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FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. M
• Date of birth : 26 May 2016
• Gender : boy
• Age : 16 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 12-10-2017 (14.00) pm
• Date of examination : 12-10-2017 (14.15)pm
ANAMNESIS
Chieft Complaint
Water stool
HISTORY OF ILLNESS
2 days before admission
• The mother said that on Wednesday evening, the
patient got vomit 2x after he drink or eat. With his
fever up and down (+) previously already given
paracetamol 150mg syrup. Cough (+) but not
accompanied by secrections, runny nose (+).
• The defecation and urination was normal.
HISTORY OF ILLNESS
1 days before admission
• The patient still got vomit 3x. Fever (+), runny nose
(+), cough (+).
• The appetite had decreased
• The defecation and urination was normal
HISTORY OF ILLNESS
The mother gave birth to her baby assisted by a obstetrician with a normal
born spontaneously delivery. 38 weeks pregnancy age, baby born with
body weight 2600 grams and body lenght 47cm . At the time of birth the
baby cries instantly, there was no congenital defect at birth.
The baby boy was born crying, active motion, red skin color, not
blue but yellow skin color (+), got milk on first day, urination and
defecation less than 24 hours
Age 5-6months
• Formula ± 6 bottles /day
Age 6 -9 months
• Formula + porridge of filter and vegetable teams smoothed 2-3 small dishes per day
• Formula + soft rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished
Conclusion : history of feeding quality was not good and quantity was
good
• The answer “Yes” = 10 poin
Vital Sign
Blood Pressure :-
Heart rate : 132x/ menit
Respiratory Rate : 24x/ menit
Temperature : 38,7º C
Nutrisional status
23
PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), 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 : symmetry right and left There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)
Sensibilitas Tonus
N N N N
N N N N
Reflek patologis
a. Reflek babinski= -
b. Reflek oppenheim=-
c. Kaku kuduk =-
Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-)
Liver : normal
Spleen : normal
•Warm of acral
•Perfusion of tissue is good
27
PHYSICAL EXAMINATION
Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring hiperemis(+)
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)
Physical examination
Blood Pressure : -
Heart rate : 132x/ menit
Respiratory Rate : 24 x/ menit temperature : 38,7º C
Thorax Lung: normal limits
Laboratorium
Normal limits
ASSESMENT
kebutuhan energi :
Nasi putih 100 gram: 178 kalori
Tumis bayam 100 gr : 193 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
` PLAN
THERAPY
• Zink 20mg/hari
• L-bio 2x1 sachet
• Ondancentron 0,1mg/kgBB x 9kg = 0,9 1mg/ 12jam
FOLLOW UP
TANGGAL SOA PLANNING
12-10- -S/on the morning, vomit (-), diare (-), recovery cough, P/ -RL : 19 tetes
2017 recovery runny nose, urination was normal. But on the makro
Jam afternoon diarrhea 2x. • -Zink 20mg/hari
O/ • L-bio 2x1 sachet
15.00
- KU : Compos Mentis • Ondancentron
- HR : 132x/menit 1mg/ 12jam
- RR : 24 x/menit
- S : 38.2 • Ambroxol : 4,5 mg
• Salbutamol : 0.9
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
mg
- Faring sulit dievaluasi. • Pseudoefedrin: 9
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-) mg
- Abd : peristaltik (+), timpani (+)
- Extremities : normal