CHAPTER I

CASE ILUSTRATION

A. IDENTITY

a. Patient

 Name : Ch. A. A. M
 Date of birth :
 Sex : Female
 Address : Bekasi
 Tribe : Medan
 Religion : Katolik
 Education : Junior High School

b. Parents

Father

 Name : Mr. A.M

 Date of birth : 06-08-1974
 Sex : Male
 Address : Bekasi
 Tribe : Medan
 Religion : Katolik
 Education : Junior High School
 Occupation : Wiraswasta

Mother

 Name : Ms. A
 Date of birth : 14-04-1982
 Sex : Female
 Address : Bekasi
 Tribe : Medan
 Religion : Katolik
 Education : Senior High School
 Occupation :
 B. HISTORY

History was taken from the patient Allo anamnesis at on -0 -

2018 Bhayangkara Hospital Said Sukanto, East-Jakarta

a. Chief Complaint

b. Additional Complaint

c. History of Present Illness

d. History of Past Illness

Disease Age

Diarrhea

Otitis

Pneumonia

Tuberculosis

Seizure

Heart

Blood

Diphtheria

Measles

Mumps
 Dengue fever

Typhoid fever

Worms infection

Allergy

Accident

Operation

Kidney stone disease

Urinary Tract Infection

e. Allergy history
 Food allergy:
 Drugs allergy:
 Asthma bronchial:

f. Dietary history

Age (years) Breast/formula Fruit/ biscuit Milk porridge Steam Rice

milk

0-6 months

6 months–1
year

1-2 years

2-5 years

g. Growth and Development history

Motoric development

 Smile : months
 Slant : months
 Prone : months
 Sit : m
 Stand up : m/y
  Walk :
 Speak :

Development disorder :

Mental/ emotion : Stable

Puberty

 Pubic hair :
 Breast :
 Menarche :

h. Marital History

Antenatal care :

Maternity care :

Mode of delivery :

Gestational age : 37-38 weeks

Child status :

 Weight of birth : 3100 g

 Length of birth : 49 cm
 Head circumference : cm
 Congenital anomaly :-

i. Immunization history

Vaccine Basic (age) Repetition (age)

BCG

DPT/ DT

Polio

Measles

Hepatitis
B

MMR

T1PA
 j. Family history

Reproduction pattern

No Age Sex Alive Stillbirth Abortion Death Health

(cause) status

1 13 years old Female

2 11 years old Female

3 9 years old Male

4 5 years old Male

 Patient’s both parents were married when they were 31 years old and 23 years old, and
this is their first marriage.
 There are not any significant illnesses or chronic illnesses in the family declared.

History of Disease in Other Family Members / Around the House

 There is no one living around their home known for having the same condition as the
patient.

Family status

Father Mother

Marriage status 1 1

Year of marriage 31 years old 31 years old

Contraception - Mini pil

Health status

Family history:

There is no history of current infected family member. There isn’t any family member
with history of coughing.

k. Physical examination
Physical examination was held on january 10th 2018 at anggrek 2 ward Bhayangkara Hospital,
Said Sukanto Jakarta

a. General Examination

General condition : looked mild ill

Vital sign :

 Heart rate : bpm

 Respiratory rate : times
 Temperature : C

Anthropometry :

 Body weight : kg
 Body height : cm

Nutritional Status
Nutritional status measured based on National Center for Health Statistics (2000):
Interprestation based on WHO
 WFA(Weight for Age): under / above percentile
 HFA (Height for Age) : under / above percentile
Nutritional status :

 WFA : 49,5/40 x 100% = 123,8 % ()

 HFA : 136/148 x 100% = 91,8 % ()
 WFH : 49,5/42 x 100% = 117,8 % ()
conclusion: Nutrition status of the patient is good

b. Head to Toe Examination

Head :

 Measurement : 136 cm
 Hair and scalp : color black, normal distribution, strong
 Eyes : pale conjunctiva -/-, icteric sclera -/-,
 Ears : normotia, secret -/-, cement -/-, hyperaemic -/-
 Nose : deviation -, nostril breathing -, secret -, oedema conca -/-
 Lips : wet
 Teeth : caries dentist -
 Mouth : wet mucosa, stomatitis -, cyanosis -, coplick’s spot –
 Tongue : wet mucosa, clean, tremor –
 Tonsil : T1/T1 , detritus -, wide crypt -
 Pharynx : hyperaemic -

Neck : No enlargement of lymph node

Thorax :

 Chest wall : epigastric retraction –

Intercostal retraction –
 Pulmo :
 Inspection : symmetric when static and dynamic
 Palpation : vocal fremitus +/+
 Percussion : sonor +/+
 Auscultation : vesicular +/+, rhonchi -/- , wheezing -/-
 Cor :
 Inspection : ictus cordis can’t saw
 Palpation : ictus cordis felt in ICS V MCS
 Percussion :
o Margin of right heart : ICS IV PSD
o Margin of left heart : ICS V MCS
o Margin of waist heart : ICS III PSS
 Auscultation : S1S2 regular, murmur -, gallop –

Abdomen:

 Inspection : even
 Auscultation : bowel sound + normal
 Palpation : Suprapubic tenderness -, hepar and lien not palpable
 Percussion : tympani
 Other : ballotement -/-, CVA pain -/-

Anal and rectum: no abnormalities

Genital:
  Pubic hair : +
 Mons pubis: tanner’s stage 1

Extremity : warm, oedema -/-/-/-, CRT < 2s, normal ROM

Vertebrae : deformity -, kyphosis -, scoliosis -, lordosis -, gibbus –

Skin : cyanosis -, icteric -, petechi –

Neurologic examination:

 Physiologic reflex:
o Brachioradialis : +2/+2
o Biceps : +2/+2
o Triceps : +2/+2
o Patella : +2/+2
o Achilles : +2/+2
 Pathologic reflex :-

 Motoric :5555 5555

5555 5555

 Meningeal sign :-

(Foto pasien)

l. LABORATORIUM EXAMINATION
a. Routine blood count ( - -2018)
Results Normal range

Haemoglobin g/dL

Leucocyte 5.000-10.000 u/dL

Haematocrit 37-43 %

Thrombocyte 150.000-400.000 /Ul

b. Urine ( - -2018)
Results Normal range
 Color

Clarity

Reaction/ Ph 5-8,5

Density 1.000-1.030

Protein Negative

Bilirubin Negative

Glucose Negative

Keton Negative

Blood/ Hb Negative

Nitrit Negative

Urobilinogen 0,1-1,0 IU

Leucocyte Negative

Sediment:

 Leucocyte 0-5

 Eritrocyte 1-3

 Epithel

 Cilinder

 Crystal

Other Bacteria (+ / -)

c. Pemeriksaan penunjang lainny

m. SUMMARY
 n. WORKING DIAGNOSIS
Contoh:
1. UTI Complex
2. Gastritis
3. Normal Growth Status
4. Good Nutritional Status
5. Complete Immunization Status

o. PROGNOSIS
Quo ad vitam :
Quo ad functionam:
Quo ad sanactionam:

p. TREATMENT

FOLLOW UP

Day-1 ()

S :

O :

 General appearance: look ill

 Vital sign:
o HR: bpm
o RR: x/minute
o S: 38 C
 Eye: pale -, icteric -, sunken –
 Mulut : coated tongue -, dry mucousa –
 ENT: hyperaemic pharynx (-), T1-T1
  Lungs: vesicular +/+, rhonki -/-, wheezing -/-
 Heart: S1S2 murmur -, gallop –
 Abdomen:
o Inspection: even
o Auscultation: Normal bowel sound
o Palpation: suprapubic tenderness +, hepar and lien not palpable, epigastric
pain +
o Percussion: tympani
o CVA +/+, Ballotment -/
 Extremity: warm, CRT < 2 s, oedema –

A :
P :

Day-2 ( - -2018)

S :

O :

 General appearance:
 Vital sign:
o HR: bpm
o RR: x/minute
o S: C
 Eye: pale -, icteric -, sunken –
 Mulut : coated tongue -, dry mucousa –
 ENT: hyperaemic pharynx -
 Lungs: vesicular +/+, rhonki -/-, wheezing -/-
 Heart: S1S2 murmur -, gallop –
 Abdomen:
o Inspection: even
o Auscultation: Normal bowel sound
o Palpation: tenderness –, hepar and lien not palpable
o Percussion: tympani
o CVA -/-, Ballotment -/-
 Extremity: warm, CRT < 2 s, oedema –
 Laboratory test (Urine)
Results Normal range
 Color

Clarity

Reaction/ Ph 5-8,5

Density 1.000-1.030

Protein Negative

Bilirubin Negative

Glucose Negative

Keton Negative

Blood/ Hb Negative

Nitrit Negative

Urobilinogen 0,1-1,0 IU

Leucocyte Negative

Sediment:

 Leucocyte 0-5

 Eritrocyte 1-3

 Epithel

 Cilinder

 Crystal

Other

A :
P :