Professional Documents
Culture Documents
Disusun oleh:
Noermawati Dewi
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. F
• Date of birth : 06 December 2016
• Gender : girl
• Age : 8 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 23-08-2017 (12.00)
• Date of examination : 23-08-2017 (18.30)
ANAMNESIS
Chieft Complaint
Fever
HISTORY OF ILLNESS
3 days before admission
• The mother said that on Sunday evening, the
patient got fever (+), and he had crying after
urination.
• The defecation was normal.
• There was no cough and runny nose.
HISTORY OF ILLNESS
2 days before admission
Tn. M 26 years
old
= Alergy of
Amoxicillin
The mother gave birth to her baby assisted by a obstetrician with a normal
delivery. 42 weeks pregnancy age, baby born with body weight 3000
grams and body lenght 49cm . 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
• Exclusive Breastmilk
• Breastmilk + instant porridge a day 3 times a small dishes and always finished
Age 7-now
• Breastmilk + porridge of filter and vegetable teams smoothed 3 small dishes per day and always finished
• The answer “Yes” = 10 poin
Vital Sign
Blood Pressure :-
Heart rate : 118x/ menit
Respiratory Rate : 26x/ menit
Temperature : 37,3º C
Nutrisional status
23
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 (-/-)
Genitalia
• OUE hiperemis (+)
• Fimosis (+)
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 (-), 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 : 118x/ menit
Respiratory Rate : 26 x/ menit
temperature : 37,3º C
Laboratorium
Leukositosis
Anemia
Trombositosis
ASSESMENT
1. Suspek infeksi
2. Common cold
Saluran Kemih
• DD : • DD:
• Dengue Fever • Rhinitis
• Morbili
• And others
infection
ACTION PLAN
• Observation of vital signs
kebutuhan energi :
Nasi tim 100 gram: 120 kalori
Bayam rebus 100 gr : 23 kalori
1/2 butir telur rebus : 77 kalori
1 tahu rebus: 32 kalori
1 ati ayam: 105 kalori
Pepaya 100 gram: 46 kalori
` PLAN
THERAPY
A/suspek ISK
FOLLOW UP
TANGGAL SOA PLANNING
25-8- -S/on the morning, fever (-), crying after urination (-) Paracetamol = 71 mg/
2017 O/ kali pemberian
Jam - KU : Compos Mentis tiap 4 jam bila
- HR : 122x/menit demam
07.00
Ceftriaxone = 532.5
- RR : 26 x/menit
mg/hari
- S : 36
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (+)
- Genitalia : OUE hiperemis (+) <<, fimosis (-)
- Urine Routine : normal limit
A/suspek ISK
THANK YOU