Tutorial Report.block13.Scenario1

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TUTORIAL REPORT

BLOCK Xlll

SCENARIO A :

BUDI’S CASE

Created by :

GROUP l

FACULTy OF MEDICINESRIWIJAyA UNIVERSITy

2008



BLOCK XIII

PROBLEM BASED LEARNING

SCENARIO A

Created by :

Group I

1.Ahmad Angga Lutfi2.Aulia Annisa Rizki3.Bedry Qintha4.Cahyani Indah5.Defayudina Dafilianty R6.Halbana Al Maududy

7.M Azril Rizal Bin Ghozali8.Naveen Kumar9.Prihatina Anjela10. Resi Anita



The Outlines

The Outlines

Chapter I : Introduction

1. Scenario : Scenario A – Budi’s case

2. Terms Clarification

3. Problems Identification

4. Problems Analysis

5. Hypothesis

Chapter II : Content

Chapter III : Conclusion

1. Conclusion



CHAPTER I

INTRODUCTION

1.SCENARIO

Budi, a boy, 12 years old, was hospitalized due to diarrhea. Four days before admission,the patient had non projectile vomiting 6 times a day. He vomited what he ate. Threedays before admission the patient got diarrhea 10 times a day around half glass in everydefecation. There was no blood and mucous. Along those 4 days, he only drank plainwater. Yesterday, he looked worsening, still diarrhea but no vomiting. Urination in 8hours was less than usual. Budi’s family is in slum area. He also got fever.

Physical examination:Look severe ill, compos mentis, BP 70/50 mmhg, RR 28x/minute, HR 144x/minute regularbut weak, body temperature 38,70C, body weight 8,8 kgs, body height 75 cm.

Hollow eye, no teras drop, and dry mouth.

Thoraks : Simetris, retraction (- /-), vesicular breath sound, normal heart sound.

Abdomen : Flat, shuffle, bowel sound was increase. Liver was palpable 1 cm below arcuscostae and xiphoid processus, spleen unpalbable. Positive turgor. Rednessskin surrounding anal orifice.

Additional information:

Laboratory examination :Hb : 12,8 g/dl; WBC : 9000/mm3 ; defferential count : 0/1/16/48/35/0

Urine :Makroscopic : yellowish colourMicroscopic : WBC (-), RBC (-), protein (-)

Faeces rutin :Macroscopic : watery more than waste material, blood (-), pus (-)WBC : 2 - 4/WF, RBC (-)

2.TERMS CLARIFICATION

Diarrhea

Loose, watery, and frequent stool

Non projectile vomitingVomiting without force

DefecationThe act or process by which organisms eliminate solid, semisolid or liquid waste material(feces) from the digestive tract via the anus

Plain waterCommon water that consumed by people

Slum area

A city district inhabited by people living in huts and shanties



FeverIncrease of body temperature

UrinationProcess of disposing urine from the urinary bladder through the urethra to the outside of the body

3.PROBLEM INDENTIFICATION

- Budi, 12 months a boy, was hospitalized due to diarrhea.

- Four days before admission, he had non projectile vomiting 6 times per day

- He vomited what he ate.- Three days before admission the patient got diarrhea 10 times a day around half

glass in every defecation.- Along those 4 days, he only drank plain water.- He looked worsening, still diarrhea but no vomiting.- Urination in 8 hours was less than usual.- He lives in slum area- He got fever

4.PROBLEM ANALYSIS

1. What is the anatomy and physiology of GI tract in infant

2. Chief complaint : Diarrhea- What is the definition?- What is the etiology?- How’s the pathophysiology ?- What is the indication of being hospitalized ?

3. Additional complaint :

1. Vomiting- What is the definition?- What is the etiology?- How’s the pathophysiology ?

2. Fever

- What is the definition?- What is the etiology?- How’s the pathophysiology ?

2. What is the pathogenesis of the disease ?

3. What is the relationship between slum area and the disease ?

4. How is the relations between only drink plain water with the disease ?

5. How to diagnose ?- Anamnesis- Physical examination- Laboratorium examination- Supporting exam

6. What is the working diagnose of the disease ?- What is the definition ?- What is the etiology ?- What is the risk factor ?



- What is the pathophysiology ?- What are the signs and symptoms ?

7. Management

8. Prevention

9. Complication

10. Prognosis

5.HYPOTHESIS

Budi, a 12 months boy, suffered from acute diarrhea and severe dehydration caused bysuspect rotavirus.



CHAPTER II

CONTENT

1. Anatomy and physiology of GI tract

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oralcavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomachand intestines to the rectum and anus, where food is expelled.

The primary purpose of the gastrointestinal tract is to break down food into nutrients,

which can be absorbed into the body to provide energy.

First food must be ingested into the mouth to be mechanically processed and moistened.

Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fatsand carbohydrates are chemically broken down into their basic building blocks. Smallermolecules are then absorbed across the epithelium of the small intestine and subsequentlyenter the circulation. The large intestine plays a key role in reabsorbing excess water.

Finally, undigested material and secreted waste products are excreted from the body viadefecation (passing of faeces). In the case of gastrointestinal disease or disorders, thesefunctions of the gastrointestinal tract are not achieved successfully. Patients may developsymptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction.Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.



Basic structure:The gastrointestinal tract is a muscular tube lined by a special layer of cells, calledepithelium. The wall is divided into four layers as follows:

Mucosa: The innermost layer of the digestive tract has specialised epithelial cells supportedby an underlying connective tissue layer called the lamina propria. The lamina propria

contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa.Depending on its function, the epithelium may be simple (a single layer) or stratified(multiple layers).

Areas such as the mouth and oesophagus are covered by a stratified squamous (flat)epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) orglandular epithelium lines the stomach and intestines to aid secretion and absorption. Theinner lining is constantly shed and replaced, making it one of the most rapidly dividingareas of the body.

Submucosa: The submucosa surrounds the muscularis mucosa and consists of fat, fibrousconnective tissue and larger vessels and nerves. At its outer margin there is a specializednerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and

submucosa.

Muscularis externa: This smooth muscle layer has inner circular and outer longitudinallayers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neuralinnervations control the contraction of these muscles and hence the mechanical breakdownand peristalsis of the food within the lumen.

Serosa/ Mesentery: The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium. The Individual Components of the GastrointestinalSystem

Oral cavityThe oral cavity or mouth is responsible for the intake of food. It is lined by a stratified

squamous oral mucosa with keratin covering those areas subject to significant abrasion,such as the tongue, hard palate and roof of the mouth. Mastication refers to themechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, astrong muscular organ, manipulates the food bolus to come in contact with the teeth. It isalso the sensing organ of the mouth for touch, temperature and taste using its specialisedsensors known as papillae.

Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions.The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limitedrole in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva,starts the process of digestion of complex carbohydrates. The final function of the oralcavity is absorption of small molecules such as glucose and water, across the mucosa. Fromthe mouth, food passes through the pharynx and oesophagus via the action of swallowing.

Salivary GlandsThree pairs of salivary glands communicate with the oral cavity:

- Parotid- Submandibular- Sublingual

OesophagusThe oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. Itextends from the pharynx to the stomach after passing through an opening in thediaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinallayers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus

surrounds the lower portion of the oesophagus. The oesophagus functions primarily as atransport medium between compartments.



StomachThe stomach is a J shaped expanded bag, located just left of the midline between theoesophagus and small intestine. It is divided into four main regions and has two borderscalled the greater and lesser curvatures. The first section is the cardia which surrounds thecardial orifice where the oesophagus enters the stomach. The fundus is the superior,dilated portion of the stomach that has contact with the left dome of the diaphragm. The

body is the largest section between the fundus and the curved portion of the J.

This is where most gastric glands are located and where most mixing of the food occurs.Finally the pylorus is the curved base of the stomach. Gastric contents are expelled intothe proximal duodenum via the pyloric sphincter. The inner surface of the stomach iscontracted into numerous longitudinal folds called rugae. These allow the stomach tostretch and expand when food enters. The stomach can hold up to 1.5 litres of material.The functions of the stomach include:

The short-term storage of ingested food.Mechanical breakdown of food by churning and mixing motions.Chemical digestion of proteins by acids and enzymes.Stomach acid kills bugs and germs.

Some absorption of substances such as alcohol.

Most of these functions are achieved by the secretion of stomach juices by gastric glands inthe body and fundus. Some cells are responsible for secreting acid and others secreteenzymes to break down proteins.

Small IntestineThe small intestine is composed of the duodenum, jejunum, and ileum. It averagesapproximately 6m in length, extending from the pyloric sphincter of the stomach to theileo-caecal valve separating the ileum from the caecum. The small intestine is compressedinto numerous folds and occupies a large proportion of the abdominal cavity. Theduodenum is the proximal C-shaped section that curves around the head of the pancreas.The duodenum serves a mixing function as it combines digestive secretions from the

pancreas and liver with the contents expelled from the stomach. The start of the jejunumis marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where themajority of digestion and absorption occurs.

The final portion, the ileum, is the longest segment and empties into the caecum at theileocaecal junction. The small intestine performs the majority of digestion and absorptionof nutrients. Partly digested food from the stomach is further broken down by enzymesfrom the pancreas and bile salts from the liver and gallbladder. These secretions enter theduodenum at the Ampulla of Vater. After further digestion, food constituents such asproteins, fats, and carbohydrates are broken down to small building blocks and absorbedinto the body's blood stream. The lining of the small intestine is made up of numerouspermanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa)and each villus is covered by epithelium with projecting microvilli (brush border). Thisincreases the surface area for absorption by a factor of several hundred. The mucosa of thesmall intestine contains several specialised cells. Some are responsible for absorption,whilst others secrete digestive enzymes and mucous to protect the intestinal lining fromdigestive actions.

Large IntestineThe large intestine is horse-shoe shaped and extends around the small intestine like aframe. It consists of the appendix, caecum, ascending, transverse, descending and sigmoidcolon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. Thecaecum is the expanded pouch that receives material from the ileum and starts tocompress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three

thick bands of muscle (taenia coli).



RectumRECTUM is where stool is stored before excreted. The opening through which stool leavesyour body is called the ANUS (double-pointed arrow).

The rectum is the final 15cm of the large intestine. It expands to hold faecal matter beforeit passes through the anorectal canal to the anus. Thick bands of muscle, known as

sphincters, control the passage of faeces. The mucosa of the large intestine lacks villi seenin the small intestine. The mucosal surface is flat with several deep intestinal glands.Numerous goblet cells line the glands that secrete mucous to lubricate faecal matter as itsolidifies. The functions of the large intestine can be summarised as:- The accumulation of unabsorbed material to form faeces.- Some digestion by bacteria. The bacteria are responsible for the formation of intestinal

gas.- Reabsorption of water, salts, sugar and vitamins.

AnusANUS has two muscular sphincters, the Internal, and the External sphincters. These strongmuscles are crucial in keeping the stool in your RECTUM until you can find a nice toilet.You can consciously control the external sphincter, but not the internal one. The Levator

Ani is part of the pelvic floor muscles that also help keep you from moving your bowelsbefore you find a toilet.

2. Diagnostic Approach

a. Anamnesis1. Identity : Budi, a boy, 12 months old, live in the slum area2. Chief complaint : Diarrhea3. Additional complaint : Non projectile vomiting

: Decrease of urination: Fever

4. Previous history : not mentioned5. Family history : not mentioned

b. Differential Diagnosis

Clinical form Classification :Clinical : acute diarrhoea, cholera, dysenterySeverity of dehydration : without dehydration

mild-moderate dehydrationsevere dehydration

Type of dehydration : isotonic, hypotonic, hypertonicClinical complicated : complicated, uncomplicated

Clinical Form:antimicrobial usage, differed to : Acute diarrhoea

CholeraDysentery

Cholera : clinical manifestation typically, child > 3 year ( especially > 5 year),outbreaks accident

Dysentery : Diarrhoea with blood and or pusà bloody stoolAcute diarrhoea: non cholera and non dysentery.

Dysentery Cholera Acute Diarrhea

Diarrhea + + +

Dehydration + + +

Vomiting + + +

Nausea - - +Fever + / - + +



Consciousness Apatis - Coma Apatis - Coma Compos mentis

Heart Rate Tachycardia Tachycardia Tachycardia

Respiration rate Tachypnea Tachypnea Tachypnea

Faeces Consist of blood +pus

Smells like“baycline”

Watery more thanthe material

c. Physical Examination

Budi Normal Interpretation

Generalappearance

Severe ill Health Abnormal

Consciousness Compos mentis Compos Mentis Normal

Blood pressure 70/50mmHg 90/60mmHg Tachycardia

Respiration rate 38x/minute 25-40x/minute Normal

Temperature 38,70C 360C Fever

Body weight 8,8 kg 10 kg ( 8 + 2N; agein year )

Under nutrition

Body height 75 cm 71 – 78 cm NormalEyes Hollow eyes No hollow eyes Dehydration

No tears drop Tears drop Dehydration

Mouth Dry mouth Not dry Dehydration

Thoraks Simetris Simetris Normal

Retraction ( - / - ) No retraction ( - /- )

Normal

Vesicular breath sound Normal Normal

Abdomen Flat, shuffle Flat, shuffle Normal

Bowel sound increased Not increase Increase peristaltis

Liver Palpable 1 cm belowarcus costae andxiphoid processus

Not palbable Undernutrition

Spleen Unpalpable Unpalpable NormalTurgor

Anal orificePositive

Reddish skinNegative

Not reddishDehydration

Irritation

d. Laboratorium Examination

Blood Hb 12,8 g/dl 10-14 g/dl Normal

WBC 9.000/mm3 5.000 – 10.000/mm3 Normal

Differential count 0/1/16/48/35/0 0-1/1-3/2-6/20-60/20-42/3-9

Shift to theleft - acute

Urine Macroscopic Yellowish Yellowish NormalMicroscopic WBC (-) WBC (-) Normal

RBC (-) RBC (-) Normal

Protein (-) Protein (-) Normal

Faeces Macroscopic Watery morethan wastematerial

Waste material morethan water

Diarrhea

Blood (-) Blood (-) Normal

Pus (-) Pus (-) Normal

Microscopic WBC : 2-4/WF WBC : 0-5/WF Normal

RBC (-) RBC (-) Normal



e. Working Diagnostic

Definition

A familiar phenomenon with unusually frequent or unusually liquid bowel movements,excessive watery evacuations of fecal material. The opposite of constipation.

Diarrhea is a common symptom that can range in severity from an acute, self-limitedannoyance to a severe, life-threatening illness. The frequency and consistency of bowelmovements vary within and between individuals. Some individuals may normallydefecate as many as three times a day, while others only two to three times per week.Diarrhea is defined as increased volume, fluidity, or frequency of fecal dischargescompared with the patient’s normal stools. Clinical features vary greatly depending onthe cause, duration, and severity of the diarrhea, on the area of bowel affected, andon the patient’s general health.

Etiology

In this case : Acute diarrhea caused by ROTAVIRUS

Rotavirus infection is an infection of the digestive tract. It is the most common cause of severe diarrhea in infants and young children. The infection is caused by group Arotaviruses, which are wheel-shaped viruses.

Rotavirus spreads very easily. The virus is transmitted by hand-to-mouth contact withstool from an infected person. The virus can be passed from one person to another bytouching a hand contaminated by the virus. The virus can also be transmitted by merelytouching a surface or object that has been contaminated by an infected person. Thevirus then enters the body through contact with the mouth. Children can spreadrotavirus both before and after they develop symptoms.

Rotavirus infection usually starts with fever and vomiting, followed by diarrhea. Thediarrhea can be mild to severe and generally lasts 3-9 days. And the illness usuallybegins 3 days after exposure.

Most children with rotavirus diarrhea recover on their own, but some children becomevery ill with severe vomiting, diarrhea, and loss of fluids (dehydration). Children with



severe diarrhea can lose body fluids very quickly and may need to be hospitalized forspecial therapy to replace fluids and restore chemical balance. The seriousness of infection generally decreases with the number of infections. First infections tend to bethe most severe.

The infection can be diagnosed by a laboratory test on a stool sample. Antibody of anti

rotavirus which called immunoglobulin A and M, is being excreted in faeces after theday of rotavirus infection. This antibody test was still positive until 10 days after thefirst infection, and could be much longer if the recurrent infection is present. So that,antibody examination could be used to diagnose the rotavirus.

Risk Factor

Every child is likely to be infected with rotavirus at least once in the first 5 years of life. Severe diarrhea and dehydration occur mainly in children aged 3 to 35 months.Children who have been infected once can become infected again.

Older children and adults can also get rotavirus infection. Young children can pass thevirus to their older brothers and sisters. In adults in the United States, rotavirus

infections sometimes cause diarrhea in travelers, persons caring for children withrotavirus diarrhea, and the elderly.

Pathophysiology

DIARRHEA:

Three mechanisms of diarrhea :1. Bcretory diarrhea

Bacteria produces toxin

Effect of toxin:

activating intracellular protein

stimulate electrolyte and water secretion

watery diarrhea

2. Osmotic diarrhea

Enzyme system insufficient or Short Bowel syndrome

Food is digested partially

Osmotic burden intraluminal

Bacterium decompose the pigswill become the short chain fatty acid and other material

Diarrhea



3. Cytotoxic / inflammatory diarrhoea

Viral, inflammatory : allergy, IBDViral

invasive and cytotoxic

damage entrocytes at villus

villus atrophy (Absorption decrease)

crypt hyperplasia (secretion increase)

mixed diarrhoea

Inflammation

immune cells

cytokines + chemokines + prostaglandinsà

induce secretion and activate enteric nerves metaloproteins destroyed entrocytes at villus

Absorption decrease

crypt hyperplasia (secretion increase)

mixed diarrhea

immature entrocyte with insufficient disacharidase and peptide hydrolase

Absorption decrease



Stool forms :

• secretory diarrhoea : watery, high level electrolyte

• osmotic diarrhoea : semisolid, low level electrolyte

• cytotoxic / inflammatory diarrhoea : mix

ROTAVIRUS :

ROTAVIRUS

Mature erythrocyte in the tip of villi of small intestine

Change of structure of mucous of small intestine

Shorten of villi & infiltrate of mononuclear inflammatory cell in lamina propria

Rotavirus attatch and come into epitel cell

Destruction of the cell

Replace by criptus cell

Criptus cell immature

Canr absorb well

Diarrhea

Loss of fluid

Loss of electrolytePGE2

Anterior hypothalamus Dehydration

Elevated thermoregulatorSet point

Increase heat conservation

Increase heat production

Fever

ROTAVIRUS : shorten the villi – decreased absorbtion

No tears drop

Dry mouth

Turgor pressure

Hollow eyes

Less of urinate

DIARRHEA



More criptus – increased secretionVOMITING :

Process of vomit :

1.Nausea

2.Retching3.Vomiting

Central of vomiting : region postrema medulla oblongata in base of 4th ventricle

Near from central of salivation and respiration -> hypersalivation and movement of respiration

Iritation of gastrointestinal tract / much of distention

Antiperistaltis in illeum

Move inward and up to

Push the content material of intestine back to duodenum & gaster

Dilatation of pper region of GI & duodenum

Hard instriction contraction in duodenum and gaster caused the relaxation of lower

oesophagus sphincter

The vomit move to oesophagus

Moved out by the movement of abdomen musles

e. Management

Criteria of being hospitalized :1. Clinical feature

2.MTBS ( Managemen Terbantu Bayi Sakit )General appearance : normal, weak, nervous, lethargy

Eyes lid : sunkenSense of thirsty : without dehydration, mild-moderate dehydration,

severe dehydrationTurgor : > 1 second[If two of these is present means let’s get hospitalized]

3. P2 Diarrhoea = Programe National Diarrhoeal Diseases Control Program (CDD)

Key points : (WHO)

1. Giving solution: prevent & treat dehydration

Peroral :



• more beneficial compared to parenteral (cheap, frequency and duration of

diarrhoea: decrease)

• Given in : without and mild-moderate dehydration

• In especially situation: can be given by NGT (≤ 20 ml/kgBW/hour)

• Home based solution, ORS, renalyte, pedialyte, etc

Parenteral (intravenously) :

•Given in severe dehydration (when oral administration unable to answer thedemand , and mild-moderate dehydration is fail to rehydrate with oral solution

• After rehydration is reached, as soon as possible ( 4-6 hours) change to oral

solution.

• Kind of intravenous solution : kristalolid ( RL, Nacl, Nacl+Dektrose)

To prevent dehydration : without dehydration(peroral)To treat dehydration : mild-moderate dehydration (peroral) and severe dehydration

( parenteral ) 2. Diet

Continue especially breast feeding, bananas, rice, applesauce, and toast diet.



3. Drug

No antibody, except for cholera and bloody stool.

WHO recommend : ZincNot yet clinically relevant : Probiotik And prebiotik

4. Education

Education is most important for prevention and treatment.

Proper ORT prevents dehydration, and early refeeding speeds recovery of intestinalmucosa.

Emphasize proper hygiene and food preparation practices to prevent future infections andspread.

f. Prognosis

With proper management, prognosis is very good.

g. Complication

HypokalaemiaHypovolaemic shockSodium levels low (urine)Depletional hyponatraemiaHypernatraemiaHypophosphataemiaHypomagnesemia

DehydrationFaecal incontinence

h. Prevention

1.Oral rotavirus immunization :

Oral rotavirus vaccine is the best way to protect infants and children against rotavirusdisease. The vaccine will not prevent diarrhoea and vomiting caused by other infections butis very good at preventing severe diarrhoea and vomiting caused by rotavirus. The oral(swallowed by mouth) rotavirus vaccine used is called RotaTeq®. RotaTeq® is a ‘live’weakened virus vaccine. The vaccination course of RotaTeq ® consists of three doses and isrecommended to be given at the same time as other vaccines included on the NationalImmunisation Program at two, four and six months of age.

The first dose of RotaTeq® should be given no later than 12 weeks of age and the thirddose should be given by 32 weeks of age.

The rotavirus vaccine is generally well tolerated. Reactions to the rotavirus vaccine aremuch less frequent than the likelihood of the disease and include:

Common side effects:• Fever• Diarrhoea (in the week after rotavirus vaccination)• Vomiting (in the week after rotavirus vaccination)

Extremely rare side effect:• Anaphylaxis (severe allergic reaction)



2. Other than vaccination, there is no effective way to completely eliminate rotavirusinfection or its spread. Washing with soaps or cleansers does not kill the virus but will helpreduce the spread of infection. Wash hands after using the toilet, after helping a child usethe toilet, after diapering a child, and before preparing or serving food.



CHAPTER III

CONCLUSION

Budi, a 12 months boy, suffered from acute diarrhea and severe dehydration caused bysuspect rotavirus.

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Tutorial Report.block13.Scenario1