ANAMNESIS

Chief Complaint

Rashes all over the body

 HISTORY OF ILLNESS

6 days before admission

• Nasal discharge (+)

• Sub febris
• No cough
• No vomitus
• No seizure and loss of consiousness
• Normal feeding
• Normal defecation
 HISTORY OF ILLNESS

4 days before admission

• Fever over come

• No cough and rhinorhea
• In the morning some rashes appeared on his face, and in the evening,
some appeared on his neck and trunk, itchy (+).
• His mother gave his betasone cream.
 HISTORY OF ILLNESS

2 days before admission

• He has rashes all over his body including both face, neck, trunk, axilla,
legs and arms, itchy especially when sweating (+)
• The mother gave his betasone cream three times daily
• Rhinorhe (+)
• Fever (-)
• Cough (-)
• Diarrhea (-), nausea (-), vomitting (-),
 HISTORY OF ILLNESS

The day admission

• The mother brought her to the pediatrician

• Fever (-)
• He has rashes all over his the body
• The rashes have structure like a sand
• Can’t sleep at night because an itchy
• Cough (-)
• Diarrhea (-), nausea (-), vomitting (-), decreased feeding (-),
konjunctivitis (-), dipsneu (-),
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of Seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food &drug : Denied
History of hospitalized : Denied

Conclusion: there is no history of past illness

 HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied

History of Seizure without fever : Denied
History of Anemia : Denied
History of asma : Denied
History of atopi : Denied
History of hypertention : (+) grandmother
History of Diabetes Mellitus : (+) grandfather

Conclusion: there is history of illness in family , hypertention and DM

 PEDIGREE

Ny. S 30 years old

Tn. S 33 years old

= DIABETES MILITUS

= HYPERTENSION
An. F 6 years 4 Month

Conclusion : there was an illness inherited

 HISTORY OF PREGNANCY

Mother with P1A0 is pregnant at 25 years old. Mother began to

check pregnancy and routinely control to the obstetriciant.
During pregnancy the mother does feel nausea, vomiting and
dizziness that interfere with daily activities. His mother is often
hospitalized because anemia. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension.

Conclusion: the history of pregnancy was good

 HISTORY OF DELIVERY
The mother gave birth to her baby assisted by a doctor with a sectio
caesaria. 42 weeks pregnancy age, baby born with body weight 3700
grams with body length 52 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.

Conclusion : history of delivery was not good (sectio caesaria because of

post date)

HISTORY OF POST DELIVERY

The baby was born crying, active motion, red skin color, not blue
and not yellow skin color, got milk on first day, urination and
defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents, and young

brother. Ceramic-floored patient houses, walled walls, tile roofs,
adequate ventilation, bathrooms in the house, water source from
well water.
A few days before the patient hospitalized, neighbors, family,
and her friends on elementary school have not experienced similar
complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to the mother's confession, the patient have
complete vaccine

Conclusion : history of vaccine was complete acording to

KEMENKES
 HISTORY OF FEEDING
0 – 6 month old
• Exclusive breastmilk + formula milk

6 – 8 month old
• Breastmilk + Formula + instan food 1 day 3 small bowls

8 – 10 month old
• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes

10 – 12 month old
• Formula + Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes and always spent

1 – 2 years old
• Formula + White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food

2 – 6 years old
• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food

Conclusion : history of feeding from quality and quantity not good

 HISTORY OF GROSS MOTOR

Competence Age of achievment Normal age

Head up 90 degress 3 month 3-4 month
Sit no support 6,5 month 6 – 7 month
Stand alone 11 month 11 - 13 month
Walk well 13 month 11-15 month
Runs 17 month 13-20 month
Jump up 24 month 21-26 month
Balance each foot 1 second 3 years 2,5-4 years
Balance each foot 4 second 4,5 years 3,5-5 years
Balance each foot 6 second 5,5 years 4-6 years

Conclusion :Development history of Gross motor according

to age
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 HISTORY OF FINE MOTOR

Competence Age of achievment Normal age

Reaches 5 month 4,5 – 5,5 month
Scribbles 12 month 12 – 17 month
Tower of 2 cubes 16 month 13-21 month
Thumb wiggle 3,5 years 2,2-3,9 years
Copy ○ 4 month 3-4 years
Pick longer line 5 years 3-5,3 years
Copy □ 6 years 4,8-6 years

Conclusion :Development
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 HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 11 month 7 – 13 month
Speech fluently 28 month 24-51 month
Name 4 pictures 3 years 2-3 years
Name 4 colors 4,5 years 3-4,8 years
Define 7 words 6 years 4 – 6 years

Conclusion :Development history of language according to

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 HISTORY OF PERSONAL SOCIAL
Competence Age of achievment Normal age

Smile spontaneously 1 month 0-2month

Feed self 6 month 5 – 6,5 month
Indicate wants 12 month 7,5- 13 month
Drink from cup 15 month 9-17 month
Remove garment 22 month 14 month – 2 years
Wash and dry hands 2,5 years 19 month - 3 years
Put on t-shirt 3 years 2,5- 3,5 years
Play board/card games 4,5 years 2,8- 5 years
Brush teeth, no help 6 years 3 - 6 years

Conclusion :Development history of social according to age

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 History of DEVELOPMENT and
INTELLEGENT

• Conclusion: History of development and

intellegent was good
 Physical Examination
 General appearance
General appearance : alert

 Vital Sign
Blood Pressure :-
Heart rate : 88 x/ menit
Respiratory Rate : 24 x/ menit
temperature : 36,8° C
 Nutrisional status

6 years 4 month WEIGHT : 32 KG Height : 120 CM BMI: 22.2

- Weight // age : > 2 SD normal

- Height // age : > 0 SD normal
- BMI // age : > 3 SD overweight

Conclusion : the nutritional status is overweight

 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: dry
Edema (-) does not exist
Multiple exanthem punctiform eruption on whole the
body. The rash has a coarse texture like sandpaper.

• Conclusion : Multiple exanthem punctiform

eruption on whole the body. The rash has a
coarse texture like sandpaper.

24
 PEMERIKSAAN FISIK
Neck : tender cervical lymphadenopathy (-) , no increase jugular venous, ,
Multiple exanthem punctiform eruption (+), the rash coarse texture
like sandpaper.
Chest : Simetris, retration (-), miss the motion (-), Multiple exanthem
punctiform eruption (+), coarse texture like sandpaper.
• 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 dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Multiple exanthem punctiform eruption (+), coarse

texture like sandpaper.
Stomach : Inspeksi : Distensi (-), sikatrik (-), purpura (-), Multiple exanthem
punctiform eruption (+),
Auskultasi : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-) Region
Inguinalis dextra, turgor kulit menurun (-), acites (-),
the rash coarse texture like sandpaper.
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : Multiple exanthem punctiform eruption (+), the rash coarse texture
like sandpaper on whole body.
 Ekstermitas

•Warm of acral
•Perfusion of tissue is good
•Multiple exanthem punctiform eruption (+),

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good
•the rash coarse texture like sandpaper.

Conclusion : Multiple exanthem punctiform eruption (+), the rash coarse

texture like sandpaper
27
 PHYSICAL EXAMINATION
Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), reflek cahaya (+/+)
isokor (+/+), sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-), tonsil hiperemis (-)
Mouth : Stomatitis (-), perdarahan gusi (-), pharynx hiperemis (+), exudative
tonsils (-), tongue hiperemis (+) and papilae protrude (strawberry
tongue)
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik), Multiple exanthem punctiform eruption (+), the rash coarse
texture like sandpaper.
Lymph nodes : tender cervical lymphadenopathy (-)
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
(-/-), Multiple exanthem punctiform eruption (+), the rash coarse
texture like sandpaper.
Conclusion: , pharynx hiperemis (+), tongue hiperemis (+) and papilae protrude
(strawberry tongue) Multiple exanthem punctiform eruption (+), the rash coarse texture
like sandpaper,
 RESUME
ANAMNESIS
Rashes all over the body, stomatitis 10 days before admission, fever 48 hours in 2
days before onset, cough (+), sore troath (+), can’t sleep at night because itchy,
she have history of alergic seafood and from the mother

Physical examination
pharynx hiperemis (+), tongue hiperemis (+), papilae protrude (strawberry
tongue), Multiple exanthem punctiform eruption (+) starts from neck to the all
over body, the rash coarse texture like sandpaper, tender cervical
lymphadenopathy (+)
 ASSESMENT

Diagnosis
Scarlet fever /demam scarlatina
DD : kawasaki disease
rubela
measles
miliaria
stapylococcal scalded skin syndrome,
 ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the effect of medication
• Observation sign of complications

DIAGNOSIS ENFORCEMENT PLAN

• Blood examination
• Culture Throat
 Terapi

Energy needed : Formula + White rice, eggs,

Kalori :32 x 90= 2880 kkal meat, fish, vegetables a day 3 times a large plate
Protein : 32 x 1.2 = 38.4 g of food.
Cairan : 32 x (90-110)= (2880  rute oral
– 3250) ml
 ` PLAN
THERAPY

• Antihistamin :
Cetirizine capsul 5 mg/daily (5-10 mg/daily)

• Antibiotik :
Amoxicilin 25-40 mg/kgbb/times
sediaan amoxicillin : 500 mg
32 kg x 25 mg = 800 mg /times
THANK YOU