CASE REPORTDIARRHEAAchmad syahid111170002Chief : dr. Irman
Permana, Sp.AFACULTY F !"#ICI$"S%A#AYA &U$U$& 'ATI
U$I(")SITYCI)"*$ 201+Pattients identityName :Mr. ADAge :2 years
oldSex : maleAddress : Kaligawe#a,e -f admissi-n: 25/06/205Date o!
examination : 2"/06/205Mot#ers Patients : Mrs. SAge : 2$ years
oldAddress : %aligawe&''()ation : *o(se +i!e,d('ation -e.el:
,lementary S'#ool.is,-ry -f ,a/in0Chief c-mp1ain : 1i23id 4-5e1
m-6emen,s.is,-ry -f presen, i11ness
:Pa,ien,sc-me,-,heh-spi,a1emer0encyr--m5i,hc-mp1ain,s
1i23id4-5e1m-6emen,s.neday4ef-reen,erin0,heh-spi,a1.
(-mi,in0789dai1y.1i23iddefeca,i-n7109:day,1i23id
c-nsis,ency,5as,e1ess,m-re5a,er,s1imy,ye11-541--d1ess. C-mp1ain,s
acc-mpanied 4y 6-mi,in0 89 : day. Pa,ien,s c-mp1ain -f a4d-mina1
pain. Pa,ien,s d- n-, 5an, ,- ea, and drin/. #3rin0 ,he pa,ien,;s
pain 4ec-mes m-re f3ssy and 1--/ 5ea/ 43, n- 1-ss
-fc-nsci-3sness.C-30h,r3nnyn-se,andsh-r,ness-fdenyin0 pa,ien,s.
C3rren,1y,hepa,ien,drin/f-rm31ac-3p1ed5i,hricesidedishes and fr3i,.
Acc-rdin0 ,- ,he m-,her -f ,he pa,ien,, ,he pa,ien, d-es n-, ha6e a
f--d a11er0y.Past medi'al #istory
:Pa,ien,sha6ee9perienceddiarrheac-mp1ain, 1,+ years -1d./amily
#istory o! disease :0#ere is no !amily #istory o! disease0reatment
o! *istory)atients #a.e gi.en oralite !rom stalls 1(t no e!!e't on
)atient*istory o! growt# and de.elo)ment :2ross motor : 3 learn to
li!t t#e #ead o! t#e age o! 2 mont#s 3 4rawling and sit wit#o(t t#e
ot#er )eo)le o! 5 mont#s
3-earntostandonitsownwit#o(tt#eassistan'e$mont#sSo!tmotor:3rea'#
o15e'ts aro(nd t#e age o! 6 mont#s 3 0rying to mo.e goods ages 6
mont#s 0al%ing : 3 la(g#ing and s'reaming$ mont#s So'ial: 3 smiled
at t#e !a'e o! t#e age o! 2 mont#s 3 -a(g#s w#en as%ed to )lay age
o! $ mont#s 7m)ression: age3a))ro)riate growt# and
de.elo)mentimm(ni8ation #istory :.epa,i,is *: 19 a, af,er
4ir,h*C& : 19. a, 1 m-n,h#PT : 19 a, 2 m-n,hsP-1i- : 19 a, <
m-n,hs!eas1es : 19 a, = m-n,hsP.YSICAL ">A!I$ATI$2eneral state :
loo%ing illnes &enera1 appearance : !(ll alert*eig#t : 2
%g+eig#t : 9 'm:ital sign :;lood )res(re : 3P(lse: 0 x/min(te<
reg(ler< e=(al>es)iration : 26x/min(te0em)erat(re : $6 ?4*ead
: C-n?3nc,i6a anemic @:@, Sc1era ic,eric @:@, $asa1 Aarin0 B@C, PC
B@C$ec/ : @ S3pras,erna1 )e,rac,i-n B@C@ Lymphaden-pa,hy B@CTh-ra9:
@ Symme,ric 5i,h 0--d e9pansi-n In,erc-s,a1 re,rac,i-nsB@C-L3n0s
:*rea,hs-3nds6esic31arri0h,D1ef,, ra1esB@C, 5heeEesB@C, rh-nchiB@C
-.ear, : S1, S2, re031ar rhy,hm, n- m3rm3rs A4d-men : @ S-f,, n-n
dis,ended, n-n ,ender@ "pi0as,ric re,rac,i-ns B@C,@ Li6er and
sp1een is n-n pa1pa41e @ increased 4-5e1 s-3nds B
