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Chieft Complaint
Cough
HISTORY OF PRESENT ILLNESS
The mother gave birth to her baby assisted by a doctor with a sectio
caesaria. 38 weeks pregnancy age, baby born with body weight 3500
grams with body length 48 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.
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
• Exclusive breastmilk
6 – 8 month old
8 – 10 month old
• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 2 small dishes
10 – 12 month old
• Breastmilk + Formula + Rice porridge, protein teams smoothed 1 day 2 small dishes
12 – 17 month old
• Breastmilk + Formula + porridge, eggs, meat, fish a day 32times a large plate of food
Conclusion :Development
12/10/2018
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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
6 words 17 month 13-22 month
Vital Sign
Blood Pressure :-
Heart rate : 112 x/ menit
Respiratory Rate : 34 x/ menit
temperature : 38,8° C
Nutrisional status
23
PHYSICAL EXAMINATION
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retraction (-), 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 dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)
•Warm of acral
•Perfusion of tissue is good
26
PHYSICAL EXAMINATION
Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), light reflek (+/+)
isokor (+/+), sunken eyes(+/+),
Nose : Secret (-), epistaksis (-), breath nostrills (-/-)
Ears : Secret (-), membrane hiperemis (-)
Mouth : Stomatitis (-), gingivitis (-), sianosis (-), pharynx hiperemis (+), exudate
(-), mucousa lips and mouth dry (+),
Skin : colour was white, pale (-), Ikterik (-), Sianosis (-)
Lymph nodes : enlargement limfadenopathy (-)
Muscle : pharese(-), atrofi (-), myalgia (-)
Bone : deformity (-)
Joints : free movement
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), warm akral (+/+), petekie (-
/-)
Conclusion: there is sunken eyes, pharynx hyperemis and dry mucousa lips and
mouth
RESUME
ANAMNESIS
Fever 3 days
Weak
Irritable
Tears do not come out when crying
Decreased feeding but excessive thirst
Urination just 1 times/day, the colour is yellow to brown
Physical examination
Fever
Look thirsty
Sunken eyes, pharynx hyperemis and dry mucousa lips and mouth
Skin turgor > 2 second
ASSESMENT
Diagnosis
1. Rhinofaringitis Acute et causa
DD : Viral Infection
Bacterial infection
2. Severely dehydration
ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the dehidration sign
• Observation the effect of mediaction
• Blood examination
• Electrolyte examination
` PLAN
THERAPY
• Rehidration plan C
Infus RL 100ml/kgBW
30 ml/kgBW= 30 ml x 7.9 kg = 237 ml / ½ hours
= 237x20/30 = 158 dpm macro
70 ml/kgBW= 70 ml x 7.9 kg = 553 ml / 2,5 hours
= 237x20/150 = 32 dpm macro
• Antipiretic
Paracetamol syrup 10 mg/ kgbw/4 hours
Paracetamol syrup 10 mg x 9 = 90 mg = 4ml/4 hours (120/5ml)
Terapi