HOLISTIC AND COMPREHENSIVE CASE MANAGEMENT PROTOCOL

A. PATIENT IDENTITY
Full name Sex : M / F
Place and date of birth Age :
Address
Phone number/ Cell phone
Occupation
Religion
Education
Blood typr
Drug allergy
MODULE OF INTERNAL MEDICINE
GASTROINTESTINAL INFECTION = DISENTRI BASILER Dan DISENTRI AMUBA

B. Anamnesis
Complaint
 Abdominal pain at lower left quadrant
 Watery Faeces mixed with blood and mucous
 Vomiting
 Headache
Keluhan
 Sakit perut terutama kuadran bawah kiri
 Faeces encer bercampur lendir dan darah
 Muntah
 Sakit kepala

Risk factor
 Less self-hygiene and sanitation environment
Faktor Risiko
 Kurang kebersihan individu dan sanitasi lingkungan
C. Physical Examination
 Fever
 Abdominal pain at left quadrant
 Sign of dehydration
 Tenesmus
Pemeriksaan Fisik
 Demam
 Nyeri perut pada penekanan di bagian sebelah kiri
 Tanda-tanda dehidrasi
 Tenesmus

D. Supporting Examination
 Complete Faeces Test
Pemeriksaan Penunjang
 Tes Faeces lengkap
E. Diagnostic
Clinical diagnostic
 Diagnosis enforcement is based on anamnesis, physical examination and supporting
examination.
Diagnosis Klinis
 Diagnosis ditegakkan berdasarkan anamnesis, pemeriksaan fisik, dan pemeriksaan
penunjang.
Differential diagnosis
 Eschericiae coli Infection
 Escherichia coli Enteroinvasive (EIEC) Infection
 Escherichia coli Enterohemoragik (EHEC) Infection
Diagnosis Banding
 Infeksi Eschericiae coli
 Infeksi Escherichia coli Enteroinvasive (EIEC)
 Infeksi Escherichia coli Enterohemoragik (EHEC)
 F. Treatment/Penatalaksanaan
Non medication
 Bed rest
 Diet soft meal until defecation less than 5 times a day.
 Given oral rehydration fluid or
 Given parenteral rehydration infusion if oral rehydration not adequate

 Tirah baring
 Diet, diberikan makanan lunak sampai frekuensi BAB kurang dari 5 kali/hari,
 Pemberian cairan rehidrasi oral atau
 Pemberian cairan infus jika rehidrasi oral tidak mencukupi

Medication
Medicine Name Type quantity/time quantity/day duration
Metronidazole 500 mg or Oral 1 3 x day 5 days
ciprofloxacin 500mg Oral 1 2 x day 5 days

Nama obat Tipe kuantitas/waktu kuantitas/hari Lama pemeberian

Metronidazol 500 mg or Oral 1 3 x sehari 5 hari
Siprofloksasin 500mg Oral 1 2 x sehari 5 hari