case report joko .pptx [autosaved]
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8/17/2019 Case Report Joko .Pptx [Autosaved]
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AUTHOR : Joko HerdiyantoNIM : I11109030LECTURE : DR. HILMI URNIA!AN RI"A!A# "$.A# M.e%DATE & DA' : rd 3 (e)r*ari +01, & -edne%day
NON D'"ENTRIORM ACUTE/A"TROENTERITI" A09 2 MILD
MODERATE DEH'DRATION E4,
Case Report
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Identitiy
A, boys, 1 years 10 month, was care inDahlia Room, no medic : 090434, KartikaHusada Hosital, !or " days, !rom date 3th
#01$ to %anuary &th #01$
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Chief Complain
De!ecate a watery stool
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'atient come de!ecate a watery stool within morethan 10()days, a yellowish color and sometimeblack, !eces resence o! mucus, dre*s ,not bloodand !e+er atient nausea and +omited # time,+omitin* o! !ood and water 'atient looks thirsty andstill want to drink water, but don-t want to eat,.rinate as usual normal De!ecation in atients alsono symtoms o! cou*h, colds, con+ulsions and losso! consciousness!ather atients were then *i+en aracetamol syrumedications, !e+er had decreased, but de!ecate the
atient-s condition does not imro+ed
1 day be!orehositali/ed
1 day be!orehositali/ed
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're+ious atient had suered !rom thesame comlaints and imro+ed without a
*i+en treatment or treated in a hosital ha+e no history o! sei/ure, aler*y , thyoid
!e+er, asthma
o !amily members with a similar
comlaints 'atient +aksin 2nly *et Bacille Calmette
Guerin ( 5 6 +accination
'atient 2nly *et 7 month o! A8 and ne(t
atient drink milk !ormula 'arents atient lowerclass economy
History o! *rowth and de+eloment isaroriate with any normal children
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56y%i7a8 Eaination
5eneral aearance : moderate sick, !ussy Awareness : omos mentis
Antroometry, ;58, #00&
;ei*ht : 10 k*
len*th : 73 cm wei*ht)a*e : 0 8D sd 1 8D
hei*ht) a*e : 0 8D sd 1 8D
;ei*ht)hei*ht : 1 8D
utrition state : normal
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Vital Sign
Heart rate : 110 ()s, re*uler, stron* in alable Res Rate : 30()s, re*uler in rythm,
thoracoabdominal tye
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5eneralist 8tatus
Head : normocheal
=ye : on%un*ti+a anemic >)6, sclera icteric >)6,sunken eye >?)?6, tears >?)?6
=ar : secret >6,
ose : secret >6
@outh : wet lis and mucosa >?6, eck : enlar*ement o! lymh nodes >6
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• un* : +esicular >?)?6, whee/in* >)6, rhonki >)6• Heart : 81, 8#, re*uler, murmur >6, *allo >6• Abdomen
• nsection : domeshaed, mass >6• Auskultation : bowel sound >?6 increased• 'alasi : hear and lymh are not alable• 'erkusi : tymani in all Cled
• Anus 5enitalia : no abnormality• =(tremity : warm akral, Capillary Refll Time >R6
• 8kin : olour o! skin is brown, icteric >6, etechie >6, rash >6,tur*or returned slowly >?6
/enera8i%t "tat*%
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lood 3 %anuary #01$6
ormal
; 1#000 ) mm3 40001#000 )mm3
R ",0$ %uta 3,"0 G ","0 %uta
Hemo*lobin 1#,# *)dl 11,"14," *)dl
H< 344 3"""
'< 1$0000)mm3 1"0000400000
)mm3
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Dierential Dia*nose
on dysentri!orm Acute *astroenteritis ? mildmoderate dehydration
Dysentri!orm Acute *astroenteritis ? mildmoderate dehydration
holera ? mildmoderate dehydration
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;orkin* Dia*nose
on dysentri!orm acute *astroenteritis ?mildmoderate dehydration
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tm6 micro• in%ection 'aracetamol 3 ( 100 m*• in%ection e!ota(ime 3("00 m*• n%eksi 2ndansetron 3 ( 1 m*• n%eksi Ranitidine # ( 10 m*• inc kid siru 1 ( 1 cth er oral• 'robiotik1(1 sachet er oral
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;&01&1, ?6,mucus>?6,blood >6, dre*s>?6,ause >6 Iomitin* water
and !ood >?6 3( time , !e+er >?6at ni*ht , drink >?6, eatdecreased >?6, .rinate>?6 *ood
De!ecate a watery stool #( >?6,dre*s >?6, mucus >6, blood >6, ause>6, Iomitin* >6, !e+er >6 , drink >?6,
.rinate>?6 *ood, eat usual
FOLLOW UP
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;&01&1,
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Discussion
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Problem of case
Dia*nose
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Discussion/a%troentiriti% ?6
Dia=no%e
In t6i% $atient:
5astroentiritis ?
dehydration de!ecate watery stoolmore than N10 times,
look !ussy- sunken eyes,
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thirsty,- wet lis and mucous, and- tur*our returned slowly
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Type of Diarrhea
Disentri!rom Diarrhea
watery stool withmucus and blood, !e+er, tenesmus ani, ain inabdomen, rolasus ani
on Disentri!rom Diarrhea Kids under #
years old, watery stool, hi*h !e+er, +omitin*,accomanied by cou*h and cold
holera diarrhea that is watery andabundant, without receded by heartburn and
without tenesmus, abdominal crams Diarrheahas chan*ed >rice water stool6
n 'atient watery stool with mucus, and notblood, +omitin*
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Stage Of Dehydration
Dehydration state can be determineob%ecti+ely by comare the body wei*htbe!ore and a!ter diarrhae 8ub%ecti+ely can beuse ;H2 criteria
n this atient, deCsit o! body wei*ht about$, and accordin* to the criteria o! ;H2 canbe classiCed as mildmoderate dehydration,
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TREATMENT
Medi7ation *n7tion
IJD R $0 tm micro Rehydration
e!ota(ime 3("00 m*i+
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omlication
omlication o! diarrhea : Dehydration =lectrolit imbalance
Death
AdeOuate treatment can re+ent thecomlication
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Prognose
Recurrence rates deendin* on the le+el o!hy*iene o! atients where the arental role ino+erseein* and hy*iene o! !ood children are+ery inPuential At this child in +itamro*nosis and !un*sionam is ad bonam, whilesanationam ad malam
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Thank You
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