Pedsos Synd. Down

CASE REPORT SOCIAL PEDIATRIC

A THREE YEARS EIGHT MONTHS OLD GIRL

WITH DOWN SYNDROME AND SPEECH DELAY

Submitted for completing the assignment for senior clerkship

in Pediatrics Health Department of Kariadi Hospital

Medical Faculty of Diponegoro University

Wahyu Kumala Dewi 22010111200140

Wang Erna 22010111200141

Examiner:

Dr. Hendriani Selina, Sp.A (K), MARS

PEDIATRIC DEPARTMENT OF KARIADI HOSPITAL

MEDICAL FACULTY OF DIPONEGORO UNIVERSITY

SEMARANG

2012

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A. IDENTITY

Name : K. I

Age : 3 years 8 months old

Date of birth : October 6th, 2008

Sex : Female

Date of entry : July 2nd, 2012

Address : Jl. Brumbungan Loyola No.79 RT/RW.002/002 Semarang

Father Mother

Name : Mr. HK Name : Mrs. S

Age : 26 years Age : 24 years

Religion : Islam Religion : Islam

Occupation : Occupation : -

B. ANAMNESIS

Alloanamnesis with patient’s mother on July 2nd, 2012 11.30 a.m. at BKIA RSDK,

Semarang.

Chief complain : 3 years old girl has not been able to speech

Present Disease History :

Since the age of 2 years, the mother noticed that her daughter could not speak like

children of her age. The child can turn her face when her name was called. She can say

words consisting of single syllable like “moh, mam, dik, ya ...”. Sometimes, she is able to

call brother for her brother, mother for her mother, and father for her father. She can

understand mother’s command, do what was asked by her mother. She can indicate her

wants by pointing the object. She can play with her friends. Because mother worried

about her daughter development, she brought her to RSUP Dr. Kariadi.

History of Past Illness

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Family History

- There is no family members who have the illness like patient

Socio Economic

- Father works as a honorer workers at SMA 1 and mother doesn’t work, their income is

Rp 800.000,00 per month. They fund two child. Medical fee is paid by Jamkesmas.

Impression : poor socioeconomic

Perinatal History

Prenatal History :

- ANC more than four times during pregnancy at, got TT (+) twice, vitamin, and iron

tablets. ANB (-), trauma history (-), the pregnancy disease (-), other drugs consumption

during pregnancy (-).

Natal :

- Born at midwife clinic from mother G2P2A0 by midwife, at term (9 months),

spontaneous delivery, body weight of birth was 2600 gr, body length of birth was 48 cm,

crying spontaneously

Postnatal History

- Control at Public Health Centre after birth; the child was healthy.

Immunization History

- BCG : 1x, 1 month

- DPT : 3x, 2,3,4 month

- Polio : 4x, 0,2,3,4 month

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- Hepatitis B : 4x, 0,2,3,4 month

- Campak : 1x, 9 month

Impression : complete basic immunizations according to his age.

Food and Drink History

- 0- ... month: breast feeding

- 3-12 month: porridge (serelac) 2 times daily , each time one small bowl (1 table spoon)

sometimes until finished

- 1-3 year: : rice porridge with meats or fish or vegetables., 3 times daily, one small bowl

but could not finished it (3/4 portion)

Growth and Developmental History

Growth :

Weight at previous month: kg, Length at previous month : ,

Body weight at present: 12 kg, Length of body at present 88 cm,

Body weight at birth 2600 gram

Body length at birth 48 cm

Impression : loss of growth

Developmental :

child can smile at 2 month, prone at 4 month, sit down at 5 month, can say one word

which has two syllables at 5 month, first teeth eruption at 9 month, but cannot stand up

yet. Child could stand up at 18 month, run at 2 year.

1.KPSP

Dapatkah anak mengenakan sepatunya sendiri? Ya Tidak

Dapatkah anak mengayuh sepeda roda tiga sejauh sedikitnya 3 meter? Ya Tidak

Setelah makan, apakah anak mencuci dan mengeringkan tangannya

dengan baik sehingga anda tidak perlu mengulanginya?

Ya Tidak

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Suruh anak berdiri satu kaki tanoa berpegangan. Jika perlu tunjukkan

caranya dan beri anak anda kesempatan melakukannya 3 kali. Dapatkah

ia mempertahankan keseimbangan dalam waktu 2 detik atau lebih?

Ya Tidak

Letakkan selembar kertas seukuran buku ini di lantai. Apakah anak dapat

melompati panjang kertas ini dengan mengangkat kedua kakinya secara

bersamaan tanpa didahului lari?

Ya Tidak

Jangan membantu anak dan jangan menyebut lingkaran. Suruh anak

menggambar seperti contoh ini dikertas kosong yang tersedia. Dapatkah

anak menggambar lingkaran?

Ya Tidak

Dapatkah anak meletakkan 8 buah kubus satu persatu di atas yang lain

tanpa menjatuhkan kubus tersebut? Kubus yang digunakan ukuran 2.5-

5cm

Ya Tidak

Apakah anak dapat bermain petak umpet, ular naga atau permainan lain

dimana ia ikut bermain dan mengikuti aturan bermain?

Ya Tidak

Dapatkah anak mengenakan celana panjang, kemeja, baju atau kaos kaki

tanpa di bantu? (tidak termasuk memasang kancing, gasper atau ikat

pinggang)

Ya Tidak

The result of KPSP score: 3 points

The conclusion: abnormality

Family Planning

Mother use injection contraception (every 3 months)

C. PHYSICAL EXAMINATION

July 2nd, 2012 at 12.00 WIB

Female, 3 years 8 months, weight: 12 kg, length: 88 cm.

General appearance: Composmentis, active, spontaneus breathing

Vital Sign : HR : 100 x/minutes t : 37 oC (axiller)

RR : 28 x/minutes N : regular, volume/pressure enough

Skin : Anemic (-), cyanotic (-), icteric (-)

Head : Fontanella: closed

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Head circumference :43 cm (mesocephal)

Eyes :Anemic conjunctival palpebrae (-), icteric sclerae (-), upslanting palpebral

fissure (+)

Ears : Discharge (-/-), cerumen (-), low set ears (-/-)

Nose : Nasal flare (-), discharge (-/-)

Mouth : Cyanotic (-), dry mucosa (-), drolling (-)

Teeth : Caries (-)

Throat : T1-1, hyperemic (-), hyperaemic pharyng (-)

Neck : Symmetric, enlargement of lymph nodes (-)

Thorax

Lungs: I : Symmetrical static and dynamic, retraction (-)

Pa : Stem fremitus right = left

Pe : Sonor in whole lung area

A : Basic sound: vesicular

Additional sound: (-)

Cor : I : Ictus cordis didn’t visible

Pa : Ictus cordis was not wide, no powerful to lift

Pe : heart margins are difficult to be examined

A : Heart sound I-II normal, murmur (-), gallop (-)

Abdomen: I : flat, supel

Pa : soft, liver /spleen: unpalpable, turgor: return fast

Pe : tympani

A : intestine sound (+) N.

Lymph nodes : no enlargement

Genital : female, vulva hiperemis (-)

Extremities : Upper Lower

Pale - / - - / -

Cyanotic - / - - / -

Cold - / - - / -

Edema - / - - / -

Capilarry refill <2” <2”

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Simian crease - / -

Tonus hipertonus hipertonus

Clonus - / - - / -

Phyisiologic reflex ++/ ++ ++ / ++

Pathologic reflex - / - - / -

D. ANTHROPOMETRICAL STATUS

Male, 3 years 8 months, recent weight: 12 kg, height: 88 cm.

WAZ : -1,96 SD

HAZ : -3,24 SD

WHZ : 0,03 SD

Head circumference: -4,3 SD

Impression: good nutrition, short stature, microchepal

E. WORKING DIAGNOSIS

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1. Main diagnosis : clinic down syndrome

2. Co-morbid diagnosis : -

3. Complication diagnosis : -

4. Growth diagnosis : good nutrition, short stature, microcephal

5. Developmental diagnosis : speech delay

6. Immunization diagnosis : Complete basic immunization according to her age

7. Social Economic diagnosis : poor social economic status

F. INITIAL PLANS

Assessment:

1. Down syndrome

Ip.Dx : S: -

O: Spasticity, hypertonus, hyperreflex, babinsky reflex (+)

Ip.Rx : medical rehabilitation for physiotherapy

consult to otopharyngology, head, and neck surgery department for BERA, OAE

examination

Ip.Mx : motoric function

child development

BERA, OAE

MRI preferred to CT scan evaluation after 6 month

Ip.Ex :

Explain to the parents that their child’s disease caused by the brain injury at the

developmental period of the brain which cause non progressive brain impairments

but the prognosis is not good either so it needs continous stimulation for better

results

Explain to the parents that their child need higher calories

Explain to the parents about the possibility of reccurent upper respiration tract

infection

Explain the parents to change the baby position regularly

2. Global Developmental Delay

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Ip.Dx : S: -

O: Denver test, Caput scale, Elms scale

Ip.Rx : medical rehabilitation for physiotherapy ( occupational therapy, speech therapy)

Stimulation and intervention

Consult to ear nose throat head and neck surgery department

Ip.Mx : KPSP, Denver II

Ip.Ex :

- Explain to the parents about global development delay that happened to the child

- Explain to the parents to stimulate their child as often as possible based on the given

program

- Explain to the parents to check-up their child to the doctor next month.

3. Short stature

DD/ Secondary

Primary

Ip.Dx : S : -

O: Mid parental height

Ip.Rx : -

Ip.Mx : body height evaluation monthly

Ip.Ex :

- Explain to the parents about the condition of their child

- Explain to the parents about the possible etilogies of that condition

HOME VISIT RESULT

Home visit was done on June 20th, 2012 at 16.30

I. HOUSE CONDITION

Main house

Status : The house owned by the grandparents. Six family member are living there.

Size : 8 m x 4 m

House terrace : No

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House yard : Yes, 1x3 m2, dirty and mess

House walls : Bricks and wood

Floor : tile and cemented floor (kitchen)

Rooms : there are 3 rooms in the main house : 2 bedrooms, 1 living room ; while

kitchen and bathroom are separated from the main house

Windows : 2

Ventilation : inadequate, every room has sufficient ventilation and opened

every day

Lighting : inadequate

Hygiene : inadequate, the house cleaned every day (twice daily)

Water source : For bathing and washing is taken from artesian well, cooking and

drinking from mineral water

Trash can : one opened-trash can

Bathroom : there is one, outside the main house with a tub, was cleaned 1-2x/week.

There is toilet, with good drainage

Sewers : There is sewer that flow to reservoir pool

Kitchen : there is one outside the main house, there is a gas stoves and dining set is

placed in shelf

II. DAILY HABIT

Asuh :

Father works as a honorer workers at SMA 1 , work location near the house. Mother

does not work . Patient cared by parents from birth. Patient’s daily care done by

parents and grandmother.

When sick, patient consumed drug from drug store first, then go to primary health

care, or hospital if there is no improvement.

Daily meal: F100 milk 120 cc 8 times daily

Asih: Love is gained from parents, grandmother, and the others family members well

Stimulation:

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Mental stimulation is accepted primary from mother who is graduated from senior

high school, and father who is graduated from junior high school

Play with her sister and cousins everyday

Toys: doll, colored toys

The child’s daily care is done by parents. Before sick the child eats porridge with meats

or fish or vegetables 3 times daily and milk but after sick she just drink F100 milk 120 cc

8 times daily. Drink water source for baby from mineral water. Dining set is washed with

water from artesis well and detergent. Dirty laundry washed everyday. The place for

washing dining set and clothes is in one different place. If there is one of family

members get an illness, then they get drugs from drug store first, then go to primary

health care or hospital if there is no improvement.

Environment

Patient’s house is located on Gergaji Pelem V no 64 RT/RW 005/006 Semarang.

Patient’s house has no terrace, but has 1x3 m2 yard that is dirty and mess, the street in

front of the house is quite large, and have a good drainage. The street in front of the

house is pavement street. No pets found near the house. Patient’s house has brick and

wood walls, tile floor at the main house and cemented floor at kitchen and bathroom,

door always open at noon and window which often open, have sufficient ventilation but

have insufficient lighting. Kitchen, bathroom are separated from the main house. Six

people are living in the house: parents, 2 children, aunt and grandmother, .

Impression: The size of the house is insufficient for the occupants, house condition and

hygiene are poor, insufficient lighting, but have a sufficient ventilation, good daily habits.

Photos:

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