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Contributors:

Arfi Syamsun
Catarina Budiyono
Diah Purnaning
Dian Puspitasari
Dyah Purnaning
Hamsu Kadriyan
Herpan Syafii Harahap
Eka Arie Yuliyani
ka Primayanti
rni!arifka
"oko Anggoro
#inda Sil$ana Sari
%arkus &ambu%as sa Ansyori
%uthia Cenderade'i
(ora )aofik
(o$rita Padauleng
Philip Habib
Prima Belia *athana
SAK ndriyani
Salim S+ )halib
Slamet ),ahyono
2011
Faculty of Medicine Mataram University
TUTORIAL
GUIDE
Block !
Res"iratory
#ystem
Contributors:
Arfi Syamsun
Catarina Budiyono
Diah Purnaning
Dian Puspitasari
Dyah Purnaning
Hamsu Kadriyan
Herpan Syafii Harahap
Eka Arie Yuliyani
ka Primayanti
rni!arifka
"oko Anggoro
#inda Sil$ana Sari
%arkus &ambu%as sa Ansyori
%uthia Cenderade'i
(ora )aofik
(o$rita Padauleng
Philip Habib
Prima Belia *athana
SAK ndriyani
Salim S+ )halib
Slamet ),ahyono
TEAM
Coordinator
dr. Arfi Syamsun, SpKF, M.Si.Med
Secretary
dr. Muthia Cenderadewi
Team Members
dr. Arif Zuhan, SpB
dr. Catarina Budiyono
dr. Hamsu Kadriyan, Sp.THT, M.Kes
dr. Ika Primayanti
dr. Irniarifka
dr. !oko An""oro, M.Si, SpP#
dr. $inda Si%&ana Sari
dr. Ma Isa Ansyori
dr. Muthia Cenderade'i
dr. (ora Taofik
dr. (o&rita Padau%en"
dr. Phi%ip Ha)i)
dr. Prima Be%ia Fathana
dr. Sa%im S. Tha%i), Sp.P
dr. SAK Indriyani, Sp.A, M.Kes
dr. S%amet T*ahyono, SpP

Expert Panel
dr. Arif Zuhan, SpB
dr. Hamsu Kadriyan, Sp.THT, M.Kes
dr. !oko An""oro, M.Si, SpP#
dr. Sa%im S. Tha%i), Sp.P
dr. SAK Indriyani, Sp.A, M.Kes
dr. S%amet T*ahyono, Sp.P
Skills Lab Instructors
+T , dr. +r'in Kresnoadi, M. Si. Med, SpAn
dr. Arif Zuhan, SpB
$un" Physi-a% +.amination , dr. Prima Be%ia Fathana
dr. Muthia Cenderade'i
Tutors
dr. Ika Primayanti
dr. Irniarifka
dr. $inda Si%&ana Sari
dr. Mas Isa Ansyori
dr. Muthia Cenderade'i
dr. (ora Taofik
dr. (o&rita Padau%en"
dr. Prima Be%ia Fathana
Preace
The )urden of respiratory diseases 'or%d'ide is &ery si"nifi-ant and has )een one of the
"reatest "%o)a% hea%th pro)%em, espe-ia%%y in the de&e%opin" 'or%d. In re-ent de-ades, their
in-iden-e has steadi%y in-reased e&ery'here. Tu)er-u%osis, a-ute respiratory infe-tions,
pneumonia, -hroni- o)stru-ti&e pu%monary diseases, and asthma ha&e )een -ontri)utin" to hi"h
mor)idity, disa)i%ity and e&en morta%ity in a%% a"e "roups in-%udin" -hi%dren and adu%ts at their
produ-ti&e a"e. Se&era% fa-tors that -ontri)ute to the rapid in-rease ofin respiratory diseases
in-%ude the to)a--o smokin" ha)its in de&e%opin" -ountries, the HI/ epidemi-, ur)aniation,
industria%iation, airtmospheri- po%%ution, and the deterioration of so-ioe-onomi- -onditions in
se&era% de&e%opin" -ertain -ountries as 'e%% as the 'eak hea%th systems and pro"ram.
0ithin this )%o-k, students 'i%% %earn to understand patho%o"i-a% pro-esses, identify -%ini-a%
manifestations, e.p%ain the differentia% dia"noseis of different -%ini-a% manifestations, and p%an the
mana"ement and pre&ention of respiratory diseases from simu%ation -ases.
0e e.pe-t that this )ook 'ou%d pro&ide a proper "uidan-e for students and tutors.
Ho'e&er, 'e )e%ie&e)e%ie&e that there are sti%% many 'eaknesses sti%% e.isted 'ithin this )ook,
and therefore 'e hope for -ontinuous input from the readers.
Author
May 12332
Introduction
The fun-tion of respiratory system fun-tion is to a%%o' "as e.-han"e of o.y"en and -ar)ondio.ide
)et'een "as of e.terna% en&ironment and )%ood. In human, the anatomi-a% features of the
respiratory system in-%ude upper and %o'er air'ays, %un" and the respiratory mus-%es.
#isorders of the respiratory system -an *eopardie the norma% "as e.-han"e and 'hen untreated,
may threaten %ife. 4espiratory diseases are a -ommon and important -ause of i%%ness and death.
A%thou"h they present 'ith a%most simi%ar si"n and symptoms, respiratory diseases -an )e
-aused )y different under%yin" -ause. 4espiratory diseases -an )e -%assified in many 'ays su-h
as )y the or"an in&o%&ed, )y the pattern of symptoms or )y the -ause of the disease. A--ordin"%y,
the dia"nosti- approa-h and mana"ement 'ou%d a%so )e different. A "enera% physi-ian shou%d )e
e5uipped 'ith ade5uate -ommuni-ation and -%ini-a% ski%%s to proper%y dia"nose and mana"e the
respiratory disorders in primary -are.
This )%o-k 'i%% present the pro)%ems of the respiratory system that are -ommon%y en-ountered )y
"enera% physi-ian in primary -are. The -ases 'i%% dea% 'ith the patho6physio%o"y and -%ini-a%
presentation of the ma*or types of respiratory disease 'ith re&ie' of the anatomy, physio%o"y and
other )iomedi-a% aspe-ts. Cases 'i%% in-%ude infe-tious and -hroni- disease as 'e%% as adu%t and
pediatri-s -onditions. $e-tures, demonstrations, %a)oratory 'ork -omputer pro"ram and other
resour-es 'i%% )e used to pro&ide )a-k"round information su-h as patho%o"y, physio%o"y and in
depth %earnin" on the -%ini-a% aspe-ts. +&a%uation 'i%% in-%ude tutoria% parti-ipation, ski%%s
assessment and an end6of6unit 'ritten e.amination.
The 4espiratory B%o-k 'i%% )e -ondu-ted for 7 'eeks. In the end of this )%o-k, students 'i%% )e
e&a%uated throu"h ora% and 'ritten e.amination. The key features of )%o-k 31 are the fo%%o'in",
Tutoria% "roups meetin" for 1 hours, 1 times a 'eek
Three to fi&e hours of %e-tures
T'o times a 'eek ski%%s %a)oratory
A patient -onta-t e.perien-e for 869 hours in )ed6side tea-hin"
:ne hour per 'eek -on-entratin" on -riti-a% appraisa%
:ne to t'o hours per 'eek on popu%ation hea%th
16hour %a)oratory e.perien-e re%ated to the -ases under study
$earnin" :ut-ome
At the end of this )%o-k, students are e.pe-ted to )e a)%e to sho' -ompeten-y in identifyin"
pro)%ems, e.tra-tin" information, su""estin" additiona% in&esti"ation, esta)%ishin" differentia%
dia"nosis and definite dia"nosis, and formu%atin" mana"ement p%an for respiratory disorders
$earnin" :)*e-ti&es
3. K(:0$+#;+
The nature and -ourse of a%terations in fun-tion produ-ed )y etio%o"i-a% a"ents
and me-hanisms <pathophysio%o"y= of the &arious disorders in the upper and %o'er
respiratory systems of pediatri- and adu%ts, a-ute and -hroni- infe-tion, autoimmune,
ma%i"nan-y, de"eneration, and trauma
The nature and -ourse of a%terations in stru-ture produ-ed )y etio%o"i-a% a"ents
and me-hanisms <patho%o"i-a% anatomy= of the respiratory systems, -hroni- infe-tion and
spe-ifi- pro-esses, ma%i"nan-y
Appropriate use of %a)oratory te-hni5ues in identifyin" diseases or hea%th
pro)%ems, radio%o"y, physio%o"y, mi-ro)io%o"y and -%ini-a% patho%o"y
Therapeuti- use of dru"s in respiratory systems, symptomati- dru"s, steroid,
anti)ioti-s and antitu)er-u%osis
Kno'%ed"e of the a-tion, meta)o%ism, and to.i- effe-ts of dru"s
1. SKI$$S
C$I(ICA$ SKI$$S
Students are a)%e to to a-5uire, interpret, synthesie and re-ord -%ini-a% information in
mana"in" the hea%th pro)%ems of patients, -onsiderin" their physi-a%, so-ia% and emotiona%
fa-tors espe-ia%%y in disorders in the upper and %o'er respiratory tra-t in-%udin" a-ute and
-hroni- infe-tion, de"eneration, neop%asms and trauma.
>ti%ie data from the history, physi-a% e.am and %a)oratory e&a%uations to identify the
hea%th pro)%em
+.tra-t the ne-essary information from anamnesis, physi-a% dia"nosis to formu%ate
differentia% dia"nosis
Ad&ise the ne-essary %a)oratory e.amination to esta)%ish dia"nosis and interpret the
resu%ts
P%an pharma-o%o"i-a% and non pharma-o%o"i-a% treatment disorders in the upper and
%o'er respiratory tra-t in adu%ts and pediatri-s
To formu%ate effe-ti&e mana"ement p%ans <dia"nosti-, treatment, and pre&ention
strate"ies= for respiratory diseases
Ad&ise the strate"ies for primary, se-ondary and tertiary pre&ention for disorders in the
upper and %o'er respiratory tra-t
4e-o"nie the re%ationship )et'een hea%th and i%%ness, the patient and the patient?s
en&ironment
#IA;(:STIC A(# TH+4AP+>TIC SKI$$S
Perform a satisfa-tory physi-a% e.amination to respiratory systems
A)i%ity to take a satisfa-tory medi-a% history in-%udin" )io%o"i-a%, psy-hoso-ia%,
nutritiona%, and o--upationa% dimensions
App%y the appropriate use of %a)oratory methods in identifyin" diseases or hea%th
pro)%ems, radio%o"i-a%, mi-ro)io%o"i-a% and -%ini-a% %a)oratory findin"s
A)i%ity to re-o"nie patients 'ith immediate%y %ife threatenin" -onditions
A)i%ity to app%y the therapeuti- use of dru"s in respiratory pro)%ems
C4ITICA$ THI(KI(;
Students are a)%e to -riti-a%%y appraise *ourna%s, app%y -ertain ru%es of e&iden-e to -%ini-a%,
in&esti"ationa% and pu)%ished data in order to determine their &a%idity and app%i-a)i%ity in their
future pra-ti-es
8. P4:F+SSI:(A$ B+HA/I:4
Students 'i%% "ain a)i%ities to de&e%op professiona% )eha&iour re5uired as a hea%th professiona%
as the fo%%o'in",
- a)%e to -ommuni-ate effe-ti&e%y 'ith -o%%ea"ues in %earnin"
- a)%e to -ommuni-ate effe-ti&e%y 'ith patient in assessment and -are
- respe-t the patient and their ri"hts
- a)%e to administer informed -onsent
Topic Tree
Etiology, patophysiology and symptoms of
disorders in the upper respiratory tract
E!aluation
Students are assessed throu"h formati&e and summati&e e&a%uation. In formati&e feed)a-k,
a%% students 'i%% re-ei&e -onstru-ti&e feed)a-k on their pro"ress from the tutor in the form of
'ritten and ora% feed)a-k. Se&era% assessment sheets 'i%% )e pro&ided to tutor and instru-tor
Respiratory
System
Upper
Lower
Allergy
Infection Common infection in upper respiratory tract
Pathogenesis
Diagnostic approach
Management
Infection
Chronic infection and specific processes in
lower respiratory tract of pediatrics/adults
Pathogenesis/pathophysiology
Clinical manifestation
Diagnostic approach
Management and prevention
Acute infection in lower respiratory tract of
pediatrics/adults
Pathogenesis/pathophysiology
Clinical manifestation
Diagnostic approach
Management
Degeneration
Degenerative diseases in lower respiratory
tract
Pathogenesis
Clinical manifestation
Diagnostic approach
Management
Malignancy
Malignancy in lower respiratory tract
Clinical manifestation
Diagnostic approach
Management
Primary prevention
Malignancy of upper respiratory tract
Clinical manifestation
Diagnostic approach
Management

Malignancy
Emergency
Trauma and respiratory emergency
Clinical manifestation
Diagnostic approach
nitial management
Allergy in upper respiratory tract
Pathogenesis
Diagnostic approach
Management
Etiology, patophysiology and symptoms of
disorders in the lower respiratory tract
in order to assess the kno'%ed"e, attitudes, and pro-edura% ski%%s of students. Tutors 'i%%
parti-u%ar%y p%ay important ro%e in 3= assurin" students@ attendan-e, dis-ip%ine and
parti-ipation and 1= assessin" student performan-e in ora% e.amination-omputer6)ased
e.amination.
Summati&e e&a%uation 'i%% )e -ondu-ted at the end of the )%o-k. Attendan-e for more than
A2B in a%% a-ti&ities 'i%% )e a prere5uisite to sit in the )%o-k e.amination, )ut 'i%% not )e
a--ounted for the fina% mark.
The o&era%% )%o-k e&a%uation of student a-hie&ement durin" the )%o-k 'i%% -onsist of se&era%
-omponents, 3= Performan-e, 'hi-h in-%ude the indi&idua% performan-e and "roup report of
tutoria%, 1= Ski%%s, 'hi-h in-%ude performan-e in ski%%s %a)oratory and %a)oratory 'ork, 8=
Kno'%ed"e, 'hi-h in-%ude "roup and indi&idua% student assi"nment, 'ritten and ora%
e.amination-omputer6)ased e.amination. The fo%%o'in" ta)%e summaries the -ontri)ution of
these -omponents in students fina% mark.
Cate"ories #!erall
Percenta"e
Component Score percenta"e
B%o-k performan-e CB Performan-e 1.CB
4eport from tutoria% 1.CB
Ski%%s %a)oratory 123CB Physi-a% e.amination 32CB
+ndotra-hea% intu)ation 32CB
$a)oratory 'ork 7.CB
Fie%d &Studentisit a
assi"nment
1.CB
+.amination 72B 0ritten e.amination ACC2B
Computer6)ased :ra%
e.amination
3C12B
:ra% e.amination 'i%% )e -ondu-ted for 82 minutes for ea-h student. +a-h student 'i%% )e
assessed )y e.aminer on the understandin" re"ardin" the -on-ept introdu-ed in the )%o-k. A
-ase re%ated to the )%o-k topi-s 'i%% )e presented and se&era% 5uestion 'i%% fo%%o'. 0ritten
e.amination a--ounts the %ar"est proportion of the o&era%% )%o-k assessment. Mu%tip%e -hoi-e
5uestion 'ith s-enarios and &i"nette 'i%% )e presented.
Instruction or Students
A. T>T:4IA$
Tutoria% is mandatory for students, and students shou%d not )e %ate in attendin" tutoria%.
Students 'ho are %ate more than 32 minutes are not a%%o'ed to attend the tutoria%. The
minimum attendan-e for tutoria% is D2B. Students are on%y a%%o'edmay )e a)sent or not
attendin"to unattend the tutoria% on e.-eptiona% )asis, su-h as si-kness, fami%y reason et-. A
%etter e.p%ainin" the reason of non6attendan-e shou%d )e sent to the tutor at the minimum 1
days )efore the day of a)sen-e. In the e&ent of si-kness, a %etter from the attendin" physi-ian
shou%d )e sent to the tutor at the ma.imum 1 days after the day of a)sen-e. Students 'ho
are not attendin" tutoria% shou%d )e "i&en assi"nment )y the tutor.
The tutoria% approa-h is de&e%oped )ased on the pro)%em )ased %earnin" approa-h 'here
students a-t as the -enter. Students are responsi)%e for their o'n %earnin" pro-esses
in-%udin" determinin" 'hat to %earn and to read. Students are dis-ussin" s-enarios in "roup
-onsistin" of 32631 students and usin" the pro)%em as the )asis to %earn, determine and
a-hie&e %earnin" o)*e-ti&es. #is-ussion shou%d )e -ondu-ted in the fo%%o'in" phases as
)e%o',
Step 3, C%arifyin" unfami%iar terms
Step 1, Pro)%ems definition
Step 8, Brainstormin"
Step 9, Ana%yin" the pro)%ems
Step C, Formu%atin" %earnin" o)*e-ti&es
Step E, Se%f6study
Step 7, 4eportin"
The tutoria% "roups 'i%% "enera%%y -omp%ete one -ase per 'eek. Students 'i%% %earn a)out the
patho%o"i-a% pro-ess, identify -%ini-a% manifestation, e.p%ain the differentia% dia"nosis of
different -%ini-a% manifestations and p%an the mana"ement and pre&ention of respiratory
diseases from simu%ation -ases. Cases that are presented 'i%% -o&er a ran"e of topi-
in-%udin" a-ute and -hroni- infe-tion, autoimmune, ma%i"nan-y, de"eneration, and trauma.
4eport of the tutoria% shou%d )e su)mitted to tutor e&ery Monday at the %atest on 31 pm. $ate
su)mission 'i%% not )e to%erated and 'i%% not )e s-ored.
B. FI+$# /ISIT A(# H:M+ /ISIT
#urin" this )%o-k <'eek 16C=, students 'i%% )e 'orkin" on a fie%d assi"nment. :ne Se&era%
"roups -onsisted of C6E students 'i%% )e sent to Puskesmas in Kota Mataram and $om)ok
Barat distri-t. The Fa-u%ty 'i%% a--ompany students 'ith introdu-tory %etter. Students may
arran"e &isit to Puskesmas on a s-hedu%e -on&enient for them <for e.amp%e, Thursday or
Saturday 'hen there is no s-hedu%e of )edside tea-hin"=. Students must meet 'ith hea%th
personne% responsi)%e for -ommuni-a)%e disease -ontro% and ha&e inter&ie' 'ith the hea%th
personne% re"ardin" the pro"ram on -ommuni-a)%e disease -ontro%, in-%udin" the )arriers.
The inter&ie' "uide 'i%% )e pro&ided )y the )%o-k -oordinator. Students shou%d a%so ask the
hea%th personne% to identify one patient 'ith tu)er-u%osis in their -at-hment area. A &isit to the
home of the patient shou%d )e arran"ed )y students. In this &isit, students must assess the
so-ia%, en&ironmenta% and )eha&iora% fa-tors inf%uen-in" the disease. 4eport must'i%% )e
presented to the -%ass-o%%e-ted on 'eek E67 on 'eek E and 7. An e&iden-e that students
ha&e &isited Puskesmas and patient shou%d )e pro&ided.
C. $+CT>4+S
$e-ture is mandatory for students. The minimum attendan-e for %e-ture is A2B.
Students may a%so put re5uest for additiona% %e-ture or e.pert -onsu%tation 'hen ne-essary.
#. C4ITICA$ APP4AISA$
S+a-h Tuesday, students 'i%% -riti-a%%y re&ie' and dis-uss a *ourna% arti-%e re%ated to
respiratory disorders. A%% students shou%d read, re&ie' and dis-uss the arti-%e on an indi&idua%
)asis. The arti-%e *ourna% for the fo%%o'in" Tuesday 'i%% )e up%oaded in the intranet at the end
of the 'eek <Friday or Saturday=. :ne of mem)er from 4esear-h Methodo%o"y di&ision 'i%%
attend the session as the resour-e person.
+. 0++K$F CAS+ 4+/I+0
:n a 'eek%y )asis, a s-enario re&ie' 'ith the -%ass 'i%% )e -ondu-ted 'ith the tutors and
e.perts as a 'rappin" up session. :ne of the "roup 'i%% )e assi"ned to present their findin"s.
Guestions and pro)%ems that -annot )e addressed in the "roup -ou%d )e ref%e-ted and
dis-ussed 'ith the e.perts.
F. B+#SI#+ T+ACHI(;
To e.pose the students as ear%y as possi)%e to the -%ini-a% -ases, students 'i%% ha&e )ed6side
tea-hin" session to fi&e outpatient and inpatient 'ard in the hospita%, 'hi-h in-%ude the
Pediatri-s 'ard, Interna% Medi-ine 'ard, Pu%monary 'ard, 4adio%o"y and +ar (ose Throat
outpatient -%ini-. Students 'i%% %earn 'ith spe-ia%ists on physi-a% dia"nosti- and radio%o"y
e.amination of patients 'ith respiratory disorders.
;. 4+A#I(; ASSI;(M+(T
In readin" assi"nment, students 'i%% )e "i&en one ma*or readin" to he%p them in
understandin" the -on-ept and approa-h to the respiratory disorders. Summary of readin"
assi"nment shou%d )e su)mitted to )%o-k team e&ery Monday. Components of the readin"
materia%s 'i%% )e assessed in the fina% e.amination.
0eek 3, Pra-ti-a% Approa-h of $un" Hea%th
0eek 1, Internationa% Standard of Tu)er-u%osis Care
0eek 8, ;%o)a% Initiati&es on Asthma
0eek 9, :--upationa% 4espiratory #iseases
0eek C, Mana*emen Terpadu Ba%ita Sakit
0eek E, Pandemi- Inf%uena in 13st -entury
0eek 7, 4e&ie' arti-%e on -ommon respiratory disease
H. $AB:4AT:4F 0:4K
See the instru-tion at the %a)oratory
I. SKI$$S $AB
See the instru-tion at the %a)oratory
Scenario $%
Sore Throat
A 'oman takes her A year o%d -hi%d to the do-tor )e-ause of sore throat sin-e t'o days )efore.
The -hi%d had fe&er three days a"o, then he a%so had -ou"h and runny nose. Sin-e the %ast four
months, he has )een sufferin" the same symptoms t'i-e. He a%so sho's %o' appetite and
rest%essness durin" s%eep.
The physi-a% e.amination re&ea%s the fo%%o'in",
(utritiona% status , under'ei"ht
CardioH4espirator y , /ita% si"ns are norma%, -hest is -%ear, heart sounds norma%.
Head and (e-k , inf%ammation si"ns of the pharyn. and tonsi% , en%ar"ement of %ymph
nodes, si"ns of ri"ht otitis media.
The physi-ian pres-ri)es anti)ioti- and symptomati- dru"s for the -hi%d. The physi-ian mentions
that the )eha&iora% and en&ironmenta% fa-tors 'ere a%so -ontri)uted to this respiratory disease.
&eerences
C%ements #A. Pharyn"itis, %aryn"itis and epi"%ottitis. In, Cohen !, et.a% editors. Infectious
Diseases, 1
nd
editions, &o% 3.(e' Fork, Mos)yI 1229. p893
#*aafar ZA. Ke%ainan te%in"a ten"ah. #a%am ,Soepardi +A, Iskandar H(, editor. Buku Ajar Ilmu
Kesehatan Telinga Hidung Tenggorok Kepala Leher. +disi ke %ima. !akarta,Ba%ai pener)it
FK>II 1223. p9D6C8
Paradise !$. :titis Media. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th
edition, 0B
Saunders,
(e' Fork, 1229, pp 138A69D
Pe%ton SI. :titis, sinusitis and re%ated -onditions. In, Cohen !, et.a% editors. Infectious Diseases,
1
nd
editions, &o% 3.(e' Fork, Mos)yI 1229. p89D
4usmar*ono, Soepardi +A. Penyakit serta ke%ainan farin" dan tonsi%. #a%am, Soepardi +A,
Iskandar H(, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher.
+disi ke%ima. !akarta, Ba%ai pener)it FK>I, 1223, pp 37A6A9
4usmar*ono, Kartosoediro S. :dinofa"i. #a%am, Soepardi +A, Iskandar H(, editor. Buku Ajar
Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher. +disi ke %ima. !akarta,Ba%ai
pener)it FK>II 1223. p37867
Turner 4B, Hayden ;F. The -ommon -o%d. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th


edition, 0B Saunders, (e' Fork, 1229, pp 38AD6D3
Turner 4B, Hayden ;F. A-ute pharyn"itis. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th


edition, 0B Saunders, (e' Fork, 1229, pp 38D869
0etmore 4F. Tonsi%s and adenoids. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th
edition,
0B Saunders, (e' Fork, 1229, 38DC67
Scenario ' %
Producti!e Cou"h
A 8CCD year o%d ma%e -omes to the pu%mono%o"y -%ini- at hospita% 'ith shortness of )reath-ou"h.
He has produ-ti&e -ou"h 'ith thi-k sputum <on-e or t'i-e tin"ed 'ith )%ood= for the %ast C
months 'ith thi-k =.=, and a%so recurrent episodes o shortness o breath. His 'ei"ht 'as
de-reasedin" sin-e the %ast 8 months, a%on" 'ith a de-reasedin" appetite. He has )een smokin"
1 pa-ks of -i"arrete per day sin-e the %ast 39C years. He has )een 'orkin" in an as)estos mine
for the %ast 1E years. He has a son that -urrent%y under"oes #:TS medi-ation. :n physi-a%
e.amination, his 'ei"ht is C2 k", his hei"ht is 372C -m, his )%ood pressure is 382HA2 mmH",
pu%se AA.Hminute, respiratory rate 1E.Hminute, temeperature 8E.7C, e.piratory 'heein" and
-ou"hin" durin" ma.ima% inspiration. In spirometry test, the F+/3HF/C ratio is EAB. The physi-ian
then p%ans further supporti&e e.aminations to sett%e the dia"nosis.
&eerences
Amin, Zu%kif%i J Bahar, Asri, 1227. Buku Ajar Ilmu Penakit Dalam. Pusat Pener)it Penyakit
#a%am FK >II !akarta.
Bi-k%ey $.S. Bates! "uide to Phsical #$amination and Histor Taking. $ippin-ott 0i%%iams and
0i%kins , 1228.
Fau-i et.a%. Harrison%s Principles of Internal &edicine 'e(enteenth #dition. The M-;ra'6Hi%%
Companies, In-. 122A , part 32.
Konsi% Kedokteran Indonesia. 'tandar Kompetensi Dokter #disi Pertama. Pener)it Konsi%
Kedokteran Indonesia 122E.
M-Phee S.!., Papadakis M.A. )urrent &edical Diagnosis * Treatment +ort,#ighth #dition. The
M-;ra'6Hi%% Companies, In-. 122D , -hapter D.
0or%d Hea%th :r"aniation Stop TB #epartment. Treatment of Tu-erculosis "uidelines +ourth
#dition. 0H: , 1232.
Scenario (%
Shortness o )reath
#r. Sanders, a pu%mono%o"ist, is %eadin" a 'ard round 'ith a "roup of medi-a% students. He %eads
the students to &isit one of his patients, a youn" ma%e.
#r. Sanders, ;ood mornin" Arthur, ho' do you fee% this mornin"K
Arthur, Mu-h )etter #r. Sanders, thank you.
#r. Sanders, 0e%% Arthur, as you see, today I )rin" some of my students 'ith me, and they
'ou%d %o&e to %earn more a)out your -ondition. 0ou%d you mind if they ask you
some 5uestionsK
Arthur, I don@t mind at a%%.
#r. Sanders, A%ri"ht peop%e, Arthur is my patient sin-e a -oup%e of years a"o. He@s 3A years o%d,
'as )rou"ht here t'o days a"o 'ith shortness of )reath. This happenned 'hen
he 'as p%ayin" so--er at s-hoo%. He 'as runnin" out of medi-ines, sin-e he hasn@t
&isited me for 1 months a%ready, so he 'as taken to the hospita% )y his friends. At
the +4, his pu%se 'as 38E.Hminute, his respiratory rate 'as 8E.Hminute, rhon-hi
and 'heein" 'as found on on )oth %un"s in %un" aus-u%tations.
So, is there anythin" you 'ou%d %ike to ask ArthurK ;o ahead.
Student A, Arthur, -ou%d you te%% us 'hat happened )efore you 'ere )rou"ht to the hospita%K
#id you ha&e any -ou"h or fe&erK #id you fee% any -hest pain 'hen you 'ere
ha&in" this atta-kK
Arthur, 0e%% I 'as p%ayin" so--er, then sudden%y I fe%t %ike it 'as "ettin" harder to )reath,
and there 'as a )urnin" pain in my -hest, and yes I had -ou"h sin-e the mornin",
)ut no fe&er or anythin" e%se.
Student B, Ha&e you e&er e.perien-ed any simi%ar -ondition )eforeK
Arthur,
#r. Sanders,
Feah, sin-e t'o years a"o. >sua%%y it 'as *ust -ou"h at ni"ht, )ut sometimes it "ot
'orse and then I 'as ha&in" diffi-u%ty to )reath. I ha&e &isited #r. Sanders
re"u%ar%y sin-e t'o years a"o, he "a&e me some pi%%s to re%ie&e the atta-ks, )ut I
ha&en@t &isited him on the %ast t'o months, so I don@t ha&e any supp%ies %eft.
So, do you ha&e any idea a)out the possi)%e me-hanism of Arthur@s -onditionK
&eerences
;%o)a% Initiati&e for Asthma +.e-uti&e Committee. "lo-al 'trateg for Asthma &anagement and
Pre(ention. South Afri-a , ;I(AI 1232.
In"ram 4H, Braun'a%d +. #yspnea and pu%monary edema. In, Kasper #$ et a% <eds=, Harrison!s
Principle of Internal &edicine. 3Eth edition <3=. (e' Fork, M-;ra' Hi%%I 122C. p 12369
#raen !4, 0ein)er"er !+. Approa-h to patient 'ith diseases of the respiratory system. In,
Kasper #$, $on"o #$, Braun'a%d +, Hauser S$, !ameson !!, editors. Harrison!s Principle
of Internal &edicine. 3Eth edition <1=. (e' Fork, M-;ra' Hi%%I 122C. p 39DC
M-Fadden +4. Asthma. In, Kasper #$, $on"o #$, Braun'a%d +, Hauser S$, !ameson !!, editors.
Harrison!s Principle of Internal &edicine. 3Eth edition, &o% 1. (e' Fork, M-;ra' Hi%%I 122C.
p 3C2A L 3E
Perhimpunan #okter Paru Indonesia. Asma. pedoman diagnosis dan penatalaksanaan di
Indonesia. !akarta , Ba%ai pener)it FK>II 1229.
4aha*oe (, Supriyatno B, Setyanto #B. Pedoman Nasional Asma Anak. !akarta, >KK
Pu%mono%o"i PP Ikatan #okter Anak IndonesiaI 1229.
Sundaru, Heru J Sukamto, 1227. Buku Ajar Ilmu Penakit Dalam. Pusat Pener)it Penyakit
#a%am FK >II !akarta.
Scenario * %
+yspnea
A 72 year o%d man -omes to the emer"en-y room 'ith diffi-u%ty of )reathin". The diffi-u%ty of
)reathin" has )een startedHe has )een ha&in" a se&ere diffi-u%ty of )reathin" sin-e 8 days a"o,
a%on" 'ith -ou"h 'ith ye%%o'ish sputum produ-tion. The patient has e.perien-ed dyspnea durin"
hard a-ti&ities for 32 years, and it 'ais "ettin" 'orse so that he hadn@t'as@t )een a)%e to to 'ork
sin-e the %ast C years%ate%y. He has )een smokin" 1 pa-ks of -i"arette per day sin-e the %ast CC
years. He retired as a -onstru-tion 'orker 12 years a"o. He is hard%y a)%e to do anythin" )y
himse%f ri"ht no'. +&en takin" a )ath or "ettin" dressed makes him short of )reath. He a%so had
-ou"h 'ith ye%%o'ish sputum produ-tion o&er the past 8 days. :n e.amination, h is )ody 'ei"ht is
C2 K", and his hei"ht is 3E1 -m. Hhis )%ood pressure is 372H322 mmH", pu%se 329.Hmin,
respiratory rate 8E.Hmin, and temperature 87.A
o
C. The %ips %ooks -yanoti-, there are inter-osta%s
retra-tion and -ontra-tion of a--essory respiratory mus-%es. Hyperresonant per-ussion in )oth
%un"s. Aus-u%tation of the -hest re&ea%s 'idespread e.piratory 'heee and inspiratory -oarse
-ra-k%es.
&eerence
Asa"aff H. Dasar,dasar Ilmu Penakit Paru. Air%an""a >ni&ersity Press, 122D, pp 18361CE
Burnside. Adams Diagnosis +isik. 3DDC, +;C, pp 3D36133
M- Phee S!. )urrent &edical Diagnosis and Treatment. $an"e6M-.;ra' Hi%%, 122D, pp 11A6188
M- Phee S!. Pathophsiolog of Disease. $an"e6M-.;ra' hi%%, 1227, pp.13A61CC,
;uyton AC, Ha%% !+. +isiologi kedokteran. Pener)it Buku Kedokteran +;C, 3DD7, pp E716E7A
4ei%%y !!, Si%&erman +K, Shapiro S#. Chroni- o)stru-ti&e pu%monary disease. Harrison!s
Principles of Internal &edicine. 3Eth edition. (e' Fork, M-;ra'6Hi% -ompanies, pp 3C976C9
Scenario , %
Put -our Seat )elt #n. Please...
A &i-tim of road traffi- a--ident, a ma%e a"e 12, 'as )rou"ht to the emer"en-y room. He 'as
dri&in" his -ar, 'ithout 'earin" a seat )e%t, 'hen sudden%y a )ike rider -rossed in front of his -ar
and instant%y he pushed the )rake so hard that he f%e' for'ard and his -hest hit the steerin"
'hee%. In the emer"en-y room, he is -ons-ious )ut -omp%ainin" of ha&in" diffi-u%ty of )reathin".
Physi-a% e.amination sho's some )ruises on the %eft -hest. His )%ood pressure is D2 mmH" on
pa%pation, pu%se 312.Hmin, and respiratory rate 89.Hmin. The attendin" physi-ian a%so notes that
there is asymmetri- mo&ement of the patient@s -hest, in 'hi-h the %eft hemithora. is de%ayed on
inspiration. Aus-u%tation re&ea%s diminished )reath sounds in the %eft hemithora.. The physi-ian
starts the initia% pro-edures to sta)i%ie the patient.
&eerence
Karnadihar*a 0, #*o*osu"ito MA, $ukitto P, 4ahmad KB, Manua)a T0. #indin" toraks dan
p%eura, trauma. #a%am , S*amsuhidayat 4, de !on" 0, editor. Buku Ajar Ilmu Bedah. +disi
kedua. !akarta , Pener)it )uku kedokteran +;CI 122C. p92E
Maddaus MA, $uketi-h !#. Chest 'a%%, %un", mediastinum and p%eura. 'ch/art0!s Principles of
'urger. +i"hth edition, M- ;ra' Hi%%, $ondon, 122C
S*amsuhidayat 4, Ahmadsyah I, Busroh I#I, 4ahmad KB. Trakea, mediastinum dan paru,
trauma. #a%am , S*amsuhidayat 4, de !on" 0, editor. Buku Ajar Ilmu Bedah. +disi kedua.
!akarta , Pener)it )uku kedokteran +;CI 122C. p91D682
Scenario /%
E!erlastin" Cou"h
An ei"ht month o%d )a)y "ir% 'as )rou"ht to the pediatri- -%ini- at 4S>P Mataram 'ith history of
re-urrent -ou"h of three months duration. The -ou"h 'as predominant%y no-tura% and in the
ear%y mornin", 'ith no asso-iated 'heee or fe&er. The )a)y@s father has )een smokin" 1 pa-ks
of -i"arrette a day for 3C years. The )a)y 'as )orn 'ith norma% %a)or at 8A 'eeks of pre"nan-y.
The )a)y 'as on%y )reast6fed on the first 1 months. The mother didn@t kno' 'hether there 'as
any history of -onta-t 'ith tu)er-u%osis patients. Fami%y history, the mother has mornin" sneein"
'ith -%ear rhinorrhea for years. :n the e.amination, her 'ei"ht 'as 32 k" and her hei"ht 'as A2
-m, the temperature 'as 87
2
C, pu%se 312.Hmin, respiratory rate 82.Hmin. There 'ere no
-yanosis, -%u))in", or ear, nose and throat a)norma%ities.
&eerences
Boat TF. Chroni- or re-urrent respiratory symptoms. In, Behrman 4+, !enson HB. Nelson
Pediatrics. 37
th
edition, 0B Saunders, (e' Fork, 1229, pp 39236C
Cherni- /, Boat TF, 0i%mott 40. Kendi"@s #isorders of the 4espiratory Tra-t in Chi%dren.
Se&enth +dition, 0B Saunders Company, $ondon, 1227
Haddad ;;, Pa%ao 4M. #ia"nosti- approa-h to respiratory diseases. In, Behrman 4+, !enson
HB. Nelson Pediatrics. 37
th
edition, 0B Saunders, (e' Fork, 1229, pp 387C6D
Ho%%in"er $#. Forei"n )odies of the air'ay. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th

edition, 0B Saunders, (e' Fork, 1229, pp 3932633
$on" SS. Pertussis. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th
edition, 0B Saunders,
(e' Fork, 1229, pp D2A631
$iu AH, Spahn !#, $eun" #FM. Chi%dhood asthma. Nelson Pediatrics. 37
th
edition, 0B Saunders,
(e' Fork, 1229, pp DCA6E9
Muno FM, Starke !4. Tu)er-u%osis. In, Behrman 4+, !enson HB. Nelson Pediatrics. 37
th
edition,
0B Saunders, (e' Fork, 1229, pp DCA6E9
Mor"an 0!, Taussi" $M. The -hi%d in persistent -ou"h. Pediatrics in 1e(ie/, A<A=, 19D6C8, 3DA7
Scenario 0
1ailin" )aby
A C month o%d ma%e infant 'as )rou"ht to emer"en-y room )e-ause of shortness of )reath. His
mother informed that the shortness of )reath appeared 32 hours a"o and 'ere "ettin" 'orse.
The )a)y@s )reathin" sounded %ike -ra-k%es, he -ried and 'ai%ed a%% the time, and %ess )reastfed.
Fi&e days a"o, the )a)y "ot dry -ou"h, runny nose, and mi%d fe&er. There 'as no history of
)reath shortness )efore.
From the physi-a% e.amination in the emer"en-y room, the infant %ooked 'eak, temperature
8A
2
C, respiratory rate CA.Hminute, inter-osta% retra-tion MHM, rhon-hi MHM. 'heein" MHM.
&E2E&E3CES
Brashers, /a%entin. $. Pathophsiolog The Biologic Basis +or Disease in Adult and )hildren 2
Alteration of pulmonar function chapter 33. st. $ouis Missouri , +%sei&er Mos)y, 122E.
(anin" 4oni, Hadianto Isman"oen, ama%ia setyati, Bronkitis Akut. In , (astiti (. 4aha*oe,
Bam)an" supriyatno, #arma'an Budi Setyanto, editor. Buku Ajar 1espirologi Anak.
+disi pertama. !akarta I Badan Pener)it I#AI, 1232, pp 8826881
Said, Mard*anis, Pneumonia. In , (astiti (. 4aha*oe, Bam)an" supriyatno, #arma'an Budi
Setyanto, editor. Buku Ajar 1espirologi Anak. +disi pertama. !akarta I Badan Pener)it
I#AI, 1232, pp 8C268EC
Stanton, !enson Behrman K%ie"man. Nelson Te$t-ook 4f pediatrics 56
th
edition . Phi%ade%phia ,
e%sei&er in-, 1227.
0i%%iam 0. Hay, !r $e&in, Myron !. Current. Diagnosis and Treatment )hapter 56. >nited Stated
of Ameri-a , M-"ra'6Hi%% Companies, 122D.