1

CASE REPORT Presenter %a&'%ate S -er.isor : Wiraharto Ismail L !is (090100034) (0"01001#$)

: Th rs(a&) 1*th o+ O,to!er $013 : (r/ 01/ 2el(a %eliana) S-/A(3) CHAPTER I INTRODUCTION

1.1.

BACKGROUND

Worl( 0ealth Or4ani5ation (W0O) (e+ines 6maln trition7 as 6the ,ell lar im!alan,e !et8een the s --l& o+ n trients an( ener4& an( the !o(&9s (eman( +or them to ens re 4ro8th) maintenan,e) an( s-e,i+i, + n,tions7/ The term -rotein: ener4& maln trition (PE2) a--lies to a 4ro - o+ relate( (isor(ers that in,l (e marasm s) ;8ashior;or) an( marasm s:;8ashior;or/ Protein:ener4& maln trition is the most ,ommon +orm o+ n tritional (e+i,ien,& amon4 -atients 8ho are hos-itali5e( in the <nite( States/ In a s r.e& +o, sin4 on lo8:in,ome areas o+ the <nite( States) $$:3#= o+ ,hil(ren a4e( $:> &ears 8ere !elo8 the 1#th -er,entile +or 8ei4ht/ In $000) W0O estimate( that malno rishe( ,hil(ren n m!ere( 1"1/9 million (3$=) in (e.elo-in4 ,o ntries/ In a((ition) an estimate( 149/> million ,hil(ren &o n4er than # &ears are malno rishe( 8hen meas re( in terms o+ 8ei4ht +or a4e/ In $00#) the -re.alen,e o+ n(er8ei4ht (lo8 8ei4ht +or a4e) in ?ietnam 8as $#/$=) the -re.alen,e o+ st ntin4 8as $9/>=) an( the -re.alen,e o+ 8astin4 8as >/9=/1 In @an4la(esh) the -ro-ortion o+ st nte( ,hil(ren a4e( 0:#9 months in r ral area in $00# 8as a!o t 39)$= (*4)>0>)) n(er8ei4ht ,hil(ren 8as a!o t 4#)*= (*4)"0")) 8aste( ,hil(ren 8as a!o t 11)4= (*4)$#0)) an( malno rishe( ,hil(ren 8as a!o t 11)"= (3")$>0)/4

CHAPTER II LITERATURE REVIEW 2.1. PROTEIN - ENERGY MALNUTRITION (PEM) 2.1.1. DEFINITION2 Worl( 0ealth Or4ani5ation (W0O) (e+ines 6maln trition7 as 6the ,ell lar im!alan,e !et8een the s --l& o+ n trients an( ener4& an( the !o(&9s (eman( +or them to ens re 4ro8th) maintenan,e) an( s-e,i+i, + n,tions7/ The term -rotein: ener4& maln trition (PE2) a--lies to a 4ro - 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 Aree; 8or( marasmos, means 68astin47/ 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 Ahana lan4 a4e 8hi,h means 6the si,;ness o+ the 8eanin47/ 38ashior;or re+ers to an ina(eB ate -rotein inta;e 8ith reasona!le or normal ,alori, (ener4&) inta;e/$ 2.1.2. EPIDEMIOLOGY1,2,3,4, Protein:ener4& maln trition is the most ,ommon +orm o+ n tritional (e+i,ien,& amon4 -atients 8ho are hos-itali5e( in the <nite( States/ In a s r.e& +o, sin4 on lo8:in,ome areas o+ the <nite( States) $$:3#= o+ ,hil(ren a4e( $:> &ears 8ere !elo8 the 1#th -er,entile +or 8ei4ht/ Another s r.e& sho8e( that 11= o+ ,hil(ren in lo8:in,ome areas ha( hei4ht:+or:a4e meas rements !elo8 the # th -er,entile/ Poor 4ro8th is seen in 10= o+ ,hil(ren in r ral -o- lations/ In $000) W0O estimate( that malno rishe( ,hil(ren n m!ere( 1"1/9 million (3$=) in (e.elo-in4 ,o ntries/ In a((ition) an estimate( 149/> million ,hil(ren &o n4er than # &ears are malno rishe( 8hen meas re( in terms o+ 8ei4ht +or a4e/ In so th ,entral Asia an( eastern A+ri,a) a!o t hal+ the ,hil(ren ha.e 4ro8th retar(ation ( e to -rotein:ener4& maln trition/$ In $00#) the -re.alen,e o+ n(er8ei4ht (lo8 8ei4ht +or a4e) in ?ietnam

8as $#/$=) the -re.alen,e o+ st ntin4 8as $9/>=) an( the -re.alen,e o+ 8astin4 8as >/9=/1 It is estimate( that there are $40)000 !a!ies !orn e.er& &ear 8ith im-aire( ,o4niti.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( 4ro8th as a res lt o+ .itamin A (e+i,ien,&/3 In @an4la(esh) the -ro-ortion o+ st nte( ,hil(ren a4e( 0:#9 months in r ral area in $00# 8as a!o t *4)>0> (39)$=)) n(er8ei4ht ,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(emiolo4i,al st (& o+ maln trition in r ral area sho8e( that the -re.alen,e o+ maln trition is .er& hi4h) es-e,iall& in r ral area/ The st (& s 44esre( that the -re.alen,e o+ maln trition amon4 the n(er +i.e ,hil(ren in $00>:$00* 8as #0)4>= (3$9 ,hil(ren +rom >#$ 8ere s ++erin4 +rom maln trition)/# 2.1.3. ETIOLOGY! Protein:ener4& maln trition is a ma,ron trient (e+i,ien,&) not a mi,ron trient (e+i,ien,&/ Ener4& (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 ri4ht inter.als : the in(i.i( al m st ha.e an a--etite to ,ons me the +oo( : there m st !e -ro-er (i4estion 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 tili5in4 the n trients or that res lt in a!normal losses o+ n trients Ca,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&in4 ,a ses ,o l( also !e ,ate4ori5e( as those relate( to the ,hil(9s +oo( se, rit&) health (in,l (in4 -rote,tion +rom

in+e,tions an( a--ro-riate treatment o+ illness) an( ,are (in,l (in4 maternal an( +amil& -ra,ti,es s ,h as those relate( to +reB en,& o+ +ee(in4) !reast+ee(in4 an( 8eanin4)/ Some eDam-les o+ the ,a ses o+ PE2 are: - the in(i.i( al9s hi4h nee(s +or !oth ener4& an( -rotein -er ;ilo4ram - ina--ro-riate se o+ in+ant +orm la in -la,e o+ !reast+ee(in4 +or the .er& &o n4 in+ants - ina(eB ate or ina--ro-riate ,hil( ,are !e,a se o+ time ,onstraints +or the mother or la,; o+ ;no8le(4e re4ar(in4 the im-ortan,e o+ eD,l si.e !reast+ee(in4 - 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 ltin4 +rom (ro 4hts) nat ral (isasters) 8ars) ,i.il (ist r!an,es Premat rit& or lo8 !irth 8ei4ht ma& -re(is-ose the ,hil( to the n tritional marasm s/ An& ,on(ition that -re.ents mother +rom !reast+ee(in4 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(in4 !& the me(i,al -ro+ession an( health ser.i,es ma& !e +a,tors in the etiolo4& o+ marasm s/ Prolon4e( eD,l si.e !reast+ee(in4 8itho t the intro( ,tion o+ other +oo(s a+ter siD months o+ a4e ma& also ,ontri! te to 4ro8th +alterin4) 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+ ener4& (e+i,ien,& is an o.ersim-li+i,ation/ @oth en(o4eno s an( eDo4eno 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 -oisonin4/ The se,on( is that +ree ra(i,als are

im-ortant in the -atho4enesis 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&$(()*)+$,)-. G-3'4 D'*).),)-. Wei4ht !elo8 = me(ian WCA 5:s,ores (S%) !elo8 me(ian WC0 G0$1).2 2il( (4ra(e 1) 2o(erate (4ra(e $) Se.ere (4ra(e 3) 2il( 2o(erate *#= : 90= WCA >0= : *4= WCA E >0= WCA "0= : 90= WC0 *0= : "0= WC0 E *0= WC0 :3= F 5:s,ore E :$ 5:s,ore E :3 :3= F 5:s,ore E :$ 5:s,ore E :3

W$,'0&-5

WHO (5$(,).2) WHO ((,/.,).2)

Se.ere 5:s,ores (S%) !elo8 2o(erate me(ian WC0 Se.ere 5:s,ores (S%) !elo8 2o(erate me(ian 0CA Se.ere

In the 19#0s an( 19>0s the (e4ree o+ maln trition 8as almost al8a&s !ase( on the ,hil(9s -er,enta4e o+ stan(ar( 8ei4ht +or a4e/ In Latin Ameri,a) the Aome5 ,lassi+i,ation 8as .er& 8i(el& se(/> T$%&' 2. G-3'4 +&$(()*)+$,)-. -* 3$&./,0),)-. %$('1 -. 5')26,-*-0-$2' (,$.1$01( C&$(()*)+$,)-. P'0+'.,$2' -* (,$.1$01 5')26, *-0 $2' N-03$& G90 G0$1' I (3)&1 3$&./,0),)-.) *#:"9/9 G0$1' II (3-1'0$,' 3$&./,0),)-.) >0:*4/9 G0$1' III$ (('7'0' 3$&./,0),)-.) EE>0 In the earl& 19*0s) a metho( 8as s 44este( that (istin4 ishe( three ,ate4ories o+ mil( to mo(erate PE2 !ase( on 8ei4ht an( hei4ht meas rements o+ ,hil(ren/ S !seB entl& these ,ate4ories ,ame to !e ;no8n as +ollo8s: - 68astin47: a, te , rrent) short:( ration maln trition) 8here 8ei4ht +or a4e an( 8ei4ht +or hei4ht are lo8 ! t hei4ht +or a4e is normal

- 6st ntin47: -ast ,hroni, maln trition) 8here 8ei4ht +or a4e an( hei4ht +or a4e are lo8 ! t 8ei4ht +or hei4ht is normal - 68astin4 an( st ntin47: a, te an( ,hroni, or , rrent lon4:( ration maln trition) 8here 8ei4ht +or a4e) hei4ht +or a4e an( 8ei4ht +or hei4ht are all lo8 A ,lassi, (istin,tion !et8een a, te maln trition (H8astin4I or lo8 8ei4ht +or hei4ht) an( ,hroni, maln trition (Hst ntin4I or lo8 hei4ht +or a4e) 8as -ro-ose( !& Waterlo8 an( has !een 8i(el& a(o-te(/* T$%&' 4. W$,'0&-5 C0),'0)$ *-0 C$,'2-0)4).2 T89' $.1 C60-.)+),8 -* M$&./,0),)-. T89' -* M$&./,0),)-. N-03$& M)&1 M-1'0$,' "'7'0' A+/,' (W')26, *-0 H')26,) (:) G 90 "0 J 90 *0 J "0 E *0 C60-.)+ (H')26, *-0 A2') (:) G 9# 90 J 9# "# J 90 E "#

The Well,ome ,lassi+i,ation o+ se.ere +orms o+ PE2 has !een 8i(el& se( +or o.er $0 &ears/ It has the a(.anta4e o+ sim-li,it& !e,a se it is !ase( on onl& t8o meas res) namel& the -er,enta4e o+ stan(ar( 8ei4ht +or a4e an( the -resen,e or a!sen,e o+ e(ema/ T$%&' 3. W'&&+-3' +&$(()*)+$,)-. -* ('7'0' *-03( -* 90-,').-'.'028 3$&./,0),)-. P'0+'.,$2' -* (,$.1$01 5')26, *-0 $2' !;-<; =!; W),6 '1'3$ 38ashior;or 2arasmi, ;8ashior;or W),6-/, '1'3$ <n(erno rishment K tritional marasm s

2.1. . PATHOGENE"I" 2,<,>,11 In 4eneral) PE2 res lts +rom an ins ++i,ient ener4& an( -rotein inta;e to mat,h the !o(&9s reB irements/ The !asi, me,hanisms o+ n trient im!alan,e in illness:relate( maln trition in,l (e (e,rease( n trient inta;e) altere( tili5ation) in,rease( n trient losses) or in,rease( n trient reB irements (h&-ermeta!olism) not mat,he( !& inta;e/" These !asi, me,hanisms ma& !e interrelate() an( more

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&siolo4i, stress) me,hani,al -ro!lems)) 8hile n trient reB irements are in+e,tions) +e.er) -h&siolo4i, stress) an( 4ro8th/ The terms primary malnutrition an( secondary malnutrition re+er) res-e,ti.el&) to maln trition res ltin4 +rom ina(eB ate +oo( inta;e an( maln trition res ltin4 +rom in,rease( n trient nee(s) (e,rease( n trient a!sor-tion) an('or in,rease( n trient losses/9

In a ,hil( 8ho ,ons mes m ,h less +oo( than reB ire( +or his or her ener4& nee(s) ener4& is mo!ili5e( +rom !oth !o(& +at an( m s,le/ 2 s,le -rotein (a,,o ntin4 +or "0= o+ lean tiss e mass) !ears the !r nt o+ the loss) 8hile the 6,entral7 lean tiss es (li.er) 4astrointestinal tra,t) ;i(ne&s) !loo( an( imm ne ,ells) are relati.el& s-are(/ As lon4 as the star.ation ration o+ ener4& an( -rotein is not too lo8) s ,,ess+ l a(a-tation 8ill re( ,e ener4& an( -rotein reB irements to mat,h it) restorin4 homeostasis an( maintainin4 ;e& -h&siolo4i, + n,tions/ The -h&siolo4i, ,ost o+ this a(a-tation is a lo8ere( meta!oli, rate an( re( ,e( m s,le mass (in,l (in4 re( ,e( ,ar(ia, an( re-irator& m s,le mass)/11 Al ,oneo4enesis in the li.er is enhan,e() an( there is loss o+ s !, taneo s +at an( 8astin4 o+ m s,les/ As a res lt) the !o(& (ra8s on its o8n stores) res ltin4 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 ma1or in,reases in rinar& nitro4en) 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 -atho4enesis o+ PE2/ Patients 8ith mali4nan,&) in+e,tion) an( se.ere tiss e in1 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 +ollo8in4 elements: +e.er (or -ro+o n( h&-othermia)) ta,h&,ar(ia) ta,h&-nea an( le ;o,&tosis (or

in,rease( n m!ers o+ !an( +orms)/ Other +eat res o+ the SIRS in,l (e ,han4es in a, te:-hase ser m -rotein ,on,entrations) in,rease( ener4& eD-en(it re) in,rease( 8hole:!o(& -rotein t rno.er) anoreDia an( -rotein 8astin4/ The -rotein 8astin4 is !elie.e( to re-resent the meta!oli, ,ost o+ ra-i(l& mo!ili5in4 amino a,i(s +or 8o n( healin4 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,reasin4l& re,o4ni5e( as ,ontri! tin4 to the -rotein 8astin4 asso,iate( 8ith or4an +ail re) in,l (in4 ,hroni, renal +ail re an( en(:sta4e 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 44este( 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, ,han4es 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 -ittin4 e(ema/ 2.1.!. CLINICAL MANIFE"TATION"2,1; M$0$(3/( 2arasm s is ,hara,teri5e( !& +ail re to 4ain 8ei4ht an( irrita!ilit&) +ollo8e( !& 8ei4ht loss/10 A++e,te( ,hil(ren are short an( li4ht +or their a4e/ 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 4ro -s) s ,h as ! tto,;s an( --er lim! m s,les) are more +reB entl& a++e,te( than others/ Ca,ial m s,les are s all& s-are( lon4er/ Ca,ial +at mass is the last to !e lost) res ltin4) 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 si4n o+ serio s +orms o+ marasm sL ,hil(ren are in,reasin4l& motionless/$ The s;in loses t r4or 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/ 0o8e.er) , taneo s +in(in4s in,l (e +ine) !rittle hair) alo-e,ia) im-aire( 4ro8th) an( +iss rin4 o+ the nails) ma& !e +o n(/ In -rotein:ener4& maln trition) more hairs are in the telo4en (restin4) -hase than in the ana4en (a,ti.e) -hase) a re.erse o+ normal/ P--0 20-5,6/ In all ,ases the ,hil( +ails to 4ro8 -ro-erl&/ In se.ere ,ases the loss o+ +lesh is o!.io s) the ri!s are -rominentL the !ell&) in ,ontrast to the rest o+ the !o(&) ma& !e -rot !erantL the +a,e has a ,hara,teristi, simian (mon;e&: li;e) a--earan,eL an( the lim!s are .er& ema,iate(/ W$(,).2/ The m s,les are al8a&s eDtremel& 8aste(/ There is little i+ an& s !, taneo s +at le+t/ The s;in han4s in 8rin;les) es-e,iall& aro n( the ! tto,;s an( thi4hs/ When the s;in is ta;en !et8een +ore+in4er an( th m!) the s al la&er o+ a(i-ose tiss e is +o n( to !e a!sent/ A.-0'?)$/ Some ,hil(ren are anoreDi,/ A.'3)$/ Anemia is s all& -resent/ "@). (-0'(/ There ma& !e -ress re sores) ! t these are s all& o.er !on& -rominen,es) not in areas o+ +ri,tion/ In ,ontrast to ;8ashior;or) there is no e(ema an( no +la;&:-aint (ermatosis in marasm s/ D)2'(,)7' ,0$+,/ The entire (i4esti.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 4astri, h&(ro,hlori, a,i( (0Cl) eD,retion an( a slo8in4 o+ -eristalsis is o!ser.e() &iel(in4 !a,terial o.er4ro8th in the ( o(en m/ 0o8e.er) these im-ortant alterations o+ the (i4esti.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 ra4e( !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/ I33/.' (8(,'3/ 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( ,in4 tiss es are a++e,te(/ 0o8e.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 aner4&/ 0o8e.er) anti!o(& -ro( ,tion is maintaine(/ In marasm s) a

11

4eneral a,B ire( imm no(e+i,ien,& o,, rs) 8ith a (e,rease in se,retor& imm no4lo! lin A (I4A) an( an im-airment o+ the nons-e,i+i, lo,al (e+ense s&stem) s ,h as m ,osal inte4rit& an( l&m-ho;ine -ro( ,tion/ B0$). $.1 .'07-/( (8(,'3/ Cere!ral tiss e is s all& -reser.e( ( rin4 marasm s/ @rain atro-h& 8ith im-airment o+ ,ere!ral + n,tions is onl& -resent in se.ere +orms o+ marasm s/ C$01)-7$(+/&$0 (8(,'3/ Car(ia, m s,le +i!er is thin) an( the ,ontra,tilit& o+ the m&o+i!rils is im-aire(/ Car(ia, o t- t) es-e,iall& s&stoli, + n,tion) is (e,rease( in the same -ro-ortion as the 8ei4ht loss/ @ra(&,ar(ia an( h&-otension ,ommonl& o,, r in se.ere +orms o+ maln trition/ Ele,trol&te im!alan,es -resent ( rin4 marasm s mo(i+& the ECA +in(in4s/ With this im-aire( ,ar(ia, + n,tion) an& in,rease o+ intra.as, lar .ol me ( rin4 reh&(ration or !loo( trans+ sion ,an res lt in a si4ni+i,ant ,ar(ia, ins ++i,ien,&/ K5$(6)-0@-0 All ,ases o+ ;8ashior;or ha.e e(ema to some (e4ree) -oor 4ro8th) an( 8astin4 o+ m s,les/ 38ashior;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.ealin4 -ale areas !et8een the ,ra,;s (,ra5& -a.ement (ermatosis)/ E1'3$. The a,, m lation o+ +l i( in the tiss es ,a ses s8ellin4L in ;8ashior;or this ,on(ition is al8a&s -resent to some (e4ree/ It s all& starts 8ith a sli4ht s8ellin4 o+ the +eet an( o+ten s-rea(s - the le4s/ 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(in4 s;in/ P--0 20-5,6. Aro8th +ail re al8a&s o,, rs/ I+ the ,hil(9s -re,ise a4e is ;no8n) the ,hil( 8ill !e +o n( to !e shorter than normal an() eD,e-t in ,ases o+ 4ross e(ema) li4hter in 8ei4ht than normal ( s all& >0 to "0 -er,ent o+ stan(ar( or !elo8 $ S%)/ W$(,).2. Wastin4 o+ m s,les is also t&-i,al ! t ma& not !e e.i(ent !e,a se o+ e(ema/ The ,hil(9s arms an( le4s are thin !e,a se o+ m s,le 8astin4/

12

M'.,$& +6$.2'(. 2ental ,han4es 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(in4s 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( nsmilin4/ A--etite is nearl& al8a&s -oor/ H$)0 +6$.2'(. In ;8ashior;or) the hair !e,omes thinner/ At the same time it ma& ,han4e 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 ,han4es an( a narro8er (iameter than normal hair/ The tensile stren4th o+ the hair is also re( ,e(/ In Latin Ameri,a !an(s o+ (is,olo re( hair are re-orte( as a si4n o+ ;8ashior;or/ These re((ish:!ro8n stri-es ha.e !een terme( the M+la4 si4nM or "signa bandera". "@). +6$.2'(. %ermatosis (e.elo-s in some ! t not all ,ases o+ ;8ashior;or/ It ten(s to o,, r +irst in areas o+ +ri,tion or o+ -ress re s ,h as the 4roin) !ehin( the ;nees an( at the el!o8/ %ar;l& -i4mente( -at,hes a--ear) 8hi,h ma& -eel o++ or (esB amate/ The similarit& o+ these -at,hes to ol( s n:!a;e() !listere( -aint has 4i.en rise to the term M+la;&:-aint (ermatosisM/ <n(erneath the +la;in4 s;in are atro-hi, (e-i4mente( areas 8hi,h ma& resem!le a healin4 ! rn/ A.'3)$. 2ost ,ases ha.e some (e4ree o+ anemia !e,a se o+ la,; o+ the -rotein reB ire( to s&nthesi5e !loo( ,ells/ Anemia ma& !e ,om-li,ate( !& iron (e+i,ien,&) malaria) hoo;8orm) et,/ M--.*$+'. The ,hee;s ma& a--ear to !e s8ollen 8ith either +att& tiss e or +l i() 4i.in4 the ,hara,teristi, a--earan,e ;no8n as Mmoon+a,eM/ M$0$(3)+ K5$(6)-0@-0 Chil(ren 8ith +eat res o+ !oth n tritional marasm s an( ;8ashior;or are (ia4nose( as ha.in4 marasmi, ;8ashior;or/ In the Well,ome ,lassi+i,ation) this (ia4nosis is 4i.en +or a ,hil( 8ith se.ere maln trition 8ho is +o n( to ha.e !oth e(ema an( a 8ei4ht +or a4e !elo8 >0= o+ that eD-e,te( +or his or her a4e/ 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/

13

2.1.#. DIAGNO"I"! The (ia4nosis o+ PE2 rests mainl& on ,lini,al eDamination +or the s&m-toms an( si4ns o+ the s&n(rome -l s anthro-ometri, assessments/ A((itionall& la!orator& in.esti4ation +or the assessment o+ ,om-li,ations an( other health -ro!lems asso,iate( 8ith maln trition is nee(e(/ L$%-0$,-08 (,/1)'( W0O re,ommen(s the +ollo8in4 la!orator& tests:

0emo4lo!in Ele,trol&tes Ser m al! min @loo( 4l ,ose 2i,ros,o-& eDamination o+ !loo( smears <rine eDamination an( , lt re Stool eDamination !& mi,ros,o-& +or o.a an( -arasites In ;8ashior;or there is a re( ,tion in total ser m -roteins/ O+ten) !e,a se

o+ in+e,tions) the 4lo! lin +ra,tion in the ser m is normal or e.en raise(/ Ser m al! min (ro-s to lo8 or .er& lo8 le.els s all& onl& in ,lini,all& e.i(ent ;8ashior;or/ It is o+ten tr e that the more se.ere the ;8ashior;or) the lo8er the ser m al! min) ! t ser m al! min le.els are not se+ l in e.al atin4 less se.ere PE2/ There is 4eneral a4reement that ser m al! min ,on,entrations !elo8 3 4'(l are lo8 an( that those !elo8 $/# 4'(l are serio sl& (e+i,ient/> Le.els o+ ser m trans+errin an( retinol !in(in4 -rotein (R@P) are also se+ l an( not (i++i, lt to (etermine/ 0o8e.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/>

14

2.1.<. TREATMENT Treatment o+ se.ere maln trition is !ase( on 10 ste-s o+ 4eneral -rin,i-le +or ro tine ,are/ These ste-s are a,,om-lishe( in t8o -hases: an initial sta!ilisation -hase an( a lon4er reha!ilitation -hase/ The 10 ste-s are as +ollo8: 1/ $/ 3/ 4/ #/ >/ */ "/ 9/ Treat'-re.ent h&-o4l&,aemia Treat'-re.ent h&-othermia Treat'-re.ent (eh&(ration Corre,t ele,trol&te im!alan,e Treat'-re.ent in+e,tion Corre,t mi,ron trient (e+i,ien,ies Start ,a tio s +ee(in4 A,hie.e ,at,h: - 4ro8th Pro.i(e sensor& stim lation an( emotional s --ort

10/ Pre-are +or +ollo8: - a+ter re,o.er& T$%&' . T)3'-*0$3' *-0 ,6' 3$.$2'3'., -* $ +6)&1 5),6 ('7'0' 3$&./,0),)-.

15

",'9 1. T0'$,A90'7'., 689-2&8+'3)$ Che,; +or h&-o4l&,emia/ I+ the ,hil( is ,ons,io s an( the !loo( 4l ,ose is E #4 m4'(l) 4i.e #0 ml !ol s o+ 10= 4l ,ose sol tion/ I+ n,ons,io s) 4i.e I? sterile 10= 4l ,ose (#ml';4)) +ollo8e( !& #0 ml o+ 10= 4l ,ose or s ,rose !& naso4astri, t !e/ 2onitor the !loo( 4l ,oseL i+ the !loo( 4l ,ose 8as lo8) tem-erat re +alls to E 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 4i.e +ee(s thro 4ho t the ni4ht/ ",'9 2. T0'$,A90'7'., 689-,6'03)$ I+ the aDillar& tem-erat re is E3#/0oC an( re,tal tem-erat re is E3#/#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 ni4ht. ",'9 3. T0'$,A90'7'., 1'6810$,)-. The stan(ar( oral reh&(ration sol tion ,ontains too m ,h so(i m (90

16

mmol so(i m'L) an( too little -otassi m +or se.erel& malno rishe( ,hil(ren/ Instea( 4i.e s-e,ial R'h&(ration "-l tion +or M$&n trition (ReSo2al)/ It is (i++i, lt to estimate (eh&(ration stat s in a se.erel& malno rishe( ,hil( sin4 ,lini,al si4ns alone/ So ass me all ,hil(ren 8ith 8ater& (iarrhea ma& ha.e (eh&(ration an( 4i.e ReSo2al # ml';4 e.er& 30 min tes +or t8o ho rs) orall& or !& naso4astri, t !e) then #:10 ml';4'h +or neDt 4:10 ho rs/ 2onitor -ro4ress o+ reh&(ration) o!ser.e hal+:ho rl& +or t8o ho rs) then ho rl& +or the neDt >:1$ ho rs +or the - lse rate) res-irator& rate) +reB en,&/ Contin in4 ra-i( !reathin4 an( - lse ( rin4 reh&(ration s 44est ,oeDistin4 in+e,tion or o.erh&(ration/ Si4ns o+ eD,ess +l i( (o.erh&(ration) are in,reasin4 res-irator& rate an( - lse rate) in,reasin4 e(ema an( - ++& e&eli(s/ I+ these si4ns o,, r) sto- +l i(s imme(iatel& an( reassess a+ter one ho r/ ",'9 4. C-00'+, '&'+,0-&8,' )3%$&$.+' All se.erel& malno rishe( ,hil(ren ha.e eD,ess !o(& so(i m e.en tho 4h -lasma so(i m ma& !e lo8/ %e+i,ien,ies o+ -otassi m an( ma4nesi 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,/ Ai.e: N eDtra -otassi m 3:4 mmol';4'( N eDtra ma4nesi m 0/4:0/> mmol';4'( N 8hen reh&(ratin4) 4i.e lo8 so(i m reh&(ration +l i( (e/4/ ReSo2al) ",'9 . T0'$,A90'7'., ).*'+,)-. In se.ere maln trition the s al si4ns o+ in+e,tion) s ,h as +e.er) are o+ten a!sent) an( in+e,tions are o+ten hi((en/ There+ore 4i.e anti!ioti, ro tinel& on a(mission/ Choi,e o+ !roa(:s-e,tr m anti!ioti,s: a) i+ the ,hil( a--ears to ha.e no ,om-li,ations 4i.e: N Co:trimoDa5ole # ml -ae(iatri, s s-ension orall& t8i,e (ail& +or # (a&s ($/# ml rine +reB en,&) an( stool'.omit

17

i+ 8ei4ht E> ;4)/ (# ml is eB i.alent to 40 m4 T2P O $00 m4 S2P)/ !) i+ the ,hil( is se.erel& ill (a-atheti,) lethar4i,) or has ,om-li,ations 4i.e: N Am-i,illin #0 m4';4 I2'I? >:ho rl& +or $ (a&s) then oral amoD&,illin 1# m4';4 ":ho rl& +or # (a&s) or i+ amoD&,illin is not a.aila!le) ,ontin e 8ith am-i,illin ! t 4i.e orall& #0 m4';4 >:ho rl& N Aentami,in */# m4';4 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 $# m4';4 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'+, 3)+0-./,0)'., 1'*)+)'.+)'( All se.erel& malno rishe( ,hil(ren ha.e .itamin an( mineral (e+i,ien,ies/ Altho 4h anemia is ,ommon) (o KOT 4i.e iron initiall& ! t 8ait ntil the ,hil( has a 4oo( a--etite an( starts 4ainin4 8ei4ht ( s all& !& the se,on( 8ee;)) as 4i.in4 iron ,an ma;e in+e,tions 8orse/ Ai.e .itamin A orall& on %a& 1 (+or a4e G1$ months) 4i.e $00)000 I<L >:1$ months) 4i.e 100)000 I<L 0:# months) 4i.e #0)000 I<) nless there is (e+inite e.i(en,e that a (ose has !een 4i.en in the last month/ Ai.e (ail& +or at least $ 8ee;s: N 2 lti.itamin s --lement N Coli, a,i( 1 m4'( (4i.e # m4 on %a& 1) N Qin, $ m4';4'( N Co--er 0/3 m4';4'( N Iron 3 m4';4'( ! t onl& 8hen 4ainin4 8ei4ht

",'9 #. ",$0, +$/,)-/( *''1).2 Cee(in4 sho l( !e starte( as soon as -ossi!le a+ter a(mission an( sho l(

18

!e (esi4ne( to -ro.i(e 1 st s ++i,ient ener4& an( -rotein to maintain !asi, -h&siolo4i,al -ro,esses/ The essential +eat res o+ +ee(in4 in the sta!ili5ation -hase are: N small) +reB ent +ee(s o+ lo8 osmolarit& an( lo8 la,tose N oral or naso4astri, (KA) +ee(s (ne.er -arenteral -re-arations) N 100 ;,al';4'( N 1:1/# 4 -rotein';4'( N 130 ml';4'( o+ +l i( (100 ml';4'( i+ the ,hil( has se.ere e(ema) N i+ the ,hil( is !reast+e() en,o ra4e to ,ontin e !reast+ee(in4 ! t 4i.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) .omitin4) +reB en,& o+ 8ater& stool) an( (ail& !o(& 8ei4ht/

",'9 <. A+6)'7' +$,+6-/9 20-5,6 In the reha!ilitation -hase a .i4oro s a--roa,h to +ee(in4 is reB ire( to a,hie.e .er& hi4h inta;es an( ra-i( 8ei4ht 4ain o+ G10 4 4ain';4'(/ The re,ommen(e( mil;:!ase( C:100 ,ontains 100 ;,al an( $/9 4 -rotein'100 ml/ Chan4e +rom starter to ,at,h: - +orm la !& re-la,in4 starter C:*# 8ith the same amo nt o+ ,at,h: - +orm la C:100 +or 4" ho rs) then in,rease ea,h s ,,essi.e +ee( !& 10 ml ntil some +ee( remains neaten/ I+ res-irations in,rease !& # or more !reaths'min an( - lse !& $# or more !eats'min +or t8o s ,,essi.e 4:ho rl& rea(in4s) re( ,e the .ol me -er +ee( (4i.e 4:ho rl& C:100 at 1> ml';4'+ee( +or $4 ho rs) then 19 ml';4'+ee( +or $4 ho rs) then $$ ml';4'+ee( +or 4" ho rs) then in,rease ea,h +ee( !& 10 ml as a!o.e)/ A+ter the transition 4i.e: N +reB ent +ee(s (at least 4:ho rl&) o+ nlimite( amo nts o+ a ,at,h - +orm la N 1#0:$$0 ;,al';4'( N 4:> 4 -rotein';4'( N i+ the ,hil( is !reast+e() en,o ra4e to ,ontin e

19

I+ 8ei4ht 4ain is: N -oor (E# 4';4'()) ,hil( reB ires + ll reassessment N mo(erate (#:10 4';4'()) ,he,; 8hether inta;e tar4ets are !ein4 met) or i+ in+e,tion has !een o.erloo;e( N 4oo( (G10 4';4'()) ,ontin e to -raise sta++ an( mothers ",'9 >. P0-7)1' ('.(-08 (,)3/&$,)-. $.1 '3-,)-.$& (/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.in4 ,are N a ,heer+ l) stim latin4 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 4h N maternal in.ol.ement 8hen -ossi!le (e/4/ ,om+ortin4) +ee(in4) !athin4) -la&) ",'9 1;. P0'9$0' *-0 *-&&-5-/9 $*,'0 0'+-7'08 A ,hil( 8ho is 90= 8ei4ht:+or:len4th (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 8ei4ht:+or:a4e !e,a se o+ st ntin4/ Aoo( +ee(in4 -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 ener4&: an( n trient:(ense +oo(s N 4i.e str ,t re( -la& thera-& A(.ise -arent or ,arer to: N !rin4 ,hil( !a,; +or re4 lar +ollo8: - ,he,;s N ens re !ooster imm ni5ations are 4i.en N ens re .itamin A is 4i.en e.er& siD months

20

CHAPTER III CA"E REPORT Kame A4e SeD %ate o+ A(mission M$). C-39&$)., : RA2 : $ &ears # month : Cemale : Se-tem!er) 10th $013 : A!(ominal !loatin4

H)(,-08 : This -ro!lem ha--ene( sin,e 14 (a&s a4o/ Patient also ,om-lains +e.er +or a!o t 3 8ee;s/ Ce.er 8as hi4h an( relie.e( !& intro( ,tion o+ anti:-&reti, (r 4s. Sei5 re 8as not +o n() %iarrhea 8as +o n( a!o t three 8ee;s a4o) > times'(a&) 8ith the ,onsisten,& o+ 8ater more than - l-) R aB a 4lass in .ol me) !loo( 8as not +o n( in stool) an( no8 the -atient hasn7t !een ha.in4 the (iarrhea +or one 8ee;s/ ?omitin4 8as not +o n() ,o 4h 8as not +o n(/ Wei4ht loss 8as

21

+o n(/ @e+ore the -atient is si,;) her 8ei4ht 8as 13 ;4) no8 her 8ei4ht is 9 ;4/ <rination normal/ H)(,-08 -* %)0,6 : normal) han(le( !& -arame(i, in home) ,rie( as soon as !a!& 8as !orn/ C&anosis 8as not +o n(/ @irth 8ei4ht 8as $"00 4 an( len4th 8as #1 ,m/ H)(,-08 -* *''1).2: 0:> months o+ !reast+ee(in4) > months:1 &ears ol( o+ !reast +ee(in4 S so+t ri,e/ 1: 1T &ears o+ so+t ri,e/ 1T : no8 o+ +amil& +oo( H)(,-08 -* I33/.)4$,)-. : @CA %PT Polio 2easles 0e-atitis I II III I? !ooster

H)(,-08 -* 90'7)-/( )&&.'((: Patient 8as re+erre( +rom R mah Sa;it Lan4sa an( 8as (ia4nose( as an -araliti, ile s s s-e,t H)(,-08 -* 90'7)-/( 3'1)+$,)-.(B Qin,) CotrimoDa5ole) 2etroni(a5ole P68()+$& E?$3).$,)-. @o(& 8ei4ht : 9 ;4 @o(& hei4ht P0'('., (,$,' Sensori m @o(& tem-erat re Localized status : Com-os 2entis : 39/1 oC P lse Res-irator& Rate : 1#0 !-m : 3$ !-m : 91 ,m

22

1/ 0ea( : Ol( man +a,e (O) E&e : S n;en e&es (O)) li4ht re+leDes (O'O)) iso,hori, - -il) -ale in+erior -al-e!ra ,on1 n,ti.a (O'O)) i,teri, (:':) Ear : Kormal a--erean,e Kose: Kormal a--erean,e 2o th : C&anosis (:)) (r& m ,osa o+ li-s $/ Ke,; : L&m-h no(e enlar4ement (:) 3/ ThoraD : S&mmetri,al + si+orm) e-i4astri, retra,tion (O)/ 0R: 1#0 !-m) re4 ler) m rm r (:) RR: 3$ !-m) re4 ler) ,ra,;les (:':)) inter-ose( ri! ,learl& .isi!le (O) 4/ A!(omen: %istention (O)) s&mmetri,al) -eristalti, (O) (e,rease(/ Li.er'S-leen: n(erteminate #/ EDtremities: P lse 1#0 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I) @P: 110'>0mm04) m s,le h&-otro-h&) !a44& -ants (O)) -ittin4 e(ema (:)/

23

L$%-0$,-08 R'(/&,B Se-tem!er) 10th $013 C-39&',' B&--1 C-/., 0emo4lo!in (0A@) Eritrosit (R@C) Le ;osit (W@C) 0emato;rit Trom!osit (PLT) 2C? 2C0 2C0C R%W 2P? PCT P%W D)*,'& Ke tro+il Lim+osit 2onosit Eosino+il @aso+il Ke tro+il A!sol t Lim+osit A!sol t 2onosit A!sol t Eosino+il A!sol t @aso+il A!sol t 4= 10>' mm3 103' mm3 = 103' mm3 +L P4 4= = +L = +L = = = = = 103'VL 103'VL 103'VL 103'VL 103'VL >.1; 3.41 1<.2< 2#.! 331U "0/9 $"/*0 33/00 14/00 "/40 0/$" "/$ "$/00 1$/#0 #/$0 0/$0 0/100 14/"" $/$9 0/9# 0/03 0/0$ 11/3 J 14/1 4/40 J 4/4" >/0: 1*/# 3* J 41 $1* J 49* "1 J 9# $# J $9 $9 J 31 11/> J 14/" */$ : 10/0

3* J "0 $0 J 40 $J" 1J> 0J1 $/4 J */3 1/* : >/1 0/3 : 0/" 0/10 : 0/30 0 : 0/1

24

L$%-0$,-08 R'(/&,B Se-tem!er) 10th $013 C&).)+$& C6'3)(,08 B&--1 2$( $.$&8()( -0 -CO$ -O$ @i,ar!onate (0C03) Total CO$ @ase eD,ess (@E) O$ sat ration HEART Al! min CARBOHYDRATE METABOLI"M @loo( 4l ,ose (As) RENAL <re m Creatinine ELECTROLYTE" Katri m (Ka) 3ali m (3) 3lori(a (Cl) m4'(L 24'(L mEB'L mEB'L mEB'L 11/$0 0/09 1$3 3/3 "* E #0 0/$4:0/41 13#:1## 3/>:#/# 9>:10> UNIT RE"ULT" #.4>3 21.1 1 #.3 1 .< 1>)4 :>/3 99/# 3/0 NORMAL VALUE */3#:*/4# 3":4$ "#:100 $$:$> 19:$# (:$):(O$) 9#:100

mm04 mm04 mmol'L mmol'L mmol'L = 4'(L

3/":#/4

m4'(L

$$9/*0

E$00

D)**'0'.,)$& D)$2.-()( 2aln trition t&-e marasm s:;8ashior;or 4ra(e ? W-0@).2 D)$2.-()( 2aln trition t&-e marasm s:;8ashior;or 4ra(e ? T0'$,3'., : :
: :

CotrimoDa5ole $ D $# m4 Para,etamol 3 D 100 m4 Coli, a,i( 1 D #m4 ) neDt 1D1 m4

?it A 1 D 100/000 I<

: :

2 lti.itamin 8itho t Ce 1 D ,th I %iet C*# 1>0 ,,'3h'KAT

25

FOLLOW UP "'9,'3%'0, 11,6 2;13 (F)0(, 1$8) "B A!(ominal !loatin4(O))Ce.er(O))Lo8 +reB en,& (e+e,ation)!loo(& stools(:) OB Sens: C2 ) Tem-: 3*)9 oC) @o(& 8ei4ht: 9)" ;4 T@: 91 ,m @@'T@ : *0= 5 s,ore :3 S% 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))s n;en e&es(O'O)) Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: Kormal a--erean,e) Ke,; : LW2P0 KO%ES ThoraD A!(omen enlar4ement(:) S&mmetri,al + si+orm) e-i4astrial retra,tion(O)) 0R: 140 !-m) re4 lar) m rm r (:)/ RR: 43 !-m) re4 lar/ Cra,;les (:':))inter-ose( ri! ,learl& .isi!le %istention/ Peristalti, (O) (e,rease(/ Li.er'S-leen'Renal: n(eterminate/)

as,ites a--earan,e EDtremities P lse 140 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)!a44& -ants(O))m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition t&-e marasm s:;8ashior;or 4ra(e ? PB : :
: :

CotrimoDa5ole $ D $# m4 Para,etamol 3 D 100 m4 Coli, a,i( 1D#m4 ) neDt 1D1 m4

?it A 1 D 100/000 I<

: : P&$. B :

2 lti.itamin 8itho t Ce 1P,th I %iet C*# 1>0 ,,'3h'KAT

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

26

"'9,'3%'0, 12,6 2;13 ("'+-.1 1$8) "B A!(ominal !loatin4(O))Ce.er(:)) )!loo(& stools(:))(iarrhea(O)$D 8ith 4reen stools).omit(:) OB Sens: C2 ) Tem-: 3>)" oC) 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))s n;en e&es(O'O)) Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: Kormal a--erean,e) Ke,; : LW2P0 KO%ES ThoraD A!(omen enlar4ement(:) S&mmetri,al + si+orm) e-i4astrial retra,tion(O)) 0R: 130 !-m) re4 ler) m rm r (:)/ RR: 34 !-m) re4 ler/Cra,;les (:':))inter-ose( ri! ,learl& .isi!le %istention (O)) -eristalti, (O) (e,rease() Li.er'S-leen'Renal: n(eterminate)

as,ites a--earan,e EDtremities P lse 140 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)!a44& -ants(O))m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition t&-e marasm s:;8ashior;or 4ra(e ? PB : :
:

CotrimoDa5ole $ D $# m4 Para,etamol 3 D 100 m4 Coli, a,i( 1D1 m4 2 lti.itamin 8itho t Ce 1P,th I %iet C*# 1>0 ,,'>h'KAT

: :

L$%-0$,-08 R'(/&,B "'9,'3%'0, 12,6 2;13 C-39&',' B&--1 C-/., 0emo4lo!in (0A@) Eritrosit (R@C) Le ;osit (W@C) 0emato;rit Trom!osit (PLT) 2C? 2C0 2C0C R%W 2P? PCT P%W D)**,'& Ke tro+il Lim+osit 2onosit Eosino+il 4= 10>' mm3 103' mm3 = 103' mm3 +L P4 4= = +L = +L = = = = >.<; 3.!4 1*/44 2>.! 3**U "1/3 $>/90 33/10 14/$0 "/90 0/33 "/$ >"/30 $3/#0 */90 0/$0 11/3 J 14/1 4/40 J 4/4" >/0: 1*/# 3* J 41 $1* J 49* "1 J 9# $# J $9 $9 J 31 11/> J 14/" */$ : 10/0

3* J "0 $0 J 40 $J" 1J>

27

@aso+il Ke tro+il A!sol t Lim+osit A!sol t 2onosit A!sol t Eosino+il A!sol t @aso+il A!sol t

= 103'VL 103'VL 103'VL 103'VL 103'VL

0/100 11.>1 $/$9 1/3* 0/04 0/0$

0J1 $/4 J */3 1/* : >/1 0/3 : 0/" 0/10 : 0/30 0 : 0/1

L$%-0$,-08 R'(/&,B Se-tem!er) 1$th $013 C&).)+$& C6'3)(,08 B&--1 2$( $.$&8()( HEART Al! min CARBOHYDRATE METABOLI"M @loo( 4l ,ose (As) RENAL <re m 3reatinin ELECTROLYTE" Katri m (Ka) 3ali m (3) 3lori(a (Cl) m4'(L 24'(L mEB'L mEB'L mEB'L 9/>0 0/10 1$9 3/$ 10> E #0 0/$4:0/41 13#:1## 3/>:#/# 9>:10> UNIT RE"ULT" NORMAL VALUE 4'(L 3/1 3/":#/4

m4'(L

1$3/40

E$00

28

"'9,'3%'0, 13,6 2;13 (,6)01 1$8) "B A!(ominal !loatin4(O))Ce.er(:)) OB Sens: C2 ) Tem-: 3>)" oC) @@ : 9)" ;4 ) LPT : #3 ,m/ LP% : #4)# ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)e-i4astrial retra,tion(:)) 0R: 94 !-m) re4 ler) m rm r (:)/ RR: 30 !-m) re4 ler/Cra,;les (:':))inter-ose( ri! ,learl& .isi!le Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) normal/

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 94 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB S s- Partial o!str ,ti.e ile s e, (('in.a4inasi O maln trition t&-e marasm s O S s- <TI t mor a!(omen P B - CotrimoDa5ole $ D $# m4 :
:

Para,etamol 3 D 100 m4 Coli, a,i( 1D1 m4 2 lti.itamin 8itho t Ce 1P,th I %iet C*# 1>0 ,,'>h'KAT

: :

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 9)# ;4 T@ 91 ,m LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m @@'T@ : E:3 S% t mor a!(omen P : : %iet C*# 1#0 ,,'3h O 2ineral miD 3 ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1 : Coli, a,i( 1 D 1 m4 "'9,'3%'0, 14,6 2;13 (*-/0,6 1$8) LP%(S) : #3 ,m

A :2aln trition marasm s t&-e O S s- <TI O S s- Partial o!str ,ti.e ile s e, (('in.a4inasi

29

"B A!(ominal !loatin4(O))Ce.er(:)) Pale +a,e(O) OB Sens: C2 ) Tem-: 3* oC) @@ : 9)" ;4 ) LPT : #1)# ,m/ LP% : #3 ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)e-i4astrial retra,tion(:)) 0R: 9> !-m) re4 ler) m rm r (:)/ RR: $> !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) normal/

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 9> !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB S s- Partial o!str ,ti.e ile s e, (('in.a4inasi O maln trition t&-e marasm s O S s- <TI t mor a!(omen

30

P B CotrimoDa5ole $ D $# m4 :
:

Para,etamol 3 D 100 m4 Coli, a,i( 1D1 m4 2 lti.itamin 8itho t Ce 1P,th I

%iet C*# 1>0 ,,'>h'KAT

:
: P&$. :

Che,; C@C)LCT

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 9)# ;4 T@ 91 ,m LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m @@'T@ : E:3 S% t mor a!(omen P : : %iet C*# 1#0 ,,'3h O 2ineral miD 3 ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1
L$%-0$,-08 R'(/&,B "'9,'3%'0, 14,6 2;13 C-39&',' B&--1 C-/., 0emo4lo!in (0A@) Eritrosit (R@C) Le ;osit (W@C) 0emato;rit Trom!osit (PLT) 2C? 2C0 2C0C R%W 2P? PCT P%W D)*,'& Ke tro+il Lim+osit 2onosit Eosino+il @aso+il Ke tro+il A!sol t 4= 10>' mm3 103' mm3 = 103' mm3 +L P4 4= = +L = +L = = = = = 103'VL 9/*0 3/>" $>/0> $9/4 49# *9/90 $>/40 33/00 14/10 "/40 0/4$ "/1 >"/#0 1"/00 13/10 0/10 0/300 1*/"> 11/3 J 14/1 4/40 J 4/4" >/0: 1*/# 3* J 41 $1* J 49* "1 J 9# $# J $9 $9 J 31 11/> J 14/" */$ : 10/0

LP%(S) : #3 ,m

A :2aln trition marasm s t&-e O S s- <TI O S s- Partial o!str ,ti.e ile s e, (('in.a4inasi

3* J "0 $0 J 40 $J" 1J> 0J1 $/4 J */3

31

"'9,'3%'0, 1 ,6 2;13 (*)*,6 1$8) "B A!(ominal !loatin4(O))Ce.er(:)) Pale(O) OB Sens: C2 ) Tem-: 3* oC 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)e-i4astrial retra,tion(:)) 0R: 110 !-m) re4 ler) m rm r (:)/ RR: $> !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) normal/

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 110 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB S s- Partial o!str ,ti.e ile s e, (('in.a4inasi O maln trition t&-e marasm s O S s- <TI t mor a!(omen PB :
:

CotrimoDa5ole $ D $# m4 Para,etamol 3 D 100 m4 Coli, a,i( 1D1 m4 2 lti.itamin 8itho t Ce 1P,th I %iet C100 130 ,,'3h'KAT

: :

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 9)# ;4 T@ 91 ,m LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m @@'T@ : E:3 S% t mor a!(omen P : : %iet C*# 1#0 ,,'3h O 2ineral miD 3 ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1 : Coli, a,i( 1 D 1 m4 "'9,'3%'0, 1!,6 C 1>,6 2;13 (!,6 - >,6 1$8) "B A!(ominal !loatin4(O)(e,rease()Ce.er(:)) Pale(:))%iarrhea(:) LP%(S) : #3 ,m

A :2aln trition marasm s t&-e O S s- <TI O S s- Partial o!str ,ti.e ile s e, (('in.a4inasi

32

OB Sens: C2 ) Tem-: 3>)* oC LPT #$ : ,m LP% : #3 ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)e-i4astrial retra,tion(:)) 0R: 9" !-m) re4 ler) m rm r (:)/ RR: $> !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) (e,rease(

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 9" !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition marasm s t&-e O a!(ominal t mor e, (('ne ro!lastoma Willms t mor PB : : : : : Three 8a& In1 ,e+triaDone $#0 m4'1$h'I? Para,etamol 3 D 100 m4 2 lti.itamin 8itho t Ce 1D,th I %iet C*# 1#0 ,,'3h'KAT O 2ineral miD 3 ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 10 ;4 @@I : 1$)" ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :$ E Q E :3 S% Willms t mor P : : %iet C*# 1#0 ,,'3h O 2ineral miD 3 ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1 "'9,'3%'0, 2;,6 2;13 (1;,6 1$8) "B A!(ominal !loatin4(O)(e,rease( Ce.er(:)

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

33

OB Sens: C2 ) Tem-: 3>)9 oC @@ : 9)# ;4 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)Retra,tion(:)) 0R: 9$ !-m) re4 ler) m rm r (:)/ RR: $> !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) (e,rease(

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 9$ !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition marasm s t&-e O t mor a!(omen e, (('ne ro!lastoma Willms t mor PB : : : : : Three 8a& In1 ,e+triaDone $#0 m4'1$h'I? Para,etamol 3 D #00 m4 (i+ nee(e() 2 lti.itamin 8itho t Ce 1 D ,th 1 Cotrimo;sa5ole 1 D ,th 1 %iet C100 1$0 ,,'3h'KAT O 2ineral miD 3)> ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 10 ;4 @@I : 1$)" ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :$ E Q E :3 S% Willms t mor P : : %iet C100 1$0 ,,'3h O 2ineral miD 3)> ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1

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

34

"'9,'3%'0, 21,6 C 23,6 2;13 (11,6 - 13,6 1$8) "B A!(ominal !loatin4(O)(e,rease()Ce.er(:) OB Sens: C2 ) Tem-: 3>)9 oC @@ : 9)" ;4 LPT : #1 ,m LP% #$ ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : L&m-h no(es enlar4ement(:) S&mmetri,al + si+orm)Retra,tion(O)) 0R: 9" !-m) re4 ler) m rm r (:)/ RR: $4 !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) (e,rease(

Li.er'S-leen'Renal: n(eterminate/ EDtremities P lse 9" !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition marasm s t&-e O s s- teratoma (('a!(omen mass O le+t hi(rone+rosis O le+t hi(ro reter P B - Three 8a& : : : : : : I?C% %S KaCl 0)$$# = 40 4tt'i mi;ro In1 ,e+triaDone $#0 m4'1$h'I? Para,etamol 3 D #00 m4 (i+ nee(e() 2 lti.itamin 8itho t Ce 1 D ,th 1 Cotrimo;sa5ole 1 D ,th 1 %iet C100 $$0 ,,'3h'KAT O 2ineral miD 4)4 ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S : ?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m @@S : 10 ;4 @@I : 1$)" ;4 LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :$ E Q E :3 S% Willms t mor P : : %iet C100 $00 ,,'3h O 2ineral miD 4 ,, : Cotrimo;sa5ole 1 D ,th 1 : 2 lti.itamin 8itho t CE 1 D ,th 1

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

35

L$%-0$,-08 R'(/&,B
"'9,'3%'0, 23,6 2;13 C-39&',' B&--1 C-/., 0emo4lo!in (0A@) Eritrosit (R@C) Le ;osit (W@C) 0emato;rit Trom!osit (PLT) 2C? 2C0 2C0C R%W 2P? PCT P%W D)*,'& Ke tro+il Lim+osit 2onosit Eosino+il @aso+il Ke tro+il A!sol t Lim+osit A!sol t 2onosit A!sol t Eosino+il A!sol t @aso+il A!sol t 4= 10>' mm3 103' mm3 = 103' mm3 +L P4 4= = +L = +L = = = = = 103'VL 103'VL 103'VL 103'VL 103'VL <.1; 3.22 2<.22 2 .# 41# *9/"0 $#/$0 31/#0 14/90 "/"0 0/3> "/* *1/>0 1#/#0 1$/40 0/$0 0/300 2;.21 4/3" 3/49 0/0> 0/0" 11/3 J 14/1 4/40 J 4/4" >/0: 1*/# 3* J 41 $1* J 49* "1 J 9# $# J $9 $9 J 31 11/> J 14/" */$ : 10/0

3* J "0 $0 J 40 $J" 1J> 0J1 $/4 J */3 1/* : >/1 0/3 : 0/" 0/10 : 0/30 0 : 0/1

36

L$%-0$,-08 R'(/&,B Se-tem!er) $3th $013 C&).)+$& C6'3)(,08 HEART @ilir !in Total @ilir !in %ire; Cos+atase Al;ali(ALP) AST'SAOT AST'SAPT L%0 UNIT RE"ULT" NORMAL VALUE m4'(L m4'(L <'L <'L <'L <'L 0/#* 0/1$ 300 34 9 10> E1 0:0/$ E $"1 E 3$ E 31 $40 : 4"0

L$%-0$,-08 R'(/&,B "'9,'3%'0, 1;,6 2;13 C&).)+$& C6'3)(,08 HEART Al! min CARBOHYDRATE METABOLISM @loo( 4l ,ose (As) RENAL <re m 3reatinin ELECTROLYTE Katri m (Ka) 3ali m (3) 3lori(a (Cl) Phos-hor 2a4nesi m(24) IMMUNO"EROLOGY TUMOR MARKER ACP(Al+a Ceto Protein) @eta 0CA %arah n4'mL mI<'mL 1/>9 0 0:1> 0:1 m4'(L 24'(L mEB'L mEB'L mEB'L mEB'L mEB'L $0/>0 0/1 1$3 3/3 "* >/> $)>> E #0 0/$4:0/41 13#:1## 3/>:#/# 9>:10> 3/4 : >/$ 1/4 :1/9 UNIT RE"ULT" NORMAL VALUE 4'(L 3/$ 3/":#/4

m4'(L

"$/>0

E$00

37

"'9,'3%'0, 24,6 C 3;,6 2;13 (14,6 C 2;,6 1$8) "B A!(ominal !loatin4(O)(e,rease()Ce.er(:))?omitin4(:) OB Sens: C2 ) Tem-: 3*)0 oC @@ : 9)" ;4 LPT : #1 ,m LP% #$ ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : L&m-h no(es enlar4ement(:) S&mmetri,al + si+orm)Retra,tion(O)) 0R: 104 !-m) re4 ler) m rm r (:)/ RR: $" !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness (O)) Peristalti, (O) (e,rease(

Li.er'S-leen'Renal: n(eterminate/) EDtremities P lse 104 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB 2aln trition marasm s t&-e O s s- teratoma (('a!(omen mass O a!ses o't m!ili,al re4ion O le+t hi(rone+rosis O le+t hi(ro reter PB : : : : : : : Three 8a& I?C% %#= KaCl 0)$$# = 40 4tt'i mi;ro In1 ,e+triaDone #00 m4'1$h'I? Para,etamol 3 D #00 m4 (i+ nee(e() 2 lti.itamin 8itho t Ce 1 D ,th 1 In1 metroni(a5ole L% 1#0 m4 L2% *# m4'"h'i. %iet C100 $$0 ,,'3h'KAT O 2ineral miD 4)4 ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))A!(ominal !loatin4(O) O : @@2 : 9)# ;4 @@S : 10 ;4 @@I : 1$)" ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :$ E Q E :3 S%

A : 2aln trition marasm s t&-e O s s- teratoma (('a!(omen mass O a!ses o't m!ili,al re4ion P : : %iet C100 $30 ,,'3h O 2ineral miD 4)>,,
- 2 lti.itamin 8itho t CE 1 D ,th 1

38

L$%-0$,-08 R'(/&,B
"'9,'3%'0, 2#,6 2;13 C-39&',' B&--1 C-/., 0emo4lo!in (0A@) Eritrosit (R@C) Le ;osit (W@C) 0emato;rit Trom!osit (PLT) 2C? 2C0 2C0C R%W 2P? PCT P%W D)*,'& Ke tro+il Lim+osit 2onosit Eosino+il @aso+il Ke tro+il A!sol t Lim+osit A!sol t 2onosit A!sol t Eosino+il A!sol t @aso+il A!sol t 4= 10>' mm3 103' mm3 = 103' mm3 +L P4 4= = +L = +L = = = = = 103'VL 103'VL 103'VL 103'VL 103'VL 13/90 #/0# 2<.3; 40/4 40> "0/00 $*/#0 34/40 14/90 "/10 0/33 "/4 *4/>0 1#/#0 10/10 0/$0 0/300 1!.4# 4/0> $/0" 0/04 0/0* 11/3 J 14/1 4/40 J 4/4" >/0: 1*/# 3* J 41 $1* J 49* "1 J 9# $# J $9 $9 J 31 11/> J 14/" */$ : 10/0

3* J "0 $0 J 40 $J" 1J> 0J1 $/4 J */3 1/* : >/1 0/3 : 0/" 0/10 : 0/30 0 : 0/1

39

L$%-0$,-08 R'(/&,B Se-tem!er) $*th $013 C&).)+$& C6'3)(,08 B&--1 2$( $.$&8()( Ph -CO$ -O$ @i,ar!onate (0C03) Total CO$ @ase eD,ess (@E) O$ sat ration UNIT RE"ULT" */4$" 32. 11 .3 21.; $$/0 :$/# 9"/# NORMAL VALUE */3#:*/4# 3":4$ "#:100 $$:$> 19:$# (:$):(O$) 9#:100

mm04 mm04 mmol'L mmol'L mmol'L =

40

O+,-%'0, 1(, C 4,6 2;13 (21,6 C 24,6 1$8) "B Post la-arotom&)+e.er(:) OB Sens: C2 ) Tem-: 3>)9 oC @@ : 9)" ;4 LPT : #1 ,m LP% #$ ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)Retra,tion(O)) 0R: 110 !-m) re4 ler) m rm r (:)/ RR: $" !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness Li.er'S-leen'Renal: (O)) Peristalti, (O) (e,rease(

n(eterminate)8o n( +rom o-eration ,lose( 8ith

!an(a4es EDtremities P lse 110 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O)

41

A : Post o- la-arotom& a'i teratoma O 2aln trition marasm s t&-e O le+t hi(rone+rosis O le+t hi(ro reter PB : : : : : : : Three 8a& I?C% %#= KaCl 0)$$# = 1# 4tt'i mi;ro In1 ,e+triaDone #00 m4'1$h'I? In1 metroni(a5ole *# m4'"h'i. In1 3etorola, 1# m4'>h 2 lti.itamin 8itho t Ce 1 D ,th 1 %iet C100 $30 ,,'3h'KAT O 2ineral miD 4)> ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))%iarrhea(:) O : @@2 : 9)# ;4 @@S : 10)# ;4 @@I : 1$)" ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :1 E Q E :$ S%

P : : %iet C100 $40 ,,'3h O 2ineral miD 4)",, : 2 lti.itamin 8itho t CE 1 D ,th 1 O+,-%'0,
,6

C #,6 2;13 (2

,6

C 2#,6 1$8)

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

42

OB Sens: C2 ) Tem-: 3>)9 oC @@ : 9)" ;4 LPT : #1 ,m LP% #$ ,m 0ea( E&e : Li4ht re+leDes(O'O)) iso,hori, - -il) -ale ,on1 n,ti.a -al-e!ra in+erior (:':)) i,teri, (:':))Ear : Kormal a--erean,e )2o th : Sianosis (:)) Kose: ThoraD A!(omen Kormal a--erean,e) Ke,; : LW2P0 KO%ES enlar4ement(:) S&mmetri,al + si+orm)Retra,tion(O)) 0R: 110 !-m) re4 ler) m rm r (:)/ RR: $" !-m) re4 ler/Cra,;les (:':) Soe-el/%istention(O))Shi+tin4 ( llness Li.er'S-leen'Renal: (O)) Peristalti, (O) (e,rease(

n(eterminate)8o n( +rom o-eration ,lose( 8ith

!an(a4es EDtremities P lse 110 !-m) re4 lar) a(eB ate -ress re an( .ol me) 8arm a,ral) CRT E 3I)m s,le h&-otro-h&(O)) little s !, taneo s +at le+t(O) AB Post o- la-arotom& a'i teratoma O 2aln trition marasm s t&-e O le+t hi(rone+rosis O le+t hi(ro reter O Periotneal T@ PB : : : : : : : Three Wa& I?C% %#= KaCl 0)$$# = 1# 4tt'i mi;ro In1 ,e+triaDone #00 m4'1$h'I? In1 metroni(a5ole *# m4'$h'i. In1 3etorola, 1# m4'>h 2 lti.itamin 8itho t Ce 1 D ,th 1 %iet C100 $30 ,,'3h'KAT O 2ineral miD 4)> ,,

N/,0)'., $.1 3',$%-&)+ 1)('$(' 3-1/&' B S:?omit(:))%iarrhea(:) O : @@2 : 9)# ;4 @@S : 11 ;4 @@I : 1$)" ;4 LLA(2) : 11 ,m LPT (S) : #1 ,m LLA (S) : 11 ,m LP%(S) : #3 ,m @@'T@ : :1 E Q E :$ S%

A : Post o- la-arotom& a'i teratoma O 2aln trition marasm s t&-e O le+t hi(rone+rosis O le+t hi(ro reter O Periotneal T@ P : : %iet C100 $40 ,,'3h O 2ineral miD 4)",,
- 2 lti.itamin 8itho t CE 1 D ,th 1

43

CHAPTER IV DI"CU""ION AND "UMMARY 2aln trition essentiall& means H!a( no rishmentI/ It ,on,erns not eno 4h as 8ell as too m ,h +oo() the 8ron4 t&-es o+ +oo() an( the !o(&9s res-onse to a 8i(e ran4e 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 8astin4) ol(:man +a,e) irrita!le) s !, taneo s +at loss) !a44& -ant/ RA2) +emale) $ &ear # month 8as a(mitte( to 0a1i A(am 2ali; Aeneral 0os-ital 8ith the main ,om-laint o+ a!(ominal !loatin4/ On -h&si,al eDamination) the -atient ha( the loo;s o+ ol( man +a,e) easil& seen ri!s (O) ) h&-otro-& m s,le (O)) s !, taneo s +at (e,rease( (O) an( !a44& -ants (O)) la!orator& +in(in4 sho8s h&-er4li,emia) lo8 hemo4lo!in an( er&thro,&te ,o nt) le ,o,&tosis) an( h&-onatremia/ 0e 8as (ia4nose( 8ith maln trition t&-e

44

marasm s:;8ashior;or 4ra(e ?/ The last +ollo8: - sho8e( the (ia4nosis 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 mana4e( 8ith I?C% %#= KaCl 0)$$# = 1# 4tt'i mi;ro , in1 ,e+triaDone #00 m4'1$h'I?) in1 metroni(a5ole *# m4'$h'i.) in1 3etorola, 1# m4'>h) m lti.itamin 8itho t Ce 1 D ,th 1, (iet C100 $30 ,,'3h'KAT O 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 Ener4& 2aln trition/ A.aila!le (A,,esse( at: >

htt-:''eme(i,ine/me(s,a-e/,om'arti,le'1104>$3:o.er.ie8 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+in4)/ $004/2I an( <KICEC/ 4/ Stall;am-) A) Sa4ar) CA@) A;hter) K) et al/ $00>/ Ann al Re-ort o+ the K tritional S r.eillan,e Pro1e,t/ 0ellen 3eller International/ #/ A.a,hat) SS) Phal;e) ?%) Phal;e) %@/ $009/ E-i(emiolo4i,al St (& o+ 2aln trition (<n(er K trition) Amon4 <n(er Ci.e Chil(ren in a Se,tion o+ R ral Area/ Pra.ara 2e( Re. $009L 1 ($)/ >/ Protein:ener4& maln trition/ CAO/ A.aila!le at:

45

888/+ao/or4'(o,re-'800*3e'800*3e0#/htmX-$919Y33011* O,to!er $013)

(A,,esse(

>

*/ Waterlo8) ZC/ 19*$/ Classi+i,ation an( %e+inition o+ Protein:Calorie 2aln trition/ @ritish 2e(i,al Zo rnal/ 3: #>>:#>9/ "/ 2ehta) K2) Cor;ins) 2R) L&man @) et al/ $013/ %e+inin4 Pe(iatri, 2aln trition: A Para(i4m Shi+t To8ar( Etiolo4&:Relate( %e+initions/ ZPEK Z Parenter Enteral K tr/ ?ol me PP K m!er P/ 9/ 0eir() WC/ $00*/ Coo( Inse, rit&) 0 n4er) an( 2aln trition/ In: 3lie4man R2) @ehrman RE) Zenson 0@) et al/ Kelson TeDt!oo; o+ Pe(iatri,s 1"th e(ition/ Phila(el-hia: Sa n(ers Else.ier/ 10/ Ash8orth) A) 3han m) S) Za,;son) A) et al/ $003/ A i(elines +or the in-atient treatment o+ se.erel& malno rishe( ,hil(ren/ S8it5erlan(: W0O/ 11/ 0o++er) LZ/ $001/ Protein:ener4& maln trition in the in-atient/ C2AZL 1># (10): 134#:1349/