pedsos synd. down
TRANSCRIPT
CASE REPORT SOCIAL PEDIATRIC
A THREE YEARS EIGHT MONTHS OLD GIRL
WITH DOWN SYNDROME AND SPEECH DELAY
Submitted for completing the assignment for senior clerkship
in Pediatrics Health Department of Kariadi Hospital
Medical Faculty of Diponegoro University
Wahyu Kumala Dewi 22010111200140
Wang Erna 22010111200141
Examiner:
Dr. Hendriani Selina, Sp.A (K), MARS
PEDIATRIC DEPARTMENT OF KARIADI HOSPITAL
MEDICAL FACULTY OF DIPONEGORO UNIVERSITY
SEMARANG
2012
1
A. IDENTITY
Name : K. I
Age : 3 years 8 months old
Date of birth : October 6th, 2008
Sex : Female
Date of entry : July 2nd, 2012
Address : Jl. Brumbungan Loyola No.79 RT/RW.002/002 Semarang
Father Mother
Name : Mr. HK Name : Mrs. S
Age : 26 years Age : 24 years
Religion : Islam Religion : Islam
Occupation : Occupation : -
B. ANAMNESIS
Alloanamnesis with patient’s mother on July 2nd, 2012 11.30 a.m. at BKIA RSDK,
Semarang.
Chief complain : 3 years old girl has not been able to speech
Present Disease History :
Since the age of 2 years, the mother noticed that her daughter could not speak like
children of her age. The child can turn her face when her name was called. She can say
words consisting of single syllable like “moh, mam, dik, ya ...”. Sometimes, she is able to
call brother for her brother, mother for her mother, and father for her father. She can
understand mother’s command, do what was asked by her mother. She can indicate her
wants by pointing the object. She can play with her friends. Because mother worried
about her daughter development, she brought her to RSUP Dr. Kariadi.
History of Past Illness
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Family History
- There is no family members who have the illness like patient
Socio Economic
- Father works as a honorer workers at SMA 1 and mother doesn’t work, their income is
Rp 800.000,00 per month. They fund two child. Medical fee is paid by Jamkesmas.
Impression : poor socioeconomic
Perinatal History
Prenatal History :
- ANC more than four times during pregnancy at, got TT (+) twice, vitamin, and iron
tablets. ANB (-), trauma history (-), the pregnancy disease (-), other drugs consumption
during pregnancy (-).
Natal :
- Born at midwife clinic from mother G2P2A0 by midwife, at term (9 months),
spontaneous delivery, body weight of birth was 2600 gr, body length of birth was 48 cm,
crying spontaneously
Postnatal History
- Control at Public Health Centre after birth; the child was healthy.
Immunization History
- BCG : 1x, 1 month
- DPT : 3x, 2,3,4 month
- Polio : 4x, 0,2,3,4 month
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- Hepatitis B : 4x, 0,2,3,4 month
- Campak : 1x, 9 month
Impression : complete basic immunizations according to his age.
Food and Drink History
- 0- ... month: breast feeding
- 3-12 month: porridge (serelac) 2 times daily , each time one small bowl (1 table spoon)
sometimes until finished
- 1-3 year: : rice porridge with meats or fish or vegetables., 3 times daily, one small bowl
but could not finished it (3/4 portion)
Growth and Developmental History
Growth :
Weight at previous month: kg, Length at previous month : ,
Body weight at present: 12 kg, Length of body at present 88 cm,
Body weight at birth 2600 gram
Body length at birth 48 cm
Impression : loss of growth
Developmental :
child can smile at 2 month, prone at 4 month, sit down at 5 month, can say one word
which has two syllables at 5 month, first teeth eruption at 9 month, but cannot stand up
yet. Child could stand up at 18 month, run at 2 year.
1.KPSP
Dapatkah anak mengenakan sepatunya sendiri? Ya Tidak
Dapatkah anak mengayuh sepeda roda tiga sejauh sedikitnya 3 meter? Ya Tidak
Setelah makan, apakah anak mencuci dan mengeringkan tangannya
dengan baik sehingga anda tidak perlu mengulanginya?
Ya Tidak
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Suruh anak berdiri satu kaki tanoa berpegangan. Jika perlu tunjukkan
caranya dan beri anak anda kesempatan melakukannya 3 kali. Dapatkah
ia mempertahankan keseimbangan dalam waktu 2 detik atau lebih?
Ya Tidak
Letakkan selembar kertas seukuran buku ini di lantai. Apakah anak dapat
melompati panjang kertas ini dengan mengangkat kedua kakinya secara
bersamaan tanpa didahului lari?
Ya Tidak
Jangan membantu anak dan jangan menyebut lingkaran. Suruh anak
menggambar seperti contoh ini dikertas kosong yang tersedia. Dapatkah
anak menggambar lingkaran?
Ya Tidak
Dapatkah anak meletakkan 8 buah kubus satu persatu di atas yang lain
tanpa menjatuhkan kubus tersebut? Kubus yang digunakan ukuran 2.5-
5cm
Ya Tidak
Apakah anak dapat bermain petak umpet, ular naga atau permainan lain
dimana ia ikut bermain dan mengikuti aturan bermain?
Ya Tidak
Dapatkah anak mengenakan celana panjang, kemeja, baju atau kaos kaki
tanpa di bantu? (tidak termasuk memasang kancing, gasper atau ikat
pinggang)
Ya Tidak
The result of KPSP score: 3 points
The conclusion: abnormality
Family Planning
Mother use injection contraception (every 3 months)
C. PHYSICAL EXAMINATION
July 2nd, 2012 at 12.00 WIB
Female, 3 years 8 months, weight: 12 kg, length: 88 cm.
General appearance: Composmentis, active, spontaneus breathing
Vital Sign : HR : 100 x/minutes t : 37 oC (axiller)
RR : 28 x/minutes N : regular, volume/pressure enough
Skin : Anemic (-), cyanotic (-), icteric (-)
Head : Fontanella: closed
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Head circumference :43 cm (mesocephal)
Eyes :Anemic conjunctival palpebrae (-), icteric sclerae (-), upslanting palpebral
fissure (+)
Ears : Discharge (-/-), cerumen (-), low set ears (-/-)
Nose : Nasal flare (-), discharge (-/-)
Mouth : Cyanotic (-), dry mucosa (-), drolling (-)
Teeth : Caries (-)
Throat : T1-1, hyperemic (-), hyperaemic pharyng (-)
Neck : Symmetric, enlargement of lymph nodes (-)
Thorax
Lungs: I : Symmetrical static and dynamic, retraction (-)
Pa : Stem fremitus right = left
Pe : Sonor in whole lung area
A : Basic sound: vesicular
Additional sound: (-)
Cor : I : Ictus cordis didn’t visible
Pa : Ictus cordis was not wide, no powerful to lift
Pe : heart margins are difficult to be examined
A : Heart sound I-II normal, murmur (-), gallop (-)
Abdomen: I : flat, supel
Pa : soft, liver /spleen: unpalpable, turgor: return fast
Pe : tympani
A : intestine sound (+) N.
Lymph nodes : no enlargement
Genital : female, vulva hiperemis (-)
Extremities : Upper Lower
Pale - / - - / -
Cyanotic - / - - / -
Cold - / - - / -
Edema - / - - / -
Capilarry refill <2” <2”
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Simian crease - / -
Tonus hipertonus hipertonus
Clonus - / - - / -
Phyisiologic reflex ++/ ++ ++ / ++
Pathologic reflex - / - - / -
D. ANTHROPOMETRICAL STATUS
Male, 3 years 8 months, recent weight: 12 kg, height: 88 cm.
WAZ : -1,96 SD
HAZ : -3,24 SD
WHZ : 0,03 SD
Head circumference: -4,3 SD
Impression: good nutrition, short stature, microchepal
E. WORKING DIAGNOSIS
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1. Main diagnosis : clinic down syndrome
2. Co-morbid diagnosis : -
3. Complication diagnosis : -
4. Growth diagnosis : good nutrition, short stature, microcephal
5. Developmental diagnosis : speech delay
6. Immunization diagnosis : Complete basic immunization according to her age
7. Social Economic diagnosis : poor social economic status
F. INITIAL PLANS
Assessment:
1. Down syndrome
Ip.Dx : S: -
O: Spasticity, hypertonus, hyperreflex, babinsky reflex (+)
Ip.Rx : medical rehabilitation for physiotherapy
consult to otopharyngology, head, and neck surgery department for BERA, OAE
examination
Ip.Mx : motoric function
child development
BERA, OAE
MRI preferred to CT scan evaluation after 6 month
Ip.Ex :
Explain to the parents that their child’s disease caused by the brain injury at the
developmental period of the brain which cause non progressive brain impairments
but the prognosis is not good either so it needs continous stimulation for better
results
Explain to the parents that their child need higher calories
Explain to the parents about the possibility of reccurent upper respiration tract
infection
Explain the parents to change the baby position regularly
2. Global Developmental Delay
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Ip.Dx : S: -
O: Denver test, Caput scale, Elms scale
Ip.Rx : medical rehabilitation for physiotherapy ( occupational therapy, speech therapy)
Stimulation and intervention
Consult to ear nose throat head and neck surgery department
Ip.Mx : KPSP, Denver II
Ip.Ex :
- Explain to the parents about global development delay that happened to the child
- Explain to the parents to stimulate their child as often as possible based on the given
program
- Explain to the parents to check-up their child to the doctor next month.
3. Short stature
DD/ Secondary
Primary
Ip.Dx : S : -
O: Mid parental height
Ip.Rx : -
Ip.Mx : body height evaluation monthly
Ip.Ex :
- Explain to the parents about the condition of their child
- Explain to the parents about the possible etilogies of that condition
HOME VISIT RESULT
Home visit was done on June 20th, 2012 at 16.30
I. HOUSE CONDITION
Main house
Status : The house owned by the grandparents. Six family member are living there.
Size : 8 m x 4 m
House terrace : No
9
House yard : Yes, 1x3 m2, dirty and mess
House walls : Bricks and wood
Floor : tile and cemented floor (kitchen)
Rooms : there are 3 rooms in the main house : 2 bedrooms, 1 living room ; while
kitchen and bathroom are separated from the main house
Windows : 2
Ventilation : inadequate, every room has sufficient ventilation and opened
every day
Lighting : inadequate
Hygiene : inadequate, the house cleaned every day (twice daily)
Water source : For bathing and washing is taken from artesian well, cooking and
drinking from mineral water
Trash can : one opened-trash can
Bathroom : there is one, outside the main house with a tub, was cleaned 1-2x/week.
There is toilet, with good drainage
Sewers : There is sewer that flow to reservoir pool
Kitchen : there is one outside the main house, there is a gas stoves and dining set is
placed in shelf
II. DAILY HABIT
Asuh :
Father works as a honorer workers at SMA 1 , work location near the house. Mother
does not work . Patient cared by parents from birth. Patient’s daily care done by
parents and grandmother.
When sick, patient consumed drug from drug store first, then go to primary health
care, or hospital if there is no improvement.
Daily meal: F100 milk 120 cc 8 times daily
Asih: Love is gained from parents, grandmother, and the others family members well
Stimulation:
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Mental stimulation is accepted primary from mother who is graduated from senior
high school, and father who is graduated from junior high school
Play with her sister and cousins everyday
Toys: doll, colored toys
The child’s daily care is done by parents. Before sick the child eats porridge with meats
or fish or vegetables 3 times daily and milk but after sick she just drink F100 milk 120 cc
8 times daily. Drink water source for baby from mineral water. Dining set is washed with
water from artesis well and detergent. Dirty laundry washed everyday. The place for
washing dining set and clothes is in one different place. If there is one of family
members get an illness, then they get drugs from drug store first, then go to primary
health care or hospital if there is no improvement.
Environment
Patient’s house is located on Gergaji Pelem V no 64 RT/RW 005/006 Semarang.
Patient’s house has no terrace, but has 1x3 m2 yard that is dirty and mess, the street in
front of the house is quite large, and have a good drainage. The street in front of the
house is pavement street. No pets found near the house. Patient’s house has brick and
wood walls, tile floor at the main house and cemented floor at kitchen and bathroom,
door always open at noon and window which often open, have sufficient ventilation but
have insufficient lighting. Kitchen, bathroom are separated from the main house. Six
people are living in the house: parents, 2 children, aunt and grandmother, .
Impression: The size of the house is insufficient for the occupants, house condition and
hygiene are poor, insufficient lighting, but have a sufficient ventilation, good daily habits.
Photos:
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