ppt diarrhea sherly rorong
DESCRIPTION
pptTRANSCRIPT
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
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 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
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