Klarifikasi Istilah :

1. ORS : yaitu pengobatan pada diare untuk mengganti kehilangan cairan (NCBI)
2. Letargi : penurunan tingkat kesadaran, ditandai dengan lesu, mengantuk, dan apatis
3. (Kamus Dorland)
4. Diare : Pengeluaran tinja berair berkali-kali yang tidak normal (Kamus dorland Ed 29,
2015:220)
5. Mukus : Mukus Lendir bebas selaput lendir, terdiri dari sekresi kelenjar-kelenjar, bersama
dengan berbagai garam anorganik, sel yang berdeskuamasi, dan leukosit.
6. Non projectile vomiting : Pengeluaran isi lambung melalui mulut tanpa disertaisemburan
muntahan yang kuat. (Kamus Kedokteran Dorland, 2002:846)
7. Sunken Eye : mata cekung yang merupakan tanda dari dehidrasi (NCBI)
8. Shuffle : Suara bising berdenyut akibat propulsi gas atau cairan melewati usus ( Dorland)

Identifikasi Masalah :

No. Identifikasi Kalimat

1. Keluhan utama Budi, a boy, 13 month, was hospitalized

due to diarrhea.

2. Keluhan tambahan He also got mild fever.

3. Riwayat perjalanan penyakit Four days before admission, the patient

had non projectile vomiting 8 times a day.
He vomited what he ate. Three days
before admision the patient got diarrhea 8
times a day around half glass in every
defecation, there was no blood and
mucous/pus in it. The frequency of
vomiting decreased. But two days before
admision the patient got bloody stool 12
times a day around quarter glass in every
defecation. The vomiting stopped. Along
those 4 days, he drank eagerly and was
given ORS (oral rehidration solution).
Yesterday, he looked worsening, lethargy,
didn’t want to drink, still had diarrhea but
no vomiting. The amount of urination in 8
hours ago was less than usual.
4. Pemeriksaan fisik Patient looks severely ill, compos mentis
but weak (lethargic), BP 70/50mmHg, RR
38x/m, HR 144 x/m regular but weak,
 body temperature 38,9 oC, BW 10 kg, BH
75 cm Head: Sunken frontanella, sunken
eye, no tears drop, and dry mouth. Thorax:
similar movement on both side, retraction
(-/-), vesicular breath sound, normal
heartsound. Abdomen: flat, shuffle, bowel
sound increases. Liver is palpable 1 cm
below arcus costa and xiphoid processus,
spleen unpalpable. Pinch the skin of the
abdomen: very slowly (longer than 2
seconds). Redness skin surrounding anal
orifice. Extremities: cold hand and feet
5. Pemeriksaan Laboratorium Hb 12,8 g/dl, WBC 20.000/mm3 ,
differential count 0/1/2/83/20/4. Urine
routine Macroscopic: yellowish colour,
Microscopic : WBC (-), RBC (-), protein (-),
keton bodies (+). Faeces routine
Macroscopic: water more than waste
material, blood (+), mucous (+) WBC:
20/HPF , RBC full, bacteria (++),
Entamoeba coli (+), fat (+
6. Riwayat social Budi’s family lives in slum area

Analisis masalah :