CASE REPORT

DIARRHEA IN CHILDREN

Identity of Patient
Nama : MFA

Tanggal lahir : 05-04-2018

Usia : 8 bulan

Jenis Kelamin : Laki-laki

Alamat : Jl. HJ Abdul Rahman, Cibubur, Ciracas

Agama : Islam

Tanggal masuk RS :

Tanggal pemeriksaan :

Ayah Ibu

Nama Tn. W Ny. S

Usia 28 tahun 26 tahun

Pekerjaan Sales Ibu rumah tangga

Suku Jawa Jawa

Agama Islam Islam

Pendidikan SMA SMA

Alamat Jl. HJ Abdul Rahman, Cibubur, Ciracas

Anamnesis
Anamnesis dilakukan pada tanggal------ secara alloanamnesis dari ibu pasien.
 Keluhan utama : Kejang sejak 1 hari sebelum masuk rumah sakit
 Keluhan tambahan : Demam,

Riwayat Penyakit sekarang

Riwayat Penyakit Dahulu

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

Mother’s Pregnancy 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.

Child’s Birth History

 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

- Breast milk : Exclusively 1 year 6 months

- Formula milk : None were given
- Baby biscuit : Milna and cerelac
- Fruit and vegetables : Banana and papaya

Immunization History
Immunizatio Frequency Time
n

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old

DPT 3 times 2, 4, 6 months old

 Polio 4 times 0, 2, 4, 6 months old

Measles 1times 9 months

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 : ( - )

History of Disease in Other Family Members / Around the House

There is no one living around their home known for having the same condition as the patient.

Social and Economic History

 The patient lived at the house with size 10 m x 8m together with father and mother.

 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.

Home ownership : private

Home condition : clean, good ventilation, good water condition
Environment : densely populated
 Hygiene:

o The patient’s mother changes her clothes everyday with clean clothes.
 o Bed sheets changed every two weeks.

Physical Examination
A. General Status

- General condition : Mild ill

- Awareness : Compos Mentis
- Pulse : 92x/min, regular, full, strong.
- Breathing rate : 20x/min
- Temperature : 37.8oC (per axilla)
- Saturation O2 : 99%

B. Antropometry Status

- Weight : 12 kilograms
- Length : 88 cm

Nutritional Status based NCHS (National Center for Health Statistics) year 2000:

WFA (Weight for Age): 12/12 x 100 % = 100 %

HFA (Height for Age): 88/87 x 100 % = 101 %

WFH (Weight for Height): 12/13 x 100 % = 92 %

Head to Toe Examination

 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

Nuchal rigidity (-)

Kernig sign (-)

Lasegue sign (-)

Brudzinski I (-)

Brudzinski II (-)

Autonom Examination

Defecation Normal
Urination Normal ( 3-4 times daily )
Sweating Normal
 D. Supporting Examination
Routine complete blood count

August 7th 2018

Hematology

Test Results Normal Value

Haemoglobin 11.7 g/dL* 13-16 g/dL

Leukocytes 17.100 /µL* 5,000 – 10,000/µL

Hematocrits 31 %* 40 – 48 %

Trombocytes 340.000/ µL 150,000 – 400,000/µL

Chemical

Natrium 138 135-145 mmol/l

Potassium 4.9 3.5 – 5.0 mmol/l

Chlorides 100 98 – 108 mmol/l

Stool Test

Physical and Chemical

Colour Yellowish

Form and Consistency Soft Solid

Mucus +

Blood -
Microscopical

Leukocytes 4–5 /LPB

Erythrocytes 0–1 /LPB

Ova and Parasites

Ascaris Sp - /LPB

Anchilostoma Sp - /LPB

Trichiuris Sp - /LPB

Oxyuris Sp - /LPB

Others -

E. Working Diagno sis

 Accute Diarrhea

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

August 07th 2018. First day of hospitalization, 2nd day of illness

S Diarrhea (+)fever (-)

O General condition: Compos mentis.

Heart rate = 104 x/min

Respiratory rate = 22x/min

Temperature = 37.4˚C

Head : normocephal, anterior fontanelle sunken -

Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema -/-

Nose : runny nose +/+ , blood -/-, nasal flaring –

Mouth : lips dry, mucosa moist, coated tounge -, pharynx hyperaemic –

Neck : lymph nodes enlargement -

Chest : symmetrical, intercostal retractions -

Cardio : S1/S2, reguler, murmur (-) , gallop (-)

Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Abdomen : bloated, peristalitic sound +, epigastrium pain (-) turgor normal

Genitalia and Anus : Rash appeared around anus

Extremities : acrals warm, edema -, crt < 2s

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

August 08th 2018. Second day of hospitalization, 3day of illness

S Diarrhea (-),fever (-)

O General condition: Compos mentis.

Heart rate = 110 x/min

Respiratory rate = 24 x/min

Temperature = 37.1˚C

Head : normocephal, anterior fontanelle sunken -

Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema
-/-

Nose : runny nose +/+ , blood -/-, gasping –

Mouth : lips dry, mucosa moist, coated tounge -, pharynx hyperaemic –

Neck : lymph nodes enlargement -

Chest : symmetrical, intercostal retractions -

Cardio : S1/S2, reguler, murmur (-) , gallop (-)

Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Abdomen :bloated, peristalitic sound+,epigastrium pain(-) turgor normal

 Genitalia and anus : Rash appeared minimal around anus

Extremities : acrals warm, edema -, crt < 2s

A Accute Diarrhea

P - IVFD KAEN 3B
- Inj. Cefotaxime 2x500mg
- P.o Lacto B 2x1 sach
- P.o Zink 1x20 mg

August 09th 2018. Third day of hospitalization, 4day of illness

S Diarrhea (-),fever (-)

O General condition: Compos mentis.

Heart rate = 112 x/min

Respiratory rate = 24x/min

Temperature = 36.2˚C

Head : normocephal, anterior fontanelle sunken -

Eye: anemic conjunctiva -/-, icteric sclera -/-, lacrimations +/+, edema
-/-

Nose : runny nose +/+ , blood -/-, gasping –

Mouth : lips dry, mucosa moist, coated tounge -, pharynx hyperaemic –

Neck : lymph nodes enlargement -

Chest : symmetrical, intercostal retractions -

Cardio : S1/S2, reguler, murmur (-) , gallop (-)

 Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Abdomen : bloated, peristalitic sound +, epigastrium pain (-) turgor

normal

Genitalia and Anus : Rash around anus (-)

Extremities : acrals warm, edema -, crt < 2s

A Accute Diarrhea

P - IVFD KAEN 3B
- Inj. Cefotaxime 2x500mg
- P.o Lacto B 2x1 sach
- P.o Zink 1x20 mg