2.

6 Problem Analysis
1. Rudi, a 14-month-old boy, was brought by his mother to the emergency room
of the RSMP because of shortness of breath that had gotten worse since 1 day ago.
Two days earlier, he started to look short of breath and had difficulty eating and
drinking. Four days ago, he had a cough and runny nose accompanied by a high
fever. He had never experienced shortness of breath before and had no history of
allergies.
a) What is the anatomy and histology in this case?
b) What is the physiology in this case ?

c) What is the meaning of Rudi, a 14-month-old boy, was brought by his

mother to the emergency room of the RSMP because of shortness of breath
that had gotten worse since 1 day ago?
The sentence "Rudi, a 14-month-old boy, was brought by his mother to the
emergency room of the RSMP because of shortness of breath that had
gotten worse since 1 day ago" describes a specific situation involving a
young child and his mother. Here's a breakdown of the meaning:

1. "Rudi": Refers to the name of the 14-month-old boy who is the subject
of the sentence.

2. "A 14-month-old boy": Specifies the age of Rudi, indicating that he is

14 months old, or approximately one year and two months.

3. "Was brought by his mother": Indicates that Rudi's mother brought him
to the emergency room. This suggests that Rudi's mother recognized his
symptoms as severe enough to warrant immediate medical attention.

4. "To the emergency room of the RSMP": Specifies the destination where
Rudi and his mother sought medical assistance, which is the emergency
room of the RSMP (unspecified acronym).

5. "Because of shortness of breath": States the primary reason for seeking

medical attention, which is Rudi experiencing difficulty in breathing,
commonly known as shortness of breath or dyspnea.
 6. "That had gotten worse since 1 day ago": Indicates that Rudi's shortness
of breath has worsened in the time period of one day leading up to the visit
to the emergency room. This implies that the symptom has progressed and
become more severe over the past day.
d) What are the possible cause of shortness of breath?
Dyspnea, or shortness of breath, can be caused by various conditions or
factors that affect the respiratory system or other parts of the body. Here
are some examples of what can happen in the body to cause dyspnea:

1. Obstruction or narrowing of the airways: Conditions such as asthma,

chronic obstructive pulmonary disease (COPD), or bronchitis can cause
inflammation, mucus production, or constriction of the airways, making it
difficult to breathe.

2. Reduced lung function: Lung diseases like pulmonary fibrosis,

interstitial lung disease, or lung cancer can lead to scarring, damage, or
impaired function of the lung tissue, resulting in decreased oxygen
exchange and breathlessness.

3. Respiratory infections: Infections such as pneumonia, bronchitis, or

influenza can cause inflammation and fluid buildup in the lungs, making
breathing more challenging.

4. Heart problems: Conditions like heart failure, coronary artery disease,

or heart valve disorders can lead to inadequate pumping of blood, causing
fluid accumulation in the lungs (pulmonary edema) and resulting in
shortness of breath.

5. Anemia: Decreased levels of red blood cells or hemoglobin can reduce

the oxygen-carrying capacity of the blood, leading to dyspnea.

6. Obesity: Excess weight can put additional strain on the respiratory

system, making breathing more difficult and causing breathlessness.

7. Anxiety and panic disorders: Psychological factors such as anxiety or

panic attacks can cause a sensation of breathlessness or hyperventilation.

8. Allergic reactions: Severe allergic reactions (anaphylaxis) can cause

airway constriction or swelling, leading to breathing difficulties.

9. Physical exertion: Engaging in intense physical activity or exercise can

temporarily increase breathing rate and result in shortness of breath.
 These are just a few examples, and there can be other causes of dyspnea
depending on an individual's medical history, overall health, and specific
circumstances.
Ferreira DH, Rodrigues MJ, Marques A. Dyspnea assessment and
management in palliative care: A review. Medicina (Kaunas).
2019;55(8):454.
e) What are the possible disease of shortness of breath?
f) What is the meaning Two days earlier, he started to look short of breath
and had difficulty eating and drinking?
The phrase "Two days earlier, he started to look short of breath and had
difficulty eating and drinking" describes a previous event related to an
individual. Here's a breakdown of the meaning:

1. "Two days earlier": This indicates that the described event took place
two days before the current time or the time of reference. It refers to a
specific point in the past.

2. "He": Refers to an individual, whose identity is not specified in the

given phrase.

3. "Started to look short of breath": Suggests that the individual began to

exhibit signs or symptoms that indicated difficulty in breathing or
shortness of breath. This implies that their breathing became visibly
labored or compromised.

4. "Had difficulty eating and drinking": Indicates that the individual

experienced challenges or problems with consuming food and beverages.
This could involve reduced appetite, discomfort while swallowing, or
other issues that hindered their ability to eat and drink normally.

g) What are the possible disease of difficulty of eating and drinking of

shortness of breath in baby?
h) How is the mechanism of difficulty eating and drinking because of
shortness of breath?
Pathogens > invasion and spread of bacteria into the lung parenchyma >
microorganisms proliferate > alveolar macrophages issue an inflammatory
response to strengthen lower respiratory tract defenses > release
proinflammatory cytokines in response to inflammatory reactions (IL-1,
TNF, IL-8, G-CSF) > accumulation of fluid exudate in the alveoli >
decreased diffusion of O2 and CO2 > decreased supply of O2 to body
tissues > hypoxemia > lack of supply of O2 and blood to peripheral tissues
(cyanosis (+)) > body increases supply of O2 by breathing faster >
shortness of breath (Sharma, 2021).
Sharma. 2021. Bacterial Pneumonia. Statpearls [internet]. NCBI
 Patogen > menginvasi dan menyebarkan bakteri ke dalam parenkim paru >
mikroorganisme berkembang biak > makrofag alveolar mengeluarkan
respons peradangan untuk memperkuat pertahanan saluran pernapasan
bagian bawah > melepaskan sitokin proinflamasi sebagai respons terhadap
reaksi inflamasi (IL-1, TNF, IL-8, G-CSF ) > akumulasi eksudat cairan di
alveoli > penurunan difusi O2 dan CO2 > penurunan suplai O2 ke jaringan
tubuh > hipoksemia > kekurangan suplai O2 dan darah ke jaringan perifer
(sianosis (+)) > tubuh meningkatkan suplai O2 sebesar bernapas lebih
cepat > sesak napas (Sharma, 2021).
i) What is the correlation between age gender in the case?
j) What are the classification of shortness of breath (onset, position, grade)
k) What is the correlation between main complaint and additional complaint?
l) What is the meaning Four days ago, he had a cough and runny nose
accompanied by a high fever?
The phrase "Four days ago, he had a cough and runny nose accompanied
by a high fever" describes a past event related to an individual. Here's a
breakdown of the meaning:

1. "Four days ago": This indicates that the described event took place four
days prior to the current time or the time of reference. It signifies a
specific point in the past.

2. "He": Refers to a male person who experienced the symptoms being

described.

3. "Had a cough and runny nose": Describes the presence of symptoms

involving coughing and a nose that produced excessive mucus, indicating
possible respiratory involvement or an upper respiratory tract infection.

4. "Accompanied by a high fever": Suggests that the individual's cough

and runny nose were accompanied by an elevated body temperature, which
indicates a fever. A high fever typically refers to a significant increase in
body temperature above the normal range.
m) How is the mechanism of cough and runny nose accompanied by a high
fever?
n) What are the classification of cough? (Time, productive/not)
Classification
Cough may be classified into 3 groups:
- Acute coughs last less than 3 weeks.
- Subacute coughs last between 3 and 8 weeks.
- Chronic coughs last longer than 8 weeks.
Irwin RS, French CL, Chang AB, Altman KW, CHEST Expert Cough Panel*
(2018). "Classification of Cough as a Symptom in Adults and Management Algorithms:
CHEST Guideline and Expert Panel Report". Chest. 153 (1): 196–
209. doi:10.1016/j.chest.2017.10.016. PMC 6689094 . PMID 29080708
 o) What are the possible disease of cough, runny nose accompanied by high
fever?
p) What is the meaning He had never experienced shortness of breath before
and had no history of allergies?

2. Rudi lives with his parents and 4 older siblings in a 6x6 m semi permanent
house with 1 room and 2 windows. His mother had a cough for one week but no
fever or runny nose. His father is known to have a habit of smoking 2 packs a day.
His family has no history of old cough and drug consumption for 6 months.
a) What is the meaning of Rudi lives with his parents and 4 older siblings in
a 6x6 m semi permanent house with 1 room and 2 windows?
b) What are the criteria of ideal house?
c) What is the meaning and correlation of his mother had a cough for one
week but no fever or runny nose and Rudi’s symptoms?
d) What is the meaning of His father is known to have a habit of smoking 2
packs a day?
The sentence "His father is known to have a habit of smoking 2 packs a
day" means that the father of the person being referred to is well-known or
recognized for engaging in a smoking habit. Specifically, the father
smokes two packs of cigarettes daily.

Here's a breakdown of the meaning:

1. "His father": Refers to the biological or adoptive father of the person

being discussed.

2. "Is known to have a habit of smoking": Indicates that the father's

smoking habit is widely recognized or acknowledged by others.

3. "2 packs a day": Specifies the extent of the father's smoking habit,
indicating that he smokes two packs of cigarettes every day.

In summary, the sentence conveys information about the smoking behavior

of the person's father, highlighting that he is a regular smoker consuming a
substantial amount of cigarettes each day.
e) What is the meaning His family has no history of old cough and drug
consumption for 6 months?
f) What are the bad effects of smoking to the baby?
Smoking during pregnancy can have severe and detrimental effects on the
baby's health and development. The harmful substances in cigarette smoke
can pass from the mother's bloodstream to the baby through the placenta,
affecting the baby's growth and overall well-being. Some of the bad effects
of smoking on the baby include:
1. Low birth weight: Babies born to mothers who smoke during pregnancy
are more likely to have low birth weight, which increases the risk of health
complications and developmental issues.

2. Premature birth: Smoking during pregnancy increases the likelihood of

premature birth, meaning the baby is born before completing the full term
of pregnancy. Premature babies may face various health challenges and
require special medical care.

3. Respiratory problems: Babies exposed to tobacco smoke in the womb

are at higher risk of developing respiratory problems, such as asthma and
respiratory infections, due to the harmful effects on lung development.

4. Sudden Infant Death Syndrome (SIDS): Babies born to mothers who

smoke have an increased risk of SIDS, a condition where an otherwise
healthy baby dies suddenly and unexpectedly during sleep.

5. Developmental delays: Smoking during pregnancy can negatively

impact the baby's brain development, leading to potential cognitive and
behavioral issues later in life.

6. Increased risk of health conditions: Children exposed to smoking during

pregnancy may have an elevated risk of developing various health
problems, including obesity, diabetes, and cardiovascular diseases in
adulthood.

7. Impaired lung function: Babies exposed to smoking in the womb may

have impaired lung function, which can persist into childhood and
adulthood.

8. Behavioral and learning problems: Some studies suggest that children

exposed to maternal smoking during pregnancy may be at a higher risk of
experiencing behavioral and learning difficulties.
 9. Nicotine addiction: Smoking during pregnancy exposes the baby to
nicotine, and there is evidence that exposure to nicotine in the womb can
lead to nicotine addiction in the baby, increasing the likelihood of future
tobacco use.

To protect the health of both the mother and the baby, it is crucial for
pregnant women to avoid smoking and exposure to secondhand smoke.
Quitting smoking during pregnancy can significantly improve the baby's
chances of a healthier start in life. If you are pregnant and struggling to
quit smoking, it is essential to seek support and guidance from healthcare
professionals to develop a safe and effective smoking cessation plan.
3. He drank breast milk for 1 month old then drank formula milk. He eats 3x half
a small bowl of rice daily. He has a history of immunization: BCG, scar (+); DPT
1,2; HiB 1,2; Hepatitis 0,1,2; Polio 0,1,2. Currently, Rudi lives in the Kertapati
area near the market in the city of Palembang.
a) What is the meaning of He drank breast milk for 1 month old then drank
formula milk?
The sentence "He drank breast milk for 1 month old then drank formula
milk" indicates a sequence of feeding choices for an individual.

Here's the breakdown of the meaning:

1. "He": Refers to a male individual, whose identity is not specified in the

sentence.

2. "Drank breast milk for 1 month old": Implies that the individual was fed
with breast milk exclusively for the first month of life. This suggests that
during the first month after birth, the baby was primarily breastfed.

3. "Then drank formula milk": Indicates that after the first month of life,
the individual's feeding method was changed, and they began consuming
formula milk instead of breast milk. Formula milk is a commercial product
designed to provide essential nutrients for infants who are not breastfed.

In summary, the sentence describes the feeding progression of the

individual. For the first month of life, they were fed with breast milk, and
after that period, they switched to drinking formula milk as an alternative
source of nutrition. This transition from breast milk to formula milk is
common in cases where breastfeeding may not be continued, or when a
combination of breastfeeding and formula feeding is adopted.
b) What are the benefit of drinking breast milk to the baby?
c) What is the meaning he eats 3x half a small a bowl of rice daily?
d) How are breastfeeding and complementary foods recommendation for
babies?
Breastfeeding and complementary foods play essential roles in the
nutrition and growth of babies. The recommendations for babies are
generally based on guidelines from reputable health organizations, such as
the World Health Organization (WHO) and the American Academy of
Pediatrics (AAP). Here are the typical recommendations:

1. **Exclusive Breastfeeding for the First 6 Months:**

- The WHO and AAP recommend exclusive breastfeeding for the first
six months of a baby's life, meaning the baby receives only breast milk and
no other foods or liquids, not even water, unless medically advised.

2. **Breastfeeding Continuation:**
- After six months, breastfeeding should continue, while complementary
foods are introduced.

3. **Introduction of Complementary Foods:**

- Around six months of age, babies need additional nutrients that breast
milk alone may not provide in sufficient quantities. Complementary foods
are introduced to complement breast milk and meet the baby's growing
nutritional needs.

4. **Age-Appropriate Complementary Foods:**

- Complementary foods should be age-appropriate, safe, and nutrient-
dense. These may include mashed fruits, vegetables, iron-fortified cereals,
and well-cooked pureed meats. New foods should be introduced one at a
time, allowing several days between each new food to monitor for
allergies or adverse reactions.

5. **Breastfeeding alongside Complementary Foods:**

- While introducing complementary foods, breastfeeding should
continue, as breast milk continues to provide essential nutrients and
immune support to the baby.

6. **Responsive Feeding:**
- Feeding should be done responsively, paying attention to the baby's
hunger and fullness cues. It's important not to force-feed the baby.

7. **Avoidance of Added Sugars, Salt, and Honey:**

- Added sugars, salt, and honey should be avoided in a baby's diet, as
they can be harmful or pose health risks to infants.

8. **Gradual Transition to Family Foods:**

 - Around 12 months of age, babies can gradually transition to consuming
family foods, while continuing to breastfeed if desired and appropriate.

9. **Continued Breastfeeding up to Two Years and Beyond:**

- The WHO recommends continued breastfeeding, alongside appropriate
complementary foods, up to two years of age or beyond, as long as both
the mother and baby desire to continue.

It's important to note that individual babies may have specific needs or
health considerations. Therefore, parents should consult with pediatricians
or healthcare professionals for personalized recommendations and
guidance on breastfeeding and introducing complementary foods to ensure
optimal growth and development for their child.
e) What is the meaning he has a history of immunization: BCG, scar (+);
DPT 1,2; HiB 1,2; Hepatitis 0,1,2; Polio 0,1,2?
f) How is the true schedule of immunization to baby?
g) What is the meaning currently currently, Rudi lives in the Kertapati area
near the market in the city of Palembang?

4. Physical examination:
BW: 8 Kg, BH: 78 cm
General state: looks sick
◦
Vital signs: BP: 80/50 mmHg, Pulse Rate: 120x/minute, T: 38,6 C, oxygen
saturation 90%.
Specific Examination:
Head: circum oral cyanosis (+), nostril breathing (+), conjungtiva not anemic, no
head bobbing.
Neck: within normal limits.

Chest:
Lung
Inspection: intercostal and subcostal retractions (+).
Palpation: stem fremitus increases in both lung fields (the child is crying)
Percussion: dim in all lung fields.
Auscultation: increased vesicular, fine wet crackles in both lung fields, no
wheezing heard
Heart
Inspection: normal chest shape, ictus cordis is not seen
Palpation: ictus cordis is not palpable
 Percussion: normal heart limits
Auscultation: normal I/II heart sound, gallop(-), murmur (-)
Stomach: flat, supple, liver and spleen are not palpable, normal bowel sound.
Extremities: no clubbing finger, no edema, no pale acral.
a) What is the interpretation of physical examination?
b) How is the abnormal mechanism of physical examination?
c) What is the interpretation of specific examination?
d) How are the abnormal mechanism of specific examination?
5. Laboratory Examination:
Blood test: Hb: 11,8 gr/dl, Leucocyte: 24.000/mm 3, diff. count: 1/1/6/72/18/2,
Blood sedimentation rate: 14 mm/hour, CRP 24 mg/L.
a) What is the interpretation of laboratory examination?
b) Ho ware the abnormal mechanism of laboratory examination?
6. How to diagnose?
7. Differential diagnosis?
8. Additional examination
9. Working diagnosis?
a) Definition
b) Epidemiology
c) Risk Factor
d) Clinical Manifestation

10. Treatment?
11. Complication?
12. Prognose?
13. SKDU?
14. NNI?
a) Al-Baqarah: 195 (Vaksinasi) dan (Kebersihan dan kesehatan)
b) An-Nisa: 71
c) An-Nisa: 29
d) Hadist terkait