IDENTITY (April 12th, 2023) EGA/GUS/ dr. DW, Sp.K.F.R., Ped.

(K)
Name : Ch. M
Age : 6 mo
Sex : Male
Religion : Moeslem
Address : Surabaya
Medical record : 12954476
Referred from Pediatric OPC with laryngomalacia + ASD secundum + hiscphrung disease + Down syndrome

HETEROANAMNESIS
II.1. Chief Complaint: Kepala masih lemah
II.2. History of Present Illness:
Heteroanamnesis from her parents.
Patient unable to move from lying to sitting, unable to sit without support, able to lift head up on prone position,
able to turn to left or right side, and able to roll from supine to prone position. He can head up in prone position and
maintain his head and neck on erect position while being carried by his parent. Patient able to say “eh, ah, eyang, ka-
kak, a-yah”, mostly mumbling and crying. Mumbling “aaa nya nyaa” without specific purpose. Eye contact (+)
approximately 5 second. He try to find the sound source and following toy that pass in front of his eye. If he wants
something, he was crying. he able to do social smile. When he feel thirsty he move her tongue in and out of his
mouth. He was able to hold toy and bring it to his mouth but sometimes miss to his nose. He also had difficulties in
defecating, got lavement by his parents 2 times/day
Initially at the age of 3 days (September 2022), he was referred from pediatric OPC Kirana hospital to Soetomo
hospital due to suspicious of anal malformation, after several examination he was assessed by laryngomalacia, ASD
secundum, malnutrition, and hischprung disease then hospitalized for 1 month. When being discharged from the
hospital, he didn’t use any medical equipment. He still can drink milk without NGT. At November 2022 he got
hospitalized again due to profuse vomit and dehydration, then he was hospitalized again for 2 weeks and then At
the age of 8 months (December 2022) she had seizures again in all extremities (duration more than 2 hour) brought
to Bangkalan hospital (7 days), when discharged parents said her left extremity looks more active than her right. On
January 2023 she controlled to pediatric OPC Bangkalan hospital and referred to neuropediatric OPC Soetomo
hospital on February 2023, then consulted to PM&R OPC.

II.3. History of Functional Ability:

Milestone:
Head up : 5 mo
Turning : 5 mo
Rolling : 6 mo
Crawling : unable
Sitting : unable0
Nutritional status: got breast milk since birth until 1 mo, formula milk since 1 mo until now, no allergy. He drinks milk
70 cc every 2-3 hours, very rarely choking or coughing event, unable to hold the milk bottle by himself. Drooling (-),
pocketing (-)
II.4. History of Medication and Rehabilitation:
 Currently prescribed no medicine
 No rehabilitation program before
II.5. History of Natal:
 Prenatal history : The mother was pregnant at 42 years old (G4P1A2). His mother controlled ANC regularly to
Midwife and doctor, got USG examination 4 times. Normal blood pressure.
 Perinatal history: Born through caesarean section at 36 weeks of gestation due to premature rupture of
membrane + breech presentation. BBL : 2400 gr PBL: 49 cm, cry immediately, no history of jaundice,
dyspnea, and cyanosis.
 Postnatal history: complete vaccination for suitable age, referred from kirana hospital to soetomo hospital
on 3 days old and hospitalized for 1 month.
II.6. History of Past Illness :
 September 2022 and november 2022 : hospitalized in Soetomo hospital due to profuse vomit with
dehydration
 December 2022 and February 2023 : hospitalized in Soetomo hospital due to upper respiratory infection and
pneumonia
II.7. History of Psycho-Social-Economic: Lives in 1-storey house with his father (40 yo, an online shop courier with
senior high school educational background), his mother (43 yo, administration staff with bachelor degree
educational background), his older sister (12 yo, elementary school student) and his grand mother (60 yo, house
wife)

II.8. Family History: no related family history

II.9. Patient’s Expectation: his father hope that the patient can do ADL independently.

PHYSICAL EXAMINATION
III.1. General Status
GCS 456 BP : - mmHg, HR: 140 x/min, RR: 45x/min, Temp: 36.7oC, SpO2 98%
Head Circ : 37,5 cm (microcephaly)
Height: 64 cm, Weight: 6,5 kg
BB/U: Normal
TB/U: Normal
BB/TB: Normal

Head & Neck : Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement of lymph node (-), Strabismus (-|-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-), stridor (+) on supine position
Abdomen : Soefl, peristaltic decreased, tenderness (-)
Extremities : Warm acral (-|-), cyanosis (-), edema (-|-)

III.2. Head/Neck/Trunk,
Look : redness (-|-), deformity (-|-)
Feel : tender point (-), spasm (-|-)
Move : pain when moving (-)

ROM MMT
Neck F|F Weak Func|Weak Func
Trunk F|F Weak Func|Weak Func

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-), deformity (-|-), palmar crease (+|+)
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain when moving (-|-), laxity on 5th finger (+|+)
Neuromuscular :
- Muscle tone : normal tonus| normal tonus
- Deep Tendon Reflex : BPR (+2/+2), TPR (+2/+2)
- Pathological reflex : Hoffmann (-/-), Tromner (-/-)
- Sensorics : dte
- Spasticity :-

Region ROM MMT

Shoulder F|F Weak Func| Weak Func
Elbow F|F Weak Func| Weak Func
Wrist F|F Weak Func| Weak Func
Fingers F|F Weak Func| Weak Func

III.4. Lower Extremities Region.

Look : redness (-|-), swelling (-|-), deformity (-|-), ankle valgus (-|-)
Feel : warmth (-|-), crepitation (-|-), tenderness (-|-)
Move : pain when moving (-|-)
Neuromuscular :
- Tonus : increased tone +|-
- Deep Tendon Reflex: KPR +2|+2; APR +2|+2
- Pathological reflex : Babinski (-|-), Chaddok (-|-)
- Spasticity : -
- Clonus : (-|-)

Region ROM MMT

Hip F|F WF|WF
Knee F|F WF|WF
Ankle F|F WF|WF
Big Toes F|F WF|WF
Toes F|F WF|WF

III.5. Functional Status

Balance : sitting balance poor
Basic functional mobility: Transfer/mobilization: lying to sitting unable, turning able, rolling able (supine to prone)
Beighton score : 2/9 (both 5th finger)
Coordination : hand to hand poor, hand to eye good, hand to mouth good
CNS maturation : Brainstem (ATNR)
Developmental Milestone (for down syndrome) : :
 Gross motor : head up (<1 minutes) ~ 5 months old
 Fine motor : holding toy ~ 6 months old
 Personal social : Recognize parents ~ 3,5 months old
 Speech : Try to find the sound source ~ 7 months old

SUPPORTING EXAMINATION:
 Echocardiography (January 13th, 2023)
Impression : ASD secundum Left to Right shunt
 Chest X-Ray (February 8th 2023)
Impression : Keradangan paru, cor tak tampak kelainan, terpasang nasogastric tube dengan tip distal
terproyeksi setinggi VTh 11 di mid clavicular line kiri.

PROBLEM LIST
o Gross motor et personal social delay
o Poor head neck and trunk control
o Weak function of head, neck, trunk, upper and lower extremities
o Unable to roll, transfer from lying to sitting
o ASD secundum
o Down Syndrome
o Suspect laryngomalacia
o Microcephaly
ICF
Body Function:
b122 Global psychosocial functions (personal-social delay)
b147 Psychomotor functions (gross motor delay)
b410 Heart functions (ASD Secundum)
b510 Ingestion functions (sometimes choking while drinking milk)
b525 Defecation functions (Need lavement 2x/day for defecate)
b730 Muscle power functions (weak functional head, neck, trunk, upper, and lower extremities)
b789 Movements function (unable to move from lying to sitting)
Body Structure:
s340 Structure of larynx (suspect laryngomalacia)
s410 Structure of the cardiovascular system (ASD Secundum)
s540 Structure of intestine (Hirschsprung disease)
s710 Structure of head and neck region (microcephaly)
Activities and Participation:
d330 Speaking (unable to speak)
d349 Communication (unable to form word)
d429 Changing and maintaining body position (unable to roll from prone to supine)
d420 Transferring oneself (unable move from lying to sitting)
Environmental Factors:
+e310 Immediate family (support from parents)
+e355 Health professional (treated by pediatrician and pediatric surgeon)
+e580 Health Services, System, and Policy (covered by BPJS)
Personal Factors:
Female, 6 mo

ASSESSMENT
Feeding Disturbance ec Suspect Laryngomalacia + Gross Motor et Personal Social Delay ec Down Syndrome +
Hirschsprung Disease + ASD Secundum + Microcephaly

PROGNOSIS
Ad vitam : Bonam
Ad sanationam : Dubia
Ad functionam :
- Transfer : independent sitting
- Ambulation : independent with or without ambulation aid
- Other ADL : independent for eating with handle spoon
- Hand Function : functional for reach, hold, and release object
- Communication : verbally effective and understandable

Short Term Goals:

 Established diagnosis related to larynx condition
 Improved milestones in 2 developmental domains that were delayed (personal social and gross motor)
according to patient’s age
 Able to have a good head, neck, and trunk control (able to maintain head up more than 5 minutes)
 Improved transfer ability (able to do rolling from prone to supine position and move from lying to sitting)
 No choking while feeding (feeding safely)

Long Term Goals:

 Keeping up developmental status for gross motor, language, fine motor and personal social according to
patient’s age
 Maintain normal nutritional status
 Independent ADL according to age
 Better quality of life

PLANNING
PDx: Suggest consult to ENT OPC
PTx:
Speech Therapy : (No solid food)
 Oromotor sensory stimulation
 Feeding therapy with various temperature, and taste
 Proper positioning while feeding
 AROM and strengthening exercise of lip, jaw, tongue, buccal, and mastication muscles

Therapeutic exercise:
 Stimulate and facilitate head, neck, and trunk control
 Stimulate and facilitate rolling, head up, chest up while on prone position, transfer from lying to sitting
 Strengthening exercise head, neck, and trunk with playing
 ROM exercise upper and lower extremities on both side with playing

PMx: Clinical findings, vital signs, head circumference, ROM, MMT, developmental milestone for Down syndrome,
transfer ability, CNS maturation
PEx:
• Explain the patient’s condition, rehab planning, and goals to the parent
• Continue exercise and practice at home (stimulate head, neck, and trunk control in half prone position,
bimanual hand exercise, ROM exercise)
• Educate parents to give oromotor sensory stimulation and proper positioning when feeding
• Give multimodal sensory stimulation
• Use 1 language (mother tongue first)
• Precaution of choking while feeding
• Regular control pediatric surgeon and pediatric OPC