Download - Case Morbili
Case Presentation Bronchopneumonia Preceptor: dr. Ulynar Marpaung, Sp.A Presenter: Julianti Mulya Utami - 1102010138
DEPARTMENT OF PEDIATRIC R. SAID SUKANTO POLICE CENTER HOSPITAL FACULTY OF MEDICINE YARSI UNIVERSITYPERIOD DECEMBER 2015 FEBRUARY 2016
Preceptor:dr. Ulynar Marpaung, Sp.APresenter:Rinto Nugroho- 1102010244MORBILI COMPLICATED WITH BRONCHOPNEUMONIA1Name : ShaafiyahBirth Date: December 12th 2013Age: 2 years oldGender: FemaleAddress: Ketapang, Munjul Nationality: IndonesiaReligion: Islam Admission : December 21th 2015Examination: December 21th 2015PATIENT IDENTITY2FatherMotherNameMr.AgusMrs. Aini Age30 years old26 years oldJobEntrepreneurHousewifeNationalityJavaneseJavaneseReligionIslamIslamEducationHigh School (graduated)sHigh School (graduated)sEarning/monthApproximately Rp.2.000.000,--AddressKetapang,Munjul.PARENTS IDENTITY3HISTORY TAKINGTaken on December 21th 2015Shortness of breath 8 hours before admission to hospitalby Alloanamnesis (from patients mother)Chief complain :High fever, productive cough, runny nose, hoarseness, red patches all over the body, loss appetiteAdditional complain :ANAMNESIS :Diambil pada tanggal 21 desember 2015Secara alloanamnesis (terhadap ibu pasien)KELUHAN UTAMA : sesak napas sejak 8 jam SMRSKELUHAN TAMBAHAN : Demam tinggi, batuk berdahak, pilek, suara serak, bercak merah disekujur tubuh, tidak nafsu makan4HOSPITALDecember 21th 2015rash appeared on her face and neck, she also present with poor feeding and irritable. BEFORE HOSPITAL ADMISSION5 DAYS1 DAYSShortness of breath,Rash spreading to thrunk and chest8 HOURSHISTORY OF PRESENT ILLNESSSudden high fever, never been measured, productive cough, runny nose with clear and mucoid secret and redness watery eye.Hoarseness occurs at night after.She was taking paracetamol, but there was no significant effect.5Pharyngitis/Tonsilitis-Bacillary Dysentry-Bronchitis-Amoeba Dysentry-Pneumonia-Diarrhea-Morbilli-Thypoid-Pertussis-Worms-Varicella-Surgery-Diphteria-Brain Concussion-Malaria-Fracture-Polio-Drug Reaction-Enteritis-HISTORY OF PAST ILLNESS6Antenatal careAntenatal check ups performed at the doctor in the hospital. There was no problems during pregnancy.No maternal illness during pregnancyDrugs consumption:Vitamins every antenatal care
Prenatal HistoryLabor : HospitalBirth attendants: doctorMode of delivery: pervaginamGestation: 38 weeksInfant state: healthyBirth weight : 3400 gramsBody length: 50 cmAccording to the mother, the baby started to cry and the baby's skin is red, no congenital defects were reported
Birth HistoryExamination by midwifeThe state of the infant: healthy
Post Natal HistoryFirst dentition: 6 monthsPsychomotor development Head Up: 1 month oldSmile: 1 month oldLaughing: 1- 2 month oldSlant: 2,5 months oldSpeech Initiation: 4 months oldProne Position: 4 months oldFood Self: 5 6 months oldSitting: 6 months old
Mental Status: Normal Conclusion: Growth and development status is still in the normal limits and was appropriate according to the patients ageDevelopment HistoryBreast MilkExclusively 6 month..Formula milk-Baby biscuitsBiscuits milnaFruit and vegetablesBanana, PapayaHistory of EatingImmunizationFrequencyTimeBCG1 time1 month oldHepatitis B3 times0, 1, 6 months oldDPT3 times2, 4, 6 months oldPolio4 times0, 2, 4, 6 months oldHib3 times 2, 4, 6 months oldMeasles--History of ImmunizationPatients both parents were married when they were 26 years old and 24 years old, and this is their first marriage.There are not any significant illnesses or chronic illnesses in the family declared.
Family HistoryChildbirthGenderAgeAge DiedSumption DiedSpontan pervaginam, gestation atermgirl 2 years old--History of siblingThere is no one living around their home known for having the same condition as the patient.
History of the disease people around the patientThe patient lived at the house with size 20m x 10 m together with father and mother.There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1 room is the bedroom of three of them and 1 room is for guest. There are 4 windows inside the house. The windows are ocassionaly opened during the day.Hygiene:The patient changes his clothes everyday with clean clothes.Bed sheets changed every two weeks.Social and Economic HistoryGeneral StatusGeneral condition: mild illAwareness: Compos MentisPulse: 109 x/min, regular, full, strong.Breathing rate: 29 x/minTemperature: 39C (per axilla)Antropometry Status Weight: 10,5 kilogram height : 80 cm
Physical Examination(December 21 2015)Nutritional Status based NCHS (National Center for Health Statistics) year 2000:a. WFA (Weight for Age): 10,5/12 x 100 % = 87.5 % (good nutrition)
b. HFA (Height for Age): 80/86 x 100 % = 93 % (good nutrition)
c. WFH (Weight for Height): 10,5/11 x 100 % = 95.5 % (normal)Conclusion: The patient has good nutritional status.
18HeadNormocephaly, hair (black, normal distributon, not easily removed) sign of trauma (-), sunken fontanelle (-).EyesIcteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++EarsNormal shape, no wound, no bleeding ,secretion or serumenNoseNormal shape, midline septum, secretion +/+MouthLips Teeth Mucous Tongue Tonsils Pharynx DryNo cariesDryNot dirtyT1/T1, no hyperemiaHyperemiaNeckLymph node enlargement (-), scrofuloderma (-)Systematic Physical ExaminationThoraxInspection:Symmetric when breathing , suprasternal and intercostal retraction (+), ictus cordis is not visiblePalpation:mass (-), tactile fremitus +/+Percussion:Sonor on both lungsAuscultationCor: Pulmo:regular S1-S2, murmur (-), gallop (-)vesicular +/+, Wheezing -/- , Rhonchy +/+Abdomen:Inspection:Convex, epigastric retraction (-), there is no a widening of the veins, no spider nevi.Palpation:supple, liver and spleen not palpable, fluid wave (-), abdominal mass (-)
Percussion:The entire field of tympanic abdomen, shifting dullness (-)Auscultation: normal bowel sound, bruit (-)VertebraScoliosis (-) kyphosis (-) lordosis(-), any mass along the line of vertebra (-)EkstremitiesWarm, capillary refill time