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follow upDate History and Physical Examination Diagnose Treatment

18 Feb 15

(08.00 WIB)

Symptom: Low of consciousness

General states

Sens : E3M5V2

BP: 130/80 mmHg

RR : 24 x/mnt

PR : 80 x/mnt T: 37,8°C

Neurolog ic states :

Cranial nerves:

n. III : pupil bulat, isokor, Rc +/+, Ø 3mm ()

n. VII : flat nasolabial fold, deviation of angle

of mouth to the left side,

lagophthalmus (-) symmetry forehead

wrinkles

N. XII: deviation of tongue (-), disartria

can’t be assessed

Motoric Function : ra la rl ll

Movement left lateralization

Muscle strength

Tonus ↑ ↑ ↑ ↑

Clonus - -

Clinical Diagnose : low of consciousness, left spastic

hemiparese + parese of left central

VII nerve + general tonic clonic

seizure observation

Topic Diagnose : hemisphere of right cerebrum

Etiological Diagnose : intracerebral toxoplasma

Additional Diagnose : Susp of HIV infection

- O2 8 L/mnt (simple mask)

- IVFD NaCl 0,9% gtt 20 x/mnt

- Inj. Ceftriaxone 2x2 gr i.v

- Inj. Dexamethasone 3x10 mg i.v

tappering off

- Drip. Paracetamol 3x1gr i.v

- Fenitoin 3x100 mg po

- Clindamisin 4x600 mg po

- Pyrimetamin1x200 mg po

- Check VCT

10

Physiologic Reflex ↑ ↑ ↑ ↑

Patologic Reflex - - +BC +BC

Sensoric function : can’t be assessed

Vegetative function : using catheter

Meningeal sign : nuchal rigidity (+),

Kerniq (+/+), lasseque (+/+)

Abnormal movements : (-)

Gait and Balance : can’t be assessed

Lab Results :

Toxoplasma igG : 2542 IU/ml (0-3) IU/ml

Toxoplasma igM : 0,217 COI

Non reactive <0,5

indeterminate <=0,5-<1,0

Reactive >= 1,0

HIV : Positive (Negative)

LCS Analysis

macroscopic

volume : 3cc

color : colorless

clarity : clear

11

odor : no odor

density : 1020

sediment : negative

PH : 8,5

Cell total : 5 cel/pl

PMN : 0

MN : 100

Blast cell : -

Nonne : negative

Pandy : positive

Protein : 0,1 g/dl

LDH : 134

Glucose : 59,8 mg/dl

(BSS before LP : 148 mg/dl)

chlorida : 128 mg/dl

-

20 Feb 2015 Symptom: Low of consciousness

General states

Sens : E3M5V2

BP: 120/80 mmHg

RR : 25 x/mnt

PR : 90 x/mnt T: 38,9°C


Cranial nerves:




seizure observation




- O2 8 L/mnt (sungkup)




tappering off




12




lagophthalmus (-) symmetry

foreheadwrinkles


can’t be assessed



Muscle strength

Tonus ↑ ↑ ↑ ↑

Clonus - -









- Pyrimetamin 3x25 mg po

- kotrimoxsazol 1x960 mg

- consul interne

13

VCT Result : positif

21 Feb 2015 Symptom: Low of consciousness

General states

Sens : E3M5V2

BP: 90/70 mmHg

RR : 22 x/mnt

PR : 85 x/mnt T: 38,9°C


Cranial nerves:





forehead wrinkles


can’t be assessed



Muscle strength




seizure observation




Internal Department

S : Lose of consciousness

O: General Conditon : Unwell

Head : Conjuctiva Anemi (-), membrane mucous of mouth

and tongue anemi (-), papil atrophy of tongue (+),

Stomatitis (+)

Neck : Limfe enlargement (-), Vein Jugular Pressure (5-2

CmH20)

Thorax : Cor : HR 90X/minute, Murmur (-), Gallop (-)





tappering off


- Fenitoin 3x100mg po



- Cek CD 4

14

Tonus ↑ ↑ ↑ ↑

Clonus - -









Pulmo : Vesikular , Ronchi (-), Whezing(-)

Abdomen : Flat, supel, hepar and lien not palpable ,

Abdominal pain pressure (-), intestinal noise

normal, turgor normal, skin normal

Ekstremitas : edem pretibial (-),tato in regio

brakhialis dextra

A : infeksi HIV stadium IV

P : plan ARV

Cek CD4

Care together with tropic infetced

23 Feb 2015 Symptom: Lose of consciousness

St. Generalis:

Sens : E4M6V4

T

BP: 120/80 mmHg RR: 27 x/mnt

PR : 100 x/mnt T: 38°C


Cranial nerves:






seizure observation




Susp HAP





tappering off





- Azitromisin 1 x 500 mg po

15



foreheadwrinkles


can’t be assessed



Muscle strength

Tonus ↑ ↑ ↑ ↑

Clonus - -









Hb : 10,8 g/dl Leukosit: 7000 /mm3

Internal Department

S : Lose of consciousness, cough (+)




Stomatitis (+)


CmH20)


Pulmo : Vesikular , Ronchi (+), Whezing(-)





brakhialis dextra


P : plan ARV

16

Eritrosit : 4800 /mm3 Hematokrit : 40 %

Trombosit: 256.000 / µL

Natrium: 140 mEq/l Kalium: 3,4 mEq/l

Ureum: 34 mg/dl Kreatinin: 0,95 mg/dl

Cek CD4

Susp HAP

P : plan giv ARV

Azitromisin 1 x 500 mg tab

26 Feb 2015 Symptom: Lose of consciousness

St. Generalis:

Sens : E2M4V1


PR : 100 x/mnt T: 38,9°C


Cranial nerves:





foreheadwrinkles





seizure observation




Susp HAP

Internal Department

S : Lose of consciousness







tappering off





- Azitromisin 1x 500mg po

- Menunggu hasil CD 4

17

can’t be assessed



Muscle strength

Tonus ↑ ↑ ↑ ↑

Clonus - -










Stomatitis (+)


CmH20)


Pulmo : Vesikular , Ronchi (+), Whezing(-)





brakhialis dextra


P : plan ARV

Cek CD4

Susp HAP

P : plan giv ARV

Azitromisin 1 x 500 mg tab

18

26 Feb 2015

(20.00 WIB)

Symptoms: Lose of consciousness

St. Generalis:

Sens : E2M3V1


PR : 130 x/mnt T: 41°C


Cranial nerves:

n. III : pupil bulat, isokor, Rc -/-, Ø 5mm ()




foreheadwrinkles


can’t be assessed



Muscle strength

Diagnosa klinik : Penurunan kesadaran + hemiparese

sinistra spastik + parese n.VII sinistra

sentral + obsevasi penurunan

kesadaran

Diagnosa topik : hemisfer cerebri sinistra

Diagnosa etiologi : - toxoplasma intraserebral

Diagnosa tambahan : infeksi HIV stadium IV

Susp HAP





tappering off





- Cek CD 4

19

22.00

Tonus ↑ ↑ ↑ ↑

Clonus - -









Os meninggal

Hasil subtype Limfosit : - CD4 - CD8

27 Feb 15 CD4 Absolut 21 404 – 1612 sel/uL CD8 Absolut 887 220 – 1129 sel/uL

CD4 % 1,73 33 – 58 % sel/uL CD8 % 73,92 13 – 39 sel/uL

Rasio CD4 : CD8 0,02 0,69 – 2,83 sel/uL (Semakin rendah rasio CD4 : CD8, semakin tinggi kemungkinan terjadinya komplikasi dan perburukan infeksi)

Kesan : Lyphocyte T helper rendah dan T suppressor normal dengan rasio CD4-CD8 rendah

20

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