Case Reportsepsis

Rianty adyati

Identity Name : An.D Age : 12 years old Sex : Male Address : Pakusamben

village Admission date : 2-7-2015 Examination date : 2-7-2015

Chief Complaint Pruritus since1weeks ago.

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.

Past Health History

He was given antifungal from doctor.

Family History

His brother was have same complaint too.

Environmental History

There no history about social and environment

because there no his friend or neighboard was

complaint too.

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.

Immunization History Immunization history complete

Name of the vaccine

Given Not given

PolioHepatitis

BBCGDPTcampak

 

Yes Yes Yes Yes Yes

Physical ExaminationThe general state: Acute-

ill lookingAwareness: Full alert Vital signs:

- RR : 32x/ mnt- HR : 145 x/

mnt- Temperature: 38,5◦C

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 (-)

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”

04/18/23

Further Examination

Differential Diagnosis Sepsis bacterialis ec. psoriasis pustulosa

generalisata Sepsis ec.dermatofitosis Sepsis ec.seboriasis

Working Diagnosis Sepsis bacterialis ec. psoriasis

pustulosa generalisata

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)

Purposed Examination Arterial Blood Gas Test CRP (C-Reactive Protein) Lactat Acid Test Blood Culture and Skin Culture

Education Bed rest. Adequate rest is important to maintain

progress toward full recovery and to avoid relaps.

Avoid risk factor

PROGNOSISQuo ad vitam : ad bonamQuo ad functionam : ad bonamQuo ad sanationam : dubia ad bonam

Thank you