A GRAND ROUND PEDIATRIC NEUROLOGY DIVISION

A 10 YEARS 7 MONTHS OLD BOY WITH

RESPIRATORY FAILURE ON VM, GUILLAIN-
BARRE SYNDROME DD / AMSAN, STOMATITIS,
HYPONATREMIA, NORMAL STATURE
 Patient Identity
■ Name : AZA
■ Date of birth : May 15th 2009
■ Age : 10 years 7 months old
■ Gender : Male
■ No. MR : C797XXX
■ Date of admission : January 5th 2020
 Present Medical History
• Chief Complaint : refered from RSUD Jepara with weakness of limb

Patient had continuous fever, 1 week before admission patient

no appetite, vomiting (-),
diarrhea (-), examined by a
doctor obtained tubex 8.
Patients get cefixim and
paracetamol, fever repair,
control children and then
given syrup and puyer
medication but the parents
don't know the contents.
Two Weeks before admission
children are healthy for 1
week, doing activities as
usual.
complained of weakness in
limbs, weak legs, trauma (-)
convulsions (-) 3 Days before
admission, patient complained
of not being able to walk, hands
could still be moved, then
children were taken to the
emergency room of Jepara
Regional Hospital. Children are
hospitalized with meningitis and
get ceftriaxone 2 grams / 24
hours, ibuprofen 100 mg / 8
hours.
The current condition is
that the legs cannot be
moved, the legs are
painful when touched
and moved. Heavy
hand, ventilator is now
installed, tightness (-),
fever (-)

3 WEEKS PRIOR TO ADMISSION 3 DAYS PRIOR TO ADMISSION Present day

Past Medical History
– There was no complaint before

Family Medical History

– There was no family have similar complaint

Socio-economic History
– The patient's father working as civil employee. Mother as a housewife.
Financing using BPJS nonPBI.
– Socioeconomic impression: moderate social economic
 Perinatal History
Prenatal
The child was born from a G2P1A0, 26-year-old mother with aterm
pregnancy. She had >4x routine antenatal care to doctor during pregnancy
and took regular vitamins daily. There was no history of fever, rash, pain,
edema, and other illness during pregnancy. She had normal blood pressure.
Natal
The child was born spontaneously at midwife. She cried directly after birth. Birth weight of
3500 gram and birth length is 50 cm.
Post
There was no history of jaundice, seizure, nor cyanosis.
Immunization History
BCG : (+) (1 month old)
Hep B : 4 times (0,2,3,4 months old)
DPT : 3 times (2,3,4 months old)
• v : 3 times (2,3,4 months old)
Nutrition History
HIB  0 - 6 months: exclusive
Polio : 4 times (0,2,3,4 months old) breastfeeding
Campak : (+)  6 – 18 months: breastfeeding ,
Impression : complete basic formula milk
immunization  18 months-now : family food 3
times a day
Impression : exclusive
Development History breastfeeding, adequate quality
The patient was 10 years 7 months old. and quantity intake
At this time the patient was student in
elementary school
Impression : normal developmental
 Physical Examination ((January 5th 2020)
Thorax : symmetric, retraction (-)
General condition : weak
Cor, pulmo : normal
Consciousness : composmentis Nn. Craniales
Abdomen : Flat, suppel,
BB 26 kg N. I: difficult to judge
abdominal
TB 130 cm N II: reflex light ++ / +, vision
sound (+) N, tymphanic,
WAZ NA was difficult to assess
Liver/spleen not palpable,
HAZ -1,69 SD N. III, IV, VI: eyeball movement
tenderness (-),skin turgor quickly
BMI -0.84 SD (+), strabismus (-)
return
Vital signs: N. V: corneal reflex + / +
Extremitas:
HR : 78x/minutes N. VII: Symmetrical nasolabial
Cold acral -/- -/-
N: regular, i/t adequate folds
CRT <2”/<2”
RR 17 x/ minutes N. VIII: hearing impression within
<2”/<2”
T : 36,2oC normal limits
Physiologic reflex ↓/↓ ↓/↓
SpO2 :99% N. IX, X: swallow (+)
Patologic reflex -/-
Eyes : anemic (-/-), pupil isocor N. XI: (+)
Strenght 333/333 222/222
(+/+) 3mm/3mm N. XII: tongue deviation (-)
Meningeal sign :
Nose : nasal flaring (-)
Laseq +/+
Mouth : cyanosis (-), symmetric (+) Impression:
Kernig +/+
Neck : stiffness (-)
Brudzinsky I dan II -/-
 LABORATORY EXAMINATION
Hematology Standard 5/1 8/1 Diffcount Standard 5/1/20
Hemoglobin 10.8 – 12.8 g/dL 11.9 13.4
Eosinophil 2–5% 0
Hematocrit 35 – 47 % 37 40.3 Basophil 0–0% 0

Erythrocytes 3.9 – 5.6 4.47 4.92 Bar 2–5% 0

10^6/μL Segment 20 – 40% 42
Lymphocyte 46 – 76% 43
MCH 23 – 31 pg 26.6 27.2
MCV 77 – 101 fL 83.2 81.9 Monocyts 5 - 15% 13
MCHC 29-36 g/dL 32 33.3
Leucocytes 6 – 17 10^3/μL 7.500 21.500
Peripheral Blood 5/1/2020
Platelets 150- 411.000 488.000 Morphology
40010^3/μL
Erythrocytes Erythrocyte distribution is normal,
normocytic, poikilocytosis :ovalosit,
CRP 0 - 0.30 mg/dL 0.12
eliptosit
Platelets Estimated platelet counts increased, giant
trombocyt (+)
Leukocytes Estimated leukocytes number normal,
hypergranulated neutrophil (+), atypical
lymphocyte +, monocytosis +
 LABORATORY EXAMINATION
CLINICAL STANDARD 5/1/20 6/1/20 BGA (6/1/20)
CHEMISTRY
pH 7.427 7.37 - 7.45

Ureum 15 – 39Mg/dl 16
PCO2 30.7 35 - 45 mmHg

Creatinine 0.6 – 1.3Mg/dl 0.5

PO2 198.3 83 -108 mmHg

Natrium 136 - 145 mmol/L 124 148

HCO3 20.6 22 - 29 mmol/L
Kalium 3.5 - 5.0 mmol/L 4.9 3.9
Chlorida 95 - 105mmol/L 105 103
BE -4.0 mmol/L
Calcium 2.12 - 2.52 mmol/L 2.4
CHEST X RAY (8/1/2020) M SC T O F H EAD W IT H C O N T R AS ( 6 /1 /20)

IMPRESSION : IMPRESSION :
• ET discharged on tip level V. Thoracalis 3 bleeding (-) infarct (-) SOL (-)
• Cor: no enlargement No visible of meningitis, No signs of an
• Bronchopneumonia increase in ICP
Hasil EMG (6/1/2020)

Impression:
currently support depictions of AMSAN variants
ECG result
LCS (10/1/2019)
 Neurology Day : 1-5(January 5-7th 2019)
BW : 26 kg
S: weak arms and legs, and the Abdomen : Flat, suppel, abdominal Program :
child is heavy to talk; eat and sound (+) N, tymphanic, - intubation
drink no complaints, eyes cannot Liver/spleen not palpable, - Plasmafaresis
close completely, forehead tenderness (-)
Extremitas:
cannot constrict; fever(+) Monitoring
Cold acral -/- -/-
CRT <2”/<2” <2”/<2” - Vital sign
General condition : weak Physiologic reflex ↓/↓ ↓/↓ - Respiratory distress
HR: 101x/minute Patologic reflex -/-
N: regular, i/t adequate, Strenght 111/111 000/000
RR: 40x/ minute,
t: 37.3°C (7/1) ERIA divisi
Eyes : anemic (-/-), pupil isocor program:
(+/+) 3mm/3mm - Lumbar puncture H7 hurts
Nose : nasal flaring (-) (Friday 10/1/20)
Mouth : cyanosis (-), symmetric - Plasmafaresis after double
(+) lumen installation
Neck : stiffness (-)
Thorax : symmetric, retraction (-)
Cor, pulmo : normal
Neurology Day : 1-10 (January 5-15th 2019)
06.00 BW : 26 kg
S: legs cannot be moved, the legs Extremitas:
are painful when touched and Cold acral -/- -/-
moved. Heavy hands, on CRT <2”/<2” <2”/<2”
ventilators, tightness (-), fever (-), Physiologic reflex ↓/↓ ↓/↓
TPE / Plasmapharesis plans today Patologic reflex -/-
Strenght 111/111 111/111
(10/1) ERIA divisi
General condition : weak,
programme:
HR: 101x/minute
- Lumbar puncture H7 (Friday 10/1/20)
N: regular, i/t adequate,
RR: 40x/ minute, - Plasmafaresis H1
t: 37.3°C
Eyes : anemic (-/-), pupil isocor
(+/+) 3mm/3mm
Nose : nasal flaring (-) Monitoring
Mouth : cyanosis (-), symmetric - Vital sign
(+) - Respiratory distress
Neck : stiffness (-)
Thorax : symmetric, retraction (-)
Cor, pulmo : normal
Abdomen : Flat, suppel,
Assesments

• Obs tetraparese
dd/ LMN dd/ SGB
dd/ UMN dd/meningitis
Stomatitis
Managements

• RL Infusion 30ml/hours
Ceftriaxone injection 1gr /12 hours

• oral : Nystatin drop 1ml /8 hours

• Program :
- plasmapharesis
- wait for LCS culture
- wait for phisis LCS
Problems
THANK YOU