Medical Education Unit 2016

Gastrointestinal System-3rd Case

BLOCK : GASTROINTESTINAL SYSTEM

SEMESTER : IV
MODUL : UPPER GASTROINTESTINAL TRACT
UNIT : 3rd WEEK
SCENARIO TYPE : NARATION, MULTILEVEL PROBLEM
SCENARIO FORMAT : PROBLEM PACK + SOEP
TOPIC : MALNOURISHED
DISORDER TO BE LEARNED :

SKDI
NO MATERI
2012
Endocrine, Nutrition and Metabolism
1 Malnutrisi energy protein 4
2 Defisiensi vitamin 4
3 Defisiensi mineral 4
4 Obesitas 4
5 Dislipidemia 4
6 Porfiria 1
7 Hiperurisemia 4
Gastrointestinal System
8 Kecacingan 4

SYMTOMPS TO BE LEARNED :
DAFTAR MASALAH KESEHATAN SISTEM PENCERNAAN SKDI 2012
NO DAFTAR MASALAH KESEHATAN
1 Nafsu makan hilang 5 Gangguan pertumbuhan
2 Gangguan gizi (kurang, 6 Berak berlendir dan
berlebih) berdarah
3 Mual, muntah 7 Gatal di anus
4 Diare 8 Keluar cacing

CASE TITLE : Boboi lost his weight

REFERENCES :
1. Ann Ashworth et all, Guidelines for the Inpatient Treatment of Severely
Malnourished Children, WHO; 2003
2. Avunduk, Canan, Manual of Gastroenterology: Diagnosis and Therapy, 3 rd edition,
Lippincot Williamms & Wilkins; 2002
3. Despoupolus A, Sibernagl S. Color Atlas of Physiology. 5th ed. Stuttgart New York:
Thieme; 2003
4. Despoupolus A, Sibernagl S. Color Atlas of Pathohysiology. 5th ed. Stuttgart New
York: Thieme; 2003
5. Graham P. Butcher, Gastroenterology: an illustrated colour text. Chruchill
Livingstone; 2003
6. Guandalini S, Textbook of pediatric Gastroenterology and nutrition. Taylor and
Francis; 2004

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7. Guyton AC, Hall JE. Textbook of Medical Physiology. 11th ed. Philadelphia:
Saunders; 2000
8. Harrisons. Principle of Internal Medicine. 17th ed. USA: McGraw Hill; 2008
9. Kleigman RM, Marcdante KJ, Jenson HB, Behrman RE, Nelson Essentials of
Pediatric, 5th Editiion, Elseiver; 2009
10. McPhee J Stephen , Pathopgysiology of Disease: an Introduction to clinical
Medicine, 2nd edition, Appleton & Lange
11. Stern SDC, Cifu AS, Altkorn D. Symptom to Diagnosis An Evidence-Based Guide,
2nd edition, Mc Graw Hill, 2010; p 199-211
12. Papadakees Ma, McPhee MJ, Current Medical Diagnosis and Treatment 2013, 52nd
ed. USA: McGraw Hill Lange, 2013

CASE III, 2 SESSIONS

TOPIC: MALNOURISHED

ANAMNESIS:

Boboi, a 3 y.o boy was brought to the primary health care when youre on duty, by his
mother. His mother worried of his weight as he looked smaller and thinner than his peers, since
the last 3 months.
Boboi is the 4th of total 5 children in his family, his father works as a construction
labour with limited income. His appetite had decreased as he only ate 5 table spoon each with
limited protein and vegetables. He used to have breast milk but had been stopped at 4 months
ago as his mother informed of limited breast milk production as well. Boboiboy did not like to
drink milk, he drank mineral water and tea most of the time.
Since 2 y.o Boboi often got diarrhea for 4-5 times a day and diminished with medication
from primary health care. Even though the diarrhea improved but since the last 3 months the
stool became softer, without blood, sometimes with mucous. His mother told of having
difficulty handling 5 children on her own on a daily basis.

Past medical illness

Often got diarrhea, no chronic cough
Family medical history:
No closed contact with TB both in the family and neighborhood
Birth history:
Boboi was born per vaginam assisted by midwife, aterm, birth weight 2700 gram, birth length
48 cm, head circumference 34 cm, APGAR score 7-9, dyspnea, no jaundice.
Nutrition history:
Boboi only got breast milk for up to 4 months and changed into formula milk up to 6 months
due to economic problem. He then started to eat solid food like rice, banana etc.
Development and growth history:
Boboi was able to crawl at the age of 9 months, able to walk at the age of 17 months and
started to talk fluently at the age of 17 months.
Immunization history:

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Basic immunization was not complete, only BCG, DPT once, Hep. B twice and Polio twice.
He was seldom brought to Posyandu due to his mother was too busy taking care all of her
children.

QUESTIONS:
1. What is Boboi medical problem?
2. List the possible hypothesis and its reasoning!

PHYSICAL EXAMINATION:

General condition : Moderately ill

Compos mentis, irritable
Body weight : 9 kg, ( Z score < -3)
Body length : 90 cm -1 <Z score< -2
BW/BL : Z score < -3 Ideal BW: 13 kg
Vital signs : RR 24 x/minutes Temp: 36,3 C
HR 88 x/minutes BP: 100/60 mmHg
Face : Old man face (+)
Head : Unevenly hair distribution (+), rarely hair (+), easily evoked (+)
Eyes : Bitot spot (+), conjunctiva anemic (+), icteric (-)
Mouth : wet Mucosa, no ulcer
Ear : no secret, ear canal was clear and tympanic membrane intact
Nose : no secret
Pharynx : uvula in the middle of pharynx, Tonsil T1-T1, hyperemic (-), detritus
(-), posterior pharynx no hyperemic
Thorax : chest movement was symmetric, float ribs was noted
Heart: I & II heart sounds were single, no murmur, no gallop
Lung: vesicular breath sounds, no rhales, no wheezing
Abdomen : I : schapoid
A : increasing bowel sounds
P : skin turgor could not be evaluated due to wrinkled skin
Hepar/slpeen was not palpable, no shifting dullness
Anal : eritema natum
Extremities : warm, wasting (+), baggy pants (+), Pitting edema (-), capillary
refill time < 2 sec
Skin : dry skin (+), no desquamation, no hipo/hiperpigmentasi, no ulcer

QUESTIONS:
1. What is the impression of physical examination ?
2. What further test do you suggest?

LABORATORY EXAMINATION

Hb (g/dL) : 9 11 14
Hct (%) : 28.2 33 - 42
Leucocyte (/uL) : 7000 5000 15.500

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Thrombocyte : 250.000 150.000-350.000

(/uL)
RBS (mg/dl) : 60
Urinalysis Clear yellow, Plasma specific weight 1020, protein (-),
bilirubin (-), urobilin (-), Glucose (-)
Urine sediment urine: eritrocyte (-), leucosyte 1-3/lpb,
bacteria (-), epithel (-)
Leucocyte esterase (-), nitrite (-)

Complete fecal : Yellow, soft, eryrthrocyte (-), leucoyte (+), Ascaris egg (+)
analysis
R thorax: : No heart enlargement, no hilus enlargement, no infiltrate at
both lungs.

QUESTIONS:
What is your diagnosis and management plan for Boboi?

DIAGNOSIS AND MANAGEMENT:

Malnourished marasmic type et causa persistent diarrhea DD chronic diarrhea Commented [VAC1]: Pada kasus ini pasien tanpa dehidrasi
dengan keadaan umum stabil
A vitamin deficiency
Askariasis
Anemia due to iron deficiency DD chronic infection

MANAGEMENT:
Read WHO guidelines :

LEARNING OBJECTIVES:
1. Explain about breast and bottle feeding.
2. Explain about the anatomy of the human breast, physiology of lactation,
Gizi anak immunologic factors of human milk, and physiologic binding.
3. Explain the composition of human milk & infant formula.
4. Explain about weaning, feeding progression, and baby foods.
5. Explain about balanced nutrition.

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Breast feeding At the end of the block, the student will be able to give breast feeding
counselling counseling and supporting skills
Nutritional assessment
At the end of the block, the student will be able to analyse nutritional status in
in children children using anthropometric indices
Macronutrient 1. Describe the management of protein energy malnutrition.
2. Describe the management of obesity in children.
malnutrition in children
Menjelaskan manfaat ASI, pemberian ASI ekslusif, komposisi ASI, jadwal
pemberian ASI (menyusui) dan cara pemberian ASI serta mampu
memberikan konseling cara menyusui
Menjabarkan (review) anatomi payudara, fisiologi laktasi, faktor imunologis
ASI dan ikatan psikologis Buteki, proses menyapih, jadwal pemberian PASI,
komposisi PASI.
Mampu menganalisa status nutrisi anak dengan pengukuran antropometri
Menjelaskan makronutrisi dan serat termasuk karbohidrat, lemak, protein,
serat, dan mikronutrisi
Menjelaskan pengaruh makanan dalam proses absorpsi dan metabolisme
Gizi
makronutrien dan mikronutrien termasuk komponen enzim penghambat,
tanin, phytat, saponin, lectin, serta kecepatan ingesti makanan dan frekuensi
makan.
Menjabarkan perbedaan pencernaan makanan dan fisiologinya termasuk
dampak, indeks glikemik, absorpsi kolon, asam lemak rantai pendek dan
rantai panjang.
Mampu menjelaskan manajemen nutrisi pada berbagai macam gangguan
sistem pencernaan seperti ulkus peptikum, gangguan hati dan pankreas, short
bowel syndrome, intoleransi laktosa, dll
Mampu menegakkan diagnosa malnutrisi marasmus, kwasiorkor dan KEP
dan manajemen nutrisinya.
PARASITE Mampu menjelaskan infestasi parasite dalam saluran pencernaan meliputi
INFESTATION cacing tambang, askariasis, strongiloidosis, skistosomiasis, taeniasis dll
LECTURE/ KULIAH PAKAR
1. Overview the effect of macronutrient and fibre, including carbohydrates,
fats, protein, dietary fibre, nutrient-nutrient interactions in foods and
Dietery factors micronutrients interactions.
affecting nutrient 2. Describe the influence of food form and non-nutrient food, including:
absorption and components, food form, enzyme inhibitors, saponins, tannins, phytates,
metabolism lectins and rate of food ingestion and meal frequency.
3. Describe the differences in digestibility of foods and physiology, including
implication, glycemic index, colonic absorption, short chain fatty acid and
long-term effects.
Nutrition management Explain about nutritional diagnosis and management in peptic ulcers including:
in peptic ulcers specific composition, dose, route, and monitoring.
Describe the effect of intestinal resection, including motility, absorption of
nutrient, fluid and electrolytes; adaptation of the intestine, complication;
Short bowel syndrome
nutritional treatment and evaluation.

Lactose intolerance At the end of the block, the student will be able to discuss the management of
the practical nutritional therapy in lactose intolerance.
Protein energy Explain about nutritional diagnosis and management in protein energy
malnutrition malnutrition, including composition, dose, route and monitoring.

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Inflammatory Bowel Explain about nutritional diagnosis and management in inflammatory bowel
Diseases disease, including: rationale for modifying food intake, special dietary
therapies, treatment of specific deficiencies and intensive nutritional support.

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