Transcript Klasifikasi, Kodifikasi Penyakit 2 Pertemuan 8

SESI 9
DISEASES of the DIGESTIVE
SYSTEM
(PENYAKIT SISTEM PENCERNAAN)
BAB XI
Disusun oleh:
Dr Mayang Anggraini Naga
1
DESKRIPSI
Pembahasan tentang gangguan/penyakit terkait
kerongkongan (esophagus), lambung (stomach.
Gaster), usus (intestine) hati (liver = hepar)) dan
vesica felea (gallbladder = kantung empedu);
struktur dan kekhususan isi Bab XI Diseases of
The Digestive System disertai pelatihan
pengkodean diagnosis gangguan sistem
pencernaan.
2
TUJUAN INSTRUKSIONAL UMUM
Memahami definisi istilah gangguan pencernaan
dan menentukan nomor kodenya dengan benar.
3
TUJUAN INSTRUKSIONAL KHUSUS
Menjelaskan:
Isi topic bacaan Reading 2.
Struktur dan kekhususan serta peraturan yang
berlaku bagi pemilihan nomor kode gangguan
sistem pencernaan
Cara memilih nomor kode diagnosis dengan akurat.
4
POKOK & SUBPOKOK BAHASAN
”Disorders of Digestive System”
Struktur dan kekhususan Bab XI
Pelatihan pencarian kode gangguan sistem
pencernaan melalui ICD-10 volume 3 dan Volume 1
5
READING 2
DISORDER of the DIGESTIVE SYSTEM
Disorder Of The Esophagus
Despite its apparently simple structure, the esophagus
is prone to a number of disorders, most of which lead to
difficulty, or completely prevent swallowing and/or
cause a pain in the chest.
Congenital Defects
Esophageal atresia is an absence from birth of a
section of the esophagus, with the remaining sections
ending in dead ends. It requires urgent surgical
correction. Rarely, babies are born with web-like
constructions of the esophagus. These are rarely,
serious enough to require treatment, but may, if
necessary, but broken down with a rubber dilator.
6
DISORDER of the DIGESTIVE SYSTEM (Cont.-1)
Infection & Inflammation
Infections of the esophagus are uncommon, but can
occur in severity immunosuppressed patients whose
defenses against infection are weakened, The most
common infections are herpes simplex infection or
candidiasis (thrush) extending downward from the
mouth. Both cause pain on swallowing.
Esophagitis is usually due to reflux of the contents of
the stomach causing heartburn. A more severe form –
corrosive esophagitis – can occur a result of
swallowing caustic chemicals. Either of these types of
esophagitis may lead to formation of an esophageal
stricture.
7
DISORDER of the DIGESTIVE SYSTEM (Cont.-2)
Injury
Apart from the damaging effects of swallowing corrosive
chemicals, the most common cause of injury to the
esophagus is severe vomiting and stretching, which
occasionally tear the esophageal lining or extreme
causes lead to rupture. A hard swallowed foreign body
can also cause injury and sometime perforation if it
lodges the esophageal wall.
Tumors
Tumors of the esophagus are not rare about 90% are
malignant, the remainder are benign. With both types the
initial symptom is usually difficult swallowing.
8
DISORDER of the DIGESTIVE SYSTEM (Cont.-3)
Other Disorderws
An esophageal diverticulum is an outwardly protruding
sac, formed usually at the top end of the esophagus in
which food may collect and cause halitosis and
sometime difficulty swallowing.
Esophageal spasm consist of uncoordinated and
uncontrollable contractions of the esophagus, which
may make swallowing difficult.
In achalasia, the spincter muscle at the junction
between esophagus and the stomach falls to relax
to allow the passage of food, causing pain on swallowing
and sometimes regurgitation of food.
9
DISORDER of the DIGESTIVE SYSTEM (Cont.-4)
Investigation
Esophageal disorders are investigated by:
barium swallow and by
endoscopy (esophagoscopy).
Occasionally, a biopsy (tissue sample), may be taken
for pathologic examination.
10
DISORDER of the STOMACH
Disorders of the stomach have a variety of causes,
because the stomach is a reservoir, disorders in
the process of emptying the stomach relate to the
stomach’s role in the preparation of ingestion food
for digestion.
Infection
The large amount of hydrochloric acid secreted by the
stomach protects the stomach from some infections by
destroying many of the bacteria, viruses, and fungi that
are taken in with food and drink.
When the protective power is insufficient, a variety of
gastrointestinal infections may occur.
11
DISORDER of the STOMACH (Cont.-1)
Tumors
Stomach cancer causes about 15.000 deaths annually
in the U.S.
Each symptoms are often mistaken for indigestion and
diagnosis is often delayed until it is too late for a cure.
Any change in the customary functioning of the digestive
system is important, especially after fifty.
A persistent feeling of fullness, or pain before or after
meals, should never be ignored.
Unexplained loss of appetite or frequent nausea should
always be reported.
12
DISORDER of the STOMACH (Cont.-2)
A tumor in the upper part of the stomach, near the
opening of the esophagus can cause obstruction and
difficulty in swallowing.
Sometime a stomach tumor remains “silent” and the
first signs are due to the appearance of secondary
growths elsewhere in the body.
Benign (non-cancerous) polyps can also develop in
the stomach.
Ulceration
The acid and other digestive juices secreted by the
stomach sometimes attack the stomach lining.
13
Ulceration (Cont.)
The healthy stomach is prevented from digesting itself
mainly by the protective layer of mucus secreted by the
lining and by the speed with which damaged surface
cells are replaced by the deeper layers. Many influents
can upset this delicate balance.
One of the most important is excessive acid secretion.
The resulting peptic ulcers are probably the most
common serious stomach disorder. Peptic ulcers are
sometimes caused by stress, or by severe injury,
such as major burns, accidents, and after surgery and
severe infections, often they occur for no apparent
reason.
The stomach lining can be damaged by large amounts
of aspirin or alcohol sometime causing gastritis. This
may lead to ulceration of the stomach lining.
14
DISORDER of the STOMACH (Cont.-3)
Autoimmune disorders
Pernicious anemia is caused by the failure of the
stomach lining to produce intrinsic factor, a
substance whose role is to facilitate the absorption
of vitamin B12.
Failure to produce the intrinsic factor occurs if there
is atrophy of the stomach lining, which also causes
failure of acid production,
Tests that determine a person’s ability to absorb
vitamin B12 are important in the investigation of
this condition.
Pernicious anemia is usually due to an
autoimmune disorder.
15
DISORDER of the STOMACH (Cont.-4)
Other disorders
Enlargement of the stomach may be caused
when scarring from a chronic peptic ulcer occurs
at the stomach outlet. It may also be complication of
pyloric stenosis, a rare but serious condition
caused by narrowing of the stomach outlet.
Rarely the stomach may become twisted and
obstructed, a condition called volvulus.
Investigation
Stomach disorders are investigated primarily by
barium X-ray examinations and/or
gastroscopy.
Occasionally, a biopsy is performed.
16
DISORDER of INTESTINE
The intestine is subject to various structural abnormalities
and to the effects of many infective organism and parasite;
it may also be affected by:
- tumors,
- impaired blood supply, and
- other disorders.
Congenital defects
- atresia,
- stenosis,
- volvulus or
- blockage by meconium.
Early surgery may be required.
17
DISORDER of the INTESTINE (Cont.-1)
Infection and Inflammation
The general term for inflammation of the stomach and
intestines is gastroenteritis.
This is caused most commonly by viral or bacterial
infections, which can range from the trivial to the life
threatening. They ecompass many causes of food
poisoning and travelers diarrhea as well as serious
diseases such as typhoid fever and cholera. Protozoal
infections includes gardiasis and amebiasis.
Intestinal worm infestations are exceedingly common
worldwide (round worms, tapeworms), includes
pinworm are prevalent.
18
DISORDER of the INTESTINE (Cont.-2)
Two important inflammatory conditions of the intestine,
not caused by infection are ulcerative colitis and
Crohn’s disease.
Sometimes, inflammation is confined to a localized area,
such as:
appendicitis and
diverticulitis disease.
19
Tumors
Tumors of the small intestine are rare, but lymphomas,
carcinoid tumors and benign growth occur.
By contrast tumors of the large intestine (colon) are
very common. Certain forms of familial polyposis may
progress to cancer.
Impaired blood supply
The intestine is dependent on an adequate blood supply.
Ischaemia may result from several causes. Causes
includes partial or complete obstruction of the
arteries in the abdominal wall, or from the blood vessels
being compressed or tapped as in volvulus,
intussusception, or hernias. Loss of blood supply to a
segment o intestine may caused gangrene requiring
immediate surgery.
20
Obstruction
Intestine obstruction may be caused by pressure
from the outside, disease of the intestinal wall, or
internal blockage.
One of the most common causes is paralytic ileus,
in which intestinal contractions cease and the
intestinal contents are no longer transported.
Oher disorders
Peptic ulcer of the duodenum is a very common
disorder, thought to affect 10% of the population.
Ulceration of the small intestine occurs in typhoid and
Crohn’s disease and may cause bleeding into the
intestine or even perforation. Ulceration of the large
intestine occurs in amebiasis and in ulcerative colitis. 21
DISORDER of the INTESTINE (Cont.-3)
Diverticula
Diverticula are small outpouchings from the inside of the
bowel.
They are usually harmless, but, in diverticular disease,
become inflamed.
Malabsorption and celiac sprue result from changes
to the intestinal lining.
Finally irritable bowel syndrome is associated with
persistent abdominal pain and either constipation or
diarrhea (or both), and is the most common intestinal
disorder.
22
DISORDER of the INTESTINE (Cont.-4)
Investigation
Intestinal disorders are investigated by physical
examination, and by techniques such as:
barium X-ray examination,
sigmoidoscopy or
possibly coloscopy, and by
laboratory examination of the feces or of a
biopsy specimen taken from the intestinal lining.
23
DISORDER of the LIVER
By far the ost common cause of liver disease in the US
and other developed countries is excessive consumption
of alcohol.
In part of Africa and Asia, up to 20% of the population
are carriers of the hepatitis B virus, the most important
liver disorders are virus-induced cirrhosis and primary
liver cancer.
Congenital defects
Choledochal cyst, a malformation of the hepatic duct
(union of the small bile ducts in the liver) may obstruct
the flow of bile in infants  jaundice.
In Billiary atresi, the bile duct are absent  jaundice.
24
DISORDER of the LIVER (Cont.-1)
Infection and inflammation
Hepatitis may be caused by viruses (A, B, and non-A
and non-B viruses).
Bacteria may spread up the billiary system toward the
liver to cause cholangitis or liver abscess.
Parasitic diseases that may affect the liver includes
schistosomiasis. Liver fluke, and the hydatid disease,
and amebiasis.
25
DISORDER of the LIVER (Cont.-2)
Poisoning and drugs
Many drugs and toxins are broken down by the
liver, damaging lever cell in the process.
Suicidal overdoses with the painkilling drug
acetaminophen causes severe liver damage,
which may not be obvious until up to two days
after the overdose.
Some medications, even in normal doses, can
cause acute or chronic hepatitis by a direct toxic
effect or through drug allergy.
Poisoning by certain types of mushrooms can cause
acute liver failure.
26
DISORDER of the LIVER (Cont.-3)
Autoimmune disorders
Liver cells and bile ducts can be targets for
autoimmune reactions. A gradual destruction of liver
is the main problem in autoimmune chronic active
hepatitis. The slowly progressive bile duct damage
that occurs in primary billiary cirrhosis and
sclerosing cholangitis possibly also has an
autoimmune basis.
Metabolic disorders
The two main metabolic disorders affecting the liver
are hemochromatosis (too much iron in the body)
and Wilson’s disease (too much copper)
27
DISORDER of the LIVER (Cont.-4)
Tumor
The liver is common site of malignant tumors that have
spread from cancers of the stomach, pancreas, or
large intestine.
Enlargement of the liver and spleen is a common
feature of:
leukaemias and
lymphomas.
Primary tumors of the liver (hepatoma) are much less
common.
28
DISORDER of the LIVER (Cont.-5)
Other disorders
In Budd-Chiari syndrome, the veins draining the liver
become blocked by blood clots, causing painful swelling
of the liver and severe ascites.
Obstruction of the portal vein is one cause of portal
hypertension, which can lead to esophageal varices,
and ascites.
Portal hypertension is also one of the usual
complications of cirrhosis.
Investigation
Disorders of the liver may be investigates by:
physical examination tests,
ultrasound scanning and
CT scanning.
29
DISORDER of GALLBLADDER
The gallbladder rarely causes problems in childhood
or early adulthood, but, from middle age onward, the
increasing occurrence of gallstones can sometimes
give rise to symptoms
Because the digestive system can function normally
without a gallbladder, its removal has little known long
term effect.
Congenital and Genetic Defects
Abnormalities present from birth may includes no
gallbladder; an oversized gallbladder; or two
gallbladders; these defects rarely cause problems
30
Metabolic Disorders
The principal disorder of the gallbladder, with which most
other problems are associated, is the formation of
gallstones. Gallstones are common, but only about 20%
of people with gallstones have symptoms requiring
cholecystectomy.
Attempts by the gallbladder to expel the stone or stones
can cause severe biliary colic (abdominal pain).
There are three main types of gallstones, cholesterol
gallstones, pigment gallstones and mixed
gallstones. The great majority are cholesterol of mixed
gallstones, and women are affected four times as often
as men.
Every year about 1 million Americans develop
gallstones. Many people carry “silent” gallstones, which
produces no symptoms.
31
Infection and Inflammation
If a gallstone becomes stuck in the outlet from the
gallbladder, the trapped bile may irritate and inflame the
gallbladder walls and the bile itself may become infected.
The first symptom may be biliary colic, which is
followed by fever and abdominal tenderness.
Repeated attacks of biliary colic and acute cholecystitis
can lead to chronic cholecystitis, in which the
gallbladder becomes schrunken and thick-walled and
ceases to function. Rarely, the gallbladder may become
inflamed without the presence of gallstones – a condition
that is called acalculous cholecystitis.
Occasionally, cholecystitis proceeds to a condition in
which the gallbladder fills with pus, called empyema of
the gallbladder. This can cause a high fever and severe
abdominal pain.
32
Tumors
Gallbladders harboring gallbladder cancer usually
contain gallstones. However the cancer is extremely
uncommon compared to the high prevalence of
gallstones.
Other Disorders
In rare cases where a gallbladder is empty when a stone
obstructs its outlet, it may filt with mucus secreted by
the gallbladder walls, resulting in a distended, mucusfilled gallbladder known as mucocele.
Investigation
• Physical examination, ultrasound scanning or
radionucleid scaning, and blood tests may also be
carried out.
33
KEKHUSUSAN BAB XI
DIESASES OF THE DIGESTIVE SYSTEM
(PENYAKIT SISTEM PENCERNAAN)
(K00 – K93) [Hal.549-596]
Perhatikan Excludes di bawah judul.
Bab ini terbagi dalam 10 blok.
K00-K14 Peny. rongga mulut, kelenjar air liur dan
rahang
K20-K31 Peny. esofagus, lambung dan usus duabelas
jari
K35-K38 Peny. Appendix (usus buntu)
K40-K46 Hernia
K50-K52 Enteritis dan colitis non-infeksi
34
KEKHUSUSAN BAB XI (Lanjutan-1)
K55-K63
K65-K67
K70-K77
K80-K87
K90-K93
Peny. lain-lain terkait usus
Peny. peritoneum (selaput pembungkus
perut)
Peny. hati
Gangguan kantung empedu, sal. empedu &
pankreas
Penyakit-2 lain terkait sistem digestif.
Ada 5 kategori bertanda-baca * yakni:
K23* K67* K77* K87* K93*
35
KEKHUSUSAN BAB XI (Lanjutan-2)
Ada Excludes yang harus diperhatikan.
Contoh pada kategori:
K00.2
Ukuran dan bentuk gigi abnormal [Hal. 550]
Excludes: …
K00.3 Mottled teeth
[Hal. 550]
Excludes: …
K00.4 Distrurbance in tooth formation
[Hal. 551]
Excludes: …
K01
Embeded and impacted teeth
[Hal. 551]
Excludes: …
K03
Peny. Lain jaringan padat gigi
[Hal. 552]
Excludes: ...
Dan seterusnya mengikuti nomor code lain-lian.
36
KEKHUSUSAN BAB XI (Lanjutan-3)
Ada Use additional external code (Chapter XX) …
Contoh ada pada:
K03.8 Peny.-2 khusus lain terkait jaringan keras gigi
[Hal. 553]
K06.2 Gangg.-2 lain gusi dan tonjolan alveoler gigi
[Hal. 556]
K10.2 Kondisi peradangan rahang bawah
[Hal. 559]
K20 Oesophagitis
[Hal. 564]
K22.1 Ulkus (tukak) esofagus
[Hal. 565]
Dan seterusnya pada nomor code lain-lain.
37
Perhatian khusus bagi K25-K28 [Hal. 566-567]
Disediakan subdivisi dengan digit-ke-4 yang harus
mengikuti code K25-K28:
.0 perdarahan akut
.1 perforasi (luka tembus) akut
.2 perdarahan dan perforasi akut
.3 tanpa perdarahan ataupun perforasi
.4 kronik atau tidak dirinci dengan perdarahan
.5 kronik atau tidak dirinci dengan perforasi
.6 kronik atau tidak dirinci disertai perdarahan dan
perforasi
.7 kronik tanpa perdarahan dan perforasi
.9 tidak dirinci apakah kronik atau akut, tanpa
perdarahan atau perforasi.
38
Gastruc ulcer & Appendicitis
Contoh:
perdarahan tukak lambung kronik: K25.4
perforasi tukak lambung
: K25.5
perdarahan dan perforasi tukak lambung (kronik):
K25.6
Perbedaan ada di digit ke-4.
Perhatian khusus untuk Appendicitis [569-570]
Diseases of appendix (K35-K38)
Di sini jelas bahwa penyakit radang usus buntu memilki
sebanyak 4 variasi, dari nomor code K35, K36, K37
dan K38.
Oleh karenanya diagnose appendicitis hendaknya
rinci terutama apabila pasien dicito operasi atau dirawat
di ICU.
39
Hernia
Perhatikan Note: … di bawah Hernia (K40-K46)
[Hal. 570-574]
Hernia dengan gangrene dan obstruksi diklasifikasi ke
hernia with (dengan) gangrene.
Hernia inguinal (K40), hernia femoral (K41) juga harus
dirinci apakah unilateral atau bilateral, dengan atau
tanpa obstruksi atau gangrene.
Apakah kanan atau kiri tidak mempengaruhi code
terpilih?
K42, K43, K44, K45, K46 hanya di satu site, tidak ada
kanan atau kiri.
40
Noninfective enteritis & colitis (K50-K52)[574-576]
Perhatikan Excludes dan Includes yang ada di bawah
grup ataupun pada masing-2 kategori. [Hal. 575]:
K52.1
Toxic gastroenteritis and colitis
Use additional …
 untuk menjelaskan agen penyebab
keracunan tersebut.
[Hal. 576]
K52.9
Noninfective gastroenteritis and colitis,
unspecified.
Perhatikan perbedaan penggunaannya dengan A09.
A09 adalah untuk ….
[lihat hal. 112]
K52.9 adalah untuk …
P78.3 adalah untuk …
41
Other diseases of Intestine (K55-K63) [Hal.576-582]
Excludes: …
K56 Paralytic ileus and intestinal obstruction without
hernia
Excludes: …
K57 Diverticulitis disease of intestine
Perhatikan Includes dan Excludes yang ada.
K59.3 Megacolon, NEC
Use additional external cause code …
42
Diseases of Peritoneum (K65-K67) [Hal. 583-585)
K65 Peritonitis
Excludes: …
K65.0 Acute peritonitis
Use additional code (B95-B97) …
Diseases of liver (K70-K77) [Hal. 585 – 590]
Perhatikan: Excludes: haemochromatosis (E83.1)
jaundice NOS (R17)
Reye’s syndrome (G93.7)
viral hepatitis (B15-B19)
Wilson’s disease (E83.0)
43
Diseases of liver (K70-K77) (Hal. 585 – 590)
K71 Toxic liver disease
Includes: drug-induced:
Ada : Use additional external cause code (Chapter
XX), if …
Excludes: …
Perhatikan Excludes dan Includes yang mengikuti
nomor code kategori ataupun subkategori  untuk
memastikan kode yang akan dipilih adalah yang
benar.
44
Disorders of Gallbladder; Biliary Tract and Pancreas
(K80-K87) [Hal. 590-594]
K80
Cholelithiasis
Perhatikan nomor code yang berbeda bila gangguan
ini disertai cholecystitis akut/kronik
K81 Cholecydtitis
Juga dibedakan antara yang akut dan kronik
tanpa/dengan calculi.
K83 Other diseases of biliary tract dan
K86 Other diseases of pancreas
Masing-masing ada Excludes:…
K85 Acute pancreatitis termasuk abses pankreas.
K84 kosong
K87* Gangguan kantung/saluran empedu dan
pancreas pada penyakit utamanya terklasifikasi
di Bab lain.
45
Other Diseases of the Digestive System (K90-K93)
[Hal. 594-596]
K90
Intestinal malabsorption
Excludes: yang terjadi postoperasi gastroentestinal
(K91.2)
K90.2 Blind loop syndrome NEC. Ada Excludes: …
K90.4 Malabsorption due to intolerance, NEC. Ada
Excludes: …
K90.8 Other intestinal malabsorption
Khusus untuk Whiplle’s disease K90.8 ! (M14.8*)
K91
Postprocedural disorders of digestive system.
NEC.
Excludes: …
Keadaan postprocedural adalah dinyatakan oleh
dokternya, bukan interpretasi atau keputusan coder!
46
Other Disease od Digestive System
K92
Other disease of digestive system
Excludes: neonatal …
K93* Gangguan organ-2 digestif lain pada penyakit
yang terklasifikasi di Bab lain-lain  penyakit
utamanya pakai tanda ! (dagger)
K93.0* TB disorders of intestines, peritoneum and
mesenteric glands (A18.3 !)
 lihat [117]
Excludes: TB peritonitis (K67.3*)
K93.1* Megacolon in Chagas’ disease (B57.3*)
K93.8* Disorders of other specified digestive organs in
diseases classified elsewhere
 lihat Ascariasis dengan komplikasi usus.
47
SOAL-SOAL LATIHAN
Cari nomor kode istilah yang dicetak tebal dan diberi
garis bawah dalam materi bacaan (reading 2)
Latihan menentukan nomor kode istilah di bawah ini
Oral leukoplakia (335)
Leukoplakia
oral epithelium, including tongue (mucosa) K13.2
[562]
K13.2 Leukoplakia and other distrurbances of oral
epithelium including tongue
Erythroplakia, Leukoedema of oral epith. …
including tongue
Leukokeratosis nicotina palati
Smoker’s palate
Excludes: hairy leukoplakia (K13.3)
48
Soal-soal Latihan (Lanjutan-1)
Dental caries
Dental (150) - see also condition (Condition – see Disease)
- examination Z01.2
Sebaiknya gunakan Caries sebagai Lead-term
Caries
(90-91)
- dental K 02.9 [552]  perlu rincian (bagian yang
caries, dsb) agar tidak menggunakan code ber .9
Herpetic gingivostomatitis (245) B00.2
Herpes
(265)
- gingivostomatitis B00.2
[148]
B00.2 Herpes viral gingivostomatitis and pharyngotonsillitis
Herpesviral pharyngitis.
Diagnose ini masuk ke laporan jumlah penyakit Herpes
(kode berdagger) bukan gingivostomatitis.
49
Soal-soal Latihan (Lanjutan-2)
Tukak duodenum dengan perdarahan dan perforasi 
Ulcer duodenum, duodenal (eroded) (peptic) K26.9
- with
- - hemorrhage K26.4
- - - and perforation K26.2
Gastroenteritis hipersensitifitas susu, pasien usia
20th (244)
- food hypersensitivity
K52.2 [575]
Bedakan dengan:
Gastroenteritis keracunan makanan tercemar
pepticida K52.1 (Use additional external cause code
(cari di Bab XX))
50
LATIHAN SOAL-SOAL
1.
2.
3.
Gangguan pencernaan
No:
GE akibat gangguan pencernaan
No:
Tukak lambung akibat minum aspirin dalam rangka
terapi jantung, disertai perdarahan
No:
4. Hernia incarcerata inguinalis kiri
No:
5. Esophageitis
No:
6. Stomatitis candidiasis, pasien HIV-AIDS No:
7. Dysentry amebiasis
No:
8. Dysentri baksiler
No:
9. Chronic Colitis
No:
10. Pamcreatitis acute
No:
51
LATIHAN SOAL-SOAL (Lanjutan)
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Insulinoma
No:
Hepatitis keracunan obat TB
No:
Hepatitis keracunan makanan
No:
Hepatoma
No:
Hepatomegaly
No:
Appendicitis abscess
No:
Peritonitis komplikasi infeksi typhoid No:
TB mensentric
No:
Regional enteritis
No:
Gigi berlubang
No:
Gigi susu tanggal
No:
Gigi patah akibat jatuh
No:
52