Presentasi Case Report

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Case ReportEnchephalopathy

Presentators: Dewi Putri Rejekinta Berutu

Azmeilia Syafitri Lubis

Supervisor:Prof. dr. H. Munar Lubis, Sp.A (K)

DEPARTMENT OF PEDIATRIC HAJI ADAM MALIK GENERAL HOSPITAL

FACULTY OF MEDICINEUNIVERSITY OF NORTH SUMATERA

2012

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Chapter 1

• Introduction• Objective

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. Introductionis a general term for a disease that alters a person’s brain function and mental state.

Enchephalopathy

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Introduction

• There are many possible precipitants of encephalopathy.• Symptomps of enchephalopathy can generalized causing

decreased level of conciousness from minimal lethargy to coma.

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Objective

• The aim of this study is to explore more about the theoritical aspects on metabolic enchephalopathy, and to integrate the theory and application of hepatic enchephalopathy case in daily life.

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Chapter 2

• Literature Review: Enchepalophathy

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Defenition

•Encephalopathy is an acute confusional state that is accompanied by an alterations in cortical function and disturbances of consciousness may range from mild confusional states to coma

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Some types of enchephalopathy :

• Glycine enchephalopathy : caused by a metabolic disorder• Hepatic enchephalopathy : caused by disorders that affect the liver• Hypoxic enchephalopathy : caused by reduce oxygen to brain• Static enchephalopathy : permanent brain damage• Uremic enchephalopathy : caused by toxins remaining in the body• Wernicke’s enchephalopathy : caused by a thiamine deficiency, usually due to alcoholism.• Hashimoto’s enchephalopathy : an autoimmune disorder • Hypertensive enchehalophaty : caused by very high blood pressure• Toxic-metabolic enchephalopathy : general term to describe enchephalopathies caused by

infections, toxins or organ failure.

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Etiology

• Infections• Trauma, Tumor/Paraneoplastic• Seizures, Stroke, (P)Sychiatric• Drugs (intoxication withdrawal), dementia

(Decompensated Dementia)• Electrolytes• Low glucose, Leukoencephalopathy• Inflammatory• Rheumatologic• Intracranial Pressure• Uremia• Metabolic, Malnutrition, Mitochondrial

Epidemiology

•Over 5.5 million people in the United States have been diagnosed with cirrhosis. One of this population, 30–45 % of patients develop overt encephalopathy during the course of their disease. This debilitating condition can negatively impact quality of life for patients and their families.•The frequency of hospitalization for enchephalopathy has nearly doubled over the last decade, with lengths of stay between 5 and 7 days.

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RISK FACTOR

DehydrationHyponatremiaHypokalemia

Excessive dietary protein

Hepatocellular carcinoma

Terminal liver disease

Superimposed liver injuryTransjugular intrahepatic

portal-systemic

shunt

SurgeryCentral nervous

system acting drugs

Infections

Renal FailureUrinary

ObstructionGastrointerstinal bleedingConstipation

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Some types of enchephalopathy :

• Glycine enchephalopathy : caused by a metabolic disorder• Hepatic enchephalopathy : caused by disorders that affect the liver• Hypoxic enchephalopathy : caused by reduce oxygen to brain• Static enchephalopathy : permanent brain damage• Uremic enchephalopathy : caused by toxins remaining in the body• Wernicke’s enchephalopathy : caused by a thiamine deficiency, usually due to alcoholism.• Hashimoto’s enchephalopathy : an autoimmune disorder • Hypertensive enchehalophaty : caused by very high blood pressure• Toxic-metabolic enchephalopathy : general term to describe enchephalopathies caused by

infections, toxins or organ failure.• Metabolic enchephalopathy : broad category that describes abnormalities of the water, electrolytes,

vitamins and other chemicals that adversely affect brain function

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Pathophysiology

The pathogenesis of encephalopathy is incompletely understood, and the discussion that follows represents a collection of ideas and concepts that have emerged from recent research.

There is probably no single pathophysiology. Rather, many different perturbations of brain function may produce the same clinical syndrome. Potential mechanisms include a deficiency of substrates for oxidative metabolism, impaired synaptic transmission, and gross alterations in the water and electrolyte composition of the internal milieu. These mechanisms may be interrelated.

For example, Hyponatraemia is defined as a serum sodium <135 mEq/l. Under normal circumstances, the human body is able to maintain the plasma sodium within the normal range (135–145 mEq/l) despite wide fluctuations in fluid intake. The body’s primary defence against developing hyponatraemia is the kidney’s ability to generate a dilute urine and excrete free water. Hyponatraemia usually develops when there are underlying conditions that impair the kidney’s ability to excrete free water. There are a few clinical settings where patients most often develop hyponatraemic encephalopathy.

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DIAGNOSIS

Mild•Change in sleep patterns•Changes in thinking•Confusion that is mild•Forgetfulness•Mental fogginess•Personality or mood changes•Poor concentration•Poor judgment•Worsening of handwriting or loss of other small hand movements

Severe•Abnormal movements or shaking of hands or arms•Agitation, excitement, or seizures (occur rarely)•Disorientation•Drowsiness or confusion•Inappropriate behavior or severe personality changes•Slurred speech•Slowed or sluggish movement

Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Patients with hepatic encephalopathy can become unconscious, unresponsive,

and possibly enter a coma.

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•Jaundice, petechial hemorrhages, gastrointestinal bleeding, ascites, or hypothermia may indicate hepatic dysfunction.• A coarse facies, dry hair, or bradycardia suggests hypothyroidism.• Acne, obesity, and hypertension are common in Cushing syndrome.• Needle tracks in the skin raise the possibility of a toxic encephalopathy.• Hypertension suggests that the encephalopathy is caused by a metabolic disorder (e.g., a renal or endocrinologic disorder) or an ischemic disorder (e.g., a cerebrovascularor cardiovascular condition), and•Hepar enlargement, lead to cirrhosis hepatic.• Hypothermia suggests a metabolic or toxic cause.•Neurologic examination

PHYSICAL EXAMINATION

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Blood testCT Scan of the head or MRIEEGLumbar PunctureArterial blood gasesElectrolyteChest radiograph

Tests may include:

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Management & Treatment

•Dehydration : diuretics, intravenous infusion of physiologic saline, and therapy for the underlying cause of increased fluid and electrolyte losses. • Gastrointestinal bleeding is identified and treated appropriately. •Hypokalemia : vigorously corrected with parenteral potassium in enchephalopathy. •Severe hyponatremia : Limited infusions of hypertonic saline (3% NaCl, 150 mL intravenous) may be needed for very severe hyponatremia.

Correction

Precipating Factor

s

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Management & Treatment

•Dietary protein : Restriction of dietary protein to 40 g/day or less used to be advocated for patients with enchephalopathy because of excessive dietary protein. The current recommended protein diet for patients is 0.8 to 1.5 g/kg/d.•Tranplantation•Adjuvant (antibiotics & dissacharides)•Symptomatic

Correction

Precipating Factor

s

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Brain herniationBrain swellingIncreased risk of: Cardiovascular collapseKidney failureRespiratory failureSepsisPermanent nervous system damage (to movement, sensation, or mental state)Progressive, irreversible comaSide effects of medications

Complication

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Acute encephalopathy may be treatable. Chronic forms of the disorder often keep getting worse or continue to come back.

Prognosis

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Chapter 3

• Case Report

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Case Report

Name : AIPAge : 4 monthsSex : Female Date of Admission:

May, 7th 2012

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Main Complain

Seizure

3 days ago

Tonic clonic

Frek 10 times/day;

5’

Precipated by fever

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Diarrhoea (+)◦ 3 days before fever◦ Frequency >10 times /day especially after having milk◦ Volume = 10-20 cc/ diarrhoea◦ Watery

Impairment of consciousness (+)◦ weak cry with moan impression (+) 2 days ago after

seizure.

Urine output(+) ◦ Colour : yellow (+)◦ Volume : less◦ Vomit (-)◦ history of melena (+) since 2 days ago◦ dyspnoe (-).

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• Spontaneous and cried immediately• Help by midwives in clinic.• BW =3 Kg and BBL =48 cm• Injection of vitamin K (+)

History of Birth

• hypertension , DM, using herbal medicine (-).

• Early fetal membrane broken (+)

Historyof Pregnancy

• From birth to 3 months : Breast milk• From 3 months to now : Breast milk

+ formula milk

Feeding History

• Patient has been able to face downward

History of Growth and

Development

• Hep B, BCG, Polio, DPTHistory of Immunisation

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Sensorium

Consciousness: ◦Alert (GCS 12: E:4, C=3, M=5)◦Temperature: 38oC.◦Body length: 63 cm. Head circumferences: 38 cm.

Upper Arm Circumferences: 9,5 cm.Anemic (-). Icteric (-). Cyanosis (-).

Oedema (-). Dyspnoe (+). BB/U = 5,3/6,2 x 100 % = 85,48 %TB/U = 63/62 x 100 % = 101,6 BB/TB = 5,3/6,6 x 100 % = 80,3 %Impression: Mild malnutrition

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Localized Status

Head Neck Thorax•Fontanella : Large open flat, concave (+)•Hair: black, rarely, easily removed (-)•Head circumference: 38 cm•Eye: light reflex (+/+), isochoric pupillary, palpebra inferior conjunctival pallor (-/-), icteric sclera (-)•Nose: nostrils in breathing (+). •Ear and mouth: within normal limit

• Lymph node enlargement (-)

• Stiff neck (-)

•Simetris fusiformis. Retraction (+) epigastrial, intercostal, and suprasternal.• HR: 158 bpm, regular, murmur (-)• RR: 30 bpm, reguler, rales (-), wheezing (-).

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Localized Status

Abdomen Urogenital Exremities

•Soepel•Peristaltik (+) normal•Hepar/Lien within normal limit

•Female,•Diapper rash (+)

•Ptechiae (-)•Pulse 158 bpm, regular, adequate pressure and volume•Warm acral•Capillary refill time < 3”.

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Parameters Value Normal Value

Complete Blood Count

Hemoglobin 10,5 gr% 11,5 – 16,5 gr%

Erithrocyte 4,05 x 106 /mm3 4,2 – 5,4 x 106 /mm3

Leucocyte 13,7 x 103 /mm3 4- 11 x 103 /mm3

Hematocrite 31,6% 37 – 47%

Platelet 80.000 /mm3 150000 – 440000 /mm3

MCV 77,8 fL 80 – 95 fL

MCH 25,9 pg 27 – 32 pg

MCHC 33,3 gr% 32 – 36 gr%

RDW 12,7 % 11,6 – 15,5 %

MPV 9,90 fL 6,5 – 12.0 fL

PCT 0,079% 0,100- 0,500

LED 8 mm/hours < 15 mm/hours

Laboratory Findings (7th May 2012):

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Diftel

Neutrophil 78,0 % 55 – 70 %

Limfosit 16 % 20 – 40 %

Monosit 4 % 2 – 8 %

Eosinophil 2 % 1 – 6 %

Basophil 0.100 % 0 – 1 %

ELECTROLYTE

Natrium 148 mEq/l 135- 155 mEq

Kalium 5,8 mEq/l 3,6- 5,5 mEq/l

Chloride 10/l2 mEq 96-106 mEq/l

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Management• Head elevation 30 °• O2 ½ - 1 L/i nasal canule• IVFD RL 99 gtt/i micro

(rehydration from 19.30 to 23.30)• Inj. Ampicilin 250 mg/6 hours/iv• Inj. Cefotaxim 350 mg/8 hours/iv• Inj. Dexamethasone 1 mg/8

hours/ iv• Paracetamol 3x 100 mg (if need)• Diet based milk or complement-

based milk 60 cc/ 2 hours/ NGT

Diagnostic Planning• Consult to neurology• Consult to respirology• Mantoux test• Lumbal Punction• EEG• Head CT-Scan• Check electrolyte (Ca, Mg),

LFT, RFT, blood culture, urine culture, AGDA, CRP,

• Blood Glucose Level• Chest X-Ray

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Follow Up

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May 7th 2012

S Seizure (-), fever (-)

O Sens: GCS:12 (E=4, V=3, M=5), Temp: 36,1°C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+),

Body weight: 5,3 kg.

Head Eye: Light reflex (+)/(+).

Conjunctiva palpebra inferior anemic (-/-).

Isochoric pupil.

Sunken eye (+).

Prominent fontanella (- )

Ear-mouth: within normal limit. Nose: nostrils in breathing (+)

Neck Lymph node enlargement (-). Stiff neck (-).

Thorax Symmetrical fusiformis. Retraction (+) epigastrial and suprasternal.

HR: 160 bpm, reguler, murmur (-).

RR: 65 bpm, regular, rales (-/-). Snoring (-).

Abdomen Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Palpable ± 1 cm under arcus costae, blunt.

Extremities Pulse 160 bpm, regular, adequate p/v, warm, CRT < 3”. Physiology reflex (APR + Normal, KPR +Normal).

Patologic reflex (Babinsky +, Meningeal -)

Genital Female. Eritematous lesion in anal area.

AEnchephalitis + bronchopneumony + mild – moderate dehydrationMeningoenchephalitis + bronchopneumony + mild – moderate dehydrationMeningoenchephalitis + bronchopneumony + Mild - moderate dehydration

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P Management:•Head elevation 30°•O2 ½ - l L/i nasal canule•Rehydration RL 99 gtt/I since 19.30 pm - 23.30 pm•Injection of Ampicillin 250 mg/6 hr/iv (Skin Test)•Injection of Cefotaxim 350 mg/8 hr/iv (Skin Test)•Injection of dexamethasone 1mg/8 hr/iv•Paracetamol 3 x 100 mg (if needed)•Diet breast milk/ PASI 60 cc/2 hr/NGT•10.00 pm Injection Phenytoin 100 mg in 20 cc NaCl 0,9 % out in 20 minutes, after 12 hours 25 mg/12 hr in 20 cc NaCl 0.9 %.

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Leucocyte 13,7 x 103 /mm3 4- 11 x 103 /mm3

Hematocrite 31,6% 37 – 47%

Platelet 80.000 /mm3 150000 – 440000 /mm3

MCV 77,8 fL 80 – 95 fL

MCH 25,9 pg 27 – 32 pg

MCHC 33,3 gr% 32 – 36 gr%

RDW 12,7 % 11,6 – 15,5 %

MPV 9,90 fL 6,5 – 12.0 fL

PCT 0,079% 0,100- 0,500

LED 8 mm/hours < 15 mm/hours

Diftel:

Neutrophil 78,0 % 55 – 70 %

Limfosit 16 % 20 – 40 %

Monosit 4 % 2 – 8 %

Eosinophil 2 % 1 – 6 %

Basophil 0.100 % 0 – 1 %

ELECTROLYTE

Natrium 148 mEq/l 135- 155 mEq

Kalium 5,8 mEq/l 3,6- 5,5 mEq/l

Chloride 10/l2 mEq 96-106 mEq/l

Laboratory Findings on 7th May 2012

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May 8 th 2012

S Seizure (-), fever (-).

O Sens: GCS:12 (E=4, V=3, M=5), Temp: 36,1°C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-).

Dyspnoe (+), Body weight: 5,3 kg.



Isochoric pupil.

Sunken eye (+).

Prominent fontanella (-)

Ear-mouth: within normal limit.. Nose: nostrils in breathing (+)


Thorax Simetrical fusiformis. Retraction (+) epigastrial and suprasternal.



Abdomen Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Palpable ± 1 cm under arcus costae, blunt.

Extremities Pulse 140 bpm, regular, adequate p/v, warm, CRT < 3”. Physiology reflex (APR + Normal, KPR

+Normal). Patologic reflex (Babinsky +, Meningeal -)

Genital Female. Eritematous lesion in anal area.

A - Enchephalitis

- Meningoenchephalitis + Bronkhopneumonia

- Meningoenchephalitis + Mild to moderate dehydration

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P Management:•Head elevation 30°•O2 ½ - l L/i nasal canule•IVFD D5 restriction 25 % 16 gtt/i•Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes•Injection of Ampicillin 250 mg/6 hr/iv (H1)•Injection of Cefotaxim 350 mg/8 hr/iv (H1)•Injection of dexamethasone 1mg/8 hr/iv (H1)•Paracetamol 3 x 100 mg (if needed)•Diet breast milk/ PASI 70 cc/3 hr/NGT.•(10.30 am) : Phenytoin 10 mg/kgBW in 6cc NaCl 0,9% out in 20 minutes•(05.00 pm): Correction of hipocalsemy (Ca= 6,6 mg/dl) 0,5 mg/kg BB= 0,5 x 5,3= 2,65 mg in 3 cc out in 20 minutes

R •Consult to neurology•Consult to respirology•Mantoux test•Lumbal punction•Electroenchepalograph•Head CT-Scan•Electrolyte test: LFT, RFT, blood culture, urine culture, AGDA, CRP, procalcitonin, lactate acid, LED

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Dipstic Results:Leu/Nit/Uro/Pro/pH/Blo/SG/Ket/Bil/Glu:± /- /- /++ /6 /1,030 /- /- /- /-

Blood Glucose Test: 46 mg/dl

Blood Culture: Bacteria was not found

41Chest Radiograph

Result of Consult to Radiology: - The heart, sinus & diaphragma are normal. - The lung: consolidation upper right lung field. There is triangle opaque shadow at lower right lung field.-Impression: a. Pneumoniab. Atelectasis segmental at posterior right lung

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Laboratory finding on 8th May 2012





Leucocyte 11,12 x 103 /mm3 6,0- 17,5 x 103 /mm3

Hematocrite 30,80 % 38 – 52%

Platelet 103.00 /mm3 217000 – 497000 /mm3

MCV 82,80 fL 93 -115 fL

MCH 27,70 pg 29 – 35 pg

MCHC 33,4 gr% 28 – 34 gr%

RDW 13,5 % 14,9 – 18,7 %

MPV 10,40 fL 7,2 – 10,00 fL

PCT 0,011 %

Diftel:

Neutrophil 94,10 % 37 – 80 %

Limfosit 4,20 % 20 – 40 %

Monosit 1,70 % 2 – 8 %

Eosinophil 0.00 % 1 – 6 %

Basophil 0,000 % 0 – 1 %

Kesan: normocrom normositter anemia+ trombositopenia

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BLOOD GASES ANALYSIS

pH 7,40 7,35- 7,45

pCO223,0 38- 42 mmHg

pO2173,3 85- 100 mmHg

HCO314,20 22- 26 mmol/l

CO2 total 14,90 19- 25 mmol/l

BE -9,3 -2 2

O2 saturation 99,3 % 95- 100

ELECTROLYTE

Calsium 6,6 8,4- 10,8 mg/dl

Natrium 134 135- 155 mEq

Kalium 3,7 3,6- 5,5 mEq

Phospor 3,2 5,0- 10,8 mEq

Cloride 110 96- 106 mEq

Magnesium 1,61 1,4- 1,8 mEq

Procalcitonin 79,03 <0.05 ng/ mL

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9th May 2012

S Seizure (-), fever (-), Conciousness: increase (this patient crying more loudly).



Head Eye: Light reflex (+)/(+)

Conjunctiva palpebra inferior anemic (-/-)

Isochoric pupil

Sunken eye (-)

Prominent fontanella (-)

Ear-mouth: within normal limit. Nose: nostrils in breathing (-)


Thorax Symmetrical fusiformis. Retraction (-)



Abdomen Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: Not palpable

Extremities Pulse 140 bpm, regular, adequate p/v, warm, CRT < 3”.

Genital Female. Within normal linit

A Enchephalopathy

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P Management:

Head elevation 30°

O2 ½ - l L/i nasal canule

IVFD D5 Na Cl 0,9 % 16 gtt/i micro

Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes

Injection of Ampicillin 250 mg/6 hr/iv (H2)

Injection of Cefotaxim 350 mg/8 hr/iv (H2)

Injection of dexamethasone 1mg/8 hr/iv (H2)

Paracetamol 3 x 100 mg (if needed)

Nebule Na Cl 2,5 cc +1 amp Ventoline/ 8 jam

Diet breast milk/ PASI 70 cc/3 hr/NGT.

R Waiting for the answer neurology consult

Consult to respirology

Mantoux test

Check electrolyte

The Result of Consult Respirology:Clinically, symptom of respirology was not found.

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Function of hemostatic

PT +INR

Protombine Time

Control

Patient

12,50 sec

18,0 sec

INR 1,36

APTT

Control

Patient

29,50

29,70

Electrolyte

Calcium 6,9 8,4- 10,8 mg/dl

Natrium 136 135-155 mEq

Kalium 3,3 3,6- 5,5 mEq

Chloride 103 95- 106 mEq

Magnesium 1,77 1,4- 1,8 meq

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10th May 2012

S Seizure (-), fever (-), diarrhoea (+)





Isochoric pupil.

Sunken eye (-).

Prominent fontanella (-).






Abdomen Soepel, skin pinch fastly, peristaltic (+) N, Hepar/Lien: not palpable


Genital Female. Within normal limit.

A Enchephalopathy ec electrolyte imbalance + GE without dehydration

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P Management:

IVFD D5 Na Cl 0,25 % 16 gtt/i2

Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20

minutes






Zink 1 x 10 mg

R Consult to gastroenterohepatology

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11th May 2012 S Seizure (-), fever (+), diarrhoea (+)





Isochoric pupil.

Sunken eye (-).









Genital Female. Within normal limit.

A Enchephalopathy + Gastroenteritis without dehydration

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P

R

Management:

IVFD D5 Na Cl 0,25 % 16 gtt/i

Injection of Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes






Zink 1 x 10 mg

Give low lactose milk

Check routine feces

Feces culture


ELECTROLYTE

Calcium (Ca) 7,2 8,4 – 10,8 mg/dL

Natrium (N) 158 135 – 155 mEq/L

Kalium (K) 3,3 3,6 – 5,5 mEq/L

Phospor 2,9 5,0 – 10,8 mEq/ L

Chloride (Cl) 108 96 – 106 mEq/L

Magnesium (Mg) 1,71 1,4 – 1,8 mEq/L

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12th May 2012


O Sens: Compos mentis Temp: 36,8°C. Anemic (-). Icteric (-). Oedema (-). Cyanosis (-).

Dyspnoe (-), Body weight: 5,6 kg.



Isochoric pupil.

Sunken eye (-).









Genital Female.

A Enchephalopathy + Gastroenteritis without dehydration + suspect cows milk allergy

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P

R

Management:


Injection of Phenytoin 2x 25 mg


Zink 1 x 10 mg

Lacto B Sach 2 x 1



Diet breast milk/ PASI low lactose 70 cc/3 hr/NGT.

Check routine feces

Feces culture

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13th May 2012


O Sens: Compos mentis Temp: 36,8°. Anemic (-). Icteric (-). Oedema (-). Cyanosis

(-). Dyspnoe (-), Body weight: 5,6 kg.



Isochoric pupil.

Sunken eye (-).









Genital Female.

A Enchephalopathy ec electrolyte imbalance+ Gastroenteritis without

dehydration + suspect cows milk allergy

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P

R

Management:




Zink 1 x 10 mg

Lacto B Sach 2 x 1




Check routine feces

Feces culture

Blood culture

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14th May 2012


O Sens: Compos mentis Temp: 36,8°. Anemic (-). Icteric (-). Oedema (-). Cyanosis




Isochoric pupil.

Sunken eye (-).









Genital Female.

A Enchephalopathy ec electrolyte imbalance+ Gastroenteritis without


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P

R

Management:




Zink 1 x 10 mg

Lacto B Sach 2 x 1




Check electrolyte (Ca, Mg)

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15th May 2012

S Seizure (-), fever (-), diarrhoea (-)

O Sens: Compos mentis Temp: 37°. Anemic (-). Icteric (-). Oedema (-). Cyanosis




Isochoric pupil.

Sunken eye (-).









Genital Female.

A Enchephalopathy ec electrolyte imbalance + Gastroenteritis without


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P

R

Management:




Zink 1 x 10 mg

Lacto B Sach 2 x 1




Waiting for blood electrolyte result

Result of bactery culture: negative

Laboratory Finding on 15th May 2012Parameters Value Normal Value

ELECTROLYTE

Calcium (Ca) 8,4 8,4 – 10,8 mg/dL

Natrium (N) 136 135 – 155 mEq/L

Kalium (K) 3,7 3,6 – 5,5 mEq/L

Phospor - 5,0 – 10,8 mEq/ L

Chloride (Cl) 109 96 – 106 mEq/L

Magnesium (Mg) 1,62 1,4 – 1,8 mEq/L

59

16th May 2012


O Sens: Compos mentis Temp: 37° C. Anemic (-). Icteric (-). Oedema (-). Cyanosis




Isochoric pupil.

Sunken eye (-).









Genital Female.

A Enchephalopathy ec electrolyte imbalance

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P Management:




Zink 1 x 10 mg

Lacto B Sach 2 x 1




Waitng for blood electrolyte result

This patient may go home

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HOME VISIT 25th May 2012


O Sens: Compos mentis Temp: 36,2°C. Anemic (-). Icteric (-). Oedema (-).

Cyanosis (-). Dyspnoe (-), Body weight: 5,6 kg. Head circumference= 38 cm,

Upper arm circumference= 9,5 cm.



Isochoric pupil.

Sunken eye (-).









Genital Female.

A

62

P

R

Management: Amoxycillin syrup 3 x 1 cthAmbroxol pulv 3 x 1

Control to General Hospital Of Haji Adam Malik Medan

63

Size of house 4 x 5 meter

Bathroom, Toilet & Location to wash Kitchen

Guest room+Family room+Making cake room Bed room

PintuJendela

Jendela

Impression: Bad ventilasion, small house but crowded people, bad sanitation.

SKETCH OF HOUSE

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Home Visit (25th May 2012)

Address:Pasar 11, Gg.Rejeki, Kec. Percut, Sei Tuan

Impression :Bad Sanitation

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Discussion

THEORY PATIENT

Definition Encephalopathy is an acute confusional state that is accompanied by an alterations in cortical function and disturbances

In this patient, mental status changes and conciousness impairment was found

Causes DehydrationElectrolyte imbalanceExcessive dietary proteinRenal FailureUrinary ObstructionGastrointerstinal bleedingSurgeryInfectionsDrugsHypoxia, intravascular diseaseetc

In this patient, the precipitating factor is dehydration (electrolyte imbalance)

Types Glycine. Hepatic, Hypoxic, Static, Uremic, Wernicke. Hashimoto’s. Hypertensive, Toxic & Metabolic

This patient is metabolic enchephalopathy

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THEORY PATIENT

Clinical Manifestation

• Change in sleep patterns• Changes in thinking• Confussion impairment• Mental fogginess• Personality or mood changes• Poor concentration• Abnormal movements or shaking of hands or arms• Agitation, excitement, or seizures (occur rarely)• Disorientation• Drowsiness or confusion• Inappropriate behavior or severe personality changes• Slurred speech• Slowed or sluggish movement

In this patient, seizure and conciousness impairment was found

Supporting Examination

Blood testCT Scan of the head or MRIEEGLumbar PunctureArterial blood gasesElectrolyteChest radiograph

In this patient, supporting examinations are:-Complete blood count-Chest radiograph-Arterial blood gases-Electrolyte

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THEORY PATIENT

Management

Correction by Precipating Factors, adjuvant therapy (antibiotics and dissacharides), transplantation and symptomatic.

Treatment of this patients are:- RL 99 gtt/i micro (rehydration from 19.30 to 23.30)•Head elevation 30°•O2 ½ - l L/i nasal canule•IVFD D5 Nacl 25 % 16 gtt/i•Phenytoin 25 mg/12 hr/iv in 20 cc NaCl 0,9 % out in 20 minutes•Injection of Ampicillin 250 mg/6 hr/iv (H1)•Injection of Cefotaxim 350 mg/8 hr/iv (H1)•Injection of dexamethasone 1mg/8 hr/iv (H1)•Paracetamol 3 x 100 mg (if needed)•Diet breast milk/ PASI 70 cc/3 hr/NGT.•(10.30 am) : Phenytoin 10 mg/kgBW in 6cc NaCl 0,9% out in 20 minutes•(05.00 pm): Correction of hipocalsemy (Ca= 6,6 mg/dl) 0,5 mg/kg BB= 0,5 x 5,3= 2,65 mg in 3 cc out in 20 minutes

Prognosis Acute encephalopathy may be treatable. Chronic forms of the disorder often keep getting worse or continue to come back.

In this patient, enchephalopathy was treatable.,

68

THANK YOU

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References

Camara-Chua, Pia Teresa A, MD., Enchephalopathies. 2010. Available from: NEJM.org\

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