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Study Guide Block Growth and Development
CURRICULUM
Aims:
 To assess growth and development in children and adolescents.
 To diagnose, manage, and refer if required, common disorders of growth and
development.
 Awareness of the general means to assess fetal growth (intrauterine growth).
 Awareness of the common health implications of normal and abnormal aging.
Learning outcomes:
 Assess physical growth of children and adolescents.
 Diagnose and manage common nutritional problems in children and adolescents.
 Investigate infant or child with suspect failure to thrive.
 Identify common congenital anomalies in infants and children.
 Assess fetal growth (intrauterine growth).
 Assess development of children in specific domains.
 Awareness of common developmental disorders in children.
 Awareness of the normal sexual developmental sequence in children and
adolescents.
 Capability to evaluate critically the use of medicine in pregnancy, children, and
elderly.
 Detection of developmental deviation in children (Screening & Stimulation).
 Awareness of the impacts of aging on the common health parameters of the elderly.
 Awareness of the common clinical manifestations and disorders in the elderly.
 Diagnose and manage common health problems and disorders in the elderly.
Curriculum contents:
 Normal growth patterns in children and adolescents.
 Nutritional impacts on growth (and development) in infant, children and adolescents.
 Clinical manifestations and diagnosis of failure to thrive.
 Common congenital anomalies in infants and young children.
 Clinical assessment of intrauterine growth (fetal growth).
 Drug recommendation and toxicity on pregnancy and Children.
 Assess development of children and adolescents in specific domains.
 Methods of developmental deviation detection and stimulation.
 Common developmental disorders in children and adolescents.
 Diagnose common sexual developmental problems in children and adolescents.
 Aging and physiologic changes in health parameters.
 Common clinical manifestations and problems and management in the elderly.
Udayana University Faculty of Medicine, DME
1
Study Guide Block Growth and Development
PLANNERS TEAM
NO
1.
2.
3.
4.
5.
6.
7.
NAME
Dr.dr. I G A Trisna Windiani, SpA (K)
(Head)
dr. I Nyoman G. Wardana, M.Biomed
(Secretary)
Prof. dr. Soetjiningsih, SpAK, IBCLC
Prof.Dr.dr.I Nym Mangku K, M.Repro
dr. Eka Putra S, Sp.THT
dr. Wayan Eka Sutyawan, SpM
Dr.dr. R A Tuty Kuswardhani, SpPD
(K.Ger).,MARS
DEPARTMENT
Child Health
Anatomy
Child Health
Anatomy
ENT
Ophthalmology
Geriatri
GROWTH AND DEVELOPMENT LECTURERS
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
NAME
Prof. dr. Soetjiningsih, SpAK, IBCLC
Dr.dr. I G A Trisna Windiani, SpA (K)
dr. I Made Kardana, SpA
dr. IGusti Agung Ngurah Sugitha
Adnyana, SpA
dr. AAN Prayoga, SpA
dr. Made Suksmawati, SpA
dr. Made Arimbawa, SpA
dr. IGA Endah Ardjana, SpKJ
dr. I Gusti Lanang Sudiartha, SpA
dr. Dewi Sutriani Mahalini, SpA
Prof.Dr.dr.I Nym Mangku K, M.Repro
dr. Eka Putra S, Sp.THT
dr. Wayan Eka Sutyawan, SpM
Dr.dr. R A Tuty Kuswardhani, SpPD
(K.Ger).,MARS
dr. Nyoman Astika, SpPD
dr. I GK Arijana, MSi.Med
Dr.dr. Made Jawi, M.Kes
Dra. Adijanti Marheni, M.Si
Udayana University Faculty of Medicine, DME
DEPARTMENT
Child Health
Child Health
Child Health
Child Health
Child Health
Child Health
Child Health
Child Health
Child Health
Child Health
Anatomy
ENT
Ophthalmology
Geriatri
Geriatri
Histology
Pharmacology
Psychology
2
Study Guide Block Growth and Development
~FACILITATORS ~
REGULAR CLASS
NO
GROUP
DEPT
PHONE
VENUE
1
Radiology
081805673099
2
Dr.dr. Elysanti Dwi Martadiani,
Sp.Rad
dr. Reni Widyastuti, S.Ked
2
Pharmacology
08174742501
3
dr. Ni Ketut Putri Ariani, Sp.KJ
3
Psychiatry
082237817384
4
dr I Gusti Agung Gede Utara
Hartawan, Sp.An, MARS
dr. Ni Luh Ariwati
4
Anasthesi
08123868126
5
Parasitology
08123662311
6
Histology
08124665966
7
Microbiology
08553711398
8
dr. I G Kamasan Nyoman
Arijana, M.Si, Med
Dr.dr. Ni Nyoman Sri
Budayanti, Sp.MK(K)
dr. Ni Nyoman Mahartini, Sp.PK
8
081337165577
9
dr. I Wayan Sugiritama, M.Kes
9
Clinical
Pathology
Histology
10
dr. Ryan Saktika Mulyana,
M.Biomed, Sp.OG
10
Obgyn
082147087905
2nd floor:
R.2.01
2nd floor:
R.2.02
2nd floor:
R.2.03
2nd floor:
R.2.04
2nd floor:
R.2.05
2nd floor:
R.2.06
2nd floor:
R.2.07
2nd floor:
R.2.08
2nd floor:
R.2.21
2nd floor:
R.2.22
GROUP
1
DEPT
Forensic
PHONE
081338472005
2
Pediatri
081353027973
3
dr. I Nyoman Budi Hartawan,
M.Sc., Sp.A(K)
dr. I Wayan Surudarma, M.Si
3
Biochemistry
081338486589
4
dr. I Gusti Ayu Artini, M.Sc
4
Pharmacology
08123650481
5
dr. I Ketut Mariadi, Sp.PD
5
Interna
08123853700
6
Dr.dr. Ni Made Linawati, M.Si
6
Histology
081337222567
7
dr. I Nyoman Gede Wardana, M
Biomed
dr. I Wyn Subawa, Sp.OT
7
Anatomy
087860405625
8
Orthopaedy
Dr.rer.Nat. dr. Ni Nyoman Ayu
Dewi, M.Kes
dr. I Komang Arimbawa, Sp.S
9
Biochemistry
081338913087
081337096388
081337141506
10
Neurology
081338226892
1
5
6
7
NAME
08164732743
ENGLISH CLASS
NO
1
2
8
9
10
NAME
dr. Kunthi Yulianti, Sp.KF
Udayana University Faculty of Medicine, DME
VENUE
2nd floor:
R.2.01
2nd floor:
R.2.02
2nd floor:
R.2.03
2nd floor:
R.2.04
2nd floor:
R.2.05
2nd floor:
R.2.06
2nd floor:
R.2.07
2nd floor:
R.2.08
2nd floor:
R.2.21
2nd floor:
R.2.22
3
Study Guide Block Growth and Development
TIME TABLE
Regular Class
DAY/
DATE
1
Monday
18 Jan 16
TIME
2
19 Jan 16
3
Wednesday
20 Jan 16
4
Thursday
21 Jan 16
5
Friday
22 Jan 16
CONVEYER
LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS
08.00 – 08.30
Intro: General Concepts of Growth and Development
Prof. Soetji
08.30 – 09.00
Lecture 1:Assessment Physical Growth of Children
Prof. Soetji
And Adolescents
09.00 – 11.30
Independent Learning + Learning Task
11.30 – 12.30
Break
LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH)
12.30 – 13.30
Lecture 2: The Stages of Prenatal Development
Mangku K
13.30 – 15.00
Independent Learning + Learning Task
08.00 – 08.30
08.30 – 09.00
Tuesday
ACTIVITY
09.00 – 11.30
11.30 – 12.30
Lecture 3: Embriology of Fetal Growth
Lecture 4: Assessment Growth and Development in
Neonatus
Independent Learning + Learning Task
Break
Mangku K
Suksmawati
LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND
CHILDREN
12.30 – 13.30
Lecture 5: Prenatal Genetic Evaluation and
Arijana
Counseling
13.30 – 15.00
Independent Learning + Learning Task
LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN
PREGNANCY, CHILDREN, AND ELDERLY
08.00 – 09.00
Lecture6: Drugs in Pregnancy, Children, and Elderly
Jawi
09.00 – 11.30
Independent Learning + Learning Task
11.30 – 12.30
Break
LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN
CHILDREN AND ADOLESCENTS
12.30 – 13.00
Lecture 7: Principles Breastfeeding for Infants With
Prof. Soetji
Normal Delivery
13.00 – 13.30
Lecture 8: Principles
Kardana
Feeding for Infants With Complicated Delivery
13.30 – 15.00
Independent Learning
08.00 – 09.00
Lecture 9: Vitamin A, Fe & Iodine Deficiencies
Prayoga
09.00 – 11.30
Independent Learning + Learning Task
11.30 – 12.30
Break
12.30 –13.30
Lecture 10: Protein Energy Malnutrition (PEM) &
Lanang
Obesity
13.30 – 15.00
Independent Learning + Learning Task
08.00 – 10.00 SGD LO 1- 5
Facilitator
10.00 – 11.00 Break
LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE
11.00 – 12.00
Lecture 11: Failure to Thrive
Lanang
12.00 – 13.30
Independent Learning + Learning Task
13.30 – 15.00
Break
LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS
08.00 – 08.30
Lecture 12: Assess Development in Motoric
Udayana University Faculty of Medicine, DME
Sugitha
4
Study Guide Block Growth and Development
6
Friday
22 Jan 16
7
Tuesday
26 Han 16
8
Wednesday
27 Jan 16
9
Thusday
28 Jan 16
10
Friday
29 Jan 16
Domains
Lecture 13: Assess Development in Language
Sugitha
Domains
09.00 – 11.30
Independent Learning + Learning Task
11.30 – 12.30
Break
LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN
(SCREENING AND STIMULATION)
12.30 – 13.00
Lecture 14: Cognitive Development
Marheni
13.00 – 13.30
Lecture 15: Psychosocial Development
Marheni
13.30 – 15.00
Independent Learning + Learning Task
08.00 – 09.00 Lecture 16: Detection of Developmental Deviation In
Trisna
Children (Screening & Stimulation)
09.00 – 10.30 Individual Learning + Learning Task
10.30 – 12.30 SGD 2 (LO 6-8)
12.30 – 13.30 Break
Facilitator
13.30 – 15.00 Individual Learning + Learning Task
LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE
IN CHILDREN AND ADOLESCENT
08.00 – 09.00
Lecture 17: Sexual
Arimbawa
Developmental Sequence in Children and Adolescent
09.00 – 11.30
Independent Learning + Learning Task
11.30 – 12.30
Break
08.30 – 09.00
LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN
CHILDREN
12.30 – 13.00
Lecture 18: Visual Impairment
Eka Sutyawan
13.00 – 13.30
Lecture 19: Hearing Impairment
Eka Putra
13.30 – 15.00
Independent Learning + Learning Task
08.00 – 08.30
08.30 – 09.00
09.00 – 11.30
11.30 – 12.30
12.30 – 13.00
13.00 – 13.30
13.30 – 15.00
08.00 – 09.00
09.00 – 11.30
11.30 – 13.30
13.30 – 14.30
14.30 – 15.00
Lecture 20: Learning Disorders
Lecture 21: Down Syndrome and Mental Retardation
Independent Learning + Learning Task
Break
Lecture 22: Attention Deficit/Hyperactivity Disorders
Lecture 23: Autism Spectrum Disorders
Independent Learning + Learning Task
Lecture 24: Cerebral Palsy
Independent Learning + Learning Task
SGD 3 (LO 9-10)
Independent Learning + Learning Task
Break
Endah
Endah
Trisna/Endah
Sugitha
D. Sutrini
Facilitators
LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS
11
Monday
1 Feb 16
12
Tuesday
2 Feb 16
08.00 – 09.00
09.00 – 11.30
11.30 – 12.30
12.30 – 13.30
13.30 – 15.00
08.00 – 10.00
10.00 – 11.00
11.00 – 12.00
12.00 – 13.00
13.00 – 14.00
14.00 – 15.00
Lecture 25: Aging Process
Independent Learning + Learning Task
Break
Lecture 26: Clinical Implication of Aging Process
Independent Learning + Learning Task
SP Presentation
SGD 3 (LO 11)
Lecture: General Principles of Physical Examination
Lecture: Vital Sign Measurement
Break
Independent Learning
Udayana University Faculty of Medicine, DME
Tuty K
N Astika
Facilitators
Tim
Ratna S
Ratna S
5
Study Guide Block Growth and Development
13
SILENT DAY
Wednesday
3 Feb 16
14
Thursday
EXAMINATION
4 Feb 16
Venue: 402 (4th Floor)
TIME TABLE
English Class
DAY/
DATE
1
Monday
18 Jan 16
TIME
Tuesday
19 Jan 16
3
Wednesday
20 Jan 16
CONVEYER
LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS
09.00 – 09.30
Intro: General Concepts of Growth and Development
Prof. Soetji
09.30 – 10.00
Lecture 1:Assessment Physical Growth of Children
Prof. Soetji
And Adolescents
10.00 – 12.30
Independent Learning + Learning Task
12.30 – 13.30
Break
LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH)
13.30 – 14.30
Lecture 2: The Stages of Prenatal Development
Mangku K
14.30 – 16.00
Independent Learning + Learning Task
09.00 – 09.30
09.30 – 10.00
2
ACTIVITY
10.00 – 12.30
12.30 – 13.30
Lecture 3: Embriology of Fetal Growth
Lecture 4: Assessment Growth and Development in
Neonatus
Independent Learning + Learning Task
Break
Mangku K
Suksmawati
LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND
CHILDREN
13.30 – 14.30
Lecture 5: Prenatal Genetic Evaluation and
Arijana
Counseling
14.30 – 16.00
Independent Learning + Learning Task
LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN
PREGNANCY, CHILDREN, AND ELDERLY
09.00 – 10.00
Lecture6: Drugs in Pregnancy, Children, and Elderly
Jawi
10.00 – 12.30
Independent Learning + Learning Task
12.30 – 13.30
Break
LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN
CHILDREN AND ADOLESCENTS
13.30 – 14.00
Lecture 7: Principles Breastfeeding for Infants With
Prof. Soetji
Normal Delivery
14.00 – 14.30
Lecture 8: Principles
Kardana
Feeding for Infants With Complicated Delivery
14.30 – 16.00
Independent Learning
Udayana University Faculty of Medicine, DME
6
Study Guide Block Growth and Development
4
Thursday
09.00 – 10.00
10.00 – 12.30
12.30 – 13.30
13.30 –14.30
21 Jan 16
5
Friday
22 Jan 16
14.30 – 16.00
09.00 – 10.00
10.00 – 12.00
Lecture 9: Vitamin A, Fe & Iodine Deficiencies
Independent Learning + Learning Task
Break
Lecture 10: Protein Energy Malnutrition (PEM) &
Obesity
Independent Learning + Learning Task
Break
SGD 1 (LO 1-5)
Prayoga
Lanang
Facilitator
LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE
12.00 – 13.00
Lecture 11: Failure to Thrive
Lanang
13.00 – 14.30
Independent Learning + Learning Task
14.30 – 16.00
Break
LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS
09.00 – 09.30
6
Friday
22 Jan 16
7
Tuesday
26 Han 16
8
Wednesday
27 Jan 16
9
Thusday
28 Jan 16
10
Friday
29 Jan 16
Lecture 12: Assess Development in Motoric
Sugitha
Domains
09.30 – 10.00
Lecture 13: Assess Development in Language
Sugitha
Domains
10.00 – 12.30
Independent Learning + Learning Task
12.30 – 13.30
Break
LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN
(SCREENING AND STIMULATION)
13.30 – 14.00
Lecture 14: Cognitive Development
Marheni
14.00 – 14.30
Lecture 15: Psychosocial Development
Marheni
14.30 – 16.00
Independent Learning + Learning Task
09.00 – 10.00 Lecture 16: Detection of Developmental Deviation In
Trisna
Children (Screening & Stimulation)
10.00 – 11.30 Individual Learning + Learning Task
11.30 – 12.30 Break
12.30 – 14.30 SGD 2 (LO 6-8)
Facilitator
14.30 – 16.00 Individual Learning + Learning Task
LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE
IN CHILDREN AND ADOLESCENT
09.00 – 10.00
Lecture 17: Sexual
Arimbawa
Developmental Sequence in Children and Adolescent
10.00 – 12.30
Independent Learning + Learning Task
12.30 – 13.30
Break
LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN
CHILDREN
13.30 – 14.00
Lecture 18: Visual Impairment
Eka Sutyawan
14.00 – 14.30
Lecture 19: Hearing Impairment
Eka Putra
14.30 – 16.00
Independent Learning + Learning Task
09.00 – 09.30
09.30 – 10.00
10.00 – 12.30
12.30 – 13.30
13.30 – 14.00
14.00 – 14.30
14.30 – 16.00
09.00 –10.00
10.00 – 10.30
12.30 – 13.30
13.30 – 15.30
15.30 – 16.00
Lecture 20: Learning Disorders
Lecture 21: Down Syndrome and Mental Retardation
Independent Learning + Learning Task
Break
Lecture 22: Attention Deficit/Hyperactivity Disorders
Lecture 23: Autism Spectrum Disorders
Independent Learning + Learning Task
Lecture 24: Cerebral Palsy
Break
Independent Learning + Learning Task
SGD 3 (LO 9-10)
Independent Learning + Learning Task
Udayana University Faculty of Medicine, DME
Endah
Endah
Trisna/Endah
Sugitha
D. Sutrini
Facilitators
7
Study Guide Block Growth and Development
LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS
11
Monday
1 Feb 16
12
Tuesday
2 Feb 16
09.00 – 10.00
10.00 – 12.30
12.30 – 13.30
13.30 – 14.30
14.30 – 16.00
09.00 – 10.00
10.00 – 12.00
12.00 – 13.00
13.00 – 14.00
14.00 – 15.00
15.00 – 16.00
Lecture 25: Aging Process
Independent Learning + Learning Task
Break
Lecture 26: Clinical Implication of Aging Process
Independent Learning + Learning Task
SGD 3 (LO 11)
SP Presentation
Break
Lecture: General Principles of Physical Examination
Lecture: Vital Sign Measurement
Individual Learning
13
Wednesday
Tuty K
N Astika
Facilitators
Tim
Ratna S
Ratna S
SILENT DAY
3 Feb 16
14
Thursday
EXAMINATION
4 Feb 16
Venue: 402 (4th Floor)
Udayana University Faculty of Medicine, DME
8
Study Guide Block Growth and Development
~ LEARNING PROGRAMS ~
LECTURE
Introductory lecture: General Concepts of
Growth and Development
Prof. dr. Soetjiningsih, SpAK, IBCLC
Learning outcomes
- To describe the general concept of growth and development
- To describe the stages in lifespan development
- To understand the conceptual differences between growth and development
- To describe the factors that may affect growth and development
Abstract
Lifespan development is a field of study that examines patterns of growth, change,
and stability in behavior that occur throughout the entire life span. The life span is usually
divided into broad age ranges: the prenatal period (the period from conception to birth);
infancy and toddler hood (birth to age 3); the preschool period (ages 3 to 6); middle
childhood (ages 6 to 12); adolescence (ages 12 to 20); young adulthood (ages 20 to 40);
middle age (ages 40 to 60); and late adulthood (age 60 to death).
Lifespan development specialists discuss development in several topics: physical
development (development involving the body’s physical make up, including the brain,
nervous system, muscles, senses, and the need for food, drink and sleep); cognitive
development (development involving the ways that growth and change in intellectual
capabilities influence a person’s behavior); personality development (development
involving the ways that enduring characteristics that differentiate one person from
another change over the life span); and social development ( the way in which
individuals’ interactions with others and their social relationships grow, change, and
remain stable over the course of life).
Growth and development are an integral process. Growth refer to the metabolic
change by which an organism increases in size and changes shape. Growth refers to
quantitative changes.
Changes in physical size and appearance are visible
manifestations of the complex morphologic, biochemical and physiologic changes taking
place during childhood.
Child development is a process, a continuous series of purposeful changes,
consisting of many aspects, moving together at differing paces. Development refers to
qualitative and quantitative changes. There are 10 fundamental principles of
development:
1. Development involves change
2. Early development is more critical than later development
3. Development is the product of maturation and learning
4. The developmental pattern is predictable
5. The developmental pattern has predictable characteristics
6. There are individual differences in development
7. There are periods in the developmental pattern
8. There are social expectations for every developmental period
9. Every area of development has potential hazards
10. Happiness varies at different periods in development
Udayana University Faculty of Medicine, DME
9
Study Guide Block Growth and Development
Environmental and genetic factors influence growth and development. In
Bronfenbrenner’s ecological system theory, development is influenced at four levels: the
microsystem, mesosystem, exosystem and macrosystem.
Lecture 1:
~ Assessment Physical Growth of
Children and Adolescents ~
Prof. dr. Soetjiningsih, SpAK, IBCLC
Learning outcomes
- Describe the clinical importance of study physical growth
- Describe the normal patterns of the physical growth
- Understand factors that affecting physical growth
- Use of common growth parameter
Abstract
Physical growth usually refers to changes in size or mass. The most people usually
think of growth at the level of the whole child, the cells and internal structures that make
up the child, primarily by increasing in number or size.
Growth assessment is essential because almost any problems within the physiologic,
interpersonal and social domains can adversely affect growth. Anthropometry is an
effective and frequently performed child health screening procedure. The value of
physical growth data depends on their accuracy and reliability, how they are recorded
and interpreted, and what follow-up efforts are made after identification of growth
abnormality.
The most powerful tool in growth assessment is the growth chart. Whenever possible,
growth should be assessed by plotting accurate measurements on growth charts and
comparing each set of measurements with previous measurements. The CDC Growth
Charts 2000 are used to measure growth, consist of 16 charts including “Body mass
index (BMI) for-age percentile” for boys and girls aged 2-20 years.
Normal growth patterns have spurts and plateaus, but some shifting on the percentile
graphs can be expected; however, large shifts warrant attention. Large discrepancies
among height, weight, and head circumference percentiles also diserve attention.
Deviation in growth patterns are nonspecific but important indicators of serious medical
disorders. Deviations often provide the first clue that something is wrong, occasionally
even when the parents do not suspect a problem. An accurate measurement of height,
weight, and head circumference should be obtained at every health supervision visit.
Serial measurements are much more useful than single measurements because they
can help detect deviations from a particular child’s growth pattern even if the value
remains within statistically defined normal limits.
Factors affecting physical growth and health in infancy and toddlerhood continue to
be influential in early childhood. Heredity affects physical growth by regulating the
production of hormones. Extreme emotional deprivation can interfere with the production
of growth hormone, thereby stunting children's growth. Sleep difficulties, in the form of
night waking and nightmares, are common during the preschool years. Appetite decline
is associated with a slower rate of physical growth. Disease can lead to malnutrition,
seriously undermining children's growth, an effect that is especially common in
developing countries.
Udayana University Faculty of Medicine, DME
10
Study Guide Block Growth and Development
Lecture 2:
~ The Stages of Prenatal
Development ~
Nym Mangku Karmaya
Learning outcomes
Describe the main stages of embryonic development for use to estimate the gestational
age of embryo.
Abstract
Early embryonic development is describe in stages because of the variable period it
takes for embryos to develop certain morphological characteristics. Stage 1 of
development begins at fertilization and embryonic development ends at stages 23, which
occur on day 57 and ends when he fetus is completely outside the mother. The stages of
embryonic development can be assessed by ultrasonography. In general the period of
prenatal development is as follows:
 1st week
: zygote-blastomeres-morula-blastocyst.
 2nd week
: bilaminar germ disc
 3rd week
: trilaminar germ disc
rd
th
 3 - 8 week
: embryonic period/organogenesis
 8th week-BIRTH
: fetal period
Lecture 3:
~ Embryology of Fetal Growth~
Mangku Karmaya
Learning outcomes
- ~ soon will be added ~
Abstract
In a low-risk pregnancy, the abdomen is measured at prenatal visits to assess the
baby's growth. The measurement in centimeters from the top of your pubic bone to the
top of your uterus (the fundus) should be about the same as the number of weeks you
are pregnant, with an allowance of up to 2 cm either way. For example, if you are 26
weeks' pregnant, you should measure between 24 and 28 cm. Your fundal height can be
measured between 24 and 36-37 weeks, since once your baby "drops" into the pelvis in
late pregnancy, the measurement may not reflect his or her true size. If there is a
variation of 3 cm or more, your doctor will arrange for an ultrasound to check your baby's
growth and the amount of amniotic fluid. If the scan indicates a problem, the doctor will
arrange for scans every two weeks since analyzing growth patterns over time gives a
more accurate assessment of whether your baby's growth is normal.
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Lecture 4:
~ Assessment of Growth and Development
in Neonatus
Dharma Artana
Learning outcomes
- Apply the New Ballard Score to assess the gestational age of infant: the small for
gestational age (SGA), appropriate for gestational age (AGA), or large for
gestational age (LGA).
Abstract
Since the late 1960s, a variety of methods for assessing the gestational age of the
newborn infant have been developed. Currently, the most widely use system for the
postnatal assessment of gestational age is the New Ballard Score (NBS). This system
includes both physical and neurologic characteristics. The score spans from 10
(correlating with 20 weeks’ gestation) to 50 (correlating with 44 weeks gestation). The
examination consists of six neuromuscular criteria and six physical criteria. The
neuromuscular criteria are based on the understanding that passive tone is more useful
than active tone in indicating gestational age. The neuromuscular maturity includes:
posture, square window, arm recoll, popliteal angel, scarf sign, and heal to ear. The
physical maturity includes: skin, lanugo hair, plantar surface, breast, ear and ear, and
genitalia. The examination of NBS is administered twice by two different examiners to
ensure objective, and the data entered on the chart.
Lecture 5:
~ Prenatal Genetic Evaluation and Counseling ~
I GK Arijana
Abstract
Genetic counseling is a process of communication and education which
addresses concerns relating to the development and/or transmission of a hereditary
disorder. The process involves several steps, namely diagnosis (based on accurate
family history, medical history, examination and investigations), risk assessment,
communication, discussion of options, long-term contact and support. Diagnosis is the
most crucial step due to if the diagnosis is incorrect hence the result is inappropriate
information and tragic consequences. The next step is risk assessment, meaning
calculating the recurrence risk for the next pregnancy (recurrence risks should be
quantified, qualified and placed in context). Discussion of options like prenatal diagnosis
or others reproductive options (donor sperm, donor ova, and preimplantation genetic
diagnosis). Communication meaning two-way process of information, not only from
counselor. Long-term contact and support meaning providing support and
companionship for example like patient supportive group. Finally, genetic counseling
should be non-directive (meaning patients can reach their own decision after full
information from counselor).
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Prenatal diagnosis is one of discussion option (as mentioned above). The
indications for prenatal diagnosis are advanced maternal age, previous child with a
chromosome abnormality, family history of a chromosome abnormality, family history of a
single-gene disorder, family history of a neural tube defect, family history of other
congenital structural abnormalities, abnormalities identified in pregnancy, other high-risk
factors. Techniques which are used in prenatal diagnosis can be divided into 2, namely
invasive and non invasive methods. Invasive methods are including amniocentesis,
chorionic villus sampling, fetoscopy, cordocentesis. Non-invasive methods are including
ultrasound, maternal serum screening, detection of fetal cells in the maternal circulation,
detection of cell-free fetal nucleic acid in the maternal circulation. Preimplantation
Genetic Diagnosis (PGD) is a special case in prenatal diagnosis.
Lecture 6:
~ Drugs in Pregnancy, Children,
and Elderly ~
Made Jawi
Learning outcomes
After completing this lecture, the students should be able to:
- Describe the effect of drugs use in pregnancy.
- To Choose the safe drugs for pregnant women, children, and elderly
Abstract
When a woman becomes pregnant, it is very important for her to lead a healthy life: to
eat plenty of nourishing food, get plenty of rest, and exercise regularly. It is also vital that
she avoid anything that might harm her or her baby-to-be. It is especially important to
give up alcohol, cigarettes, and drugs. For a pregnant woman, drug abuse is doubly
dangerous. First, drugs may harm her own health, interfering with her ability to support
the pregnancy. Second, some drugs can directly impair prenatal development. Both
prescription and over-the-counter drugs can be harmful, for her own health and the
health of her baby-to-be. So a woman should avoid all of them as much as possible, from
the time she first plans to become pregnant or learns that she is pregnant. Some drugs
can be harmful when used at any time during pregnancy; others, however, are
particularly damaging at specific stages. Most of the body organs and systems of the
baby-to-be are formed within the first ten weeks or so of pregnancy (calculated from the
date of the last menstrual period). During this stage, some drugs and alcohol in particular
can cause malformations of such parts of the developing fetus as the heart, the limbs,
and the facial features. After about the tenth week, the fetus should grow rapidly in
weight and size. At this stage, certain drugs may damage organs that are still developing,
such as the eyes, as well as the nervous system. Continuing drug use also increases the
risk of miscarriage and premature delivery. But the greatest danger drugs pose at this
stage is their potential to interfere with normal growth. Intrauterine growth retardation
(IUGR) is likely to result in a low-birth weight baby a baby born too early, too small, or
both. Low-birth weight babies require special care and run a much higher risk of severe
health problems or even death.
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Current Categories for Drug Use in Pregnancy
Category
A
B
C
D
X
Description
Adequate, well-controlled studies in pregnant women have not
shown an increased risk of fetal abnormalities.
Animal studies have revealed no evidence of harm to the fetus;
however, there are no adequate and well-controlled studies in
pregnant women.
Or
Animal studies have shown an adverse effect, but adequate and
well-controlled studies in pregnant women have failed to
demonstrate a risk to the fetus.
Animal studies have shown an adverse effect and there are no
adequate and well-controlled studies in pregnant women.
Or
No animal studies have been conducted and there are no adequate
and well-controlled studies in pregnant women.
Studies, adequate well-controlled or observational, in pregnant
women have demonstrated a risk to the fetus. However, the benefits
of therapy may outweigh the potential risk.
Studies, adequate well-controlled or observational, in animals or
pregnant women have demonstrated positive evidence of fetal
abnormalities. The use of the product is contraindicated in women
who are or may become pregnant.
Both prescription and over-the-counter drugs can be harmful, for children and
elderly. There are a number of pharmacokinetic and pharmacodynamic differences
between children or pediatric, elderly and adult patients. Neonates ( 0 to 1 month),
infants (1 to 12 month) and children of increasing age are not simply small adult.
The drugs used by the elderly are the same as those that a younger person might
take--yet they can have a far different effect. It doesn’t matter whether a person has heart
disease or arthritis, osteoporosis, or high blood pressure, the story is the same: Because
the organ systems tend to function less efficiently as we age, medications are handled
differently by our bodies. Here are some of the most common changes affecting our
health and our response to medicines:
The stomachs may not absorb food and medication as well as they did before.
The kidneys and livers don’t eliminate fluids and toxins in the same efficient manner.
All of the above contribute to the potential harm that medications can cause in the aging
body. If a kidney can’t eliminate a drug after it has done its work, it remains in the body
longer, perhaps causing an overdose or an adverse effect. If someone forgets to take a
medication that regulates the heart or blood pressure, a stroke or heart attack could be
the result.
Any person over the age of 65 who is taking medications in the following categories
should be aware of the potential for increased side effects, overdose, and diminished
efficacy: Antibiotics, Anti histamines, Anti hypertensives, Antiulcer medicines, Blood
thinners, Bronchodilators, Calcium or potassium supplements, Cardiac medications,
Corticosteroids, Estrogens, Over-the-counter drugs containing alcohol (cough and cold
medications) or caffeine, Pain relievers, Psychiatric medications, Skin medications and
creams
In the lecture will be discuss the effects of drugs to the embryo and how to
choose drugs for pregnant women, Children and Elderly
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Lecture 7:
Apply the Principles of Breastfeeding for Infants
with Normal Deliveries
Prof. dr. Soetjiningsih, SpAK, IBCLC
Abstract
Breast-feeding exclusively the recommended method for feeding normal infants
during the first 6 months of life. Breastfeeding should continue with the addition of
appropriate foods, for two years or more.
Breastfeeding has advantages for infants, mothers, families, and society. These
advantages include health, nutritional, immunologic, developmental, psychologic, social,
economic, and environmental benefits. Breast milk contains the right balance of
nutrients to help the infant grow into a strong and healthy toddler. Some of the nutrients
in breast milk also help protect the infant against some common childhood illnesses and
infections. While nutrients and antibodies pass to the baby, beneficial hormones are
released from the mother's body. Colostrums, a high protein and low fat lactose product,
are produced in small amounts during the first few postpartum days. It has some
nutritional value but primarily has important immunologic and maturational properties.
The bond between baby and mother can also be strengthened during breastfeeding.
Breastfeeding doesn't always happen easily. Some new mums find it hard to get
started, while others hit problems later on. Breast tenderness, engorgement, and cracked
nipples are the most common problems encountered by mothers who are breast-feeding.
Lecture 8:
~ The Principles of Feeding for Infants with
Complicated Deliveries ~
Kardana
Learning outcomes
- To know indication of enteral and parenteral nutrition
- To know the type nutrition’s for enteral feeding
- To know the routes of enteral feeding and feeding technique
- To know the administration for parenteral nutrition
- To know the contents of total parenteral nutrition
Abstract
Providing adequate nutrition support to newborns is an important to know and
understanding the maturation, functional and physical disturbances to the baby. Optimal
nutrition after birth enhances future neurodevelopmental outcome. For term healthy
infants should be breast-fed as soon as possible within the first hour. Human milk is
preferred for feeding term, preterm and sick infants. The following criteria should usually
be met before initiating infant’s feedings: no history of excessive oral secretions,
vomiting, or bilous-stained gastric aspirate, non-distended, soft abdomen with normal
bowel sound, and no respiration distress. If the baby is small or complicated baby such
as baby with the following associated conditions: perinatal asphyxia, hemodynamic
instability, sepsis, frequent episodic apnea and bradycardia etc, initiation of enteral
feeding is often precluded and parenteral nutrition can be initiation. Nutritional
requirements in neonate includes: calories to maintain weight and to induce weight gain,
carbohydrates, proteins, fats, vitamins and minerals and fluids.
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Lecture 9:
~ Vitamin A and Fe Deficiency ~
~ Iodine Deficiency ~
A A Ngr Prayoga
~ Vitamin A and Fe Deficiency ~
Learning outcomes
- To understand the sign and symptom of patient with vitamin A and Fe deficiency
- To built diagnosis of patient with vitamin A and Fe deficiency
- To understand the treatment and prevention of patient with vitamin A and Fe
deficiency
Abstract
Vitamin A is the generic term used to describe all retinoid having the biologic
activity of all-trans retinol. Vitamin A, a light yellow crystalline alcohol, has been named
retinol in reference to its specific function in the retina of the eye. The yellow-orange-red
provitamin carotinoids, are describe in the term of beta-carotene
A deficiency of Vitamin A is accompanied by keratinization of the mucous membranes
that line the respiratory tract, the alimentary canal, and the urinary tract, and by
keratinization of the body skin and epithelium of the eye, which lowers the barrier role
played by these membranes in protection of the body against infections. Prolonged
deficiency may produce skin changes, night blindness, and corneal ulceration.
Primary deficiencies of vitamin A are the result of dietary inadequacies. Secondary can
result from liver disease, protein-energy malnutrition, abetalipoproteinemia, or
malabsorption due to bile acid insufficiency. Acute deficiency is treated with large oral
doses of vitamin A and correction of the usually concomitant protein-energy malnutrition.
Massive intermittent dosing with 200,000 IU of vitamin A can reduced mortality by 35 to
70 %.
Iron deficiency anemia is characterized by the production of small erythrocytes
and diminished level of circulating hemoglobin.
The three primary causes of iron deficiency anemia are chronic blood lose, faulty iron
intake or absorption and increased iron requirement.
The clinical findings are fatigue, anorexia, pica (pagophagia). Growth abnormalities,
epithelial disorders, and reduction in gastric acidity are common. Defect in structure and
function of epithelial tissue of tongue, nails, mouth, and stomach as deficiency becomes
more severe.
The chief treatment for iron deficiency consists of oral administration of inorganic iron in
the ferrous form and nutritional care.
~ Iodine Deficiency ~
Learning outcomes
- To understand the sign and symptom of patient with iodine deficiency.
- To built diagnosis of patient with iodine deficiency.
- To understand the treatment and prevention of patient with iodine deficiency.
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Abstract
Iodine is absorbed easily in the form of iodide, in circulation it occurs both as free
and protein-bound iodine. Iodine is stored in the thyroid, where it is used for synthesis of
T3 and T4 when needed.
Lack of iodine intake is associated with the development of endemic or simple goiter,
which is an enlargement of thyroid gland. The deficiency may be absolute, especially in
areas of subnormal iodine intake, or relative subsequent to increased need for thyroid
hormones, such as in the female during adolescence, pregnancy, and lactation. Severe
iodine deficiency during gestation and early postnatal growth results in cretinism, a
syndrome characterized by mental deficiency, spastic diplegia, or quadriplegia, deaf
mutism, dysarthria, a characteristic shuffling gait, shortened stature, and hypothyroidism.
Early diagnosis and treatment are needed to prevent more severe of clinical sign and
symptom
Lecture 10:
~ Protein Energy Malnutrition (PEM) ~
~ Obesity ~
Lanang
~ Protein Energy Malnutrition (PEM) ~
Learning outcomes
- To understand the sign & symptom of patient with protein energy malnutrition
(PEM)
- To built diagnosis of patient with protein energy malnutrition (PEM)
- To understand the treatment and prevention of the patient with protein energy
malnutrition (PEM)
Abstract
Definition
PEM is a spectrum of conditions caused by varying levels of protein and calorie
deficiencies. The common form of primary PEM is marasmus and caused by severe
caloric depletion. Kwashiorkor, presenting with pitting edema caused by inadequate
protein intake in the presence of fair to good caloric intake. Secondary form of PEM is
associated with other diseases.
Clinical manifestation
The clinical manifestation of marasmus: The body weight below 60% of expected for age
or below 70% of the ideal weight for height and depleted body fat stores. Edema usually
is absent. The head may appear large but generally proportional to the body length. The
clinical manifestation of kwashiorkor: presenting pitting edema that starts in lower
extremities and ascends with increasing severity, may be a complication of critical illness
(acute and chronic infections, multiorgan system failure, anorexia nervosa, etc)
Treatment and prevention
Calories account of nutritional rehabilitation can be safety started at 20% above the
child’s recent intake. The calorie intake can be increased 10-20% per day until
appropriate re-growth is initiated. This may require 150% or more of the recommended
calories for an age-matched, well nourished child.
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~ Obesity ~
Learning outcomes
- To understand the sign & symptom of patient with obesity
- To built diagnosis of patient with obesity
- To understand the treatment and prevention of the obesity
Epidemiology
The prevalence of obesity in children has increased in the last 2-3 decades, mainly in
children as young as 4-5 years.
Clinical manifestation
In children BMI (body mass index) age and gender specific percentile curves allow an
assessment of BMI percentile. In adolescent and adult BMI has been used in
weight/height2 (kg/m2).
The effects of obesity complication; such as psychosocial effect, growth (advanced bone
age, increased height, early menarche), CNS (pseudo tumor cerebri, respiratory (sleep
apnea, pickwickian syndrome), cardiovascular (hypertension, cardiac hypertrophy,
ischemic heart disease, sudden death), orthopedic (slipped capital femoral epiphysis,
Blount disease), metabolic (insulin resistance, type II diabetes mellitus,
hypertriglyceridemia, hypercholesterolemia, gout, hepatic steatosis, ovary disease,
cholelithiasis).
Treatment and prevention
The treatment and prevention of obesity includes a combination of education, behavior
modification, exercise and diet.
Lecture 11:
~ Failure to Thrive ~
Lanang
Learning outcomes
1. To apply the diagnostic criteria of patient with failure to thrive (FTT).
2. To discuss the cause or path physiology of patient with FTT.
3. To evaluate and manage a child with FTT.
Definition
The term ‘failure to thrive’ first was used to describe the malnutrition and depressed
condition of many institutionalized infants in early 1900s. It remains a descriptive rather
than a diagnostic label applied to children whose attained weight or rate of weight gain is
significantly below that of other children of similar age and same sex.
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Table Definition of failure to thrive
Attained growth
1. Weight < 3rd percentile on NCHS growth chart
2. Weight for height < 5th percentile on NCHS growth chart
3. Weight 20% or more below ideal weight for height
4. Triceps skin fold thickness < 5 mm
Rate of growth
1. Depressed rate of weight gain
< 20 g/d from 0-3 months of age
< 15 g/d from 3-6 months of age
2. Fall-off from previously established growth curve
Downward crossing of > 2 major percentiles on NCHS growth
chart
3. Documented weight loss
Patho physiology and clinical manifestation
FTT can result from wide range of factors, including serious medical disease,
dysfunctional child-caregiver interactions, poverty, parental misinformation, and child
abuse. The physical examination of a child who is growing poorly should focus on
identifying sign of underlying organic disease, severity of malnutrition, and important
concomitant finding such as evident of physical abuse/neglect or the presence of
deprivational behaviors.
Treatment and prevention
Management of the child with psychosocial failure to thrive must be individualized to the
specific needs of the child and family. Nutritional rehabilitation, efforts are focused on
correcting the dysfunctional child-parent interaction by addressing areas of parental
misinformation, providing and helping to implement specific feeding guidelines, and
addressing the larger psychosocial needs of the family. A multidisciplinary team
approach involving the primary-care provider, nutritionist, social worker, child behavior
specialist, and community-based outreach services is often most beneficial.
Lecture 12 &13:
~ Assess Development in the Motoric and
Language Domains ~
I GA Trisna W
~ Assess Development in The Motoric Domain ~
Learning outcomes:
- Describe gross and motor development
- Determine factors affecting motor development
Abstract
Child developmental consist of several skills like: 1) Gross motor: using large groups
of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions; 2) Fine
motor: using hands to be able to eat, draw, dress, play, write, and do many other things;
3) Language: speaking, using body language and gestures, communicating, and
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understanding what others say; 4) Cognitive: Thinking skills: including learning,
understanding, problem-solving, reasoning, and remembering; 5) Social: Interacting with
others, having relationships with family, friends, and teachers, cooperating, and
responding to the feelings of others.
Developmental milestones are a set of functional skills or age-specific tasks that most
children can do at a certain age range. Milestone can be described as what a child
accomplishes throughout the different stages in their life. We can use milestones to help
check how our child is developing. Although each milestone has an age level, the actual
age when a normally developing child reaches that milestone can very quite a bit. Every
child is unique. To determine whether a child has developmental delay, the physician
must understand normal milestones
The red flag age is the age at which you would expect almost every child to have
already mastered a particular skill. For example walking, most children walk on their own,
without holding on, around their first birthday. By 15 months--the red flag age for walking-a child who has not taken his first independent steps is certainly slower to walk than 90
percent of other children. Red flag milestones are helpful because they put a limit on
when you, as a good, concerned parent, should worry.
Motor development means the development of control over bodily movements
through the coordinated activity of the nerve centers, the nerves and the muscles. This
control comes from the development of the reflexes and mass activity present at birth.
Until this development occurs, the child will remain helpless.
From longitudinal studies of babies and young children, five general principles of
motor development have emerged: 1) motor development depends on neural and
muscular development; 2) learning skills cannot occur until the child is maturationally
ready; 3) motor development follows a predictable pattern; 4) it is possible to establish
norms for motor development; and 5) there are individual differences in rate of motor
development.
Motor development is divided into gross motor and fine motor development. Gross
motor skills refer to the ability of children to carry out activities that require large muscles
or groups of muscles. Muscles or groups of muscles should act in a coordinated fashion
to accomplish a movement or a series of movements. Examples of gross motor tasks are
walking, running, throwing something, jumping, standing on 1 leg, playing hopscotch, and
swimming. Posture is an important element to consider in the assessment of gross motor
skills. Adequate posture may make all the difference between being able or not able to
execute a movement.
Fine motor skills consist of movements of small muscles that act in an organized and
subtle fashion, for instance, the hands, feet, and muscles of the head (as the tongue,
lips, facial muscles), to accomplish more difficult and delicate tasks. Fine motor skills are
the basis of coordination, which begins with transferring from hand to hand crossing the
midline when aged 6 months. Examples of fine motor activities are writing, sewing,
drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words
(which involve coordination of the soft palate, tongue, and lips), blowing bubbles, and
whistling. Many children who have difficulties in their fine motor skills also have
difficulties in articulating sounds or words.
The static and motor development of newborn into adult depends on the maturation
process of the central nervous system. The process of this development is determined by
genetically established patterns of behavior and stimulation from the environment.
Some conditions that influence the rate of motor development. These factors include
genetic constitution, prenatal condition, prematurity, nutrition, physical defects,
stimulation, etc. They may contribute to poor abilities in motor functioning and
coordination difficulties
A decrease in movement during the process of motor development in the early stage
of development and abnormal reactions on examination of primary reflexes may reflect
early signs of motor handicaps.
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I GA Trisna W
~ Assess Development in The Language Domain ~
Learning outcomes
- Describe language development
- Determine factors affecting language development
Abstract
Speech and language are tools that humans use to communicate or share thoughts,
ideas, and emotions. Language is different from speech. Language is an elaborate
system of communication that uses arbitrary and socially agreed on symbols to transmit
and to receive messages from one human to another. Language is made up of socially
shared rules that include the following: what words mean; how to make new words; how
to put words together; and what word combinations are best in what situations. Speech is
the verbal means of communicating. Speech consists of the following: articulation (how
speech sounds are made); voice (use of the vocal folds and breathing to produce sound);
and fluency (the rhythm of speech).
There are many languages in the world, each includes its own set of rules for
phonology (phonemes or speech sounds or, in the case of signed language, hand
shapes), morphology (word formation), syntax (sentence formation), semantics (word
and sentence meaning), prosody (intonation and rhythm of speech), and pragmatics
(effective use of language).
The most intensive period of speech and language development for humans is during
the first three years of life, a period when the brain is developing and maturing. These
skills appear to develop best in a world that is rich with sounds, sights, and consistent
exposure to the speech and language of others. Children vary in their development of
speech and language. There is, however, a natural progression or "timetable" for mastery
of these skills for each language. The milestones are identifiable skills that can serve as
a guide to normal development. Typically, simple skills need to be reached before the
more complex skills can be learned. There is a general age and time when most children
pass through these periods. These milestones help doctors and other health
professionals determine when a child may need extra help to learn to speak or to use
language.
When a person has trouble understanding others (receptive language), or sharing
thoughts, ideas, and feelings completely (expressive language), then he or she has a
language disorder. Receptive language refers to the ability to understand, encompasses
visual (reading, sign language comprehension) and auditory (listening comprehension)
skills. Expressive language refers to the ability to produce symbolic communication, this
output may be either visual (writing, signing) or auditory (speech)
Delay in speech and language development in children can be defined as a “delay in
speech and / or language development compared with controls matched for age, sex,
cultural background, and intelligence”, or a discrepancy between a child’s potential ability
to speak and the performance that is actually observed. Three common causes of
speech delay are mental retardation, hearing loss and maturation delay.
There are some conditions that contributing to variations in learning to speak i.e.
health; intelligence; socioeconomic status; sex; desire communicate; stimulation; size of
family; ordinal position; child-training methods; multiple birth; contact with peers;
personality, etc.
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Lecture 14:
~ Cognitive Development ~
Marheni
Learning outcomes:
a. To understand the basic principles of cognitive process.
b. To understand four stages of cognitive development
Abstract:
Most progressive change of human behavior related to cognitive development, so if
someone wants to understand growth and development of human being
comprehensively, they should learn about cognitive development.
Piaget specifies four stages of cognitive development. The major cognitive
achievement in the sensorimotor stage (which lasts from birth to about two years) is the
development of the schema of object permanency. Thus, the attainment of this
knowledge is indicative of representational ability. Such ability is involved in the major
cognitive achievements in the preoperational stage (which lasts from about two through
six years). Here, true systems of representation develop (e.g., as indexed by language,
symbolic play, and delayed imitation). With the emergence of the concrete operational
stage, however (which lasts from about six through twelve years), conservations are
typically seen; thus, operational structures – internalized actions that are reversible – are
evidence. The child cannot think counterfactually or hypothetically. Such ability
characterizes the last stage of cognitive development, the formal operational stage
(which lasts from about year twelve onward).
Lecture 15:
~Psychosocial and Emotional Development~
Marheni
Absract:
Psychosocial development as propounded by Erik Erikson describes eight
developmental stages through which a healthily developing human should pass from
infancy to late adulthood. In each stage the person confronts, and hopefully masters,
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as
problems in the future.
Erik Erikson developed the theory in the 1950s as an improvement on Sigmund
Freud's psychosexual stages. Erikson accepted many of Freud's theories (including the
id, ego, and superego, and Freud's infantile sexuality represented in psychosexual
development), but rejected Freud's attempt to describe personality solely on the basis of
sexuality. Also, Erikson criticized Freud for his concept of originology. This states that all
mental illness can be traced to early experiences in childhood. According to Erikson,
experience in early childhood is important, but the individual also develops within a social
context. Erikson believed that childhood is very important in personality development
and, unlike Freud, felt that personality continued to develop beyond five years of age. In
his most influential work, Childhood and Society 1950, he divided the human life cycle
into eight psychosocial stages of development.
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“
Human personality, in principle, develops according to steps predetermined in
the growing person's readiness to be driven toward, to be aware of, and to
interact with a widening social radius.
”
—Erik Erikson
Lecture 16:
~ Detection of Developmental Deviation in
Children (Screening & Stimulation) ~
dr. I GA Trisna Windiani, SpA/dr. I GA Ngurah Sugitha
Learning outcomes
- Describe the aims of detection developmental deviation
- Recognize the methods of detection developmental deviation
- Apply methods of detection developmental deviation (Denver test, Pediatric
Symptom Checklist / PSC test)
- Describe the aims of stimulation developmental deviation
- Understand the principles of early stimulation
- Recognize the methods of stimulation developmental deviation
Abstract
Developmental screening is a brief evaluation of developmental skills that is applied
to a total population of children to identify children with suspected delays who require
further diagnostic assessment. Developmental screening involves the use of
standardized screening tests. Screening tests can be categorized as general screening
tests that cover all behavioral domains or as targeted screens that focus on one area of
developmental. They can administer in the office setting by professionals or completed at
home by parents.
The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the
recognition of cognitive, emotional, and behavioral problems so that appropriate
interventions can be initiated as early as possible. Included here are two versions, the
parent-completed version (PSC) and the youth self-report (Y-PSC). PSC can be
administered to 4-18 years old while Y-PSC can be administered to adolescents ages 11
and up.
The Denver II is design to be used with apparently well children between birth and six
years of age and is administered by assessing a child’s performance on various age
appropriate tasks. The test is valuable in screening asymptomatic children for possible
problem, in continuing intuitive suspicious with an objective measure, and in monitoring
children at risk for developmental problems, such as those who have experienced
perinatal difficulties. The Denver II consist of 125 tasks, or items which arranged on the
test form in four sectors to screen areas of function: 1) personal social; 2) Fine motor
adaptive; 3) Language; and 4) gross motor
Early intervention or stimulation is necessary and effective because development
is malleable and readily affected by the environment. In large part, early intervention
works by systematically removing external risk factors. Early intervention programs place
children in developmentally enriching settings; train parents in responsiveness and
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effectiveness, and provide continuous positive redirection and focused building of skills.
The benefits of early intervention clearly depend on early detection, which requires that
clinicians know how to identify accurately patients who have disabilities. Because time
and reimbursement are limited, clinicians also should know how to identify patients
quickly. Appropriate stimulation in childhood ranks as one of the most important factors
that influence childhood development.
Lecture 17:
~ Sexual Developmental Sequence in Children
and Adolescents ~
W Bikin Suryawan/Arimbawa
Learning outcomes
- To interpret maturation of the hypothalamic-pituitary-gonadal axis and connecting
with the onset of puberty starts.
- To explain positive feedback and negative feedback in puberty regulation.
- To interpret kind of the factors affecting for sexual developmental.
- To explain the pubertal staging in boys and girls.
- To interpret the ovarian development and testicular development.
- To explain the process of adrenarche and gonarche in puberty starts.
Introduction
Puberty can be defined as maturation of the hypothalamic-pituitary-gonadal axis that
results in growth and development of the genital organs, and leads to the capacity to
reproduce. Puberty is characterized by a number of physical and psychological changes.
The onset of puberty starts with slow, frequent releases of gonadotropin releasing
hormone (GnRH). GnRH is transported via the portal system to gonadotropic cells at the
pituitary level, where it stimulates the production and release of the gonadotropins
luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH then
stimulate growth and production of hormones and other factors in the ovaries and the
testes, respectively. These secreted products are inhibitory (via negative feedback) at the
pituitary and hypothalamic levels. During maturation in females, positive feedback
occurs, leading to the mid-cycle LH surge.
Hormonal regulation
The release of the hypothalamic neurotransmitter GnRH is regulated by many factors,
and is subject to negative and positive feedback at the pituitary and hypothalamic levels.
During gestation, GnRH plasma levels increase; maximum levels are attained at 22-25
weeks of gestation in female fetuses and at 34-38 weeks of gestation in male fetuses. In
primate studies, gamma-amino butyric acid (GABA) and other substances have been
associated with decreased GnRH release, although stimulating effects of GABA have
been observed as well. In primates, disinhibition of GnRH neurons by GABA is critical for
the onset of puberty. In humans, low gonadotropin levels during childhood may in fact be
due to tonic inhibition of GnRH by GABA. GnRH stimulates the production and release of
both LH and FSH. GnRH levels are difficult to measure directly, since GnRH is secreted
into the portal circulation and transported directly to the pituitary. GnRH is secreted in a
pulsatile pattern. Simultaneous episodic fluctuations of GnRH in the portal blood and LH
in the peripheral blood have been observed in sheep. A pulsatile pattern of LH release
has been observed in humans as well, and it can be assumed that this pattern reflects
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pulsatile GnRH release. Fluctuations in FSH levels are not as marked as those in LH
levels in humans, and are not always synchronized with LH pulses. As puberty
progresses, LH secretion gradually increases, and occurs both during the day and during
the night. This increase in LH secretion can be attributed to both enhanced LH pulse
frequency and enhanced LH pulse amplitude. During puberty, the day-night rhythm is
maintained; however, this with the progression of puberty in girls, the response to a
challenge of exogenous GnRH increases as well. During prepuberty (pubertal stage B1),
when endogenous GnRH stimulation is low, there is little or no increase in gonadotropins
following such a challenge. From pubertal stages B2 to B5, a GnRH challenge leads to
increases in LH and FSH in girls (see also the subchapter entitled ‘Pubertal staging’).
In girls, there is a remarkable exception for FSH in stage B2. High GnRH-stimulated
levels of FSH alone characterize this stage. The FSH response is much lower in stage
B3. In their study, they observed that the mean weight of 48 kg at menarche remained
constant with increasing menarcheal age, while mean height increased significantly with
increasing menarcheal age. Later studies in both female rats and humans showed that a
particular ratio of fat to lean body mass is necessary for puberty to begin and for
maintainance of reproductive capacity.
Pubertal staging
In girls, puberty, which begins following increased release of GnRH, can best be defined
as the estrogen-dependent onset of breast development (thelarche), as increased
estrogen levels are the result of an active hypothalamic-pituitary-gonadal axis. Growth of
pubic hair (pubarche) begins following secretion of adrenal and ovarian androgens. In
general, pubic hair appears a few months after the onset of breast development.
However, pubic hair development can occur in the absence of breast development, as
the result of an early adrenarche.
Below are the 5 stages of breast development
described by Marshall and Tanner.
B1: In this pre-pubertal stage, which persists until puberty begins, only the nipple is
raised above the level of the skin.
B2: In this budding stage, a bud-shaped elevation of the areola and papilla becomes
noticeable. On palpation, a fairly hard “button” can be felt, and may be painful to the
touch. The areola increases in diameter and the surrounding area can be elevated.
These changes may occur earlier in one breast than in the other.
B3: Further elevation of the breasts occurs. The diameter of the areola increases further.
The shape of small adult mammary glands, with continuous contours, is apparent.
B4: Fat deposits increase. The areola and papilla enlarge further. The areola forms a
secondary elevation above that of the breast. This secondary mound is apparent in
roughly half of girls and may persist into adulthood.
B5: In this adult stage, the areola is usually recessed to the general contour of the
breast. Pubic hair grows as a result of exposure to androgens. In girls, these androgens,
including DHEA-S, are of adrenal origin. The ovaries also produce androgens such as 4androstenedione.
Below are the 6 stages of pubic hair development in girls.
P1: In this pre-pubertal stage, there is no growth of pubic hair.
P2: A few lightly pigmented hairs, usually straight or only slightly curled, appear, chiefly
along the labia.
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P3: Pubic hair is still sparse, yet there is definite pigmented, curly hair on the labia that
also spreads onto pubic mons.
P4: Pubic hair is “adult” in type, but the area covered is still considerably smaller than in
adults. There has been no spread of pubic hair up to inguinal fold.
P5: Pubic hair has an adult distribution in an inverse triangle, with horizontal lining on the
pubic mons and lateral spreading up to the inguinal fold.
P6: This stage is reached after adolescence in only in a minority of women. There is a
further extension of pubic hair laterally onto the thighs or upward onto the abdominal
wall. In boys, the first sign of pubertal development is testicular growth. A testicular
volume greater than or equal to 4 mL indicates that the gonadal axis is active. Marshall
and Tanner have described different stages of testicular and penile growth. Below are
the 5 stages of genital development described by Marshall and Tanner.
G1: In this pre-pubertal state, the testes, scrotum, and penis are the same size and
shape as in a young child.
G2: The testes and scrotum become larger, with testicular volume greater than or equal
to 4 mL. The skin of the scrotum becomes redder, thinner, and wrinkled. The size of the
penis is similar to that in G1.
G3: The penis becomes larger, particularly in length. The testes and scrotum become
even larger, and the scrotum descends.
G4: The testes and scrotum become even larger, and the scrotal skin shows increased
pigmentation. This stage is “not quite adult”.
G5: In this stage, the external genitalia are adult in size and shape. The scrotum is
ample, and the penis and bottom of the scrotum reach to about the same level. Below
are the 6 stages of pubic hair development in boys.
P1: In this pre-pubertal stage, there has been no growth of pubic hair. There may be fine
hair over the pubes, but this growth is not different from that on the rest of the abdomen.
P2: A few lightly pigmented, longer, straight hairs, often still downy, appear at base of the
penis and sometimes on the scrotum.
P3: Hair that is still sparse, yet definitely pigmented, coarser, and curlier appears around
the base of the penis.
P4: Hair is “adult” in type, but the area covered by hair is still considerably smaller than
in adults, not going further than in the inguinal fold.
P5: Hair is adult in quantity and type and spreads up to the medial surface of the thighs,
but not up the linea alba.
P6: Further extension occurs laterally and up the linea alba after adolescence. The
majority of adult men reach this stage.
Ovarian development
Menarche, which usually occurs about 2.4 years after the start of breast development,
does not necessarily indicate that there is full interaction among the hypothalamus, the
pituitary, and the ovaries. In fact, during the first years after menarche, anovulatory
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cycles occur. Following this stage, ovulation occurs after an LH surge as a result of
positive feedback to estrogens. During menstruation, gonadotropin levels (primarily
levels of FSH) increase. FSH levels then decrease, with gradual increases in estradiol.
Testicular development
In young, developing, 6- to 7-week-old embryos, gonadal tissue is undifferentiated. The
presence of the sex-determining region of the Y chromosome (SRY) triggers the tissue to
differentiate to become testes. In the absence of this SRY, the tissue would differentiate
to become ovaries. Undifferentiated gonadal tissue consists of 4 major cell lines:
1. Supporting cells develop into Sertoli cells, which have a paracrine function in
spermatogenesis. Their number is a limiting factor in spermatogenesis. AntiMullerian hormone, a hormone secreted by Sertoli cells, is necessary for
regression of the Mullerian duct and influences gonadal differentiation.
2. Leydig cells, which are steroidogenic, produce androgens, which induce
development of secondary sex characteristics. In the human fetus, Leydig cells
are present after 8 weeks of gestation. During gestation and shortly after birth,
these cells are functionally active, secreting testosterone. Fetal Leydig cells
eventually develop into adult-type Leydig cells, which are responsible for pubertal
development.
3. Connective cells give rise to peritubular myoid cells. These cells function along
with Sertoli cells to produce the basal lamina of testicular tissue. This basal
lamina serves as a base for testis cord formation.
4. Germ cells develop through several stages into spermatozoa. Testicular volume
increases 3-fold between birth and 9 years of age, but remains at a prepubertal
volume (i.e., <4 mL).
Gonadarche versus adrenarche
Androgens of adrenal origin, particularly dehydroepiandrosterone (DHEA) and its sulfate
(DHEA-S), are responsible for sexual hair development in girls. The point at which the
adrenals increase production of DHEA is known as adrenarche. In girls, pubic hair
development occurs around the same mean age as breast development (11 years).
Premature adrenarche is characterized by an early development of pubic hair, with little
or no increase in height velocity and without progressive bone maturation. Early pubic
hair growth may be an isolated event or may be accompanied by increased sweat and
body odor, acne, axillary hair, and/or fatty skin. In general, premature adrenarche does
not require treatment.
In boys, pubic hair development is caused by adrenal and testicular androgens.
Premature adrenarche may occur in boys, but is diagnosed more often in girls. When
early growth of pubic hair occurs along with an increase in height velocity and
progression of bone development, one should be aware of diagnoses associated with an
excess of sex steroids. In such cases, a late-onset adrenal hyperplasia caused by a
partial enzyme deficiency can often be diagnosed.
Maturation of the gonadal axis and the adrenal axis occur separately, which means that
in cases of adrenal insufficiency, gonadarche will occur appropriately. In cases of
gonadal failure, the adrenals will contribute to adrenarche. It is well known that delayed
and early-onset puberty are related, although specific genes contributing to these
phenomena have not yet been recognized. To date, several gene mutations and
polymorphisms of GnRH and its receptor, and of the gonadotropins LH and FSH and
their receptors, have been identified.
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Lecture 18:
~ Visual Impairment ~
W. Eka Sutyawan
Abstract
Many people have some type of visual problem at some point in their lives. Some
can no longer see objects far away. Others have problems reading small print. These
types of conditions are often easily treated with eyeglasses or contact lenses. But when
one or more parts of the eye or brain that are needed to process images become
diseased or damaged, severe or total loss of vision can occur. In these cases, vision
can't be fully restored with medical treatment, surgery, or corrective lenses like glasses or
contacts.
Blindness. They haven't lost their sight completely but have lost enough vision that
they'd have to stand 20 feet from an object to see it as well as someone with perfect
vision could from 200 feet away.
What Causes Visual Impairment?
People rarely lose their eyesight during their teen years. When they do, it's usually
caused by an injury like getting hit in the eye or head with a baseball or having an
automobile or motorcycle accident.
Some babies have congenital blindness, which means they are visually impaired at
birth. Congenital blindness can be caused by a number of things — it can be inherited,
for instance, or caused by an infection (like German measles) that's transmitted from the
mother to the developing fetus during pregnancy.
Conditions that may cause vision loss after birth include: amblyopia, strabismus,
cataracts, diabetic retinopathy, glaucoma, macular degeneration, trachoma
Lecture 19:
~ Hearing Impairment ~
Eka Putra S
--------------
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Lecture 20:
~ Learning Disorders ~
I GA Endah Ardjana
Learning outcomes
Learning disorders are diagnosed when standardized est. achievement in reading, math,
or written expression are substantially lower than expected for a particular age, school
level, or intelligence. These disorders involve academic deficits and impairments in
specific areas of reading, math, spelling, and writing. About 5 percent of students in
public schools in the United States are estimated to have a learning disorder, and up o
40 percent of these students drop out of school.
Reading Disorders:
a. Reading achievement, as measured by individually administered standardized
tests of reading accuracy or comprehension, is substantially below that expected
given the person’s chronological age, measured intelligence, and age-appropriate
education.
b. The disturbance in Criterion A significantly interferes with academic achievement
or activities of daily living ha require reading skills.
c. If a sensory deficit is present, the reading difficulties are in excess of those
usually associated with it.
Mathematic Disorders
a. Mathematical ability, as measured by individually administered standardized
tests, is substantially below that expected given the person’s chronological age,
measured intelligence, and age appropriated education.
b. The disturbance in Criterion A significantly interferes with academic achievement
or activities of daily living that require mathematical ability.
c. If sensory deficit is present, the difficulties in mathematical ability are in excess of
hose usually associated with it.
Disorders of Written Expression
a. Writing skills, as measured by individually administered standardized tests (or
functional assessments writing skills), are substantially below those expected
given the person’s chronological age, measured intelligence, and age-appropriate
education.
b. The disturbance in Criterion A significantly interferes with academic achievement
or activities of daily living that require the composition of written text (e.g., writing
grammatically correct sentences and organized paragraphs).
c. If a sensory deficit is present, the difficulties in writing skills are in excess of those
usually associated with it.
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Lecture 21:
~ Mental Retardation and Down Syndrome ~
I GA Endah Ardjana
~ Mental Retardation ~
Abstract:
For a definite diagnosis, there should be a reduced level of intellectual functioning
resulting in diminished ability to adapt to the daily demands of the normal social
environment. Associated mental or physical disorders have a major influence on the
clinical picture and the use made of any skills. The diagnostic category chosen should
therefore be based on global assessments of ability and not on any single area of
specific impairment or skill. The IQ levels given are provided as a guide and should not
be applied rigidity in view of the problems of cross-cultural validity. The categories are
given below are arbitrary divisions of complex continuum, and cannot be defined with
absolute precision. The IQ should be determined from standardized, individual’s level of
functioning and additional spesific handicapping conditions, e.g. expressive language
problem, hearing impairment, physical involvement. Scales of social maturity and
adaptation, again locally standardized, should be completed if at all possible by
interviewing a parent or care provider whi is familiar with the individual’s skills in
everyday life. Without the use of standardized procedures, the diagnosis must be
regarded as a provisional estimete only.
According to Diagnosis and Statistical Manual of Mental Disorders (DSM-IV-TR),
mental retardation is defined as,
a. Significantly subaverage general intellectual functioning: an IQ of approximately
70 or below on an individually administered IQ test (for infants, a clinical judgment
of significantly subaverage intellectual functioning).
b. Concurrent deficits or impairments in present adaptive functioning (i.e., the
person’s effectiveness in meeting the standards expected for his or her age by his
or her cultural group) in at least two of the following areas: communication, selfcare, home living, social/interpersonal skills, use of community resources, selfdirection, functional academic skills, work, leisure, health and safety.
c. The onset before age 18 years.
Degree of Mental Retardation:
- Mild Mental Retardation
- Moderate Mental Retardation
- Severe Mental Retardation
- Profound Mental Retardation
: IQ level 50 to 69.
: IQ level 35 to 49.
: IQ level 20 to 34.
: IQ is under 20.
~ Down Syndrome ~
Learning outcomes:
- Understand the genetic aspect of Down Syndrome.
- Understand the screening test of Down Syndrome.
- Understand the clinical aspect of Down Syndrome.
- Understand the diagnosis and therapy of Dwon Syndrome.
- Understand the genetic counselling of Down Syndrome.
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Abstract:
Dwon Syndrome, also known as trisomy 21, is a disorder caused by a
chromosomal abnormality, and the most common cause of birth defect including mental
child is born. Women over the age of 35 are in the most risk. The incidence of Down
Syndrome is estimated 1 in every 800 to 1000 babies born. They don’t appear to be
associated with paternal age.
Down Syndrome is a chromosomal abnormalty characyerized by extra copy of
genetic maternal on the 21st chromosome, either in whole (trisomy 21) or due to
translocation (Robertsonian translocation or familial Down Syndrome), mosaicism or
duplication of portion of chromosome 21.
Patient with Down Syndrome chare certain physical features such as a flat facial
profile, an upward slant to the eyes, small ear, a single crease across the centre of the
palms, and an enlarge tongue. Down Syndrome affect cognitive abilities in different
ways, but most have mild to moderete mental retardation.
Diagnostic test are about 99% accurate in detecting Down Syndrome. They are
generally recommended only for women age 35 or older, and those with a familial history
of genetic defect. Screening test include nuchal translucency testing, alpha fetoprotein,
ultrasound, amniocentesis, chorionic villus sampling, and percutaneus umbilical blood
sampling, now widely available for early detection.
Lecture 22:
~ Attention Deficit / Hyperactivity Disorder
(ADHD) ~
~
I GA Trisna W/Endah Ardjana
Learning outcomes:
Awarness of common developmental disorders in children:
- Suspect children with ADHD
- Refer children with ADHD
Abstract:
Attention Deficit Hyperactivity Disorders (ADHD) is the most common
neurobehavioral disorders of childhood. ADHD is also among the most prevalent chronic
health conditions affecting school-aged children. Recorded prevalence rates for ADHD
vary substantially, partly because of changing diagnostic criteria over time, partly
because of variations in ascertainment in different settings and the frequent use of
referred samples to estimate rate. Prevalence rates also vary significantly depending on
whether they reflect school samples 6.9% (5.5%-8.5%) versus community samples
10.3% (8.2%-12.7%).
The core symptoms of ADHD include inattention, hyperactivity and impulsivity.
Children with ADHD may experience significant functional problems, such as school
difficulties, academic underachievement, troublesome interpersonal relationships with
family members and peers, and low self-esteem. Individuals with ADHD present in
childhood and may continue to show symptoms as they enter adolescence and adult life.
Early recognition, assessment and management of this condition can redirect the
educational and psychosocial development of most children with ADHD. The American
Academy of Pediatrics (AAP) recommended that the primary care physicians should
initiate an evaluation for ADHD. The clinician during routine health supervision may
assist in early recognition of ADHD. So, knowledge, skill for screening, diagnosis and
manage children with ADHD is mandatory understood by primary care physician
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Lecture 23:
~ Autism Spectrum Disorders ~
I GA Ngurah Sugitha
Learning outcomes
Awareness of common developmental disorders in children:
- Suspect children with Autism
- Refer children with Autism
Abstract
Autism describes a spectrum of clinical conditions of neurobiological origin that are
characterized by: (1) qualitative dysfunctions of social interaction, (2) qualitative
impairments in communication abilities, and (3) unusual or restricted ranges of play and
interests. The totality of these impairments, though quite variable from person to person,
is usually a lifelong condition that results in some degree of social isolation and varying
amounts of unusual behavior.
Despite extensive investigation, no consistent pattern of the cause of autism has
emerged. In fact, more than 60 different disease entities have been shown to be likely
causes of autism, including genetic, infectious, endocrine, toxic, and space-occupying
etiologies. This suggests that autism is a final common clinical presentation of a variety
of underlying neurobiological and genetic processes.
The prevalence of autism appears to have increased during the past decade,
perhaps due to (1) greater awareness about autism and its symptoms, (2) more-inclusive
recent definitions, and (3) possibly a true increase in incidence. Overall, the ratio of
males to females is about 3:1 to 4:1. Prevalence estimates range from 2 to 6 per 1,000
children. This wide range of prevalence points to a need for earlier and more accurate
screening for autism.
Many instruments can used to screen for autism. The brief instruments such as the
Checklist for Autism in Toddlers (CHAT), designed to screen for autism in 18-months old.
Screening instruments do not provide individual diagnosis but serve to assess the need
for referral for possible diagnosis of Autism. Criteria for the diagnosis of autism are
included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR). The earlier the disorder is diagnosed, the sooner the child
can be helped through treatment interventions.
For most children who have a disorder within the autistic spectrum, results of the
physical and neurology examinations will entirely normal. No routine laboratory tests
seem necessary. When autistic disorders are associated with general medical condition,
laboratory findings consistent with general condition will be observed.
Although no definitive treatments are yet available, remarkable progress in the area
of intervention has occurred. Primary modalities include (1) educational programs,
including early intervention, school-based programs, and prevocational services; (2)
behavioral techniques; (3) speech and language therapy programs; (4) family support
services; and (5) adjunctive psychopharmacologic management of specific symptoms.
Early intensive intervention may dramatically improve outcome.
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Lecture 24:
~ Cerebral Palsy Syndrome ~
Dewi Sutriani Mahalini
Abstract
Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive, noncontagious diseases that cause physical disability in human development. The incidence
in developed countries is approximately 2.12–2.45 per 1000 live births. Incidence has not
declined over the last 60 years despite medical advances (such as electro-fetal
monitoring) because these advances allow extremely low birth weight and premature
babies to survive. Cerebral refers to the affected area of the brain, the cerebrum
(however the centres have not been perfectly localised and the disease most likely
involves connections between the cortex and other parts of the brain such as the
cerebellum) and palsy refers to disorder of movement. CP is caused by damage to the
motor control centers of the young developing brain and can occur during pregnancy
(about 75 percent), during childbirth (about 5 percent) or after birth (about 15 percent) up
to about age three. Eighty percent of causes are unknown; for the small number where
cause is known this can include infection, malnutrition, and/or head trauma in very early
childhood.
Lecture 25:
~ Aging Process ~
R A Tuty Kuswardhani S
Abstract
Aging is a process of the loosing of ability the tissue slowly to develop itself and to
maintain the structure and the normal function; so it cannot stand towards the trauma to
develop the damage. The human being progressively will lose his defense against the
infection it will pile the more metabolic and structural distortion.
Aging process theory, according to this theory aging has been programmed genetically
for some certain species.
Different of aging process theories which support the process of aging i.e.:
1.
2.
3.
4.
5.
Genetic clock theory
The damaged of body immune system.
Metabolic theory.
The shortening of telomere theory.
The damaged by free radical.
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Lecture 26:
~ Clinical Implication of Aging Process ~
Nym Astika
Learning outcomes
- To describe the changes associated with aging
- To know common problem of Geriatrics (a series of I’s)
- To knows components of assessment of older patients
Abstract
The care of older patients differs from that of younger patients for number of
reasons. Some of these can be traced to the change that occur in the process of aging,
some are caused by the plethora of diseases and disruptions that accompany seniority,
and still other result from the way old people are treated
We have already noted the critical and difficult distinction a clinician must make to
attribute a finding to either the expected course of aging or the result of pathology
changes.
Many of the changes associated with aging result from gradual loss, most organ
systems seem loss function at about 1 percent a year beginning around age 30 year.
Other data suggest that the changes in people followed longitudinally are much less
dramatic and certainly begin well after age 70 years
Comprehensive evaluation of an older individual’s health status is one of the most
challenging aspects of clinical geriatrics.
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CLINICAL SKILLS PROGRAMS
LECTURE
General Principles of Physical Examination
dr. Ni Made Ratna Saraswati, Sp.PD
Abstract
The specific skill necessary to perform a proper physical examination will be
introduced. The four cardinal principles of physical examination are the following:
inspection, palpation, percussion, and auscultation. The student should “teach the eye to
see, the finger to feel, and the ear to hear.” Inspection can provide an enormous amount
of information. Proper techniques require more than just a glance. Examiner must be
trained to look at the body using a systematic approach. Palpation should use tactile
sense to determine the characteristic of an organ system. Percussion relates to the
tactile sensation and sound produce when a sharp blow is struck to an area being
examined. Auscultation involves listening to sounds produced by internal organ. This
technique furnishes information about an organ’s pathophysiology. The physical
examination generally begins after the history has been completed. The goal of physical
examination is to determine valid information concerning the health of the patient. The
examiner must be able to identify, analyze, and synthesize the accumulated knowledge
into comprehensive assessment.
LECTURE
Vital Sign Measurement
dr. Ni Made Ratna Saraswati, Sp.PD
Abstract
Vital sign measurement consists of taking temperature, blood pressure measurement,
and respiration evaluation. Taking temperature could be obtained from oral, axilla, and
rectal technique. We could use electronic thermometers or a glass-mercury thermometer.
There several factors could affect temperature reading we should consider. Student must
be experienced in taking all steps needed in taking temperature procedure and well
skilled in recording the temperature.
Assessing blood pressure is probably the commonest procedure undertaken in
clinical practice. Accurate blood pressure measurement is very important. There will be
systolic and diastolic blood pressure should be obtained from a patient. There will be two
steps in blood pressure measurement. The first step is preparation patient arm and
positioning the cuff. The second step is to do a procedure to obtain the systolic and
diastolic blood pressure. Student should be familiarized with the Korotkoff sound that
technically identifies the blood pressure from the patient. Several errors could happen
during this measurement, and we have to be well known by the student.
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~ LEARNING TASKS ~
LECTURE 1:
Case 1
A mother came to the physician to consult about her child development. Her child is a
boy 10 months old. His mother complained that he cannot crawl and cannot stand up
alone. When he was 8 months old, he has sir alone. He was born at midwife,
spontaneously; his birth weight was 2700 gram.
Assignment:
a. Please describe, is it a normal child development?
b. Please describe, was the child had sequential normal development?
c. As a physician, what kind information that you give to his mother?
Self Assessment
a. Describe the lifespan developing stages
b. What is the differentiate between growth and development
c. Describe factors that affecting growth and development
Case 2:
A 15 months old girl was brought by her mother to the Growth and Development Clinic to
know whether her child’s growth normal or not. On the physical examination revealed
that her weight was 9 kg; her length was 75 cm; her head circumference was 47 cm. Her
father’s height was 176 cm; her mother’s height was 157 cm.
Assignment:
a. Please plot all of the data to the CDC 2000 curve, and interpret it
b. Please calculate the potential genetic height of the child
c. Please plot the head circumference measurement to the Nellhauss curve and
interpret it
Case 3:
An infant, girl, was brought by her mother to the Growth and Development Clinic for
immunization, on September 22, 2007. She was born on December 9, 2006. The
following are the data of her weight based on measurement at Primary Health Care.
Birth weight 2900 grams
1 month
3800 gram
2 months
5600 grams
3 months
6000 grams
5 months
6500 grams
6 months
6700 grams
8 months
7000 grams
Assignment:
a. Please calculate the chronological age
b. Please plot the data into KMS (Road to Health Chart)
c. Please interpret the result of the measurement
Self Assessment
a. Please differentiate physical growth patterns between boy and girl
b. Describe the factors that affecting physical growth
c. Describe the normal pattern of the body system growth
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LECTURE 2:
1. Describe the embryonic development phases and its morphological characteristic.
2. Explain the main phenomena during human development on the 1st week, 2nd week,
3rd week, 3rd-8th week and 8h week to birth.
3. Explain the clinical correlation in each phase.
4. Predict the time of birth based on the LNMP.
LECTURE 3 :
Learning Task
Vignette 1
A mother, 36 years old, with history the first child diagnosed with Down Syndrome, come
to you (general practitioner). She denies any family history with the same disease. She
asks to you about her next pregnancy, because she is afraid her second child will be like
the first one.
Learning Task 1
1. Do you think she has indication for prenatal diagnosis? If yes, please describe the
optional test!
2. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are trisomi 21 and normal karyotyping
respectively? (The information should cover the four steps of process in genetic
counseling)?
3. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are trisomi 21 and Robertsonian
translocation respectively? (The information should cover the four steps of
process in genetic counseling)
4. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are mosaicism trisomi 21 and normal
karyotyping respectively? (The information should cover the four steps of process
in genetic counseling)
Vignette 2
A marriage woman, 23 years old, come alone, complained have not pregnant since
married 3 years ago. She has history have not menstruation since teenage and she also
said that her husband complained her vagina is short. From physical examination, she
has breast and external genetalia like ordinary women, and by using speculum
examination, the length of vagina is confirmed (around 2-3 cm) and without appearance
of ostium cervix. Then, ultrasound examination (by referring to Gynecologist) has shown
that there is no female internal genetalia, but testis in abdomen. Karyotyping test show
the patient has 46, XY. Others biochemical and genetic tests also had conducted. The
patient is diagnosed with complete androgen insensitivity syndromescribed in vignette).
1. Do you think “her” husband need to know? What is your opinion?
2. What will you tell to “her” husband if “her” husband comes to you for asking about
his wife?
Self Assessment
1. There are 2 kinds of prenatal diagnostic, describe them, with their pros and cons!
2. There are 4 steps in genetic counseling, describe them!
3. Which one from the 4 steps is the crucial part?
4. Please mention the indication for prenatal diagnosis.
5. What is the end result from genetic counseling, directive or non-directive?
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LECTURE 4:
An infant weighting 1500 g is born at 38 weeks gestation. The mother had a chronic
abuse of cigarettes and alcohol.
a. What is the diagnosed of this infant?
b. What methods you used to estimate the gestational age postnatal?
LECTURE 5:
Vignette 1
A mother, 36 years old, with history the first child diagnosed with Down Syndrome, come
to you (general practitioner). She denies any family history with the same disease. She
asks to you about her next pregnancy, because she is afraid her second child will be like
the first one.
Learning Task 1
5. Do you think she has indication for prenatal diagnosis? If yes, please describe the
optional test!
6. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are trisomi 21 and normal karyotyping
respectively? (The information should cover the four steps of process in genetic
counseling)?
7. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are trisomi 21 and Robertsonian
translocation respectively? (The information should cover the four steps of
process in genetic counseling)
8. What kind of information would you like to give to this patient if the karyotyping
test for the first child and the mother are mosaicism trisomi 21 and normal
karyotyping respectively? (The information should cover the four steps of process
in genetic counseling)
Vignette 2
A marriage woman, 23 years old, come alone, complained have not pregnant since
married 3 years ago. She has history have not menstruation since teenage and she also
said that her husband complained her vagina is short. From physical examination, she
has breast and external genetalia like ordinary women, and by using speculum
examination, the length of vagina is confirmed (around 2-3 cm) and without appearance
of ostium cervix. Then, ultrasound examination (by referring to Gynecologist) has shown
that there is no female internal genetalia, but testis in abdomen. Karyotyping test show
the patient has 46, XY. Others biochemical and genetic tests also had conducted. The
patient is diagnosed with complete androgen insensitivity syndromescribed in vignette).
3. Do you think “her” husband need to know? What is your opinion?
4. What will you tell to “her” husband if “her” husband comes to you for asking about
his wife?
Self Assessment
6. There are 2 kinds of prenatal diagnostic, describe them, with their pros and cons!
7. There are 4 steps in genetic counseling, describe them!
8. Which one from the 4 steps is the crucial part?
9. Please mention the indication for prenatal diagnosis.
10. What is the end result from genetic counseling, directive or non-directive?
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LECTURE 6:
Many medications have side effects that are potentially harmful during pregnancy, but
their benefits may outweigh their risks. A woman should consult her doctor or midwife
before taking any drug, even one sold over the counter. If you to be a medical doctor can
you explain to a pregnant women if she want to take medicine like:
1. Anticonvulsants, such as phenytoin (Dilantin) and carbamazepine (Tegretol), to
prevent epileptic seizures?
2. Aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDs)?
3. Could you explain to her about the effect of drugs at different stages of
pregnancy?
4. Paracetamol is a drugs that A category. Could you explain it? How about B
category, C category and X category?
Lecture 7:
Case 1
A mother came to the clinic with lactation problem. During the first week she found that
her breasts were very swollen, tender, throbbing, lumpy, and uncomfortably full.
Sometimes the swelling extends all the way to the armpit. She panicked, thinking that her
milk ducts were blocked, even though she had been through exactly the same
experience with her first child.
Assignment
a. What kind of the mother lactation problem?
a. How can the mother treat it (What should the mother do?)
b. How long does it last?
c. Can the mother still breastfeed?
d. Will the conditions affect her baby?
Self Assessment
a. Describe the composition of human milk
b. Describe the benefits of breastfeeding
c. Describe the most common problems encountered by mothers who are breastfeeding and management of the breastfeeding problems
LECTURE 8
Case 1
A female neonate was born at 30 weeks gestation with severe asphyxia. The baby
weight was 1200 gram. After resuscitation and stabilization, the baby was transferred to
the NICU. The baby was under infant warmer for prevention hypothermia. For nutrition,
parenteral nutrition was started.
Assignment
1. Why parenteral nutrition was chosen in this case?
2. What type of nutrition you will give in the first day?
3. How many fluids will you give in the first day?
4. What do you know about trophic feeding?
5. When will you start the enteral feeding?
How you give enteral feeding in this case?
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DAY
6
LECTURE 9:
Case 1
Armani, two years old boy, with body weight of 7.7 kg and length of 70 cm came with the
main complains of spot on his left eyes since 1 month ago and cannot seeing object in
the evening before night. He suffered edema on his feet (dorsum pedis), looked pale and
often suffered infection.
Assignment:
1. What is the diagnosis of this case?
2. What are the reasons?
3. Formulate the management of vitamin A and Fe deficiency.
Self Assessment:
1. Describe the definition of the vitamin A and iron deficiency.
2. Describe the etiology and pathogenesis of the vitamin A and iron deficiency.
3. Describe the prognosis and prevention of the vitamin A and iron deficiency.
Case 2
Doni is 6-month old infant came with main complain of mental deficiency, spastic
diplegia, or quadriplegia, deaf mutism, dysarthria, a characteristic shuffling gait,
shortened stature, and hypothyroidism.
Assignment
1. What is the diagnosis of this case?
2. What are the reasons?
3. Formulate the management of iodine deficiency
Self assessment
1. Describe the definition of the iodine deficiency.
2. Describe the etiology and pathogenesis of the iodine deficiency.
3. Describe the prognosis and prevention of the iodine deficiency.
LECTURE 10:
Case 1
A 3 years old adolescent with body weight 11 kg and height 95 cm; he looks pale, with
pitting edema in the lower extremities and scrotum. He comes to the pediatrics clinic with
acute respiratory problems. He is belonging to poor family; the food intake is always low
compare with other children.
Assignment
1. What is the diagnosis of the patient above?
2. Formulate the management of protein energy malnutrition!
Self assessment
1. Describe differentiation of primary PEM and secondary PEM.
2. Describe differentiation of clinical manifestations between marasmus and
kwashiorkor.
3. Explain the path physiology of pitting edema of patient with kwashiorkor.
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Case 4
A 14 years old adolescent with body weight 132 kg and height 200 cm; he looks likes
‘sumo player’, a popular traditional sport in Japan. He usually comes to the pediatrics
clinic because of respiratory problems. His father and mother are overweight.
Assignment
1. Calculate the BMI of the patient; is he overweight or obesity!
2. Formulate the management of obesity in childhood!
Self assessment
1. Describe the risk factors of obesity.
2. Describe the clinical manifestations and complications of obesity.
3. Describe the diseases associate with childhood obesity.
LECTURE 11:
Case
Because the weight gains of a 3 months old infant (the body weight 4050 g and length
50 cm) was poorly since 3 month, the parents brought him to hospital. Breast milk intake
is always low compared with others healthy infant; and the infant often suffered from
respiratory tract problems. Normal weight gain in healthy infant < 3 months is 750-1000
g/month.
Assignment
1. What is the ‘diagnoses’ of the patient above?
2. Formulate the management of patient above!
Self assessment
1. Describe definition/criteria of patient with FTT.
2. What kind of multidisciplinary approach in Indonesia could be organized as a
team work to solve the problem (FTT)?
3. List the risk factors could cause FTT and focus to the factors of patient who need
refer to the hospital!
LECTURE 12 + 13:
Case 1
An infant, boy, 7 months old consulted by his mother to the Growth and Development
clinic for immunization. He was born at Sanglah Hospital, spontaneously, asphyxia, and
birth weight was 2300 g, gestational age 37 weeks. There is no congenital anomaly. She
had antenatal care at midwife. On the physical examination always found fist right hand.
His mother did not know about this.
Assignment:
a. Describe the motor developmental milestones in 7 months infant
b. Describe the risk factors that influence the motor development deviation in infant
c. What kind examination that necessary for motor development deviation?
Self Assessment
a. Please differentiate between gross and fine motor development
b. Describe the factors that affect motor development
c. Describe the primitive and postural reflexes; when these reflexes present or
absent?
Case 2
TR, girl, 24 months old consulted to the Growth and Development clinic, by her mother
with chief complaint cannot compose 2 word combinations yet. She just only says 1 word
like “mama”; “papa”. She was born at Sanglah Hospital by caesarean section, helped by
obstetrician, cried spontaneously, and birth weight was 2700 g, gestational age was 38
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weeks. There is no congenital anomaly. She has febrile convulsion when she was 10
months old. Five months ago she got febrile convulsion but never hospitalized.
Assignment:
a. Describe the language developmental milestone in 24 months old
b. Describe the red flag of the language developmental milestone in 24 months old
c. Describe the risk factors that influence the language development deviation
toward that girl
d. What should we suggest to her mother?
Self Assessment
a. Please differentiate between speech and language
b. Please differentiate expressive and receptive language
c. Describe the factors that affecting language development
Case 3
SI, girl, 19 months came with her mother to the Growth and Development clinic with
complaint cannot walk well yet. She can stand alone 2 months ago. She can speak
mama/papa specific. She was born at midwife, spontaneously, asphyxia, and birth weight
was 2800 g, gestational age 38 weeks. There is no congenital anomaly.
Assignment:
a. Has the child in the normal development?
b. Describe the developmental milestones in 19 months child
c. Describe the red flag of the developmental milestone in 19 months old
d. What should we suggest to her mother?
Self Assessment
a. Describe the development milestone from birth until 5 years old
b. Describe the red flag of development from birth until 5 years old
Lecture 14 + 15:
Assignments 1
a. Describe about organization and adaptation in biological systems and cognitive
development!
b. Describe about assimilation! (Demonstrate some examples)
c. Describe about accommodation! (Demonstrate some examples)
d. Explain about equilibration in cognitive development!
e. Explain the role of reproductive assimilation in cognitive development!
f. Describe about schema!
g. Compare The Sensorimotor Stage and The Preoperational Stage!
h. Describe about conservation! (Demonstrate some examples)
i. Compare The Concrete Operational Stage and The Formal Operational Stage!
Assignments 2
a. Differentiate between Erikson and Freud’s Development Theory.
b. Discuss the ego implication in social life.
c. Why does every Erkson’s phase in Psychosocial Development is critical period.
d. Identify eight phases in psychosocial development and their psychosocial needs.
e. Diferentiate the adult mature personality and immature personality.
Discuss this case: Sanjaya familiy is the obedient familiy in religion and very diligent goes
to the churc and pray to god. Although Mr and Mrs. Sanjaya are very busy, they never
forget to remain their children to pray. One day Mr. Sanjaya feel upset when he heard
and saw from TV news, that his child name John (17 years old) was capture by the cop
in drug’s party.
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LECTURE 16:
Case 1
A mother brought her child to Growth and Development clinic at December 9, 2005 with
chief complaint her child was still unable to walk. He was born at January 24, 2003, with
gestational age 37 weeks. The following were his history of development:
1. Gross motor:
- Walk well (-)
- Pull to stand (+)
- Sit, no support (+)
2. Language:
- Can speak 3 words (+)
- Papa/mama specific (+)
- Point 2 body part (+)
- Name 1 picture (+)
3. Fine motor:
- Put block in cup (+)
- Scribbles (+)
- Takes 2 cubes (+)
- Tower of cubes 4 (+)
- Initiate vertical line (-)
4. Personal social:
- Play pat-a-cake (+)
- Wave bye-bye (+)
- Drink from cup (+)
- Remove garment (-)
- Put on clothing (-)
- Wash and dry hands (-)
Assignment:
a. Complete the Denver test and the interpretation
Case 2
A Mother brought her son to general physician. He is 5 years old with asthma since he
was 2 years old. The asthma relapses almost every month. Now he is in kindergarten.
According to his mother and his teacher report, his complained were:
- Often absent from school
- Often distracted easily
- Irritable and often angry
- Has trouble concentrating
- Less interested in friends, often fights with other children
- Sometimes takes things that do not belong to him
- Often does not listen to rules
Assignment:
a. Scoring these symptoms, fill the Pediatric Symptom Checklist and the
interpretation!
b. As a general physician, what is your planning after PSC screening?
Case 3
A 5 months old infant, boy, brought by his mother to the Growth and Development Clinic.
On the developmental examination found that he could not roll over and he was has
head leg
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Assignment:
a. Please describe is it normal development?
b. Please describe the method of stimulation in this child?
c. If you are a general physician, when will you refer the child who has
developmental deviation?
Case 4
A 2 years old girl, consulted to the Growth and Development Clinic with chief complained
that she cannot speak 4-5 syllables
Assignment:
a. Please describe is she has normal development?
b. How to give stimulation to this child?
Self Assessment
a. What is the aim of early detection and stimulation; describe the benefit of
early detection and stimulation.
b. Describe the principles of early stimulation
LECTURE 17:
Case 1
A girl with a painful nipple
An 11-year-old girl attends your outpatient clinic because her left nipple is painful to the
touch. She has been healthy and has had no complaints until now.
Her height is 150 cm (0 SD), and her weight is 35 kg (-1 SD). Physical examination
reveals no abnormalities. There is a small, pea-like lump, which is painful to the touch,
below her left nipple.
Which diagnosis do you consider? (Choose 1 answer.)
a. The start of puberty
b. A breast tumor
c. A breast cyst
Case 2
A 6-year-old girl with pubic hair. At the outpatient clinic, you see a 6-year-old girl who has
had pubic hair since the age of 6 months. For the past few weeks, she has also had
some body odor. Her mother is very worried about her pubertal development, particularly
about the timing of menarche. She knows that after menarche, her daughter will not grow
very much. Other than these complaints, the girl is healthy.
Physical examination reveals a healthy-looking girl with a height within the target range (1 SD). She has no breast development, but does have some pubic and axillary hair.
What would your diagnosis be? (Choose 1 answer.)
a. Presence of an androgen-producing tumor
b. Central precocious puberty
c. Premature adrenarche
d. Hirsutism
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Self Assessment:
01. Describe the onset of puberty starts in boys and girls.
02. Describe the factors to influence release of the hypothalamic neurotransmitter
GnRH.
03. Describe changes of FSH/LH secretion from the fetal stage to adulthood.
04. Describe difference GnRH release in fetal period, prepuberty period and adult
period.
05. Describe factors to block release GnRH from hypothalamus in puberty starts.
06. Describe stages of breast development in girls.
07. Describe stages of pubic hair development in boys and girls.
08. Describe stages of genital development in boys.
09. Describe of ovarian development in puberty girls.
10. Describe of testicular development in puberty boys.
11. Describe difference of adrenarche and gonarche in puberty.
12. Describe the process of spermatogenesis.
LECTURE 18 + 19:
Case 1
Young mother came to Eye Clinic with complain that her baby has white pupil in the both
eye. The age of baby is 3 month old. The age of gestation and birth weight of the baby
are normal. At external examination we found opacity on both lens.
Assignment:
a. Describe ocular examination of infants and young children
b. How to distinguish differential diagnosis of leucocorea
c. Describe about the complication congenital cataract if we late starting therapy
Case 2
A 6-year old boy, still unable to speak, with a history of fall from his bed during infancy,
was sent by his parents to attend a school for the handicapped. This decision was made
following the advice of several friends and relatives. A hearing-aid device was prescribe
and the boy was trained some techniques of communication such as reading verbal and
lip signs, etc and various vocational skills needed to function as member in the society.
Case 3
A 6-year old boy with a hearing-aid device and being able to speak, entered a normal
primary school with special attention from the teacher. During pregnancy, his mother was
suspected to have contracted a viral infection. His mother noted that at age 18 months,
the boy couldn’t speak like other children of comparable age. Following the
administration of various hearing tests, the boy was found several deaf. A hearing-aid
device was fitted and the boy has then been intensely trained in verbal communication.
Assignment
1. Describe the influence of delayed detection and rehabilitation of the boys.
2. Will there be any difference in the outcomes of rehabilitation started early (2 years
of age) and years later (6 years of age)?
3. Describe the social impacts of delayed rehabilitattion on the boys future.
4. Desbribe the prospects for obtaining a decent education and job for the boys.
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LECTURE 20 + 21:
Case 1
Janet, 13 years old, had a long history of school problems. She failed first grade,
supposedly because her teacher was “mean”, and was removed from special classroom
because she kept getting into fights with the other children. Currently in a normal sixthgrade classroom, she is failing reading, barely passing English and spelling, and doing
satisfactory work in art and sports. Her teacher describes Janet as a ”slow learner with a
poor memory”, and states and requires a great deal of individual attention.
Janet’s medical history was unremarkable except for a tonsillectomy at age 5 years
and an early history of chronic otitis. She sat up at 6 months, walked at 12 months, and
began taking at 18 months. An examination revealed an open and friendly girl who was
nonetheless touchy about her academic problems. She stated that she was “bossed
around” at school but had good friends in the neighborhood. Intelligence testing revealed
a full-scale intelligence quotient of 97. Wide-range achievement testing produced gradelevel scores of 4.8 for reading, 5.3 for spelling, and 6.3 for arithmetic.
The most likely diagnosed is:
a. Disorder of written expression.
b. Expressive language disorder.
c. Phonological disorder.
d. Reading disorder.
e. None of the above.
Disorder of written expression is often associated with:
a. Reading disorder.
b. Mixed expressive-receptive language disorder.
c. Developmental coordination disorder.
d. Mathematics disorder.
e. All of the above.
Assignment:
a. Explain the criteria diagnostic for mental retardation.
b. Explain four degree of mental retardation and developmental characteristics of
Mentally Retarded Persons.
c. Explain the etiology and pathophysiology Mental Retardation.
d. Explain what is the differential diagnosis for Mental Retardation.
e. Explain the strategy of holistic therapy for Mental Retardation.
Self assessment:
Select the one that is the best in each case.
1. DSM-IV-TR lists the prevalence of mental retardation in the United States as:
a. 1 percent.
b. 3 percent.
c. 5 percent.
d. 6 percent.
e. 10 percent.
2. Mental Retardation should be diagnosed when the intelligence Quotion (IQ) is below:
a. 100.
b. 85.
c. 70.
d. 65.
e. 60.
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3. A decline in IQ begins at approximately 10 to 15 years in which of the following
disorders?
a. Down’s syndrome.
b. Fragile X syndrome.
c. Cerebral palsy.
d. Nonspecific mental retardation.
e. None of the above.
Self assessment:
Select the one that is the best in each case:
1. All of the following chromosomal aberrations associated with Down’s syndrome lead
to a phenotypic expression of the disorder except:
a. Patient have 45 chromosomes.
b. Patient have three of chromosome 21.
c. Patient have 47 chromosomes with an extra chromosome 21.
d. Patient have 46 chromosomes, but two, usually 21 and 15, are fused.
e. Patient have mosaicism, with normal and trisomic cells in various tissues.
2. The genetic finding linked most closely to advancing maternal age is:
a. Translocation between chromosome 14 and chromosome 21.
b. Mitotic nondisjunction of chromosome 21.
c. Partially trisomic karyotipe.
d. Meiotic nondisjunction of chromosome 21.
e. All of the above.
LECTURE 22+23:
Case
GD, 5 years old boy came to Growth and Development Clinic, Sanglah Hospital
accompanied by his mother. His mother complained about her son which is hyperactive
and lack of communication. He is constantly running around and climbing tables and
chairs. He can’t sit still for long, except while watching television. He gets bored easily
with new toys. Now GD is a kindergarten student. His teacher complained GD cannot
pay attention in class. He is very hard to control because he is always wants to run
around and he is restless most of the time. He always grabs toys from other children and
hits other children. His mother also said that there is no history of serious illness. His
mother had normal pregnancy period, birth weight was 3.000 gram, spontaneous delivery
in midwife, the baby cried spontaneously.
Assignment:
a. What is the differential diagnosed of this case?
b. Please examine this child using Conners Parent Rating Scales (CPRS). What are
the points that necessary to fill observation item in the CPRS?
c. According to DSM IV-TR criteria, is he an ADHD? Why?
Self Assessment
a. Describe how to diagnose the ADHD
b. Describe the etiology of the ADHD
c. Describe the patophysiology of ADHD
d. Describe the treatment of ADHD
e. Describe the prognosis of ADHD
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Case
A 2 years old boy, came to the Growth and Development Clinic with chief complaint
deficient verbal and non verbal communication; unusual use of language and echolalia.
He spent more time alone; he cannot join with another child, and lack of eye contact. He
always arranges something everyday and repetitive. He cannot play peek-a- boo.
Assignment:
a. Please examine this child using CHAT. What are the points that necessary to fill
observation item in the CHAT?
b. According to DSM IV criteria, is he suffering from autism? Why?
c. Please differentiate between autism and delayed speech development?
Self Assessment
a. Describe how to diagnose the autism
b. Describe the cause of the autism
c. Describe the interventions of the autism
LECTURE 24:
Case
A boy was brought to the ambulatory service of the Central General Hospital of Denpasar
on February 13, 2006, for being unable to walk. The boy was born on January 12, 2004
in the same Hospital following a seemingly normal delivery with a weight of 1450 gram,
spontaneous cry after birth and appeared robust. Gestation age is 36 weeks
Assignment
a. To estabilish accurate diagnosis, what other additional information is required?
b. When the child is lifted up by the axilla, one of the legs appers shorter. What
additional investigation is required to determine the location of abnormality, and
what would be result?
c. CT scan of the head revealed periventricular leucomalacea. Based on the
findings so far, what do you think about the diagnosis?
d. When for the first time, do you suspect the boy may have had some neurological
abnormalities?
e. What other consultations are required?
f. How Would you manage the child?
LECTURE 25+26:
Assignment:
a. What is “aging”?
b. Describe the various theories of aging
c. Explain in more detail the genetic clock theory
d. What do you know about the connection between caloric metabolism and aging?
e. Why free radicals are thought into influence the process of aging?
f. How does the shortening of telomere cause the death of cell?
g. Explain what is meant by lengthening of telomere theory
Case
Mrs. L, a 75-year-old widow, came to your office after being discharged from the
hospital, where she underwent surgery for a fracture of her right shoulder. Mrs. L has
been under your care for several years and has been treated for hypertension,
osteoarthritis of both knees, and obesity. She had a stroke 4 years ago but the deficit
resolved. She has no history of diabetes or glaucoma. Her hypertension had been well
controlled with daily hydrochlorothiazide 25 mg and atenonol 50 mg. Because she does
not tolerate nonsteroidal anti-inflammatory agents, she acetaminophen for her knee pain
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but still has pain when she walks and sometimes uses a cane. Other medications include
enteric-coated aspirin and a multivitamin.
Mrs. L explains that, on the night of the fracture, she woke up to urinate around
midnight, and then fell the broke her shoulder. She related her fall to drinking wine that
night with a friend, which had made her a little drowsier than usual when she got up at
midnight. She drinks alcohol only occasionally, and has not had trouble before. The
conversation reminded Mrs. L that she experienced frequent nocturnal urination during
the hospitalization and on several occasions was unable to get to the toilet on time and
became incontinent. When questioned, she admits that she has had urinary frequency
for several years but managed it by avoiding beverages before sleep or before leaving
her house. She also avoids going out for long periods during the day, and, whenever she
returns from her brief excursions, she develops urinary urgency “as soon as the key goes
into the lock.” She has occasionally experienced leakage when sneezing, standing, or
coughing, but this most commonly occurs when she is trying to hold her urine during one
of her “urgent” episodes. Still, she did not view her urinary pattern as a big problem until
her recent hospitalization.
Mrs. L last visited her gynecologist 1 year ago. She has no cystocele, rectocele,
or uterine prolapse. She denies dysuria, fever, or constipation.
Assignment:
Evaluating this geriatric patient:
a. Physical assessment.
b. Functional assessment.
c. Nutritional Assessment.
Self assessment:
1. Describe the changes associated with “normal” aging.
2. Explain of classifying geriatric problems.
3. Describe the components of assessment of older patients.
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Clinical skill 1
General Principles of Physical Examination
Training Task #1
Training Session : Physical Examination 1
Preparation : Student should bring their own stethoscope for this training session.
Scenario
Wawan now has graduated from the medical school and he holds his private medical
practice at his home. He has already carried out for a month and patients start to visit his
office. Today, he prepares to run the medical practice as usual. He is arranging the
books and suddenly a patient has already sat down in front of his table. “Good afternoon,
Doc!” said the patient. He was startled and replied:”Good afternoon!”
Then the interview and physical examination has been done and doctor Wawan writes
down a prescription for influenza. “Thanks, Doc!” said the patient. Dr. Wawan replies,”
You are welcome and get well soon, Sir”. Wawan then turns over his body and continues
to arrange the books on the shelf. The patient then gets up and walks through the door,
with wide step and a little bit straddle as if he was afraid of something was going to fall.
Unlike normal person, the way he walks seems peculiar. It needs to keep in mind that
this walking style can be found in a patient who is suffering from syphilis with
neurological complication. Unfortunately, doctor Wawan was so concerned with his work
and kept sitting to back the patient who was at that time was walking through the door in
a specific, odd way.
Learning task
1) Identify mistakes have been made by doctor Wawan on that case!
2) When do we start examination to a patient?
3) What are the general features should be elicit from the patient?
4) Should we use all examination technique in organ system examination?
5) Define the indication or purpose of each examination technique!
6) Define the examination technique that should be used in these system organ:
a. Cardiovascular
b. Respiratory
c. Gastrointestinal
d. Genital tract
e. Breast examination
f. Central nervous system
g. Musculoskeletal
Training Task #2
Training Session : Physical Examination 2
Instruction
1) Each student should explain the basic technique that use in physical examination,
inspection, palpation, percussion, and auscultation to the facilitator.
2) After explanation, he should perform the technique on their friend. It will be
observed by the facilitator! You should perform this training in your subgroup of
three. Each of you will be act as the doctor, observer and patient.
3) The doctor then performs the physical technique for each organ system on his
friend who acts as a patient. Explain the technique you are using and the sign that
should be noticed.
4) Perform the auscultation technique for the heart and lung examination. Explain
the technique and the sign that should be noticed.
5) Perform percussion technique for thorax and abdominal examination. Explain the
technique and the sign that should be noticed.
Udayana University Faculty of Medicine, DME
50
Study Guide Block Growth and Development
6) Perform palpation technique for abdominal examination. Explain the technique
and the sign that should be noticed.
7) The student should change the role after completion of the task.
8) Discuss the questions arise or things that you could not understand well. Make a
note when it necessary! Write down your note on Worksheet #7 in your workbook.
Clinical Skill
Vital Sign Measurement
Training Task #3
Training Session : Taking Temperature and Breath Evaluation
Preparation : Student should bring their own stethoscope, sphygmomanometer,
flashlight, reflex hammer, and termometer.
Instruction
1) Explain the technique need for temperature taking; include oral temperature, core
temperature, rectal temperature and each condition. Should be noticed the
contraindication for each technique!
2) How can we examine the breath? What are the parameters for qualitative’ or
quantitative’ examination.
3) Explain the steps for blood pressure measurement, what is the condition should
be addressed, how you write and interpret the result.
4) You might use Worksheet #8 as an observation guide. Student should perform
this training in your subgroup of three. Each will be act as the doctor, observer
and patient.
5) The doctor then performs taking temperature on friend who acts as a patient.
Explain the technique to your partner!
6) Perform respiratory evaluation on your friend and explain the technique to your
partner! What is the result?
7) You should change role after one student have completed the task!
Training Task #4
Training Session : Blood Pressure Measurement
Instruction
1) You might use Worksheet #8 as an observation guide. In subgroup each student
should explain the blood pressure measurement technique. They should explain
the steps correctly before proceed to the training session.
2) Perform blood pressure measurement with your subgroup partner. Student who
performs the measurement should compare the result obtained in one patient with
another. Is it different? Can you explain the variable that might affected the
result?
3) Each student should do the measurement at least five times.
Udayana University Faculty of Medicine, DME
51
Study Guide Block Growth and Development
TOPIC FOR PAPER WORK
GROUP
TOPIC
SUPERVISOR
A1
Red Flag of Developmental Milestones
Comparation between CDC Chart 2000
with WHO 2006 Growth Chart
Mikroftalmus
Congenital Catarract
Management of Hearing Loss Disorder
in Children
Base Community Elderly Health Care
Service
Red Flag of Developmental Milestones
Comparation between CDC Chart 2000
with WHO 2006 Growth Chart
Mikroftalmus
Congenital Catarract
Management of Hearing Loss Disorder
in Children
Base Community Elderly Health Care
Service
Red Flag of Developmental Milestones
Comparation between CDC Chart 2000
with WHO 2006 Growth Chart
Mikroftalmus
Congenital Catarract
Management of Hearing Loss Disorder
in Children
Base Community Elderly Health Care
Service
Red Flag of Developmental Milestones
Comparation between CDC Chart 2000
with WHO 2006 Growth Chart
Mikroftalmus
Dr.dr. I GA Trisna Windiani, Sp.A
Dr.dr. I GA Trisna Windiani, Sp.A
A2
A3
A4
A5
A6
A7
A8
A9
A10
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
Udayana University Faculty of Medicine, DME
Dr. Wayan Eka Sutyawan, SpM
Dr. Wayan Eka Sutyawan, SpM
Dr. Eka Putra S, SpTHT
Dr.dr. R A Tuty Kuswardhani,
SpPD (K.Ger).,MARS
Dr.dr. I GA Trisna Windiani, Sp.A
Dr.dr. I GA Trisna Windiani, Sp.A
Dr. Wayan Eka Sutyawan, SpM
Dr. Wayan Eka Sutyawan, SpM
Dr. Eka Putra S, SpTHT
Dr.dr. R A Tuty Kuswardhani,
SpPD (K.Ger).,MARS
Dr.dr. I GA Trisna Windiani, Sp.A
Dr.dr. I GA Trisna Windiani, Sp.A
Dr. Wayan Eka Sutyawan, SpM
Dr. Wayan Eka Sutyawan, SpM
Dr. Eka Putra S, SpTHT
Dr.dr. R A Tuty Kuswardhani,
SpPD (K.Ger).,MARS
Dr.dr. I GA Trisna Windiani, Sp.A
Dr.dr. I GA Trisna Windiani, Sp.A
Dr. Wayan Eka Sutyawan, SpM
52
Study Guide Block Growth and Development
TITLE
(subject/topic: choose from compentency list)
Name
NIM
Faculty of Medicine, Udayana University
2015
______________
1. Introduction (Pendahuluan)
2. Content (Isi, sesuai topik yang dibahas)
3. Summary (Ringkasan)
4. Refferences: (Daftar Pustaka) Van Couver style
Example:
Journal
Sheetz MJ, King GL. Molecular understanding of hyperglycemia’s adverse effect
for diabetic complications. JAMA. 2002;288:2579-86.
Textbook
Libby P. The Pathogenesis of atherosclerosis. In: Braunwald E, Fauci A, Kasper
D, Hoster S, Longo D, Jamason S (eds). Harrison’s principles of internal
medicine. 15th ed. New York: McGraw Hill; 2001. p. 1977-82.
Internet
WHO. Obesity: preventing and managing the global epidemic. Geneva: WHO
1998.
[cited
2005
July].
Available
from:
http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en.
6 – 10 pages, 1.5 space, Times new romance 12
Udayana University Faculty of Medicine, DME
53
Study Guide Block Growth and Development
PAPER ASSESSMENT FORM
BLOCK GROWTH AND DEVELOPMENT
Name
Student Register Number
Facilitators
Title
: .................................................................
: ................................................................
: .................................................................
: ................................................................
Supervisor’s (facilitator) scoring with 60%qualification:
No
1
2
3
4
Item Asessment
Ability to find the literature
Communication Attitude
Quality of Material
Student’s Interest and motivation
TOTAL
Range Score (%)
0 – 20
0 – 30
0 – 40
0 – 10
100
Score
Supervisor,
(
)
Udayana University Faculty of Medicine, DME
54
Study Guide Block Growth and Development
Basic References:
1. Behrman RE, Kliegman RM. Nellson Textbook of Pediatrics. 17th ed. Philadelphia,
WB Saunders. 2004.
2. Sadler TW: Langman’s Medical Embryology, 10th ed. Philadelphia, Lippincott
Williams and Wilkins. 2006.
3. Soetjiningsih. Tumbuh Kembang Anak. EGC. 1995.
4. Thompson JS and Thompson MW.Genetics in Medicine. 4th ed. Philadelphia, WB
Saunders. 1986.
5. Ultrasound and Doppler. In Cunningham F G et al, in Williams Obstetrics, 21 st ed.
1997; 1111-1139.
Additional References:
1. Ballantyne J, Groves J. Scott-Brown’s Diseases of the ear, Nose, and Throat. 4th
ed, Boston, Butterworths.
2. Elizabeth B. Hurlock. Child Development. 6th ed. Mc Graw Hill. 1984.
3. Eva PR, Whitcher JP. Vaughan & Asbury’s General Ophthalmology. 16th ed.
Lange Medical Book.
4. Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Geriatric Medicine and Gerontology. 4th ed. McGraw-Hill Co.
Jeremy KH, Jan Maarten W, Alan D Rogol. Pediaric Endocrinology and Growth.
2nd ed. Saunders Co, Philadelphia. 2003.
Kane RL, Ouslander JG, Abrass IT, Essentials of Clinical Geriatrics. 5th ed.
McGraw-Hill Co. 2004.
Klaus MH, Fanacroff AA. Care of the High-Risk Neonate. 5th ed. Philadelphia, WB
Saunders Co. 2001.
Koren G, Pastuszak A, Ito S. Drugs in Pregnancy. New Engl J Med. 1998. 338;
(16). 1128-1137.
L Kathleen M, Marian TA. Nutritional care in anemia in Krause’s Food nutrition &
diet therapy. W B Saunders Co, Philadelphia, 5th Ed, 1992. pp 558-563.
Lawrence RA, Lawrence RM. Breast feeding a Guide for the Medical Profession.
5th ed. Philadelphia, Mosby. 1999.
Lerner RM. Concepts and Theories of Human Development.
Mahan KL, Escott-Stump: Krause’s Food, Nutrition, & Diet Therapy, 11th ed.
Philadelphia, WB Saunders, 2004.
Soetjiningsih, Moersintowarti, Sudiyanto, Titi Sularyo. Pedoman Deteksi Dini
Penyimpangan Tumbuh Kembang Balita bagi Keluarga. Komie Tumbuh
Kembang Anak Indonesia. 1996.
Soetjiningsih. Pentingnya Stimulasi Dini Untuk mengoptimalkan Kecerdasan
Otak. SMF Ilmu Kesehatan Anak K UNUD/RS Sanglah Denpasar.
Tricia LG, Cunningham MD, Fabien GE, Karin EZ. Neonatology: Management,
Procedures, On-Call Problems, Disease, and Drugs. 5th ed. McGraw-Hill Co.
2004.
Udayana University Faculty of Medicine, DME
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Study Guide Block Growth and Development
CURRICULUM MAP
Smstr
10
9
8
7
6
5
4
3
2
1
Health Systembased Practice
(3 weeks)
BCS (1 weeks)
The Cardiovascular
System and
Disorders
(3 weeks)
BCS (1 weeks)
Neuroscience and
neurological
disorders
(3 weeks)
BCS (1 weeks)
Musculoskeletal
system &
connective tissue
disorders
(3 weeks)
BCS (1 weeks)
Basic microbiology
& parasitology
(3 weeks)
Basic Infection
& infectious
diseases
(3 weeks)
BCS (1 weeks)
Medical
communication
(3 weeks)
Basic pharmacology
(2 weeks)
BCS (1 weeks)
Studium
Generale and
Humaniora
(2 weeks)
Basic Anatomy
( 4 weeks)
Program or curriculum blocks
Senior Clerkship
Senior Clerkship
Senior Clerkship
Community-based
Evidence-based
Elective Study IV
practice
Medical Practice
(evaluation)
(4 weeks)
(2 weeks)
(3 weeks)
Special topics :
Health
Ergonomic &
Health
Environment
(2 weeks)
Medical Emergency
The Urinary
The Reproductive
(3 weeks)
System and
System and Disorders
Disorders
(4 weeks)
(3 weeks)
BCS (1 weeks)
BCS (1 weeks)
BCS (1 weeks)
The Respiratory System
The skin & hearing Special Topic :
and Disorders
system
- Palliative med
(4 weeks)
& disorders
- Complemnt &
(3 weeks)
Alternative Med.
BCS (1 weeks)
- Forensic
BCS (1 weeks)
(3 weeks)
Alimentary
The Endocrine
Clinical Nutrition and
& hepatobiliary systems
System,
Disorders
& disorders
Metabolism and
(2 weeks)
(3 Weeks)
Disorders
(4 weeks)
BCS (1 weeks)
BCS (1 weeks)
BCS (1 weeks)
Immune system &
Hematologic
Special Topic
disorders
system & disorder
- sexology & anti
(2 weeks)
& clinical
aging
oncology
- Geriatri
(3 weeks)
-Travel medicine
BCS (1 weeks)
BCS (1 weeks) (4 weeks)
Medical
Professionalism
(2 weeks) + medical
ethic (1 weeks)
Basic Anatomy
Pathology & Clinical
pathology (3 weeks)
BCS (1 weeks)
Behavior Change
and disorders
(3 weeks)
The cell
as biochemical machinery
(2 weeks)
Basic Histology
(2 weeks) &
Basic Physiology
(3 weeks)
BCS (1 weeks)
Growth &
development
(2 weeks)
Basic
Biochemistry
(2 weeks)
BCS (1 weeks)
Comprehensi
ve Clinic
Orientation
(Clerkship)
+ medical
ethic
(4 weeks)
19 weeks
Elective
Study III
19 weeks
(3 weeks)
Elective
Study II
(2 weeks)
18 weeks
The Visual
system &
disorders
(2 weeks)
19 weeks
BCS (1weeks)
Basic
Pharmaceutica
l medicine &
drug etics
19 weeks
(1 weeks)
Elective Study I
(2 weeks)
19 weeks
BCS (1 weeks)
19 weeks
Pendidikan Pancasila & Kewarganegaraan ( 3 weeks )
Inter Professional Education (smt 3-7)
Udayana University Faculty of Medicine, DME
56