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

A. IDENTITY Name Age : K. I : 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 Name Age Religion Occupation : Mr. HK : 26 years : Islam :

Mother Name Age Religion Occupation : Mrs. S : 24 years : Islam :-

B. ANAMNESIS Alloanamnesis with patients 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 mothers 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

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 doesnt 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 - DPT - Polio : 1x, 1 month : 3x, 2,3,4 month : 4x, 0,2,3,4 month 3

- Hepatitis B - Campak

: 4x, 0,2,3,4 month : 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? Dapatkah anak mengayuh sepeda roda tiga sejauh sedikitnya 3 meter? Setelah makan, apakah anak mencuci dan mengeringkan tangannya dengan baik sehingga anda tidak perlu mengulanginya? 4 Ya Ya Ya Tidak Tidak Tidak

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? Letakkan selembar kertas seukuran buku ini di lantai. Apakah anak dapat melompati panjang kertas ini dengan mengangkat kedua kakinya secara bersamaan tanpa didahului lari? Jangan membantu anak dan jangan menyebut lingkaran. Suruh anak menggambar seperti contoh ini dikertas kosong yang tersedia. Dapatkah anak menggambar lingkaran? Dapatkah anak meletakkan 8 buah kubus satu persatu di atas yang lain tanpa menjatuhkan kubus tersebut? Kubus yang digunakan ukuran 2.55cm Apakah anak dapat bermain petak umpet, ular naga atau permainan lain dimana ia ikut bermain dan mengikuti aturan bermain? Dapatkah anak mengenakan celana panjang, kemeja, baju atau kaos kaki tanpa di bantu? (tidak termasuk memasang kancing, gasper atau ikat pinggang) The result of KPSP score: 3 points The conclusion: abnormality Family Planning Mother use injection contraception (every 3 months)

Ya

Tidak

Ya

Tidak

Ya

Tidak

Ya

Tidak

Ya

Tidak

Ya

Tidak

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 RR Skin Head : 100 x/minutes : 28 x/minutes t N : 37 oC (axiller) : regular, volume/pressure enough

: Anemic (-), cyanotic (-), icteric (-) : Fontanella: closed 5

Head circumference :43 cm (mesocephal) Eyes :Anemic conjunctival palpebrae (-), icteric sclerae (-), upslanting palpebral fissure (+) Ears Nose Mouth Teeth Throat Neck Thorax Lungs: I : Symmetrical static and dynamic, retraction (-) : Discharge (-/-), cerumen (-), low set ears (-/-) : Nasal flare (-), discharge (-/-) : Cyanotic (-), dry mucosa (-), drolling (-) : Caries (-) : T1-1, hyperemic (-), hyperaemic pharyng (-) : Symmetric, enlargement of lymph nodes (-)

Pa : Stem fremitus right = left Pe : Sonor in whole lung area A : Basic sound: vesicular Additional sound: (-) Cor : I : Ictus cordis didnt 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 Extremities : Pale Cyanotic Cold Edema Capilarry refill : female, vulva hiperemis (-) Upper -/-/-/-/<2 Lower -/-/-/-/<2 6

Simian crease

-/-

Tonus Clonus Phyisiologic reflex Pathologic reflex

hipertonus -/++/ ++ -/-

hipertonus -/++ / ++ -/-

D. ANTHROPOMETRICAL STATUS Male, 3 years 8 months, recent weight: 12 kg, height: 88 cm. WAZ HAZ WHZ : -1,96 SD : -3,24 SD : 0,03 SD

Head circumference: -4,3 SD

Impression : good nutrition, short stature, microchepal

E. WORKING DIAGNOSIS 7

1. Main diagnosis 2. Co-morbid diagnosis 3. Complication diagnosis 4. Growth diagnosis

: clinic down syndrome ::: 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 childs 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 8

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 Size : The house owned by the grandparents. Six family member are living there. :8mx4m : No 9

House terrace

House yard House walls Floor Rooms

: Yes, 1x3 m2, dirty and mess : Bricks and wood : tile and cemented floor (kitchen) : there are 3 rooms in the main house : 2 bedrooms, 1 living room ; while kitchen and bathroom are separated from the main house

Windows Ventilation Lighting Hygiene Water source

:2 : inadequate, every room has sufficient ventilation and opened every day : inadequate : inadequate, the house cleaned every day (twice daily) : For bathing and washing is taken from artesian well, cooking and drinking from mineral water

Trash can Bathroom

: one opened-trash can : there is one, outside the main house with a tub, was cleaned 1-2x/week. There is toilet, with good drainage

Sewers Kitchen

: There is sewer that flow to reservoir pool : 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. Patients 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:

10

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 childs 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 Patients house is located on Gergaji Pelem V no 64 RT/RW 005/006 Semarang. Patients 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. Patients 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.

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