Professional Documents
Culture Documents
Disusun oleh:
Noermawati Dewi
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. E
• Date of birth : 03 July 2015
• Gender : Boy
• Age : 25 months (2 years 1 months old)
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 26-08-2017 (23.00)
• Date of examination : 27-08-2017 (07.00)
ANAMNESIS
Chieft Complaint
Seizure
HISTORY OF ILLNESS
The day on admission
• The mother said that the patient got fever (+)
on 19.00, then he got seizure. The seizure <15
minute, and it was the third time in a day. He
was still conscious when seizure happened.
There was no vomit (-), cough (-), runny nose
(-).
• The defecation was normal. But when the
patient urinated, he got bulging on the end of
penis.
HISTORY OF PAST ILLNESS
The mother gave birth to her baby assisted by a midwife with normal
delivery. 40 weeks pregnancy age, baby born with body weight 3300
grams and body lenght 54 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
• Breastmilk + porridge of filter and vegetables teams smoothed a day 2-3 times small dishes of food is always
finished
• Breastmilk + soft rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished
• Formula + rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished
• The answer “Yes” = 9 poin
Vital Sign
Blood Pressure :-
Heart rate : 108x/ menit
Respiratory Rate : 24x/ menit
Temperature : 37,2º C
Nutrisional status
21
PEMERIKSAAN KHUSUS
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 : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)
Genital
•Fimosis (+)
24
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 sulit dievaluasi
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-)
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 : 108x/ menit
Respiratory Rate : 24 x/ menit
Temperature : 37,2º C
Genital : fimosis (+)
Laboratorium
Bacterial infection
ASSESMENT
1. Kejang
2. Fimosis
Demam Komplek
• DD : • DD:
• Kejang konversi
ACTION PLAN
• Observation of vital signs
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
1 potong pepaya 100gr: 46 kalori
` PLAN
THERAPY