SKENARIO C BLOK 17
Amir, a boy, 13 month, was hospitalized due to diarrhea. Four days before admission, the patient had non projectile vomiting 6 times a day. He vomited what he ate. Three days before admission the patient got diarrhea 10 times a day around half glass in every defecation, there was no blood and mucous/ pus in it. The frequency of vomiting decreased. Along those 4 days, he drank eagerly and was given plain water. He also got mild fever. Yesterday, he looked worsening, lethargy, le thargy, didn’t want to drink, still had diarrhea but no vomiting. The amount of urination in 8 hours ago was less than usual. Amir’s family lives in slum area. Physical examination:
Patient looks severely ill, compos mentis but weak (lethargic), BP 70/50 mmHg, RR 38x/m, HR 144x/m regular but weak, body temperature 38,7o C, BW 10 kg, BH 75cm Head: sunken frontanella, sunken eye, no tears drop, and dry mouth. Thorax: similar movement on both side, retraction (-/-), vesicular breath sound, normal hearth sound. Abdomen: flat, shuffle, bowel sound increase. Liver is palpable 1 cm below arcus costa and xiphoid processus, spleen unpalpable, pinch the skin of the abdomen: very slowly (longer than 2 seconds). Redness skin surrounding anal orifice. Extremities: cold hand and feet Laboratory examination:
Hb 12,8 g/dl, WBC 14.000/mm3, differential count: 0/1/16/48/35/0 Urine routine: macroscopic:yellowish colour, microscopic: WBC (-), RBC (-), protein (-), keton boides (+). Faeces routine: macroscopic: water more than waste material, blood (-), mucous (-), WBC: 46/HPF, RBC 0-1/HPF, bacteria (++), entamoeba coli (+), fat (+)
I.
KLARIFIKASI ISTILAH
1. Diarrhea: pengeluaran feses dengan konsistensi yang cair dan frekuensi yang abnormal 2. Non projectile vomiting: muntah yang tidak disertai dengan semburan 3. Defecation: pengeluaran feses dari rektum
4. Lethargy: tingkat kesadaran yang menurun disertai dengan pusing dan berkurangnya fungsi pendengaran dan apatis 5. Shuffle abdomen: 6. Anal orifice: lubang pada ujung traktus digestivus, tempat keluarnya kotoran padat dari dalam tubuh 7. Sunken frontanella: ubun-ubun pada bayi yang cekung sebagai tanda dehidr asi 8. Slum area: Kawasan dengan populasi yang padat
II.
IDENTIFIKASI MASALAH
1. Amir, a boy, 13 month, was hospitalized due to diarrhea (1) 2. Four days before admission, the patient had non projectile vomiting 6 times a day. He vomited what he ate (4) 3. Three days before admission the patient got diarrhea 10 times a day around half glass in every defecation, there was no blood and mucous/ pus in it. The frequency of vomiting decreased.(3) 4. Along those 4 days, he drank eagerly and was given plain water. He also got mild fever Yesterday, he looked l ooked worsening, lethargy, didn’t want to drink, still had diarrhea but no vomiting. The amount of urination in 8 hours ago was less than usual (2) 5. Amir’s family lives in slum area.(5) 6. Physical examination: (6) Patient looks severely ill, compos mentis but weak (lethar gic), BP 70/50 mmHg, RR 38x/m, HR 144x/m regular but weak, body temperature 38,7o C, BW 10 kg, BH 75cm Head: sunken frontanella, sunken eye, no tears drop, and dry mouth. Thorax: similar movement on both side, retraction (-/-), vesicular breath s ound, normal hearth sound. Abdomen: flat, shuffle, bowel sound increase. Liver is palpable 1 cm below arcus costa and xiphoid processus, spleen unpalpable, pinch the skin of the abdomen: very slowly (longer than 2 seconds). Redness skin surrounding anal orifice. Extremities: cold hand and feet
7. Laboratory examination:
Hb 12,8 g/dl, WBC 14.000/mm3, differential count: 0/1/ 16/48/35/0 Urine routine: macroscopic:yellowish colour, microscopic: WBC (-), RBC (-), protein (-), keton boides (+). Faeces routine: macroscopic: water more than waste material, blood (-), mucous (-), WBC: 46/HPF, RBC 0-1/HPF, bacteria (++), entamoeba coli (+), fat (+)
III.
ANALISIS MASALAH
1.
Amir, a boy, 13 month, was hospitalized due to diarrhea (1) a. Apa saja etiologi diare pada anak usia 13 bulan? b. Bagaimana klasifikasi diare? c. Bagaimana kriteria diare pada anak 13 bulan? d. Bagaimana kaitan antara usia dan jenis kelamin kela min dengan diare? e. Bagaimana mekanisme diare terkait kasus?
2. Four days before admission, the patient had non projectile vomiting 6 times a day. He vomited what he ate (4) a. Bagaimana keterkaitan antara muntah dan diare? b. Bagaimana kondisi pasien setelah muntah sebanyak enam kali dalam sehari? c. Bagaimana perbedaan mekanisme muntah projectile dengan muntah non projectile? d. Apa makna dari ia memuntahkan yang sebelumnya dimakan? 3. Three days before admission the patient got diarrhea 10 times a day around half glass in every defecation, there was no blood and mucous/ pus in it. The frequency of vomiting decreased.(3) a. Mengapa frekuensi muntah berkurang? b. Berapa frekuensi dan jumlah BAB normal pada anak 13 bulan? c. Apa makna tidak adanya darah dan lendir/ pus pada feces? d. Apa hubungan frekuensi BAB yang meningkat dengan frekuensi muntah yang menurun?
4. Along those 4 days, he drank eagerly and was given plain water. He also got mild fever. Yesterday, he looked worsening, lethargy, didn’t want to drink, still had diarrhea but no vomiting. The amount of urination in 8 hours ago was less than usual (2) a. Bagaimana klasifikasi dehidrasi? b. Apa hubungan banyak minum dengan keluhan diare dan muntah? c. Mengapa diare tetap terjadi meskipun Amir sudah tidak ingin minum? d. Mengapa anak dengan dehidrasi berat cenderung tidak ingin minum? e. Bagaimana mekanisme demam pada kasus? f. Mengapa jumlah urin berkurang pada kasus? 5. Amir’s family lives in slum area.(5) a. Apa hubungan daerah kumuh dengan diare? 6. Physical examination: (6) Patient looks severely ill, compos mentis but weak (lethargic), BP 70/50 mmHg, RR 38x/m, HR 144x/m regular but weak, body temperature 38,7o C, BW 10 kg, BH 75cm Head: sunken frontanella, sunken eye, no tears drop, and dry mouth. Thorax: similar movement on both side, retraction (-/-), vesicular breath s ound, normal hearth sound. Abdomen: flat, shuffle, bowel sound increase. Liver is palpable 1 cm below arcus costa and xiphoid processus, spleen unpalpable, pinch the skin of the abdomen: very slowly (longer than 2 seconds). Redness skin surrounding anal orifice. Extremities: cold hand and feet a. Bagaimana interpretasi dari hasil pemeriksaan fisik? b. Bagaimana mekanisme abnormalitas dari hasil pemeriksaan fisik? c. Bagaimana gambaran dari hasil pemeriksaan fisik? 7. Laboratory Laboratory examination: (6)
Hb 12,8 g/dl, WBC 14.000/mm3, differential count: 0/1/16/48/35/0
Urine routine: macroscopic:yellowish colour, microscopic: WBC (-), RBC (-), protein (-), keton boides (+). Faeces routine: macroscopic: water more than waste material, blood (-) , mucous (-), WBC: 4-6/HPF, RBC 0-1/HPF, bacteria (++), entamoeba coli (+), fat ( +) a. Bagaimana interpretasi dari hasil pemeriksaan laboratorium? b. Bagaimana mekanisme abnormalitas dari hasil pemeriksaan laboratorium? HIPOTESIS: Amir, anak laki-laki 13 bulan, menderita diare akut disertai dehidrasi berat TEMPLATE: 1. DD 2. WD 3. Definisi 4. Etiologi 5. Epidemiologi 6. Factor risiko 7. Manifestasi klinis 8. How to diagnose 9. Pemeriksaan penunjang 10. Pathogenesis dan patofisiologi 11. Tatalaksana 12. Pencegahan dan edukasi 13. Komplikasi 14. Prognosis 15. SKDI Learning issues: 1. Diare pada anak 2. Dehidrasi karena diare 3. Pemeriksaan fisik 4. Pemeriksaan laboratorium
