Acute

Gastroenteritis

Arranged by
Annisa Zahra Ashari

Patients identity
Name
: Miss J
Age
: 18 years
Sex
: Female
Hospitalize : 22 Descember 2016

ANAMNESIS
Chief Complaint :
Diarrhea more than 5 a day, one days before
hospitalized
Additional Complaint :
Nausea, vomiting, abdominal pain, and fever

1/4/17

Havara Kausar Akbar

History of Present Illness

5 h prior

Eat chicken
noodles on
street vendors,
no traveling

Night>
Diarrhea
5x/day, no
blood /
mucous, water
and spraying
Abdominal
pain
Nausea and
vomiting >
5x/day, food
and water no
blood and no
mucous
Fever, no high,
no shivering,
and felt all day

Admisson
Diarrhea
accompanied
by weakness,
fever, nausea,
abdominal pain
and decreased
appetite

History of past illness

No
No
No
No
No
No
No

history
history
history
history
history
history
history

of
of
of
of
of
of
of

Hypertension
DM
urinary or kidney disease
asthma
allergic
hematologic disease
hepatitis
5

History of family

None of his family has same problem

No history of hypertension
No history of DM
No history of allergic
No history of hematologic disease

History of Treatment and Allergy

Patient just consume Diapet to healing his

problem, but that`s not work

Patient

has no allergy to food, drugs and

weather.
7

Habits
Smoking habits
:
Denied
Drinking alcohol
:
Denied
Taking any medication or herbal :
Denied
8

Physical examination
Generalist status
General condition :
Moderate ill
Conciousness :
Composmentis (E4
M6 V5)
Body weight : 40 kg
Body height
: 150
cm

Vital signs :
Blood pressure
120/80 mmHg
Pulse
84x/minute

:
:

Respiratory rate :
20x/minute
Temperature
37.8c

:
9

General
physical
examinati
on
Thorax

Heart

Head : normocephal, deformity (-), black hair (+),

hair loss (-)
Eyes : sunken eyes (-/-), anemic conjungtiva (-/-),
icteric sclera (-/-)
Mouth : dry mouth mucosa (-/-), coated tongue (-)
Nose : septum deviasi (-/-), rhinorea (-/-), epistaksis
(-/-)
Ears : otorea (-/-), secret (-/-)
Neck : not palpable mass, lymphadenopathy (-),
hipertiroid (-)
Inspection : the movement of the chest symmetrical
when static and dynamic
Palpation : same vocal fremitus in dextra and
sinistra
Percussion : Sonor in both lung fields
Auscultation : vesicular breath sounds + / +, ronkhi
- / -, wheezing - / -

Inspection : ictus cordis not seen

Palpation : ictus cordis palpable in ICS V LMC sinistra
Percussion: heart border in the normal range
Auscultation : Regular 1st & 2nd heart sounds,
murmur (-), gallop(-)
10

Abdome
n

Inspection : looked flat

Auscultation: bowel (+) sounds,
14x/minutes
Palpation: Hepatomegali (-), asites (-),
epigastric tenderness (+), tenderness Mc
Burney (-), normal skin turgor
Percussion: shifting dullness (-), Timpani
in abdomen fields

Extremiti
es

Superior: Edema (- / -), warm akral(+ /

+), RCT <2 seconds (+ / +)
Inferior: Edema (- / -), warm akral (+ / +),
RCT <2 seconds (+ / +)

11

Resume
Female 18 years old come with Diarrhea more than 5
times a day, one days before hospitalized. Diarrhea
yellow, no mucus, and no blood. Diarrhea in the form of
plenty of water and spraying. Diarrhea accompanied by
abdominal pain in most stomach. nausea and vomiting
around 5 times a day. The vomiting of food and water,
no mucus and no blood. Patients also have a fever but
not high.
Physical examination : Blood pressure : 120/80 mmHg,
Pulse : 84x/minute, Temperature : 37.8c, Respiratory
rate : 20x/minute. Dry mouth mucosa, hiperperistaltik,
sunken eyes (-), and normal skin turgor.
12

Assesment

Gastroenteritis acute with dehidration mild ec bacterial

Infection
S : Diarrhea more than 5 times a day, one days before
hospitalized. Diarrhea yellow, no mucus, and no blood. Diarrhea
in the form of plenty of water and spraying. Diarrhea
accompanied by abdominal pain in most stomach and
sometimes hearing the sound of rumbling. nausea and vomiting
around 5 times a day. The vomiting of food and water, no mucus
and no blood. Patients also have a fever but not high.
O : Physical examination ; Blood pressure : 120/80 mmHg,
Pulse : 86x/menit, Temperature : 37.8c, Respiratory rate :
20x/menit.
A : Gastroenteritis Akut Dehidrasi Ringan Sedang ec bakterial
13
infection

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THANK YOU

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