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PROBLEM BASED

LEARNING (PBL) HAND


BOOK
5th Semester
FOR STUDENT

MKK PULMONOLOGI
& KEDOKTERAN
RESPIRASI
MKK IKM-KP

Contributors,
dr. NUNUK SRI MUKTIARTI, Sp.P(K)
dr. TEGUH R SARTONO, Sp.P(K)
dr. YANI JANE SUGIRI, Sp. P(K)
Dr. dr. SUSANTHY DJAJALAKSANA,
Sp.P(K)
dr. NGAKAN PUTU P PUTRA, Sp.P(K)
dr. TRIWAHJU ASTUTI, M.Kes,
Sp.P(K)
dr. SURYANTI DWI PRATIWI, Sp.P(K)
dr. IIN NORCHOZIM, Sp.P(K)
dr. UNGKY AGUS SETYAWAN, Sp.P
dr. RAHCMAD SARWO BEKTI, MMed
dr. YHUSI KARINA R., MSc.
dr. DEWI MUSTIKA, M.Biomed

Medical Faculty
Universitas Brawijaya
2016
PBL HANDBOOK FOR TUTOR
6th SEMESTER
ACADEMIC YEAR 2016/2017

Belajar Sepanjang Hayat dengan Belajar Berbasis


Masalah 7 Langkah
(Problem Based Learning 7 Jumps)
Oleh: MEU FKUB

Metode belajar berbasis masalah dengan 7 langkah (PBL 7 jumps)


merupakan salah satu metode belajar yang sering digunakan di dunia
pendidikan kedokteran. Metode ini pertama kali dikenalkan oleh Barrow
(1980) sebagai bentuk pembelajaran yang diyakini dapat menstimulus
kemampuan penalaran klinis calon dokter. Barrow dan Tamblyn (1980),
yang dianggap sebagai Bapak-bapak PBL, mengatakan bahwa selama
berpuluh-puluh tahun pembelajaran di kedokteran terlalu menekankan
pada hafalan yang seringkali tidak dapat dimanfaatkan secara langsung
untuk menyelesaikan masalah kedokteran riil. Mereka berpikir alangkah
baiknya bila pembelajaran mendekatkan masalah riil dengan ilmu yang
akan digunakan sehingga pada saat menjumpai masalah, ilmu, konsep
dan teori dapat lebih optimal digunakan. Oleh karena itu metode yang
dikenalkan oleh Barrow dan Tamblyn ini dilakukan dengan memberikan
kepada mahasiswa masalah pasien untuk dipelajari dan diselesaikan
daripada menjejali dengan materi kuliah berjam-jam. Pendekatan belajar
ini dengan demikian memiliki dua tujuan utama, yaitu: 1) mengasah
kemampuan pemecahan masalah (problem solving) sekaligus 2)
mendapatkan pengetahuan yang terintegrasi yang relevan dengan
masalah yang dihadapi. Dalam perkembangannya metode belajar PBL ini
ternyata juga berkontribusi positif pada peningkatan penguasaan
pengetahuan, kemampuan komunikasi kolaboratif serta aplikasi
kedokteran berbasis bukti (evidence based medicine).

Dalam dasawarsa terakhir, PBL telah menjadi salah satu trend


setter pembelajaran di fakultas kedokteran di dunia. Oleh karenanya,
Standar Pendidikan Profesi Dokter Indonesia menjadikan PBL sebagai
pendekatan standar untuk Kurikulum Berbasis Kompetensi di Pendidikan
Dokter Indonesia. Metode pembelajaran PBL biasanya didisain sebagai
suatu pembelajaran dalam kelompok yang terdiri dari 10-15 mahasiswa
yang sering disebut kelompok diskusi kecil yang difasilitasi oleh
seorang dosen yang disebut dengan Tutor. Tutor dalam PBL bukanlah
seorang pakar/narasumber dalam diskusi namun sebagai penstimulus
dinamika kelompok serta memonitor jalannya diskusi dalam mencapai
sasaran belajar yang telah ditetapkan. Diskusi PBL dimulai dengan

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paparan masalah yang biasanya berupa deskripsi dari suatu fenomena


yang membutuhkan penjelasan. Masalah ini sering disebut dengan
skenario pemicu. Kelompok diskusi kecil, tutor dan skenario pemicu
merupakan tiga unsur utama dalam pembelajaran PBL.

Gambar 1 Tiga Unsur Utama dalam Pembelajaran PBL

Langkah-langkah dalam PBL 7 Jumps


PBL 7 jumps, seperti namanya terdiri dari 7 langkah sebagai berikut:

1. Reading the Case and Clarifing unclear terms or concepts


2. Define the problem
3. Analyze the problem using prior knowledge
4. Order Ideas and systematically analyze them in depth
5. Formulate learning objective
6. Seek additional information (individual learning)
7. Synthesize and test the new information by sharing

Pembelajaran PBL 7 jumps biasanya dibagi dalam dua sesi pembelajaran


yang dilakukan dalam hari yang berbeda. Langkah 1 s/d 5 dilakukan pada
sesi pertama, dan langkah 7 dilakukan pada sesi kedua, sementara
langkah 6 dilakukan diantara dua sesi sebagai bentuk tugas individu.
Dalam KBK Pendidikan Dokter, sesi I biasanya dilakukan pada hari Senin,
sementara untuk sesi II dilakukan pada hari Rabu atau Kamis. Sementara
belajar individu dilakukan dengan cara menggali informasi dari kuliah-
kuliah terjadwal, wawancara narasumber, praktikum, maupun mencari
informasi dari literatur di internet maupun text book di perpustakaan
dilakukan diantara sesi I dan Sesi II. Pada sesi II setiap individu
melaporkan hasil belajarnya dalam kelompok diskusi untuk kemudian
disusun menjadi hasil diskusi kelompok dalam bentuk Laporan Diskusi
PBL.

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Langkah 1 : Membaca skenario pemicu (trigger scenario)

Hal pertama yang perlu dilakukan dalam menghadapi masalah adalah


membuat segala yang tidak jelas, terutama terhadap penggunaan istilah
dalam masalah. Dengan melakukan hal ini diharapkan setiap peserta
diskusi memiliki pandangan yang sama tentang skenario yang dihadapi
serta ruang lingkupnya.

Setidaknya ada tiga aktivitas yang dilakukan langkah pertama ini, yaitu;

1. Memastikan bahwa setiap peserta diskusi memiliki pemahaman


yang sama terhadap istilah (cue and clue) yang ada dalam skenario
2. Memastikan bahwa setiap peserta diskusi memiliki gambaran ruang
lingkup yang sama dari kasus yang akan didiskusikan
3. Memastikan bahwa setiap peserta diskusi menyepakati hal-hal apa
yang diluar ruang lingkup diskusi

Langkah 2: Define the problem (menentukan masalah)

Pada tahap ini, peserta diskusi harus memiliki kesepakatan terhadap


masalah atau fenomena yang membutuhkan penjelasan dan hubungan-
hubungan teoritik yang ada diantara masalah. Kadang masalah sudah
jelas sejak awal sehingga kelompok dapat langsung menuju langkah 3.
Namun demikian pada beberapa kasus, hubungan variable penting dalam
kasus tidak selalu jelas dan membutuhkan penjelasan. Dalam langkah ini,
kelompok mengidentifikasi hal-hal yang kemungkinan menjadi masalah
dalam kasus dari cue and clue yang ada.

Langkah 3: Analyze the problem (menganalisa masalah, dengan


brainstorming)

Langkah ini merupakan langkah untuk menggunakan pengetahuan yang


telah didapatkan sebelumnya untuk menjelaskan daftar masalah yang
telah disepakati pada langkah kedua. Masing-masing peserta tim
diharapkan dapat berkontribusi menyumbangkan ide konstruktifnya
dalam menjelaskan masalah yang ditemukan berdasarkan pengetahuan
terbaik yang telah dimiliki.

Langkah 4: Order Ideas and systematically analyze them in depth

Pada tahap ini, peserta diskusi diharapkan telah memiliki kerangka


konsep yang lebih jelas dari masalah-masalah yang telah dijelaskan,
termasuk hubungan antara pertanyaan dan variabel baru yang muncul
saat brainstorming. Pada tahap ini pemimpin diskusi diharapkan mampu

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membuat anggota kelompok menyepakati urutan prioritas masalah yang


akan menjadi tujuan belajar.

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Langkah 5 State Learning Objective (Menentukan Tujuan Belajar)

Langkah ini merupakan konklusi sementara dari langkah 4, dimana semua


peserta diskusi bersepakat terhadap masalah yang dapat dipahami (dapat
dijelaskan secara logis dan meyakinkan) serta masalah mana yang
menjadi kebutuhan bersama untuk dipelajari baik dari kuliah, baca
literatur, diskusi dengan pakar serta aktivitas akademik lain yang mungkin
dilakukan pada langkah 6. Pada langkah ini anggota kelompok
menyepakati rencana aksi (action plan) dengan distribusi tugas masing-
masing anggota.

Langkah 6 Seek additional information (individual learning)

Masing-masing peserta diskusi mencari informasi terkait dengan teori,


konsep, atau penjelasan akademik yang relevan dengan daftar tujuan
belajar yang telah ditetapkan pada langkah 6.

Langkah 7 :Synthesize and test the new information by sharing

Anggota kelompok bertemu kembali untuk mendiskusikan informasi yang


didapat masing-masing sebagai tahap akhir dari PBL. Pada tahap ini
peserta diskusi menyepakati bentuk laporan bersama

Pembagian Peran dalam Diskusi PBL


Dalam pelaksanaan belajar kelompok kecil dalam PBL, mahasiswa
membagi diri kedalam peran-peran tertentu untuk melancarkan jalannya
diskusi. Diantara peran yang dijalankan antara lain:

A. Chair/leader (pemimpin diskusi)

Seperti namanya, tugas pemimpin diskusi adalah menjamin agar


diskusi berjalan lancar sesuai dengan tahap-tahapnya. Pemimpin
bertanggung jawab mendistribusikan kesempatan setiap anggota
diskusi untuk berpendapat, menjaga dinamika diskusi dan melakukan
monitor terhadap waktu serta hasil diskusi. Tugas pemimpin diskusi
juga memastikan scribe dapat mengimbangi jalannya/dinamika diskusi
serta melakukan perekaman pendapat yang muncul dalam diskusi
secara akurat. Pemimpin juga memiliki tanggung jawab dalam
memastikan pembagian tugas belajar kelompok.

B. Scribe (Sekretaris kelompok)

Tugas dari Scribe adalah mencatat jalannya diskusi, termasuk


merekam sumber-sumber belajar yang dikemukakan atau digunakan di

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dalam diskusi. Scribe mengumpulkan catatan atau ide dari semua


anggota dan menyarikannya sebagai hasil diskusi kelompok.

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C. Anggota Diskusi

Peran anggota diskusi adalah mengikuti langkah-langkah diskusi sesuai


tahapannya dan secara aktif berpartisipasi dalam diskusi. Kelancaran
diskusi ditentukan oleh keterbukaan masing-masing anggota kelompok
untuk saling mendengar dan menerima/berbagi informasi yang dimiliki
serta saling menghargai pendapat yang dikemukaan di dalam diskusi.

Peran Tutor dalam PBL


Secara umum, peran tutor dalam PBL adalah untuk memfasilitasi,
menciptakan pembelajaran aktif, serta mendorong seluruh anggota
kelompok untuk berkolaborasi mengembangkan ide-ide dan konsep yang
relevan dengan masalah yang disajikan. Para tutor harus dilatih, mereka
tidak menyajikan informasi maupun memberikan jawaban. Dalam grup
yang baik, para siswa lah yang aktif mengidentifikasi masalah, berbagi
informasi, dan mencari kejelasan dari kesulitan yang mereka hadapi. Para
tutor diharapkan dapat menyesuaikan pendekatan pembelajaran mereka
dengan tingkat pengetahuan siswa, kualitas interaksi dalam grup PBL, dan
konten dari permasalahan yang disajikan (Sefron & Frommer, 2013).
Dalam PBL, tutor memiliki beberapa peran yang spesifik, yaitu :
1. The tutor as diagnostician
Tutor harus mampu menentukan dan mendiagnosis sejauh mana
pengetahuan dan keterampilan (prior knowledge)para siswa dalam
konteks masalah yang disajikan. Dengan mengetahui prior
knowledge mereka, tutor akan dapat melihat secara langsung
bagaimana para siswa belajar, dan selanjutnya akan
mempermudah tutor dalam menfasilitasi proses belajar. Pada tahap
ke tujuh (information sharing), tutor juga diharapkan
mengobservasi sampai sejauh mana para siswa mampu menguasai
materi, dan apakah mereka mampu mengaplikasikan pengetahuan
mereka ke dalam masalah yang disajikan.
2. The tutor as challenger
Siswa, baik secara individu maupun kelompok, tidak selalu dalam
kondisi terdorong untuk memaksa diri mereka sendiri untuk terlibat
dalam proses belajar dan berpikir, baik di dalam maupun di luar
proses tutorial. Seringkali para tutor harus menantang para siswa
untuk bereksperimen dengan strategi belajar yang baru.
Contohnya, pada tahap diskusi (reporting), siswa cenderung hanya
semata-mata menjawab pertanyaan dari LO tanpa keinginan atau
rasa penasaran tentang bagaimana mengaplikasikannya pada

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kasus riil atau kasus lainnya. Disinilah tugas tutor untuk


merangsang mereka berpikir dan menvisualisasikannya.

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3. The tutor as role model


Pemberian contoh (modelling) bisa dilakukan secara lebih eksplisit
atau kurang eksplisit, tergantung dari problem yang dihadapi dalam
dinamika kelompok. Dengan mengembangkan berbagai
keterampilan yang diperlukan untuk ber-PBL, tidak hanya tutor,
namun para siswa pun, juga dapat menjadi contoh yang efektif
dalam strategi belajar dan berpikir, serta mengembangkan
keterampilan yang esensial dalam problem-based learning.
4. The tutor as activator
Para siswa, terutama pada tingkat lanjut, seringkali sudah memiliki
cukup prior knowledge serta strategi belajar dan berpikir yang
memadai, namun sayangnya mereka belum berhasil untuk
menggunakan modal ini dengan baik pada saat PBL. Disinilah para
tutor berperan sebagai activator, mengaktivasi para siswanya
untuk mengaplikasikan pengetahuan mereka secara efektif. Peran
tutor sebagai activator berbeda dengan peran tutor sebagai
challenger, dimana pada peran ini siswa sudah memiliki
pengetahuan dan keterampilan namun belum mampu
mengemasnya secara optimal. Sedangkan peran challenger, lebih
cenderung kepada mendorong dan merangsang siswa untuk
mencoba perilaku belajar yang baru serta memaksa diri mereka
sendiri untuk memaksimalkan potensi sesuai dengan konteks
permasalahan yang disajikan dalam PBL.
5. The tutor as monitor
Tugas ini mengharuskan tutor untuk melihat keseluruhan proses
dan progress dari grup tutorial serta masing-masing anggotanya
selama PBL berlangsung. Selain itu, tutor juga diharapkan mampu
menentukan sejauh mana ketercapaian tujuan belajar selama
proses pembelajaran dalam PBL. Contohnya, jika tujuan belajar
kelompok yang disepakati terlalu simpel atau sedikit, maka tutor
boleh menambahkan atau menambah kompleksitas dari masalah.
Pada tahap ini tentunya tutor harus dapat menentukan terlebih
dahulu tingkat pengetahuan siswanya, sehingga tutor bisa
menggiring para siswa sedekat mungkin dengan konteks kasus
sebenarnya.
6. The tutor as evaluator
Pada akhir sesi, para tutor akan diminta untuk berperan sebagai
evaluator. Tahap assessment ini akan memfokuskan terutama pada
keterampilan profesional siswa secara keseluruhan serta attitude
mereka selama proses PBL berlangsung. Selain itu, tutor

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diharapkan mampu menstimulasi refleksi dari para siswa selama


proses PBL, sehingga para siswa dan tutor sendiri bisa
mengevaluasi kemampuan masing-masing dalam proses
pembelajaran.

OVERVIEW OF STUDENT SKILLS in PBL


STE DESCRIPTION CHAIR SCRIBE
P
1 Clarifying Invites group members to read the
unfamiliar terms problem Divides the
Checks if everyone has read the blackboiard
Unfamiliar terms is problem into three
the problem text are Checks if there are unfamiliar terms parts
clarified in the problem
Concludes and proceeds to the next Notes down the
phrase unfamiliar
terms
2 Problem Asks the group for possible problem Notes down
definition(cue and definitions the problem
clue) Paraphrases contributions of group definitions
members
The tutorial group Checks if everyone is satisfied with
defines the problem the problem definitions
in a set of questions Concludes and proceeds to the next
phrase
3 Brainstorming Allows all group members to Makes brief and
(dari cue and clue contribute one by one clear
bisakah dibikin cerita Summarizes contributions of group summaries of
sendiri) members contributions
Stimulates all group members to Distinguishes
Preexisting contribute between main
knowledge is points and
Summarizes at the end of the
activated and side issues
brainstorm
determined,
Makes sure that a critical analysis of
hypothesis are
all contributions is postphoned until
generated
step four
4 Analyzing the Makes sure that all points from the Makes brief
problem(skala brainstorm are discussed and clear
prioritas, mana LO Summarizes contributions of groups summaries
yg menjadi prioritas members contributions
utama dst) Asks questions, promotes depth in Indicates
the discussion relations
Explanations and between
Makes sure the group does not
hypotheses are topics, makes
stray from the subject

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discussed in depth Stimulates group members to find schemata


and are relations between topics
systematically Stimulates all group members to
analyzed to each contribute
other
5 Formulating Asks for possible learning issues Notes down
learning issues Paraphrases contributions of group the learning
member issues
It is determined what Checks if everyone is satisfied with
knowledge the group the learning issues
lacks, and learning
Checks if all obscurities and
issues are
contradictions from the problem
formulated on these
analysis have been converted into
topics
learning issues
7 Reporting Prepares the structure of the Makes brief
reporting phase and clear
Findings from the Makes an inventory ofa what summaries of
literature are sources have been used contributions
reported and Repeats every learning issue and Indicates
answers to the asks what has been found relations
learning issues are between
Summarizes contributions of group
discussed topics, makes
members
Asks questions, promotes depth in schemata
the discussion Distinguishes
Stimulates group members to find between main
relations between topics points and
side issues
Stimualtes all group members to
contribute
Concludes the discussion of each
learning issue with a summary

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Topic tree/LO Blok

THE MANAGEMENT OF DISEASEREHABILITATION


THE PREVENTION

THT/ENT
DIAGNOSIS OF CERTAINRESPIRATORY AND PULMONARY DISEASE
OBSTRETIC &
GYNECOLOG
Y
UROLOGY
MUSCULOSC CLINICAL SKILLS SUPPORTING
ELETAL THE DIAGNOSIS OF RESPIRATORY & PULMONARY DISEASES
PATHOPHYSIOLOGY
CARDIOLOGY
OF RESPIRATORY &
PSICHIATRY
HEMATO-
PULMONARY SYSTEM
ONKOLOGY
IMMUNOLOG
Y
NEUROLOGY
GASTROENTE
ROLOGI

THE ANATOMY
THE PHYSIOLOGY OF SUPPORTING MODALITIES
OF RESPIRATORY
RESPIRATORY & PULMONARY & IN DIAGNOSIS
SYSTEM PULMONARY OF
SYSTEMRESPIRATORY &
PULMONARY DISEASES

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CASES
SECTION

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SCENARIO 1

Diesel and Dust (1)


You are a GP in a Town in Sulawesi, You see Mr. Andi Agam, one Saturday morning. He is a
46-year-old plant operator at the open-cut mine, and says 'Sorry to bother you about this,
Doc. My wifes been on at me for ages to come and see you, but you know what a worrier
she is. Im just here to keep the peace. I get a bit short of breath sometimes, not much really.
I just put it down to not being 20 anymore. I suppose the middle age spread doesnt help,
does it?'

You ask Mr.Andi Agam when he gets short of breath, and he says that it is only when he
works hard, 'like changing the tyre the other day I havent had to do that for ages. I had to
rest a couple of times. I was pretty well buggered for the rest of the day. Same thing
happened last week when I dug some new garden beds'.

History
You ask Mr. Andi Agam some specific questions about his recent health and the history is
clarified. He has been having some breathlessness on exertion for about eighteen months.
He thinks it is fairly constant but never happens at rest and never disturbs his sleep. He does
not wheeze. He has had a cough for as long as he can remember, worst in the mornings, but
also periodically during the day. He brings up 'about a teaspoon' of brownish sputum during
his morning coughing but He has never coughed up any bright blood.
He has gradually gained weight (about 10 kg) over the last three or four years. He puts this
down to a less active job.

You review his history:


Smokes: 3040 cigarettes a day since his late teens
Alcohol: 4 pots of beer on Friday nights

Past medical history: usually has 'bronchitis' each winter, requiring one or two courses of
antibiotics. No other past history of note.
Family history: nil of note.

Occupational history: He has worked in the mining industry since the age of 16 years, in
Western Australia, Northern Territory, and currently in Moura for 12 months. He has never
worked underground. When not working in the mining industry, he has done contracting work
for councils or builders. He has had occupational exposure to gold, silver and copper
although mostly to 'diesel and dust!' he says. To his knowledge he has never been exposed
to uranium, asbestos or nickel.

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SCENARIO 2

Diesel and Dust (2)

Examination
He is a slightly overweight man, not cyanosed, and with no finger clubbing. You note that he
is using accessory muscles of respiration while sitting quietly.

Respiratory system:
RR 20/min at rest, with a slightly prolonged expiratory phase. His chest is barrel shaped.
Percussion of his chest reveals an inferior displacement of his diaphragm. On auscultation of
his lungs you note that his breath sounds are reduced throughout both lung fields. There are
no wheezes or other abnormal sounds.

Cardiovascular System:
BP 150/80. HR 88/min and regular. Heart sounds normal, with no added sounds. JVP not
elevated.
Abdominal examination does not reveal any abnormality and he has no lymphadenopathy.

You are in no doubt that some investigations are in order and write out the request forms
while Mr. Andi Agam dresses.

Investigation Result:

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Mr. Andi Agam returns for spirometry next day, after work, bringing his films with him. You
have already received his blood results from the lab.

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SCENARIO 3

Diesel and Dust (3)

ARTERIAL BLOOD GASES:


Hb = 17.8g/dL (ref range 12-15 g/dL)
pH = 7.4 (ref range 7.35-7.45)
pO2 = 59 mmHg (ref range 80-100 mmHg)
pCO2 = 46 mmHg (ref range 36-44 mmHg)
HCO3 = 32 mmol/L (ref range 21-28 mmol/L

SPIROMETRY

FEV1 1.69 litres (predicted 2.92),


FVC 2.78 litres (predicted 3.69) - unchanged after bronchodilator;
TLCO 13.1 (predicted 26.4).

You explain the results to Mr. Andi Agam and tell him that he has poor lung function,
most likely due to emphysema. You decide to refer him to a respiratory physician as

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it seems likely to you that Mr. Andi Agam will need aggressive management, if the
progress of his problem is to be arrested and his working life extended.

SCENARIO 4

Diesel and Dust (4)

Further Advice
Mr. Andi Agam sees the respiratory physician the next week. The physician reviews his
history, repeats the examination and investigations, and confirms the diagnosis of
emphysema.
Mr. Andi Agam listens to the explanation of the condition and its implications but, when the
physician starts to emphasise the role of cigarette smoking, he interrupts with 'Ive worked in
diesel and dust for years, mostly in the mines, I reckon thats the cause. WorkCover should
cop this one. If I cant keep working, theyll have to give me a big payout.'
The physician emphasises that emphysema is almost always related to smoking and,
whereas certain lung diseases can be caused by some types of dust and fumes, Mr. Andi
Agams condition does not come into that category. She offers to organise a second opinion
for Mr. Andi Agam, but Mr. Andi Agam declines, saying 'All you doctors are the same about
smoking!'
Mr. Andi Agams initial belief that his problem was due to his work was based on his fear that
he would soon be incapacitated by this 'incurable' illness, and no longer able to earn a living
and support his family. He is reassured that, although the underlying damage cannot be
reversed, the progress can be slowed, and the symptoms treated. The physician offers to
negotiate with Mr. Andi Agams employers for him to move into a less physically demanding
job.
The physician suggests that he return to see you for advice about smoking cessation. She
then prescribes two metered aerosols (salbutamol and ipratropium). The practice nurse
reinforces the medication advice and provides some education on the medication, stressing
the importance of regular use.

Progress
The mining company is very pro-active and arranges for its own occupational health unit to
assess Mr. Andi Agam on site. As he is shown to have exercise-related oxygen desaturation,
he is offered a sedentary job and copes well with this.

He is still short of breath with significant effort, but is pleased when his lung function is
improved a month after his initial assessment.

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FEV 1 has improved 20%


BLOOD GASES: pH = 7.4 (ref range 7.35-7.45)
PO2 = 68 mmHg (ref range 80-100 mmHg)
pCO2 = 40 mmHg (ref range 36-44 mmHg)
HCO3 = 30 mmol/L (ref range 21-28 mmol/L)

Mr. Andi Agam really struggles with the smoking habit. He does not to smoke for the first
month, and thinks he has beaten it. He takes it up again, without even knowing why. He tries
nicotine patches, joins a Quit program, and even tries hypnotherapy (after initially refusing,
saying he didnt want anyone fiddling with his brain). Eventually however he succeeds in
ceasing smoking and states that he feels better for it.

During one particularly bad bout of bronchitis, Mr. Andi Agam asks about home oxygen
therapy, and you discuss the indications for its use, and the requirements for supply through
the health system.

Outcome
Mr. Andi Agam remains off cigarettes, although never completely loses the occasional desire
for a cigarette. He becomes a vocal and persistent 'ex-smoker' and even nags perfect
strangers about the habit, much to his familys embarrassment. He continues to have annual
flu vaccine, but most winters gets at least one bout of bronchitis.

SCENARIO 5

Dont Have Doctor in House (1)

Beryl rings her GP early one morning, worried about her husband, Robert.
They live on a small farm about 10 km from town. She says he has been
awake all night with cough, chest pain and sweating, and he looks sick,
but absolutely refuses to see a doctor. She thinks he is too sick to come
into town, and asks what she should do. The doctor offers to visit, but
Robert, obviously angry, can be heard in the background calling out Im
telling you Beryl, Im not having a doctor in this house.

History

The doctor asks Beryl some more questions. From what Beryl says,
Roberts answers are rational and coherent, and he remains adamant
about not being seen, so the doctor eventually decides not to visit. He
asks Beryl to ring again anytime if the situation changes or if she is

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worried.
The next night Robert becomes worse, and Beryl rings their son Peter at
about 6.00am. Peter talks to his father, and subsequently drives him to
the hospital where you are on duty in the Emergency Department.
Robert, aged 63 years, is obviously unwell and somewhat unco-operative.
Beryl does most of the talking. She says that Robert has been a fit man all
his life, until recently, and, as he 'hates doctors', it is fortunate that the
only time he has had to have medical attention was when he had a
laceration and once when he broke his leg in his 20s.
'He hasnt been really well now for weeks. He has been cranky, and tired
all the time, not like his usual self. He has been getting up to the toilet a
bit at night, and often has a nap in the afternoon, which he never normally
does. Peter has had to help him with the farm work.
Another thing he often gets little cuts and scratches with his work, but
lately they dont heal very well. Hes got an awful sore on his shin at the
moment, and he is putting Goanna Salve on it. He wont even let me do
anything more with it.
The last couple of days hes been really crook, with pains in his chest, and
he has the shivers and sweats, and cough. She says that Robert woke her
up in the early hours again this morning, and this time he was worse. He
was sitting up in bed, clutching his chest, saying he had a pain 'like a
knife' that made it hard to breathe.
She gives you his past history. He has smoked 20 cigarettes a day all his
adult life, but rarely drinks. His father died at 70 from 'gangrene'
complicating diabetes that was diagnosed at the age of 60. Robert was
unhappy with the treatment his father had received, and believed that
doctors do 'more harm than good'. He only occasionally takes Panadol,
and although he has had a 'crook' knee since his old fracture, he usually
treats it himself with Goanna Salve.

SCENARIO 6

Dont Have Doctor in House (2)


Examination
You examine Robert: He looks ill, and is sweaty, but his lips and
tongue are dry and bluish in colour. He is holding the left side of his

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chest. His breathing is shallow, and appears painful. You notice his
skin is sun damaged and generally dry, but there is no specific rash.
His fingers are nicotine stained and there is no clubbing.
Temperature 39 C. BP 90/60. RR 30/min. HR 132/min. JVP not visible
at 45 degrees.
Chest Examination: Left hemithorax hardly moves on respiration; on
the left side there is dullness to percussion from upper to mid zone,
at the back and laterally. Breath sounds are loud and harsh on the
left side, especially with whispering, and vocal resonance is
increased on the left.
Apex beat is just palpable in the 5th interspace in the mid clavicular
line. Heart sounds are normal, with no added sounds.
Abdomen: Soft, non tender, no organomegaly.
He has several small sores on his hands, and a stained dressing on
his left shin, with pus leaking from underneath.
There are no other abnormalities found on general examination.
You decide what investigations are indicated, and discuss these with
Robert.

Investigations
You take some arterial blood from Robert's left radial artery for
immediate blood gas analysis (being thankful that you paid
attention during the tutorial on the anatomy of the wrist!). Venous
blood is also sent to the lab for a range of other tests that you have
decided are necessary.

An intravenous cannula is inserted and Robert leaves the


Department for a chest x-ray. You give him a specimen jar and
explain that a sputum sample is helpful.
You review him a short time later, when the films are available.

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Chest x-ray showing volume reduction on left; infiltration in upper third of


the left hemothorax with interposed cavitation. Tuberculosis in an
adolescent.

BLOOD GASES: pH = 7.42 (ref range 7.35-7.45)


pO2 = 50 mmHg (ref range 80-100 mmHg)
pCO2 = 32 mmHg (ref range 35-44 mmHg)
HCO3 = 32 mmHg (ref range 24-32 mmHg)

overall: hypoxic (V/Q mismatch) --> hypoxic drive to breathe -->


tachypnoea --> but reduced SA therefore still inefficient exchange
--> hypocapnia
inititally a obstructive problem, possibly complicated by a restrictive
problem
shunting is occurring (less blood is flowing into the consolidated
area)
probably some background COPD

You check Robert's allergies and give a first dose of antibiotics, write
up fluid orders and speak to the resident on the ward Robert will go

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up to.
Results available later in the day are:

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Ziehl Neelsen
Stain :
AFB 2+ / 2+ / 1+

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SCENARIO 7

Dont Have Doctor in House (3)

Initial Treatment
Roberts initial treatment included:

IV fluids

Analgesia - titrated to pain

Insulin

Oxygen at 40% concentration and with humidification

Antibiotics: Ceftriaxone and vancomycin.

After 24 hours he is feeling much better, with only minor chest discomfort
on deep respiration, and is clinically improved.
His vital signs are: RR 28/min. HR 102/min. BP 110/70. T 38.5 C.
Blood gases on 40% oxygen are as follows:
pH = 7.40 (ref range 7.35-7.45)
pO2 = 70 mmHg (ref range 80-100) low
pCO2 = 36 mmHg (ref range 35-44)
HCO3 = 30 mmHg (ref range 24-32)
Cultures: Sputum, skin and blood become available at this point. The
pathology report states that the sputum and blood cultures had grown S.
pneumoniae, Mycobacterium tuberculosis and the skin culture had grown
S. aureus. Roberts start to consume medication for tuberculosis for 6
month.
Robert asks why he got pneumonia and tuberculosis. 'I suppose you are
going to tell me its from smoking?' he says. You start to explain about the
diabetes. Robert was unaware he could have the same disease as his
father.

Progress and Ongoing Care

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A week later Robert is well, and his blood glucose levels are satisfactory.
He has been too ill to smoke, and he has said he will try and stay off the
cigarettes. He has had consultations with the diabetes educator and
dietician while in hospital. GP follow up of the pneumonia , tuberculosis
and for ongoing advice about diabetes is arranged and the discharge
summary forwarded to the GP practice.
A week later he sees his GP, and his clinical progress is as expected.
Robert says he has had 'only a couple' of cigarettes since leaving hospital.
His blood sugars are within acceptable limits, and he is checking BSLs
regularly. Robert also says that he does not want to get pneumonia again,
and asks if he is immune now.
A repeat x-ray are arranged for the following 6 month, and the x-ray is
normal.

Outcome

Robert returns to running his farm, and subjectively remains well. His
management of his diabetes is reasonable, and it is well controlled most
of the time. His GP suggests flu and pneumococcal vaccine the following
autumn, and although Roberts initial response is reluctance, he agrees
given that he has his farm animals vaccinated for risky illnesses.

REFERENSI
1. Alfred P. Fishman, Jack A. Elias, Jay A.Fishman (2015). Fishman's Pulmonary
Diseases And Disorders 5th Edition. New York : McGraw Hill
2. Murray and Nadel's Textbook of Respiratory Medicine: 2-Volume Set, 5e
(Textbook of Respiratory Medicine (Murray)) 5th Edition
3. James D. Crapo, Joel Karlinsky,Jeffrey Glassroth (2004). Baum's Textbook Of
Pulmonary Diseases Seventh Edition. LWW (Lippincott Williams & Wilkins)
4. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan
PPOK (Penyakit Paru obstruktif Aktif) 2016
5. GOLD 2017
6. Perhimpunan Dokter Paru Indonesia (PDPI) Pedoman Diagnosis dan
Penatalaksanaan Pneumonia - CAP (2014)
7. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan
Asma Bronkiale (2011)
8. GINA 2016
9. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan
Tuberkulosis (2011)
10. Pedoman Nasional Penatalaksanan Tuberkulosis, Kemenkes, 2016
11. Tietz Fundamental of Clinical Chemistry, 6th ed, 2008
12. Burtis CA, Ashwood ER, Burns DE, ST Louis : Saunders Elseveir, 2008

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13. Diagnostic radiology a textbook of medical imaging by edinburgh london new


york oxford philadelphia st louis sydney toronto 2002.

STRUKTUR PBL SEMESTER VI


Pengarah Konsep PBL : dr. RAHMAD SARWO BEKTI,
M.Med, Ed
Koordinator Sistem, Konsep, Nilai&Soal : dr. NURRAHMA W.
FITRIYANI, M.Med, Ed
Koordinator Jadwal, & Modul : dr. DEWI MUSTIKA,
M.Biomed
Koordinator Administrasi&Mahasiswa : ARIEF AGUSTIAN PRASETYA,
A.Md
PJMK MKK PULMONOLOGI & K. RESPIRASI : dr. TRIWAHJU ASTUTI,
M.Kes, Sp.P(K)
Wakil PJMK PULMONOLOGI & K. RESPIRASI :dr. UNGKY AGUS SETYAWAN,
Sp.P

JADWAL PBL SEMESTER VI


Ruang Diskusi GPP FKUB lt. 2 dan 3 (202 310)
PUKUL 08.00 10.00 WIB

No Hari, Tanggal
JUDUL MODUL
. PBL STEP 1-5 PBL STEP 6-7
Rabu, 1 Mar Jumat, 3 Mar
1 Diesel and Dust : History
2017 2017
Jumat, 3 Mar Rabu, 8 Mar
2 Diesel and Dust : Examination
2017 2017
Rabu, 8 Mar Jumat, 10 Mar
3 Diesel and Dust : Laboratory Finding
2017 2017
Jumat, 10 Mar Rabu, 15 Mar Diesel and Dust : Further Advice,
4
2017 2017 Progress, & Outcome
Rabu, 15 Mar Jumat, 17 Mar
5 Dont Have Doctor in House
2017 2017
Jumat, 17 Mar Rabu, 22 Mar Dont Have Doctor in House
6
2017 2017 (Examination & Investigation)

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Rabu, 22 Mar Jumat, 24 Mar Dont Have Doctor in House (Initial


7
2017 2017 Treatment, Progress & Outcome)

DAFTAR TUTOR PBL MKK RESPIRASI


NO NAMA TUTOR PBL RUANG
1 dr. TRIWAHJU ASTUTI,M.Kes., Sp.P(K) 202
2 dr. UNGKY AGUS SETYAWAN, Sp.P. 203
3 dr. IIN NOOR CHOZIN, Sp.P(K) 204
4 dr. SURYANTI DWI PRATIWI, Sp.P(K) 205
5 dr. DANIK AGUSTIN PURWANTININGRUM, M.Kes 206
6 dr. KHUZNITA DASA NOVITA, Sp.THT-KL. 207
7 WIKE ASTRID CAHAYANI, S.Ked., M.Biomed. 301
8 dr. INDRIATI DWI RAHAYU, M.Kes 302
9 dr. NURUL HIDAYATI, M.Sc 303
10 dr. OBED TRINURCAHYO KINANTYO PAUNDRALINGGA, M.Sc 304
11 dr. ARIS WIDAYATI, Sp.S. 305
12 dr. DEWI MUSTIKA, M.Biomed. 306
13 dr. NIA KURNIANINGSIH, M.Biomed 307
14 dr. ARDANI GALIH PRAKOSA, M.Biomed 308
15 dr. YHUSI KARINA RISKAWATI, M.Sc 309
16 dr. IHDA DIAN KUSUMA 310
17 dr. RACHMAD SARWO BEKTI, MMedEd 311
18 dr. NURRAHMA WAHYU FITRIYANI, MMedEd 312
19 dr. ALIDHA NUR RAKHMANI, S.Ked. 313

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