CASE REPORT SOCIAL PEDIATRICS

Arranged by :Aldila Purani Putri

Amalia Puswitasari

Amarilla Riandita

Duta Indriawan

Ericko Hartanto LaymenaSupervisor:

dr. Hendriani Selina, Sp. A(K)PEDIATRICS DEPARTMENTFACULTY OF MEDICINE

DIPONEGORO UNIVERSITYSEMARANG2012CASE REPORT SOCIAL PEDIATRICSI. IDENTITYName

: S.A.LDate of birth

: 17th June 2011Age

: 18 Months 22 DaysSex

: FemaleReligion

: MoslemAddress

: Jl. Jatiluhur RT 01 RW 04 SemarangDate of visit

: 7 Januari 2013Registration number: C386488Name of father: Mr. RAge

: 42 yearsOccupation: entrepreneur Education

: Senior high schoolReligion

: MoslemRace

: JavaneseAddress

: Jatiluhur RT 01 RW 04 Semarang Name of mother: Mrs. N.D.Age

: 37 yearsOccupation: entrepreneurEducation

: Senior high schoolReligion

: MoslemRace

: JavaneseAddress

: Jatiluhur RT 01 RW 04 Semarang II. Basic INFORMATIONA. SUBJECTIVEANAMNESIS

Alloanamnesis with patients mother on 9th January 2013 at 15.00 (GMT + 07.00) in her parents house.The Main Complain

Can not walkHistory of Present IllnessPatient can not walk, already able to sit without support since the age of 1 year 2 months. Patient can stand when supported, but fell when released. She can crawls, can not say several words, only says "a", "maem", "mbah", "ka", "pak". She can smile and laugh.History of Disease Before (-)There was no history of previous illnessFamily History of DiseasePatients father and mother are healthyFamily Tree

Socioeconomics HistoryFather as an entrepreneur. Mother as an entrepreneur. Monthly income about 900,000.00. Bear one child. Hospital fee is paid with personal expense.Summary: socio-economically disadvantagedHistory of Prenatal CareWhen deliver her, her mother obstetric status is G3P2A1, 35 years old, 38 weeks pregnant, antenatal care once a month with midwife, tetanus toxoid immunization once, ANB (-), fever (-), Hypertension (-), Diabetes Mellitus (-), Rash (-), take vitamins and iron supplements.

Impression: prenatal care enoughRegular pregnancy check at the health center> 4 times. 1x TT immunization, denied a history of trauma, history of fever and illness during pregnancy denied, denied a history of radiation exposure. Drugs taken during pregnancy blood added vitamins and tablets. Impression: prenatal care enoughHistory of Pregnancy and ChildbirthNoPregnancy and childbirthDate of birth / age

1Female, 38 weeks gestation, delivery mode SCTP as indicated PROM, assisted by General Praticioner, birth weight 3000 grams, birth length is unknown, burst into tears17 June 2011 / 18 months 22 days

On 17 June 2011, was born a daughter of the mother G3P2A1. 38 weeks pregnant, the baby was born spontaneously in RSDK, assisted by General Praticioner, burst into tears, bluish (-), seizures (-), yellow (+) on day 2nd to 7th . Post natal History3 months old had a furuncle in her head, pus (+), small size. He parent brought her to a general pratitioner 2 times for treatment, the furuncles was not recover ad her parent brought her to dermatologist for the treatment and then she recover.

1 year old had diarrheal illness, was treated in hospital for 15 days, she was diagnosed diarrhea and urinary tract infections..History of ContraceptionPatients mother is currently using injectable contraceptives.Historical Development and Growth Growth by KMS:

birth weight 3000 grams, birth length unknown, present weight 10.150 grams, present height 82 cm, head circumference 48 cm, mid arm circumference 13 cm.

WAZ = -0,23

HAZ = 0,19

WHAZ= -0,45

HC= 1,18

Summary: well nourished, normal posture or stature, mesocephalLongitudinal: normal growth

Growth pattern : normal Development : Patient can not walk, already able to sit without support since the age of 1 year 2 months. Patient can stand when supported, but fell when released. She can crawls, can not say several words, only says "a", "maem", "mbah", "ka", "pak". She can smile and laugh.

History of Food and Drink From birth until now exclusively breast-fed children, according to the wishes of children 5-6x/hari, each sucking sekitar1 long-2 hours.

Milk SGM is given from the age of 1 year 2-3x/hari @ 120cc 4 tsp

Summary: exclusive breastfeeding, the quality and quantity is sufficient.History of ImmunizationsBCG: 1x (1 month)

Polio: 4x (0, 2, 4, 6 months)

Hepatitis B: 4x (0 months)

DPT: 3x (2, 4, 6 months)

Measles: 1x (9 months)

Summary: complete immunization.B. OBJECTIVEPHYSICAL EXAMINATIONS9th January 2013 at 15.00 (GMT + 07.00) in her parents house.

, age 18 months 22 days , weight 10150 grams , length 82 cm .General appearrance: concious, active, breath spontaneously (+).Status Internus:

Vital sign

: HR: 110 x/mnts Pulse: normal, content and tensin is enoughRR: 28 x/minute

t : 37oC

Head: HC: 48 cm (mesocephal)

Black hair, not easily revoked, flat large fontanel.Skin

: anemic (-), cyanotic (-), icteric (-).

Eyes: anemic palpebra conjunctiva (-), icteric sclera (-), pupillary reflex +N/+NEars: Discharge (-)

Nose: Discharge (-), breath lobe (-)

Mouth: cyanotic (-) dry lips (-), normoglossiNeck: symmetric, nnll enlargement (-)

Chest: symmetric, retraction (-)LungsI: symmetric, retraction (-)

Pa: cannot be assessed

Pe: resonant entire lung field

A: Basic sound : vesicular

Additional sound : wheezing -/-, ronchi -/-

Cor I: invisible ictus cordis

Pa: palpable ictus cordis on SIC IV LMC sinistra

Pe: cannot be assessed

A: normal I II heart sound, murmur (-), gallop (-)Abdomen I: flat abdomen

Pa: Supel, not palpable liver and spleen

A: intestinal sound (+) normal

Pe: Tymphani

Limbs

:

superior

inferior

Oedem

- / -

- / -

Cold acral - / - - / -

Cyanosis - / - - / -

Capillary refill < 2 < 2

Physiological reflexes +/+ +/+

Tone +/+ +/+Additional AssessmentDate : 9th January 2013Anthropometric

Weight = 1015 grams Length = 82cm Age = 18 month 22 days

Head circumference = 48 cm Chest circumference = 45 cm

MUAC = 13 cm

WAZ = - 0,23

HAZ = 0,19

WHZ = - 0,45

HC = 1,18Assessment : well nourished, normal posture or stature, mesocephalDDSTConclusion:

Personal Social: fit to the present ageFine motor: fit to children aged 11 months

Language skills: fit to children aged 13.5 months

Gross motor: fit to children aged 7 months

Summary: Global Developmental Delayed (from sectors fine motor, language, gross motor)

Early language examination scale millestone examinationconclusion:

Auditory Expresive: fit to children aged 2 months

Auditory receptive: fit to children aged 10 months

Visual: fit to children aged 12.5 months

Global Language: fit to children aged 11 months

Capute Scale Examinationconclusion:

DQ CAT = 70

Clams = 50

FSDQ = 60

Summary: Mental Retardation Cairan (cc)Kalori (kkal)Protein (g)

Kebutuhan 24 jam

ASI ad Lib

C. Home Visite1. Condition of HouseholdOwner: parentSize: 30 m2House yard: -Occupant: 4 personsTerrace: Available, sized 3 x 2 m2Wall: brickFloor: ceramicNumber of rooms: 6 rooms (1 living room, 1 bed room, 1 kitchen, 1 rest room, 1 dining room)

Rest room: private restroom sized 2 x 2 m2, open bucket 0,6 x 0,8 m2, cleaned once a week. Ventilation : lack of ventilation (no ventilation in bedroom)Water source : PAM waterWater storage: plastic bucketHygiene and sanitation: good enough2.Daily activity

The patient lived with his father, mother, and a brother. His father and mother worked as a self-employed people. Children cared for by the mother. Children are rarely given a toy, just held or lap. Food and drink cooked before eating. Wearing hoods food in food storage. Cutlery washed with soap. 2x daily bath with well water and soap, washing dirty clothes every day. Houses were washed 2x a day. The bin with a lid, and placed in the back of the house, every 1 days dibuanh into landfills. If there is a sick family member brought to the health center or hospital3.EnvironmentPatient home located between buildings houses in Jatiluhur. The distance between crowded homes. Terrace is used for a place to sit. Patient-walled house wall, a window in the front living room, bedroom and kitchen. Adequate ventilation. In the rainy season did not flood. Objec less clear about one ditch that flows smoothly. The trash no cover. The road in front of the house in the form of cement roads with a width of 2.5 m, only pedestrians can pass.

Summary : - Cleanliness and home environments quite

- The pattern of life and daily health not good1II.PROBLEMS

Active ProblemsDatePassive ProblemDate

1. Global Developmental delay09-01-2013Sosial ekonomi kurang09-01-2013

IV.DIAGNOSIS Diagnosis of main illness: (-) Diagnosis of additional illness: (-) Diagnosis of growth

: normal growth Diagnosis of develompent : Global Developmental Delayed (from sectors fine motor, language, gross motor Diagnosis of nutrition

: well nourished, normal posture or stature, normoweight, mesocephal Diagnosis of immunisation : complete basic immunisation according to age Diagnosis of socio-economy: Socio-economic disadvantagedVI.INITIAL PLAN1. Assesment:Global Developmental DelayedDiagnosis:Subjective: (-)Objective: (-)Therapy:(-)Monitoring:(-) Education:Explain to parents about the child's weight, explains possible causes, and provide education so that mothers breastfeed exclusively for as often as the child wishes..

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