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Chieft Complaint
Vomitus
HISTORY OF PRESENT ILLNESS
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
6 – 8 month old
8 – 10 month old
• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes
10 – 12 month old
• Formula + Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes and always spent
1 – 3 years old
• Formula + White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food
Conclusion :Development
12/14/2018
add footerhistory
here (go toof fine
view menumotor
and according to age 12
choose header)
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
Speech fluently 28 month 24-51 month
Name 4 pictures 2.3 years 2-3 years
Vital Sign
Blood Pressure :-
Heart rate : 122 x/ menit
Respiratory Rate : 28 x/ menit
temperature : 37.2° C
Nutrisional status
21
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 (-/-)
•Warm of acral
•Perfusion of tissue is good
24
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 (-
/-)
Diagnosis
faringitis
DD : food poisoning
measles
rubella
dengue fever
urinary track infection
ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the effect of mediaction
• Blood examination
• Urine routine
• RO thorax
` PLAN
THERAPY
• fluid maintenance
100 x 10 = 1000 ml
100 x 2.7 = 270
total 1270
oral = 423
IV = 847 /3/24 = 11 dpm/24 hour
• Antipiretics
• Paracetamol syrup 10 mg/kgbb/times(4hours)
• 10 x 12.7 = 127 mg/4 hours = 5.3 ml / 4 hours p.r.n fever
Terapi
Calori : 12.7 x 102 = 1295 kkal Energy needs : White rice, eggs, meat, fish,
Protein : 12.7 x 1.23 = 15.562 g vegetables a day 3 times a large plate of
Fluid : 100 x 10 = 1000 ml food + 1 glasess milk + snack 2 times per
100 x 2.7 = 270 day
total 1270 rute oral
oral = 423
IV = 847 /3/24 = 11 dpm/24 hour
THANK YOU