CHAPTER I

INTRODUCTION

1.1 Background
Digestive system are the eleventh block in the 4th semester
competency-based curriculum in medical faculty of Muhammadiyah Palembang
University . Learning in this block is very important to learn in medical faculty
of Muhammadiyah Palembang University.
On this occasion, a case study tutorial of scenario A which presents cases
that related to the Digestive System .
Diwan, a 2 years old, came to the hospital with chief complaints of fluid
defecating since 4 days ago. Frequency of defecation are 3-4 times a day,
consistency of feces more liquid than pulp, as much as ¼ cup, yellowish color, no
blood and mucus in the feces. He had experienced fever. He also suffers nausea
and vomiting with frequency 1-2 times a day, as much as ¼ cup, contain with his
consumed, and not expulsion. He began lethargic but still want to drink. Last
urinate was 4 hours ago.
Physical Examination:
General Condition : moderate illness; weight 11 kg, height 8 cm
Vital signs : compos mentis; pulse rate 140x/min; respiratory rate 32x/min;
temperature 36.4ᵒC
Specific Condition
Head : close forehead, sunken eyes, no tears, wet mouth mucous
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, hepar and lien are not palpable, decreases turgor
pressure
Extremities : palms and soles are warm.
Laboratory Examination
Hb: 12 g/dl, WBC 6,000/mm3, differential count 0/1/2/45/48/4.
Routine examination of the feces:
Macroscopic: more liquid than pulp, blood (-), pus (-), mucous (-),
yellowish color.

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 Leucocyte feces: 1-2/hpf, erythrocytes: 0-1/hpf, bacteria (-), hyfa (-)

1.2 Purpose
the purpose of this case study tutorial report are:
1. As a group task report which is a competency-based curriculum learning
system in the medical faculty of Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning methods
3. The purpose of the tutorial learning method is reached

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. Ratika Febriani.
Moderator : Muthia Khairunnisa
Desk Secretary : Desty Ariani
Bord Secretary : Muhammad Raflie Ghifarie
Time : Monday, March 19th 2018
(13.00 – 15.30 p.m)
Wednesday, March 21st 2018
(13.00 – 15.30 p.m)

The Rule of Tutorial : 1. Deactivate the phone or condition the phone in

silence.
2. Raise your hand when going to argument.
3. Get permission when going out of the room.
4. It is prohibited to bring food or eat in the room
during the discussion process is in progress.

2.2 Scenario A
“When Feces in Trouble”

Diwan, A 2 years old, is bought by his mother to puskesmas with chief complaints of
fluid defecating since 4 days ago. Frequency of defecation are 3-4 times a day,
consistency of feces more liquid than pulp, as much as 1/4 cup, yellowish color,
nblood and mucus in the feces. He had experienced fever. He also sufferes nausea and
vomitting with frequency 1-2 times a day, as much as 1/4 cup, contain what his
consumed, and not explusion. He began lethargic but still want to drink. Last urinate
was 4 hours ago.

Physical Examination:
General Condition : moderate illness; weight 11 kg, height 8 cm
Vital signs : compos mentis; pulse rate 140x/min; respiratory rate 32x/min;
temperature 36.4ᵒC

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 Specific Condition
Head : close forehead, sunken eyes, no tears, wet mouth mucous
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, hepar and lien are not palpable, decreases turgor
pressure
Extremities : palms and soles are warm.
Laboratory Examination
Hb: 12 g/dl, WBC 6,000/mm3, differential count 0/1/2/45/48/4.
Routine examination of the feces:
Macroscopic: more liquid than pulp, blood (-), pus (-), mucous (-),
yellowish color.
Leucocyte feces: 1-2/hpf, erythrocytes: 0-1/hpf, bacteria (-), hyfa (-)

2.3 Terms of Clarfication

No Clarifications Meaning
The chance of fesses consistention being
1 Fluid defecating
fluid (Dorland, 2010).
1
The pressure produced by a solution against
the semipermeable membrane enclosing the
2 Turgor cell due to osmotic pressure differences
between the inside and outside of the cell
(Dorland, 2010)

Free mucus in the membran mucus, consist

3 Mucous of glandula secretion salt descamation cell
and leucocyte (Dorland, 2010)

Sensation of unease and discomfort in the

4 Nausea upper stomach with an involuntary urge to
vomit. (Dorland, 2010).
Ejecting all of the contents of the stomach
5 Vomiting
through the mouth (Dorland, 2010).
State of tiredness wearingness fatigue or leck
6 Lethargic
it can be compained by depretion decrease

4
 motivation or apthy (Dorland, 2010).
The appearence of the person that have a
sign a hollowing under the eyes, dark
7 Sunken eyes
shadow over the lower eyelid, dark circles
underness be eyes.(Dorland, 2010).

2.2 Problem Identification

1. Diwan, a 2 years old, came to the hospital with chief complaints of fluid
defecating since 4 days ago. Frequency of defecation are 3-4 times a day,
consistency of feces more liquid than pulp, as much as ¼ cup, yellowish
color, no blood and mucus in the feces.
2. He had experienced fever. He also suffers nausea and vomiting with
frequency 1-2 times a day, as much as ¼ cup, contain with his consumed,
and not expulsion. He began lethargic but still want to drink. Last urinate
was 4 hours ago.
3. Physical Examination:
General Condition : moderate illness; weight 11 kg, height 8 cm
Vital signs : compos mentis; pulse rate 140x/min; respiratory rate
32x/min; temperature 36.4ᵒC
Specific Condition
Head : close forehead, sunken eyes, no tears, wet mouth
mucous
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, hepar and lien are not palpable, decreases
turgor pressure
Extremities : palms and soles are warm.
4. Laboratory Examination
Hb : 12 g/dl, WBC 6,000/mm3, differential count 0/1/2/45/48/4.

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 5. Routine Examination of the feces.
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-),
yellowish color
Leucocyte feces : 1-2/hpf, erythrocytes: 0-1/hpf, bacteria (-), hyfa (-)

2.4 Priority Issue

Number 1, Because if not immediately managed, will cause the patient’s condition
worse.

2.5 Problems Analysis

1. Diwan, A 2 years old, is bought by his mother to puskesmas with chief
complaints of fluid defecating since 4 days ago. Frequency of defecation are
3-4 times a day, consistency of feces more liquid than pulp, as much as
1/4 cup, yellowish color, nblood and mucus in the feces.
a. What is the anatomy and physiology in this case?

Answer :

The digestive system or the gastroinstestinal system (from the mouth to

the anus) is the system the internal organs that function to receive food,
digest it into nutrients and energy, absorb nutrients into the bloodstream and
dispose of parts of the food that can not be digested or the rest of the process
from the body.

The digestive tract consists of the mouth, throat (pharynx), esophagus,

stomach, small intestine, colon, rectum and anus. The digestive system also
includes organs located outside the gastrointestinal tract, the pancreas, the
liver and the gallbladder.

Mouth

The inside of the mouth is covered by mucous membranes. The tasting is felt
by the taste organ found on the surface of the tongue. The tasting is
relatively simple, consisting of sweet, sour, salty and bitter. Smell is felt by
the olfactory nerves in the nose and more complicated, consisting of various
odors.

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Food is cut by the front teeth (incisivus) and chewed by the back teeth
(molar, molars), into small parts that are more easily digested. Saliva from
the salivary glands will wrap parts of the food with digestive enzymes and
start digesting them. Saliva also contains antibodies and enzymes (eg
lysozyme), which break down proteins and attack bacteria directly.
Swallowing process starts consciously and continues automatically.

Throat (Faring)

It is the link between the oral cavity and the esophagus. A native of Pharynk.
In the curve of the pharynx there are tonsils (tonsils) lymph glands that
contain many lymphocytes gland and is a defense against infection, here lies
in the intersection between the airway and road food, located behind the oral
cavity and nasal cavity, in front of the vertebrae

Upward the front corresponds to the nasal cavity, by means of a hole called
koana, the physique is associated with the oral cavity by the mediation of a
hole called ismus fausium

The heap consists of; The superior part = the very high part with the nose,
the media part = the same height with the mouth and the inferior part = the
same height with the larynx.

The superior part is called the nasopharynx, the nasopharynx of the tube that
connects the throat with the eardrum space, the media part is called the
oropharynx, this section of the forehead until the inferior tongue root is
called the laryngeal gofaring that connects the oropharynx with the larynx

Esophagus

The esophagus is a tube (tube) muscled in the vertebrates passed when food
flows from the mouth into the stomach. Food runs through the esophagus
using peristalsis. Often also called esophagus (from Greek: οσωσω, oeso -
"bring", and έφαγον, phagus - "eat").

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The esophagus meets the pharynx of the 6th spine. According to histology.
The esophagus is divided into three parts:

a. superior parts (mostly skeletal muscle)

b. the middle (a mixture of skeletal muscle and smooth muscle)

c. as well as the inferior part (mainly consisting of smooth muscle).

Stomach

Food enters the stomach from the esophagus through a ring-shaped muscle
(sfinter), which can open and close. Under normal circumstances, the sfinter
precludes re-entry of the stomach contents into the esophagus.

The stomach serves as a food storehouse, which contracts rhythmically to

mix food with enzymes. The cells that line the stomach produce three
important substances:

• Mucus

Mucus protects the stomach cells from damage by stomach acid. Any
abnormalities in this mucous layer, can cause damage that leads to the
formation of peptic ulcers.

• Hydrochloric acid (HCl)

Hydrochloric acid creates a very acidic atmosphere, which is needed by

pepsin to break down proteins. High acidity of the stomach also acts as a
barrier against infection by killing various bacteria.

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• Precursor pepsin (enzyme that solve protein)

(Adam, 2008)

Intestinum Tenue (Small Intestine)

Intestinal wall is rich in blood vessels that transport substances that are
absorbed into the liver through the portal vein. The intestinal wall releases
mucus (which lubricates intestinal contents) and water (which helps dissolve
fragments of digested food). The intestinal wall also releases small amounts
of enzymes that digest proteins, sugars and fats.

Lining of the small intestine; the mucosal layer (inside), the circular muscle
layer circular (M circular), longitudinal muscle layer (Longitidinal M) and
serosa layer (Outside) al membranes. Normal twelve pH intestines ranged in
degree nine. In the gut of twelve fingers there are two estuarine channels of
the pancreas and gallbladder.

1. Duodenum

The name duodenum comes from the Latinduodenum digitorum, which

means twelve fingers. The stomach releases food into the duodenum, which
is the first part of the small intestine. The food enters the duodenum through
the pyloric sphincter in an amount that the intestine can digest. If full, the
duodenum will send a signal to the stomach to stop flowing food.

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2. Jejunum

Jejunum is the second part of the small intestine, between the duodenum and
intestine (ileum). In adult humans, the length of the entire small intestine
between 2-8 meters, 1-2 meters is part of the empty intestine. The empty
intestine and intestinal tract are suspended in the body with mesentery.

The surface in the empty intestine is a mucous membrane and there are
intestinal (villi), which extend the surface of the intestine. Histologically
distinguishable from the twelve-finger intestine, ie, the loss of Brunner's
glands. Hypologically also can be distinguished from intestinal absorption, ie
at least goblet cell and Peyeri plaque. It is a little difficult to distinguish the
gut absorption and macroscopic absorption.

3.Ileum

Ileum is the last part of Small Intestine (intestinum tenue) . At the digestive
system of human, the length is around 2-4m and the location is after the
duodenum and jejunum. pH in ileum is around 7 – 8 (netral or a little bit
base) and the function is to absorb b12 vitamin.

(Adam, 2008)

Intestinum Crassum

The large intestine or colon in the anatomy is the part of the intestine between
the appendix and the rectum. The main function of this organ is to absorb

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water from feces. The amount of bacteria present in the large intestine serves
to digest some of the ingredients and helps the absorption of nutrients.

Bacteria in the colon also function to make important substances, such as

vitamin K. These bacteria are important for normal function of the intestine.
Some diseases and antibiotics can cause disruption of bacteria in the colon.
The result is irritation that can lead to the release of mucus and water, and
there is diarrhea.

(Adam, 2008)

Caecum (appendix)

The appendix or cecum (Latin: caecus, "blind") in anatomical terms is a sac

connected to the intestinal absorption as well as the upward colonic part of
the colon. Appendix Vermiformis (Umbai worm) Umbai worm or appendix
is an additional organ in the appendix. The infection of this organ is called
appendicitis or inflammation of the worms uk. Severe appendicitis can cause
the appendix to rupture and form pus in the abdominal cavity or peritonitis
(infection of the abdominal cavity

Rectum and Anus

is a room that starts from the end of the large intestine (after the sigmoid
colon) and ends in the anus. This organ serves as a temporary storage place of
feces. Usually this rectum is empty because feces is stored in a higher place,
that is in the descending colon. If the descending colon is full and the stool
enters the rectum, then there is a desire to defecate. The expansion of the

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rectum wall due to the accumulation of material in the rectum will trigger the
nervous system that causes the desire to defecate. If defecation does not occur,
often the material will be returned to the colon, where the water absorption
will be re-done. If defecation does not occur for prolonged periods,
constipation and hardening of the stool will occur. Adults and older children
can withstand this desire, but younger infants and children experience a lack
of muscle control that is important for delaying bowel movements. Anus is a
hole in the end of the gastrointestinal tract, where waste material comes out of
the body. Some of the anus is formed from the surface of the body (skin). The
opening and closing of the anus is regulated by the sphincter muscle. Feces are
discharged from the body through a defecation process), which is the main
function of the anus.

Pancreas

Pancreas is an organ in the digestive system that has two main functions that
produce digestive enzyme as well as some important hormones such as
insulin. The pancreas is located on the posterior abdomen and is closely
related to the duodenum (the twelve-finger gut). Pancreas consists of 2 basic
tissues:

• Asini, produces digestive enzymes

• Island of pancreas, produces hormones

Pancreas releases digestive enzymes into the duodenum and releases

hormones into the blood. Enzymes released by the pancreas will digest
proteins, carbohydrates and fats. The proteolytic enzyme breaks down the
protein into a form that the body can use and released in its inactive form.
This enzyme will only be active if it has reached the digestive tract. The
pancreas also releases large amounts of sodium bicarbonate, which serves to
protect the duodenum by neutralizing stomach acid.

Liver

The liver is the largest organ in the human body and has many functions, some
of which are related to digestion. This organ plays an important role in

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 metabolism and has several functions in the body including glycogen storage,
plasma protein synthesis, and drug neutralization. He also produces bile,
which is important in digestion. The medical term concerned with the liver
usually begins in hepat- or hepatic from the Greek word for the liver, the liver.
Nutrients from food are absorbed into the intestinal wall that is rich in small
blood vessels (capillaries). This capillary drains blood into the vein that joins
the larger vein and eventually enters the liver as a portal vein. Portal vein is
divided into small vessels in the liver, where the incoming blood is processed.
The liver performs the process at high speed, once the blood is enriched with
nutrients, blood is passed into the general circulation.

Gallbladder (gallbladder)

Gallbladder is a pear-shaped organ that can store about 50 ml of bile the

body needs for the digestive process. In humans, the length of the
gallbladder is about 7-10 cm and dark green - not because of the color of the
tissue, but because of the color of the bile it contains. This organ is
connected to the liver and the intestine of twelve fingers through the bile
ducts.
(Sherwood, 2014)

b. What is physiology of food absorbtion ?

Answer :

1) Ingestion : taking in food the mouth

2) Propulsion :

-Swallowing

- Peristaltic

- Propulsion by alternate contraction and relaxation

3) Mechanical digestion

- Chewing

- Churning in stomach

- Mixing by segmentation

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 4) Chemical digestion

- By secreted enzyme

5) Absorption

- Transport of degested end products into blood and lymph in wall of

canal

6) Defecation

- Elimination of indigestible substamces from body as feces

(Sherwood, 2014)

c. What is the relation of between age and gender in this case?

Answer :

Age
When viewed per age group of diarrhea spread across all age groups with the highest
prevalence detected in children under five (1-4years old) is 16,7%. Meanwhile,
according to gender of male and female prevalence is almost same, that is 8,9% in
men and 9,1% in woman. This is because of the immune system of childrens was
still low, so its easily to get infection by bacteria, viruses or others microorganism.
(Guandalini, 2016)

Gender

In some studies, more frequently in boys than girls. This may be due poor
hygiene and boys more exposure to the outside world than girls. But in other
studies said that there were no significant differences between boys and
girls.
(Manoppo, 2010)

d. What is the meaning Diwan complained of fluid defecation since 4 days

ago?

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 Answer :

Diwan complained of fluid defecation since 4 days ago is acute dyarrhea

(Sudoyo, 2014)

e. What is the etiology fluid defecation?

Answer :

Enteral
a. Bacterial infections: Vibrio, E. coli, Salmonella, Shigella,
Campylobacter, Yersinia, Aeromonas and so on.
b.Viral Infections: Enterovirus (ECHO Virus, Coxsackie, Poliomyelitis),
Adenovirus, Rotavirus, Astrovirus and others.
c. Parasitic Infection: Worms (Ascaris, Trichiuris, Oxyuris,
Strongyloides), Protozoa (Entamoeba histolytica, Giardia Lamblia,
Tricomonas Hominis), Mushrooms (Candida Albicands).
(Mandal, 2008)

Parenteral
Parenteral infection is infection of other body parts outside the digestive
ract, such as Acute Otitis Media (OMA), Tonsilofangitis,
Bronkopnemonia, Ensefaliti and so on.

Malabsorpstion factor
a. Carbohydrate malabsorption: Disaccharide (lactose intolerance, maltose
and sucrose), Monosaccharide (Glucose Intolerance, Fructose and
Galactose). In infants and children the most important and the most
common is lactose intolerance.
b. Fat Malabsorption
c. Malabsorption of Protein

Food factors

15
 The suddenly changed food and poisonous, stale, and food. allergic to
food. And lack of cleanliness when consuming food
(Marcellus, 2015)

f. What is the patophysiology of fluid defection?

Answer :

Invasion of microorganism → entering the GI tract → infecting the

ephitelium ceel of small intestine → multiples in mature enterocyte →
replaced by enterosite immature and intestinal villous distract become
shorter and crypt hypertrophy → absorption function inadequate →
interference osmotic pressure in intestinal → secretion increase → fluid
defecation
(Sintamurniwaty, 2006)

g. What is the impact of fluid defecation since 4 days ago?

Answer :

The impact of fluid defecation since 4 days ago is dehydration, because of

excess fluid.

(Price and wilson, 2012)

h. What is the meaning of fluid defecation are 3-4 times a day, consistency
of feces more liquid than pulp, as much as 1/4 cup, yellowish color, no
blood and mucus in the feces?

Answer :

The meaning of fluid defecation are 3-4 times a day consistency of feces more
liquid than pulp as much as ¼ cup means gastroenteritis, gastroenteritis is
defined as defeate with shapeless feces or liquid with frequency bmore than 3
times in 24 hours. Yellowish color means that the gastroenteritis its not
caused by kolera because the typical cholera symptoms begin with the
emergence of watery and abundant diarrhea, in a short time the stools that
originally colored and smelled feces turned into a turbid white liquid that

16
 resembles rice laundry water. No blood and mucus means gastroenteritis not
because bactery.

(Amin, L, Z. 2015)

i. What is the characteristic of feces and normal frequency defecation?

Answer :

 Characteristic
Normal Abnormal
Color Yellow - Brown Clay/white (absence of bille pigment )
Black/ Tarry (drug e.g. iron. Bleeding
from upper gastrointestinal tract. Diet high
red meat and dark green vegetables)
Red (bleeding from lower gastrointestinal
tract)
Pale (malabsorption of fats, dieth igh in
milk)
Consistency Formed, soft, Hard, dry, constipated stool.
semisolid, moist. Diarrhea
Shape Cylindrical about 1 Narrow, pencil shaped, string like stool
inch in diameter in
adult
Odor Aromatic, affected by Pungent
ingestion food
Constituents Small amount of Pus
undigested roughage, Mucus
dead bacteria, Parasites
epithelial cells, fat, Blood
protein, dried
constituents of
digestive juice,
inorganic matter.

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  Frequency: 1-2 times for a day.
(Nelson, 2014)

2. He had experienced fever. He also suffers nausea and vomiting with

frequency 1-2 times a day, as much as ¼ cup, contain with his consumed,
and not expulsion. He began lethargic but still want to drink. Last urinate
was 4 hours ago.

a. What is the the grade of dehydration?

Answer :

Grade of Dehydration according to WHO (2009):

Signs / Symptoms Not Dehydration Dehydration

Dehydrated Not Weight Weight
1. Good / Restless Unconscious G
general Condition ordinary
2. Ordinary Seemed Unable L
lust Drinking thirsty
3. (+) (++) (+++) S
sunken eyes
4. (+) (-) (-) T
tears
5. (-) (+) (++) D
dry Mouth
6. <1 1-2 second >2 second T
turgor skin second

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b. What is the relation fever, nausea, vomiting with fluid defecation?

Answer :

The relation about fever, nausea, vomiting with fluid defecation is infected
by virus that infecting a stomach and be inflammation, the process
stimulate to fever, nausea and vomiting.

(Sherwood, 2014)

c. What is the patophysiology of fever, nausea, vomiting?

Answer :

Viral transmission through oral fecal causes viral infections to infect the
gastrointestinal tract -> will multiply by spreading through intracellular as
well intersel -> releases exotoxins in the form of cytotoxic effects invade the
intestinal mucosa infiltrate inflammatory cells-> mediator inflamsasi
IL-1 -> this cytokine will circulate and will stimulate acid arachidonic
->arachidonic acid is what will stimulate the formation of prostaglandins ->
prostaglandins which causes the setting of the thermostat set point in the
hypothalamus -> so the temperature is now higher than the temperature of
his body and it increase (fever)

(Sherwood, 2014)

The presence of Invasion of the virus so that the virus enters the upper
gastrointestinal tract -> some viruses are deactivated in the stomach by
stomach acid and some will be distal -> the virus infects the epithelium layer
in the small intestine -> viruses enter and multiplying in a mature enterocyte at
the end of the proximal small intestinal villi thus spreading to the distal
intestine-> within 48 hours of incubation and destruction of enterocytes in
the intestinal villus -> the broken enterosit is replaced by the new
enterocytes -> which formkuboid imatur, vilus have atrophy -> obstruct
function so that absorption disorders (can not absorb well) fluids and
nutrientscan not be absorbed -> lumen in full intestinum tenue -> occurs

19
 intestinal tenue causes the sensory receptors in the intestinal tunes to transmit
sensory signals of vomiting to the vomiting center -> in the medulla oblongata
through the afferent nerve of the vagal and the sympathetic nerves ->
stimulation of the vomiting center results -> deep inspiration and closure of
the glottis and diaphragm contraction pressed down into the stomach ->
contraction of the abdominal muscles suppressing the abdominal cavity -> the
abdomen moving upwards causing the hardened hull to cause the contents of
the stomach pushed upward -> the sphincters causing the glottis to close, the
uvula raises food comes out through the mouth and occurs nausea vomiting.

(Guyton, 2008)

d. What is the meaning from nausea and vomiting with frequency 1-2 times
a day, as much as 1/4 cup, contain what his consumed, and not expulsion?

Answer :

The meaning of the complaint is not due to intestinal obstruction, CNS

abnormalities, lower esophageal sphincter hypothony, abnormal position of
esophageal connections with cardiac and gastric emptying of solid contents.
In the disease usually occurs projectile vomiting (spray strongly)

(Sudoyo, 2014)

e. What is the type of dyarrhea?

Answer :

Classification based on its duration:

a. Acute diarrhea
Acute diarrhea is diarrhea occurring at any time, lasting less than 14
days, with the release of soft or liquid stools that can or without mucus
and blood

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 b. Persistent dyarrhea
Persistent diarrhea is diarrhea lasting 15-30 days, a continuation of
acute dyarrhea or a transition between acute and chronic diarrhea.

c. Chronic diarrhea
Chronic diarrhea is diarrhea, 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.
Based on the duration, Diwan experienced acute dyarrhea because it is
still less than 14 days

Classification by caused:

a. Osmotic Diarrhea
Osmotic diarrhea is diarrhea caused by osmotic ingredients, ie certain
foods that can not be transported by the blood and left in the intestine.
Some examples of osmotic materials are hexitol, sorbitol, and mannitol.
Another cause of osmotic diarrhea is lack of lactase enzymes. Lactase
enzyme is an enzyme produced in the small intestine. This enzyme
works to convert lactose (gut sugar) to glucose and galactose, so it can be
absorbed by the blood. If a person lacking lactase enzymes
consumes milk or dairy products then lactose will accumulate in
the small intestine resulting in osmotic diarrhea.
b. Secretory Diarrhea
Secretory diarrhea occurs when the small intestine and colon secrete salt
compounds (especially sodium chloride) and water into the feces.
Excessive secretion of salt and water can be caused by various factors,
such as the presence of toxins, castor oil, or bile acids in the intestine. In
addition, secretory diarrhea can also be caused by the presence of certain
tumors, such as carcinoids, gastrinomas, and vipomas

c. Malabsorption Syndrome
Malabsorption syndrome is a disorder absorption of food juices in the
small intestine. Patients with this disorder usually can not digest food
normally. In the event of complete malabsorption syndrome, fats and
carbohydrates can not be absorbed properly. The fat left in the colon may

21
 result in secretory diarrhea, whereas the carbohydrates left in the colon
may result in osmotic diarrhea.
d. Extramatic diarrhea
Exudative diarrhea is diarrhea caused by inflammation or formation of
ulcers in the colon. This inflammation or ulcers can trigger the release of
proteins, blood, mucus, and other fluids that can increase the fiber
content in the feces and make the feces become watery. Exudative
diarrhea is usually triggered by other types of diseases, such as
tuberculosis, lymphoma, cancer, Chorn disease, and ulcerative colitis.
e. Diarrhea Due to Amendment of the Intestine
If too quickly leave the colon, the feces become very dilute. Conversely,
the stool will become very hard and dry if too long in the colon.
The alteration of the intestine (passage) part of the intestine causes the
stool to leave the colon too soon, so the feces becomes very dilute.
Some things that can shorten the presence of feces in the colon include
hyperthyroid, partial removal of the small intestine or colon, abdominal
surgery, ulcer treatment by cutting the vagus nerve, and the consumption
of laxatives.

(Abdoerrachman, dkk. 2007)

f. What is the etiology dehydration?

Answer :

Some of the pathological factors that cause dehydration are often:

• Gastroenteritis
Diarrhea is the most frequent etiology. In diarrhea accompanied by
vomiting, dehydration will be progressive. Dehydration because diarrhea
is the leading cause of infant and child mortality in the world.
• Stomatitis and pharyngitis
The pain of the mouth and throat can limit the intake of food and drink by
mouth.
• Diabetic ketoacidosis (KAD)

22
 KAD is caused by osmotic diuresis. Weight loss due to fluid loss and
tissue catabolism.
• Fever
Fever can increase IWL and decrease appetite. In addition to the above,
dehydration can also be triggered by conditions of heat stroke,
thyrotoxicosis, gastrointestinal obstruction, cystic fibrosis, diabetes
insipidus, and burns

Patients with liquid diarrhea secrete stools containing a number of sodium,

chloride, and bicarbonate ions. This loss of water and electrolytes increases
when there is vomiting and water loss also increases when there is heat. It
can cause dehydration, metabolic acidosis, and hypovolemia. Dehydration is
the most dangerous condition because it can cause hypovolaemia,
cardiovascular collapse and death if not treated appropriately. Dehydration
that occurs by plasma tonisitas can be isotonic dehydration, hypertonic
dehydration (hipernatremik) or hypotonic dehydration. According to the
degree of dehydration it can be without dehydration, mild dehydration,
moderate dehydration or severe dehydration
(Juffrie, 2010)

g. What is the meaning he began lethargic but still want to drink?

Answer :

The meaning he began lethargic but still want to drink he has moderate
dehydration

(Guyton, 2007)

h. What is the meaning of last urinate was 4 hours ago?

Answer :

23
 The meaning of ;ast urinate was 4 hours ago is that patient get a Moderate
Dehydration, which is the dehydration make fluid intake was decrease, so
intestinal absorbtion was decrease and the result is output (urinate) was
decrease too.

(Guyton, 2007)

3. Physical Examination
General Condition : moderate illness; weight 11 kg, height 8 cm
Vital signs : compos mentis; pulse rate 140x/min; respiratory
rate 32x/min; temperature 36.4ᵒC
Specific Condition
Head : close forehead, sunken eyes, no tears, wet mouth mucous
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, hepar and lien are not palpable, decreases
turgor pressure
Extremities : palms and soles are warm.

a. How is interpretation of physical examination and specific condition?

Answer :

Examination Normal Interpretation

General Condition : Child: 11-16 gr / dl
Normal
moderate illness Below 3 years old : 9-15 gr /
weight 11 kg, height Below 5 dl
years old : Normal
84 cm. 5000-18.000 cells / mm3
Compos Mentis Compos Mentis Normal
Neonates 100-180
1 week - 3 months 100-200
PR : 140 times per
3 months - 2 years 80-150 Normal
minute, regular
2 yrs - 10 yrs 70-110
> 10 yrs 55-90
RR : 32 times per
< 1 years old : 30-40
minute Normal
2-5 years old : 20-30

Temp : 36.4◦C. <36◦C: hypothermia Normal

24
 36.5-37,5◦C: Normal
37.5-40◦C: febrile
≥40◦C: hyperthermic
Head : closed
Closed Forehead
Normal
forehead, sunken No sunken eyes
Abnormal
No tears
eyes, no tears, wet Abnormal
Wet mouth mucous
Normal
mouth mucous.

Thorax :
symmetrical,
Thorax : symmetrical,
retraction (-)
retraction (-)
Cor : S1-SII
Cor : S1-SII normal, no
normal, no heart
heart noisy Normal
noisy
Lung : vesicular,
Lung : vesicular,
wheezing (-), ronki (-)
wheezing (-),
ronki (-)

Abdomen : flat,
increased bowel
sounds, liver and
no increased bowel
lien are not
sounds, Abnormal
palpable,
decreases turgor
pressure

Extremities :
palms and soles
Palms and soles are warm Normal
are warm

b. How is abnormal mechanism of physical examination and specific

condition?

25
 Answer :
- Moderate illness
The presence of vomiting and fluid defecating cause the body fluids
decreased, resulting in disruption of fluid balance. This fluid balance
disorder causes the blood volume to decrease and the oxygen
distribution decreases, causing moderate illness and weakening pulse
quality.

- Sunken Eyelid, No Tears & Turgor Slows

The presence of vomiting and fluid defecating cause the body fluids
decreased and disturbed fluid balance, resulting in extravascular fluid
volume decreased. This causes the solute to become concentrated,
resulting in increased extravascular fluid osmolarity and presence of
extravascular fluid hypertonicity. This causes osmosis (CIS to CES)
and fluid to move out of cells, so that the cell will gradually shrink.
There will be compensation of the body by reducing the fluid in the
loose connective tissue and soft tissues, and there are signs of
dehydration, ie sunken eyelids, no tears, decreased skin elasticity
(turgor slows).
(Price and wilson, 2012)

4. Laboratory Examination

Hb: 12 g/dl, WBC 6,000/mm3, differential count 0/1/2/45/48/4.

a. How is interpretation of laboratory examination?
Answer :

Examination Normal Interpretation

Child: 11-16 gr / dl
Hb 12.6 g/dl Normal
Below 3 years old : 9-15 gr / dl
WBC Below 5 years old : 5000-18.000 Normal
6.000/mm3 cells / mm3
Basophils: 0-1%
Eosinophils: 1-3%
Differential Neutrophil segment
Neutrophil rods: 2-6%
count ↓
Neutrophil segments: 50-70%
0/1/2/45/48/4 Lymphocytes ↑
Lymphocytes: 20-40%
Monocytes: 2-8%

26
 b. How is abnormal mechanism of laboratory examination?
Answer :

Increased lymphocyte cell

Because of infection, causing active immune system in the acute phase of

PMN will work for viruses radication so that the increased of lymphocyte
cell.

(Sudoyo, 2014)

5. Routine examination of the feces

Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color
Leucocyte feces : 1-2/hpf, erythrocytes: 0-1/hpf, bacteria (-), hyfa (-)
a. How is interpretation of routine examination?
Answer :
Abnormal
More liquid than pulp soft and shaped disrupted in food
absorption
Normal
Blood (-) (-) no bleeding in the
digestive system
Pus (-) (-) Normal
Mucous (-) (-) Normal
Yellowish Yellowish Normal
Leucocyte feces : 1-2/hpf 1-2/hpf Normal
Erythrocytes : 0-1/hpf 0-1/hpf Normal
Normal
Bacteria (-) (-) Infection is not
caused by bacteria
Normal
Infection is not
Hyfa (-) (-)
caused by parasites
(fungi)

b. How is abnormal mechanism of routine examination?

Answer :
Invasion of microorganism → entering the GI tract → infecting the ephitelium
ceel of small intestine → multiples in mature enterocyte → replaced by

27
 enterosite immature and intestinal villous distract become shorter and crypt
hypertrophy → absorption function inadequate → interference osmotic
pressure in intestinal → secretion increase → More liquid than pulp.

(Sintamurniwaty, 2006)

6. How to diagnose?
Answer :
Chief complaints : of fluid defecating since 4 days ago.
Additional complaints :
- Suffers nausea and vomitting with frequency 1-2 times a day, as much as ¼
cup, contain what his consumed, and not expulsion.
- Began lethargic but still want to drink.
- Dehidration
History : He had experienced fever.
Physical Examination :
General Condition : moderate illness
Spesific Condition :
Head : Sunken eyes, no tears.
Abdomen : Increased bowel sounds, decreases turgor pressure
Laboratory Examinations : Limfositosis
Routine examination of the feces :
Macroscopic : more liquid than pulp

7. What are the differential diagnostic in this case?

Answer :

Rotavirus Shigella V cholerae

Nausea&vomiti From the baginning rarely rarely

28
 ng

defecate liquid + + +

fever + + -

Other - convulsion,vomiting, -
symptoms hematochezia

Fecal
properties:

Volume medium A little Very much

Frequensi Up to 10x / more Very often Almost

continuously

Consistency Aqueous (liquid> pulp) Aqueous (liquid> pulp) Aqueous

Mucus Rarely + Flacks

Blodd - + -

smell - No smell Rancid

colour Grenn , yellow Green -

Leukosit - + -

(Sudoyo, 2014)

8. What are the supporting examination to diagnose in this case?

Answer :
a. Stool culture, is a laboratory test to determine the type of organism in the
stool (feces) that causes diarrhea in patients.

b. Enzymes Immunoassay, is to detected all antigent of the viruses in

diarrhea, like Rotavirus group A. The serotype of Rotavirus can detected
to find the viruses and feces with EIA method, and also like electron
microscope, it is RT-PCR (reverse transcription polymerase chain
reaction).
(Sudoyo, 2014)

29
9. What is the working diagnostic in ths case?
Answer :
Acute Gastroenteritis with moderate dehydration et causa virus

10. How to manage comprehensively?

Answer :

1. Rehydration using low osmolality Oralite

a. Diarrhea without dehydration

• Age <1 year: ¼ - ½ cup every time the child diarrhea (50-100 ml)
• Age 1 - 4 years: ½-1 glass each time the child diarrhea (100-200 ml)
• Age over 5 years: 1-1½ glasses each time the child diarrhea (200-300
ml)

b. Diarrhea with mild moderate dehydration oral doses administered

within the first 3 hours of 75 ml / kg and thereafter continued with oral
administration such as diarrhea without dehydration.

c. Diarrhea with severe dehydration

Patients with diarrhea who cannot drink should be immediately referred
to the Puskesmas to infuse. For children under 2 years of fluid should be
given with spoon by way of 1 spoon every 1 to 2 minutes. Giving with
no bottle may be done. Older children can drink directly from the glass.
When it happens vomit stop for 10 minutes then start again slowly for
example 1 spoon every 2-3 minutes. This fluid administration continues
until diarrhea stop.

2. Zinc (Zinc)
Zinc is given for 10 days in a row, zinc serves to restore the appetite eat.
Zinc dose for children:
 Children under 6 months: 10 mg (1/2 tablet) per day
 Children over 6 months of age: 20 mg (1 tablet) per day

30
 Zinc is given for 10-14 consecutive days even though the child has
recovered from diarrhea. For babies, zinc tablets can be dissolved with
boiled water, breast milk, or ORS. For a child which is larger, zinc can be
chewed or dissolved in boiling water or oralite.

3. Continue Breastfeeding and Food

Feeding during diarrhea aims to provide nutrition to the patient especially
in children to stay strong and grow and prevent loss weight. Children who
still drink breast milk should be more often breastfed. Children drinking
formula is also given more often than usual. Children aged 6 months or
more including babies who have received solid foods should be given
easily digested food and given a little more and more often. After diarrhea
stops, extra feeding is continued for 2 weeks to help weight recovery

4. Selective Antibiotics
Antibiotics should not be used routinely because of the small incidence of
diarrhea in toddlers caused by bacteria. Antibiotics are only useful on
people with diarrhea with blood (mostly due to Shigellosis) and cholera
suspects Anti-diarrhea drugs should also not be given to a child suffering
diarrhea because it proved to be useless. Anti-vomiting drugs are not
recommended unless severe vomiting. These drugs do not prevent
dehydration or improve status child nutrition even most of the side effects
are dangerous and can be fatal. Anti-protozoan drugs are used when
proven diarrhea is caused by parasites (amoeba, giardia).

5. Advice to parents / cares

Mothers or cares who are closely related to toddlers should be given
advice about:
a. How to administer fluids and home remedies
b. When to bring back a toddler to a health worker if:
• Diarrhea is more frequent
• Vomiting over and over
• Very thirsty
• Eat / drink a little
• Fever

31
 • Bloody stools
• Not improving within 3 days.
(Kementrian Kesehatan RI, 2011)

11. What is the complication?

Answer :
- Dehydration (mild, moderate, severe, hypotonic, isotonic or hypertonic)
- Hypovolemic shock.
- Hypokalemia (with symptoms of meteorismus, muscle hypotony, weakness,
bradycardia, changes in the electrocardiogram).
- Hypoglycemia.
Secondary lactose intolerance, as a result of deficiency of lactase enzymes
due to damaged mucosal villi damage.
- Seizures, especially on hypertonic dehydration.

(Widoyono, 2011)

12. How the prognostic in this case?

Answer :
Bonam

13. What is the general practitioner’s competence in this case?

Answer :
Level Ability 4: diagnose, perform self-management and complete
Doctor graduates are able to make clinical diagnoses and perform the
management of the disease independently and thoroughly.
4A. Competencies achieved at the time of graduation.

14. What is islamic view in this case?

Answer :

َّ ‫طيِبًا َح َٰلَ ًل‬

‫ٱّللُ َرزَ قَ ُك ُم ِم َّما فَ ُكلُوا‬ َ ‫ٱّللِ نِ ْع َمتَ َوٱ ْش ُك ُروا‬
َّ ‫ت َ ْعبُدُونَ إِيَّاهُ ُكنت ُ ْم إِن‬

32
 “Then eat of what Allah has provided for you which is lawful and good.
And be grateful for the favor of Alla, if it is He whom you whorship”
(An-Nahl : 114)

2.6. Conclusion
Diwan, A 2 years old, complain fluid defecation, nausea, vomiting because of
Acute Gastroentritis with moderate dehydration et causa viruses.

2.7. Framework

Invation of viruses

Infecting small intestine Fever

33
 Mature enterocyte
replaced with immature
enterocyte &
hypertrophy villi

Absorption ↓

Nausea and vomiting Osmotic intestinal

(Pressure increase)

Fluid defecation

Moderate dehydration

Moderate Turgor
illness pressure

Sunken eyes No tears

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