PORTOFOLIO

DENGUE HEMORRHAGIC
TOPIK
FEVER
PENDAMPING DR. YOLANDA DESIRE
PRESENTAN
TANGGAL
KASUS
TANGGAL
PRESENTASI

DR. I MADE SETIADJI

27 JUNI 2016
JULI 2016

OBJEK PRESENTASI

OBJEKTIF
BAHAN
PRESENTASI BAHASAN
DIAGNOSTIK
TATALAKSAN GUIDELINE
A
DHF WHO
2009
UPDATE

PEMBAHASA
N
PRESENTASI
DAN DISKUSI

OBJEK

DESKRIPSI
PASIEN WANITA USIA 45 TAHUN
DATANG KE IGD DENGAN KELUHAN DEMAM
SEJAK 3 HARI YLL
DEMAM MUNCUL MENDADAK DAN SELALU
TINGGI
DISERTAI PUSING SELURUH KEPALA, MUAL
SEJAK 3 HARI YLL
MUNTAH 1-2X/ HARI, ULU HATI TERASA
SAKIT

PEMERIKSAAN FISIK NYERI OTOT PUNGGUNG DAN BAHU SEJAK

2 HARI YLL
COMPOS MENTIS, TAMPAK
SAKIT SEDANG
MAKANAN
TERASA PAHIT, NAFSU MAKAN
TEKANAN DARAH: 130/80
MMHG,
NADI:
DAN
MINUM
TURUN
O
88X/MENIT, RR: 20X/MENIT, S: 38.2 C
KONJUNGTIVA TIDAK ANEMIS
TIDAK ADA BLOOD STOLSEL HIDUNG, DAN
GUSI BERDARAH
NYERI TEKAN EPIGASTRIUM (+)
PTECHIE (-), RUMPLE LEEDE TEST (+)

OBJEK PRESENTASI
HB: 14,7 G/DL
HT: 40%
LEUKOSIT:
3.300/MM
THROMBOSIT:
88.000/MM3

S. TYPHI H :
1/160
S. PARATYPHI
HB : 1/320
S. PARATYPHI
HC : 1/80

PEMERIKSAA
N
PENUNJANG
DR

PEMERIKSAA
N
PENUNJANG
WIDAL

MENEGGAKAN DX
MENENTUKAN TX
PEMERIKSAAN
NS1
TRANFUSI
THROMBOSIT
VAKSIN DENGUE
STEROID
TUJUAN

DATA PASIEN
NAMA: NY. DS
NOMOR RM: 059596
NAMA RS: RUMKIT TK. IV
CIJANTUNG KESDAM JAYA
TERDAFTAR SEJAK: 27 JUNI 2016

 COMPOS
MENTIS,
TAMPAK SAKIT
SEDANG
TEKANAN
DARAH: 130/80
MMHG, NADI:
88X/MENIT, RR:
20X/MENIT, S:
38.2OC
KONJUNGTIVA
TIDAK ANEMIS
TIDAK ADA
BLOOD
STOLSEL
HIDUNG, DAN
GUSI
BERDARAH
NYERI TEKAN
EPIGASTRIUM
(+)
PTECHIE (-),

WORKING
DX/
DHF CO INF.
WITH
TYPHOID
DIFF. DX/
DF
MALARIA
CHIKUNGUN
YA
VIRAL
INFECTION

S
WANITA USIA
45 TAHUN
DATANG KE IGD
DENGAN
KELUHAN
DEMAM SEJAK
3 HARI YLL
DEMAM
MUNCUL
MENDADAK
DAN SELALU
TINGGI
DISERTAI
PUSING
SELURUH
KEPALA, MUAL
DAN MUNTAH
SEJAK 3 HARI
YLL
ULU HATI
TERASA SAKIT
NYERI OTOT

RL 20 TPM
INJ.
RANITIDIN
2X1 AMP
(I.V.)
INJ.
ONDANSETR
ON 2X1 AMP
(I.V.)
PARACETAM
OL
3X500MG
TAB (P.O.)
PIRALEN
3X1

RIWAYAT PENYAKIT
RIWAYAT PENYAKIT DAHULU
OS. BELUM PERNAH MENGALAMI DEMAM BERDARAH SEBELUMNY
RIWAYAT KELUARGA
TIDAK ADA YANG MENGALAMI PENYAKIT SERUPA DENGAN PASIEN DI KELUARGA SAAT
INI. TIDAK ADA RIWAYAT PENYAKIT DM, HIPERTENSI, PENYAKIT JANTUNG ATAU ALERGI DI
KELUARGA
RIWAYAT SOSIAL EKONOMI
PASIEN MERUPAKAN PEKERJA DI PABRIK KONVEKSI, MEMILIKI 2 ORANG ANAK
RIWAYAT LINGKUNGAN
RUMAH PASIEN TIDAK PERNAH DI FOGGING. TEMPAT KERJA BANYAK NYAMUK

ASSESSMENT

ASSESSMENT

Follow Up
Hari/Tgl/Jam
Selasa, 28-06-16
08.00 WIB

Mual (+), pusing (+), lemas TD : 110/70 mmHg

A
DHF

P
Tirah baring

(+), nyeri ulu hati (+), nyeri RR : 18 x/mnt

Infus RL

sendi (+)

N : 88 x/mnt

Th/ simptomatik:

T : 36,5 oC

Antipiretik : Paracetamol

Nyeri tekan epigastrium (+),

Antiemetik : rantin

Lab : Hb : 14,9 g/dL

Ht : 43 %
Trombosit : 56 ribu/mm3
15.00 WIB

Pusing (+), demam sdh , TD : 90/60 mmHg

nyeri ulu hati (+), nyeri RR : 17 x/mnt
pinggang (+), mual , BAB N : 80 x/mnt
cair 3x

T : 36,5 oC

DHF

Lanjutkan Th/

Rabu, 29-06-16
09.00 WIB

Pusing (+), mual TD : 110/70 mmHg

()

DHF

Lanjutkan Th/

DHF

Lanjutkan Th/

RR : 18 x/mnt
N : 82 x/mnt
T : 37,3 oC
Nyeri

tekan

epigastrium (+)
16.00 WIB

Pusing (+)

TD : 110/70 mmHg
RR : 20 x/mnt
N : 80 x/mnt
T : 36 oC

Kamis, 30-06-16
08.00 WIB

DHF

Lanjutkan Th/

15.00 WIB

DHF

Lanjutkan Th/

Jumat, 30-06-16
08.00 WIB

DHF

Lanjutkan Th/

15.00 WIB

DHF

Lanjutkan Th/

GRAFIK TROMBOSIT
Chart Title
100
90
80
70
60
50
40
30
20
10
0
27/6/2016

28/6/2016

29/6/2016
Thrombo

30/6/2016
Suhu

1/7/2016

HASIL PEMBAHASAN

PENEGAKKAN DIAGNOSIS HNP

TATALAKSANA HNP

RANGKUMAN
DENGUE
DIAGNO
HEMORRHAGIC
FEVER
SIS
EDUKASI PASIEN
DAN KELUARGA
DALAM PROSES
PENYEMBUHAN,
MEMBERI
INFORMASI
PENYAKIT

PENDIDI
KAN

SUPPORTIF
MENGGANTI
VOLUME DARAH
DENGAN
KRISTALOID +
SIMPTOMATIK

PENGOB
ATAN

KONSULT
SPESIALIS
PENYAKIT DALAM
ASI

PROTOKOL 1
(Penanganan tersangka DBD dewasa tanpa syok)
Keluhan DBD
(Kriteria WHO
2005)

Hb, Ht,
Trombosi
t normal

Observasi
Rawat jalan
Periksa Hb,
Ht,
Leuko,
Tromb/24
jam

Hb, Ht
normal
Trombosi
t
100.000
-150.000
Observasi
Rawat jalan
Periksa Hb,
Ht,
Leuko,
Tromb/24
jam

Hb, Ht
normal
Trombosi
t
<100.00
0

Hb, Ht
meningkat
Trombosit
normal/tur
un

Rawat

Rawat
Penangana
n dg
protokol 2

PROTOKOL 2
(Pemberian cairan pd tersangka DBD dewasa di ruang rawat)
Suspek DBD
Perdarahan
spontan & masif
(-)
Syok (-)
Hb, Ht normal
Tromb <100.000
Infus kristaloid
Periksa Hb, Ht,
Leuko, Tromb/24
jam

Hb, Ht
meningkat 1020%
Tromb <100.000
Infus kristaloid
Periksa Hb, Ht,
Leuko, Tromb/12
jam

Hb, Ht
meningkat
>20%
Tromb
<100.000

Penanganan
dg
protokol 3

Vaksin
CYD-TDV is the first
dengue vaccine to be
licensed. It was first
licensed in Mexico in
December 2015 for use
in individuals 9-45 years
of age living in endemic
areas. CYD-TDV is a
live recombinant
tetravalent dengue
vaccine developed by
Sanofi Pasteur (CYDTDV), given as a 3-dose
series on a 0/6/12
month schedule.

The WHO Strategic Advisory Group of Experts (SAGE) on

Immunization reviewed CYD-TDV in April 2016 and
recommended countries consider introduction of the
vaccine only in geographic settings (national or
subnational) with high endemicity. A WHO vaccine
position paper will be published outlining WHO
recommendations in July 2016.

Steroid
Dengue infection causes significant morbidity and mortality in over 100 countries worldwide, and
its incidence is on the rise. The pathophysiological basis for the development of severe dengue,
characterized by plasma leakage and the shock syndrome are poorly understood. No specific
treatment or vaccine is available, and careful monitoring and judicious administration of fluids
forms the mainstay of management at present. It is postulated that vascular endothelial
dysfunction, induced by cytokine and chemical mediators, is an important mechanism of plasma
leakage. Although corticosteroids are potent modulators of the immune system, their role in
pharmacological doses in modulating the purported immunological effects that take place in
severe dengue has been a subject of controversy. The key evidence related to the role of
corticosteroids for various manifestations of dengue are reviewed here. In summary, there is
currently no high-quality evidence supporting the beneficial effects of corticosteroids for
treatment of shock, prevention of serious complications, or increasing platelet counts. Nonrandomized trials of corticosteroids given as rescue medication for severe shock have shown
possible benefit. Nonetheless, the evidence base is small, and good-quality trials are lacking. We
reiterate the need for well-designed and adequately powered randomized controlled trials of
corticosteroids for the treatment of dengue shock.

Thrombosit Tranfusi
This study suggests that bleeding occurs more
often in patients with severe thrombocytopenia.
High-risk patients having platelet count <
20,000/cumm and risk of bleeding require urgent
platelet transfusion. Patients with platelet count
21-40,000/cumm are in moderate risk and
require platelet transfusion only if they have any
haemorrhagic manifestations and other
superadded conditions.