IDENTITY (February, 15th, 2023) CIN/WIC/ dr. NH, Sp. K.F.R., Ped.

(K)
Name/Gender : Ch. T
Age : 4 years 8 months old
Sex : Male
Religion : Islam
Address : Surabaya
Referred from Pediatric OPC with Global Developmental Delay suspect ASD

HETEROANAMNESIS
II.1. Chief Complaint: Belum bisa berbicara
II.2. History of Present Illness:
The patient cannot speak yet, still babbling. His mother realized that he had a speech delay
since he was 2.5 years old. He understands simple command from his parents (sit down, washing
hand, etc). When he wants something, he will point out and pulling his parents’ hand. He does not
respon when called. There is brief eye contact during the conversation for 3-5 seconds. He likes to run
around and climb the bed. He likes to play alone than playing with his friends. When in a group he
still play by himself. He likes to play with toys car. Used to be taken care by his grandmother until 2,5
yo and had screen time 2 hours/day.
He has history of being picky eater But now he will eat all kind of foods prepared by his
mother. He eats 3 times a day as his parents’ food and finish his food less than 20 minutes and mostly
spoon feeding by himself. He also able to drink by himself using glass. There is no choking or
vomiting history while eating or drinking. He is able to brush teeth by himself with instruction. He is
able to pun on clothes without button and srapless shoes.
Currently, he is able to speak some word like ‘mama, baba, mimic, mam’. Unable to speak on
two words or sentences. He doesn’t watch any video on handphones and television since last month.
He is a preschool student, but at school teachers complain lack of attention, unable to socialize,
doesn’t try to established friendships and doesn’t approach socially to other children. Micturition and
defecation go to toilet directly but can’t clean up, helped by his mom, still using diapers.

II.3. History of Functional Ability:

 Milestone: headup : 3 mo, rolling: 4 mo, sitting: 6 mo, standing: 9 mo, walking: 11 mo
 Nutritional Status: he drinks ASI since birth until 2 yo. Since 6 months he started to eat
complementary food with various types of meal. He now wants to eat various type of food
and no picky eating.

II.4. History of Prenatal, Natal, and Post Natal:

 Prenatal history : he was the 1st child has twin brother. The mother was pregnant when she
was 24 years old.
 Perinatal history: At 38 weeks of gestation age (G1P0A0), give birth normally. Birth weight:
2180 grams. Cried spontaneously. No cyanosis nor icterus.
 Postnatal history : Have complete immunization, never got seizure, icterus, or trauma.
II.5. History of Medication and Rehabilitation:
 May 2021 until September 2022, attended private clinic, got speech therapy
 August to September 2022, attended Physiatric OPC in Menur Hospital, got speech and
occupational therapy (follow instruction, mouth opening exercise) referred to Day Care of
Soetoemo Hospital
 February 2023, attendedPediatric OPC Soetomo Hospital, consulted to Rehabilitation OPC
and ENT OPC.
 February 10th Audiometri and Communication evaluation.

II.6. History of Hobby and Work: He likes to play with cars toy and drawing. Mostly play by himself
or with his twin brother at home. He attends school since July 2022, unable to write but can draw
by following lines. Sometimes want to play with his friend, but mostly prefers to play alone.
II.7. History of Psycho-Social-Economic: The patient lives with his parents. His father is 32 yo, last
education bachelor degree, works as private employee. His mother is 28 yo, last education
bachelor degree, currently she is a housewife. His mother worked until he was 3,5 years old,
while at that time the patient was taking care by his grandmother.

II. 8. Family History: His twin brother also has developmental delay.
II.9. Patient’s Expectation: The mother wants her child to be able to talk and has normal
developmental milestone as other children’s.

PHYSICAL EXAMINATION
III.1. General Status
Compos Mentis, BP: - mmHg, HR: 115 x/min, RR: 24x/min, Temp: 36.6oC,
Height: 105 cm (HAZ, Normal), Weight: 16 kg, (WAZ, Normal), BMI: BW/BH: (<-1SD), Head
Circumference: 51 cm (normal)
Eye contact : + 3-5 seconds

Head and neck :

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), dyspnea (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral (-|-), cyanosis (-), edema (-|-)

III.2. Head/Neck/Trunk,
Look : forward head (-), deformity (-)
Feel : warmth (-), tender point (-), laxity (-)
Move :
ROM MMT
Neck F|F F|F
Trunk F|F F|F

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-), laxity -
Move : crepitation (-|-)
Neuromuscular :
- Muscle tone : Normal
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : 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

III.4. Lower Extremities Region.

Look : redness (-|-), swelling (-|-), genu recurvatum (-|-), flat foot (+|+), Feiss line grade I
Feel : warmth (-|-)
Move : crepitation (-|-)
Neuromuscular :
- Muscle tone : normal
- Deep Tendon Reflex : KPR (+2|+2); APR (+2|+2)
- Pathological reflex : Babinski (-|-) , Chaddock (-|-)
- Sensorics : unable 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

III.5. Functional Status

- Mobilization : turning able, bridging able, move from lying to sitting able, sitting to
standing able
- Transfer : move between bed and chair able, rised from seated position to standing
position able
- Balance : Sitting balance (static & dynamic) Good, Standing Balance: (static &
dynamic) Good
- CNS Maturation Level : Cortical
- Beighton Score : 0/9 (bilateral little fingers)
- Developmental milestone:
 Gross Motor: throws ball overhand 10 feet, catches ball (4 yo),
 Fine Motor: copies square (4 yo),
 Self help: independent eating (3yo)
 Personal Social : imitates adult activities eg. sweeping (30 mo),
 Receptive Language : follows two step command (24 months),
 Expressive Language: uses three to five words (15 months)

- DSM-5 ASD:
A1: (+) Failure to respond when name called or when spoken directly to
A2: (+) Impairment in social use of eye contact
(+)Lack of interest in peers
(+)Withdrawn; aloof; in own world
(+)Does not try to attract the attention of others
(+)Limited interest in others;  
(+)Unaware or oblivious to children or adults
(+)Limited interaction with others
A3: (+) doesn’t try to establish friendships
(+) doesn’t have preferred friends
(+) Lack of cooperative play
B1: (+) excessive teeth grinding
(+) repetitive hand movements
B2: (-)
B3: (-)
B4: (+) High tolerance for pain
C: (+) Early childhood (2,5 yo)
D: (+) Limited everyday functions

Supporting Examination :
Audiometry-Communication Evaluation (February 10th, 2023)
PROBLEM LIST
o Speech delay
o Personal social delay
o Poor eye contact
o Autism spectrum disorder
o Bilateral Flat Foot
ICF
Body Function:
b112 Global Psychosocial function (Autism spectrum disorder)
b229 Seeing and related functions other specified and unspecified (Poor eye contact)
b398 Voice and speech function, other specified (Speech delay)
b715 Stability of joint function (bilateral flat foot )
Body Structure:
s750 Structure of lower extremity (bilateral flat foot)
Activities and Participation:
d161 Direction attention
d330 Speaking (Speech delay)
d710 Basic Interpersonal interaction (Less interaction with other people and his friends)
d350 Conversation
d540 Dressing
d710 Basic interpersonal interactions
d760 Family relationship
d920 Recreation and leisure
d835 School life and related activities
Environmental Factors:
e310 Immediate family (Support from parents)
e580 Health Services, System and Policy (Patient covered by BPJS)

ASSESSMENT
Personal Social et Speech Delay ec Autism Spectrum Disorder + Bilateral Flat Foot

PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Dubia
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent
- Communication : dubia

Goals:
Short Term:
1. Speech ability and social interactionimproved
2. Eye contact duration increased
3. Able to produce more syllable and words
4. Better articulation
5. Vocabularies increased
6. Interaction and stimulation by the caregiver increased

Long Term:
1. Achieved milestone in 4 developmental domains as his age
2. Independent child
3. Catching up developmental status according to age
4. Community integration
5. Better quality of life
Plan:
PDx: -
Speech Therapy:
 Oromotor sensory stimulation
 Language concept exercise
 Phonation exercise
 Articulation exercise
 Word vocabulary exercise
 Word and syllables forming exercise
 2-way communication exercise
 Stimulation with story telling
Occupational Therapy:
 Paralel stimulation and interactive playing
 ADL exercise according to patient’s age (buttoning, and toilet training)
PMx: Clinical signs, speech ability, body height and weight, milestone
PEdx:
 Explain the treatment and the rehabilitation goal
 Continue exercise and practice at home
 Oromotor sensory stimulation
 Stimulate verbal communication (keep eyes contact, say word clearly and slowly, with clear
mouth movement. Firstly, use simple bilabial word: ma, ba, pa)
 Toilet training
 Encourage learning with reward such as praise or hug