SCENARIO B TUTORIAL REPORT

BLOCK XXI: GROWTH AND DEVELOPMENT & GERIATRIC

Group 5
Tutor :
dr. H. Achmad Azhari, DAHK
Members:
1. Armiko Bantara (702013010)
2. Istiqomah Maximiliani (702014057)
3. Aisyah Azani (702014066)
4. Dwi Puspita Sari (702014001)
5. Ardiansyah Wijaya (702014080)
6. Vonny Alfanda (702014085)
7. Viena Aprilia (702014029)
8. Tharisa Kurnia (702014043)
9. Muhammad Aiman (702014017)
10. Ghinafahriyah Delihefian (702014073)
11. Ahmad Reyhan (702014063)

MEDICAL FACULTY
MUHAMMADIYAH PALEMBANG UNIVERSITY
2017
 PREFACE

Thanks to Allah SWT for helping and give us chance to finish this
Scenario B tutorial report on the 21st blok timely. Shalawat and salam always be
with our prophet Muhammad SAW and his family, friends, and followers until the
end of time.
We recognize that this tutorial report is far from perfect. Therefore we
expect constructive criticism and suggestions, in order to refine the next tasks.
In completing this tutorial task, we got a lot of help, guidance and advice.
On this occasion we would like to express our respect and gratitude to:
1. dr. Achmad Azhari, DAHK, as a tutor of group 5
2. All of the members who involved in the making of this report
May Allah SWT give a reward for all the charity given to all those who
have supported us and hopefully this tutorial report, useful for us and the
development of science. May we always be in the protection of Allah SWT.
Amen.

Palembang, September 30th, 2017

Author

i
 TABLE OF CONTENT

PREFACE ................................................................................................................. 1
TABLE OF CONTENT ............................................................................................ 2
CHAPTER I INTRODUCTION
1.1 Issue Background .......................................................................................... 3
1.2 Purpose and Objectives ................................................................................. 3
BAB II DISCUSSION
2.1 Tutorial Data ................................................................................................ 4
2.2 Case Scenario ............................................................................................... 4
2.3 Clarification of Terms .................................................................................. 6
2.4 Identification of Problem .............................................................................. 7
2.5 Analysis and Synthesis of Problem .............................................................. 9
2.6 Hypothesis .................................................................................................... 40
2.7 Conceptual Framework ................................................................................ 40
BIBLIOGRAPHY ...................................................................................................... 41

ii
 CHAPTER I
INTRODUCTION

1.1 Issue Background

Growth and Development & Geriatric Block is the 21st Block in the
seventh semester of the Competency Based Curriculum System Doctor
Education Faculty of Medicine, Muhammadiyah Palembang University. One
of the learning strategies of Competency Based Curriculum system is Problem
Based Learning (PBL). Tutorial is the implementation of 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 the
existing case. On this occasion a case study of scenario B is presented which
presents the case; Ana, 10 months old girl, visited the outpatient clini RSMP
with recurrent diarrhea with her mother. She suffered from diarrhea almost
once a month since she was 4 months old. The length of diarrhea was 7 to 10
days. Her mother said that her daughters appetite was like usual. Ana is not
having fever, cough, cold and hard to breathe now.
Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown. Ana was given exclusive breastfeeding
just until 3 months of age. Since her age was 3 months, she was given only
regular formula milk 6 times a day @90 cc until now. After her age was 4
months. She was given instant porridge as a complementary feeding (MP ASI)
2 times a dat @1/2 sachet (1 sachet is 80 kcal). She also was given cooked
rice (tajin) 2-3 times a day @50 cc since her age was 4 months.

1.2 Purpose and Objectives

1. The purpose and objectives of this case study tutorial, namely:
2. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
3. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
4. Achieving the objectives of the tutorial learning method

3
 CHAPTER II
DISCUSSION

Seven Jump Steps

2.1 Tutorial Data

Tutor : dr. H. Achmad Azhari, DAHK
Moderator : Ahmad Reyhan
Secretary : Istiqomah Maximiliani
Notulis : Ardiansyah WIjaya
Day and date : Tuesday, September 26th, 2017
(08:00 am -10:30 am)
Thursday, September 26th, 2017
(08:00 am -10:30 am)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their opinion.
3. Ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Case Scenario

Ana, 10 months old girl, visited the outpatient clini RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost once a month
since she was 4 months old. The length of diarrhea was 7 to 10 days. Her
mother said that her daughters appetite was like usual. Ana is not having
fever, cough, cold and hard to breathe now.
Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown. Ana was given exclusive breastfeeding
just until 3 months of age. Since her age was 3 months, she was given only
regular formula milk 6 times a day @90 cc until now. After her age was 4

4
months. She was given instant porridge as a complementary feeding (MP ASI)
2 times a dat @1/2 sachet (1 sachet is 80 kcal). She also was given cooked
rice (tajin) 2-3 times a day @50 cc since her age was 4 months.

The mothers pregnancy and childbirth history:

Ana is the first child from a 24 years old mother. During pregnancy,
mother was healthy and pre natal care to a midwife 4 times. Ana was
delivered spontaneously at 37 weeks gestation. Immediately cried after
birthed, APGAR score 1st minute is 9 and the 5th minute is 10. Birth weight
was 2800 grams. Birth length was 49 cm. Head circumference was 33 cm.

Immunization History: BCG 1 time but DPT, polio, hepatitis dan measles
vaccines were never given.
Growth history: image attachment of ANAs KMS
Development history: Ana can only sit with help
Medication history: Ana was never got treatment
Physical examination:
General status: the child is not looking thin, round cheeks, pale, apathetic,
whiny, weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm
circumference 12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
Spesific Status:
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:

5
 - Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and groin
Neurologicus status:
- normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes

2.3 Clarification of Terms

No. Istilah Klarifikasi
1. Diarrhea The condition of having at least three loose or
liquid bowel movements each day
2. Exclusive breastfeeding an infant's consumption of human milk with
no supplementation of any type (no water, no
juice, no nonhuman milk and no foods) in 6
months
3. Formula milk An artificial substitute for breast milk
intended for feeding infants. It can come in
powdered form to be mix with water or
instant liquid form
4. Complementary feeding Process when breast milk alone is no longer
sufficient to meet the nutrtional requirements
of infants and therefore other food and liquid
are neededly, along with breastmilk
5. KMS Cards that create growth charts and
developmental indicators to record and
monitor the growth of toddlers every month
from birth until 5 years old
6. Piano Sign A manuever to determine injury to the

6
 thoraco-clavicula ligament
7. Dismorphic face One or more aspect of the persons face are
abnormal in some way
8. Yellowish Red head The hair is hipopigmented vary in color from
hair a reddish yellow to gray or even white
9. Baggy Pants Skin disorders where the patient looks like
wearing loose pants due to loss of fat reserves
under the skin
10. Dermatosis A noninflammatory skin disorder

2.4 Identification of Problems

1. Ana, 10 months old girl, visited the outpatient clini RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost once a
month since she was 4 months old. The length of diarrhea was 7 to 10
days.
2. Her mother said that her daughters appetite was like usual. Ana is not
having fever, cough, cold and hard to breathe now.
3. Anas weight was never weighed (she was never taken to Public Health
Center). Highest weight was unknown.
4. Ana was given exclusive breastfeeding just until 3 months of age. Since
her age was 3 months, she was given only regular formula milk 6 times a
day @90 cc until now.
5. After her age was 4 months. She was given instant porridge as a
complementary feeding (MP ASI) 2 times a dat @1/2 sachet (1 sachet is
80 kcal). She also was given cooked rice (tajin) 2-3 times a day @50 cc
since her age was 4 months.
6. The mothers pregnancy and childbirth history:
Ana is the first child from a 24 years old mother. During pregnancy,
mother was healthy and pre natal care to a midwife 4 times. Ana was
delivered spontaneously at 37 weeks gestation. Immediately cried after
birthed, APGAR score 1st minute is 9 and the 5th minute is 10. Birth

7
 weight was 2800 grams. Birth length was 49 cm. Head circumference
was 33 cm.
7. Immunization History: BCG 1 time but DPT, polio, hepatitis dan
measles vaccines were never given.
8. Growth history: image attachment of ANAs KMS
9. Development history: Ana can only sit with help
10. Medication history: Ana was never got treatment
11. Physical examination:
General status: the child is not looking thin, round cheeks, pale,
apathetic, whiny, weight 5.5 kg, length 60 cm, head circumference 43
cm, upper arm circumference 12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
12. Spesific Status:
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and
groin
13. Neurologicus status:
- Normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone

8
 - No uncontrollable movements
- No pathological reflexes

2.5 Analysis of Problems

1. Ana, 10 months old girl, visited the outpatient clini RSMP with
recurrent diarrhea with her mother. She suffered from diarrhea
almost once a month since she was 4 months old. The length of
diarrhea was 7 to 10 days.
a. What are the causes of recurrent diarrhea?
Answer:
Based on the causes agents;
1. Infectious agents:
a. Bacteria: Salmonella, Shigella, E. coli, Bacillus cereus
b. Virus: Rotavirus, Astrovirus, Koronavirus
c. Parasites: Cryptosporidium, Cyclospora sp, Giardial
Lamblia
2. Noninfectious agents:
a. Food poisoning
b. Anatomical defects (Hisprung Disease, Short Intestine,
Striktura)

9
 c. Malabsorption (Deficiency of Disaccharides)
d. Endocrinopathy (Tiroxicosis, Addison's disease)
e. Neoplasm
f. Other causes (milk allergy, chron disease, immune
deficiency, water laxative)

Based on other factors:

1. Infection Factor
a. Enteral Infections
Enteral infections are gastrointestinal infections that are
the main cause of diarrhea in children. These parenteral
infections include;
1) Bacterial infections: E.coli, Salmonella, Shigella,
2) Viral infections: Enteroovirus, Adenovirus, Rotavirus.
3) Parasite infestation: Worm (Ascaris) fungi (candida
albicans)
b. Parenteral infection
Parenteral infection is infection of other body parts
outside the digestive tool, such as acute otitis media
(OMA), Tonsilofaringitis, Bronkopneumonia, Encephalitis
and so on.
2. Malabsorption Factors
a. Carbohydrate malabsorption:
disaccharides (lactose intolerance, maltose and sucrose),
monosaccharides (glucose intolerance, fructose and
galactose).
b. Malabsorption of fat
c. Malabsorption of proteins
3. Food Factor: stale food, toxic.
In this case, diarrhea is caused by protein malabsorption.

Sumber:
(Subagyo dan Santoso, 2012)

10
b. What is the determinology of diarrhea almost once a month since
she was 4 months old and the lengsht of diarrhea was 7 to 10 days?
Answer:
Ana has a chronic diarrhea.
Based on the duration, diarrhea are divided into:
1) Acute diarrhea
Acute diarrhea is a bowel movement with increasing
frequency and consistency of soft or fluid stools and is suddenly
coming and lasting in less than 2 weeks.
2) Persistent diarrhea
Persistent diarrhea is diarrhea lasting 15-30 days, is a
continuation of acute diarrhea or a transition between acute and
chronic diarrhea.
3) Chronic diarrhea
Chronic diarrhea is diarrhea that comes and goes, or lasts
long with non-infectious causes, such as gluten-sensitive disease
or decreased metabolic disorders. The duration of chronic
diarrhea is more than 30 days. According to (Suharyono, 2008),
chronic diarrhea is diarrhea that is chronic or persistent and lasts
more than 2 weeks.
Source:
Suharyono, 2008
c. What is the pathophisiology of recurrent diarrhea in this case?
Answer:

Lactase enzyme deficiency in the small intestine brush border

lactose-breaking disorder into glucose impaired absorption of

food or substances osmotic pressure in the intestine increases

water and electrolyte shifts in the intestinal cavity excessive

intestinal contents of cavities diarrhea

11
2. Her mother said that her daughters appetite was like usual. Ana is
not having fever, cough, cold and hard to breathe now.
a. What is the meaning of her daughters appetite was like usual?
Answer:
Her daughters appetite was like usual means that there is no
problems with her appetite. The problem may caused by other causes
such as the lack ammount of compsumption or the metabolism
disorder.
b. How is the correlation between appetite like usual with the
complaints?
Answer:
The complaints is not caused by her appetite.
c. What is the meaning of ana is not having fever, cough, cold and
hard to breathe now?
Answer:
The meaning is the diarrhea that happened to Ana is not caused
by infectious factors.
3. Anas weight was never weighed (she was never taken to Public
Health Center). Highest height was unknown.
a. What is the meaning of Anas weight was never weighed and her
height was unknown?
Answer:
Anas family is not a KADARZI family. Keluarga Sadar Gizi
(KADARZI) is a family that is able to recognize, prevent and
overcome the nutritional problems of each member. A family is
called KADARZI if it has a good nutritional behavior that is
characterized by at least:
1. Weigh the weight regularly.
2. Provide breast milk (breast milk) only to infants from birth to
age 6 months (exclusive breastfeeding).
3. Eat the variaton food
4. Using iodized salt.

12
 5. Drink nutritional supplements (TTD, high doses of Vitamin A
capsules) as recommended.
Source:
(DEPKES, 2012)
b. How about normal weight and height in infant aged 10 months?
Answer:
Based on Z-score growth chart;
Age:10 months
a. Weight : 8,2 kg
b. Lenght : 71,5 cm
c. Head circumference : 44,4 cm

Based on NCHS;

13
 c. How is the normal growth and development of a 10-months-old
baby?
Answer:
The normal growth and development of a 9-12 months baby;
1. Can stand alone without help
2. Can walk guided
3. Imitate sound
4. Repeat the sound he heard
5. Learn to declare one or two words
6. Understand simple command or prohibition
7. Show great interest in exploring the surroundings, eant to touch
anything and put things into his mounth
8. Participating and games
Some milestones of child development that must be know
(developmental milestone is the level of development that must be
achieved by a child at a certain age) :
child 9-10 month :
1. Pointing with the index finger
2. Holding objects with thumb and forefinger
3. crawl
4. sound dadadada
Source:
Soetjiningsih, 2012

Synthesis:
Age Rough Fine motor Personal- Language
motoric and adaptive Social
2 weeks Head shifted - Recognize Alert to the bell
to the right the face
ang left
2 months Shrugs on his Follow the Smile as a Cooing
stomach object past the response Looking for a sound

14
 center line source using the eyes
4 months Raise hands Looking for See the Laughing and crying
stomach objects hand
not found Raking grasp
headlag if Start
pulled from playing
supine with toys
sleeping
position
6 months Sitting alone Move objects Can feed Babble
from hand to yourself
hand Holding
the bottle
9 months Start learing start pincer Can waved Say bye-bye and
to stand up grasp bye-bye Mama, but not
Can sit alone bring together 2 play pat-a- spesific
blocks cake Say 2 syllables

12 walk Insert the beam Drink from say mama and

monthhs rise up and in the cup a glass papa, spesific
stand up Imitating say 1-2
movement the other word
Other
people

d. How many times weight and body height checks are

recommended at the Public Health Center?
Answer:

15
 According to the Decree of the health minister of the Indonesia
Republic number: 747 / menkes / sk / vi / 2007 on operational
guidelines of nutritionally conscious families in Desa Siaga, the
recommendation to weigh baby weight are the following;

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

Since her age was 3 months, she was given only regular formula milk
6 times a day @90 cc until now.
a. What are the contents and the benefits of breast milk?
Answer:
The composition of human milk is the biologic norm for infant
nutrition. Human milk also contains many hundreds to thousands of
distinct bioactive molecules that protect against infection and
inflammation and contribute to immune maturation, organ
development, and healthy microbial colonization. Some of these
molecules, e.g., lactoferrin, are being investigated as novel
therapeutic agents.

16
 Colostrum, produced in low quantities in the first few days
postpartum, is rich in immunologic components such as secretory
IgA, lactoferrin, leukocytes, as well as developmental factors such as
epidermal growth factor. The macronutrient composition of human
milk varies within mothers and across lactation but is remarkably
conserved across populations despite variations in maternal
nutritional status. The macronutrient composition of mature, term
milk is estimated to be approximately 0.9 to 1.2 g/dL for protein, 3.2
to 3.6 g/dL for fat, and 6.7 to 7.8 g/dL for lactose (Ballard et al,
2013).
The most abundant proteins are casein, -lactalbumin,
lactoferrin, secretory immunoglobulin IgA, lysozyme, and serum
albumin.Non-protein nitrogen-containing compounds, including urea,
uric acid, creatine, creatinine, amino acids, and nucleotides,
comprise ~25% of human milk nitrogen. And many micronutrients
vary in human milk depending on maternal diet and body stores
including vitamins A, B1, B2, B6, B12, D, and iodine. Also, Human
milk contains numerous growth factors that have wide-ranging
effects on the intestinal tract, vasculature, nervous system, and
endocrine system (Ballard et al, 2013).
Human milk is a dynamic, multi-faceted fluid containing
nutrients and bioactive factors needed for infant health and
development. Its composition varies by stage of lactation and
between term and preterm infants. While many studies of human
milk composition have been conducted, components of human milk
are still being identified. Standardized, multi-population studies of
human milk composition are sorely needed to create a rigorous,
comprehensive reference inclusive of nutrients and bioactive factors.
Nevertheless, knowledge of human milk composition is increasing,
leading to greater understanding of the role of human milk in infant
health and development (Ballard et al, 2013).

17
Benefits:
1. Lactose
As an energy-producing source, as a major carbohydrate, it
increases the absorption of calcium in the body, stimulating the
growth of lactobacilli bifidus.
2. Protein
Has a function for the regulator and builder of the baby's body.
3. Fat
Serves as a major heat / energy hazard, decrease the risk of heart
disease at a young age.
4. Vitamin A
Vitamins are very useful for the development of infant vision.
5. Iron
Substances that help the formation of blood to prevent the baby
from less blood or anemia.
6. Taurine
Neotransmitters are good for brain development of children.
7. Lactoferrin
Inhibits the development of candida and bacterial
staphylococcal fungi that harm the health of the baby.
8. Lisozyme

18
 Very useful to reduce dentis caries and malocclusion and can
break down the walls of harmful bacteria.
9. Colostrum
10. Important substances that contain many nutrients and substances
of the baby's body from disease attack.
11. AA and DHA
Substances obtained from changes in omega-3 and omega-6 that
work for fetal and infant brain development.

b. How long exclusive breastfeeding was given to a baby?

Answer:
Exclusive breastfeeding should given to a baby for 6
months long. Review of evidence has shown that, on a population
basis, exclusive breastfeeding for 6 months is the optimal way of
feeding infants. Thereafter infants should receive complementary
foods with continued breastfeeding up to 2 years of age or beyond.
Source: WHO,2017

c. What are the effects of breastfeeding not given exclusively?

Answer:

1. Short-term Infant Health Outcomes

a. Infection
Not breastfeeding significantly increases an infants risk of
illness from infectious diseases. For every additional month of
full breast- feeding, 30.1% of hospitalizations resulting from
infection could have been prevented. An estimated 53% of
diarrhea hospitaliza- tions and 27% of lower respiratory tract
infections could have been prevented monthly by exclusive
breastfeeding and 31% and 27% respectively by partial
breastfeeding.
b. Sudden infants Death syndrome
Not breastfeeding increases the chance of an infant dying

19
from sudden infant death syndrome (SIDS). In a 2009 German
study, exclusive breastfeeding at one month of age halved the
risk of SIDS, and partial breastfeeding at one month of age also
reduced the risk. Being exclusively breastfed in the last month
of life fur- ther reduced the risk of SIDS, as did being partially
breastfed
c. Mortality
Not breastfeeding significantly increases a childs risk of
dying in infancy. In both developed and developing countries,
breastfeed- ing and human milk protects against post-neonatal
death.In developing countries infants who are not breastfed
have higher rates of diarrhea and respiratory diseases, both of
which are main causes of infant death. A cohort case study in
Ghana found a marked dose response of increasing risk of
neonatal mortality with increasing delay in initiation of
breastfeeding from 1 hourto day 7.

d. Weight
Not breastfeeding increases a childs risk of being both
overweight and obese. The estimated percentage of 6-11
year old U.S. chil- dren considered to be obese has more
than quadrupled to 19% since 1960. Infants who have never
been breastfed are at higher risk for later childhood obesity
than infants who have ever been breastfed.
e. Temperature and Respiratory Regulation
Bottle feeding puts an infant at risk for physiological
instabil-ity. Oxygen saturation and body temperature
were found to be significantly lower in preterm infants who
were bottle fed versus those who were directly breastfed.
f. Necrotizing Enterocolitis
Not breastfeeding significantly increases an infants risk of
nec- rotizing enterocolitis (NEC). NEC occurs in 3-10% of

20
 VLBW infants and rarely in compromised term infants. It is
associated with an increased morbidity and mortality,
including growth and neurodevelopmental impairment,
infection and increased need for central line placement.
g. Pain
Not breastfeeding increases the infants response to pain.
An analysis of eleven studies demonstrates that both
breastfeeding and human milk are pain relieving. Neonates
who were swaddled or received a pacifier exhibited more
crying times (proportion and duration) and increased heart
rates when compared to breastfeed- ing infants. Pain scores
were significantly worse (more pain) for infants who were
not breastfeeding.

2. Long-term Infant Health Outcomes

a. Atopic Dermatitis
b. Asthma
c. Cognitive and Development disorder, etc

Source: (Spatz and Lessen, 2011)

d. How is the correlation between breastfeeding was given until 3

months of age with complaints?
Answer:
Exclusive breastfeeding for up to 6 months will provide
immunity to infants against various diseases. Asi contains sIgA, T
lymphocytes, B lymphocytes, and lactoferrin which can improve
immune status in infants. Infants who are not exclusively breastfed
for 6 months will be susceptible to infections and metabolism
disorder that cause diarrhea.

21
 e. What are the effects of the infant was given formula milk?
Answer:
We must restrict the formula milk feeding because it will bring
the Jellife triage that are diarrhea due to infection, moniliasis in the
mouth and marasmus. The situation is caused because the bottle is
less hygiene cleaned up, bottle milk tends to dilute, thus reducing the
nutritional value.

5. After her age was 4 months. She was given instant porridge as a
complementary feeding (MP ASI) 2 times a dat @1/2 sachet (1 sachet
is 80 kcal). She also was given cooked rice (tajin) 2-3 times a day @50
cc since her age was 4 months.
a. What is the meaning of she was given instant porridge as a
complementary feeding when she was 4 months?
Answer:
It means that breastfeeding was not given exclusively.
b. How to feed children by age?
Answer:
Pattern of giving the breast milk and complementary feeding;

Frequency and the amount of giving MP-ASI;

22
Example of Daily Menu;

Source: (Kemenkes, 2011)

23
c. How is the caloric needs based on age?
Answer:
Ideal weight: 8,5 kg
Caloric Needs:
Ideal Weight x RDA cased on height age= caloric needs
8,5x 100 =850 kkal

d. How are the compositions of instant porridge and cooked rice?

Answer:
Instant porridge composition
The nutrient content and quality of instant porridge that has been
qualified is energy (minimum 80 kcal / 100 g), ash (maximum
3.5%), protein (8-22%), zinc (minimum 2.5 mg / 100 g), Fe (at least
5 mg / 100 g), and protein digestibility (at least 70%). Meanwhile,
the content and quality of nutrients that have not fulfilled SNI are
water content (maximum 4%), fat content (6-15%), total dietary
fiber (maximum 5%), calcium (minimum 200 mg / 100 g), and total
plate number (maximum of 104 colonies / gram). The instant serving
quantity of instant porridge is 27 g which contains 22.25% protein,
55.25% iron, 27.63% zinc based on nutritional label (ALG) of
children aged 7-24 months so it can be claimed as food source of
protein and zinc and high in iron.
(Yustiani, 2013)

24
 Cooked rice water composition
It contains 7-10% protein, low calcium, glucose and other minerals.
(Silvia, 2010)

6. The mothers pregnancy and childbirth history:

Ana is the first child from a 24 years old mother. During pregnancy,
mother was healthy and pre natal care to a midwife 4 times. Ana was
delivered spontaneously at 37 weeks gestation. Immediately cried after
birthed, APGAR score 1st minute is 9 and the 5th minute is 10. Birth
weight was 2800 grams. Birth length was 49 cm. Head circumference
was 33 cm.
a. How is the interpretation and abnormal mechanism of mothers
pregnancy and childbirth history?
Answer:
- Normal age of pregnant women: 20 30 years old
In this case, her mother is 24 years old when she was pregnant
with Ana normal
- Normal gestasional age : 37 42 weeks
In this case, gestasional age was 37 weeks, cried after birth :
normal
APGAR score :
1st minute = 9 normal
5th minute = 10 normal
- Normal weight of newborn baby : 2500 4000 gram
In this case : 2800 gram normal
- Normal Lenght of newborn baby: 48 52 cm
In this case : 49 gram normal
- Normal head circumference of newborn baby:33 35 cm
In this case : 33 cm normal

25
 b. How to assess APGAR Score on newborns?
Answer:

Interpretation:
7-10 = Normal
4-6 = Mild
0-3 = Severe

7. Immunization History: BCG 1 time but DPT, polio, hepatitis dan

measles vaccines were never given.
a. How is the interpretation of immuunization history?
Answer:
Ana immuunization history is incomplete
b. What immunization should be given to a child?
Answer:

26
 IDAI, 2017
8. Growth history: image attachment of ANAs KMS

27
 a. How is the interpretation of growth history?
Answer:
At the age of 0-2 months the growth rate pattern follows the
normal growth curve (SD 0), on month 3 to month 9 growth rate

deviate Failure to thrive

b. What is the ideal pattern of normal child growth from KMS

drawing?
Child growth is said to be normal if it follows the normal
percentile curve of the KMS chart.
9. Development history: Ana can only sit with help
a. How is the interpretation of development history?
Answer:

Can only sit but with the help rough motoric development

disorder
10. Medication history: Ana was never got treatment
a. How is the interpretation of medication hisory?
Answer:
Anas parent never take ana to take a treatment may caused by many
factors; knowledge factor, socioeconomic factor and caring factor.
11. Physical Examination
General status: the child is not looking thin, round cheeks, pale,
apathetic, whiny, weight 5.5 kg, length 60 cm, head circumference 43
cm, upper arm circumference 12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
a. How is the interpretation of physical examination?
Answer:
Physical Examination Normal Interpretation
Not looking thin Not looking thin Normal
Round Cheeks Abnormal, Edema
Pale Abnormal
Apatis Compos mentis Loss of

28
 consciousness
Whiny Not Whiny Abnormal, more
often in
malnourished
children
Weight 5,5 kg 8,5 kg >-3 SD
Malnutrition
under percentil -
3
Length 71 cm Failed to grow
Head Circumference 45-48 cm Normal
45 cm
HR 112 x/menit 120-160 Normal
x/menit
RR 32 x/menit 20-60 x/menit Normal
37,50C 36,5-37,2oC Normal

b. How is the abnormal mechanism of physical examination?

Answer:

(Rabinowitz dkk, 2016)

29
12. Spesific Status
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and
groin
a. How is the interpretation of spesific status?
Answer:
Spesific Status Normal Interpretation
Round cheeks, easy recoked Tidak ada Clinic manifestation i
sheer yellowish red head hair, Kwashiokor patient
wistfull eyes, look and cry at the
examiner, abdomen bloated,
edema in four extremities and
dermatosis in the buttocks and
groin
No ribs (piano sign), no baggy Tidak ada edema Normal, Usually in marasmus
pants

30
 b. How is the abnormal mechanism of spesific status?
Answer:

13. Neurologicus status

- Normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes
a. How is the interpretation of neurologicus status?
Answer:
- Normal movements, motoric muscle strenght 4: normal, parese
- Normal physiological reflexes: normal

31
 - Normal clonus and tone: normal
- No uncontrollable movements: normal
- No pathological reflexes: normal

14. How to Diagnose?

Answer:
Anamnesis
Complaints are often found is less growth, thin children, or less weight.
In addition there are complaints of children less / do not want to eat,
often suffering from recurrent pain or swelling on both feet, sometimes
until the whole body.
Physical examination
1. Mental changes to apathy
2. Anemia
3. Changes in color and texture of hair, easily revoked / fall
4. Gastrointestinal system disorders
5. Enlarged heart
6. Skin changes (dermatosis)
7. Muscle atrophy
8. Symmetrical edema on both backs of the foot, can be up to the whole
body
Source:
(Pudjiadji et al, 2010) (Puone et al, 2001)

32
15. How is the differential diagnosis in this case?
Answer:

Marasmus-
Gejala Kasus Kwashiorkor Marasmus
kwashiorkor

Tampak kurus + - + -
Rambut tipis mudah
+ + + +
di lepas
Infeksi berulang + + + +
Iga gambang
+ - + +
Dan edema
Abdomen cekung + - + -
Baggy pants + - + -
Penurunan BB + + + -

16. How is the additional examination in this case?

Answer:
Required additional examination:
1. Laboratory examination: blood glucose, complete peripheral blood,
complete feces, serum electrolytes, serum protein (albumin, globulin),
ferritin. On laboratory examination, anemia is always found primarily
normocytic normocytic types due to eritropoesis system disorders due
to chronic bone marrow hypothlasia in addition to poor dietary intake
of iron, liver damage and impaired absorption. In addition can be
found decreased serum albumin levels 4.
2. Radiological examination (chest, AP and lateral) is also necessary to
find any abnormalities in the lung.
3. The mantoux test
4. EKG (Hidajat et al, 2011)

17. What is the working diagnosis in this case?

Answer:
Malnutrition (type Kwashiokor) + failed to thrive

33
18. What treatment should be given in this case?
Answer:

These steps are accomplished in two phases: an initial stabilisation phase

where the acute medical conditions are managed; and a longer
rehabilitation phase. Note that treatment procedures are similar for
marasmus and kwashiorkor. The approximate time-scale is given in the
box below:

1. Step 1 : Treat/prevent hypoglycaemia

Hypoglycaemia and hypothermia usually occur together and are

signs of infection. Check for hypoglycaemia whenever hypothermia
(axillary<35.0oC; rectal<35.5oC) is found. Frequent feeding is
important in preventing both conditions.

Treatment:

If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl

give:

a. 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded

teaspoon of sugar in 3.5 tablespoons water), orally or by
nasogastric (NG) tube. Then feed starter F-75 (see step 7) every
30 min. for two hours (giving one quarter of the two-hourly
feed each time)

34
 b. antibiotics (see step 5)
c. two-hourly feeds, day and night (see step 7)
If the child is unconscious, lethargic or convulsing give:
a. IV sterile 10% glucose (5ml/kg), followed by 50ml of 10%
glucose or sucrose by Ng tube. Then give starter F-75 as
above
b. antibiotics
c. two-hourly feeds, day and night

Monitor:

blood glucose, rectal temperature and level of consciousness: if this

deteriorates, repeat dextrostix

2. Step 2: Treat/ prevent hypothermia

Treatment:
If the axillary temperature is <35.0oC, take the rectal temperature
using a low reading thermometer.
If the rectal temperature is <35.5oC (<95.9oF):
a. Feed straightaway (or start rehydration if needed)
b. Rewarm the child: either clothe the child (including head), cover
with a warmed blanket and place a heater or lamp nearby (do
not use a hot water bottle), or put the child on the mothers bare
chest (skin to skin) and cover them
c. Give antibiotics (see step 5)
Monitor:
a. body temperature: during rewarming take rectal temperature
two- hourly until it rises to >36.5oC (take half-hourly if heater is
used)
b. ensure the child is covered at all times, especially at night
feel for warmth
c. blood glucose level: check for hypoglycaemia whenever
hypothermia is found

35
3. Step 3: Treatment/ Prevent dehydration
Treatment:
It is difficult to estimate dehydration status in a severely malnourished
child using clinical signs alone. So assume all children with watery
diarrhoea may have dehydration and give:
a. ReSoMal 5 ml/kg every 30 min. for two hours, orally or by
nasogastric tube, then
b. 5-10 ml/kg/h for next 4-10 hours: the exact amount to be given
should be determined by how much the child wants, and stool
loss and vomiting. Replace the ReSoMal doses at 4, 6, 8 and 10
hours with F-75 if rehydration is continuing at these times, then

c. continue feeding starter F-75 (see step 7) During treatment,
rapid respiration and pulse rates should slow down and the child
should begin to pass urine.

Monitor progress of rehydration:Observe half-hourly for two

hours, then hourly for the next 6-12 hours, recording: pulse rate,
respiratory rate ,urine frequency ,stool/vomit frequency

4. Step 4: Corect Electrolite imbalance

Give:
a. Extra potassium 3-4 mmol/kg/d
b. Extra magnesium 0.4-0.6 mmol/kg/d
c. When rehydrating, give low sodium rehydration fluid (e.g.
Resomal)
d. Prepare food without salt
5. Step 5:Treat/prevent infection
In severe malnutrition the usual signs of infection, such as fever, are often
absent, and infections are often hidden.Therefore give routinely on
admission:
a. broad-spectrum antibiotic(s) AND
b. measles vaccine if child is > 6m and not immunised (delay if the
child is in shock)

36
6. Step 6: Correct micronutrient deficiencies
Give:
Vitamin A orally on Day 1 (for age >12 months, give 200,000 IU; for
age 6-12 months, give 100,000 IU; for age 0-5 months, give 50,000
IU) unless there is definite evidence that a dose has been given in the
last month

Give daily for at least 2 weeks:

a. Multivitamin supplement
b. Folic acid 1 mg/d (give 5 mg on Day 1)
c. Zinc 2 mg/kg/d
d. Copper 0.3 mg/kg/d
e. Iron 3 mg/kg/d but only when gaining weight
7. Step 7: Start caution feeding
The essential features of feeding in the stabilisation phase are:
a. small, frequent feeds of low osmolarity and low lactose
b. oral or nasogastric (NG) feeds (never parenteral preparations)
c. 100 kcal/kg/d
d. 1-1.5 g protein/kg/d
e. 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema)

f. if the child is breastfed, encourage to continue breastfeeding but
give the prescribed amounts of starter formula to make sure the
childs needs are met.
8. Step 8: Achieve catch-up growth
9. Step 9 : Provide sensory stimulation and emotional support
severe malnutrition there is delayed mental and behavioural
development.
Provide:
a. tender loving care
b. a cheerful, stimulating environment

37
 c. structured play therapy 15-30 min/d (Appendix 10 provides
examples)
d. physical activity as soon as the child is well enough
e. maternal involvement when possible (e.g. comforting, feeding,
bathing, play)
10. Step 10: Prepare for follow-up after recovery
Good feeding practices and sensory stimulation should be continued at
home. Show parent or carer how to:
a. feed frequently with energy- and nutrient-dense foods
b. give structured play therapy
Advise parent or carer to:
a. bring child back for regular follow-up checks
b. ensure booster immunizations are given
c. ensure vitamin A is given every six months

Source: (Ashworth et al, 2003)

19. What is the complication in this case?

Answer:
Children with kwashiorkor will be more susceptible to infection due
to weakness of the immune system. The maximum height and potential
growth will never be achieved by a child with a history of kwashiorkor.
The statistical evidence suggests that kwashiorkor that occurs early in life
(infants and children) can decrease IQ permanently. Another
complication that can be generated from kwashiorkor is :
1. Iron deficiency
2. Hyperpigmentation of the skin
3. Anacaral edema
4. Immunity decreases so easily infection
5. Diarrhea due to atrophy of the intestinal epithelium
6. Hypoglycemia, hypomagnesemia

38
 Refeeding syndrome is one of the metabolic complications of
nutritional support in severe malnourished patients characterized by
hypophosphatemia, hypokalemia, and hypomagnesemia. This occurs as a
result of changes in the main energy source of the body's metabolism,
from fat at the time of starvation to carbonhydrate given as part of
nutritional support, resulting in an increase in insulin levels and the
electrolyte displacement required for intracellular metabolism. Clinically
patients may develop dysrhythmias, heart failure, acute respiratory
failure, coma paralysis, nephropathy, and liver dysfunction. Therefore, in
the provision of nutritional support in patients with severe malnutrition
needs to be given gradually
(Pudjiadi et al, 2010)
20. What is the medical doctor compentences in this case?
Answer:
4A
Ability level 4. Doctor graduates are able to make a clinical diagnosis
and manage the disease independently and thoroughly.
21. What is the prognosis in this case?
Answer:
Quo ad vitam: dubia ad bonam
Quo ad functionam: Dubia ad malam
22. NNI
Right to get breastfeeding exclusively
Al-Baqarah: 233

39
 Mothers may breastfeed their children two complete years for
whoever wishes to complete the nursing [period]. Upon the
father is the mothers' provision and their clothing according to
what is acceptable. No person is charged with more than his
capacity. No mother should be harmed through her child, and no
father through his child. And upon the [father's] heir is [a duty]
like that [of the father]. And if they both desire weaning through
mutual consent from both of them and consultation, there is no
blame upon either of them. And if you wish to have your children
nursed by a substitute, there is no blame upon you as long as you
give payment according to what is acceptable. And fear Allah and
know that Allah is Seeing of what you do.

2.6 Hypothesis
Ana, a 10 months old girl, experiencing malnutrition type kwashiokor+
failure to thrive et causa Breastfeeding is not given exclusively dan recurrent
diarrhea.

2.7 Conceptual framework

Breastfeeding is not given exclusively

Lactosa intolerance

Recurrent diarrhea

Malnutrition (Kwashiokor)

growth + development disrupted

failure to thrive

40
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