Clinical Exposure

1. Data Pasien
Jenis Kelamin: wanita
Usia : 2 tahun 11 bulan
Berat : 8! "# $in##i : 81 cm
%tatus e"onomi: ren&ah
2. 'namnesis
Keluhan utama
(#antu" lemas &an ti&a" bertena#a &an berat ba&an ti&a"
bertambah.
Keluhan lain
$i&a" a&a
)iwa*at pen*a"it ter&ahulu
$i&a" a&a riwa*at *an# si#ni+"an
)iwa*at pen*a"it "eluar#a
$i&a" a&a riwa*at *an# si#ni+"an
,ainn*a
'na" pertama. Pen&apatan *an# san#at ren&ah sehin##a oran# tua
san#at sulit untu" mencu"upi "ebutuhan +si" ana".

!. Pemeri"saan -isi"
.eart rate : 11/ 01min
Bloo& pressure : 2/13/
)espirator* rate : !/ 01min
4nspection : $hin rib apparent limbs loo"e& small marasmic
apperance
Palpation : ,i5er an& spleen are normal no pain in
ab&omen
Percussion : (o mass no or#ans enlar#ement no pain
'uscultation : ,i5er an& spleen are normal no bruit soun&
normal intestine soun&
timpani soun& on epi#astric
'nthropometr* : B64 : 12378Un&er 79Percentile: Born wei#ht :
!"#
;. Pemeri"saan penun<an# *an# perlu &ila"u"an
,aborator* %tu&ies
$he most help=ul laborator* stu&ies in assessin# malnutrition in a
chil& are hematolo#ical stu&ies an& laborator* stu&ies e5aluatin#
protein status.
o .ematolo#ical stu&ies shoul& inclu&e a CBC count with )BC
in&ices an& a peripheral smear. $his coul& also help exclu&e
anemias =rom nutritional &e+ciencies such as iron =olate an&
5itamin B912 &e+ciencies.
o 6easures o= protein nutritional status inclu&e serum albumin
retinol9bin&in# protein prealbumin trans=errin creatinine
an& BU( le5els. )etinol9bin&in# protein prealbumin an&
trans=errin &eterminations are much better short9term
in&icators o= protein status than albumin. .owe5er in the +el&
a better measure o= lon#9term malnutrition is serum albumin
because o= its lon#er hal=9li=e.
'&&itional &ia#nostic e5aluation
o 4n chil&ren who ha5e a histor* o= a&e>uate =oo& inta"e an&
si#ns1s*mptoms o= malnutrition =ocus on i&enti=*in# the cause
o= malnutrition. Per=orm laborator* stu&ies base& on
in=ormation =rom a complete histor* an& ph*sical examination.
o 4nitial &ia#nostic laborator* stu&ies inclu&e a CBC count
se&imentation rate serum electrol*tes an& urinal*sis an&
culture. %tool specimens shoul& be obtaine& i= the chil& has a
histor* o= abnormal stools or stoolin# patterns or i= the =amil*
uses an unreliable or >uestionable source o= water.
o '&&itional stu&ies ma* =ocus on th*roi& =unctions or sweat
chlori&e tests particularl* i= hei#ht 5elocit* is abnormal.
-urther &ia#nostic stu&ies shoul& be &etermine& as &ictate& b*
the histor* an& ph*sical examination. -or example lab tests
e5aluatin# renal =unction such as phosphorus an& calcium
shoul& be obtaine& in the presence o= renal s*mptoms.
Chil&ren with suspecte& li5er &isease shoul& ha5e tri#l*ceri&e
an& 5itamin le5els obtaine& while ?inc le5els shoul& be
obtaine& in patients with chronic &iarrhea.
Celiac serolo#* is a use=ul screenin# test an& shoul& be consi&ere&
especiall* i= there is a =amil* histor* o= celiac &isease or i= other
autoimmune &iseases such as t*pe 4 &iabetes mellitus are present.
7. )in#"asan
@irl 2 *ears 11 months 8! "# with 81 cm hei#ht. .eart rate
11/ 01min BP 2/13/ )) !/ 01min. 4nspection +n& $hin rib apparent
limbs loo"e& small marasmic apperance. Palpation an& percussion
+n&in# normal. 'uscultation +n&in#s li5er an& spleen are normal no
bruit soun& normal intestine soun& timpani soun& on epi#astric.
3. Dia#nosis
Aor"in# &ia#nosis
6arasmus
DiBerential &ia#nosis
Kwashior"or 6arasmus Kwashior"or
7. Diagnostic reasoning
Dia#nostic reasonin# an& &iBerential &ia#nosis
6arasmus li"el* become the &ia#nosis. Unable to thri5e or
catch9up is a car&inal si#n =or malnutrition especiall* people in rural
area with low income population. Kwashior"or an& 6arasmus
Kwashior"or can be exclu&e& because these &isease si#n is oe&ema
on ab&omen.
8. Patient Reaction
-eelin#s : ,ethar#*
4nsi#ht : .er mother "now that her &au#hter lac" o= nutrition but
she canCt aBor&
=oo& to =ee& her &au#hter
-ear : %he =eels sa& with her &au#hter con&ition
Expectations : %he hope her &au#hter reco5er as =ast as possible
2. Disease )e5iew
Malnutrition is globally the most important risk factor for illness and death,
contributing to more than half of deaths in children worldwide; child
malnutrition was associated with 54% of deaths in children in developing
countries in 200!

"rotein#energy malnutrition $"%M&, 'rst described in the
(20s, is observed most fre)uently in developing countries but has been
described with increasing fre)uency in hospitali*ed and chronically ill children
in the +nited ,tates! -he e.ects of changing environmental conditions in
increasing malnutrition is multifactorial! "oor environmental conditions may
increase insect and proto*oal infections and also contribute to environmental
de'ciencies in micronutrients! /verpopulation, more commonly seen in
developing countries, can reduce food production, leading to inade)uate food
intake or intake of foods of poor nutritional )uality! 0onversely, the e.ects of
malnutrition on individuals can create and maintain poverty, which can
further hamper economic and social development!
Marasmus involves inade)uate intake of protein and calories, whereas a child
with kwashiorkor has fair#to#normal calorie intake with inade)uate protein
intake! 1lthough signi'cant clinical di.erences between kwashiorkor and
marasmus are noted, some studies suggest that marasmus represents an
adaptation to starvation whereas kwashiorkor represents a dysadaptation to
starvation! 2n addition to "%M, children may be a.ected by micronutrient
de'ciencies, which also have a detrimental e.ect on growth and
development! -he most common and clinically signi'cant micronutrient
de'ciencies in children and childbearing women throughout the world include
de'ciencies of iron, iodine, *inc, and vitamin 1 and are estimated to a.ect as
many as two billion people! 1lthough forti'cation programs have helped
diminish de'ciencies of iodine and vitamin 1 in individuals in the +nited
,tates, these de'ciencies remain a signi'cant cause of morbidity in
developing countries, whereas de'ciencies of vitamin 0, 3, and 4 have
improved in recent years! Micronutrient de'ciencies and protein and calorie
de'ciencies must be addressed for optimal growth and development to be
attained in these individuals!
Pathoph*siolo#*
Malnutrition a.ects virtually every organ system! 4ietary protein is
needed to provide amino acids for synthesis of body proteins and other
compounds that have various functional roles! %nergy is essential for all
biochemical and physiologic functions in the body! 5urthermore,
micronutrients are essential in many metabolic functions in the body as
components and cofactors in en*ymatic processes! 2n addition to the
impairment of physical growth and of cognitive and other physiologic
functions, immune response changes occur early in the course of signi'cant
malnutrition in a child! -hese immune response changes correlate with poor
outcomes and mimic the changes observed in children with ac)uired immune
de'ciency syndrome $124,&! 6oss of delayed hypersensitivity, fewer -
lymphocytes, impaired lymphocyte response, impaired phagocytosis
secondary to decreased complement and certain cytokines, and decreased
secretory immunoglobulin 1 $2g1& are some changes that may occur! -hese
immune changes predispose children to severe and chronic infections, most
commonly, infectious diarrhea, which further compromises nutrition causing
anore7ia, decreased nutrient absorption, increased metabolic needs, and
direct nutrient losses!
%arly studies of malnourished children showed changes in the
developing brain, including, a slowed rate of growth of the brain, lower brain
weight, thinner cerebral corte7, decreased number of neurons, insu8cient
myelini*ation, and changes in the dendritic spines! More recently,
neuroimaging studies have found severe alterations in the dendritic spine
apparatus of cortical neurons in infants with severe protein#calorie
malnutrition! -hese changes are similar to those described in patients with
mental retardation of di.erent causes! -here have not been de'nite studies
to show that these changes are causal rather than coincidental!
4
/ther pathologic changes include fatty degeneration of the liver and
heart, atrophy of the small bowel, and decreased intravascular volume
leading to secondary hyperaldosteronism!
4nternational Epi&emiolo#*
-he 9orld :ealth /rgani*ation estimates that by the year 205, the
prevalence of malnutrition will have decreased to ;!<% globally, with =!4
million children younger than 5 years a.ected as measured by low weight for
age! -he overwhelming ma>ority of these children, 2!? million, will live in
developing countries with ;0% of these children in 1sia, particularly the
southcentral region, and 2<% in 1frica! 1n additional <5 million $2(!0%&
children will have stunted length@height secondary to poor nutrition!
0urrently, more than half of young children in ,outh 1sia have "%M,
which is <!5 times the prevalence in the western hemisphere! 2n sub#,aharan
1frica, =0% of children have "%M! 4espite marked improvements globally in
the prevalence of malnutrition, rates of undernutrition and stunting have
continued to rise in 1frica, where rates of undernutrition and stunting have
risen from 24% to 2<!?% and 4;!=% to 4?%, respectively, since ((0, with
the worst increases occurring in the eastern region of 1frica!