ACUTE DIARRHEA IN A 2-MONTH-OLD BABY

ACUTE DIARRHEA
PRECEPTOR :
dr. Ulynar Marpaung, Sp.A
BY :
Vilona Afrita Zilmi (1102012302)
Clerkship of Pediatrics Department
Faculty of Medicine YARSI University
Police Hospital, Bhayangkara Tk.I Raden Said Sukanto
Name
Birth Date
: Child A.A
: March 16th, 2016
IDENTITY
Age : 2 months
Gender : Male
Religion : Islam
MR No. : 8143**
Date of admission : May 05th, 2016
Date of examination : May 05th, 2016
Father Mother
Name Mr. M Mrs. M
Age 40 years old 38 years old
Job Private employees Housewife
Nationality Indonesian Indonesian
Religion Islam Islam
Education High school Junior High school
Address Suralaya street No.122 RT.004/04, Cilangkap. East Jakarta
ANAMNESIS
The anamnesis was taken on May 05th 2016 using alloanamnesis
method. It was taken at room No. 5 Anggrek 2 Ward, RS
Bhayangkara tk.I R. Said Sukanto, Jakarta.
Main complaint : Fever since 6 days prior to admission to hospital.
Additional complaint : Watery stools ≥ 10x/day since 3 days before

admission to hospital, spray, dregs (-), foam (+), bad odor, blood (-), the
color is yellow. Vomiting after drinking, frequency ≥5x/day, nausea
(+),cold(+)
• A 2 months old boy
with body weight
5,5 kg came to RS • diarrhea since 3 days
Bhayangkara tk.I R. ago. frequency ≥
Said Sukanto 10x/days, consistency
Emergency Room at • Since 6 days ago, the liquid, no dregs, foam
May, 05th 2016 on 2 patient has gotten positive, no blood,
am with a main fever. The fever high bad odor, the color is
complaint of fever constantly and wasn’t yellow.
since 6 days ago. measured. His • vomiting, frequency
mother gave sanmol ≥5x every after
syrup to decrease the drinking, yellow
temperature but it liquid, and spray,
did not go down well. • nausea, and cold.
HISTORY OF ILLNESS
History of Past Illness
Pharyngitis/Tonsilitis -
Bronchitis -
Pneumonia -
Morbilli -
Varicella -
Diphteria -
Malaria -
Polio -
Enteritis -
Bacillary Dysentry -
Amoeba Dysentry -
Diarrhea -
Thypoid -
Worms -
Surgery -
Brain Concussion -
Fracture -
Drug Reaction -
Febril seizure -
ALLERGIC HISTORY
• The patient didn’t

have allergy to CHILD’S BIRTH HISTORY
medicine
• The patient didn’t
have allergy to food • Labor : Hospital
• The patient didn’t • Birth attendants : Doctor
have allergy to • Mode of delivery : SC
weather and pollen • Gestation :36 weeks
• Infant state :Healthy
• Birth weight : 3500
grams
• Body length : 51 cm
DEVELOPMENT
HISTORY
Raised hand
Smile 1months
2 months
Conclution : growth and developmental is still

in the normal limits and was appropriate
according to the patient’s age
Child’s Eating History
• Breast milk : Exclusive until now

IMMUNIZATION HISTORY
Immunization Frequency Time
BCG - -
Hepatitis B 1 time 0 month
DPT - -
Polio - -
Campak - -
FAMILY HISTORY
There are not any

Patient’s father is significant illnesses or
healthy chronic illnesses in the
Patient’s mother is
family declared
healthy
PHYSICAL EXAMINATION
- General condition : Mildly ill

- Consciousness : Compos Mentis
- Pulse : 101 x/min, regular, strong
- Breathing rate : 35 x/min
- Temperature : 38,72°C per axilla
ANTHOPOMETRY STATUS
Weight : 5,5 kg
Height : 60 cm
WFA (Weight for Age) : 5,5/5,2 x 100 % =

105 % (good nutrition)
HFA (Height for Age) : 60/58 x 100 % =
103 % (good noutrition)
WFH (Weight for Height) : 5,5/5,4 x
100 % = 101 % (good noutrition)
Conclution : The patient has good
noutritional status.
Head to Toe Examination
Head
Normocephal, hair (black, normal distribution, not easily removed), sign of
trauma (-), large fontanelle closed, fontanel concave (+)
Eyes
Icteric sclera -/-, pale conjungtiva -/-, hyperaemia conjungtiva -/-, Tears +/+
sunken eyes +/+, pupils 3mm/3mm isokor, direct and indirect light response
++/++.
Ears
Normal shape, no wound, no bleeding, secretion or serumen.
Nose
Normal shape, midline septum, secretion +/+.
Mouth
Lips : dry
Teeth : no caries
Mucous : dry
Tongue : clean
Tonsils : T1/T1, no hyperemia
Pharinx : no hyperemia
Neck
Lymph node enlargement (-), scrofuloderma (-).
Thorax
Inspection : Symmetric when breathing, retraction (-), ictus cordis is not visible,
rash (+)
Palpation : Fremitus tactile +/+ symmetric, mass (-)
Percussion : Sonor on both lungs
Auscultation : Cor : S1-S2 regular, murmur (-), gallop (-)
Pulmo : vesicular +/+, ronchy -/-, wheezing -/-
Abdomen
Inspection : Convex, epigastric retraction (-), spider nevi (-), rash (-)
Palpation : Supple, abdominal mass (-), liver and spleen not palpable, fluid wave
(-)
Percussion : tympanic abdomen on the entire field, shifting dullness (-), bloated
(+), Auscultation : bowel sound increase, bruit (-)
Vertebra
There weren’t appear scoliosis, kyphosis, lordosis, and any massa long the vertebral
line.
Ekstremities
Warm, capillary refill time <2 second, edema (-)
Skin
Turgor slowly, rash (-), dry skin (+)
Genitalia
Anus Hyperemis (+)
MOTORIC EXAMINATION
Power
- Hand 5555/5555
NEUROGICAL EXAMINATION - Feet
Tonus
5555/5555
- Hand Normotonus / Normotonus

- Feet Normotonus / Normotonus
Trophy
Meningeal Sign -
-
Hand
Feet
Normotrophy / Normotrophy
Normotrophy / Normotrophy
Nuchal rigidity (-) Physiologic Reflex
Upper extremities
Kernig sign (-) -

-
Biceps
Triceps
+/+
+/+
Lasegue sign (-) -

Lower extremities
Patella +/+
- Achilles +/+
Brudzinski I (-) Pathologic Reflex
Upper extremities
Brudzinski II (-) - Hoffman -/-
- Trommer -/-
Lower extremities
- Babinsky -/-
- Chaddock -/-
- Oppenheim -/-
- Gordon -/-
- Schaeffer -/-
Clonus
AUTONOM EXAMINATION
Defecation Diarrhea (frequency 10 times daily)

Urination Normal (4-5 times daily)
Sweating Normal
LABORATORY INVESTIGATION
Hematology (May, 05th, 2016)

Hematology Results Normal Value
Hemoglobin 11,9 13 – 16 g/dl
Leukocytes 18.600 5.000 – 10.000 u/l
Hematocrits 34 40 – 48 %
Thrombocytes 605.000 150.000 – 400.000

/ul
Complete feces (May, 05th 2016) Complete urin (May, 05th, 2016)
Results Normal Value Results Normal Value

Color Yellow
Macroscopic
Purity Clear
Color Yellow Ph 5.0 5 – 8.5
Consistency Liquid Specific Weight 1.030 1.000 – 1.030
Protein - Negative
Mucous - Bilirubin - Negative
Blood - Glukosa - Negative
Microscopic Keton - Negative
Blood/ Hb - Negative
Leucocytes 0-1/LPB Nitrite - Negative
Eritrocytes 2-3/LPB Urobilinogen 0,1 0,1 – 1,0 IU
Leucocytes - Negative
Worm eggs
Sedimen :
Ascaris Sp - *Leucocytes 1–2 0 – 5 /LPB
Anchilostoma Sp - *Erythrocytes 0–2 1 – 3 /LPB
*Epitel Cell +
Trichuris Sp - *Silinder - /LPK
Oxyuris Sp - *Crystal -
Others - Others -
WORKING DIAGNOSIS
• Acute Diarrhea with Mild-Moderate Dehydration
MANAGEMENT
• IVFD RL 600 cc/ 24 hours (32 tpm)

• Paracetamol 3x0,6cc per oral
• Inj. Cefotaxime 2x300mg
• Lacto B 1x1 sachet
• Zinkkid 1x10mg
PROGNOSIS
Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam
Follow up
May, 06th 2016, second day of hospitalization, 8th day of illness
S Fever (+)
Defecation (+) frequency 8x, consistency liquid, yellow color, bad odor, foam(+) dregs (-) no
mucous nor blood
Bloated (+)
Seizure (+), tonik klonik, duration ≤ 5 minutes, 1 times/per day
O • Compos Mentis, Midly ill
• Temperature : 39°C, Pulse : 101 x/min, Respiratory rate : 32 x/min
• Head :Normocephal, fontanel concave (+)
• Eyes : Pale conjungtiva (-), icteric sklera (-), hyperemia conjungtiva (-), sunken eyes +/+, tears
+/+
• Mouth : Dry lips, dry mucous, tonsils T1/T1,hyperemia pharinx
• Pulmonary : Vesiculer +/+, ronchi -/-, wheezing -/-
• Cardio : S1/S2 normal regular, murmur (-), gallop (-)
• Abdomen : Distention (+), bowel sound (+) increase, bloated (+)
• Skin : dry (+), Turgor Slowly (+)
• Akral : Warm
• Anus : Hyperemis (+)
Serology/Imunology (May, 06th 2016)
Kimia clinic (May,06th 2016)
Electrolite Results Normal Value Results Normal Value
Natrium 121 135-145 mmol/l Thypi O +1/80 Negative

Parathypi AO Negative Negative
Kalium 5,0 3,5-5,0 mmol/l
Parathypi BO Negative Negative
Chlorida 94 98-108 mmol/l Parathypi CO Negative Negative
Thypi H Negative Negative
Parathypi AH Negative Negative
Parathypi BH Negative Negative
Parathypi CH Negative Negative
A Acute Diarrhea with mild-moderate
dehydration and seizure dd KDS
P IVFD KAEN 3B 550 cc/24 hours
IVFD NaCl 3% 50 cc in 6 hours
Dummin sup 65mg
Stesolid sup 5mg
Paracetamol 3x0,6cc per oral
Inj. Ceftriaxone 2x300mg
Lacto B 1x1 sachet
Zinkkid 1x10mg
Follow up
May, 07th 2016, third day of hospitalization, 9th day of illness
S Fever (+)
mucous nor blood
Seizure (-)

+/+
• Akral : Warm
Hematology (May, 07th 2016)
Leukocytes 12,400 5.000 – 10.000 u/l
Thrombocytes 354.000 150.000 – 400.000
/ul
Kimia clinic (May, 07th 2016)
Electrolite Results Normal Value
Natrium 118 135-145 mmol/l
Chlorida 91 98-108 mmol/l

A Acute Diarrhea with mild-
moderate dehydration and
seizure dd KDS
P NaCl 3% 50 cc in 6 hours
Loading RL 100 cc
KaEN 3B 550cc/day
PCT drip 4 x 60mg (0,6cc)
Lacto B 1x1 sachet
Zinkkid 1x10mg
Follow up
May, 08th 2016, fourth day of hospitalization, 10th day of illness
S Fever (↑↓)
mucous nor blood
Seizure (-)

+/+
• Akral : Warm
Kimia Clinic (May, 08th 2016)

Hyponatremia
P IVFD KaEN 3B 550CC/day
IVFD NaCl 0,9% (31 tpm micro)
PCT drip 4 x 60mg
Lacto B 2x1 sachet
Zinkid 1x10mg
Follow up
May, 09th 2016, fifth day of hospitalization, 11th day of illness
S Fever (↑↓)
mucous nor blood
Seizure (-)

+/+
• Akral : Warm
Leukocytes 10,000 5.000 – 10.000 u/l
Thrombocytes 493.000 150.000 – 400.000
/ul
Count of Leukocytes type
Basofil 2 0-13 %
Eosinofil 3 1-3 %
Rod 1 2-6 %
Segmen 52 50-70%
Limfocytes 26 20-40%
Monocytes 16 2-8%
LED 10 <15mm/hour
Eritrocytes 3,09 Milyar/ul
Hyponatremia
P IVFD KaEN 3B 600cc/24 hours
IVFD NaCl 0,9% (31 tpm micro)
PCT drip 4 x 60mg
Lacto B 2x1 sachet
Zinkid 1x10mg
Follow up
May, 10th 2016, sixth day of hospitalization, 12th day of illness
S fever (-)
mucous nor blood
Seizure (+), tonik klonik, fokal, lower extremity dextra, ≤5minutes per day
O • Somnolen (E2M3V2), Moderate ill

+/+
• Akral : Warm
Analysis Blood Gas ( May, 10th 2016 at 07:04) Hematology ( May, 10th 2016 at 10:13)
Test Results Normal value Hematology Results Normal Value
pH 7,26 7,35-7,45 Hemoglobin 8,3 13 – 16 g/dl
Leukocytes 33,700 5.000 – 10.000
pCO2 43 35-45 mm Hg
u/l
pO2 207 85-95mm Hg Hematocrits 25 40 – 48 %
CO2 Saturation 99 85-95% Thrombocytes 466.000 150.000 –
HCO3 19 21-25 mmol/L 400.000 /ul
Base Excess -8 -2,5-+2,5 mmol/L Count of Leukocytes type
Basofil 0 0-13 %
SBC 19 22-26 mmol/L
Eosinofil 1 1-3 %
Total CO2 20 21-70 mmol/L Rod 10 2-6 %
SBE -7 -2,4-+2,3 mmol/L Segmen 45 50-70%
Limfocytes 14 20-40%
Kimia Clinic (( May, 10th 2016 at 10:13) Monocytes 29 2-8%
LED 5 <15mm/hour
Eritrocytes 2,80 Milyar/ul
GDS 293
Kimia Clinic ( May, 10th 2016 at 21:41)

A Acute diarrhea with severe dehydration and
seizure
Hyponatremia
Hyperkalemia
P Inj, Dexamethasone 3x0,5mg
Candistatin 3x0,5ml
Lacto B 3x1/2 sach
Zinkid 1x10mg
IVFD RL 800cc/day
IVFD NaCl 3% 500cc
O2 3liters/minutes
Pro ICU
Follow up
May, 11th 2016, seventh day of hospitalization, 13th day of illness
S Fever (-)
mucous nor blood
Seizure (-)
O • Somnolen (E2M3V2), Midly ill

• Temperature : 36,9°C, Pulse : 112 x/min, Respiratory rate : 42 x/min
+/+
• Akral : Warm
A Acute diarrhea with severe
dehydration
Hyponatremia
Candistatin 3x0,5ml
Lacto B 3x1/2 sach
Zinkid 1x10mg
IVFD RL 800cc/day
IVFD NaCl 3% 500cc
O2 3liters/minutes
Pro ICU
Follow up
May, 12th 2016, eighth day of hospitalization, 14th day of illness
S Fever (-)
Defecation (+) frequency 4x, consistency liquid, yellow color, bad odor, foam(+) dregs (-) no mucous
nor blood
Seizure (-)
Child can cry
O • Composmentis, Midly ill
• Eyes : Pale conjungtiva (-), icteric sklera (-), hyperemia conjungtiva (-), sunken eyes +/+, tears +/+
• Mouth : Dry lips, wet mucous, tonsils T1/T1,hyperemia pharinx
• Akral : Warm
• Anus : Hyperemis (-)
Hematology ( May, 12th 2016)

Leukocytes 16,600 5.000 – 10.000 u/l
Thrombocytes 442.000 150.000 – 400.000
/ul
A Acute diarrhea with
improvement
Inj. Ceftriaxone 2.300mg
Candistatin 3x0,5ml
Lacto B 3x1/2 sach
Zinkid 1x10mg
IVFD RL 800cc/day
Follow up
May, 13th 2016, nineth day of hospitalization, 15th day of illness
S Fever (-)
Defecation (+) frequency 3x, consistency liquid, yellow color, bad odor, foam(+) dregs (+) no
mucous nor blood
Seizure (-)
Child can cry
O • Composmentis, Midly ill
• Eyes : Pale conjungtiva (-), icteric sklera (-), hyperemia conjungtiva (-), sunken eyes -/-, tears
+/+
• Mouth : Dry lips, wet mucous, tonsils T1/T1,hyperemia pharinx
• Skin : dry (+), Turgor Slowly (-)
• Akral : Warm
• Anus : Hyperemis (-)
A Acute diarrhea with
improvement

Inj. Ceftriaxone 2.300mg
Candistatin 3x0,5ml
Lacto B 3x1/2 sach
Zinkid 1x10mg
IVFD RL 800cc/day
Hematology ( May, 13th 2016)
Hemoglobin 12 13 – 16 g/dl
Leukocytes 10,600 5.000 – 10.000 u/l
Thrombocytes 442.000 150.000 – 400.000 /ul
Kimia Clinic ( May, 13th 2016)


SECTION II
LITERATURE
REVIEW
DEFINITION
Diarrhea is the passage of loose or watery stools at

least 3 times in a 24- hour period. However, it is the
consistency of the stools rather than the number
that is most important. Acute diarrhea may be
caused by different viruses, bacteria, and parasites
EPIDEMIOLOGY
CLINICAL
MANIFESTATION
DIAGNOSIS
• should be asked the following matters: a long diarrhea, frequency, volume, fecal consistency, color, odor, presence or absence of
mucus and blood.
• Frequency of urination, volume and frequency of vomitting, food and drinks were given, Is there any heat or other accompanying
Anamnesis diseases, other actions that have been carried out during diarrhea.
• On physical examination need to be examined: weight, body temperature, heart rate and respiration and blood pressure.
• Further need to find the main signs of dehydration: awareness, thirst and skin turgor abdomen and signs of other extras: fontanel
Physical concave or not, the eyes: cowong or not, the presence or absence of tears, lips, oral mucosa and tongue dry or wet.
examination
• Detailed laboratory examination in acute diarrhea is generally not required, only in certain circumstances may be required, for
example the underlying cause is unknown or there are other causes other than acute diarrhea in patients with severe dehydration.
• Microscopic examination for the presence of leukocytes can provide information about the cause of diarrhea, anatomical location
Laboratorium and the presence of mucosal inflammation process.
THERAPY
Ministry of Health identified five pillars of the management of diarrhea in all cases of diarrhea
that affects children under five treated both at home and was hospitalized, namely:
1.Rehydrate by using the new ORS
2.Zinc is given for 10 consecutive days
3.Breast milk and food to be continued
4.Antibiotics selective
5.Advice to parents
Recommendations for inpatient hospital based on consensus and is followed by the following
conditions:
1.Shock
2.Dehydration weight (> 9% weight)
3.Neurological abnormalities (lethargy, convulsions)
4.Intractable, bilious vomiting
5.Kegalalan oral rehydration
6.Allegedly abnormality surgery
7.Conditions for safe follow-up and management can not be done at home
Seizure with electrolyte imbalance
Seizures occurring in patients with sodium disorders, hypocalcemia,
and hypomagnesemia, are usually generalized tonic-clonic, but also
focal (partial) seizures or other seizure types may be present. Rapidly
evolving electrolyte disturbances are more likely to cause seizures
than those developing more gradually
TREATMENT
The most common treatment for hyponatremia

consists of hypertonic saline (3%), which
produces a rapid reduction in brain volume and
intracranial pressure. An increase in serum
sodium to values of 120 mEq/L to 125 mEq/L
should be the target of therapy
CONCLUSSION
Diarrhea is the passage of loose or watery stools at least 3 times in a 24
hour period. However, it is the consistency of the stools rather than the
number that is most important. Acute diarrhea may be caused by different
viruses, bacteria, and parasites. It is most practical to base the treatment of
diarrhea on the clinical type of the illness, which is easy to establish when a
child is first examined. Usually there is no need for laboratory tests.
One of complication of diarrhea is seizure. Seizures represent an important
clinical manifestation of electrolyte disorders and are more frequently
observed in patients with hyponatremia, hypocalcemia, and hypomagnese-
mia

ACUTE DIARRHEA IN A 2-MONTH-OLD BABY

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ACUTE DIARRHEA

Main complaint : Fever since 6 days prior to admission to hospital.

Additional complaint : Watery stools ≥ 10x/day since 3 days before

• The patient didn’t

Conclution : growth and developmental is still

• Breast milk : Exclusive until now

Immunization Frequency Time

There are not any

- General condition : Mildly ill

WFA (Weight for Age) : 5,5/5,2 x 100 % =

- Hand Normotonus / Normotonus

Kernig sign (-) -

Lasegue sign (-) -

Defecation Diarrhea (frequency 10 times daily)

Hematology (May, 05th, 2016)

Hemoglobin 11,9 13 – 16 g/dl

Leukocytes 18.600 5.000 – 10.000 u/l

Thrombocytes 605.000 150.000 – 400.000

Results Normal Value Results Normal Value

• Acute Diarrhea with Mild-Moderate Dehydration

• IVFD RL 600 cc/ 24 hours (32 tpm)

Quo ad vitam : dubia ad bonam

Natrium 121 135-145 mmol/l Thypi O +1/80 Negative

O • Compos Mentis, Midly ill

Natrium 118 135-145 mmol/l

Kalium 5,1 3,5-5,0 mmol/l

Chlorida 91 98-108 mmol/l

O • Compos Mentis, Midly ill

Electrolite Results Normal Value

Natrium 126 135-145 mmol/l

Kalium 5,0 3,5-5,0 mmol/l

Chlorida 98 98-108 mmol/l

O • Compos Mentis, Midly ill

O • Somnolen (E2M3V2), Moderate ill

Electrolite Results Normal Value

Natrium 126 135-145 mmol/l

Kalium 4,2 3,5-5,0 mmol/l

Chlorida 98 98-108 mmol/l

O • Somnolen (E2M3V2), Midly ill

Hematology Results Normal Value

P Inj, Dexamethasone 3x0,5mg

Leukocytes 10,600 5.000 – 10.000 u/l

Thrombocytes 442.000 150.000 – 400.000 /ul

Kimia Clinic ( May, 13th 2016)

Natrium 136 135-145 mmol/l

Kalium 5,0 3,5-5,0 mmol/l

Chlorida 104 98-108 mmol/l

Diarrhea is the passage of loose or watery stools at

The most common treatment for hyponatremia

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