CHAPTER I

INTRODUCTION

1.1 Background
The Growing and Geriatric Medicine is the twenty-first block in the
seventh semester of the Competency-Based Curriculum of Doctor Education of
the Faculty of Medicine, Muhammadiyah University of Palembang.
On this occasion, a scenario case study B was conducted on Ana, a 10
months old girl who visited the outpatient clinic RSMP with recurrent diarrhea
with her mother. She suffered from diarrhea almost every 1 time in a month since
she was 4 months old. The length of diarrhea was 7 to 10 days. Her mother said
that her daughters appetite was like usual. Ana is not having fever, cough,
cold and hard to breath now.
Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown. Ana was given exclusive breastfeeding
just until 3 months of age. Since her age was 3 months, she was only given
regular formula milk 6 times a day @90 cc until now. After her age was 4
months, she was given instant porridge as the complementary feeding (MP ASI)
2 times a day @1/2 sachet (1 sachet is 80 kcal). She also was given cooked rice
water (tajin) 2-3 times a day @50 cc since her age was 4 months.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Tutorials Data

Tutor : dr. Sheila Yonaka, M. Kes.
Moderator : Ragil Putra Jaya
Desk secretary : Della Kartika Corie
Board secretary : Annisa Nurul Jannah
Time : 1. Tuesday, September 26, 2017
At : 08.00-10.00 WIB
2. Thursday, September 28, 2017
At : 08.00-10.00 WIB
Rule 1. Communication tool disabled or in silent
state.
2. All members of the tutorial should express
their opinions by first raising their hands.
3. Ask for permission when going out of the
room.
4. Prohibited from eating and drinking during
discussions.

2.2 Case Scenario

Ana, a 10 months old girl, visited the outpatient clinic RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost every 1 time in a
month since she was 4 months old. The length of diarrhea was 7 to 10 days. Her
mother said that her daughters appetite was like usual. Ana is not having fever,
cough, cold and hard to breath now.
Anas weight was never weighed (she was never taken to Public Health Center).
Highest weight was unknown. Ana was given exclusive breastfeeding just until 3
months of age. Since her age was 3 months, she was only given regular formula

2
milk 6 times a day @90 cc until now. After her age was 4 months, she was given
instant porridge as the complementary feeding (MP ASI) 2 times a day @1/2
sachet (1 sachet is 80 kcal). She also was given cooked rice water (tajin) 2-3 times
a day @50 cc since her age was 4 months.
The mothers pregnancy and childbirth history:
Ana is the first child from a 24 years old mother. During pregnancy, mother was
healthy and prenatal care to a midwife 4 times. Ana was delivered spontaneously
at 37 weeks gestation. Immediately cried after birthed, APGAR score 1 minute 9
and 5 minutes 10. Birth weight was 2800 grams. Birth length was 49 cm. Head
circumference was 33 cm.
Immunization history: BCG 1 time but DPT , polio, hepatitis and measles
vaccines were never given.
Growth history: Image attachment of Anas KMS
Development history: Ana can only sit with help.
Medication history: Ana was never got treatment.
Physical examination:
General status: the child is not looking thin, round cheeks, pale, apathetic, whiny,
weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm circumference
12 cm.
Vital Sign: HR 112x/minute, RR 32x/minute, T:36.5 celcius degree.
Spesifics status:
Head:
- No dismorphic face face
- Round cheeks
- Easy revoked sheer yellowfish red head hair
- Wistful eyes
- Look and cry at the examiner
- Look towards when her name was called
Thoracs: no ribs (piano sign)
Abdoment: bloated

3
 Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin abnormalities (dermatosis) in the buttocks and groin
Neurologicus status:
- Normal movements, ;motoric muscle strength 4
- Normal physical reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes

2.3 Clarification of Terms

1. Diarrhea : Abnormally frequence evacuation of watery feces.
2. Exclusive : The feeding of babies and young children with
Breastfeeding milk from womans breast for six months.
3. Formula milk : An infant's liquid food preparation based on cow's
milk or soy protein, given as a substitute for
breast milk.
4. Complementary : Defined as the process starting when breast milk
feeding alone is no longer sufficient to meet the
nutritional requirements of infants, and therefore
other foods and liquids are needed, along with
breast milk.
5. APGAR score : A measure of the physical condition of a newborn
infant. It is obtained by adding points (2, 1, or 0)
for heart rate, respiratory effort, muscle tone,
response to stimulation, and skin coloration; a
score of ten represents the best possible condition.
6. Dismorphic Face : An abnormality in the development of form or

4
 face's structure.
7. Dermatosis : A disease of the skin, especially one that does not
cause inflammation.
8. Baggy pants : The skin is dry and wrinkled and looks too big for
the body, but does not break or change color.

2.4 Problem Identification

1. Ana, a 10 months old girl, visited the outpatient clinic RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost every 1 time in a
month since she was 4 months old. The length of diarrhea was 7 to 10 days.
2. Her mother said that her daughters appetite was like usual. Ana is not
having fever, cough, cold and hard to breath now.
3. Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown. Ana was given exclusive
breastfeeding just until 3 months of age. Since her age was 3 months, she
was only given regular formula milk 6 times a day @90 cc until now.
After her age was 4 months, she was given instant porridge as the
complementary feeding (MP ASI) 2 times a day @1/2 sachet (1 sachet is 80
kcal). She also was given cooked rice water (tajin) 2-3 times a day @50 cc
since her age was 4 months.
4. The mothers pregnancy and childbirth history:
Ana is the first child from a 24 years old mother. During pregnancy, mother
was healthy and prenatal care to a midwife 4 times. Ana was delivered
spontaneously at 37 weeks gestation. Immediately cried after birthed,
APGAR score 1 minute 9 and 5 minutes 10. Birth weight was 2800 grams.
Birth length was 49 cm. Head circumference was 33 cm.
5. Immunization history: BCG 1 time but DPT , polio, hepatitis and measles
vaccines were never given.
Growth history: Image attachment of Anas KMS
Development history: Ana can only sit with help.

5
 Medication history: Ana was never got treatment.
6. Physical examination:
General status: the child is not looking thin, round cheeks, pale, apathetic,
whiny, weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm
circumference 12 cm.
Vital Sign: HR 112x/minute, RR 32x/minute, T:36.5 celcius degree.
Spesifics status:
Head:
- No dismorphic face face
- Round cheeks
- Easy revoked sheer yellowfish red head hair
- Wistful eyes
- Look and cry at the examiner
- Look towards when her name was called
Thoracs: no ribs (piano sign)
Abdoment: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin abnormalities (dermatosis) in the buttocks and groin
Neurologicus status:
- Normal movements, ;motoric muscle strength 4
- Normal physical reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes

6
2.5 Problem Analysis
1. Ana, a 10 months old girl, visited the outpatient clinic RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost every 1 time in a
month since she was 4 months old. The length of diarrhea was 7 to 10 days.
a. What is the meaning of Ana, a 10 months old girl visited the outpatient
visited the outpatient clinic RSMP with recurrent diarrhea with her
mother and she suffered from diarrhea almost every 1 time in a month
since she was 4 months old?
Answer:
It means Anna suffered chronic diarrhea.

b. What are etiologies of diarrhea?

Answer:
Infection causes (bacterial, viral, and parasitic) account for most cases
of diarrhea. A potential pathogen can be identified in up to 70% of
acute diarrheas presenting at treatment facilities and in about 50% of
cases from the community. In general, the same pathogens are
responsible for diarrhea worldwide, with only variations in the
frequency of occurrence of each pathogen in different localities. The
following are the commonest etiologic agents of diarrhea for all ages
in decreasing order of prevalence obtained from pooled data
worldwide: rotavirus, ETEC, shigella, campylobacter, Vibrio cholerae,
and non-typhoidal salmonella. Similar organisms have been isolated
from epidemiologic studies done in the Philippines. Other important
viral agents of diarrhea are Norwalk and adenovirus; among parasites,
cryptosporidium, Entamoeba histolytica, and Giardia intestinalis. A
number of pathogens have also been associated with the presence of

7
 bloody stools and cases of persistent diarrhea. The usual pathogenic
mechanisms for infectious diarrhea are toxin production and tissue
invasion. Noninfectious causes of diarrhea include drugs, surgical
conditions, systemic infections and food intolerance (Celia C, et al.,
1990).

c. What are the effects of diarrhea?

Answer:
1. Dehidration
2. Hypovolemic
3. Hypocalemia
4. Hypoglycemia
5. Seizures
6. Intolerance lactose
7. Malnutrition
(FKUI, 2005)

d. What is the pathophysiology of diarrhea in this case?

e. What are the classification of diarrhea?
Answer:
According to WHO (2014), diarrhea classified into 4 types:
Acute Diarrhea
A diarrhea lasts for less than 14 days
Persistent Diarrhea
A child who has had diarrhea for 14 days or more and who has no
signs of dehydration
Severe Persistent Diarrhea
If a child has had diarrhea for 14 days or more and also has some or
severe dehydration
Chronic Diarrhea

8
 Diarrhea in child for 14 days or more, recurrent, and had no related
to infection, butcaused by malabsorption, or intolerance of food.

f. What is the correlation between Anas age and her symptoms?

2. Her mother said that her daughters appetite was like usual. Ana is not
having fever, cough, cold and hard to breathe now.
a. What is the meaning that Anas appetite was like usual, no fever,
cough, cold and hard to breathe now?
Answer:
Fever is one of the symptoms of infection. If Ana had no fever, it
means there is no any gastrointestinal infection, or other infection.
There were no cough, cold, and hard to breath means there is no acute
respiratory tract infection.

3. Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown. Ana was given exclusive breastfeeding
just until 3 months of age. Since her age was 3 months, she was only given
regular formula milk 6 times a day @90 cc until now. After her age was 4
months, she was given instant porridge as the complementary feeding (MP
ASI) 2 times a day @1/2 sachet (1 sachet is 80 kcal). She also was given
cooked rice water (tajin) 2-3 times a day @50 cc since her age was 4 months.
a. What is the meaning Anas weight was never weight (she was never
taken to public health center)?
b. What is the correlation between Ana was given exclusive
breastfeeding until 3 months and diarrhea?
c. What are the compotition and benefits of breastmilk?
Answer:
THE COMPOTITION OF BREASTMILK

9
 The benfits of ASI are:

a. Colostrum is the most superior and well-designed nutrition for

your baby in the first few days of life.
b. Breast milk contains a full range of vitamins and minerals in an
easily digestible combination.
c. Special immune system protective proteins are present in breast
milk. These proteins offer protection against diarrhoea, food
allergies and infections.
d. Lactoferrin : binds to iron, thus rendering it unavailable to
viruses and bacteria.
e. Lysozymes and milk leucocytes: destroy viruses and bacteria
f. Secretory IgA: immunoglobulin that destroys viruses and
bacteria
g. Bifidus factor: promotes the growth of beneficial bacteria in the
gut and limits the growth of disease causing bacteria.

d. What are the effects of lacking exclusive breast feeding?

e. What are the effects if the infant just consumed the formula milk?
Answer:
1. Gastrointestinal disorder, example: diarrhea.
2. Obesity.
3. Infection risk from unhygienic formuler milk.
4. Malnutrition.
5. Not get all the benefits of breast milk such as protection from
illness

10
 6. Have lower iron levels
7. Have a diet low in protein, fat, and other important nutrients
(Roesli, 2008).

f. What made the mothers are not breast feeding?

g. How many calories/day does Ana get when she was 3 months, and
how many calories should she got?
h. How many calories/day does Ana get when she was 4 months, and
how many calories should she got?
i. How many calories should a normal 10 months infant got per day
compared to Anas case?
j. What are the effects of giving rice water/tajin 2-3 times a day?
k. How to give complementary feeding?
l. What are the effects of giving complementary feeding since 4 months?

11
4. The mothers pregnancy and childbirth history:
Ana is the first child from a 24 years old mother. During pregnancy, mother was healthy
and prenatal care to a midwife 4 times. Ana was delivered spontaneously at 37 weeks
gestation. Immediately cried after birthed, APGAR score 1 minute 9 and 5 minutes 10.
Birth weight was 2800 grams. Birth length was 49 cm. Head circumference was 33 cm.
a. What are the interpretation of the mothers pregnancy and childbirth history?

5. Immunization history: BCG 1 time but DPT , polio, hepatitis and measles vaccines
were never given.
Growth history: Image attachment of Anas KMS
Development history: Ana can only sit with help.
Medication history: Ana was never got treatment.
a. What are the interpretation of immunization, growth history, development
history and medication history?
Answer:
Immunization history : According to the recommendations of the
Indonesian Pediatric Association, Ana's immunization history is not
complete. Supposedly at the age of 10 months, Ana has been immunized
Hepatitis B 3 times, DPT 3 times, Polio 4 times and Measles 1 time.
Growth history: Based on the weight-for-age girls chart, Anas curve is
below the -3 percentile. This means that Ana is malnourished.
Development history : The significance of Ana's development history
shows that Ana is experiencing a delay in development where the 9-12
month child should have increased mobility and can walk with guided,
imitate sounds, repeat the sounds he/she heard, learn to say a word or two,
understand simple commands or prohibitions, showing great interest in
exploring the surroundings, wanting to touch anything and put things into
his mouth, participate in the game. 10 months infant should be able to sit
alone without help.
Medication history : thie mean is a delay in preventing growth and
development disorders in Ana, because with a history of less growth when

12
 viewed from KMSnya then Ana should have been given treatment before
the current age so that the progress of the disease does not gain weight.

b. How is the immunization history based on IDAI?

Answer:

c. What are the effects if the immunization incompleted?

Answer:
Incomplete immunization history is one of the factors of diarrhea. In a study ever
conducted by Yanti (2001) states that there is a significant relationship between

13
 immunization status and the incidence of diarrhea. This means that infants who
are not immunized are more likely to suffer from diarrhea.

d. What are the growth milestone of 0-12 months?

Answer:

14
6. Physical examination:
General status: the child is not looking thin, round cheeks, pale, apathetic, whiny,
weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm circumference 12
cm.
Vital Sign: HR 112x/minute, RR 32x/minute, T:36.5 celcius degree.
Spesifics status:
Head:
- No dismorphic face face
- Round cheeks
- Easy revoked sheer yellowfish red head hair
- Wistful eyes
- Look and cry at the examiner
- Look towards when her name was called
Thoracs: no ribs (piano sign)
Abdoment: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin abnormalities (dermatosis) in the buttocks and groin
Neurologicus status:
- Normal movements, ;motoric muscle strength 4
- Normal physical reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes
a. What are the interpretations of the physical examination?
b. What are the mechanism for the abnormal outcomes?
7. How to diagnose?
8. What are the differential diagnosis?
9. What are emeriksaan penunjang

15
 10. What is the working diagnosis?
11. What is the treatment for this case?
Answer:
Treatments lesion on kwarshiokor:
Defiency Zn; almost happened on child with kwashiokor and their skin will soon be
better with zinc suplementation. In addition to:
1. Compress the wound with Calium permanganat solution (PK;KmnO4) 0,01% for
10 minutes/day
2. Fill the ointment/cream (zinc with castor oil, tulle gras) on rough areas, and fill
gentian violet (or available, nistatin ointment) on lesion
3. Avoid use diapers disposable order perineum area still dry.

12. What are the complications if she doesnt get the treatment?
13. What is the prognosis?
14. What is the doctors competention for this case?
15. How are Islamic values in this case?

2.6. Conclusion
Ana, a 10 months old girl suffered Kwashiorkor et causa Gastroenteritis and malnutrition.

2.7. Concept Framework

Infant (10 months) Output

Input
(GE)

Protein and other

nutritions

malnutrition

Kwashiorkor

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Growth and development
disorders
 DAFTAR PUSTAKA

Hassan, R. 2007. Ilmu Kesehatan Anak FK UI. Jakarta : Info Medika.

Marcdante, KJ et al. 2011. Ilmu Kesehatan Anak Nelson. Singapura: Elsevier.

Staf Pengajar Ilmu Kesehatan anak FKUI. 2007. Ilmu Kesehatan Anak. Jakarta : FKUI
WHO. 2014. Integrated Management of Childhood Illness :Diarrhoea. Switzerland: WHO.

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