CASE DISCUSSION

PAUL HARIJANTO
 Case 1. DIAGNOSIS ??

 Male 26 years old, referred by peripheral hospital(PH) with

fever for 3 days and diagnosed as DHF grade 1, because
his condition getting worse, developed loss of concious, he
had been referred to district hosp. In PH, platelets was
42.000, 18.000. Ht 43.3% then 30.3%. Ig.G positif, IgM
negatif
 Examination in DH : afebrile, pale, GCS : E4M1V2, no
Hepatosplenomegaly, no neurological defisit, Lab : Hb 12
gr%, WBC 14750/ mm3, granulocyte 90% , malaria falcip
+4 (15.000 per 200 leuco), parasite count 1.050.000/uL,
thrombocyte 30.000 mg/dL, Random blood sugar 26
mg/dL, SGOT 300 IU, SGPT 325 IU.
E.D.S
Expanded
Dengue
Syndrome
 Was treated with artesunate 120 mg on 0 hr, 12 hrs
and 24 hrs, also 40% dextrose 75cc was given
intravenously. Six hours later he developed
breathless, kussmaul breathing was noted, fever 39C,
patient was referred to ICU.
 Parasite count 12000/200WBC, bl.glucose 103 mg%,
SGOT 597IU, SGPT 259 IU, Bilirubin total 18.05
U/dL, direct bill 13.8 U/dl. WBC 20.370/mm3.

What’s your management ?

 On the second day he developed
convulsion, parasite count 6910/200 wbc,
110 par/ 1000 rbc. 6hours later the
parasite count 4175/ 200 wbc, SGOT
470u/L , SGPT 345 u/L. GCS E1/M2/V2,
oliguria and furosemide was given.
 On the third day, bleeding in the sclera, BP
90/60, Kussmaul, CVP was inserted, the
patient go to cardiac arrest and died.
Case 2

 Wanita 37 tahun dengan demam ulang-ulang 5

hari, sakit kepala, badan agak kuning, belum bab.
 KU Cukup, sadar, tek. Darah 100/60, nadi 116,
temp 38 C
 Cor/ pulmo : tak ada kelainan
 Hepar teraba 2 jari
 Diagnosa : Suspek Hepatitis
 Apa Differential Diagnosisnya ?
Laboratorium

 Hb. 8.5 gr%, leuko 4900, trombo 81.000

 Total bil : 4,4 mg%, direk 1.97 mg%, indirek 2,4
mg%, SGOT 55u/L, GPT : 55 u/L, gamma-GT 61,4
u/L, alk.PO4 : 174 u/L, urea 27.5, creat. 1.3, gula
darah 148 u/L, Na 135, K 3.3
 Bagaimana Diagnosa penderita ini ?
 Apa masih perlu pemeriksaan lain untuk diagnosa
?
Lab
 Ig M dengue negatif, Ig G dengue positif
 NS1 : negatif
 Tubex M : + 4
 Widal tes : + 1/80

 Diagnosa ??
Malaria : Fal ring : +++, 380 par/ 200 Leuko,
2 par/ 1000Eri
 Apa pengobatannya ?
Case 3.
Seorang perempuan, 19 tahun, MRS Bethesda
Tomohon tgl 2 Maret 2012 jam 07.49 dengan
keluhan utama panas.
RPS: - panas 1 minggu SMRS, menggigil +
- nyeri ulu hati +, mual +, muntah +
- BAB cair + frek 2x/hari selama 3 hari
- sakit kepala +
- badan lemah +
- batuk -, muntah -, BAK biasa
RPD: Hpt, DM, peny jantung, liver, paru, ginjal tidak
diketahui
• Pemeriksaan fisik:
KU: sedang Kesadaran: CM
T: 100/70 N:90x/m R:20x/m Sb:39,6
conjungtiva anemis - sclera icterik -
Thorax: Cor/Pulmo tidak ada kelainan
Abdomen: lemas, NTE +, BU+ normal
Hepar tak teraba, Lien tak teraba
Extremitas: hangat, edema -

DIAGNOSA ??
 Laboratorium:
Hb: 15,5 Leukosit:6900 Trombosit: 29.000
Diagnosa ? Tatalaksana ?

DDR: Plas. Falciparum ring +++

200 leuco 220 p, 1000 ery 6 p

Apa Pengobatannya ?
• WDx: Malaria uncomplicated
• Therapy:
Co-artem 2x4 tab/hari (3 hari)
Primakuin 1x3 tab ( 1x pemberian)
Domperidone 3x1 tab
Ranatidin 2x1 tab
Parasetamol 3x500 mg
Levofloxacin 1x500 mg
• Planning: DDR serial, fungsi ginjal, fungsi liver, bilirubin
• Follow up
3 Maret 2012
Hb: 14,9 Leuko:6000 Trombo: 40.000
DDR: Plas. Falciparum ring ++++
200 leuco >3000 p, 1000 ery 24 p
Ureum: 54 Kreatinin: 1,41Urea N: 25,1
Bilirubin total: 2,07 Direct:0,98 Indirect:1,1
SGOT: 45,6 SGPT:28,3 ALP1:47,3 GGT:80,4
Protein total:7,3

4 Maret 2012
DDR: Plas. Falciparum ring + gamet +
200 leuco 2 p, 1000 eri –

5 Maret 2012
DDR: Plas. Falciparum -
Case-4 • YM, 134311

• Male, 33 years old, admitted to Bethesda

hospital fever 2 days, vomiting, headache. He
had a history suffering from falciparum malaria
in Timika-Papua, 8 weeks ago and treated with
arterakin.
• G.C : well, febrile 38.7 C, BP 110/80, heart &
lung : normal, no spleen , no liver was felt.
• Diagnosis : ??
• Hb 14.3gr/dL, WBC 7100/uL, Platelets 103.000,
Ht 40.4%, neutrophil 56.2%
• Bilirubin ttl 1.84 mg%, direct 1.08 mg%, SGOT 21
u/L, SGPT 28 u/L, gamma-GT 72 u/L, Alk PO4
75.8 u/L, urea 35 mg%, creatinin 1.0 mg%, bl.
Glucose 134 mg%, Na 147 meq/L, K 4.0 meq/L.

Malaria : Vivax ring +++, gamet ++

Parasite count : 340 par/ 200 Leuco
What’s the treatment ??
• After the treatment Arterakin 4 Tablets/ daily for
3 days + Primaquine 15 mg/day for 14 days ,
malaria day 1, 2, 3 : negative
On day 17 , on follow up , malaria smear : gamet +

Was treated with primaquine 30 mg ( 2 tabl)/ day for 14 days

3 months later, he is back to hospital with fever, malaria smear

vivax ring +++, parasite count 340 par/200 Leuco

Tafenoquine ??
 VT-21617
Case -5

• Female, 33 years old, pain on hypogastrium,

fever 2 weeks, pain on muscle, headache,
cough. She is pregnant 5 months.
• Seriously ill, fever 41 C, BP 80/ 37 mmHg,
pulse 124/ min, pale, no jaundice, heart & lung :
clear.

What is the diagnosis & management ?

• Lab : Hb 8.3 gr/dL,WBC 4690/uL, platelets
45.000, Ht 23 %, neutrophile 87.3%, MCV 79.3,
MCHC 36.1, MCH 28.6
• Urinalysis : leuco 4 -6, erythrocyte 10-15,
micro-organisme ++
• Bl glucose 122, urea 32, creat 1.1, Na 138, K
3.6
• Day 1 : vivax ring +++, gamet ++, parasite
count 250 par/ 200 leuco, 4 par/ 1000 eri
• Day 2 : vivax ring ++, 130 par/ 200 leuco, 1
par/ 1000eri

Diagnosis & Management ?

Kasus 6
Anamnesa:
Laki-laki, 34 tahun tinggal di Tomohon,
datang ke RS dengan demam sudah 3 hari.
Penderita baru tiba dari Papua 2 hari lalu
dan sudah merasa tidak sehat
P. Fisik : tensi 80/60 mmHg, Temp 38.5 C
Cor/ Pulmo : taa
Abd : taa
 Laboratorium
5/10/2011 6/10/2011
• Hb: 8,0
• Leuko : 5,300 DDR: (-)
• Ht: 27% • Bil.direct: 1,2
• Segmen 90% • Bil.indirect: 2,4
• Limfosit 10%
• Bil.total: 3,6
• SGOT: 51
• SGPT: 16
• Ureum: 28
• Creatinin 1,2
• DDR: Fal.ring (+), Fal.gamet (+)
200 lp: 42 parasit
1000 lp: 2 parasit
Pengobatan
 5/10/2011  Apa Pilihan ?
 Coartem 2x4 tab  ACT ? Apa ?
 Sanmol 3x1 k/p  Malaria berat ?
 Primakuin 1x3 tab
Kasus 7
demam, ikterik, perdarahan

Laki2 20 thn, MRS dengan badan kuning 1 mgg.

Riw demam 2 mgg, muntah2 campur darah, BAB hitam,
perdarahan hidung.
TD 110/70, N 96, T 37,4, KU: CM, C/P TAK, Abd: nyeri
kanan atas
Diagnosis?
 Pasien dirujuk dari RS perifer, dengan IVFD
D5%, Lab: L 10.100, Plt 78.888, Ur 148, SGOT
132, SGPT 57,6, D/: Cholelithiasis,
cholecystitis. dd/ Hep virus akut.

Komentar ??
E.D.S
Expanded
Dengue
Syndrome
 Hasil pemeriksaan darah di RS ini menunjukkan
: Falc ring ++++, Hitung parasit > 3000
parasit/200 leko, 12 parasit/1000 eri, Ureum 302
mg%, Cr 7,8 mg%, Bil tot 22,7 mg%, Bilirubin Dir
12,1 mg%, Bil. ind 10,5 mg%.

Apa Diagnosis saudara??

Apa Manajemen saudara??
 Case 8
 Male 26 years old, referred by peripheral hospital(PH)
with fever for 3 days and diagnosed as DHF grade 1,
becaused his condition didn’t getting better and deve
loped loss of concious, then referred to District
Hospital. In PH, platelets was 42.000, 18.000. Ht 43.3%
then 30.3%.
In DH afebrile, pale, GCS : E4M1V2, no Hepatosplenomegaly,
no neurological defisit
Malaria falciparum +4 (15.000 per 200 leukosit) dengan
hitung parasit 1.050.000/uL (seperti tertera pada gambar 2).
Nilai trombosit 30.000 mg/dL, gula darah sewaktu 26 mg/dL,
SGOT 300 IU dan SGPT 325 IU.Hb 12 gr%, WBC 14750/ mm3,
granulocyte 90%
DIAGNOSIS ??
 Was treated with artesunate 120 mg on 0 hr, 12 hrs
and 24 hrs, also 40% dextrose 75cc was given
intravenously. Six hours later he developed breathless,
kussmaul breathing was noted, fever 39C, patient was
referred to ICU.
 Parasite count 12000/200WBC, bl.glucose 103 mg%,
SGOT 597IU, SGPT 259 IU, Bilirubin total 18.05 U/dL,
direct bill 13.8 U/dl. WBC 20.370/mm3.

What’s your management ?

 On the second day he developed
convulsion, parasite count 6910/200 wbc,
110 par/ 1000 rbc. 6hours later the
parasite count 4175/ 200 wbc, SGOT
470u/L , SGPT 345 u/L. GCS E1/M2/V2,
oliguria and furosemide was given.
 On the third day, bleeding in the sclera,
BP 90/60, Kussmaul, CVP was inserted,
the patient go to cardiac arrest and died.
Case 9.
 Laki-laki 14 tahun, masuk RS dengan demam satu minggu,
menggigil, berkeringat, batuk dan muntah 4 x. makan
minum sedikit, bibir pecah-pecah. Bab sulit sudah 1
minggu, bak biasa.

Pemeriksaan Fisik :
Sadar, tampak sakit, bibir pecah-pecah
Tensi 60/ 40 mmHg, 90/50 mmHg, 95/50 mmHg
Temperatur 40 C, Resp 26 x/ men, Nadi 100x/men
Jantung : S1-2, bising tdk ada, besar normal
Paru : ronki tadk ada
Abdomen : bising usus positif, tidak nyeri, defance –
Ascites : positif.Acral hangat.

Diagnosa : ?? DD : ??
Lab : hematologi, Malaria, ---cito
Urinalisis, IgM anti salmonella, x-fotothorak, GDS

 Terapi :
 Ivfd R/L 3 liter/hari ( di UGD guyur 500
cc )
 Sanmol 3 x 1 tbl
 Omeprazole 1 x 1 tbl
 Vomistop 3 x 1
 Extropect 3 x 1
 Observasi T, N, R, S
 Lapor dokter peny Dalam
 Riwayat berkemah di Tombatu minggu lalu

 LABORATORIUM :
 Hematologi : Hb. 12.3 gr%, Leuko 5110 mm3/L, Ht.
33.6%, Trombosit 24.000/mm3, Diff neutro 70%,
limf 23%, mono 3.6%, eos 2.5%, baso 0.2%

Malaria : P. Falcip +++, 3000 par/200leuko, 12 par/ 1000 eri

1000 par/ 200 leuko, 6 par/ 1000 eri
45 par/ 200 leuko, 1 par/ 1000 eri
20 par/ 200 leuko, negatip/ 1000 eri
 Kimia Darah :
 SGOT/ SGPT : 42.5/ 55, Alb/Glob : 3.03/
2.2
 Bil D/ In : 0.92/ 0.4, gamma-GT : 36.2,
Alk.PO4 : 222
 Urea : 47, Creatinine : 1.05, Uric acid :
1.05
Case 10
 pria 35 thn, panas 2 hr, ikterus, penurunan
kesadaran1 hr. Tiba dari Sorong 3 hr lalu.
 Pemeriksaan Fisik : GCS 6 - 7. Sklera
ikterik. T 110/ 80 per menit. Nadi 116,
Resp 30x ,Temp 38.2. Fisik : lain-lain
Normal
 Apa differential diagnosis ?
 Apa manajemen ?
 Hb 12.6gr%, leuko 12.200/mm3, tromb.
218.000/mm3 Granulosit 87,9%. Ureum
21 mg%, creat.0.8 mg%, Gds 119 mg%, na
127, k 3,8 .
 Apa diagnosa ?
 Apa rencana/ planning ?
 Malaria(1): ring falcip 3 +. Malaria (2) ring
falcip 2+,Vivax gamet 1+. D3 : neg.
 Follow up : Hematemesis + ,Prod urine 50
cc per jam.
 Dx. Diagnosa ?
 Terapi ?
KASUS 11-a
Seorang laki - laki 62 tahun, dengan riwayat panas-dingin 3 hari, sakit kepala, mual.
Pemeriksaan :K.U. baik, febris, tidak anemi, sadar. Tensi, nadi, resp. normal. Jantung
dan paru normal. Hepar dan lien : normal
Diagnosa : observasi malaria.
Laboratorium : Darah malaria : Falciparum ring + . Hb. 12 gr %, Leuko 8600 / mm3.
Hitung jenis leukosit eos/baso/neutro/limfo/mono : -/-/2/93/3/2. LED : 16 / 1 jam. Urine
mikroskopik : normal
Pengobatan: klorokuin difosfat 4-4-2 tb.Penderita K.U baik dan tidak muntah.
Follow up :
Dua hari kemudian sakit kepala masih, penderita muntah, hiccup + +, tidak bisa
makan.Malaria : falcip ring +; vivax +. Hari IV : Gula darah 61 mg % ; ureum 313 mg % ;
kreatinin 7,35 mg %,Se. natrium 114 meq / L; kalium 3,4 meq / L, berat jenis Urine 1,012.

Pertanyaan :
1. Apa penderita ini resisten klorokuin ? Dan apa pengobatannya ?
2. Apakah insuffisiensi ginjal (ureum 313 mg % ; kreatinin 7,35 mg %) dapat
disebabkan karena penyakit ginjal sebelumnya (glomerulonefritis) ?

39
Kasus 11-b

Hari ke V :
Jaundice pada sklera, Hb. 11. gr %, leuko 18.100, Se. Bilirubin total 4,46 mg % ;
indirek 2,98 mg % ; direk 1,48 mg %, S.G.O.T 43 u / L, S.G.P.T 59 u / L, Gamma -GT
256,7 u / L, Alk. fosfatase 300 u / L, albumin 3,18 gr %, globulin 3,90 gr %.

3. Apa diagnosa saudara ?

4. Apa pengobatan penderita ini ?
4. Pemeriksaan apa saja yang masih diperlukan ?

40
Kasus 11-c

Setelah pengobatan dengan kina, maka pada hari ke XII, keadaan umum membaik,
panas hilang, akan tetapi penderita tampak pucat. Tidak ditemukan tanda perdarahan.
Hb. 6.9 gr %, retikulosit 9,3 %, trombosit 252.000 / mm3. Diberikan tranfusi darah 2
bag(1000cc), Hb menjadi 7,9 gr %, hari ke XV penderita pulang Hb 8,2 gr % Retik 0,6 %,
ureum 87 mg %, kreatinin 2,18 mg %.

Pertanyaan :
6. Apa penyebab anemianya ?
7. Pemeriksaan apa yang perlu dilakukan ?

41
 Case 12

 Pasien wanita 33 th P2A0 post partus prematurus

lahir normal, dikonsulkan dari bagian obgyn ke
penyakit dalam.
 Sebelumnya Os gravid 32-33 mgg dengan
perdarahan pervaginam disertai keluar cairan
sekonyong-konyong 1 hr SMRS.
 Demam 5 hari, menggigil (+),Nyeri tulang (-).
 Lemah badan (+), nafsu makan menurun (+).
 Mual (-), Muntah (-), Batuk (-).
 BAB & BAK dbn.
 Pemeriksaan Fisik
KU: sedang, compos mentis
BB: 64 Kg, TB: 160 cm
T: 110/70mmhg, N: 78x/m reguler, R:22x/m, S:37,8oC
 Mata: conj. Anemis (+/+), sklera ikterik (-)
 Mulut: faring/tonsil dbn.
 Thoraks: cor/pulmo dbn.
 Abdomen: supel, BU (+), H/L ttb, perdarahan
pervaginam (-).
 Ext: hangat, Oedem (-/-)
 Laboratorium
• Hb 7,1
• Leukosit 12.300  Urinalisis:
• Ht 22% ◦ Leu +1
• Trombosit 178.000 ◦ Eri +5
• Ureum 21
 EKG: Sinus rythm
• Creatinine 0,8
• Na 132
• K 3,1
• Cl 98
• Widal (-)
• DDR: plasmodium vivax +
Diagnosis
 P2A0 33 thn post partus prematurus.
 Malaria vivax uncomplicated
 Anemia ec perdarahan pervaginam
Terapi interna
 DHP 1x4 tablet selama 3 hari
 Primakuin (tidak diberikan karena
pasien menyusui bayi)
 Paracetamol 3x500 mg po
 Transfusi PRC 1 bag/ hari sd hb >10
 Follow up hari ke-2
S:Keluhan (-)
O: KU: sedang, compos mentis Terapi:
T: 110/70mmhg, N: 70x/m reguler, • DHP 1x4 tablet selama 3
R:20x/m, S:36,7oC hari (hari ke 2)
 Mata: conj. Anemis (+/+), sklera ikterik • Primakuin (tidak diberikan
(-) karena pasien menyusui
 Mulut: faring/tonsil dbn. bayi)
 Thoraks: cor/pulmo dbn. • Paracetamol 3x500 mg po
 Abdomen: soepel, BU (+), H/L ttb, • Transfusi PRC 1 bag/ hari
perdarahan pervaginam (-). sd hb >10
 Ext: hangat, Oedem (-/-)
A: Malaria vivax uncomplicated
P2A0 post partus prematurus
Lab:
Hb 9,2 (post transfusi 1 bag)
DDR: negatif
 Follow up hari ke-3
S:Keluhan (-)
Terapi:
O: KU: sedang, compos mentis
• DHP 1x4 tablet selama 3
T: 100/70mmhg, N: 88x/m reguler,
hari (hari ke 2)
R:20x/m, S:36,5oC
• Primakuin (tidak diberikan
 Mata: conj. Anemis (+/+), sklera
ikterik (-) karena pasien menyusui
bayi)
 Mulut: faring/tonsil dbn.
• Paracetamol 3x500 mg po
 Thoraks: cor/pulmo dbn.
• Transfusi PRC 1 bag/ hari
 Abdomen: soepel, BU (+), H/L ttb, sd hb >10
perdarahan pervaginam (-).
 Ext: hangat, Oedem (-/-)
A: Malaria vivax uncomplicated
P2A0 post partus prematurus
Lab:
DDR: negatif
PAKATUAN WO PAKALAWIREN
Sampai Baku Dapa !
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT/ RSUP Manado
RSU Bethesda -Tomohon

Telp.:
0431-351024/046 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com