Modul Pbl - Student Guidance Respirasi Case 1-7

PROBLEM BASED LEARNING (PBL) HAND BOOK 5th Semester FOR STUDENT

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

Medical Faculty Universitas Brawijaya 2016

PBL HANDBOOK FOR TUTOR 6th SEMESTER ACADEMIC YEAR 2016/2017

Belajar Sepanjang Hayat dengan Belajar Berbasis Masalah 7 Langkah (Problem Based Learning 7 Jumps) Oleh: MEU FKUB Metode belajar berbasis masalah dengan 7 langkah (PBL 7 jumps) merupakan salah satu metode belajar yang sering digunakan di dunia pendidikan kedokteran. Metode ini pertama kali dikenalkan oleh Barrow (1980) sebagai bentuk pembelajaran yang diyakini dapat menstimulus kemampuan penalaran klinis calon dokter. Barrow dan Tamblyn (1980), yang dianggap sebagai Bapak-bapak PBL, mengatakan bahwa selama berpuluh-puluh tahun pembelajaran di kedokteran terlalu menekankan pada hafalan yang seringkali tidak dapat dimanfaatkan secara langsung untuk menyelesaikan masalah kedokteran riil. Mereka berpikir alangkah baiknya bila pembelajaran mendekatkan masalah riil dengan ilmu yang akan digunakan sehingga pada saat menjumpai masalah, ilmu, konsep dan teori dapat lebih optimal digunakan. Oleh karena itu metode yang dikenalkan oleh Barrow dan Tamblyn ini dilakukan dengan memberikan kepada mahasiswa masalah pasien untuk dipelajari dan diselesaikan daripada menjejali dengan materi kuliah berjam-jam. Pendekatan belajar ini dengan demikian memiliki dua tujuan utama, yaitu: 1) mengasah kemampuan pemecahan masalah (problem solving) sekaligus 2) mendapatkan pengetahuan yang terintegrasi yang relevan dengan masalah yang dihadapi. Dalam perkembangannya metode belajar PBL ini ternyata juga berkontribusi positif pada peningkatan penguasaan pengetahuan, kemampuan komunikasi kolaboratif serta aplikasi kedokteran berbasis bukti (evidence based medicine). Dalam dasawarsa terakhir, PBL telah menjadi salah satu trend setter pembelajaran di fakultas kedokteran di dunia. Oleh karenanya, Standar Pendidikan Profesi Dokter Indonesia menjadikan PBL sebagai pendekatan standar untuk Kurikulum Berbasis Kompetensi di Pendidikan Dokter Indonesia. Metode pembelajaran PBL biasanya didisain sebagai suatu pembelajaran dalam kelompok yang terdiri dari 10-15 mahasiswa yang sering disebut kelompok diskusi kecil yang difasilitasi oleh seorang dosen yang disebut dengan Tutor. Tutor dalam PBL bukanlah seorang pakar/narasumber dalam diskusi namun sebagai penstimulus dinamika kelompok serta memonitor jalannya diskusi dalam mencapai sasaran belajar yang telah ditetapkan. Diskusi PBL dimulai dengan

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paparan masalah yang biasanya berupa deskripsi dari suatu fenomena yang membutuhkan penjelasan. Masalah ini sering disebut dengan skenario pemicu. Kelompok diskusi kecil, tutor dan skenario pemicu merupakan tiga unsur utama dalam pembelajaran PBL.

Gambar 1 Tiga Unsur Utama dalam Pembelajaran PBL

Langkah-langkah dalam PBL 7 Jumps PBL 7 jumps, seperti namanya terdiri dari 7 langkah sebagai berikut: 1. 2. 3. 4. 5. 6. 7.

Reading the Case and Clarifing unclear terms or concepts Define the problem Analyze the problem using prior knowledge Order Ideas and systematically analyze them in depth Formulate learning objective Seek additional information (individual learning) Synthesize and test the new information by sharing

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

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Langkah 1 : Membaca skenario pemicu (trigger scenario) Hal pertama yang perlu dilakukan dalam menghadapi masalah adalah membuat segala yang tidak jelas, terutama terhadap penggunaan istilah dalam masalah. Dengan melakukan hal ini diharapkan setiap peserta diskusi memiliki pandangan yang sama tentang skenario yang dihadapi serta ruang lingkupnya. Setidaknya ada tiga aktivitas yang dilakukan langkah pertama ini, yaitu; 1. Memastikan bahwa setiap peserta diskusi memiliki pemahaman yang sama terhadap istilah (cue and clue) yang ada dalam skenario 2. Memastikan bahwa setiap peserta diskusi memiliki gambaran ruang lingkup yang sama dari kasus yang akan didiskusikan 3. Memastikan bahwa setiap peserta diskusi menyepakati hal-hal apa yang diluar ruang lingkup diskusi Langkah 2: Define the problem (menentukan masalah) Pada tahap ini, peserta diskusi harus memiliki kesepakatan terhadap masalah atau fenomena yang membutuhkan penjelasan dan hubunganhubungan teoritik yang ada diantara masalah. Kadang masalah sudah jelas sejak awal sehingga kelompok dapat langsung menuju langkah 3. Namun demikian pada beberapa kasus, hubungan variable penting dalam kasus tidak selalu jelas dan membutuhkan penjelasan. Dalam langkah ini, kelompok mengidentifikasi hal-hal yang kemungkinan menjadi masalah dalam kasus dari cue and clue yang ada. Langkah 3: Analyze the problem (menganalisa masalah, dengan brainstorming) Langkah ini merupakan langkah untuk menggunakan pengetahuan yang telah didapatkan sebelumnya untuk menjelaskan daftar masalah yang telah disepakati pada langkah kedua. Masing-masing peserta tim diharapkan dapat berkontribusi menyumbangkan ide konstruktifnya dalam menjelaskan masalah yang ditemukan berdasarkan pengetahuan terbaik yang telah dimiliki. Langkah 4: Order Ideas and systematically analyze them in depth Pada tahap ini, peserta diskusi diharapkan telah memiliki kerangka konsep yang lebih jelas dari masalah-masalah yang telah dijelaskan, termasuk hubungan antara pertanyaan dan variabel baru yang muncul saat brainstorming. Pada tahap ini pemimpin diskusi diharapkan mampu

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membuat anggota kelompok menyepakati urutan prioritas masalah yang akan menjadi tujuan belajar.

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Langkah 5 State Learning Objective (Menentukan Tujuan Belajar) Langkah ini merupakan konklusi sementara dari langkah 4, dimana semua peserta diskusi bersepakat terhadap masalah yang dapat dipahami (dapat dijelaskan secara logis dan meyakinkan) serta masalah mana yang menjadi kebutuhan bersama untuk dipelajari baik dari kuliah, baca literatur, diskusi dengan pakar serta aktivitas akademik lain yang mungkin dilakukan pada langkah 6. Pada langkah ini anggota kelompok menyepakati rencana aksi (action plan) dengan distribusi tugas masingmasing anggota. Langkah 6 Seek additional information (individual learning) Masing-masing peserta diskusi mencari informasi terkait dengan teori, konsep, atau penjelasan akademik yang relevan dengan daftar tujuan belajar yang telah ditetapkan pada langkah 6. Langkah 7 :Synthesize and test the new information by sharing Anggota kelompok bertemu kembali untuk mendiskusikan informasi yang didapat masing-masing sebagai tahap akhir dari PBL. Pada tahap ini peserta diskusi menyepakati bentuk laporan bersama

Pembagian Peran dalam Diskusi PBL Dalam pelaksanaan belajar kelompok kecil dalam PBL, mahasiswa membagi diri kedalam peran-peran tertentu untuk melancarkan jalannya diskusi. Diantara peran yang dijalankan antara lain: A. Chair/leader (pemimpin diskusi) Seperti namanya, tugas pemimpin diskusi adalah menjamin agar diskusi berjalan lancar sesuai dengan tahap-tahapnya. Pemimpin bertanggung jawab mendistribusikan kesempatan setiap anggota diskusi untuk berpendapat, menjaga dinamika diskusi dan melakukan monitor terhadap waktu serta hasil diskusi. Tugas pemimpin diskusi juga memastikan scribe dapat mengimbangi jalannya/dinamika diskusi serta melakukan perekaman pendapat yang muncul dalam diskusi secara akurat. Pemimpin juga memiliki tanggung jawab dalam memastikan pembagian tugas belajar kelompok. B. Scribe (Sekretaris kelompok) Tugas dari Scribe adalah mencatat jalannya diskusi, termasuk merekam sumber-sumber belajar yang dikemukakan atau digunakan di This book is only for teacher, please saveproperly 6|Page

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dalam diskusi. Scribe mengumpulkan catatan atau ide dari semua anggota dan menyarikannya sebagai hasil diskusi kelompok.

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C. Anggota Diskusi Peran anggota diskusi adalah mengikuti langkah-langkah diskusi sesuai tahapannya dan secara aktif berpartisipasi dalam diskusi. Kelancaran diskusi ditentukan oleh keterbukaan masing-masing anggota kelompok untuk saling mendengar dan menerima/berbagi informasi yang dimiliki serta saling menghargai pendapat yang dikemukaan di dalam diskusi.

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

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kasus riil atau kasus lainnya. Disinilah tugas tutor merangsang mereka berpikir dan menvisualisasikannya.

untuk

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

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diharapkan mampu menstimulasi refleksi dari para siswa selama proses PBL, sehingga para siswa dan tutor sendiri bisa mengevaluasi kemampuan masing-masing dalam proses pembelajaran. OVERVIEW OF STUDENT SKILLS in PBL STE P 1

DESCRIPTION Clarifying unfamiliar terms

CHAIR 

 Unfamiliar terms is the problem text are  clarified 

2

3

Problem definition(cue and clue)



The tutorial group defines the problem in a set of questions

 

Brainstorming  (dari cue and clue bisakah dibikin cerita  sendiri) Preexisting knowledge is activated and determined, hypothesis are generated

4



Analyzing the problem(skala prioritas, mana LO yg menjadi prioritas utama dst) Explanations and hypotheses are

 

SCRIBE

 Divides the blackboiard into three parts  Notes down the unfamiliar terms Asks the group for possible problem  Notes down definitions the problem definitions Paraphrases contributions of group members Checks if everyone is satisfied with the problem definitions Concludes and proceeds to the next phrase Allows all group members to  Makes brief and contribute one by one clear summaries of Summarizes contributions of group contributions members  Distinguishes Stimulates all group members to between main contribute points and Summarizes at the end of the side issues brainstorm Invites group members to read the problem Checks if everyone has read the problem Checks if there are unfamiliar terms in the problem Concludes and proceeds to the next phrase

 Makes sure that a critical analysis of all contributions is postphoned until step four  Makes sure that all points from the  brainstorm are discussed  Summarizes contributions of groups members   Asks questions, promotes depth in the discussion  Makes sure the group does not stray from the subject

Makes brief and clear summaries contributions Indicates relations between topics, makes

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5

discussed in depth and are systematically analyzed to each other Formulating learning issues

   

It is determined what  knowledge the group lacks, and learning  issues are formulated on these topics 7

Reporting



Findings from the literature are reported and answers to the learning issues are discussed

      

schemata

Stimulates group members to find relations between topics Stimulates all group members to contribute Asks for possible learning issues Paraphrases contributions of group member Checks if everyone is satisfied with the learning issues Checks if all obscurities and contradictions from the problem analysis have been converted into learning issues Prepares the structure of the reporting phase Makes an inventory ofa what sources have been used Repeats every learning issue and asks what has been found Summarizes contributions of group members Asks questions, promotes depth in the discussion Stimulates group members to find relations between topics Stimualtes all group members to contribute Concludes the discussion of each learning issue with a summary



Notes down the learning issues



Makes brief and clear summaries of contributions Indicates relations between topics, makes schemata Distinguishes between main points and side issues





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Topic tree/LO Blok

THE MANAGEMENT OF DISEASEREHABILITATION THE PREVENTION

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

THE PHYSIOLOGY OF RESPIRATORY & PULMONARY SYSTEM

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

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CASES SECTION

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SCENARIO 1

Diesel and Dust (1) You are a GP in a Town in Sulawesi, You see Mr. Andi Agam, one Saturday morning. He is a 46-year-old plant operator at the open-cut mine, and says 'Sorry to bother you about this, Doc. My wife’s been on at me for ages to come and see you, but you know what a worrier she is. I’m just here to keep the peace. I get a bit short of breath sometimes, not much really. I just put it down to not being 20 anymore. I suppose the middle age spread doesn’t help, does it?' You ask Mr.Andi Agam when he gets short of breath, and he says that it is only when he works hard, 'like changing the tyre the other day – I haven’t had to do that for ages. I had to rest a couple of times. I was pretty well buggered for the rest of the day. Same thing happened last week when I dug some new garden beds'.

History You ask Mr. Andi Agam some specific questions about his recent health and the history is clarified. He has been having some breathlessness on exertion for about eighteen months. He thinks it is fairly constant but never happens at rest and never disturbs his sleep. He does not wheeze. He has had a cough for as long as he can remember, worst in the mornings, but also periodically during the day. He brings up 'about a teaspoon' of brownish sputum during his morning coughing but He has never coughed up any bright blood. He has gradually gained weight (about 10 kg) over the last three or four years. He puts this down to a less active job. You review his history: Smokes: 30–40 cigarettes a day since his late teens Alcohol: 4 pots of beer on Friday nights Past medical history: usually has 'bronchitis' each winter, requiring one or two courses of antibiotics. No other past history of note. Family history: nil of note. Occupational history: He has worked in the mining industry since the age of 16 years, in Western Australia, Northern Territory, and currently in Moura for 12 months. He has never worked underground. When not working in the mining industry, he has done contracting work for councils or builders. He has had occupational exposure to gold, silver and copper – although mostly to 'diesel and dust!' he says. To his knowledge he has never been exposed to uranium, asbestos or nickel.

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SCENARIO 2

Diesel and Dust (2)

Examination He is a slightly overweight man, not cyanosed, and with no finger clubbing. You note that he is using accessory muscles of respiration while sitting quietly. Respiratory system: RR 20/min at rest, with a slightly prolonged expiratory phase. His chest is barrel shaped. Percussion of his chest reveals an inferior displacement of his diaphragm. On auscultation of his lungs you note that his breath sounds are reduced throughout both lung fields. There are no wheezes or other abnormal sounds. Cardiovascular System: BP 150/80. HR 88/min and regular. Heart sounds normal, with no added sounds. JVP not elevated. Abdominal examination does not reveal any abnormality and he has no lymphadenopathy. You are in no doubt that some investigations are in order and write out the request forms while Mr. Andi Agam dresses.

Investigation Result:

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

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SCENARIO 3

Diesel and Dust (3) ARTERIAL BLOOD GASES: Hb = 17.8g/dL (ref range 12-15 g/dL) pH = 7.4 (ref range 7.35-7.45) pO2 = 59 mmHg (ref range 80-100 mmHg) pCO2 = 46 mmHg (ref range 36-44 mmHg) HCO3 = 32 mmol/L (ref range 21-28 mmol/L SPIROMETRY

FEV1 1.69 litres (predicted 2.92), FVC 2.78 litres (predicted 3.69) - unchanged after bronchodilator; TLCO 13.1 (predicted 26.4).

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

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

SCENARIO 4

Diesel and Dust (4)

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

Progress The mining company is very pro-active and arranges for its own occupational health unit to assess Mr. Andi Agam on site. As he is shown to have exercise-related oxygen desaturation, he is offered a sedentary job and copes well with this. He is still short of breath with significant effort, but is pleased when his lung function is improved a month after his initial assessment.

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FEV 1 has improved 20% BLOOD GASES: pH = 7.4 (ref range 7.35-7.45) PO2 = 68 mmHg (ref range 80-100 mmHg) pCO2 = 40 mmHg (ref range 36-44 mmHg) HCO3 = 30 mmol/L (ref range 21-28 mmol/L) Mr. Andi Agam really struggles with the smoking habit. He does not to smoke for the first month, and thinks he has beaten it. He takes it up again, without even knowing why. He tries nicotine patches, joins a Quit program, and even tries hypnotherapy (after initially refusing, saying he didn’t want anyone fiddling with his brain). Eventually however he succeeds in ceasing smoking and states that he feels better for it. During one particularly bad bout of bronchitis, Mr. Andi Agam asks about home oxygen therapy, and you discuss the indications for its use, and the requirements for supply through the health system.

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

SCENARIO 5

Don’t Have Doctor in House (1) Beryl rings her GP early one morning, worried about her husband, Robert. They live on a small farm about 10 km from town. She says he has been awake all night with cough, chest pain and sweating, and he looks sick, but absolutely refuses to see a doctor. She thinks he is too sick to come into town, and asks what she should do. The doctor offers to visit, but Robert, obviously angry, can be heard in the background calling out “I’m telling you Beryl, I’m not having a doctor in this house”. History The doctor asks Beryl some more questions. From what Beryl says, Robert’s answers are rational and coherent, and he remains adamant about not being seen, so the doctor eventually decides not to visit. He asks Beryl to ring again anytime if the situation changes or if she is

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

SCENARIO 6

Don’t Have Doctor in House (2) Examination You examine Robert: He looks ill, and is sweaty, but his lips and tongue are dry and bluish in colour. He is holding the left side of his

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

Investigations You take some arterial blood from Robert's left radial artery for immediate blood gas analysis (being thankful that you paid attention during the tutorial on the anatomy of the wrist!). Venous blood is also sent to the lab for a range of other tests that you have decided are necessary. An intravenous cannula is inserted and Robert leaves the Department for a chest x-ray. You give him a specimen jar and explain that a sputum sample is helpful. You review him a short time later, when the films are available.

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Chest x-ray showing volume reduction on left; infiltration in upper third of the left hemothorax with interposed cavitation. Tuberculosis in an adolescent.

BLOOD GASES: pH = 7.42 (ref range 7.35-7.45) pO2 = 50 mmHg (ref range 80-100 mmHg) pCO2 = 32 mmHg (ref range 35-44 mmHg) HCO3 = 32 mmHg (ref range 24-32 mmHg) overall: hypoxic (V/Q mismatch) --> hypoxic drive to breathe --> tachypnoea --> but reduced SA therefore still inefficient exchange --> hypocapnia inititally a obstructive problem, possibly complicated by a restrictive problem shunting is occurring (less blood is flowing into the consolidated area) probably some background COPD You check Robert's allergies and give a first dose of antibiotics, write up fluid orders and speak to the resident on the ward Robert will go

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up to. Results available later in the day are:

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

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SCENARIO 7

Don’t Have Doctor in House (3) Initial Treatment Robert’s initial treatment included: 

IV fluids



Analgesia - titrated to pain



Insulin



Oxygen at 40% concentration and with humidification



Antibiotics: Ceftriaxone and vancomycin.

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

Progress and Ongoing Care

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A week later Robert is well, and his blood glucose levels are satisfactory. He has been too ill to smoke, and he has said he will try and stay off the cigarettes. He has had consultations with the diabetes educator and dietician while in hospital. GP follow up of the pneumonia , tuberculosis and for ongoing advice about diabetes is arranged and the discharge summary forwarded to the GP practice. A week later he sees his GP, and his clinical progress is as expected. Robert says he has had 'only a couple' of cigarettes since leaving hospital. His blood sugars are within acceptable limits, and he is checking BSLs regularly. Robert also says that he does not want to get pneumonia again, and asks if he is immune now. A repeat x-ray are arranged for the following 6 month, and the x-ray is normal. Outcome Robert returns to running his farm, and subjectively remains well. His management of his diabetes is reasonable, and it is well controlled most of the time. His GP suggests flu and pneumococcal vaccine the following autumn, and although Robert’s initial response is reluctance, he agrees given that he has his farm animals vaccinated for risky illnesses.

REFERENSI 1. Alfred P. Fishman, Jack A. Elias, Jay A.Fishman (2015). Fishman's Pulmonary Diseases And Disorders 5th Edition. New York : McGraw Hill 2. Murray and Nadel's Textbook of Respiratory Medicine: 2-Volume Set, 5e (Textbook of Respiratory Medicine (Murray)) 5th Edition 3. James D. Crapo, Joel Karlinsky,Jeffrey Glassroth (2004). Baum's Textbook Of Pulmonary Diseases Seventh Edition. LWW (Lippincott Williams & Wilkins) 4. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan PPOK (Penyakit Paru obstruktif Aktif) 2016 5. GOLD 2017 6. Perhimpunan Dokter Paru Indonesia (PDPI) Pedoman Diagnosis dan Penatalaksanaan Pneumonia - CAP (2014) 7. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan Asma Bronkiale (2011) 8. GINA 2016 9. Perhimpunan Dokter Paru Indonesia (PDPI) Diagnosis dan Penatalaksanaan Tuberkulosis (2011) 10. Pedoman Nasional Penatalaksanan Tuberkulosis, Kemenkes, 2016 11. Tietz Fundamental of Clinical Chemistry, 6th ed, 2008 12. Burtis CA, Ashwood ER, Burns DE, ST Louis : Saunders Elseveir, 2008 This book is only for teacher, please saveproperly 27 | P a g e

PBL HANDBOOK FOR TUTOR 6th SEMESTER ACADEMIC YEAR 2016/2017

13. Diagnostic radiology a textbook of medical imaging by edinburgh london new york oxford philadelphia st louis sydney toronto 2002.

STRUKTUR PBL SEMESTER VI Pengarah Konsep PBL

: dr. RAHMAD SARWO BEKTI,

M.Med, Ed Koordinator Sistem, Konsep, Nilai&Soal

: dr. NURRAHMA W.

FITRIYANI, M.Med, Ed Koordinator Jadwal, & Modul

: dr. DEWI MUSTIKA,

M.Biomed Koordinator Administrasi&Mahasiswa

: ARIEF AGUSTIAN PRASETYA,

A.Md PJMK MKK PULMONOLOGI & K. RESPIRASI

: dr. TRIWAHJU ASTUTI,

M.Kes, Sp.P(K) Wakil PJMK PULMONOLOGI & K. RESPIRASI

:dr. UNGKY AGUS SETYAWAN,

Sp.P

JADWAL PBL SEMESTER VI Ruang Diskusi GPP FKUB lt. 2 dan 3 (202 – 310) PUKUL 08.00 – 10.00 WIB No . 1 2 3 4 5 6

Hari, Tanggal PBL STEP 1-5 Rabu, 1 Mar 2017 Jumat, 3 Mar 2017 Rabu, 8 Mar 2017 Jumat, 10 Mar 2017 Rabu, 15 Mar 2017 Jumat, 17 Mar 2017

PBL STEP 6-7 Jumat, 3 Mar 2017 Rabu, 8 Mar 2017 Jumat, 10 Mar 2017 Rabu, 15 Mar 2017 Jumat, 17 Mar 2017 Rabu, 22 Mar 2017

JUDUL MODUL Diesel and Dust : History Diesel and Dust : Examination Diesel and Dust : Laboratory Finding Diesel and Dust : Further Advice, Progress, & Outcome Don’t Have Doctor in House Don’t Have Doctor in House (Examination & Investigation)

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7

Rabu, 22 Mar 2017

Jumat, 24 Mar 2017

Don’t Have Doctor in House (Initial Treatment, Progress & Outcome)

DAFTAR TUTOR PBL MKK RESPIRASI NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

NAMA TUTOR PBL dr. TRIWAHJU ASTUTI,M.Kes., Sp.P(K) dr. UNGKY AGUS SETYAWAN, Sp.P. dr. IIN NOOR CHOZIN, Sp.P(K) dr. SURYANTI DWI PRATIWI, Sp.P(K) dr. DANIK AGUSTIN PURWANTININGRUM, M.Kes dr. KHUZNITA DASA NOVITA, Sp.THT-KL. WIKE ASTRID CAHAYANI, S.Ked., M.Biomed. dr. INDRIATI DWI RAHAYU, M.Kes dr. NURUL HIDAYATI, M.Sc dr. OBED TRINURCAHYO KINANTYO PAUNDRALINGGA, M.Sc dr. ARIS WIDAYATI, Sp.S. dr. DEWI MUSTIKA, M.Biomed. dr. NIA KURNIANINGSIH, M.Biomed dr. ARDANI GALIH PRAKOSA, M.Biomed dr. YHUSI KARINA RISKAWATI, M.Sc dr. IHDA DIAN KUSUMA dr. RACHMAD SARWO BEKTI, MMedEd dr. NURRAHMA WAHYU FITRIYANI, MMedEd dr. ALIDHA NUR RAKHMANI, S.Ked.

RUANG 202 203 204 205 206 207 301 302 303 304 305 306 307 308 309 310 311 312 313

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