+

Rabu, 28 September 2016

LAPORAN KASUS
+ IDENTITAS PASIEN
Nama : An. CBL
Tanggal Lahir : 31/10/2007
Usia : 8 tahun 7 bulan
Alamat : Sekehaji II G2/95, Bandung
Tanggal MRS : 25 Juni 2016
Jam MRS : 16.45 WIB
N
+

Normal
Normal

Normal
 Penilaian
+ Primer
Airway : Obstruksi jalan napas : Tidak ada

Breathing: Laju napas 22 x/menit

Retraksi: suprasternal tidak ada, Saturasi Oksigen:
intercostal tidak ada, subcostal tidak ada, 97%
Suara napas VBS kiri=kanan,
Crackles tidak ada, slem tidak ada,
wheezing tidak ada
Akral: hangat
Circulation: Laju nadi: 106 x/menit ptekiae tidak ada

Disability: GCS : E4M6V5

Exposure: Suhu : 38,4 C

+ ANAMNESIS
Keluhan utama : Panas Badan

1 minggu 1 hari SMRS 2 jam SMRS MRS

SMRS

Os mengeluh Panas badan Os sudah

batuk dirasakan minum obat IGD RSAB
Muntah setiap
minum
Os juga
mengeluh
pusing
+ ANAMNESA TAMBAHAN

Riwayatkeluhan yang serupa dengan yang dialami

pasien belum pernah terjadi.

Riwayat keluarga & tetangga yang sakit seperti yang

dialami pasien tidak ada.

Keluhantidak disertai dengan bintik kemerahan,

perdarahan hidung, perdarahan gusi, BAB hitam, BAK
kemerahan

Keluhantidak disertai kejang, sesak napas, atau

penurunan kesadaran

Riwayat Imunisasi: Lengkap

+
PEMERIKSAAN FISIS
Keadaan umum : Tampak sakit ringan
Kesadaran : Composmentis
Tanda vital
Tekanan darah : 110/70 mmHg
HR = Nadi : 106 kali/menit
Respirasi : 22 kali/ menit
Suhu : 38,40C
Saturasi Oksigen : 97%
+ PEMERIKSAAN FISIS 8

Kepala : Konjungtiva anemis tidak ada

Sklera tak ikterik
Pernafasan cuping hidung tidak ada
Perdarahan hidung tidak ada
Perdarahan gusi tidak ada
Sekret hidung tidak ada
Sekret telinga tidak ada
Faring
tidak hiperemis, tidak ada detritus
Tonsil T1-T1

Leher : Kelenjar Getah Bening tak teraba

+
Toraks : Bentuk dan gerak simetris
Retraksi suprasternal tidak ada, retraksi subcostal tidak ada
Cor : S1 S2 normal
Pulmo : VBS kanan = kiri, crackles tidak ada, Slem tidak ada

Abdomen :Datar lembut, nyeri tekan epigastrium (-)

Hepar : tak teraba

Lien : tak teraba

Bising usus (+) normal

+

Ekstremitas : Akral hangat

Ptechiae tidak ada
+

TGL WBC
25/06
26/06
27/06
28/06
29/06
30/06
01/07
NILAI RUJUKAN
 +
HASIL LABORATORIUM
Pemeriksaan Darah 25 Juni 26 Juni 27 Juni 28 Juni 29 Juni 30 Juni 01 Juli Nilai Rujukan
2016 2016 2016 2016 2016 2016 2016
WBC 4900 3500 (Pkl. 5000-11000
00:28
WIB)

4100 (Pkl.
18:10
WIB)

HB 12,2 13,3 (Pkl. 11,5-14,5

00:28
WIB)

12,1 (Pkl.
18:10
WIB)
HT 36,9 33,7 34,7 35,7 39,9 (Pkl. 33,0-43,00
00:28
+

PLT 214000 214000 176000 91000 67000 (Pkl. 150000-

00:28 WIB) 440000

108000
(Pkl. 18:10
WIB)
Dengue Positive Negative
NS1
Widal
S. Typhi O 1/32O <1/80
S. Paratyphi 1/80 <1/80
BO
S. Paratyphi 1/80 <1/80
CO
+
HASIL LABORATORIUM
Pemeriksaan 25 Juni 26 Juni 27 Juni 28 Juni 29 Juni 30 Juni 01 Juli Nilai Rujukan
Darah 2016 2016 2016 2016 2016 2016 2016

SGOT 35 152 0-32

SGPT 11 30 0-31

Ureum 23 10-50

Creatinine 0,60 0,50-0,90

 PEMERIKSAAN PENUNJANG

Laboratorium 2 Mei 2016 (9.00 WIB):

Hb : 13,0 g/dL 11,5-15,5
Ht : 40 % 35 45
Lekosit : 5.000/mm3 4.500 13.500
Tr : 86.000/mm3 150.000-450.000

NS1 : Non reaktif

15
 PEMERIKSAAN PENUNJANG

Laboratorium RSHS 2 Mei 2016 (19.00 WIB)

Hb : 13,1 g/dL 11,5-15,5
Ht : 41 % 35 45
Lekosit : 5.100/mm3 4.500 13.500
Tr : 109.000/mm3 150.000-450.000
Hitung jenis
Basofil : 0 0-1
Eosinofil : 3 1-6
Batang : 0 3-5
Segmen : 39 33-59
Limfosit : 52 33-50
Monosit : 4 2-10 16
 Morfologi darah tepi
- Eritrosit : normokrom normositer
- Leukosit : jumlah cukup, limfosit atipik ada
- Trombosit : jumlah cukup, tersebar

Dengue Fever Test

- IgM : non reaktif
- IgG : non reaktif
+ DIAGNOSIS BANDING

Infeksi virus Dengue

Undifferentiated Fever (viral syndrome)
+ DIAGNOSIS KERJA

Infeksi virus Dengue

+ TATALAKSANA
Istirahat, banyak minum
Parasetamol 500 mg ~3/4 tablet setiap 4-6 jam bila demam di
atas 38 C, per oral
Kontrol rawat jalan
+ PROGNOSIS

Ad Vitam : ad bonam
Ad Functionam : ad bonam
+

TERIMA KASIH
 Trombosit merupakan fragmen
sitoplasma megakariosit

Umur dalam sirkulasi darah 7 12 hari

+ 15% terpakai tiap hari

Jumlah normal dlm sirkulasi 150.000 -

400.000/ml
+ 24
+
+
DENGUE
+
+
Tourniquet Test
+
+
+
+
+
+ Natural Course of Dengue Virus
Infection

Warning signs
+
+
+
+
+
+ Immunopathogenesis

Immune deviation
Cytokine over-production
Anti-platelet and anti-endothelial cell autoantibody
Antibody-dependent enhancement
Molecular mimicry
Dengue virus-induced vasculopathy and coagulopathy
Lei HY, et al.J Biomed Sci 2001;8:377-88.
 DENGUE VIRUS INFECTION
FEVER BLEEDING HEPATOMEGALY INCREASE TROMBOCYTOPENIA
ANOREXIA MANIFESTATION VASCULAR
VOMITING PERMIABILITY

Plasma leakage :
Hemoconcentration
Hipoproteinemia
Dehydration Pleural effusion
Ascites

Hypovolemia

DIC Shock

G.I. bleeding Anoxia Acidosis

Suchitra (1993) Death

Demam Dengue (1)

Masa inkubasi: 3 14 hari

Demam
Panas tinggi mendadak
Menghilang hari ke-3 atau 4 sembuh
atau
Berkurang hari ke-3 atau 4 lalu timbul lagi
setelah 1 - 3 hari seperti pelana onta

Total lama demam 5 7 hari

Demam Dengue (2)

Gejala lain :

nyeri kepala, nyeri retroorbital (belakang mata)

Nyeri sendi, tulang, punggung (backborne fever)

Lemah, malaise

Flushing (tampak kemerahan): muka, leher

Fotofobi (silau), sakit menelan, batuk

Demam Dengue (3)

Ruam kulit:

Ruam primer:
bercak seperti penyakit campak (makulopapular)
terdapat di daerah dada , lipat sendi

Ruam sekunder:
Setelah hari ke-4,tersering hari ke-6 atau 7
Makulopapular / ptekiae / purpurik / campuran
Konfluen, biasanya kaki dan tangan
Kadang-kadang gatal
 Demam Dengue (4)

Perdarahan ?

meskipun tidak biasa, bisa didapatkan

perdarahan:
- ptekiae (bintik-bintik perdarahan pada kulit)
- epistaksis (perdarahan dari hidung,mimisan)
- perdarahan gusi, muntah / berak darah
- menorrhagi (perdarahan haid yang bertambah)
Pola panas Demam Dengue

40 oC

39 oC

38 oC

37 oC

36 oC

I II III IV V VI VII VIII

Ruam primer Ruam sekunder

+
+
+
HOW MUCH TO GIVE

Administration of iv fluid
is necessary as patients have a >20% increase of hematocrit

~ 5-8% dehydration

CALCULATE THE IV FLUID NEEDED:

Used ideal body weight
Maintenance
Deficit/replacement fluid
Concomitant loss
Then sum all of iv fluid to get total fluid needed

Rate should be administered hourly; not per day

+ DHF GRADE I AND II

Intravenous fluid infusion

crystalloid 67 mL/kgbw/h, or
2 gtt/kgbw/min (macro drip)
Improvement no improvement
Ht falls, Ht rises
pulse rate & BP stable, Pulse rate rises
urine output rises Vital signs or
Ht worsen

3 mL/kgbw/h
1 gtt/kgbw/min (macro drip)
Improvement 10 mL/kgbw/h
3 gtt/kgbw/min (macro drip)

no improvement
Further Improvement unstable vital signs,
urine output falls,
signs of shock
Vital signs & Ht stable,
Adequate diuresis DHF GRADE III AND IV
Discontinue IV therapy
After 2448 hours
+
DHF GRADE III AND IV

Shock
Oxygenation
Immediate, rapid volume Shock + Look after Ht
Shock improvement replacement
crystalloid 20 mL/kgbw, as iv bolus

RL 10 ml/kgbw/h Ad colloid 10 ml/kg bw / h

1 hour

RL 5 ml/kgbw/h Shock - Shock +

colloid 20 ml/kgbw/h
RL 3 ml/kgbw/h

Shock - Shock +
stop

ICU
+

Alarm Signals
Four Criteria for DHF Severe abdominal pain
Fever Prolonged vomoting
Hemorrhagic Abrupt change from
manifestasions fever to hypothermia
Excessive capillary Change in level of
permeability consciousness
100,000/mm3 platelets (irritability or
somnolence)
Initial Warning Signals
Disappearance of When Patients Develop
fever DSS:
Drop in platelets 3 to 6 days after onset
Increase in of symptoms
hematocrite
+

CRITERIA OF DISCHARGED

1. Clinical improvement
2. No fever within 24 hours without antipyretic
3. No respiratory distress
4. Stabilizing of hematocrit
5. Tendency of platelets increase (>50.000/mm3)
6. Three days after shock overcome
7. Increasing of appetite
+
COMMON COLD
+
+
+
+
Virus Influenza

Mengalami antigenic drift

(influenza A dan B) dan
antigenic shift (hanya
influenza A) virus
berubah
Vaksin setiap tahun ganti

Kingsbury D. W., Virology, IInd edition, New York, 1990, 1076-87

+
Influenza vs Common Cold
+
Perjalanan Penyakit Influenza
Masa inkubasi
Isolasi virus
(RMKTCID50/ml)
LOG10 titer virus
nasofaringeal
41

Temperature (C)
5 Kurva demam
4

Oral
3 39
2
1
0 37
Hari 0 1 2 3 4 5 6 7 8 9 10

Nyeri tenggorok, mialgia

Nyeri kepala
Batuk
Coryza
Malaise, lemah

Onset penyakit Komplikasi

Kilbourne E. D., Influenza, New York, plenum 1987:156-218
+
RCT
+ 68
+
+
+
Randomized Clinical Trials

Epitome of all research designs.

Provide the strongest evidence for concluding causation.

Provides the best insurance that result was due to the intervention
+
Randomized Clinical Trials
Design of a randomized clinical trial

Defined Population

RANDOMIZED

New Current
Treatment Treatment

Improved Not Improved Improved Not Improved

+
Randomized Clinical Trials Selection of
Subjects
The criteria for determining who will or will not be included in the study must be
precise.

Should be no element of subjective decision making.

+
Randomized Clinical Trials
Allocation of Subjects to Treatment Groups

Studies without comparison

Studies with comparison

+
Randomized Clinical Trials
Allocation of Subjects to Treatment Groups

Studies without comparison

The 1st possible alternative : case study or case series

No comparison is made with an untreated group or with a group that is receiving

some other treatment.

Important because of possibility to derive a causal inference regarding the

relationship of treatment & subsequent outcome
+
Randomized Clinical Trials
Allocation of Subjects to Treatment Groups

Studies without comparison

What are the possible designs?

1. Historical controls

- comparison group from the past

2. Simultaneous nonrandomized controls

- use simultaneous controls that are not

selected in a randomized manner

+
Randomized Clinical Trials
Randomization
The best approach in the design of a trial.

Critical element : unpredictability of the next assignment

+
Inclusion and Exclusion Criteria

Inclusion Criteria: patients really do have the condition bein studied

Exclusion criteria: Patients with comorbid; not expected to live long enough;
patients with contraindication to treatment; patients who refuse to participate;
patients who do not follow instructions during the early stages of the trial.
+
+ Randomized Clinical Trials
Observational Vs Experimental Studies
+
Randomized Clinical Trials
Data Collection on Subjects

It is essential that the data collected for each of the study groups be of the same
quality

The variables about which data need to be obtained on the subjects :

1. Treatment (Assigned & received)

2. Outcome

3. Prognostic Profile at entry

4. Masking (Blinding)
+
BLINDING

Blinding can take place in CT at 4 levels:

1. Allocation concealment

2. Patients should be unaware of which treatment they are taking

3. Physicians who take care of patients in the study

4. The researchers who access outcomes are unaware of which

treatment offered

A trial in which no blinding --> open label

+
+
Randomized Clinical Trials Crossover

Planned

Unplanned
+
Randomized Clinical Trials
Design of a planned crossover trial
+
Randomized Clinical Trials Unplanned
crossover in a study of cardiac bypass surgery : I.
Original study design
+
Randomized Clinical Trials Unplanned
crossover in a study of cardiac bypass surgery : II.
Reality: Unplanned crossovers
Randomized Clinical Trials
Factorial Design for studying the effects of two treatments

Treatment B
+ -

Both A only
+ A and B
(Cell a) (Cell b)
Treatment A
B only Neither
-
A nor B
(Cell c) (Cell d)
Randomized Clinical Trials
Factorial Design : The effect of treatment A Vs No treatment A

Treatment B
+ -

Both A only
+ A and B
(Cell a) (Cell b)
Treatment A
B only Neither
-
A nor B
(Cell c) (Cell d)
Randomized Clinical Trials
Factorial Design : The effect of treatment B Vs No treatment B

Treatment B
+ -

Both A only
+ A and B
(Cell a) (Cell b)
Treatment A
B only Neither
-
A nor B
(Cell c) (Cell d)