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IDENTITAS PASIEN
Nama Usia Jenis kelamin Alamat No.RM Nama orangtua Pekerjaan orangtua : An RT : 6 tahun : laki-laki : Pundungan 2/6 Jonggrangan, Klaten Utara : 593xxx : Bp. Subardi/ Ibu. Kujaima : Buruh/IRT
ANAMNESIS
Keluhan Utama : Demam 7 hari
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
42 th
39 th
18 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 Ibu berusia 33 tahun P3A0 melahirkan di rumah sakit. Bayi berat lahir 2200 gr, UK 32 minggu, secara spontan, menangis kuat (+)
natal
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
RIWAYAT MAKANAN
UMUR
0 21 bulan 21 bulan sekarang (6 tahun) ASI Nasi dengan lauk dan tidak suka sayuran 2-3 x 1 porsi/hari. Suka jajan jajanan di sekolah
JENIS MAKANAN
RIWAYAT PERKEMBANGAN
Motorik kasar Motorik halus Bicara Sosial
Duduk (7 bulan) Jalan (13 bulan) Lari (2 tahun) Naik Sepeda (5 tahun)
Menulis (5 tahun)
Bermain (4 tahun)
Saat ini anak sudah duduk di kelas I SD, tinggal kelas (-), suka bermain bersama temanteman
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 LEHER
Inspeksi Palpasi : JVP tak meningkat, benjolan (-) : JVP tak meningkat, lnn. tidak teraba
SISTEM KARDIOVASKULAR
Inspeksi Palpasi Perkusi Auskultasi : IC tidak tampak : IC teraba pada SIC IV LMCS : tidak dilakukan : S1 tunggal, S2 split tak konstan, bising (-), murmur (-)
SISTEM GASTROINTESTINAL
Pemeriksaan Abdomen I A Pe Pa : DP//DD, distended (-) : BU (+) kesan normal : Tympani : Supel, hepar tidak teraba, lien tidak teraba, ginjal tidak teraba, T/E dbn
SISTEM GENITOURINARY
Flank Suprapubic OUE : bulging (-), nyeri ketok ginjal (-) : nyeri tekan (-); bulging (-) : inflamasi (-)
ANOGENITAL
Laki-laki , anus (+)
EKSTREMITAS
Akral hangat Nadi kuat CRT<2 Edema
PEMERIKSAAN KEPALA
Bentuk Mata Hidung Telinga : Mesocephal :Conjunctiva Anemis (-), Sklera Ikterik(-) : Sekret (-), nafas cuping hidung (-) : 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
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
TERIMA KASIH
KASUS II
IDENTITAS PASIEN
Nama : An. R.A
Jenis kelamin
Usia No. RM Tempat tinggal Masuk Bangsal
: Laki-laki
: 5 tahun 6 bulan (24/1/2008) : 787169 : Jemawan, Jatinom : 24 Juli 2013, jam 13.15
Tgl. Periksa
ANAMNESIS
Keluhan Utama : Demam mendadak tinggi
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.
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 (-) .
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.
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.
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 (-)
PEMERIKSAAN
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 C 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
Simetris Retraksi dinding dada (-) fremitus taktil +/+ Ketinggalan Gerak (-)
Sonor +/+
Perkusi
Auskultasi
PEMERIKSAAN FISIK
ABDOMEN
: Dinding dada = dengan dinding perut,distensi (-), rash(-) : Bising usus normal : 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 Gerakan Tonus Trofi Clonus Refleks fisilogis Refleks patologis sensibilitas bebas N Eutrofi (-) (+) (-) (+) N
PEMERIKSAAN FISIK
Kulit Limfonodi : RL (+), rash (+) : 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
Sendi
: deformitas(-)
: deformitas(-)
DIFFRENTIAL DIAGNOSIS
Dengue Fever
PEMERIKSAAN PENUNJANG
Tanggal 24/7/2013 (Puskesmas) 24/7/2013 (IGD RSST) 12.53 24/7/2013 17.41 24/7/2013 23.20 25/7/2013 5.40 25/7/2013 17.06 25/7/2013 22.09 Hb 11,8 12,9 Hct 37 38,3 AT 60.000 51.000
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
Terima kasih
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 blooda 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 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 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 symptomsso 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 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
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
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 signssevere 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