CASE REPORT

Wilutami Rahardiyaning Tyas

030.06.277

General Information
Name
: Mrs. C
Sex
: Female
Age
: 42 years old
Address
: Cilamaya

Wetan,Karawang
Occupation
: Housewife
Religion
: Islam
Marital Status
: Married
Date of admission : May, 25th
2011
Taken from
: Rengasdengklok

Picture taken May, 30th 2011

Chief Complaint :
Diarrhea since 5 weeks before
hospitalized

Additional Complain :
Nauseous, abdominal pain
Cough, shortened of
breaths
Loss of appetite and
weight

History of present illness

The patients present condition started 5 weeks

before being admitted to the hospital. Her

complained prior to admission was diarrhea
started 5 weeks before admission.
Five weeks before admitted, she loss her
appetite and her weight started to decreased.
The patient said she only wants to drink instead
of ate the food. Few weeks after that, she
started having diarrhea.The diarrhea was
watery, brownish, sometimes it has blood and
mucus or oily mixed with the stools and
happened 3-4 times/day, in random time.

History of present illness

Patient said the diarrhea happened

repeatedly almost 3 times in 1 year.

Patient also complained about weakness of
her body, abdominal pain and nauseous, but
she didnt vomit.
Apart from that, she also felt shortened of
breaths and cough with white phlegm for
almost a month.
After 5 weeks the symptoms not getting
better, she went to RSUD karawang.
She has no fever, night sweat

History of past illness

Patient already had the same symptoms

before
DM (-)
Hypertension (-)
Allergy (-)
Cardiovascular disease (-)
Pulmonary disease (-)
Kidney disease (-)
Never been hospitalized before

History
of
family
illness
Same illness before (-)
DM (-)
Hypertension (-)
Asthma / Allergic (-)
Cardiovascular / pulmonary disease
(-)

Personal and Social History

Like to eat spicy foods and meats,

never ate contaminated foods or
drinks
She didnt exercise regularly
Never smoke or drank alkohol before

General Condition
General
appearance
Moderately ill

Conciousness

Compos mentis
Weight
39 kg
Height
155 cm
BMI

16,23 (under
weight)

Vital sign
BP:
90/60
mmHg
Pulse:
90x/m
in

Temp:
36oC

Resp:
32x/m
in

Physical Examination
Head
Normocephaly

Eyes
Conjunctiva anemic +/+
Sclera icteric -/-

Neck
Lymph gland is not palpable
Thyroid gland is not palpable

Thorax Examination
Lung examination

Inspection : Symmetrical

Palpation

Percussion : Sonor

: Equal vocal fremitus

Auscultation : Vesicular breath sound in

both lungs
No ronchi and wheezing
Heart examination
Inspection : Ictus cordis is invisible
Palpation
: Ictus cordis is palpable at
5th ICS LMCS
Percussion : No enlargement of the heart
Auscultation
: Regular I - II heart sound

Abdominal Examination
Inspection
:
flat
Palpation
:
Pain present on palpation at middle
abdominal region
No liver and spleen enlargement
Percussion
:
No pain present on abdominal percussion
Sounds tympani
Auscultation :
Bowel sound 6x/minute

Extremity Examination
Warm
acrals

+ +
+ +

Oedema

- - -

Laboratory Examination
May 26th 2011
Hb

4,5

12 17 g%

Leukocyte

1600

5 10 rb

Trombocyte 231.000

150 450rb

Ht

14

37 48 %

Basofil

0-1

Eosinofil

1-3

Basil

2-6

Segmen

48

40 - 70

Lymphocyt
e

46

20 - 40

Monocyte

28

GDS

84

80 140
mg/dl

Ureum

19,8

10 45
mg/dl

3,6

3,5
5,6
mmol/l

Na

135

134145
mmol/l

Cl

98

100110
mmol/l

Laboratory Examination
May 27th 2011
Hb

4, 8

12 17 g%

Total protein

4, 87

6,5 8,5 mg%

Albumin

2,25

3,5 5,0 mg%

Globulin

2,62

2,6 3,6 mg%

Retikulosit

1,9

0,5 1,5 %

May 30th 2011

June 6th 2011 post transfussion (2)Hb

4,8

12 - 17 g%

Electrocardiography (ECG)

Electrocardiography (ECG)
interpretation

Sinus tachycardia

Thorax X-Ray
Normal heart , fine
aortae
The lungs pattern
increased on both
lungs
Fine sinus
costophrenicus right
and left, fine
diaphragm archs.
Interpretation:

Abdominal USG (June, 1

2011)

Abdominal USG within normal range

Interpretation :
Hepar : No

hepatomegaly,
homogen
echoparenchyme,
no nodule
Lien, Pancreas, Gall
bladder:
Ren dextra & sinistra
: no no
no
enlargement, normalenlargement,
pelviocalyceal
system, no stones. nodule or stones

Vesica urinaria : normal

Resume
Symptoms

Signs

Diarrhea 5 weeks BP: 90/60 mmHg

HR: 96 x/minute
before
T: 36oC
hospitalized
RR: 32 x/minute
Watery stools,
sometimes mixed eyes : CA +/+
pain present on
with blood and
palpation at
mucus
middle
Nausea, no
abdominal region
vomitting
bowel sounds
Loss of appetite
6x/min
Weakness
Cough with white
phlegm
shortened of
breaths

Laboratory
and others
Hb 4,8 g%
Leucocyte: 1600
Total protein 4,87
Albumin 2,25
ECG sinus
tachycardia
x-ray : suspect
bronchitis chronic
USG within normal
range

Differential Diagnosis
Chronic Diarrhea e.c Malabsorption
Chronic Diarrhea e.c viral infection
Chronic Diarrhea e.c bacterial infection
Chronic Diarrhea e.c paracyte infection
Chronic Diarrhea e.c Food allergic
Irritable bowel syndrome
Anemia gravis e.c Fe Deficiency
Anemia gravis e.c Folic acid deficiency
Anemia gravis e.c vitamine B12 deficiency
Malnutrition

Working Diagnosis
Chronic Diarrhea e.c

malabsorption
Anemia gravis e.c Fe
deficiency
Malnutrition

Suggested Examination
Colonoscopy
Intestinal biopsy
CD4
LED
SI, TIBC
Mean Cell Volume (MCV)
Feses examination : culture, fecal fat,

paracyte

Treatment
Packed Red Cell Transfussion (4)
IVFD NaCl 0,9% 30 tpm
Ceftriaxone 1 x 2gr
Ranitidine 2 x 1 amp
Bisolvon syr 3 x C1
Sohobion 1 x 1 tab
Albumin 20% 1fl
Imodium 3 x 1 tab

Prognosis
Ad
Ad vitam
bonam
Dubia
Ad
sanation ad
am
bonam
Dubia
Ad
functiona ad
m
bonam

THANK YOU