IDENTITY (March 3rd, 2023) DEL/CIA/ dr. NH, Sp.K.F.R., Ped.

(K)
Name : Ch. K
Age : 4 y 4 mo
Sex : Male
Religion : Islam
RM : 12978485
Address : Surabaya
Referred from Psychiatric OPC with Atypical Autism, Speech Delay Pro terapi wicara dan okupasi.
Heteroanamnesis
Chief Complaint: Belum bisa bicara

History of Present Illness:

Parents realized that their 2nd son couldn’t speak when he was 2 years old (2020). Couldn’t say a single word and tend
to behave differently from his older brother. Very little eye contact, didn’t turn when his name is called, not babbling,
no expression when played peek-a-boo, often claps and walks on tiptoe, eat unusual objects (hair, rock, wall shred),
screaming and rolling around if he doesn’t get what he wants. The parents took the child to RSI Surabaya and was
diagnosed with speech delay, underwent speech therapy for 2 months, but stopped due to the Pandemic.
In December 2021 parents took patients to private therapy places but can only do it once every 1-2 months because of
the long list of queues, where he received speech, occupational, and behavioral therapy.
In 2022 parents brought their children to Pediatric OPC at Soewandhi Hospital, had his ears examined with normal
results, diagnosed with ASD, received speech therapy for 3 months, stopped for several months because parents did
not have time to bring patients for therapy. In December 2022, after 12x session of speech therapy, the patient was
referred to Psychiatric OPC (Daycare) at RSDS for behavioral therapy. After 4 visits to Daycare, the patient was
referred to PMR OPC RSDS occupational and speech therapy.
Currently, the patient is willing to follow orders, such as cleaning up toys, coming to mother when she called, and
shakes adult’s hand. Then leave and continue his activity. Able to finish the putting buttons into bottle game, able to
sort numbers from 1-10 and the letters A-Z. He talks no syllables or words, only vocalizations. Doesn’t want to play /
interact with other children. Only wants to play with his older brother. The patient will pull his mother's hand if he
wants something, with minimal eye contact (1-2 seconds).
The patient still wears diapers, if he defecates, he comes to the mother and circles around her. When he wants to eat,
patient will take a plate, head to the mother and pull his mother's hand to go to the kitchen. Not yet able to wash
hands, shower, remove and put on clothes independently. He doesn't like brushing his teeth, usually mother brushes
patient's teeth once every 2 days, with patient crying.
The patient unable to scoop rice by himself (assisted by the mother), but able to bring a spoon filled with food to his
mouth. He eats 3 times a day. 1 cup of rice, with a side dish of chicken/meatballs, doesn't want vegetables (only want
the broth). Duration of eating > 30 minutes, while watching youtube or walking around. Does not like soft foods such
as eggs, porridge, soft rice, soft bread. Can't drink from a cup yet, currently still using milk bottle to drink water and
milk. Drink full cream milk 2 x 480 ml a day. Do not choke while eating or drinking.
For screentime, he watches 3 hours of YouTube, cartoons and children's songs in English. Daily conversation at home
using Indonesian and Javanese.
Milestone:
Head up : 3 months old
Rolling : 5 months old
Standing : 14 months old
Walking : 16 months old

Developmental milestone:
 Gross motor ~ 4 years (catches bounced ball)
 Fine motor ~ 30 months (makes “train” of cubes)
 Self-help ~ 20 months (places only edibles in mouth)
 Problem solving ~ 3 years (matches letters/numeral)
 Social emotional ~ 24 months (parallel play)
 Receptive language ~ 30 months (understand actions words)
 Expressive language~ 5 months (Expresses anger with sound other than crying)

History of Functional Ability

 Nutritional Status: He eats 3 times/day, assist by his mother to scoop rice. 1 cup of rice for > 30 minutes. He likes
to eat rice with chicken, meatball, and broth. He doesn’t like vegetables and soft texture food like egg, porridge,
tim rice, soft bread. Drink water and milk with milk bottle by himself. Formula milk 2 x 480 ml per day. Unable
to drink from cup independently. No choking or drooling.
 He wears diaper. Tend to circles around mother when defecate.
History of Medication and Rehabilitation:
 Rehabilitation:
o 2020 : speech therapy (2 months) at RSI Surabaya
o 2021 : speech therapy, occupational therapy, behavioral therapy at private therapy places (1x/months)
o 2022 : speech therapy (3 months) at RS Soewandhi
 January 2023 : controlled in Daycare (Psychiatric OPC) for behavior therapy, got medication:
o Morning : Abilify 1 mg, folic acid 0,5 mg, vitamin B12 ¼ tablet,
o Night : Risperidone 0,1 mg, vitamin B6 ½ tablet, Vitamin B12 ¼ tablet

History of Past Illness:

 Prenatal history : The mother was pregnant when she was 26 yo, 2 nd pregnancy, regular ANC in Puskesmas
by midwife. Can’t eat rice because nausea and vomit until 7 months of pregnancy. Hitory of hospitalized (3
days) at 7 months pregnancy due to diarrhea (dehydration). Hospitalized at 36 weeks of pregnancy (8 days)
due to high fever illness during pregnancy.
 Perinatal history : He was born full term, normal delivery, birth weight 3400 grams, length 50 cm, cry
spontaneously, no history of bluish.
 Postnatal history : There is no history of jaundice or seizures. Hospitalized at 8 months (10 days) because of
respiratory infection.

History of Psycho-Social-Economic
He lives with her father (35 yo, laptop distributor, high school graduate), mother (31 yo, housewife, high school
graduate), older brother (10 yo, elementary student) grand mother (57 yo), grand father (57 yo). Lives in a 2-story
house. They are covered by BPJS.
He doesn’t go to school.
Parents and other family member mostly communicate in Bahasa Indonesia mixed with Bahasa Jawa

Family History
His cousin also has autism

Parent’s Expectation
Their child able to speak and become independent.

PHYSICAL EXAMINATION :
Objective :
Compos Mentis, HR: 100 x/mnt, RR: 24 x/mnt, Temp: 36,30C
Body weight : 18 kg, Body height : 104 cm, Head circumference: 49 cm (normoweight)

Posture : normal, ambulation : independent without assistive device

General status :
 Head : anemic conjunctiva (-/-), icteric sclera (-/-)
Thorax : retraction (-/-), S1-S2 single regular, murmur (-), gallop (-), vesicular, rhonki (-/-), wheezing
(-/-)
Abdomen : no distension, normal peristaltic sound
Extremity : warm acral, CRT< 2 seconds
 Beighton score : 2/9 (thumbs)
 CNS maturation: Cortical

Neurological examination :
Cranial Nerve I –XII : Impression Normal
Physiological Reflexes : BPR ++/++ KPR ++/++
TPR ++/++ APR ++/++
Pathological Reflexes : Babinski -/-, Chaddock -/-
Hoffman -/-, Tromner -/-
Sensory : difficult to evaluate

Musculoskeletal state :
Head/Neck/Trunk,
Look : forward head (-), deformity (-)
Feel : warmth (-), tender point (-)
Move :
ROM MMT
Neck F|F F
Trunk F|F F

Upper Extremities Region

Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Muscle tone : Normal
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensory : unable to evaluate
- Spasticity :-
Region ROM MMT
Shoulder F/F F/F

Elbow F/F F/F

Wrist F/F F/F
Fingers F/F F/F

Lower extremity:
Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Muscle tone : normal
- Deep Tendon Reflex : KPR (+2|+2); APR (+2|+2)
- Pathological reflex : Babinski (-|-) , Chaddock (-|-)
- Sensory : difficult to evaluate
- Spasticity :-
Region ROM MMT
Hip F/F F/F
Knee F/F F/F
Ankle F/F F/F
Big Toes F/F F/F
Toes F/F F/F

Functional Status
Balance : Sitting balance static good, dynamic good. Standing balance static good, dynamic good.
Transfer : Lying to sitting able independently, sitting to standing able independently
Coordination : Hand-eye coordination good, hand to hand coordination good, hand to mouth coordination
Flat foot : -/-
Laxity : Thumb D/S

Autism DSM-V:
A1 : Abnormal social approach
Failure of normal back and forth conversation
Reduced sharing of interest
Reduced sharing of emotions/affect
A2 : impairments in social use of eye contact
Impairments in the use and understanding of body contact
Impairments in the use and understanding of gesture
Abnormalities in use and understanding of affect
Lack of coordinated verbal and nonverbal communication
A3 : Difficulties adjusting behavior to suit social contexts
Difficulties in sharing imaginative play
Difficulties in making friends
Absence of interest in other
B1 : Stereotype or repetitive motor movements
B2 : Excessive resistance to change
B3 : Narrow range of interest
Focused on the same few objects
B4 : Preoccupation with texture or touch
C : present in early childhood
D : symptoms together limit and impair everyday functioning

Supporting examination:
Audiometri March 2nd 2022
Hasil :
ADS : Ambang Dengar Dalam Batas Normal
Saran : terapi wicara dan terapi okupasi/perilaku
PROBLEM LIST
1. Attention deficit
2. Poor eye contact
3. Speech delay
4. Fine motor delay
5. Personal-social delay
6. Picky eater
7. Autism spectrum disorder

ICF PROBLEM
Body Function:
b398 Voice and speech function (speech delay)
b147 Psychomotor functions (fine motor delay)
b122 Global psychosocial functions (personal-social delay)
Body Structure:
-
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)
d710 Basic interpersonal interactions
Environmental Factors:
e310 Immediate family (mother as a fulltime primary caregiver, supportive father)
e580 Health Services, System and Policy (patient covered by BPJS)

ASSESSMENT
Tetraplegic spastic ec History of Seizure + Sensory Integration Disorder + Hyperlaxity + Bilateral Pes Plano Valgus

PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Malam
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent dressing, toileting, bathing, brushing teeth
- Personal social and communication : bonam
- Feeding : bonam

Goals:
Short Term
 Improved attention (eye contact > 30 sec and concentration)
 Achieved milestone :
o Language : Can make syllable, word
o Fine motor : able to hold pencil/crayon and draw shapes, coloring
o Personal social : use spoon, drink from cup, put on and put off clothes, wash hands
 Eat various texture of food (smooth texture)

Mid Term
 Attention concentration (Good eye contact and could finish an activities without distracted)
 Achieved milestone:
o Language: could make sentences
o Fine motor: learn to write alphabeth and numbers
o Personal social: brush teeth and toilet training, parallel play with other child
Long Term
 Two way communication with comprehend, fluent, clear conversation and concentration
 Good social interaction
 Independent ADL
 Preparation for school
 Better quality of life

Plan
PDx: -
PTx:
OT:
 Attention exercise at snoezelen room
 Task specific exercise : hold pencil/ crayon, draw circle and other shapes, coloring, put on and put off garment
 Basic ADL exercise: scooping food with spoon, wash hands, drink from cup, putting on and off clothes, brushing
teeth, toilet training
ST:
 Oromotor and sensory stimulation
 Feeding therapy : proper posture while eating, texture, taste and temperature variation
 Language concept exercise
 Phonation and articulation exercise
 Syllable and word formation exercise
 Two way communication exercise

PEx:
 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)
 Communicate with 1 language at home
 Stimulate verbal communication (introduce things in daily life by showing the objects and telling their names and
functions. Put object near parent's face 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 he doesn’t want to eat, do not force and continue with the
food he likes. Duration of eat 30 minutes maximally.
 Give patient opportunity to try scoop his own food, to drink from cup, to put on and put off clothes, to brush teeth,
and toilet training. If the child do not want to try, lead his hand to practice it.
 Encourage parents to do parallel and interactive play with him
 Take medication and control regularly