Professional Documents
Culture Documents
DIARRHEA
Aditya Prambudhi
111170004
Chief : dr. Irman Permana, Sp.A
FACULTY OF MEDICINE
SWADAYA GUNUNG JATI UNIVERSITY
CIREBON
2015
Pattients identity
Name
: Mr. AD
Age
: 2 years old
Sex
: male
Address
: Kaligawe
Date of admission
: 25/06/2015
Date of examination
: 27/06/2015
Mothers Patients
: Mrs. S
Age
: 23 years old
Address
: kaligawe
Occupation
: House Wife
Education Level
: Elementary School
History of taking
Treatment of History
patients have given oralite from stalls but no effect on patient
immunization history :
Hepatitis B
: 1x at after birth
BCG
: 1x. at 1 month
DPT
: 1x at 2 months
Polio
: 1x at 4 months
Measles
: 1x at 9 months
PHYSICAL EXAMINATION
General state
: looking illnes
General appearance
Height
: 12 kg
Weight
: 91 cm
Vital sign
: full alert
Blood presure
:-
Pulse
Respiration
Temperature : 36 C
Head
flaring
Neck
Thorax
retractions(-)
-
Extremities
: - Warm
- Acrocyanosis -/- Capillary refill time < 2
Neurological Examination
Differential Diagnosis
Intolerance lactose
Further Examination
Hematology :
Hemoglobin
: 12 g / dl
Hematocrit
: 40 %
Leukocytes
: 13.000 / ul
Platelets
: 413,000 / ul
Stool :
Color: yellow
Blood: -
Smell: characteristic
Slime: -
Consistency: soft
Working diagnosis
Treatment
Education
Parents are asked to bring the child back to the
hospital if symptoms of fever, bloody bowel
movements
Promotive and preventive
Breast milk is still given
personality of hygiene
washing hands before eating
Environmental Hygiene
Prognosis
Quo ad vitam
: dubia ad bonam
Quo ad functionam
: dubia ad bonam
Quo ad sanationam
: dubia ad bonam
Thank you