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By:
Fuad Zainani, S.Ked
Famelia, S.Ked
Advisor:
dr. Yulia Iriani, SpA(K)
Identification
Name : Ch. M
Age : 3 years
Sex : Girl
Weight : 10.3 kg
Height : 69 cm
Religion : Moslem
Address : Palembang
Nationality : Indonesian
DoA : October 14th 2009
Anamnesis (alloanamnesis)
History of illness
Veneral Condition
ÿ Conciousness : compos mentis
ÿ Pulse rate: 122 x/m, regular, adequate tension
ÿ RR : 24 x/m
ÿ Temperature : 39.20 C
ÿ Weight : 10.3 kg
ÿ Height : 69 cm
ContŨ
Õ tritional stat s :
W/A : 10.3/14 x 100% = 73,57%
H/A : 69/96 x 100% = 71,88%
W/H : 10.3/14.5 x 100% = 71,03%
Based on WHO 2000, W/A SD SD
: malnutrition grade II
ContŨ
Ú orax
Yung
ÿ Inspection : Statically & dynamically
Symmetric, retraction /
ÿ Palpation : Right & left stemphremitus equal
ÿ Percussion : Sonor on both lungs surface
ÿ Auscultation : Vesicular (+) normal, rales (),
wheezing ()
ContŨ
peart
ÿ Inspection : ictus cordis is not seen
ÿ Palpation : thrill is not palpable
ÿ Auscultation : HR: 122 x/m, regular, HS III
are normal, murmur (), gallop ()
ContŨ
domen
ÿ Inspection : flat
ÿ Palpation : soft, liver and spleen are
not palpable, pinch on
abdomen skin is fast
retightened
ÿ Percusion : tympani
ÿ Auscultation : bowel sound (+) normal
ContŨ
Mxtremities
ÿ Cold acral ()
ÿ Cyanotic ()
ÿ Edema ()
ÿ Petechiae (+), Rumple Yeed ()
ContŨ
ÿ Õeurologic Examination
M
6
ContŨ
Different Diagnoses
Typhoid fever + malnutrition grade II
Dengue fever + malnutrition grade II
Úreatment
Supportive therapy
ÿ Bed rest
ÿ Refined porridge diet
Medication therapy
ÿ Amoxicillin 3 x 150 mg
ÿ Paracetamol 3 x 125 mg
Planning
Physical examination:
1. Hyperemic pharynx
2. Hyperemic tonsils
Acute
Tonsilloph
aryngitis
ContŨ
Õ tritional stat s :
W/A : 10.3/14 x 100% = 73,57%
H/A : 69/96 x 100% = 71,88%
W/H : 10.3/14.5 x 100% = 71,03%
Based on WHO 2000, W/A SD SD