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TUTORIAL REPORT OF SCENARIO A

BLOK XI : DIGESTIVE SYSTEM

GROUP 8

Lecturer : dr. Iskandar Z A, DTM&H, M.Kes, Sp.ParK

Clarisa Lucia Valerina (702013076)


Nanik Wardani Muslikah (702016007)
Ahmad Nanda Maulana (702016014)
Muhammad Abidinsyah (702016020)
Ria Adiba (702016039)
Yanisah Afuah Defriva (702016070)
Erika Alviyanti (702016072)
Alifah Dimar Ramadhina (702016078)
M. Arif Qobidhurahmat (702016083)
Anita Febrianti (702016086)
Muhammad Rizky Febriyadi (702016089)

FACULTY OF MEDICINE
MUHAMMADIYAH PALEMBANG UNIVERSITY
2018
CHAPTER II
DISCUSSION

2.1 Tutorial Data


Tutor : dr. Iskandar Z A, DTM&H, M.Kes, Sp.ParK
Moderator : M. Arif Qobidhurahmat
Desk Secretary : Ria Adiba
Bord Secretary : Muhammad Rizky Febriyadi
Time : Monday, March 19th 2018
(13.00 – 15.30 p.m)
Wednesday, March 21st 2018
(13.00 – 15.30 p.m)

The Rule of Tutorial : 1. Deactivate the phone or condition the phone in


silence.
2. Raise your hand when going to argument.
3. Get permission when going out of the room.
4. It is prohibited to bring food or eat in the room
during the discussion process is in progress.

2.2 Scenario A
“When Feces in Trouble”

Diwan, A 2 years old, is bought by his mother to puskesmas with chief


complaints of fluid defecating since 4 days ago. Frequency of defecation are 3-4
times a day, consistency of feces more liquid than pulp, as much as 1/4 cup,
yellowish color, nblood and mucus in the feces. He had experienced fever. He
also sufferes nausea and vomitting with frequency 1-2 times a day, as much as
1/4 cup, contain what his consumed, and not explusion. He began lethargic but
still want to drink. Last urinate was 4 hours ago.
Physical Examination :

General condition : moderate illness, weight 11 kg, height 84 kg

Vital signs : composmentis; PR : 140 times per minute, regular ; RR : 32 times


per minute ; temp : 36, 4°c

Specific condition :

Head : close forehead, sunken eyes, no tears, wet mouth mucous

Thorax : symmetrical, retraction : (-)

Cor : SI - SII normal, no heart noisy

Lung : vesicular, wheezing (-), ronki (-)

Abdomen : flat, increased bowel sounds, liver and lien are not palpable, decrease
turgor pressure

Extremitas : palms and soles are warm

Laboratory Examination :

Hb 12,6 g/dl, WBC 6.000/mm, differential count 0/1/2/45/48/4

Routine Examination of the Feces :

Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color

Leukocyte Feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)

2.3 Terms of Clarfication


No Clarifications Meaning
11 Turgor condition become swallen or congesti
2 Wheezzing is high pitch white whistly sound made when
you breath
a normal condition which there’s no
3 Wet mouth mucous
dehidration
The appearence of the person that have a
sign a hollowing under the eyes, dark
4 Sunken eyes
shadow over the lower eyelid, dark circles
underness be eyes
5 Palpable the act of feeling with the hand
bursts of gastric content that come out by
6 Vomiting
force through the mouth
State of tiredness wearingness fatigue or leck
7 Lethargic it can be compained by depretion decrease
motivation or apthy
8 feces Excretion that come out through the intestine

2.4 Problems Identification


1. Diwan, A 2 years old, is bought by his mother to puskesmas with chief
complaints of fluid defecating since 4 days ago. Frequency of defecation
are 3-4 times a day, consistency of feces more liquid than pulp, as much as
1/4 cup, yellowish color, no blood and mucus in the feces.
2. He had experienced fever. He also sufferes nausea and vomitting with
frequency 1-2 times a day, as much as 1/4 cup, contain what his
consumed, and not explusion. He began lethargic but still want to drink.
Last urinate was 4 hours ago.

3. Physical Examination :

General condition : moderate illness, weight 11 kg, height 84 kg

Vital signs : composmentis; PR : 140 times per minute, regular ; RR : 32


times per minute ; temp : 36, 4°c

Specific condition :
Head : close forehead, sunken eyes, no tears, wet mouth mucous

Thorax : symmetrical, retraction : (-)

Cor : SI - SII normal, no heart noisy

Lung : vesicular, wheezing (-), ronki (-)

Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decrease turgor pressure

Extremitas : palms and soles are warm.

4. Laboratory Examination :

Hb 12,6 g/dl, WBC 6.000/mm, differential count 0/1/2/45/48/4

5. Routine Examination of the Feces :

Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-),
yellowish color

Leukocyte Feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)

2.5 Priority Issue


Number 1.

2.6 Problems Analysis


1. Diwan, A 2 years old, is bought by his mother to puskesmas with chief
complaints of fluid defecating since 4 days ago. Frequency of defecation are 3-
4 times a day, consistency of feces more liquid than pulp, as much as
1/4 cup, yellowish color, nblood and mucus in the feces.
a. How is the anatomy, physiology, histology in this case?
1.Stomach
The stomach is a J-shaped saclike chamber lying between the
esophagus and the small intestine. It is divided into three sections based
on structural and functional distinctions .The fundus is the part of the
stomach that lies above the esophageal opening. The middle or main part
of the stomach is the body. The smooth muscle layers in the fundus and
body are relatively thin, but the lower part of the stomach, the antrum,
has heavier Musculature. This difference in muscle thickness plays an
important role in gastric motility in these two regions, The terminal
portion of the stomach is the pyloric sphincter, which acts as a barrier
between the stomach and the upper part of the small intestine, the
duodenum.

Figure 1. Anatomy of the stomach.

The stomach stores food and begins protein digestion.


The stomach performs three main functions:
1. The stomach’s most important function is to store ingested food until it
can be emptied into the small intestine at a rate appropriate for optimal
digestion and absorption. It takes hours to digest and absorb a meal that
was consumed in only a matter of minutes. Because the small intestine is
the primary site for this digestion and absorption, it is important that the
stomach store the food and meter it into the duodenum at a rate that does
not exceed the small intestine’s capacities.
2. The stomach secretes hydrochloric acid (HCl) and enzymes that begin
protein digestion.
3. Through the stomach’s mixing movements, the ingested food is
pulverized and mixed with gastric secretions to produce a thick liquid
mixture known as chyme. The stomach contents must be converted to
chyme before they can be emptied into the duodenum.
The four aspects of gastric motility are (1) filling, (2) storage, (3)
mixing, and (4) emptying. We begin with gastric filling.
1. Gastric filling involves receptive relaxation.
When empty, the stomach has a volume of about 50 mL, but it can
expand to a capacity of about 1 liter (1000 mL) during a meal.
2. Gastric storage takes place in the body of the stomach.
Because only feeble mixing movements occur in the body and fundus,
food delivered to the stomach from the esophagus is stored in the
relatively quiet body without being mixed. The fundic area usually does
not store food but contains only a pocket of gas. Food is gradually fed
from the body into the antrum, where mixing does take place.
3. Gastric mixing takes place in the antrum of the stomach.
The strong antral peristaltic contractions mix the food with gastric
secretions to produce chyme. Each antral peristaltic wave propels chyme
distally toward the pyloric sphincter
4. Gastric emptying is largely controlled by factors in the duodenum.
In addition to mixing gastric contents, the antral peristaltic contractions
are the driving force for gastric emptying . The amount of chyme that
escapes into the duodenum with each peristaltic wave before the pyloric
sphincter tightly closes depends largely on the strength of antral
peristalsis. The intensity of antral peristalsis and thus the rate of gastric
emptying can vary markedly under the influence of various signals from
both the stomach and duodenum.
2. Small Intestine
The small intestine is the site where most digestion and
absorption take place. No further digestion is accomplished after the
luminal contents pass beyond the small intestine, and no further
absorption of ingested nutrients occurs, although the large intestine does
absorb small amounts of salt and water. The small intestine lies coiled
within the abdominal cavity, extending between the stomach and the
large intestine. It is arbitrarily divided into three segments—the
duodenum, the jejunum, and the ileum. Segmentation, the small
intestine’s primary motility during digestion of a meal, both mixes and
slowly propels the chyme. Segmentation consists of oscillating, ringlike
contractions of the circular smooth muscle along the small intestine’s
length; between the contracted segments are relaxed areas containing a
small bolus of chyme. Segmentation is slight or absent between meals
but becomes vigorous immediately after a meal. Both the duodenum and
the ileum start to segment simultaneously when the meal first enters the
small intestine.

Figure 2 Segmentation
The small intestine is remarkably well adapted for its primary role
in absorption.
All products of carbohydrate, protein, and fat digestion, and most of the
ingested electrolytes, vitamins, and water, are normally absorbed by the
small intestine indiscriminately. Usually, only the absorption of calcium
and iron is adjusted to the body’s needs. Thus, the more food consumed,
the more that will be digested and absorbed, as people who are trying to
control their weight are all too painfully aware. Most absorption occurs
in the duodenum and jejunum; very little occurs in the ileum, not
because the ileum does not have absorptive capacity but because most
absorption has already been accomplished before the intestinal contents
reach the ileum. The small intestine has an abundant reserve absorptive
capacity. About 50% of the small intestine can be removed with little
interference to absorption—with one exception. If the terminal ileum is
removed, vitamin B12 and bile salts are not properly absorbed because
the specialized transport mechanisms for these two substances are
located only in this region. All other substances can be absorbed
throughout the small intestine’s length. The mucous lining of the small
intestine is remarkably well adapted for its special absorptive function
for two reasons: (1) it has a large surface area, and (2) the epithelial cells
in this lining have a variety of specialized transport mechanisms.

Adaptation that increase the small intestine”s surface area


The following special modifications of the small-intestine mucosa
greatly increase the surface area available for absorption
 The inner surface of the small intestine is thrown into permanent
circular folds that are visible to the naked eye and increase the surface
area threefold.
 Extending from this folded surface are microscopic, fingerlike
projections known as villi, which give the lining a velvety appearance
and increase the surface area another 10 times . The surface of each
villus is covered by epithelial cells interspersed occasionally with
mucous cells (see chapter opener photo).
 Even smaller hairlike projections, the microvilli or brush border, arise
from the luminal surface of these epithelial cells, increasing the surface
area another 20-fold. Each epithelial cell has as many as 3000 to 6000 of
these microvilli, which are visible only with an electron microscope. The
small-intestine enzymes perform their functions within the membrane of
this brush border

Figure 3 Small-intestine absorptive surface.


Extensive absorption by the small intestine keeps pace with
secretion.
The small intestine normally absorbs about 9 liters of fluid per day in the
form of H2O and solutes, including the absorbable units of nutrients,
vitamins, and electrolytes. How can that be, when humans normally
ingest only about 1250 mL of fluid and consume 1250 g of solid food
(80% of which is H2O) per day illustrates the tremendous daily
absorption performed by the small intestine. Each day, about 9500 mL
of H2O and solutes enter the small intestine. Note that of this 9500 mL,
only 2500 mL are ingested from the external environment. The
remaining 7000 mL (7 liters ) of fluid are digestive juices derived from
the plasma. Recall that plasma is the ultimate source of digestive
secretions because the secretory cells extract from the plasma the
necessary raw materials for
their secretory product. Considering that the entire plasma volume is
only about 2.75 liters, absorption must closely parallel secretion to keep
the plasma volume from falling sharply. Of the 9500 mL of fluid
entering the small-intestine lumen per day, about 95%, or 9000 mL of
fluid, is normally absorbed by the small intestine back into the plasma,
with only 500 mL of the small-intestine contents passing on into the
colon. Thus, the body normally does not lose the digestive juices. After
the constituents of the juices are secreted into the digestive tract lumen
and perform their function, they are returned to the plasma. The only
secretory product that escapes from the body is bilirubin, a waste
product that must be eliminated.

3.Large Intestine
The large intestine consists of the colon, cecum, appendix, and
rectum. The cecum forms a blind-ended pouch below the junction of the
small and large intestines at the ileocecal valve. The small, fingerlike
projection at the bottom of the cecum is the appendix, a lymphoid tissue
that houses lymphocytes .The colon, which makes up most of the large
intestine, is not coiled like the small intestine but consists of three
relatively straight parts—the ascending colon, the transverse colon, and
the descending colon. The end part of the descending colon becomes
shaped, forming the sigmoid colon (sigmoid means “S shaped”), and
then straightens out to form the rectum (meaning “straight”).

Figure 4 Anatomy of the large intestine.

The large intestine is primarily a drying and storage organ.


The colon normally receives about 500 mL of chyme from the small
intestine each day. Because most digestion and absorption have been
accomplished in the small intestine, the contents delivered to the colon
consist of indigestible food residues (such as cellulose), unabsorbed
biliary components, and the remaining fluid. The colon extracts more
H2O and salt, drying and compacting the contents to form a firm mass
known as feces for elimination from the body. The primary function of
the large intestine is to store feces before defecation. Cellulose and other
indigestible substances in the diet provide bulk and help maintain regular
bowel movements by contributing to the volume of the colonic contents.
(Sherwood,lauralee,2014)

HISTOLOGY
1.Stomach
The stomach is an expanded hollow organ situated between the
esophagus and small intestine.At the esophageal-stomach junction, there
is an abrupt transition from the stratified squamous epithelium of the
esophagus to the simple columnar epithelium of the stomach. the
stomach is divided into the narrow cardia, where the esophagus
terminates, an upper dome-shaped fundus, a lower body or corpus, and a
funnel-shaped, terminal region called the pylorus.

Figure 5. Stomach: fundus and body regions

2. Small Intestine
The small intestine is a long, convoluted tube about 5 to 7 m
long; it is the longest section of the digestive tract. The small intestine
extends from the junction with the stomach to join with the large
intestine or colon. For descriptive purposes, the small intestine is divided
into three parts: the duodenum, jejunum, and ileum. Although the
microscopic differences among these three segments are minor, they
allow for identification of the segments. The main function of the small
intestine is the digestion of gastric contents and absorption of nutrients
into blood capillaries and lymphatic lacteals.
Regional Differences in the Small Intestine
 The duodenum is the shortest segment of the small intestine. The villi in
this region are broad,tall, and numerous, with fewer goblet cells in the
epithelium. Branched duodenal (Brunner’s) glands with mucus-secreting
cells in the submucosa characterize this region.
 The jejunum exhibits shorter, narrower, and fewer villi than the
duodenum. There are alsomore goblet cells in the epithelium.
 The ileum contains few villi that are narrow and short. In addition, the
epithelium contains more goblet cells than in the duodenum or jejunum.
The lymphatic nodules are particularly large and numerous in the ileum,
where they aggregate in the lamina propria and submucosa to form the
prominent Peyer’s patches.

Figure 6. Duodenum of the small intestine (longitudinal section


Figure 7. Small intestine: jejunum

Figure 8. Small intestine: ileum with lymphatic nodules (Peyer’s


patches) (transverse section).
Figure 9. Villi of small intestine

3.Large Intestine
The wall of the colon has the same basic layers as the small
intestine. The mucosa consists of simple columnar epithelium, intestinal
glands , lamina propria , and muscularis mucosae . The underlying
submucosa contains connective tissue cells and fibers, various blood
vessels, and nerves. Two smooth muscle layers make up the muscularis
externa . The serosa (visceral peritoneum and mesentery) covers the
transverse colon and sigmoid colon. There are several modifications in
the colon wall that distinguish it from other regions of the digestive tract
(tube). (Eroschenko,victor,p.2016)

Figure 10 Large intestine: colon wall (transverse section)


b. what is the etiology of the case?
Answer :
There are 4 factors that cause diarrhea is (FKUI, 2007):
1. Infection Factor:
a) Enternal infections are gastrointestinal infections that are the main
cause of diarrhea in children. Enternal infections include:
• Bacterial infections: Vibrio, E. coli, Salmonella, Shigella,
Campylobacter, Yersinia, Aeromonas and so on.
• Viral Infections: Enterovirus (ECHO Virus, Coxsackie,
Poliomyelitis), Adenovirus, Rotavirus, Astrovirus and others.
• Parasitic Infection: Worms (Ascaris, Trichiuris, Oxyuris,
Strongyloides), Protozoa (Entamoeba histolytica, Giardia Lamblia,
Tricomonas Hominis), Mushrooms (Candida Albicands).
b) Parenteral infection is infection of other body parts outside the
digestive tract, such as Acute Otitis Media (OMA), Tonsilofangitis,
Bronkopnemonia, Ensefaliti and so on. This situation is mainly found in
infants and children under 2 years old (FKUI, 2007).
2. Malabsorption Factors
a) Carbohydrate malabsorption: Disaccharide (lactose intolerance,
maltose and sucrose), Monosaccharide (Glucose Intolerance, Fructose
and Galactose). In infants and children the most important and the most
common is lactose intolerance.
b) Fat Malabsorption
c) Malabsorption of Protein (FKUI, 2007).
3. Food factors:
The suddenly changed food and poisonous, stale, and food. allergic to
food. And lack of cleanliness when consuming food (FKUI, 2007).
4. Psychic factors:
Fear and Worry. Although rarely can cause diarrhea, especially in older
children. And can be disesbabkan 'broken family' or other emotional
stress (FKUI, 2007).
c. how is the phatophysiology?
Answer :

Infection of Microorganisms through oral transmission (fecal) sign


in the upper gastrointestinal tract most Microorganisms in disable in
the stomach by gastric acid and some going to the distal
Microorganisms infecting the lining epithelium in the intestine
Microorganisms enter and multiply in the maturaenterosit at the
proximal part of the small intestine villi and spread to distal intestine in
a 48-hour incubation period Microorganisms and then damaging
enterosit in intestinal vilus later replaced by enterosit new immature
form of cuboidal villus atrophy will become function inadekuat and
absorption absorption disorders occur (can notmengabsorbsi well) so
that the food is not absorbed colloidal osmotic pressure will increase
gut hiperperistaltikintestinal fluids and foods that are not absorbed
pushed out through the anus  defecatingliquid(Diarrhea).(Price and
Wilson, 2012).

d. what is classification of diarrhae?


Answer :

Diarrhea can be clarified on the basis of:


• Duration of diarrhea
a. Acute diarrhea is diarrhea lasting less than 15 days and fluid and soft
passage of stool with more than normal amount and will subside
without specific therapy if dehydration does not occur
b. Chronic diarrhea is diarrhea lasting more than 15 days
• Pathophysiology (patomechanism)
a. Increased intraluminal osmolarity is called osmotic diarrhea
b. Increased secretion of fluid and electrolytes is called secretory
diarrhea
c. Malabsorption of bile acids, fat malabsorption
d. Electrolyte switch / electrolyte switching system is active in
enterocytes
e. Impaired bowel permeability
f. Abnormal bowel mobility and timing transit
g. Inflammation of the intestinal wall is called inflammatory diarrhea
h. Intestinal wall infection is called infectious diarrhea
(Setiawan, 2006)

e. What is the meaning of fluid defecation are 3-4 times a day,


consistency of feces more liquid than pulp, as much as 1/4 cup,
yellowish color, no blood and mucus in the feces?
Answer :

Fluid defecation mean is diwan already has an acute diarrhea,


consistency of feces more liquid than pulp, as much as 1/4 cup,
yellowish color mean it is caused by enterotoxin virus, and no blood
and mucus in the feces is signifies to get rid of an infection caused by a
bacteria (Sudoyo, 2009).

2. He had experienced fever. He also sufferes nausea and vomitting with


frequency 1-2 times a day, as much as 1/4 cup, contain what his consumed, and
not explusion. He began lethargic but still want to drink. Last urinate was 4
hours ago.

a. what is the meaning of the experienced fever?


Answer :
The meaning is that he has experienced a process of inflammation, and
frim the complaints that he is experiencing now still has a relation with
fever.

b. What is the patophysiology of fever, nausea, vomiting?


Answer :
Fever: Exogenous pyrogens phagocytosis by blood leukocytes, tissue
macrophages and large granular lymphocytes this cell will digest the
result of pyrogen breakdown and release interleukin 1 into the body
fluids interleukin 1 induces the formation of PGE2 PGE2 works
in the hypothalamus to evoke a fever reaction (Guyton, 2008).
Nausea and vomiting: Infection there is a change in gastrointestinal
activity salivation, tone and peristalsis of the stomach duodenal
tone and jejunum reflux of duodenal contents into the stomach
nausea stimulates the afferent nerve pathway by stimulation of the
vagus and sympathetic nerves stimulates the vomiting center in the
posterma medulla oblongata area at the base of the 4th ventricle
activates CTZ (chemoreceptor triggerer zone) the efferent pathway
receives signals that lead to an explosive movement of the abdominal,
gastrointestinal, and coordinated respiratory muscles vomiting.

c. What is the meaning from nausea and vomiting with frequency 1-2
times a day, as much as 1/4 cup, contain what his consumed, and
not expulsion?
Answer:
The meaning of nausea and vomiting with frequency 1-2 times a day,
as much as 1/4 cup is to Indicates there has been dehydration at Roni.
With the possibility of being viral infection of the stomach thus
damaging the gastric mucosal layer irritation and cause vomiting with
what content is eaten (Sherwood, 2014).
The meaning of contain what his consumed, and not expulsion is
To eliminate the alleged occurrence of intestinal obstruction and
nervous system disorders centers that cause increased intracranial
pressure (eg neoplasm, encephalitis, hydrocephalus) Also to exclude the
possibility of esophageal sphincter hypothony lower part, abnormal
position of esophageal joint with cardiac and gastric emptying of solid
contents. Because usually in this disease vomiting projectile (spray with
strong) (Sudoyo, 2009)

d. what is the meaning of began lethergic but still want to drink?


Answer :
The meaning of Roni seem lethargic but still want to drink shows
roni has experienced mild dehydration.
According to WHO, the signs and symptoms of mild dehydration (fluid
loss are 5 – 10%), namely:
• there are two or more alerts
• State public agitation or maudlin
• large slightly concave Cantle Height, eyes slightly concave, the tears
less, mucosa of the mouth and the lips a bit dry
• A Kral, turgor, pinch the stomach back slowly Looks thirsty
(Nelson, 2014).

e. What is the classification dehidration?


Answer :
The degree of dehydration can be determined by lose weight
a) mild dehydration: in case of weight loss 2 ½ -5%.
Symptoms:
• The skin appears reddened
• Thirsty increases
• Warm and dry skin
• No urination or reduced urine volume with dark color
• Dizziness and the body feels weak
•Sleepy
• The mouth and tongue feel dry with less saliva
b) moderate dehydration: in case of weight loss 5-10%.
Symptoms:
• Blood pressure decreases
• Fainting
• Strong contractions of muscles, arms, legs, abdomen and back
• Seizures
•Bloated
•Heart failure
• Sunken crowns
• Fast and weak pulse rate
c) severe dehydration: in case of weight loss> 10%.
Symptoms:
• Reduced consciousness and no urination
• The hands and feet feel cold and moist
• An increasingly rapid and weak pulse that is not palpable
• Lowering blood pressure can not be measured
• Bluish on the tip of the nail, mouth, and tongue

f. What is the meaning of last urinate was 4 hours ago?


Answer :
The meaning is the imbalance of water in the body with the
consumed. lack of fluid increases ionic concentration in extra cellular
compartments because the brain sensor controls drinking and controls
urinary secretions

3. Physical Examination :

General condition : moderate illness, weight 11 kg, height 84 kg

Vital signs : compos mentis; PR : 140 times per minute, regular ; RR : 32 times
per minute ; temp : 36, 4°c

Specific condition :

Head : close forehead, sunken eyes, no tears, wet mouth mucous


Thorax : symmetrical, retraction : (-)

Cor : SI - SII normal, no heart noisy

Lung : vesicular, wheezing (-), ronki (-)

Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decrease turgor pressure

Extremitas : palms and soles are warm.

a. What is the interpretation of physical examination?

Examination Result Normal Condition Interpretation

General Condition:
-Moderate Illness -No illness Abnormal

-BMI=15 -19-24 Underweight


Vital Sign:
 Composmentis -Composmentis Normal

 PR=140
x/minute(regular) -Neonatus 100-180
Normal
1 minggu – 3 bln 100-200
3 bln – 2 thn 80-150
2 thn – 10 thn 70-110
 RR=32 x/minute
> 10 thn 55-90

 Temp=36, 4°c -< 2 bln< 60


Normal
2-12 bln< 50
1-5 thn< 4

-Hipotermia< 36oC
Normotermia
Normotermia 36,5-37,2oC
Subfebris 37,3-38oC
Febris> 38oC

Hiperpireksia≥ 41,2oC

Specific condition :

Head : close forehead, -Close Forhead Normal

sunken eyes, no tears, wet -No sunken eyes Abnormal


-Has a tears
mouth mucous Abnormal
-wet mouth mucous
Normal
Abdomen : flat, increased
bowel sounds, liver and lien -No increasing bowel sound
are not palpable, decrease Abnormal
-No deacrasing turgour
turgor pressure pressure Abnormal

b. What is the abnormal mechanism abnormal physical examination?

Answer :

Sunken eyes, no tears

Diarrhea and vomiting ->Excessive nutrient and electrolyte exertion -


>decreased plasma volume ->Disorder of tear secretions -> sunken eyelids,
no tears

Dry mouth mucosa

Diarrhea and vomiting ->Excessive nutrient and electrolyte exertion -


>decreased plasma volume ->impaired salivary secretion -> Dry mouth
mucosa

The skin pinch (turgor) returns very slowly


Diarrhea and vomiting -> Excessive nutrient and electrolyte exhaust -
>dehydration ->decreased skin elasticity ->Skin tissor (turgor) returns very
slowly

4. Laboratory Examination :

Hb 12,6 g/dl, WBC 6.000/mm, differential count 0/1/2/45/48/4

a. What is the interpretation of laboratory examination?

Examination Normal Interpretation


Child: 11-16 gr / dl
Hb 12.6 g/dl Below 3 years old : 9-15 gr / Normal
dl

Below 5 years old : 5000- Normal


WBC 6.000/mm3
18.000 cells / mm3

Basophils: 0-1%
Eosinophils: 1-3%
Neutrophil segment
Differential count Neutrophil rods: 2-6%

0/1/2/45/48/4 Neutrophil segments: 50-70%
Lymphocytes ↑
Lymphocytes: 20-40%
Monocytes: 2-8%

b. What is the abnormal mechanism abnormal laboratory examination?


Answer :
Differential Count (an increase in Lymphocytes)
occurs because of infection, where virus infection causing her immune
system, acute phase on a will work for mengeradikasi virus
Stool more fluid than the dregs
viral infections acquired through transmission via fecal oral (through
breathing, contaminated food, do not wash your hands) virus infects the
lining epithelium in the intestinevirus enters and multiply in enterosit
the Matura at the proximal small intestine villiViruses will spread to
distal ileum and colon and damaging enterosit in intestinal vilus
replaced by the new enterosit immature, cuboidal form villus atrophy
the absorption of liquids and food disturbed liquids and food is not
easily absorbed or ingested colloidal osmotic pressure increased
intestinal intestinal fluid hiperperistaltik and more the absorption
decreased, increased secretions liquid diarrhea (more than the dregs of
liquid) (Price and Wilson, 2012).

5. Routine Examination of the Feces :

Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color

Leukocyte Feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)

a. What is the interpretation of routine examination?

Examination Normal Interpretation


Abnormal
More than liquid pulp soft and shaped

Blood (-) (-) Normal


Pus (-) (-) Normal
Mucous (-) (-) Normal
Yellowish Yellowish Normal
Leucocyte feces : 1-2/hpf 1-2/hpf Normal
Erythrocytes : 0-1/hpf 0-1/hpf Normal
Normal
Bacteria (-) (-) The Infection is not
caused by bacteria
Normal
Hyfa (-) (-) The Infection is not
caused by parasite

b. What is the abnormal mechanism abnormal routine examination?


Answer :
Viral infections via oral fecal then virus infects the peithellium layer
in the small intestine afterthat it multiplying in a mature enterocyte at the
end of the proximal small intestine villi then spreading to distal ileum and
colon then impairingentrosite in intestinal villi afterward replaced with
new entrosite that causing fluid and food intake to be impaired that make
undigested of fluids and foods andincreasing colonic osmotic colloid
pressure that causing peristaltic hyper and more fluid so there is more
liquid than pulp (Price, 2012)

6. How to diagnose?
Answer :

1. Chief complaints : fluid defecating since 4 days ago.


Additional complaints :
 Suffers nausea and vomitting with frequency 1-2 times a day, as much
as ¼ cup, contain what his consumed, and not expulsion.
 Began lethargic but still want to drink.
 Dehidration
2. He had experienced fever.
3. Physical Examination :
 General Condition : moderate illness
 Spesific Condition :
 Head : Sunken eyes, no tears.
 Abdomen : Increased bowel sounds, decreases turgor pressure
4. Laboratory Examinations : Limfositosis 0/1/2/45/48/4
5. Routine examination of the feces :
 Macroscopic : more liquid than pulp

7. What are the differential diagnostic in this case?


Answer :

Virus Bakteri (Shigella) V cholerae


Nausea & vomitting From the beginning Sometimes Sometimes
Fluid Defecating + + +
Fever + + -
Another sign - Can be -
convulsions,vomitting,
Melena
The characteristic of Feces
Volume Moderate A little Very much
Frequency Until 10x/ more Very often Almost
continuously
Consistensy Watery (fluid>pulp) Watery (fluid>pulp) Water
Blood - + -
Smell - No smell Rancid
Warna Green, Yellow Green -
Leukocyte Increased + -

8. What are the supporting examination to diagnose in this case?


Answer :
 Examination of acid – base balance disturbance in blood, by determining
Ph and alkaline reserve or more correctly a blood gas analysis with an
examination according to ASTRUP (whenever possible).
 Examination levels ureum and creatinin for knowing the faal the kidneys.
 Examinations electrolyte sodium levels, especially potassium, calcium
and phosphorus in serum (especially in people with diarrhea accompanied
by convulsions).
 Examination of duodenal intubasi to know the type of the remains
miniscule or qualitative and quantitative parasites, especially in people
with chronic diarrhea.
 Specific immunological examination to check for virus antigen in stool
specimens.

9. What is the working diagnostic in this case?


Answer :
Acute diarrhea (acute gastroenteritis) et causa rotavirus

10. How to manage the case’s procedure comprehensively?


Answer:
1. Preventive
a. To prevent diarrhea due to rotavirus infection, can be given rotavirus
vaccine per-oral (by mouth).
b. Exclusive breastfeeding
c. Supplementary feeding of clean and nutritious milk after 6 months old
baby
d. Washing hands
2. Curative
 Rehydration using low osmolality Oralite
To prevent the occurrence of dehydration can be done starting from the
household by providing low osmolarity ORS, and when not available
household fluids such as brine solution. Oralit currently circulating in
the market has new oralit with low osmolarity, which can reduce nausea
and vomiting. Oralit is the best fluid for the patient diarrhea to replace
lost fluids. If the patient can not drink should immediately taken to the
health facilities to get fluids help through the infusion. Oral disposal is
based on the degree of dehydration (Kemenkes RI, 2011)
a. Diarrhea without dehydration
• Age <1 year: ¼ - ½ cup every time the child diarrhea (50-100 ml)
• Age 1 - 4 years: ½-1 glass each time the child diarrhea (100-200 ml)
• Age over 5 years: 1-1½ glasses each time the child diarrhea (200-
300 ml)
b. Diarrhea with mild moderate dehydration
oral doses administered within the first 3 hours of 75 ml / kg and
thereafter continued with oral administration such as diarrhea without
dehydration.
c. Diarrhea with severe dehydration
Patients with diarrhea who can not drink should be immediately
referred to the Puskesmas to diinfus. For children under 2 years of
fluid should be given with spoon by way of 1 spoon every 1 to 2
minutes. Giving with no bottle may be done. Older children can drink
directly from the glass. When it happens vomit stop for 10 minutes
then start again slowly for example 1 spoon every 2-3 minutes. This
fluid administration is continued until diarrhea Stop.

 Zinc is given for 10 days in a row Zinc reduces the duration and
severity of diarrhea. Zinc can also restore the child's appetite. Based
on their effect on the immune function or on the structure and
function of the gastrointestinal tract and to the process of improving
the gastrointestinal epic during diarrhea. Administration of zinc in
diarrhea can increase the absorption of water and electrolytes by the
small intestine, increase the rate of bowel epithelial regeneration,
increase the number of brush bordering apical, and increase the
immune response that speeds up colon clearance from the gut.
Provision of zinc can reduce the frequency and volume of bowel
movements so as to reduce the risk of dehydration in children.
Children over 6 months of age: 20 mg (1 tablet) per day
Zinc is given for 10-14 consecutive days even though the child has
recovered from diarrhea. For older children, zinc can be chewed or
dissolved in boiled water or oralit.
Non-pharmacology:
1. Advice to mother or caregiver: return immediately if fever, bloody
stool, recurrent, eat or drink a little, very thirsty, diarrhea more often,
or have not improved within 3 days.
2. Provision of food should be continued during diarrhea and
improved after recovery. Continuing feeding will speed up the return
of normal bowel function including the ability to receive and absorb
various nutrients, thus deteriorating nutritional status can be
prevented or at least reduced. At least 50% of the diet should be from
food and administered in small or frequent (6 or more) meals and the
child is persuaded to eat. The combination of infant formula with
supplementary foods such as serelia is generally well tolerated in
weaned children. In older children, food can be provided consisting
of: local staple foods, such as rice, potatoes, wheat, bread or noodles.
To increase its energy content can be added 5-10 ml of vegetable oil
for every 100 ml of food.
3. Giving extra foods rich in nutrients a few weeks after recovery to
improve malnutrition and to achieve and maintain normal growth.
(Juffrie, M., et al., 2015)

6. What is the complication?


Answer:
The possible complications of an acute diarrheal illness include dehydration,
metabolic acidosis, impaired consciousness, convulsions,circulatory shock,
and prerenal azotemia (Suharyono, 2008).
10. How the prognostic in this case?
Answer:

Quo ad Vitam : Bonam


Quo ad Functionam : Bonam
Quo ad Sanationam : Bonam

11. What is the general practitioner’s competence in this case?


Answer:
Level Ability 4a: diagnose, perform self-management and complete
Doctor graduates are able to make clinical diagnoses and perform the
management of the disease independently and thoroughly.

12. What is islamic view in this case?


Answer:

An-Nahl : 114

Then eat of what Allah has provided for you [which is] lawful and good. And
be grateful for the favor of Allah, if it is [indeed] Him that you worship.

2.6 Conclusion
Diwan, A 2 years old suffering of acute diarrhea (acute gastroenteritis)
with mild-moderate dehydration due to viral infection
2.7 Conceptual Framework

Virus infection

Demage enterocyte of intestinum vili → vomitting

Spread to the distal with incubation time

in 24-48 hours

Diarrhea

Reduce of extracell fluid volume


dehydration

Daftar Pustaka

Aru W, Sudoyo. 2009. Buku Ajar Ilmu Penyakit Dalam, jilid II, edisi V. Jakarta:

Interna Publishing

Arvin, B.K. 2000. Nelson Health Sciences kid, Issue 15, vol. 3, books of

medicine EGC, Jakarta.

Eroschenko,victor,p. 2016. Atlas of histology difiore’s: with functional

correlations.ed.12 jakarta: EGC

Juffrie, M., et al., 2015. Gastroenterology-Hepatology. Fourth Print. Jakarta:

IDAI, 96-98

Price SA, Wilson LM. 2012. Patofisiologi konsep klinis proses-proses penyakit,

edisi ke-6. Jakarta: EGC


Setiawan B. Diare akut karena Infeksi, Dalam : Sudoyo A, Setyohadi B, Alwi I

dkk. Buku Ajar Ilmu Penyakit Dalam.Jilid 3.Edisi IV. Jakarta.

Departemen IPD FK UI Juni 2006

Sherwood,l auralee. 2014. Introduction to human phisyology. Jakarta: EGC

Suharyono. 2008. Diare AkutKlinikdanLaboratorik. Jakarta: RinekaCipt