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MR DR. GEBYAR Naner
MR DR. GEBYAR Naner
Pediatric Department
Oleh:
DM Denaner
Mentor:
dr. Gebyar Tri Baskoro, Sp.A
Pediatric Department
dr. SOEBANDI REGIONAL HOSPITAL JEMBER
2019
1
PATIENT’S IDENTITY
Name : An. A
Age : 4 y.o
Sex : Female
Address : Jember
Ethnic : Madura
Religion : Moslem
Admission : September 24th 2016
Examination : 1st day of admission
Medical Record : 2*****
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PARENTS’ IDENTITY
Father Mother
Education S1 S1
3
ANAMNESIS
4
HISTORY OF PRESENT ILLNESS
CHIEF COMPLAINT
Fever , Dhiarrhea
HISTORY OF MEDICATION
Paracetamol
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HISTORY OF PAST ILLNESS
HISTORY OF PAST
No history of trauma, diarrhea, no asthma, and no allergic reaction to drug or food
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FAMILY TREE
62 60 56
60 y.o
y.o y.o y.o
25 y.o 21 y.o
4 yo
Keterangan:
: Perempuan
: perempuan
: pasien
HISTORY OF GESTASIONAL
The patient was born from a mother G1P0000Ab000. The pregnancy was up to 9 months and the mother checked up
her pregnancy routinely at SpOG. During pregnancy the patient's mother does not experience high blood pressure, no
seizures, no excessive vomiting, no fever, no congestion, no bleeding through the birth canal. The quantity and
quality of food consumed is good, eat 3-4 times a day, a portion of rice, vegetables and side dishes. The mother did
consume any alcohol or jamu during pregnancy.
HISTORY OF LABORY
This patient was born to mother G1P0000Ab000, spontaneously, helped by midwives, first head born, clear
amniotic water, baby crying, birth weight 3000 grams, birth length 48 cm. There was no trauma at birth, no
disability, no finger abnormalities and umbilical cord care was carried out by midwives.
Conclusion: History of gestational and labory were good
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PATIENT’S HISTORY
9
Social Economy and Environmental
History
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SYSTEMIC ANAMNESIS
Systemic Anamnesis
Cerebrospinal system fever (+) seizure (-)
Cardiovascular system Chest pain (-)
Respiration system cough (-), flu (+)
Gastrointestinal system nausea (-), vomitting (+), constipation (+)
Urogenitalia system urination (+) normal
Integumentum system Normal, rash (-)
Muskuloskeletal system normal
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Physical Examination
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General Examination
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NUTRITIONAL STATUS
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SPECIFIC EXAMINATION
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SPESIFIC EXAMINATION
Lung
Stomach
Dekstra Sinistra
Inspection : round, hematom (-), ptekie (-)
Insp : Simetris Insp : Simetris Auscultation : Bowel sound (+) normal 14x/minute
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Differential
Anamnesis Diagnosis Planning Therapy
Diagnosis
Chief complaint : Pale Dengue Fever Influenza Infusion:
History of present illness : Dhirrea acute Chikungunya Inf Asering 1100
4 years old girl was taken to the IGD RS D.S. because the patient complained cc/hr
of fever since 6 months ago, the heat went up and down. the patient said that if Santagesk 4x120mg
the febrile patient was only given paracetamol to relieve the fever. Patients say Ondamcentron inj
that there is bleeding gums too.The patient also complained of diarrhea since jika muntah
this morning, the consistency of liquid, no mucus, no blood, no nausea, Planning Psiidi syr 3x 1 cth
vomiting, no abdominal pain and flu. Diagnosis
Physical Examination Blood smear
General condition : Limp Blood Observe awareness,
Awareness : Compos Mentis examination vital sign, sign
Vital Sign : HR 128, RR 28, Tax 37,2 dehydration
Head & Neck : anemis (-), pale (-), shunken eyes (+), dry mouth (-)
Chest : normal
Stomach : normal, hepatomegali (-) tenderness on lower right abdomen
Limb : oedem(-), hematom (-), ptekie (-)
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