Lectures Coas

8/13/2019 Lectures Coas

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TEORI


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TOPIK IKA

1. GEH

2. Gizi dan metabolik

3. Endokrin4. Neurologi

5. kardiologi


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Diare 4

Lesi korosif esofagus 3B

Peritonitis, Appendisitis, abses appendiks,

invaginasi 3B

Perdarahan GIT 3B

Kolesistis 3B


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Solid mass

40%Intravasculler

5%albumin

Intertitiel

15%

Intracelluler

40%

Diartrhea


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Solid mass

40%Intravascule

r

albumin

Intertitie

l

IntracelullerDiare

dehidrasi


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Solid mass

40%Intravascule

r

albumin

Intertitie

l

IntracelullerIVFD

rehydration

Need time


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Need of maintenance water (= need of

energy/callory) in day equal with bodyweight.

010 kg = 100 ml/kgBW/day

>10-20 kg = 1000 ml+(BW-10kg) x 50ml/kgBW/day

>20 kg = 1500 ml + (BW-20kg) x 20

ml/kgBW/day OR


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Other way

010 kg = 4 ml/kgBW/hour96 ml/kgBW/day

>10-20 kg = + 2 ml/kgBW/hour

48 ml/kgBW/dayx(BW-10kg) +960 ml

>20 kg = + 1 ml/kg/hour

24 ml/kg/dayx (BW-20kg) + 1440 ml


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DiarrheaDefinitionAcute Diarrhoea : < 14 days & < 4 x / month

Clinical manifestation: Acute Diarrhoea,Cholera, Dysentri

Chronic Diarrhoea : Persistence and Chronic

Persistence (Acute Diarrhoea)Chronic (multiple times)


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Frequency of defecation


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Clinical form ClassificationClinical (simple) :acute diarrhoea, cholera, dysentery

Severity of dehydration:

without dehydration, mild-moderate dehydration,and severe dehydrationType of dehydration:

isotonic, hypotonic, hypertonic

Clinical complicated:complicated and uncomplicated


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Determining degree of dehydration

1. Clinical feature

2. IMCI/MTBS, practical and easy to applied

3. P2 Diarrhoea = Programe National

Diarrhoeal Diseases Control Program (CDD)4. Maurice King Score

5. etc


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General clinical manifestation


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Clinical form based on MCI/ MTBS

Acute

Persistent

Disentry


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Clinical form based on WHO/Depkes: RSUD kab (district hospital)

1. Acute

2. Persistent

3. Disentry

4. cholera

5. + severe malnourish

6. AAD (antibiotic associated diarrhea)

7. Intusuception


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acute chronic

Acute prolong persistent chronic

Acute

Dysentri >< INTUSUCCEPTIONcholera


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MTBS = IMCI


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P l h l


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P2 Diare program = National Diarrhoeal

Diseases Control Program (CDD)Evaluation A B C

1 look

- generalapperance

good, CM *irratable, crying *lethargy,decrease ofconsiousness

-Eyes normal sunken Very sunken or

dry- tear + - -

- mouth andtonge

wet dry Extremely dry

- thristhy no *(+), disere to

drink

*weak or dont

want to drink2. Eximine

- Turgor (returnto normal)

quick *slow (1-2seconds)

*evremely slow(> 2 seconds)

3. Degree ofdehydration

Without Mild to moderate

Sign : 1* + 1

severe

Sign : 1* + 1


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WHO:(1) giving solution: prevent & treat dehydration(2) diet: continue especially breast feeding(3) drug: no AB,

except for cholera and bloody stoolWHO recommend : Zinc,

not yet: Probiotik And prebiotik(4) education


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Giving solution

Loss of Body Weight

0% 5% 10% 15%Ex : normal BW 10 kg, if diarrhea 9 kg :

loss of BW 10%

Dehydration

No,Mild, moderate, severe, shock,death

No, Mild-moderate, severe, shock,death

Rehydration

Mild-moderate : (5%+10%):2 = 7,5% = 75 ml/kgBW

Severe : WHO 10% (100ml/kgBW), FK Unsri = 12%


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PERDARAHAN GIT

1. Looking for shock signs: manage and stabilize shock

and general condition.

2. Rule out food, TNT disorder, trauma, systemic

problem.3. Rule out diathesis hemorrhagic (CT, BT, PT, aPTT).

4. Assest the blood loss volume and characteristic

5. Assest: UGIB or LGIB, Age6. Analize: clinical features

7. Do the supporting examination


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Neonatus : Hiperbilirubin indirek

hari 1 : Inkompatibilitas golongan darah (Rh, ABO),

infeksi intra uterin (TORCH)

hari ke 2-3: Inkompatibilitas golongan darah, infeksi,

polisitemia, darah ekstra vasasi (hematom sefal,perdarahan intra kranial), kelainan morfologi RBC,

defisiensi enzim G6PD, SGNN

hari ke 4- 5: breast feeding jaundice, SGNN, infeksi

hari ke 7: breast feeding jaundice, infeksi, neonatalhepatitis, peningkatan sirkulasi enterohepatik

(stenosis pilorik, obstruksi usus)


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Neonatus : Hiperbilirubin direk

Neonatal hepatitis, sepsis neonatal, infeksi intra

uterin, obstrusi saluran empedu (bile flug

syndrome, kista duktus kholedokus) dan atresia

biliaris


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GIZI DAN METABOLIK

MEP

Difisiensi vitamin

Defisiensi mineral Obesitas


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GIZI BURUK

Dasar Diagnosis:

Usia 5 tahun dengan growth chart WHO

2006, Z score < -3 SD

Usia > 5 tahun memakai CDC 2000, BB/TB :< 70%

Klasifikasikan berdasarkan manifestasi klinis


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Intake kurang (kemiskinan, ketidaktahuan,

penyakit),

penyakit sistemik

Diare/muntah


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Klasifikasi berdasarkan klinis:

Marasmus

Marasmik kwashiorkor Kwashiorkor


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DM tipe 1 :

Sel beta pankreas mengalami kerusakan

(sebagian besar oleh faktor autoimun)

produksi insulin turunpenggunaan glukosasebagai sumber energi terganggu tubuh

menggunakan lemak dan protein sebagai

sumber energimetabolisme tidak sempurna.


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Diabetes simtomatis/klinis

Gejala klasik: polidipsia, poliuria, polifagia,

berat badan turun.

Gula darah puasa > 120 mg/dl atau

Gula darah 2 jam PP > 200 mg/dl atau

Gula darah sewaktu > 200 mg/dl.

Diabetes ketoasidosis Hiperglikemia, ketonemia, asidosis, ketonuria,

glukosuria.


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Kompensi Neuro

KD 4

Kejang dg demam 3B

Tetanus 4

Tet neo 3B

Poliomielitis 3B

Rabies 3B

Ensefalopati 3B

Koma 3B

Epilepsi 3B

Trauma 3B

GBS 3B

Miastinia gravis 3B


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Skor normal :

- Lahir6 bulan 9

6-12 bulan 11

1-2 tahun 12

2-5 tahun 13

> 5 tahun 14


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Beberapa kiat:

1. Angka 2

2. Dosis obat: rerata dosis dewasa untuk 40 kg

(30-60 kg)

3. Onset, penyebaran, dan gambaran klinik :Infeksi virus > bakteri


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Beberapa kiat:

Berat badan

1. Berat badan : lahir (1x), 4 bulan (2x), 1 th (3x),

2 th (4x), 5 th (5x) ......6,5 bulan (2,5x)

2. 1-9 tahun: BB = (4+umur thn) x 23. 7-12 tahun: BB = umur thn x 3

Tinggi badan

1. Lahir 50 cm, 1 th 75 cm, 4 th 100 cm2. > 4 tahun : + 5 cm/thn


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Beberapa kiat:

1. Pertumbuhan: 3, 4, 8, 9, 11, 13

2. Perkembangan: 5-6 bln takut, 1 th kata bearti, 2

th kalimat. 5-6 thn kal resmi

3. Spincter control : siang 2 th, malam 3 th


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HEMATOLOGI


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WHO:(1) giving solution: prevent & treat dehydration(2) diet: continue especially breast feeding(3) drug: no AB,

except for cholera and bloody stoolWHO recommend : Zinc,

not yet: Probiotik And prebiotik(4) education


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KONSTIPASI


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KONSTIPASI

Batasan bervariasifrekuensi dan konsistensidefekasi setiap anak berbeda

KONSTIPASI :

1. frekuensi < 3 kali/minggu,

2. konsistensi keras,

3. Distress : nyeri, pengeluaran periodik sejumlah

feses besar 1 x / 7 - 30 hari, perut kembung,

sensasi penuh, teraba massa di abdomen atau

rektum


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Konstipasi : akut atau kronik

- Konstipasi akut : < 1-4 minggu

- Konstipasi kronik : > 1 bulan

Konstipasi fungsional selalu kronik.Konstipasi fungsional :

1.Usia makanan tambahan

2.Usia toilet traning

3.Usia masuk sekolah


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MASALAH BEDAH GIT

The term surgical gastrointestinal problem =

surgical abdomen problem* : constellation of

symptoms and signs indicative of an intra-

abdominal process that may require surgery.

The term acute abdomen (AA) implies the

sudden onset of abdominal symptoms

(especialy pain) for which a surgically

correctable cause is likely

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*Lloyd DA, Surgical abdomen. in Walker, Pediatric GIDisease 2004


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INTRODUCTION (2)

ENTERY POINT

Intestinal obstructionall cases need

surgical intervention, AA : total obstruction

Peritonitissecondary peritonitis needssurgical intervention, AA: secondary

peritonitis

Congenital intestinal conditions if thereis symptom need surgical abdomen, AA :

acute symptoms, e.g.: respiratory distress

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DISTENDED ABDOMEN (5)

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HYPERTROPHIC PYLORIC STENOSIS (2)

Progressing of the obstructive pyloric mass.Infants are well for the first 2-3 weeks of life, severe

symptoms in the first 2 months of life.

Nonbilious vomiting as a major symptom:

progressive, repetitive, after feeds (30-60 min ).Cause: dehydration, alkalosis, weight loss,constipation.

Colicky abd pain (few seconds) occur intermittentlyevery few minutes.

Peristaltic waves in epigastrium (from left to right).Palpation of the pyloric tumor.

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ATRESIA

Usually presents the first few days of life

Vomiting

Esophageal: immediately, OG tube wont pass

Duodenal: immediately, Associated anomalies :Downs, malrotation, VACTER

Jejunal: 24 hours

Ileal: 24-48 hours

Colonic: after 2-3 days

Anal: should be diagnosed at birth.

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INTUSSUSCEPTION

Vomiting may become bilious

Stools will appear dark red and mucoid-

resembling currant jelly (very late sign of

intestinal ischemia and mucosal sloughing)Distended abdomen +/-

Mass may be felt in the abdomen in 85% of

patients in the RUQ- sausage-like, typicallyileocolic, referred to as Dancas sign

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INTUSSUSCEPTION

Peak incidence : 4 - 14 months, as early as 1 month

Typically :

colicky abdominal pain, bilious vomiting, bloody and

mucus stool / currant-jelly stool(later sign).

Between bouts of colic, infants are quiet but irritable.

When incarcerated progress to continuous lethargy

Sausage-shaped abdominal mass may be palpated.

Atypically with lethargy: no colic; mild abdominal

tenderness, and mucoid rectal blood.

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APPENDICITIS

Diagnosis difficult in neonate / young children

Abdominal pain migrates to the right iliac fossa,Rebound tenderness in the right iliac fossa,

Nausea or vomiting, 37.5oC, anorexia

Perforated appendix : history suggestive ofappendicitis, fever > 38,6oC, diffuse abdominal

pain, abdominal distention. Bowel obstructionin a < 5 year old without obvious etiology isperforated appendix until proven otherwise

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HIRSCHSPRUNGSDISEASE

Long segment: first few days of life: total colonobstruction

Short segment : often tolerated for months, history

of delayed meconium, constipation in neonate.Rectal exam : contricted rectum, explosive

release of liquid stool / semisolid stool

HD must be distinguihed with functional

constipation

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PERITONITIS IN CHILDREN

Presents with acute abdomen

Severe abdominal pain, may localize near site of

infection (rebound tenderness). Intensifies with

movement

Abdomen is tender with rigidity of abdominal muscle

Paralytic illeus : bowel sounds: /-, progressive

abdominal distention; pooling of GI secretions lead

to nausea and vomiting Systemically: fever, malaise, tachycardia,

tachypnea, disorientation, dehydration, and shock


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PERITONITIS IN CHILDREN

Etiology :

Appendicular peritonitis

Gastric ulcer perforation

Traumatic perforation of the intestine

Neutropenic colitis

Perforation of meckel diverticulum


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