Patient: Ch.

Y / 24mo/ 11555303/ - / Malang

Referred from : Pediatric department RSSA (Expressive Speech Delay)
Resident: IFA/ MAS/ INA
Anamnesis Problem List Diagnosis Planning
Anamnesis: Medical: Expressive Speech Delay + Clinical diagnosis: PDx :
Chief Complaint Susp. ADHD Inattention + Expressive Speech Delay + Susp. PTx:
Unable to speak at the age of 2 years Hyperactivity Subtype ADHD Inattention + Hyperactivity OT :
Subtype - Focus and attention training
History of Present Illness : Surgical: - Functional diagnosis: - Behavior therapy
• Patient was unable to say any word Impairment:
• Patient’s mother realized that he was unable to R1 (M): - - Speech Delay ST :
speak since 1 month ago R2 (A): - - Difficulty in focusing & attention - Vocal & Vocabulary stimulation
• The patient only able to do babbling, and said 1 R3 (C): Difficulty in communication Disability: - Making sentences
syllables. R4 (P): His parents worried about -Difficulty in communication
• If she wanted something, she would take it by herself his condition Handicap: PMo: attention, speech (sentences), behavior, social
• Patient able to do 2-3 simple commands such as R5 (S): Behavior problem -Behavior problem activities
throwing garbage in its place or told to put things on (less interest to play with the other (playing with the other children)
the table children) PEd:
• Patient was slightly interested to play with other R6 (V): - - Explain the condition of the patient
children R7 (O): - Purpose & benefit of PMR Therapy
• Patient still able to make eye contact with relatives, - Speech Delay - Continue training & stimulation at home
but not to strangers. - Difficulty in focusing and - Decreased screen time at home
• Patient rarely focus and giving attention when some attention - Family support
talk to her - Routine control
• Patient still giving response (dance, clapping) when
songs played
• The patient is easily distracted while playing, she
can’t play toys for a long time.
• Patient never do something aggressive (hit friends,
throwing thing) to anyone
• She had screen time for about 5 hours a day
Patient: Ch. Y / 24mo/ 11555303/ - / Malang
Referred from : Pediatric department RSSA (Expressive Speech Delay)
Resident: IFA/ MAS/ INA

Anamnesis Problem List Diagnosis Planning

• She didn’t have difficulty in eating nor drinking and could eat the same food with her
family
• There’s no bowel and bladder problem. She still unable to say when she needed to pee,
and she peed and defecated on her diapers

07 November 2022
• Patient’s parents consulted to Pediatric department at RSSA regarding patient’s
condition
• Patient was examined and was referred to PM&R department for further treatment
Patient: Ch. Y / 24mo/ 11555303/ - / Malang
Referred from : Pediatric department RSSA (Expressive Speech Delay)
Resident: IFA/ MAS/ INA

Anamnesis Problem List Diagnosis Planning

• Milestone
• Motoric
• Head up : 5 months
• Prone : 5 months
• Rolling : 7 months
• Sitting : 7 months
• Crawling : 8 months
• Standing : 9 months
• Walking : 10 months
• Running : 14 months
• Language
• Babbling : 5 months
• 1 syllable : 18 months old but later had
regression in speaking
• Mama: (-) Ayah : (-)
• 2 words : (-)
• Combine words : (-)
• Naming picture : (-)

• Pre-Postnatal
• Prenatal : routine control midwife and
obstetricians, USG routinely (+) maternal
complications (-) infection(-), never smoking,
never drink alcohol
• Antenatal : 28 weeks, spontaneous birth, body
weight of the baby : 3200 gram, body length
49cm, cried immediately, no jaundice, no
cyanosis
• Post natal : Patient completed mandatory
immunization. Seizure (-), jaundice (-)
Patient: Ch. Y / 24mo/ 11555303/ - / Malang
Referred from : Pediatric department RSSA (Expressive Speech Delay)
Resident: IFA/ MAS/ INA

Anamnesis Problem List Diagnosis Planning

History of Family Illness:

• There was no family history related to patient’s
condition

Physical Activity:
• Patient played with his brother at home (7yo)
• Patient was slightly interested to play with other
childre
• Patient still needed help from his mother to do
dressing, bathing, and using toilet
Psycho-Socio-Economic:
• Patient is the 2nd son. He has one big brother
• Patient’s parents worried about his condition
• Patient’s father is a freelancer designer and his
mother is housewife

History of Medication:
• Patient didn’t have any routine medication before
Patient: Ch. Y / 24mo/ 11555303/ - / Malang
Referred from : Pediatric department RSSA (Expressive Speech Delay)
Resident: IFA/ MAS/ INA

Positive Findings

General Status:
Compos mentis, independent ambulation Reflexes:
BW: 12 kg (0 to -2SD, normoweight) Physiological Reflexes: Pathological Reflexes:
BH : 85 cm (0 to -2SD, normoheight) BPR +2/+2 - Babinski -/-
HC : 48 cm (0 to +2SD, normocephal) TPR +2/+2 - Chaddock -/-
KPR +2/+2 - Hoffman -/-
HR : 121x/min RR : 22x/min
APR +2/+2 - Tromner -/-
• Head and neck : Anemic -/-, jaundice -/-, cyanosis -, oedema -, nasal
flaring - ROM: Full (on all extremity)
• Chest : MMT: Neck functional
Cor : S1S2 (single) regular, murmur (-), gallop (-) Trunk functional
Pulmonary : Ves +/+ , Rh-/-, Wh-/- UE/LE functional/functional
• Abdomen : Soefl, hepar and lien unpalpable
• Extremities : Warm +/+, oedema (-) CRT < 2s
• Eye contact (+), focus (-), attention (-)
DDST
Personal social :
(according to the age)

Fine motor:
(according to the age)

Speech:
9 months old

Gross motor:
(according to the age)
DDST
Personal social :
(according to the age)

Fine motor:
(according to the age)

Speech:
9 months old

Gross motor:
(according to the age)
ICF DIAGNOSIS PATIENT CONDITION
Body Function
B140 Attention functions Attention deficit
B152 Emotional functions Behaviour problem
B398 Voice and speech functions Unable to speak a word
Body Structure

Activity and Participation

D160 Focusing attention Lack focus and attention
D330 Speaking Speech delay
D710 Basic interpersonal interactions Difficult to do social activities
D880 Engagement in play less interest to play with other
Environment
E310 Immediate family Patient lived with his parents
E580 Health services, systems, and policies BPJS
Personal Factor Child Y/24mo/ female
Prognosis

Ad Vitam • Bonam

Ad Sanationam • Bonam

Ad Functional • Bonam
 Goal

Short Term Mid Term Long Term

• Educate family to care and
support the patient
• Improved focus and
attention
• Improve behavior
• Improved speech : patient • Improved speech : patient
able to say 2 words able to make a sentence
• Improve speech : patient • Improve social activity
able to say more than 2
words