mr developmental delayed 6-9-14

8/10/2019 MR Developmental delayed 6-9-14

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MORNING REPORTSept 8th2014

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II. Anamnesis (alloanamnesis by her mother)

Chief complaint: unable to speech and walk

History of Present illness:Parents noticed that the patient couldnt speak and walk

since 1 y.o. He was able to stand and walk while held unto

various things around her (such as chair or table) or with

parents support (held his hands). Patient could rolling herbody on the bed and sit herself and maintain the sitting

position in a long period of time.

Couldnt speak words clearly , just began to say ta..ta..ta.

Eat and drink needed parents help, no swallowing

disturbance. Toileting using diaper.

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Hospitalized at prof Kandou hosp on Agust 2014

for 2 weeks due to unknown seizures.

History of past illness

Febrile convulsion (-) from age 8 month

convulsion without febrile, less than 1 minute.

Every teethingconvulsion. Seizure

frequency up to 2 times per months with

duration less than minute.

Icteric (-), trauma (-)

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History of family illness:

In parents family never have history like this.

patient

5 years old

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History of antenatal: regular control at posyandu and

public health centre, got TT shot twice, never been sick

during the pregnancy, age when pregnant was 37

History of natal: at hospital by doctor, SC, was not

immediately crying after born, BW 3460gr, BL 50 cm

History in development:

begun lift head3 month

lying flat on stomach4-5month

rolling5-6 month

sitting 6-7monthcrawl on hands and knessunable

stand up1 year and 4 monthwith support

walkingwith support

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Immunization: complete

History for feeding:

ASIfrom born until 6 month

PASI 6 month until present

Gruel6 month until 1 y.o

Porridge10 month until present

Rice1 year and 2 month until present

Social & economics:

Live in a permanent house with 1 floor and 2 rooms and1 bathroom.

Medical expenses by ASKES

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live with her parents and 1 older brother (5

y.o). He usually left alone with house maid while

his mother was working. His brother were

used to playing with him and usually take himtoys. His parents infrequently teach his new

things or words.

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Physical Examination

HR 100x/mnt RR 24x/mnt Temp. afebris

height: 82 cm

weight: 12 kg

Ideal height: cm and weight: kg (based on height and

weight for age table in 1 y 9 mo Indonesian child)

Head circumferences: 49 cm

Chest circumferences: 53 cm

Abdomen circumferences: 51cm

Head: normocephali, conj. Anemis -/-, scl icterik -/-

Thorax: cor murmur -, pulmo ronchi -/-, whezing -/-

Abdomen: flat, hepar/lien not palpable, peristaltic normal.

Extremity: warmth


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Denver II

Social personal : 13 month

Fine motor-adaptive : 13 month

Language : 9 month Gross motor : 10 month

True age : 17 month

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Motoric Status

Upper Ekstremity Lower Ekstremity

Right Left Right Left

Movement Normal Normal Normal Normal

Muscle strength Looks >3 Looks >3 Looks >3 Looks >3

Muscle Tone Normal Normal Normal Normal

Muscle atrophy 16/15 cm 16,5/15 24/19 24/19

Physiological

Reflex

+ normal + normal + normal + normal

Patologic Reflex Absent Absent Absent Absent

Sensibility N/E N/E N/E N/E

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REFLEXES

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Spinal:

Flexor withdrawal : -

Extensor thrust : -

Brainstem:

Asymmetric Tonic Neck : -

Symmetrical Tonic Neck 2 : -

Mid brain:

Neck righting : -

Optical Righting 2 : - Optical righting 1,3,4 : -

Automatic Movement Reactions:

Moro reflex : -

Landau reflex : -


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DIAGNOSIS Clinical diagnosis : global developmental delayed

()

Topical diagnosis : brain

Etiology diagnosis : post natal brain hypoxia

Functional diagnosis:

Impairment : disturbance in fine motor, gross motor,

language, and personal social skill

Disability : unable to speak words, crawl, stand and

walk without support

Handicap : playing disturbance

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Rehabilitation Program:

Trunk control exercise

Stimulation with massage (sensory integration)

Strengthening extremities muscles with playing and

recreational activity

Speech stimulation

Education for parents to pay attention to patients

development, with always talking and playing with her

Home program: stimulation with playing cubic, ball, etc

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Psikolog: Psikological support for parents, intelegentia

Enviroment evaluation

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THANK YOU

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mr developmental delayed 6-9-14

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