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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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