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Disusun oleh:
Noermawati Dewi
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. I
• Date of birth : 2 Juny 2013
• Gender : Boy
• Age : 4 years 2 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 19-08-2017 (00.00)
• Date of examination : 19-08-2017 (06.30)
ANAMNESIS
Chieft Complaint
Fever
HISTORY OF ILLNESS
4 day before admission
= Kejang Demam
The mother gave birth to her baby assisted by a midwife with a normal
delivery. 39 weeks pregnancy age, baby born with body weight 3500
grams and body lenght 48 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 not yellow skin color, got milk on first day, urination
and defecation less than 24 hours
Age ≥ 12 months
• Rice + vegetables + egg+ fish 1 day 2 small dishes and always finished
2/7/2018
Conclusion :Development
add footerhistory
here (go toof fine
view menumotor
and according to age 15
choose header)
HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Bersuara 3 bulan 1 – 3 bulan
Menoleh ke arah suara 5 bulan 3,5 – 7 bulan
Meniru bunyi kata-kata 6 bulan 3,5 – 9 bulan
Berbicara beberapa kata 2 tahun 17-39 bulan
Bicara semua dimengerti 2,5 tahun 1,5-3 tahun
Menyebut 4 warna 4 tahun 3-4 tahun
Vital Sign
Blood Pressure : 120/60 mmHg
Heart rate : 70x/ menit
Respiratory Rate : 22x/ menit
temperature : 36,8º C
Nutrisional status
23
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 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 (-/-)
•Warm of acral
•Perfusion of tissue is good
26
PHYSICAL EXAMINATION
• Analisa Hb (HPLC)
- HbA2 : >13 % (2.3-3.5)%
- HbF : 32,4 % (<1) %
- Fraksi lain: -
RESUME
ANAMNESIS
Pale
Physical examination
Blood Pressure : 120/60 mmHg
Heart rate : 70x/ menit
Respiratory Rate : 22 x/ menit
temperature : 36,8º C
Laboratorium
Anemia
ASSESMENT
Differential Diagnosis
Anemia Hemolitik Autoimun
Sickle Cell
Malaria
ACTION PLAN
• Observation of vital signs
• Elektroforesis Hb
Terapi
• Vit E: 2 x 200IU
FOLLOW UP
TANGGAL SOA PLANNING
17-8- -S/on the morning, the patient felt better P/
2017 O/ -Asam folat: 2 x 1mg
Jam - KU : Compos Mentis -Vit C: 50mg/hari
07.00 - HR : 78x/menit -Vit E : 2x200 IU
- RR : 22 x/menit
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (+)
- Hb: 13,5 g/dl
- Feritin : 478,86