2011

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Faculty of Medicine Mataram University

TUTORIAL GUIDE Block 12Respiratory SystemContributors:Formatted: Font: 10 pt Formatted: Font: 10 pt, Indonesian

Arfi Syamsun Catarina Budiyono Diah Purnaning Dian Puspitasari Dyah Purnaning Hamsu Kadriyan Herpan Syafii Harahap Eka Arie Yuliyani Ika Primayanti Irnizarifka Joko Anggoro Linda Silvana Sari Markus RambuMas Isa Ansyori Muthia Cenderadewi Nora Taofik Novrita Padauleng Philip Habib Prima Belia Fathana

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TEAMCoordinator dr. Arfi Syamsun, SpKF, M.Si.Med Secretary dr. Muthia Cenderadewi Team Members dr. Arif Zuhan, SpB dr. Catarina Budiyono dr. Hamsu Kadriyan, Sp.THT, M.Kes dr. Ika Primayanti dr. Irnizarifka dr. Joko Anggoro, M.Si, SpPD dr. Linda Silvana Sari dr. Maz Isa Ansyori dr. Muthia Cenderadewi dr. Nora Taofik dr. Novrita Padauleng dr. Philip Habib dr. Prima Belia Fathana dr. Salim S. Thalib, Sp.P dr. SAK Indriyani, Sp.A, M.Kes dr. Slamet Tjahyono, SpP

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Expert Panel dr. Arif Zuhan, SpB dr. Hamsu Kadriyan, Sp.THT, M.Kes dr. Joko Anggoro, M.Si, SpPD

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dr. Salim S. Thalib, Sp.P dr. SAK Indriyani, Sp.A, M.Kes dr. Slamet Tjahyono, Sp.P Skills Lab Instructors ET : dr. Erwin Kresnoadi, M. Si. Med, SpAn dr. Arif Zuhan, SpB Lung Physical Examination : dr. Prima Belia Fathana dr. Muthia Cenderadewi Tutors dr. Ika Primayanti dr. Irnizarifka dr. Linda Silvana Sari dr. Mas Isa Ansyori dr. Muthia Cenderadewi dr. Nora Taofik dr. Novrita Padauleng dr. Prima Belia Fathana

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PrefaceThe burden of respiratory diseases worldwide is very significant and has been one of the greatest global health problem, especially in the developing world. In recent decades, their incidence has steadily increased everywhere. Tuberculosis, acute respiratory infections, pneumonia, chronic obstructive pulmonary diseases, and asthma have been contributing to high morbidity, disability and even mortality in all age groups including children and adults at their productive age. Several factors that contribute to the rapid increase ofin respiratory diseases include the tobacco smoking habits in developing countries, the HIV epidemic, urbanization, industrialization, airtmospheric pollution, and the deterioration of socioeconomic conditions in several developing certain countries as well as the weak health systems and program. Within this block, students will learn to understand pathological processes, identify clinical manifestations, explain the differential diagnoseis of different clinical manifestations, and plan the management and prevention of respiratory diseases from simulation cases. We expect that this book would provide a proper guidance for students and tutors. However, we believebelieve that there are still many weaknesses still existed within this book, and therefore we hope for continuous input from the readers. Author May 20110Formatted: Indonesian Formatted: Justified

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IntroductionThe function of respiratory system function is to allow gas exchange of oxygen and carbondioxide between gas of external environment and blood. In human, the anatomical features of the respiratory system include upper and lower airways, lung and the respiratory muscles. Disorders of the respiratory system can jeopardize the normal gas exchange and when untreated, may threaten life. Respiratory diseases are a common and important cause of illness and death. Although they present with almost similar sign and symptoms, respiratory diseases can be caused by different underlying cause. Respiratory diseases can be classified in many ways such as by the organ involved, by the pattern of symptoms or by the cause of the disease. Accordingly, the diagnostic approach and management would also be different. A general physician should be equipped with adequate communication and clinical skills to properly diagnose and manage the respiratory disorders in primary care. This block will present the problems of the respiratory system that are commonly encountered by general physician in primary care. The cases will deal with the patho-physiology and clinical presentation of the major types of respiratory disease with review of the anatomy, physiology and other biomedical aspects. Cases will include infectious and chronic disease as well as adult and pediatrics conditions. Lectures, demonstrations, laboratory work computer program and other resources will be used to provide background information such as pathology, physiology and in depth learning on the clinical aspects. Evaluation will include tutorial participation, skills assessment and an end-of-unit written examination. The Respiratory Block will be conducted for 7 weeks. In the end of this block, students will be evaluated through oral and written examination. The key features of block 12 are the following: 1. Tutorial groups meeting for 2 hours, 2 times a week 2. Three to five hours of lectures 3. Two times a week skills laboratory 4. A patient contact experience for 3-4 hours in bed-side teaching 5. One hour per week concentrating on critical appraisal 6. One to two hours per week on population health 7. 2-hour laboratory experience related to the cases under studyFormatted: Not Highlight Formatted: Justified, Bulleted + Level: 1 + Aligned at: 0,63 cm + Tab after: 1,27 cm + Indent at: 1,27 cm Formatted: Justified

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

Learning Objectives1. KNOWLEDGEa. The nature and course of alterations in function produced by etiological agents and mechanisms (pathophysiology) of the various disorders in the upper and lower respiratory systems of pediatric and adults: acute and chronic infection, autoimmune, malignancy, degeneration, and trauma b. The nature and course of alterations in structure produced by etiological agents and mechanisms (pathological anatomy) of the respiratory systems: chronic infection and specific processes, malignancyFormatted: Justified, Indent: Hanging: 1,27 cm, Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0,63 cm + Tab after: 1,27 cm + Indent at: 1,27 cm, Tab stops: 0,63 cm, List tab + Not at 1,27 cm

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

2. SKILLSCLINICAL SKILLS Students are able to to acquire, interpret, synthesize and record clinical information in managing the health problems of patients, considering their physical, social and emotional factors especially in disorders in the upper and lower respiratory tract including acute and chronic infection, degeneration, neoplasms and trauma. Utilize data from the history, physical exam and laboratory evaluations to identify the health problem Extract the necessary information from anamnesis, physical diagnosis to formulate differential diagnosis Advise the necessary laboratory examination to establish diagnosis and interpret the results Plan pharmacological and non pharmacological treatment disorders in the upper and lower respiratory tract in adults and pediatrics To formulate effective management plans (diagnostic, treatment, and prevention strategies) for respiratory diseases Advise the strategies for primary, secondary and tertiary prevention for disorders in the upper and lower respiratory tract Recognize the relationship between health and illness, the patient and the patient's environment DIAGNOSTIC AND THERAPEUTIC SKILLS Perform a satisfactory physical examination to respiratory systems Ability to take a satisfactory medical history including biological, psychosocial, nutritional, and occupational dimensions Apply the appropriate use of laboratory methods in identifying diseases or health problems: radiological, microbiological and clinical laboratory findings Ability to recognize patients with immediately life threatening conditions Ability to apply the therapeutic use of drugs in respiratory problems

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

3. PROFESSIONAL BEHAVIORStudents will gain abilities to develop professional behaviour required as a health professional as the following: 1.- able to communicate effectively with colleagues in learning 2.- able to communicate effectively with patient in assessment and care 3.- respect the patient and their rights 4.- able to administer informed consent

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Topic TreeEtiology, patophysiology and symptoms of disorders in the upper respiratory tract

Respiratory System

Upper

Allergy

Allergy in upper respiratory tract Pathogenesis Diagnostic approach Management Common infection in upper respiratory tract Pathogenesis Diagnostic approach Management n Malignancy of upper respiratory tract Clinical manifestation Diagnostic approach Management

Infection

Malignancy

Etiology, patophysiology and symptoms of disorders in the lower respiratory tract Chronic infection and specific processes in lower respiratory tract of pediatrics/adults Pathogenesis/pathophysiology Clinical manifestation Diagnostic approach Management and prevention Acute infection in lower respiratory tract of pediatrics/adults Pathogenesis/pathophysiology Clinical manifestation Diagnostic approach Management

Lower

Infection

Degeneration

Degenerative diseases in lower respiratory tract Pathogenesis Clinical manifestation Diagnostic approach Management Malignancy in lower respiratory tract Clinical manifestation Diagnostic approach Management Primary prevention Trauma and respiratory emergency Clinical manifestation Diagnostic approach Initial management

Malignancy

Emergency

EvaluationStudents are assessed through formative and summative evaluation. In formative feedback, all students will receive constructive feedback on their progress from the tutor in the form of written and oral feedback. Several assessment sheets will be provided to tutor and instructor in order to assess the knowledge, attitudes, and procedural skills of students. Tutors will particularly play important role in 1) assuring students attendance, discipline and participation and 2) assessing student performance in oral examinationcomputer-based examination. Summative evaluation will be conducted at the end of the block. Attendance for more than 80% in all activities will be a prerequisite to sit in the block examination, but will not be accounted for the final mark. The overall block evaluation of student achievement during the block will consist of several components: 1) Performance, which include the individual performance and group report of tutorial, 2) Skills, which include performance in skills laboratory and laboratory work, 3) Knowledge, which include group and individual student assignment, written and oral examinationcomputer-based examination. The following table summarizes the contribution of these components in students final mark. Categories Block performance Skills laboratory Overall Percentage 5% 2015% Component Performance Report from tutorial Physical examination Endotracheal intubation Score percentage 2.5% 2.5% 105% 105%

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Laboratory work Field vStudentisit assignment Examination

a

7.5% 2.5% 70% Written examination Computer-based Oral examination 8550% 1520%

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

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Instruction for StudentsA. TUTORIAL Tutorial is mandatory for students, and students should not be late in attending tutorial. Students who are late more than 10 minutes are not allowed to attend the tutorial. The minimum attendance for tutorial is 90%. Students are only allowedmay be absent or not attendingto unattend the tutorial on exceptional basis, such as sickness, family reason etc. A letter explaining the reason of non-attendance should be sent to the tutor at the minimum 2 days before the day of absence. In the event of sickness, a letter from the attending physician should be sent to the tutor at the maximum 2 days after the day of absence. Students who are not attending tutorial should be given assignment by the tutor. The tutorial approach is developed based on the problem based learning approach where students act as the center. Students are responsible for their own learning processes including determining what to learn and to read. Students are discussing scenarios in group consisting of 10-12 students and using the problem as the basis to learn, determine and achieve learning objectives. Discussion should be conducted in the following phases as below: Step Step Step Step Step Step Step 1: Clarifying unfamiliar terms 2: Problems definition 3: Brainstorming 4: Analyzing the problems 5: Formulating learning objectives 6: Self-study 7: ReportingFormatted: Justified, Indent: Hanging: 1,27 cm, Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0,63 cm + Tab after: 1,27 cm + Indent at: 1,27 cm, Tab stops: 0,63 cm, List tab + Not at 1,27 cm Formatted: Justified

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The tutorial groups will generally complete one case per week. Students will learn about the pathological process, identify clinical manifestation, explain the differential diagnosis of different clinical manifestations and plan the management and prevention of respiratory diseases from simulation cases. Cases that are presented will cover a range of topic including acute and chronic infection, autoimmune, malignancy, degeneration, and trauma. Report of the tutorial should be submitted to tutor every Monday at the latest on 12 pm. Late submission will not be tolerated and will not be scored. B. FIELD VISIT AND HOME VISITFormatted: Justified, Indent: Hanging: 1,27 cm, Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at: 0,63 cm + Tab after: 1,27 cm + Indent at: 1,27 cm, Tab stops: 0,63 cm, List tab + Not at 1,27 cm

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

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C. LECTURES Lecture is mandatory for students. The minimum attendance for lecture is 80%. Students may also put request for additional lecture or expert consultation when necessary. D. CRITICAL APPRAISAL SEach Tuesday, students will critically review and discuss a journal article related to respiratory disorders. All students should read, review and discuss the article on an individual basis. The article journal for the following Tuesday will be uploaded in the intranet at the end of the week (Friday or Saturday). One of member from Research Methodology division will attend the session as the resource person. E. WEEKLY CASE REVIEW On a weekly basis, a scenario review with the class will be conducted with the tutors and experts as a wrapping up session. One of the group will be assigned to present their findings. Questions and problems that cannot be addressed in the group could be reflected and discussed with the experts. F. BEDSIDE TEACHING To expose the students as early as possible to the clinical cases, students will have bed-side teaching session to five outpatient and inpatient ward in the hospital, which include the Pediatrics ward, Internal Medicine ward, Pulmonary ward, Radiology and Ear Nose Throat outpatient clinic. Students will learn with specialists on physical diagnostic and radiology examination of patients with respiratory disorders. G. READING ASSIGNMENT In reading assignment, students will be given one major reading to help them in understanding the concept and approach to the respiratory disorders. Summary of reading assignment should be submitted to block team every Monday. Components of the reading materials will be assessed in the final examination. Week 1: Practical Approach of Lung Health

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Week Week Week Week Week Week

2: International Standard of Tuberculosis Care 3: Global Initiatives on Asthma 4: Occupational Respiratory Diseases 5: Manajemen Terpadu Balita Sakit 6: Pandemic Influenza in 21st century 7: Review article on common respiratory diseaseFormatted: Justified

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

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Scenario 1: Sore Throat A woman takes her 8 year old child to the doctor because of sore throat since two days before. The child had fever three days ago, then he also had cough and runny nose. Since the last four months, he has been suffering the same symptoms twice. He also shows low appetite and restlessness during sleep. The physical examination reveals the following: Nutritional status : underweight Cardio/Respiratory : Vital signs are normal, chest is clear, heart sounds normal. Head and Neck : inflammation signs of the pharynx and tonsil, enlargement of lymph nodes, signs of right otitis media. The physician prescribes antibiotic and symptomatic drugs for the child. The physician mentions that the behavioral and environmental factors were also contributed to this respiratory disease. References Clements DA. Pharyngitis, laryngitis and epiglottitis. In: Cohen J, et.al editors. Infectious Diseases, 2nd editions, vol 1.New York: Mosby; 2004. p341 Djaafar ZA. Kelainan telinga tengah. Dalam :Soepardi EA, Iskandar HN, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher. Edisi ke lima. Jakarta:Balai penerbit FKUI; 2001. p49-53 Paradise JL. Otitis Media. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 2138-49 Pelton SI. Otitis, sinusitis and related conditions. In: Cohen J, et.al editors. Infectious Diseases, 2nd editions, vol 1.New York: Mosby; 2004. p349 Rusmarjono, Soepardi EA. Penyakit serta kelainan faring dan tonsil. Dalam: Soepardi EA, Iskandar HN, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher. Edisi kelima. Jakarta: Balai penerbit FKUI, 2001, pp 178-84

Rusmarjono, Kartosoediro S. Odinofagi. Dalam: Soepardi EA, Iskandar HN, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher. Edisi ke lima. Jakarta:Balai penerbit FKUI; 2001. p173-7 Turner RB, Hayden GF. The common cold. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 1389-91 Turner RB, Hayden GF. Acute pharyngitis. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 1393-4 Wetmore RF. Tonsils and adenoids. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, 1395-7

Scenario 2 : Productive Cough A 3559 year old male comes to the pulmonology clinic at hospital with shortness of breathcough. He has productive cough with thick sputum (once or twice tinged with blood) for the last 5 months with thick ).), and also recurrent episodes of shortness of breath. His weight was decreaseding since the last 3 months, along with a decreaseding appetite. He has been smoking 2 packs of cigarrete per day since the last 145 years. He has been working in an asbestos mine for the last 26 years. He has a son that currently undergoes DOTS medication. On physical examination, his weight is 50 kg, his height is 1705 cm, his blood pressure is 130/80 mmHg, pulse 88x/minute, respiratory rate 26x/minute, temeperature 36.7C, expiratory wheezing and coughing during maximal inspiration. In spirometry test, the FEV 1/FVC ratio is 68%. The physician then plans further supportive examinations to settle the diagnosis.

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References Amin, Zulkifli & Bahar, Asri, Dalam FK UI; Jakarta. 2007. Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbit Penyakit

Bickley L.S. Bates Guide to Physical Examination and History Taking. Lippincott Williams and Wilkins : 2003. Fauci et.al. Harrison's Principles of Internal Medicine Seventeenth Edition. The McGraw-Hill Companies, Inc. 2008 : part 10. Konsil Kedokteran Indonesia. Standar Kompetensi Dokter Edisi Pertama. Penerbit Konsil Kedokteran Indonesia 2006.

McPhee S.J., Papadakis M.A. Current Medical Diagnosis & Treatment Forty-Eighth Edition. The McGraw-Hill Companies, Inc. 2009 : chapter 9. World Health Organization Stop TB Department. Treatment of Tuberculosis Guidelines Fourth Edition. WHO : 2010.

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Shortness of Breath Dr. Sanders, a pulmonologist, is leading a ward round with a group of medical students. He leads the students to visit one of his patients, a young male. Dr. Sanders: Arthur: Dr. Sanders: Arthur: Dr. Sanders: Good morning Arthur, how do you feel this morning? Much better Dr. Sanders, thank you. Well Arthur, as you see, today I bring some of my students with me, and they would love to learn more about your condition. Would you mind if they ask you some questions? I dont mind at all. Alright people, Arthur is my patient since a couple of years ago. Hes 18 years old, was brought here two days ago with shortness of breath. This happenned when he was playing soccer at school. He was running out of medicines, since he hasnt visited me for 2 months already, so he was taken to the hospital by his friends. At the ER, his pulse was 136x/minute, his respiratory rate was 36x/minute, rhonchi and wheezing was found on on both lungs in lung auscultations. So, is there anything you would like to ask Arthur? Go ahead. Arthur, could you tell us what happened before you were brought to the hospital? Did you have any cough or fever? Did you feel any chest pain when you were having this attack? Well I was playing soccer, then suddenly I felt like it was getting harder to breath, and there was a burning pain in my chest, and yes I had cough since the morning, but no fever or anything else. Have you ever experienced any similar condition before? Yeah, since two years ago. Usually it was just cough at night, but sometimes it

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Student A: Arthur: Student B: Arthur:

Dr. Sanders:

got worse and then I was having difficulty to breath. I have visited Dr. Sanders regularly since two years ago, he gave me some pills to relieve the attacks, but I havent visited him on the last two months, so I dont have any supplies left. So, do you have any idea about the possible mechanism of Arthurs condition?

References Global Initiative for Asthma Executive Committee. Global Strategy for Asthma Management and Prevention. South Africa : GINA; 2010. Ingram RH, Braunwald E. Dyspnea and pulmonary edema. In: Kasper DL et al (eds), Harrisons Principle of Internal Medicine. 16th edition (1). New York: McGraw Hill; 2005. p 201-4 Drazen JR, Weinberger JE. Approach to patient with diseases of the respiratory system. In: Kasper DL, Longo DL, Braunwald E, Hauser SL, Jameson JJ, editors. Harrisons Principle of Internal Medicine. 16th edition (2). New York: McGraw Hill; 2005. p 1495 McFadden ER. Asthma. In: Kasper DL, Longo DL, Braunwald E, Hauser SL, Jameson JJ, editors. Harrisons Principle of Internal Medicine. 16th edition, vol 2. New York: McGraw Hill; 2005. p 1508 16 Perhimpunan Dokter Paru Indonesia. Asma, pedoman diagnosis dan penatalaksanaan di Indonesia. Jakarta : Balai penerbit FKUI; 2004. Rahajoe N, Supriyatno B, Setyanto DB. Pedoman Nasional Asma Anak. Jakarta: UKK Pulmonologi PP Ikatan Dokter Anak Indonesia; 2004. Sundaru, Heru & Sukamto, 2007. Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbit Penyakit Dalam FK UI; Jakarta.

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Scenario 4 :

Dyspnea

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A 70 year old man comes to the emergency room with difficulty of breathing. The difficulty of breathing has been startedHe has been having a severe difficulty of breathing since 3 days ago, along with cough with yellowish sputum production. The patient has experienced dyspnea during hard activities for 10 years, and it wais getting worse so that he hadntwast been able to to work since the last 5 yearslately. He has been smoking 2 packs of cigarette per day since the last 55 years. He retired as a construction worker 20 years ago. He is hardly able to do anything by himself right now. Even taking a bath or getting dressed makes him short of breath. He also had cough with yellowish sputum production over the past 3 days. On examination, h is body weight is 50 Kg, and his height is 162 cm. Hhis blood pressure is 170/100 mmHg, pulse 104x/min, respiratory rate 36x/min, and temperature 37.8 oC. The lips looks cyanotic, there are intercostals retraction and contraction of accessory respiratory muscles. Hyperresonant percussion in both lungs. Auscultation of the chest reveals widespread expiratory wheeze and inspiratory coarse crackles.

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Reference Asagaff H. Dasar-dasar Ilmu Penyakit Paru. Airlangga University Press, 2009, pp 231-256 Burnside. Adams Diagnosis Fisik. 1995, EGC, pp 191-211 Mc Phee SJ. Current Medical Diagnosis and Treatment. Lange-Mc.Graw Hill, 2009, pp 228-233 Mc Phee SJ. Pathophysiology of Disease. Lange-Mc.Graw hill, 2007, pp.218-255, Guyton AC, Hall JE. Fisiologi kedokteran. Penerbit Buku Kedokteran EGC, 1997, pp 672-678 Reilly JJ, Silverman EK, Shapiro SD. Chronic obstructive pulmonary disease. Harrisons Principles of Internal Medicine. 16th edition. New York: McGraw-Hil companies, pp 1547-54

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Scenario 5 : Put Your Seat Belt On, Please... A victim of road traffic accident, a male age 20, was brought to the emergency room. He was driving his car, without wearing a seat belt, when suddenly a bike rider crossed in front of his car and instantly he pushed the brake so hard that he flew forward and his chest hit the steering wheel. In the emergency room, he is conscious but complaining of having difficulty of breathing. Physical examination shows some bruises on the left chest. His blood pressure is 90 mmHg on palpation, pulse 120x/min, and respiratory rate 34x/min. The attending physician also notes that there is asymmetric movement of the patients chest, in which the left hemithorax is delayed on inspiration. Auscultation reveals diminished breath sounds in the left hemithorax. The physician starts the initial procedures to stabilize the patient. Reference Karnadiharja W, Djojosugito MA, Lukitto P, Rahmad KB, Manuaba TW. Dinding toraks dan pleura: trauma. Dalam : Sjamsuhidayat R, de Jong W, editor. Buku Ajar Ilmu Bedah. Edisi kedua. Jakarta : Penerbit buku kedokteran EGC; 2005. p406 Maddaus MA, Luketich JD. Chest wall, lung, mediastinum and pleura. Schwartzs Principles of Surgery. Eighth edition, Mc Graw Hill, London, 2005 Sjamsuhidayat R, Ahmadsyah I, Busroh IDI, Rahmad KB. Trakea, mediastinum dan paru, trauma. Dalam : Sjamsuhidayat R, de Jong W, editor. Buku Ajar Ilmu Bedah. Edisi kedua. Jakarta : Penerbit buku kedokteran EGC; 2005. p429-30

Scenario 6: Everlasting Cough An eight month old baby girl was brought to the pediatric clinic at RSUP Mataram with history of recurrent cough of three months duration. The cough was predominantly noctural and in the early morning, with no associated wheeze or fever. The babys father has been smoking 2 packs of cigarrette a day for 15 years. The baby was born with normal labor at 38 weeks of pregnancy. The baby was only breast-fed on the first 2 months. The mother didnt know whether there was any history of contact with tuberculosis patients. Family history: the mother has morning sneezing with clear rhinorrhea for years. On the examination, her weight was 10 kg and her height was 80 cm, the temperature was 370C, pulse 120x/min, respiratory rate 30x/min. There were no cyanosis, clubbing, or ear, nose and throat abnormalities. References Boat TF. Chronic or recurrent respiratory symptoms. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 1401-5 Chernic V, Boat TF, Wilmott RW. Kendigs Disorders of the Respiratory Tract in Children. Seventh Edition, WB Saunders Company, London, 2007 Haddad GG, Palazzo RM. Diagnostic approach to respiratory diseases. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 1375-9 Hollinger LD. Foreign bodies of the airway. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 1410-11 Long SS. Pertussis. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 908-12

Liu AH, Spahn JD, Leung DYM. Childhood asthma. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 958-64 Munoz FM, Starke JR. Tuberculosis. In: Behrman RE, Jenson HB. Nelson Pediatrics. 17th edition, WB Saunders, New York, 2004, pp 958-64 Morgan WJ, Taussig LM. The child in persistent cough. Pediatrics in Review, 8(8): 249-53, 1987

Scenario 7

Wailing Baby

A 5 month old male infant was brought to emergency room because of shortness of breath. His mother informed that the shortness of breath appeared 10 hours ago and were getting worse. The babys breathing sounded like crackles, he cried and wailed all the time, and less breastfed. Five days ago, the baby got dry cough, runny nose, and mild fever. There was no history of breath shortness before. From the physical examination in the emergency room, the infant looked weak, temperature 380C, respiratory rate 58x/minute, intercostal retraction +/+, rhonchi +/+. wheezing +/+. REFERENCESFormatted: Indonesian

Brashers, Valentin. L. Pathophysiology The Biologic Basis For Disease in Adult and Children : Alteration of pulmonary function chapter 33. st. Louis Missouri : Elseiver Mosby, 2006. Naning Roni, Hadianto Ismangoen, amalia setyati, Bronkitis Akut. In : Nastiti N. Rahajoe, Bambang supriyatno, Darmawan Budi Setyanto, editor. Buku Ajar Respirologi Anak, Edisi pertama. Jakarta ; Badan Penerbit IDAI, 2010, pp 330-332 Said, Mardjanis, Pneumonia. In : Nastiti N. Rahajoe, Bambang supriyatno, Darmawan Budi Setyanto, editor. Buku Ajar Respirologi Anak, Edisi pertama. Jakarta ; Badan Penerbit IDAI, 2010, pp 350-365

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Stanton, Jenson Behrman Kliegman. Nelson Textbook Of pediatrics 18 elseiver inc, 2007.

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edition. Philadelphia :

William W. Hay, Jr Levin, Myron J. Current. Diagnosis and Treatment Chapter 18. United Stated of America : Mcgraw-Hill Companies, 2009.