History

a. Main complaint
Os present with fever
b. History of present illness
Os came to the hospital ID waled escorted by her parents with symptoms of fever
perceived since five days ago. Fever suffered ups and downs, where the body
temperature os as measured by touching the hand increased in the early afternoon, and
down in the morning. On the first day of fever appeared, had suffered a seizure os 1
times. seizure looks at the whole body, head thrown back and eyes move upwards.
Seizures lasted = - 10 minutes followed by loss of consciousness for a = - 1 hour later.
Seizures do not appear again after this. According to the mother os patient also
complained of headaches since the fever appears. Increasingly severe headache when
the patient is woken up from a lying position.
Os also complained of pain in the gut, vomiting (+) 5 days ago 1 times. Vomiting
spurts, containing food and yellowish liquid without mucus and blood. Os greatly
decreased appetite during illness.
pain around the eyes, vision glare, cough and cold, pain and discharge from the ears,
toothache, sore throat and shortness of breath denied by the patient's mother. Urinate
smoothly and without complaint. Whether there is a history of weight loss over the
last few months is not known by the family.
Past medical history
- A history of febrile seizures (+) when os 9 months old. seizures 1 times, duration of
seizures took place is unknown
- History of epilepsy denied
- A history of cough illness (+) 3 months ago. cough with phlegm, sputum viscous
greenish, for = - 1 week duration. cough cured after treatment in enumerations
- A history of lung spots, diseases of the eyes, nose, ears, mouth and throat also denied
- A history of asthma and allergy drugs also denied
Family history of disease
no family who have complaints like os or have ever been hospitalized because of
illness such as os
history of lung infection (+) suffered by the patient's father, not a specific disease
diketahuo family, father patients currently being treated in GP practices. treatment has
been going on for + - 6 months
treatment history
family never brought os treatment at village health worker setem [at. tera [pi obtained
in the form of medicine in syrup form, containing antibiotics and fever, but the
complaint does not improve with treatment and eventually os waled taken to hospitals
for treatment.
Age of growth and development
3 months Start lying on your side
6 months Os can be prone
8 months Sit down and say the word mother, father
1 year to crawl, increasing spoken vocabulary
1 years to communicate fluently
history of pregnancy and childbirth

Prenatal: os is the first child, who was conceived during 9-10 months. during
pregnancy the mother os routine controls in health centers. supplements such as iron
and folic acid (+) during pregnancy, TT (+) and no history of pain during pregnancy
perinatal and post natal
Os was born at the hospital with the help of vacuum extraction. KPD history (+)
before delivery. the length of time of the rupture until the baby is born + - 8 hours
(rupture of membranes at 18:00, was born at 02.00). at birth os indirect cry, amniotic
fluid is green. os crying after the liquid cleared by disuction, then further IMD. BBL
3800 g, body length is unknown.
Breast milk
Additional food: porridge nestle
adult meals
Physical examination
a. present status
general state; being sick
awareness: somnolence
b. vital signs
c. Anthropometric status
6. physical examination
- Head: black hair, uneven distribution is not easily broken not easily fall
- Edema (-) tenderness (-) mass (-)
scar (-)
-hidung:
nasus dekstra: within normal limits?
7. neck
dam vein
tenderness?
thoracic
normotoraks, symmetrical left and right, dilation of blood vessels, tenderness, crepitus
while static and dynamic symmetric retraction ics
palpation: tenderness expansion fremitus breathing hard checked
Abdominal
Inspection: soft flat symmetrical caput medusa (-), striae (-) cicatricial (-), scars (-)
auscultation:
percussion: timpani in the ninth quadrant.
palpation: defans muscular, superficial and deep tenderness, rebound tenderness,
lumps,
extremity
akral? within normal limits? wound?
treatment in general practice, lasts for 6 months, contact with children (+). did not
provide repair? ptekiae rash on both legs,
turbidity?
installation ngt liquid diet?
bed rest
keep the nutritional intake of food to avoid hard consistency,liquid meal diet