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ANAMNESIS

Chieft Complaint

Vomitus
HISTORY OF PRESENT ILLNESS

The day of admission


• Nausea and Vomitting > 10 times, containing food and fluid
• Fever (+), 37.8°C at 14.00 pm
• Sore throat (+)
• Weak
• No cough and rhinorhea
• No dyspneu
• No seizure, no loss of consciousness
• Decreased feeding
• Decreased urination
• The mother said that before her son started vomitting, he ate cha-cha
KW (candy).
HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied


History of Bronchopneumonia : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food and drug : Denied
History of hospitalized : (+), because of
Bronchopneumonia
History of malnutrition : Denied

Conclusion: there is history of hospitalized because of


Bronchopneumonia
HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied


History of Seizure without fever : Denied
History of Anemia : Denied
History of asma : Denied
History of atopi : Denied
History of hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that correlated with


patient’s disease
PEDIGREE

Tn. A 33 years old Ny. N 32 years old

An. A 3 year 2 month old

Conclusion : there is no illness is inherited


HISTORY OF PREGNANCY

Mother with P3A0 is pregnant at 29 years old. Mother began to


check pregnancy and routinely control to the doctor. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension.

Conclusion: the history of pregnancy is was good


HISTORY OF DELIVERY

The mother delivered her baby by normal delivery. 36 weeks pregnancy


age, baby born with body weight 3500 grams with body length 49cm. At
the time of birth the baby cries instantly, there is no congenital defect at
birth.
Conclusion : history of delivery was good.

HISTORY OF POST DELIVERY

The baby was born crying, active motion, red skin color, not blue
and not yellow skin color, got milk on first day, urination and
defecated less than 24 hours

Conclusion : history of post delivery was good


HISTORY OF ENVIRONMENT

The patient lives at home with both parents, sister, and


broher. Ceramic-floored patient houses, walled walls, tile roofs,
adequate ventilation, bathrooms in the house, water source from
well water.
A few days before the patient was treated in the hospital,
neighbors have not experienced similar complaints.

Conclusion : there is no a risk factors for transmitted disease


HISTORY OF VACCINE

• At that time of examination, the mother did not bring


KMS.
• According to the mother's confession, the patient have
complete recieve vaccine.

Conclusion : the history of vaccine is complete acording


to KEMENKES
HISTORY OF FEEDING
0 – 6 month old

• breastmilk + formula milk

6 – 8 month old

• Breastmilk + Formula + instan food 1 day 3 small bowls

8 – 10 month old

• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes

10 – 12 month old

• Formula + Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes and always spent

1 – 3 years old

• Formula + White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food

Conclusion : history of feeding from quality and quantity was not


good
HISTORY OF GROSS MOTOR

Competence Age of achievment Normal age


Head up 90 degress 3 month 3-4 month
Sit no support 6,5 month 6 – 7 month
Stand alone 11 month 11 - 13 month
Walk well 13 month 11-15 month
Runs 17 month 13-20 month
Balance each foot 4 second Can’t 3,5-5 years

Conclusion :Development history of Gross motor according


to age
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HISTORY OF FINE MOTOR

Competence Age of achievment Normal age


Reaches 5 month 4,5 – 5,5 month
Scribbles 12 month 12 – 17 month
Tower of 2 cubes 16 month 13-21 month
Thumb wiggle 2.5 years 2,2-3,9 years

Conclusion :Development
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HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 11 month 7 – 13 month
Speech fluently 28 month 24-51 month
Name 4 pictures 2.3 years 2-3 years

Conclusion :Development history of language according to


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HISTORY OF PERSONAL SOCIAL
Competence Age of achievment Normal age

Smile spontaneously 1 month 0-2month


Feed self 6 month 5 – 6,5 month
Indicate wants 12 month 7,5- 13 month
Drink from cup 15 month 9-17 month
Remove garment 22 month 14 month – 2 years
Put on t-shirt Can’t 2,5- 3,5 years

Conclusion :Development history of social according to age

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History of DEVELOPMENT and
INTELLEGENT

• Conclusion: History of development and


intellegent is good
Physical Examination
 General appearance
General appearance : alert

 Vital Sign
Blood Pressure :-
Heart rate : 122 x/ menit
Respiratory Rate : 28 x/ menit
temperature : 37.2° C
Nutrisional status

3 years 2 month old WEIGHT : 12.7 KG Height : 94 CM

-Weight // age : < 0 SD


-Height // age : < 0 SD
-Weight // height : < 0 SD

Conclusion : nutritional status is good


Physical examination
• Skin examination
Color : brown
Skin turgor: < 2 sec
Moisture: moist
Edema (-) does not exist

• Conclusion : skin examination was normal

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PHYSICAL EXAMINATION
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retraction (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi subcostal (-/-),
retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : neck, heart and lung examination was good


Stomach :
Inspeksi : Distensi (-), sikatrik (-), purpura (-), darm contour (-),
darm steifung (-)
Auskultasi : Peristaltik (+) normal, metalic sound (-)
Perkusi : timpani (+)
Palpasi : supel (+), acites (-), abdominal mass (-), tenderness (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : in stomach examination is good


Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities


CRT <2 sec
Turgor < 2 second

Conclusion : extremity was normal

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PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), light reflek (+/+)
isokor (+/+), sunken eyes (-/-),
Nose : Secret (-), epistaksis (-), breath nostrills (-/-)
Ears : Secret (-), membrane hiperemis (-)
Mouth : Stomatitis (-), gingivitis (-), sianosis (-), pharynx hiperemis (+), exudate
(-), mucousa lips and mouth dry (-),
Skin : colour was white, pale (-), Ikterik (-), Sianosis (-)
Lymph nodes : enlargement limfadenopathy (-)
Muscle : pharese(-), atrofi (-), myalgia (-)
Bone : deformity (-)
Joints : free movement
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), warm akral (+/+), petekie (-
/-)

Conclusion: there was pharynx hyperemis


Isaac score
Criteria Score Patient’s score
Temperature > 38°C 1 1
No cough 1 0
Tender anterior cervical 1 0
adenophaty
Tonsillar swelling or 1 0
exudate
Age 3-14 yr 1 0
Age 15-44 yr 0 0
Age > 45 yr -1 0
Total score 0

Score 1 = no culture or antibiotics required


LABORATORY TEST
INDIKATOR NILAI RUJUKAN
Leukosit 7.71 6 – 17.5
Eritrosit 4.2 3.6 – 5.2
Hemoglobin 11.4 10.5 – 12.9
Hematokrit 35,4 35.0 – 43.0
Trombosit 497 229 – 553
Neutrofil 76.8 50 – 70
Limfosit 17.4 25 – 40
Monosit 2.8 2–8
Basofil 0,1 0-1
Eusinofil 0.1 2-4
MCV 77.3 74.0 – 106.0
MCH 23.1 21.0 – 33.0
MCHC 32.4 28.0 – 36.0

Conclusion : neutrofilia and limfositopenia


RESUME
ANAMNESIS Physical examination
Nausea and Vomitting > 10 times, containing
food and fluid General appearance : weak, alert
Fever (+), 37.8°C at 14.00 pm (1 day) pharynx hyperemis (+)
Sore throat (+)
Weak
Decreased feeding
Decreased urination
The mother said that before her son started
vomitting, he ate cha-cha KW (candy). Laboratory test ; neutrofilia and
limfositopenia
.
ASSESMENT

Diagnosis
faringitis
DD : food poisoning
measles
rubella
dengue fever
urinary track infection
ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the effect of mediaction

DIAGNOSIS ENFORCEMENT PLAN

• Blood examination
• Urine routine
• RO thorax
` PLAN
THERAPY

• fluid maintenance
100 x 10 = 1000 ml
100 x 2.7 = 270
total 1270
oral = 423
IV = 847 /3/24 = 11 dpm/24 hour
• Antipiretics
• Paracetamol syrup 10 mg/kgbb/times(4hours)
• 10 x 12.7 = 127 mg/4 hours = 5.3 ml / 4 hours  p.r.n fever
Terapi

Calori : 12.7 x 102 = 1295 kkal Energy needs : White rice, eggs, meat, fish,
Protein : 12.7 x 1.23 = 15.562 g vegetables a day 3 times a large plate of
Fluid : 100 x 10 = 1000 ml food + 1 glasess milk + snack 2 times per
100 x 2.7 = 270 day
total 1270  rute oral
oral = 423
IV = 847 /3/24 = 11 dpm/24 hour
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