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CASE REPORT Baiq
CASE REPORT Baiq
DIARRHEA IN CHILDREN
Identity of Patient
Nama : MFA
Usia : 8 bulan
Agama : Islam
Tanggal masuk RS :
Tanggal pemeriksaan :
Ayah Ibu
Anamnesis
Anamnesis dilakukan pada tanggal------ secara alloanamnesis dari ibu pasien.
Keluhan utama : Kejang sejak 1 hari sebelum masuk rumah sakit
Keluhan tambahan : Demam,
Pharyngitis/ -
Tonsilitis
Bronchitis -
Pneumonia -
Morbilli -
Pertussis -
Varicella -
Diphteria -
Malaria -
Polio -
Enteritis -
Bacillary Dysentry -
Amoeba Dysentry -
Diarrhea -
Thypoid -
DHF -
Worms -
Surgery -
Brain Concussion -
Fracture -
Alergi -
Birth History
The mother routinely checked her pregnancy to the doctor in the hospital. She denied any
problem noted during her pregnancy. She took vitamins routinely given.
Labor : Hospital
Birth attendants : Doctor
Mode of delivery : Normal
Gestation : 38 weeks
Infant state : Healthy
Birth weight : 3500 grams
Body length : 49 cm
According to the mother, the baby started to cry and the baby's skin is red.
Development History
First dentition: 6 months
Psychomotor development
Head Up : 1 month old
Smile : 1 month old
Laughing : 1- 2 month old
Slant : 5 months old
Speech Initation : 5 months old
Prone Position : 6 months old
Food Self : 6 months old
Sitting : 8 months old
Crawling : 9 months old
Mental Status:Normal
Conclusion: Good motor development status
Feeding History
Immunization History
Immunizatio Frequency Time
n
Family History
Patient’s both parents were married when they were 25 years old and 23 years old, and
this is their first marriage
There are not any significant illnesses or chronic illnesses in the family declared
Born died : ( - )
Child dies : ( - )
Miscarriage : ( - )
There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1 room
is the bedroom of three of them and 1 room.. There are 4 windows inside the house. The
windows are occasionally opened during the day.
o The patient’s mother changes her clothes everyday with clean clothes.
o Bed sheets changed every two weeks.
Physical Examination
A. General Status
B. Antropometry Status
- Weight : 12 kilograms
- Length : 88 cm
Nutritional Status based NCHS (National Center for Health Statistics) year 2000:
Head
Normocephaly, hair (black, rare distribution or almost bald, not easily removed) sign of
trauma (-)
Eyes
Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation +/+, sunken
eyes -/-, pupils cant be examined/3mm isokor, direct and indirect light response +/+and
+/+
Ears
AD: Normal shape, no wound, no bleeding, secretion or serumen
AS: Normal shape, no wound, no bleeding, secretion or serumen
Nose
Normal shape, midline septum, secretion -/-
Mouth
Lips: dry
Teeth: no caries
Mucousa: moist
Tongue: coated -
Tonsils: T1/T1, no hyperemia, no detritus
Pharynx: hyperemia (-)
Neck
Lymph node enlargement (-), scrofuloderma (-)
Thorax :
i. Inspection : symmetric when breathing ,retraction (-),ictus cordis is not visible
ii. Palpation : mass (-), tactile fremitus -/-
iii. Percussion : sonor on both of lungs
iv. Auscultation :
1. Cor : regular S1-S2, murmur (-), gallop (-)
2. Pulmo : vesicular +/+, Wheezing -/- , Rhonchi -/-
Abdomen :
i. Inspection : Convex, epigastric retraction (-), there is no a widening of the veins, no
spider nevi
ii. Palpation : supple, liver and spleen not palpable, fluid wave (-),abdominal mass (-),
turgor normal
iii. Percussion : The entire field of tympanic abdomen, shifting dullness (-)
iv. Auscultation: normal bowel sound, bruit (-)
Vertebra : There are no scoliosis, kyphosis, and lordosis, no mass along the
vertebral line
Genitalia and Anus : Rash appeared around anus
Extrimities : warm, capillary refill time < 2 seconds, edema(-)
Skin : Good turgor.
C. Neurological Examination
Meningeal Sign
Brudzinski I (-)
Brudzinski II (-)
Autonom Examination
Defecation Normal
Urination Normal ( 3-4 times daily )
Sweating Normal
D. Supporting Examination
Routine complete blood count
Hematology
Hematocrits 31 %* 40 – 48 %
Chemical
Stool Test
Colour Yellowish
Mucus +
Blood -
Microscopical
Ascaris Sp - /LPB
Anchilostoma Sp - /LPB
Trichiuris Sp - /LPB
Oxyuris Sp - /LPB
Others -
F. Management
- IVFD RL 1000 cc / day (14dpm macro)
- Inj. Cefotaxime 3x250mg
- P.O Lacto B 2x1 sach
- P.O Zink 1x1 cth
G. Prognosis
Quo ad vitam : ad bonam
Quo ad functionam : ad bonam
Quo ad sanationam : ad bonam
A. FOLLOW UP August 07th 2018- 09th 2018
Temperature = 37.4˚C
Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema -/-
A Accute Diarrhea
P - IVFD Ringer Lactate 1000cc/24hrs, 14dpm macro
- Inj. Cefotaxime 2x500mg
- P.o Lacto B 2x1 sach
- P.o Zink 1x20 mg
- P.o Paracetamol 4 x 1 cth
Temperature = 37.1˚C
Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema
-/-
A Accute Diarrhea
P - IVFD KAEN 3B
- Inj. Cefotaxime 2x500mg
- P.o Lacto B 2x1 sach
- P.o Zink 1x20 mg
Temperature = 36.2˚C
Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema
-/-
A Accute Diarrhea
P - IVFD KAEN 3B
- Inj. Cefotaxime 2x500mg
- P.o Lacto B 2x1 sach
- P.o Zink 1x20 mg