pediatric surgery station case report,.pptx

pediatric surgery station case report

1. PARTIAL DUODENAL OBSTRUCTION ET CAUSA ANNULAR PANCREAS, MILD MALNUTRITION, GLOBAL DEVELOPMENTAL DELAY, AND INCOMPLETE IMMUNIZATION IN A CHILD   Supervised by : Dr. dr. Jeanette I. Ch. Manoppo , Sp.A (K ) Dr. dr . Harsali F. Lampus , MHSM, Sp.BA By : Maria Consita Sulayman Case Report January 24 th , 2022 Department of Pediatrics Medical Faculty of Sam Ratulangi University - Prof. Dr. R. D. Kandou Hospital Manado 2022

2. TIMELINE December 2 th , 2021 January 3 rd , 2022 January 4 th , 2022 January 8 th , 2022 January 24 th ,, 2022 Patient admitted to the the hospital Initial Observation Observation Started Final Observation Report 1

3. PATIENT’S IDENTITY Registration number: 73.71.XX Name of patient : M.O Date of birth : Oct 22 th , 2021 (13 months old) Gender : Female Nationality : Indonesian Ethnicity : Minahasanese Address : Kairagi Wenu   Name FATHER : M.O MOTHER M.T Age : 42 years old 35 Years old Occupation : Soldier Prist Education : Senior High School Bachelor PARENT ’ S IDENTITY FAMILY TREE 2

4. Main Complaint : VOMITING 3

5. History of Present Illness 4

6. History of Previous Illness 5

7. ANTENATAL CARE HISTORY The Patient is the 1 st child in the family. Her mother had routinely antenatal care, regularly consumed iron supplements, two doses of tetanus toxoid (TT) immunization , never consumed any drugs, alcohol, and non-smoker LABOR HISTORY born spontaneously, full-term, BW 2,800 grams, BL 49 cm, and cry immediately. She breathe normally after being born, was born at the hospital was helped by a midwife, and was discharged after 2 days. POSTNATAL HISTORY The Patient had never experienced yellowish or bluish discoloration of the skin. She was formula milk well . No abnormality in antenatal, labor and postnatal history 6

8. GROWTH The g rowth was routinely examined at primary health care. Until this time the growth of this patient was normal, she looked the same as her peers.   Development Lift head & smile spontaneously  4 months old Babble  5 months old Be able to roll over  4 months old Sit without help  6 monts old Began to walk  - months old Saying mama and papa  12 months old Normal developmental milestone before the illness 7

9. FEEDING HISTORY breastfed : - formula milk : born – 13 months old Milk porridge : 6 months prior to the illness strained porridge : 8 months prior to the illness soft porridge : 10 months old prior to the illness soft rice : - family meal : - Normal feeding before the illness Incomplete basic immunization history IMMUNIZATIONS HISTORY BCG Polio fours times DPT three times Hepatitis B three times 8

10. Physic-biomedic: received adequate primary needs (clothes, food, and housing). She eats three times daily, enough recreations , completed immunization programs due to national government policy. When she got sick, her parents took her to the nearest health facility in the area.  Mental stimulation: The patient played like her peers. Before her illness, she did not have problems with memory, language, and attention.   Emotional needs : Affection is received from parents and family. The patient`s parents accept her illness and took care of her to get routine medication. The patient received enough care and love from her parents and family for her recovery. The patient played like her peers. Before her illness, she did not have problems with memory , language, and attention.   Patient received adequate love and care from her family. 9

11. SOCIO-ECONOMIC Both of her parents work as a soldier . Healthcare expenses are covered by national insurance class I.   ENVIRONMENT The patient lives with her parents in a permanent house with a tin roof, concrete wall, concrete floor. This house consists of two bedrooms, inhabited by 3 persons (2 adults and 1 child). The bathroom is inside the house, the water source is from mineral water, and the electricity source is from the government electric company. Waste is handled by dumping outside the house Mild-Class social economy status 10

12. Anthropometric Status Bodyw eight : 6,8 kg Body h eight : 70 cm Ideal body weight : 8,8 kg Nutritional status : Underweight, Normal Height, Mild malnutritional status ( based on WHO 2000 child growth chart for girls ) 11

13. Vital sign Blood pressure : 9 0/ 60 mmHg Pulse : 128 bpm ( regular, full pulse) Respiratory rate : 36 bpm Body Temperature : 37,5 C (a x il l a) Skin : light brown colored, no efflores cent , BCG scar on upper right arm 12 Physical Examination

14. Head and Neck Head : Normacephaly (head circumference 45 cm), black hair, Eyes : No anemic conjunctiva and no icteric sclera, pupils were round, isocor , 3-3 mm, light reflex was normal, clear lenses, normal eye movements to all directions Nose : No nasal flaring, there was no secrets Ears : Clear external ear canal, normal ear drums, no secretion Mouth : No perioral cyanosis, moist buccal mucosa and lips, no tongue papillae atrophy, no dental caries Throat : Tonsils T1-T1 no hyperemic, pharynx no hyperemic Neck : Centered trachea, no enlargement lymph nodes 13 NORMAL

15. Heart Inspection : no visible ictus cordis , no precordial bulging Palpation : ictus cordis not palpable Percussion : right border at right parasternal line, left border at left midclavic le line, upper border at 2 nd - 3 rd left intercostal space. Auscultation : rhythm was regular, no mu rmur , no gallop Lungs Inspection : symmetrical movemen t on both side of hemithorax Palpation : symmetrical vocal fremitus Percussion : symmetrical resonant sounds Auscultation : symmetrical vesicular breath sounds, no rales, no wheezing   14 NORMAL

16. Abdomen Inspection : post operation scar length 10 cm, covered with sterille gauze Auscultation : norm al bowel sounds Palpation : Liver and spleen were not palpable, abdomen circumference 44 cm Percussion : tympanic percussion Vertebrae : no deformity Extremities : Warm, capillary refill time (CRT) ≤2”, no deformity, no cyanosis , normal muscle tone, normal physiological reflexes , no pathological reflexes, no clonus, no spastic, no edema 15

17. Cranial nerves examination: N I = no abnormality N II = r ound , isochoric pupils, positives direct and indirect light reflexes N III,IV,VI = no strabismus, normal movements of the eyeballs N V = no abnormality N VII = s ymmetrical nasolabialis s ulci , no lago ph talmus N VIII = cant’t be assessed N IX = No swallow disorder N X = uvula in central, no deviation N XI = can shrug shoulders and turn head against resistance N XII = no deviation of the tongue 17 16 NORMAL

18. Laboratory results Hb : 11.6 g/dL Ht : 32.3 % Leucocyte : 27.600 /  L Platelet : 654.000/  L Na : 129 mEq /L K : 3 mEq /L Cl : 90 mEq /L Ca : 9.9 mg/dL PT : 17.5 ( 14.0) seconds INR : 1.32 ( 1.08) seconds APTT : 40.4 ( 34) seconds AST : 20 U/L ALT : 22 U/L Ureum : 29 mg/dL Creatinine : 0.2 mg/dL Anti HCV : non reactive HBsAg : non reactive Anti HIV : non reactive Antigen SARS CoV-2 : non reactive 17

19. Suspect duodenal web dd / duodenal stenosis 18 Radiological Examination results

20. DIAGNOSIS Post eksploration laparotomy et cause partial duodenal obstruction et causa annular pancreas ( Q45.1 ) Mild Malnutrion ( E44.1 ) Global Developmental Delay ( F88 ) - Incomplate Immunization ( Z28.3 )   LIST OF PROBLEM Diagnosis, treatment and prognosis of 13 months old girl with post eksploration laparatomy et cause annular pancreas. 19

21. Pediatric Nutritional Care : A. Assessment : This case was a girl, 13 months old with body weight 6,8 kg and height 70 cm. this patient was diagnosed with Post laparatomy et cause partial duodenal obstruction et causa annular pancreas, mild malnutrion , global developmental delay and Incomplete immunization   B. Nutritional requirements according to the Recommended Dietary Allowance ( RDA ) based on height - age for children aged 1 – 2 years old Energy : 98 kcal/kg/day = 862.4 kcal/day Protein : 10% kcal = 1.56 g/day Fat : 30 % kcal = 28.7 g/day Karbohidrat : 60% kcal = 129.4 g/day Fluid : 1137 – 1319 mL/day   C. Nutritional route: parenteral 20

22. Pediatric Nutritional Care : D . Type of food : in the form of : IVFD KaEN 3A 35 ml/hour = 64.3 kcal IVFD Aminofusin 5%= 65 kcal IVFD Ivelip 20% = 70 kcal Total 200 kcal ( 23% RDA ) E. Monitoring and evaluation : Monitoring of acceptability, food tolerance, adverse reactions and body weight changes 21

23. Counseling plans and Education Plans Describes the illnesses of the patient: causes, treatment, prognosis and complications. Educate proper feeding to meet nutritional needs and disease Educate to maintain oral hygiene and environment  Educate about further evaluation after the patient’s discharged ( routine control for easy follow-up patient condition ) Educate the family members about the importance of family support Educate the impact on the child's social-economic life because of long-term treatment 22

24.   January 4 th , 2022 (1 st Observation day, 5 th - day post laporatomy ) in PICU S Retention (-), NGT is clean, febris (-), defecation (-), Pain around surgical wound (-) O General condition : Looked ill Conscious ness : CM Blood Pressure : 90/60 mmHg BW : 6,78Kg Pulse : 120 bpm Temperature : 36 o C Respiratory rate : 28 cpm GDS : 104   Head : no anemic conjunctiva, anicteric sclera, pupil isocor Chest : symmetrical movement, no retraction Heart : regular rhythm, no thrill, no murmurs Lung : normal bronchovesicular breathing sound on both lungs, no rales, no wheezing Abdomen : Post operation scar length 10 cm covered with sterilized gauze,wound looks dry, convex, no distended abdomen, no sign of ascites, soft, liver and spleen not palpable, Abdomen circumference 44 cm, normal bowel sound Extremities : warm, CRT <2”, normal physiologic reflexes, no pathologic reflex, no spastic, no clonus. Motoric strength 5555 5555 5555 5555   A - Post eksploration laparotomy et causa partial duodenal obstruction et cause annular pancreas ( Q45.1 ) - Mild Malnutrion ( E44.1 ) - Global Delayed Development ( F88 ) - Incomplate Imunization ( Z28.3 ) P Medications : - IVFD KaEN 3A 35 ml/hour - IVFD Aminofusin 5% 130 ml still 5 hours - IFVD Ivelip 20% 35 ml still 2 hours - Meropenem 3 x 165 mg intravenously (6) - Paracetamol 3 x 80 mg intravenously - Oralit 8 x 5 – 10 ml / NGT - Abdomen circumference every 24 hours - Manual Rapid Glucose every 24 hours - Collaboration between Nutritional and metabolims pediatric subdivision - Collaboration between Pediatric Surgery division   Pediatric Nutritional care: Same as before   Nursing care Same as before   FOLLOW UP 23

25.   January 5 th , 2022 (2 nd Observation day, 6 th - days post laparotomy ) in PICU S Retention 30ml, Defecation (-) O General condition : Looked ill Conscious ness : CM Blood Pressure : 90/60 mmHg Temperature : 36,8 o C Pulse : 118 bpm GDS : 95 Respiratory rate : 28 cpm Bw : 6,8 kg   Head : no anemic conjunctiva, anicteric sclera, pupil isocor Chest : symmetrical movement, no retraction Heart : regular rhythm, no thrill, no murmurs Lung : normal bronchovesicular breathing sound on both lungs, no rales, no wheezing Abdomen : Post operation scar length 10 cm covered with sterilized gauze,wound looks dry, convex, no distended abdomen, no sign of ascites, soft, liver and spleen not palpable, Abdomen circumference 44 cm, normal bowel sound Extremities : warm, CRT <2”, normal physiologic reflexes, no pathologic reflex, no spastic, no clonus. Motoric strength 5555 5555 5555 5555   A - Post eksploration laparotomy et causa partial duodenal obstruction et cause annular pancreas ( Q45.1 ) - Mild Malnutrion ( E44.1 ) - Global Delayed Development ( F88 ) - Incomplate Imunization ( Z28.3 )   P Medications : - IVFD KaEN 3A 35 ml/hour - IVFD Aminofusin 5% 130 ml still 5 hours - IFVD Ivelip 20% 35 ml still 2 hours - Meropenem 3 x 160 mg intravenously (7) - Paracetamol 3 x 80 mg intravenously - Milk 8x40 ml by mouth low lactose milk - Abdomen circumference every 24 hours - Manual Rapid Glucose every 24 hours - Collaboration between Nutritional and metabolims pediatric subdivision - Collaboration between Pediatric Surgery division   Pediatric Nutritional care: Same as before   Nursing care Same as before   24

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27. P Medications : - IVFD KaEN 3A 35 ml/hour - IVFD Aminofusin 5% 130 ml still 5 hours - IFVD Ivelip 20% 35 ml still 2 hours - Meropenem 3 x 160 mg intravenously (9) - Metronidazole 3 x 60 mg intravenously (1) - Paracetamol 3 x 80 mg intravenously - Milk 8 x 100 – 110 ml by mouth - Multivitamin according to AKG : folat acid 1 x 1 mg, vit C1 x 50 mg, Vit.Bcomp 1 x 1 tab - Abdomen circumference every 24 hours - Manual Rapid Glucose every 24 hours - Pro blood culture, complete blood, ALT/AST - Collaboration between Nutritional and metabolims pediatric subdivision - Collaboration between Pediatric Surgery division   Pediatric Nutritional care: A . Assessment : 13 months years old young girl; actual body weight 6.8 kg ( ideal body weight 8.8 kg), body height 73 cm. Nutritional status : underweight, normal height and mild malnutrion status ( Based on the WHO girl growth chard ).   26

28. P B . Nutritional requirements according to the Recommended Dietary Allowance ( RDA ) based on height-age for children aged years. Energy : 98 kcal/kg/day = 862,4 kcal/day Protein : 10%kcal = 21,56 g/day Fat : 30 %kcal = 28,7 g/day Karbohidrat : 60%kcal = 129,4 g/day Fluid : 1137 – 1319 ml/day Nutritional route: parenteral and oral Type of food: In the form of : IVFD KaEN 3A 35 ml/hour = 64,3 kcal IVFD Aminofusin 5 % = 65 Kcl IFVD Ivelip 20% = 70 kcal Total 200 Kcal ( 23% RDA ) Pepti – junior milk 8 x 80 ml ( 50% RDA ) Pepti – junior milk 8 x 120 ml ( 100% RDA ) E. Monitoring and evaluation: Monitoring of acceptability, food tolerance, adverse reactions and body weight changes Nursing care Same as before   27

29.   January 8 th , 2022 (5 th Observation day, 9 th -day p ost laparatomy ) in ward S Defecation (-), febris (-), intake oral 6x100ml, vomit (-) O General condition : Looked ill Conscious ness : CM Blood Pressure : 90/60 mmHg Temperature : 36.5 o C Pulse : 108 bpm GDS : 77 Respiratory rat e : 30 cpm BW : 6,9kg Head : no anemic conjunctiva, anicteric sclera, pupil isocor Chest : symmetrical movement, no retraction Heart : regular rhythm, no thrill, no murmurs Lung : normal bronchovesicular breathing sound on both lungs, no rales, no wheezing Abdomen : Post operation scar length 10 cm covered with sterilized gauze, dry wound, convex, no distended abdomen, no sign of ascites, soft , liver and spleen not palpable, Abdomen circumference 44 cm, normal bowel sound Extremities : warm, CRT <2”, normal physiologic reflexes, no pathologic reflex, no spastic, no clonus. Motoric strength 5555 5555 5555 5555 Laboratorium : Haemoglobin 11,6 g/ dL,Haematocrit 33,2 %,Leukocyte 8900/ UL,Platelet 731.000/ UL,Natrium 131 Mmol / L,Kalium 5,2 Mmol / L,Chlorida 92 Mmol /L Calsium 9,6 Mmol /L,ALT 65 U/L,AST 43 U/ L,Ureum 27 mg/ dL,Creatinine 0,3 mg/ dL,MCH 34,9,MCH 24,6,MCHC 70,5,GDS 77,CRP 48 A - Post eksploration laparotomy et causa partial duodenal obstruction et cause annular pancreas ( Q45.1 ) - Mild Malnutrion ( E44.1 ) - Global Delayed Development ( F88 ) - Incomplate Imunization ( Z28.3 ) P Medications : - IVFD KaEN 3A 35 ml/hour - IVFD Aminofusin 5% 130 ml still 5 hours - IFVD Ivelip 20% 35 ml still 2 hours - Meropenem 3 x 160 mg intravenously (10) - Metronidazole 3 x 60 mg (2) - Paracetamol 3 x 80 mg intravenously - Milk 8 x100 -110 ml by mouth - Multivitamin according to AKG : folat acid 1 x 1 mg, Vit.C 1 x 50 mg,Vit.Bcomp 1 x 1 tab - Abdomen circumference every 24 hours - Manual Rapid Glucose every 24 hours - Collaboration between Nutritional and metabolims pediatric subdivision - Collaboration between Pediatric Surgery division - Waiting Blood culture (7/1/22)   Pediatric Nutritional care: Same as before   Nursing care Same as before 28

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32. CASE ANALYSIS This case was a girl, 13 months old with body weight 6,8 kg and height 70 cm. this patient was diagnosed with Post laparatomy et causa partial duodenal obstruction et cause annular pancreas, mild malnutrion , global developmental delay and Incomplete immunization Congenital duodenal obstruction approximately one in 2500 to 10000 live births, and accounting for nearly half of all cases of neonatal intestinal obstruction it was approximately 23% of congenital duodenal obstruction. The reported incidence of the annular pancreas is 1 in 20000 live births 31

33. CASE ANALYSIS This patient had a duodenoduodenostomy on December 2021 due to her obstructive duodenum that was caused by a suspected annular pancreas. At that time she had frequent vomiting and difficulty of activity for 6 months 32

34. CASE ANALYSIS The causes of annular pancreas      1. Embryologic deformity of the pancreas    2. Pancreas normally develops from one dorsal and two ventral buds    3. Ventral buds normally rotate with the duodenum, but if they fail to do so , the  annular pancreas may form. 33

35. CASE ANALYSIS The Annular pancreas is usually manifested itself in the form of acute recurrent duodenal obstruction  40 % atresia or obstruction The most common cause of obstruction  partial or complete obstruction from annular pancreas with symptoms of poor feeding, vomiting bilious or not and irritability, abdominal distention Partial and complete  2/3 of the case are asymptomatic throughout their life symptomatic most commonly present in infancy or early childhood. 50% pediatric group  86% at neonatal case  surgery 34

36. CASE ANALYSIS In this patient : ( The annular pancreas with partial duodenal obstruction ) Vomiting Poor feeding Irritability Distanded abdomen ( circumference abdomen until 49 cm ) ( These complaints occurred since 5 months ago ) 35

37. CASE ANALYSIS Deng et al,. a retrospective study review of 152 patients with the annular pancreas, who were treated with surgical repair between January 2009 and August 2017 was performed at our pediatric surgical unit. 66% of patients presented symptoms during the neonatal period and 28% of patients had duodenal obstruction diagnosed by prenatal ultrasound scan. All cases were managed surgically by open laparotomy, and all patients were duly charged discharged. 36 Level of evidence 3b, recommendation B Pediatri Surgery int.2018

38. CASE ANALYSIS Dopkins et al,.Reported the rare diagnosis of annular pancreas diagnosis with endoscopic to management of congenital duodenal stenosis, and surgery is the only effective way to diagnose and treat annular pancreas to having prepare the patient condition 37 Level of evidence 3b, recommendation B Pediatr Gastroenterol Nurt.2021

39. CASE ANALYSIS Bing et al ,. Thirty-five A total of 35 patients with congenital annular pancreas in neonates were operated on by laparoscopic procedure at our hospital during January 2015 and September 2020. Feedings started on postoperative 3-7 days. The cases in the group were discharged uneventfully. all the cases were doing well at the last follow-up examination 38 Level of evidence 3b, recommendation B Pediatri Surgery int.2021

40. CASE ANALYSIS Gfroere r et al,. a retrospective study total of 50 patients underwent surgical repair of CDO. The patient cohort consisted of a group of 27 patients with CCDO and 23 patients with ICDO. In conclusion, Achievement of full feeds, length of postoperative hospital stay and morbidity did not differ between CCDO and ICDO in this subgroup. It appears that CHD and prematurity are predominant factors that widely influence postoperative outcome, while in contrast the degree of duodenal obstruction is limited to impact time from operation to initiation of enteral feeding. 39 Level of evidence 3b, recommendation B World journal of gastroenterology.2019

41. PROGNOSIS Ad Vitam : dubia ad Bonam Ad Functionam : dubia ad Bonam Ad Sanationam : dubia ad Bonam 40

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