Name : Riki Utomo

Age : 13 year 9 months

Date of admission : June 15
th
2011
Address : Jl. Sei Sematang LK III
Gender : Male
RU, a thirteen-year-old boy was admitted to Adam Malik Hospital on june 15
th

2011 with chief complaint of headache 2 months ago which became worst 1 month
ago. Fever was found 4 days ago and was characterised as high fever, which was
relieved with fever relieving medication. 5 days ago, patient had seizures with
frequency of 4 times, duration of seizure was around 5 minutes. During his seizure,
the entire of body was involved. Patient also complaint of pain while moving his neck
since one month ago, cough with yellowish phlegm was found 3 days ago. He had no
history of contact with other patients with prolonged cough. In addition, he had a
lump on his back bone since 6 months ago. The lump was painful and became larger
each day. In the past day, the patient vomited after each and every meal with a
frequency of up to 2-3 times daily, volume around 20cc-30cc/time, no blood was
found. Urination and defecation were normal.
Before this, patient was treated in Intensive Care Unit of Martha Friska
Hospital for 4 days before transferred to Adam Malik Hospital. History of past
medication is not clear.

Physical Examination
Generalised Status :
Body Weight (BW) : 28 kg Body Length (BL) : 142 cm
BW/BL : 80% (moderate malnutrition) BW/Age : 56 % BL/Age : 88,2 %
Presens Status :
Consciousness : Alert Temperature : 37,8 C
Anemic (-), icteric (-), cyanosis (-), oedema (-), dyspnea (+)
Localized Status :
Head : Eye : Light reflex (+/+), isochoric pupil (Right = Left) ,
paleness of conjunctiva palpebra inferior (+/+), sclera icteric (-/-)
: Nose : Nasal flare (+)
: Mouth: Mucous pale or cyanosis (-)
: Ears : Secrete (-)
Neck : Lymph node enlargement (-)
Thorax : Symmetrical fusiform Retraction (+) intercostal
HR: 132x/i, reguler, murmur (-)
RR: 40x/i, reguler, rales (-) diminished of breath sound in left lower lung.
Abdomen: Soepel, normal peristaltic, normal skin turgor, Liver/Spleen not palpable
Back : Lump (+) on thoraco region.
Extremities: Pulse 132x/i, regular, adequate pressure and volume, warm, CRT < 3
Urogenital : male, within normal limit

Laboratory Findings : (Adam Malik Hospital / 15/6/2011)
Complete Blood Count :
Hb : 9,86g% PLT : 333.000/mm3
Ht : 31,1% MCV : 80,80 fL
WBC : 2,590/mm3 MCH : 25,00 pg
MCHC : 31,1 g %
Liver Function Test
SGOT : 10 U/L
SGPT : 7 U/L
Kidney Function Test
Ureum : 15,3 mg/dL
Creatinine : 0,34 mg/dL
Blood Glucose level ad random : 102,70 mg/dL
Electrolite
Sodium : 122 mEq/l
Potassium : 3,6 mEq/l
Chloride : 100 mEq/l
Blood Gas Analysis

pH : 7,498
pCO
2
: 32,6 mmHg
pO
2
: 137,4 mmHg
HCO
3
: 24,7 mmHg
Total CO
2
: 25,7 mmol/L
BE : 1,7
Saturasi O
2
: 99,3%





Chest X-ray

Diagnosis :
Suspect Space Occupying Lesion + Suspect Spondilitis TB + Pleura Effusion
Treatment:
Regular Food 1650kcal with 56gr of protein
IVFD D5% NaCl 0,9% 70gtt/i (micro) for 24 hours to correct hyponatremia
Inj Cefotaxim 1gr/ 12 hours/ iv
Inj Ketorolac 15mg /8 hours/ iv
Inj Ranitidine 25mg/ 8 hours/ iv
Paracetamol 3x500mg
Further Plan
Mantoux test
AFB direct smear
Head CT-Scan with contrast
Refer to Neurology division
Refer to Respirology division

















FOLLOW UP
June 16
th
-21
th
, 2011
S Headache (+)

O Sens: CM, Temp: 36,3-36, 9
o
C.
Body weight: 28 kg, Body length: 142 cm.
Head Paleness of onjunctiva palpebra inferior (
-
/
-
).Light reflex (
-
/
-
). Isochoric
pupil.
Neck Jugular vein pressure R-2cm H
2
O. Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (+).
HR: 96-100 bpm, reguler. Murmur (-).
RR:28- 30 x/i, regular. Breath sound: vesicular. Additional sound: (-).
Abdomen
Back
Soepel, Peristaltic (+) normal. Liver and spleen unpalpable.
Lump (+) on thoraco region.
Extremities Pulse 96-100 x/i, regular, adequate p/v, warm, CRT < 3. BP: 140-
110/70-100 mmHg (normal: 104-117 / 60-75). Hypertrophy (+) lower
extremities.
Genital Male, within normal limit

A Suspect SOL + Suspect Spondilitis TB + Pleura Effusion +
Anemia ec DD : - Chronic disease
-Iron deficiency
P Management:
- Regular Food 1650kcal with 56gr of protein
- IVFD D5% NaCl 0,9% 70gtt/i (micro) for 24 hours to correct hyponatremia
(15
th
-16
th
)
- IVFD D5% NaCl 0,9% 20gtt/i (micro) 17
th
-21
th

- Inj Cefotaxim 1gr/ 12 hours/ iv in 50cc of NaCl 0,9% for 20mins
- Inj Ketorolac 15mg /8 hours/ iv
- Inj Ranitidine 25mg/ 8 hours/ iv
- Inj Methylprednisone 750mg/24 hours for 3 days (18
th
20
th
)
- Paracetamol 3x500mg
Further plan:
- Mantoux test (16/6/2011)
- AFB direct smear
- Head CT-Scan with contrast(16/8/2011)
- Right lateral decubitis chest x-ray
- Blood culture and sensitivity test (16/6/2011)
- Refer to Neurology division
- Refer to Respirology division
- X-ray cervical spine AP-Lateral
- X-ray thoracic-lumbar spine AP- Lateral
- Lumbar puncture (17/6/2011)
- CSF analysis (17/6/2011)
- CSF culture and sensitivity test (17/6/2011)
Results
- Mantoux test (18/7/2011)
indurasion 12mm, hyperemis (+)
- Blood culture : (16/7/2011)
no microorganism was found.
- CSF analysis : (17/6/2011)
Colour : clear
LDH : 120 U/L
Total Protein : 24mg/dL
Total Cell : 0 mm
3
Glucose : 51 mg/dL
pH : 9
PMN : undetermine
MN : undetermined
- CSF culture & sensitivity test (21/6/2011)
Culture : Growth of staphylococcus epidermidis
Sensitivity test : resistance to Amoxycillin/ Clavulanic acid, Ampicillin,
ciprofloxacin, chloramphenicol,cotrimoxazole, erythromycin, gentamycin,
penicillin.
- AFB Smear : (17/6/2011)
Negative
- Head CT Scan with contrast : (18/6/2011)
No sign of SOL, bleeding or meningitis
- X-ray thoracic-lumbar spine AP- Lateral
Destruction of vertebra T11 and T12.
Destruction of vertebra L1,2 and 5
17 th June , 2011
S Headache (+)
O Sens: CM, Temp: 37, 3
o
C.
Body weight: 28 kg, Body length: 142 cm.
Head Paleness of onjunctiva palpebra inferior (
-
/
-
).Light reflex (
-
/
-
). Isochoric
pupil.
Neck Jugular vein pressure R-2cm H
2
O. Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (+).
HR: 96 bpm, reguler. Murmur (-).
RR: 28 x/i, regular. Breath sound: vesicular. Additional sound: (-).
Abdomen
Back
Soepel, Peristaltic (+) normal. Liver and spleen unpalpable.
Lump (+) on thoraco region.
Extremities Pulse 96 x/i, regular, adequate p/v, warm, CRT < 3. BP: 100/70 mmHg
(normal: 104-117 / 60-75). Hypertrophy (+) lower extremities.
Genital Male, within normal limit

A Suspect SOL + Suspect Spondilitis TB + Pleura Effusion +
Anemia ec DD : - Chronic disease
-Iron deficiency
P Management:
- Regular Food 1650kcal with 56gr of protein
- IVFD D5% NaCl 0,9% 20gtt/i (micro)
- Inj Cefotaxim 1gr/ 12 hours/ iv in 50cc of NaCl 0,9% for 20mins
- Inj Ketorolac 15mg /8 hours/ iv
- Inj Ranitidine 25mg/ 8 hours/ iv
- Inj Methylprednison 750mg/24 hours
- Paracetamol 3x500mg
Further plan:
- AFB direct smear - CSF analysis
- Head CT-Scan with contrast - CSF culture and sensitivity test
- Right lateral decubitis chest x-ray
- Blood culture and sentivity test
- X-ray cervical spine AP-Lateral
- X-ray thoracic-lumbar spine AP- Lateral
- Lumbar Puncture
- Mantoux Test result on 18/6/2011

18 th June , 2011
S Headache (+)

O Sens: CM, Temp: 36, 9
o
C.
Body weight: 28 kg, Body length: 142 cm.
Head Paleness of onjunctiva palpebra inferior (
-
/
-
).Light reflex (
-
/
-
). Isochoric
pupil.
Neck Jugular vein pressure R-2cm H
2
O. Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (+).
HR: 100 bpm, reguler. Murmur (-).
RR: 30 x/i, regular. Breath sound: vesicular. Additional sound: (-).
Abdomen
Back
Soepel, Peristaltic (+) normal. Liver and spleen unpalpable.
Lump (+) on thoraco region.
Extremities Pulse 100 x/i, regular, adequate p/v, warm, CRT < 3. BP: 110/70 mmHg
(normal: 104-117 / 60-75). Hypertrophy (+) lower extremities.
Genital Male, within normal limit

A Suspect SOL + Suspect Spondilitis TB + Pleura Effusion +
Anemia ec DD : - Chronic disease
-Iron deficiency
P Management:
- Regular Food 1650kcal with 56gr of protein
- IVFD D5% NaCl 0,9% 70gtt/i (micro) for 24 hours to correct hyponatremia
- Inj Cefotaxim 1gr/ 12 hours/ iv
- Inj Ketorolac 15mg /8 hours/ iv
- Inj Ranitidine 25mg/ 8 hours/ iv
- Paracetamol 3x500mg
Further plan:
- Mantoux test
- AFB direct smear
- Head CT-Scan with contrast
- Right lateral decubitis chest x-ray
- Blood culture and sentivity test
- Refer to Neurology division
- Refer to Respirology division

19 th June , 2011
S Headache (+)
O Sens: CM, Temp: 37, 3
o
C.
Body weight: 28 kg, Body length: 142 cm.
Head Paleness of onjunctiva palpebra inferior (
-
/
-
).Light reflex (
-
/
-
). Isochoric
pupil.
Neck Jugular vein pressure R-2cm H
2
O. Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (+).
HR: 96 bpm, reguler. Murmur (-).
RR: 28 x/i, regular. Breath sound: vesicular. Additional sound: (-).
Abdomen
Back
Soepel, Peristaltic (+) normal. Liver and spleen unpalpable.
Lump (+) on thoraco region.
Extremities Pulse 96 x/i, regular, adequate p/v, warm, CRT < 3. BP: 100/70 mmHg
(normal: 104-117 / 60-75). Hypertrophy (+) lower extremities.
Genital Male, within normal limit

A Suspect SOL + Suspect Spondilitis TB + Pleura Effusion +
Anemia ec DD : - Chronic disease
-Iron deficiency
P Management:
- Regular Food 1650kcal with 56gr of protein
- IVFD D5% NaCl 0,9% 20gtt/i (micro)
- Inj Cefotaxim 1gr/ 12 hours/ iv in 50cc of NaCl 0,9% for 20mins
- Inj Ketorolac 15mg /8 hours/ iv
- Inj Ranitidine 25mg/ 8 hours/ iv
- Inj Methylprednison 750mg/24 hours
- Paracetamol 3x500mg
Further plan:
- AFB direct smear - CSF analysis
- Head CT-Scan with contrast - CSF culture and sensitivity test
- Right lateral decubitis chest x-ray
- Blood culture and sentivity test
- X-ray cervical spine AP-Lateral
- X-ray thoracic-lumbar spine AP- Lateral
- Lumbar Puncture
- Mantoux Test result on 18/6/2011