REPORT: TUTORIAL SCENARIO D

7th Group:

Ahmad Muchlisin 702018003

Raga Tetra Putra 702018017

Fransiska Delvia 702018020

Camelia Panache 702018046

Rima Putri 702018050

Tasya Salsabila 702018055

Rahmi Nurbadriya N 702018062

Putri Umniyah 702018075

Azka Nabila Hani 702018076

Shafa Almira 702018097

Advisor:

dr. Sheila Yonaka Lindri, M.Kes

MEDICAL SCHOOL

MUHAMMADIYAH UNIVERSITY OF PALEMBANG

2019/2020

1
 PIG

PRELIMINARY

1.1 Background

The Respiratory System Block is the thirteenth block in semester IV

from the Competency Based Curriculum (CBC) Medical system

Education, Faculty of Medicine, Muhammadiyah University, Palembang

One learning strategy is Competency Based Curriculum

(CBC) system is Problem Based Learning (PBL). Tutorial is

the application of the Problem Based Learning (PBL) method. In

Tutorial students are divided into small groups and each group is guided by

a tutor / lecturer as a facilitator to resolve existing cases.

1.2 Purpose and objectives

The purpose and objectives of this case study tutorial report are:

1. As a tutorial report group project that is part of the CBC learning system

at the Faculty of Medicine, Muhammadiyah University, Palembang.

2. Can resolve the case given in the scenario with the analysis method

and study group discussions.

3. Achieving the objectives of the tutorial learning method.

2
 CHAPTER II

DISCUSSION

2.1 Tutorial Data

Tutor : dr. Sheila Yonaka Lindri, M.Kes

Moderator : Tetra Putra Body

Desk secretary : Rima Putri

Board secretary : Tasya Salsabila

Time : Tuesday, June 2, 2020

10:30 - WIB

Tutorial rules:

1. Turn off cellphone or idle.

2. Raise your hand when asking relevant opinions and questions.

3. Permission when leaving the room.

4. Respect each other's opinions and remain calm and not noisy.

3
2.2 Case Scenarios

"Gesundheit"

Mr. Fazli, a 25-year-old janitor came to the doctor with a doctor

the main complaint is excessive sneezing which has become worse since 2

a few days ago. Complaints have been felt since 2 years ago. Complaints arise

especially in the morning and at work, more than 4 times a week and moderate

feel disturbed by the activities of Mr. Fazli. Mr. Fazli also complained

colds, itching in the eyes and nasal congestion. Mr. Fazli never received

medicine and only take cold medicine purchased at street vendors. Sir.

Grandfather Fazli has a history of asthma.

Physical Examination: General Appearance: looks rather sick, composted

mentis

Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and

normal resistance, RR: 22x / m T: 37.0 0 C

Head: Eyes: Alergic shiner (+)

ENT Status:

- Ears: intact lymph membrane, light reflection ++ / +

- Nose: Cavum rice is narrow, secreting (+/ +) white, hypertrophy concha, livide,

mass (-) transverse nasal fold (+), allergy salute (+).

- Throat: pharyngeal arcus symmetrically, uvula in the middle, tonsils T1-T1 are

calm, normal posterior pharynx ,.

Laboratory tests: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500,

200,000 platelets, 4.6 x 10 erythrocytes 12, count of 0/7/45/0/45/3 diff

2.3 Clarification of Provisions:

Not. Clarification of Terms

1 Sneezing Spasmodically release strong air

nose and mouth (dorland, 2015)

2 Asthma Repeated paroxysmal dyspnoea attacks, with

4
 wheezing due to spasmodic
contractions

bronchi. this condition is usually caused

by manifestations of allergies (allergic or
allergic)

extreme. a) or secondary to chronic or

recurring conditions (intrisic. a) (dorland,

2015)

3 Nasal congestion Blockage due to inflammation of the nose

lining (dorland, 2015).

4 Compositionist Normal consciousness, fully conscious, can

to answer all questions about that

circumstances around it (dorland, 2015).

5 Lymphatic Thin layer of tissue covering

intac membrane tymphani surface (dorland, 2015).

6 Diamond allergies Allergy shiners is blood collection

or fluid under the eyes due to swelling

tissue in the nasal cavity (Dorland, 2015).

7 Uvula Small fleshy objects hanging from soft

ceiling (dorland, 2015).

8 Salute allergy Rub your nose for itching with your palm in

upward movement (dorland, 2015).

9 Cold The temperature is lower when compared to

human body temperature (dorland, 2015).

10 Itchy eye It's an annoying sensation that makes you want

to scratch your skin. (Dorland, 2015).

11 Cavum rice Empty place or room or potential space

on the nose (Dorland, 2015).

substa
12 Secrete Compound with certain nce

produced by glands (dorland, 2015).

13 Concha hypertrophy Increased concha volume (thin bone

a plate that forms the lateral bottom

the walls of the nasal cavity and mucous
membranes

5
 lining the plate) (Dorland, 2015)

14 Livide Change the color caused by contusion or

bruises (Dorland, 2015)

2.4 Identification of problems

1. Mr. Fazli, a 25-year-old janitor goes to the doctor with a doctor

the main complaint is excessive sneezing which has become worse since then

2 days ago. Complaints have been felt since 2 years ago. Complaint

arise mainly in the morning and at work, more than 4 times a week

and was felt to disturb the activities of Mr. Fazli.

2. Mr. Fazli also complained of colds, itching of the eyes and nose
congestion.

3. Mr. Fazli never took medicine and only took cold medicine
street seller.

4. Pak Fazli's grandfather has a history of asthma.

5. Physical Examination: General Appearance: looks rather sick,

composted mentis

Vital signs: TD: 110 / 70mmHg, pulses: 90x / minute regular, containing and

normal resistance, RR: 22x / m T: 37.0 0 C

Head: Eyes: Alergic shiner (+)

ENT status:

Ears: intact lymph membrane, light reflection ++ / +

Nose: Cavum rice is narrow, secreting (+/ +) white, hypertrophy concha, livide,

mass (-) transverse nasal fold (+), allergy salute (+).

Throat: pharyngeal arcus symmetrically, uvula in the middle, tonsils T1-T1 are

calm, normal posterior pharynx ,.

6. Laboratory tests: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, 200,000

platelets, 4.6 x 10 erythrocytes 12, count of 0/7/45/0/45/3 diff

6
 2.5 Priority Problems

Problem identification number 1, because it can increase morbidity and numbers

Dead. excessive sneezing which has become worse since 2 days

then is the main complaint brought by mr. fazli to see a doctor so we have to

cure it first and it won't create other undesirable complications.

2.6 Analysis of the problem

1. Mr. Fazli, a 25-year-old janitor, comes to the doctor with a chief

excessive sneezing complaints that have become worse since 2 days

then. Complaints have been felt since 2 years ago. Complaints arise

especially in the morning and at work, more than 4 times a week and moderate

feel disturbed by the activities of Mr. Fazli.

A. How anatomy, and physiology of this case?

b. What does it mean Mr. Fazli, a 25-year-old janitor came

to the doctor with the main complaint of excessive sneezing

getting worse since 2 days ago?

The meaning is that Mr. Fazli experienced a hypersensitivity reaction as a

result inflammation of the nasal mucosa caused by allergies to particles
such as house dust mites, smoke, pollen / pollen that is in the air, and has
been worse since 2 days ago shows the progression of the disease or a
worsening keluham because of the influence of various factors .

c. What is the etiology of sneezing?

Sneezing is caused by irritation of histamine in the
sensory nerve (trigeminus) in the nasal mucosa which can be
triggered by various types of allergens, namely:
1) Inhalant allergens
a) Air pollution
Over the years, urban air pollution has been the subject of
research as an important extrinsic etiology of allergic diseases.
Attention is concentrated on gaseous substances such as ozone and
nitrogen dioxide. Epidemiological studies show a strong
relationship between air pollution and allergic diseases. It has
been proven that air pollution can strengthen allergic reactions
with epithelial modification, affect immunity, and increase
sensitivity to allergens.
b) Airborne allergens
This allergen triggers perennial rhinitis (animal hair) and
seasonal types (pollen). The development of hypersensitivity is
associated with the presence of secretions from house dust mites.
Pet's fur, skin, saliva and urine (especially cats and dogs) are
 also important sources of allergens. Animal fur
livestock such as horses and cows can be allergens that play a role
in allergy related to labor. Exacerbation of allergic symptoms
during a particular season is related to pollen from certain plants
that bloom during that season. Pollination of plants assisted by
insects produces relatively small amounts of pollen and can only
trigger symptoms with close contact.

2). Ingestan Allergen

Based on WHO data, food allergies affects 4-10% of children and 2-4% of
adults. IDAI states that ingestant allergens play a greater role in
infancy and childhood.

3). Contactant allergens

contactant allergens do not have a significant role in allergic
rhinitis because these allergens have more impact on contact / irritant
dermatitis

4) .Injection Allergens
Injectant allergens can be in the form of injected drugs or venom from
insect bites. This allergen does not play a significant role but can
trigger exacerbations in allergic rhinitis.

d. What causes sneezing complaints since 2 days ago?

Sneezing complaints increased since 2 days ago can be caused by various triggering factors
such as cold air, animal hair, or dust. In this case, the possibility has increased since
Allergic reactions consist of 2 phases, namely immediate
phase allergic reaction (RAFC) which lasts from contact with
allergens to 1 hour afterwards and late phase allergic
reaction (RAFL) which lasts 2-4 hours with peak 6-8 hours
(hyperreactivity phase) after exposure and can last 24-48
hours. The possibility of getting worse since 2 days ago
because Mr. Fazli who worked as a janitor made contact with
allergens in the form of dust, causing a slow phase
hyperactivity reaction.

e. What were the triggering factors for the complaints experienced by Mr. Fazli?
In this case Mr. Fazli who is a janitor made contact with
Inhalant Allergens, which enters together with respiratory
air, for example house dust there are two main species of
mites namely Dermatophagoides Farinae and Dermatophagoides
Pteronyssinus, mites, epithelial flakes from animal hair and
fungi.
Risk factors for dust mite exposure are usually carpet and
bed linen, high temperatures, and air humidity factors.

f. What is the correlation between age, sex and occupation in

this case?
Work relationships are to increase internal trigger factors, i.e. inhalent
allergens in the form of dust mites and mold, also exposed to cold air in the
morning. Where is workMr. Fazli as cleaning staff make it possible Mr.
 Fazli get a factor frequent contact with allergens and also exposed to cold
air from in the morning after work starts.

g. What is the pathophysiology of sneezing on the case ?

h. What are the chances of sneezing?

Diseases with complaints of sneezing are as follows:

i. What meaning has the complaint felt since 2 years ago?

j. What does it mean complaints appear especially in the morning da hour work, more than 4
times a week and feels disturbing Mr. Fazli's activities?
The meaning of the complaint appears especially in the
morning at work hours is a risk factor / trigger complaints
in the case. In the morning the ambient temperature is
cooler and the job as a janitor makes Mr. Fazli make contact
with allergens. more than 4 times a week shows that he has
persistent allergic rhinitis which occurs> 4 days per week
or> 4 weeks, and is felt to interfere with Mr. Fazli's
activity, addressing complaints as classified as moderate-
severe allergic rhinitis. rhinitis).

A. Based on ARIA classification that based on the time of

occurrence of allergic rhinitis can be divided into two
namely,
1) intermittent allergic rhinitis
Intermittent allergic rhinitis occurs <4 days per week or <4
weeks

2) persistentallergic rhinitis.
Rhpersistent allergic arthritis occurs> 4 days per week or >
4 weeks.

B. Bbased on severity
1) mild allergic rhinitis (mild allergic rhinitis)
In mild allergic rhinitis, patients can sleep soundly, there
is no disruption of daily activities or work or school, and
does not have symptoms that interfere
2) moderate-severe allergic rhinitis)
sufferers must have one or more symptoms as follows:
disturbed sleep, disruption of daily activities, disruption
of work or school, and have disturbing symptoms.
 k. What are the sneezing relationships that occur mainly in the
morning and at work, more than 4 times a week and are felt to
interfere with activities with perceived complaints?
Sneezing occurs in the morning because in the morning the temperature of the
environment is cooler, and while working Mr. Faizal will make contact with the
allergen inhalant in the form of dust mite fungi. these things happen repeatedly so that
they trigger itallergic reaction to Mr. Faizal who had previously been sensitized with
the same allergen. complaints occur for 4 days a week because of the risk factors of
complaints are still being carried out so that complaints continue and interfere with
their activities.In this case, allergic rhinitis is included in type I hypersensitivity
reactions.
 2. Mr. Fazli also complained about cold, itchy eyes and nasal congestion.

A. What does it mean that Mr. Fazli also complained about catching a cold, itching on
the eyes and stuffy nose?
The meaning is that this is a clinical manifestation of allergic rhinitis, namely bertin that
occurs more than 5 times per attack, as a result of the release of histamine. Also called
pathological sneezing. Other symptoms are runny (runny nose) runny and many, nasal
congestion, itchy nose and eyes, which are sometimes accompanied by lots of tears coming
out (lacrimation). Signs of allergies are also seen in the nose, eyes, ears, pharynx or larynx.
Nasal markings include transverse nasal folds - transverse black lines in the middle of the
back of the nose due to frequent rubbing of the nose up to mimic respect (allergic salute),
pale and edema.

b. What is the etiology of colds, itching of the eyes and nasal

congestion?

c. What is the pathophysiology of colds, itching of the eyes and nasal

congestion?

d. What is the relationship between additional complaints and major complaints?

The main complaint and additional complaints occurred because of their presence nasal
mucosal inflammation caused by an allergy to particles, including: house dust mites, smoke,
pollen / pollen in the air mediated by IgE.

3. Mr. Fazli never took medicine and only took street flu medicine?
A. . What does it mean that Mr. Fazli never took medicine?

B. Does that mean Mr. Fazli only buys cold medicine at street
 vendors?

c. What are the chances of cold medicines being consumed?

Possible cold medicine bought by Mr. Fazli is a class of medicine
Antihistamines which are useful in dealing with rapid phase allergic reactions.
Antihistamines can reduce sneezing, itching of the nose, throat and palate, but
they have little effect on nasal congestion. Antihistamines consist of
generation-1 and generation-2. First-generation antihistamines are lipophilic so
they can cross the blood and brain placental barrier and have anticholinergic
effects. These first-generation antihistamines include diphenhydramin,
promethacin, cyproheptadine, chlorpheniramine and those used topically such
as azelastin. Generation 2 antihistamines are lipophobic, making it difficult to
penetrate the blood brain barrier, are selectively binding to H-1 receptors and
do not have anticholinergic effects including loratadine, desloratadine,
cetirizine, levocetirizin and fexofenadin

4. Grandfather Mr. Fazli has a history of asthma.

A. . What does it mean that Pak Fazli's grandfather has a history of

asthma?

b. What is the relationship between history and the head of his

grandfather complaining?
5. Physical Examination: General Appearance: looks rather sick,
composted
Mentis Vital signs: TD: 110 / 70mmHg, pulse: 90x / minute regular,
containing and normal resistance, RR: 22x / m T: 37.0 0 C
Head: Eyes: Alergic shiner (+)
ENT Status:
- Ears: intact lymph membrane, light reflection ++ / +
- Nose: Narrow Cavum rice, white (+ / +) secreting,
concha hypertrophy, livide, mass (-) transverse nasal
folds (+), allergic salute (+).
Throat: Symmetrical arcetric pharynx, uvula in the middle, T1-T1 tonsils are calm,
normal posterior pharynx ,.
A. What is the interpretation of the results of physical examination and
ENT status?
physical examination
Check up result Normal state Interpretation
General condition: Does not look sick Abnormal
moderate pain
Awareness:
Compositional Composer Normal
TD: 110/70 mmHg 120/80 mmHg Normal
Pulse: 90x / minute, 60-100x / minute, Normal
content and voltage are enough contents and
sufficient voltage
RR: 22x / minute 16-24x / minute Normal
Q: 37oC 36.5 ˚C - 37.2 ˚C Normal

ENT status
Check up result Normal state Interpretation
Ears:
 Tympanic Tympanic membrane Normal
membrane intact intact
 Light reflexes Normal
+/+ Light reflexes + / +
Nose:
 Narrow rice Narrow rice cavum Abnormal, edema of the
cavum nasal mucosa
 secretions (+ / +) There are no secretions Abnormal, rhinorrhea
are white
 Konka Konka is pink Abnormal, hypertrophy
hypertrophy is
dark red mass (-)

 mass (-) Normal

Throat:
 symmetrical symmetrical pharyngeal Normal
pharyngeal arc arc
 uvula in the Normal
middle uvula in the middle Normal
  T1-T1 tonsils are T1-T1 tonsils are calm
calm Normal
 the posterior the posterior pharyngeal
pharyngeal wall wall is calm
is calm

b. What is the abnormal mechanism of physical examination results? \

B. What is the ENT examination procedure \

The procedure for examining ENT status is as follows:
1) The examiner greets and introduces himself to the patient.
2) Asking the patient's identity.
3) Explain the purpose and procedure of the inspection to be carried out.
4) Ask the patient for permission to do an ENT examination.
5) Patients are invited to sit, face to face with the examiner.
6) Position the examiner's feet to the right of the patient's feet.
7) The tools are to the right of the examiner.
8) Front nasal examination (anterior rhinoscopy)
a) The examiner wears a head lamp whose light is directed at the
patient's nose.
b) Look at the shape of the nose symmetric or not.
c) Install a nasal speculum in one of the nostrils and pay attention to
the nasal mucosa, concha nasales, nostrils (nasal cavity), nasal
septum (rice septum), nasal discharge, mass.

9) Nasal examination (posterior rhinoscopy or nasopharyngoscopy)

a) Ask the patient to open his mouth wide then spray enough xyllocain
spray into the oral cavity.
b) Wait a few minutes until the patient does not feel any more time
swallowing.
c) The pharyngeal glass is heated with a spiritus lamp (slightly higher
than 37 ° C) so that it does not become opaque later. Then place it
on our hands to control whether the mirror is too hot or not.
d) Again ask the patient to open his mouth and remove his tongue.
Press the tongue with the tongue spatula.
e) Insert the pharynx glass into the mouth, hold with the right hand,
 like holding a pencil, and directed down.
f) The pharyngeal glass is inserted into the pharynx and takes position
in front of the uvula. If necessary the uvula is pushed slightly back
with the back of the pharyngeal glass. Then the pharynx glass is
illuminated with head lights.
g) Look in the mirror: the eustachian tube, Rosenmuller fossa, choana,
mass.
h) Interpret posterior rhinoscopy results.
10) Throat examination
a) The examiner uses a head lamp whose light is directed at the
patient's mouth
b) The patient is asked to open his mouth.
c) The tongue is pressed down with the tongue spatula held in the left
hand.
d) Look at the right and left palatine tonsils and the pharynx of the
patient.
e) Interpret the results of the throat examination.
11) Laryngeal examination
a) External inspection
Inspection: neck skin color, mass
Palpation: mass
b) Indirect laryngoscopy, which is seeing the larynx indirectly with
lighting reflected from the glass inside the pharynx which is
illuminated by head lamps. Inspection technique:
i. Ask the patient to open his mouth wide then spray enough
xyllocain spray into the oral cavity.
ii. Wait a few minutes until the patient does not feel any more
time swallowing.
iii. Again ask the patient to open his mouth and tongue out as
long as possible.
iv. Wrap the part of the tongue that is outside the mouth with a
tissue then we hold with your left hand with enough energy.
Not loose because the tongue can be separated from the
handle and also not strong because the patient will be in
pain.
 v. The laryngeal glass is heated with a spiritus lamp (slightly
higher than 37 ° C) so that it does not become opaque later.
Then place it on our hands to control whether the mirror is
too hot or not.
vi. The larynx glass is held with the right hand, like holding a
pencil, and directed down.
vii. The laryngeal glass is inserted into the pharynx and takes a
position in front of the uvula. If necessary uvula pushed a
little back with the back of the larynx glass. The larynx glass
is illuminated with head lights.
viii. Ask the patient to say the letter "i" for a longer period so that
we can pay attention:
a) Aloe tongue, epiglottis, and surrounding areas
b) Larynx and lumen glottidis
c) The part that lies caudally from the rhyme
glotidis.

6. Laboratory tests: Hb 14.0 g / dl, HT: 42 g / dl, leukocytes 3500, 200,000

platelets, 4.6 x 10 erythrocytes 12, count of 0/7/45/0/45/3 diff

a. What is the interpretation of the results of laboratory tests?

b. What is the mechanism for abnormal laboratory examination results?

7. How to diagnose?

8. What is the differential diagnosis in this case?

9. What is the additional examination in this case?

1) In a complete blood count, peripheral eosinophilia can be found but

this finding is inconsistent.
2) Nasal smears show high eosinophil counts in allergic rhinitis. This
examination should be done when allergic rhinitis is clinically active
or after a nasal provocation test.
3) Allergy skin testing helps identify specific allergens
4) The radioallergosorbent test (RAST) is an in vitro test and measures
the concentration of specific IgE antibodies in a patient's serum. This
examination can be done but the results are less specific when compared
with allergy testing on the skin
5) Nasal provocation test is a method to stimulate the nasal mucosa by
placing a small amount of allergen on the tip of a toothpick and asking
the patient to breathe. It is also used to observe whether allergy
symptoms appear.
6) Skin prick test This examination is more sensitive and allows
examination with more varied allergens.
7) Specific IgE (RAST) Only recommended in patients with extensive
 dermatitis or dermatographism.
8) Examination of peripheral blood On the count of leukocytes and count of
eosinophils there is an increase in peripheral blood eosinophils. This
examination cannot be used to filter because allergic rhinitis can
occur without an increase in eosinophils, the opposite is found in
allergic rhinitis (NARES)
9) skin prict test (SPT / cukit skin test),
10) Serum IgE total and Specific serum IgE,
11) histological examination
12) if you want to determine the type of rhinitis between allergic / non
allergic and rhinitis due to infection and follow up on responses to
therapy or see morphologic changes of the nasal mucosa
10.What is the working diagnosis in this case?

a. Definition

b.Epedemiology

c. Etiology:
based on the type of allergen, the causes of allergic
rhinitis can be classified into two groups, namely specific
and non-specific causes.
1) Specific Causes Most of the members of this group are
inhalant allergens (inhalants), where inhalant allergens are
allergens that are often found, usually divided into 2 types
based on the ability to live in their environment, namely
perennial and seasonal
A) Perennial allergens
Allergens are available throughout the year and are
difficult to avoid. asHouse dust consisting of mites,
cockroaches, cotton particles, human skin flakes, and
others. Is an air allergen with a size> 10 µm which is
often in a confined space. House dust mitesmis the most
common allergic component that lives from human skin
flakes. There are two main species namely
Dermatophagoides farinae and Dermatophagoides
pteronyssinus. They prefer to live at a temperature of
21.1-26.6 ° C so that it is not found at an altitude
of more than 5000 feet. Animal skin flakes, Mushroom
bIt develops well in damp areas over rotten goods,
 basements, old newspaper stacks, wood dust, and other
places. The most common causes include the genera
Alternaria, Aspergillus, Pullularia, Hormodendrum,
Penicillium, and Cephalosphorium. Cockroaches Allergens
come from insect secretions, which are found on the
body and wings of cockroaches.

B) Seasonal allergens
Usually caused by plant pollen which appears
seasonally.

2. Nonspecific Causes
Non-specific causes of allergic rhinitis include climate,
hormonal, psychological, infection, and irritation. Climate
change will cause environmental change. Humid air, changes
in temperature, and wind indirectly affect the spread of
house dust and flower pollen, in addition to providing a
good atmosphere for the growth of various kinds of mold.

d.Risk factor

e. Classification
According to the classification, allergic rhinitis based on
the duration of symptoms is divided into:
1. Intermittent: symptoms ≤4 days per week or duration ≤4
weeks
2. Persistent: symptoms> 4 days per week and duration> 4
weeks
based on the severity of the symptoms, allergic rhinitis is
divided into:
1. Light: 
 Normal sleep
 Daily activities
 during normal exercise and relaxation
 Normal work and school
  No annoying complaints
2. Moderate or severe: (one or more symptoms) 
 Sleep disturbed (not normal)
 Daily activities
 when exercise and leisure are disturbed
 Disturbances at work and school
 There are annoying complaints

f.Pathogenesis / Pathophysiology

g. Clinical manifestations

11. How is the treatment in this case?

12.What are the complications in this case?

13.What is the prognosis in this case?

14.What is SKDU in this case?

15.What is the point of view of Islam ??

2.7 Hypothesis

Mr. Fazli, a 25-year-old janitor complained of sneezing

excessive, colds, itchy eyes and nasal congestion are likely to

experience allergic rhinitis.

Dapus

Arivalagan A. 2011. Gambaran rhinosinutsitis kronis di RSUP Haji Adam Malik pada tahun
2011. Medan. Fakultas kedokteran USU.

Asyari A. . 2012. Pengukuran Sumbatan Hidung Pada Deviasi Septum Nasi. Padang.
Universitas Andalas.

Guyton, Arthur C dan John E. Hall. 2008. Buku Ajar Fisiologi Kedokteran, Edisi 11. Jakarta:
EGC.
Silverthorn, D. U. (2014). Fisiologi Manusia ( Sebuah Pendekatan Terintegrasi) (Vol. Edisi
6). Jakarta: Penerbit Buku Kedokteran : EGC.

Soepardi, Afiatu dkk. 2014. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan Kepala
dan Leher. Ed 7. Hal 113-115. Jakarta: Fakultas Kedokteran Universitas Indonesia.
2.8 Conceptual framework

Atopy factor of a Rainfall Factor:

grandfather who has one allergen

history of asthma

Hypersensitivity reactions

Releasing inflammation

mediator

Allergic rhinitis

Sneezing
Cold Itchy eye Nasal congestion
exaggerated

10