Case Report Social Pediatri II

7/30/2019 Case Report Social Pediatri II

1/15

1

CASE REPORT SOCIAL PEDIATRIC

A TWO-YEARS OLD BOY WITH GLOBAL DEVELOPMENTAL DELAYED

Submitted for completing the assignment for senior clerkship

in Pediatrics Health Department of Kariadi Hospital

Medical Faculty of Diponegoro University

Eko Yuli Prianto 22010110200057

Ercila Rizky Rolliana 22010110200058

Examiner:

Dr. HendrianiSelina, Sp.A (K), MARS

PEDIATRIC DEPARTMENT OF KARIADI HOSPITAL

MEDICAL FACULTY OF DIPONEGORO UNIVERSITY

SEMARANG

2011


2/15

2

A. IDENTITY

Name : Y. F

Medical Record : DDST

Age : 2 years

Date of birth : December 1st, 2009

Sex : Male

Date of entry : November 2nd 2011

Address : Malabar RT/RW 002/004 Gajahmungkur, Semarang

Father Mother

Name : Mr. K. M Name : Mrs. N. N

Age : 35 years Age : 30 years

Religion : Islam Religion : Islam

Occupation : Police Occupation : Nurse

B. ANAMNESIS

Alloanamnesis with patients mother November 2nd

2011 at 12.00 a.m. at BKIA RSDK,

Semarang.

Chief complain :2-years old child still not talking

Present Disease History :

Since 3-months old, the parents started realize that their child is late in talking. Right now

the child is only able to say ayah, ibu, mam. Now the child only make

undistinguished sound when she wanted something. The child could turn her face

whenever called and paid attention and understood whenever talked to. The child could

also take small things like buttons. The child could walk, run, and climb stairs by his

own. The child had not friends and could socialize with them. The child could only point

at whenever wanted something.

History of Past Illness


3/15

3

- History of other past illnesses was denied

Family History

- No family members get illness like the patient

Socio Economic

- Father and mother a retraders, their income is Rp 6.000.000,00 each month. They fundone children. Medical fee is paid by asurance.

Impression : enough socioeconomic

Perinatal History

Prenatal History :

- 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 :

- Born at midwife clinic from mother G1P1A0, by midwife, aterm (9 months),spontaneous, body weight of birth was 3000 gr, mother forgot body length of birth,

crying spontaneously

Postnatal History

- Control at Public Health Centre after birth; the child was healthy.

Immunization History

- BCG : 1x, 1 month

- DPT : 3x, 2,3,4 month

- Polio : 4x, 0,2,3,4,18 month

- Hepatitis B : 4x, 0,2,3,4,18 month

- Campak : 1x, 9 month

Impression : complete basic immunizations according to her age.


4/15

4

Food and Drink History

- Breast feeding(+),birth until 6 month- Formulated milk SGM 6-7 months, 3 times per day, 1 spoon on 60 cc warm water- 4-6 month : milk porridge, 3 times per day, each time one small bowl sometimes until

finished

Impression: exclusive breast feeding (-), early weaning, sufficient quality, sufficient

quantity

Growth and Developmental History

Growth :

Weight at previous month: 11,5 kg, Length at previous month : no data,

Body weight at present: 11,8 kg, Length of body at present 89 cm,

Body weight at birth 3000 gram

Impression : Normal growth

Developmental :

1.KPSP

Ya Tidak

Ya TidakYa Tidak

Ya Tidak

Ya Tidak

Ya Tidak

Ya Tidak

Ya Tidak

Ya Tidak

The result of KPSP score: points

The conclusion: deviation


5/15

5

2. Tes daya dengar

Umur lebih dari 3 tahun Ya Tidak

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. Suruhanak 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 23 months

Gross motoric skill 23 months

Language 16 months

Personal/social 2 months

Family Planning

Mother using 3 months injection contraception

C. PHYSICAL EXAMINATION

November 2nd

, 2011 at 12.30 WIBFemale, 2-years, weight: 11,8 kg, length: 89 cm.

General appearance: Composmentis, active,spontaneus breathing

Vital Sign : HR : 110 x/minutes t : 37 oC (axiller)

RR :30 x/minutes N : regular, vol/pres enough

Skin :Anemic (-), cyanotic (-), icteric (-)


6/15

6

Head : Fontanella: not yet closed, widen

Head circumference :40 cm (mikrosefal)

Eyes :Anemicconjunctivalpalpebrae (-), ictericsclerae (-),

Ears : Discharge (-/-), cerumen (-), low seat ear (-/-)

Nose : Nasal flare (-), discharge (-/-)

Mouth : Cyanotic (-), dry mucosa (-), drolling (-)

Teeth : Caries (-)

Throat : T1-1, hyperemic (-), faring hyperemic (-)

Neck : Symmetric, enlargement of lymph nodes (-)

Thorax

Lungs: I : 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 : female, vulva hiperemis (-)

Extremities : Upper Lower

Pale - / - - / -


7/15

7

Cyanotic - / - - / -

Cold - / - - / -

Edema - / - - / -

Capilarry refill


8/15

8

HAZ : 1,09

WHZ : -0,40

Head circumference: -0,03


9/15

9

Impression :well nourished, normal stature, normal weight, mesochepal

E. WORKING DIAGNOSIS

1. Main diagnosis : Developmental disorder of speech and language,unspecified (F80.9)

2. Co-morbid diagnosis : -


10/15

10

3. Complication diagnosis : -4. Nutritional diagnosis : Well nourished5. Growth diagnosis : Normal weight, normal stature.6. Developmental diagnosis : Delayed in one sector (language and speech)7. Immunization diagnosis : Complete basic immunization according to her age8. Social Economic diagnosis: Enough social economic status

F. INITIAL PLANS

Assessment:

1. Developmental DelayedDx : S: -

O: Audiometric test (95.41; 95.42), consult to ophthalmologist, endokrin and

rehabilitasi medik.

Rx : Speech therapy, stimulation appropriate for age

Mx : KPSP, Denver II,

Ex :

- Explain to the parents about delayed development that happened to the child- 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.


11/15

11

HOME VISIT RESULT

Home visit was done on October 5th

, 2011 at 16.00

I. HOUSE CONDITIONMain house

Status : The house owned by the parents. Five family member are living there.

Size : 10 m x 6 m

House terrace : Yes, 1x2 m2, clean

House yard : No

House walls : Brick

Floor : Ceramic

Rooms : A parlor, living room together with dining room, 2 bedrooms, 1

bathroom, 1 kitchen

Ventilation : Adequate, every room has sufficient ventilation and opened every day

Lighting : Adequate

Hygiene : Adequate, the house cleaned every day


12/15

12

Water source : For bathing, washing, cooking and drinking is taken from PDAM

Trash can : one closed-trash can

Bathroom : Yes, inside the house, has cemented-tub, cleaned 1-2x/week. There is

toilet, sewers flowing smoothly

Sewers : There is sewer that flow to reservoir pool

Kitchen : Yes, inside the house, there is pile of used plastic bottles and dining set is

not stored in cupboard

II. DAILY HABITAsuh:

Father works as tempe maker, work location near the house. Mother work as trader intraditional market

Patient cared by parents from birth. Patients daily care done by parents and twosiblings

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 1 plate, consist of rice +side dish:meat/fish/vegetable/tofu/tempe/egg

Childs wish fulfilled if there is moneyAsih: Love is given by parents and two siblings

Asah:

Mental stimulation is accepted primary from mother who is graduated from highschool, 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


13/15

13

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 3/ RW11, Plantaran village, Kaliwungu, Kendal.

Patients house has terrace, the street in front of the house is quite large and clean, 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.

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 :

Dining room


14/15

14

Bedroom Living room

Kitchen Bathroom


15/15

15

Terrace

Case Report Social Pediatri II

Documents

Transcript of Case Report Social Pediatri II