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TUTORIAL REPORT
SCENARIO A BLOCK XXI

Group 8
Tutor : dr. Siti Rohani, M. Biomed

Muhammad Akbar N (702017060)

Khalifah Hasanah Ilham (7020188009)
Siska Indriyani (7020188011)
Ghina Zalmih (7020188025)
Nadia Rachmafitria Nanda S (7020188033)
Nuryani Rahmania H (7020188037)
Dinda Karunia Putri (7020188060)
Rahmi Nurba Driya Ningsih (702018062)
Ahmad Rosihan (7020188065)
Azka Nabila Hani (7020188076)

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH PALEMBANG
2021
 FOREWORD

Praise and gratitude the author prays to Allah SWT for all His graces and
gifts so that the author can complete the tutorial report entitled "Scenario Tutorial
Report" A Block XXI” as a group competency task. Shalawat and greetings are
always poured out to our lord, the great Prophet Muhammad SAW and his family,
friends, and followers until the end of time.
The author realizes that this tutorial report is far from perfect. Therefore, the
authors expect constructive criticism and suggestions for improvement in the
future.
In completing this tutorial report, the author received a lot of help, guidance
and advice. On this occasion, the author would like to express his respect and
gratitude to:
1. dr Siti Rohani, M. Biomed
2. Both parents who always provide material and spiritual support.
3. Comrades in arms.
4. All parties who helped the author.
May Allah SWT reward you for all the deeds given to everyone who has
supported the author and hopefully this tutorial report will be useful for us and the
development of science. May we always be in the protection of Allah SWT.
Amen.

Palembang, October 2021

Writer

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 TABLE OF CONTENTS

Foreword............................................................................................................2

list of contents....................................................................................................3

Chapter I : Preliminary

1.1 Background..............................................................................4

1.2 Aims and Objectives ...............................................................4

Chapter II : Discussion

2.1 Tutorial Data ...........................................................................5

2.2 Case Scenarios..........................................................................6

2.3 Clarification of Terms..............................................................7

2.4 Problem Identification .............................................................8

2.5 Priority Problem.......................................................................9

2.6 Problem analysis and synthesis ...............................................10

2.7 Conclusion ..............................................................................35

2.8 Conceptual Framework ...........................................................46

REFERENCES..............................................................…...............................37

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 CHAPTER I
PRELIMINARY

1.1 Background
Growth and Geriatric Blocks are Blocks XXI on the seventh semester
of the Competency-Based Curriculum (KBK) system for Medical
Education, Faculty of Medicine, University of Muhammadiyah Palembang.
One of the learning strategies for the Competency-Based Curriculum (KBK)
system is Problem Based Learning (PBL). The tutorial is an implementation
of the Problem Based Learning (PBL) method. In the tutorial students are
divided into small groups and each group is guided by a tutor/lecturer as a
facilitator to solve existing cases.
On this occasion, a case study of scenario A is carried out which
describes theng A baby girl was delivered spontaneously at PONEK RSMP
Emergency Department, the baby wasn’t crying, from a 43 weeks G1P0A0
mother ,and birth weigh 2800 gram. The Apgar score on the first minute
was three, five on the fifth minute, and eight on the tenth minute. There was
fever history in mother when giving birth with leukocytes 18.000/ mm3. The
baby moved to perinatology care, when being treated, the baby looks short
of breath and starts to turn blue. The amniotic fluid were Green.

1.2 Purpose and objectives

The aims and objectives of this case study report are:
1. As a tutorial group assignment report which is part of the Competency-
Based Curriculum learning system.
2. Can solve the cases given in the scenario with analysis methods and
group study learning.
The achievement of the objectives of the tutorial learning based on the
seven jumps steps.

1
 CHAPTER II
DISCUSSION

2.1 Tutorial Data

tutor :dr. Siti Rohani, M. Biomed
Moderator : Ahmad Rosihan
desk secretary : Rahmi Nurbadriyah N
board secretary : Nadia Rachmafitria Nanda S
Time : 1. Tuesday, September 28 2021
13.00-15.00 WIB
2. Thursday, September 30, 2021
13.00 - finished

Tutorial rules:
1. Turn off the phone or on silent.
2. Raise your hand when you will ask relevant opinions and questions.
3. Permission to leave the room.
4. Respect the opinions of other participants and remain calm and not noisy.

2
 2.2 Case Scenario

“Silence of the Baby”

A baby girl was delivered spontaneously at PONEK RSMP Emergency

Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother ,and birth
weigh 2800 gram. The Apgar score on the first minute was three, five on the fifth
minute, and eight on the tenth minute. There was fever history in mother when
giving birth with leukocytes 18.000/ mm3. The baby moved to perinatology care,
when being treated, the baby looks short of breath and starts to turn blue. The
amniotic fluid were Green.
Physical Examination
General Appearance: hipoactive, whimpering, weak suction reflexes, BL: 49cm,
BBW: 2800 g, HC : 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.
Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis (+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)
Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl,
trombocyte 208.000/mm3,, leukocyte 34.000/mm3, LED: 15 mm/jam, CRP:
20mg/L

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Rontgen thoraks:

2.3 Clarification of Terms:

No Clarification of terms Meaning

.
1. Apgar score Activity, pulse, Grimmace, Appereance,
Respiration is a test given to newborn soon
after birth
2. Cyanosis discoloration of the skin mucous membrane
to a bluish color due to excessive reduce
concentration in the blood
3. Spontaneously Normal vaginal delivery that takes place
without the use of certain tools or drugs.
4. mekonium dark green slimy material or liquid in the
intestines of term infant
5. Whimpering the sounds that arise are expressions of fear,
pain, and discomfort
6. Hipoactive An abnormal of motoric and cognitive
activity such as slowing the movement.
7. Amniotic fluid the protectuve liquid contained by the
amniotic salc of a grabid amniote
8. Perinatology a special service unit for newborns who
have problems/illness
9. Caput succesaneum swelling of the scalp in a newborn. It is
most often brought on by pressure from the

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 uterus or vaginal wall during a head-first
(vertex) delivery.
10. Down score Clinical Assesment for hypoxemia in
neonatus with respiratory distress

2.4 Identification of problems

1) A baby girl was delivered spontaneously at PONEK RSMP Emergency
Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother ,and
birth weigh 2800 gram. The Apgar score on the first minute was three, five on
the fifth minute, and eight on the tenth minute.
2) There was fever history in mother when giving birth with leukocytes 18.000/
mm3. The baby moved to perinatology care, when being treated, the baby
looks short of breath and starts to turn blue. The amniotic fluid were Green
3) Physical Examination
General Appearance: hipoactive, whimpering, weak suction reflexes, BL:
49cm, BBW: 2800 g, HC : 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.
Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis (+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)
4) Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl,
trombocyte 208.000/mm3,, leukocyte 34.000/mm3, LED: 15 mm/jam, CRP:
20mg/L

5) Rontgen thorax

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2.5 Priority Problem
Problem identification number 1, the reason is because is a major complaint if not
treated immediately will increase mortality and morbidity.

2.6 Problem analysis

1) A baby girl was delivered spontaneously at PONEK RSMP Emergency
Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother ,and
birth weigh 2800 gram. The Apgar score on the first minute was three, five on
the fifth minute, and eight on the tenth minute.
a) What is the anatomy and physiology in this case?
Paru-paru manusia terletak pada rongga dada, bentuk
dari paruparu adalah berbentuk kerucut yang ujungnya berada
di atas tulang iga pertama dan dasarnya berada pada
diafragma. Paru terbagi menjadi dua yaitu bagian yaitu, paru
kanan dan paru kiri. Paru-paru kanan mempunyai tiga lobus
sedangkan paru-paru kiri mempunyai dua lobus. Setiap
paruparu terbagi lagi menjadi beberapa sub-bagian, terdapat
sekitar sepuluh unit terkecil yang disebut bronchopulmonary
segments. Paru-paru bagian kanan dan bagian kiri dipisahkan
oleh sebuah ruang yang disebut mediastinum.
Paru-paru manusia dibungkus oleh selaput tipis yang bernama
pleura. Pleura terbagi menjadi pleura viseralis dan pleura

6
 pariental. Pleura viseralis yaitu selaput tipis yang
langsung membungkus paru, sedangkan pleura parietal yaitu
selaput yang menempel pada rongga dada. Diantara kedua
pleura terdapat rongga yang disebut cavum pleura

b) What is the meaning A baby girl was delivered spontaneously at

PONEK RSMP Emergency Department, the baby wasn’t crying, from a
43 weeks G1P0A0 mother ,and birth weigh 2800 gram?
setelah DIlahirkan, bayi tidak menangis :
Artinya, ia menderita asfiksia karena adanya gangguan pada sistem
pernapasannya.
from a 43 weeks G1P0A0 mother ,and birth weigh 2800 gram:

c) What are the criteria of PONEK?

d) What the etiology of the baby wasn’t crying?
e) What is the meaning The Apgar score on the first minute was three, five
on the fifth minute, and eight on the tenth minute?
Skor APGAR 0-3 menunjukkan distres berat, 4-7 menunjukkan
distres sedang, dan 7-10 menunjukkan tidak adanya kesulitan dalam
menyesuaikan diri dengan kehidupan ekstrauterin (Queensland
Government, 2016).
Dalam hal ini, interpretasi menit pertama adalah tiga menunjukan
terjadinya distres berat, lima pada menit kelima mewakili distres
sedang, dan delapan pada menit kesepuluh mewakili tidak adanya
kesulitan dalam menyesuaikan diri dengan kehidupan ekstrauterin
(bukan distres). Sehingga terjadi peningkatan skor status APGAR
pada bayi perempuan ini.

f) What is the relationship between age, gender and GPA?

g) What is the patofisiology of a baby wasn’t crying?
h) What is the possible disease on the case?

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i) How to counting apgar score?
j) What the classification of birth weight?
Klasifikasi dari berat lahir:
- Makrosomia: >4000g
- Normal: 2500-4000 g
- Berat badan lahir rendah (BBLR) <2500 g (<5 lb 8 oz)
- Berat badan lahir sangat rendah (BBLR) <1500 g (<3 lb 5 oz)
- Berat badan lahir sangat rendah (ELBW ) <1000 g (<2 lb 3 oz)
Klasifikasi dari usia kehamilan:
- Persalinan prematur < 37 minggu, dibagi menjadi 3 bagian:
abortus (< 22 minggu), partus immaturus (22-28 minggu) dan
partus prematur (28-37 minggu)
- Persalinan aterm 37-42 minggu
- Persalinan post-term (partus serotinus) > 42 minggu

k) What is the relation between the 2800gr babby was born with a complain
baby wasn’t crying?
l) What are the impact of posterm pregnancy?
Risiko janin
Morbiditas janin meningkat pada kehamilan postterm dan kehamilan
yang berkembang lebih dari 41 minggu kehamilan. Ini termasuk
pengeluaran mekonium, sindrom aspirasi mekonium, makrosomia dan
dismaturitas. Kehamilan lewat waktu juga merupakan faktor risiko
independen untuk tingkat pH tali pusat yang rendah (asamemia
neonatus), skor Apgar 5 menit yang rendah, ensefalopati neonatus, dan
kematian bayi pada tahun pertama kehidupan (Badawi et al., 1998).
Risiko ibu
Kehamilan lewat waktu dikaitkan dengan risiko yang signifikan bagi
ibu. Ada peningkatan risiko: 1) distosia persalinan (9-12% versus 2-
7% saat aterm); 2) laserasi perineum parah (robekan derajat 3 & 4),
berhubungan dengan makrosomia (3,3% versus 2,6% saat aterm); 3)
persalinan pervaginam operatif; dan 4) menggandakan angka seksio

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 sesarea (CS) (14% berbanding 7% saat aterm). Persalinan caesar
dikaitkan dengan insiden yang lebih tinggi dari endometritis,
perdarahan, dan penyakit tromboemboli (Galal, dll. 2012).

2) There was fever history in mother when giving birth with leukocytes 18.000/
mm3. The baby moved to perinatology care, when being treated, the baby
looks short of breath and starts to turn blue. The amniotic fluid were Green.
a) What is the meaning There was fever history in mother when giving birth
with leukocytes 18.000/ mm3
b) What is the meaning The baby moved to perinatology care, when being
treated, the baby looks short of breath and starts to turn blue?
c) What is the patofisiology of the baby looks short of breath and starts to
turn blue?
d) What is the etiology of the baby looks short of breath
Some causes of birth shortness of breath include:
• Too little oxygen in the mother’s blood before or during birth
• Problems with the placenta separating from the womb too soon
• Very long or difficult delivery
• Problems with the umbilical cord during delivery
• A serious infection in the mother or baby
• High or low blood pressure in the mother
• Baby’s airway is not formed properly
• Baby’s airway is blocked
• Baby’s blood cells cannot carry enough oxygen (anemia)
(Seattle Children, 2019)

e) What is the meaning of amniotic fluid were green?

f) What is the classification of amniotic fluid and interpretation?
g) What is the correlation about amniotic fluid were green and the main
complain?

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 h) What is the corelation between the baby wasn’t crying with the baby
looks short of breath?
The baby wasn’t crying, it means that baby was asphyxia, causes of
decreases to get oxygen supplies (hypoxia). So, it is one of etiology in
shortness of breath case (Kosim, et al., 2014)

i) What is the classification of asphyxia?

Menurut Dahlan (2008), asfiksia diklasifikasikan menjadi:
 Bayi yang kuat dengan skor Apgar 7-10
 Asfiksia ringan-sedang dengan skor Apgar 4-6 dan pemeriksaan
fisik HR <100/menit sianosis dan tonus otot baik
 Skor Apgar Asfiksia Berat 0-3 dan Pemeriksaan Fisik
HR<100/menit, sianosis berat dan tonus otot lemah
 Asfiksia berat dengan henti jantung.

j) What are the sign of neonatal asphyxia?

3) Physical Examination
General Appearance: hipoactive, whimpering, weak suction reflexes, BL:
49cm, BBW: 2800 g, HC : 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.

Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis (+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)

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 a) How is the normal value of vital sign examination of the newborn
baby?

Pemeriksaan Tanda Vital Nilai Normal

Sumber: Leduc D, Wood S. 2015

b) What is the interpretation of physical and specific examination?

c) How is the abnormal mechanism of physical and specific
examination?

4) Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl,

trombocyte 208.000/mm3,, leukocyte 34.000/mm3, LED: 15 mm/jam, CRP:
20mg/L

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 a) What is the interpretation of laboratory examination?
b) What is abnormal mechanism of laboratory examination?

5) Rontgen thorax

a) What is the interpretation of rontgen thorax?

b) What is the abnormal mechanism of rontgen thorax?

6) How to diagnose in case?

7) What is the differential diagnosis in this case?
8) What are the investigations in the case?
9) What is the working diagnosis in the case?
10) How is the case handled?
11) What are the complications in the case
a)) Otak: hipoksia iskemik ensefalopati, edema serebri, kecacatan
cerebral palsy.
b)) Jantung dan paru-paru: hipertensi pulmonal presisten pada
neonatus,
perdarahan paru dan edema paru.
c)) Fastrointestinal: enterokolitisnekrotikana
d)) Ginjal: tubular nekrosis akut, SIADH
e)) Hematologi: DIC.

12) (Louis D, dll, 2014).

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 13) What is the prognosis in this case?
14) What is the Competency Standard of General Practitioners in this case?
5) What are the Islamic values in the case?
QS Al- Kahfi : 46

QS Asy- Syuro : 49
ُّ ‫ب لِ َمنْ يَشَا ُء‬
َ ‫الذ ُك‬
‫ور‬ ُ ‫ب لِ َمنْ يَشَا ُء إِنَاثًا َويَ َه‬
ُ ‫ق َما يَشَا ُء ۚ يَ َه‬ ِ ‫ت َواأْل َ ْر‬
ُ ُ‫ض ۚ يَ ْخل‬ ِ ‫اوا‬ َّ ‫هَّلِل ِ ُم ْل ُك ال‬
َ ‫س َم‬
“Belonging to Allah is the kingdom of heaven and earth, He creates what
He wants. He gives daughters to whom He wants and gives sons to whom
He wants”

QS At- Taqwir : 8-9

QS An-Nahl : 58-59
QS Luqman : 13

2.7 Hypothesis
The baby wasn’t crying, looks short of breath and starts to turn blue because of
she experienced respiratory distress ec meconium aspiration

2.8 Conceptual framework

Infection

Amniotic fluid mixed with

meconium

Aspirate the fluid and enter

the lungs

The
13 process of alternating between
liquid and air at interrupted birth (RDS)
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