LAPORAN KASUS 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 ANAMNESIS Keluhan Utama : Demam 7 hari RIWAYAT PENYAKIT SEKARANG • 2MSMRS 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. •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 RIWAYAT PENYAKIT DAHULU •Riw diare (+) usia 1 tahun •Riw asma (-) •Riw alergi (-) RIWAYAT PENYAKIT KELUARGA •Riw asma (-) •Riw alergi (-) •Keluarga serumah dengan demam (-) 42 th 18 th 39 th 12 th 6 th 6 th RIWAYAT ANC/NC/PNC • Ibu G3P2A0 rutin kontrol di bidan, tdk pernah ada keluhan, HT(-), DM(-), kejang (-), demam (-) antenatal natal • Ibu berusia 33 tahun P3A0 melahirkan di rumah sakit. Bayi berat lahir 2200 gr, UK 32 minggu, secara spontan, menangis kuat (+) • Kontrol teratur dan imunisasi di puskesmas sesuai postnatal buku KMS. Ikterik (-) Kesan: BBLR, preterm 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 RIWAYAT MAKANAN UMUR JENIS MAKANAN 0 – 21 bulan ASI 21 bulan – sekarang (6 tahun) Nasi dengan lauk dan tidak suka sayuran 2-3 x 1 porsi/hari. Suka jajan jajanan di sekolah KESAN: riwayat makan kurang baik RIWAYAT PERKEMBANGAN 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) • Saat ini anak sudah duduk di kelas I SD, tinggal kelas (-), suka bermain bersama temanteman Kesan Riwayat Perkembangan baik 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 dan cahaya rumah baik. Pembiayaan RS menggunakan jamkesmas. Kesan Sosial, ekonomi menengah ke bawah, dengan kondisi lingkungan cukup baik 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 (-) 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 ºC • TD : 100/50 mmHg STATUS GIZI DAN ANTOPOMETRI • BB : 16 kg • TB : 105 cm • BB/U: -3<z-score<-2 (underweight) • TB/U : -2<z-score<-1 (normal) • BMI/U : -1<z-score<0 (normal) Simpulan : Status gizi underweight PEMERIKSAAN LEHER • Inspeksi : JVP tak meningkat, benjolan (-) • Palpasi : JVP tak meningkat, lnn. tidak teraba Simpulan : Dalam batas normal 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 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 SISTEM GENITOURINARY • Flank : bulging (-), nyeri ketok ginjal (-) • Suprapubic : nyeri tekan (-); bulging (-) • OUE : inflamasi (-) Simpulan : Dalam batas normal ANOGENITAL • Laki-laki , anus (+) EKSTREMITAS • Akral hangat • Nadi kuat • CRT<2” • Edema - - - - Simpulan : Dalam batas normal 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 (-) LABORATORIUM DR 29/7/2013 WBC RBC HGB HCT MCV MCH MCHC PLT LYM MXD NEUT 24.3 5.41 13.4 40.5 74.9 24.8 33.1 467 12.2% 6,4 % 81,4 % GDS : 127 mg/dl Widal Typhi H : +1/80 Widal Typhi O : +1/320 Na : 133 mmol/L K : 4.3 mmol/L Cl : 97 mmol/L DIAGNOSIS KERJA Susp. Typhoid fever TATA LAKSANA • IVFD D5 ½ 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 TERIMA KASIH KASUS II 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 ANAMNESIS Keluhan Utama : “Demam mendadak tinggi” RIWAYAT PENYAKIT SEKARANG 4 HSMRS 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. RIWAYAT PENYAKIT SEKARANG 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. RIWAYAT PENYAKIT SEKARANG IGD 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 38ₒc, takikardi (-), takipneu (-), Rumple Leed (+), hepatomegali 1 cm bac, tanda plasma leakage (-) berupa odem palpebra (-), ascites (-), efusi pleura (-), tanda syok (-) . • 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, parasetamol 10mg/kgbb/kali sprn, plan monitor KU, tanda vital, tanda syok, monitor HCT/AT tiap 6 jam. RIWAYAT PENYAKIT SEKARANG Hari I perawatan Hari ke 5 25 Juli 2013 • Pasien masih demam (38,3 ₒc), 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. RIWAYAT PENYAKIT DAHULU • Riw. sakit serupa (-) • Riw. Mondok (-) RIWAYAT PENYAKIT KELUARGA • Riw. sakit serupa (-) 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 (-) PEMERIKSAAN PEMERIKSAAN FISIK (24 Juli 2013) Kesan Umum • CM, kesan gizi cukup Tanda Vital • 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 ⁰C Kesimpulan : suhu badan meningkat PEMERIKSAAN FISIK Status Gizi BB 15 kg TB 105 cm BB/U : 0 < Z < -2 SD TB/U : 0 < Z < -2 SD BB/TB : -1 < Z < -2 SD KESAN: Status Gizi normal 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 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 Auskultasi S1 regular, S2 split tak konstan Sonor +/+ vesikular (+/+), RBB (-/-), RBK (-/-), egofoni (-/-) PEMERIKSAAN FISIK ABDOMEN Inspeksi rash(-) : Dinding dada = dengan dinding perut,distensi (-), Auskultasi : Bising usus normal Perkusi : Hipertimpani (+) Palpasi : Supel, nyeri tekan epigastrik (+), hepar teraba 1 cm b.a.c dan lien ttb PEMERIKSAAN FISIK ANOGENITAL : Laki-laki, sirkumsisi (-), testis (+/+) PEMERIKSAAN FISIK Extremitas Akral hangat, CRT <2’’, edema (-) Tungkai kanan Tungkai kiri Lengan kanan Lengan kiri Gerakan bebas bebas bebas bebas Tonus N N N N Trofi Eutrofi Eutrofi Eutrofi Eutrofi Clonus (-) (-) Refleks fisilogis (+) (+) (+) (+) Refleks patologis (-) (-) (-) (-) sensibilitas (+) N (+) N (+) N (+) N PEMERIKSAAN FISIK Kulit : RL (+), rash (+) Limfonodi : Lnn. Cervicalis Anterior Sinistra (+) multiple. Diameter 0,5 cm. 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(-) DIFFRENTIAL DIAGNOSIS • Dengue Fever • Dengue Hemorhagic Fever • Thypoid Fever PEMERIKSAAN PENUNJANG 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 DIAGNOSIS KLINIS • Demam Berdarah Dengue derajat I 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 Terima kasih 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) 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) Dengue Virus 1. Causes dengue and dengue hemorrhagic fever 2. It is an arbovirus 3. Transmitted by mosquitoes 4. Composed of single-stranded RNA 5. Has 4 serotypes (DEN-1, 2, 3, 4) Dengue Virus •Each serotype provides specific lifetime immunity, and short-term cross-immunity •All serotypes can cause severe and fatal disease •Genetic variation within serotypes •Some genetic variants within each serotype appear to be more virulent or have greater epidemic potential The most common epidemic vector of dengue in the world is the Aedes aegypti mosquito. It can be identified by the white bands or scale patterns on its legs and thorax. Clinical Characteristics of Dengue Fever •Fever •Headache •Muscle and joint pain •Nausea/vomiting •Rash •Hemorrhagic manifestations Patients may also report other symptoms, such as itching and aberrations in the sense of taste, particularly a metallic taste. In addition, there have been reports of severe depression after the acute phase of the illness. 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 released from these tissues and spreads through the blood to infect white blood cells and other lymphatic tissues. 4.The virus is then released from these tissues and circulates in the blood. 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 body cavity, and later infects the salivary glands. 7.The virus replicates in the salivary glands and when the mosquito bites another human, the cycle continues. The transmission cycle of dengue virus by the mosquito Aedes aegypti begins with a dengue-infected person. This person will have virus circulating in the blood—a viremia that lasts for about five days. During the viremic period, an uninfected female Aedes aegypti mosquito bites the person and ingests blood that contains dengue virus. Although there is some evidence of transovarial transmission of dengue virus in Aedes aegypti, 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 bite—this is the intrinsic incubation period, within humans. While the intrinsic incubation period averages from four to seven days, it can range from three to 14 days. 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 symptoms—so the illness persists several days after the viremia has ended. 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. 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 Fever 4 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 “leaky capillaries:” • elevated hematocrit (20% or more over baseline) • low albumin • pleural or other effusions Clinical Case Definition for Dengue Shock Syndrome •4 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 Hemorrhagic Manifestations of Dengue •Skin hemorrhages: petechiae, purpura, ecchymoses •Gingival bleeding •Nasal bleeding •Gastrointestinal bleeding: Hematemesis, melena, hematochezia •Hematuria •Increased menstrual flow Signs and Symptoms of Encephalitis/Encephalopathy Associated with Acute Dengue Infection •Decreased level of consciousness: lethargy, confusion, coma •Seizures •Nuchal rigidity •Paresis Four Grades of DHF Grade 1 Fever and nonspecific constitutional symptoms Positive tourniquet test is only hemorrhagic manifestation Grade 2 Grade 1 manifestations + spontaneous bleeding Grade 3 Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension, cold/clammy skin) Grade 4 Profound shock (undetectable pulse and BP) Danger Signs in Dengue Hemorrhagic Fever •Abdominal pain - intense and sustained •Persistent vomiting •Abrupt change from fever to hypothermia, with sweating and prostration •Restlessness or somnolence *All of these are signs of impending shock and should alert clinicians that the patient needs close observation and fluids. This thermometer illustrates the developments in the illness that are 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 worst is 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 signs—severe abdominal pain, change in mental status, vomiting and abrupt change from fever 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. TERIMA KASIH
