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ANAMNESIS

Chieft Complaint

Cough
HISTORY OF PRESENT ILLNESS

4 days before admission


• Cough and Rhinore with mucous since 2 weeks ago
• Nosebleed (+), the patients is taken to a nose ear specialist, then
• No seizure, no loss of consciousness
• No nausea
• Vomitting while he cough, contain food and mucous, no blood
• Weak
• Irritable
• Cough, no dispneu
• Decreased feeding
• Urination just 2 times/day, the colour is yellow to brown
HISTORY OF PRESENT ILLNESS

2 days before admission


• Still Fever 38.2°C
• No seizure, no loss of consciousness
• No nausea
• Vomitting while he cough, contain food and mucous, no blood
• Weak
• Irritable
• Cough, no dispneu
• Decreased feeding
• Urination just 2 times/day, the colour is yellow to brown
• The mother brought her to the midwife, midwife give pimtrakol syrup
(contain paracetamol, glyceryl guaiacolate, ephedrine hcl and
chlorpheniramine maleate) 5ml / 6 hours
HISTORY OF PRESENT ILLNESS

the days before admission


• Still Fever 38.8°C
• No seizure, no loss of consciousness
• No nausea
• Vomitting while he cough, contain mucous, no blood
• Weak and Irritable
• Cough, no dispneu
• Tears do not come out when crying
• Decreased feeding but excessive thirst
• Urination just 1 times/day, the colour is yellow to brown
• The mother brought her to the emergency room
HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied


History of Seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food and drug : Denied
History of hospitalized : Denied
History of malnutrition : Denied

Conclusion: there is no history of past illness


HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied


History of Seizure without fever : Denied
History of Anemia : Denied
History of asma : Denied
History of atopi : Denied
History of hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that correlated with


patient’s disease
PEDIGREE

Tn. A 35 years old Ny. N 32 years old

An. H 1 years 5 month old

Conclusion : there is no illness is inherited


HISTORY OF PREGNANCY

Mother with P1A0 is pregnant at 30 years old. Mother began to


check pregnancy and routinely control to the doctor. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension.

Conclusion: the history of pregnancy is not good (mother have 2 times


spontaneous abortion)
HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a doctor with a sectio
caesaria. 38 weeks pregnancy age, baby born with body weight 3500
grams with body length 48 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.

Conclusion : history of delivery was good (sectio caesaria)

HISTORY OF POST DELIVERY

The baby was born crying, active motion, red skin color, not blue
and not yellow skin color, got milk on first day, urination and
defecated less than 24 hours

Conclusion : history of post delivery was good


HISTORY OF ENVIRONMENT

The patient lives at home with both parents and sisters.


Ceramic-floored patient houses, walled walls, tile roofs, adequate
ventilation, bathrooms in the house, water source from well water.
A few days before the patient was treated in the hospital,
neighbors have not experienced similar complaints.

Conclusion : there is no a risk factors for transmitted disease


HISTORY OF VACCINE

• At that time of examination, the mother did not bring


KMS.
• According to the mother's confession, the patient have
comlete recieve vaccine.

Conclusion : the history of vaccine is complete acording


to KEMENKES
HISTORY OF FEEDING
0 – 6 month old

• Exclusive breastmilk

6 – 8 month old

• Breastmilk + Formula + instan food 1 day 3 small bowls

8 – 10 month old

• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 2 small dishes

10 – 12 month old

• Breastmilk + Formula + Rice porridge, protein teams smoothed 1 day 2 small dishes

12 – 17 month old

• Breastmilk + Formula + porridge, eggs, meat, fish a day 32times a large plate of food

Conclusion : history of feeding from quality and quantity was not


HISTORY OF GROSS MOTOR

Competence Age of achievment Normal age


Head up 90 degress 3 month 3-4 month
Sit no support 6,5 month 6 – 7 month
Stand alone 11 month 11 - 13 month
Walk well 13 month 11-15 month
Runs 17 month 13-20 month

Conclusion :Development history of Gross motor according


to age
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HISTORY OF FINE MOTOR

Competence Age of achievment Normal age


Reaches 5 month 4,5 – 5,5 month
Scribbles 12 month 12 – 17 month
Tower of 4 cubes 17 month 13-21 month

Conclusion :Development
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HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 11 month 7 – 13 month
6 words 17 month 13-22 month

Conclusion :Development history of language according to


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HISTORY OF PERSONAL SOCIAL
Competence Age of achievment Normal age

Smile spontaneously 1 month 0-2month


Feed self 6 month 5 – 6,5 month
Indicate wants 12 month 7,5- 13 month
Drink from cup 15 month 9-17 month
Remove garment 17 month 14 month – 2 years

Conclusion :Development history of social according to age

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History of DEVELOPMENT and
INTELLEGENT

• Conclusion: History of development and


intellegent was good
Physical Examination
 General appearance
General appearance : look thirsty, alert

 Vital Sign
Blood Pressure :-
Heart rate : 112 x/ menit
Respiratory Rate : 34 x/ menit
temperature : 38,8° C
Nutrisional status

1years 5 month old WEIGHT : 9 KG Length : 75 CM

-Weight // age : < 0 SD normal


-length // age : < 0 SD normal
-Weight // length : < 0 SD normal

Conclusion : nutritional status is normal


Physical examination
• Skin examination
Color : brown
Skin turgor: >2 sec
Moisture: moist
Edema (-) does not exist

• Conclusion : Skin turgor: >2 sec

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PHYSICAL EXAMINATION
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retraction (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi subcostal (-/-),
retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : neck, heart and lung examination was good


Stomach :
Inspeksi : Distensi (-), sikatrik (-), purpura (-), darm contour (-),
darm steifung (-)
Auskultasi : Peristaltik (+) normal, metalic sound (-)
Perkusi : timpani (+)
Palpasi : supel (+), acites (-), abdominal mass (-), tenderness (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : in stomach examination is good


Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities


CRT <2 sec
Turgor> 2 second

Conclusion : turgos > 2 second

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PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), light reflek (+/+)
isokor (+/+), sunken eyes(+/+),
Nose : Secret (-), epistaksis (-), breath nostrills (-/-)
Ears : Secret (-), membrane hiperemis (-)
Mouth : Stomatitis (-), gingivitis (-), sianosis (-), pharynx hiperemis (+), exudate
(-), mucousa lips and mouth dry (+),
Skin : colour was white, pale (-), Ikterik (-), Sianosis (-)
Lymph nodes : enlargement limfadenopathy (-)
Muscle : pharese(-), atrofi (-), myalgia (-)
Bone : deformity (-)
Joints : free movement
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), warm akral (+/+), petekie (-
/-)

Conclusion: there is sunken eyes, pharynx hyperemis and dry mucousa lips and
mouth
RESUME
ANAMNESIS
Fever 3 days
Weak
Irritable
Tears do not come out when crying
Decreased feeding but excessive thirst
Urination just 1 times/day, the colour is yellow to brown

Physical examination
Fever
Look thirsty
Sunken eyes, pharynx hyperemis and dry mucousa lips and mouth
Skin turgor > 2 second
ASSESMENT

Diagnosis
1. Rhinofaringitis Acute et causa
DD : Viral Infection
Bacterial infection
2. Severely dehydration
ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the dehidration sign
• Observation the effect of mediaction

DIAGNOSIS ENFORCEMENT PLAN

• Blood examination
• Electrolyte examination
` PLAN
THERAPY

• Rehidration plan C
Infus RL 100ml/kgBW
30 ml/kgBW= 30 ml x 7.9 kg = 237 ml / ½ hours
= 237x20/30 = 158 dpm macro
70 ml/kgBW= 70 ml x 7.9 kg = 553 ml / 2,5 hours
= 237x20/150 = 32 dpm macro
• Antipiretic
Paracetamol syrup 10 mg/ kgbw/4 hours
Paracetamol syrup 10 mg x 9 = 90 mg = 4ml/4 hours (120/5ml)
Terapi

Energy needs : White rice, eggs, meat, fish,


Calori : 9 x 102 = 918 kkal
vegetables a day 3 times a large plate of
Protein : 9 x 1.23 = 11.07 g
food + 1 glasess milk + snack 2 times per
Fluid : 100 x 9 = 900
day
= 900 ml/day
 rute oral
p.o : 300 ml/day
i.v : 600 ml/day
Follow up
Monday , 07/05/2018
S/ still fever, still diarrhea 3 times, no nausea and no vomittus, can sleep, already
appetite, urination was good every defecate and the color is yellow clear
O/ N : 110 x/minutes
RR : 24 x peer times
S : 37,9°C
eyes : sunken eyes (-/-)
mouth : dry lips (-), pharynx hiperemis, no exudate
stomach : increased peristaltik and timpani

A/ rhinofaringitis acute viral with severely dehydration resolved

P/ infus RL 11 dpm macro


Paracetamol syrup 4 ml / 4 hours
THANK YOU
TINJAUAN PUSTAKA