PIG

PRELIMINARY

1.1 Background
The Respiratory System Block is Block XIII in 4 semesters of curriculum based on
medical education competency, Faculty of Medicine, Muhammadiyah University,
Palembang. This block learning is very important to learn in the block education component
at the Faculty of Medicine, Muhammadiyah University, Palembang. On this occasion a case
study scenarioMr. Fazli, a 25-year-old janitor came to the doctor with the chief complaint of
excessive sneezing which had become worse since 2 days ago. Complaints have been felt
since 2 years ago. Complaints arise mainly in the morning and at work, more than 4 times a
week and are felt to interfere with the activities of Mr. Fazli. Mr. Fazli also complained
about colds, itchy eyes and nasal congestion. Pak Fazli never took medicine and only took
cold medicine bought at street vendors. Pak Fazli's grandfather has a history of asthma.
Physical Examination: General Appearance: looks a bit sick, mentis composition
Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and normal
resistance, RR: 22x / m T: 37.00C
Head: Eyes: Alergic shiner (+)
ENT Status:
- Ears: intact lymph membrane, light reflection ++ / +
- Nose: Narrow Cavum rice, white (+ / +) secreting, concha hypertension, livide, mass (-)
transverse nasal folds (+), allergic salute (+).
- Throat: Symmetrical Arcetric pharynx, uvula in the middle, T1-T1 tonsils are calm,
normal posterior pharynx,
Laboratory examination: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, platelets 200,000,
erythrocytes 4.6 x 1012, calculation of diff 0/7/45/0/45/3

1.2 Purpose and objectives

The purpose and objectives of this case study tutorial report, namely:
1. As a tutorial group task report that is part of the KBK learning system at the Faculty of
Medicine, Muhammadiyah University, Palembang.
2. Can solve the case given in the scenario with the method of analysis and learning of
group discussion.
3. Achievement of the objectives of the tutorial learning method.
4. Students can understand and comprehend new material that has been taught in the
learning process.

CHAPTER II
DISCUSSION
2.1 Tutorial Date
Tutor : dr. Otchi Putri Wijaya
Moderator : Pitantio Sagi Syahputra
Desk secretary : Salsabila Putri Aqilah
Board secretary : Yolanda Fitriani
Time : Tuesday, 2 June 2020 (tutorial phase 1)
8:00 - 10:00
Thursday, 4 June 2020 (Tutorial Stage 2)
8:00 - 100.00

2.2 Rules
1. Turn off the phone or be quiet
2. Hold hands when asking questions and arguments
3. Ask permission in advance when leaving the room
4. Every tutor member is expected to wear a marker

2.3 Scenario
"Gesundheit"
Mr. Fazli, a 25-year-old janitor came to the doctor with the chief complaint of excessive
sneezing which had become worse since 2 days ago. Complaints have been felt since 2 years
ago. Complaints arise mainly in the morning and at work, more than 4 times a week and are felt
to interfere with the activities of Mr. Fazli. Mr. Fazli also complained about colds, itchy eyes and
nasal congestion. Pak Fazli never took medicine and only took cold medicine bought at street
vendors. Pak Fazli's grandfather has a history of asthma.

Physical Examination: General Appearance: looks a bit sick, mentis composition

Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and normal resistance,
RR: 22x / m T: 37.00C
Head: Eyes: Alergic shiner (+)
ENT Status:
 - Ears: intact lymph membrane, light reflection ++ / +
- Nose: Narrow Cavum rice, white (+ / +) secreting, concha hypertension, livide, mass (-)
transverse nasal folds (+), allergic salute (+).
- Throat: Symmetry of the pharyngeal arcus, uvula in the middle, T1-T1 tonsils are calm,
normal posterior pharynx ,.

Laboratory examination: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, platelets 200,000,
erythrocytes 4.6 x 1012, calculation of diff 0/7/45/0/45/3

2.4 Clarification of Terms

1 Nasal congestion Nasal obstruction caused by the lining of
the nose becomes swollen due to inflamed
blood vessels (Dorland, 2015).
2 Leukocytes colorless blood cells that are able to move
ameboidically, with their main function
being to protect the body against
microorganisms that cause disease
(Dorland, 2015).
3 Asthma Repeated paroxysimal dyspnoea attacks,
accompanied by wheezing due to
spasmodic bronchial contractions (Dorland,
2015).
4 Sneezing Sneezing is an adjustment reaction to get rid
of phlegm containing foreign particles or
disorders and cleanse the nasal cavity
(Dorlan, 2015).
5 Uvula Time is like hanging meat (Dorlan, 2015).
6 Shiner allergy Spread of allergies is also known as
periorbital venous congestion or congestion.
The sign consists of dark circles under the
eyes and in the form of bruises or "black
eyes." Spread of allergies caused by blood
or fluid under the eyes due to tissue
 swelling in the nasal cavity (Dorland,
2015).
7 Pharyngeal arcus the curved part of the membranous musculo
space behind the nasal cavity, mouth and
larynx (Dorlan, 2015).
8 Tonsil Round and small tissue masses, special
lymphoid tissue (Dorland, 2015).
9 Erythrocytes Red blood cells (Dorland, 2015).
10 Concha hypertrophy increased volume of concha (thin bone
plates that form the bottom of the nasal
cavity of the lateral wall and mucous
membrane lining the plate) (Dorland, 2015).
11 Itchy An uncomfortable sensation in the nose that
evokes a desire to scratch (KBBI, 2019).
12 Cold common infections where the nasal mucous
membranes of the nose and throat become
inflamed, usually causing the nose to run
(Oxford, 2019).

2.5 Identification of problems

1. Mr. Fazli, a 25-year-old janitor came to the doctor with the chief complaint of excessive
sneezing which had become worse since 2 days ago. Complaints have been felt since 2
years ago. Complaints arise mainly in the morning and at work, more than 4 times a week
and are felt to interfere with the activities of Mr. Fazli.
2. Mr. Fazli also complained about colds, itchy eyes and nasal congestion.
3. Pak Fazli never took medicine and only took cold medicine bought at street vendors. Pak
Fazli's grandfather has a history of asthma.
4. Physical Examination: General Appearance: looks a bit sick, mentis composition
Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and normal
resistance, RR: 22x / m T: 37.00C
Head: Eyes: Alergic shiner (+)
ENT Status:
 - Ears: intact lymph membrane, light reflection ++ / +
- Nose: Narrow Cavum rice, white (+ / +) secreting, concha hypertension, livide,
mass (-) transverse nasal folds (+), allergic salute (+).
- Throat: Symmetry of the pharyngeal arcus, uvula in the middle, T1-T1 tonsils are
calm, normal posterior pharynx ,.
5. Laboratory tests: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, platelets 200,000,
erythrocytes 4.6 x 1012, different amounts 0/7/45/0/45/3

2.6 Problem Priority

1
Mr. Fazli, a 25-year-old janitor came to the doctor with the chief complaint of excessive
sneezing which had become worse since 2 days ago. Complaints have been felt since 2 years
ago. Complaints arise mainly in the morning and at work, more than 4 times a week and are
felt to interfere with the activities of Mr. Fazli.
Reason:
Because this is the main complaint patients come to the doctor, and if complaints are not
managed properly will increase morbidity and mortality.
2.7 Problem analysis
1. Mr. Fazli, a 25-year-old janitor came to the doctor with the chief complaint of excessive
sneezing which had become worse since 2 days ago. Complaints have been felt since 2
years ago. Complaints arise mainly in the morning and at work, more than 4 times a week
and are felt to interfere with the activities of Mr. Fazli.
a. What is the physiology of anatomy in this case?
Answer:
NOSE PHYSIOLOGY

Based on structural theory, evolutionary theory and functional theory, the

physiological functions of the nose and paranasal sinuses are: 1) as an airway; 2) regulating
air condition (air conditioning); 3) as a filter and protector; 4) smell sense; 5) sound
resonance; 6) speech process; 7) nasal reflexes.
1. As a way of breathing
 On inspiration, air enters through the anterior nares, then rises up to the height of
the concha medium and then downward to the nasopharynx, so that the air flow is
arched or arched. On expiration, air enters through the koana and then follows the
same path as inspiration air. However, at the front of the air flow split, some others
back to back form a vortex and join the flow from the nasopharynx.
2. Regulating air condition
The function of the nose as a regulator of air conditions is to prepare the air that
will enter the alveoli. This function is carried out by:
a. Regulates air humidity. This function is carried out by the mucous palette. In
summer, the air is almost saturated with water vapor, evaporation from this layer
is slightly, whereas in winter the opposite will occur.
b. Set the temperature. This function is possible because of the large number of blood
vessels under the epithelium and the presence of a large surface of the concha and
septum, so that radiation can take place optimally. Thus the air temperature after
going through the nose is approximately 37o C.
3. As a filter and protector
This function is useful for cleaning inspirational air from dust and bacteria and is
carried out by:
 Hair (vibrissae) in the rice vestibulum
 Cilia
 Mucous blanket. Dust and bacteria will be attached to the mucous membrane and
large particles will be removed by a sneeze reflex. This mucous membrane will be
flowed into the nasopharynx by ciliary movements.
 An enzyme that can destroy several types of bacteria, called lysozime.
4. Smelling senses
The nose also works as a sense of smell in the presence of the olfactory mucosa
on the roof of the nasal cavity, the superior Konka and the upper third of the septum.
Odor particles can reach this area by diffusion with mucous palms or when breathing
deeply.
5. Voice resonance
 It is important for sound quality when speaking and singing. Nasal obstruction
will cause less or less resonance, so that nasal sounds.
6. The process of talking
Assist the formation of words with nasal consonants (m, n, ng) where the oral
cavity is closed and the nasal cavity is open, the soft palate descends for air flow.
7. Nasal reflexes
Nasal mucosa is a reflex receptor associated with the digestive tract,
cardiovascular and respiratory. Example: irritation of the nasal mucosa causes a
sneezing reflex and breathing stops. Certain odor stimuli cause secretions of the
salivary glands, stomach and pancreas (Soepardi E, 2004).

b. What does it mean Mr. Fazli, a 25-year-old janitor came to the doctor with the main
complaint of excessive sneezing which has become worse since 2 days ago.
Complaints have been felt since 2 years ago?
c. What is the etiology of excessive sneezing?
Answer:
Due to the presence of allergens, based on the way the allergen is divided into:
1. Inhalant allergens, which enter along with respiratory air, such as house dust mites
(D. pteronyssinus, D. farinae, B. tropicalis), cockroaches, animal skin epithelial flakes
(cats, dogs), grasses (Bermuda grass) and fungi (Bermuda grass) and fungi (Bermuda
grass) Aspergillus, Alternaria).
2. Ingestant allergens that enter the digestive tract, in the form of food, such as milk,
beef, eggs, chocolate, sea fish, crab shrimp and beans.
3. Injectant allergens, which enter by injection or prick, such as penicillin and bee
stings.
4. Allergen contactants, which enter through skin contact or mucosal tissue, such as
cosmetic ingredients, jewelry (Soepardi, 2004).

d. What is the relationship between age, gender, and major complaints?

Answer:
 e. How is pathophysiology of sneezing execezseively?
f. What disease might occur with the main complaint of excessive sneezing which has
become worse since 2 days ago?
g. What does it mean Complaints appear mainly in the morning and at work, more than
4 times a week and are felt to interfere with Mr. Fazli?
Answer:
The meaning is Mr.Fazli including persistent moderate to severe type of allergic
rhinitis. Classification of allergic rhinitis according to WHO ARIA based on the
nature of the progression and severity of the disease.4,5 Based on the nature of the
progress, can be divided into two, namely intermittent if symptoms occur less than
four days / week or less than four weeks and persistent or persistent if symptoms are
more than four days / weeks or more than four weeks. Based on the severity of the
disease is divided into two, namely mild if no sleep disturbance is found, disruption
of daily activities, exercise, relax, work, school and severe if there is one or more
disorders.4,5

2. Mr. Fazli also complained about colds, itchy eyes and nasal congestion.
a. Does it mean that Mr. Fazli also complains about catching a cold, itchy eyes and
nasal congestion?
 b. How do pathophysiological colds, itching of the eyes and nasal congestion?
c. What is the relationship between additional complaints and main complaints?
d. What are the possible causes of additional complaints (runny nose, itchy eyes and
nasal congestion)?

3. Pak Fazli never took medicine and only took cold medicine bought at street vendors. Pak
Fazli's grandfather has a history of asthma.
a. What does it mean that Mr. Fazli never took medicine and only took cold medicine
bought at street vendors?
b. What is the meaning of Mr. Fazli's grandfather who has a history of asthma?

4. Physical Examination: General Appearance: looks a bit sick, mentis composition

Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and normal
resistance, RR: 22x / m T: 37.00C
Head: Eyes: Alergic shiner (+)
ENT Status:
- Ears: intact lymph membrane, light reflection ++ / +
- Nose: Narrow Cavum rice, white (+ / +) secreting, concha hypertension, livide,
mass (-) transverse nasal folds (+), allergic salute (+).
- Throat: Symmetry of the pharyngeal arcus, uvula in the middle, T1-T1 tonsils are
calm, normal posterior pharynx ,.
a. What is the interpretation of physical examination and ENT?
Answer:
Examination Category Interpretation
General Looks moderate pain Abnormal
condition Mentos compos Optimal state of
consciousness
TD 110 / 70mmHg Normal
N 90x / minute Normal
RR 22x / minute Normal
Ear intact tympanic membrane, light Normal
reflexes + / +
Nose narrow rice cavity, white (+ / +) Abnormal
 secretions, konka hypertrophy livid
(pale), mass (-) transverse nasal
crease (+), allergic salute (+).
Throat Symmetrical pharyngeal arcus, Normal
middle uvula, T1-T1 tonsils are
calm, normal posterior pharyngeal
wall

b. What is the abnormal mechanism of physical examination and ENT?

c. How do I do an ENT examination?
Answer:
Ear inspection : to see abnormalities in the external ear, including:
1. Earlobe skin: Normal / abnormal
2. Estuary / ear hole: There or not
3. The existence of the ear: - Formed / not formed - The size: small / medium / large
or normal / abnormal. - Are there any abnormalities such as hematoma of the auricle
(cauliflower ear).
4. Ear canal: - Get to know the pars ossea, isthmus and pars cartilaginea from the ear
canal - Are there any signs of inflammation - Whether the discharge comes out / not -
Are there any abnormalities behind the front / ear
5. Eardrum: Assessed in color, its size, presence or absence of light reflexes (cone of
light), perforation, brushes, retraction, protrusion of the brevis process.

Ear palpation: Around the ear: - Behind the earlobe 14 - Front of the earlobe - Is
there any pain / not (retroauricular pain / tragus pain)

Do a nose inspection, starting from :

- Nasal lobe (rice vestibulum)
- Buildings in the nasal cavity
- Inferior rice meatus: normal / not - Inferior Konka: normal / not - Medius nasi
meatus: normal / not
- Konka medius: normal / not
- The state of septa rice: normal / not, is there a deviation of the septum
- State of the nasal cavity: normal / not; narrow / wide; abnormal growths: polyps,
tumors; Foreign objects / not: smelling / not
- Is there a discharge in the nasal cavity, if there is a description of the discharge
(many / few, clear, mucous, purulent, color of the discharge, whether smelling).

POSTERIOR RINOSCOPY EXAMINATION

Inspection order:
1) Spray the oral cavity with 2% lidocaine spray.
2) Wait a few minutes.
3) Take a small size laryngeal glass.
4) Insert / install the laryngeal glass in the area of the faucum ismus in the direction
of the glass into the cranial.
5) Evaluation of shadows in the posterior nasal cavity (nasopharynx).
6) Look at shadows in the nasopharynx: • Rossenmuler Fossa 22 • Torus tubarius •
Estuary auditory tube Eustachii • Adenoids • Konka superior • Posterior rice septum •
Choana

LIGHT EXAMINATION AND MOUTH SKIN

Are there abnormalities in the lips and oral cavity:
• Dry lips
• Lip ulcers
• Drolling (drooling)
• Tumor
• Difficult to open the mouth (trismus)
TONSIL EXAMINATION
• Large tonsils
• Surface:
- Smooth / bumpy,
- Ulceration,
- Detritus,
- Widening cryptes,
- Micro abscess
- lobbed tonsillons
- Thickening of the arcus
- Large right and left tonsils are the same / not
- Accompanied by enlargement of the neck gland / not
Indirect laryngoscope procedure :
- Patient sitting facing the doctor, the patient's position is slightly higher than the
doctor.
- The patient's body is leaning slightly forward, with the mouth wide open and the
tongue sticking out. So that the larynx glass is not foggy by the patient's breath,
warm the larynx glass to a little above body temperature.
- Hold the tip of the patient's tongue with sterile gauze to remain outside the mouth.
Ask the patient to calm down and take deep and slow breaths through the mouth.
- Focus the beam from the head lamp on the patient's oropharynx.
- To prevent vomiting reflexes, point the laryngeal glass into the oropharynx
without touching the oral cavity mucosa, soft palate or posterior wall of the
oropharynx.
- Turn the larynx glass downward until you can see the surface of the larynx and
hypopharynx. Remember that in indirect laryngoscopy, the image of the larynx and
pharynx is reversed: 30 plica right vocalist is visible on the left side of the laryngeal
glass and plica right vocalist is visible on the left side of the laryngeal glass.
- Ask the patient to say "aaahh", observe the movements of the vocal cords (true
vocal cords) and the arytenoid cartilage.
- Plika vocalist will elongate and reduce along the median line. Observe the
movement of the vocal cords (are there paresis, asymmetry of movements, vibration
and attenuation of the vocal cords, granulation, nodules or tumors in the vocal
cords).
- To expand the visualization, ask the patient to stand while the examiner sits, then
vice versa, the patient sits while the examiner stands.
- Also observe the glottis, supraglottis and subglottis.
Adams, George, Boies, Lawrence, Higler, Peter. BOIES Textbook for ENT. VI Edition. Jakarta:
EGC. 2012.

5. Laboratory tests: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, platelets 200,000,
erythrocytes 4.6 x 1012, different amounts 0/7/45/0/45/3
a. What is the interpretation of the Laboratory Examination?
Answer:
a. Supporting Check up Normal Informatio
investigation result value n
Hb 14.0 gr% 13-18 gr% Abnormal
Leukocytes 3500 / mm3 4000-10000 Normal
/ mm3
HT 42% 40% - 50% Normal
Platelets 200,000 mm3 170 - 380x Normal
103 / mm3
Diff.Count 7/7/45/0/45/3 Basophil 0- Eosinophilia
1 (N) ,
Eosinophils Lymphocyte
1-3 (AB) s, and
Rod 2-6 Neutrophils
Segment of stems and
50-70 segments
Lymphocyt (neutrophili
es 20-40 a)
(AB)
Monocytes
2-8 (AB)

b. What is the abnormal mechanism of the Laboratory Examination?

6. How to diagnose?
Answer:
 1) The main complaint: sneezing since 2 days ago appeared in the morning, about four
times a week
2) Additional complaints: runny nose, nose and eyes and nasal congestion
3) Physical examination: General Appearance: looks rather sick, compositional: Not
normal
4) ENT examination: Nose: narrow Cavum rice, secret vaginal discharge (+ / +), konka
livide hypertrophy conca (+): Abnormal
5) There are leukopenia, neutrophilia and eosinophilia.

7. What is the differential diagnosis in this case?

8. What is the additional examination in this case?
Answer:
a. In vitro
Eosinophil count in peripheral blood can be normal or increased. Likewise, the total
IgE examination (prist-paper radio immunosorbent test) often shows normal values,
except when there are signs of allergies in patients with more than one disease, for
example other than allergic rhinitis also suffer from bronchial asthma or urticaria. More
meaningful is the RAST (Radio Immuno Sorbent Test) or ELISA (Enzyme Linked
Immuno Sorbent Assay Test). Nasal cytology examination, although it cannot confirm
the diagnosis, is still useful as a supplementary examination. The discovery of
eosinophils in large numbers indicates the possibility of allergic inhalation. If basophils
(5 cells / lap) may be caused by food allergies, whereas if found PMN cells indicate a
bacterial infection (Soepardi, 2004).
b. Serum total IgE examination
In general, serum total IgE levels are low in normal people and increase in people
with atopy, but normal IgE levels do not rule out allergic rhinitis. In normal people, IgE
levels increase from birth (0-1 KU / L) to puberty and decrease gradually and persist
after the age of 20-30 years. In adults levels> 100-150 KU / L are considered normal.
Increased levels were only found in 60% of people with allergic rhinitis and 75% of
people with asthma. There are various situations in which IgE levels increase, namely
parasitic infections, skin diseases (chronic dermatitis, bullous pemphigoid disease) and
 decreased levels in immunodeficiency and multiple myelom. IgE levels are also affected
by race and age, so reporting results must attach to the normal limit values according to
age group. This check can still be used as a filter check,
c. Serum specific IgE examination (by the RAST method
This test is to prove the presence of specific IgE against an allergen. This
examination is quite sensitive and specific (> 85%), can be repeated accurately and is
quantitative. Research studies prove a good correlation between specific IgE with skin
tests, clinical symptoms, and nasal provocation tests when using standardized allergens.
New results are significant when there is a correlation with clinical symptoms, such as a
skin test. Another way is Modified RAST with a scoring system (Soepardi, 2004).
d. Other Inspections
This examination is not the first examination to establish a diagnosis, but can be
used as a supporting examination or to look for other causes that influence the onset of
clinical symptoms (Soepardi, 2004).
1) Calculate peripheral blood cell types
This check is used if other facilities are not available. The number of peripheral
blood eosinophils may sometimes increase in the incidence of aleric rhinitisgi but not
clinically meaningful.
2) Secret cytological examination and nasal mucosa
The examination material is obtained by direct nasal secretions (smears), scrapings,
rinses and mucosal biopsy. Taking the preparations for this examination should be
donen at the peak of RAFL post-race allergen or when symptomatically severe and
usually only for research purposes and must be done by trained personnel.
3) Nasal provocation test / nasal challenge test (if facilities are available).
This examination is carried out bilThere is no match between the results of primary
diagnostic tests (skin tests) with clinical symptoms. In general, this test is more
difficult to repeat compared to skin tests and specific IgE tests. The provocation test
places the patient at risk of anaphylactic reaction.
4) Mucociliary function test (assess ciliary movements)
This examination is for research purposes
5) Examination of nasal air flow
 The degree of nasal obstruction is measured quantitatively by a romanomanometry
(anterioror posterior) or acoustic rhinomanometry, for example after a nasal
provocation test. This check is not routine.
6) Radiological examination
Paranasal sinus plain radiograph examination, CT Scan or MRI (if facilities are
available) cannot be used for establish a diagnosis of allergic rhinitis, but to rule out
pathological abnormalities or complications of allergic rhinitis especially if the
treatment response is unsatisfactory. On plain photo examination, thickening of the
sinus mucosa can be found (a characteristic feature of sinusitis due to allergies) and
homogeneous intercourse as well as a picture of the fluid air margin in the maxillary
sinus.
7) Other tests are: the function of smell and measurement of NO (nitric oxide) levels
(Soepardi, 2004).

e. Skin Test
Skin tests can be done in several ways, namely: a scratch test, chilly skin test,
intradermal injection test and skin endointiration (SET). To ensure its accuracy, a skin
test must be carried out after the 'wash out' mass for corticosteroids has exceeded 2-3
months
Skin testing as an allergy test using allergen extract is a surefire diagnostic tool
that proves the phase of sensitization by certain allergens in an individual. Positive test
results indicate an immediate hypersensitivity reaction in the individual, or in other
words, in the individual episodes there is an IgE-mast cell complex.
Skin testing has been used as one to establish a diagnosis of allergies to allergens
and is a safe, easy to do, quick results obtained, relatively inexpensive cost with high
sensitivity and can be used as a screening test. Slough skin test can diagnose moderate
to severe allergic rhinitis, but in patients with low sensitivity, it may not be detected
even though there is a correlation with clinical symptoms. If there is suspicion on the
history of allergies, the skin test is negative. Actions that need to be done are:
1) Check medicines that can affect test results
2) Check whether there is a cause for false negative results
3) Observe the patient during high allergen exposure
 4) Perform provocation tests or intradermal tests (Soepardi, 2004).

9. What is the working diagnosis in this case?

a. Definition
 Treatment
a. Antihistamines
Antihistamines can be taken orally and topically to control symptoms such as
sneezing, rhinorrhea, itching, and conjunctivitis.
1) Oral
First generation antihistamine drugs such as diphenhydramine 15-25 mg,
clorfeniramin, and cyprohetadine.
Second-generation antihistamines such as cetirizine and loratidin 10 mg
daily.
2) Topic
Azelastine and levocabastin 1-2 spray 137 ug.
b. Decongestants
1) Oral
Pseudoephedrine 30-60mg tab and phenileferine
2) Topic
Oxymetazoline 0.05% (3-5 days)
c. A combination of antihistamines and decongestants
Loratadine and pseudoeferin 120 mg
d. Corticosteroids
1) Topic
Budesonide 64-100mcg and benometasone
e. Anti leukotriene
Zafirlukast / montelukast
For this case, the medium-severe grade uses oral / topical antihistamines or
antihistamines and oral decongestants or topical corticosteroids (Soepardi, 2012).
 Promotive
Educate patients about their allergens and how they deal with them.
  Prevention
a. Prevention includes avoiding their allergens.
b. Other methods include not having a pet, not having a carpet at home, and keeping
the house dry.
c. Wearing a mask.

b. Epedemiology
Answer:

c. Etiology
Answer:
Etiology based on how to enter is divided into 4:

Allergen inalan allergens that enter along with respiratory air (mites, house dust, animal

skin epithelial flakes etc.)

Ingestant allergens allergens that enter the digestive tract (milk, eggs, chocolate, nuts,

shrimp, crabs, etc.)

Injectant allergens allergens that enter by injection / prick (penicillin, bee sting)

Allergen contactants  allergens that enter through skin / mucosal tissue contact (cosmetic

ingredients, jewelry).

Allergic rhinitis and atopy are generally caused by interactions in patients who
genetically have potential allergies to the environment. Genetics clearly has an important
role. In 20-30% of the population and in 10-15% of children all are atopy. If both parents
have atopy, the risk of atopy becomes 4 times greater or reaches 50%. The role of the
environment in allergic rhinitis is that allergens are present throughout the environment, are
exposed and stimulate an immune response that genetically has allergic tendencies. The
common allergen is in the form of inhalant allergens that enter with respiratory air that is
house dust, mites, attack feces, animal fleas, pollen, etc. (Soeparfi E, 2012).
 d. Risk factor
Answer:

e. Classification
Answer:

f. Pathogenesis / Pathophysiology
Answer:
Pathogenesis of Allergies and Allergic Rhinitis
Allergic reactions consist of 2 phases, viz
rapid phase allergic reactions (RAFC) which
lasts since contact with allergens
up to 1 hour after contact and reaction
slow phase allergy (RAFL) which
lasts 2-4 hours with a peak of 6-8
hour (hyper-reactivity phase) after exposure
allergens and can last up to 24–
48 hours. In its pathogenesis, reaction
allergies can be divided into two phases, namely phases
sensitization and elicitation which consists of activation and effector stages.

Sensitization Phase
All human nasal mucosa are exposed to various particles, such as pollen, dust, animal skin
flakes, and other proteins that are inhaled with inhalation of breath air.
Dendritic cells are antigen presenting cell (APC) in the lungs and plays an important role in
inhalant allergic immune responses such as house dust mites. On first contact with allergens,
macrophages or dendritic cells that act as APCs will capture aeroallergens that stick to the
surface of the nasal mucosa. Allergens deposited in the nasal mucosa are then processed by
macrophages / dendritic cells that function as phagocytes and APC into short peptides consisting
of 7-14 amino acids that bind to the site
introduction of antigens from the MHC complex (major histocompatibility complex) class II.
This APC will migrate to adenoids, tonsils or lymph nodes which are then presented to naive Th
(Th0) cells.

In patients with atopy, T cell receptors (TCR) on Th0 lymphocytes along with CD4 molecules
can recognize the peptides presented by the antigen-presenting cell.
APC releases cytokines, such as IL-1, which will activate Th0 to proliferate into Th1 and
Th2. Th2 produces various cytokines, such as IL-3, IL-4, IL-5, and IL-13. Excessive production
of cytokines by TH2 in the lungs is one of the causes of asthma.

Continuous exposure to low dose allergens to someone with allergic talent (atopy) and
allergen presentation by cells from APC to B cells accompanied by the influence of cytokines
IL-4 and IL-13 which are bound by their receptors on the surface of B lymphocyte cells,
triggering lymphocyte cells B becomes active and will produce ever increasing IgE. Specific IgE
binds to the surface of mast cells and has an important role in the emergence of acute allergic
reactions. Mast cells then enter the postcapillary venules in the mucosa which then exit the
circulation and are in the tissues, including in the nasal mucosa and sub-mucosa. In this situation,
a person is said to be sensitive or sensitized, and gives a positive result on a skin test.

Elicitation Phase
Activation Stage
In patients who are already sensitized, if re-exposed to an allergen is similar to previous
allergen exposure to the nasal mucosa, bridging can occur between two IgE molecules that are
adjacent to the mast / basophil cell surface with the polyvalent allergen (cross-linking). The
interaction between IgE bound to the surface of mast cells or basophils with the same allergen
triggers the activation of guanosine triphosphate (GTP) which activates the enzyme
phospholipase C to catalyze phosphatidyl inositol bisphosphate (PIP2) to inositol triphosphate
(IP3) and activate the enzyme phospholipase C to catalyze phosphatidyl inositol bisphosphate
(PIP2) to inositol triphosphate (IP3) and diacylglycerol (DIP) on the membrane PIP2 in the
membrane . Inositol triphosphate (IP3) causes the release of intracellular calcium ions (Ca ++)
from the endoplasmic reticulum. The Ca ++ ion in the cytoplasm directly activates several
enzymes, like phospholipase-A and the complex Ca ++ - calmodulin which activates the enzyme
myosin light chain kinase. Furthermore, Ca ++ and DAG together with the phospholipid
membrane activate protein kinase C. As a result of this activation is the formation of lipid
mediators belonging to newly formed mediators, such as prostaglandin D2 (PGD2) leukotriene
C4 (LTC-4), platelet activating factors ( PAF), and exocytosis of mast cell granules which
contain chemical mediators called preformed mediators such as histamine, tryptase, and
bradykinin. Research by Post et al. Shows that house dust mites can be a cause of calcium
signaling in bronchial epithelial cells and play a role in the production of chemical mediators.
The final result of this activation is the formation of lipid mediators classified as newly formed
mediators, such as prostaglandin D2 (PGD2) leukotriene C4 (LTC-4), platelet activating factors
(PAF), and exocytosis of mast cells containing chemical mediators called preformed C4 (LTC-4)
mediators such as histamine, tryptase, and bradykinin. Research by Post et al. Shows that house
dust mites can be a cause of calcium signaling in bronchial epithelial cells and play a role in the
production of chemical mediators. The final result of this activation is the formation of lipid
mediators classified as newly formed mediators, such as prostaglandin D2 (PGD2) leukotriene
C4 (LTC-4), platelet activating factors (PAF), and exocytosis of mast cells containing chemical
mediators called preformed C4 (LTC-4) mediators such as histamine, tryptase, and bradykinin.
Research by Post et al. Shows that house dust mites can be a cause of calcium signaling in
bronchial epithelial cells and play a role in the production of chemical mediators. tryptase, and
bradykinin. Research by Post et al. Shows that house dust mites can be a cause of calcium
signaling in bronchial epithelial cells and play a role in the production of chemical mediators.
tryptase, and bradykinin. Research by Post et al. Shows that house dust mites can be a cause of
calcium signaling in bronchial epithelial cells and play a role in the production of chemical
mediators.

6.11
Histamine has a direct effect on endothelium, which increases capillary permeability
which causes a transudation process that aggravates the symptoms of rhinorrhea. Histamine
binding to nociceptive type C nerve receptors on nasal mucosa originating from NV causes
itching in the nose and stimulates sneezing. The effect of histamine on the gland due to
activation of the parasympathetic reflex has the effect of increasing glandular secretion which
causes serous rhinorrhea symptoms. In addition, it also causes nasal congestion because it causes
vasodilation of blood vessels so that transudation to the interstitial occurs resulting in nasal
mucosa, especially edema. Symptoms that arise immediately after allergen exposure are called
rapid phase reactions or immediate phase reactions (RFS).
in epithelial cells or in the endothelium.

6
Effector Stage
After the activation phase reaction, with the release of cytokines and endothelial activation,
a slow phase reaction occurs. Late-phase reaction (RFL) occurs in some patients (30-35%)
allergic rhinitis between 4-6 hours after exposure to allergens and persists for 24-48 hours.
A typical feature of RFL is the attraction of various types of inflammatory cells, especially
eosinophils to the location of allergic reactions which are major effector cells in chronic allergic
reactions, such as allergic rhinitis and bronchial asthma. The course of eosinophils from the
blood circulation to the tissue / location of the allergy is influenced by chemotactic factors,
through several stages such as migration (displacement) of eosinophils from the middle to the
edge of the vessel wall and begins to bind reversibly to the endothelium which is inflamed
(rolling), followed by attachment to the vessel wall which is mediated by interactions of
endothelial adhesion molecules, such as intercell adhesion molecule – 1 (ICAM-1) and vascular
cell adhesion molecule-1 (VCAM-1) which is specific to the attachment of eosinophils because
eosinophils express VLA-4 which will bind to VCAM-1. ICAM-1 is also expressed by the nasal
mucosal epithelial cells of allergic rhinitis patients who are constantly exposed to specific
allergens and form the basis of the conceptminimal persistent inflammation(MPI) seen in allergic
rhinitis to house dust mites (TDR) in a symptom-free state. Eosinophilus l nasal mucosa cells
play an important role in the pathophysiological changes of allergic sufferers, because they
contain various chemical mediators, such asmajor basic protein (MBP), eosinophile cationic
protein (ECP), eosinophile derived neurotoxin (EDN), and eosinophile peroxidase (EPO) which
causes desaggregation and desquamation of the epithelium,
cell death, mucosal nerve inactivation, and cell damage due to free radicals.
(Mantu, Wahongan and Bernadus, 2016)

Mantu, BG, Wahongan, GJ and Bernadus, JB (2016) 'Relationship between house dust mite density and
degree of allergic rhinitis', Journal of e-Biomedics, 4 (1). doi: 10.35790 / ebm.4.1.2016.11056.

g. Clinical manifestations
Answer:

10 What is the treatment in this case?

Answer:
 Treatment
f. Antihistamines
Antihistamines can be taken orally and topically to control symptoms such as
sneezing, rhinorrhea, itching, and conjunctivitis.
3) Oral
First generation antihistamine drugs such as diphenhydramine 15-25 mg,
clorfeniramin, and cyprohetadine.
Second-generation antihistamines such as cetirizine and loratidin 10 mg
daily.
4) Topic
Azelastine and levocabastin 1-2 spray 137 ug.
g. Decongestants
3) Oral
Pseudoephedrine 30-60mg tab and phenileferine
4) Topic
Oxymetazoline 0.05% (3-5 days)
h. A combination of antihistamines and decongestants
Loratadine and pseudoeferin 120 mg
i. Corticosteroids
2) Topic
Budesonide 64-100mcg and benometasone
j. Anti leukotriene
Zafirlukast / montelukast
 For this case, the medium-severe grade uses oral / topical antihistamines or
antihistamines and oral decongestants or topical corticosteroids (Soepardi, 2012).
 Promotive
Educate patients about their allergens and how they deal with them.
 Prevention
d. Prevention includes avoiding their allergens.
e. Other methods include not having a pet, not having a carpet at home, and keeping
the house dry.
f. Wearing a mask.

10. What are the complications in this case?

11. What is the prognosis in this case?
12. What is SKDU in this case?
13. What is the point of view of Islam?
Answer:
"O people, verily you have come to learn from your Lord and the healers for the diseases
that are in the bosom and guidance and mercy for those who believe." (QS Jonah 57)

Dafus:
Soepardi.EA, N.Iskandar, J.Bashiruddin, RDRestuti. Science Teaching Book
Head and Neck Throat Nose Health. Vol VI (6).
Jakarta: Faculty of Medicine, University of Indonesia. 2012.