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Case Report : Acute diarrhea e.

c
susp. Shigellosis With mildmoderate Dehydration
Devia Mufida Zahara, S.Ked
Ronalisa Anriz, S.Ked
Jefri Karsoni, S.Ked

Supervisor: dr. Achirul


Bakri, Sp.A (K)

Pediatric Status
IDENTIFICATION
Name : By. MJ
Age/birth of date : 1 years old, may 06 2014
Sex : Woman
Father Name : Mr. A
Mother Name: Mrs. S
Nationality/Tribe: Sumatera
Adress : Jl. Desa Tirta Mulya RT.11 RW.06 No. 26 Kab. Banyuasin
Palembang
Transferred by : Hospitalized : May 22 2015

ANAMNESIS
Date

: may 22 2015
Given by : Patients mother (Alloanamnesis)

Medical History
Chief Complain
: liquid stools mixed with mucus and blood
Secondary Complain
: Vomiting
History of illness:
3 days before hospitalized, patient has defecate a liquid stool frequency > 4
times / day, volume starfruit cup, liquid> pulp, no blood, no mucus, no
nausea and vomiting, there are sudden high fever, no cough, no runny nose,
no seizures, no shortness of breath, urinating within normal limit patient still
want to drink and eat but the amount and frequency diminishing, then the
patient was taken to the midwife and then given paracetamol and zinc but
no improvement.
6 hours before hospitalized, patients s defecation is liquid stool
mixed with mucus and blood, blood colour is fresh red, the
frequency > 7 times / day, volume starfruit cup, liquid> pulp,
patient looked pain every want defecation, nausea and vomiting
(+), frequency 1 x, the contents of what to eat, vomiting not
projectile, volume starfruit cup, patient looked fussy and still
want to eat and drink, the tears (+), there are fever but not so high,
no cough, no runny nose, no seizures, no shortness of breath,
urinating within normal limit , the patient was brought to the GP
clinic and then referred to RSMH.

Past Medical History


History of the disease with the same complaint (-).
History of previous trauma (-).

Medical History in Family


History of the disease with the same complaint in

the family denied.

Medical History Before


Hospitalized
History of Pregnancy and Birth

Pregnancy
: Full term
Partus : Spontan
Place : clinic
Helped by : midwife
Date : may 06 2014
Birth Weight : 3 kg
Birth length : 49 cm
History of food:
Breastfeeding: Until now
Formula Milk : 6 months
Milk porridge: 6-8 months
Rice: 12 months - now

DEVELOPMENT HISTORY
Prone
Seated
Standing
Walk

: 3 months
: 6 months
: 11 months
: 12 months

Impression : motor development within normal


limits

IMMUNIZATION HISTORY
BCG: 1 time, scar + (on the right arm)
DPT: 3 times
Polio: 3 times
Hepatitis B: 3 times
Measles: 1 times
Impression: complete basic immunization according to
age

PHYSICAL EXAMINATION
General Physical Examination
General Condition : looked moderate sick
Sensorium : Compos Mentis
Weigh : 7 Kg
Height : 90 Cm
Nutritional Status
BB/U : - 2 SD

TB/U : - 2 SD (-3 SD)


BB/TB : - 1 SD (-2SD)
immersion : good nutrition
Head Circumference : 41 Cm (normosefali)
Temperature : 38,2 OC
Respiration : 28 x/minute, Respiration Type : Thorakoabdominal
Pulse : 118 x/ minute,
contain/quality : enough

Regularity
: Regular
Skin : Sawo Matang, within normal limit

SPESIFIC EXAMINATION

Head :
shape: normocephali, symmetric, large fontanel concave (+)
hair: black, straight, strong
Eye: conj.anemis(-/-), sklera ikterik (-/-), concave (+/+), pupil is round
isokor 3mm, light reflex (+/+)

Nose: discharge (-), nasal flaring (-).

Ears: discharge (-).


Mouth: The oral mucosa and lips dry (+), cyanosis (-).
Throat: The pharynx hyperemia (-)

Neck
: enlarged lymph nodes(-).
Thoraks: Cor:

Inspection : ictus cordis isnt visible


Palpation : ictus cordis isnt palpable
Percussion : upper margin in intercostalis II,

right margin in linea sternalis dextra,


left margin in linea midclavicularis sinistra
intercostalis V,
Auscultation
: Heart sound I dan II normal, HR: 118x/ minute,

Pulmo:

Inspection:
Static : symmetrical, thorax in normal shape
dynamic
: symmetrical (right=left)
Palpation
: left and righ stem fremitus normal
Percussion : sonor in both lungs
Auscultation
: vesikuler (+) normal in both lungs, paru, rhonki (-),

wheezing (-)
Abdomen:
Inspection : flat
Palpation
: flexible, pain (-), hepar adnd lien is not palpable, turgor >
2 detik, tenderness (+)
Percussion : tymphani
Auscultation
: bowel movement (+) incrase, 10 x /m
Extremity
: cold acral (-), cyanosis(-), edema (-)

NEUROLOGICAL STATUS
examination

Tungkai

Tungkai Kiri Lengan

Kanan

Lengan

Kanan

Kiri

motion
strenght
Tonus
clonus

Large
+5
Eutoni
-

Large
+5
Eutoni
-

Large
+5
Eutoni

large
+5
Eutoni

Physiological

+ normal

+ normal

+ normal

+ normal

reflex
Pathological
reflex
Meningeal sign
Sensoric Function
Nervi craniales

:: within normal limit


: within normal limit

Laboratorium Finding
Laboratorium
Hemoglobin : 11,6 mg/dL
Eritrosit : 4,63 x 106/mm3
Leukosit : 11.700 mm3
Hematokrit : 34 %
Trombosit : 412 x 103/L
Differential Count
Basofil
Eosinofil

: 0%
:1 %
Netrofil : 56 %
Limfosit
: 36 %
Monosit
: 7%

Problem List
Acute diarrhea
Stool mixes with mucus ad blood
Mild-moderate dehidration
Failed oral rehydration efforts
Differential Diagnosis
Acute diarrhea e.c susp. Shigellosis with mild-moderate
dehydration + Failed Oral Rehydration efforts
Acute diarrhea ec amoeba infection with mild- mildmoderate dehydration + Failed Oral Rehydration efforts
Working Diagnosis
Acute diarrhea e.c susp. Shigellosis with mild-moderate
dehydration + Failed Oral Rehydration efforts

Supporting Examination
Laboratorium Examination
routine urinalysis and feces, feces culture
Therapy ( SUPORTIF SIMPTOMATIS-CAUSATIF)
NON Pharmacology
Bed rest
Diet BB TKTP
Education
Pharmacology
IVFD Ringer lactate 75 ml / KgBW / 4jam 525 ml /

4 hours (130 ml / hour) GTT 32 x /m macro


oralit 70-140 ml, each Liquid defecation or vomiting
(p.o)
1x 20 mg zinc for 10 days
Paracetamol syr 3 x 80 ml
nalidixat acid 4 x 100 mg (po) for 10 days

PROGNOSIS
a. Quo ad vitam
: Dubia ad Bonam
b.Quo ad functionam : Dubia ad Bonam
c. Quo ad sanationam
: Dubia ad Bonam

Follow up
Date

Explanation

23/052015

S: Complaints: liquid stool (+) 2x, blood (-), mucus (-)


O: Sense: CM
N: 110x / min RR: 26x / min T: 37,1oC
Skin: normal turgor
Head: large fontanel concave (-), sunken eyes (-), the tears
+ / +, dry mouth mucosa (-)
Thorax: symmetrical, retraction (-)
Pulmo: vesicular (+) normal, ronkhi (-), wheezing (-)
cor : HR = 124x / min, BJ I and II normal, murmur (-), gallops
(-)
Abdomen: convex, flexible, BU (+) increased, liver / spleen
not palpable
Extremities: no cold akral
A: Acute diarrhea e.c susp. Shigellosis with mild-moderate
dehydration (repair)
P: - IVFD KAEN 3A GTT 10 x / m macro
- Zinc 20 mg 1x1 tab
- oralit 80 ml eachdefecation is Liquid or vomiting
- Paracetamol syr 3 x 80 ml (if T: 38.5 0C)
- Nalidixat acid 4 x 100 mg (p.o)