Case Report

NON DYSENTRIFORM ACUTE

GASTROENTERITIS (A09) + MILDMODERATE DEHYDRATION (E86)
AUTHOR :
NIM
:
LECTURE :
DATE / DAY

Joko Herdiyanto
I11109030
DR. HILMI KURNIAWAN RISKAWA, Sp.A, M.Kes
: rd 3 februari 2016 / wednesday

Identitiy

A, boys, 1 years 10 month, was care in

Dahlia Room, no medic : 090434, Kartika
Husada Hospital, for 5 days, from date 3 th
2016 to january 7th 2016

Chief Complain

Defecate a watery stool

1 day before
hospitalized

1 day before
hospitalized

Patient come defecate a watery stool within more

than 10x/days, a yellowish color and sometime
black, feces presence of mucus, dregs ,not blood
and fever. patient nausea and vomited 2 time,
vomiting of food and water. Patient looks thirsty and
still want to drink water, but dont want to eat,.
Urinate as usual normal. Defecation in patients also
no symptoms of cough, colds, convulsions and loss
of consciousness.
father patients were then given paracetamol syrup
medications, fever had decreased, but defecate the
patients condition does not improved.

Previous patient had suffered from the

same complaints and improved without a
given treatment or treated in a hospital.
have no history of seizure, alergy , thypoid
fever, asthma.
No family members with a similar
complaints.
Patient vaksin Only get Bacille Calmette
Guerin (BCG ) vaccination .
Patient Only get 8 month of ASI and next
patient drink milk formula .
Parents patient lower-class economy
History of growth and development is
appropriate with any normal children

Physical Examination

General appearance
: moderate sick, fussy
Awareness
: Compos mentis
Antropometry, WCGS, 2007
Weight
: 10 kg
length
: 83 cm
weight/age
: 0 SD s.d -1 SD
height/ age
: 0 SD s.d -1 SD
Weight/height
: -1 SD
Nutrition state

: normal

Vital Sign

Heart rate : 110 x/s, reguler, strong in palpable

Resp. Rate : 30x/s, reguler in rythm,
thoracoabdominal type
Temperature : 37,6o C

Generalist Status

Head : normochepal

Eye
: Conjungtiva anemic (-/-), sclera icteric (-/-),
sunken eye (+/+), tears (+/+)

Ear

: secret (-),

Nose

: secret (-)

Mouth : wet lips and mucosa (+),

Neck

: enlargement of lymph nodes (-).

Generalist Status

Lung
: vesicular (+/+), wheezing (-/-), rhonki (-/-)
Heart
: S1, S2, reguler, murmur (-), gallop (-)
Abdomen
Inspection
: dome-shaped, mass (-)
Auskultation
: bowel sound (+) increased
Palpasi
: hepar and lymph are not palpable
Perkusi
: tympani in all filed
Anus & Genitalia : no abnormality
Extremity : warm akral, Capillary Refill Time (CRT) <2,
cyanosis (-)
Skin : Colour of skin is brown, icteric (-), petechie (-), rash (-),
turgor returned slowly (+)

Blood Test ( 3 january 2016)

Normal
WBC

12.000 / mm3

4.000-12.000 /mm3

RBC

5,06 juta

3,50 5,50 juta

Hemoglobin

12,2 g/dl

11,5-14,5 g/dl

HCT

34.4 %

35-55%

PLT

160.000/mm3

150.000-400.000
/mm3

Differential Diagnose
Non dysentriform Acute gastroenteritis + mildmoderate dehydration
Dysentriform Acute gastroenteritis + mildmoderate dehydration
Cholera + mild-moderate dehydration

Working Diagnose
Non

dysentriform acute gastroenteritis +

mild-moderate dehydration

Treatment

IVFD Ringer laktat 60 (tpm) micro

injection Paracetamol 3 x 100 mg
injection Cefotaxime 3x500 mg
Injeksi Ondansetron 3 x 1 mg
Injeksi Ranitidine 2 x 10 mg
Zinc kid sirup 1 x 1 cth per oral
Probiotik1x1 sachet per oral

FOLLOW UP
S
U
B
J
E
C
T
I
V
E

4/01/16

7/01/16

Defecate a watery stool 9x (+),

mucus(+),blood
(-),
dregs
(+),Nause (-) Vomiting water
and food (+) 3x time , fever (+)
at night , drink (+), eat
decreased (+), Urinate(+) good.

Defecate a watery stool 2x (+),

dregs (+), mucus (-), blood (-), Nause
(-), Vomiting (-), fever (-) , drink (+),
Urinate(+) good, eat usual

O
B
J
E
C
T
I
V
E

4/01/16

7/01/16

General appearance :
moderate sick,
RR 30 x/m, HR 110 X/menit, T: 38
C, sunken eyes +/+, tears +/+,
wet lips (+), turgor returned fast,
abdomen supel, tympanic, bowel
sound increased

General appearance : good, RR

24 x/m, HR 100 X/menit, T: 36,8
C, sunken eyes -/- , tears +/+,
wet lips (+), turgor returned
fast, abdomen supel, tympanic,
bowel sound normal.

Discussion

Problem of case
Diagnose

Gastroentiritis
The main symptoms are
diarrhea, vomiting,
nausea and fever and
acute abdominal pain.
Gastroentiritis or
Acute diarrhea:
defecate more than 3
times in 24 hours,
watery stool, less than 1
week
Dehydration sign:
-fussy
- sunken eye,
- thirsty,
- turgour returned
slowly,
- Wet lips and mucous,
- tears (+)

Discussion

Diagnose

In this patient:
Gastroentiritis +
dehydration
- defecate watery stool
more than 10 times,
- look fussy
- sunken eyes,
- thirsty,
- wet lips and mucous, and
- turgour returned slowly

Type of Diarrhea
Disentrifrom Diarrhea watery stool with
mucus and blood, fever, tenesmus ani, pain in
abdomen, prolapsus ani
Non- Disentrifrom Diarrhea Kids under 2
years old, watery stool, high fever, vomiting,
accompanied by cough and cold
Cholera diarrhea that is watery and
abundant, without preceded by heartburn and
without tenesmus, abdominal cramps. Diarrhea
has changed (rice water stool).
In Patient watery stool with mucus, and not
blood, vomiting.

Stage Of Dehydration

Dehydration
state
can
be
determine
objectively by compare the body weight
before and after diarrhae. Subjectively can be
use WHO criteria.
In this patient, defisit of body weight about
6%, and according to the criteria of WHO can
be classified as mild-moderate dehydration,

TREATMENT
Medication

Function

IVFD RL 60 tpm micro

Rehydration

Cefotaxime 3x500 mg
iv

To treat E. Coli, Preventing nosocomial infection

PCT inf 3x100 mg iv

Antipyretic

Ondansentron 3x1 mg
iv

Antiemetic

Ranitidin 2x10 mg iv

Inhibit gastric secretion

Probiotic 1x1 sach

Inhibit the growth of bacterial pathogens

Zync kids syrup 1x1

cth po

Reduce the duration and severity of diarrhea, increase

appetite

Complication

Complication of diarrhea :

Dehydration
Electrolit imbalance
Death

Adequate treatment can prevent the

complication

Prognose

Recurrence rates depending on the level of

hygiene of patients where the parental role in
overseeing and hygiene of food children are
very influential. At this child in vitam
prognosis and fungsionam is ad bonam, while
sanationam ad malam

Thank You