Acute Diarrhea e.c Susp.

vyrus With Mild-Moderate

Dehydration
Suci Fahlevi Masri, S.Ked
Inne Fia Mariety, S.Ked
Supervisor:
dr. Achirul Bakri, Sp.A (K)
DEPARTMENT OF PEDIATRIC
RUMAH SAKIT DR. MUHAMMAD HOESIN
PALEMBANG
MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY

INTRODUCTION

Diarrhea is still a major problem in children,

especially children under five years in
developing countries due to morbidity and
death is still high.
The cause of diarrhea is a multifactorial,
mostly caused by the infection. Damage to
the intestinal mucosa with mild or severe, it
takes time to return to normal.
The main treatment for diarrhea is to
overcome dehydration. Rehydration therapy
is effective for reducing the number of
deaths from acute watery diarrhea diare

CASE
REPORT

IDENTIFICATION
NAME

: AN. HRP

AGE/BIRTH OF DATE : 1 YEARS OLD 1 MONTH,

MARCH 18
2015
SEX : MALE
FATHER NAME

: MR. D

MOTHER NAME : MRS. R

NATIONALITY/TRIBE

: SUMATERA

ADRESS : JL. MAY ZEN, LR. AMPERA I RT.21

RW.04, KALIDONI,PALEMBANG
HOSPITALIZED

: MAY 09 2016

ANAMNESIS

DATE

: MAY 10 2016

GIVEN BY

: PATIENTS MOTHER (ALLOANAMNESIS)

CHIEF COMPLAIN

: LIQUID STOOLS

SECONDARY COMPLAIN: VOMITING

HISTORY OF ILLNESS:

3 DAYS BEFORE HOSPITALIZED, PATIENT HAS

DEFECATE A LIQUID STOOL FREQUENCY >8
TIMES/DAY,
VOLUME CUP, LIQUID = PULP,
BLOOD (-), MUCUS (-), NAUSEA (-) AND VOMITING (-),
THERE ARE SUDDEN HIGH FEVER, COUGH (-), RUNNY
NOSE (-), SEIZURES (-), 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.


1
DAYS
BEFORE
HOSPITALIZED,
PATIENTSS
DEFECATION IS LIQUID STOOL THE FREQUENCY >10
TIMES/DAY, VOLUME CUP, LIQUID = PULP, BLOOD (-),
MUCUS (-), AND VOMITING (+), FREQUENCY >8
TIMES/DAY, THE CONTENTS OF WHAT TO EAT, VOMITING
NOT PROJECTILE, VOLUME CUP, PATIENT LOOKED
FUSSY AND NOT WANT TO EAT AND DRINK, THE TEARS
(+), THERE ARE SUDDEN HIGH FEVER, COUGH (-),
RUNNY NOSE (-), SEIZURES (-), SHORTNESS OF BREATH
(-). URINATING WITHIN LIMIT, PATIENT WAS BROUGHT TO
THE GP CLINIC AND THEN REFERRED TO RSMH.

MEDICAL HISTORY BEFORE

HOSPITALIZED
HISTORY OF
PREGNANCY AND BIRTH

HISTORY OF FOOD
BREASTFEEDING: UNTIL NOW

PREGNANCY : FULL TERM

FORMULA MILK : 7 MONTHS

PARTUS

MILK PORRIDGE : 6-8 MONTHS

RICE
: 12 MONTHS
UNTIL NOW

: SPONTAN

PLACE: CLINIC
HELPED BY

: MIDWIFE

DATE : MARCH 18 2015

BIRTH WEIGHT

: 3,3 KG

BIRTH LENGTH

: 48 CM

DEVELOPMENT

IMMUNIZATION

HISTORY

HISTORY

PRONE

: 3 MONTHS

SEATED
MONTHS

:6

BCG
(ON
ARM)

: 1 TIME, SCAR +
THE RIGHT

STANDING

: 11 MONTHS

DPT

: 3 TIMES

WALK

: 12 MONTHS

POLIO

: 3 TIMES

HEPATITIS B

: 3 TIMES

MEASLES

: 1 TIMES

IMPRESSION: MOTOR
DEVELOPMENT WITHIN
NORMAL LIMITS

IMPRESSION: COMPLETE
BASIC IMMUNIZATION
ACCORDING TO AGE

PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINATION
GENERAL CONDITION : LOOKED MODERATE SICK
SENSORIUM

: COMPOS MENTIS

HEAD CIRCUMFERENCE
TEMPERATURE

: 47 CM (NORMOSEFALI)

: 37 OC

RESPIRATION : 28 X/MINUTE (THORAKOABDOMINAL)

PULSE RATE
SKIN

: 100 X/ MINUTE (CONTAIN/QUALITY NORMAL, REGULAR)

: SAWO MATANG, WITHIN NORMAL LIMIT

WEIGHT

: 8,2 KG

HEIGHT

: 75 CM

NUTRITIONAL STATUS
BB/U

: - 2 SD

TB/U

: 0 SD (-2 SD)

BB/TB : - 1 SD (-2SD)

good
nutrition

SPESIFIC EXAMINATION

15

NEUROLOGICAL STATUS
Pemeriksaan

Tungkai

Tungkai Kiri

Lengan

Kanan

Lengan Kiri

Kanan

Gerakan

Luas

Luas

Luas

Luas

Kekuatan

+5

+5

+5

+5

Tonus

Eutoni

Eutoni

Eutoni

Eutoni

Klonus

Reflek fisiologis

(+) normal

(+) normal

(+) normal

(+) normal

Reflek patologis

Meningeal sign

Sensoric Function

within normal limit

Nervi craniales

within normal limit

LABORATORIUM RESULT
HEMOGLOBIN
ERITROSIT

: 10,7 MG/DL

: 4,27 X 106/MM3

LEUKOCYTE : 14.700 MM3

HEMATOKRIT

: 32 %

TROMBOSIT : 391 X 103/MM3

DIFFERENTIAL COUNT
BASOFIL

:0%

EOSINOFIL

:2%

NETROFIL

: 51 %

LIMFOSIT

: 42 %

MONOSIT

:5%

THERAPY
NON PHARMACOLOGY

BED REST
DIET BB TKTP
EDUCATION

PHARMACOLOGY
IVFD RINGER LACTATE
75 ML / KGBW / 4JAM
615 ML / 4 HOURS GTT
39 X /M MACRO
ORALIT 80-160 ML, EACH
LIQUID DEFECATION OR
VOMITING (P.O)
1X 20 MG ZINC FOR 10
DAYS
PARACETAMOL SYR 3 X
80 ML IF T>38,5 0C

FOLLOW UP
DATE
11-05-2016

S: Keluhan : BAB cair (-), Muntah (-)

O: Sense: CM
N: 110x/menit RR : 26x/menit T : 36,8oC
Kulit
: turgor normal
Kepala : UUB cekung (-), mata cekung (-),
air mata +/+, mukosa bibir kering (-)
Thoraks : simetris, retraksi (-)
Pulmo : vesikuler (+) N, ronkhi (-), wheezing (-)
Cor
: HR= 110x/menit, BJ I dan II normal,
murmur (-), gallop (-)
Abdomen : cembung, lemas, BU (+) normal,
hepar/lien tidak teraba, cubitan
kulit
perut kembali cepat
Ekstremitas
: akral dingin tidak ada
A:Diare akut e.c susp. virus dengan dehidrasi
ringan-sedang telah terehidrasi (perbaikan)

DATE

11-05-2016

P: - IVFD KAEN 3A gtt 8 x/m makro

- zinc 20 mg 1x1 tab
- oralit 100 ml tiap BAB Cair atau muntah
- Paracetamol syr 3 x 80 ml (jika T: 38,5 0C)
Gizi: BBI: 10 Kg
Diet BB TKTP
Kebutuhan nutrisi; E= 1000 kalori, P= 20 gr,
K=22,2 gr, L162,5 gr. Diet diberi dalam bentuk
lunak mudah dicerna.
Asupan diberi porsi kecil tapi sering
Asupan sekarang: BB dimakan 5 sdm, susu
diminum 10 cc pada pagi hari

DATE

12-05-2016

S: Keluhan : BAB cair (-), Muntah (-)

O: Sense: CM
N: 118x/menit RR : 28x/menit T : 36,8oC
Kulit
: turgor normal
Kepala : UUB cekung (-), mata cekung (-),
air mata +/+, mukosa bibir kering (-)
Thoraks : simetris, retraksi (-)
Pulmo : vesikuler (+) N, ronkhi (-), wheezing
(-)
Cor
: HR= 118x/menit, BJ I dan II normal,
murmur (-), gallop (-)
Abdomen : cembung, lemas, BU (+) normal,
hepar/lien tidak teraba, cubitan
kulit
perut kembali cepat
Ekstremitas
: akral dingin tidak ada
A: Diare akut e.c susp. virus dengan dehidrasi
ringan - sedang telah terehidrasi (perbaikan)

DATE

24-05-2015

P: - zinc 20 mg 1x1 tab

- Paracetamol syr 3 x 80 ml (jika Temp:
>38,50C)
- oralit 100 ml tiap BAB Cair atau muntah
- Rencana pulang
Gizi : BBI: 10 Kg
Diet BB TKTP
Kebutuhan nutrisi; E= 1000 kalori, P= 20
gr,
K=22,2 gr, L162,5 gr. Diet diberi dalam
bentuk
lunak mudah dicerna
Asupan diberi porsi kecil tapi sering .
Asupan sekarang: BB dimakan 5 sdm,
susu
diminum 10 cc pada pagi hari

LITERATURE
REVIEW

DEFINITION
DIARRHEA
Diarrhea is defined as an increase the
Fluidity Volume Number relative to the
usual habits of each. Passage of 3 or
more loose/ watery stools in a 24 hrs
period. Consistency and character of
stool and its water content rather than
the number of stools

ETIOLOGY OF
DIARRHEA

Rotavirus
(15-25%)

Cryptosporidium

Shigella
5-15%

Enterotoxigenic Campylobacter
E. Coli 10-20%
jejuni
10-15%

food

PATHOGENESIS OF
DIARRHEA

Secretory
diarrhea

Osmotic
diarrhea

Motility-related
Diarrhea

oMaldigestion
o Osmotic laxatives
o Lactose intolerance
o Fructose malabsorption

Inflammatory
diarrhea

water is drawn
into the bowels

OSMOTIC DIARRHEA
DUE TO PRESENCE OF NON-ABSORBABLE
SOLUTES IN THE GIT
CLASSIC EXAMPLE: LACTOSE INTOLERANCE
WHICH IS CAUSED BY LACTASE DEFICIENCY
LACTOSE IN COLON
COLON BACTERIA LACTIC ACIDS &
SHORT-CHAIN ORGANIC ACIDS OSMOTIC
LOAD
WATER SECRETED INTO THE
LUMEN

MECHANISMS OF SECRETORY
DIARRHEA

ACUTE DIARRHEA

SYMPTOMS OF DIARRHEA
HIGH FEVER
FUSSY
AMOUNT AND FREQUENCY OF
EAT AND DRINK WAS
DIMINISHING
PATIENT HAS DEFECATE A
LIQUID STOOL, FLUIDITY
VOLUME NUMBER RELATIVE
TO THE USUAL HABITS OF
EACH

DEHYDRATION SYMPTOMS

Symptoms Depends on the Organism

Organism

Inkubasi

Duration Vomiting

Fever

Abdominal
Pain

Rotavirus

1-7 day

4-8 day

Yes

Low

No

Enterohemorrhagic

1-8 day

3-6 day

No

+/-

Yes

1-3 day

3-5 day

Yes

Low

Yes

Salmonella species

0-3 day

2-7 day

Yes

Yes

Yes

Shigella species

0-2 day

2-5 day

No

High

Yes

Vibrio species

0-1 day

5-7 day

Yes

No

Yes

Cryptosporidium

5-21 day

Months

No

Low

Yes

5-7 day

1-2+ mg

No

Yes

No

E coli
Enterotoxigenic
E.Coli

species
Entamoeba species

COMPLICATION OF
DIARRHEA

MANAGEMENT OF
DIARRHEA

PROBLEM
ANALYSIS

PROBLEM ANALYSIS

Defecation is liquid
Vomiting (-)
frequency > 8 times/day
Nausea (-)
volume cup
High Fever
(+)
liquid = pulp
Runny
Nose (-)
blood (-)
Cough (-)
mucus (-)
3 days before hospitalized
Seizure (-)
Shortness of breath (-)
still want to drink and eat,

patient was taken to

the midwife and then
given zinc and
paracetamol but no
improvement

39

Defecation is liquid
frequency > 10 times/day
Nausea (-)
volume cup
Fever (+) Not High
liquid = pulp
Runny Nose
(-)
Vomiting > 8 times/ day Cough (-)
Volume cup
Shortness of
breath (-)
the contents of what to eat Seizure (-)
Urinating
1 daylimit
before hospitalized
within
Tears (+)

patient was brought to

the GP clinic then
referred to RSMH
40

ALLOANAMNES
IS
defecation without mucus
and blood from three days
ago.
Patient was taken to the
midwife and then given
paracetamol and zinc but no
improvement
diarrhea may
occur due to the
infection

1day before hospitalized

obtained patient defecation is
liquid stool, frequency > 10
times, volume cup.
Vomiting, frequency > 8
times, volume cup, fever is
not too high.

found less than 14

days

Acute Diarrhea
(defecation with liquid or mushy stool
with / without mucus or blood, with a
frequency of 3 times or more a day,
lasts not more than 14 days, less than
4 episodes / month)

PHYSICAL
EXAMINATION

fussy patients condition

sunken eyes
tears (+)
large fontanel is concave
skin turgor back in > 2 seconds
dry mouth mucosa
still want to drink.
signs of circulatory disorders such
as
pulse and rapid breathing, cold
akral
extremities and lethargy was not
found.
Nutritional Status
BB/U : - 2 SD
TB/U : 0 SD (-2 SD)
BB/TB
: - 1 SD (2SD)

Mild to
moderate
dehydration

good nutrition

LABORATORIUM
RESULT

DD
acute diarrhea e.c
susp. bacterial
infection with mild
dehydration +
Failed Oral
Rehydration
efforts