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CONGENITAL TALIPES EQUINO VARUS (CLUBFOOT)Complied: dini noviani p Preceptor : Dr. Arsanto Triwidodo, SpOT,FICS, K Spine, MHKes
ANAMNESEAllonamnesis with the patient's mother called Mrs. I on the 14th January 2013 on 10.00 am.
Name Age Sex Address Mother name Occupation Religion
An. J 5months male warakas
Mrs. I Housewife Islam 10th January 2013 the 5th floor team B
HISTORY TAKINGCHIEF COMPLAINT
Both ankles bent inwards from birth
HISTORY OF PRESENT ILLNESSA mother brings her 2 months old boy to a pediatric policlinic RSUD Koja. She noticed that both of her boys foot looks excessively turned inward since he was born. Twisted ankle is not accompanied by swelling, pain when held, and redness and can not be straightened out like a normal foot. Movement of the foot are normal. There is no abnormality at the other part of his body. Lump on spine denied. Patient's mother was worried about her son's leg. There is no fever, cough, shortness of breath.
Prenatal history (ANC)
During pregnancy mothers patient who have checked regularly to obstetrician midwife once a month to 8 months gestation, then weekly at 9 months gestation. During pregnancy was never sick, never taking drugs purchased alone, except vitamin obtained from obstetrician midwife. TT immunization 2 times. The first child was born 6 years spontaneously and second child born 3 years spontaneous. Age of the mother when pregnant patients 35 years (TB: 160 cm, weight: 50 kg)
HISTORYAntenatal History: Post natal History :
Spontaneous labor at antenatal clinics assisted by Primary immunization a midwife on the 18th August are compeletely on 2012. 2 hours before partus, time. Patients patients mother admitted consume breast milk premature rupture of and soft porridge. The membranes. birth weight is patient was prone. 4300 grams, body length at birth 60 cm, Apgar score 7-9. Cried spontaneously.
History of family illness: No one in hIs family got disease like him
History of past illness: Others disease (-)-
MEDICATION HISTORYPatients had consulted an orthopedic doctor at the age of 8 weeks. Then do the correction of serial cast 6 times until the age of 5 months.
Physical examinationPrimary surveyAirway : Clear, patients can speak spontaneously. stridor (-), gargling () Breathing : Look : Spontaneous breathing regular, symmetrical chest wall movement. Not look any supraclavicular retractions, suprasternal, and intercostal. no muscle contractions seem a respirator. Listen : Vesicular breath sounds (+ / +), ronchi (- / -), wheezing (- / -) Feel The chest wall movement is palpable symmetricly with a frequency of 20 times / minutes Circulation : patients compos mentis skin cyanosis (-) carotid artery and radial artery pulse are palpable pulse 90 beats / minute, the content is quite, equal symmetric CRT