PREFACE

Thanks to Allah SWT for helping and give us chance to finish this
Scenario B tutorial report on the 21 Blok timely. Shalawat and Salam always be
with our prophet Muhammad SAW and his family, friends, and followers until the
end of time.
We recognize that this tutorial report is far from perfect. Therefore we
expect constructive criticism and suggestions, in order to refine the next tasks.
In completing this tutorial task, we got a lot of help, guidance and advice.
On this occasion we would like to express our respect and gratitude to:
1. dr. Iskandar Z A, DTM&H, M.Kes, Sp. Park as tutor of group 6
2. All of the members who involved in the making of this report

May Allah SWT give a reward for all the charity given to all those who
have supported us and hopefully this tutorial report, useful for us and the
development of science. May we always be in the protection of Allah SWT.
Amen.

Palembang, September 27st, 2017

Author

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 TABLE OF CONTENT

PREFACE .................................................................................................................. 1
TABLE OF CONTENT ............................................................................................. 2
CHAPTER I INTRODUCTION
1.1 Issue Background .......................................................................................... 3
1.2 Purpose and Objectives ................................................................................. 3
CHAPTER II DISCUSSION
2.1 Tutorial Data .................................................................................................4
2.2 Case Scenario ................................................................................................4
2.3 Clarification of Terms ...................................................................................6
2.4 Identification of Problem ..............................................................................7
2.5 Problem Analyze ...........................................................................................8
2.6 Conclusion ....................................................................................................27
2.7 Conceptual Framework .................................................................................27
BIBLIOGRAPHY ......................................................................................................28

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 CHAPTER I
INTRODUCTION

1.1 Issue 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 daughter’s appetite was like “usual”. Ana is not
having fever, cough, cold and hard to breath now.
Ana’s 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. Data Tutorial

Tutor : dr. Iskandar Z A, DTM&H, M.Kes, Sp. Park
Moderator : Falaah Islama
Secretary : Altiara Risky Suciandari
Notulen : Mia Audina
Day and date : Tuesday, September 26th 2017
08.00 - 10.30 am
Thursday, September 28th 2017
08.00 - 10.30 am
Rule of tutorial : 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 diarrhea was 7 to 10 days.
Her mother said that her daughter’s appetite was like “usual”. Ana is not having
fever, cough, cold, and hard to breathe now.
Ana’s 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 given only
regular formula milk 6 times a day @ 90 cc until now. After her age was 4
months, she was given cooked rice water (tajin) 2-3 times a day @ 50 cc since her
age was 4 months.

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The mother’s 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 Ana’s 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 signs: HR: 112x/minute, RR: 32x/minute, T: 36,5oC
Specifics status:
Head:
 No dimorphic face
 Round cheeks
 Easy revoked sheer yellowish red head hair
 Wistful eyes
 Look and cry at the examiner
 Look towards when her name was called
Thoraxs: no ribs (piano sign)
Abdomen: 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:

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  Normal movements, motoric muscle strength 4
 Normal physiological reflexes
 Normal clonus and tone
 No uncontrollable movements
 No pathological reflexes

2.3. Clarification of Terms

No. Terms Definition
1. Recurrent Abnormally frequent evacuation of watery
Diarrhea feces.
2. Exclusive Breastfeeding has given since birth until 6
breastfeeding month with or without given regular formula
and complementary feeding.
3. Complementary The transition from exclusive breastfeeding to
feeding (MPASI) family foods.
4. APGAR A quick test for a baby at 1 and 5 minutes after
birth. The 1-minute score determines how well
the baby tolerated the birthing process. The 5-
minute score tells the health care provider how
well the baby is doing outside the mother’s
womb.
5. Edema A swelling because accumulation of excessive
fluid in tissue.
6. Dermatosis Is define as a disorder involving lesion or
eruption of the skin.
7. Bloated abdomen The condition when the gastrointestinal tract is
filled with air or gas.
8. Piano sign Tulang rusuk menonjol.
9. Baggy pants The skin is dry and wrinkled and looks too big
for the body, but does not break or change
color.

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 11. Apatis shows no interest or energy and shows that
someone is unwilling to take action.
2.4. Identification of Problem
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 diarrhea was 7 to 10 days.
2. Her mother said that her daughter’s appetite was like “usual”. Ana
is not having fever, cough, cold, and hard to breathe now.
3. Ana’s weight was never weighed (she was never taken to Public
Health Center). Highest weight was unknown.
4. Ana was given exclusive breastfeeding just until 3 months of age.
Since her age was 3 months, she was given only regular formula
milk 6 times a day @ 90 cc until now. After her age was 4
months, she was given cooked rice water (tajin) 2-3 times a day @
50 cc since her age was 4 months.
5. Immunization history: BCG 1 time but DPT, polio, hepatitis and
measles vaccines were never given.
6. Growth history: image attachment of Ana’s KMS
7. Development history: Ana can only sit with help
8. Medication history: Ana was never got treatment
9. 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 signs: HR: 112x/minute, RR: 32x/minute, T: 36,5oC
10. Specifics status:
Head:
 No dimorphic face
 Round cheeks
 Easy revoked sheer yellowish red head hair
 Wistful eyes

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  Look and cry at the examiner
 Look towards when her name was called
Thoraxs: no ribs (piano sign)
Abdomen: 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
11. Neurologicus status:
 Normal movements, motoric muscle strength 4
 Normal physiological reflexes
 Normal clonus and tone
 No uncontrollable movements
 No pathological reflexes

2.5. Problem Analyze

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 diarrhea was 7 to 10 days.
a) What are the etiologies of diarrhea?
Answer:
1. Infection Factors:
 Enternal infections are gastrointestinal infections that
are the main cause of diarrhea in children. Enternal
infections are:
 Bacterial infections: Vibrio, E. coli, Salmonella,
Shigella, Campylobacter, Yersinia, Aeromonas and so
on.

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  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),
Candida Albicands.
2. Malabsorption Factors:
 Carbohydrate malabsorption: Disaccharides (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.
 Fat Malabsorption
 Protein Malabsorption
3. Diarrhea caused by food poisoning
Food poisoning is a brief illness that is caused by toxins
produced by bacteria. With some bacteria, the toxins are
produced in the food before it is eaten, while with other
bacteria, the toxins are produced in the intestine after the
food is eaten.
4. Diarrhea caused by drugs
5. Drug induced diarrhea is very common because many drugs
cause diarrhea. The clue to drug-induced diarrhea is that the
diarrhea begins soon after treatment with the drug is begun.
The medications that most frequently cause diarrhea are
antacids and nutritional supplements that contain
magnesium. Other classes of medication that cause diarrhea
include:
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Chemotherapy medications
 Antibiotics

9
  Medications to control irregular heartbeats
(antiarrhythmics)
 Medications for high blood pressure
(Celia C, et al., 1990 and Subagyo, 2012)

b) What is the meaning of Ana diarrhea almost every 1 time in a

month since she was 4 months old and the length diarrhea was
7 to 10 days?
Answer:
Ana has chronic diarrhea.
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
Diarrhea in child for 14 days or more, recurrent, and had no
related to infection, but caused by malabsorption, or
intolerance of food.

c) What is the pathophysiology of recurrent diarrhea in this case?

Answer:
Inadequate nutritional intake (Breastfeeding 3 months) → lack
of IgA → Gastrointestinal disturbance due to lactose intolerance
→ → deficiency of lactose → ↑ osmotic pressure → crypto cells
secrete water → ↑ bowel peristaltic movement → fluid and food
scraps pushed out through the anus → diarrhea. (Hassan, 2007).

10
 The basic mechanisms that cause diarrhea are:
 Osmotic disorders
Due to the presence of food or substances that can not be
absorbed will causing osmotic pressure in the intestinal cavity to
rise, so there is a shift of water and electrolyte into the intestinal
cavity. The contents of intestinal cavity that excessive will
stimulate the intestine to leave it out causing diarrhea.
 Disturbance of secretions
Due to certain stimuli (eg by toxins) on the intestinal wall will
occurs increase secretion of water and electrolyte into the
intestinal cavity and then diarrhea caused by an increase in the
contents of the intestinal cavity. Due to stimulation of abnormal
mediators such as enterotoxins, causing the villi to fail to absorb
sodium, while secretion klorida epithelial dilatation continues or
increases. This matter causing increased secretion of water and
electrolytes into the intestinal cavity. The contents of the
intestinal cavity will excessively stimulate the intestine to
remove it causing diarrhea.
 Impaired bowel motility
Hyperperistaltik will lead to reduced intestinal opportunities to
absorb food, resulting in diarrhea. Conversely when decreased
bowel peristaltic will result in bacteria growing excessively
which can lead to diarrhea as well (Hassan, 2007).

d) What are the effects of recurrent diarrhea?

Answer:
1. Dehydration (mild, moderate, severe)
2. Shock Hypovolemic
3. Hypokalemia
4. Hypoglycemia
5. Malnutrition protein
6. Seizures
7. Malnutrition

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 8. Lack of immune
9. Delayed growth and development (Subagyo, 2012).

2. Her mother said that her daughter’s appetite was like “usual”. Ana
is not having fever, cough, cold, and hard to breathe now.
a) What is the meaning Ana’s is appetite was like “usual”. not
having 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. Infections from
viruses, bacteria, or parasites sometimes lead to chronic
diarrhea

b) How the nutritional needs for children aged 0-10 months ?

Answer:

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3. Ana’s weight was never weighed (she was never taken to Public
Health Center). Highest weight was unknown.
a) How much normally weight of 10 months years old baby?
Answer:
Mean weight in children:
 3.5 kg at birth
 10 kg at 1 year of age
 20 kg at the age of 5 years
 30 kg at the age of 10 years
Daily weight gain:
 20-30 grams in the first 3-4 months
 15-20 grams in the remainder of the first year

The formula of body weight 3-12 months

Age (month) +9
2
10+9 = 8,5 kg
2 (Soetjiningsih, 2012)
b) How much the minimum weight increase per month up to for
10 months years old baby?
Answer:
The weight gain per month in the first year, ranges from:
1) 700-1000 grams / month in the first quarter
2) 500-600 grams / month in the second quarter
3) 350-450 gram / month in quarter III
4) 250-350 gram / month in quarter IV
(Soetjiningsih, 2012)

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 c) What is the effects Ana’s weight was never weighted (she was
never taken to public health center)?
Answer:
Children who have never been taken to a health center may not
be able to monitor the growth and development of the child, as
in every contact with the child is expected to conduct
examination or giving treatment or counseling about:
1. length or height, increase in length or height by one month
or third month, growth status.
2. psychomotor development, psychomotor development
status.
3. diet, weight, weight gain every month or every three
months, nutritional status.
4. immunization, immunization status.
5. physical health, causes of morbidity include diseases,
disabilities, injuries, emotional disorders, behavioral
disorders (Hassan, 2007).

4. Ana was given exclusive breastfeeding just until 3 months of age.

Since her age was 3 months, she was given only regular formula
milk 6 times a day @ 90 cc until now. After her age was 4 months,
she was given cooked rice water (tajin) 2-3 times a day @ 50 cc
since her age was 4 months.
a) How does a baby's diet age 0-12 months?
Answer:
Age of Child Type of Food Frequency/day
(month)
0-6 Breast milk Give when the baby
need
6-9 breast milk / formula milk, breast milk/ formula
crushed food (milk porridge, milk give when the
porridge, marrow, scraped banana, baby need and
papaya or tamato. tim rice. crushed food 2 times.

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 9-12 Formula milk, crushed foods (rice Breast milk/ formula
porridge, chicken porridge, tim milk, crushed foods 2-
rice, etc. 3 times.
12-24 Breast milk/formula milk, family breast milk/ formula
foods. milk give when the
baby need and
crushed food 3-5
times.

b) How long should exclusive breastfeeding be?

Answer:
In developing countries, optimal breastfeeding starting within
one hour of birth, exclusive breastfeeding (no additional foods
or liquids, including water) for the first 6 months of life, and
continued breastfeeding until age 2 or longer (Hegar, 2013).

c) What are the composition and benefits of breastmilk?

Answer:

Benefits:
 Lactose
As a source of energy producing, as a carbohydrate, it increases the
absorption of calcium in the body, stimulating the growth of
lactobacilli bifidus.

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 Protein
Has a function for the regulator and builder of the baby's body.
 Fat
Serves as a heat / energy hazard, lowering the risk of heart disease
at a young age.
 Vitamin A
Vitamins are very useful for the development of infant vision.
 Iron (Fe)
Substances that help the formation of blood to prevent the baby
from less blood or anemia.
 Taurine
Neotransmitters for brain development of children.
 Lactoferrin
Inhibits the development of candida and bacterial staphylococcus.
 Lisozyme
Reduce dentis caries and malocclusion and can break down the
walls of bacteria.
 Colostrum
Important substances that contain many nutrients and substances of
the baby's body from disease attack.
 AA and DHA
Omega-3 and omega-6 that works for fetal and infant brain
development.

d) What are the effects if the infant just consumed the formula
milk?
Answer :
For the first six months of life breast milk is the only food
that your baby needs to grow and be healthy. Breastfeeding is
the normal way to feed babies. If you give your baby any other
food, including infant formula, you will make less breast milk.
If you stop breastfeeding, it can be hard to start breastfeeding

16
 again. Your baby will not get all of the benefits of
breastfeeding.
In this case, the impact of given formula too early :
1. Breastfeed less often causing you to make solid foods too
early less breast milk
2. Not get all the benefits of breast milk such as protection
from illness
3. Have lower iron levels
4. Have a diet low in protein, fat, and other important
nutrients. (Hirsch, 2008)

5. Immunization history: BCG 1 time but DPT, polio, hepatitis and

measles vaccines were never given.
a) What are the interpretation of immunization history?
Answer:
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.

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b) How is the immunization history based on IDAI?
Answer:

c) What are the effects if the immunization incomplete?

Answer:
Immunization is a way of boosting immunity to an antigen
that can be divided into active immunization and passive
immunization. Active immunization is the benefit of germs or
toxins that have been attenuated or killed to stimulate the body
to produce its own antibodies while passive immunization is
the injection of antibody levels so that levels of antibodies in
the body increases. The most important group to get
immunization is babies and toddlers because they are the most
sensitive to disease and the body system of children under five
is immature.
If toddlers do not immunize, then the body of the toddler
body will be reduced and will be susceptible to disease. This
has an indirect impact with the incidence of nutrition.
Immunization is not enough to do just one time but gradually

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 and completely to various diseases to maintain in order to
survive the exposure of disease (Liansyah, 2015)

6. Growth history: Image attachment of Ana’s KMS.

a) What are the interpretation and abnormal mechanism of growth
history?
Answer:
Based on the weight-for-age girls chart, Ana’s curve is below
the -3 percentile. It means that Ana is malnourished.

b) What are the growth milestone of 10 months?

Answer:
In children 9-12 months:
1. Can stand alone without help
2. Can walk with a guide
3. Imitate the sound
4. Repeating the sounds he/she heard
5. Learn to state one or two words
6. Understanding simple commands or prohibitions
7. Showing a great interest in exploring the surroundings,
wanting to touch anything and put things into his mouth.
8. Participate in the game
Some milestones of child development should be known
(development milestone is the rate of development a child
should reach at age 9-10 months:
1. pointing with the index finger
2. holding the object with the thumb and forefinger
3. crawl
4. voiced da ... da ... (Soetjiningsih, 2012)

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 c) How is the ideal of child growth from the KMS?
Answer:

(Kementrian Kesehatan RI, 2013)

7. Development history: Ana can only sit with help.

a) What is the interpretation and abnormal mechanism of
development history?
Answer:
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 (Richard, 2012)

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8. Medication history: Ana was never got treatment.
a) What is the interpretation of medication history?
Answer:
It means a delay in preventing growth and development
disorders in Ana, because with a history of less growth when
viewed from KMS Ana should have been given treatment
before the current age so that the progress of the disease does
not gain weight.

9. 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 signs: HR: 112x/minute, RR: 32x/minute, T: 36,5oC
a) What are the interpretation and the mechanism for the
abnormal outcome of physical examination?
Answer:
Examination Normal Interpretation
the child is not is not looking thin Normal
looking thin
Apathetic Not apathetic ↓oxygen to brain
Whiny Not whiny malnutrition
weight 5 kg 8,5 kg >-3 SD
lenght 60 cm 67,2-73,6 Growth disorder
Head 45-48 cm Normal
circumference 45
cm
HR 112 x/minute 2 – 12 month :< 50 Tachycardia
RR 32 x/minute 20-60 x/minute Normal
36,50C 36,5-37,2oC Normal

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 Apathetic and tachycardia
Inadequate nutritional intake→ lack of IgA → Gastrointestinal
disturbance due to lactose intolerance → deficiency of lactose →
↑ osmotic pressure → crypto cells secrete water → ↑ bowel
peristaltic movement → fluid and food scraps pushed out through
the anus → diarrhea (for a long time and without treatment) →
Hypovolemic → Periphery organ vasoconstriction as a
compensation (heart and brain) → apathetic and tachycardia
 Whiny, weight >-3, growth disorder.
Inadequate nutritional intake→ lack of IgA → Gastrointestinal
disturbance due to lactose intolerance → deficiency of lactose →
↑ osmotic pressure → crypto cells secrete water → ↑ bowel
peristaltic movement → fluid and food scraps pushed out through
the anus → diarrhea (for a long time and without treatment) →
malnutrition, weight >-3, growth disorder.

10. Specifics status:

Head:
 No dimorphic face
 Round cheeks
 Easy revoked sheer yellowish red head hair
 Wistful eyes
 Look and cry at the examiner
 Look towards when her name was called
Thoraxs: no ribs (piano sign)
Abdomen: 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.

22
a) What are the interpretation and abnormal mechanism of
specifics status?
Answer:

Spesific status Normal Interpretations

Head: Round cheeks, Sign and symptom
Round cheeks, easy revoked yellowish red kwashiorkor
sheer yellowish red head hair, head hair, and
and wistful eyes wistful eyes (-)
Thorax: piano sign Piano sign (-) thoracic wall fat
reserves ↓
Abdomen: Bloated Bloated edema Malnutrition
(-)
Extremities: Extremities
Edema in the four extremities edema (-)
No baggy pants baggy pants (-) Normal
Dermatosis in the buttocks Dermatosis (-)
and groin
 Easy revoked sheer yellowish red head hair:
Inadequate nutritional intake → deficiency of calorie, protein
and copper → ↓ Nutrition Adequacy Rate → nutrition for hair
↓ → yellowish red hair head and easily revoked
 Piano sign:
Inadequate nutritional intake for a long time→ malnutrition →
↑ catabolism, ↓ anabolism → thoracic wall fat reserves ↓ →
piano sign
 Bloated abdomen:
Inadequate nutritional intake for a long time→ malnutrition →
↑ catabolism, ↓ anabolism → thoracic wall fat reserves ↓ →
bloated abdomen

23
 b) How much normally weight and height on Ana should be?
Answer:
Ana’s weight for age = 8,5 kg and Ana’s length for age = 72
cm.

11. Neurologicus status:

 Normal movements, motoric muscle strength 4
 Normal physiological reflexes
 Normal clonus and tone
 No uncontrollable movements
 No pathological reflexes

a) What are the interpretation of neurologicus status?

Answer:
There is no abnormality of Ana’s neurologists status. It means
normal.

12. How to diagnose in this case?

Answer:
1. History
 Diet before illness
 Breastfeeding History
 Food and fluids eaten a few days before the illness
 Duration and frequency of vomiting or diarrhea;
display of vomit and liquid feces
 Last time urination
 Contact with people with measles and tuberculosis
 History of sibling's death
 Birth weight
 Development status
 Immunization status

24
 2. Physical Examination
 Measuring height and weight
 Calculate body mass index, ie weight (in kilograms)
divided by height (in meters)
 Measuring the thickness of the skin fold on the back
side (triceps fold) is pulled away from the arm, so
that the layer of fat under the skin can be measured,
usually using a caliper. Fat under the skin is 50% of
body fat. Normal fat folds are about 1.25 cm in
males and about 2.5 cm in females.
 Nutritional status can also be obtained by the size of
LLA for the amount of muscle mass in the body
(thin body mass, lean body mass).
 Enlargement and heart, jaundice.
 Abdominal deafness, bowel sound.
 Pale
 Circulatory collapse marks; cold hands and feet,
weak radial pulse, decreased consciousness
 Body temperature; hypothermia or fever
 Thirst
 Eyes; corneal lesions (KVA markers)
 ENT: is there any sign of infection
 Skin: is there any sign of infection or purpura
 Frequency and type of breathing; signs of
pneumonia or heart failure (Lin, 2007).

13. What is the differential diagnostic in this case?

Answer:
1. Growth and development disorder caused malnutrition type
kwashiorkor.
2. Growth and development disorder caused malnutrition type
marasmus.

25
14. What is the supported examination in this case?
Answer:
1. Routine blood test
2. Faces test
3. Protein
4. Iron (Fe)
5. Thorax photo
(Behrman dkk, 2014)

15. What is the working diagnostic in this case?

Answer:
Growth and development disorder caused malnutrition type
kwashiorkor.

16. What is the treatment in 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.

17. What is the complication in this case?

Answer:
Children with severe malnutrition can get complications
more susceptible to infection, vitamin A deficiency, worm
infestation, dermatitis tuberculosis, bronchopneumonia, anemia,
failure to grow as well as delayed mental and psychomotor
development.

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 18. What is the prognostic in this case?
Answer:
Fungsionam : Dubia ad Bonam
Vitam : Dubia ad Bonam

19. What is the doctor’s competention in this case?

Answer:
Ability level 4.
Doctor graduates are able to make a clinical diagnosis and manage
the disease independently and thoroughly.
(Konsil Kedokteran Indonesia, 2012)

20. What is the Islamic values in this case?

Answer:
“And let those [executors and guardians] fear [injustice] as if they
[themselves] had left weak offspring behind and feared for them.
So let them fear Allah and speak words of appropriate justice.”
(Q.S An-Nisa:9)

2.6 Conclusion
Ana, a 10 months old girl suffered malnutrition type Kwashiorkor.

2.7 Conceptual framework

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