Presentasi Kasus Bayi Sehat

7/23/2019 Presentasi Kasus Bayi Sehat

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CASE PRESENTATION & CLINICAL GUIDELINE

HEALTHY INFANT

APRIL 20

BAYI SEHATDR ADOLFINA VITRIA

Consultant:

CASE

A. PATIENT’S IDENTITY

Name : GOF

Sex : Female

Age : 26 month

Height : 81 cm

Weight : 10 kg

Marital status : Single

Occupation : -

Pregnancy status* : -

Address : Bantul

Examination date : 15 April 2013

B. ANAMNESIS

1. CHIEF COMPLAINT : Datang ke Posyandu untuk penimbangan rutin

2. CURRENT HISTORY :

Anak tidak dalam kondisi sakit. Pola makan saat ini cukup baik (makan besar : pagi,

siang, sore; camilan : kadang sebelum makan siang, kadang saat sore hari; buah :

selang-seling dengan camilan). Saat ini anak sudah dapat berjalan dengan lancarbahkan sudah berlari, dapat berdiri dengan satu kaki kira-kira 1 detik. Sudah dapat

bermain-main sendiri, mencoret-coret. Sudah dapat diajak berkomunikasi meski

kata-kata yang diucapkannya terkadang sulit dimengerti tapi sudah spesifik. Anak

tampak aktif sulit untuk diajak duduk lama.

3. PAST HISTORY :

Riwayat kelahiran : lahir secara caesar terencana saat cukup bulan (kurang 2

minggu dari HPL) karena kata dokter tidak mau masuk panggul

Riwayat imunisasi : mendapatkan imunisasi dasar lengkap : Hepatitis B saat lahir,

usia 2, 3 dan 4 bulan; BCG: saat usia 1 bulan; Polio saat usia 2,3,4 dan 10 bulan; DPT:

saat usia 2,3, dan 4 bulan; Campak : saat usia 10 bulan.Riwayat perkembangan : menurut ibu masih sesuai dengan anak lain, hanya anak

terlihat lebih banyak gerak dan sulit tidur. Merangkak usia 8 bulan. Berdiri usia 15

bulan.

Riwayat sakit : anak tidak pernah mondok di rumah sakit. Beberapa kali sakit

demam kadang disertai batuk, pilek. Dapat sembuh setelah berobat ke Puskesmas.

Tidak ada riwayat kejang saat demam.

4. SYSTEM

a. Cerebrospinal : None

b. Cardiovascular : None

c. Respiratory : Dyspnoe -, cough -,

d. Gastrointestinal : Nauseous -, vomiting-, dyspepsia-.

e. Urogenital : Urine clear, polyuria-, dysuria-.

f. Musculoskeletal : None

g. Integument : Lymph nodes : none

h. Eye : none




HEALTHY INFANT

APRIL 20

i. ENT : None

5. FAMILY ILLNESS HISTORY :

Riwayat darah tinggi dalam keluarga : kakek dari pihak ayah

Tidak ada riwayat sakit gula. Tidak ada riwayat sakit jantung. Tidak ada riwayat

sakit asma. Tidak ada riwayat sakit berat pada keluarga.

Riwayat alergi : ayah (biduren), tante (biduren) dan kakek (dari garis keturunan

ayah)

6. FAMILY TREE : Dibuat tgl 15 Aril 2013

HT

A

A

A

Legend :

HT:hipertensi

A:riwayatalergi

:Breadwiner

7. FAMILY LIFE CYCLE : Families with young children

8. FAMILY SCREEM :

Resources Pathology

SOCIAL Interaksi sosial dengan

tetanngga kanan-kiri baik

Interaksi sosial dengan

keluarga baik, jika ada acara

keluarga mau menghadiri

Tidak selalu ikut kegiatan

yang ada di tempat tinggal

karena tinggal di rumah

kontrakan dan merupakan

pendatang baru

KTP orang tua masih

mengikuti alamat kakek-

nenek dari pihak ayah Kegiatan gereja juga masih

mengikuti gereja waktu

orang tua kuliah (di Yogya)

sehingga tidak aktif

mengikuti kegiatan gereja

setempat

CULTURAL Kakek nenek dari pihak ibu

merupakan pendatang dan

sering berpindah-pindah

sehingga kultur daerahnya

tidak terlalu kental

Nenek dari pihak ibu

bekerja sebagai baby sitter

sehingga pola asuh anak

sangat ditentukan oleh

nenek

RELIGIOUS Rajin beribadah ECONOMIC Sumber pendapatan : ayah

bekerja sebagai karyawan

swasta pada kantor yang

bonafid

EDUCATION Orang tua anak lulusan sarjana




HEALTHY INFANT

APRIL 20

MEDICAL Ayah ikut dalam jamsostek,

beitu juga ibu dan anak

Tetapi lebih sering datang ke

Puskesmas

Jika berobat ke Puskesmas

tidak dapat menggunakan

Jamsostek

C. PHYSICAL EXAMINATION

1. General Appearance : Sehat, aktif bergerak

2. Vital Signs

BP

RR

HR

T

:

:

:

:

-

30, regular

80, regular, strong.

36.5 0t

3. Nutritional status

Weight/Age

Height/Age

:

:

:

BB : 10, TB 81, umur 26 bulan

Sesuai umur

Sesuai umur

4. Head : symmetric, haematoma -, conj : not pale

Neck : lymph node : -, JVP: normal, thyroid: not

palpable/,

Thorax : Symmetric, , no retraction

Cardiac : Ictus cordis :normal, S1-S2, murmur : negative,

HR: 67/mnt, regular, pulse strong

Pulmonary : Symmetric, , sonor +/+.no wheezing/rales

Abdomen : protuberance, tympani, tenderness : neg,

peristaltic + normal.

Extremity : Simetrik, hangat, kekuatan baik,

D. ADJUNCT EXAMINATIONS

1. Blood test : -

2. Urinalysis : -

3. Stool examination : -

4. Rontgen : -

5. Other examination : Menilai konsentrasi anak : anak masih dapat

forkus pada satu hal selama kurang lebih 3

menit. Anak diajak bicara masih

memperhatikan yang mengajak bicara

E. DIAGNOSIS (HOLISTIC DIAGNOSIS)

Bayi sehat, dengan pertumbuhan dan perkembangan sesuai umur pada keluarga baru.

F. THERAPY

-

G. PATIENT EDUCATION AND COUNSELING

EDUCATION : -

COUNSELING :

Mengatakan kepada orangtua anak bahwa pertumbuhan dan perkembangan anak

sudah sesuai umum. Pola makan juga sudah baik, meskipun akan lebih baik jika

buah diberikan setiap hari.

Terkait dengan banyaknya aktivitas anak, masih dalam batas normal.




HEALTHY INFANT

APRIL 20

Mengatakan kepada orang tua untuk terus memantau perkembangan anak di

Posyandu

H. MONITORING :

Pengukuran pertumbuhan anak dan memantau perkembangan anak setiap bulan di

Posyandu

I. PROGNOSIS : baik

J. SHORT TERM PLAN: -

K. LONG - TERM PLAN:

a. Targets and Commitments of Care-Plan: untuk selalu datang ke Posyandu

b. Family Empowerment: keluarga harus selalu memperhatikan pertumbuhan dan

perkembangan anak

L. FIVE LEVEL OF PREVENTION :

PRIMARY PREVENTION

HEALTH PROMOTION : Pemberian makanan 4 sehat 5 sempurna

Makan besar 3 kali. Diantaranya buah dan

camilan.

SPESICIF PROTECTION : -

SECONDARY PREVENTION :

EARLY DIAGNOSIS &

PROMPT TREATMENT :

Segera ke puskesmas jika anak sakit atau

ibu merasa ada gangguan tumbang

DISABILITY LIMITATION : -

TERTIARY PREVENTION : -

DISCUSSION

Self Raising Questions

1. Q : apa kriteria untuk anak hiperaktif?

2. Q :apa sajakah yang perlu diperiksa pada anak sehat?

3. Q :untuk memantau perkembangan anak paling mudah dan cepat menggunakan

kriteria apa?

4. Q : kapan dokter umum merujuk pada dokter spesialis terkait dengan

kemungkinan hiperaktif?

5. Q : kapan dokter umum merujuk pada dokter spesialis terkait dengan gizi

buruk?

6.

Q : kapan dokter umum merujuk pada dokter spesialis terkait denganketerlambatan perkembangan?




HEALTHY INFANT

APRIL 20

CLINICAL GUIDELINE

HEALTH SUPERVISION: 2 YEARS

1. ALLOANAMNESIS WITH PARENTS

THIS KIND OF QUESTIONS :

How are you?

How are things going in your family?

Do you have any questions or concerns about your child?

What do you and your partner enjoy most about him/her? What seems to be

most difficult?

Have there been any major changes or stresses in your family since your last

visit?

How is your child toilet training progressing?

What are your child sleeping habits? Eating habits?

Do you think your child hears all right? Sees all right?

Does your child eat nonfood substances such as clay, dirt, or paint chips?

What language(s) does your family speak at home?

Is your child fastened securely in a safety seat in the back seat every time he rides

in the car?

Are you happy with your child care arrangements?

Do both parents and all caregivers agree on disciplinary style and setting limits?

How are you dealing with setting limits for your child and disciplining her?

How do you deal with tantrums?

Do you ever get so angry with your child that you are worried about what you

might do next?

Do you know how to reduce your child’s risk of exposure to lead hazards if you

live in an older home or one that has been renovated recently?

Have you ever been in a relationship where you have been hurt, threatened, or

treated badly?

Have you ever been worried that someone was going to hurt your child? Has your

child ever been abused?

Do you feel safe in your neighborhood?

2. DEVELOPMENTAL SURVEILLANCE AND MILESTONES

ASK THIS KIND OF QUESTIONS

Do you have any specific concerns about your child development or behavior?

How does your child communicate what he wants?

o Vocalizes and gestures

o Speaks words (rapidly expanding vocabulary)

o Uses phrases of two or three words

o Speaks intelligibly to strangers (25 percent of the time)

What do you think your child understands?

o Names of family members

o Names of familiar objects, including those in pictures

o Names of seven body parts

o Simple instructions without gestured cues (“sit down”)

How does your child get from one place to another?

o Walks, climbs, runs

o Goes up and down stairs (one step at a time)

o How does Lincoln act around family members?

o Responsive or withdrawn

o Affectionate or hostile/aggressive




HEALTHY INFANT

APRIL 20

o Cooperative or defiant

o Dependent or self-reliant

o Anxious when separated from parents

How does your child react to strangers?

o Outgoing or slow to warm up

o Cautious/resistant o How does Lincoln act around other children?

o Interactive or withdrawn/resistant

o Friendly or hostile/aggressive (hitting, biting)

To what extent has your child developed independence in eating and dressing?

o Uses cup, spoon, and fork

o Helps to dress himself

o Tell me about your child s typical play.

o Plays with favorite toys (describe how used)

o Listens to stories

o Engages in simple fantasy playo Engages in parallel play with peers

o Has manual dexterity

3. OBSERVATION OF PARENT-CHILD

Interaction

How do the parent and child communicate? (Parents vary in their awareness of

language

milestones and the ability to report this information.)

What words do they use?

What is the tone of the interaction and the feeling conveyed?

Does the parent teach the child the name of a person or object during the visit?

How does the parent discipline or restrain the child? Does the parent seem positive

when speaking about the child?

4. PHYSICAL EXAMINATION

a. Measure the child’s length or height and weight, and calculate body mass index

(BMI).

Plot these on the growth charts (see BUKU KIA)

Share the information with the family.

b. As part of the complete physical examination, the following should be particularly

noted:

• Early childhood caries (baby bottle tooth decay), developmental dental

anomalies, malocclusion, pathologic conditions, or dental injuries

• Excessive injuries or bruising that may indicate inadequate supervision or

possible abuse

• Other evidence of possible neglect or abuse

c. Additional Screening Procedures

Vision: Examine eyes; assess for strabismus.

Hearing: Conduct initial hearing screening if not previously done; otherwise,

assess for possible hearing loss, with follow-up screening as needed

Lead exposure: Assess risk of lead exposure and screen as needed

Anemia: Assess risk of anemia and screen as needed

Hyperlipidemia: Assess risk of hyperlipidemia

Tuberculosis: Administer tuberculin test (PPD) if child meets any of the

following risk criteria: Exposure to tuberculosis, Radiographic or clinical




HEALTHY INFANT

APRIL 20

findings, Homelessness, HIV infection, or living with person who has HIV, Other

medical risk factors

5. IMMUNIZATIONS

For 2 years: MMR, Tiphoid, Hepatitis A

REFERENCES “

M. Joycelyn Elders, M.D. EARLY CHILDHOOD 1-4 YEARS. BRIGHT FUTURES GUIDELINES

FOR HEALTH SUPERVISION OF INFANTS, CHILDREN, AND ADOLESCENTS.

www.brightfuture.aap.org pada tanggal 17 April 2013

http://www.brightfuture.aap.org/



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