Tuberculous Meningitis

7/21/2019 Tuberculous Meningitis

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History of disease:

AS, a 11 month old boy, with 6,5 kg of BW

and 66 cm of BH, came to Haji Adam MalikGeneral Ho!ital Medan on 1"th #o$ember at""%&' with dy!nea a chief com!laint% (he!atient ha$e been e)!erienced thi abo*t 1week before admitted to ho!ital% +y!neawa not directed with weather and acti$ity%

yanoi -./, !atient alo e)!erienced co*gh ince " week ago followed by !*t*m%

Hitory of contact with ad*lt co*gh -./%



0e$er ha been e)!erienced by!atient ince " week and the bodytem!erat*re rie and dro!%

Shi$ering wa not fo*nd%

omiting -./ and na*ea -./%+efecation and *rination i normal%Hitory of weight looe i not fo*nd%



Hitory of medication



Hitory of birth(



)hyical *+amination

)reenttat(

Senori*m 2 M, body tem!erat*re2 &3,64, H2 1&b!m, 2 57 )8i, BW2 6,5 kg, BH2 66 cm, BW8A2 9 core :.& , B;8A2 9 core : .&,BW8B;2 .1: 9 core : .", anemic -./, icteric -./, dy!nea-</, cyanoi -./, edema -./%

-ocali.edtat(

Head 2•0ace 2 within normal range

•=ye 2 light re>e) <8<, iochoric !*!il, !ale inferior!al!ebral conj*ncti$a .8., *!erior and inferior!al!ebra , edema.8.•=ar 2 within normal range•

#oe 2 naal >aring•Mo*th 2 within normal range



•#eck 2 lym!h node enlargement -./• (hora) 2 Symmetrical f*iform, retraction intercotaland e!igatric -</, H2 1& b!m, reg*lar,m*rm*r -./,

2 57)8i, reg*lar, ronchi -<8</,whee?ing -.8./

•Abdomen 2 Symmetric, *!!le, normal !eritaltic,li$er and !leen2 normal•=)tremitie 2 !*le 1& b!m reg*lar, ade@*ate !8$,

felt warm,( : &

++ . bronko!ne*monia . bronchioliti

Working

diagnoi



;aboratory 0inding

/et 0elt nit 0eferenceHemoglobin %"' gC 11%&.17%1

=rythrocyte &%51 1'68mm& 7%7'.7%7

;e*cocyte 1%37 1'&8mm& 6%'.13%5

(hrombocyte "6& 1'&8mm& "13.73

Hematocrite "%3' C &3.71

=oino!hil '%5' C 1.6

Bao!hil '%5'' C '.1

#e*tro!hil 51%'' C &3.'

;ym!hocyte &%' C "'.7'

Complete blood analysis (12th November 2015 / 23.03)

M 1' C "



Monocyte %1' C ".

#e*tro!hil

abol*te

1'%' 1'&8D; 1%.5%7

;ym!hocyte

abol*te

3% 1'&8D; &%3.1'%3

Monocyte

abol*te

1%5 1'&8D; '%&.'%

=oino!hil

abol*te

'%' 1'&8D; '%"'.'%5'

Bao!hil abol*te '%1' 1'&8D; '.'%1

M 1%' f; 1.5

MH "6%"' Eg "5."

MH &"%1' gC ".&1

Blood Gl*coe 31%3' mg8d; : "''

rbohydrate Metabolim



Fre*m 17%3' mg8d; : 5'

reatinine '%"& mg8d; '%"7.'%71

enal 0*nction

ali*m %& mg8d; %7.1'%7

#atri*m 1&6 m=@8; 1&5.155

Eotai*m 5%& m=@8; &%6.5%5

hloride 1'' m=@8; 61'6

lectrolyte

Erocalcitonin '%7" mg8d; : '%'5

ther(et



!H 3%155 3%&5.3%75

!" &%3 mmHg &.7"

!" 133%5 mmHg 5.1''Bicarbonate

-H&/

1&%7 mmol8; "."6

(otal " 17%5 mmol8; 1."5

Bae =)ce -B=/ .17%5 mmol8; -."/ -<"/" Sat*ration % C 5.1''

Ga bloodanalyi





• "

1." ;8 min $ia naal cann*la

• J0+ +5C #al ',""5C "5 gtt8menit-micro/

•

0l*id challenge 1' cc8kgBB -65 cc/• Jnj eftria)one &'' mg8 1" ho*r 8i$

• Earacetamol &) cth 18"

/hera!y

1&th # b "'15



1&th #o$ember "'15

S +y!nea-</

2 Senori*m2 M, (em!2 &3,"4, BW2 6,5 kg, BH2 66 cm

Head 2 0ontanella Major wa cloed =ye 2 ;ight re>e) -<8</, iochoric !*!il, !aleinferior conj*ncti$a !al!ebra -.8./, cleraicteric -.8./ =ar 2 within normal range #oe 2 naal >aring

Mo*th 2 within normal range #eck 2 lym!h node enlargement -./ (hora) 2 ymmetrical f*iform, retraction -</

intercotal, e!igatric H2 17' b!m, reg*lar, m*rm*r -./ 2 5")8i, reg*lar, ronchi -<8</,whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2no !al!able

2--2W )



A 44Bronco!nemonia Bronchioliti

) " 1 ;8min naal can*le

J0+ +5C #al ',""5 C "5gtt8i -micro/Earacetamol &) 35 mg

Jnj Am!icilin 16' mg86hJnj Gentamycin 7' mg8"7h#eb*le entolin 1 re!*l< #al , C 86hMeylon " m=@, K doi J2 17 m=@ meylon in 1''cc +5C in 7 ho*r+iet S* 65' kkal and 1& gr !rotein

1&th #o$ember "'15



1&th #o$ember "'15

S dy!nea LL, fe$er -</

2 Senori*m2 GS 1& -=7, &, M6/ , ( &, 4 (hora)2 Simetri 0*iformi, retraki -</ e!igatrialH2 165)8i, reg, m*rm*r -./2 65)8i, reg, tridor -</, ronchi -</

) #eb*le entolin 1 re!*l< #al ',C 8 h

0 Check blood gas analysis Check electrolite post correction

Ad$ie from dr% Wiman +alim*nthe, S!AM*colitic 2G= & ) K tab -!*l$/Analgetic Earacetamol2 7 ) 1' mg -!*l$/

t ""%&'

a oo ana y o$em er



a oo ana y o$em er"'%5/

arbohydrate Metabolim

Blood Gl*coe 1'%& mg8d; : "''

=lectrolyte

ali*m %' mg8d; %7.1'%7

#atri*m 1&5 m=@8; 1&5.155

Eotai*m 7% m=@8; &%6.5%5

hloride 1'" m=@8; 61'6

!H 3%7"3 3%&5.3%75

!" "3% mmHg &.7"

!" 165%' mmHg 5.1''

Bicarbonate -H&/ 1%' mmol8; "."6

(otal " 1% mmol8; 1."5

Bae =)ce -B=/ .5%5 mmol8; -."/ -<"/

" Sat*ration %7 C 5.1''



1th #o$ember "'15



1th #o$ember "'15

S +y!nea-</

2 Senori*m2 M, (em!2 &34, BW2 6,5 kg, BH2 66 cm

Head 2 0ontanella Major wa cloed=ye 2 ;ight re>e) -<8</, iochoric !*!il, !ale inferior conj*ncti$a!al!ebra -.8./, clera icteric -.8./=ar 2 within normal range#oe 2 naal >aringMo*th 2 within normal range

#eck 2 lym!h node enlargement (hora) 2 ymmetrical f*iform, retraction -</ intercotal, e!igatricH2 17' b!m, reg*lar, m*rm*r -./ 2 5')8i, reg*lar, ronchi -<8</, whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2 no !al!able=)tremitie 2 !*le 17' b!m, reg*lar, ade@*ate !8$ , felt warm, ( :

&

2--2W )






Jnj Am!icilin 16' mg86 jam8i$Jnj Gentamycin 7' mg8"7 jam8i$Jnj +e)ametaon ",5 mg8 jam8i$#eb*le entolin 1 re!*l< #al , C 8 jam+iet S* 65' kkal dengan 1& gr !rotein

15th #o$ember "'15



15th #o$ember "'15

S +y!nea-</

2 Senori*m2 M, (em!2 &3,14, BW2 6,5 kg, BH2 66 cm

Head 2 0ontanella Mayor wa cloed=ye 2 ;ight re>e) -<8</, iochoric !*!il, !ale inferior conj*ncti$a!al!ebra -.8./, clera icteric -.8./=ar 2 within normal range#oe 2 naal >aringMo*th 2 within normal range

#eck 2 lym!h node enlargement (hora) 2 ymmetrical f*iform, retraction -</ intercotal, e!igatricH2 1& b!m, reg*lar, m*rm*r -./ 2 76)8i, reg*lar, ronchi -<8</, whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2 no !al!able=)tremitie 2 !*le 1& b!m, reg*lar, ade@*ate !8$ , felt warm, ( :

&

2--2W )






Jnj Am!icilin 16' mg86hJnj Gentamycin 7' mg8"7hJnj +e)ametaon ",5 mg8h8i$Jnj Amino!hylline M+ 1 cc81" jam8i$ dil*ted in 5 cc #al ', C bol*lowly#eb*le entolin 1 re!*l< #al , C 86h

16th #o$ember "'152--2W )



16 #o$ember "'15

S +y!nea-</ NN


Head 2 0ontanella mayor wa cloed=ye 2 ;ight re>e) -<8</, iochoric !*!il, !ale inferior conj*ncti$a!al!ebra -.8./, clera icteric -.8./=ar 2 within normal range#oe 2 naal >aringMo*th 2 within normal range

#eck 2 lym!h node enlargement (hora) 2 ymmetrical f*iform, retraction -</ intercotal, e!igatricH2 1"' b!m, reg*lar, m*rm*r -./ 2 7')8i, reg*lar, ronchi -<8</, whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2 no !al!able=)tremitie 2 !*le 1& b!m, reg*lar, ade@*ate !8$ , felt warm, ( :

&

2--2W )





J0+ +5C #al ',""5 C "5gtt8i -micro/Jnj Am!icilin 16' mg86hJnj Gentamycin 7' mg8"7h

Jnj +e)ametaon ",5 mg8h8i$Jnj Amino!hylline M+ 1 cc81" jam8i$ dil*ted in 5 cc #al ', C bol*lowlyEaracetamol 35 mg -if needed/G= &) K tab

!dvise "rom dr. #isman $alim%nthe &p!

' !"" N' Cons%l "or Cardiology $ivision (echocardiography)

' appering o"" *n+ de,amethasone

17th #o$ember "'152--2W )



17 #o$ember "'15

S +y!nea-</ NN


Head 2 0ontanella Mayor wa cloed=ye 2 ;ight re>e) -<8</, iochoric !*!il, !ale inferior conj*ncti$a!al!ebra -.8./, clera icteric -.8./=ar 2 within normal range#oe 2 within normal rangeMo*th 2 within normal range

#eck 2 lym!h node enlargement (hora) 2 ymmetrical f*iform, retraction -</ intercotal, e!igatricH2 11 b!m, reg*lar, m*rm*r -./ 2 &5)8i, reg*lar, ronchi -<8</, whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2 no !al!able=)tremitie 2 !*le 11 b!m, reg*lar, ade@*ate !8$ , felt warm, ( :

&

2--2W )








) J0+ +5C #al ',""5 C "5gtt8i -micro/Jnj Am!icilin 16' mg86h8i$Jnj Gentamycin 7' mg8"7h8i$Jnj +e)ametaon "mg81"h8i$ -ta!ering oO/Jnj Amino!hylline -M+/ 1 cc81"h 8i$ dil*ted in 5 cc #al ', C bol*lowlyEaracetamol 35 mg -if needed/#eb*le entolin 1 re!*l< #al , C 8h

19th #o$ember "'152--2W )



19 #o$ember "'15

S +y!nea-./


Head 2 0ontanella Mayor wa cloed=ye 2 ;ight re>e) -<8</, iochoric !*!il, !ale inferior conj*ncti$a!al!ebra -.8./, clera icteric -.8./=ar 2 within normal range#oe 2 within normal rangeMo*th 2 within normal range

#eck 2 lym!h node enlargement (hora) 2 ymmetrical f*iform, retraction -./H2 116 b!m, reg*lar, m*rm*r -./ 2 "")8i, reg*lar, ronchi -<8</, whee?ing-.8./Abdomen 2 *!!le, !eritaltic -</#, ;i$er and S!leen2 no !al!able=)tremitie 2 !*le 11' b!m, reg*lar, ade@*ate !8$ , felt warm, ( :

&

2--2W )





DISCUSSIONCHAPTER IV







SUMMARYCHAPTER V



AS, a 11 month old boy, with 6,5 kg of BW and 66cm of BH, came to Haji Adam Malik GeneralHo!ital Medan on 1"th #o$ember at ""%&'% Hi

chief com!laint wa dy!nea% Eatient wadiagnoed a broncho!ne*monia which conRrmedwith clinical manifetaion -fe$er, hortne ofbreath, co*gh/ and chet .ray% Eatient wa

treated with !aracetamol, am!icilin, gentamycin,$entolin, meylon and amino!hylline -M+/% Eatienti dicharged from ho!ital on 1 #o$ember"''15 after !atient condition wa table

Smmary



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Tuberculous Meningitis