CHAPTER I

INTRODUCTION

1.1 Background
The Digestive System is the eleven block in the 4th semester of the
competency based curriculum in medical faculty of Muhammadiyah Palembang
University . Learning in this block is very important to learn in medical faculty of
Muhammadiyah Palembang University.
On this occasion, a case study tutorial of scenario A which presents cases
that related to the digestive system. It’s about Diwan, A 2 year old, is brought 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 ¼ cup, yellowish color, no blood, and mucus in the feces.
He had experienced fever. He also suffers nausea and vomitting with frequency 1-
2 times a day, as much as ¼ cup, contain what his consumed, and not expulsion.
He began lethargic but still want to drink. Last urinate was 4 hours ago.

1.2 Purpose
The purpose of this case study tutorial report are:
1. As a group task report which is a competency-based curriculum learning
system in the medical faculty of Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning
methods.
3. The purpose of the tutorial learning method is reached.

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. R.A.Tanzila, M.Kes
Moderator : Achmad Ridhoullah Pratama
Secretary I : Zafira Ananda Raisha
Secretary II : Muhammad Reza Alfath
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 year old, is brought 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 ¼ cup,
yellowish color, no blood, and mucus in the feces.
He had experienced fever. He also suffers nausea and vomitting with frequency 1-
2 times a day, as much as ¼ cup, contain what his consumed, and not expulsion.
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 cm.

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Vital signs : domposmentis; PR : 140 times per minute, regular; RR : 32 times per
minute; Temp : 36.4◦C.
Spesific Condition :
Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : S1-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm.
Laboratory Examinations :
Hb 12.6 g/dl, WBC 6.000/mm3, differential count 0/1/2/45/48/4.
Routine examination of the feces :
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color.
Leucocyte feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)

2.3 Terms of Clarfication

No Clarifications Meaning
Stool removal from the rectum (Dorland,
1 Defecation
2015).
Solid bodily waste discharge from large
2. Feces
intestine (Dorland, 2015).
3. Fluid defecating diarrhea (Dorland, 2015)
Free mucus in the mucous membrane
4. Mucous consists of glandular secretions (Dorland,
2015).
The yellowish color seen in the feces
5. Yellowish
(Dorland, 2015).
A bad sensation in epigastrium in abdomen,
6. Nausea
with tendency to vomit (Dorland, 2015).

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 Expenditure of gastric contents through the
7. Vomitting
mouth (Dorland, 2015).
8. Expulsion (Dorland, 2015).
Having little energy, feeling, willing and
9. Lethargic
unable to do something (Dorland, 2015).
the release of urine from the urinary bladder
10. Urinate through the urethra to the outside of the body
(Dorland, 2015).
The black circle around eyes which
11. Sunken eyes indicating of anemia, hepar disease and
dehidration (Dorland, 2015).
The degree of elasting of skin, sometimes
12. Turgor
refferes to as skin turgor (Dorland, 2015).
Noises from the abdomen caused by the
13. Bowel sound muscullar contraction of peristaltic (Dorland,
2015).
14. Pus The liquid rich of basil protein process of
inflammation which contains leucocyte.
Celular of debris, and liquor puris (Dorland,
2015).
15. hyfa The fungis formed from the growth of spores
or conidia

2.4 Problems Identification

1. Diwan, A 2 year old, is brought 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 ¼ cup, yellowish color, no blood, and mucus in the feces.
2. He had experienced fever. He also suffers nausea and vomitting with
frequency 1-2 times a day, as much as ¼ cup, contain what his consumed,
and not expulsion.
3. He began lethargic but still want to drink. Last urinate was 4 hours ago.

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4. Physical Examination :
General Condition : moderate illness, weight 11 kg, height 84 cm.
Vital signs : domposmentis; PR : 140 times per minute, regular; RR : 32 times
per minute; Temp : 36.4◦C.
Spesific Condition :
Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : S1-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm.
5. Laboratory Examinations :
Hb 12.6 g/dl, WBC 6.000/mm3, differential count 0/1/2/45/48/4.
6. Routine examination of the feces :
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color
Leucocyte feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)

2.5 Priority Issue

No.1. Because, if he does not administered immediately can lead to
dehydration and can even abandon the patient's death.

2.6 Problems Analysis

1. Diwan, A 2 year old, is brought 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
¼ cup, yellowish color, no blood, and mucus in the feces.
a. What are the anatomy and physiology in this case? (Ridho, dita, rahma)
b. What is the relationship between gender and age in this case ? (rafian, biyol,
alteza)

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c. What is the meaning of chief the complaints of fluid defecating since 4 days
ago? (zafira, nabila, reza)
d. What is the etiology of fluid defecating ? (rafian, kak irma, dita)
e. How many the normal frequency of defecation in one day? (lalak, rahma, reza)
f. How is the pathophysiology of fluid defecating ? (nabila, rahma, dita)
g. What are classifications of diarrhea? (zafira, biyol, alteza)
h. What is the meaning of Frequency of defecation are 3-4 times a day,
consistency of feces more liquid than pulp, as much as ¼ cup, yellowish color,
no blood, and mucus in the feces ? (ridho, lalak, reza)
i. What are the characteristics normal and abnormal of feces and when we can
said that it was diarrhea? (nabila, dita, lalak)

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

frequency 1-2 times a day, as much as ¼ cup, contain what his consumed,
and not expulsion.
a. What is the corelation of fever, nausea and vomitting with chief complaints?
(kak irma, lalak, ridho)
b. What is the pathophysiology of fever in this case? (biyol, rafian, rahma)
c. What are the claffications of vomit? (zafira, lalak, dita)
d. How is the pathophysiology nausea and vomitting ? (nabila, rahma, lalak)
e. What is the meaning he also sufferes nausea and vomitting with frequency 1-2
times a day , as much as ¼ cup, contain what his consumed, and not expulsion?
(reza, alteza, kak irma)

3. He began lethargic but still want to drink. Last urinate was 4 hours ago.
a. What is the meaning of he began lethargic but still want to drink and last
urinate was 4 hours ago? (zafira, lalak, ridho)
b. What are dehydration degrees? (rafian, biyol, nabila)
c. What is the pathophysiology of dehidration in this case? (dita, biyol, kak irma)
d. What is the meaning of last urinate was 4 hours ago? (ridho, alteza, kak irma)
e. How are the characteristics and frequency normal urine in baby below 3 years
old? (nabila, zafira, reza)

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4. Physical Examination :
General Condition : moderate illness, weight 11 kg, height 84 cm.
Vital signs : domposmentis; PR : 140 times per minute, regular; RR : 32 times
per minute; Temp : 36.4◦C.
Spesific Condition :
Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : S1-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm
a. What are the interpretations of physical examination? (reza, alteza, rafian)
b. What are the abnormal mecanism of physical examination? (ridho, zafira,
rahma)

5. Laboratory Examinations :
Hb 12.6 g/dl, WBC 6.000/mm3, differential count 0/1/2/45/48/4.
a. What are the interpretations of laboratory examination? (alteza, kak irma,
rahma)
b. What are the abnormal mecanism of laboratory examination? (biyol, dita,
lalak)

6. Routine examination of the feces :

Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-),
yellowish color
Leucocyte feces : 1-2/hpf, erythrocytes : 0-1/hpf, bacteria (-), hyfa (-)
a. What are the interpretations of routine examination of the feces? (biyol, rafian,
alteza)
b. What are the abnormal mecanisms of routine examination of the feces? (zafira,
rahma, ridho)

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7. How to diagnose? (reza, kak irma, dita)
8. What are the differential diagnostic in this case? (nabila, lalak, zafira)
9. What are the supporting examination to diagnose in this case? (ridho,
biyol, rafian)
10. What is the working diagnostic in this case? (ridho, rafian, kak irma)
11. How to manage the case’s procedure comprehensively? (nabila, rahma,
biyol)
12. What is the complication of this case? (rafian, ridho, dita)
13. How is the prognostic in this case? (zafira, nabila, rahma)
14. What is the general practitioner’s competence in this case? all
15. What is islamic view in this case? all

2.7 Conclusion
Diwan, A 2 years old has an acute diarrhea with mild-to-moderate
dehydration caused by virus.

2.8 Conceptual Framework

Invasive virus → virus will multiply in mature enterocytes at the end of proximal
small intestine villi → spread to distal → damaged microvilly → disruption of
fluid absorption → acute diarrhea → mild-to-moderate dehydration.