IDENTITY (April 13th, 2023) GES/SAR/ dr. AL, Sp.K.F.R., Ped.

(K)
Name : Ch. A
Age : 5 y 8 mo
Sex : Female
Religion : Islam
Address : Surabaya
Referred from Pediatric OPC with GDD

AUTOANAMNESIS
II.1. Chief Complaint: Pasien belum bisa bicara
II.2. History of Present Illness:
Parents realized that the patient was not fluent in speech since she was 3 years old, unlike other
children she could only say 2 words, "ma makan" "ma minum". Never been taken for treatment. When she
was 4 years old, she entered reguler kindergarten (TK A) starting in July 2022. Children tend to be quiet at
school, she could finish and follow task by teacher. Teacher suggested to take her to a psychologist. had IQ
examination said that her IQ below the standard. Then her parents brought her to pediatrician.
Currently patient can say 3 words in one sentence. if she want something the patient says " ma mau
makan, ma ataya minum". She couldn't speak cleary some consonent letter like 'd j f l n s z r t'. when the
mother tries to give the right sound, the patient has difficulty imitating. She can answer simple question, she
can sing a song, can recite quran. she couldn't tell story.
She is able to walk independently, can walk on tip toe, short jump, walking backwards, climb stairs
with holding, kicking ball. She has difficulty standing on one foot and squating. she able to hold pencil and
draw circle. She can go to toilet and wipes independently, bathing helped by her mother. She able to wear
pants independently, but difficult to put off or on shirts. She can eat independently using spoon, eat 3 times a
day, rice with minched meat, soften vegetables. She chews the food for a short time then swallow it with
water/gravy to smoothen texture and easy to swallow. She can eat cookies, pudding and juice but she didnt
like eat sliced fruits. She drinks using glass with straw hold by herself. she never get choked or cough. No
urination and defecation problem.

II.3. History of Past Illness:

She had febrile convulsions 1x general stiffness, eye glancing up for 1 minute, she had vomiting and diarrhea
hospitalized for 3 days in regular wards.

II.4 History of Functional Ability:

Milestone: Head up: 3 months old
Side lying: 4 months old
Rolling: 5 months old
Sitting: 9 months old
Walking : 2,5 years old

II.5. History of Medication and Rehabilitation:

 Went to physiotherapist at Mulyosari Surabaya, had treatment for 1 month, her children taught to
jump and balance exercise

II.6. History of Natal:

 Prenatal history : She is first child (G1P1A0). Her mother was pregnant at 28 years old. There is
no history of other illnesses. Regular checkups to the Midwife. ultrasound to the obstetrician is
normal No medication consumed during pregnancy.
 Perinatal history : Born at 9 months gestation, normal delivery helped by doctor at hospital
because her mother had myopia. Immediately crying. BW 3000 gr, BL 48 cm. No history of
cyanosis, icterus, and shortness of breath.
 Postnatal history : Complete immunization

II.7. History of Hobby and Work: -

II.8. History of Psycho-Social-Economic: She lives with her father (32 yo, company accounting, bachelor
graduate), mother (34 yo, housewife, previously she work as admin at dentistry clinic, stopped a year
ago), and aunt (38 yo, housewife) uncle (40 yo, businessman) and 2 cousins (6 yo, 3 yo). Her caregiver is
her mother, and grandmother.

II.9. Family History: No family with speech delay. Her little cousin has gross motor delay, but speak more
fluently.

II.10. Patient’s Expectation: the patient’s can talk normal like other kids

PHYSICAL EXAMINATION
III.1. General Status
GCS 456 BP : - mmHg, HR: 110 x/min, RR: 24x/min, Temp: 36.8oC, SpO2 99%
Anthropometry : Height: 111 cm, Weight: 21 kg, (normal)
Head circumference: 52 cm (normocephaly)
Conjunctiva anemia (-/-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Supple, peristaltic (+), tenderness (-)
Extremities : Warm acral (-|-), cyanosis (-), edema (-|-)

III.2. Head/Neck/Trunk,
Look : deformity (-|-), oral drooling (-), lip closure good, Caries (-), Candidiasis (-),
Feel : tender point (-), spasm (-|-)
Move : pain when move (-)
ROM MMT
Neck F|F F|F
Trunk F|F F|F

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-), deformity (-|-)
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Muscle tone : normal tonus| normal tonus
- Deep Tendon Reflex : BPR (+3|+3), TPR (+3|+3)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : normal impression
- Spasticity :Elbow flexor MAS (1+|1+)

Region ROM MMT

Shoulder F|F Functional|Functional
Elbow F|F Functional|Functional
Wrist F|F Functional|Functional
Fingers F|F Functional|Functional

III.4. Lower Extremities Region.

Look : redness (-|-), swelling (-|-), deformity (-|-), flat foot (+/+)
Feel : warmth (-|-), crepitation (-|-), tenderness (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Tonus : normal tonus| normal tonus
- Deep Tendon Reflex : KPR +3|+3; APR +4|+4
- Pathological reflex : Babinski (-|-), Chaddok (-|-)
- Spasticity : Ankle plantarflexor MAS 2/2
- Clonus : (+|+) unsustained
Region ROM MMT
Hip F|F Functional|Functional
Knee F|F Functional|Functional
Ankle F|F Functional|Functional
Big Toes F|F Functional|Functional
Toes F|F Functional|Functional

III.5. Functional Status

Balance : Sitting balance (static and dynamic) good, standing balance (static and dynamic)
good
Basic functional mobility : lying to sitting able, sitting to standing able
Coordination : hand to hand is good, hand to mouth is good and hand eye coordination is good
GH:3 tahun (catches ball with stiff hand)
FM: 3 years (cuts with scissors awkwardly )
Self help: 4 years (goes to toilet alona)
Problem solving: 5 years (names 10 colors)
Social/emotional:4 years (has a preferred friend)
receptive language: 5 years (knows right and left on self)
expresive language: 3 years (three word sentences)

CNS Maturation : Cortical

Beighton score : 5/9 (digiti I D, digiti V D/S, Elbow D/S)

III.6. Supporting Examination

Tes kecerdasan 22/10/22: 90-99 rata rata bawah

PROBLEM LIST
o Tetraplegic spastic
o Speech delay
o Personal social delay
o Gross motor delay
o Fine motor delay
o Sensory Integration Disorder
o History of Seizure
o Hyperlaxity
o Bilateral flat foot

ICF
Body Function:
b147 Psychomotor functions (gross and fine motor delay)
b398 Voice and speech functions (speech delay)
b122 Global psychosocial functions (personal-social delay)
b279 Additional sensory functions, other specified and unspecified (sensory integration disturbance)
b710 Mobility of joint function (hyperlaxity)
b735 Muscle tone function (spasticity elbow flexor and ankle plantarflexor)
B750 Motor reflex function (increased physiological reflex)
Body Structure:
S730 Sturcture of upper extremity (hyperlaxity, elbow spasticity)
s750 Structure of lower extremity (ankle spasticity, bilateral flat foot)
Activities and Participation:
d440 Fine hand use (unable to imitates shapes)
d330 Speaking (unable to story telling)
d540 Dressing (unable to put on and put off shirt)
d550 Eating (doesn’t like hard consistency food)
d560 Drinking (unable to drink from cup)
d530 Toileting (difficult at squatting)
Environmental Factors:
e310. Immediate family (Support from parents)
e598. Services, systems and policies, other specified (BPJS)
Personal Factor
Female, 5 y 8 mo, support from family

ASSESSMENT
Tetraplegic spastic ec History of Seizure + Sensory Integration Disorder + Hyperlaxity + Bilateral Flat Foot

PROGNOSIS
Ad vitam : Bonam
Ad sanationam : Dubia ad Bonam
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent
- Communication : verbally effective and understandable

GOALS
Short Term Goals:
 Improved milestone according to patient’s age
 Gross motor (balance on one foot, hopping one foot)
 Fine motor (copies square)
 Self help (independent dressing and bathing)
 Problem solving (names 10 colors)
 Social/emotional (has group of friend)
 Receptive language (produces word that rhyme)
 Expressive language (tell stories, uses word that tell time)
 Able to eat various texture of food (solid texture)

Long Term Goals:

 Keeping up normal growth and developmental as age
 Good communication and personal social interaction
 Maintain normal nutritional status
 Independent child
 Better quality of life

PLANNING
PDx: -
PEdx:
 Explain about patient condition, the goals that have to be achieved, and the rehabilitation program we
give
 Continue the exercises and stimulation at home (using gauze to massage on buccal, palate, and gum area)
 Reduce screen time gradually (< 1 hour/ day)
 Stimulate verbal communication (at the level of patient's eye, keep eye contact, speak slowly and clearly
in Indonesian with visible mouth movement, doing storytelling and singing)
 Encourage parents to arrange the patient’s meal time on the same time as theirs and eat together on the
same table.
 Give variation of texture, taste and temperature food. If she doesn’t want to eat, do not force and
continue with the food he likes. Duration of eat 30 minutes maximally.
 Routinely control to Pediatric OPC

PTx:
Precaution: avoid motion beyond normal ROM
Speech Therapy :
 Oromotor sensory stimulation
 Breathing exercise active with blow trumpet
 Phonation and articulation exercise
 Word vocabulary exercise
 Sentence forming exercise
 Feeding therapy (proper positioning during feeding, modification texture, taste, temperature and
color of the food)
 AROM and Strengthening lip, tongue, jaw, buccal, and mastication muscles
Thera exc:
 AROM exercise both lower extremity
 Strengthening exercise both lower extremity with playing
 Balance exercise with one leg stand
Occupational Therapy :
 AROM exercise both upper extremity
 Strengthening intrinsic hand muscle
 ADL exercise: wearing t-shirt, buttoning, brush teeth independently
 Task spesific exercise: drawing shapes, coloring, writing
OP : Medial arch support
PMx: Clinical findings, Anthropometry, Developmental milestone, Feeding function, Feiss line