ppt diarrhea sherly rorong

CASE REPORTDIARRHEA

Pembimbing:

dr. Irman Permana, Sp.A

dr. Tatan Tandubela, Sp.A

dr. Ineu Nopita, Sp.A

Sherly rorong111170062

Patient’s identity

• Name : K N• Age : 9 m.ol• Sex : female• Date of admission:6/7/15

• Date of examination: 9/7/15

• Father’s patient: Mr. A• Age : 35 y.o• Address : kaligawe

History taking

• Main complain: watery diarrhea

• A 9-month-old baby girl presented to hospital with a 2-day

history of watery diarrhea with a frequency of 5x, There

was no blood and mucus in feces. Also complained fever

during 4 day up and down. This complaint accompanied

with a productive cough and cold. out of breath, loss of

consciousness, vomiting and seizures denied. mother

patient took him to the community health center

for treatment to the patient, but there was no

improvement.

her mother also said that the water from the boreholes, only have 2 bottles of milk, rarely wash their hands.

• Past health history There was no history the same as complain like

as now There was no History of nonstop bleeding There was no history of congenital heart There was no history of ulcus peptikum There was no history of asma There was no history of long treatment

• Family history There was no history the same as complain like as patient There was no history of allergy

• Treatment history

mother patient took him to the community health center for

treatment to the patient, but there was no improvement.

• History growth and development

there was no history about delay growth and development

• Immunization history

Measles immunization has not been given, because patients in treatment.

Physical Examination

• Status Present Awareness : full alert

Pulse : 120 x/minute, regularRespiration : 28 x/minuteTemperature : 38,8o C

• Antropometry StatusWeight : 6,5 KgHeight : 70 cm

• Nutrition Status • BMI/Age : - 2 SD (wasted)• Height/Age : 1 SD

• Weight / age : - 2 SD (underweight)• Weigt/Height : - 2 SD (wasted)

Head• Form: Normocephal, fontanelle sunken• Eyes: Conjunctiva are not anemic, sclera not icteric, Enophthalmos (+), Tears (-)

• Nasal : within normal limits, and no secret • Ears: within normal limits• Mouth: Cyanosis (-), Dry mouth (+)Neck : within normal limits, suprasternal retaction (-), Lymph nodes enlargment (-)

Thorax : Symmetryc with good expantion Intercostal retraction (-)

• Lung : Breath sounds vesicular right = left, wheezing -/-and rhonchi -/-

• Heart : S1, S2 reguler rhytm, murmurs (-) and gallop (-)

Abdomen Soft, non distended, non tender, no epigastrium

retraction, Bowel sound (+), Mild decreased tissue turgor (+)

Genetalia She has normal female genitalia

Extremites Warm, Capillary refill time < 2”

Skin

perianal rash (-)

Differential diagnostic• Diarrhea mild/moderate dehidration non dysentery• Diarrhea mild/moderate dehidration dysentry

Further examination

• complete blood count• Routine feces

Further exemination

complete blood count

Component 6 July 2015

Hb 10,3

Leukosit 12,6

Eritrosit 4,35

Hematokrit 31

Trombosit 416

MCH 23,7

MCHC 33,4

MCV 23,7

RDW CV 14,2

RDW SD 35,4

Basofil 1

Eosinofil 0

Neutrofil batang 0

Neutrofil Segmen 22

Limfosit 63

Monosit 14

Routine feces

Working diagnostic• Diarrhea mild/moderate dehidration non dysentery +

Anemia

Management

- Oralit 75 ml/body weight/ in 3 hours = 480 ml - Zinc 1 x 20mg- L Bio 2 x 1 sachet- Paracetamol 70 mg (3-4x) prn- Exemination ferritin fe serum and TIBC

Prognosis

PROGNOSIS• Quo ad vitam : ad bonam• Quo ad functionam : ad bonam• Quo ad sanationam : dubia ad bonam

Preventive• Hand hygiene• Food hygiene• Rotavirus immunization

Thank You