Presentasi Kasus Sepsis
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Case Reportsepsis
Rianty adyati
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Identity Name : An.D Age : 12 years old Sex : Male Address : Pakusamben
village Admission date : 2-7-2015 Examination date : 2-7-2015
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Chief Complaint Pruritus since1weeks ago.
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History takingAn.D, 12 years old was admitted to General
hospital Waled with the main complaint of pruritus since1
weeks ago. The mother said that the pruritus started from
back and suddenly made his body feel itch that became red
and painful. An then, the pruritus appeared widespread and
almost appeared in his entire body. Then it becomes more
red and painful. After that patient had a fever which was
not decreased but increased continously and there wasn't
improvement.
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Past Health History
He was given antifungal from doctor.
Family History
His brother was have same complaint too.
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Environmental History
There no history about social and environment
because there no his friend or neighboard was
complaint too.
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History of pregnancy and childbirth
Pregnancy HistoryThere is no history about bleeding and hypertension during the pregnancy, the mother always exam her self to the midwife, she had 6 ANC exam until the baby was born.
Birth HistoryThe baby was delivery spontaniuosly and normal helped by the midwife.
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Immunization History Immunization history complete
Name of the vaccine
Given Not given
PolioHepatitis
BBCGDPTcampak
Yes Yes Yes Yes Yes
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Physical ExaminationThe general state: Acute-
ill lookingAwareness: Full alert Vital signs:
- RR : 32x/ mnt- HR : 145 x/
mnt- Temperature: 38,5◦C
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10
Specific examination
Head : Normocephaly
Eyes : Sclera Icteric (-) Conjungtiva Anemis (-)
Ears : Ears symmetric dextra = sinistra, without
any discharges from the ears.
Nose : Secret (-), nasal flaring (-)
Mouth : Perioral cyanosis (-)
Neck : Lymphadenopathy (-), Suprasternal
retractions (-)
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Thorax : good expansion and symmetric, intercostal
retractions +/+
Pulmo : bronkovasikular breath sound +/+, wheezing
-/-, ronkhi -/-
Cor : S1,S2 regular rhythm. Abdomen : Soft, Liver and spleen is not palpable,
Bowel sound are present with reguler movement,
epigastrium retractions (-), turgor is normal, eritema
(+), skuama (+) Extremities : Warm, Acrocyanosis (-) , CRT < 3”
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04/18/23
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Further Examination
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Differential Diagnosis Sepsis bacterialis ec. psoriasis pustulosa
generalisata Sepsis ec.dermatofitosis Sepsis ec.seboriasis
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Working Diagnosis Sepsis bacterialis ec. psoriasis
pustulosa generalisata
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Treatment
Infus KAEN 3B Paracetamol syr 3x1 tea spoon Cetrizin syr 3x1 eat spoon Ctm 3x4 mg Gentamisin 2x/day (krusta) Ceftazidin 2x750 mg iv Metronidazol 3x500 mg iv Carmed 10 %+memetason 2x/day (yellow lession) Compress nacl 0,9 % (krista)
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Purposed Examination Arterial Blood Gas Test CRP (C-Reactive Protein) Lactat Acid Test Blood Culture and Skin Culture
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Education Bed rest. Adequate rest is important to maintain
progress toward full recovery and to avoid relaps.
Avoid risk factor
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PROGNOSISQuo ad vitam : ad bonamQuo ad functionam : ad bonamQuo ad sanationam : dubia ad bonam
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Thank you