Study Guide The Respiratory System and Disorders 2017

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Study Guide Respiratory System and Disorders

Department of Medical Education - Faculty of Medicine - Universitas Udayana, 2017

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Study Guide Respiratory System and Disorders

STUDY GUIDE THE RESPIRATORY SYSTEM AND DISORDERS

Planners

Prof. Dr. dr. Ida Bagus Ngurah Rai, SpP Dr. dr. I Made Muliarta, M.Kes

Prof. Dr. dr. Wiryana, Sp.An., KIC Prof. Dr. dr. I Gusti Made Aman, Sp.FK

dr. Winarti, Sp.PA

Dr. dr. Desak Made Wihandani, M.Kes dr. Ayu Setyorini, Sp.A

dr. Putu Gede Sudira, Sp.S

Contributors

Prof. Dr. dr. Ida Bagus Ngurah Rai, SpP dr. IGN Sri Wiryawan, M.Repro

dr. Gede Wardana, M.Biomed

Dr. dr. Desak Made Wihandani, M.Kes Dr. dr. Ida Bagus Subanada, Sp.A dr. Dewa Artika, Sp.P

dr. Ida Bagus Suta, Sp.P dr. Made Bagiada, Sp.PD-KP Prof. dr I Gst. Md. Aman, Sp.FK Dr. dr. Muliarta, M.Kes

dr. IGN Bagus Artana, Sp.PD

Dr. dr. Ketut Putu Yasa, Sp.BTKV Dr. dr. Elysanti Martadiani, Sp.Rad dr. Putu Ekawati, M.Repro, Sp.PA dr. Aryabiantara, Sp.An KIC dr.Putu Siadi Purniti, Sp.A dr. Ayu Setyorini, Sp.A dr. DGA Eka Putra, Sp.THT

dr. Luh Made Ratnawati, Sp.THT(KL) dr. Putu Andrika, Sp.PD-KIC

dr. Gede Ketut Sajinadiyasa, Sp.PD Prof. Dr. dr. Suardana, Sp.THT

Editors

dr. Putu Gede Sudira, Sp.S Dr. dr. I Made Muliarta, M.Kes

Layout

Anak Agung Istri Sarastriyani Dewi

Department of Medical Education - Faculty of Medicine - Universitas Udayana, 2017

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Second Edition October 2017

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior written permission of the publisher.

Published by Department of Medical Education Medicine Programme, Faculty of Medicine, Universitas Udayana.

PREFACE

The medical curriculum has become increasingly vertically integrated, with stronger basic concept and support by clinical examples and cases to help in the understanding of the relevance of the underlying basic science. Basic science concepts may help in the understanding of the pathophysiology and treatment of diseases. Respiratory system and disorders block has been written to take account of this trend, and to integrate core aspects of basic science, pathophysiology and treatment into a single, easy to use revision aid.

The respiratory system consists of a pair of lungs within the thoracic cage. Its main function is gas exchange, but other roles include speech, filtration of microthrombin arriving from systemic veins and metabolic activities such as conversion of angiotensin I to angiotensin II and removal or deactivation of serotonin, bradykinin, norepinephrine, acetylcholine and drugs such as propranolol and chlorpromazine. So this block will discuss about anatomy, histology, symptom and signs of lung disease and its pathophysiology, major upper respiratory diseases, major lung diseases, major pediatric lung disease, and basic principle concept to education, prevention, treatment and rehabilitation in respiratory system disorder in patient, family and community.

The learning process will be carried out for 5 weeks starts from 27th_{of October 2017 as}

shown in the time table. The final examination will be conducted on 11th_{of December 2017 in}

the form of MCQ. The learning situation include lecture, individual learning, small group discussion, plenary session, practice, and clinical skills.

Most of the learning material should be learned independently and discuss in SGD by the students with the help of facilitator. Lecture is given to emphasize the most important thing of the material. In small group discussion, the students gave learning task to lead their discussion.

This simple study guide need more revision in the future, so that the planners kindly invite readers to give any comments and critics for its completion. Thank you.

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GENERAL CURRICULUM RESPIRATORY SYSTEM AND DISORDERS

Aims:

 Comprehend the structure, physiologic, and pathologic of the respiratory system.

 Interpret the laboratory and imaging examination of the respiratory system disorders.

 Diagnose and treat the patient with common respiratory system disorders.

 Plan education, prevention, management and rehabilitation of respiratory system disorders to patient, family and community.

Learning outcomes:

 Concern about the size of problem and diversity of respiratory disease in the community.

 Able to describe the structure and function of the respiratory system.

 Able to interpret the result of examination (physical, laboratory, function test, blood gas analysis and chest imaging).

 Able to explore patients with respiratory problem (runny nose, cough, dyspnea, non cardiac chest pain, hemoptysis).

 Able to manage major upper respiratory diseases (tonsillitis, rhinitis, sinusitis).

 Able to manage major lung diseases (TBC, asthma, COPD, lung cancer, pneumonia, occupational lung disease, pleural disease) on patient, family and community.

 Able to manage major pediatric lung disease (bronchiolitis, TB, asthma).

 Able to implement DOTS program against TB.

 Able to implement the strategy of smoking cessation, especially in patient with respiratory disease.

Curriculum contents:

 Structural and function of the respiratory system.

 Physiology of lung in related with oxygen consumption and acid base balance.

 Symptoms and signs of lung disease.

 Pathophysiology of respiratory system disorders.

 Basic physical, laboratory and imaging examination.

 Interpretation of examination results.

 Drugs that commonly used in respiratory system disorders (decongestant, anti-asthma & bronchodilators, antitussive, expectorant.

 Basic principle concept to education, prevention, treatment and rehabilitation in respiratory system disorders in patient, family and community.

Curriculum structure:

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No Daftar Penyakit sesuai SKDI 2012 Tingkat Kemampuan

1 Influenza 4A

2 Pertusis 4A

3 Acute Respiratory distress syndrome (ARDS) 3B

4 SARS 3B

5 Flu burung 3B

Laring dan Faring

6 Faringitis 4A

7 Tonsilitis 4A

8 Laringitis 4A

9 Hipertrofi adenoid 2

10 Abses peritonsilar 3A

11 Pseudo-croop acute epiglotitis 3A

12 Difteria (THT) 3B

13 Karsinoma laring 2

14 Karsinoma nasofaring 2

Trakea

15 Trakeitis 2

16 Aspirasi 3B

17 Benda asing 2

ParuParu

18 Asma bronkial 4A

19 Status asmatikus (asma akut berat) 3B

20 Bronkitis akut 4A

21 Bronkiolitis akut 3B

22 Bronkiektasis 3A

23 Displasia bronkopulmonar 1

24 Karsinoma paru 2

25 Pneumonia, bronkopneumonia 4A

26 Pneumonia aspirasi 3B

27 Tuberkulosis paru tanpa komplikasi 4A

28 Tuberkulosis dengan HIV 3A

29 Multi Drug Resistance (MDR) TB 2

30 Pneumothorax ventil 3A

31 Pneumothorax 3A

32 Efusi pleura 2

33 Efusi pleura masif 3B

34 Emfisema paru 3A

35 Atelektasis 2

36 Penyakit Paru Obstruksi Kronik (PPOK) eksaserbasi akut 3B

37 Edema paru 3B

38 Infark paru 1

39 Abses paru 3A

40 Emboli paru 1

41 Kistik fibrosis 1

42 Haematothorax 3B

43 Tumor mediastinum 2

44 Pnemokoniasis 2

45 Penyakit paru intersisial 1

46 Obstructive Sleep Apnea (OSA) 1

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PEMERIKSAAN FISIK

1 Inspeksi leher 4A

2 Palpasi kelenjar ludah (submandibular, parotid) 4A

3 Palpasi nodus limfatikus brakialis 4A

4 Palpasi kelenjar tiroid 4A

5 Rhinoskopi posterior 3

6 Laringoskopi, indirek 2

7 Laringoskopi, direk 2

8 Usap tenggorokan (throat swab) 4A

9 Oesophagoscopy 2

10 Penilaian respirasi 4A

11 Inspeksi dada 4A

12 Palpasi dada 4A

13 Perkusi dada 4A

14 Auskultasi dada 4A

PEMERIKSAAN DIAGNOSTIK

15 Persiapan, pemeriksaan sputum, dan interpretasinya

(Gram dan Ziehl Nielsen [BTA]) 4A

16 Pengambilan cairan pleura (pleural tap) 3

17 Uji fungsi paru/spirometri dasar 4A

18 Tes provokasi bronkial 2

19 Interpretasi Rontgen/foto toraks 4A

20 Ventilation Perfusion Lung Scanning 1

21 Bronkoskopi 2

22 FNAB superfisial 2

23 Trans thoracal needle aspiration (TINA) 2

TERAPEUTIK

24 Dekompresi jarum 4A

25 Pemasangan WSD 3

26 Ventilasi tekanan positif pada bayi baru lahir 3

27 Perawatan WSD 4A

28 Pungsi pleura 3

29 Terapi inhalasi/nebulisasi 4A

30 Terapi oksigen 4A

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~ CURRICULUM MAP ~

Program or curriculum blocks 1

0

Senior Clerkship

9 Senior Clerkship

8 Senior Clerkship

7

Health System-based Practice

(3 weeks)

BCS (1 weeks)

Community-based practice (4 weeks) Evidence-based Medical Practice (2 weeks)

Special topics : Health Ergonomy &

Health Environment (2 weeks) Elective Study IV (evaluation) (2 weeks) Compre Clinic Orientation (Clerkship) + medical

ethic (4 weeks) 18 6 The Cardiovascular System and Disorders (3 weeks) BCS (1 weeks)

Medical Emergency

(3 weeks)

BCS (1 weeks)

The Urinary System and Disorders (3 weeks) BCS (1 weeks)

The Reproductive System and

Disorders (3 weeks)

BCS (1 weeks)

Elective Study III (3 weeks) 19 5 Neuroscience and neurological disorders (3 weeks)

BCS (1 weeks)

The Respiratory System and

Disorders (3 weeks)

BCS (1 weeks)

The skin & hearing system & disorders

(3 weeks)

BCS (1 weeks)

Special Topic : - Palliative med - Complemnt & Alternative Med. (2 weeks) Forensic Medicine and Medicolegal (2 weeks) Elective Study II (2 weeks) 18

4 Musculoskeletalsystem & connective tissue disorders

(3 weeks) BCS (1 weeks)

Alimentary & hepatobiliary

systems & disorders (3 Weeks) BCS (1 weeks)

The Endocrine System, Metabolism and Disorders

(3 weeks) BCS (1 weeks)

Clinical Nutrition and Disorders

(2 weeks)

BCS (1 weeks)

The Visual system & disorders (2 weeks) BCS (1weeks) 18 3 Behavior Change and disorders (3 weeks)

BCS (1 weeks)

Basic Infection & infectious

diseases (3 weeks) BCS (1 weeks)

Immune system & disorders (2 weeks) BCS (1 weeks)

Hematologic system & disorder & clinical oncology

(3 weeks) BCS (1 weeks)

Special Topic - Andro & aging

- Geriatri - Travel medicine (4 weeks) 19 2 BIOMEDIK III (4 weeks) Growth & development (2 weeks) BCS: (1 weeks)

Medical communicatio

n (2 weeks) BCS (1 weeks)

Medical Professionalism

(2 weeks)

BCS (1 weeks)

Basic Pharmaceutical medicine & drug etics (2 weeks) Elective Study I (2 weeks) 17

1 Generale andStudium Humaniora

(2 weeks)

BIOMEDIK I

(8 weeks) The cellas biochemical

machinery (2 weeks) BCS(1 weeks)

BIOMEDIK II

(6 weeks) 19

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PLANNERS AND LECTURERS

No Name Department Phone

1 Prof. Dr. dr. Ida Bagus Ngurah Rai, Sp.P

(Coordinator) Pulmonology 08123804579

2 Dr. dr. I Made Muliarta, M.Kes (Secretary) Physiology 081338505350

3 Prof. dr. Wiryana, Sp.An KIC (member) Anaesthesiology 0811392171

4 Prof. dr I Gst. Md. Aman, SpFK (member) Pharmacology 081338770650

5 dr. Winarti, Sp.PA (member) Pathology Anatomy 08123997328

6 Dr. dr. Desak Wihandani, M.Kes (member) Biochemistry 081338776244

7 dr. Putu Gede Sudira, Sp.S (member) DME 081805633997

8 dr. I GN Sri Wiryawan, M.Repro Histology 08123925104

9 dr. Gede Wardana, M.Biomed Anatomy 0361-7864957

10 Dr. dr. Ida Bagus Subanada, Sp.A Paediatric Dept. 0812399533

11 dr. Dewa Artika, Sp.P Pulmonology 08123875075

12 dr. Ida Bagus Suta, Sp.P Pulmonology 08123990362

13 dr. Made Bagiada, Sp.PD-KP Pulmonology 08123607874

14 dr. IGN Bagus Artana, Sp.PD Pulmonology 08123994203

15 Dr. dr. Ketut Putu Yasa, Sp.BTKV Thorax surgery 08123843260

16 Dr. dr. Elysanti Martadiani, Sp.Rad Radiology 08123807313

17 dr. Putu Ekawati, M.Repro, Sp.PA Pathology Anatomy 08123958158

18 dr. Aryabiantara, Sp.An KIC Anaesthesiology 08123822009

19 dr. Putu Siadi Purniti, Sp.A Paediatric 08123812106

20 dr. Ayu Setyorini, Sp.A Paediatric 081353286780

21 dr. DGA Eka Putra, Sp.THT Otorhinolaryngology 0813387826317

22 dr. Luh Made Ratnawati, Sp.THT(KL) Otorhinolaryngology 08123806108

23 dr. Putu Andrika, Sp.PD-KIC Pulmonology 08123989192

24 dr. Gede Ketut Sajinadiyasa, Sp.PD Pulmonology 085237068670

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FACILITATORS

Regular Class (Class A)

No Name Group Departement Phone ₍₂Venuend_floor)

1 dr Ni Putu Wardani _{M.Biomed Sp.An} A1 DME 08113992784 2nd floor:_R.2.01

2 Dr.dr. Luh Made Mas

Rusyati, SpKK, FINSDV A2

Dermatovener

ology 081337338738

2nd floor: R.2.02 3 dr. Dudut Rustyadi, Sp.F., _S.H. A3 Forensic 08123994234 2nd floor:_R.2.03

4 Prof. dr. I D P Sutjana, M.Erg A4 Physiology 08123924477 2nd floor:_R.2.04

5 Dr. dr. Desak Made

Wihandani, M.Kes A5 Biochemistry 081338776244

2nd floor: R.2.05 6 Dr. dr. BK. Satriyasa,

M.Repro A6 Pharmacology 087777790064

2nd floor: R.2.06 7 dr. I Nyoman Gede Wardana,_{S.Ked., M.Biomed} A7 Anatomy 087860405625 2nd floor:_R.2.07

8 Dr. dr. Ni Nyoman Sri

Budayanti, Sp.MK (K) A8 Microbiology 08553711398

2nd floor: R.2.08 9 dr. IGN Sri Wiryawan,

M.Repro A9 Histology 082341768888

2nd floor: R.2.21 10 Dr. rer nat dr. Ni Nyoman Ayu_{Dewi M.Kes} A10 Biochemistry 081337141506 2nd floor:_R.2.22

English Class (Class B)

No Name Group Departement Phone Venue

(2nd_floor)

1 Prof. Dr. I Nyoman Adiputra,

M.O.H. PFK B1 Physiology 0811397971

2nd floor: R.2.01

2 dr. Kunthi Yulianti, Sp.KF B2 Forensic 081338472005 2nd floor:_R.2.02

3 Prof. dr. Ketut Tirtayasa, MS, _{AIF, AIFO, Sp.Erg} B3 Physiology 08123623422 2nd floor:_R.2.03

4 dr. Made Widhi Asih,

Sp.Rad(K) B4 Radiology 081916442626

2nd floor: R.2.04 5 Dr. dr. I Made Sudarmaja,

M.Kes B5 Parasitology 081239539945

2nd floor: R.2.05 6 dr. I Wayan Juli Sumadi, _Sp.PA B6 _PathologyAnatomy 082237407778 2nd floor:_R.2.06

7 Dr.dr. I Made Jawi, M.Kes B7 Pharmacology 08179787972 2nd floor:

R.2.07

8 dr Putu Gede Sudira Sp.S B8 DME 081805633997 2nd floor:

R.2.08 9 dr. I Gusti Ngurah Mayun, _Sp.H.K B9 Histology 081237395050 2nd floor:_R.2.21

10 Dr. dr. I Wayan Weta, MS,

SpGK B10 Public Health 081337005360

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LEARNING ACTIVITY

There are several types of learning activity:

 Lecture

 Plenary session

 Independent learning based on the lecture’s topic

 Small group discussion to solve the learning task

 Practicing

 Student project

 Clinical skill and demonstration

 Self assessment at the end of every topic

Lecture will be held at room 4.02 (2nd_{floor), while discussion rooms available at 2}nd_floor (room 2.01-08, 2.21 and 2.22).

IMPORTANT INFORMATIONS

Meeting of the students’ representative

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STUDENT PROJECT

Title of student project

Group discussion Topic

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

B1 B2 B3 B4 B5 B6 B7 B8 B9 B10

NOTE:

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TITLE

(subject/ topic: choose from compentency list)

Name NIM

Faculty of Medicine, Udayana University 2017

______________

1. Introduction (Pendahuluan)

2. Content (Isi, sesuai topik yang dibahas) 3. Summary (Ringkasan)

4. Refferences: (Daftar Pustaka) Van Couver style

Example:

Journal

Sheetz MJ, King GL. Molecular understanding of hyperglycemia’s adverse effect for diabetic complications. JAMA. 2002;288:2579-86.

Textbook

Libby P. The Pathogenesis of atherosclerosis. In: Braunwald E, Fauci A, Kasper D, Hoster S, Longo D, Jamason S (eds). Harrison’s principles of internal medicine. 15th_ed.

New York: McGraw Hill; 2001. p. 1977-82.

Internet

WHO. Obesity: preventing and managing the global epidemic. Geneva: WHO 1998.

[cited 2005 July]. Available from:

http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en.

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ARTICLE REVIEW ASSESSMENT FORM FOR FACILITATOR

Faculty of Medicine, Udayana University

___________________________________________________________________________

Block : Respiratory System and Disorders

Name : ________________________________________

Student No. (NIM) : ________________________________________

Facilitator : ________________________________________

Title :

__________________________________________________

Time table of consultation

Point of discussion Week Date Tutor sign

1. Title 1

2. Refferences 1

3. Outline of paper 2

4. Content 3

5. Final discussion 4

Assessment

A. Paper structure : 7 8 9 10

B. Content : 7 8 9 10

C. Discussion : 7 8 9 10

Total point : ( A + B + C ) : 3 = _____________

Denpasar, ______________________

Facilitator

ARTICLE REVIEW ASSESSMENT FORM FOR EVALUATOR

Faculty of Medicine, Udayana University

___________________________________________________________________________

Block : Respiratory System and Disorders

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Student No. (NIM) : ________________________________________

Evaluator : ________________________________________

Title :

__________________________________________________

Assessment

A. Paper structure : 7 8 9 10

B. Content : 7 8 9 10

C. Discussion : 7 8 9 10

Total point : ( A + B + C ) : 3 = _____________

Denpasar, ______________________

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SELF ASSESSMENT

Self assessment of each lecture will be given after each lecture session, and will be marked. This mark can determine whether the student pass this block or not. Any final mark between 62-64 will be reconsidered with self assessment’s mark to see the student’s status. Any student with self assessment’s mark 70 or more will pass this block. And for the lower one will have to attend the remedial examination. It is important to do this self assessment cautiously, because this activity may be your ticket to pass this block just at First examination.

ASSESSMENT METHOD

Assessment in this theme consists of:

 SGD : 5%

 Final Exam : 80%

 Student Project : 15%

Final mark 65 or more considered to pass this block. Certain conditions applied for those with final mark between 62 – 64. These students will be analyzed using their self assessment’s mark. Students with final mark 62 – 64 and self assessment’s mark equal or more than 65 will also considered pass this block. The value of marking:

 A ≥ 80

 B+ >70-79

 B 65-70

GENERAL TIME TABLE FOR A AND B CLASSES

CLASS B CLASS A

TIME ACTIVITIES TIME ACTIVITIES

08.00-09.00 Lecture 09.00-10.00 Lecture

09.00-10.30 Independent learning 10.00-11.30 Student project

10.30-12.00 SGD 11.30-12.00 Break

12.00-12.30 Break 12.00-13.30 Independent learning

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14.00-15.00 Plenary session 15.00-16.00 Plenary session

TIME TABLE OF CLASSES

DAY/DATE Class B Class A ACTIVITY VENUE PIC

1

Friday

Oct 27,

2017

08.00-08.15 09.00-09.15 Block Introduction Class room Prof IB Rai

08.15-09.00 09.15-10.00

Lecture 1

Anatomy of

Respiratory System

Class room dr.Wardana 09.00-10.30 12.00-13.30 Independent learning

10.30-12.00 13.30-15.00 SGD Disc room Facilitator 12.00-12.30 11.30-12.00 Break

12.30-14.00 10.30-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr.Wardana

2

Monday

Oct 30,

2017

08.00-09.00 09.00-10.00

Lecture 2

_{Histology of}

Respiratory System

Class room

dr. Sri Wiryawan 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Sri _Wiryawan

3

Friday

Nov 3,

2017

08.00-09.00 09.00-10.00

Lecture 3

Physiology of Respiratory System: Ventilation

Class room dr. Muliarta

09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Muliarta

4

Monday

Nov 6,

2017

08.00-09.00 09.00-10.00

Lecture 4

Physiology of Respiratory System: Gas Exchange, diving, altitude

Class room dr. Muliarta

09.00-15.00 10.00-16.00

Independent learning

Practice:

Anatomy, Histology

Anatomy:

1st floor dr. Wardana Histology:

4th floor

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5

Tuesday

Nov 7,

2017

08.00-09.00 09.00-10.00

Lecture 5

_{Carriage of oxygen and}

Carbon dioxide

Class room dr. Desak Wihandani 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Desak Wihandani

6

Wed

Nov 8,

2017

08.00-09.00 09.00-10.00

Lecture 6

Control of acid base balance, Arterial Gas Analysis (AGA)

Class room dr. Desak Wihandani 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Desak Wihandani

7

Thursday

Nov 9,

2017

08.00-09.00 09.00-10.00

Lecture 7

Control of Respiratory Function and Blood Gas Analyzes

Class room dr. Arya Biantara 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. Wiryana

8

Monday

Nov 13,

2017

08.00-09.00 09.00-10.00

Lecture 8

_{Pathology of}

Respiratory Tract

Class room dr. Ekawati 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project Hospital Visit

14.00-15.00 15.00-16.00 Plenary session Class room dr. Ekawati

9

Tuesday

Nov 14,

2017

08.00-09.00 09.00-10.00

Lecture 9

Lung Defense Mechanism

Class room dr. Ekawati

09.00-15.00 10.00-16.00

Independent learning Practice : Physiology, Pathology Anatomy (PA)

Physiology:

2nd floor dr. Muliarta PA: Joint Lab

(4th floor) dr. Ekawati

10

Wed

Nov 15,

2017

08.00-09.00 09.00-10.00 Lecture 10 Pharmacological and non pharmacological interventions

Class room Prof. Aman

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12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. Aman

11

Thursday

Nov 16,

2017

08.00-09.00 09.00-10.00 Lecture 11 Pharmacological and non pharmacological interventions

Class room Prof. Aman 09.00-10.30 12.00-13.30 Independent learning

14.00-15.00 15.00-16.00 Plenary session Class room Prof. Aman

12

Friday

Nov 17,

2017

08.00-09.00 09.00-10.00 Lecture 12

Respiratory Imaging Class room dr. Elysanti

09.00-10.00 Lecture 13

TB in children Class room dr. S Purniti

13.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Elysanti dr. S Purniti

13

Monday

Nov 20,

2017

08.00-09.00 09.00-10.00 Lecture 14 Pneumonia, Pneumonia Aspirasi

Class room dr. Ayu Setyorini 09.00-10.00 10.00-11.00 Lecture 15

Difteri dan Pertusis Class room

dr. Ayu Setyorini 10.00-11.30 12.00-13.30 Independent learning

14.00-15.00 15.00-16.00 Plenary session Class room dr. Ayu Setyorini

14

Tuesday

Nov 21,

2017

14

Tuesday

Nov 21,

2017

08.00-09.00 09.00-10.00 Lecture 16

Bronkhiolitis Class room

dr. IB Subanada 09.00-10.00 10.00-11.00

Lecture 17

Child Asma and Status Asmaticus

Class room dr. IB _Subanada 10.00-11.30 12.00-13.30 Independent learning

13.30-14.00 11.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. IB Subanada

15

Wed,

08.00-09.00 09.00-10.00

Lecture 18

Pulmonary TB and Extrapulmonary TB,

Class room dr. Sutha 09.00-10.00 10.00-11.00 Lecture 19

TB in the

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Nov 22

2017

Immunocompromised Host, Abses TB

14.00-15.00 15.00-16.00 Plenary session Class room dr. Sutha, dr. Bagiada

16

Thursday,

Nov 23

2017

08.00-09.00 09.00-10.00 Lecture 20

Asthma and COPD Class room

Prof. IB Rai, dr. Artana 09.00-10.30 12.00-13.30 Independent learning

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. IB Rai, dr. Artana

17

Friday,

Nov 24

2017

08.00-09.00 09.00-10.00 Lecture 21 Pleural effusion, Emfisema, edema paru

Class room dr. Andrika,

09.00-10.00 10.00-11.00

Lecture 22

Pneumothorax and Hematothorax

Class room dr. Yasa 10.00-11.30 12.00-13.30 Independent learning

14.00-15.00 15.00-16.00 Plenary session Class room dr. Andrika, dr, Yasa

18

Monday

Nov 27

2017

18

Monday

Nov 27

2017

08.00-09.00 08.00-09.00 Lecture 23 Bronchitis and Bronchiectasis

Class room dr.IB Suta

09.00-10.00 09.00-10.00

Lecture 24

Lung Ca and Education of Smoking Cessation

Class room dr. Saji 10.00-11.30 12.00-13.30 Independent learning

13.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr.IB Suta, dr. Saji

19

Tuesday

Nov 28,

2017

08.00-08.30 08.30-09.00 09.00-09.30 09.30-10.00 Lecture 25

Disorder of nose, Disorder of sinus, and Nose foreign Bodies

Class room dr. Ratna

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20

Wed

Nov 29,

2017

08.00-09.00 08.00-09.00 Lecture 26

Disorder of larynx, Disorder of Pharynx, Throat foreign bodies

Class room

Prof. Suardana, dr. Dewa Artha Eka Putra, 09.00-10.30 09.00-10.30 Independent learning

12.30-14.00 12.30-14.00 Student project

14.00-15.00 14.00-15.00 Plenary session Class room

Prof. Suardana, dr. Dewa Artha Eka Putra

21

Thursday,

Nov 30

2017

08.00-15.00 08.00-15.00

BCS: Physical diagnostic examination of Thorax’s in adult patients

BCS: Radio Imaging BCS: Pemasangan dan Perawatan WSD (Pre-test, lecture, demo Practice, discussion) Physiology Dept. (2nd floor Joint Lab Anatomy (1st floor) Dr. Saji dr. Elysanti dr. Yasa

22

Monday,

Dec 4

2017

08.00-15.00 08.00-15.00 BCS: Spirometri

BCS: Pengambilan cairan Pleura, Punksi, Dekompresi jarum

BCS: Nebulisasi dan terapi oksigen

(Pre-test, Lecture, practice, demo)

Physiology Dept.

Joint Lab (4th Floor) Anatomy (1st floor) dr. Muliarta dr. Yasa dr. Arya Biantara

23

Tuesday

Dec 5,

2017

08.00-15.00 08.00-16.00

BCS: Radio imaging

BCS: Physical diagnostic examination of Thorax’s in baby-children patients BCS: Physical diagnostic examination of Thorax’s in adult patients

(Pre-test, lecture, practice, demo)

Physiology Dept.

Joint Lab (4th Floor) Anatomy (1st floor) dr. Elysanti dr. Ayu Setyorini dr. Saji

24

Wed,

Dec 6

2017

08.00-15.00 08.00-16.00 BCS: Bronchoscopy, Provocation test, Radio Imaging

BCS: CPEP pada Bayi

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BCS: Physical diagnostic examination of Thorax’s in adult patients

(Pre-test, lecture, demo)

Anatomy (1st floor)

dr. Saji

25

Thursday,

Dec 7

2017

08.00-15.00 08.00-16.00

BCS: Physical diagnostic examination of Thorax’s in baby-children patients BCS: Perawatan WSD, Decompresi Jarum

BCS: Rhinoskopi Posterior (Practice, post-test)

Physiology Dept. (2nd floor

Joint Lab (4th Floor)

Anatomy (1st floor)

dr. Ayu Setyorini

dr. Yasa

THT staff

26

Friday

Dec 8,

2017

Pre-Evaluation Break

27

Monday,

Dec 11

2017

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LEARNING PROGRAMS

LECTURE 1

ANATOMY OF RESPIRATORY TRACT

dr. I Nyoman Gede Wardana, M.Biomed

The respiratory system consists of conducting zone and respiratory zone. Conducting zone, whose walls are too thick to permit exchange of gases between the air in the tube and the blood stream. The nostrils (nares), nasal cavity, pharynx, larynx, trachea, bronchi, and terminal bronchioles are included in this zone. Respiratory zone, whose walls are thin enough to permit exchange of gases between tube and blood capillaries surrounding them. Air travels to the lungs through that zone. The right lung divided into three lobes: superior, middle, and inferior. The left lung divided into two lobes: superior and inferior. Each lung cover by a membrane that called pleura. Both lungs are inside the thoracic cage. The thoracic cage is formed by the vertebral column behind, the ribs, and intercostal spaces on other side and the sternum and costal cartilages in front. Below it separated from the abdominal cavity by diaphragm

Learning Task

Vignette 1:

Kesawa, 32 years old, was seen in the clinic ten days ago, was diagnosed with rhinitis and sent home with instructions for increased fluids, decongestants, and rest. Kesawa presents today with worsened symptoms of malaise, low-grade temperature, nasal discharge, night time coughing, mouth breathing, early morning pain over sinuses, and congestion. The doctor diagnose he is suffering sinusitis.

1. Describe the boundaries of the nasal cavity and its blood supply! 2. Describe the paranasal sinuses and its opening at nasal cavity!

Vignette 2:

Gotawa, a singer-18 years old came to clinic with complain a hoarse voice for 3 days. She also suffers sore throat, nose block, and fever. She was diagnosed laryngitis

1. Describe the structure of larynx and location of vocal cord! 2. Describe the intrinsic and extrinsic muscle of larynx!

Vignette 3:

Mande, 30 years old male came to clinic with chief complaint difficulty to breath start from this morning. He also suffers cough, runny nose and fever. He has history bronchial asthma when he was 2 years old. The doctor diagnose he is suffering bronchial asthma.

1. Describe the structure of trachea!

2. Describe the different between right and left main bronchus!

3. Describe the principal different between trachea, bronchi, and bronchioles!

Vignette 4:

A 57-year-old male is admitted to the hospital with a chief complaint of shortness of breath for 2 weeks. The radiology examination shows a large left-side pleural effusion.

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3. Describe the structure of thoracic wall!

LECTURE 2

HISTOLOGY OF RESPIRATORY TRACT

dr. Sri Wiryawan, M.Repro

The lower respiratory tract consists of: the lower part of the trachea, the two main bronchi, lobar, segmental, and smaller bronchi, bronchioles and terminal bronchioles, and last but not least is the end respiratory unit. These structure make up the tracheobronchial tree. As for the structure distal to the main bronchi along with a tissue known as the lung parenchyma.

There are several structure we should also understand, when talking about lower respiratory tract. Several structures such as thorax, mediastinum, pleurae and pleural cavity, and lung. Thorax especially thoracic cavity and thoracic wall protect our lung and mediastinum and also play an important role in respiratory process. The mediastinum, which has a role in protecting our heart , located between the two lungs, and contains the heart and great vessels, trachea and esophagus, phrenic and vagus nerves, and lymph nodes.

The pleurae covers the external surface of the lung, and is then reflected to cover the inner surface of thoracic cavity. Pleurae divided into the visceral (lines the surface of the lung) and parietal (lines the thoracic wall and diaphragm) one. The space between these two pleurae called as pleural cavity which contains a thin film fluid to allow the pleurae to slip over each other during breathing.

The lungs are placed within the thoracic cavity. The lungs contain airways structure, vessels, lymphatic and lymph nodes, nerves, and supportive connective tissue. The trachea divides and form the left and right primary bronchi, which in turn divide to form lobar bronchi. Each lobar bronchi divide again to give segmental bronchi to supply air to bronchopulmonary segments. The tracheobronchial tree can also be classified into two functional zones: the conducting zone (proximal to the respiratory bronchioles) which involved in air movement, and the respiratory zone (distal to the terminal bronchioles) which involved in gaseous exchange.

The other term to show functional structure of the lower respiratory tract is the acinus. The acinus defined as the part of the airway that is involved in gaseous exchange. The acinus consist of respiratory bronchioles, alveolar ducts, and alveoli as the smallest functional structure of the lung. The areas of lung containing groups of between three to five acini surrounded by parenchimal tissue are called lung lobules.

The alveolus is an blind-ending terminal sac of respiratory tract. Most gaseous exchange occurs in the alveoli. The alveoli are lined with type I (structural) and type II (produce surfactant) of pneumocytes cell. The understanding about histological pattern of these functional structures of the lung is important in pathophysiology of lung problems.

Learning Tasks

A. Structure of The Upper Respiratory tract

Krishna, a man, 25 years old came to doctor Arjuna clinic with fever, sore throat, sneezing, runny nose and sometimes blocked nose. He also cannot smell well. The doctor diagnoses Krishna with acut Rhinopharingitis.

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3. Compare the histological structure and function between vestibular fold and vocal fold! B. Structure of The Lower Respiratory tract

Radha, a 17 years old beautiful girl, came to doctor Laksmi clinic with shortness of breath, wheezing and cough with phlegm. The doctor diagnoses Radha with Asthma.

1. Describe the histological structure of the lower respiratory tracts are involved?

2. Compare the histological structure and function between terminal bronchioles and respiratory bronchioles!

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LECTURE 3

PHYSIOLOGY OF RESPIRATORY SYSTEM: VENTILATION

dr. I Made Muliarta, MKes

 In living cells aerobic metabolism consumes oxygen and produces carbon dioxide. Gas exchange requires a large , thin, moist exchange surface, a pump to move air circulatory system to transport gases to cells. The primary function system are:

 Exchange the gases between atmosphere and the blood.

 Homeostatic regulation of body pH .

 Protection from inhaled pathogens and irritation substance

 Vocalization.

 In addition to serving these function, the respiratory system also source of significant losses of water and heat from the lung.

 A single respiratory cycle consists of an inspiration and expiration. Relation with ventilation had to know about compliance, surfactant, lung volume and capacities

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Learning Task

1. What is the sequence of event during quiet inspiration (muscle involvement, pressure changes (intrapulmonary and intrapleura), volume changes)!

2. What is pulmonary ventilation and alveolar ventilation means?

3. Andi, male, 30 years old, has a puncture wound due to car accident in his right chest and penetrate his pleural cavity. The patient has complained shortness of breathing and doctor determine that his lung is collapsed.

a. What is this condition called?

b. Describe the mechanism of the lung collapse!

c. What kind respiratory system compensation to anticipate this condition (lung collapse)? d. How can he still be alive in this condition?

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LECTURE 4

PHYSIOLOGY OF RESPIRATORY SYSTEM: GAS EXCHANGE, DIVING, ALTITUDE

dr. I Made Muliarta, Mkes

Gas exchange during external respiration occurs in respiratory membrane. Several factors may influence gas exchange. Dalton’s law and Henry’s law may apply during gas exchange.

Some physiologic responses on respiratory system at high altitude and during diving. Some illnesses/injuries related pressure change may occurs at high altitude and during diving.

Learning Task

1. Describe the Dalton’s Law!

2. Describe the factors that influence oxygen diffusion from alveoli into the blood!

3. Predict the response of the pulmonary arterioles and bronchioles when PO2 increase

and PCO2 decrease!

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LECTURE 5

CARRIAGE OF OXYGEN AND CARBON DIOXIDE

dr. Desak Wihandani

The supply of oxygen to the tissues is our most immediate physical need. We take in about 250 ml of oxygen gas per minute and this is our most pressing physical need. If our oxygen supply is interrupted for more than a few minutes, irreversible damage is done to some tissues, notably the brain. Oxygen is abundantly available in the air around us but cannot diffuse into our tissues at sufficient rate to meet our needs. It must be transported from the lung, the specialized organ for gas exchange, by the blood to all the other tissue.

While oxygen has to be transported from lungs to tissues, carbon dioxide must be transported from the tissues for excretion by the lungs. Carbon dioxide has physicochemical properties that make its transport less difficult then transport of oxygen. Carbon dioxide can be transported in the blood in three ways: in simple solution, by reversible conversion to bicarbonate and by reversible combination with haemoglobin to form carbamino haemoglobin.

Learning Task:

1. Describe the structure and function of hemoglobin!

2. Describe the mechanism of oxygen binding to hemoglobin! 3. Describe the differences between hemoglobin and myoglobin! 4. Describe the mechanism of oxygen binding to myoglobin!

5. Describe conformational differences between deoxygenated and oxygenated Hb!

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LECTURE 6

CONTROL OF ACID BASE BALANCE, ARTERIAL GAS ANALYSIS (AGA)

dr. Desak Wihandani

Acid-Base Balance

There is large daily flux of oxygen, carbon dioxide and hydrogen ion through the human body. Carbon dioxide generated in tissues dissolves in H2O to form carbonic acid, which in turn

dissociates releasing hydrogen ion. The blood concentration of hydrogen ion is constant, it remains between 36 and 46 nmol/L (pH 7,36-7,46). Changes in pH will affect the activity of many enzyme and tissue oxygenation. Problems with gas exchange and acid-base balance underlie many diseases of respiratory system.

Blood Gases

Blood gas measurement is an important first-line investigation performed whenever there is a suspicion of respiratory failure or acid-base disorders. In respiratory failure, the results of such measurements are also an essential guide to oxygen therapy and assisted ventilation. The key clinically used parameters are pH, pCO2 and pO2, the bicarbonate concentration is calculated

from pH and pCO2 values.

Learning Task:

1. Describe organs in our body involved in acid-base balance, and how they work! 2. Describe acid-base balance disorders! What is mean by :

a. Respiratory alkalosis, b. metabolic alkalosis, c. respiratory acidosis, and d. metabolic acidosis?

3. In which condition respiratory acidosis and respiratory alkalosis occurs?

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LECTURE 7

CONTROL OF RESPIRATORY FUNCTION

Prof. Dr. dr. Wiryana, Sp.An, KIC

When considering contol of breathing, the main control variable is PaCO2 (we try to control

this value near to 40 mmHg). This can be carried out by adjusting the respiratory rate, the tidal volume, or both. By controlling PaCO2 we are effectively controlling alveolar ventilation (see

Ch.3) and thus PACO2. Although PaCO2 is the main control variable, PaO2 is also controlled, but

normally to a much lesser extent than PaCO2. However, the PaO2 control system can take over

and become the main controlling system when the PaO2 drops below 50 mmHg.

Control can seem to be brought about by:

1. Metabolic demands of the body (metabolic control)-tissue oxygen demand and acid-base balance.

2. Behavioural demands of the body (behavioral control) – singing, coughing, laughing (i.e.control is voluntary).

These are essentially feedback and feed-forward control systems, respectively. The behavioural control of breathing overalys the metabolic control. Its control is derived from higher centres of the brain. The axons of neurons whose cell bodies are situated in the cerebral cortex bypass the respiratory centres in the brainstem and synapse directly with lower motor neurons that control respiratory muscles. This system will not be dealt with in this next;we shall deal only with the the metabolic control of respiration.

Learning Tasks

1. Discuss the central control of breathing with reference to the pontine respiratory group and the dorsal-ventral respiratory groups of medulla spinalis!

2. List the different types of receptors involved in controlling the respiratory system! 3. Describe factors that stimulate central and peripheral chemoreceptor!

4. Outline the response of the respiratory system to change in carbon dioxide concentration, oxygen concentration and pH!

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LECTURE 8

PATHOLOGY OF UPPER AND LOWER URINARY TRACT dr. Ni Wayan Winarti, SpPA

The term “upper airways” is used here to include the nose, pharynx, and larynx and their related parts. Disorders of these structures are among the most common afflictions of humans, but fortunately the overwhelming majority are more nuisances than threats. Inflammatory diseases are the most common disorders of the upper respiratory tract, i.e. rhinitis, sinusitis, pharyngitis, tonsillitis and laryngitis. It may occur as the sole manifestation of allergic, viral, bacterial or chemical insult. Although most infections are self-limited, they may at times be serious, especially laryngitis in infancy or childhood, when mucosal congestion, exudation, or edema may cause laryngeal obstruction. Tumors in these locations are infrequent but include the entire category of mesenchymal and epithelial neoplasms. Some distinctive types are nasopharyngeal angiofibroma, Sinonasal (Schneiderian) Papilloma, Olfactory Neuroblastoma and Nasopharyngeal Carcinoma.

Classification of lower respiratory tract (lung) diseases can be made based on the result of lung function test, although some authors prefer etiology and pathogenesis background. Some important diseases are obstructive lung disease (asthma, COPD, bronchiectasis) and restrictive lung disease (ARDS), and also infections, diseases of vascular origin and tumors. Pleura as

protective structure of the lungs, are sometimes involved as secondary complication of some

underlying disease, but in rare case, can be primary.

Because of the complexity of respiratory disease, it is important to understand their pathogenesis, supported by recognizing their morphologic changes.

LEARNING TASK Case 1

A male patient, 16 year old, came to a doctor with chief complaint difficulties in breathing. It has occurred since 1 month ago. This patient suffers from rhinitis alergica since he was 3 year old. On physical examination, a pedunculated nodule in right nasal cavity was found. It was whitish in color, 1.5 cm in diameter occluding the nasal cavity.

1. Based on clinical finding, what is the most possible diagnosis? 2. What are the DDs?

3. Describe the morphological appearance (macroscopy and microscopy) that supposed to be found to confirm your diagnosis!

4. Explain the pathogenesis of this diasease!

Case 2

A male patient, 65 year old, has suffered from dyspnea and productive cough since 1 year ago. Lung function test showed increased of FEV1 with normal FVC (confirm an obstructive lung disease). He is a heavy smoker since he was 25 year old. No history of atopy. No evidence of cardiac disorders.

1. Mention 4 diseases including in the spectrum of obstructive lung disease! 2. Explain their pathogenesis!

3. Distinguish their morphology!

Case 3

A female patient, 50 year old, has suffered from tumor of right lung with pleural effusion. As the first step to confirm the diagnosis, doctor asked the patient to do cytology test.

1. Mention some cytology test can be choose for this patient!

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LECTURE 9

LUNG DEFENCE MECHANISM

dr. Ni Wayan Winarti, SpPA

Respiratory tract is an organ that constantly exposed by contaminated air. It is there fore a small miracle that the normal lung parenchyma remains sterile. Fortunately, a plethora of immune and non immune defense mechanisms exist in the respiratory system, extending from the nasopharynx all the way into alveolar airspaces.

The major categories of defense mechanisms to be discussed include : (1) physical or anatomic factors related to deposition and clearance of inhaled materials, (2) antimicrobial peptides, (3) phagocytic and inflammatory cells that interact with inhaled materials, (4) adaptive immune response, which depends on prior exposure to recognize the foreign materials. Each components appears to have a distinct role, but a tremendous degree of redundancy and interaction exists among different components.

Any condition breaks down the lung defense mechanism may result in lung injury and respiratory tract infections

Learning Tasks

1. Defense mechanism of the lung and respiratory tract ca be divided into four major categories. Mention them, their components and explain how each of them acts against foreign materials!

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LECTURE 10

PHARMACOLOGICAL AND NON PHARMACOLOGICAL INTERVENSION I

Prof. dr. GM Aman

Drugs for cough, rhinitis, asthma bronchiale

Cough is a protective reflex mechanism that removes foreign material and secretions from the bronchi and bronchioles. It can be inappropriately stimulated by inflammation in the respiratory system or by neoplasia. In these cases, antitussive (cough suppressant) drugs are sometimes used. It should be understood that these drugs merely suppress the symptom without influencing the underlying condition. In cough associated with bronchiectasis or chronic bronchitis, antitussive drugs can cause harmful sputum thickening and retention. They should not be for the cough associated with asthma.

Most drugs used in rhinitis are effectively relief the symptom of rhinitis, not affect the underlying disease. No drug can relief symptom completely. Drugs are more effective for allergic rhinitis than non allergic rhinitis, and acute form of allergy respond more favorable than chronic form of allergy. The most common drugs used for rhinitis are antihistamine, nasal disodium cromoglycate, nasal decongestant, anticholinergic, intranasal corticosteroid.

Bronchial Asthma is a disease characterized by airway inflammation, edema and reversible bronchospasm. Bronchodilator and anti-inflammatory are the most useful drugs used in asthma. B2 selective agonists, muscarinic antagonists, aminophylline and leucotriene receptor blockers are the most effective bronchodilator. Anti-inflamatory drugs such as corticosteroid, mast cell stabilizers, leucotriene antagonists, and an anti IgE antibody are widely used. Short acting B2 agonist are the most widely used for acute asthma attack, by relaxing airway smooth muscle. Theophylline, aminophylline and antimuscarinic agent are also used for acute asthma attack. Long term control can be achieved with an anti-inflammatory agent such as corticosteroid (systemic or inhaled), with leucotriene antagonist, mast cell stabilizers (cromolyn or nedocromil). Long acting B2 agonists such as Salmeterol and Formeterol, are effectively in improving asthma control, when taken regularly.

Learning Tasks

The patient complained about a sore throat and a nasty cough. It started two weeks ago with a cold. The cold was over within a week, but he continued coughing, especially at night. He is a heavy smoker. After physical examination you diagnosed a dry, tickling cough.

Task 1

1) Differentiate between Antitussive, Expectorant, Mucolytic!

2) Differentiate the effects of Codeine, Dextromethorphan and Diphenhydramine! 3) List the side effects of Codeine!

4) In this patient, what kind of anti cough you give best?

Task 2

If the patient also has sneezing, rhinorrhea and congested nose and then you diagnosed as rhinitis.

1) List the group of drugs used for Rhinitis!

2) List the drugs used as oral nasal decongestant, and describe the important side effects! 3) List the side effects of intranasal decongestant!

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LECTURE 11

PHARMACOLOGICAL AND NON PHARMACOLOGICAL INTERVENSION II

Prof. dr. GM Aman

Learning Task

If the patient come with cough, breathless, and in your examination, you found wheezing. After physical examination you diagnosed Acute attack of bronchial asthma.

1. Chose the drug of first choice for this patient! 2. List the side effects of this drug!

3. Compare the effect of this drug with Salmeterol!

4. Theophyllin is a bronchodilator, but has a narrow safety margin. List the side effects & toxic effect of Theophyllin!

5. Ipratropium not as effective as Salbutamol in treating bronchial asthma. What is the main use of Ipratropium?

6. Cromolyn and Nedocromil are often used for Asthma bronchial. Describe the mechanism of action of Cromolyn (Disodium Cromoglycate)!

7. To decrease the side effet of Corticosteroid in asthma patient, Corticosteroid often use as inhaled Corticosteroid. What are the side effect of inhaled Corticosteroid?

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LECTURE 12

RESPIRATORY IMAGING

dr. Elysanti, Sp.Rad

The imaging investigations of the chest may be considered under the following heading: 1. Simple X- ray (conventional X-ray).

2. Chest screening. 3. Tomography. 4. Bronchography.

5. Pulmonary angiography. 6. Isotope scanning.

7. Computed tomography(CT-scan). 8. MRI.

9. Needle biopsy.

The conventional Chest X-ray has to diagnose the anatomical disorders of the chest for example:

1. Lungs disease---pneumonia, mass, atelectasis etc. 2. Pleural disease----pleural effuse, pneumothorax etc. 3. Cardiac disease----cardiomegali.

4. Bone disorders---fracture.

5. Soft tissue disease—emphysema cutis.

Sometimes conventional X-ray diagnostic can not enough for diagnostic of the chest disorders, for this the CT scan, MRI, bronchography, and arteriography can be help.

Learning Tasks

A male patient, 68 years old, with chronic cough and hemoptoe. 1. What is the imaging choice for establish the diagnosis ?

2. What kind of diagnosis you will consider if the imaging revealed some consolidation at the apex of the right lung accompanied by rib destruction?

A 1- month old female patient is suffered from fever and dyspneu.

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LECTURE 13

TUBERCULOSISIN CHILD

dr. Ni Putu Siadi Purniti, SpA

Tuberculosis (TB) is systemic infection cause by Mycobacterium tuberculosis complex : M tuberculosis, M. Bovis, M. africanum, M. microti, and M. canetti. Tuberculosis infection occurs after inhalation of infective droplet nuclei containing M. tuberculosis. A reactive tuberculin skin test and the absence of clinical and radiographic manifestations are the hallmark of this stage. Tuberculosis disease occurs when sign and symptoms or radiographic changes becaome apparent. In the year 2001 prevalens rate of TB is 5,6/100.000 population, of these, 931 (6 % ) cases occurred in children < 15 year of age (rate 1,5/100.000 population). Transmission of M tuberculosis is person to person, usually by airborne mucus droplet nuclei, particles 1-5 µm in diameter that contain M tuberculosis. In the United States, most children are infected with M. tuberculosis in their home by adult patient tuberculosis close to them. The tubercle bacilli multiply initially within alveoli and alveolar duct. Most of bacilli are killed, but some survive within nonactivated macrophages, which carry them through lymphatic vessels to the regional lymph nodes. When the primary infection is the lung, the hilar lymph nodes ussualy are involved. The primary complex of tuberculosis includes local infection at the portal of entry ( primary focus) and the regional lymph nodes that drain the area. During the development of the primary complex, tubercle bacilli are carried to most tissues of the the body through the blood and lymphatic vessels.Pulmonary tuberculosis that occurs more than a year4 after the primary infection is usually caused by endogenous regrowth of bacilli persisting in partially encapsulated lesions. The majority of children with tuberculosis infection develop no signs or symptoms at any time. Occasionally, infection is marked by low grade fever and mild cough, and rarely by high fever, cough, malaise, and flu like symptoms. Several drugs are used to effect a relatively rapid cure and prevent the emergence of secondary drug resistance during therapy. The standard therapy of intrathoracic tuberculosis (pulmonary disease and/or hilar lymphadenopathy) in children, recommended by the CDC and AAP, is 6 month regiment of isoniazid (INH), rifampin (RIF) supplemented in the first 2 month of treatment by pyrazinamide (PZA).

Learning Tasks

In Outpatient Clinic Department of Pediatric, the baby 10 month of age carried by the mother with the chief complaint is loss of weight since 3 month, suffered low grade fever, chronic cough, malaise and flu like symptoms. The grandfather whom was diagnosed pulmonary tuberculosis and she has been in recent closed contact. In physical examination found that there were enlargement of neck lymph nodes.

Learning Resources

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LECTURE 16-17

BRONCHIOLITIS AND ASTHMA IN CHILD

dr. IB Subanada, SpA

Bronchiolitis is an acute inflammatory disease of the lower respiratory tract (bronchioles) caused predominantly by respiratory syncytial virus (RSV). The inflammation response characterized by bronchiolar epithelial necrosis, bronchiolar occlusion, and peribronchiolar collection of lymphocytes. Bronchiolus become edematous and obstructed with mucus and celluler debris, which may lead to partial or complete collapse of the bronchioles. By the age 2 years nearly all children have been infected, with severe disease more common among infants aged 1-3 months.

The clinical manifestation, initially upper respiratory signs and symptoms and followed by obstructed bronchioles signs and symptoms. The white blood cell and differential counts are usually normal. Chest x-ray reveals hyperinflation, peribronchial cuffing, and atelectasis. The mainstay of therapy is supplemented oxygen with close monitoring and supportive care.

There are higher incidence of wheezing and asthma in children with history of bronchiolitis. Pooled hyperimmune RSV intravenous immunoglobulin (RSV-IVIG) and palivizumab intramuscular are effective to preventing severe RSV disease in high risk infants. The case fatality rate is less than 1%.

Learning Tasks

A 6-months old male infant came to Outpatient Clinic, Department of Child Health, Medical School, Udayana University, Sanglah Hospital, Denpasar with the chief complaint of difficult to breath since yesterday. According to his mother, three days before, he suffered from coryza, cough, and low grade fever. On physical examination, fast breathing, wheezing and a prolonged expiratory phase were found.

Please discuss his mother the disease of the infant!

Learning Tasks

1. Explain the pathological concept of asthma in child! 2. Explain the clinical manifestations of asthma in child! 3. Explain the diagnosis principles of asthma in child!

4. Determine the severity of asthma and the degree of asthma attack in child!

5. Construct management plans for asthma attack in child (reliever) and determine the need for controller management!

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LECTURE 18

PULMONARY TB AND EXTRAPULMONARY TB

dr. IB Sutha, SpP

WHO estimates that about 9.27 million new cases in 2007 compared with 2.24 million cases in 2006, with 44% or 4.1 million cases of the infectious cases (sputum smear new cases with positive). TB problem in Indonesia is a national problem, the case is increasing and increasingly concerned with the increasing HIV infection and AIDS are rapidly growing emergence of multi-drug resistance TB problem.

Tuberculosis is an infectious disease directly caused by the bacteria Mycobacterium tuberculosis that primarily attacks the lungs. TB bacteria are rod-shaped, aerobic with a complex cell wall structure, it was mainly composed of fatty acids that are acid resistant and can survive in a dormant form.

TB germs enter through inhalation of the bacteria will reach the alveoli and catched by alveolar macrophages, the bacteria will die. If the germs stay alive it will proliferate to form primary apex (Primer Apex) and will limphogen or hematogenous spread. Primary apex surround by limphogen spreading form the "primary complex of Ghon" and formed specific cellular immunity is characterized by a positive tuberculin test. If the immunity is low, complex primary complications, the patient became ill and the symptoms and clinical signs of disease. M. tuberculosis may attack any organ of the body and most importantly the lungs.

Clinical symptoms involve respiratory symptoms and prodromal symptoms, whereas clinical signs obtained at once with the examination depends on the type and extent of lesions in the lungs and surrounding organs. Radiological examination of the thorax will get the infiltrates, fibrosis and kaverna. Bacteriological examination by smear and culture of sputum smear examination.

TB treatment follow national treatment program. Tuberculosis control which refers to the eradication of TB WHO guideline.

General Objectives

1. Knowing the microbiology, epidemiology and pathogenesis of tuberculosis.

2. Knowing the clinical symptoms, clinical and radiological signs of pulmonary TB and extra-pulmonary TB.

3. Able to clasify Tuberculosis.

4. Able to explain treatment program of tuberculosis and side effect. 5. Able to describe the prevention of tuberculosis and MDR TB.

Triger

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Physical examination has been found: look thin, alert state, blood pressure 110/70 mmHg; pulse rate 108 x/mnt; Respiration rate 24 breaths/mnt T.aksila 370_{C. Lymph nodes enlargement}

on the right neck. On chest examination: symmetrical right-left chest, normal heart, vesicular breath sounds in the chest and rhales on the third upright.

Learning Tasks:

1. What should you do to ensure the diagnosis of this patient?

2. What should you do for this patient with enlargement of gland in the neck? 3. If the sputum smear examination results - / +2 / -, what is diagnosis? 4. Explain the treatment program appropriate to this patient!

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LECTURE 19

TB IN THE IMMUNOCOMPROMISED HOST dr. Made Bagiada, SpPD-KP

Sebagai seorang dokter yang bekerja di tingkat pelayanan primer, pemahaman tentang diagnosis dan penatalaksanaan TB pada imunokompromais sangatlah penting. Kejadian TB lebih tinggi pada imunokompromais dibanding dengan non-imunokompromais. Penyakit infeksi kronik ini bila tidak ditangani dengan baik menyebabkan morbiditas dan mortalitas yang tinggi. Di Indonesia dengan beban TB tinggi (nomor 5 di dunia) akan lebih tinggi lagi dengan meningkatnya prevalensi penderita HIV/AIDS.

TB adalah penyakit infeksi kronis yang disebabkan oleh M.tuberculosis. Tempat masuk dan target organ terbanyak adalah paru. Orang yang terinfeksi M.tuberculosis hanya sebagian kecil yang menjadi sakit TB dan sebagian besar tidak menjadi sakit (latensi). Orang yang tidak sakit (latensi) akan menjadi sakit (reaktivasi) atau TB aktif bila terjadi penurunan daya tahan tubuh atau imunitas (imunokompromais). Secara umum klinis TB ditandai dengan batuk-batuk produktif lebih dari 2 – 3 minggu disertai dengan gejala-gejala respiratorik lainnya dan gejala non-respiratorik. Namun, manifestasi klinis dari TB pada individu imunokompromais terletak pada derajat beratnya penurunan imunitas. Sering tanda dan gejala TB atipikal, sering terjadi kesalahan diagnosis, sehingga prognosis menjadi lebih buruk.

Imunokompromais adalah suatu kondisi dimana sistem kekebalan tubuh seseorang melemah atau tidak ada. Individu yang imunokompromais kurang mampu melawan atau memerangi infeksi karena respon imun yang berfungsi tidak benar. Contoh orang imunokompromais adalah mereka yang terinfeksi HIV atau AIDS, wanita hamil, atau sedang menjalani kemoterapi atau terapi radiasi untuk kanker. Kondisi lain dengan imunokompromais, seperti kanker tertentu dan kelainan genetik, diabetes mellitus, dan penderita yang mendapatkan terapi TNF-α. Individu immunocompromised kadang-kadang lebih rentan terhadap infeksi serius dan /atau komplikasi dibanding orang sehat. Mereka juga lebih rentan untuk mendapatkan infeksi oportunistik, yaitu infeksi yang biasanya tidak mengenai orang yang sehat.

Dalam keadaan penderita dengan imunokompromais, seorang dokter harus dapat mengenali penyakit TB aktif. Diagnosis TB pada imunokompromais adalah dengan menemukan kuman BTA pada sputum baik dengan pemeriksaan langsung BTA maupun kultur. Pengobatan TB penderita imunokompromais sama dengan pada non-imunokompromais dan pengobatan TB-nya diutamakan. Dokter harus mampu mengidentifikasi penderita TB pada imunokompromais yang tidak respon (resisten) dengan obat TB, sehingga dapat melakukan tindakan lebih dini untuk menurunkan perburukan prognosis (kematian).

General Objektif

1. Mampu menjelaskan penegakan diagnosis TB pada imunokompromais.

2. Mampu menyusun program pengobatan jangka panjang penderita TB pada imunokompromais.

3. Mampu mengidentifikasi kemungkinan gagal respon pengobatan (resisten) penderita TB pada imunokompromais.

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5. Mampu mengidentifikasi penderita TB dengan imunokompromais yang perlu rujukan lebih lanjut.

Trigger

Anda sebagai seorang dokter yang bekerja di sebuah Puskemas, datang seorang pasien laki-laki, usia 28 tahun. Dia mengeluhkan panas badan sejak lebih kurang 2 minggu. Demam tidak begitu tinggi dan tidak sampai menggigil. Disamping demam juga ada batuk-batuk ringan tanpa disertai dahak yang dialami lebih dari 1 minggu. Penderita sudah minum obat penurun panas dan obat batuk yang dibeli di warung tapi tidak ada kesembuhan. Berat badan penderita dirasakan menurun drastis belakangan ini. Napsu makan berkurang sehingga badan penderita dirasakan semakin kurus. Penderita adalah seorang sopir pengangkut barang jawa – bali, sudah menikah dan mempunyai anak wanita usia 4 tahun. Sesekali penderita minum bir. Penderita mempunyai tattoo di badannya yang dibuat sewaktu penderita klas 1 SMA.

Learning Task

1. Jelaskan bagaimana saudara memastikan bahwa pasien tersebut memang menderita TB dan imunokompromais!

2. Mengapa TB laten menjadi reaktivasi (TB aktif)?

3. Bagaimana saudara mengenali pasien TB imunokompromais mengalami Immune Reconstitution Inflammatory Syndrome (IRIS)?

4. Jika ternyata pasien tersebut menderita TB dengan imunokompromais bagaimana cara menyusun pengobatan penderita?

5. Bagaimana cara menilai respon pengobatan TB pada pasien dengan imunokompromais?

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LECTURE 20.1

ASTHMA

Prof. IB Rai

Airway hyper responsiveness is known as the denominator underlying all form of asthma. The basis of this abnormal bronchial response is not fully understood. Most current evidence suggests that bronchial inflammation is the substrate for this hyper responsiveness, manifested by the presence of inflammatory cells and by damage of bronchial epithelium. In extrinsic (allergic) asthma, bronchial inflammation is caused by type I hypersensitivity reactions, but in intrinsic asthma, the cause is less clear. Incriminated in such cases are viral infections of the respiratory tract and inhaled air pollutant such as sulfur dioxide, ozone and nitrogen dioxide.

Tujuan Umum:

1. Mampu menjelaskan penegakan diagnosis asma.

2. Mampu menyusun program pengobatan jangka panjang asma. 3. Mampu mengidentifikasi pasien dengan serangan asma akut.

4. Mampu memberikan pengobatan awal pasien dengan se

Study Guide The Respiratory System and Disorders 2017

STUDY GUIDE THE RESPIRATORY SYSTEM AND DISORDERS

CONTENTS

STUDY GUIDE THE RESPIRATORY SYSTEM AND DISORDERS...2

ASSESSMENT METHOD... 17

LECTURE 24... 49

PREFACE

GENERAL CURRICULUM RESPIRATORY SYSTEM AND DISORDERS

Learning outcomes:

Curriculum contents:

Curriculum structure:

Trakea

PEMERIKSAAN FISIK

PEMERIKSAAN DIAGNOSTIK

TERAPEUTIK

Program or curriculum blocks 1

Medical Emergency

BCS (1 weeks)

(3 weeks) BCS (1 weeks)

(3 weeks) BCS (1 weeks)

BIOMEDIK I

(8 weeks) The cellas biochemical

BIOMEDIK II

No Name Department Phone

FACILITATORS

Regular Class (Class A)

English Class (Class B)

LEARNING ACTIVITY

There are several types of learning activity:

IMPORTANT INFORMATIONS

Meeting of the students’ representative

STUDENT PROJECT

1. Introduction (Pendahuluan)

Internet

ARTICLE REVIEW ASSESSMENT FORM FOR FACILITATOR

Point of discussion Week Date Tutor sign

ARTICLE REVIEW ASSESSMENT FORM FOR EVALUATOR

ASSESSMENT METHOD

Assessment in this theme consists of:

GENERAL TIME TABLE FOR A AND B CLASSES

DAY/DATE Class B Class A ACTIVITY VENUE PIC

Friday

Respiratory System

Monday

Respiratory System

Friday

Tuesday

Carbon dioxide

Lecture 6

Control of acid base balance, Arterial Gas Analysis (AGA)

Thursday

Control of Respiratory Function and Blood Gas Analyzes

Monday

Respiratory Tract

Tuesday

Thursday

Monday

Tuesday

Lecture 17

TB in the

Thursday,

Lecture 22

Monday

Lecture 24

Tuesday

Disorder of nose, Disorder of sinus, and Nose foreign Bodies

Thursday,

Tuesday

Thursday,

Pre-Evaluation Break

dr. I Nyoman Gede Wardana, M.Biomed

LECTURE 2

dr. Sri Wiryawan, M.Repro

Learning Tasks

LECTURE 3

dr. I Made Muliarta, MKes

Learning Task

LECTURE 4

dr. I Made Muliarta, Mkes

LECTURE 5