You are on page 1of 48

MARASMUS

Presenter :
Rivhan Fauzan
(100100236)

Supervisor : DR. dr. Oker Rina


Ramayani, Sp.A (K)

INTRODUCTION
The term marasmus is
derived from the Greek
marasmos, which means
wasting.
Marasmus involves
inadequate intake of
protein and calories and is
characterized by
emaciation.
Marasmus represents the
end result of starvation

EPIDEMIOLOGY
Marasmus is a serious worldwide
problem that involves more than 50
million children younger than 5
years. According to the
World Health Organization (WHO),
49% of the 10.4 million deaths
occurring in children younger than 5
years in developing countries are
associated with PEM
Highly prevalent in developing
countries among <5 children;
severe forms 1-10% & underweight
20-40%.
Seen most commonly in the first
year of life due to lack of breast
feeding and the use of dilute animal

ETIOLOGY
Nutrition
Infection
Socio-economic factor

Clinical Features of
Marasmus

Very wasted
Old man face
Baggy Pants
Hipotrophy muscle
subcutaneous fat thinning
thinning hair and hair fall out easily
Severe growth retardation
No oedema

PATOPHYSIOLOGY
Marasmus is compensated
malnutrition or an adaptation
mechanism of the body to the
lack of energy in a long time. In
a state of lack of food, the body
is always trying to maintaining
life by meeting basic needs or
energy
(1) body composition changes,
(2) metabolic changes, and (3)
anatomic changes

DIAGNOSIS
History taking
Physical Examination
Anthropometri
Laboratory Features

TREATMENT

CASE REPORT

Name : MG
Age: 2 years and 2 months old
Sex : Male
Date of Admission: November,
23rd 2014

Chief Complaint : Weight is not age


appropriate
History:
It was realized by his mother in 3 months, his weight was
about 7 kg 3 months ago , the highest weight ever achieved
by him was 8.5 kg at 1 year old.
Diarrhea was suffered by him 3 days ago, with frequency was
10 times per day, volume about 100cc in every diarrhea,
mucous (+), blood (+), history of diarrhea (+), it was suffered
by patient about 5 months ago.
Vomiting was suffered by patient one day ago, with frequency
once per day, the amount of vomiting was not clear, vomiting
what he eat and drink, vomit contains blood and brownish
color was denied by his mother.
Cough was suffered by patient since this week, productive
cough (-), cough contain blood was denied by his mother,
history of contact with people with chronic cough was found,
his grandfather is diagnosed with Tuberculosis and was taking
drugs of tuberculosis. He lived with his grandfather for 6
months
History of fever was suffered by patient since about 1 month

History of previous illness


The patient was treated by Pediatrician
before the admission to HAM Hospital
with diagnose Marasmus and suspect
HIV

History of drugs

Transfusion of PRC 40cc, Ringer laktat,


Inj Ampicilin, Inj. Gentamycin, Zinc,
Nystatin

Food Recall

Eat once a day, with half a plate of


small pores with a vegetables menu
without fish and meet. Lactegan milk 4
times a day @120cc.

Famil History
His father worked as a farm worker in
Jambi, His mother is a housewife

Pregnant History
Patient is the second child in his family. His
mother got antenatal care during
pregnancy. There was no history of fever,
hypertension, diabetic mellitus, and
consumption of drugs and herbal medicine

Birth History

Patient was aterm when delivered on


spontaneous labor, attended by midwife.
He cried immediately. Birth weight was
2800 grams, birth length was 49 cm, and
no history of cyanosis was found during the

Imunization History
Not complete

Feeding History
From birth to 6 months : Breast milk
From 6 to 12 months : Breast milk + rice
porridge
From 12 months until now: daily menu +
Lactagen of
milkGrowth and
History

Development

9 months : sitting
14 months : walking
2 yr 2 mo : just say mama mimi
mamam

Physical Examination
Generalized status
Body weight: 5,4kg, Body length:
73 cm , MUPC: 8,8 cm
Weight for age : Zscore< -3 SD
Lenght for age : Zscore< -3 SD
Weight for length : Zscore< -3
SD
Interpretation : under nutrition

Present status
Consciousness: alert
Blood pressure 90/60 mmHg,
HR: 116 bpm,
RR: 34 bpm,
body temperature: 37oC,
body weight : 5,4 kg,
body length : 73 cm
Anemic (+), Icteric (-), Cyanosis (-), Edema (-),
Dyspnea (-).

Head :
Face: Old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palp.
conjunctiva pale (+/+), icteric sclera (-/-).
Hair: easily removed
Mouth: oral thrush (+).
Nose and Ear were normal limit
Neck :
TVJ: R-2 cmH2O, Lymph node enlargement (-).
Thorax:
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly
visible (+) HR : 116 bpm, reguler, murmur (-), RR: 34 tpm, regular,
rales (-).
Abdomen:
Soepel, Normoperistaltic. Liver, spleen and renal were unpalpable.
Extremities:
Baggy pants (+), pulse 116 bpm, regular, adequate pressure and
volume, warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar
palmar pale (+/+), oedem (-/-)
Urogenital:

Laboratory Findings on HAM Hospital (November 23 rd


2014)IGD:
Parameters
Value
Normal Value
Complete Blood Count
Hemoglobin

4,9 gr%

11,3 14,1

Hematocrite

15,3 %

37 41

Erythrocyte

1,89 x 106/mm3

4.50 6.50 x 106/mm3

Leucocyte

4.900 /mm3

4.500 13.500/mm3

Platelet

192.000 /mm3

150.000 450.000 /mm3

MCV

81 fl

8l -99 fl

MCH

25,4 pg

27 31pg

MCHC

31,4 g/dl

31 37 g/dl

RDW

22,60 %

10 15 %

Difftel

Neutrophil

72,90

37 80

Lymphocyte

14,10

20 40

Monocyte

13.0

28

Eosinophil

0.00

16

Basophil

0.000

01

Natrium

142

135 - 155

Kalium

2,8

3,6 5,5

Chloride

116

96 106

Blood Glucose adRandom

89

<200

Electrolyte

Working Diagnosis:
Marasmus + Suspect TB + suspect HIV
Management:
Diet F75 68cc/3 hours + mineral mix 0,1cc
Vit A 1 x 200.000 IU
Folic Acid 1 x 5mg 1 x 1mg
Multivitamin without Fe 1 x cth
Cotrimoxazole 2 x cth
Diagnostic Planning:
Check Complete Blood Count, RFT, LFT, Mantoux Test, BTA
Sputum

FOLLOW UP
November 24th 2014 December
17th 2014

November 24th 2014

S
O

Diarrhea (-), Vomiting (-), Fever (+)


Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 37,8 0C . Body weight: 5,4 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
110bpm, reguler, murmur (-), RR: 30 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti Baggy pants (+), pulse 116 bpm, regular, adequate pressure and volume, warm acral,
es
CRT < 3, Blood Pressure 100/70 mmHg, Plantar palmar pale (+/+)
Genital
Male, within normal limit
A
Marasmus + Susp. Tuberculosis + Susp. HIV
P
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
Die F75 90cc/3hours with mineral mix 1,08cc

Planning:
Consult Hematology-Oncology
Screening HIV
Consult Alergi and Imunology
Consult Nutrition an Metabolic Disease
Mantoux Test
Consult Respirology

November 25th 2014


S
Diarrhea (-), Vomiting (-), Fever (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 37,8 0C . Body weight: 5,4 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :110bpm, reguler, murmur (-), RR: 30 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 116 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 100/70 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Susp. Tuberculosis + Susp. HIV
- Cotrimoxsazole syr 2 x cth
P
- Folic Acid 1 x 1mg
- Multivitamin without Fe 1 x 1 cth
- Vit A 1 x 20.000 IU
- Die F75 90cc/3hours with mineral mix 1,08cc

Planning:

November 26th 2014


S

Diarrhea (-), Vomiting (-), Fever (+)

Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body Temperature : 37,8 0C .
Body weight: 5,4 kg, Body length: 73 cm. BW/age: <-3SD, BL/age: <-3SD, BW/BL: <-3SD

Head

Face: old man face (+)


Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)

Neck

VJP: R-2 cmH2O, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :100bpm, reguler,
murmur (-), RR: 28 x/i, regular, rales (-).

Abdomen

Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.

Extremities Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, Blood
Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Genital

Male, within normal limit

Marasmus + Susp. Tuberculosis + Susp. HIV

Counseling HIV result:


HIV risk factor from blood transfusion
Planning:
Fe profile
Rapid Test 3 methods

Inj. Ceftriaxone 300mg/12hr/IV


Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
Diet F75 90cc/3hours with mineral mix 1,08cc
INH prophylaxis 1 x 30mg
Candistatin Oral drop

November 27th 2014


S
Diarrhea (-), Vomiting (-), Fever (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 37,8 0C . Body weight: 5,4 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Susp. Tuberculosis + Susp. HIV
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
INH prophylaxis 1 x 30mg
Diet F100 90cc/3hours with mineral mix 1,8cc
Candistatin Oral drop
Mantoux Test Result:
Induration 0 mm

November 28th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), Diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,1 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD , MUPC: 9cm
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 130cc/3hours with mineral mix 2,6cc (day 1) via oral
Candistatin Oral drop

November 29th 2014


S
Diarrhea (-), Vomiting (-), Fever (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,1 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD MUPC : 9cm
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva
pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
es
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Genital
Male, within normal limit
A
Marasmus + Tuberculosis + Susp. HIV
P
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
-

FDC RHZ 1x1tab


B6 1x10mg

Diet F100 130cc/3hours with mineral mix 2,6cc (day 2) via oral
Candistatin Oral drop
Planning:
-

November 30th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), Diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,1 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
es
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Genital
Male, within normal limit
A
Marasmus + Tuberculosis + Susp. HIV
Diet F100 130cc/3hours with mineral mix
P
Inj. Ceftriaxone 300mg/12hr/IV
2,6cc (day3) via oral
Cotrimoxsazole syr 2 x cth
Candistatin Oral drop
Folic Acid 1 x 1mg
PRC transfusion 35cc
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg

Lab Result:
Hb: 9,7, Ht: 31,2 L:5930 T: 194000

December 1st 2014


S
Diarrhea (-), Vomiting (-), Fever (-), Diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra onjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:
-

December 2nd 2014


S
Diarrhea (+), Vomiting (-), Fever (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,4 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD MUPC : 9cm
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:
-

December 3rd 2014


S
Diarrhea (-), Vomiting (-), Fever (-), Diet is done (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6 kg, Body length: 73 cm. BW/age: <-3SD, BL/age:
<-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:
-

December 4th 2014


S
Diarrhea (-), Vomiting (-), Fever (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva
pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
es
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Genital
Male, within normal limit
A
Marasmus + Tuberculosis + Susp. HIV
P
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop

Hasil Lab:
Ferritin: 526,2, Fe: 42, TIBC 180

December 5th 2014


S
Diarrhea (-), Vomiting (-), Fever (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva
pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV + Anemia Iron Deficiency
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet Soft food 1000kkal + 12gr protein
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:

December 6th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), Diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis + Susp. HIV + Anemia Iron Deficiency
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet Soft food 1000kkal + 12gr protein
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:

December 7th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis+ Susp. HIV + Anemia Iron Deficiency
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet Soft food 1000kkal + 12gr protein
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:

December 8th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,8 kg, Body length: 73 cm. BW/age: <-3SD,
BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva
pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible (+) HR :
100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdomen Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
Extremiti
es
Genital
A
P

Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume, warm acral,
CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/+)
Male, within normal limit
Marasmus + Tuberculosis+ Susp. HIV + Anemia Iron Deficiency
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet Soft food 1000kkal + 12gr protein
Diet F100 130cc/3hours with mineral mix 2,6cc
Candistatin Oral drop
Planning:

December 9th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,8 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis+ Susp. HIV + Anemia Iron Deficiency
- Inj.
P
Ceftriaxone - FDC RHZ 1x1tab
- B6 1x10mg
300mg/12hr/IV
- Cotrimoxsazole syr 2 x cth - Diet Soft food 1000kkal + 12gr protein
- Folic Acid 1 x 1mg
- Diet F100 130cc/3hours with mineral
- Multivitamin without Fe 1 x 1
mix 2,6cc
- Candistatin Oral drop
cth

December 10th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,5 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj.
P
Ceftriaxone - Diet Soft food 1000kkal + 12gr protein
- Diet F100 130cc/3hours with mineral
300mg/12hr/IV
- Cotrimoxsazole syr 2 x cth
mix 2,6cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 - Lamivudin pulv 2x24mg
- Stavudin pulv 2x6mg
cth

December 11th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (-)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,5 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV - Diet Soft food 1000kkal + 12gr
P
- Cotrimoxsazole syr 2 x cth
protein
- Folic Acid 1 x 1mg
- Diet F100 130cc/3hours with mineral
- Multivitamin without Fe 1 x 1
mix 2,6cc
- Candistatin Oral drop
cth
- Vit A 1 x 20.000 IU
- Lamivudin pulv 2x24mg

December 12th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV
- Diet F100 150cc/3hours with
P
- Cotrimoxsazole syr 2 x cth
mineral mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 cth
- Lamivudin pulv 2x24mg
- Vit A 1 x 20.000 IU
- Stavudin pulv 2x6mg
- FDC RHZ 1x1tab
- Nevirapin 2x64mg

December 13th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV - Diet F100 150cc/3hours with mineral
P
- Cotrimoxsazole syr 2 x cth
mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 - Lamivudin pulv 2x24mg
- Stavudin pulv 2x6mg
cth
- Vit A 1 x 20.000 IU
- Nevirapin 2x64mg

December 14th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,6 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV
- Diet F100 150cc/3hours with
P
- Cotrimoxsazole syr 2 x cth
mineral mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 cth
- Lamivudin pulv 2x24mg
- Vit A 1 x 20.000 IU
- Stavudin pulv 2x6mg
- FDC RHZ 1x1tab
- Nevirapin 2x64mg

December 15th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 6,9 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV
- Diet F100 150cc/3hours with
P
- Cotrimoxsazole syr 2 x cth
mineral mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 cth
- Lamivudin pulv 2x24mg
- Vit A 1 x 20.000 IU
- Stavudin pulv 2x6mg
- FDC RHZ 1x1tab
- Nevirapin 2x64mg

December 16th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 7,2 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV
- Diet F100 150cc/3hours with
P
- Cotrimoxsazole syr 2 x cth
mineral mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 cth
- Lamivudin pulv 2x24mg
- Vit A 1 x 20.000 IU
- Stavudin pulv 2x6mg
- FDC RHZ 1x1tab
- Nevirapin 2x64mg

December 17th 2014


S
Diarrhea (-), Vomiting (-), Fever (-), diet is done (+)
O
Sens: Alert, Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body
Temperature : 36,8 0C . Body weight: 7,2 kg, Body length: 73 cm. BW/age: <3SD, BL/age: <-3SD, BW/BL: <-3SD
Head
Face: old man face (+)
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+)
Hair: easily removed
Nose and ear were within normal limit. Mouth: oral thrush (+)
Neck
VJP: R-2 cmH2O, Lymph node enlargement (-).
Thorax
Symmetrical fusiformis, Chest retraction (-), intercostal space clearly visible
(+) HR :100bpm, reguler, murmur (-), RR: 28 x/i, regular, rales (-).
Abdome Soepel. Normoperistaltic. Liver, spleen and renal unpalpable.
n
Extremit Baggy pants (+), pulse 110 bpm, regular, adequate pressure and volume,
ies
warm acral, CRT < 3, Blood Pressure 90/60 mmHg, Plantar palmar pale (+/
+)
Genital Male, within normal limit
A
Marasmus + Tuberculosis + HIV + Anemia Iron Deficiency
- Inj. Ceftriaxone 300mg/12hr/IV
- Diet F100 150cc/3hours with
P
- Cotrimoxsazole syr 2 x cth
mineral mix 3cc
- Folic Acid 1 x 1mg
- Candistatin Oral drop
- Multivitamin without Fe 1 x 1 cth
- Lamivudin pulv 2x24mg
- Vit A 1 x 20.000 IU
- Stavudin pulv 2x6mg
- FDC RHZ 1x1tab
- Nevirapin 2x64mg

Discussion

MG, male, 2 years and 2 months old, was reffered to RSUP HAM at
November 23 th 2014 from Pediatrician with the diagnosed of
Marasmus and susp HIV.
For a diagnosis of Marasmus a
case must be:
1. Hitory taking (descreas of
weight, food dietery,
previous illness, anorexia)
2. Physical Examination: very
wasted, old man face,
baggy pants, intercostal is
clearly visible, hipotrophy
muscle
3. Antrhopometry: weight for
height must be < -3SD
(WHO), MUPC < 11,5cm,
very wasted.
4. Laboratorium (Anemia,
Hipoglichemy,
hiponatremi)

Clinical findings :
Weight is not age appropriate,
anorexia, decreas of weight
Physical examination : very
wasted, old man face (+),
baggy pants, intercostal is
clearly visible, hypotrophy
musle.
Antrophometry: weight for
height < -3SD, MUPC: 8,8cm,
and very wasted, oedem (-)
Laboratorium: Hb 4,9g/dl
(Anemia)

Etiology of
Marasmus:
1.Nutrition
2.Infection (TB,
pneumonia,
diarrhea, HIV)
3.SocioEconomic

In this patiens:
The etiology are
nutrition and
infection, who
patient had bad
dietery, and the
patient had been
diagnosed with HIV
and tuberculosis

Conclusion
The conclusion of this paper is a boy, 2 years and 2 months
old, diagnosed with Marasmus, HIV, Tuberculosis, Anemia iron
deficiency. The patient received :
Inj. Ceftriaxone 300mg/12hr/IV
Cotrimoxsazole syr 2 x cth
Folic Acid 1 x 1mg
Multivitamin without Fe 1 x 1 cth
Vit A 1 x 20.000 IU
FDC RHZ 1x1tab
B6 1x10mg
Diet F100 150cc/3hours with mineral mix 3cc
Candistatin Oral drop
Lamivudin pulv 2x24mg
Stavudin pulv 2x6mg
Nevirapin 2x64mg