Submitted for completing the assignment for senior clerkship in Pediatrics Health Department of Kariadi Hospital Medical Faculty of Diponegoro University Rizky Ferrian Ferdiansyah RR. Lely Insani Tezza Dinayanti Tri Wijayanti Ulfah Permatasari Dahlia Khairun N Dantik Setiana Examiner: Dr. Hendriani Selina, Sp.A (K), MARS PEDIATRIC DEPARTMENT OF KARIADI HOSPITAL MEDICAL FACULTY OF DIPONEGORO UNIVERSITY SEMARANG 2011 22010110200190 22010110200191 22010110200192 22010110200193 22010110200194 22010111200055 22010111200056
A. IDENTITY Name Medical Record Age Date of birth Sex Date of entry Address Father Name Age Religion Occupation : Mr. S : 31 years : Islam : labor : N.S : DDST : 2 years and 7 months : March 23th, 2009 : Female : November 16th, 2011 : Desa Sumber Agung RT02/RW06 Weleri Kendal Mother Name Age Religion Occupation : Mrs. A : 29 years : Islam : labor
B. ANAMNESIS Alloanamnesis with patients grandmother and uncle November 16th 2011, 11.30 a.m. at BKIA RSDK, Semarang. Chief complain :8-years old child still cannot walking Present Disease History : When patient is 6-months old, he had a febrile conulsion. After it, patient had regression in growth and development. His muscles became stiff slowly. Now the child only make undistinguished sound when she wanted something. The child could not turn his face whenever called and paid attention and understood whenever talked to. The child could not also take small things like buttons. The child not could stand up, walk, run, and climb stairs by his own. The child had not friends and could socialize with them. The parents brought him to paranormal to get massaged, but there were no improvements. Then the parents brought him to RSUD Ketileng and had referred to RSUP Dr Kariadi.
Socio Economic
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Father and mother work as labor, their income is Rp 750.000,00 each month. They fund three children. Medical fee is paid by Jamkesmas. Impression : poor socioeconomic
ANC more than four times at midwife, got TT (+) twice, vitamin, and iron tablets. ANB (-), trauma history (-), the pregnancy disease (-), other drugs consumption during pregnancy (-).
Natal :
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Born at midwife clinic from mother G7P7A0, by midwife, aterm (9 months), spontaneous, body weight of birth was 3600 gr, mother forgot body length of birth, crying spontaneously
Postnatal History
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Control at Public Health Centre after birth; the child was healthy.
Immunization History BCG DPT Polio Campak : 1x, 1 month : 3x, 2,3,4 month : 4x, 0,2,3,4 month : 1x, 9 month
Breast feeding (+), from birth until 7 month Dancow milk 0-12 months, 5 times per day, 1 spoon on 60 cc warm water, continued with Bendera milk 12-24 months, 3 times a day 3-5 month : milk porridge, 3 times per day, each time one small bowl sometimes until finished 5-12 moths : rice porridge, 3 times a day, a half of bowl. Impression: exclusive breast feeding (-), early weaning, insufficient quality, insufficient
quantity Growth and Developmental History Growth : Weight at previous month: no data, Length at previous month : no data, Body weight at present: 10 kg, Length of body at present 98 cm, Body weight at birth 3600 gram Impression : Normal growth Developmental : 1.KPSP Ya Ya Ya Ya Ya Ya Ya Ya Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak
Tidak
The conclusion: deviation 2. Tes daya dengar Umur lebih dari 3 tahun Ya 1. Perhatikan benda-benda yang ada disekeliling anak seperti sendok, cangkir, bola, bunga, dan sebagainya. Suruh anak menyebutkan nama benda-benda tersebut. Apakah anak dapat menyebutkan nama benda-benda tersebut dengan benar?
2. Suruh anak duduk, anda duduk dalam jarak 3 meter di depan anak. Suruh
Tidak
anak mengulangi angka-angka yang telah anda ucapkan : empat, satu delapan, atau menirukan dengan dengan jari tangannya. Kemudian tutp mulut anda dengan buku atau kertas, ucapkan empat angka yang berlainan. Apakah anak dapat mengulangi atau menirukan ucapan anda dengan menggunakan jari tangannya?(anda dapat mengulanginya dengan suara yang lebih keras) Result: probable hearing disorder 5.DDST result Fine motoric skill 0 months Gross motoric skill 0 months Language 1 months Personal/social 1 months Family Planning Mother didnt use any contraception C. PHYSICAL EXAMINATION November 8nd, 2011 at 12.30 WIB Female, 8-years, weight: 10 kg, length: 98 cm. General appearance: Composmentis, active,spontaneus breathing Vital Sign : HR RR : 100 x/minutes : 20 x/minutes t N : 37 oC (axiller) : regular, vol/pres enough
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Skin Head Eyes Ears Nose Mouth Teeth Throat Neck Thorax Lungs: I
:Anemic (-), cyanotic (-), icteric (-) : Fontanella: closed Head circumference :49 cm (mesosefal) :Anemic conjunctival palpebrae (-), icteric sclerae (-), : Discharge (-/-), cerumen (-), low seat ear (-/-) : Nasal flare (-), discharge (-/-) : Cyanotic (-), dry mucosa (-), drolling (-) : Caries (-) : T1-1, hyperemic (-), faring hyperemic (-) : Symmetric, enlargement of lymph nodes (-) : Symmetrical static and dynamic, retraction (-)
Pa : Stem fremitus right = left Pe :Sonor in whole lung area A : Basic sound: vesicular Additional sound: (-) Cor : I : Ictus cordis didnt visible Pa : Ictus cordis was not wide, no powerful to lift Pe : Leftmargin : Ictus cordis is palpable 2 cm medial lineamidclaviculasinistra Uppermargin :Spatiumintercostae II lineaparasternalsinistra Right margin :Spatiumintercostae II lineaparasternaldextra A : Heart sound I-II normal, murmur (-), gallop (-) Abdomen: I : flat, supel Pa : soft, liver /spleen: unpalpable, turgor: return fast Pe : tympani A : intestine sound (+) N. Lymph nodes : no enlargement Genital Extremities : : female, vulva hiperemis (-) Upper Lower
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Pale Cyanotic Cold Edema Capilarry refill Tonus Clonus Phyisiologicreflect Pathologic reflect
D. ANTHROPOMETRICAL STATUS Male, 8-years, recent weight: 10 kg, height: 98 cm. WAZ HAZ WHZ : -3,259 : -5,61 : -3,446
Head circumference: -0,03 Impression: poor nourished, normal stature, normal weight, mesochepal
E. WORKING DIAGNOSIS
1. Main diagnosis 2. Co-morbid diagnosis
: Infantile cerebral palsy unspecified (G80.9) : Global developmental delay. Developmental disorder of : : Poor nourished : very thin, very short, mesocephal, severe stunting
6. Developmental diagnosis : Delayed in four sector 7. Immunization diagnosis : Complete basic immunization according to his age 8. Social Economic diagnosis: poor social economic status
Dx
: S: O:
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Rx Mx Ex
- Explain to the parents to stimulate their child as often as possible based on the given program
- Explain to the parents to check-up their child to the doctor next month.
HOME VISIT RESULT Home visit was done on October 9th, 2011 at 16.00 I. HOUSE CONDITION Main house Status Size : The house owned by the parents. Six family member are living there. : 10 m x 5 m : Yes, 1x2 m2, clean : No : Brick : Ceramic : A parlor, living room together with dining room, 2 bedrooms, 1 bathroom, 1 kitchen Ventilation day Lighting Hygiene Water source Trash can Bathroom Sewers Kitchen : Adequate : Adequate, the house cleaned every day : For bathing, washing, cooking and drinking is taken from PDAM : one closed-trash can : Yes, inside the house, has cemented-tub, cleaned 1-2x/week. There is : There is sewer that flow to reservoir pool : Yes, inside the house, there is pile of used plastic bottles and dining set is : Adequate, every room has sufficient ventilation and opened every
Father works as a labor, work location near the house. Mother work as trader in traditional market
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Patient cared by parents from birth. Patients daily care done by parents and two siblings When sick, patient consumed drug from stand first, then go to primary health care, doctor, or hospital if there is no improvement. Daily meal: three times, each time a half of plate, consist of ssmashed rice +side dish: fish/vegetable/tofu/tempe/egg
Asih: Love is given by parents and two siblings Asah: Mental stimulation is accepted primary from mother who is graduated from high school, and father who is graduated from high school Play with two siblings who are 9 and 14 years old and still going to school Toys: krincingan, colored toys, dolls
The childs daily care is done by parents, and two siblings (take turns). The child eats family food like rice and side dish. Drink water source from PDAM. Dining set is washed by PDAM water and dab of soap. Dirty laundry washed everyday. The place for washing dining set and clothes is in one place. If there is a sick family member, then he/she consumed drug from stand first, then go to primary health care, doctor, or hospital if there is no improvement. Environment Patients house is located on RT 11/ RW9, Kec. Jomblang, Semarang. Patients house has terrace, the street in front of the house is quite narrow, sewers flowing smoothly. One house close to the others, environment near the house is crowded environment. The street in front of the house is ground. No pets found near the house. Patients house has brick walls, ceramic floor, windows that often open, sufficient ventilation and lighting. Kitchen, bathroom and toilet are inside the house. Five people are living in the house: parents and three children.
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Impression: The size of the house is sufficient for the occupants, house condition and hygiene are good, sufficient ventilation and lighting, good daily habits, environment near the house is crowded environment. Photos:
Bedroom
Living room
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Kitchen
Bathroom
Terrace
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