PROTEIN-ENERGY MALNUTRITION

Presented by Wiraharto 090100034 Ismail Lubis 080100152

Supervised by Dr. Hj. Melda Deliana, Sp.A(K)
DEPARTEMEN ILMU KESEHATAN ANAK PROGRAM PENDIDIKAN PROFESI DOKTER FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA 2013

DEFINITION
Malnutrition (WHO): the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions

Protein-energy malnutrition (PEM) a group of related disorders including marasmus, kwashiorkor, and marasmic-kwashiorkor Marasmus inadequate intake of protein and calories and is characterized by emaciation
Kwashiorkor inadequate protein intake with reasonable or normal caloric (energy) intake

EPIDEMIOLOGY
WHO (2000) 181.9 million malnourished children in developing countries Vietnam (2005) 25,2% underweight, 29,6% stunting, 6,9% wasting Bangladesh (2005) in rural area 45,7% underweight, 11,4% wasting India (2006-2007) 50,46% of under five children were suffering from malnutrition

ETIOLOGY
the individual's high needs for both energy and protein inappropriate use of infant formula in place of breastfeeding for the very young infants inadequate or inappropriate child care lack of knowledge regarding the importance of exclusive breastfeeding inadequate availability of food for the family infections famine resulting from droughts, natural disasters, wars, civil disturbances Prematurity or low birth weight

CLASSIFICATION
1. Gomez classification (based on weight-for-age standards)
Classification Normal Grade I (mild malnutrition) Grade II (moderate malnutrition) Grade IIIa (severe malnutrition) Percentage of standard weight for age >90 75-89.9 60-74.9 <<60

CLASSIFICATION
2. Waterlow criteria (Type and Chronicity)
Type of Malnutrition Normal Mild Moderate Severe Acute (Weight for Height) (%) > 90 80 90 70 80 < 70 Chronic (Height for Age) (%) > 95 90 95 85 90 < 85

CLASSIFICATION
3. Wellcome classification of severe forms of proteinenergy malnutrition
Percentage of standard With edema weight for age 60-80 <60 Kwashiorkor Without edema Undernourishment

Marasmic kwashiorkor

Nutritional marasmus

PATHOGENESIS

The mechanisms of nutrient imbalance in illness-related malnutrition

Decreased nutrient intake

Altered utilization

Increased nutrient losses

Increased nutrient requirements (hyper metabolism)

CLINICAL MANIFESTATIONS

TREATMENT

CASE REPORT

Name Age Sex Date of Admission

: RAM : 2 year 5 months : Female : September, 10 th 2013

Main Complaint : Abdominal Bloating History : This problem happen since 14 days ago Patient also complains of fever for about three weeks, Fever was high and relieved by consumption of anti-pyretic drugs Seizure (-),Diarrhoea (+) three weeks, 6x/day frequency, consistensy water more than pulp (-), aqua glass in volume, blood (-),and now patient dont have diarrhea in one weeks Vomiting(-),Cough(-), The patients body weight decreased(+).Before patient is sick,her weight is 13 kg,now her weight is 9 kg. Urination normal

History of feeding: 0-6 months: exclusive breastfeeding 6-1 years old : breast feeding & soft rice 1- 1 years : Soft rice 1 - now : Family food . History of birth Normal, handled by midwife in home, cried as soon as baby was born. Weight 2800 g and Length 51 cm

BW/Age: -2 < Z <-3SD BH/Age: 0 < Z < 2 SD BW/BH: < -3SD Presens status Sens. Compos Mentis Body temperature: 39.1 oC Pulse: 150 bpm Respiratory Rate: 32 bpm.

Localized status Head : old man face (+) Eye : Sunken Eyes (+),Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+), icteric (-/-) , Ear : Normal ,Mouth : Sianosis (-),Dry mucosa lips , Nose: Normal Neck : Lymph node enlargement (-) Thorax : Symmetrical fusiform, easily seen ribs(+) retraction (-) HR: 150x/i, reguler, sigh (-). RR: 32 x/i, regular, crackles (-/-) Abdomen: Distention(+),Soepel. Peristaltic (+) decreased. Liver/Spleen/Renal :undeterminate Extremities: pulse : 150 x/i, regular, adequate pressure and volume, warm acral, CRT <3, baggy pants (+), muscle hypertrophy (+), TD=110/60mmhg.

Labotary result(September,10th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 9.10 3.41 18.28 27.6 331 80.90 28.70 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Difftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

33.00
14.00 8.40 0.28 8.2 82.00 12.50 5.20

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.100 14.88 2.29 0.95 0.03 0.02

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

Clinical Chemistry Blood gas analysis

SATUAN

HASIL

RUJUKAN

Ph pCO2 mmHg

7.493 21.1

7.35-7.45 38-42

pO2
Bicarbonate (HC03) Total CO2 Base excess (BE) O2 saturation

mmHg
mmHg mmol/L mmol/L %

157.3
15.8 16.4 -6.3 99.5

85-100
22-26 19-25 (-2)-(+2) 95-100

Clinical Chemistry HEART Albumin ELECTROLYTES Natrium (Na) Kalium (K) Klorida (Cl) RENAL Ureum Kreatinin g/dL

SATUAN 3.10

HASIL

RUJUKAN 3.8-5.4

mEq/L mEq/L mEq/L

123 3.3 87

135-155 3.6-5.5 96-106

Mg/dL mg/dL

11.20 0.09

<50 0.24-0.41

Clinical Chemistry CARBOHYDRATE METABOLISM Blood glucose (As) Mg/dL 229.7 <200

 Differential Diagnosis Malnutrition type marasmus-kwashiorkor grade V Working Diagnosis Malnutrition type marasmus-kwashiorkor grade V P: Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x5mg , next 1x1 mg Vit A 1 x 100.000 IU Multivitamin without Fe 1Xcth I Diet F75 160 cc/3h/NGT Planning Complete Blood Count Blood Glucose LFT,RFT electrolytes

September, 11th 2013 (First day) S: Abdominal bloating(+),Fever(+),Low frequency defecation,bloody stools() O: Sens: CM , Temp: 37,9 oC, Body weight: 9,8 kg bh: 91 cm bw/bh : 70% z score -3 SD Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-),sunken eyes(+/+), Ear : Normal appereance ,Mouth : Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis, epigastrial retraction(+), HR: 140 bpm, reguler, murmur (-). RR: 43 bpm, reguler.Crackles (-/-), interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance

Extremities :Pulse 140 bpm, regular, adequate pressure and volume, warm acral, CRT < 3,baggy pants(+), muscle hypotrophy(+), little subcutaneous fat left(+) A: Malnutrition type marasmuskwashiorkor grade V P: Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x5mg , next 1x1 mg Vit A 1 x 100.000 IU Multivitamin without Fe 1Xcth I Diet F75 160 cc/3h/NGT Plan : - Nutrient and metabolic disease consult

September, 12th 2013 (Second day) S: Abdominal bloating(+),Fever(-), ,bloody stools(-),diarrhea(+)2x with green stools,vomit(-) O: Sens: CM , Temp: 36,8 oC, bw : 9,8 kg , abdominal circumference (supine) : 53 cm. LPD : 54,5 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-),sunken eyes(+/+), Ear : Normal appereance ,Mouth : Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis, epigastrial retraction(+), HR: 130 bpm, reguler, murmur (-). RR: 34 bpm, reguler.Crackles (-/-), interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance

Extremities :Pulse 130 bpm, regular, adequate pressure and volume, warm acral, CRT < 3,baggy pants(+), muscle hypotrophy(+), little subcutaneous fat left(+) A: Malnutrition type marasmuskwashiorkor grade V P: Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x1 mg Multivitamin without Fe 1Xcth I Diet F75 160 cc/6h/NGT Abdomen 3 Position result : Intra abdomen mass suggestive with ileus obstruktif

Labotary result(September,12th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 9.80 3.64 17.44 29.6 377 81.30 25.20 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

31.50
14.90 8.80 0.36 8.7 71.60 15.50 12.40

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.300 11.91 2.29 1.37 0.04 0.02

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

Clinical Chemistry HEART Albumin ELECTROLYTES Natrium (Na) Kalium (K) Klorida (Cl) g/dL

SATUAN 3.1

HASIL

RUJUKAN 3.8-5.4

mEq/L mEq/L mEq/L

129 3.2 106

135-155 3.6-5.5 96-106

Clinical Chemistry RENAL Ureum Kreatinin

SATUAN

HASIL

RUJUKAN

Mg/dL mg/dL

9.60 01

<50 0.24-0.41

Clinical Chemistry

SATUAN

HASIL

RUJUKAN

CARBOHYDRATE METABOLISM

Blood glucose (As)

Mg/dL

123.4

<200

September, 13th 2013 (Third day) S: Abdominal bloating(+),Fever(-) O: Sens: CM , Temp: 36,8 oC, bw : 9,8 kg , abdominal circumference (supine) : 53 cm. LPD : 54,5 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 94 bpm, reguler, murmur (-). RR: 30 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 94 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Susp Partial obstructive ileus ec dd/invaginasi;tumor abdomen + malnutrition type marasmus + Susp UTI P: Management Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x1 mg Multivitamin without Fe 1Xcth I Diet F75 160 cc/6h/NGT Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : BW : 9,5 kg Arm Circumference: 11 cm Abdominal Circumference (Supine): 51 cm Abdominal Circumference (Erect): 53 cm BH: 91 cm BW/BH : <-3 SD A :Malnutrition marasmus type + Susp UTI + Susp Partial obstructive ileus ec dd/invaginasi; tumor abdomen P : - Diet F75 150 cc/3h + Mineral mix 3 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1 - Folic acid 1 x 1 mg

September, 14th 2013 (Fourth day) S: Abdominal bloating(+),Fever(-), Pale face(+) O: Sens: CM , Temp: 37 oC, bw : 9,8 kg , abdominal circumference (supine) : 51,5 cm. LPD : 53 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 96 bpm, reguler, murmur (-). RR: 26 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 96 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Susp Partial obstructive ileus ec dd/invaginasi;tumor abdomen + malnutrition type marasmus + Susp UTI P: Management Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x1 mg Multivitamin without Fe 1Xcth I Diet F75 160 cc/6h/NGT Plan : Check CBC and LFT Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine): 51 cm abdominal circumference (erect) : 53 cm bh 91 cm bw/bh : <-3 SD A :Malnutrition marasmus type + Susp UTI + Susp Partial obstructive ileus ec dd/invaginasi; tumor abdomen P : - Diet F75 150 cc/3h + Mineral mix 3 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1

Labotary result(September,14th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 9.70 3.68 26.06 29.4 415 79.80 25.20 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

31.50
14.90 8.80 0.36 8.1 68.50 15.50 12.40

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.300 17.86 4.68 3.49 0.06 0.08

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

Clinical Chemistry HEART Bilirubin Total Bilirubin direk Fosfatase Alkali(ALP) AST/SGOT AST/SGPT LDH

SATUAN mg/dL mg/dL U/L U/L U/L U/L 0.27 0.18 0.1 129 3.2 106

HASIL <1

RUJUKAN

0-0.2 <281 <32 <31 240-480

September, 15th 2013 (Fifth day) S: Abdominal bloating(+),Fever(-), Pale face(+) O: Sens: CM , Temp: 37 oC, bw : 9,8 kg , abdominal circumference (supine) : 51,5 cm. LPD : 53 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 96 bpm, reguler, murmur (-). RR: 26 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 96 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Susp Partial obstructive ileus ec dd/invaginasi;tumor abdomen + malnutrition type marasmus + Susp UTI P: Management Cotrimoxazole 2 x 25 mg Paracetamol 3 x 100 mg Folic acid 1x1 mg Multivitamin without Fe 1Xcth I Diet F100 130 cc/3h/NGT Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine) (S) : 51 cm bwS : 9,5 kg LLA (S) : 11 cm abdominal circumference (erect) : 53 cm bh 91 cm bw/bh : <-3 SD A :Malnutrition marasmus type + Susp UTI + Susp Partial obstructive ileus ec dd/invaginasi; tumor abdomen P : - Diet F75 150 cc/3h + Mineral mix 3 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1

September, 16th 19th 2013 (6th - 9th day) S: Abdominal bloating(+)decreased,Fever(-), Pale(-),Diarrhea(-) O: Sens: CM , Temp: 36,7 oC abdominal circumference (supine) 52 : cm LPD : 53 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 98 bpm, reguler, murmur (-). RR: 26 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 98 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Malnutrition marasmus type + abdominal tumor ec dd/neuroblastoma;Willms tumor P: Management Three way Inj ceftriaxone 250 mg/12h/IV Paracetamol 3 x 100 mg Multivitamin without Fe 1xcth I Diet F75 150 cc/3h/NGT + Mineral mix 3 cc Plan : BNO-IVP,CT Scan Abdomen Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine): 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -2 < Z < -3 SD A : Malnutrition marasmus type + abdominal tumor ec dd/neuroblastoma;Willms tumor dd/invaginasi; tumor abdomen P : - Diet F75 150 cc/3h + Mineral mix 3 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1

September, 20th 2013 (tenth day) S: Abdominal bloating(+)decreased Fever(-) O: Sens: CM , Temp: 36,9 oC bw : 10 kg abdominal circumference (supine) 52 : cm LPD : 53 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 92 bpm, reguler, murmur (-). RR: 26 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 92 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+) A: Malnutrition marasmus type + abdominal tumor ec dd/neuroblastoma;Willms tumor

P: Management Three way Inj ceftriaxone 250 mg/12h/IV Paracetamol 3 x 500 mg (if needed) Multivitamin without Fe 1 x cth 1 Cotrimoksazole 1 x cth 1 Diet F100 120 cc/3h/NGT+Mineral mix 3,6 cc BNO-IVP Result : mass in lower abdomen,left hidronefrosis and hidroureter CT Scan Results : Susp Teratoma dd/Adneksa Mass,with left hidronefrosis and hidroureter, hepatosplenomegaly Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine): 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -2 < Z < -3 SD A : Malnutrition marasmus type + abdominal tumor ec dd/neuroblastoma;Willms tumor dd/invaginasi; tumor abdomen P : -Diet F100 120 cc/3h + Mineral mix 3,6 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1

September, 21th 23th 2013 (11th - 13th day) S: Abdominal bloating(+)decreased Fever(-) O: Sens: CM , Temp: 36,9 oC bw : 10 kg abdominal circumference (supine) : 51 cm LPD 52 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 98 bpm, reguler, murmur (-). RR: 24 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 98 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Malnutrition marasmus type + susp teratoma dd/abdomen mass + left hidronefrosis + left hidroureter P: Management Three way IVFD DS NaCl 0,225 % 40 gtt/i mikro Inj ceftriaxone 250 mg/12h/IV Paracetamol 3 x 500 mg (if needed) Multivitamin without Fe 1 x cth 1 Cotrimoksazole 1 x cth 1 Diet F100 220 cc/3h/NGT+Mineral mix 4,4 cc Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine) : 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -2 < Z < -3 SD A : Malnutrition marasmus type + susp teratoma dd/abdomen mass + left hidronefrosis + left hidroureter dd/invaginasi; tumor abdomen P : -Diet F100 200 cc/3h + Mineral mix 4 cc - Cotrimoksazole 1 x cth 1 - Multivitamin without FE 1 x cth 1

Labotary result(September,23th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 8.10 3.22 28.22 25.7 415 79.80 25.20 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

31.50
14.90 8.80 0.36 8.7 71.60 15.50 12.40

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.300 20.21 4.38 3.49 0.06 0.08

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

Clinical Chemistry HEART Bilirubin Total Bilirubin direk Fosfatase Alkali(ALP) AST/SGOT AST/SGPT LDH

SATUAN mg/dL mg/dL U/L U/L U/L U/L 0.57 0.12 300 34 9 106

HASIL <1

RUJUKAN

0-0.2 <281 <32 <31 240-480

Albumin
electrolytes Natrium (Na) Kalium (K) Phosphor Magnesium(Mg) Klorida (Cl)

g/dL

3.2

3.8-5.4

mEq/L mEq/L mEq/L mEq/L mEq/L

123 3.3 123 6.6 2.66

135-155 3.6-5.5 135-155 3.4-6.2 1.4-1.9

Clinical Chemistry IMUNOSEROLOGY AFP(Alfa Feto Protein) AFP(Alfa Feto Protein)

SATUAN

HASIL

RUJUKAN

ng/mL mIU/mL

1.69 0

0-16 0-1

Clinical Chemistry

SATUAN

HASIL

RUJUKAN

CARBOHYDRATE METABOLISM

Blood glucose (As)

Mg/dL

82.6

<200

September, 24th 30th 2013 (14th 20th day) S: Abdominal bloating(+)decreased,Fever(-), Vomiting(-) O: Sens: CM , Temp: 37,0 oC bw : 10 kg abdominal circumference (supine) : 51 cm LPD 52 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 104 bpm, reguler, murmur (-). RR: 28 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 104 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Malnutrition marasmus type + susp teratoma dd/abdomen mass + abses o/t umbilical region + left hidronefrosis + left hidroureter P: Management Three way IVFD D5% NaCl 0,225 % 40 gtt/i mikro Inj ceftriaxone 500 mg/12h/IV Paracetamol 3 x 500 mg (if needed) Multivitamin without Fe 1 x cth 1 Inj metronidazole LD 150 mg ;MD 75 mg/8h/iv Diet F100 220 cc/3h/NGT+Mineral mix 4,4 cc Nutrient and metabolic disease module : S:Vomit(-),Abdominal bloating(+) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine): 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -2 < Z < -3 SD A : Malnutrition marasmus type + susp teratoma dd/abdomen mass + abses o/t umbilical region + left hidronefrosis + left hidroureter P : - Diet F100 230 cc/3h + Mineral mix 4,6cc - Multivitamin without FE 1 x cth 1

Labotary result(September,27th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 13.90 5.05 28.3 40.4 406 80.00 27.50 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

34.40
14.90 8.10 0.33 8.4 74.60 15.50 10.10

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.300 16.47 4.06 2.08 0.04 0.07

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

Clinical Chemistry Blood gas analysis

SATUAN

HASIL

RUJUKAN

Ph pCO2 mmHg

7.428 32.5

7.35-7.45 38-42

pO2
Bicarbonate (HC03) Total CO2 Base excess (BE) O2 saturation

mmHg
mmHg mmol/L mmol/L %

115.3
21.0 22.0 -2.5 98.5

85-100
22-26 19-25 (-2)-(+2) 95-100

Labotary result(September,30th 2013): Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg 11.10 4.18 14.58 33.9 190 81.10 25.20 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29

MCHC
RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit

g%
% fL % fL % % %

31.50
14.90 8.80 0.36 8.7 59.80 23.50 15.90

29 31
11.6 14.8 7.2 - 10.0

37 80 20 40 28

Eosinofil
Basofil Neutrofil Absolut Limfosit Absolut Monosit Absolut Eosinofil Absolut Basofil Absolut

%
% 103/L 103/L 103/L 103/L 103/L

0.20
0.500 7.18 2.81 1.90 0.02 0.06

16
01 2.4 - 7.3 1.7 - 6.1 0.3 - 0.8 0.10 - 0.50 0 - 0.1

October, 1st 4th 2013 (21th 24th day) S: Post laparotomy,fever(-) O: Sens: CM , Temp: 36,9 oC bw : 10,5 kg abdominal circumference (supine) : 51 cm LPD 52 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 110 bpm, reguler, murmur (-). RR: 28 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 110 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Post op laparotomy a/i teratoma + Malnutrition marasmus type + left hidronefrosis + left hidroureter P: Management Three way IVFD D5% NaCl 0,225 % 15 gtt/i mikro Inj ceftriaxone 500 mg/12h/IV Inj metronidazole 75 mg/8h/iv Inj Ketorolac 15 mg/6h Multivitamin without Fe 1 x cth 1 Diet F100 230 cc/3h/NGT+Mineral mix 4,6 cc Nutrient and metabolic disease module : S:Vomit(-), Diarrhea(-) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine) : 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -1 < Z < -2 SD A : Post op laparotomy a/i teratoma + Malnutrition marasmus type + left hidronefrosis + left hidroureter P : - Diet F100 240 cc/3h + Mineral mix 4,8cc - Multivitamin without FE 1 x cth 1

October, 5th 7th 2013 (25th 27th day) S: Post laparotomy,fever(-) O: Sens: CM , Temp: 36,9 oC bw : 11 kg abdominal circumference (supine) : 51 cm LPD 52 cm Head: Old man face (+), Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-), icteric (-/-), sunken eyes(+/+), Ear : Normal appereance ,Mouth :Sianosis (-), Nose: Normal appereance, Neck : KGB enlargement(-) Thorax :Symmetricalfusiformis,epigastrial retraction(+), HR: 110 bpm, reguler, murmur (-). RR: 28 bpm, reguler.Crackles (-/-),interposed rib clearly visible Abdomen :Distention. Peristaltic (+) decreased. Liver/Spleen/Renal: undeterminate., ascites appearance Extremities :Pulse 110 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants(+),muscle hypotrophy(+), little subcutaneousfat left(+)

A: Post op laparotomy a/i teratoma + Malnutrition marasmus type + left hidronefrosis + left hidroureter + bh Peritoneal P: Management Three way IVFD D5% NaCl 0,225 % 15 gtt/i mikro Inj ceftriaxone 500 mg/12h/IV Inj metronidazole 75 mg/2h/iv Inj Ketorolac 15 mg/6h Multivitamin without Fe 1 x cth 1 Diet F100 230 cc/3h/NGT+Mineral mix 4,6 cc Nutrient and metabolic disease module : S:Vomit(-), Diarrhea(-) O : body weight : 9,5 kg Arm circumference : 11 cm abdominal circumference (supine): 51 cm abdominal circumference (erect) : 53 cm bw : 12,8 kg bw/bh : -1 < Z < -2 SD A : Post op laparotomy a/i teratoma + Malnutrition marasmus type + left hidronefrosis + left hidroureter + bh Peritoneal P : - Diet F100 240 cc/3h + Mineral mix 4,8cc - Multivitamin without FE 1 x cth 1

DISCUSSION
RAM, female, 2 year 5 month was admitted to RS Haji Adam Malik with the main complaint of abdominal bloating. On physical examination the patient looks old man face in appereance, easily seen ribs (+) , hypotropy muscle (+), subcutan lipid decreasing (+) and baggy pants (+),

SUMMARY
RAM was diagnosed with Post op laparotomy a/i teratoma with Malnutrition marasmus type and left hydronefrosis and left hidroureter and bh Peritoneal, and is managed with IVFD D5% NaCl 0,225 % 15 gtt/i mikro,Inj ceftriaxone 500 mg/12h/IV,Inj metronidazole 75 mg/2h/iv,Inj Ketorolac 15 mg/6h,Multivitamin without Fe 1 x cth 1,Diet F100 230 cc/3h/NGT + Mineral mix 4,6 cc

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