SKENARIO C BLOK 15.pptx

SKENARIO C BLOK 15

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SKENARIO C BLOK 15 Budi, a boy, 13 month, was hospitalized due to diarrhea. Four days before admission, the patient had non projectile vomiting 8 times a day. He vomited what he ate. Three days before admission the patient pati ent got diarrhea 8 times a day around half glass in every defecation, there t here was no blood and mucous/pus in it. The frequency of vomiting decreased. But two days before admission the patient got

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Physical Examination 

Patient looks severely ill, compos mentis but weak (lethargic), BP 70/50 mmHg, mmHg, RR 38x/m, HR 144x/m regular but weak, body temperature 38,9oC, BW 10 kg, BH 75 cm.



Head: Sunken fontanella, sunken eye, no tears drop, and dry mouth.



Thorax: Similar movement on both side, retraction (-/-), vesicular breath sound, normal heart sound.

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Laboratory Examination 

Hb: 12,8 g/dl, WBC 20.000/mm3, differential count 0/1/2/83/20/4.



Urine Routine



Macroscopic: yellowish colour colour,,



Microscopic: WBC WBC (-), RBC (-), (-), protein (-), keton bodies (+).



Faeces Routine

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KLARIFIKASI ISTILAH No.

Istilah

Pengertian

1.

Diarrhea

- Peng Pengel elua uara ran n tinj tinjaa bera berair ir yang yang berk berkal alii-ka kali li yang yang tida tidak k norm normal al.. (Dor (Dorla land nd)) - Keluarnya (konsistensi) tinja yang lunak atau cair dengan frekuensi ≥ 3x  perhari dengan atau tanpa darah atau lendir dalam tinja. (WHO)

2.

Leth Lethar arg gy

Penuru nuruna nan n ting tingk kat kesa esadaran ran, dita ditand ndaai dengan gan lesu, esu, meng engantu antuk k, dan apat apatis is;; Kead eadaan tidak tidak acuh. acuh. (Dorla (Dorland) nd)

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IDENTIFIKASI MASALAH No.

1.

Topik

Budi, a boy, 13 month, was hospit spitaalized due to diarrh rrhea. Yeste sterday, he looked looked worsen worsening ing,, lethar lethargy gy,, didn’t want to drink, sti still had diarrhea but no vomiting. The amount of urination in 8 hours ago was less than usual. Budi’s fami family ly live livess in slum slum area area..

Kesesuaian

Concern

Tidak Se Sesuai

***

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4. Along those 4 days, he drank eagerly and was given ORS (Oral

Tidak 

*

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6. La Labo bora rato tory ry Ex Exam amin inati ation on

Tidak 

*

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ANALISIS MASALAH

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b. Ba Baga gaim iman ana a me meka kani nism smee le leth thar argi gi pa pada da ka kasu sus? s?

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d. Apa indikasi keluhan yang membuat Budi harus dirawat di rumah sakit?

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

Turgor >2 detik:

Di bagian bagian ba bawa wah h ku kuli litt te terda rdapa patt ja jarin ringa gan n el elas asti tin n yang beris berisii ca caira iran, n, jika te terj rjadi adi de dehid hidra rasi si ma maka ka ca cair iran an yang yan g meng mengisi isi jari jaringa ngan n ela elasti stin n ter terseb sebut ut jug jugaa ikut ber berkura kurang ng seh sehingg inggaa tim timbul bullah lah man manife ifesta stasi si kli klinis nis turgor (+). 

Kemera Kem erahan han dis diseki ekitar tar anu anus: s:

War arna na ku kuli litt ke keme mera raha han n di se seki kita tarr an anus us in inii te terja rjadi di ka karen renaa ad adan anya ya ir irit itas asii ak akib ibat at se serin ringn gnya ya de defek fekas asii da dan n  perubahan derajat keasaman feses yang menjadi lebih karena laktat yang tidak

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6. Laboratory Examination 

Hb: 12,8 g/dl, WBC 20.000/mm3, differential count 0/1/2/83/20/4.



Urine Routine



Macroscopic: yellowish colour colour,,



Microscopic: WBC (-), RBC RBC (-), protein protein (-), keton bodies (+).



Faeces Routine

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Pemeriksaan

Nilai Normal

Interpretasi

Hb 12 12,8 ,8 g/ g/dl dl

10,5 -13,5 g/dl

Normal

WBC 9.00 9.000/m 0/mm m3

6-18.000 /mm3

Normal

Diff. Dif f. Cou Count nt

Basofil

0/1/16/48/35/0

:

Eosinofil

0 :

1

 –   – 

1

(%)  Normal

4

(%)

 Normal

Batang

:

2

 – 

5

(% )

Segmen

:

50

 – 

70

(%)

Limfosit

:

20

 – 

40

(%)  Normal

Monosit : 0 – 6  – 6 (%)

Meningkat  karena karena adanya adanya infeks infeksii

 Normal

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Faeces

Agak Ag ak lu luna nak k da dan n be berb rben entu tuk  k  Ti Tida dak k No Norm rmal al

Macroscopic:

water da dara rah h ((-))

more

waste

than

material, mucou mu couss ((-))

blood

muco mu cous us ((-))

Normal

W BC : -

Normal

(-),

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b. Bagai Bagaimana mana mekan mekanisme isme abnorm abnormalitas alitas pemer pemeriksaan iksaan labora laboratorium torium? ? 

Mekanism Meka nismee abno abnormal rmal dari neut neutrofil rofil bata batang: ng:



Perubahan Peruba han str strukt uktur ur mu mukos kosaa usu ususs hal halus us  pemendekan vili sehingga sehingga terdapat infiltrat infiltrat sel sel radang mononuklear di lamina propria.



Reaksi infl Reaksi inflamas amasii  sekre sekresi si kem kemokin okin (IL-8 dan dan granulosit granulosit stim stimulat ulating ing colony) colony)  neu neutro trofil fil me menin ningka gkatt ( shift to the left )



Pada kas Pada kasus us ini dar darii hit hitun ung g jen jenis, is, ne neutr utrofi ofill me menin ningka gkatt me menan nanda dakan kan inf infeks eksii aku akutt ( shift to the left ). ). Neutrofil  batang adalah neutrofil yang immatur immatur yang dapat bermultiplik bermultiplikasi asi dengan cepat selama infeksi akut sehingga  pada kasus ini, neutrofil batang meningkat karena diare yang dialami dialami oleh Amir merupakan merupakan diare akut.



Pada Urin Pada Urin did didapa apatka tkan n bad badan an ket keton on kar karena ena di didug dugaa tel telah ah ter terjad jadii lip lipoli olisis sis aki akibat bat ren renda dahny hnyaa glu glukos kosaa yan yang g ada dalam dal am dar darah, ah, sehi sehingg nggaa me mengh nghasi asilka lkan n zat sis sisaa yan yang g lainny lainnyaa yai yaitu tu bad badan an keton. keton.



Pada diare karena infeksi perubahan ini terjadi karena adanya rangsangan pada mukosa usus oleh shiga

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7. Apa diagnosis kerja pada kasus? 

Disentri

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9. Apa saja diagnosis banding pada kasus?

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10. Apa saja komplikasi penyakit pada kasus? 

Komplikasi shigelosis berat menjadi fatal adalah perforasi usus, megakolon toksik, prolapsus

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KESIMPULAN

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