pressure
Severe increases in intracranial pressure can cause potentially deadly brain herniationin