Case Report

A Boy With Undernutrition Marasmus Type and Acyanotic Congenital Heart

Disease

Arranged by:

Meidiana Risty P G99172113 (G-17)

Pritta Gracia G99162070 (G-18)

Adviser :

dr. Annang Giri Moelyo, Sp.A(K), M.Kes

DEPARTMENT OF PEDIATRIC FACULTY OF MEDICINE

SEBELAS MARET UNIVERSITY DR. MOEWARDI HOSPITAL

2018
 HALAMAN PENGESAHAN

Presentasi kasus ini disusun untuk memenuhi persyaratan Kepaniteraan Klinik Ilmu
Kesehatan Anak Fakultas Kedokteran Universitas Sebelas Maret / RSUD Dr. Moewardi.
Presentasi kasus dengan judul:

Seorang Anak Lelaki Dengan Gizi Buruk Tipe Marasmus dan PJB Asianotik

Oleh:
Meidiana Risty Pratama G99172113 (G-17)
Pritta Gracia G99162070 (G-18)

Hari, tanggal : Jumat, 20 Juli 2018

Mengetahui dan menyetujui,

Pembimbing Presentasi Kasus

dr. Annang Giri Moelyo, Sp.A(K), M.Kes

NIP. 19730410 200501 1 001
 CHAPTER I
PATIENT STATUS

A. PATIENT IDENTITY
Name : Child Y
Date of Birth : March 1, 2018 (4 months old)
Sex : Male
Address : Ngawi
Weight : 3,5 kg
Height : 55 cm
Date of Admission : July 6, 2018
Date of Examination : July 16, 2018
Medical Record : 014189xx

B. ANAMNESIS (16/07/2018)
1. Chief Complaint
Shortness of breath

2. History of Chief Complaints

Three days before came to the hospital (July 3,2018) the patient’s parent
complained that the patient was fever. The fever was continous and reach the highest
temperature was 38.50C. That complain made the patient fussy and made the
consumption of mothers milk was decreased. The mother said that the complain was
decreased if the patient given the anti-fever drug but a few hours later fever was
reappeared. The other complain of this patient is cough and cold without seizure, sweat
in the night,shortness of breath, nausea, vomiting, abdominal pain and diarrhea.
Two days before came to the hospital, the patient`s complain was getting worse.
The fever was continously high, also found productive cough, cold, and in the evening
there are shortness of breath in the patient. The patient became more fussy, iritable and
weaker. The consumption of mother`s milk was more little than before, and just want
to drank infantrini milk 4x20 ml. There are not found sianotic, abdominal dillate, or
diarrhea on the patient. The volume and frequency of defecate and urinate was reduced.
One day before came to the hospital, the shortness of breath in the patient was
more severe, continously, and not reduced with the changes of the position and weather.
The frequency of productive cough was increased, with cold and persistent fever. The
patient became weaker because the intake of drink was decreased. And then because of
this condition, the parents came to the Emergency unit in Muwardi Hospital.
When in the emergency unit of Muwardi Hospital, the patient was conscious,
active in movement. In the patient was found shortness of breath, fever, productive
cough, ronkhi, cold but the are not found mengi, snoring, sianotic, nausea and vomiting.
The last urinate was two hours before came to the hospital and the last defecate was 1
days ago. The history of cold sweath in the night, active contact with adult patient who
prolonged cough or bloody cough was denied.

3. History of Past Illness

History of similar problem : denied
History of hospitalization : (+) when the patient was 2 months old because of
diarrhea and dehidration. The diarrhea was caused by comsumption soy milk. The
frequency of diarrhea was five times, the consistency was dilute and watery, mucus
(-), blood (-), smells (-). During this hospitalization, patient was also diagnosed
with Down Syndrome and congenital heart disease.
History of shortness of breath : denied
Allergic history : denied

4. History of Family Illness

History of similar problem : denied
History of allergic : denied
History of tuberculosis : denied
History of congenital heart disease : denied
History of down syndrome : denied

5. History of Socio-Demographic
Based on the alloanamnesis with the parents, the patient was lived with his parents
and his grandmother. The similar complain in member of family and neighboorhood
was denied. The rooftop of patient`s house was covered by tile, the floor covered
by cement and the bathroom is equipped with latrines.
6. History of Pregnancy
 The patient`s mother was pregnant when she 26 years old and the status was the
second pregnancy (P2A0). During the pregnancy, complain about cough, cold,
fever, hospitalization, bleeding was denied. The mothers routine check her
pregnancy to the doctor once in a month. During pregnancy, the mother never
consume drugs. History of trauma denied.

7. History of Birth
The patient was born with sectio caesaria in the hospital when the gestational age
was 37 weeks because of the history of preeclampsia in mother. His birth weight
was 2200 grams, the lenght was 44 cm. When he was born, the mothers cannot
check the patient was cry or not because the patient was brought to HCU neonatus.
After birth, the patient was placed in incubator for 5 days.

8. History of Growth and Development

a. Growth
The birth weight was 2200 grams, the lenght was 44 cm. The patient routine
came to Posyandu to check the weight, lenght, and healthy status. The
progression of weight was not significant like boys/girls who same aged with
him.
Impression : Growth is not coressponding with age
b. Development
The patient can bablling, like to scream, like to looking to the mother, can move
side to side, and begin to training to lie on stomach.
Impression : Developmental is corresponding with age

9. History of Immunization
a. HB1, Polio 0 : 0 month
b. HB2, BCG : 1 month
Conclusion : The patient do not get complete imunization according to age
based on guidelines from ministry of health 2008. This condition of this patient
caused by the history of hospitalization when the patient was 2 months old.

10. History of Nutrition

 The patient consume milk mother since born until now. The frequency is 4-5 times
a day, approximately 15 minutes every breastfed, but patient not fall to sleep when
he is done with breastfed. The mothers give infantrini milk to sufficient the calories
need. The patient drank the infantrini milk around 5 bottles per day, each bottles
contains 60 ml with 2 spoon of milk (suggestion dilution : 1 spoon for 25 ml).
Impression : The quantity and quality of nutrition is under the normal

11. History of Socio-Economic

The patient is the second child in the nuclear family of Mr. S (26 yo) as entrepreneur
and Mrs. W (26 yo) as housewife. The religion is Islam. The patient is facilitated
by BPJS class III.

12. Family Tree

An. Y
(4bulan)

C. PHYSICAL EXAMINATION
1. General Status
a. General State : moderate pain, compos mentis, undernutrition
b. Vital Sign
Heart rate : 140x/minute, regular
Respiration rate : 45x/minute
Temperature : 37.30C (per axilla)
O2 saturation : 98%
c. Nutritional Status
1) Clinically : undernutrition
 2) Anthropometry
W: 3.5 kg; L : 55 cm; A : 4 months
W/A : W/A < -3 SD (severely underweight)
L/A : L/A < -3 SD (severely stunted)
W/L : -3 SD < W/L < -2 SD (wasted)
Mid-upper arm circumference: 7 cm: < -3 SD
(WHO, 2006)
d. Head : mongoloid face, head circumference = 36 cm; microcephal ( HC < -2
SD Nellhaus scale)
e. Eyes : No conjunctiva pallor, no icterus scleral, positive pupillary light reflex,
no sunken eyes
f. Nose : no nostril breathing, no secrete, flat nasal bridge
g. Ears : no secrete
h. Mouth : wet mucous, no cyanotic
i. Neck : no swollen lymph node
j. Chest : symmetric, no retraction, floating ribs
1) Cor
Inspection : Ictus cordis not seen
Palpation : Ictus cordis palpable, not strong lift
Percussion : the heart border is widen
Auscultation : heart sound I-II normal, regular, systolic murmur at the left
parasternal border
2) Pulmo
Inspection : chest expansion right side = left side
Palpation : Fremitus right side = left side
Percussion : sonor/sonor
Auscultation : vesicular sound breathing (+/+), no rhonchi
k. Abdomen
Inspction : abdomen and thorax are parallel
Auscultation : bowel sound (+)
Percussion : tympanic
Palpation : tender, no palpable liver and spleen, normal skin turgor
l. Extremity : warm, no swelling, muscle wasting, no baggy pants, dorsalis
pedis artery is palpable, capillary refill time < 2 seconds
D. WORK UP
1. Laboratory Test (06/07/ 2018)

Examination Result Unit Reference

Complete Blood Count
Hemoglobin 11.5 g/dl 9.4 – 13.0
Hematocrite 36 % 28 – 42
Leucocytes 9.5 thousand/u 5 – 19.5
l
Thrombocytes 145 thousand/u 150 – 450
l
Erythrocytes 3.80 million/ul 3.10 – 4.30
Erythrocytes Index
MCV 95.8 /um 80,0 – 96,0
MCH 30.3 Pg 28,0 – 33,0
MCHC 31.6 g/dl 33,0 – 36,0
RDW 14.9 % 11,6 – 14,6
MPV 7.4 Fl 7.2 – 11.1
PDW 17 % 25 – 65
Diff Count
Eosinophile 0.10 % 0,00 – 4,00
Basophile 0.20 % 0,00 – 1,00
Netrophile 62.50 % 29,00 – 72,00
Lymphocytes 32.80 % 60,00 – 66,00
Monocytes 4.40 % 0,00 – 6,00
Clinical Chemistry
Random blood sugar 67 mg/dl 50 – 80
Electrolyte
Blood sodium 133 mmol/L 129 – 147
Blood kalium 5.1 mmol/L 3.6 – 6.1
Ion calcium 1.21 mmol/L 1.17 – 1.29

2. Chest X-Ray (06/07/2018)

 Finding: Pneumonia, cardiomegaly

E. SUMMARY
Three days before came to the hospital (July 3,2018) the patient’s parent
complained that the patient was fever. The fever was continous and reach the
highest temperature was 38.50C. That complain made the patient fussy and made
the consumption of mothers milk was decreased. The mother said that the
complain was decreased if the patient given the anti-fever drug but a few hours
later fever was reappeared. The other complain of this patient is cough and cold
without seizure, sweat in the night,shortness of breath, nausea, vomiting,
abdominal pain and diarrhea.
Two days before came to the hospital, the patient`s complain was getting
worse. The fever was continously high, also found productive cough, cold, and in
the evening there are shortness of breath in the patient. The patient became more
fussy, iritable and weaker. The consumption of mother`s milk was more little than
before, and just want to drank infantrini milk 4x20 ml. There are not found
sianotic, abdominal dillate, or diarrhea on the patient. The volume and frequency
of defecate and urinate was reduced.
One day before came to the hospital, the shortness of breath in the patient
was more severe, continously, and not reduced with the changes of the position
and weather. The frequency of productive cough was increased, with cold and
persistent fever. The patient became weaker because the intake of drink was
decreased. And then because of this condition, the parents came to the Emergency
unit in Muwardi Hospital.
 When in the emergency unit of Muwardi Hospital, the patient was conscious,
active in movement. In the patient was found shortness of breath, fever, productive
cough, ronkhi, cold but the are not found mengi, snoring, sianotic, nausea and vomiting.
The last urinate was two hours before came to the hospital and the last defecate was 1
days ago. The history of cold sweath in the night, active contact with adult patient who
prolonged cough or bloody cough was denied.
From the anthropometry, the patient was classified by WHO chart as severely
underweight, severely stunted, and wasted. From the physical examination, there are
mongoloid face, microcephal, flat nasal bridge, floating ribs, systolic murmur, and
muscle wasting at the upper and lower extremities.

F. PROBLEM LIST
G. WORKING DIAGNOSIS
1. Undernutrition Marasmus type in the rehabilitation phase
2. Acyanotic congenital heart disease
3. Down Syndrome

H. PLAN OF THERAPY
Calories needed (0-1 year old boy): 110-120 cal/kg/day = 385-420 cal/day
1. Diet F100 8x65 ml via NGT
2. Folic acid 1 mg/24 hour po
3. Zinc 10 mg/24 hour po
4. Zamel drop 1,5 ml/24 hour po

I. PLAN OF DIAGNOSTIC
-
J. PLAN OF MONITORING
1. Vital sign/8 hours
2. Weight/day
3. Height/day
4. Mid-arm circumference/day
5. Head circumference

K. PLAN OF COUNSELING
 1. About the patient condition
2. Educate mother to breasfeeding and give the patient formula milk according to the
measure.
3. Educate mother to take the patient to Posyandu for routine measurement and write
on KMS. If the weight is not increased (4 months = 600 grams), take the patient to
Community Health Center (Puskesmas)

L. PROGNOSIS
Ad vitam : dubia ad bonam
Ad sanam : dubia ad malam
Ad fungtionam : dubia ad malam