VennDiag Lola

PATIENT IDENTITY
Name
: Mrs. ER Age : 39 years old Marital state : married Admission date : May 2nd, 2013
10 STEPS VENNDIAG
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Define a Chief Complaint Draw a VennDiag & Fill It With Possible Disease Literature Review Scan on Patient Signs & Symptoms Make a Working Diagnosis Define Initial Treatment Further Investigation Make a Definitive Diagnosis Define Causative Treatment Show a Clinical Course of the Disease
STEP VENNDIAG
STEP 1 : Define the Chief Complaint
Step 2 : Draw a Venndiag and Fill it with Possible Diseases

Step 3 : Make a Brief Literature Review of Each Disease Step 4 : Scan on Patients Sign & Symptoms STEP 5 : Make a Working Diagnosis
Female 39 years old, came with acute diarrhea
STEP 1 : DEFINE THE CHIEF COMPLAINT
STEP VENNDIAG

Step 3 : Make a Brief Literature Review of Each Disease Step 4 : Scan on Patients Sign & Symptoms STEP 5 : Make a working diagnosis
Drugs Protozoa : Giardia, Cryptospora Toxins Dietary: Intoleransi lactosa Bacterial : Vibrio cholera Viral : Rotavirus, Norwalk Irritable Bowel Syndromme Thyroid Storm Acute Watery Acute appendicitis ACUTE DIARRHEA NON INFECTIOUS
Acute Bloody
INFECTIOUS
Drugs: NSAIDs Inflammatory Bowel Disease
Bacterial: Shigella, Campylobacter, Salmonella, Escherchia coli, Aeruginosa Protozoa: Entamoeba hystoliytica
1. 2.
Ferri, FF. 2006. Ferris Differential Diagnosis : A Medical Guide to the Differential Diagnosis of Symptoms, Signs, and Clin ical Disorders. 2nd eds. Philadelphia : Mosby Elsevier. Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.
STEP VENNDIAG

Protozoa : Giardia, Cryptospora Drugs Toxins Bacterial : Vibrio cholera Dietary: Intoleransi lactosa : Rotavirus, Norwalk Irritable Bowel Syndromme Viral Acute Watery Thyroid Storm Acute appendicitis ACUTE DIARRHEA
NON INFECTIOUS Acute Bloody Drugs: NSAIDs Inflammatory Bowel Disease INFECTIOUS
1. 2.
COMMON IN INFECTIOUS ACUTE WATERRY DIARRHEA

Waterry diarrhea Blood (-) Abdominal pain
Nausea and vomit

Fever
Protozoa : Giardia lamblia Symptom : Sulfurous bleaching Flatus Loose stools with mucus (-) Extra intestinal : Urticaria Anterior uveitis Artritis Physical : Bloating abdominal
Diagnose : Antigens in the feces Cysts in the feces Trophozoites in the feces or small intestine
1.
Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.
INFECTIOUS
Protozoa : Cryptosporidium Symptom : Immunocompetent host Anorexia Weight loss Physical : Low fever Dehydration
Diagnose : Small oocyts , cyst, trophozoites in feces Direct immunofluorescent stains Enzyme immunoassay Biopsy specimen of the small bowel
1.
INFECTIOUS
Bacterial : Vibrio cholera

Symptom : - Incubation 24 - 48 hour - Fever (-) - Sudden painless quickly become voluminous - The stool: nonbilious, gray, slightly cloudy fluid with fleck s of mucus = rice water stool - Odor sweet Physical : - Muscle cramps electrolyte imbalance
Diagnosed by Dark field microscopy on wet mount of fresh stool : V. Cholera Antiserum specific: serotype Isolation with thiosulfate-citrate-bile salts-sucrose (TCBS) agar : flat yellow colony . Biochemical confirmation : oxidase + Monoclonal Ab in PCR : V. Cholerae O1 and O 139
1.
INFECTIOUS
Virus : Rotavirus and Norwalk

Symptom : - Incubation 1-3 day, abrupt onset - Mostly in children - Chill and myalgia - Mucus (-) - Self limiting Physical : - High fever > 39 c
Diagnosed EIAs (Enzyme immunoassay) PCR WBC normal, rarely leucocytosis with relative lymphopenia
1.
INFECTIOUS
Virus : Rotavirus and Norwalk

Symptom : - Incubation 1-3 day, abrupt onset - Mostly in children - Chill and myalgia - Mucus (-) - Self limiting Physical : - High fever > 39 c
Diagnosed EIAs (Enzyme immunoassay) PCR WBC normal, rarely leucocytosis with relative lymphopenia
1.
INFECTIOUS
Drugs Protozoa : Giardia, Cryptospora Toxins Bacterial : Vibrio cholera Dietary: Intoleransi lactosa Viral : Rotavirus, Norwalk Irritable Bowel Syndromme Acute Watery Thyroid Storm Acute appendicitis ACUTE DIARRHEA NON INFECTIOUS
Acute Bloody
INFECTIOUS
1. 2.
COMMON IN INFECTIOUS ACUTE BLOODY DIARRHEA

Bloody diarrhea Blood (+) Mucus (+/-) Abdominal pain Nausea and vomit Fever Malaise Diagnosed with oocyst/trophozoit in feces, high PMN in feces Leucocytosis peripher
Protozoa : Entamoeba hystolitica

Symptom Incubation : 2-6 weeks May pass 10-12 stools per day The stool: little fecal material, consist mainly blood and mucus Physical Weight loss Diffuse lower abdomen or back pain, cramping
Diagnosed by - Culture of stool for E. Hystolytica tropozoites - PCR assay for DNA in stool - ELISA ag E. hystolytica
INFECTIOUS
1.
Bacterial : Shigella
Symptom : 4 stages Incubation Period - Lasts 1-4 days - Transient fever (40-41c) Watery Diarhhea Mild abdominal discomfort severe cramps, tenesmus Dysentry Follow hours or days. Uninterupted excretion of small volume of bloody mucopurulent stool diarrhea with increased tenesmus and abdominal cramps Post infection Diagnosed - Isolation pathogen from fecal material Medium: agar mac conkey: nonlactose fermeting colonies: 0,5-1mm in diameter, convex, translucent, smooth surface
1.
INFECTIOUS
Bacterial : Campylobacter
Symptom Prodorme 12-48 hour before onset of diarrheal - Degree of diarrhea varies from several loose stool to grossly blood stool, > 10 bowel movement - Abdominal pain: cramping, general/local Physical - Abdominal pain: cramping, general/local Diagnosed - Direct microscopy: vibroid morphology - Isolate from culture of stool, blood
INFECTIOUS
1.
Bacterial : Salmonella
Symptom Incubation 10-14 days (3-21 days) - High fever characteristic - Coated tongue, splenomegaly, abdominal tenderness Physical - Coated tongue, splenomegaly, abdominal tenderness Diagnosed by - Leukopenia, neutropenia - Elevated liver function test and muscle enzyme level - Isolation of S. Typhi or S. Paratyphi from blood, bone marrow - Widal test - PCR and DNA assay : S.typhi in blood
INFECTIOUS
1.
Bacterial : Escherchia.coli
Symptom Incubation 24 - 72 hours. Other symptoms may include: Distension abdominal Physical Gas in abdominal Bruises that happen easily Pale skin Red or bloody, reduced amount urine Diagnosed by - E. coli strains O157, is the most common method currently used to detect STEC/EHEC - Testing for Shiga toxins or toxin genes is more sensitive, specic, and rapid. It detects both non- O157 STEC/EHEC and sorbitol-fermenting strains of O157:H7 difcult to identify.
INFECTIOUS
Vorvick LJ. E.coli Enteritis. US National Library of Medicine NIH. Medline. 2011
Bacterial : Aeruginosa
- Immunocompromised host - Antibiotic associated - Profuse diarrhea, mucus +, blood + - Low-grade fever Diagnosed - Innoculation on blood agar plates and Mac Conkey agar plates, then incubated at 370c for 18-24 hours
Infectious
Porco EV, Visconte EB. Pseudomonas Aeruginosa as a Cause of Infectious Diarrhea Successfully Treated With Oral Ciprofloxacin. Department of Internal Medicine. Pubmed. USA. 1995 Nov;29(11):1122-3 Brad GF et al. Pseudomonas Aeruginosa and Antibiotic Associated Diarrhea In Children. Department of Pediatric, Victor Babes University Medicine and Pharmacy. Timisora. Jan 2011.
Drugs Toxins Protozoa Bacterial Dietary: Intoleransi lactosa Viral Irritable Bowel Syndromme Acute Watery Thyroid Storm Acute appendicitis ACUTE DIARRHEA
NON INFECTIOUS
Acute Bloody
: Giardia, Cryptospora : Vibrio cholera : Rotavirus, Norwalk
INFECTIOUS
Drugs: NSAIDs Bacterial: Shigella, Campylobacter, Salmonella, Inflammatory Bowel Escherchia coli, Aeruginosa Protozoa: Entamoeba hystoliytica Disease
1. 2.
COMMON IN NON INFECTIOUS WATERY DIARRHEA

Fever (-) Watery diarrhea Abdominal pain
Nausea and vomit

Hematology routine : normal Feses routine :
Erytrocyte (-) Leucocyte (-)
Drugs and Toxin

- Antibiotics: cephalosporin, amynoglicoside, amoxillin clavulanate, clarithomycin - Cardiac antidysrhthmics, antihypertensive - certain depressant, chemotherapeutic agent - Brochodilator - Antacid - Laxatives Toxin caused acute watery diarrhea - Organophospate inseticides - Amanita and other mushroom - Arsenic - Preformed in seafood Physical History of consumption/ingest Diagnose Hematology routine : normal Feses routine : - Erytrocyte (-) - Leucocyte (-)
1.
NON INFECTIOUS
Lactose Intolerance
Symptom - Flatus - History of ingest carbohydrates that contain actively transported monosaccharide (ec: glucose, galactose) - Flatus - History of ingest carbohydrates that contain actively transported monosaccharide (ec: glucose, galactose)
Diagnosed by Stool fat/steatorrhea quantitative Test- Sudan III stain Blood breath and isotopic test Blood routine: depletion iron, folate, cobalamin, vitamins D and K Schilling test, D-xylose test, duodenal mucosal biopsy, small intestinal RO, test of pancreatic exocrine function
1.
NON INFECTIOUS
Irritable Bowel Syndromme

Abdominal pain/discomfort (25% hypogastrium, 20% right side, 10% epigastrium. Episodic and crampy, can be constant, nocturnal pain, exacerbate by eating, emotional stress, improved by passage of flatus/stools Constipation > diarrhea. Diarrhea in small volume <200 mL, large amount of mucus, bleeding Abdomen distension and belching or flatulence Fecal mucus Diagnostic Criteria : Rome II Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with two or more of the following 1. Improvement with defecation 2. Onset associated with a change in frequency of stool 3. Onset associated with a change in form (appearance) of stool Diagnosed by - Sigmoidoscopic - Air contrast barium enema or colonoscopy - Lab: anemia, ESR, presence of leucocytes or blood is stool, and stool volume > 200-300 ml/d
*Non Infectious
1.
Thyroid Storm

Agitation
Tachycardia Sweating Fever Seizure History of hypertiroidism
T1 dan T4
*Non Infectious
1.
Acute appendicitis

Anorexia
Pain in periumbilical goes to right upper quadrant
Pain in mc burney area

Rebounf tenderness Fever 37,2 - 38
USG Ct scan: thickened appendix with periappendical
*Non Infectious
1.
Drugs Toxins Dietary: Intoleransi lactosa Acute Irritable Bowel Syndromme Thyroid Storm Acute Appendicitis
Protozoa : Giardia, Cryptospora Bacterial : Vibrio cholera Viral : Rotavirus, Watery Norwalk
ACUTE DIARRHEA INFECTIOUS

Acute Bloody
NON INFECTIOUS
1. 2.
COMMON IN NON INFECTIOUS BLOODY DIARRHEA

Fever (-) Bloody diarrhea Abdominal pain
Nausea and vomit

Hematology routine : normal Feses routine :
Erytrocyte (-) Leucocyte (-)
Drugs
- Causes: NSAIDs - Mild side effects from short-term use may include diarrhea - Blood related ulcer because long term use Diagnosed by History of consumption Hematology routine : normal Feses routine : - Erytrocyte (-) - Leucocyte (-)
1.
NON INFECTIOUS
Inflammatory Bowel Disease

Crohns disease Clinical Findings Weight loss, low grade fever, perianal disease, abdominal mass Ulcerative colitis Rectal bleeding, tenesmus, crampy, liquid stool containing blood, pus
Laboratory
Elevated CRP, ESR, more severe hypoalbuminemia, anemia, leucocytosis
Rise in CRP, platelet count, ESR, leucocyte, and decrease Hb Spesific marker: - fecal lactoferin intestinal inflammation - Fecal calprotectin histologic inflammation, prognosis,
Rectal involvement with continuous superficial ulceration. Loss of haustra, continous ulceration, collar button ulcer
Endoscopy
Patchy involvement, rectal sparing, aphthous ulcers, ileal ulcers Stricture, fistulas, terminal ileal disease (string sign), skip lesieon
Radiology
NON INFECTIOUS
1.
STEP VENNDIAG

Characteristic: Acute Diarrhea started 12 hours before admission Diarrhea characteristic : Watery Mucus (+) Bad stink - Frequency > 8 times/day - Stool volume > 250 ml
Protozoa : Giardia, Drugs Cryptospora Toxins Dietary: Intoleransi lactosa Bacterial : Vibrio cholera Viral : Rotavirus, Norwalk Irritable Bowel Syndromme Acute Watery Thyroid Storm ACUTE DIARRHEA
Blood (+), no gross, no pus
Acute Bloody
Acute Diarrhea Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
Possible : 1, 3, 4,5,6 Less : 2 Not related : 7,8
7. NSAIDs 8. Inflammatory Bowel Disease
Acute Bloody
HISTORY TAKING
High fever 38c
Continous
No spesific characteristic
Acute Bloody
Bacterial: Shigella, Campylobacter, Salmonella, Escherchia coli, Aeromonas Protozoa: Entamoeba hystoliytica
Possible : 1, 3, 4,5,6 Less : 2, 3, 8 Not related : 7
Acute Bloody
HISTORY TAKING
Nausea
Vomit (-)
Acute Bloody
Acute Diarrhea Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeromonas Protozoa 6.Entamoeba hystoliytica
Possible : 2,4,5,6 Less : 1, 3, 7, 8 Not related :
Acute Bloody
HISTORY TAKING
Weight Loss
Acute Bloody
Possible : 6,8 Less : 1,2,3,4,5,7 Not related :
Acute Bloody
HISTORY TAKING
History consumption of food
in the street
Acute Bloody
Acute Diarrhea
Possible : 1,2,3,4,6
7. NSAIDs 8. Inflammatory Bowel Disease Acute Bloody Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeromonas Protozoa 6.Entamoeba hystoliytica
Less : Not related : 5, 7,8
HISTORY TAKING
History of her children was admitted hospital because of amoeba diarrhea
Acute Bloody
Possible : 6 Less : Not related : 1,2,3,4, 5, 7,8
Acute Bloody
HISTORY TAKING
History of consumption drug induced acute bloody diarrhea was denided
Acute Bloody
Acute Diarrhea Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeromonas Protozoa 6.Entamoeba hystoliytica
Possible : Less : Not related : 1,2,3,4, 5,6 7,8
Acute Bloody
HISTORY TAKING
Last menarche March 30th, 2013
History of Diabetes Mellitus

Medication since 3 years ago: glimepirid 1x1 gr metformin 1x500 mg No history of Hypertension No history of Alergic
HISTORY TAKING
Vital sign:
General appearance : moderately ill Conciousness : compos mentis
Blood Pressure
Pulse Respiratory rate H/W BMI
Possible : 1,2,3,4,6 Less :5
: 100/60 mmHg
: 96x/min ( reguler rhythm, strong, and full in palpation ) : 22x/min : 154 cm / 57 kg : 24,1 kg/m2 (overweight)7. NSAIDs
8. Inflammatory Bowel Disease
Acute Diarrhea Bacterial Acute 1.Shigella Bloody 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
Axillary temperature : 39,6 C
Not related : 7,8
PHYSICAL EXAMINATION
Head Eye Nose Ear Mouth Neck
: normocephaly : conjunctiva anemic -/: normal : normal : dry mucosa lip and oral : nodul lymph not palpable
Acute Diarrhea Bacterial 7. NSAIDs Acute 1.Shigella 2.Campylobacter 8. Bloody .3.Salmonella Inflammatory 4. Escherchia coli Bowel 5. Aeromonas Disease Protozoa 6.Entamoeba hystoliytica
Possible : 1,2,3,4,5,6 Less : 7, 8
Not related : ----
Lungs ( normal ) Inspection : symetric in both static and dynamic state. Palpation : fremitus tactile equal on both lungs. Percussion : sonor Auscultation : vesicular breath sounds, no additional sound.
Heart : Inspection Palpation Percussion - upper border - right border - left border Auscultation : ictus cordis visible : ictus cordis is palpable in ICS V linea midclavicularis sinistra : ICS 3 linea parasternalis sinistra : linea sternalis dextra : linea midclavicularis sinistra : regular heart sound, no additional sound Acute Diarrhea Bacterial 7. NSAIDs Acute 1.Shigella 2.Campylobacter 8. Bloody .3.Salmonella Inflammatory 4. Escherchia coli Bowel 5. Aeruginosa Disease Protozoa 6.Entamoeba hystoliytica
Abdomen: Inspection Palpation
Percussion Auscultation Extremities Skin
: convex : pain (+) lower abdominal hepatosplenomegaly : timpani : bowel sound 12-13x/minute : CRT < 2 second, warm : turgor normal
Acute Diarrhea Bacterial 7. NSAIDs Acute 1.Shigella 2.Campylobacter 8. Bloody .3.Salmonella Inflammatory 4. Escherchia coli Bowel 5. Aeruginosa Disease Protozoa 6.Entamoeba hystoliytica
Possible : 1,2,3,5,6 Less : 4, 7, 8
Not related : ----
Female 39 years old, came with acute diarrhea 12 hours before admission. - Diarrhea characteristic : watery+, mucus (+), blood (+) no gross, no pus, frequency > 8 times/day, stool volume >250 ml, high fever 38c = 1,3,4,5, 6 - Nausea = 2,4,5, 6 - Weight loss = 6, 8 - History of comsumption food in the street = 1,2,3,4, 6
Acute Diarrhea
Acute 7. NSAIDs Bloody 8. Inflammatory Bowel Disease
RESUME
Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
- History of her children was admitted hospital because of amoeba diarrhea = 6 - History of diabetes mellitus, her medication since 3 years ago : glimepirid 1x1 gr and metformin 1x500 mg.
Possible : 4, 6 Less : 2,3,5
Acute Diarrhea Acute 7. NSAIDsBloody 8. Inflammatory Bowel Disease Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
Not related : 8
RESUME
Physical examination found - Axillary temperature 39,6 C - Dry lip and oral mucosa - Abdomen seemed convex, pain in lower abdominal, tympani, bowel sound 12 -13x/minute = 1,2,3,4, 6 = 1,2,3,4,5, 6 = 1,2,3,5, 6
Possible
: 1,2,3, 6
Acute Diarrhea Acute 7. NSAIDs Bloody 8. Inflammatory Bowel Disease Bacterial 1.Shigella 2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
Less Possible
: 4,5
RESUME
STEP VENNDIAG
Step 3 : Make a Brief Literature Review of Each Disease
Step 4 : Scan on Patients Sign & Symptoms

STEP 5 : Make a Working Diagnosis STEP 6 : Define Initial Treatment Step 7 : Further Investigation
WORKING DIAGNOSIS
Acute Gastroenteritis et causa Entamoeba hystolytica
Acute Gastroenteritis et causa Shigella Acute Gastroenteritis et causa Campylobacter Acute Gastroenteritis et causa Salmonella
Acute Diarrhea
Bacterial 7. NSAIDs Acute 1.Shigella Acute Gastroenteritis et causa Escherchia coli 8. Bloody 2.Campylobacter Inflammatory .3.Salmonella Bowel 4. Escherchia coli Disease 5. Aeruginosa EXCLUDED Protozoa Acute Gastroenteritis et causa Aeruginosa 6.Entamoeba Acute Gastroenteritis et causa NSAIDs hystoliytica Acute Gastroenteritis et causa Inflammatory Bowel Disease
Acute Gastroenteritis et causa NSAIDs

No history of consumption NSAIDs Acute Gastroenteritis et causa Inflammatory Bowel Disease Chrons disease Perianal disease, low grade fever, abdominal mass - Colitis ulcerativa Rectal bleeding, tenesmus, liquid stool containing blood (+) pus (+)
Acute Gastroenteritis et causa Aeruginosa No history consumption antibiotic No immunocompromised host Low grade fever
EXCLUDED
STEP VENNDIAG
STEP 5 : Make a working diagnosis

STEP 6 : Define Initial Treatment Step 7 : Further Investigation STEP 8 : Make a Definitive Diagnosis
STEP 9 : Define the Causative Treatment
INITIAL TREATMENT
Female 39 years old, came with acute diarrhea 12 hours before admission. 1. Diarrhea characteristic : watery+, mucus (+), blood (+) no gross, no pus, frequency > 8 times/day, stool volume >250 ml, got dry lip and oral mucosa. For this condition : REDUCE the diarrhea with Antispasmodic (Buscopan 10 mg 1 tab)
Antidiarrheal (New Diatabs 2x 600 mg
CORRECT for mild dehydration Begin IV fluid with isotonic fluid Fluid theraphy = maintenance + 5% deficit of body weight = 30 ml/kgBB + 5% BB(kg) = (30x57) + 5/100 x 57 = 1710 + 162.45 1872.45 cc/24 jam 2000 cc/24 jam
Guillot AP. Fluid and Electrolyte Management Theraphy. University of Vermont Collenge of Medicine
INITIAL TREATMENT
2. Her past temperature, fever 38c. Now, the temperature was 39,6 C The theraphy was Antipyretic (Paracetamol 500 mg 3 tab) 3. She felt nausea but no vomit Antinausea (Domperidone 10 mg 2tab) 4. She felt her weight had some loss but never been scaled
Education for eat more food, but no stimulated the stomach like spicy food
STEP VENNDIAG
Step 3 : Make a Brief Literature Review of Each Disease

STEP 5 : Make a Working Diagnosis STEP 6 : Define Initial Treatment Step 7 : Further Investigation
FURTHER INVESTIGATION
Acute Diarrhea 7. NSAIDs 8. Inflammato ry Bowel Disease Bacterial Acute 1.Shigella Bloody2.Campylobacter .3.Salmonella 4. Escherchia coli 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
HEMATOLOGY Hemoglobine Leukocyte Erythrocyte Hematocrit Platelet 13 18 4 11 4.5 - 6.5 40 54 150 450 80 96 27 32 32 36 11.6 - 14.8 10 50 0.7 - 1.2 g% 103 /ul 106 /ul % 103 /ul fl pg g/dl % mg/dl mg/dl 14.4 11.9 5.66 41.0 164 82.4 27.4 35.1 13.6 25 0.84
ERYTHROCYTE INDEX
MCV MCH MCHC RDW-CV Kidney Function Ureum Creatinine
Possible : 1,2,3,4,5, 6
Exclude : 7,8
Acute Diarrhea Bacterial 7. NSAIDs 1.Shigella Acute 8. 2.Campylobacter Bloody Inflammato .3.Salmonella ry Bowel 4. Escherchia coli Disease 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
HEMATOLOGY Eosinophil Basophil Neutrophil Lymphocyte Monocyte LED 1 jam LED 2 jam Liver Function Test SGOT 0-38 U/l 13 1-6 1-2 40-80 20-40 2-10 10 -15 10 - 15 % % % % %
mm/jam mm/jam
0 0.1 88,9 6.3 4.7 90 107
SGPT
Renal Function Test Asam Urat Diabetes Glukosa
0-41
3.4-7 70 - 110
U/l
U/l mg/dl
13.9
5.6 285
Possible : 1,2,3,4,5, 6
HbA1c
<6.5
8.6
Exclude : 7,8
Diabetes mellitus
Acute Diarrhea Bacterial 7. NSAIDs 1.Shigella 8. Acute 2.Campylobacter Inflammato Bloody .3.Salmonella ry Bowel 4. Escherchia coli Disease 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica
Electrolyte
Natrium Kalium 136 145 3.3 - 5.1 % % 130 3.0
Chlorida
Fat LDL HDL TG
98-106
< 150 > 40 < 150
g/dl
g/dl g/dl g/dl
99
65 15 197
Hypertrygliserida
Macroscopic Consistency liquid brown + 0 0 0 Color Mucus Blood Pus Worm Microscopic
Acute Diarrhea Bacterial 7. NSAIDs Acute 1.Shigella 8. Bloody 2.Campylobacter Inflammato .3.Salmonella ry Bowel 4. Escherchia coli Disease 5. Aeruginosa Protozoa 6.Entamoeba hystoliytica Possible : 6
Leucocytes
Erytrocytes Worm eggs Amoeba Other parasites
20 - 25
10 - 15 0 Cyst + 0
STOOL TEST
STEP VENNDIAG
STEP 5 : Make a working diagnosis STEP 6 : Define Initial Treatment Step 7 : Further Investigation STEP 8 : Make a Definitive Diagnosis STEP 9 : Define the Causative Treatment STEP 10 : Show Clinical Course of the Disease
DEFINITE DIAGNOSIS
Definite Diagnosis : Acute gastroenteritis ec amoeba) (amoeba cyst +) Milld dehydration Diabetes mellitus type 2 Excluded: Acute Gastroenteritis et causa Shigella Acute Gastroenteritis et causa Campylobacter Acute Gastroenteritis et causa Salmonella Acute Gastroenteritis et causa Escherchia coli
STEP VENNDIAG
STEP 5 : Make a working diagnosis
STEP 6 : Define Initial Treatment

Step 7 : Further Investigation STEP 8 : Make a Definitive Diagnosis STEP 9 : Define the Causative Treatment
STEP 10 : Show Clinical Course of the Disease
Fluid therapy (IVFD asering 2000ml/24hr)

Antipyretic (Paracetamol 500 mg 3 tab) Antispasmodic (Buscopan 10 mg 1 tab)
Antidiarrheal (New Diatabs 2x 600 mg)

Antinausea (Domperidone 10 mg 2tab) Additional treatment:
Antibiotic for amoeba (Metronidazol 2 x 500mg/day)

Observation for hyperglicemia Lowering triglicerida : fibrate 1x300 mg tab at night
DEFINE THE CAUSATIVE TREATMENT
STEP VENNDIAG
STEP 5 : Make a working diagnosis STEP 6 : Define Initial Treatment Step 7 : Further Investigation STEP 8 : Make a Definitive Diagnosis STEP 9 : Define the Causative Treatment STEP 10 : Show Clinical Course of the Disease
Fluid therapy (IVFD asering 2000ml/24hr)

Antipyretic (Paracetamol 500 mg 3 tab) Antispasmodic (Buscopan 10 mg 1 tab)
Antidiarrheal (New Diatabs 2x 600 mg)

Antinausea (Domperidone 10 mg 2tab) Additional treatment:
Antibiotic for amoeba (Metronidazol 2 x 500mg/day)

Lowering blood glucose with insulin drip 3 IU/hour Lowering triglicerida : fibrate 1x300 mg tab at night
DEFINE THE CAUSATIVE TREATMENT
eat contaminated/raw food
gastroenteritis
mostly recovered (self limited) death dehydration shock
SHOW CLINICAL COURSE OF THE DISEASE
Hyperglicemia
Diabetes Mellitus
Diabetic Ketoacidosis
acute
Complication
chronic
Hyperglicemic hyperosmolar
Eye Skin Cardiovascular Abdominal Renal Genitourinary Neurophathy Lower extremity Dhermatologic Infection
SHOW CLINICAL COURSE OF THE DISEASE
REFERENCES
1. Ferri, FF. 2006. Ferris Differential Diagnosis : A Medical Guide to the Differential Diagnosis of Symptoms, Signs, and Clinical Disorders. 2nd eds. Philadelphia : Mosby Elsevier. Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds. Stern, Scott D. C. 2010. Symptom to Diagnosis: An Evidence Based Guide. 2nd eds. Guillot AP. Fluid and Electrolyte Management Theraphy. University of Vermont Collenge of Medicine
2. 3. 4.
Metode yang beguna dalam menegakkan diagnosis karena dari awal kita diajak memikirkan segala kemungkinan diagnosa yang mungkin terjadi pada pasien sehingga menemukan yang paling tepat dan bisa memberikan terapi yang terbaik bagi pasien.
VENNDIAG IS....
SPECIAL THANKS to

VennDiag Lola

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PATIENT IDENTITY

Step 2 : Draw a Venndiag and Fill it with Possible Diseases

Female 39 years old, came with acute diarrhea

STEP 1 : DEFINE THE CHIEF COMPLAINT

Step 2 : Draw a Venndiag and Fill it with Possible Diseases

Drugs: NSAIDs Inflammatory Bowel Disease

Step 2 : Draw a Venndiag and Fill it with Possible Diseases

COMMON IN INFECTIOUS ACUTE WATERRY DIARRHEA

Nausea and vomit

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Bacterial : Vibrio cholera

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Virus : Rotavirus and Norwalk

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Virus : Rotavirus and Norwalk

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Drugs: NSAIDs Inflammatory Bowel Disease

COMMON IN INFECTIOUS ACUTE BLOODY DIARRHEA

Protozoa : Entamoeba hystolitica

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

: Giardia, Cryptospora : Vibrio cholera : Rotavirus, Norwalk

COMMON IN NON INFECTIOUS WATERY DIARRHEA

Nausea and vomit

Erytrocyte (-) Leucocyte (-)

Drugs and Toxin

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Irritable Bowel Syndromme

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Pain in mc burney area

USG Ct scan: thickened appendix with periappendical

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

ACUTE DIARRHEA INFECTIOUS

Drugs: NSAIDs Inflammatory Bowel Disease

COMMON IN NON INFECTIOUS BLOODY DIARRHEA

Nausea and vomit

Erytrocyte (-) Leucocyte (-)

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Inflammatory Bowel Disease

Elevated CRP, ESR, more severe hypoalbuminemia, anemia, leucocytosis

Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17th eds.

Step 2 : Draw a Venndiag and Fill it with Possible Diseases

Blood (+), no gross, no pus

Drugs: NSAIDs Inflammatory Bowel Disease

Possible : 1, 3, 4,5,6 Less : 2 Not related : 7,8

7. NSAIDs 8. Inflammatory Bowel Disease

High fever 38c

Drugs: NSAIDs Inflammatory Bowel Disease

Possible : 1, 3, 4,5,6 Less : 2, 3, 8 Not related : 7

7. NSAIDs 8. Inflammatory Bowel Disease

Drugs: NSAIDs Inflammatory Bowel Disease

Possible : 2,4,5,6 Less : 1, 3, 7, 8 Not related :

7. NSAIDs 8. Inflammatory Bowel Disease

Drugs: NSAIDs Inflammatory Bowel Disease

Possible : 6,8 Less : 1,2,3,4,5,7 Not related :

7. NSAIDs 8. Inflammatory Bowel Disease

History consumption of food