Laporan Kasus 26 Juli 2013

8/14/2019 Laporan Kasus 26 Juli 2013

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LAPORAN KASUS


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IDENTITAS PASIEN

Nama : An RT

Usia : 6 tahun

Jenis kelamin : laki-laki

Alamat : Pundungan 2/6 Jonggrangan, Klaten Utara

No.RM : 593xxx

Nama orangtua : Bp. Subardi/ Ibu. Kujaima

Pekerjaan orangtua : Buruh/IRT


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ANAMNESIS

Keluhan Utama :

Demam 7 hari


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RIWAYAT PENYAKIT SEKARANG2MSMRS Anak mengeluhkan batuk (+), dahak (+), dahak susah keluar, sesak napas (-), pilek (-),

demam (-), mual (+), muntah (-).

1MSMRS Anak demam (+) tidak tinggi, naik turun, panas hanya di pagi hari, BAB cair (+) 2x/hari,

mual (+), muntah (-), nafsu makan turun, pusing (+), batuk (+), sesak napas (+), berobat ke bidan.


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2HSMRS Demam (+) tidak tinggi, nyeri perut (+), mual (+), muntah (-), nafsu makan turun, BAB (+)

N, BAK (+) N.

HMRS Demam (+), mual (+), muntah (-), nafsu makan turun, ke RSIA cek darah , rujuk ke RSST


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RIWAYAT PENYAKIT DAHULU

Riw diare (+) usia 1 tahun

Riw asma (-)

Riw alergi (-)


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RIWAYAT PENYAKIT KELUARGA

Riw asma (-)

Riw alergi (-)

Keluarga serumah dengan demam (-)


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42

th39 th

6 th6 th12

th

18

th


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RIWAYAT ANC/NC/PNC

antenatal Ibu G3P2A0 rutin kontrol di bidan, tdk pernah ada

keluhan, HT(-), DM(-), kejang (-), demam (-)

natal

Ibu berusia 33 tahun P3A0 melahirkan di rumah sakit.Bayi berat lahir 2200 gr, UK 32 minggu, secaraspontan, menangis kuat (+)

postnatal

Kontrol teratur dan imunisasi di puskesmas sesuaibuku KMS. Ikterik (-)

Kesan: BBLR, preterm


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RIWAYAT IMUNISASI

Menurut ibu, anak mendapatkan imunisasi dasar program pemerintah sesuai jadwal di

puskesmas.

BCG = usia 1 bulan

Hep B = usia 0, 2, 3, 4 bulan

Polio = usia 1, 2, 3, 4 bulan DPT = usia 2, 3, 4 bulan

Campak = usia 9 bulan

KESAN: imunisasi sesuai jadwal


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RIWAYAT MAKANAN

KESAN: riwayat makan kurang baik

UMUR JENIS MAKANAN

021 bulan ASI

21 bulan

sekarang (6 tahun) Nasi dengan lauk dan tidak suka sayuran 2-3 x 1porsi/hari. Suka jajan jajanan di sekolah


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RIWAYAT PERKEMBANGAN

Saat ini anak sudah duduk di kelas I SD, tinggal kelas (-), suka bermain bersama teman-

teman

Motorik kasar Motorik halus Bicara Sosial

Duduk (7 bulan)

Jalan (13 bulan)

Lari (2 tahun)

Naik Sepeda (5 tahun)

Menulis (5 tahun) Ucapkan kata (2

tahun)

Bermain (4

tahun)

Kesan Riwayat Perkembangan baik


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RIWAYAT SOSIAL, EKONOMI, DAN LINGKUNGAN

Anak tinggal bersama kedua orang tua. Rumah berisi 6 orang ; orang tua dan keempat anak.

Pekerjaan bapak sebagai buruh di luar kota, sedangkan ibu sebagai ibu rumah tangga.

Penghasilan perbulan Rp. 1 juta.

Rumah sederhana, beratapkan genting dan beralaskan ubin. Rumah memiliki 3 kamar tidur

dan 1 kamar mandi yang terletak di dalam. Sumber air minum dan kebutuhan sehari-hari

berasal dari pompa air. Rumah memiliki halaman rumah, dan dekat jalan raya. Ventilasi dancahaya rumah baik. Pembiayaan RS menggunakan jamkesmas.

Kesan Sosial, ekonomi menengah ke bawah, dengan kondisilin kun an cuku baik


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ANAMNESIS SISTEM

Sistem CNS: penurunan kesadaran (-), kejang (-),

demam (+)

Sistem Cardiovaskular: kebiruan (-), bengkak (-), akral

hangat

Sistem Respiratorius: batuk (+), dahak (+), sesak (+),

pilek (-)

Sistem GIT: nyeri perut (+), mual (+), muntah (-), BAB (+)

N, diare (-), Intake (+)

Sistem Genitourinari: BAK dbn

Sistem Musculoskeletal: Kelainan bentuk (-), bengkak (-).

Nyeri sendi(-). Nyeri otot (-).

Sistem Integumentum: Kuning(-), pucat (-)


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PEMERIKSAAN FISIK 30 JULI 2013

Keadaan Umum : CM, anak tampak lemah

Tanda Vital

Nadi : 120 x/menit, teratur, kuat

RR : 24 x/menit

Suhu : 36,7 C

TD : 100/50 mmHg


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STATUS GIZI DAN ANTOPOMETRI

BB : 16 kg TB : 105 cm BB/U: -3


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PEMERIKSAAN LEHER

Inspeksi : JVP tak meningkat, benjolan (-)

Palpasi : JVP tak meningkat, lnn. tidak teraba

Simpulan :

Dalam batas normal


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SISTEM KARDIOVASKULAR

Inspeksi : IC tidak tampak

Palpasi : IC teraba pada SIC IV LMCS

Perkusi : tidak dilakukan

Auskultasi : S1 tunggal, S2 split tak konstan, bising (-), murmur (-)

Simpulan :

Dalam batas normal


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SISTEM GASTROINTESTINAL

Pemeriksaan Abdomen

I : DP//DD, distended (-)

A : BU (+) kesan normal

Pe : Tympani

Pa : Supel, hepar tidak teraba, lien tidak teraba, ginjal tidak teraba, T/E dbn

Simpulan :

Dalam batas normal


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SISTEM GENITOURINARY

Flank : bulging(-), nyeri ketok ginjal (-)

Suprapubic : nyeri tekan (-); bulging(-)

OUE : inflamasi (-)

Simpulan :

Dalam batas normal


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ANOGENITAL

Laki-laki , anus (+)


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EKSTREMITAS

Akral hangat

Nadi kuat

CRT


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PEMERIKSAAN KEPALA

Bentuk : Mesocephal

Mata :Conjunctiva Anemis (-), Sklera Ikterik(-)

Hidung : Sekret (-), nafas cuping hidung (-)

Telinga : Nyeri tekan (-), Sekret (-)

Mulut : Sianosis (-), Mukosa bibir kering (-), bibir pucat (-

), stomatitis (-), lidah kotor (-)

Orofaring : Hiperemis (-) Pembesaran Tonsil (-)


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LABORATORIUM DR 29/7/2013

WBC 24.3

RBC 5.41

HGB 13.4

HCT 40.5

MCV 74.9

MCH 24.8 MCHC 33.1

PLT 467

LYM 12.2%

MXD 6,4 %

NEUT 81,4 %

GDS : 127 mg/dl

Widal Typhi H : +1/80

Widal Typhi O : +1/320

Na : 133 mmol/LK : 4.3 mmol/L

Cl : 97 mmol/L


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DIAGNOSIS KERJA

Susp. Typhoid fever


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TATA LAKSANA

IVFD D5 NS 10 tpm makro Inj. Chlorampenicol 100mg/kgBB/hari ~ 4 x 400mg IV

Paracetamol 10mg/kgBB/x ~ Cth 1 1/2 k/p t 38oC


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TERIMA KASIH


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KASUS II


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IDENTITAS PASIEN

Nama : An. R.A

Jenis kelamin : Laki-laki

Usia : 5 tahun 6 bulan (24/1/2008)No. RM : 787169

Tempat tinggal : Jemawan, Jatinom

Masuk Bangsal : 24 Juli 2013, jam 13.15

Tgl. Periksa : 25 Juli 2013, jam 14.00


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ANAMNESIS

Keluhan Utama :

Demam mendadak tinggi


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RIWAYAT PENYAKIT SEKARANG

Hari Minggu (21 Juli 2013) pagi sekitar jam 10.00

anak mendadak demam tinggi terus terusan, nyeri

kepala (+), mual (+), muntah (-), nyeri belakang mata

(-), merasa pegal-pegal (-), gusi berdarah (-), mimisan(-), rash (-) batuk (+), pilek (+), nyeri perut (+) BAB

dan BAK t.a.k, nafsu makan menurun, lemas (+).

Anak dibawa ke dokter, diagnosis tidak diketahui,

diberi obat thiamphenicol syrup dan paracetamol

syrup.

4

HSMRS


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1 HSMRS

Keluhan dirasakan tidak membaik,panas tidak

turun turun , anak semakin lemas, akhirnya dibawa

kembali berobat ke puskesmas. Dilakukan tes darah

didapatkan Hb:11.8 AT:60.000 HCT:37% AL:1700.Didiagnosa sebagai DHF grade I. Pasien diusulkan

untuk dirujuk ke RSUP Suradji Tirtonegoro.


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Anak dibawa ke RSS (24 Juli 2013) jam 13.15

Demam (+), mual (-), muntah (-), nyeri belakang

bola mata (+), nyeri otot (-), lemas (+), tidak nafsu

makan, perdarahan spontan (-), BAB dan BAK t.a.k,nyeri perut (+). Pemeriksaan fisik didapatkan demam

38c, takikardi (-), takipneu (-), Rumple Leed (+),

hepatomegali 1 cm bac, tanda plasma leakage (-) berupa

odem palpebra (-), ascites (-), efusi pleura (-), tanda

syok (-) .

IGD


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Hasil Lab: Hb 12,9 Hct 38,3 % AT 51.000

Didiagnosis DHF grade I (hari ke IV)

Terapi IVFD RL 3 cc/kg/jam, parasetamol10mg/kgbb/kali sprn, plan monitor KU, tanda

vital, tanda syok, monitor HCT/AT tiap 6 jam.


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Pasien masih demam (38,3 c), lemas, ada nyeri

perut, dan nafsu makan cukup.

Dari pemeriksaan fisik ditemukan edema

palpebral (+), nyeri tekan epigastrik(+),

hepatomegali 2cm bac, dan ascites(-). Tidak ada

perdarahan spontan. Tidak terdapat tanda syok.

Hb 13,1 Hct 38% AT 33.000

Assessment DHF grade I (hr ke-5), terapi

dilanjutkan, monitor HCT/AT tiap 6 jam.

Hari I perawatan Hari ke 5 25 Juli 2013


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RIWAYAT PENYAKIT DAHULU

Riw. sakit serupa (-)

Riw. Mondok (-)


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RIWAYAT PENYAKIT KELUARGA

Riw. sakit serupa (-)


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ANAMNESIS SISTEM

Demam(+) Sistem serebrospinal : kejang (-), penurunan

kesadaran (-)

Sistem kardiovaskular : deg-degan (-), bising (-),sesak nafas (-), kebiruan (-)

Sistem pernapasan : sesak nafas (-), batuk (-)

Sistem gastrointestinal : mual(+), muntah (-), diare (-)

Sistem urogenital : BAK (+)

Sistem muskuloskeletal : pegal-pegal (-), deformitas (-)

Integumentum: ikterik (-), rash (+), kebiruan (-)


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PEMERIKSAAN


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PEMERIKSAAN FISIK (24 Juli 2013)

CM, kesan gizi cukup

Kesan Umum

Tekanan Darah : 100/60, manset kecil, posisi berbaring

Nadi : 120 x/menit, simetris, isi dan tegangan cukup, teratur

Napas : 24 x/menit, tipe abdominothoracal, reguler

Suhu : 38,3 C

Tanda Vital

Kesimpulan : suhu badan meningkat


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PEMERIKSAAN FISIK

Status GiziBB 15 kg

TB 105 cm

BB/U : 0 < Z < -2 SDTB/U : 0 < Z < -2 SDBB/TB : -1 < Z < -2 SD

KESAN: Status Gizi normal


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PEMERIKSAAN FISIK


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PEMERIKSAAN FISIK

Pulmo Pemeriksaan Thorax Cor

Simetris

Retraksi dinding dada (-)Inspeksi IC tidak tampak

fremitus taktil +/+

Ketinggalan Gerak (-)Palpasi IC teraba di SIC IV LMCS

Sonor +/+ Perkusi

Batas kanan atas: SIC II LPSD

Batas kanan bawah: SIC IV

LPSD

Batas kiri atas: SIC II LPSS

Batas kiri bawah: SIC IV LMCS

vesikular (+/+), RBB

(-/-), RBK (-/-), egofoni (-/-)Auskultasi S1 regular, S2 split tak konstan


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PEMERIKSAAN FISIK

ABDOMEN

Inspeksi : Dinding dada = dengan dinding perut,distensi (-), rash(-)

Auskultasi : Bising usus normal

Perkusi : Hipertimpani (+)

Palpasi : Supel, nyeri tekan epigastrik (+), hepar teraba 1 cm

b.a.c dan lien ttb


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PEMERIKSAAN FISIK

ANOGENITAL:

Laki-laki, sirkumsisi (-), testis (+/+)

PEMERIKSAAN FISIK


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PEMERIKSAAN FISIK

Akral hangat, CRT


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PEMERIKSAAN FISIK

Kulit :RL (+), rash (+)

Limfonodi :Lnn. Cervicalis Anterior Sinistra (+) multiple. Diameter 0,5cm. Nyeri tekan (-).

Kepala:

Bentuk mesocephal

Ubun-ubun kepala tertutup, ubun-ubun cekung (-)

Mata: konjungtiva anemis (-) sklera ikterik(-), mata cowong (-), Edem

Palpebra (+)

Hidung:discharge(-), nasal flare (-)

Telinga:discharge(-)

Mulut: bibir kering(-), sianosis (-), stomatitis (-), lidah kotor (-)

Otot : eutrofi

Tulang : deformitas(-)

Sendi : deformitas(-)


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DIFFRENTIAL DIAGNOSIS

Dengue Fever

Dengue Hemorhagic Fever

Thypoid Fever

PEMERIKSAAN PENUNJANG


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Tanggal Hb Hct AT

24/7/2013(Puskesmas) 11,8 37 60.000

24/7/2013

(IGD RSST)

12.53

12,9 38,3 51.000

24/7/2013

17.41

13 38,2 60.000

24/7/2013

23.20

13,3 39 39.000

25/7/2013

5.40

13,1 38,3 33.000

25/7/2013

17.06

12,1 35,6 24.000

25/7/2013

22.09

12,2 36 25.000

26/7/2013

5.08

13,7 40,6 29.000

PEMERIKSAAN PENUNJANG


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DIAGNOSIS KLINIS

Demam Berdarah Dengue derajat I


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PENATALAKSANAAN

Monitor KU/VS/BC per 6 jam

Monitor Hct/PLT per 6 jam

Infus RL 3 cc/kgbb/jam

Paracetamol 10mg/kgbb/kali Sprn

PLAN: cek IgM/IgG anti Dengue

Cek widal


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Terima kasih


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DENGUE & DENGUE

HEMORRHAGIC FEVER

DR.I.SELVARAJ, IRMS

Sr.D.M.O (Selction Grade), INDIAN RAILWAYS

B.SC.,M.B.B.S.,(M.D Community Medicine)., D.P.H., D.I.H., PGCH&FW (NIHFW, New Delhi)


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BURDEN OF DISEASE IN S.E.ASIA

CATEGORY-A (INDONESIA,MYANMAR,AND THAILAND)

CATEGORY-B (INDIA,BANGALADESH,MALDIVES,AND

SRILANKA)

CATEGORY-C (BHUTAN, NEPAL) CATEGORY-D (DPR KOREA)


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Dengue Virus1. Causes dengue and dengue hemorrhagic fever

2. It is an arbovirus3. Transmitted by mosquitoes

4. Composed of single-stranded RNA

5. Has 4 serotypes (DEN-1, 2, 3, 4)


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Dengue VirusEach serotype provides specific lifetime immunity,

and short-term cross-immunity

All serotypes can cause severe and fatal diseaseGenetic variation within serotypes

Some genetic variants within each serotype appear

to be more virulent or have greater epidemic potential


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The most common epidemic vector of dengue in the world is

theAedes aegyptimosquito. It can be identified by the whitebandsor scale patternson its legs and thorax.


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Clinical Characteristics of Dengue Fever

Fever

HeadacheMuscle and joint pain

Nausea/vomiting

Rash

Hemorrhagic manifestations

Patients may also report other symptoms, such as

itching and aberrationsin the sense of taste,

particularly a metallic taste.In addition, there have

been reports ofsevere depressionafter the acutephase of the illness.


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1.The virus is inoculated into

humans with the mosquito

saliva.

2.The virus localizes and

replicates in various target

organs, for example, local

lymph nodes and the liver.

3.The virus is then releasedfrom these tissues and

spreads through the blood to

infect white blood cells and

other lymphatic tissues.

4.The virus is then releasedfrom these tissues and

circulates in the blood.


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5.The mosquito ingests blood containing the virus.

6.The virus replicates in the mosquito midgut, the ovaries,

nerve tissue and fat body. It then escapes into the bodycavity, and later infects the salivary glands.

7.The virus replicates in the salivary glands and when the

mosquito bites another human, the cycle continues.


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The transmission cycle of dengue virus by the mosquito Aedes aegyp t ibegins

with a dengue-infected person. This person will have virus circulating in the

blooda viremia that lasts for about five days. During the viremic period, an

uninfected female Aedes aegyp t imosquito bites the person and ingests blood

that contains dengue virus. Although there is some evidence of transovarial

transmission of dengue virus in Aedes aegyp t i, usually mosquitoes are only

infected by biting a viremic person.

Then, within the mosquito, the virus replicates during an extrinsic incubation

period of eight to twelve days.

The mosquito then bites a susceptible person and transmits the virus to him or

her, as well as to every other susceptible person the mosquito bites for the rest of

its lifetime.

The virus then replicates in the second person and produces symptoms. The

symptoms begin to appear an average of four to seven days after the mosquito

bitethis is the intrinsic incubation period, within humans. While the intrinsic

incubation period averages from four to seven days, it can range from three to 14days.

The viremia begins slightly before the onset of symptoms. Symptoms caused by

dengue infection may last three to 10 days, with an average of five days, after the

onset of symptomsso the illness persists several days after the viremia has

ended.


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There are actually four dengue clinical

syndromes:

1.Undifferentiated fever;

2.Classic dengue fever;3.Dengue hemorrhagic fever, or DHF; and

4.Dengue shock syndrome, or DSS.

Dengue shock syndrome is actually a severe

form of DHF.


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Clinical Case Definition for Dengue Fever

Classical Dengue fever or Break bone fever is an acute febrile

viral disease frequently presenting with headaches, bone or joint

pain, muscular pains,rash,and leucopenia

Clinical Case Definition for Dengue Hemorrhagic Fever4 Necessary Criteria:

1. Fever, or recent history of acute fever

2. Hemorrhagic manifestations

3. Low platelet count (100,000/mm3 or less)

4. Objective evidence of leakycapillaries:

elevated hematocrit (20% or more over baseline)

low albumin pleural or other effusions


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Clinical Case Definition for Dengue Shock Syndrome4 criteria for DHF

+Evidence of circulatory failure manifested indirectly by

all of the following:Rapid and weak pulse

Narrow pulse pressure (< 20 mm Hg) OR

hypotension for age

Cold, clammy skin and altered mental status


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Hemorrhagic Manifestations of DengueSkin hemorrhages:

petechiae, purpura, ecchymoses

Gingival bleeding

Nasal bleedingGastrointestinal bleeding:

Hematemesis, melena, hematochezia

Hematuria

Increased menstrual flow


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Signs and Symptoms of Encephalitis/Encephalopathy

Associated with Acute Dengue InfectionDecreased level of consciousness:

lethargy, confusion, coma

Seizures

Nuchal rigidity

Paresis


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Four Grades of DHFGrade 1

Fever and nonspecific constitutional symptoms

Positive tourniquet test is only hemorrhagic

manifestation

Grade 2

Grade 1 manifestations + spontaneous bleedingGrade 3

Signs of circulatory failure (rapid/weak pulse,

narrow pulse pressure, hypotension,

cold/clammy skin)Grade 4

Profound shock (undetectable pulse and BP)


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Danger Signs in Dengue Hemorrhagic

Fever

Abdominal pain - intense and sustainedPersistent vomiting

Abrupt change from fever to hypothermia,

with sweating and prostration

Restlessness or somnolence

*All of these are signs of impending shock andshould alert clinicians that the patient needs close

observation and fluids.


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This thermometer illustrates the developments in the illness that are

progressive warning signs that DSS may occur.


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progressive warning signs that DSS may occur.

The initial evaluation is made by determining how many days have passed

since the onset of symptoms.

Most patients who develop DSS do so 3-6 days after onset of symptoms.

Therefore, if a patient is seven days into the illness, it is likely that the worstis over.

If the fever goes between three and six days after the symptoms began, this is

a warning signal that the patient must be closely observed, as shock often

occurs at or around the disappearance of fever.

Other early warning signs to be alert for include a drop in platelets, an

increase in hematocrit, or other signs of plasma leakage.If you document hemoconcentration and thrombocytopenia and other signs

of DHF and the patient meets the criteria for DHF, the prognosis and the

patient's risk category have changed. Though dengue fever does not often

cause fatalities, a greater proportion of DHF cases are fatal.

The next concern would be observation of the danger signssevere

abdominal pain, change in mental status, vomiting and abrupt change fromfever to hypothermia. These often herald the onset of DSS.

The goal of treatment is to prevent shock.The plasma leakage syndrome is

self-limited. If you can support the patient through the plasma leakage phase

and provide sufficient fluids to prevent shock, the illness will resolve itself.


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TERIMA KASIH

Laporan Kasus 26 Juli 2013

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Transcript of Laporan Kasus 26 Juli 2013