CASE REPORT SOCIAL PEDIATRICS

Arranged by :
Aldila Purani Putri
Amalia Puswitasari
Amarilla Riandita
Duta Indriawan
Ericko Hartanto Laymena
Supervisor:
dr. Hendriani Selina, Sp. A(K)

PEDIATRICS DEPARTMENT
FACULTY OF MEDICINE
DIPONEGORO UNIVERSITY
SEMARANG
2012

CASE REPORT SOCIAL PEDIATRICS

I.

IDENTITY
Name

: S.A.L

Date of birth

: 17th June 2011

Age

: 18 Months 22 Days

Sex

: Female

Religion

: Moslem

Address

: Jl. Jatiluhur RT 01 RW 04 Semarang

Date of visit

: 7 Januari 2013

Registration number

: C386488

Name of father

: Mr. R

Age

: 42 years

Occupation

: entrepreneur

Education

: Senior high school

Religion

: Moslem

Race

: Javanese

Address

: Jatiluhur RT 01 RW 04 Semarang

Name of mother : Mrs. N.D.

Age

: 37 years

Occupation

: entrepreneur

Education

: Senior high school

Religion

: Moslem

Race

: Javanese

Address

: Jatiluhur RT 01 RW 04 Semarang

II.

BASIC INFORMATION
A. SUBJECTIVE
ANAMNESIS
Alloanamnesis with patients mother on 9th January 2013 at 15.00 (GMT
+ 07.00) in her parents house.
The Main Complain
Can not walk
History of Present Illness
Patient can not walk, already able to sit without support since the age of 1
year 2 months. Patient can stand when supported, but fell when released.
She can crawls, can not say several words, only says "a", "maem",
"mbah", "ka", "pak". She can smile and laugh.
History of Disease Before (-)
There was no history of previous illness
Family History of Disease
Patients father and mother are healthy

Family Tree

Socioeconomics History
Father as an entrepreneur. Mother as an entrepreneur. Monthly income
about 900,000.00. Bear one child. Hospital fee is paid with personal
expense.
Summary: socio-economically disadvantaged
History of Prenatal Care
When deliver her, her mother obstetric status is G3P2A1, 35 years old, 38
weeks pregnant, antenatal care once a month with midwife, tetanus toxoid
immunization once, ANB (-), fever (-), Hypertension (-), Diabetes Mellitus
(-), Rash (-), take vitamins and iron supplements.
Impression: prenatal care enough
Regular pregnancy check at the health center> 4 times. 1x TT
immunization, denied a history of trauma, history of fever and illness
during pregnancy denied, denied a history of radiation exposure. Drugs
taken during pregnancy blood added vitamins and tablets.
Impression: prenatal care enough
History of Pregnancy and Childbirth
No
1

Pregnancy and childbirth

Female, 38 weeks gestation, delivery mode

Date of birth / age

17 June 2011 / 18 months

SCTP as indicated PROM, assisted by

22 days

General Praticioner, birth weight 3000 grams,

birth length is unknown, burst into tears
On 17 June 2011, was born a daughter of the mother G3P2A1. 38 weeks
pregnant, the baby was born spontaneously in RSDK, assisted by General
Praticioner, burst into tears, bluish (-), seizures (-), yellow (+) on day 2nd to
7th .

Post natal History

4

3 months old had a furuncle in her head, pus (+), small size. He parent
brought her to a general pratitioner 2 times for treatment, the furuncles was
not recover ad her parent brought her to dermatologist for the treatment and
then she recover.
1 year old had diarrheal illness, was treated in hospital for 15 days, she was
diagnosed diarrhea and urinary tract infections..
History of Contraception
Patients mother is currently using injectable contraceptives.
Historical Development and Growth

Growth by KMS:
birth weight 3000 grams, birth length unknown, present weight 10.150
grams, present height 82 cm, head circumference 48 cm, mid arm
circumference 13 cm.
WAZ = -0,23
HAZ = 0,19
WHAZ= -0,45
HC= 1,18
Summary: well nourished, normal posture or stature, mesocephal
Longitudinal: normal growth
Growth pattern : normal

Development :
Patient can not walk, already able to sit without support since the age of 1
year 2 months. Patient can stand when supported, but fell when released.
She can crawls, can not say several words, only says "a", "maem",
"mbah", "ka", "pak". She can smile and laugh.

History of Food and Drink

5

 From birth until now exclusively breast-fed children, according to the

wishes of children 5-6x/hari, each sucking sekitar1 long-2 hours.
Milk SGM is given from the age of 1 year 2-3x/hari @ 120cc 4 tsp
Summary: exclusive breastfeeding, the quality and quantity is sufficient.
History of Immunizations
BCG: 1x (1 month)
Polio: 4x (0, 2, 4, 6 months)
Hepatitis B: 4x (0 months)
DPT: 3x (2, 4, 6 months)
Measles: 1x (9 months)
Summary: complete immunization.
B. OBJECTIVE
PHYSICAL EXAMINATIONS
9th January 2013 at 15.00 (GMT + 07.00) in her parents house.
, age 18 months 22 days , weight 10150 grams , length 82 cm .
General appearrance: concious, active, breath spontaneously (+).
Status Internus

Vital sign

: HR

: 110 x/mnts

Pulse : normal, content and tensin is enough

RR
t
Head

: HC

: 28 x/minute
: 37oC
: 48 cm (mesocephal)

Black hair, not easily revoked, flat large fontanel.

Skin

: anemic (-), cyanotic (-), icteric (-).

Eyes

: anemic palpebra conjunctiva (-), icteric sclera (-),

pupillary reflex +N/+N

Ears

: Discharge (-)

Nose

: Discharge (-), breath lobe (-)

Mouth

: cyanotic (-) dry lips (-), normoglossi

Neck

: symmetric, nnll enlargement (-)

Chest

: symmetric, retraction (-)

Lungs

: symmetric, retraction (-)

Pa : cannot be assessed
Pe : resonant entire lung field
A : Basic sound : vesicular
Additional sound : wheezing -/-, ronchi -/Cor

: invisible ictus cordis

Pa : palpable ictus cordis on SIC IV LMC sinistra

Pe : cannot be assessed
A : normal I II heart sound, murmur (-), gallop (-)
Abdomen

: flat abdomen

Pa : Supel, not palpable liver and spleen

A : intestinal sound (+) normal
Pe : Tymphani
Limbs

:
superior

inferior

Oedem

-/-

-/-

Cold acral

-/-

-/-

Cyanosis

-/-

Capillary refill

<2

Physiological reflexes
Tone

-/<2

+/+

+/+

+/+

+/+

Additional Assessment

Date : 9th January 2013

Anthropometric
Weight = 1015 grams

Length = 82cm

Age = 18 month 22 days

Head circumference = 48 cm Chest circumference = 45 cm

MUAC = 13 cm
WAZ = - 0,23
HAZ = 0,19
WHZ = - 0,45
HC = 1,18
Assessment : well nourished, normal posture or stature, mesocephal
DDST
Conclusion:
Personal Social: fit to the present age
Fine motor: fit to children aged 11 months
Language skills: fit to children aged 13.5 months
Gross motor: fit to children aged 7 months
Summary: Global Developmental Delayed (from sectors fine motor,
language, gross motor)
Early language examination scale millestone examination
conclusion:
Auditory Expresive: fit to children aged 2 months
Auditory receptive: fit to children aged 10 months
Visual: fit to children aged 12.5 months
Global Language: fit to children aged 11 months

Capute Scale Examination

conclusion:
DQ CAT = 70
Clams = 50
FSDQ = 60
Summary: Mental Retardation
Cairan (cc)

Kalori (kkal)

Protein (g)

Kebutuhan 24 jam
ASI ad Lib

C. Home Visite
1.

Condition of Household

Owner

: parent

Size

: 30 m2

House yard

:-

Occupant

: 4 persons

Terrace

: Available, sized 3 x 2 m2

Wall

: brick

Floor

: ceramic

Number of rooms : 6 rooms (1 living room, 1 bed room, 1 kitchen, 1 rest

room, 1 dining room)
Rest room

: private restroom sized 2 x 2 m2, open bucket 0,6 x 0,8 m2,

cleaned once a week.

Ventilation

: lack of ventilation (no ventilation in bedroom)

Water source

: PAM water

Water storage

: plastic bucket

Hygiene and sanitation

: good enough

2. Daily activity

The patient lived with his father, mother, and a brother. His father and mother
worked as a self-employed people. Children cared for by the mother. Children
are rarely given a toy, just held or lap. Food and drink cooked before eating.
Wearing hoods food in food storage. Cutlery washed with soap. 2x daily bath
with well water and soap, washing dirty clothes every day. Houses were
washed 2x a day. The bin with a lid, and placed in the back of the house, every
1 days dibuanh into landfills. If there is a sick family member brought to the
health center or hospital
3. Environment
Patient home located between buildings houses in Jatiluhur. The distance
between crowded homes. Terrace is used for a place to sit. Patient-walled
house wall, a window in the front living room, bedroom and kitchen.
Adequate ventilation. In the rainy season did not flood. Objec less clear about
one ditch that flows smoothly. The trash no cover. The road in front of the
house in the form of cement roads with a width of 2.5 m, only pedestrians can
pass.
Summary : - Cleanliness and home environments quite
- The pattern of life and daily health not good

1II. PROBLEMS
Active Problems
1. Global
Developmental
delay

Date
Passive Problem
09-01-2013 Sosial
ekonomi
kurang

IV. DIAGNOSIS

Diagnosis of main illness

Diagnosis of additional illness: (-)

: (-)

10

Date
09-01-2013

Diagnosis of growth

: normal growth

Diagnosis of develompent

: Global Developmental Delayed (from

sectors fine motor, language, gross motor

Diagnosis of nutrition

: well nourished, normal posture or stature,

normoweight, mesocephal

Diagnosis of immunisation

: complete basic immunisation according to

age

Diagnosis of socio-economy : Socio-economic disadvantaged

VI. INITIAL PLAN

1. Assesment
Diagnosis

: Global Developmental Delayed

: Subjective : (-)
Objective : (-)

Therapy

: (-)

Monitoring : (-)
Education

: Explain to parents about the child's weight, explains

possible causes, and provide education so that mothers
breastfeed exclusively for as often as the child wishes..

11