Anda di halaman 1dari 17

CASE REPORT

DIARRHEA

Aditya Prambudhi
111170004
Chief : dr. Irman Permana, Sp.A

FACULTY OF MEDICINE
SWADAYA GUNUNG JATI UNIVERSITY
CIREBON
2015

Pattients identity

Name

: Mr. AD

Age

: 2 years old

Sex

: male

Address

: Kaligawe

Date of admission

: 25/06/2015

Date of examination

: 27/06/2015

Mothers Patients

: Mrs. S

Age

: 23 years old

Address

: kaligawe

Occupation

: House Wife

Education Level

: Elementary School

History of taking

Chief complain : liquid bowel movements


History of present illness :
Patients come to the hospital emergency room with
complaints liquid bowel movements. One day before entering
the hospital. Vomiting > 3x daily. liquid defecation > 10 x /
day, liquid consistency, waste less, more water, slimy, yellow
bloodless. Complaints accompanied by vomiting 3x / day.
Patients complain of abdominal pain. Patients do not want to
eat and drink. During the patient's pain becomes more fussy
and look weak but no loss of consciousness. Cough, runny
nose, and shortness of denying patients.
Currently the patient drink formula coupled with rice side
dishes and fruit. According to the mother of the patient, the
patient does not have a food allergy.

Past medical history :


Patients have experienced diarrhea complaint
1,5 years old.

Family history of disease :


There is no family history of disease

Treatment of History
patients have given oralite from stalls but no effect on patient

History of growth and development :


Gross motor : - learn to lift the head of the age of 2 months
- Crawling and sit without the other people of 5 months
- Learn to stand on its own without the assistance 13 months Soft motor : - reach
objects around the age of 4 months
- Trying to move goods ages 6 months
Talking : - laughing and screaming 3 months Social:
- smiled at the face of the age of 2 months
- Laughs when asked to play age of 3 months
Impression: age-appropriate growth and development

immunization history :
Hepatitis B
: 1x at after birth
BCG
: 1x. at 1 month
DPT
: 1x at 2 months
Polio
: 1x at 4 months
Measles
: 1x at 9 months

PHYSICAL EXAMINATION

General state

: looking illnes

General appearance

Height

: 12 kg

Weight

: 91 cm

Vital sign

: full alert

Blood presure

:-

Pulse

Respiration

Temperature : 36 C

: 110 x/minute, reguler, equal


: 24x/minute

Head
flaring
Neck

: Conjunctiva anemic -/-, Sclera icteric -/-, Nasal


(-), POC (-)
: - Suprasternal Retraction (-)
- Lymphadenopathy (-)

Thorax

: - Symmetric with good expansion Intercostal

retractions(-)
-

Lungs : Breath sounds vesicular right=left,

rales(-), wheezes(-), rhonchi(-)


- Heart : S1, S2, regular rhythm, no murmurs

Abdomen : - Soft, non distended, non tender


- Epigastric retractions (-),
- Liver and spleen is non palpable
- increased bowel sounds (40 x/minute)

Extremities
: - Warm
- Acrocyanosis -/- Capillary refill time < 2

Neurological Examination

Meningeal reflex : Neck stiffness (-)


Brudzinsky I/II/III (-)
Cranial nerve
: pupil isochors 3 mm within normal
limit
Motoric
: within normal limit
Sensoric
: within normal limit
Patology reflex
: Babynsky +/+ ; Chaddock -/-,
oppenheim -/- ; Gordon -/-

Differential Diagnosis

Diarrhea acute mild-moderate without dehidration

Intolerance lactose

Further Examination
Hematology :

Hemoglobin

: 12 g / dl

Hematocrit

: 40 %

Leukocytes

: 13.000 / ul

Platelets

: 413,000 / ul

Stool :

Color: yellow

Blood: -

Smell: characteristic

Slime: -

Consistency: soft

Leukocytes: 1-3 / LPB

The eggs of worms: -

Erythrocytes: 0-1 / LPB

Working diagnosis

Diarrhea acute mild-moderate without dehidration

Treatment

IVFD KaEN 3 B 11 dpm


Sanmol syr 3 x 1 cth
Oralite ad libitum
Ranitidine 2 x 12,5 mg
Zinc 1 x 1 tab
Cotry syr 2 x cth

Education
Parents are asked to bring the child back to the
hospital if symptoms of fever, bloody bowel
movements
Promotive and preventive
Breast milk is still given
personality of hygiene
washing hands before eating
Environmental Hygiene

Prognosis

Quo ad vitam

: dubia ad bonam

Quo ad functionam

: dubia ad bonam

Quo ad sanationam

: dubia ad bonam

Thank you