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    SECTION I

    Case Report

    IDENTITY

    Patient   Name : L.A

    Birth Date : May 4th, 200

    A!e : "0 years # mo$ths

    %e$&er : Ma'e

    A&&ress : (p Ta$!si RT#)R*+ Ciara$!, East -aarta

     Natio$a'ity : I$&o$esia

    Re'i!io$ : Mos'em

    MR No. : +0//

    Date o1 a&missio$ : A!st 2th  20"

    Date o1 eami$atio$ : A!st 2th 20"

    Father Mother

    Name Mr. S Mrs. M

    Age 40 years o'& # years o'&

    Job Emp'oyee 3osei1e

    Nationality I$&o$esia$ I$&o$esia$

    Religion Mos'em Mos'em

    Education 3i!h S5hoo' 3i!h S5hoo'

    Earning/month Rp..000.000, 

    Address (p Ta$!si RT#)R*+ Ciara$!, East -aarta

    ANAMNESIS

    The a$am$esis as tae$ o$ A!st 2th 20", si$! a''oa$am$esis metho&.

    The a$am$esis tae$ at room $o.+ A$!!re II *ar&, RS 6OLRI R Sai& Sa$to

    hie! com#lain $ 7e8er si$5e 1or &ays prior to a&missio$ at hospita'.

    Additional com#lains :Rash, 5o!h, 1', hea&a5he, $asea, 8omiti$!, &iarrhea,

    a9&omi$a' pai$

    3istory O1 6rese$t I'$ess

    A "0 years # mo$ths o'& 9oy ith 9o&y ei!ht 2+ !, 5ame to Ra&e$ Sai&

    Sa$to 6o'i5e Ce$ter 3ospita' ER at 0/.#0 am, ith a 5hie1 5omp'ai$ o1 1e8er. The

    1e8er 'asts 1rom 4 &ays 9e1ore a&missio$ to the hospita'. The mother says that the

    1e8er are s&&e$ 9e5ame hi!h a$& o$t !oes &o$. The 1e8er 5ame p hi!h at $oo$.

    The mother !a8e pa$a&o' to &e5rease the temperatre. This 5omp'ai$s a'so 1o''oe&

     9y rash a'' o8er his 9o&y, 5o!h, 1', hea&a5he, $asea, 8omiti$!, &iarrhea, a9&omi$a'

     pai$ si$5e 4 &ays a$& sa''oi$! pai$ si$5e " &ay 9e1ore a&missio$.

    3istory O1 6ast I''$ess

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    6hary$!itis)To$si'itis ;

    Bro$5hitis 

    6$emo$ia 

    Mor9i''i 

    6ertssis 

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    De(elo#ment %istory

     7irst &e$titio$: + mo$ths o'&

     6sy5homotor &e8e'opme$t

     Smi'e : " mo$th o'&

     S'a$t : 2 mo$ths o'&

     Spee5h I$itatio$ : 2 mo$ths o'&

     6ro$e 6ositio$ : 4 mo$ths o'&

     Sitti$! : + mo$ths o'&

     Cra'i$! : = mo$ths o'&

     Sta$&i$! : "0 mo$ths o'&

     *a'i$! : "2 mo$ths o'&

     Co$5'sio$: !roth a$& &e8e'opme$ta' is sti'' i$ the $orma' 'imits a$& as

    appropriate a55or&i$! to the patie$ts a!e

    Post Natal %istory

     A1ter 9irth, the 9a9y 5he5e& at 'o5a' &o5tor a$& the i$1a$t state is hea'thy.

    3istory o1 Eati$!

     Breast Mi' : + mo$ths.

     7orm'a mi' : S%M si$5e / mo$ths o'&

     Ba9y 9is5its : Mi'$a, Re!a'

     7rit a$& 8e!eta9'es : Ba$a$a, papaya

     So'i& 1oo&s a$& si&e &ishes : Ba9y porri&!e

    Imm$i?atio$ 3istory

    Imm$i?atio$ 7re@e$5y Time

    BC% " time " mo$th o'&

    3epatitis B # times 0, ", + mo$ths o'&

    D6T # times 2, 4, + mo$ths o'&

    6o'io 4 times 0, 2, 4, + mo$ths o'&

    3i9 4 times 2, 4, +, mo$ths o'&

    Meas'es " time  mo$ths o'&

    7ami'y 3istory

    • 6atie$ts 1ather &i&$t ha8e hyperte$sio$ $or &ia9etes me''its

    • 6atie$ts mother &i&$t ha8e hyperte$sio$ $or &ia9etes me''its

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     The patie$t has " sister, a$& he is the 1irst 5hi'& o1 2 si9'i$!s.

     Bor$ &ie& :   

     Chi'& &ies :   

     Mis5arria!e :   

    3istory o1 Disease i$ Other 7ami'y Mem9ers ) Aro$& the 3ose

    3er $ei!h9ors so$ ha& meas'es a ee a!o.

    P%YSIA) E*AMINATI+N ,August -.th  -0.1

    2eneral Status

    - %e$era' 5o$&itio$ : Mi'&'y i''

    - Co$s5ios$ess : Compos Me$tis

    - 6'se : "00 )mi$, re!'ar, 1'', stro$!.

    - Breathi$! rate : 20 )mi$

    - Temperatre : #=.#o C per ai''a

    Anthro#ometry Status

    -*ei!ht : 2+ i'o!ram

    -3ei!ht : "#" 5m

     Ntritio$a' Stats 9ase& NC3S Natio$a' Ce$ter 1or 3ea'th Statisti5s year 2000:

    *7A Weight for Age: 2+)#"  "00   =#  !oo& $tritio$

    37A 3ei!ht 1or A!e: "#")"#/  "00     !oo& $tritio$

    *73 *ei!ht 1or 3ei!ht: 2+)2+  "00   "00  !oo& $tritio$

    Conclusion: The patient has good nutritional status.

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    %ead to Toe E3amination

     

    %ead

     Normo5epha'y, hair 9'a5, $orma' &istri9to$, $ot easi'y remo8e&  si!$ o1 

    trama , 'ar!e 1o$ta$e''e 5'ose&. Rash ,41

     

    Eyes

    I5teri5 s5'era ), pa'e 5o$F$5ti8a ), hy#eraemia con5uncti(a 4/4,

    'a5rimatio$ ), s$e$ eyes ), ppi's #mm)#mm isoor, Dire5t a$& i$&ire5t

    'i!ht respo$se ;;);;

    5

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    Ears

     Norma' shape, $o o$&, $o 9'ee&i$! ,se5retio$ or serme$. Rash ,41

     

    Nose

     Norma' shape, mi&'i$e septm, se5retio$ ). Rash ,41

     

    Mouth

    − Lips: &ry

    − Teeth: $o 5aries

    − M5os: moist

    − To$!e: Not &irty

    − To$si's: T")T", No hyperemia

    − 6hary$: hyperemia

     

    Nec6 

    Lymph $o&e e$'ar!eme$t ;, s5ro1'o&erma , Rash ,41

     

    Thora3 :

    i7 I$spe5tio$ : symmetri5 he$ 9reathi$!  8 $o retra5tio$,  i5ts 5or&is is $ot

    8isi9'e. Rash ,41

    ii7 6a'patio$ : mass , ta5ti'e 1remits ;);

    iii7 6er5ssio$ : so$or o$ 9oth '$!s

    i(7 As5'tatio$ : ". Cor : re!'ar S"S2, mrmr , !a''op 

    2. 6'mo : 8esi5'ar ;);, *hee?i$! ) , Rho$5hy )

     

    Abdomen :

    i7 I$spe5tio$ : Co$8e, epi!astri5 retra5tio$ , there is $o a i&e$i$! o1 the

    8ei$s, $o spi&er $e8i. Rash ,41

    ii7 As5'tatio$ : 9oe' so$& $orma' , 9rit 

    iii7 6a'patio$ : spp'e, 'i8er a$& sp'ee$ $ot pa'pa9'e, 1'i& a8e ,

    a9&omi$a' mass 

    i(7 6er5ssio$ : The e$tire 1ie'& o1 tympa$i5 a9&ome$, shi1ti$! &''$ess 

     

    9ertebra : There &oes $ot appear s5o'iosis, yphosis, a$& 'or&osis, &o $ot

    'oo a$y mass a'o$! the 'i$e o1 the 8erte9ra'

    E6stremities : arm, 5api''ary re1i'' time G 2 se5o$&, e&ema rash ,41

     

    S6in : %oo& tr!or.

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    Neurological E3amination

    Meningeal Sign

    Motoric E3amination

    Po:er

      3a$&   7eet

       )        )    

    Tonus

      3a$&

      7eet

     Normoto$s ) Normoto$s

     Normoto$s ) Normoto$s

    Tro#hy

      3a$&

      7eet

     Normotrophy ) Normotrophy

     Normotrophy ) Normotrophy

    Physiologic Re!le3

      Hpper etrimities

      Bi5eps

      Tri5eps

      Loer etrimities

      6ate''a

    A5hi''es

     

    ; ) ;

    ; ) ;

    ; ) ;

    ; ) ;

    Pathologic Re!le3

      Hpper etrimities

      3o11ma$

      Trommer 

      Loer etrimities

      Ba9i$sy

      Cha&&o5 

      Oppe$heim

      %or&o$

      S5hae11er 

     ) 

     ) 

     ) 

     ) 

     ) 

     ) 

     ) 

    lonus

      6ate''a

      A5hi''es

     ) 

     ) 

    7

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    Autonom E3amination

     

    De1e5atio$

      Hri$atio$

      Seati$!

     Norma'  " times &ai'y, $orma' 5o$siste$5y 

     Norma'  4 times &ai'y 

     Norma'

    )aboratory In(estigation

    %ematology August -.th -0.

    3emato'o!y Res'ts Norma'

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    O %e$era' 5o$&itio$: Compos Me$tis

    3eart rate  "00 )mi$

    Respiratory rate  2+ )mi$

    Temperatre  #/.C

    Car&io : S")S2, re!'er, $o mrmr, $o !a''op

    6'mo$ary : 8esi5'er ;);, rho$5hi ), hee?i$! ) A9&ome$ : &iste$tio$ , 9oe' so$& ; $orma'

    Rash ,41

     

    A Mor9i''i

    6   −  I

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    7e8er 