1.

History of Present Illness

Chief complaint: Shortness of breath (referral case from Cardiology outpatient clinic)

One month prior to admission, patient was diagnosed with PMO VSD with MSA and small
secundum ASD.

Three days prior to admission, the patient started to have a fast breathing and cough. There
were also wheezing and lower chest wall indrawing. There were no fever, no runny nose, no
vomiting, no diarrhea, no reduced level of consciousness or interrupted feeding. The patient have no
history of bluish skin and lips.

Two days prior to admission, the previous symptoms were still persisted. Patient control to
cardiology pediatric and treated with nebulization, ambroxol, triamcinolone and salbutamol. The
symptoms was relieved.

One day prior to admission, the patient started to have a fast breathing again with severe chest
indrawing. The patient seemed to be more irritable and her appetite was decreased with interrupted
feeding. There were no fever.

On the day of admission (July 9 th, 2020), the symptoms was persisted. The patient control to
Cardiology outpatient clinic and was referred to Respirology outpatient clinic. The patient also be
screened to COVID because she was showing signs or symptoms of COVID. She was admitted with
working diagnosis of suspect COVID19, community acquired pneumonia, VSD and ASD

On the 2nd day of hospitalization (July 10, 2020). Patient are taken as case for board
evaluations and observations begin.

2. History of Family illness

- History of travelling to other area were denied

- Mother has a history of allergy
- Father has a history of cough and runny nose for 3 days before patient’s admission

Conclusion: there were risk factors communicable disease among family members, associated
with patient’s recent condition
3. Personal History
History of pregnancy, labor and post natal care
The patient born by spontaneous delivery from 19 years old mother G2P1A0 at 39 weeks of
gestational age. The mother had routine checkup with good ANC. At 3 rd trimester, the mother has
urinary tract infection and was treated with antibiotic. The baby cried immediately after born, birth
weight was 3200 grams, body length 49 cm, head circumference was 33 cm. The post-natal care were
given, without any particular problems.
Conclusion: history of pregnancy, labor, and post-natal care were good.

4. Feeding History
0 – 3 months old: Exclusive breastfeeding, every 2 hours.
For now, she was given Infantrini 5x80 ml and continue breastfeeding on demand
Conclusion: intake with breast milk and infantrini

5. Growth and development (Based to the data recorded in the Kartu Menuju Sehat (KMS)
- Growth

Age (month) Weight (kg) Length (cm) Head circumference (cm)

Birth 3.2 49 33
1 3.4 58 37.5
2 4.2 59 38.5
3 4.5 59.5 40

- Development
The patient able to roll over to right and left side and cooing at 3 months-old. She likes to smile
and laugh at 3 months old.
Conclusion: Insufficient weight increment and delay in gross motor attainment

6. Immunization status (Based to the data recorded in the Kartu Menuju Sehat (KMS)

Vaccination Date of administration (age) Health facility

Hepatitis B-0 26th of March 2020 (0 day old) Hospital
BCG 11th April 2020 (1 month old) Hospital
DTP-HepB-HiB 1, Polio 1 2nd of June 2020 (2 months old) Hospital
DTP-HepB-HiB 2, Polio 2 4th of July 2020 (3months old) Hospital
DTP-HepB-HiB 3, Polio 3 Postponed -
 Conclusion: the immunization history was incomplete

7. History of past illness

No previous history of hospitalization and respiratory infections
Conclusion: there was no history of past illness related to recent condition

8. Social economy and environment

The monthly income of both parents is approximately IDR 2,000,000.00. Health funding is covered
by the national insurance program (BPJS). The patient lives in a small house in the crowded area, the
patient sleeps in one room with her parents. There are no smokers at home.
Conclusion: low-middle social economy and crowded area

9. History of needs fulfillment

Parents are provide adequate nutritional intake, clean clothes, affection
Conclusion: Adequate fulfillment of needs