PPT B20

7/23/2019 PPT B20

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CaseReport

Pembimbing : dr. Toton Suryotono, Sp.PD

7/23/2019 PPT B20


Tn. S, laki-laki berusia 38

tahun bertempat tinggal diCibinong, datang ke IGD

RSUD Cianur dengan bab !air

October 20, 2015 2

Identitas Pasien

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Kronologis Penyakit

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"aki-laki dengan tinggi badan #$% !mdan berat badan &% kg, I'T #(,$

kg)m* terbaring lemas han+a dapat

berbi!ara kata per kata, tekanandarah %)$% mmg, rekuensi nadi

#%% kali)menit, pernapasan **kali)menit, suhu 3/,(oC.

October 20, 2015 4

Status Generalis

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0 Kepala, mata, hidung, telinga, tenggorokan.

Kepala: bentuk normo!ephal, simetris, rambut

hitam, tidak mudah di!abut. Mata: konungti1a

anemis tidak ada, sklera ikterik tidak ada, mata

!ekung ada, pupil isokor kanan dan kiri, releks

!aha+a positi pada kedua mata. Hidung: tidak

ada de1iasi septum, pernapasan !uping hidung

tidak ada, se!ret dan darah tidak ada. Telinga2

simetris kiri dan kanan, liang lapang, membrantimpani intak, serumen tidak ada Tenggorokkan

(mulut dan faring : mukosa bibir kering, lidah

oral thrust, aring dan tonsil tidak hiperemis.

October 20, 2015 5

Pemeriksaan !isik

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0 "eher: pada inspeksi bentuk normal, pembesarankelenar tiroid dan kelenar getah bening tidak ada,45 tidak meningkat

0 Thoraks: pada inspeksi bentuk dada kanan dan kirisama, pergerakan naas kanan dan kiri sama, iktus

kordis tidak terlihat, palpasi remitus taktil dan 1okalkanan dan kiri sama, iktus kordis teraba di sela iga 4garis midkla1ikula kiri, perkusi sonor pada kedualapang paru, batas atas +aitu sela iga III garissternalis kiri, batas kanan sela iga I4 garis

parasternalis kanan, batas kiri sela iga 4 garis

midkla1ikula kiri, auskultasi pernaasan tidakterdapat bun+i tambahan pada kedua lapang paru,

bun+i antung I-II reguler, murmur dan gallop tidakada.

October 20, 2015 6

Pemeriksaan !isik

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0 #$domen: pada inspeksi perut tampak

!ekung, dan tidak ada aringan parut,

palpasi supel, terdapat nyeri tekan

epigastrium, turgor kulit kem$alilam$at, hepar tidak teraba, perkusi

seluruh lapang abdomen timpani,

auskultasi bising usus meningkat

0 %kstremitas : bagian superior dan

inerior akral hangat, sianosis dan edema

tidak ada

October 20, 2015 7

Pemeriksaan !isik

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HematologiRutin

Hasil Nilai Rujukan Satuan

Hemoglobin 10,3 13,5 – 17,5 g/dl

Hematokrit 29,3 42 – 52 %

ritrosit 3,53 4!7 – ",1 10#"/$l

Leukosit 6, !." # $%." $%&'ul

Trombosit $(" $)% # !)% $%&'ul

*+ ",% "% # (! -L

*+H (, / # $ pg

*+H+ ), # / 0RD12SD )$,/ / # )! -L

PD1 $)," ( # $! -L

*P (,6 " # $ -L

October 20, 2015 8

Pemeriksaan "a$oratorium tanggal &'

Septem$er '&)

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Dierential asil 6ilai Ruukan Satuan

"*M + &', - /- +

'7D *,# % 9 ##

0%1 + -,) 2' 3' +

:;S %,& # 9 3

<=S %,* > #

=bsolut

"*M 4 ',- &.'' &.2/ &'5/6ul

'7D ? %,#& % 9 #,* #%@3)ul

6:U ? (,&$ #.8 9 /.$ #%@3)ul

:;S ? %,%* %,%* 9 %,(% #%@3)ul

<=S ? %,%# %,%% 9 %,#% #%@3)ul

October 20, 2015 9

5emeriksaan "aboratorium

tanggal #% September *%#(

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:lektrolit asil 6ilai Ruukan Satuan

6atrium A6aB #*,$ #3( - #&8 m:)"

alium AB #,( 3,(% - (,3% m:)"

alsium ACaB %,# #,#( - #,* m:)"

October 20, 2015 10

5emeriksaan laboraturium

tanggal #% September *%#(

imia klinik asil 6ilai Ruukan Satuan

Glukosa rapidseEaktu

/ >#8% mg)d"

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October 20, 2015 11

Pemeriksaan la$oratorium tanggal &&

Septem$er '&)

FungsiGinal

asil 6ilai Ruukan Satuan

Ureum #$(,$ #% 9 (% mg

reatinin &,( % - #,% mg

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3rine Rutin Hasil Nilai Rujukan Satuan

1arna 4uning 4uning

4ejerni5an erni5 erni5

erat &enis 1,005 1,003 –1,030

pH 6,) !.6 # ",%

Nitrit Negati- Negati-

Protein 3rin )'$7 Negati- mg'dL

8lukosa9Reduksi

Normal Normal mg'dL

4eton Negati- Negati- mg'dL3robilinogen Normal Normal 3;

<ilirubin Negati- Negati- mg'dL

;ritrosit )'7 Negati- '=L

Leukosit )%%'7 Negati- '=L

Pemeriksaan laboratorium tanggal 11

September 2015

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'ikroskopis asil 6ilai Ruukan Satuan

"eukosit / - 8 # 9 & )"5<

:ritrosit * 9 3 % - # )"5<

:pitel * - 3

ristal 6egati 6egati

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#. I4 Disease !lini!al stage 3 denganI;

#.#. Diare A<a!terial :nteri! Ine!tionsB

#.#.# ipokalemia

#.*. Candidiasis ;ral

*. =!ute idne+ Inur+

October 20, 2015

14

Datar 'asalah

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Clini!al Stage 3

0 Uneplained se1ere Eeight loss Ao1er #% o presumed ormeasured bod+ EeightB

0 Uneplained !hroni! diarrhoea or longer than # month

0 Uneplained persistent e1er Aintermittent or !onstant or longerthan # monthB

0 5ersistent oral !andidiasis

0 ;ral hair+ leukoplakia

0 5ulmonar+ tuber!ulosis

0 Se1ere ba!terial ine!tions Ae.g. pneumonia, emp+ema,meningitis, p+om+ositis, bone or oint ine!tion, ba!teraemia,se1ere pel1i! inlammator+ diseaseB

0 =!ute ne!rotiHing ul!erati1e stomatitis, gingi1itis or periodontitis

0 Uneplained anaemia AbeloE 8 g)dl B, neutropenia AbeloE %.( #%)lB and)or !hroni!

0 thrombo!+topenia AbeloE (% #%)lB

WHO. 2010. Antiretroviral therapy for HIV infection in a!lt" an aole"cent" #eco$$enation" for a p!blic health approach 2010 revi"ion% p%

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Clini!al stage &0 I4 Easting s+ndrome

0 Pneumocystis jiroveci pneumonia0 Re!urrent se1ere ba!terial pneumonia

0 Chroni! herpes simple ine!tion Aorolabial, genital or anore!tal o more than # months

0 duration or 1is!eral at an+ siteB

0 ;esophageal !andidiasis Aor !andidiasis o tra!hea, bron!hi or lungsB

0 :trapulmonar+ tuber!ulosis

0 aposi sar!oma

0 C+tomegalo1irus disease Aretinitis or ine!tion o other organs, e!luding li1er, spleen and

0 l+mph nodesB

0 Central ner1ous s+stem tooplasmosis

0 I4 en!ephalopath+

0 :trapulmonar+ !r+pto!o!!osis in!luding meningitis

0 Disseminated nontuber!ulous m+!oba!teria ine!tion

0 5rogressi1e multio!al leukoen!ephalopath+

0 Chroni! !r+ptosporidiosis

0 Chroni! isosporiasis

0 Disseminated m+!osis Ahistoplasmosis, !o!!idiom+!osisB

0 Re!urrent septi!aemia Ain!luding nont+phoidal SalmonellaB

0 "+mphoma A!erebral or < !ell non-odgkinB

0 In1asi1e !er1i!al !ar!inoma

0 =t+pi!al disseminated leishmaniasis

0 S+mptomati! I4-asso!iated nephropath+ or I4-asso!iated !ardiom+opath+

WHO. 2010. Antiretroviral therapy for HIV infection in a!lt" an aole"cent" #eco$$enation" for a p!blic health approach 2010 revi"ion% p%

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0 7en8ana Terapi

9 In. Cetriaone #gr)hari)i1

9 CotrimoaHole # $% mg

9 =ttapulgit *-*-*

9 Jin! # *%mg A#% hariB

0 7en8ana Diagnosis

9 5eriksa eses

0 Cek elektrolit

17

Ren!ana 5ela+anan untuk Diare

ronik

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9a8terial %nteri8 Infe8tions

The three maor !lini!al s+ndromes o ine!tion

Eith Gram-negati1e enteri! ba!teria among I4-

ine!ted patients are2

0Sel-limited gastroenteritisK

0'ore se1ere and prolonged diarrheal disease,

potentiall+ asso!iated Eith e1er , blood+ diarrhea,

and Eeight lossK and

0<a!teremia asso!iated Eith etra-intestinal

in1ol1ement, Eith or Eithout !on!urrent or

pre!eding gastrointestinal illness

=IDS-ino. Guidelines or pre1ention and treatment o opportunisti! ine!tions in hi1-ine!ted adults and adoles!ents. *

September *%#&. =1ailable at http2))aidsino.nih.go1)!ontentiles)l1guidelines)adultLoi.pd .pg. I-#

http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf


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General onsiderations ;hen

Managing Patients ;ith

9a8terial %nteri8 Infe8tions0 ;ral or I4 h+dration therap+ Ai indi!atedB should be gi1en to patients Eithdiarrhea (#III.

0 Diagnosti! e!al spe!imens should be obtained prior to initiation o empiri!antimi!robial therap+.

0 =ntibioti! su!eptibilties should be obtained to !onirm and inorm antibioti!!hoi!e.

0 Risk o a ba!terial enteri! ine!tion in!reases as CD& de!lines Eith greatest

risk Eith CD& >*%% !ells)mm3. Risk o ba!teremia also in!reases Eithde!reasing CD& !ount.

0 =nti-motilit+ agents should be a1oided i there is !on!ern about inlammator+diarrhea in!luding Clostridium difficile ine!tion (9III

0 I no !lini!al response ater ( to / da+s, !onsider olloE-up stool !ulture Eithantibioti! sus!eptibilit+ testing and other methods to dete!t enteri! pathogensAe.g., toin assa+s, mole!ular methodsB, alternati1e diagnosis, antibioti!resistan!e, or drug-drug intera!tions.

0 :e!ti1e =RT ma+ redu!e the reuen!+, se1erit+, and re!urren!e o ba!terialenteri! ine!tions.

=IDS-ino. Guidelines or pre1ention and treatment o opportunisti! ine!tions in hi1-ine!ted adults and adoles!ents. *September *%#&. =1ailable at http2))aidsino.nih.go1)!ontentiles)l1guidelines)adultLoi.pd . pg. I-$



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%mpiri8 Treatment of


(Pending <iagnosti8 StudiesFor patients Eith ad1an!ed I4 ACD& >*%% !ells)mm3 or

!on!omitant =IDS-deining illnessesB and !lini!all+ se1ere

diarrhea AM$ stools)da+ or blood+ stool and)or a!!ompanied

e1er or !hillsB.

Preferred Therapy: 9 Ciproloa!in (%%9/(% mg 5; Aor &%% mg I4B #*h (#III

Alternative Therapy:

9 Cetriaone I4 # gm *&h (9III

9 Ceotaime I4 #gm 8h (9III




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%mpiri8 Treatment of


(Pending <iagnosti8 Studies0ote:

0I4 antibioti! therap+ Eith hospitaliHation should be !onsidered in patients

Eith marked nausea, 1omiting, diarrhea, ele!trol+te abnormalities, a!idosis,

blood pressure instabilit+, and)or Ehen !lini!al udgment indi!ates se1erit+ o

disease.

0For patients Eith persistent diarrhea AN#& da+sB in the absen!e o other

se1ere !lini!al signs Ae.g., deh+dration, blood in stoolBO!an Eithhold

antibioti! therap+ until a diagnosis is !onirmed.

0Diarrhea is a !ommon illness o internationl tra1elers. =ntimi!robial

resistan!e among enteri! ba!terial pathogens outside the United States is

!ommon. Clini!ians should !onsider the possibilit+ o resistant ine!tions

Ehen pres!ribing empiri! antibioti!

0therap+ or I4 ine!ted tra1elers Ehile tra1eling or upon return to the

United States.




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October 20, 2015 22

Candidiasis oral

0 Guidelines or the 5re1ention and Treatment o ;ppurtuni!ti! Ine!tions in I4-Ine!ted =dults and =doles!ents

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October 20, 2015 2&

Ren!ana terapi Candidiasis

;ral

Guidelines or the 5re1ention and Treatment o ;ppurtuni!ti! Ine!tions in I4-Ine!ted =dults and =doles!ents

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0 7en8ana Terapi

9 Resusitasi Cairan

0 7en8ana Diagnosis

9 5eriksa ureum kreatinin ulang

9 Takar urin

24

Ren!ana 5ela+anan untuk =I

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DIG;. idne+ International Supplements2 DIG; Clini!al 5ra!ti!e Guideline or =!ute idne+

Inur+. *%#*. =1ailable athttp2))EEE.kdigo.org)!lini!alLpra!ti!eLguidelines)=I.php. pg. 8

=I is deined as an+ o the olloEingA6ot GradedB2

0 In!rease in SCr b+ M%.3 mg)dl AM *$.(

lmol)lB Eithin &8 hoursK or 0 In!rease in SCr to M #.( times baseline,

Ehi!h is knoEn or presumed to ha1e

o!!urred Eithin the prior / da+sK or

0 Urine 1olume > %.( ml)kg)h or $hours.

http://www.kdigo.org/clinical_practice_guidelines/AKI.php


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Tabel stage =IStage

Serum 8reatinin 1rine output

#

*3

#.(9#. times baseline;R M%.3 mg)dl AM*$.( mmol)lB in!rease

*.%9*. times baseline3.% times baseline;R In!rease in serum !reatinine to M&.% mg)dl AM3(3.$mmol)lB;R Initiation o renal repla!ement therap+;R, In patients >#8 +ears, de!rease in eGFR to >3(ml)min per #./3 m*

>%.( ml)kg)h or $9#* hours

>%.( ml)kg)h or M#* hours>%.3 ml)kg)h or M*& hours;R =nuria or M#* hours

DIG;. idne+ International Supplements2 DIG; Clini!al 5ra!ti!e Guideline or =!ute idne+

Inur+. *%#*. =1ailable at http2))EEE.kdigo.org)!lini!alLpra!ti!eLguidelines)=I.php. pg. 8



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!ollo; 1p

Tanggal S = # P

#/))*%#( "emas, demam, mual, muntah<ab !air /)hr, lendirAPB, darahA-B

alium #,$( m:)"Ureum ##3,/ mgreatinin &,% mg

ipokalemia=I

In.aen 'G3#%%%!!)hr In.Cl #%% m:)hr

#8))*%#( "emas, demam, mual, muntah<ab !air ()hr, lendirAPB, darahA-B

alium #, m:)" ipokalemia#*%me)8"AT<QB#(5eningkatan%,3& A*,*$BShit intrasel/,/3=I

In.aen 'G3#%%%!!)hr In.Cl #%% m:)hr

#))*%#( "emas, demam, mual, muntah

<ab !air #*)hr, lendirAPB, darahA-B

alium *,*# m:)" +pokalemia

#*%me)8"AT<QB#(5eningkatan%,** A#%,*BShit intrasel8,(3=I

In.aen 'G3

#%%%!!)hr In.Cl #%% m:)hr

*%))*%#( "emas, demam, mual, muntah<ab !air #*)hr, lendirAPB, darahA-B

alium 3,/& m:)" ipokalemia#*%me)8"AT<QB#(5eningkatan#,(3 A#,&$B

Shit intrasel8,8=I

In.aen 'G3#%%%!!)hr

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!ollo; 1p

Tanggal S = # P

*#))*%#( "emas, demam, mual, muntah<ab !air #*)hr, lendirAPB, darahA-B

alium *,$( m:)" ipokalemiaDengan Cl *% mealium turun kembali=I

In.aen 'G3#%%%!!)hr SR 3#

*3))*%#( "emas, demam, mual, muntah<ab !air #*)hr, lendirAPB, darahA-B

Ureum 8$, mgreatinin 3,/ mg

ipokalemia

=I2 perbaikan

In.aen 'G3#%%%!!)hr In.Cl *( m:)hr

*&))*%#( "emas, demam, mual, muntah<ab !air #*)hr, lendirAPB, darahA-B

alium #,8# m:)" ipokalemia

=I

In.aen 'G3#%%%!!)hr In.Cl (% m:)hrAren!ana #%% 'eB

*())*%#( "emas, demam, mual, muntah<ab !air #*)hr, lendirAPB, darahA-B

alium #,88 m:)" ipokalemia=I2 sta

In.aen 'G3#%%%!!)hr "operamid *-#-#

*8)%)*%#( 'asih Diare #* alium *,%& 'e)" ipokalemia=I2 sta

In.aen 'G3#%%%!!)hr In.Cl #%% m:)l

*)%*%#& 'asih diare / alium *,#8 'e)" ipokalemia In.aen 'G3#%%%!!)hr In.Cl #%% m:)l

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5erkembangan alium

Serum

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T%7IM# K#SIH

Documents

PPT B20