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Disusun oleh:
Ratna Ayu Wulandari
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. A
• Date of birth : 13 Februari 2001
• Gender : Girl
• Age : 16 years 8 months old
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 27-10-2017 (13.15)
• Date of examination : 27-10-2017 (13.25)
ANAMNESIS
HISTORY OF ILLNESS
Sero imunologi
Urobilinogen 3.2 <16.9
Nitrit negatif negatif
29 yo 30 yo
16 years 8
Asthma
months old
The mother gave birth to her baby assisted by a obstetrian with a normal
delivery. 37 weeks pregnancy age, baby born with body weight 3000 grams
and body lenght 47 cm . 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 and yellow skin color, got milk on first day, urination and
defecation less than 24 hours
JENIS JM USIA
Hepatitis B 4 kali 0, 2, 3,4 bulan
BCG 1 kali 1 bulan
DPT 4 kali 2, 3, 4,18 bulan
Hib 3 kali 2, 3 , 4 bulan
Polio 4 kali 1, 2, 3, 4 bulan
Campak 3 kali 9, 24 bulan, SD kelas 1
dT 3 kali SD kelas 1, 2 , 3
HISTORY OF FEEDING
Umur
Conclusion :Development
1/8/19
history
add footer here (go to viewof social
menu and according to age 23
choose header)
History of Development
• Patient in Senior High School
• Patient can follow the lesson in the class
• Patient play with his friends and he has a lot of
friends
Physical Examination
General appearance
General appearance : Good
Awareness : Compos Mentis
Vital Sign
Blood Pressure : 100/80 mmHg
Heart rate : 90x/ menit
Respiratory Rate: 20x/ menit
Temperature : 37.0º C
Nutrisional status
28
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 lif
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi suprasternal (-)
Palpasi : There is no missed breath
Perkusi : Sonor
Auskultasi : Vesicular (+/+) normal, Rhonki (-/-), wheezing (-/-)
Conclusion : Abdominal pain in the epigastric region and the hypogastric region
Ekstermitas
•Warm of acral
•Perfusion of tissue is good
31
PHYSICAL EXAMINATION
Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), sianosis (-).
Skin : 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 : sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-/-)
Physical examination
• Physical Examination :
Vital sign : fever
Stomach : Abdominal pain in the epigastric region and the hypogastric region
Laboratorium
1. ISK
DD
Gastritis
ACTION PLAN
• Observasi Fever
kebutuhan energi :
Nasi putih 100 gram: 176kalori
Bayam rebus 100 gr : 23 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
Pepaya 100 gram : 46 kalori
` PLAN
THERAPY