kekurangan energi protein (Malnutrisi)

8/13/2019 kekurangan energi protein (Malnutrisi)

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CASE REPORT

Presenter : Wiraharto (090100034)

Ismail L !is (0"01001#$)

%a&'%ate : Th rs a& 1* th o+ O,to!er $013

S -er.isor : r/ / 2el a %eliana S-/A( )

CHAPTER I

INTRODUCTION1.1. BACKGROUND 1

Worl ealth Or ani5ation (W O) e+ines 6maln trition7 as 6the ,ell lar

im!alan,e !et8een the s --l& o+ n trients an ener & an the !o & s eman +or

them to ens re ro8th maintenan,e an s-e,i+i, + n,tions7/ The term -rotein

ener & maln trition (PE2) a--lies to a ro - o+ relate isor ers that in,l e

marasm s ;8ashior;or an marasm s ;8ashior;or/

Protein ener & maln trition is the most ,ommon +orm o+ n tritional

e+i,ien,& amon -atients 8ho are hos-itali5e in the


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CHAPTER II

LITERATURE REVIEW

2.1. PROTEIN - ENERGY MALNUTRITION (PEM)

2.1.1. DEFINITION 2

Worl ealth Or ani5ation (W O) e+ines 6maln trition7 as 6the ,ell lar

im!alan,e !et8een the s --l& o+ n trients an ener & an the !o & s eman +or

them to ens re ro8th maintenan,e an s-e,i+i, + n,tions7/ The term -rotein

ener & maln trition (PE2) a--lies to a ro - o+ relate isor ers that in,l e

marasm s ;8ashior;or an marasm s ;8ashior;or/ The 8or 6marasm s is

eri.e +rom the ree; 8or marasmos, means 68astin 7/ 2arasm s re+ers to an

ina eB ate inta;e o+ -rotein an ,alories an is ,hara,teri5e !& ema,iation/ The

8or 6;8ashior;or7 is ta;en +rom the hana lan a e 8hi,h means 6the si,;ness

o+ the 8eanin 7/ 8ashior;or re+ers to an ina eB ate -rotein inta;e 8ith

reasona!le or normal ,alori, (ener &) inta;e/ $

2.1.2. EPIDEMIOLOGY 1,2,3,4,

Protein ener & maln trition is the most ,ommon +orm o+ n tritional

e+i,ien,& amon -atients 8ho are hos-itali5e in the


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8as $#/$= the -re.alen,e o+ st ntin 8as $9/>= an the -re.alen,e o+ 8astin

8as >/9=/ 1 It is estimate that there are $40 000 !a!ies !orn e.er& &ear 8ith

im-aire ,o niti.e -er+orman,e e to io ine e+i,ien,& a!o t $ 000 ,hil ren

ie e to re ,e in+e,tion resistan,e 10= o+ ,hil ren 8ith im-aire imm ne

s&stem an ro8th as a res lt o+ .itamin A e+i,ien,&/ 3

In @an la esh the -ro-ortion o+ st nte ,hil ren a e 0 #9 months in

r ral area in $00# 8as a!o t *4 >0> (39 $=) n er8ei ht ,hil ren 8as a!o t

*4 "0" (4# *=) 8aste ,hil ren 8as a!o t *4 $#0 (11 4=) an malno rishe

,hil ren 8as a!o t 3" $>0 (11 "=)/ 4 In In ia e-i emiolo i,al st & o+

maln trition in r ral area sho8e that the -re.alen,e o+ maln trition is .er& hi h

es-e,iall& in r ral area/ The st & s esre that the -re.alen,e o+ maln trition

amon the n er +i.e ,hil ren in $00> $00* 8as #0 4>= (3$9 ,hil ren +rom >#$

8ere s ++erin +rom maln trition)/ #

2.1.3. ETIOLOGY !

Protein ener & maln trition is a ma,ron trient e+i,ien,& not a

mi,ron trient e+i,ien,&/ Ener & e+i,ien,& is more im-ortant an more ,ommon

than -rotein e+i,ien,&// The ,a se o+ PE2 sho l not !e .ie8e sim-l& in terms

o+ ina eB ate inta;e o+ n trients/ >

Some +a,tors that ha.e in+l en,es in PE2 are:

+oo s an the n trients the& ,ontain m st !e a.aila!le to the +amil& in a eB ate

B antit&

the ,orre,t !alan,e o+ +oo s an n trients m st !e +e at the ri ht inter.als

the in i.i al m st ha.e an a--etite to ,ons me the +oothere m st !e -ro-er i estion an a!sor-tion o+ the n trients in the +oo

the meta!olism o+ the -erson m st !e normal

there sho l !e no isor ers that -re.ent !o & ,ells +rom tili5in the n trients

or that res lt in a!normal losses o+ n trients

a,tors that a .ersel& in+l en,e an& o+ these +a,tors ,an !e the ,a ses o+

maln trition -arti, larl& PE2/ The n erl&in ,a ses ,o l also !e ,ate ori5e

as those relate to the ,hil s +oo se, rit& health (in,l in -rote,tion +rom


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in+e,tions an a--ro-riate treatment o+ illness) an ,are (in,l in maternal an

+amil& -ra,ti,es s ,h as those relate to +reB en,& o+ +ee in !reast+ee in an

8eanin )/

Some eDam-les o+ the ,a ses o+ PE2 are:

- the in i.i al s hi h nee s +or !oth ener & an -rotein -er ;ilo ram

- ina--ro-riate se o+ in+ant +orm la in -la,e o+ !reast+ee in +or the .er& &o n

in+ants

- ina eB ate or ina--ro-riate ,hil ,are !e,a se o+ time ,onstraints +or the

mother or la,; o+ ;no8le e re ar in the im-ortan,e o+ eD,l si.e !reast+ee in

- ina eB ate a.aila!ilit& o+ +oo +or the +amil& !e,a se o+ -o.ert& an -ro!lems

relate to intra+amil& +oo istri! tion

- in+e,tions (.iral !a,terial an -arasiti,) 8hi,h ma& ,a se anoreDia re ,e

+oo inta;e hin er n trient a!sor-tion an tili5ation or res lt in n trient

losses

- +amine res ltin +rom ro hts nat ral isasters 8ars ,i.il ist r!an,es

Premat rit& or lo8 !irth 8ei ht ma& -re is-ose the ,hil to the n tritional

marasm s/ An& ,on ition that -re.ents mother +rom !reast+ee in their ne8!orn

in+ants ma& ,a se PE2/ There+ore -romotion o+ in+ant +orm la an ins ++i,ient

s --ort o+ !reast+ee in !& the me i,al -ro+ession an health ser.i,es ma& !e

+a,tors in the etiolo & o+ marasm s/ Prolon e eD,l si.e !reast+ee in 8itho t

the intro ,tion o+ other +oo s a+ter siD months o+ a e ma& also ,ontri! te toro8th +alterin PE2 an e.ent all& n tritional marasm s/

The .ie8 that ;8ashior;or is the res lt o+ -rotein e+i,ien,& an

n tritional marasm s the res lt o+ ener & e+i,ien,& is an o.ersim-li+i,ation/ @oth

en o eno s an eDo eno s ,a ses are li;el& to in+l en,e 8hether a ,hil e.elo-s

n tritional marasm s ;8ashior;or or the interme iate +orm ;no8n as marasmi,

;8ashior;or/ T8o ne8 theories eD-lain the ,a se o+ ;8ashior;or/ The +irst is that

;8ashior;or is e to a+latoDin -oisonin / The se,on is that +ree ra i,als are


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im-ortant in the -atho enesis o+ ;8ashior;or/ It has !een h&-othesi5e that most

o+ the ,lini,al +eat res o+ ;8ashior;or ,o l !e ,a se !& an eD,ess +ree ra i,al

stress/

2.1.4. CLA""IFICATION !,#

T$%&' 1. C&$ * +$ * M$& / 0

C&$ * +$ D'* G0$

G '

Wei ht !elo8 =

me ian W A

2il ( ra e 1)

2o erate ( ra e $)Se.ere ( ra e 3)

*#= 90= W A

>0= *4= W A >0= W A

W$ '0& 55 s,ores (S%) !elo8

me ian W

2il

2o erate

Se.ere

"0= 90= W

*0= "0= W

*0= W

WHO (5$ )5 s,ores (S%) !elo8

me ian W

2o erate

Se.ere

3= F 5 s,ore $

5 s,ore 3

WHO ( / )5 s,ores (S%) !elo8

me ian A

2o erate

Se.ere

3= F 5 s,ore $

5 s,ore 3

In the 19#0s an 19>0s the e ree o+ maln trition 8as almost al8a&s

!ase on the ,hil s -er,enta e o+ stan ar 8ei ht +or a e/ In Latin Ameri,a the

ome5 ,lassi+i,ation 8as .er& 8i el& se / >

T$%&' 2. G ' +&$ * +$ * $& / 0 %$ ' 5' 6 -* 0-$ ' $ $0

C&$ * +$ P'0+' $ ' * $ $0 5' 6 * 0

$ 'N 0 $& G90G0$ ' I ( & $& / 0 ) *# "9/9G0$ ' II ( '0$ ' $& / 0 ) >0 *4/9G0$ ' III $ ( '7'0' $& / 0 ) >0

In the earl& 19*0s a metho 8as s este that istin ishe three

,ate ories o+ mil to mo erate PE2 !ase on 8ei ht an hei ht meas rements o+

,hil ren/ S !seB entl& these ,ate ories ,ame to !e ;no8n as +ollo8s:

- 68astin 7: a, te , rrent short ration maln trition 8here 8ei ht +or a e an

8ei ht +or hei ht are lo8 ! t hei ht +or a e is normal


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than one me,hanism is o+ten in.ol.e . Some +a,tors that -la& the role in n trient

inta;e are +oo inta;e (so,ioe,onomi, !eha.ior emotions , lt re) an

a!sor-tion ( isease -h&siolo i, stress me,hani,al -ro!lems) 8hile n trient

reB irements are in+e,tions +e.er -h&siolo i, stress an ro8th/ The terms

primary malnutrition an secondary malnutrition re+er res-e,ti.el& to

maln trition res ltin +rom ina eB ate +oo inta;e an maln trition res ltin

+rom in,rease n trient nee s e,rease n trient a!sor-tion an 'or in,rease

n trient losses/ 9


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In a ,hil 8ho ,ons mes m ,h less +oo than reB ire +or his or her

ener & nee s ener & is mo!ili5e +rom !oth !o & +at an m s,le/ 2 s,le -rotein

(a,,o ntin +or "0= o+ lean tiss e mass) !ears the !r nt o+ the loss 8hile the

6,entral7 lean tiss es (li.er astrointestinal tra,t ;i ne&s !loo an imm ne

,ells) are relati.el& s-are / As lon as the star.ation ration o+ ener & an -roteinis not too lo8 s ,,ess+ l a a-tation 8ill re ,e ener & an -rotein reB irements

to mat,h it restorin homeostasis an maintainin ;e& -h&siolo i, + n,tions/ The

-h&siolo i, ,ost o+ this a a-tation is a lo8ere meta!oli, rate an re ,e m s,le

mass (in,l in re ,e ,ar ia, an re-irator& m s,le mass)/ 11 l ,oneo enesis

in the li.er is enhan,e an there is loss o+ s !, taneo s +at an 8astin o+

m s,les/ As a res lt the !o & ra8s on its o8n stores res ltin in ema,iation/

The a,t al role o+ in+e,tion has not !een a eB atel& eD-laine ! t ,ertain

in+e,tions ,a se ma or in,reases in rinar& nitro en 8hi,h eri.es +rom amino

a,i s in m s,le tiss e/

In+lammation also -la&s some r le in the -atho enesis o+ PE2/ Patients

8ith mali nan,& in+e,tion an se.ere tiss e in r& ,ommonl& e.elo- a

h&-ermeta!oli, res-onse terme the s&stemi, in+lammator& res-onse s&n rome

(SIRS) 8hi,h is e+ine !& the -resen,e o+ $ or more o+ the +ollo8in elements:

+e.er (or -ro+o n h&-othermia) ta,h&,ar ia ta,h&-nea an le ;o,&tosis (or


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in,rease n m!ers o+ !an +orms)/ Other +eat res o+ the SIRS in,l e ,han es in

a, te -hase ser m -rotein ,on,entrations in,rease ener & eD-en it re in,rease

8hole !o & -rotein t rno.er anoreDia an -rotein 8astin / The -rotein 8astin is

!elie.e to re-resent the meta!oli, ,ost o+ ra-i l& mo!ili5in amino a,i s +or

8o n healin an s&nthesis o+ imm ne ,ells an -roteins/ 11

The PE2 asso,iate 8ith ,hroni, mil in+lammation is not restri,te to

-atients 8ith ,ertain neo-lasms or in+lammator& iseases/ It is in,reasin l&

re,o ni5e as ,ontri! tin to the -rotein 8astin asso,iate 8ith or an +ail re

in,l in ,hroni, renal +ail re an en sta e heart isease/

In ;8ashior;or a eB ate ,ar!oh& rate ,ons m-tion an e,rease -rotein

inta;e lea to e,rease s&nthesis o+ .is,eral -roteins/ $ It has !een s este that

n er ,ir, mstan,es 8hen -rotein inta;e is .er& lo8 relati.e to ,ar!oh& rate

inta;e .ario s meta!oli, ,han es ta;e -la,e 8hi,h ,ontri! te to the e.elo-ment

o+ e ema/ 2ore so i m an more 8ater are retaine an m ,h o+ the 8ater

,olle,ts o tsi e the ,ar io.as, lar s&stem in the tiss es 8hi,h res lts in -ittin

e ema/

2.1.!. CLINICAL MANIFE"TATION" 2,1;

M$0$ /

2arasm s is ,hara,teri5e !& +ail re to ain 8ei ht an irrita!ilit&

+ollo8e !& 8ei ht loss/ 10 A++e,te ,hil ren are short an li ht +or their a e/ The

most -er,e-ti!le an +reB ent ,lini,al +eat re in marasm s is the loss o+ m s,le

mass an s !, taneo s +at mass/ There is m s,le atro-h& an res ltant h&-otonia/

Some m s,le ro -s s ,h as ! tto,;s an --er lim! m s,les are more

+reB entl& a++e,te than others/ a,ial m s,les are s all& s-are lon er/ a,ial

+at mass is the last to !e lost res ltin in se.ere ,ases in the ,hara,teristi, el erl&

a--earan,e o+ ,hil ren 8ith marasm s/ AnoreDia is +reB ent an inter+eres 8ith

ren trition// A-ath& is a si n o+ serio s +orms o+ marasm s ,hil ren are

in,reasin l& motionless/ $

The s;in loses t r or an !e,omes 8rin;le an loose as s !, taneo s +at

isa--ears/ The a! omen ma& !e isten e or +lat 8ith the intestinal -attern


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rea il& .isi!le/ 2arasm s ma& ha.e no ,lini,al ermatosis/ o8e.er , taneo s

+in in s in,l e +ine !rittle hair alo-e,ia im-aire ro8th an +iss rin o+ the

nails ma& !e +o n / In -rotein ener & maln trition more hairs are in the telo en

(restin ) -hase than in the ana en (a,ti.e) -hase a re.erse o+ normal/

P 0 0 5 6 / In all ,ases the ,hil +ails to ro8 -ro-erl&/ In se.ere ,ases

the loss o+ +lesh is o!.io s the ri!s are -rominent the !ell& in ,ontrast to the rest

o+ the !o & ma& !e -rot !erant the +a,e has a ,hara,teristi, simian (mon;e&

li;e) a--earan,e an the lim!s are .er& ema,iate /

W$ / The m s,les are al8a&s eDtremel& 8aste / There is little i+ an&

s !, taneo s +at le+t/ The s;in han s in 8rin;les es-e,iall& aro n the ! tto,;s

an thi hs/ When the s;in is ta;en !et8een +ore+in er an th m! the s al la&er

o+ a i-ose tiss e is +o n to !e a!sent/

A 0'? $ / Some ,hil ren are anoreDi,/

A ' $ / Anemia is s all& -resent/

"@ 0' / There ma& !e -ress re sores ! t these are s all& o.er !on&

-rominen,es not in areas o+ +ri,tion/ In ,ontrast to ;8ashior;or there is no e ema

an no +la;& -aint ermatosis in marasm s/

D ' 7' 0$+ / The entire i esti.e tra,t +rom mo th to re,t m is

a++e,te / The m ,osal s r+a,e !e,omes smooth an thin an se,retor& + n,tions

are im-aire / A e,rease in astri, h& ro,hlori, a,i ( Cl) eD,retion an a

slo8in o+ -eristalsis is o!ser.e &iel in !a,terial o.er ro8th in the o en m/

o8e.er these im-ortant alterations o+ the i esti.e tra,t inter+ere onl&

mo eratel& 8ith normal n trient a!sor-tion/ There+ore earl& enteral ren trition is

not ,ontrain i,ate ! t is en,o ra e !e,a se some o+ the n trients ne,essar& +or

the re,o.er& o+ the intestinal m ,osa are se ire,tl& +rom the l men/

I / ' 8 ' / Imm ne im-airment an in+e,tions are s all&

asso,iate 8ith marasm s/ Th&m s atro-h& is a ,hara,teristi, mani+estation o+

marasm s ! t all T l&m-ho,&teJ-ro ,in tiss es are a++e,te / o8e.er @

l&m-ho,&te tiss es s ,h as Pe&er -at,hes the s-leen an the tonsils are

relati.el& -reser.e / Cell lar imm nit& is most a++e,te 8ith a ,hara,teristi,

t !er, lin aner &/ o8e.er anti!o & -ro ,tion is maintaine / In marasm s a


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eneral a,B ire imm no e+i,ien,& o,, rs 8ith a e,rease in se,retor&

imm no lo! lin A (I A) an an im-airment o+ the nons-e,i+i, lo,al e+ense

s&stem s ,h as m ,osal inte rit& an l&m-ho;ine -ro ,tion/

B0$ $ '07 / 8 ' / Cere!ral tiss e is s all& -reser.e rin

marasm s/ @rain atro-h& 8ith im-airment o+ ,ere!ral + n,tions is onl& -resent in

se.ere +orms o+ marasm s/

C$0 7$ +/&$0 8 ' / Car ia, m s,le +i!er is thin an the ,ontra,tilit&

o+ the m&o+i!rils is im-aire / Car ia, o t- t es-e,iall& s&stoli, + n,tion is

e,rease in the same -ro-ortion as the 8ei ht loss/ @ra &,ar ia an h&-otension

,ommonl& o,, r in se.ere +orms o+ maln trition/ Ele,trol&te im!alan,es -resent

rin marasm s mo i+& the EC +in in s/ With this im-aire ,ar ia, + n,tion

an& in,rease o+ intra.as, lar .ol me rin reh& ration or !loo trans+ sion ,an

res lt in a si ni+i,ant ,ar ia, ins ++i,ien,&/

K5$ 6 0@ 0

All ,ases o+ ;8ashior;or ha.e e ema to some e ree -oor ro8th an

8astin o+ m s,les/ 8ashior;or t&-i,all& -resents 8ith a +ail re to thri.e

e ema moon +a,ies an a s8ollen a! omen (-ot!ell&)/ When -resent the s;in

!e,omes ar; r& an then s-lits o-en 8hen stret,he re.ealin -ale areas

!et8een the ,ra,;s (,ra5& -a.ement ermatosis)/

E ' $ . The a,, m lation o+ +l i in the tiss es ,a ses s8ellin in

;8ashior;or this ,on ition is al8a&s -resent to some e ree/ It s all& starts 8ith

a sli ht s8ellin o+ the +eet an o+ten s-rea s - the le s/ Later the han s an

+a,e ma& also s8ell/ I+ e ema is -resent the -it +orme ta;es a +e8 se,on s to

ret rn to the le.el o+ the s rro n in s;in/

P 0 0 5 6 . ro8th +ail re al8a&s o,, rs/ I+ the ,hil s -re,ise a e is

;no8n the ,hil 8ill !e +o n to !e shorter than normal an eD,e-t in ,ases o+

ross e ema li hter in 8ei ht than normal ( s all& >0 to "0 -er,ent o+ stan ar

or !elo8 $ S%)/

W$ . Wastin o+ m s,les is also t&-i,al ! t ma& not !e e.i ent

!e,a se o+ e ema/ The ,hil s arms an le s are thin !e,a se o+ m s,le 8astin /


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M' $& +6$ ' . 2ental ,han es are ,ommon ! t not in.aria!l& noti,e /

The ,hil is s all& a-atheti, a!o t his or her s rro n in s an irrita!le 8hen

mo.e or ist r!e / The ,hil -re+ers to remain in one -osition an is nearl&

al8a&s misera!le an nsmilin / A--etite is nearl& al8a&s -oor/

H$ 0 +6$ ' . In ;8ashior;or the hair !e,omes thinner/ At the same time

it ma& ,han e in ,olo r to !ro8n or re ish !ro8n/ Sometimes small t +ts ,an !e

easil& an almost -ainlessl& -l ,;e o t/ On eDamination n er a mi,ros,o-e

-l ,;e hair eDhi!its root ,han es an a narro8er iameter than normal hair/ The

tensile stren th o+ the hair is also re ,e / In Latin Ameri,a !an s o+ is,olo re

hair are re-orte as a si n o+ ;8ashior;or/ These re ish !ro8n stri-es ha.e !een

terme the M+la si nM or "signa bandera".

"@ +6$ ' . %ermatosis e.elo-s in some ! t not all ,ases o+

;8ashior;or/ It ten s to o,, r +irst in areas o+ +ri,tion or o+ -ress re s ,h as the

roin !ehin the ;nees an at the el!o8/ %ar;l& -i mente -at,hes a--ear 8hi,h

ma& -eel o++ or esB amate/ The similarit& o+ these -at,hes to ol s n !a;e

!listere -aint has i.en rise to the term M+la;& -aint ermatosisM/ 0= o+ that eD-e,te +or his or her a e/

Chil ren 8ith marasmi, ;8ashior;or ha.e all the +eat res o+ n tritional marasm s

an ma& also ha.e an& o+ the +eat res o+ ;8ashior;or/


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2.1.#. DIAGNO"I" !

The ia nosis o+ PE2 rests mainl& on ,lini,al eDamination +or the

s&m-toms an si ns o+ the s&n rome -l s anthro-ometri, assessments/

A itionall& la!orator& in.esti ation +or the assessment o+ ,om-li,ations an

other health -ro!lems asso,iate 8ith maln trition is nee e /

L$% 0$ 08 / '

W O re,ommen s the +ollo8in la!orator& tests:

emo lo!in Ele,trol&tes

Ser m al! min

@loo l ,ose

2i,ros,o-& eDamination o+ !loo smears

Le.els o+ ser m trans+errin an retinol !in in -rotein (R@P) are alsose+ l an not i++i, lt to etermine/ o8e.er le.els o+ ser m trans+errin are

in+l en,e !& iron stat s 8hi,h re ,es their se+ lness as an in i,ator o+

;8ashior;or/ Other iseases s ,h as li.er isease .itamin A an 5in,

e+i,ien,ies an h&-erth&roi ism ma& also in+l en,e R@P le.els/ >


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2.1./ Corre,t mi,ron trient e+i,ien,ies

*/ Start ,a tio s +ee in

"/ A,hie.e ,at,h - ro8th

9/ Pro.i e sensor& stim lation an emotional s --ort

10/ Pre-are +or +ollo8 - a+ter re,o.er&

T$%&' . T '-*0$ ' * 0 6' $ $ ' ' * $ +6 & 5 6 '7'0' $& / 0


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" '9 1. T0'$ 90'7' 689 &8+' $

Che,; +or h&-o l&,emia/ I+ the ,hil is ,ons,io s an the !loo l ,ose is

#4 m ' l i.e #0 ml !ol s o+ 10= l ,ose sol tion/ I+ n,ons,io s i.e I?

sterile 10= l ,ose (#ml'; ) +ollo8e !& #0 ml o+ 10= l ,ose or s ,rose !&

naso astri, t !e/ 2onitor the !loo l ,ose i+ the !loo l ,ose 8as lo8

tem-erat re +alls to 3#/# oC an the le.el o+ ,ons,io sness eteriorates re-eat

a+ter $ ho rs/ Also +ee t8o ho rl& an al8a&s i.e +ee s thro ho t the ni ht/

" '9 2. T0'$ 90'7' 689 6'0 $

I+ the aDillar& tem-erat re is 3#/0 oC an re,tal tem-erat re is 3#/# oC

re8arm the ,hil either ,lothe the ,hil ,o.er 8ith a 8arm !lan;et or - t on

mother7s !are ,hest an ,o.er them/ 2onitor the !o & tem-erat re t8o ho rl&

ntil it rises to G3>/# oC an ens re the ,hil is ,o.ere at all times es-e,iall& at

ni ht .

" '9 3. T0'$ 90'7' '68 0$

The stan ar oral reh& ration sol tion ,ontains too m ,h so i m (90


16/45

16

mmol so i m'L) an too little -otassi m +or se.erel& malno rishe ,hil ren/

Instea i.e s-e,ial R' h& ration " l tion +or M$&n trition (ReSo2al)/ It is

i++i, lt to estimate eh& ration stat s in a se.erel& malno rishe ,hil sin

,lini,al si ns alone/ So ass me all ,hil ren 8ith 8ater& iarrhea ma& ha.e

eh& ration an i.e ReSo2al # ml'; e.er& 30 min tes +or t8o ho rs orall& or

!& naso astri, t !e then # 10 ml'; 'h +or neDt 4 10 ho rs/ 2onitor -ro ress o+

reh& ration o!ser.e hal+ ho rl& +or t8o ho rs then ho rl& +or the neDt > 1$

ho rs +or the - lse rate res-irator& rate rine +reB en,& an stool'.omit

+reB en,&/

Contin in ra-i !reathin an - lse rin reh& ration s est

,oeDistin in+e,tion or o.erh& ration/ Si ns o+ eD,ess +l i (o.erh& ration) are

in,reasin res-irator& rate an - lse rate in,reasin e ema an - ++& e&eli s/ I+

these si ns o,, r sto- +l i s imme iatel& an reassess a+ter one ho r/

" '9 4. C 00'+ '&'+ 0 &8 ' %$&$ +'

All se.erel& malno rishe ,hil ren ha.e eD,ess !o & so i m e.en tho h

-lasma so i m ma& !e lo8/ %e+i,ien,ies o+ -otassi m an ma nesi m are also

-resent an ma& ta;e at least t8o 8ee;s to ,orre,t/ E ema is -artl& e to these

im!alan,es/ %o KOT treat E ema 8ith a i reti,/

i.e:

N eDtra -otassi m 3 4 mmol'; '

N eDtra ma nesi m 0/4 0/> mmol'; '

N 8hen reh& ratin i.e lo8 so i m reh& ration +l i (e/ / ReSo2al)

" '9 . T0'$ 90'7' *'+

In se.ere maln trition the s al si ns o+ in+e,tion s ,h as +e.er are o+ten

a!sent an in+e,tions are o+ten hi en/ There+ore i.e anti!ioti, ro tinel& on

a mission/

Choi,e o+ !roa s-e,tr m anti!ioti,s:

a) i+ the ,hil a--ears to ha.e no ,om-li,ations i.e:

N Co trimoDa5ole # ml -ae iatri, s s-ension orall& t8i,e ail& +or # a&s ($/# ml


17/45

17

i+ 8ei ht > ; )/ (# ml is eB i.alent to 40 m T2P $00 m S2 )/

!) i+ the ,hil is se.erel& ill (a-atheti, lethar i,) or has ,om-li,ations i.e:

N Am-i,illin #0 m '; I2'I? > ho rl& +or $ a&s then oral amoD&,illin 1#

m '; " ho rl& +or # a&s or i+ amoD&,illin is not a.aila!le ,ontin e 8ith

am-i,illin ! t i.e orall& #0 m '; > ho rl&

N entami,in */# m '; I2'I? on,e ail& +or * a&s/ I+ the ,hil +ails to

im-ro.e ,lini,all& 8ithin 4" ho rs A%%:

N Chloram-heni,ol $# m '; I2'I? " ho rl& +or # a&s

Where s-e,i+i, in+e,tions are i enti+ie A%%:

N s-e,i+i, anti!ioti,s i+ a--ro-riate

N antimalarial treatment i+ the ,hil has a -ositi.e !loo +ilm +or malaria

-arasites/

" '9 !. C 00'+ +0 / 0 ' '* + ' + '

All se.erel& malno rishe ,hil ren ha.e .itamin an mineral e+i,ien,ies/

Altho h anemia is ,ommon o KOT i.e iron initiall& ! t 8ait ntil the ,hil

has a oo a--etite an starts ainin 8ei ht ( s all& !& the se,on 8ee;) as

i.in iron ,an ma;e in+e,tions 8orse/ i.e .itamin A orall& on %a& 1 (+or a e

G1$ months i.e $00 000 I< > 1$ months i.e 100 000 I< 0 # months i.e

#0 000 I


18/45

18

!e esi ne to -ro.i e st s ++i,ient ener & an -rotein to maintain !asi,

-h&siolo i,al -ro,esses/ The essential +eat res o+ +ee in in the sta!ili5ation

-hase are:

N small +reB ent +ee s o+ lo8 osmolarit& an lo8 la,tose

N oral or naso astri, (K ) +ee s (ne.er -arenteral -re-arations)

N 100 ;,al'; '

N 1 1/# -rotein'; '

N 130 ml'; ' o+ +l i (100 ml'; ' i+ the ,hil has se.ere e ema)

N i+ the ,hil is !reast+e en,o ra e to ,ontin e !reast+ee in ! t i.e the

-res,ri!e amo nts o+ starter +orm la to ma;e s re the ,hil 7s nee s are met/

2onitor amo nts o++ere an le+t o.er .omitin +reB en,& o+ 8ater&

stool an ail& !o & 8ei ht/

" '9


19/45

19

I+ 8ei ht ain is:

N -oor ( # '; ' ) ,hil reB ires + ll reassessment

N mo erate (# 10 '; ' ) ,he,; 8hether inta;e tar ets are !ein met or i+

in+e,tion has !een o.erloo;e

N oo (G10 '; ' ) ,ontin e to -raise sta++ an mothers

" '9 >. P0 7 ' ' 08 /&$ $ ' $& /99 0

In se.ere maln trition there is ela&e mental an !eha.io ral

e.elo-ment/

Pro.i e:

N ten er lo.in ,are

N a ,heer+ l stim latin en.ironment

N str ,t re -la& thera-& 1# 30 min'

N -h&si,al a,ti.it& as soon as the ,hil is 8ell eno h

N maternal in.ol.ement 8hen -ossi!le (e/ / ,om+ortin +ee in !athin -la&)

" '9 1;. P0'9$0' * 0 * && 5-/9 $* '0 0'+ 7'08

A ,hil 8ho is 90= 8ei ht +or len th (eB i.alent to 1S%) ,an !e

,onsi ere to ha.e re,o.ere / The ,hil is still li;el& to ha.e a lo8 8ei ht +or a e

!e,a se o+ st ntin / oo +ee in -ra,ti,es an sensor& stim lation sho l !e

,ontin e at home/ Sho8 -arent or ,arer ho8 to:

N +ee +reB entl& 8ith ener & an n trient ense +oo s

N i.e str ,t re -la& thera-&

A .ise -arent or ,arer to:

N !rin ,hil !a,; +or re lar +ollo8 - ,he,;s

N ens re !ooster imm ni5ations are i.en

N ens re .itamin A is i.en e.er& siD months


20/45

20

CHAPTER III

CA"E REPORT

Kame : RA2

A e : $ &ears # month

SeD : emale

%ate o+ A mission : Se-tem!er 10 th $013

M$ C 9&$ : A! ominal !loatin

H 08 : This -ro!lem ha--ene sin,e 14 a&s a o/ Patient also ,om-lains +e.er

+or a!o t 3 8ee;s/ e.er 8as hi h an relie.e !& intro ,tion o+ anti -&reti,

r s . Sei5 re 8as not +o n %iarrhea 8as +o n a!o t three 8ee;s a o >

times' a& 8ith the ,onsisten,& o+ 8ater more than - l- aB a lass in .ol me

!loo 8as not +o n in stool an no8 the -atient hasn7t !een ha.in the iarrhea

+or one 8ee;s/ ?omitin 8as not +o n ,o h 8as not +o n / Wei ht loss 8as


21/45

21

+o n / @e+ore the -atient is si,; her 8ei ht 8as 13 ; no8 her 8ei ht is 9 ; /


22/45

22

1/ ea : Ol man +a,e ( )

E&e : S n;en e&es ( ) li ht re+leDes ( ' ) iso,hori, - -il -ale

in+erior -al-e!ra ,on n,ti.a ( ' ) i,teri, ( ' )

Ear : Kormal a--erean,e

Kose: Kormal a--erean,e

2o th : C&anosis ( ) r& m ,osa o+ li-s

$/ Ke,; : L&m-h no e enlar ement ( )

3/ ThoraD: S&mmetri,al + si+orm e-i astri, retra,tion ( )/

R: 1#0 !-m re ler m rm r ( )

RR: 3$ !-m re ler ,ra,;les ( ' ) inter-ose ri! ,learl& .isi!le ( )

4/ A! omen: %istention ( ) s&mmetri,al -eristalti, ( ) e,rease /

Li.er'S-leen: n erteminate

#/ EDtremities: P lse 1#0 !-m re lar a eB ate -ress re an .ol me 8arm

a,ral CRT 3 @P: 110'>0mm m s,le h&-otro-h&

!a & -ants ( ) -ittin e ema ( )/


23/45

23

L$% 0$ 08 R' /&

Se-tem!er 10th $013

C 9&' ' B& C /emo lo!in ( @) = >.1; 11/3 J 14/1Eritrosit (R@C) 10 >' mm 3 3.41 4/40 J 4/4"Le ;osit (W@C) 10 3' mm 3 1/0 1*/#emato;rit = 2#.! 3* J 41Trom!osit (PLT) 10 3' mm 3 331U $1* J 49*2C? +L "0/9 "1 J 9#2C P $"/*0 $# J $92C C = 33/00 $9 J 31R%W = 14/00 11/> J 14/"2P? +L "/40 */$ 10/0PCT = 0/$"P%W +L "/$D * '&

Ke tro+il = "$/00 3* J "0Lim+osit = 1$/#0 $0 J 402onosit = #/$0 $ J "Eosino+il = 0/$0 1 J >@aso+il = 0/100 0 J 1

Ke tro+il A!sol t 10 3'VL 14/"" $/4 J */3Lim+osit A!sol t 10 3'VL $/$9 1/* >/12onosit A!sol t 10 3'VL 0/9# 0/3 0/"Eosino+il A!sol t 10 3'VL 0/03 0/10 0/30@aso+il A!sol t 10 3'VL 0/0$ 0 0/1


24/45

24

D **'0' $& D $

2aln trition t&-e marasm s ;8ashior;or ra e ?

W 0@ D $

2aln trition t&-e marasm s ;8ashior;or ra e ?

T0'$ '

CotrimoDa5ole $ D $# m

Para,etamol 3 D 100 m

oli, a,i 1 D #m neDt 1D1 m

?it A 1 D 100/000 I0 ,,'3h'K T

L$% 0$ 08 R' /&

Se-tem!er 10 th $013C& +$& C6' 08

B& $ $ $&8

UNIT RE"ULT" NORMAL

VALUE - #.4>3 */3# */4# -CO $ mm 21.1 3" 4$ -O $ mm 1 #.3 "# 100@i,ar!onate ( C0 3) mmol'L 1 .< $$ $>

Total CO $ mmol'L 1> 4 19 $#

@ase eD,ess (@E) mmol'L >/3 ( $) ( $)

O$ sat ration = 99/# 9# 100

HEARTAl! min ' L 3/0 3/" #/4

CARBOHYDRATE METABOLI"M@loo l ,ose (As) m ' L $$9/*0 $00

RENAL

10>


25/45

25

FOLLOW UP

"'9 ' %'0, 11 6 2;13 (F 0 $8)" A! ominal !loatin ( ) e.er( ) Lo8 +reB en,& e+e,ation !loo & stools( )O Sens: C2 Tem-: 3* 9 oC @o & 8ei ht: 9 " ; T@: 91 ,m @@'T@ : *0= 5 s,ore 3 S%

ea E&e : Li ht re+leDes( ' ) iso,hori, - -il -ale ,on n,ti.a -al-e!ra in+erior

( ' ) i,teri, ( ' ) s n;en e&es( ' ) Ear : Kormal a--erean,e 2o th :

Sianosis ( ) Kose: Kormal a--erean,e Ke,; : L 2P KO%ES

enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 140 !-m re lar

m rm r ( )/ RR: 43 !-m re lar/ Cra,;les ( ' ) inter-ose ri! ,learl& .isi!leA! omen %istention/ Peristalti, ( ) e,rease / Li.er'S-leen'Renal: n eterminate/

as,ites a--earan,eEDtremities P lse 140 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT

3 !a & -ants( ) m s,le h&-otro-h&( ) little s !, taneo s +at le+t( )

A 2aln trition t&-e marasm s ;8ashior;or ra e ?P

CotrimoDa5ole $ D $# mPara,etamol 3 D 100 m

oli, a,i 1D#m neDt 1D1 m

?it A 1 D 100/000 I0 ,,'3h'K T

P&$

K trient an meta!oli, i.ision ,ons lt


26/45

26

"'9 ' %'0, 12 6 2;13 ("'+ $8)" A! ominal !loatin ( ) e.er( ) !loo & stools( ) iarrhea( )$D 8ith reen stools .omit( )O Sens: C2 Tem-: 3> " oC


( ' ) i,teri, ( ' ) s n;en e&es( ' ) Ear : Kormal a--erean,e 2o th :

Sianosis ( ) Kose: Kormal a--erean,e Ke,; : L 2P KO%ES

enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 130 !-m re ler

m rm r ( )/ RR: 34 !-m re ler/Cra,;les ( ' ) inter-ose ri! ,learl& .isi!leA! omen %istention ( ) -eristalti, ( ) e,rease Li.er'S-leen'Renal: n eterminate

as,ites a--earan,eEDtremities P lse 140 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT

3 !a & -ants( ) m s,le h&-otro-h&( ) little s !, taneo s +at le+t( )

A 2aln trition t&-e marasm s ;8ashior;or ra e ?P

CotrimoDa5ole $ D $# m


oli, a,i 1D1 m2 lti.itamin 8itho t e 1 ,th I

%iet *# 1>0 ,,'>h'K TL$% 0$ 08 R' /&

"'9 ' %'0, 12 6 2;13

C 9&' ' B& C /emo lo!in ( @) = >.' mm 3 3.!4 4/40 J 4/4"Le ;osit (W@C) 10 3' mm 3 1*/44 >/0 1*/#emato;rit = 2>.! 3* J 41Trom!osit (PLT) 10 3' mm 3 3**U $1* J 49*2C? +L "1/3 "1 J 9#2C P $>/90 $# J $92C C = 33/10 $9 J 31R%W = 14/$0 11/> J 14/"2P? +L "/90 */$ 10/0PCT = 0/33P%W +L "/$D ** '&

Ke tro+il = >"/30 3* J "0Lim+osit = $3/#0 $0 J 402onosit = */90 $ J "

Eosino+il = 0/$0 1 J >


27/45

27

@aso+il = 0/100 0 J 1 Ke tro+il A!sol t 10 3'VL 11.>1 $/4 J */3

Lim+osit A!sol t 103

'VL $/$9 1/* >/12onosit A!sol t 10 3'VL 1/3* 0/3 0/"Eosino+il A!sol t 10 3'VL 0/04 0/10 0/30@aso+il A!sol t 10 3'VL 0/0$ 0 0/1

L$% 0$ 08 R' /&

Se-tem!er 1$th $013C& +$& C6' 08

B& $ $ $&8

UNIT RE"ULT" NORMAL

VALUEHEART

Al! min ' L 3/1 3/" #/4

CARBOHYDRATE METABOLI"M@loo l ,ose (As) m ' L 1$3/40 $00

RENAL


28/45

28

"'9 ' %'0, 13 6 2;13 ( 6 0 $8)" A! ominal !loatin ( ) e.er( )O Sens: C2 Tem-: 3> " oC @@ : 9 " ; LPT : #3 ,m/ LP% : #4 # ,m


( ' ) i,teri, ( ' ) Ear : Kormal a--erean,e 2o th : Sianosis ( ) Kose:

Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 94 !-m re ler m rm r

( )/ RR: 30 !-m re ler/Cra,;les ( ' ) inter-ose ri! ,learl& .isi!leA! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) normal/

Li.er'S-leen'Renal: n eterminate/

EDtremities P lse 94 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT 3 m s,le h&-otro-h&( ) little s !, taneo s +at le+t( )

A S s- Partial o!str ,ti.e ile s e, 'in.a inasi maln trition t&-e marasm s S s- 0 ,,'>h'K T

N/ 0 ' $ ' $% & + '$ ' /&'

S:?omit( ) A! ominal !loatin ( )

O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 9 # ; LLA (S) : 11 ,m LP%(S) : #3 ,m

T@ 91 ,m @@'T@ : 3 S%

A :2aln trition marasm s t&-e S s-


29/45

29

" A! ominal !loatin ( ) e.er( ) Pale +a,e( )O Sens: C2 Tem-: 3* oC @@ : 9 " ; LPT : #1 # ,m/ LP% : #3 ,m



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 9> !-m re ler m rm r

( )/ RR: $> !-m re ler/Cra,;les ( ' )A! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) normal/

Li.er'S-leen'Renal: n eterminate/EDtremities P lse 9> !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT

3 m s,le h&-otro-h&( ) little s !, taneo s +at le+t( )

A S s- Partial o!str ,ti.e ile s e, 'in.a inasi maln trition t&-e marasm s S s-


30/45

30

P CotrimoDa5ole $ D $# m


oli, a,i 1D1 m

2 lti.itamin 8itho t e 1 ,th I

%iet *# 1>0 ,,'>h'K T

P&$ :

Che,; C@C L T

N/ 0 ' $ ' $% & + '$ ' /&'


O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 9 # ; LLA (S) : 11 ,m LP%(S) : #3 ,m

T@ 91 ,m @@'T@ : 3 S%

A :2aln trition marasm s t&-e S s- ' mm 3 3/>" 4/40 J 4/4"Le ;osit (W@C) 10 3' mm 3 $>/0> >/0 1*/#emato;rit = $9/4 3* J 41

Trom!osit (PLT) 103

' mm3

49# $1* J 49*2C? +L *9/90 "1 J 9#2C P $>/40 $# J $92C C = 33/00 $9 J 31R%W = 14/10 11/> J 14/"2P? +L "/40 */$ 10/0PCT = 0/4$P%W +L "/1D * '&

Ke tro+il = >"/#0 3* J "0Lim+osit = 1"/00 $0 J 402onosit = 13/10 $ J "Eosino+il = 0/10 1 J >@aso+il = 0/300 0 J 1

Ke tro+il A!sol t 10 3'VL 1*/"> $/4 J */3


31/45

31

"'9 ' %'0, 1 6 2;13 (* * 6 $8)" A! ominal !loatin ( ) e.er( ) Pale( )O Sens: C2 Tem-: 3* oC



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 110 !-m re ler

m rm r ( )/ RR: $> !-m re ler/Cra,;les ( ' )A! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) normal/

Li.er'S-leen'Renal: n eterminate/

EDtremities P lse 110 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT 3 m s,le h&-otro-h&( ) little s !, taneo s +at le+t( )

A S s- Partial o!str ,ti.e ile s e, 'in.a inasi maln trition t&-e marasm s S s-


32/45

32

O Sens: C2 Tem-: 3> * oC LPT #$ : ,m LP% : #3 ,m



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm e-i astrial retra,tion( ) R: 9" !-m re ler m rm r

( )/ RR: $> !-m re ler/Cra,;les ( ' )A! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) e,rease

Li.er'S-leen'Renal: n eterminate/EDtremities P lse 9" !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT


A 2aln trition marasm s t&-e a! ominal t mor e, 'ne ro!lastoma

Willms t mor P

Three 8a&

In ,e+triaDone $#0 m '1$h'I?


2 lti.itamin 8itho t e 1D,th I

%iet *# 1#0 ,,'3h'K T 2ineral miD 3 ,,

N/ 0 ' $ ' $% & + '$ ' /&'


O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 10 ; LLA (S) : 11 ,m LP%(S) : #3 ,m

@@I : 1$ " ; @@'T@ : $ Q 3 S%

A : 2aln trition marasm s t&-e a! ominal t mor e, 'ne ro!lastoma

Willms t mor

P : %iet *# 1#0 ,,'3h 2ineral miD 3 ,,

Cotrimo;sa5ole 1 D ,th 1

2 lti.itamin 8itho t E 1 D ,th 1"'9 ' %'0, 2; 6 2;13 (1; 6 $8)

" A! ominal !loatin ( ) e,rease e.er( )


33/45

33

O Sens: C2 Tem-: 3> 9 oC @@ : 9 # ;



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm Retra,tion( ) R: 9$ !-m re ler m rm r ( )/ RR:

$> !-m re ler/Cra,;les ( ' )A! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) e,rease

Li.er'S-leen'Renal: n eterminate/EDtremities P lse 9$ !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT


A 2aln trition marasm s t&-e t mor a! omen e, 'ne ro!lastoma

Willms t mor P - Three 8a&

In ,e+triaDone $#0 m '1$h'I?

Para,etamol 3 D #00 m (i+ nee e )

2 lti.itamin 8itho t e 1 D ,th 1


%iet 100 1$0 ,,'3h'K T 2ineral miD 3 > ,,

N/ 0 ' $ ' $% & + '$ ' /&'


O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 10 ; LLA (S) : 11 ,m LP%(S) : #3 ,m

@@I : 1$ " ; @@'T@ : $ Q 3 S%

A : 2aln trition marasm s t&-e t mor a! omen e, 'ne ro!lastoma

Willms t mor

P : %iet 100 1$0 ,,'3h 2ineral miD 3 > ,,


2 lti.itamin 8itho t E 1 D ,th 1


34/45


35/45

35

L$% 0$ 08 R' /&

"'9 ' %'0, 23 6 2;13

C 9&' ' B& C /emo lo!in ( @) = ' mm 3 3.22 4/40 J 4/4"Le ;osit (W@C) 10 3' mm 3 2/0 1*/#emato;rit = 2 .# 3* J 41Trom!osit (PLT) 10 3' mm 3 41# $1* J 49*2C? +L *9/"0 "1 J 9#2C P $#/$0 $# J $92C C = 31/#0 $9 J 31R%W = 14/90 11/> J 14/"2P? +L "/"0 */$ 10/0PCT = 0/3>P%W +L "/*D * '&

Ke tro+il = *1/>0 3* J "0Lim+osit = 1#/#0 $0 J 402onosit = 1$/40 $ J "Eosino+il = 0/$0 1 J >@aso+il = 0/300 0 J 1

Ke tro+il A!sol t 10 3'VL 2;.21 $/4 J */3Lim+osit A!sol t 10 3'VL 4/3" 1/* >/12onosit A!sol t 10 3'VL 3/49 0/3 0/"Eosino+il A!sol t 10 3'VL 0/0> 0/10 0/30@aso+il A!sol t 10 3'VL 0/0" 0 0/1


36/45


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37

"'9 ' %'0, 24 6 3; 6 2;13 (14 6 2; 6 $8)

" A! ominal !loatin ( ) e,rease e.er( ) ?omitin ( )O Sens: C2 Tem-: 3* 0 oC @@ : 9 " ; LPT : #1 ,m LP% #$ ,m



Kormal a--erean,e Ke,; : L&m-h no es enlar ement( )ThoraD S&mmetri,al + si+orm Retra,tion( ) R: 104 !-m re ler m rm r ( )/

RR: $" !-m re ler/Cra,;les ( ' )A! omen Soe-el/%istention( ) Shi+tin llness ( ) Peristalti, ( ) e,rease

Li.er'S-leen'Renal: n eterminate/EDtremities P lse 104 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT


A 2aln trition marasm s t&-e s s- teratoma 'a! omen mass a!ses o't m!ili,al re ion

le+t hi rone+rosis le+t hi ro reter P

Three 8a&

I? % %#= KaCl 0 $$# = 40 tt'i mi;ro

In ,e+triaDone #00 m '1$h'I?

Para,etamol 3 D #00 m (i+ nee e )


In metroni a5ole L% 1#0 m 2% *# m '"h'i.

%iet 100 $$0 ,,'3h'K T 2ineral miD 4 4 ,,

N/ 0 ' $ ' $% & + '$ ' /&'


O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 10 ; LLA (S) : 11 ,m LP%(S) : #3 ,m

@@I : 1$ " ; @@'T@ : $ Q 3 S%

A : 2aln trition marasm s t&-e s s- teratoma 'a! omen mass a!ses o't m!ili,al re ion

P : %iet 100 $30 ,,'3h 2ineral miD 4 >,,

- 2 lti.itamin 8itho t E 1 D ,th 1


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38

L$% 0$ 08 R' /&

"'9 ' %'0, 2# 6 2;13

C 9&' ' B& C /emo lo!in ( @) = 13/90 11/3 J 14/1Eritrosit (R@C) 10 >' mm 3 #/0# 4/40 J 4/4"Le ;osit (W@C) 10 3' mm 3 2/0 1*/#emato;rit = 40/4 3* J 41Trom!osit (PLT) 10 3' mm 3 40> $1* J 49*2C? +L "0/00 "1 J 9#2C P $*/#0 $# J $92C C = 34/40 $9 J 31R%W = 14/90 11/> J 14/"2P? +L "/10 */$ 10/0PCT = 0/33P%W +L "/4D * '&

Ke tro+il = *4/>0 3* J "0Lim+osit = 1#/#0 $0 J 402onosit = 10/10 $ J "Eosino+il = 0/$0 1 J >@aso+il = 0/300 0 J 1

Ke tro+il A!sol t 10 3'VL 1!.4# $/4 J */3Lim+osit A!sol t 10 3'VL 4/0> 1/* >/12onosit A!sol t 10 3'VL $/0" 0/3 0/"Eosino+il A!sol t 10 3'VL 0/04 0/10 0/30@aso+il A!sol t 10 3'VL 0/0* 0 0/1


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39

L$% 0$ 08 R' /&

Se-tem!er $*th $013C& +$& C6' 08

B& $ $ $&8

UNIT RE"ULT" NORMAL

VALUEPh */4$" */3# */4#

-CO$ mm 32. 3" 4$ -O$ mm 11 .3 "# 100@i,ar!onate ( C03) mmol'L 21.; $$ $>Total CO$ mmol'L $$/0 19 $#

@ase eD,ess (@E) mmol'L $/# ( $) ( $)

O$ sat ration = 9"/# 9# 100


40/45

40

O+ %'0, 1 4 6 2;13 (21 6 24 6 $8)

" Post la-arotom& +e.er( )O Sens: C2 Tem-: 3> 9 oC @@ : 9 " ; LPT : #1 ,m LP% #$ ,m



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm Retra,tion( ) R: 110 !-m re ler m rm r ( )/


Li.er'S-leen'Renal: n eterminate 8o n +rom o-eration ,lose 8ith

!an a esEDtremities P lse 110 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT



41/45

41

A : Post o- la-arotom& a'i teratoma 2aln trition marasm s t&-e le+t hi rone+rosis le+thi ro reter

P

Three 8a&

I? % %#= KaCl 0 $$# = 1# tt'i mi;ro


In metroni a5ole *# m '"h'i.

In etorola, 1# m '>h


%iet 100 $30 ,,'3h'K T 2ineral miD 4 > ,,

N/ 0 ' $ ' $% & + '$ ' /&'

S:?omit( ) %iarrhea( )

O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 10 # ; LLA (S) : 11 ,m LP%(S) : #3 ,m

@@I : 1$ " ; @@'T@ : 1 Q $ S%

P : %iet 100 $40 ,,'3h 2ineral miD 4 ",,

2 lti.itamin 8itho t E 1 D ,th 1

O+ %'0, 6 # 6 2;13 (2 6 2# 6 $8)

" Post la-arotom& +e.er( )


42/45

42

O Sens: C2 Tem-: 3> 9 oC @@ : 9 " ; LPT : #1 ,m LP% #$ ,m



Kormal a--erean,e Ke,; : L 2P KO%ES enlar ement( )ThoraD S&mmetri,al + si+orm Retra,tion( ) R: 110 !-m re ler m rm r ( )/


Li.er'S-leen'Renal: n eterminate 8o n +rom o-eration ,lose 8ith

!an a esEDtremities P lse 110 !-m re lar a eB ate -ress re an .ol me 8arm a,ral CRT


A Post o- la-arotom& a'i teratoma 2aln trition marasm s t&-e le+t hi rone+rosis le+t

hi ro reter Periotneal T@P

Three Wa&

I? % %#= KaCl 0 $$# = 1# tt'i mi;ro


In metroni a5ole *# m '$h'i.

In etorola, 1# m '>h


%iet 100 $30 ,,'3h'K T 2ineral miD 4 > ,,

N/ 0 ' $ ' $% & + '$ ' /&'

S:?omit( ) %iarrhea( )

O : @@2 : 9 # ; LLA(2) : 11 ,m LPT (S) : #1 ,m

@@S : 11 ; LLA (S) : 11 ,m LP%(S) : #3 ,m

@@I : 1$ " ; @@'T@ : 1 Q $ S%

A : Post o- la-arotom& a'i teratoma 2aln trition marasm s t&-e le+t hi rone+rosis le+t

hi ro reter Periotneal T@

P : %iet 100 $40 ,,'3h 2ineral miD 4 ",,

- 2 lti.itamin 8itho t E 1 D ,th 1


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43

CHAPTER IV

DI"CU""ION AND "UMMARY

2aln trition essentiall& means H!a no rishment / It ,on,erns not eno h

as 8ell as too m ,h +oo the 8ron t&-es o+ +oo an the !o & s res-onse to a

8i e ran e o+ in+e,tions that res lt in mala!sor-tion o+ n trients or the ina!ilit& to

se n trients -ro-erl& to maintain health/ The ,lini,al mani+estation are eDtreme

8astin ol man +a,e irrita!le s !, taneo s +at loss !a & -ant/

RA2 +emale $ &ear # month 8as a mitte to a i A am 2ali;

eneral os-ital 8ith the main ,om-laint o+ a! ominal !loatin / On -h&si,al

eDamination the -atient ha the loo;s o+ ol man +a,e easil& seen ri!s ( )

h&-otro-& m s,le ( ) s !, taneo s +at e,rease ( ) an !a & -ants ( )

la!orator& +in in sho8s h&-er li,emia lo8 hemo lo!in an er&thro,&te ,o nt

le ,o,&tosis an h&-onatremia/ e 8as ia nose 8ith maln trition t&-e


44/45

44

marasm s ;8ashior;or ra e ?/ The last +ollo8 - sho8e the ia nosis o+ -ost

o- la-arotom& o'i teratoma 8ith 2aln trition marasm s t&-e an le+t

h& rone-hrosis an le+t h& ro reter an -eriotneal T@ an is mana e 8ith

I? % %#= KaCl 0 $$# = 1# tt'i mi;ro , in ,e+triaDone #00 m '1$h'I? in

metroni a5ole *# m '$h'i. in etorola, 1# m '>h m lti.itamin 8itho t e 1 D

,th 1 , iet 100 $30 ,,'3h'K T 2ineral miD 4 > ,,

REFERENCE

1/ Pe iatri, K trition S r.eillan,e S&stem (Pe KSS)/ $00#/ C%C/

$/ S,hein+el KS/ $013/ Protein Ener & 2aln trition/ A.aila!le at:

htt-:''eme i,ine/me s,a-e/,om'arti,le'1104>$3 o.er.ie8 (A,,esse >

O,to!er$013)/

3/ 2I (2i,ron trient Initiati.e) : ?itamin an 2ineral %e+i,ien,& A re-ort

assessment +or ?ietnam (lea ershi- !rie+in )/ $004/2I an / Ann al Re-ort o+ the

K tritional S r.eillan,e Pro e,t/ ellen eller International/

#/ A.a,hat SS Phal;e ?% Phal;e %@/ $009/ E-i emiolo i,al St & o+

2aln trition (


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