Case Presentation

Malnutrition
Adviser : dr. Bina Akura, SpA

Author:
Muhammad Fernando Pratama
1110103000052

Patient Identity

Name
: An. HFI
Medical Record : 01324032
Age
: 1 years old
Address
: Kp. Pulo Kencana Kec.
Pontang, Serang
Religion
: Islam
Gender
: Boys
Admitted to ER : 15 October 2015

Chief Complaint
Watery stool since 18 days ago

Recent history of illness

Patient got watery stool since 18
days ago, defecate was watery,
about 7 times/day. The color was
yellow-green, less grout without
mucus and blood.
The volume of eachstool is half of
diapers.

Recent history of illness

Patient was loss of appetite, still
had little tears when crying, and
still fully awake. Patient also had
fever.

Recent history of illness

9 days ago patient was admitted to
clinic. From there, he got
medicine Lacto-B and antibiotic
syrup.

Recent history of illness

After 3 days, the complaint was not
improve, then patient bought another
antibiotic and used it. The complaint
was not improve too, then patient
carried over ER of RSUP Fatmawati.

Past History of Illness

Patient never suffered from complaint
like this before

Socioeconomic History
Patient is the first child
Mother and father had work from morning until
afternoon Mother did know more about
patient health.

History of Pregnancy
Mother was control to nursery regulary.
Mother have got Vaginal wet mount
while pregnant.
Mother never smoke and not drink
alcohol beverage before.
She had doing TT injection once and
never did USG before.

History of Delivery
The first son of husband and wife
Birth
: Spontant, bigemini, helped by nursery
Neonatal age
: Premature (28 weeks)
1st baby Birth weight : 900 gram
The 2nd neonates was death after birth. Patient was
admitted to NICU until 2 month of birth weight was
2700 gr.

History of Immunization

13

Physical Examination
General Physics

: looks moderate sick

Conciousness

: Compos Mentis

Vital Sign
Respiratory Rate : 44 x/minute,
Heart Rate
Temperature

: 124 x/minute, regular

: 37,60 C (axilla)

Physical Examination
Head
: normocephal, fontanel concave
(+), .
Eyes
: Conjungtiva Anemic-/-, Icterus of
sclera -/-, deficit tears, concave
palpebra
Nose
: Nostril breath (-) septum
deviation (-), secret (+/+)
Neck
: Lymph node not palpable
Mouth
: mucose not sianotic
Pharynx : T1/T1, mild, not hiperemic (-),

Physical Examination
Cor:
I
: iktus cordis not visible
P : iktus cordis palpable in ICS V linea
midclavicula sinistra
P :
Right
: ICS IV linea parasternalis dekstra
Left : ICS V medial from linea midclavicula sinistra
Waist
: ICS II linea parasternalis sinistra

: S I-II regular, murmur (-), gallop (-)

Physical Examination
Pulmo :
I : chest movement was symmetries when static and
dynamic,
P : Chest expansion was symmetries
P : Sonor in both of pulmonary
A:
Vesiculer +/+, ronkhi -/-, wheezing -/- stridor (-)
Abdomen : epigastric retraction (-) mild, Bowel sound
(+) increased , hepar and lien not palpable, slow turgor
return
Extremity : Warm acral, CRT > 2 second, cyanosis (-),

Physical Examination
Antropometric :
Weight

: 6 kg

Height

: 72 cm

Waist Circumfence

: 11 cm

Weight/height : z-score <-3

Weight/Age : z-score <3
Height/Age : 0 <z-score <-2
HC/Age : -2 SD
Nutritional Status: Malnutrion, normal height

Lab Examination (15/10/2015)

Examination

Result

Refrence Number

Hemoglobin

11,6

10,8-15,6 g/dl

Hematokrit

36

35-43 %

Leukocyte

18700

6,0-17,0 thousand/ul

Trombocyte

182000

150-440 thousand/uL

Eryhtocye

5,44

3,60-5,20 jt/ul

MCV

66,4

73,0-101,0 fl

MCH

21.1

23,0-31,0 pg

MCHC

31,7

28,0-32,0 g/dl

HEMATOLOGIC

MCV/MCH/MCHC

Lab Examination (15/10/2015)

Liver Function

Result

Reference

SGOT

78

0-34 U/l

SGPT

66

0-40 U/l

pH

7,371

7,370-7,440

pCO2

22,6

35,0-45,0 mmHg

pO2

104,7

83,0-108,0 mmHg

BP

756,0

mmHg

HCO3

12,8

21,0-28,0 mmol/L

O2 Saturation

97,8

95,0-99,0 %

Base Excess

-10,1

-2,5 2,5 mmol/L

Blood Gas Analysis

Lab Examination (15/10/2015)

Examination

Results

Reference

Ureum

11

20-40 mg/dl

Creatinin

0,2

0,6-1,5 mg/dl

62

60-100 mg/dl

Sodium

134

135-147 mmol/l

Potassium

2,88

3,10-5,10 mmol/l

Chloride

108

95-108 mmol/l

Renal Function

Diabetic
Glucose
Electrolyte

Diagnosis
Persistent Diarrhea with mild-moderate
dehydration e.c dd/bacterial infection
Malnutrition type Marasmic
Delayed development
Hypokalemia
Difficult Intake

Therapy
IVFD KaEn 3B 600 cc/24 hours iv
Bicarbonate 25 mEq in Dextrose 5% 50 ml (2
hours) iv
Peptamen Junior 8 x 70 cc po
Vit A 1 x 100.000 iu Days 1, 2, 14 po
Folic Acid 1 x 1mg po
Zink syr 1 x 20mg po
Probiotic 2x1 sachet po

Further Examination

Fecal Analysis, fecal culture

Mantoux Test
Thorax CR
ELISA HIV
Blood gas anylisis after correction

Education
Give enough fluid to prevent dehydration and
constipation
Do not use laxative because it would make
child diarrhea again
Genital hygine
Household hygine

Prognosis
Ad Vitam
: dubia ad bonam
Ad fungsionam : dubia ad bonam
Ad sanactionam : dubia ad bonam

Case Discussion
The diagnosis Malnutrition type Marasmic,
Persistent Diarrhea with mild-moderate
dehydration e.c dd/bacterial infection,, Difficult
Intake, hipokalemia because:
Anamnesis :
Patient got watery stool since 18 days ago,
defecate was watery, about 7 times/day.
Given nutrition from only formula milk, low intake
nutriton.
Patient was loss of appetite
Family socioeconomic condition

Case Discussion
Physical Examination :

Head : normocefal, Fontanel concave\

Eyes : deficit tears (+/+)
Abdomen : slow turgor return, BS (+) Increased
Extremity : CRT > 2 second

Lab Examination

Leukocyte : 18700/uL
MCV/MCH/MCHC : 66,4/21,1/31,7
Blood Gas Analysis : metabolic Acidosis
Potassium : 2,88 mmol/L

5 Pillar of Diarrhea
ORS
Selective of
Antibiotic use

Education to
Family

Supplement of
Zinc

Keep giving
Breastmilk/food

Malnutrition

/ nt
w cie e
o
L ffi tak
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s
in od
fo

Malnutrition

Im
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ab fo ire
so od d
rp
tio
n

Protein Energy Malnutrition

Condition when body is insuficient protein and
energy and other nutrient.
Clinical sign and symptoms include the
following:
Poor weight gain
Slowing of linear growth
Behavioral changes : irritability, apathy,
decreased, social repsonsiveness, anxiety, and
attention deficits.

Severe
Malnutrition
Children
STEP I
Stabilization
(1-2 days)
F75 : 80-100
kkal/kgBB/day
1 cc = 0,75 kkal)

STEP II
Transition
(3-7 days)
F100 : 100-150
kkal/kgBB/day
Vitamin
A (Day 1,2,14)
1 cc = 1 kkal)
<6 month:
50.000 u

6 mth-1 yrs: 100.000

>1 yrs : 200.000
Folic Acid (14 days)
Day 1 : 1x 5 mg
Day 2-14 : 1x1 mg
Zinc (14 days)
<6 month : 10 mg

STEP III
Rehabilitation
(8-until done)
F135 : 150-220
kkal/kgBB/day
1 cc = 1,35 kkal)

Prognosis
Adecuate therapyThe ideal weight can achieve in
2-3 month.
Intelectual developmentcan be a permanent
disorders like altered mental status and perception
deficiency.
The disease is get worst if suffered in children
under 2 years. When is still being proliferation,
myelination, and migration of neuron cells.

Thank you