Case Report 2nd

Diare akut
OLEH:
dr. Erina Puspitasari Priyatna

PENDAMPING:
d r. M D i a n a R a h i m
Patient Identity
Name : Mrs.A
Age : 48 years old
Gender : Female
No. RM : 163579
Admission Date : March, 02nd 2021
Address : KP.Gunung Limbung Kab.Garut
Course of disease

28/02/2021 02/03/2021
Watery stool, Referred to :
epigatric pain with
heartburn, nausea Emergency Department
and vomit Unit Guntur Hospital with
CC: Waterry stool
10x/day,epigastric
pain,nausea,vomit,fatigue
(+)
History Taking
Chief complain : watery stool
The patient came to the emergency unit at Guntur Hospital with complaint
of watery stool since 3 days before admission. Watery stool occurs
10x/days with consistency watery, bloody (-) mucus in feces (-). The patient
also feels weakness.Nausea (+), epigastric pain (+), Vomiting (+),
heartburn (-).
Symptoms of cough, runny nose, shortness of breath, history of going out of
town and contact history with confirmed covid were denied by the patient.
 Course of disease
EMERGENCY DEPARTMENT
UNIT

O : BP:110/80mmHg, N: 98x/m, RR: 20x/m, T:36 • Advice dr Feri SpPD

Abdomen : tenderness (+), epigastruim pain (+),skin turgor normal IVFD RL 20 dpm
A : acute diarhea Ondansentron 2x4mg IV
P: omeprazole 1x40mg IV
IVFD RL 30 dpm L-Bio 2x1caps PO
Omeprazole 1x40mg IV Nucral 3x1 cth PO
Ondansentron 2x4mg IV New diatab 2 tab prn max
Lodia 3x1 PO 12tab/days
Clinical pathway
Laboratory examination
Hemoglobin 11.9 gr/dl
Leukosite 12.400 /m3
Trombosite 289.000/ mm3
Hematocrit 33.9 %
erythrosite 4.08 million/mm3
NLR 5,64 (<3,12)
Diff count 0/2/3/79/14/2
IgM /IgG covid-19 Non-reaktif

SWAB PCR (1) NEGATIF

DIAGNOSIS
Acute diarrhea with mild dehidration
Follow Up
March, 3th 2021 March, 4th 2021
No Data
S: watery stool (-) epigastric pain (-)
O: BP: 120/80 mmHg, PR: 98 bpm,
RR: 20 bpm, S: 36 OC, SpO2
98%free air, epigastric tenderness (-)
A: acute diarrhea
P: BLPL
PATOGENESIS
Faktor Infeksi Faktor Malabsorpsi Faktor makanan Faktor psikososial
karbohidrat, protein
dan lemak

Masuk dan Peningkatan Toksin dari Anxiety

tumbuh di tekanan osmotik makanan tidak
usus halus dapat diserap oleh
tubuh

Hipersekresi air Perpindahan cairan Hiperperistaltik

dan elektrolit dan elektrolit ke ↓kesempatan usus halus untuk
rongga usus menyerap makanan

DIARE