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• Menjadi Program Pendidikan Dokter Spesialis Gizi

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Klinik yang unggul di Indonesia dan di kawasan Asia

VISI
Pasifik pada tahun 2019

• Menyelenggarakan Program Studi Pendidikan Dokter Spesialis Gizi


Klinik, untuk menghasilkan dokter spesialis gizi klinis yang:
• Menjunjung tinggi etika keilmuan dan etika profesi kedokteran
• Memenuhi standar kompetensi internasional

MISI • Mampu melakukan penelitian dalam bidang gizi klinis


• Mampu melakukan pelayanan gizi klinis secara paripurna.
CONFERENCE OF CLINICAL NUTRITION
SURGEON
March 4th , 2019

dr. Murni
dr. Benedicta Afianti Indrastuti
dr. Lista Andriyati *
dr,. Fatmawati Nur Husain
dr. Iman Prawira Saputra
dr. Dina Noerlaila Hadju
dr. Indrawaty Alimuddin
dr. Ni Luh Eka Suprapti
dr. Urfa
PATIENT IDENTITY
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No. MR : 841780
Room : The front top of 2nd Lontara, 10th Room Bed 4
Name : Mrs. H
Age : 60 years old
Gender : Woman
Date of Admission : March 23rd , 2019
Date of Consul : March 28th , 2019
Medical Diagnosis :
AN INTRA-ABDOMINAL MASS DUE TO PANCREATIC TAIL TUMOR
PATIENT’S PHOTO
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SUBJECTIVE
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• Chief Complaint : Inadequate oral intake


• Additional complaint
Inadequate oral intake is experienced since two months ago, getting worse
in two days ago due to abdominal pain and there was a lump in the
stomach that slowly enlarges. There wasn’t nausea, vomiting and
swallowing pain, yet no history of it either. but there was abdominal pain
since 2 months ago. There wasn’t cough, dyspnea and fever, neither did
the history .
There wasn’t seizure, yet no history of it
There was weight loss for ± 4 kg since 2 months ago,
Defecate : not yet for a day, The history of defecation like goat droppings
in the last 2 months.
Miksi : The impression is enough, via toilet
SUBJECTIVE
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Medical History
 No history of Hypertension and diabetic
 A lump in the stomach has appeared since a year ago

Family Medical History


 There no Hypertension and diabetic
 History of the tumor is unknown
SUBJECTIVE
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Therapy’s Histories
 2 weeks ago, got diagnosed intraabdominal tumor in the surgery polyvclinic
at Awal Bross Hospital
 5 days ago, the patient hospitalized in RSWS until today waiting for operation
schedule.
SUBJECTIVE
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Psychosocial History
• Patient is a housewife
• Passive smoking from her husband for > 20 years, 5 stick – a pack /day
• Non alcoholism
SUBJECTIVE
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Food History
 Healthy, She ate 1 – 1 ½ portion of rice, veggies and fruits 3 times a day. Fish
cooked with coconut milk dominantly. She also liked fries 3 – 4 times a week.
 2 months ago, there was descreasing in ½ portion of rice.
 2 weeks ago, she only ate 2 – 3 spoons rice, a few side dish and veggies.
 2 days ago, only 1 -2 spoons porridge with fruit and veggies in a day.
 There are no restriction and no allergic for food and milk.
OBJECTIVE
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General Condition: Moderate pain, GCS 15
(E4V5M6)
• Energy : 70 kcal
24 hours • Carbohydrate : 1.6 gr
• Protein : 16 gr
Food Recall • Fat : 0 gr

• Blood pressure : 130/90 mmHg


• Pulse : 92 x/minute
Vital Sign • Respiratory rate : 22 x/minute
• Temperature : 36.7 ºC

•Body Length : 151 cm


•Ideal Body Weight : 45.9 kg
Anthropometry •MUAC : 21.3 cm
•MUAC Weight : 38.04 kg
•Handsgrip : 32.0
OBJECTIVE
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Head and Neck
P • Conjunctiva anemic, sclera non icteric.
H • Non O2 supporting
Y
S Thorax
I
C • Symmetric, there is Loss of subcutaneous fat
A • Vesicular
L • There aren’t rhonchi and wheezing.

E Abdomen
X
A • Distended
M • Normal peristaltic
I • The hepar palpates 3 fingers under the arcus costae.
N • Tumor mass in the right hypochondrium
A
T Extremities
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O • There is wasting, no edema
N
LABORATORY
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Type of Test Februari 25th 2019 Normal
Hb 11.2 12.0 – 16.0 g/dl
WBC 11.890 4.0 – 10.0 x 10³/µL
TLC 735.9 2 – 4 x 10³/µL
PLT 498,000 150 – 400 x10³/µL
MCV 82 80 – 100 µM³

MCH 28 27.0 – 32.0 pg


MCHC 34 32.0 – 36.0 gr/dl
GDS 86 140 mg/dl
SGOT 91 P < 32 U/L , L < 38 U/L
SGPT 58 P < 31 U/L , L < 41 U/L
Albumin 3.3 3.5 – 5 gr/dl
Urea 46 10 – 50 mg/dl
Creatinine 0.87 < 1.1 mg/dl
LABORATORY
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Type of Test February 25th 2019 Normal

Sodium 139 135 – 145 mmol/L

Potassium 4.7 3.5 – 5.1 mmol/L

Chloride 106 97 – 111 mmol/L

PT 10,5 10 – 14 seconds

INR 1.01 --

APTT 23.6 22.0 – 30.0 seconds


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Type of Test February 25th 2019 Normal

Amylase Blood 28.0 < 100 U/L

Blood Lipase 29.6 < 60 U/L

AFP 60.48 0 – 7.02 IU/ml

CEA 3.82 0 – 4.70 ngml

PNI 41.67 50
SUPPORTING EXAMINATION
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MRI Chorangiopancreatography (without contras), February 25th,
2019
 No result at all.
Thorax X-ray, February 25th, 2019
 There are no signs of metastasis in the thorax photo
 Cardiomegaly
MSCT Whole Abdomen, May 3rd 2018
 Massa Cauda pancreas
 Hepatomegaly accompanied Hypodens multiple lesions on hepar
 Cholelithiasis
THERAPY OF COLLEAGUES
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 DIGESTIF (February 28th , 2019)


- Bilirubin direct is check
- Waiting for the results
ASSESMENT
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 Metabolic Status
(February 25th , 2019)
- Normocytic Normochrome Anemia (11.2)
- Leukocytosis (11,890)
- Thrombocytosis (498,000)
- Hypoalbuminemia (3.3)
- PNI 41.67

Gastrointestinal status : Fungsional

 Nutritional Diagnosis : Moderate Protein Energy Malnutrition

 Medical Diagnosis :
AN INTRA – ABDOMINAL MASS DUE TO PANCREATIC TAIL TUMOR
PLANNING
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 Basal Energy Expenditure : 1,023.3 kcal
 Total Energy Expenditure : 1,600 kcal (Af : 1.2/Sf : 1.3)
 Macronutrient composition :
• Protein 1.5 g/kg IBW/day = 68.85 g = 17.2 %
• Carbohydrate 50 % = 200 g
• Fat 32.8 % = 58.3 g
 Diet is given 40 % TEE (640 kcal ) :
A. Oral
• Peptisol 5 x 100 kcal
B. Parenteral
• Lipofundin 100 ml /24 hours/intravena
PLANNING
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 Hypoalbuminemia Correction with protein intake 1.5 kg/KgIBW/day
 Fluid maintenance 1,300 – 1,600 ml/day
 Oral Supplementation :
- Zinc 20 mg/24 hours
- B-Complex 2 tablet/8 hours
 Evaluation and Monitoring :
- Vital signs
- Daily intake
- Gastrointestinal tolerance
 Nutritional education
 Laboratory : Total Protein, Lipid’s profile, UUN
Subjective Objective Assesment Planning
Oral intake. There are General Condition : Moderate pain , Nutrition status : Basal Energy Expenditure : 1.023.3 kcal
no nausea and GCS E4M5V6 Subjective Global Assessment score B Total Energy Expenditure : 1.600 kcal
vomiting. There no Blood Pressure : 110/70 mmHg
abdominal pain. RR : 24 x/ minute Metabolic status: Macronutrient composition :
Pulse : 90 x/ minute  Protein 1.5 g/kgIBW/day = 68.86 g = 17.2 %
Defecate : 1 x T : 37.6° C (25/02/2019)  Carbohydrate 50 % = 68.85 g
yellowish SpO2 : 97 % Normocytic Normochrome Anemia (11.2)  Fat 32.8 % = 58.9 g
Urinate: via toilet 24 hours Food Recall via oral and Leukocytosis (11,890)
parenteral : Thrombocytosis (498,000) 1. Diet is given 60 % TEE (960 kcal) :
- Energy : 483 kcal ( 44.03 %) Hypoalbuminemia (3.3) A. oral :
- Protein : 12.4 g ( 15.04 %) PNI (41.67) • Porridge with side dish and vegetable (ad
- Carbohydrate : 151 g (53.95 % %) libitum)
- Fat: 22.71 g (29.02 %) Gastrointestinal status : Fungsional • Fruit juice 100 kcal
Anthropometry • Peptisol 300 kcal
Body Length : 151 cm B. Parenteral
Ideal Body Weight : 41 kg Nutritional Diagnosis : Moderate Protein • Smoflipid 100 ml/24 hours
MUAC : 21.3 cm Energy Malnutrition
MUAC Body Weight : 38.0 kg 2. Fluid maintenance 1300 - 1600 ml/24 hours
Medical Diagnosis :
Physical Examination: 3. Hypoalbuminemia correction with protein
Pancreatic Cauda Tumor
Head and neck : Conjunctiva anemic, intake 1.5 g/KgIBW/day and Cork fish capsule
sclera isn’t icteric. Non O2 supporting .
Thorax : symmetric. There is Lost of 4. Oral Supplementation :
Subcutaneous Fat. Vesicular, There - Zinc 20 mg/24 hours
FOLLOW UP aren’t rhonchi and wheezing . - B. Complex 2 tablet/8 hours
Abdomen: Flat, normal peristaltic , The 5. Monitoring and evaluation
1st day hepar palpates 3 fingers under the - Daily intake
(March 1st , 2019) arcus costae.Tumor mass in the right
hypochondrium - Gastrointestinal tolerance:
Extremities: There is wasting, non 6. Nutritional education
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Type of Test March 1st 2019 Normal

Total Protein 7.1 6.6 – 8.7 gr/dl

Total Cholesterol 168 200 mg/dl

HDL Cholesterol 14 L > 55 ; P > 65 mg/dl

LDL Cholesterol 103 < 130 mg/dl

Triglycerida 121 200 mg/dl


Subjective Objective Assesment Planning
Oral and parenteral General Condition : Moderate , GCS Nutrition status : Basal Energy Expenditure : 1.023.3 kcal
intake. There are no E4M5V6 Subjective Global Assessment score B Total Energy Expenditure : 1.600 kcal
nausea and vomiting. Blood Pressure : 110/80 mmHg
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Appetite descreases. RR : 24 x/ minute Metabolic status: Macronutrient composition :
No fever. Pulse : 90 x/ minute  Protein 1.5 g/kgIBW/day = 68.86 g = 17.2 %
T : 37.6° C (25/02/2019)  Carbohydrate 50 % = 68.85 g
Defecate : not yet for a SpO2 : 97 % Normocytic Normochrome Anemia (11.2)  Fat 32.8 % = 58.9 g
day Leukocytosis (11,890)
Urinate : via toilet 24 hours Food Recall via oral and Thrombocytosis (498,000) 1. Diet is given 80 % TEE (12800 kcal) :
parenteral : Hypoalbuminemia (3.3) A. oral
- Energy : 663.87 kcal ( 42 %) PNI (41.67) - Porridge with side dish and veggies
- Protein : 16.86 g ( 10.5 %) - Peptisol 250 kcal
- Carbohydrate : 97.2 g (58 %) Gastrointestinal status : Fungsional - Fruit juice 100 kcal
- Fat: 22.4 g (30 %) B. Parenteral
- Smoflipid 100 ml/24 hours
Nutritional Diagnosis : Moderate Protein 2. Fluid maintenance 1600 ml/24 hours
Physical Examination: Energy Malnutrition 3. Hypoalbuminemia correction with protein
Skull and neck : Conjunctiva anemic, intake 1.5 g/KgIBW/day and Cork fish capsule
sclera isn’t icteric. Non O2 supporting . 4. Oral Supplementation :
Medical Diagnosis :
Thorax : symmetric. There is Lost of - Zinc 20 mg/24 hours
Pancreatic Cauda Tumor
Subcutaneous Fat. Vesicular, There - B. Complex 2 tablet/8 hours
aren’t rhonchi and wheezing . - Vitamin A 6000 IU / 24 hours
Abdomen: Flat, normal peristaltic , The - Vitamin C 100 mg/24 hours
hepar palpates 3 fingers under the - Curcuma 400 mg / 8 hours
FOLLOW UP arcus costae.Tumor mass in the right 5. Monitoring and evaluation
hypochondrium - Daily intake
2nd day Extremities: There is wasting, non
(March 2nd , edema . - Gastrointestinal tolerance
2019) 6. Nutritional education
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