ACUTE DIARRHEA

DYSENTERIC WITH
MILD-MODERATE
DEHYDRATION
By:
Salwa Nurfathirahma, MD
Supervisor:
M. Diana Rahim, MD

INDONESIAN DOCTOR INTERNSHIP PROGRAM

GUNTUR HOSPITAL GARUT
NOVEMBER 2021
 PATIENT IDENTITY

An. K/1 y.o./173608

Nov 18 21/11.39
GP : Martinus Toro, MD
 HISTORY TAKING
Baby girl brought to the emergency room by her parents due to watery stool
more than 5 times/day since 1 day ago. The watery stool is accompanied with
mucus, presence of blood was denied by her parents. The complaints is also
accompanied with fever since 3 days ago, loss of appetite, and fatigue.
Complaints of nausea, vomitting, cough, runny nose, and dyspnea were denied
by her patient. The patient has been treated with antipiretic.
 PHYSICAL EXAMINATION
General Condition : moderately illness
Awareness : conscious
GCS : 15
Pulse Rate : 96 x/minute
Respiratory Rate : 20 x/minute
Temperature : 36,5 C
Oxygen Saturation : 95% free air
Body weight : 7,9 kg
 PHYSICAL EXAMINATION

Head

Eyes : anemic conjungtiva -/-, icteric sclera -/-, sunken eyes +/+

Nose : nostring breathing (-)

Mouth : cyanosis (-), dry mouth (+)

Neck : lymph node enlargment (-)

Thorax : symmetrical chest movements

Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : vesicular breath sounds , crackles -/-, wheezing -/-
 PHYSICAL EXAMINATION

Abdomen : flat, soepel, bowel sound (+) increase, tenderness (-), quick return
turgor
Liver : within normal limits
Spleen : within normal limits

Extremities :
warm, CRT <2 seconds, Edema (-)
 SUPPORTING EXAMINATION

The Result of Laboratory Examination (Nov 18 21)

 Blood routine
- Hb : 13 gr/dL
- Leukocyte : 6.500/mm3
- Trombocyte : 200.000/mm3
- Ht : 55
- Erythrocyte : 5,12 millions/mm3
 Immunology
Rapid antigen Covid-19 : Negative
 DIAGNOSE

Acute diarrhea dysenteric with mild-moderate dehydration.

MANAGEMENT
 IVFD RL 20 dpm Advice dr.Manan, Sp.A
 Inj. Cefotaxime 2x400 mg IV (ST)  Acc non-isolation ward
 PO L-Bio 2x1
 PO L-Zinc 1x1 cth
 PO sanmol drop 3x0,8 cc
 FOLLOW UP
Friday Saturday
Nov 19 Nov 20

Watery stool 3 times, mucus (-), blood

Subjective Watery stool (-), fever (-), fatigue (-)
(-), fever (-), fatigue (-)

RR : 22 x/m RR : 20 x/m
N : 89 x/m N : 96 x/m
T : 36,0 C T : 36,6 C
Objective Sp02 : 95% free air Sp02 : 96% free air
Sunken eyes -/- Sunken eyes -/-
Dry mouth (-) Dry mouth (-)
Bowel sound (+) increase Bowel sound (+) normal

Acute diarrhea nondysenteric without dehydration.

 IVFD RL 20 dpm
 Inj. Cefotaxime 2x400 mg IV
 Inj. Mikasin 2x60 mg IV
Diagnose and
Planning  PO L-Bio 2x1
 PO L-Zinc 1x1 cth
 PO sanmol drop 3x0,8 cc
 PO Nifural 3x1 cth
 Advice dr.Manan, Sp.A (Nov 21 2021)
 Patient can go home
PATHOPHYSIO
LOGY