PROVISIONAL REPORT TUTORIAL SCENARIO C

BLOCK XII

GROUP 4
Supervisor : dr. Fadillah, Sp. PA

Member :
Tata Rizky Astuti 702020003
Nadhirah HR 702020014
Rizka Nabila Safitri 702020027
M. Imam Faris Aqil 702020032
Putri Salsabila 702020046
Fierzi Ratu Amalia 702020051
Rashieka Adawiya Azzahra 702020069
Kuntafie Tarik Al Haq Mukhtarudin 702020079
Sonia Fitriani Hasanah 702020101
Bimo Rizki 702020108

MEDICAL FACULTY
UNIVERSITY OF MUHAMMADIYAH PALEMBANG
2021/2022 ACADEMIC YEAR

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 PREFACE

Praise and gratitude we say to Allah SWT for all His graces and gifts so that we can
complete the Scenario B Block XII Semester 4 tutorial report. Shalawat as greetings always goes
to our lord, the great Prophet Muhammad SAW and his family, friends, and followers until the
end era.
We realize that this tutorial report is far from perfect, therefore we expect constructive
criticism and suggestions to improve future assignments.
In completing this tutorial task, you have received a lot of help, guidance and advice. We
take this opportunity to express our respect and gratitude to :
1. Dear, dr. Fadillah, Sp. PA as Tutorial Supervisor.
2. All Members and parties involved in the preparation of this report.
May Allah SWT reward us for all the deeds given to everyone who has supported us 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, 23 May 2022

Author

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 TABLE OF CONTENT
INTRODUCTION .................................................................................... ii
TABLE OF CONTENTS ........................................................................ iii
CHAPTER I ............................................................................................. 1
FOREWORD ........................................................................................... 1
1.1 Background .................................................................................... 1
1.2 Purpose and Objective .................................................................... 1
CHAPTER II ............................................................................................ 2
DISCUSSION ........................................................................................... 2
2.1 Tutorial Data .................................................................................. 2
2.2 Case Scenario ................................................................................. 2
2.3 Term Clarification .......................................................................... 3
2.4 Problem Identification .................................................................... 4
2.5 Problem Priority ............................................................................ 4
2.6 Problem Analysis ........................................................................... 5
2.7 Conclusion ..................................................................................... 29
2.8 Conceptual Framework ................................................................... 29
BIBLIOGRAPHY .................................................................................... 31

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 CHAPTER I
PRELIMINARY

1.1 Background
The Endocrine System Block is the twelveth block in the fourth semester of the
Medical Education Competency-Based Curriculum (KBK) system of the Faculty of
Medicine, Muhammadiyah University of Palembang. One of the learning strategies for
the Competency-Based Curriculum (CBC) system is Problem Based Learning (PBL).
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, BLOK XI tutorial with
case study scenario C entitled "Tense and Heavy Neck".

1.2 Purpose and Objective

The objectives of this case study tutorial report are:
1. As a tutorial group assignment report which is part of the KBK learning system at the
Faculty of Medicine, University of Muhammadiyah Palembang.
2. Can solve the cases given in the scenario with the analysis method and group
discussion learning.
3. The achievement of the objectives of the tutorial learning method.
4. Students can understand and understand the new material that has been taught in the
learning process.
5. Students can add insight.

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 CHAPTER II

DISCUSSION

2.1 Tutorial Data

Lecture Mentor : dr. Fadillah, Sp. PA

Moderator : Putri Salsabila

Table’s Secretary : Nadhirah HR

Board’s Secretary : Rashieka Adawiya Azzahra

Time : Monday, May 23rd 2022, 08.00 – 10.30.

Wednesday, May 25th 2022, 08.00 – 10.30.

Tutorial Rules:

1. Mutual respect among fellow tutorial participants

2. Using good and appropriate communication

3. Raise your hand when you want to submit an opinion

4. Can answer/ask questions after being appointed by the moderator

5. Not activating communication tools during the tutorial process

6. Permission to leave the room

7. On time

2.2 Case Scenario

“Tense and Heavy Neck”

Mrs. C, 42 years old, a housewife came to the Family Doctor's Clinic because her neck
felt tense and heavy which had been coming and going since 1 month ago. Mrs. C also
complains of frequent thirst, frequent hunger, and frequent urination. Mrs. C is assisted
by a household assistant every day, for her activities, Mrs. C sits more and watches TV
while consuming fried foods and ready-to-eat foods. Mrs. C rarely exercises. Mrs. C has

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 never been to a doctor to have her complaints checked. History of illness in the family is
known that Mrs. C’s mother has diabetes.

Physical examination :
General condition: appears to be mildly ill, compos mentis, BH: 164 cm, BW 84 kg
Vital signs: BP 150/90 mmHg, Pulse 88x/minute, Temp. 36,8°C, RR: 20x/minute.
Head : conjunctiva not pale, sclera not yellow.
Neck : JVP 5-2 cmH2O
Thoraks : Heart and lungs within normal limits
Abdomen : flat, tender, bowel sounds (+) normal, abdominal
circumference 125 cm.
Extremity : cold akral (-/-), edema (-/-).

Laboratory examination:
Routine blood: Hb 13g/dl, Leukocyte 8.000/mm3, platelets 250.000/ mm3
Random blood sugar 230 mg/dl, HDL 25 mg/dl, LDL 210 mg/dl , triglycerides 220
mg/dl, total cholesterol 235 mg/dl.

2.3 Clarification of Term

a. LDL: Low Density Lipoprotein or plasma lipoprotein class whose job is to transport
extrahepatic cholesterol (Dorland 30th ed).
b. Total cholesterol
c. Diabetes: Diabetes: Any disorder characterized by abnormal urinary excretion
excessive (Dorland, 30th ed)
d. HDL:
e. Triglyserides: Compounds consisting of three acid molecules esterified fat to
glycerol; Neutral fat is a form of storage common lipids in animals (Dorland 30 th
ed).
f. Edema: Abnormal collection of fluid in the space intercellular body (Dorland 30th
ed).

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2.4 Identification of Problem

1. Mrs. C, 42 years old, a housewife came to the Family Doctor's Clinic because her
neck felt tense and heavy which had been coming and going since 1 month ago.
2. Mrs. C also complains of frequent thirst, frequent hunger, and frequent urination.
3. Mrs. C is assisted by a household assistant every day, for her activities, Mrs. C sits
more and watches TV while consuming fried foods and ready-to-eat foods. Mrs. C
rarely exercises.
4. Mrs. C has never been to a doctor to have her complaints checked. History of illness
in the family is known that Mrs. C’s mother has diabetes.

5. Physical examination :
General condition: appears to be mildly ill, compos mentis, BH: 164 cm, BW 84 kg
Vital signs: BP 150/90 mmHg, Pulse 88x/minute, Temp. 36,8°C, RR: 20x/minute.
Head : conjunctiva not pale, sclera not yellow.
Neck : JVP 5-2 cmH2O
Thoraks : Heart and lungs within normal limits
Abdomen : flat, tender, bowel sounds (+) normal, abdominal
circumference 125 cm.
Extremity : cold akral (-/-), edema (-/-).

6. Laboratory examination:
Routine blood: Hb 13g/dl, Leukocyte 8.000/mm3, platelets 250.000/ mm3
Random blood sugar 230 mg/dl, HDL 25 mg/dl, LDL 210 mg/dl , triglycerides 220
mg/dl, total cholesterol 235 mg/dl.

2.5 Priority of Problem

No. 1,

Reason: Main complaint of Mrs. C, if it not be cure it can make another complication.

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2.6 Analysis of Problem

1. Mrs. C, 42 years old, a housewife came to the Family Doctor's Clinic because her
neck felt tense and heavy which had been coming and going since 1 month ago.
a. What is the anatomy, fisiology, and histology in this case?
Answer:
Anatomy of Pankreas

The pancreas is an organ in the form of a gland with a length and thickness of
about 12.5 cm and a thickness of + 2.5 cm (in humans). The average weight is
69-90 grams. The structure is soft and lobulated. The pancreas can be divided
into:

a) Pancreatic head (caput pancreatic), shaped like a disc and is located in the
concave part of the duodenum. Part of the head extends on the left behind the
superior mesenteric artery and vein and is called the uncinate process.
b) Collum Pancreatis is the part of the pancreas that shrinks and connects the
head and the body of the pancreas. The pancreatic neck is located in front of
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 the origin of the hepatic portal vein and where the superior mesenteric artery
branches from the aorta.
c) Corpus Pancreatis runs up and to the left, crossing the midline. In cross
section slightly triangular. Cauda Pancreatis runs forward towards the splenic
ligament and communicates with the bilum splenic (Paulsen & Waschke,
2019).

fisiology
Insulin has important effects on carbohydrate, fat and protein metabolism. This
hormone lowers blood glucose, fatty acid and amino acid levels and promotes
storage of these materials. When these nutrient molecules enter the blood during
the absorptive state, insulin promotes the uptake of these substances by cells
and their conversion to glycogen, triglycerides and protein, respectively. Insulin
performs many of its functions by influencing the transport of specific blood
nutrients into cells or altering the activity of enzymes involved in certain
metabolic pathways.
1. Effect on carbohydrates
Insulin has four effects that lower blood glucose levels and promote
carbohydrate storage:
a. Insulin facilitates the transport of glucose into most cells.
b. Insulin stimulates glycogenesis, the formation of glycogen from glucose
in skeletal muscle and liver.
c. Insulin inhibits glycogenolysis, the breakdown of glycogen into
glucose. By inhibiting the breakdown of glycogen into glucose, insulin
tends to cause storage of carbohydrates and reduce the release of
glucose by the liver.
d. Insulin also decreases the production of glucose by the liver by
inhibiting gluconeogenesis, the conversion of amino acids to glucose in
the liver. Insulin does this by reducing the amount of amino acids in the
blood available to the liver for gluconeogenesis and by inhibiting liver
enzymes needed to convert amino acids into glucose. Therefore, insulin
reduces blood glucose concentration by promoting the uptake of
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 glucose by cells from the blood for use and storage, and simultaneously
inhibits two mechanisms of glucose release by the liver into the blood
(glycogenolysis and gluconeogenesis) (Sherwood L, 2009).
2. Effects of insulin on fat
Insulin has many effects to lower blood fatty acids and promote triglyceride
storage:
a. Insulin increases the uptake of fatty acids from the blood into fat tissue
cells.
b. Insulin increases glucose transport into adipose tissue cells via GLUT-4
recruitment. Glucose serves as a precursor for the formation of fatty
acids and glycerol, which is the raw material for forming triglycerides.
c. Insulin promotes chemical reactions that ultimately use fatty acid
derivatives and glucose for the synthesis of triglycerides.
d. Insulin inhibits lipolysis (the breakdown of fat), reducing the release of
fatty acids from fat tissue into the blood. Collectively, these effects tend
to remove fatty acids and glucose from the blood and promote their
storage as triglycerides.
3. Effects of insulin on protein
Insulin lowers blood amino acid levels and increases protein synthesis
through several effects:
a. Insulin promotes the active transport of amino acids from the blood into
muscles and other tissues. This effect lowers the levels of amino acids
in the blood and provides the materials for building proteins in cells.
b. Insulin increases the rate of incorporation of amino acids into proteins
by protein-forming devices present in cells.
c. Insulin inhibits protein breakdown. The overall result of these effects is
the anabolic effect of the protein. Therefore, insulin is essential for
normal growth (Sherwood, L. 2014)
b. What is the meaning of ‘Mrs. C, 42 years old, a housewife came to the Family
Doctor's Clinic because her neck felt tense and heavy which had been coming
and going since 1 month ago’?

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 Answer:
This means that Mr C is experiencing manifestations of vascular disease such as
dyslipidemia and hypertension (Price, S. A. & Wilson, L. M., 2012).
c. What is the correlation with gender and age in this case?
Answer:
 By age
In the age group >40 years, the body's ability to secrete insulin and the ability
of insulin receptors to work will reduce the risk of metabolic syndrome. The
prevalence of metabolic syndrome in the population aged > 20 years is 25%
and in the population > 50 years is 45%. Disease syndromes often develop
along with the increasing prevalence of obesity (Setiati, 2017).
 By Gender
In the case of Metabolic Syndrome, the prevalence is more in men than
women. Skeletal muscle in men is more resistant to insulin than women. In
addition, fat accumulation in men often occurs in the abdomen and liver.
Whereas in women, a lot of fat accumulation in the subcutaneous, hips and
thighs (associated with central obesity). However, with increasing age the
prevalence of SM in women increases. Because in women over the age of 50
years there is an increase in central obesity found during menopause. At
menopause, the pattern of hormone secretion changes gradually leading to fat
accumulation in the visceral abdominal tissue and as a result of central obesity.
Where central obesity is one of the criteria for the Metabolic Syndrome (Rini,
2015).
d. What is the etiology of neck felt tense and heavy?
Answer:
Due to hypertension, because the blood vessels around the neck will be
narrowed periodically so that the neck will experience shrinkage both by the
neck and the blood vessels which causes stiffness in the neck (Dalimartha, S.,
Purnama, B. T., Sutarina, N., Mahendra, B., Darmawan, R. 2008).

Neck felt tense and heavy can occur due to the buildup of lactic acid due to
anaerobic metabolism, this can also occur due to metabolism due to increased
8
 lipolysis and insulin resistance as in the case of metabolic syndrome.High
lipolysis causes the amount of oxidative stress produced also very high. An
increase in the number of reactive oxygen species (ROS) due to increased
activity of oxidase enzymes and regulated adiposity hormones. Increased
oxidative stress causes metabolic disorders, both intake and glucose in muscle
and in adipose tissue, decreased insulin secretion and cell damage resulting in
endothelial dysfunction, atherosclerosis until finally vascular disease occurs
(Rini, 2015).
e. How is the pathophysiology of neck felt tense and heavy which had been coming
and going since 1 month ago?
Answer:
neck felt tense and heavy is a result of poor posture and slouching for long
periods. neck tension typically refers to muscle spasms or soft tissue injuries.
Muscle twitches are caused by our muscles tightening up ("contracting")
involuntarily — in other words, when we're not actually controlling them.
Muscle twitches can happen for lots of reasons, like stress, too much caffeine, a
poor diet, exercise, or as a side effect of some medicines.
Poorly controlled diabetes can also reduce muscle blood flow [37] High blood
glucose levels cause fatty deposits to form inside blood vessels. Over time, these
deposits make your blood vessels narrow and hard, lessening blood flow. Excess
glucose gets stored in the liver as glycogen or, with the help of insulin, converted
into fatty acids, circulated to other parts of the body and stored as fat in adipose
tissue. During digestion, insulin stimulates muscle, fat, and liver cells to absorb
glucose. The cells either use this glucose for energy or convert it into fat for
long-term storage. If you eat more sugar than your liver and muscles can store as
glycogen, the excess will be converted to fat and deposited into adipose tissue.
This process is called lipogenesis. In other words, sugar turns into fat when
consumed in large amounts.
Glucose is a six-carbon sugar molecule. Your body first converts this molecule
into two three-carbon pyruvate molecules through the process of glycolysis and
then into acetyl CoA. When your body requires immediate energy, acetyl CoA

9
 enters the Citric Acid Cycle creating energy molecules in the form of ATP.
When glucose intake exceeds your body's energy needs--for example, you eat an
ice-cream sundae and then go relax on the sofa for five hours--your body has no
need to create more energy molecules. Therefore, acetyl CoA begins the process
of fatty acid synthesis becoming triglycerides that are stored in the fat tissues of
your body. These triglycerides are stored energy molecules which can be broken
down later to give you the energy you need to, for example, get up off the couch
and go for a bike ride (Glimcher and Lee, 2009).
f. What is the possible disease of neck felt tense and heavy?
Answer:
Tension Headache
Neck felt tense and heavy lead to a condition known as a tension headache. This
disease has symptoms of pain in the back of the head to the neck, and sometimes
feels stiff. The causes of tension headaches vary: ranging from muscle stiffness,
changes in hormone levels, to the wrong sitting position (Sudoyo AW,
Setiyohadi B, Alwi I, Simadibrata M, Setiati S. 2014).
2. Mrs. C also complains of frequent thirst, frequent hunger, and frequent urination.
a. What is the meaning of ‘Mrs. C also complains of frequent thirst, frequent
hunger, and frequent urination’?
Answer:
The meaning is that the complaints felt by Mrs. C Symptoms of diabetes mellitus
include polyphagia, polyuria and polydipsia due to hyperglycemia. And also,
Diabetes mellitus is a health disorder in the form of a collection of symptoms
that caused by an increase in blood sugar (glucose) levels due to deficiency or
insulin resistance (Sugianto, 2016). In addition, Mrs. C has insulin deficiency
where insulin deficiency causes hyperglycemia, if hyperglycemia is severe and
exceeds the renal threshold, glycosuria occurs which will result in osmotic
diuresis which increases urine output and creates thirst. Because increased urine
output causes glucose to be lost along with urine which causes hunger
(PERKENI,2015).
b. What is the correlation between main complaint and additional complaint?

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 Answer:
The correlation between the main complaint and additional complaints is the
possibility Mrs. C has metabolic syndrome. Metabolic syndrome is a group of
concomitant conditions, including dyslipidemia, increased blood pressure,
obesity, and insulin resistance. Based on additional complaints, Mrs. C indicated
type 2 diabetes mellitus due to insulin resistance. Resistance Insulin has an effect
on lipid metabolism, namely increasing catabolism lipids so that free fatty acids
in the liver increase, this will trigger lipogenesis in the liver that produces LDL
and increases HDL catabolism thereby decreasing HDL levels. Then, increase fat
metabolism too causes the production of Reactive Oxygen Species (ROS) which
will reduce antioxidant enzymes in the circulation, cholesterol can penetrate the
vessel wall blood is in an oxidized state so that when antioxidant enzymes
decrease will cause cholesterol to accumulate on the walls of blood vessels and
Over time, plaque will form. This will block blood flow to muscle cells so that
muscle cells do not get an adequate supply of oxygen. State This causes a shift
from aerobic metabolism to anaerobic metabolism and produce a byproduct in
the form of lactic acid, so that lactic acid will accumulate in the muscle cells,
causing aches in Ny.C (Sartika, Cyntia. 2006.)

c. What is the etiology of frequent thirst, frequent hunger, and frequent urination?
Answer:
The etiology of frequent thirst is because the patient has frequent urination or
polyuria
The etiology of frequent hunger is the body's response, caused by a disturbance
in the body's insulin hormone wherein, any food consumed (energy) is not stored
in the cells while circulating in the blood, due to damage from the insulin
hormone.
The etiology of frequent urination is that osmotic diuretics (substances in the
urine are attracting water) can occur because these substances are too dominant
in the kidneys.

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 For example, in hyperglycemic patients where the kidneys are not able to filter
glucose which is too high, it will cause glucosuria and cause the osmotic
pressure of glucose to increase and cause polyuria (Price & Wilson. 2020).
1. Polyuria
a. Diuretic drugs
b. Overdrinking
c. Diabetes mellitus
d. Diabetes insipidus
e. Kidney failure
f. Autoimmune chronic hepatitis
2. Polydipsia
a. Psychogenic
b. Hot air
c. When working hard
d. Diabetes mellitus
e. Individual diabetes
f. Lactation
3. Polyphagia
a. Depression/anxiety
b. Bulimia
c. Hyperthyroidism / graves' disease
d. Dm
e. Hypoglycemia
f. Premenstrual syndrome
In this case, the cause of the above symptoms is caused by hyperglycemia,
where glucose cannot enter the cells causing hunger quickly, becoming an
osmotic burden that will pull water out of the body so that there is a lot of
defecation (appleton, et al. 2015).
d. What is pathophysiology of frequent thirst, frequent hunger, and frequent
urination?
Answer:

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  FR (diet tinggi kalori + kurang aktifitas) > asupan kalori tinggi > diet lemak
tinggi > usus , trigliserida merubah menjadi asam lemak dan gliserol >
absrobsi > trigliserida + apolipoprotein + kolestrol > kilomicron tinggi >
asam lemak dan gliserol disimpan didalam sel > suplai asam lemak tinggi +
tinggi stikon proinflamasi obesitas > toksisitas lipid > stress RE dan difungsi
mitokondria > hambatan insulin > resistensi insulin > DM tipe 2 >
polidypsi, polyfagia, polyuria (Price, S. A. & Wilson, L. M., 2012).
 FR (high calorie diet + lack of activity) > high calorie intake > high fat diet
> intestines, triglycerides convert to fatty acids and glycerol > absorption >
triglycerides + apolipoprotein + cholesterol > high chylomicrons > fatty
acids and glycerol stored in cells > fatty acid supply high + high obesity
proinflammatory steroids > lipid toxicity > ER stress and mitochondrial
dysfunction > insulin resistance > insulin resistance > type 2 diabetes >
polydypsy, polyphagia, polyuria (Price, S. A. & Wilson, L. M., 2012).
e. What is possible disease with symptoms of frequent thirst, frequent hunger, and
frequent urination?
Answer
- Diabetes Mellitus Tipe 1
- Diabetes Mellitus Tipe 2
- Hipoglikemia (Kurniawaty, Evi. 2014).
f. How is energy metabolism in human body?
Answer:
Or shortly energy metabolism in energy from Sugar in the blood is formed in
the form of glucagon in the body --> the glucagon is brought into the cells with
the help of the hormone insulin --> inside the cells, glucagon will break down
with the help of oxygen --> so that energy is formed.
Sugar in the blood is formed in the form of glucagon in the body --> the
glucagon is brought into the cells with the help of the hormone insulin -->
inside the cells, glucagon will break down with the help of oxygen --> so that
energy is formed.
or

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 Monosaccharides from the small intestine are converted into glycogen and
stored in the liver (glycogenesis). From this glycogen depot, glucose is
constantly released into the blood, or the process is glycogenolysis to meet the
body's needs. Some of the glucose is metabolized in the tissues to produce
energy, the rest is converted into glycogen and stored in the subcutaneous tissue
as energy reserves. The liver is also able to synthesize glucose from protein and
fat (gluconeogenesis) (Price, S.A. and Wilson, L.M. 2012).
3. Mrs. C is assisted by a household assistant every day, for her activities, Mrs. C sits
more and watches TV while consuming fried foods and ready-to-eat foods. Mrs. C
rarely exercises.
a. What is the meaning of ‘Mrs. C is assisted by a household assistant every day,
for her activities, Mrs. C sits more and watches TV while consuming fried foods
and ready-to-eat foods’?
Answer :
The meaning is that Mrs. C's bad habits are a risk factor for the disease she is
experiencing because the increased food intake and little physical activity causes
glucose from food to accumulate which can lead to obesity. Mrs. C's lifestyle
influences the risk factors for Mrs. C's disease, where the lifestyle in question is
a sedentary lifestyle (not a lot of movement or exercise) and a shift in diet to a
western diet with an increase in consumption of fast food, processed foods, and
beverages with artificial sweeteners. Consumption of fast food is associated with
increased body weight, insulin resistance and other metabolic disorders
(Bahadoran, 2013).
b. What are the effect of rarely exercise?
Answer:
At this time there are many very deadly diseases caused by lack of physical
activity, such as obesity, heart attacks, and other non-communicable diseases. In
a state of body lack of activity causes various health problems that most people
suffer from degenerative or non-infectious diseases such as coronary heart
disease, hypertension and other diseases (Majid, W. 2020).

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 People who never exercise have some similarity characteristics. Physical
characteristics of people who never exercise namely as follows:
a) The accumulation of fat in several areas of the body, especially in the
abdomen, arms and thighs
b) The body does not look tight, but flabby or flabby
c) The face looks lethargic and less enthusiastic
d) Often complains of sleepiness in the morning
e) Easily tired or short of breath when you have to walk long distances or
go up and down the stairs
f) Often experience muscle disorders such as cramps or stiffness (Prasetyo,
2011).
c. What is the correlation between Mrs. C habbit and her complaints?
Answer :
 Mrs. C habbit is a risk factor for the main complaint, namely the neck
feels tense and heavy. A bad lifestyle such as sitting too much, eating fast
food, and rarely exercising can cause the fat profile in the body to
increase and HDL decreases, LDL increases, and cholesterol increases
and dyslipidemia will occur in the body which causes fat metabolism to
increase excessively). This excessive increase in fat metabolism will
stimulate the production of RAS (reactive oxygen species) in the blood
circulation and then oxidative stress will occur in the body and cause
damage to muscles, nerves and blood vessels and then occur in the
muscles, especially the upper back and neck, causing the main complaint,
namely: neck tense and heavy (Price & Wilson, 2012).
 Mrs. C who likes to eat fried and ready-to-eat foods will have a bad
impact on health. Fast food can increase the risk of several diseases, such
as obesity, diabetes, hypertension, and dyslipidemia causing excess
calories for the body so that it will be converted in the form of glycogen
and fat by insulin, at a certain limit insulin is unable to overcome excess
calories caused by greater intake. than the output. Then the calories in the

15
 form of glucose will remain in the blood vessels, causing hyperglycemia
and then causing complaints of Diabetes Miletus (Pamelia, I. 2018).
 Mrs. C rarely exercise physical activity carried out by humans will be
closely related to the quality of life, health, and well-being. On the other
hand, if humans do not carry out physical activity according to their
needs, they are more likely to be susceptible to diseases due to lack of
movement (hypokinetic) such as type 2 diabetes. Low levels of physical
activity will increase the risk of obesity and many other chronic diseases
including coronary heart disease, diabetes and cancer. intestine (oktriani,
2019).
 This means that mr.C habits are a risk factor for metabolic
syndrome.Some factors that can increase a person's risk of developing
metabolic syndrome are
1. an unhealthy diet by eating too many fatty foods and sweet
foods.
2. Do not exercise regularly.
3. Have a habit of smoking.
4. Getting older.
5. Have a family affected by metabolic syndrome.
According to Bruscato (2010) fast food is a food that is high in saturated
fat and carbohydrates, Saturated fat consumption can affect the formation
of visceral fat. Increased fat Visceral contributes to metabolic syndrome.
There are many factors that affects the nutritional status of adolescents,
among which are physical activity, fondness, malabsorption, allergies,
intolerance of certain food substances, stress / depression levels, chronic
diseases suffered,metabolic processes, heredity, hormonal balance,
economic level, knowledge level. There is a relationship between fast
food consumption patterns and metabolic syndrome and not There is a
relationship between consumption patterns and physical activity with the
incidence of the syndrome. Metabolic. It is recommended to avoid fast
food because it can Causes metabolic syndrome. Food consumption is
better in form fresh processed food (Pugud Samodro,Nurul Hasna
Zulfannisa,Agus Prastowo,Nunung Wahyuni.2019).
4. Mrs. C has never been to a doctor to have her complaints checked. History of illness
in the family is known that Mrs. C’s mother has diabetes.
a. What is the meaning of ‘Mrs. C has never been to a doctor to have her
complaints checked. History of illness in the family is known that Mrs. C’s
mother has diabetes’?
Answer:

16
 This means that there are genetic risk factors that are inherited from the mother
for diabetes mellitus (Price & Wilson, 2012).
b. What is the correlation between Mrs. C family history with her main complaint?
Answer:
The existence of a history of diabetes mellitus experienced by Mrs. C's family is
a possibility that Mrs. C also experienced the same thing because family history
is one of the risk factors for diabetes mellitus. The existence of a family history
of diabetes mellitus can be a factor that aggravates the occurrence of insulin
resistance in Ny.C where, this insulin resistance can cause anaerobic metabolism
which causes neck felt tense and heavy Ny.C (Setiati, s et al. 2017).
c. What are the effect Mrs. C has never been to a doctor to have her complaints
checked?
Answer:
Rarely, medical check-ups cannot detect the possibility of a patient's illness due
to an unfavorable lifestyle (Mahmudah, 2019).

d. What are the risk factor of Mrs. C disease?

Answer:
a. Unhealthy Lifestyle
 Increased food portions (excess calorie intake) causes lipogenesis and
glycogenesis resulting in obesity
 Sedentary lifestyle causes FFA to increase so that the risk of DM2 with
insulin resistance, Most people with diabetes have other cardiovascular
risk factors (smoking, hypertension and dyslipidemia) that contribute to
the development of PAP.
 Obesity in childhood
 Very fast weight gain in infancy
 Insufficient sleep duration
 Consumption of drinks high in glucose causes lipogenesis and
glycogenesis so obesity (Johanes Rumaratu, Richard Sumangkut, Djony
Tjandra, Billy Karundeng. 2021).
b. Genetic Factors
17
  Obese twin brother
 Obesity in the elderly
c. Maternal Factors and Fetal Development
 Obesity in pregnancy
 Excessive weight gain during pregnancy
 Maternal obesity before pregnancy
 Overfeeding in neonates (Price, SA, Wilson. LM 2015)
e. What are the classification of diabetes?
Answer:
Klasifikasi diabetes menurut (American Diabetes Association, 2018) dibagi
dalam 4 jenis yaitu:
 Type 1 diabetes mellitus is a metabolic disorder disease characterized by an
increase in blood sugar levels due to the destruction of pancreatic beta cells
due to a certain reason that causes no insulin production at all, so the patient
desperately needs additional insulin from the outside.
 Type 2 diabetes mellitus is a metabolic disorder disease characterized by an
increase in blood sugar levels due to a decrease in insulin secretion by
pancreatic beta cells and or insulin function (insulin resistance).
 Other types of diabetes mellitus are metabolic disorders characterized by
elevated blood sugar levels due to genetic defects in beta cell function,
genetic defects in insulin action, diseases of the exocrine pancreas,
endocrinopathy due to drugs or chemicals, infections, rare immunologic
causes, other genetic syndromes associated with diabetes mellitus. related to
DM
 Gestational diabetes mellitus is a metabolic disorder disease characterized by
an increase in blood sugar levels that occurs in pregnant women, usually
occurs at the age of 24 weeks of gestation, and after giving birth blood sugar
returns to normal.
5. Physical examination :
General condition: appears to be mildly ill, compos mentis, BH: 164 cm, BW 84 kg
Vital signs: BP 150/90 mmHg, Pulse 88x/minute, Temp. 36,8°C, RR: 20x/minute.
18
Head : conjunctiva not pale, sclera not yellow.
Neck : JVP 5-2 cmH2O
Thoraks : Heart and lungs within normal limits
Abdomen : flat, tender, bowel sounds (+) normal, abdominal
circumference 125 cm.
Extremity : cold akral (-/-), edema (-/-).
a. What is the interpretation of physical examination?
Examination Normal In the case Interpretation

General Healthy Appears to be Abnormal

condition mildly ill
Conciousness Compos mentis Compos mentis Normal

IMT 18,5-22,9 31,32 Obese type 2

(BH: 164 cm;
BW: 84 kg)
Blood 90-120/60-80 150/90 mmHg Hypertention
Pressure mmHg grade 1

Pulse 60-100x/minute 88x/minute Normal

Temperature 36,50 - 37,50C 36,80C Normal

Respiration 16-24x/minute 22x/minute Normal

Rate
Head
Conjunctiva Conjunctiva pale Conjunctiva not Normal
Sclera (-/-) pale
Sclera not yellow Sclera not yellow
(-/-)
Neck JVP 5-2 cm H2O JVP 5-2 cmH2O Normal

Thoraks Heart and lungs Heart and lungs Normal

within normal within normal
limits limits

19
 Abdomen - Flat, tender, - Flat, tender,
bowel sounds (+) bowel sounds (+)
normal normal Abnormal
- Abdominal - Abdominal
circumference circumference
♂️: < 90 cm ♀: 125 cm
♀: < 80 cm

Extremity Cold akral (-/-) Cold akral (-/-) Normal

Edema (-/-) Edema (-/-)

b. How is the abnormal mechanism of physical examination?

Answer:
BH: 164 cm, BW 84 kg (obesity)

Lack of physical activity, bad food intake  Serum blood glucose increases 
lipogenesis  obesity  accumulation in the stomach  central obesity

BP 150/90 mmHg (hypertensi)

Lack of physical activity and bad food intake  Serum blood glucose
increases continuous increase in insulin secretion  insulin resistance 
diabetes melitus type 2  persistent hyperglycemia  increased production of
ROS (reactive oxygen species) in the blood circulation  oxidative stress 
reduced levels of NO ( nitric oxide) endothelium  vasoconstriction 
hypertension

abdominal circumference 125 cm

Lack of physical activity, bad food intake  Serum blood glucose increases 
lipogenesis  obesity  accumulation in the stomach  central obesity 
increase in abdominal circumference

c. what is correlation abdominal circumference with the metabolic syndrome?

Answer:
 The correlation is one of the clinical manifestations of metabolic
syndrome, where the abdominal circumference dilates from the normal
20
 state, due to the accumulation of fat in the patient's body, especially in the
abdominal part.
 abdominal circumference is also a sign of obesity which is one of the
metabolic symptoms of syndrome. The of metabolik syndrome is based
on the criteria of the national cholestrol education program adult
treatment panel III (NCEP-ATP III) Which has Been adjusted For
asians,which is categorized as metabolik syndrome if three or mode risk
faktor For central obesity are found With abdominal circumference>90
cm For me and > 80 cm For woman:fasting blood sugar > blood pressure
130/85 mmHg,triglyceride level 150 mg/dl and HDL Levels (Price &
Wilson, 2012).
6. Laboratory examination:
Routine blood: Hb 13g/dl, Leukocyte 8.000/mm3, platelets 250.000/ mm3
Random blood sugar 230 mg/dl, HDL 25 mg/dl, LDL 210 mg/dl , triglycerides 220
mg/dl, total cholesterol 235 mg/dl.
a. What is the interpretation of laboratory examination?
Answer:
Examination Result Normal Interpretation

Lk : 13 - 18
gr/dl
Hb 13g/dl Normal
Pr : 12 - 16
gr/d
Routine
Leukocyte 5.000-
blood Normal
8.000/mm3 10.000/mm3

platelets 150.000-
250.000/ 450.000/mm Normal
mm3 3

Random Random 0-120 before Abnormal /

blood blood sugar eating increase

21
 230 mg/dl < 140 after (hyperglycemia)
eating

< 100 fasting

Lk : > 40
Abnormal /
HDL 25 mg/dl
decrease
mg/dl Pr : > 50
(dyslipidemia)
mg/dl

Abnormal /
LDL 210
< 130 mg/dl Increase
mg/dl
(dyslipidemia)

Abnormal /
triglycerides
< 150 mg/dl Increase
220 mg/dl
(dyslipidemia)

total Abnormal /
140 – 200
cholesterol Increase
mg%
235 mg/dl (dyslipidemia)

b. How is the abnormal mechanism of laboratory examination?

Answer:
Hyperglycemia:
FR: consumption of snacks + fast food (contains lots of calories, cholesterol),
and low physical activity + rarely exercise (slow body metabolism) →
imbalance of calorie intake and output from the body → fat accumulation in the
body → obesity → insulin intolerance to glucose → resistance insulin →
glucose cannot enter the cells → glucose accumulates in the blood →
hyperglycemia (Price & Wilson, 2012).

Dyslipidemia:

22
 FR: consumption of snacks + fast food (contains lots of calories, cholesterol),
and low physical activity + rarely exercise (slow body metabolism) →
imbalance of calorie intake and output from the body → fat accumulation in the
body → obesity → insulin intolerance to glucose → resistance insulin →
glucose cannot enter cells → energy is not formed → tissue that needs energy
does not get enough energy → energy is formed from the breakdown of fat
(lipolysis) → release of free fatty acids in the body → passes through the blood
→ dyslipidemia (increased LDL, increased triglycerides) , Total Cholesterol
increases, HDL decreases) (Price & Wilson, 2012).
7. How to diagnose the case?
Answer:
Anamnesis 
 Mrs. C, 42 years old with neck felt tense and heavy which had been coming
and going since 1 month ago
 Also complains of frequent thirst, frequent hunger, and frequent urination.
History of illness in the family is known that Mrs. C’s mother has diabetes
 Assisted by a household assistant every day, for her activities, Mrs. C sits
more and watches TV while consuming fried foods and ready-to-eat foods.
 Rarely exercises
 Criteria for diagnosis of metabolic syndrome according to WHO (World
Health Organization) are:
1. Impaired glucose regulation or diabetes
2. insulin resistance or Dm
3. TD hypertension > 140/90 mmHg or History of antihypertensive
therapy
4. dyslipidemia with plasma triglycerides >150 mg/dL and/or high
density lipoprotein (HDL–C) cholesterol <35 mg/dL for men; <39
mg/dL for women;
5. central abdominal obesity (male: waistto–hip ratio >0.90; female:
waist–to– hip ratio >0.85) and/or body mass index (BMI) >30 kg/m2;
and
23
 6. Microalbuminuria (ratio of urine albumin and creatinine 30 mg/ g or
albumin excretion rate of 20 mcg / min (Sandra Rini.2015).

Physical Examination

 General condition: appears to be mildly ill

 BH: 164 cm, BW 84 kg. Abdominal circumference 125 cm.
 BP 150/90 mmHg
Laboratory Examination 
 Random blood sugar 230 mg/dl,
 HDL 25 mg/dl, LDL 210 mg/dl , triglycerides 220 mg/dl, total cholesterol
235 mg/dl (Shahab, A. 2017).
8. What is the differential diagnose in this case?
Answer:
Metaboli Cushing Obesity Diabetes Hiperlipidemia Sekunder
c Syndrom Melitus , Hypertension
Syndrom e Type 2 Hipertrigliseri
e da,
Dislipidemia
Genetic, Set of Accumul Blood Hiperlipidemia: Blood pressure
due to symptoms ation of sugar LDL > 200 140/90 or higher
insulin that arise fat in the levels Hipertrigliderid: Secondary
resistence due to body due exceed TG > 200 mg/dl hypertension:
high to normal Dislipidemia: cause can be
levels of calories values due LDL> 200, found
the in more to insulin HDL < 40, TG (dyslipidemia,
hormone than resistance. > 200 adrenal gland
cortisol in burned. disease).
the body
(excess
steroid
consumpt

24
 ion).

Typical Clinical Typical Typical Typical Typical

symptom disorders: symptom symptoms: symptoms: symptoms:
s: Bufallo s: Polidipsi, Leg pain, There is no
- hump, - BMI > poliuri, Chest pain, history of
Abdomin moon 30 kg/m2 polifagi, shortness of hypertension in
al face, - achantosis breath, pain eg. the family.
cirfumfer striae, Abdomin nigricans, Pressure on the Sudden attack of
ence > 90 obesity, al neuropati neck, jaw, high blood
cm in hypertens cirfumfer DM shoulders and pressure before
men and ion. ence > 90 back. the age of 30
> 80 cm cm in Headache, years, The
in women men and usually presence of other
- > 80 cm accompanied by symptoms
Trigliser in obesity. related to
ida women, diseases that
>150 OSA, cause secondary
mg/dl shortness hypertension.
- HDL of breath Not obese.
in Men:
<40
mg/dl
in
woman:

25
<50
mg/dl
- Blood
Pressure:
>130/85
- GPS
>100,
mg/dl

9. What is additional examination in this case?

Answer:
No additional examination is required, because the diagnosis is established. Where
according to NCEP-ATP III the enforcement of metabolic syndrome if more than 3
criteria are met, then it is upright. In the 5th case the criteria are met.
 Fasting blood sugar 100 mg/dL (or taking antihyperglycemic drugs)
 Blood pressure 130/85 mmHg (or taking antihypertensive drugs)
 Triglycerides 150 mg/dL (or taking medication for hypertriglyceridemia)
 High-density lipoprotein (HDL) cholesterol < 40 mg/dL in men and < 50 mg/dL
in women (or taking medications to increase HDL)
 Waist circumference 90 cm for men and 80 cm for women (Price & Wilson,
2012).
10. What is the working diagnose in this case?
Answer:
Metabolik syndrome ec bad lifestyle
11. What is the treatment in this case?
Answer:
 Lifestyle modification
 Management according to components of Metabolic Syndrome Type 2 DM,
Hypertension, Dyslipidemia
 DM medication:
26
  Metformin 2-3 x 500 mg
 Sufonilurea (Glibenclamide 1-2 x 5 mg or Glimepiride 1-2 x 5 mg)
 Medical hypertension (JNC – VIII)
 CCB alone or in combination with ACE inhibitors / Aldosterone Renin
Blockers (ARBs)
 CCB  Amlodipine 5-10 mg/day (1x a day)
 ACE  inhibitor Captopril 1-2 x 12.5-25 mg
 ARB  Candesartan 1-2 x 8-16 mg/day
 Medical dyslipidemia:
 Simvastatin 1x 20-40 mg
 Atorvastatin 1x20-40 mg (Shahab, A. 2017).
12. What is the complication in this case?
Answer:
 Cardiovascular disease: myocardial infarction
 Cerebrovascular disease: stroke
 DM complications: hyperglycemic crisis, diabetic retinopathy,
 diabetic nephropathy, ulcer
 Obesity: Fractures, osteoarthritis
 Some complications of the metabolic syndrome include coronary heart disease,
heart failure, stroke, and other complications include an increased risk of atrial
fibrillation, venous thromboembolism and sudden death and decreased cognitive
function (Setiati, s et al. 2017.).
13. What is the prognosis in this case?
Answer:
Quo ad Vitam :dubia ad bonam
Quo ad Functionam : dubia ad bonam
Quo ad Sanationam : dubia ad bonam
14. What is the SKDU in this case?
Answer:

27
 4A : mendiagnosis, melakukan penatalaksanaan secara mandiri dan tuntas Lulusan
dokter mampu membuat diagnosis klinik dan penatalaksanaan penyakit tersebut
secara mandiri dan tuntas.
15. NNI
1.Mengatur pola makan :
- QS. Al-Baqarah/2: 168

َ ‫شي ْٰط ِۗ ِن ِا َّنهٗ لَكُ ْم‬

‫عد ٌُّو ُّم ِبيْن‬ َّ ‫ت ال‬ َ ‫ض َح ٰل اًل‬
ِ ‫ط ِيباا َّۖو َْل تَت َّ ِبعُ ْوا ُخطُ ٰو‬ ُ ‫ٰ ٰٓيا َ ُّي َها ال َّن‬
َ ْ ‫اس كُلُ ْوا ِم َّما فِى‬
ِ ‫اْل ْر‬

Artinya:
“Wahai manusia! Makanlah dari (makanan) yang halal dan baik yang terdapat di
bumi, dan janganlah kamu mengikuti langkah-langkah setan. Sungguh, setan itu
musuh yang nyata bagimu.”
Penjelasan:
Dalam ayat al quran diatas dijelaskan bukan hanya makanan halal yang harus
dikonsumsi namun makanan yang baik pun harus dikonsumsi. Mengonsumsi
makanan siap saji dan makanan ringan secara berlebihan dapat memicu pada
kebiasaan yang buruk dan tidak baik bagi kesehatan.
- QS. Al A’raf/ 7: 31
َ‫ٰيبَنِ ْٰٓي ٰادَ َم ُخذ ُ ْوا ِز ْينَتَكُ ْم ِع ْندَ كُ ِل َمس ِْج ٍد َّوكُلُ ْوا َوا ْش َرب ُْوا َو َْل تُس ِْرفُ ْو ۚا اِنَّهٗ لَ يُحِ بُّ ْال ُمس ِْرفِيْن‬
Artinya:
“Wahai anak cucu Adam! Pakailah pakaianmu yang bagus pada setiap (memasuki)
masjid, makan dan minumlah, tetapi jangan berlebihan. Sungguh, Allah tidak
menyukai orang yang berlebih-lebihan.”
2. Berobat secara teratur
- QS. Ar Rad/ 13: 31

َ‫اْل ْم ُر َج ِم ْيعا ِۗا ا َ َفلَ ْم يَ ۟ايْـ ِس الَّذِ يْن‬ ِ ‫ض ا َ ْو كُل َِم بِ ِه ْال َم ْو ٰت ِۗى بَ ْل ِ ه‬
َ ْ ‫لِّل‬ ُ ‫اْل ْر‬ َ ْ ‫ت بِ ِه‬ ْ َ‫ت بِ ِه ْال ِجبَا ُل ا َ ْو قُ ِطع‬
ْ ‫َولَ ْو ا َ َّن قُ ْر ٰا انا سُيِ َر‬
‫عة ا َ ْو ت َ ُحلُّ َق ِر ْيباا ِم ْن‬ َ ‫ار‬ ِ َ‫صنَعُ ْوا ق‬
َ ‫ص ْيبُ ُه ْم ِب َما‬ ِ ُ ‫اس َج ِم ْيعا ِۗا َو َْل يَزَ ا ُل ا َّل ِذيْنَ َكف َُر ْوا ت‬ ‫ٰا َمنُ ْٰٓوا ا َ ْن َّل ْو يَش َۤا ُء ه‬
َ َّ‫ّٰللاُ لَ َهدَى الن‬
َ‫ِف ْال ِم ْي َعاد‬
ُ ‫ّٰللا َْل يُ ْخل‬ ِ ‫دَ ِار ِه ْم َحتهى َيأْت َِي َو ْعد ُ ه‬
َ ‫ّٰللا ِۗا َِّن ه‬

28
 Artinya:
“Dan sekiranya ada suatu bacaan (Kitab Suci) yang dengan itu gunung-gunung
dapat digoncangkan, atau bumi jadi terbelah, atau orang yang sudah mati dapat
berbicara, (itulah Al-Qur'an). Sebenarnya segala urusan itu milik Allah. Maka
tidakkah orang-orang yang beriman mengetahui bahwa sekiranya Allah
menghendaki (semua manusia beriman), tentu Allah memberi petunjuk kepada
manusia semuanya. Dan orang-orang kafir senantiasa ditimpa bencana
disebabkan perbuatan mereka sendiri atau bencana itu terjadi dekat tempat
kediaman mereka, sampai datang janji Allah (penaklukkan Mekah). Sungguh,
Allah tidak menyalahi janji.
- HR Al hakim dalam al mustadroknya 4:341

Dari Ibnu ‘Abbas radhiyallahu ‘anhuma, Rasulillah SAW pernah menasehati

seseorang,

“Manfaatkanlah lima perkara sebelum lima perkara:

1) Waktu mudamu sebelum datang waktu tuamu,
2) Waktu sehatmu sebelum datang waktu sakitmu,
3) Masa kayamu sebelum datang masa kefakiranmu,
4) Masa luangmu sebelum datang masa sibukmu
5) Hidupmu sebelum datang matimu.”

2.7 Conclusion

Mrs. C, 42 years old, complained of myalgia, polyfagia, polyuria, polydipsia, due to

having a metabolic syndrome et causa bad lifestyle.

2.8 Conceptual Framework

29
 RF : a lot of sitting,eat fast
food and rarely exercise

Insulin is often exposed to Cholesterol is transported in the

glucose continuously form of chylomicrons into blood
uessels →lymph uessels

Resistension Insulin
Total cholesterol and trigliserid
meningkat

Little glucose is brought into

cells to be converted into Trigliserid wil be save in
energy adipose tissue

Bss meningkat

circumference LDL meningkat

Glucose meningkat dan HDL menurun

DM tipe 2 Obesity Vasoconstriction

type 2 of blood vessels

Polyfagia,polydipsia,polyu
ria,needles in finger
Transduction The body compensation
nerve menurun increases the
sympathetic nervuous
system

Stiffness
Co meningkat

HT grade 1

Metabolic syndrome

30
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