Student Guide Block 12 Scenario 1

Block 12: Respiratory System
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Contributors:
Astri Ferdiana
Dian Puspita Sari
Dyah Purnaning
Hamsu Kadriyan
Herpan Syafii Harahap
Markus Rambu
Philip Habib
SAK Indriyani
Salim S. Thalib
Slamet Tjahyono
2009

FacultyofMedicineMataramUniversity
STUDENTGUIDE
Block12
RespiratorySystem

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TEAM

Coordinator
dr. Astri Ferdiana, MPH

Secretary
dr. Dian Puspita Sari
dr. Dyah Purnaning

Team Member
dr. Hamsu Kadriyan, Sp.THT, M.Kes
dr. Herpan Syafii Harahap
dr. Markus Rambu, Sp.THT
dr. Philip Habib
dr. Salim S. Thalib, Sp.P
dr. SAK Indriyani, Sp.A
dr. Slamet Tjahyono, Sp.P


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Preface

The burden of respiratory diseases worldwide is very significant and has been one of the
global health problem especially in the developing world. In recent decades, their incidence has
steadily increased everywhere. Tuberculosis, acute respiratory infections, pneumonia, chronic
obstructive pulmonary diseases and asthma have been contributing to high morbidity, disability and
even mortality in all age groups including children and adults at their productive age. Several
factors that contribute to the rapid increase in respiratory diseases include the tobacco smoking
habits in developing countries, the HIV epidemic, urbanization, industrialization, atmospheric
pollution, and the deterioration of socioeconomic conditions in certain countries as well as the weak
health systems and program.
Within this block, students will learn pathological process, identify clinical manifestation,
explain the differential diagnosis of different clinical manifestations and plan the management and
prevention of respiratory diseases from simulation cases.
We expect that this book would provide a proper guidance for students and tutors. However,
we believe that there are still many weaknesses in this book, and therefore we hope for continuous
input from the readers.

Author
May 2009


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Introduction

The function of respiratory system function is to allow gas exchange of oxygen and carbondioxide
between gas of external environment and blood. In human, the anatomical features of the
respiratory system include upper and lower airways, lung and the respiratory muscles.

Disorders of the respiratory system can jeopardize the normal gas exchange and when untreated,
may threaten life. Respiratory diseases are a common and important cause of illness and death.
Although they present with almost similar sign and symptoms, respiratory diseases can be caused
by different underlying cause. Respiratory diseases can be classified in many ways such as by the
organ involved, by the pattern of symptoms or by the cause of the disease. Accordingly, the
diagnostic approach and management would also be different. A general physician should be
equipped with adequate communication and clinical skills to properly diagnose and manage the
respiratory disorders in primary care.

This block will present the problems of the respiratory system that are commonly encountered by
general physician in primary care. The cases will deal with the patho-physiology and clinical
presentation of the major types of respiratory disease with review of the anatomy, physiology and
other biomedical aspects. Cases will include infectious and chronic disease as well as adult and
pediatrics conditions. Lectures, demonstrations, laboratory work computer program and other
resources will be used to provide background information such as pathology, physiology and in
depth learning on the clinical aspects. Evaluation will include tutorial participation, skills assessment
and an end-of-unit written examination.

The Respiratory Block will be conducted for 7 weeks. In the end of this block, students will be
evaluated through oral and written examination. The key features of block 12 are the following:
Tutorial groups meeting for 2 hours, 3 times a week
Three to five hours of lectures
Two times a week skills laboratory
A patient contact experience for 3-4 hours in bed-side teaching
One hour per week concentrating on critical appraisal
One to two hours per week on population health
a 2-hour laboratory experience related to the cases under study

Learning Outcome

At the end of this block, students are expected to be able to show competency in identifying
problems, extracting information, suggesting additional investigation, establishing differential
diagnosis and definite diagnosis, and formulating management plan for respiratory disorders

Learning Objectives

1. KNOWLEDGE
The nature and course of alterations in function produced by etiological agents and
mechanisms (pathophysiology) of the various disorders in the upper and lower respiratory
systems of pediatric and adults: acute and chronic infection, autoimmune, malignancy,
degeneration, and trauma
The nature and course of alterations in structure produced by etiological agents and
mechanisms (pathological anatomy) of the respiratory systems: chronic infection and
specific processes, malignancy

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Appropriate use of laboratory techniques in identifying diseases or health problems:
radiology, physiology, microbiology and clinical pathology
Therapeutic use of drugs in respiratory systems: symptomatic drugs, steroid, antibiotics
and antituberculosis
Knowledge of the action, metabolism, and toxic effects of drugs

2. SKILLS
CLINICAL SKILLS
Students are able to to acquire, interpret, synthesize and record clinical information in
managing the health problems of patients, considering their physical, social and emotional
factors especially in disorders in the upper and lower respiratory tract including acute and
chronic infection, degeneration, neoplasms and trauma.
Utilize data from the history, physical exam and laboratory evaluations to identify the
health problem
Extract the necessary information from anamnesis, physical diagnosis to formulate
differential diagnosis
Advise the necessary laboratory examination to establish diagnosis and interpret the results
Plan pharmacological and non pharmacological treatment disorders in the upper and lower
respiratory tract in adults and pediatrics
To formulate effective management plans (diagnostic, treatment, and prevention
strategies) for respiratory diseases
Advise the strategies for primary, secondary and tertiary prevention for disorders in the
upper and lower respiratory tract
Recognize the relationship between health and illness, the patient and the patient's
environment

DIAGNOSTIC AND THERAPEUTIC SKILLS
Perform a satisfactory physical examination to respiratory systems
Ability to take a satisfactory medical history including biological, psychosocial,
nutritional, and occupational dimensions
Apply the appropriate use of laboratory methods in identifying diseases or health
problems: radiological, microbiological and clinical laboratory findings
Ability to recognize patients with immediately life threatening conditions
Ability to apply the therapeutic use of drugs in respiratory problems

CRITICAL THINKING
Students are able to critically appraise journals, apply certain rules of evidence to clinical,
investigational and published data in order to determine their validity and applicability in their
future practices

3. PROFESSIONAL BEHAVIOR
Students will gain abilities to develop professional behaviour required as a health professional
as the following:
- able to communicate effectively with colleagues in learning
- able to communicate effectively with patient in assessment and care
- respect the patient and their rights
- able to administer informed consent


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Evaluation

A. STUDENT EVALUATION
Students are assessed through formative and summative evaluation. In formative feedback, all
students will receive constructive feedback on their progress from the tutor in the form of
written and oral feedback. Several assessment sheets will be provided to tutor and instructor in
order to assess the knowledge, attitudes, and procedural skills of students. Tutors will
particularly play important role in 1) assuring students attendance, discipline and participation
and 2) assessing student performance in oral examination.

Summative evaluation will be conducted at the end of the block. Attendance for more than
80% in all activities will be a prerequisite to sit in the block examination, but will not be
accounted for the final mark.

The overall block evaluation of student achievement during the block will consist of several
components: 1) Performance, which include the individual performance and group report of
tutorial, 2) Skills, which include performance in skills laboratory and laboratory work, 3)
Knowledge, which include group and individual student assignment, written and oral
examination. The following table summarizes the contribution of these components in students
final mark.

Categories Overall
Percentage
Component Score percentage
Block performance 5% Performance 2.5%
Report from tutorial 2.5%
Skills laboratory 10% Physical examination 2.5%
Endotracheal intubation 2.5%
Clinical reasoning 5%
Laboratory work 2.5%
Student assignment 2.5%
Examination 80% Written examination 80%
Oral examination 20%

Oral examination will be conducted for 30 minutes for each student. Each student will be assessed
by examiner on the understanding regarding the concept introduced in the block. A case related to
the block topics will be presented and several question will follow. Written examination accounts
the largest proportion of the overall block assessment. Multiple choice question with scenarios and
vignette will be presented.

B. PROGRAM EVALUATION
To evaluate the effectiveness of the program, a weekly meeting evaluation will be conducted
with students, tutor and block team to discuss progress and any barriers encountered during
the implementation of the block. A short questionnaire will be passed to students and tutors
after the completion of each scenario.


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Instruction
A. TUTORIAL
Tutorial is mandatory for students and students should not be late in attending tutorial.
Students who are late more than 10 minutes are not allowed to attend the tutorial. The
minimum attendance for tutorial is 90%. Students may be absent or not attending the tutorial
on exceptional basis such as sickness, family reason etc. A letter explaining the reason of non-
attendance should be sent to the tutor at the minimum 2 days before the day of absence. In
the event of sickness, a letter from the attending physician should be sent to the tutor at the
maximum 2 days after the day of absence. Students who are not attending tutorial should be
given assignment by the tutor.

The tutorial approach is developed based on the problem based learning approach where
students act as the center. Students are responsible for their own learning processes including
determining what to learn and to read. Students are discussing scenarios in group consisting of
10-12 students and using the problem as the basis to learn, determine and achieve learning
objectives. Discussion should be conducted in the following phases as below:

Step 1: Clarifying unfamiliar terms
Step 2: Problems definition
Step 3: Brainstorm
Step 4: Analyzing the problems
Step 5: Formulating learning objectives
Step 6: Self-study
Step 7: Reporting

The tutorial groups will generally complete one case per week. Students will learn about the
pathological process, identify clinical manifestation, explain the differential diagnosis of different
clinical manifestations and plan the management and prevention of respiratory diseases from
simulation cases. Cases that are presented will cover a range of topic including acute and
chronic infection, autoimmune, malignancy, degeneration, and trauma.

Report of the tutorial should be submitted to tutor every Tuesday at the latest on 2 pm. Late
submission will not be tolerated and will not be scored.

B. FIELD VISIT AND HOME VISIT
During this block (week 2-5), students will be working on a field assignment. One group
consisted of 5-6 students will be sent to Puskesmas in Kota Mataram and Lombok Barat district.
The Faculty will accompany students with introductory letter. Students may arrange visit to
Puskesmas on a schedule convenient for them (for example, Thursday or Saturday when there
is no schedule of bedside teaching). Students must meet with health personnel responsible for
communicable disease control and have interview with the health personnel regarding the
program on communicable disease control including the barriers. The interview guide will be
provided by the block coordinator. Students should also ask the health personnel to identify
one patient with tuberculosis in their catchment area. A visit to the home of the patient should
be arranged by students. In this visit, students must assess the social, environmental and
behavioral factors influencing the disease. Report will be presented to the class on week 6 and
7. An evidence that students have visited Puskesmas and patient should be provided.


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C. LECTURES
Lecture is mandatory for students. The minimum attendance for lecture is 80%. Students may
also put request for additional lecture or expert consultation when necessary.

D. CRITICAL APPRAISAL
Each Tuesday, students will critically review and discuss a journal article related to respiratory
disorders. All students should read, review and discuss the article on an individual basis. The
article journal for the following Tusday will be uploaded in the intranet at the end of the week
(Friday or Saturday). One of member from Research Methodology division will attend the
session as the resource person.
E. WEEKLY CASE REVIEW
On a weekly basis, a scenario review with the class will be conducted with the tutors and
experts as a wrapping up session. One of the group will be assigned to present their findings.
Questions and problems that cannot be addressed in the group could be reflected and
discussed with the experts.
F. BEDSIDE TEACHING
To expose the students as early as possible to the clinical cases, students will have bed-side
teaching session to five outpatient and inpatient ward in the hospital, which include the
Pediatrics ward, Internal Medicine ward, Pulmonary ward, Radiology and Ear Nose Throat
outpatient clinic. Students will learn with specialists on physical diagnostic and radiology
examination of patients with respiratory disorders.

G. READING ASSIGNMENT
In reading assignment, students will be given one major reading to help them in understanding
the concept and approach to the respiratory disorders. Summary of reading assignment should
be submitted to block team every following Wednesday. Components of the reading materials
will be assessed in the final examination.

Week 1: Practical Approach of Lung Health
Week 2: International Standard of Tuberculosis Care
Week 3: Global Initiatives on Asthma
Week 4: Occupational Respiratory Diseases
Week 5: Manajemen Terpadu Balita Sakit
Week 6: Pandemic Influenza in 21st century
Week 7: Review article on common respiratory disease

H. LABORATORY WORK
See the instruction at the laboratory
I. SKILLS LAB
See the instruction at the laboratory

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Scenario 1: Fever and Cough

A medical intern who is stationed in a Puskesmas is observing an examination in the outpatient
clinic. The Puskesmas physician is examining a 4-year-old girl who is brought by her mother with
the complaints of fever since two days before, also cough and running nose. Since the last six
month, the child has been suffering the same symptoms twice. Mother usually only gives her cough
syrup and never bring her to physician. She also shows low appetite and restlessness during sleep.
The physician prescribes amoxycillin dry syrup for three days, cough syrup and paracetamol.

After the patient leaves, the physician mentions that respiratory disease is the most frequent
disease found in the outpatient clinic in that health center, especially among under-five children.

References

Clements DA. Pharyngitis, laryngitis and epiglottitis. In: Cohen J , et.al editors. Infectious
Diseases, 2
nd
editions, vol 1.New York: Mosby; 2004. p341

Djaafar ZA. Kelainan telinga tengah. Dalam :Soepardi EA, Iskandar HN, editor. Buku Ajar Ilmu
Kesehatan Telinga Hidung Tenggorok Kepala Leher. Edisi ke lima. J akarta:Balai
penerbit FKUI; 2001. p49-53

Paradise J L. Otitis Media. In: Behrman RE, J enson HB. Nelson Pediatrics. 17
th
edition, WB
Saunders, New York, 2004, pp 2138-49

Pelton SI. Otitis, sinusitis and related conditions. In: Cohen J , et.al editors. Infectious diseases.
2
nd
editions, vol 1.New York: Mosby; 2004. p349

Rusmarjono, Soepardi EA. Penyakit serta kelainan faring dan tonsil. Dalam: Soepardi EA, Iskandar
HN, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher.
Edisi kelima. J akarta: Balai penerbit FKUI, 2001, pp 178-84

Rusmarjono, Kartosoediro S. Odinofagi. Dalam: Soepardi EA, Iskandar HN, editor. Buku Ajar Ilmu
Kesehatan Telinga Hidung Tenggorok Kepala Leher. Edisi ke lima. J akarta:Balai
penerbit FKUI; 2001. p173-7

Turner RB, Hayden GF. The common cold. In: Behrman RE, J enson HB. Nelson Pediatrics. 17
th

edition, WB Saunders, New York, 2004, pp 1389-91

Turner RB, Hayden GF. Acute pharyngitis. In: Behrman RE, J enson HB. Nelson Pediatrics. 17
th

edition, WB Saunders, New York, 2004, pp 1393-4

Wetmore RF. Tonsils and adenoids. In: Behrman RE, J enson HB. Nelson Pediatrics. 17
th
edition,
WB Saunders, New York, 2004, 1395-7

www.who.int/topics/respiratory_tract_diseases/en/


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LECTURE SYLLABLES

Week Topic Subtopic Department
I Managing Learning Resources - Identify learning resources
- Critical reading
- Critical thinking
Public health
Diagnostic Approaches and
Management of Upper
Respiratory Disorders
- Clinical manifestations of
common upper respiratory
disorders
- Diagnostic procedures of
upper respiratory disorders
- Management and
treatment modalities of
common upper respiratory
disorders
ENT
Rational Drug Use in Upper
Respiratory Infections
- Use of symptomatic drugs
in respiratory disorders
- Use of antibiotics in
respiratory disorders
- Indication, contraindicaton,
adverse effects of
pharmacotherapy in
Pharmacology
Causal Inference in Epidemiology - Relative risk in cohort
studies
- Odds ratio in cohort and
case control studies
- Significance tests
Public health
II Diagnostic Approach and
Management of Lower
Respiratory Tract Disorders
common lower respiratory
disorders
lower respiratory disorders
- Management and
lower respiratory disorders
- Algorithm of dyspnea,
cough and other
respiratory symptoms
Pulmonology
Diagnostic Approach and
Management of Tuberculosis
tuberculosis in adults
tuberculosis
- DOTS approach in
tuberculosis
Pulmonology
Principles of Disease Control - Primary, secondary and
tertiary prevention
strategies
- Principles of disease control
in primary care
Public health
Pharmacotherapy of tuberculosis,
MDR and XDR
- Principles of
pharmacotherapy in TB
Pharmacology

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- Determinants of multidrug
and extreme drug
resistance
Principles of Radiodiagnostic for
Respiratory Diseases
- Normal radiologic
appearance of the lung
- Abormal radiologic
appearance of the lung
disorders
Radiology
III Diagnosis and Management of
Asthma in Adults
- Algorithm of asthma
asthma in adult
Pulmonology
Clinical Laboratory Procedures for
Respiratory Diseases
- Clinical laboratory
procedures for diagnosis of
- Blood gas analyses in
Clinical pathology
Steroid and Bronchodilator in
Bronchial Asthma
- Use ad indication of steroid
and bronchodilator in
asthma
- Maintenance therapy of
asthma
Pharmacology
Diagnosis and Management of
Asthma in Pediatrics
- Algorithm of asthma in
pediatrics
asthma in pediatrics
- Management and
prevention of asthma in
pediatrics
Pediatrics
IV Diagnosis and Management of
Tuberculosis in Pediatrics
tuberculosis in pediatric
- Management of
Pediatrics
Common infection agent in
respiratory tract
- Microbiological aspects of
common infection agent in
respiratory tract
- Epidemiological features
and characteristics of
infection agent in
respiratory tract
Microbiology
Diagnosis and Management of
Common Respiratory Problem in
Pediatrics
common respiratory
disorders in pediatrics
common respiratory
- Management and
common respiratory
Pediatrics
Surveillance - Definition and use of
surveillance
Public health

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- Steps of surveillance
- The use of surveillance in
primary care
V Newly Emerging Diseases in 21st
century
- Epidemiology and global
distribution of SARS, AI,
swine flu, HIV AIDS
- Control and prevention of
newly emerging diseases
Microbiology
Screening - Definition and use of
screening
- Validity, reliability,
sensitivity and specificity
- Steps of screening
Public health
Respiratory Problem in the
Newborns
- Respiratory problem in
newborns: hyaline
membrane disease,
bronchopulmonary
dysplasia and other
congenital disease
- Clinical manifestation,
diagnosis and management
Pediatrics
VI Surgery and Invasive Procedures
for Respiratory Disorders
- Indication of surgery
procedures
- Pre-surgical preparation of
- Surgery approaches in
including emergency
Surgery
Physiotherapy in Respiratory
Diseases
- Indication and clinical use
of physiotherapy
- Techniques of
physiotherapy
- Advantages and
disadvantages of
physiotherapy
Pulmonology
WSD and Pulmonary Punction Demonstration of WSD and
pulmonary punction
Pulmonology
Respiratory Emergency - Initial approaches to
emergency situation
- Management to emergency
situation
Anesthesiology
Environment and Health - Environment as
determinant of health
- Environmental related
diseases
- Control and prevention of
environmental related
diseases
Public health
VII Systemic Diseases and the Lung - Common systemic diseases
that have complication to
lung
- Complication of lung
disease to systemic
Internal medicine

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disorders
- Management of systemic
disorders and primary lung
diseases
Radiotherapy for Lung Diseases - Principles of radiotherapy
for lung disease
Radiology
Principles of Clinical Epidemiology - Prognosis and risk factors
- Survival rate
Public health

LABORATORY PRACTICES SYLLABLE

Week Topic Sub Topic Department
I Microbiology of M. tuberculosis Sputum examination
Acid bacillus examination
Gram positive and negative
Microbiology
II Physiology of respiration Spirometry
Peak flowmetry
Physiology
III Pathological anatomy of
respiratory abnormalities
Chronic infection,
inflammation, tuberculosis,
NPC, lung cancer etc
Pathology Anatomy
IV Pharmacology therapy Inhalation therapy Pharmacology

Forensic Case Study
1. Forensic tests for infanticide
2. Toxicology of Respiratory System
3. Asphyxia


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SCHEDULE WEEK 1

WEEK TIME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
One
1-6
June
2009
08.00 - 08.50
Introduction
Lecture
(Team)
SKILLS LAB
Tutorial
Scenario 1
SKILLS LAB
Tutorial
Scenario 1
Tutorial
Scenario 2

Bedside Teaching
(ENT, Internal
Medicine,
Pulmonology,
Radiology and
Pediatrics Ward)
09.00 - 09.50
Managing
Learning
Resources
(Team)
10.00 - 10.50 Self Study
Lecture
Causal Inference
1
dr Astri Ferdiana,
MPH
Lecture
Rational Drug Use
in Respiratory
Disorders
Dept of
Pharmacology
Self Study
Weekly Case
Review
Scenario 1
Dept of ENT
11.00 - 11.50
Tutorial
Scenario 1
Lecture
Diagnostic
approaches,
management and
implication
of upper
respiratory tract
disorders
Dept of ENT
Lecture
Causal Inference
2
Dept of Public
Health

12.00 - 12.50 Self Study Self Study

Student Guide Block 12 Scenario 1

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