Patient : Ch. Y / 24 m.

o / 11555303 / Malang
Refereed From :-
Resident : IFA/MAS/INA

Anamnesis Problem List Diagnosis Planning

Anamnesis: Medical: Clinical diagnosis: PDx: -

Chief Complain : Difficult to eat rough and Feeding problem Feeding problem PTx: -
fiber textures
History of Present Illness : Surgical: - Functional diagnosis: ST :
• The complain was realized when patient R1 (M):- Impairment: - Oromotor stimulation
had stagnant weight for some months, R2 (A): Difficult in eating rough food • Feeding problem - Feeding therapy
than he was brought to pediatric, and textures
assessed there was problem in feeding R3 (C): - Disability: PMo: feeding ability
habits, so it can be risk for malnutrition. R4 (P): - - Difficult to chew rough/fibers
• Patient can eat a variety food like other R5 (S): - textures PEd:
family member. But he had difficulty to R6 (V): - - Explain the condition of the patient
eat rough / fibers texture like vegetables R7 (O): Handicap: - Purpose & benefit of PMR Therapy
meat, and chicken. - Difficult to chew rough/fibers - Continue training & stimulation at
• History of choking is denied. textures home
• He had difficulty to chew rough / fibers - Family support
textures, he will spit it out. - Routine control
• Speech delay was denied.
• He eats 3 times a day, drinks 200 ml of
milk twice times a day and 400 cc of
water per day. There is no chocking
• There’s no bowel and bladder problem.
But the patient still use diapers.
Patient:
Patient Child. A/2: year
Ch. Y6/ days/11544876/ Malang
24 m.o / 11555303 / Malang
Referred from: -
Refereed From :-
Resident SHE : IFA/MAS/INA
Resident:
Anamnesis Problem List Diagnosis Planning

Milestone:
• Head up (+) 4 months
• Rolling (+) 5 months
• Sitting (+) 9 months
• Crawling (+) 10 months
• Standing (+) 11 months
• Walking (+) 12 months

• Babbling (+) 8 months

• 1 syllabel 14 months
• 1 word (+)
• Combine words (+) 2 words
• Naming picture (+)

Family history:
No family member had similar symptoms as the patient

Medications:
-
Psycho-Socio-Economic
• Patient is the 1st child. Her younger brother is 6m.o
• The patient lives at home with his mother, father and brother.
• His father works as nurse (surgeon assistance) and his mother is a housewife
• Medical insurance : -
• Economic status : middle class
Patient Child. A/2: year
Patient: Ch. Y6/ days/11544876/
24 m.o / 11555303 / Malang
Malang
Refereed From
Referred from: - :-
Resident SHE : IFA/MAS/INA
Resident:
Positive Findings

Physical examination: Primitive Reflex :

• GCS: E4M6V5, CM (Compos mentis) Spinal level:
• BW: 11 kg (z-score: 0 to -2 SD) (normoweight) • Flexor withdrawal -
• BH: 80 cm (z-score: 0 to -2 SD) (normoheight) • Extensor thrust -
• Head circumference: 47 cm (z-score: 0 to -2 SD) Brainstem level:
• HR : 112 x/menit. RR : 22x/menit • ATNR -
• Cranial Nerve: I-XII -NA • STNR -
• Sensoric deficit : NA Midbrain level
• Physiological Reflexes: • Neck Righting -
• BPR/TPR/KPR/APR : +2/+2/+2/+2 • Body Righting -
• Clonus -/-, spasticity (-) Cortical level
• Pathological Reflexes: • Four foot kneeling +
• Hoffmann -/-, Tromner -/-, Babinski -/-, Chaddock -/-, Oppenheim -/- • Sitting reflex +
• ROM (passively): Full / Full • Hopping Reflex +
Full / Full Automatic reflexes
• MMT: - Trunk : F • Moro -
- UE/LE : Functional / Functional • Landau -

• Eye contact (+), focus (+), attention (+) Laxity:

Local Status

Muscle athropy (-)

Muscle weakness (-)
tied tounge (-)
Palatum : intact
Mouth (teeth, labial) : normal
Swallowing Test
 DDST
• Personal social
• According to age
• Fine motor
• According to age
• Speech
• According to age
• Gross motor
• According to age
 DDST
• Personal social
• According to age
• Fine motor
• According to age
• Speech
• According to age
• Gross motor
• According to age
Milestone
 ICF CODE DESCRIPTION PATIENT’S CONDITION

BODY FUNCTION  
BODY STRUCTURE
S320 Structure of mouth Difficult to chew rough texture

ACTIVITY AND PARTICIPATION  

D550 Eating Difficult in ealting rough food texture

ENVIRONMENT  
E310 Immediate family Lack of stimulation from parents

PERSONAL FACTOR

Male, 24 month, Javanese, Moeslem

PROGNOSIS

Ad Vitam : Bonam

Ad Functionam: Bonam

Ad Sanationam: Bonam
 GOALS
SHORT TERM

• Able to eat various textures