SCENARIO TUTORIAL D

GROUP 4

Supervisior : dr. Miranti Dwi Hartanti,

M.Biomed Member’s Name:
Taris Ade Sulistiani 702020002
Nadhirah HR 702020014
Ramadhan Surya Al-Akbar 702020023
Lulu Sabila 702020028
Assyfa Antonia 702020029
Putri Salsabila 702020046
Vicky Kelvino 702020048
Nur Adha Febiola 702020066
Kuntafie Tarik Al Haq Mukhtarudin 702020079
Rizki Amanah 702020104
Puri Mayang Salsabila 702020114

MEDICAL SCHOOL
MUHAMMADIYAH UNIVERSITY OF PALEMBANG
TEACHING YEAR 2021
 FOREWORD

We give our thanks to Allah SWT for His blessings and gifts so that we can
complete the tutorial report entitled "Scenario D Tutorial Report" as a group competency
task. The blessings of greeting and greetings are always devoted to our lord, the great
prophet Muhammad and his family, friends and followers until the end oftime.

We realize that this tutorial report is far from perfect. Therefore we expect
constructive criticism and suggestions to improve in the future. In completing this tutorial
report, we got a lot of help, guidance and advice. On this occasion, we would like to
express our respect and thanks to

1. Allah SWT, who has given His health and mercy.

2. Both parents who always provide material and spiritualsupport.
3. dr. Miranti Dwi Hartanri, M.Biomed. as a group 4 tutor.
4. Friends in arms.
5. All parties involved in making this tutorial report.

May Allah SWT give rewards for all the charity given to all those who compile and assist
in making this report and hopefully this tutorial report is useful for us and the
development of science. May we always be protected by Allah SWT. Amiin.

Palembang, 23 November 2021

Author

i
 TABLE OF CONTENTS

FOREWORDTABLE OF CONTENTS...........................................................................i

CHAPTER I INTRODUCTION......................................................................................1

1.1 Background................................................................................................................1

1.2 Purpose and Objectives..............................................................................................1

CHAPTER II DISCUSSION............................................................................................2

2.1 Tutorial Data..............................................................................................................2

2.2 Case Scenario............................................................................................................2

2.3 Term's clarifications..................................................................................................3

2.4 Identification of problems..........................................................................................4

2.5 Priority Problem........................................................................................................5

2.6 Problem Analysis.......................................................................................................5

2.7 Hypotesis...................................................................................................................8

2.8 Conseptual Framework..............................................................................................8

BIBLIOGRAPHY..............................................................................................
 CHAPTER I
INTRODUCTION
1.1 Background
In semester 3 of the Competency-Based Curriculum for Medical Education, Faculty of
Medicine, University of Muhammadiyah Palembang is block IX on Neuro Musculo
Skeletal. As we know that the learning program at FK UMP uses the KBK learning
system so that it is expected that doctor graduates from FK UMP become doctors who
are able to communicate effectively as a fulfillment of superior and Islamic doctor
competency standards, not only to their patients, but also to their work environment as
a doctor. an excellent doctor, and a relationship to the Creator as taught at the
Muhammadiyah Palembang Medical Faculty.

1.2 Purpose and Objectives

The purpose and objectives of the D case study tutorial report, namely:
1. As a tutorial group task report that is part of the Problem Based Learning system
at the Faculty of Medicine, University of Muhammadiyah Palembang.
2. Can resolve the case given in scenario E with the method of analysis and
learningof group discussion.
3. The achievement of the objectives of the tutorial learning method.

1
 CHAPTER II
DISCUSSION

2 Tutorial Data
Tutor : dr. Miranti Dwi Hartanri, M.Biomed
Moderator : Kuntafie Tarik Al Haq Mukhtarudin
Secretary of the Table : Lulu Sabila
Board Secretary : Puri Mayang Salsabila
Time : Tuesday, 23 November 2021
08.00-10.30
Regulations :
1. Mutual respect between participants of the tutorial.
2. Using good and proper communication
3. Raise your hand when submitting an opinion
4. Do not activate communication tools during the tutorial process
5. Permission when going out of the room
6. Be on time

2.1 Case scenario

“Something Bounces On The Head But Not The Ball”

Ms. Mimi, 25 years old, a kindergarten teacher, was brought by her friend to the RSMP ER with a
complaint of severe pain in the right side of her head since this morning. Complaints of this pain felt
throbbing, like something was bouncing in the head and getting so heavy that she was not strong enough to
teach. Ms. Mimi also complained of nausea and vomiting once.
When she arrived at school this morning her friend said that Ms. Mimi had difficulty in speaking,
so people did not understand what she was saying. The complaint lasted about 15 minutes, and then
followed by headache. Ms. Mimi also felt her hands and feet go numb at that time.
The pain medication (ibuprofen) that she took did not relieve the complaint. Ms. Mimi feels more
comfortable when she is away from the noise around her.
Two nights earlier Ms. Mimi admits that she lacks sleep because she was looking for ideas to teach
her students in kindergarten online, so she opened y*ube until morning. Ms. Mimi said that she had
experienced headaches like this twice with similar characteristics. Her mother also has a history of similar
headaches.

Physical examination: Consciousness: compost mentis, BW: 75 kg, BH: 155 cm, VAS score 8-9
Vital signs: BP: 110/80 mmHg, Pulse: 72 x /menit, RR: 20x/menit, T 37˚C,
Head: no abnormality
Cor and Lung: no abnormality.
Abdomen: no abnormality
Ektremity: no abnormality

Neurological examination:
GCS E4M6V5
Pupil: round, isokor
Paresis N. kranialis (–)
Motorik 5555/5555
5555/5555
Physiological reflex: within normal limit dalam batas normal
Pathological reflex: -/-
Sensoric: within normal limit
2.2 Term’s clarifications
Ibuprofen = Drug that belongs to group of nonsteroideal anti-inflammatory drugs and it used
to reduce parin (Dorlan 30 edition)
Isokor = Equality in size of the two pupil (Dorland, ed.29)
Vomiting = Explousio of gastric contents through the mouth (dorland 30)
Headache = The most common from of pain (dorland, ed. 30)
Compos mentis = Fully aware (Dorland 30)
Nausea = Something not confortable in stomatch and epigastrium also feels like want
vomit (dorland ed 30)
VAS = Visual analog scale (the scale of pain in our body) (dorland ed 30)

2.3 Identifications of problems

1. Ms. Mimi, 25 years old, a kindergarten teacher, was brought by her friend to the RSMP ER with a
complaint of severe pain in the right side of her head since this morning. Complaints of this pain
felt throbbing, like something was bouncing in the head and getting so heavy that she was not
strong enough to teach. Ms. Mimi also complained of nausea and vomiting once.
2. When she arrived at school this morning her friend said that Ms. Mimi had difficulty in speaking,
so people did not understand what she was saying. The complaint lasted about 15 minutes, and then
followed by headache. Ms. Mimi also felt her hands and feet go numb at that time.
3. The pain medication (ibuprofen) that she took did not relieve the complaint. Ms. Mimi feels more
comfortable when she is away from the noise around her.
4. Two nights earlier Ms. Mimi admits that she lacks sleep because she was looking for ideas to teach
her students in kindergarten online, so she opened y*ube until morning. Ms. Mimi said that she had
experienced headaches like this twice with similar characteristics. Her mother also has a history of
similar headaches.
5. Physical examination: Consciousness: compost mentis, BW: 75 kg, BH: 155 cm, VAS score 8-9
Vital signs: BP: 110/80 mmHg, Pulse: 72 x /menit, RR: 20x/menit, T 37˚C,
Head: no abnormality
Cor and Lung: no abnormality.
Abdomen: no abnormality
Ektremity: no abnormality
6. Neurological examination:
GCS E4M6V5
Pupil: round, isokor
Paresis N. kranialis (–)
Motorik 5555/5555
5555/5555
Physiological reflex: within normal limit dalam batas normal
Pathological reflex: -/-
Sensoric: within normal limit

2.4 Priority problem

No 1.
because there are a major complaint and if its not manaaged properly, it can caused a complication

2.5 Problem analysis

1. Ms. Mimi, 25 years old, a kindergarten teacher, was brought by her friend to the RSMP ER with a
complaint of severe pain in the right side of her head since this morning. Complaints of this pain felt
throbbing, like something was bouncing in the head and getting so heavy that she was not strong enough to
teach. Ms. Mimi also complained of nausea and vomiting once.
a) What is anatomy, fisiology, histology in the case?
 b) What is te relation between a kindergarten teacher and with her complaint?
c) What the meaning ms. Mimi, 25 years old, a kindergarten teacher, was brought by her friend to the
RSMP ER with a complaint of severe pain in the right side of her head since this morning?
d) What the meaning of the Complaints of this pain felt throbbing, like something was bouncing in the
head and getting so heavy that she was not strong enough to teach. Ms. Mimi also complained of
nausea and vomiting once?
e) What any disease with complaints of nausea and vomiting?
f) What any disease with complaint of headache?
g) What is are the causes and pathophysiologi of pain in this case?
h) What is the cause and patofisiology nausea and vomiting in this case?
i) What is the trigger factor of the headache ?
Apa faktor pemicu sakit kepala tersebut?

Endogen Stres, waktu tidur yang tidak konsisten atau lebih/kurang dari biasanya,
fluktuasi hormonal (misalnya hamil, haid)

Diet
Terlambat/ menunda makan, makanan olahan susu, daging yang diawetkan,
kafein, minuman beralkohol (khususnya anggur merah), aspartam, monosodium glutamat/vetsin,
nitrit

Obat
Obat & minuman berkafein, obat Terlarang

Inggris

Eksogen
Faktor lingkungan, suara yang keras, perubahan udara, aroma yang kuat, zat
kimia tertentu, insektisida, bensol, nikotin

Endogenous
Stress, inconsistent sleep time or more/less than usual,
hormonal fluctuations (eg pregnancy, menstruation)

Diet
Late/delayed meals, dairy foods, cured meats,
caffeine, alcoholic beverages (especially red wine), aspartame, monosodium glutamate/vetsin,
nitrites

Drug
Drugs & caffeinated drinks, illicit drugs

Exogenous
Environmental factors, loud noises, changes in the air, strong smells, substances
certain chemicals, insecticides, benzol, nicotine

Tuda AEJ, Ritung N, Mawuntu AHP. 2020. MIGRAINE: PATHOMECHANISM, DIAGNOSIS, AND
MANAGEMENT. Jurnal Sinaps, Vol. 3, No.3 (2020), hlm. 1-13
http://webcache.googleusercontent.com/search?
q=cache:YrHJ2q8DRQoJ:jurnalsinaps.com/index.php/sinaps/article/download/123/75/206+&cd=4
&hl=id&ct=clnk&gl=id

j) What is the correlation between any complaints of nausea and vomiting once with main
complain?
 Apa hubungan keluhan mual muntah sekali dengan keluhan utama?

Menurut goadsby et al 2008, dua jenis migraine yang sering di temui

a) migraine tanpa aura disebut migraine biasa (common migraine) di tandai dengan nyeri
kepala berdenyur di salah satu sisi, dengan insensitas sedang-berat dan semakin parah saat
penderitamelakukan aktifiktas, ditandai mual. Muntah, sensitive terhadap cahaya, suara dan
bau.
b) migraine dengan aura disebut migraine klasik (classical migraine) didahului gejala
sensoris terjadi 10-30 menit sebelum munculnya gejala aura, cirinya melihat sinar
berkedip, mati rasa kesemutan di muka atau tangan, terganggunya indra penciuman perasa
atau peraa dan tidak dapat melihat benda dengan jelas
Nyeri kepala yang disebut migrain adalah nyeri kepala dengan serangan nyeri yang
berlangsung 4 –72 jam. Nyeri biasanya unilateral, sifatnya berdenyut,intensitas nyerinya
sedang sampai berat dan diperhebat oleh aktivitas, dan dapat disertai mual muntah,
fotofobia dan fonofobia. Nyeri kepala ini diakibatkan pembuluh darah yang menuju otak
mengalami vasokontriksi yang disebabkan oleh karena adanya peningkatan kadar serotonin
dan kemudian mengalami vasodilatasi (Karmilawati, 2013)

INGGRIS

According to Goadsby et al 2008, two types of migraine are often encountered:

a) migraine without aura is called a common migraine (common migraine) characterized by

throbbing headache on one side, with moderate-severe intensity and getting worse when the
sufferer does activity, is characterized. Vomiting, sensitivity to light, sound and smell.
b) migraine with aura is called classic migraine (classic migraine) preceded by sensory
symptoms occurring 10-30 minutes before the appearance of aura symptoms, characterized
by seeing flashing light, numbness, tingling in the face or hands, impaired sense of smell, taste
or taste and can see objects clearly

Headaches called migraines are headaches with pain attacks lasting 4-72 hours. Pain is
usually unilateral, throbbing, moderate to severe pain intensity and exacerbated by activity,
and is accompanied by nausea and vomiting, photophobia and phonophobia. Headaches due
to blood vessels leading to the brain experiencing vasoconstriction caused by an increase in
serotonin levels and then experiencing vasodilation (Karmilawati, 2013)

That means possibly Ms. mimi experiences migraines without aura which is usually a
headache accompanied by nausea and/or vomiting, photophobia and phonophobia.

Source : Karmilawati, C.D. 2013. Pengaruh Manipulasi Nervus Opthalmicus Terhadap

Penurunan Nyeri Pada Penderita Nyeri Kepala. Universitas Muhammadiyah Surakarta.

Source : Al’amali MK, Imandiri A, Sukardiman. 2018. ACUPRESSURE AND

AROMATIC GINGER HERB FOR A MIGRAINE. journal of Vocational Health
Studies 02 (2018): 80–85

https://webcache.googleusercontent.com/search?q=cache:Ozgpy4JiFtoJ:https://e-
journal.unair.ac.id/JVHS/article/download/11467/6485+&cd=3&hl=id&ct=clnk&gl=id

k) How is the relation between age and gender with her symptoms?
 Bagaimana hubungan antara usia dan jenis kelamin dengan gejala yang dialaminya?

Untuk jenis kelamin : Migrain pada wanita terjadi 3 kali lebih sering dari pada pria, migrain bisa dikatakan
merupakan penyakit kronis yang paling umum terjadi pada wanita
Untuk Umur : sering terjadi di usia belasan dengan prevalensi puncak pada usia 35-45 tahun Migrain pada anak
dan remaja biasanya terjadi secara relatif. 20% pasien migraine mengalami migrain pertama mereka sebelum
berusia lima tahun, sekitar 5% anak usia pra-sekolah, 4-11% anak usia sekolah dasar, dan hampir dialami oleh
sekitar 23% remaja dan dewasa muda Frekuensi terjadinya migrain tertinggi terjadi pada usiadi bawah 20 tahun
(16%) (pria 8% dan wanita 18.8%) dan puncak frekuensi pada pria terjadi pada usia 20 – 26 tahun (15.3%) dan
pada wanita usia di bawah 20 tahun (18.8%)

INGGRIS

For gender: Migraine in women occurs 3 times more often than men, migraine is arguably the most
common chronic disease in women.

For Age: often occurs in the teens with a peak prevalence at the age of 35-45 years Migraine in children
and adolescents usually occurs relatively. 20% of migraine patients experience their first migraine before
the age of five, about 5% of preschool children, 4-11% of primary school-aged children, and almost 23%
of adolescents and young adults experience migraines. The highest frequency of migraine occurs in people
under 20 years (16%) (men 8% and women 18.8%) and the peak frequency in men occurred at the age of
20 – 26 years (15.3%) and in women aged under 20 years (18.8%)

Source : Bahri TS, Zulfazli. 2014. The Causing Factors of Migraine and Types of Migraine. Idea Nursing
Journal Vol. VI No. 1

http://webcache.googleusercontent.com/search?
q=cache:Ea_UMycKpv4J:www.jurnal.unsyiah.ac.id/INJ/article/download/6638/5431+&cd=2&hl=id&ct=clnk&
gl=id

2. When she arrived at school this morning her friend said that Ms. Mimi had difficulty in speaking, so
people did not understand what she was saying. The complaint lasted about 15 minutes, and then followed
by headache. Ms. Mimi also felt her hands and feet go numb at that time.
a) What is the meaning of Ms. Mimi had difficulty in speaking, so people did not understand what
she was saying?
b) What is the meaning The complaint lasted about 15 minutes, and then followed by headache?
c) What is cause and patofisiology of hands and feet go numb at the time?
d) What are the types of headache?
e) What is the coralation between the main complaint and the additional complaint in this case?
f) What are the possible disease experienced by ms mimi?

3. The pain medication (ibuprofen) that she took did not relieve the complaint. Ms. Mimi feels more
comfortable when she is away from the noise around her.
a) How does ibubprofen works?
b) What are the pharmacodinamic and pharmacocinetik of ibuprofen?
c) Why ibuprofen does’t work to the complaint that ms mimi felt?
Mengapa ibuprofen tidak mempan terhadap keluhan yang ms mimi rasakan?

Ibuprofen adalah salah satu NSAID. Konsensus umum adalah bahwa NSAID
paling efektif bila diambil pada awal serangan migrain. Namun,
efektivitas agen ini dalam migrain biasanya kurang optimal
pada serangan migrain sedang atau berat. Sementara dalam kasus Ms mimi dia memiliki
sakit kepala parah. Serangan migrain ringan biasanya dapat dikelola dengan:
agen oral; tingkat kemanjuran rata-rata adalah 50-70%. Migrain parah
serangan mungkin memerlukan terapi parenteral Dia harus mengambil lini kedua
pengobatan.

INGGRIS
 Ibuprofen is one of NSAID. A general consensus is that NSAIDs
are most effective when taken early in the migraine attack. However,
the effectiveness of these agents in migraine is usually less than optimal
in moderate or severe migraine attacks. While in Ms. mimi case she has
severe headache. Mild migraine attacks can usu¬ally be managed by
oral agents; the average efficacy rate is 50–70%. Severe migraine
attacks may require parenteral therapy She have to take the second line
medication.

Source : Setiawan I. 2014. Nyeri kepala. Vol. 10 No.1 Tahun 2014

http://webcache.googleusercontent.com/search?
q=cache:XB2B3ij7MY8J:eprints.umm.ac.id/60729/21/Setiawan%2520-%2520Common
%2520Headache%2520Rhinogenic%2520Headache.pdf+&cd=18&hl=id&ct=clnk&gl=id

d) What is the meaning Ms. Mimi feels more comfortable when she is away from the noise
around her?
Apa artinya Bu Mimi merasa lebih nyaman saat berada jauh dari kebisingan di sekitarnya?

Maknanya adalah mengalami migrain dengan gejala phonophobia (peka terhadap

suara) sedangkan untuk phonophobia adalah (peka terhadap cahaya).

Inggris

The meaning is ms mimi experiencing symptoms of fonofobia (sensitive to sound)

while for phonophobia is (sensitive to light)

Source : haryani S, Tandy V, Vania A, Barus J. 2018. PENATALAKSANAAN NYERI

KEPALA PADA LAYANAN PRIMER. Callosum Neurology Journal, Volume 1, Nomor
3: 83-90, 2018

https://webcache.googleusercontent.com/search?
q=cache:nZ_dl4Fz5ikJ:https://callosumneurology.org/index.php/callosumneurology/a
rticle/download/16/19+&cd=2&hl=id&ct=clnk&gl=id

e) What is the composation of ibuprofen?

Apa komposisi ibuprofen?

Ibuprofen merupakan suatu zat berupa serbuk putih yang agak larut dalam air (<1 mg/mL)
dan segera larut dalam pelarut organic seperti etanol, metanol aseton dan kloroform, serta
sukar larut dalam etil asetat. Ibuprofen memiliki rumus molekul C13H18O2 dengan berat
molekul 206,28 dan memiliki titik leleh 75°C serta pKa sebesar 5,2.

Inggris

Ibuprofen is a substance in the form of a white powder which is slightly soluble in air
(<1 mg/mL) and readily soluble in organic solvents such as ethanol, methanol, acetone
and chloroform, and is difficult to dissolve in ethyl acetate. Ibuprofen has the
molecular formula C13H18O2 with a molecular weight of 206.28 and has a melting
point of 75°C and a pKa of 5.2.
 Soruce : Ningtyas KW, Zulfikar, Piluharto B. 2015. Identification of Ibuprofen,
Ketoprofen and Diclofenac by Using Test Strip Based on Imobilized Spesific Reagent on
Nata De Coco Membrane. Jurnal ILMU DASAR Vol. 16 No. 2, Juli 2015 : 49 – 54

f) What drug are include in the ibuprofen group?

g) what is the classification of pain medication?

4. Two nights earlier Ms. Mimi admits that she lacks sleep because she was looking for ideas to teach her
students in kindergarten online, so she opened y*ube until morning. Ms. Mimi said that she had
experienced headaches like this twice with similar characteristics. Her mother also has a history of similar
headaches.
a) What is the correlation from open yt until morning with her complain?
b) What is the meaning Her mother also has a history of similar headaches?
c) What is the meaning Ms. Mimi said that she had experienced headaches like this twice with similar
characteristics?

5. Physical examination: Consciousness: compost mentis, BW: 75 kg, BH: 155 cm, VAS score 8-9
Vital signs: BP: 110/80 mmHg, Pulse: 72 x /menit, RR: 20x/menit, T 37˚C,
Head: no abnormality
Cor and Lung: no abnormality.
Abdomen: no abnormality
Ektremity: no abnormality
a) How is intepretasi physical examination?
b) How is abnormal mechanism of physical examination?
c) How to do vas examinations?

6. Neurological examination:
GCS E4M6V5
Pupil: round, isokor
Paresis N. kranialis (–)
Motorik 5555/5555
5555/5555
Physiological reflex: within normal limit dalam batas normal
Pathological reflex: -/-
Sensoric: within normal limit
a) How is interpretation neurogical examinations?
Bagaimana interpretasi pemeriksaan neurogikal?

Ekstremitas Superior Ekstremitas Inferior Nilai Intepretasi

Normal

GCS E4M6V5
Compos
mentis

Pupil Round Normal

Isokor

Paresis N. kranialis Normal

Motorik 5 5 5 5 5 Normal

Physiological reflex Normal

Pathological reflex Normal

b) How is the level of consciousness quantitative and qualitative?

 Bagaimana tingkat kesadaran kuantitatif dan kualitatif?

Kualitatif
a) Kompos mentis (conscious) yaitu kesadaran normal, sadar sepenuhnya, dapat menjawab
semua pertanyaan tentang keadaan sekeliling
b) Apatis, yaitu keadaan kesadaran yang segan untuk berhubungan dengan sekitarnya,
sikap acuh tak acuh
c) Delirium, yaitu gelisah, disorientasi (orang, tempat, waktu), memberontak, berteriak-
teriak, berhalusinasi, kadang berhayal.
d) Somnolen (obtundasi, letargi), yaitu kesadaran menurun, respon psikomotor yang
lambat, mudah tertidur, namun kesadaran dapat pulih bila dirangsang (mudah
dibangunkan) tetapi jatuh tertidur lagi, mampu memberi jawaban verbal.
e) Stupor (Soporo koma), yaitu keadaan seperti tertidur lelap, tetapi ada respon terhadap
nyeri.
f) Coma (comatose), yaitu tidak bisa dibangunkan, tidak ada respon terhadap rangsang
apapun (tidak ada respon kornea/reflex muntah, mungkin juga tidak ada respon pupil
terhadap cahaya

7. how to diagnose in the case?

Bagaimana cara mendiagnosis pada kasus tersebut?

8. what is differential diagnose in the case?

9. what is additionalexamination in the case?
10. What is the working diagnosis in the case?
a) definisi migrain
b) clasifications migraine
c) triger factor migraine
11. What is the treatment in the case
12. What is complication in the case?
13. What is prognosis in the case?
14. What is SKDU in the case?
Apa SKDU dalam kasus ini?
4A

2.6 NNI
a) Qr al araf : 31
b) Hadis riwayat bukhari about tidak berlebihan
c) Hadis riwayat bukhari tentang istirahat yang cukup

2.7 Hypotesis
Putri : Ms. Mini 25 years old have a headache, nausea, vomit, talk not properly because she have
migraine ec genetic, stress & tired.

2.8 Scema of synthesis

Risk factor

Genetic Trigger Factor

Tired, stress

Vasocontriction of intracranial Vassels

Stimulate medulla oblongata Stimulate trigerminal sensory nervus

Nausea & Vomit Headache, talk not properly