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Cr Dr.dedi Hidropneumothorax Ec Tb Paru

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Case Report

Created By : BUNGA LISTIA PARAMITA (110.2006.059) RIA RIZKY DESLISYAHPUTRI (110.2006.221) RESI TRISMAYENNY (0718011078)

Perceptor: Dr. DEDY ZAIRUS, Sp.P

CLINICAL WORK OF INTERNAL MEDICINE, SMF. PULMONOLOGY

PERIOD 26TH MARCH – 26TH MAY 2012 ABDUL MOELOEK HOSPITAL, BANDAR LAMPUNG

1

THE UNIT PULMONOLOGY OF INTERNAL MEDICINE
…………………………………………….……

RSUD Dr. Hi. ABDUL MOELOEK
…………………………………………….……

BANDARLAMPUNG

PATIENT STATUS
PATIENT IDENTITY Full Name Sex Age Nationality Marital status Religion Occupation Educational background Address ANAMNESIS Taken From : Autoanamnesis The main complained The additional complained The History of the Illness : : Dyspneu : Chest pain, Febris, Purulent cough, Night sweat. Date 12nd April 2012 11.30 WIB : Nuriman : male : 35 years old : Javanese : Married : Islam : Farmer : Senior High school : Rantau Tijang Tanggamus

Patients come to RSUDAM with complaints of shortness of breath since 2 months ago and felt become heavy since one week before entering RSUDAM. Perceived shortness of breath and intermittent positions are not affected by weather and activity. Patients also complained of intermittent cough since one year ago. Cough accompanied by a discharge of pus, in which pus is reduced when the patient entered the hospital. Other than that the patient also complained of chest pain that arises after the cough. Cough is more severe if the patient is seated. Patients also felat that he had water on the right chest move the patient to move position. In addition, patients also complain of fever, sepecially late afternoon and night sweat. The patient claimed to have anever treated before and patient also claimed to have never felt this before.
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Patient admitted to TB treatmen in 2010 for 6 months. Denied a history of TB medication discontinuation by patients. Positive smoking history as much as 2 packs a day since the age of 11 years and quit as early as 2 months before hospital admission. History of hypertension and diabetes is denied. The History of Illness : ( ) (√ ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) (√) Small pox Chicken pox Difthery Pertusis Measles Influenza Tonsilitis Kholera Demam Rematik Akut Pneumonia Pleuritis Tuberkulosis ( ( ( ( ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) ) ) ) ) Malaria Disentri Hepatitis Tifus Abdominalis Skirofula Sifilis Gonore Hipertensi Ulkus Ventrikuli Ulkus Duodeni Gastritis Stone Gall others : ( ( ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) Kidney stone Burut (Hernia) Prostat Melena Diabetic Alergyc Tumor Vaskular Disease

) Operation ) Accident

History of Family : Connection Grandfather Grandmother Father Mother Brother-sister Children Age (th) 75 60 70 63 33 8 Sex Male Female Male Female Male Male Healthy Death Death Death Death Healthy Healthy Causa of Death

DM

An any relation who suffer : Illness Yes Alergyc Asthma Tuberkulosa Artritis Rematisme Hipertensi Cor Kidney Gaster Diabetes √

No √ √ √ √ √ √ √ √ √

Connection

Mother
3

ANAMNESIS SISTEM Note Complain Positif beside the title Skin ( ) Boil ( ) Nail

( ) ( )

Hair Yellow / Ikterus

(√) ( ) ( )

Night swet Sianotic Others

Head ( ) Trauma ( ) Sinkop Eye ( ) Pain ( ) Secret ( ) yellow / Ikterus Ear ( ) Pain ( ) Secret

( ) ( )

Headache Pain of the sinus

( ) ( ) ( )

Inflammation of night sweat Eye disorder Sharpness to see

( ) ( ) ( )

Tinitus Ear disorder Deaf

Nose ( ) Trauma ( ) Pain ( ) Sekret ( ) Epistaksis Mouth ( ) Lip ( ) Gums ( ) Membrane Throat ( ) Throats pain Neck ( ) Protruding Cor / Lung (√) Chest pain (Left) ( ) Pulse ( ) Ortopnoe

( ) ( ) ( )

Clogging Nose disorder Have a cold

( ) ( ) ( )

Tongue Mouth disorder Stomatitis

( )

Voice (change)

( )

Necks pain

(√) ( ) (√)

Dyspneu Hemoptoe Cough
4

Abdomen (Gaster / intestine) ( ) Puffing () Nausea ( ) Emesis ( ) Hematemesis ( ) Disfagi ( ) Kholik

( ( ( ( ( ( (

) ) ) ) ) ) )

Acites Hemoroid Diarrhea Melena Pale colour of feses Black colour of feses Nodul

Urogenital ( ) Disuria ( ) Stranguri ( √ ) Poliuria (√ ) Polakisuria ( ) Hematuria ( ) Kidney stone ( ) Wet the bed Katamenis ( ) Leukore ( ) Others Haid ( ) Last menarche ( ) ( ) frequently / no Menarche disorder

( ( ( ( ( ( (

) ) ) ) ) ) )

Pyuria Kolik Oliguria Anuria Urine retention Drip urine Prostat

( ) ( )

Bleeding

( ) ( ) ( )

Quantity and ( ) duration Pain ( ) Post menopause

Menarche Klimakterium symptom

Muscle and neuro ( ) Anestesi ( ) Parestesi ( ) Weak muscle ( ) Convultion ( ) Afasia ( ) Amnesis ( ) Others

( ( ( ( ( ( (

) ) ) ) ) ) )

Bite less Ataksia Hipo/hiper-estesi Syncope Tick Vertigo Disartri

Ekstremitas ( ) Edema ( ) Hinge pain

( ) ( )

Deformitas Sianotic

5

Weight Average weight (kg) Height (cm) Present weight (kg)

: 75 kg : 165 cm : 60 kg

(if the patient doesn’t know certainly) Steady ( ) Down ( √ ) Up ( )

6

THE HISTORY OF LIFE
Birth place Helped by : ( ) in home : ( ) Doctor ( ) Others ( √) matrinity ( √) nurse ( ) Matrinity hospital ( )Traditional matrinity

Imunitation History ( ) Hepatitis ( ) BCG ( ) Tetanus Food History Frekuensi/day Amount /day Variation /day Appetite

( ) Campak

( ) DPT

( ) Polio

: 3x/day : 2 plate/eat (health), ½ plate/eat (illness) : Rice, vegetables, egg, fish : Enough

Educational ( ) SD Problem Financial Works Family Others

( ) SLTP

( √ ) SLTA

( ) SMK ( ) Course

( ) Academy ( ) Unschool

: Low : Farmer : Good relation :-

Body Check Up General Check up Height Weight Blood Pressure Pulse Temp Breath (frequence&type) Nutrition condition Consciousness Cianotic General edema Habity The way of walk Mobility (active/pasive)

: 165cm : 60 kg : 120/80 mmhg : 68 x/minute, regular, volume normal : 36,5 oC : 23 x / minute : Enough : Compos mentis ::: Piknikus : Normal : Active
7

The age prediction based on check up Mentality Aspects Behavior Nature of feeling The thinking process Skin Color Efloresensi Keloid Pigmentasi Hair Growth Arteries Touch temperature Humid/dry Sweat Turgor Icterus Fat layers Edema Others Lymphatic Gland Submandibula Neck Supraklavikula Armpit Head Face expression Face symmetric Hair Temporal artery Eye Exopthalmus Enopthalmus Palpebra Lens Conjungtiva Visus Sklera Eye movement

: 35

: Normal : Normal : Normal

: : : : : : : : : : : : : :

Brown Normal feel Afebris Humid Night sweat Normal Anicteric -

: Untouched enlargement : Untouched enlargement : Untouched enlargement : Untouched enlargement

: Normal : Symmetric : Black and uprooted : Normal

::: edeme : Clear : Ananemis : 6/6 : Anicteric : Good in every side
8

Vision scope Eye ball pressure Deviatio konjungae Nystagmus Ear Deaf Membrane tymphani Foramen Obstruction Serumen Bleeding Liquid Mouth lips Tonsil Palatal Halibsts Teeth Trismus Farings Liquid layer Tongue Neck JVP Tiroid gland Limfe gland Chest Shape Artery Breast Lung Anterior Inspeksi Palpasi Perkusi

: : : :

Normal Normal Perpalpation -

: negative / negative : intac / intac : wide / wide ::::-

: cyanosis : T1 / T1 : Normal : No : Caries :: Unhiperemis : Unhiperemis, cyanosis : Not dirty

: Normal : Untouched enlargement : Untouched enlargement

: Simetric : Normal : Normal, man

Left Right Left Right Left Right

: Asimetric, massa -, retraction : Asimetric massa -, retraction : tactil fremitus & vocal fremitus normal : tactil fremitus & vocal fremitus decrease : Sonor : Dim
9

Auskultasi

Left : Vesiculer , ronchi -, wheezing Right : Vesiculer ↓, ronchi -, wheezing -

Posterior Inspeksi Palpasi Perkusi Auskultasi

Left Right Left Right Left Right Left Right

: Asimetric, massa -, retraction : Asimetric massa -, retraction : tactil fremitus & vocal fremitus normal : tactil fremitus & vocal fremitus decrease : Sonor : Dim : Vesiculer , ronchi -, wheezing : Vesiculer ↓, ronchi -, wheezing -

Cor Inspection Palpation Percution Right boundary The left boundary Upper limit Auskultation

: IC unseen : IC feel in linea midclavicula sinistra ICS V : ICS V linea parasternalis dextra : ICS V linea midclavicula sinsitra : ICS III linea parasternalis sinsitra : heart voice I and II normal, murmur (-), gallop (-)

Artery Artery temporalis Artery karotis Artery brakhialis Artery radialis Artery femoralis Artery poplitea Artery tibilias posterior Stomach Inspection Palpation Stomach wall Heart Limfe Kidney Percution Auscultation Refleks stomach wall Genital (based on indication)

: No distinct : No distinct : No distinct : No distinct : No distinct : No distinct : No distinct

: normal in 4 region : pressure pain (-) : not feel : not feel : ballotemen (-) : Timpani, shifting dullness (-) : intestine sounds (+), normal : normal

10

Female OUE Flour albus

: no indication : no indication : no indication

Movement joint Arm Muscle Tonus Massa Joint Movement Strength Others

Right normal normotonus Eutrofi normal Active 5

Left normal normotonus eutrofi normal Active 5

Heel and leg Wond/injury Varices Muscle (tonus & mass) Joint Movement Strength/power Edema Others Reflexs Tendon reflex Bisep Trisep Patela Achiles Cremaster Skin reflex Patologic reflex

: not found : (-) : normotonus & eutrofi : normal : Active :5 : (-) : (-)

Right normal normal normal normal normal not done normal not found

Left normal normal normal normal normal not done normal not found

LABORATORY (9 April 2012) Blood Hb : 13,1 gr/dl ESR :0 Leukosit : 5000/µl Variety count Basofil :0% Eusinofil :0%

(13,5 – 18,0 gr/dl) (0 – 20 mm/hour) (4.500 – 10.700/ µl) (0 – 1 %) (1 – 3 %)
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Batang Segmen Limfosit Monosit Chemical Blood SGOT SGPT Ureum Creatinine Blood Glucosa During Nacture Glucosa Post Prandial Glucosa BTA Examination Fluid WSD Culture and Resistance Urine Faeces

:0% : 73% : 21% :6%

(2 – 6 %) (50 – 70 %) (20 – 40 %) (2 – 8 %)

: 34 U/L : 42 U/L : 9 mg/dL : 0,7 mg/dL : 372 mg/dL : 299 mg/dL : 409 mg/dL

(6 – 30 U/L) (6 – 45 U/L) (10 – 40 mg/dL) (0,7 – 1,3 mg/dL) (70 – 200 mg/dL) ( < 120 mg/dL) (< 140 mg/dL)

: Negative : types of discharge are greenish yellow pus from the pleural cavity as much as 1000 cc, undulations +, bubbles + : Sterile : no examination : no examination

RADIOLOGY (10 April 2012)

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Lung:

Right pleural effusion Fibrotic in the left lung, superior lobe Difficult to assess

Cor:

RADIOLOGY (14 April 2012)

Lung:

Cor:

Broncovaskular spots on the lower right lung Minimal right pleural effusion Radiolucent in the right inferior pulmonary Fibrotic lug superior lobe of the left Difficult to assess

RESUME Patients come to hospital with complaints of dyspneu. The complain held since 2 months ago and felt become heavy since one week before entering hospital. He also complained chest pain, febris, purulent cough and night sweat. Cough is more severe if the

13

patient is seated. The patient claimed to have anever treated before and patient also claimed to have never felt this before. Patient admitted to TB treatment in 2010 for 6 months. Denied a history of TB medication discontinuation by patients. Positive smoking history as much as 2 packs a day since the age of 11 years and quit as early as 2 months before hospital admission.

Height

: 165 cm

Weight Blood Pressure Pulse Touch temperature

: 60 kg : 120/80 mmhg : 68 x/minute, regular, volume normal : 36,5ºC, Afebris

Lung Anterior Inspeksi Palpasi Perkusi Auskultasi

Left Right Left Right Left Right Left Right

: Asimetric, massa -, retraction : Asimetric massa -, retraction : tactil fremitus & vocal fremitus normal : tactil fremitus & vocal fremitus decrease : Sonor : Dim : Vesiculer , ronchi -, wheezing : Vesiculer ↓, ronchi -, wheezing -

Posterior Inspeksi Palpasi Perkusi Auskultasi

Left Right Left Right Left Right Left Right

: Asimetric, massa -, retraction : Asimetric massa -, retraction : tactil fremitus & vocal fremitus normal : tactil fremitus & vocal fremitus decrease : Sonor : Dim : Vesiculer , ronchi -, wheezing : Vesiculer ↓, ronchi -, wheezing -

Cor Inspection Palpation

: IC unseen : IC feel in linea midclavicula sinistra ICS V
14

Percution Right boundary The left boundary Upper limit Auskultation

: ICS V linea parasternalis dextra : ICS V linea midclavicula sinsitra : ICS III linea parasternalis sinsitra : heart voice I and II normal, murmur (-), gallop (-)

LABORATORY (9 April 2012) Blood Hb : 13,1 gr/dl ESR :0 Leukosit : 5000/µl Variety count Basofil :0% Eusinofil :0% Batang :0% Segmen : 73% Limfosit : 21% Monosit :6% Chemical Blood SGOT SGPT Ureum Creatinine Blood Glucosa During Necture Glucosa Post Prandial Glucosa

(13,5 – 18,0 gr/dl) (0 – 20 mm/hour) (4.500 – 10.700/ µl) (0 – 1 %) (1 – 3 %) (2 – 6 %) (50 – 70 %) (20 – 40 %) (2 – 8 %)

: 34 U/L : 42 U/L : 9 mg/dL : 0,7 mg/dL : 372 mg/dL : 299 mg/dL : 409 mg/dL

(6 – 30 U/L) (6 – 45 U/L) (10 – 40 mg/dL) (0,7 – 1,3 mg/dL) (70 – 200 mg/dL) ( < 120 mg/dL) (< 140 mg/dL)

BTA Examination Fluid WSD Culture and Resistance

: Negative : types of discharge are greenish yellow pus from the pleural cavity as much as 1000 cc, undulations +, bubbles + : Sterile

Working diagnose and basic diagnose 1. Working diagnose Right Lung Empiema e.c Lung Tuberculosis, old case + DM type II 2. Basic Diagnose Anamnesis : Dyspneu, Sputum cough, Chest pain, Hard breathing, Night sweat,and Weakness Has a history of TB treatment
15

Physical Examination Lung: I :Asimetric, hemithorax dextra lagging P:Tactile and vocal fremitus lagging P: Dim/ Resonant A:Right lung Vesiculer ↓, Ronkhi -, Wheezing Support checkup : Chest X-Ray : Lung: (10 April 2012) Right pleural effusion Fibrotic in the left lung, superior lobe (14 April 2012) Broncovaskular spots on the lower right lung Minimal right pleural effusion Radiolucent in the right inferior pulmonary Fibrotic lug superior lobe of the left Blood Blood Glucosa During Nacture Glucosa Post Prandial Glucosa : 372 mg/dL : 299 mg/dL : 409 mg/dL

Differencial diagnose 1. Differencial diagnose Right Lung Empiema ec Non Tuberculosis + DM type II 2. Differencial basic diagnose Culture and Resistance of the Pus is Sterile BTA Sputum Negative Plan treatment 1. General Treatment IVFD RL gtt XX/ min Methyl prednisolone 4 mg, 3x1 Metformin 500 mg 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD Injection ketorolac drip 1 ampoule/ 12 hours 1700 kKal per day diet 2. Prevention - Do not smoke and avoid pollution and cigarette smoke - Diligent exercise and of drinking water
16

-

Avoid keeping your diet and foods containing sugar Keep somewhat wounded Diet to lose weight

Prognose Quo ad vitam Quo ad functionam Quo ad sanationam

: Dubia ad bonam : Dubia ad bonam : Dubia ad bonam

17

Follow up

Date

9/ 04 / 2012

10 / 04 / 2012

11 / 04 / 2012

Clinical symptoms : - Right chest has liquid - Painful breathing - Blown - Cough - Back flushing such as burs - Pain at the site of puncture WSD
(+) (-) (+) (-) (-) (+) (+) (+) (+) (+) (+) (+) (+) (+) (+) (-) (+) (+)

General State Of

Looks sick is Compos mentis

Awareness

Vital sign BP Temperature RR HR 120/80 mm Hg 36,30 C 20 x / menit 68 x / menit 110/70 mmHg 36,70 C 22 x / menit 70 x / menit 120/70 mm Hg 36,5 C 22x / menit 70 x / menit

18

Physical Examination

-

Inspection

Asimetric, right Asimetric, right chest Asimetric, right chest decrease, decrease, massa -, chest decrease, massa -, retraction massa -, retraction retraction Right chest Right chest tactil tactil fremitus & fremitus & vocal vocal fremitus fremitus decrease decrease Right chest tactil fremitus & vocal fremitus decrease, Crepitation on the neck and axilla

-

Palpation

-

Percution Auscultation

Dim / Sonor Vesiculer +/+, ronchi -/-, wheezing-/ -

Dim / Sonor

Dim / Sonor

Vesiculer +/+, ronchi -/-, wheezing-/ Vesiculer +/+, ronchi -/-, wheezing-/ -

WSD

yellow-

yellow-

green pus liquid with green pus liquid wit a amount of 500cc, undulations and posit ive bubble h a amount of 200cc/day, undulations and pos itive bubble

Rontgen

Lung: Right pleural effusion, Fibrotic in the left lung, superior lobe Cor:Difficult to assess

19

Laboratorium

Therapy

Blood glucose during 372 mg/dL IVFD RL gtt XX/ min Inj. Ceftriaxone 1 g /12 hour Methyl prednisolone 4 mg, 3x1 Metformin 500 mg, 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours 1700 kKal per day diet

-

-

IVFD RL gtt XX/ min Inj. Ceftriaxone 1 g / 12 hour Methyl prednisolone 4 mg, 3x1 Metformin 500 mg, 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Ciprofloxacin infusion 200mg, 2x1 Metronidazol infusion 500 mg, 3x1 Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD Injection ketorolac drip 1 ampoule/ 12 hours 1700 kKal per day diet

IVFD RL gtt XX/ min Inj. Ceftriaxone 1 g / 12 hour Methyl prednisolone 4 mg, 3x1 Metformin 500 mg, 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Ciprofloxacin infusion 200mg, 2x1 Metronidazol infusion 500 mg, 3x1 Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD Injection ketorolac drip 1 ampoule/ 12 hours 1700 kKal per day diet

20

Date

12/ 04 / 2012

13 / 04 / 2012

14 / 04 / 2012

Clinical symptoms : - Right chest has liquid - Painful breathing - Blown - Cough - Back flushing such as burs - Pain at the site of puncture WSD
(-) (+) (-) (-) (-) (-) (-) (+) (+) (-) (-) (+) (-) (-) (-) (-) (-) (-)

General State Of

Looks sick is Compos mentis

Awareness

Vital sign BP Temperature RR HR 120/80 mm Hg 360 C 24 x / menit 68 x / menit 110/70 mmHg 36,30 C 22 x / menit 72 x / menit 110/80 mm Hg 36,6 C 22x / menit 70 x / menit

Physical Examination

Asimetric,

right
21

-

Inspection

-

Palpation

chest decrease, Asimetric, right massa -, retraction - chest decrease, massa -, retraction Right chest tactil fremitus & vocal fremitus decrease Right chest tactil fremitus & vocal fremitus decrease Dim / Sonor

Asimetric, right chest decrease, massa -, retraction -

Right chest tactil fremitus & vocal fremitus decrease, Crepitation on the neck and axilla

-

Percution Auscultation

Vesiculer +/+, ronchi -/-, wheezing-/ -

Dim / Sonor Dim / Sonor Vesiculer +/+, ronchi -/-, wheezing-/ Vesiculer +/+, ronchi -/-, wheezing-/ -

WSD

yellowgreen pus liquid wit h a small of amount, undulation s and positive bubb le

Undulation and bubble negative

Repotition WSD

Rontgen

-

Pro Rontgen

Lung:Broncovaskul ar spots on the lower right lung Minimal right pleural effusion Radiolucent in the right inferior pulmonary Fibrotic lug superior lobe of the left Cor: Difficult to assess

Therapy

IVFD RL gtt XX/ IVFD RL gtt XX/ IVFD RL gtt XX/ min min min
22

Methyl prednisolone 4 mg, 3x1 Metformin 500 mg 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Ciprofloxacin infusion 200mg, 2x1 Metronidazol infusion 500 mg, 3x1 Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD Injection ketorolac drip 1 ampoule/ 12 hours 1700 kKal per day diet

Methyl prednisolone 4 mg, 3x1 Metformin 500 mg 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD 1700 kKal per day diet

Methyl prednisolone 4 mg, 3x1 Metformin 500 mg 3 x 1 tab B1, B6, B12 3 x 1 tab Ranitidine injection 0f 1 ampoule/ 12 hours Spooling with 0,9 % NaCl 100 cc per day Observe the development of WSD if the undulations and Bubble negative Chest X-Ray if the lug re-expands, then off WSD 1700 kKal per day diet

23

TUBERCULOSIS TB is a infection disease that caused of mycobacterium tuberculosis. The spots of TB infection germ are respiratory tracts, absorption tracts and opened injury in skin. Most of TB infection occur pass through air , by means of droplet inhalation that consist of basil which come from person who infected. The spreading capacity from a sufferer is depended on the number of germ that issued from the lung.someone might be infected by TB from the droplet concentration in the air, and how long they breath that air.

TB is a disease that controlled by imunity response insequenced cell. Efector cells are macrofag and limfosit ( usually T cell ). They are imunoresponsive cells. This type usually local, involving macrofag which actived in infection spot by limfosit and it’s limfokin. The response is called as hypersensitivity cellular reaction ( slow reaction )

CLASSIFICATION OF TBC BASE ON THE HISTORY

1. Primary TBC it’s happen when someone attack primarly by TBC germ. The infection started when the TBC germ replicated successfully in the lung. That’s cause the inflammation. Limfe tractus will carry TBC germ into limfe gland around lung hilus and it.s called as primary complexs. Time between infection happens until primary complexs form are around 4 – 6 weeks. The infection cold be proven by by the occur of tuberculin reaction that changes from negative into positive. The incubation period is time needed from infected till become sick, approximated for about 6 month.

2. After Primary TBC Usually happen after several month or year. After primary infection, for example because of the descent body defense in consequence infected by HIV or malnutrient status. The main characteristic for after primary TBC is the broadening lung damage in occurring cavity or pleural effusion.

24

Primary Progressive Tuberculosis Active tuberculosis develops in only 5% to 10% of persons exposed to M tuberculosis. When a patient progresses to active tuberculosis, early signs and symptoms are often nonspecific. Manifestations often include progressive fatigue, malaise, weight loss, and a low-grade fever accompanied by chills and night sweats.22 Wasting, a classic feature of tuberculosis, is due to the lack of appetite and the altered metabolism associated with the inflammatory and immune responses. Wasting involves the loss of both fat and lean tissue; the decreased muscle mass contributes to the fatigue.23 Finger clubbing, a late sign of poor oxygenation, may occur; however, it does not indicate the extent of disease.24 A cough eventually develops in most patients. Although the cough may initially be nonproductive, it advances to a productive cough of purulent sputum. The sputum may also be streaked with blood. Hemoptysis can be due to destruction of a patent vessel located in the wall of the cavity, the rupture of a dilated vessel in a cavity, or the formation of an aspergilloma in an old cavity. The inflamed parenchyma may cause pleuritic chest pain. Extensive disease may lead to dyspnea or orthopnea because the increased interstitial volume leads to a decrease in lung diffusion capacity. Although many patients with active disease have few physical findings, rales may be detected over involved areas during inspiration, particularly after a cough. Hematologic studies might reveal anemia, which is the cause of the weakness and fatigue. Leukocytosis may also occur because of the large increase in the number of leukocytes, or white blood cells, in response to the infection.7

PATOGENENCY

The risk factor are : 1. must have infection sorce 2. the number of bacillus as an infection cause must be sufficient 3. the high virulence of TBC bacillus 4. The descent of body defense make the bacillus reproduce

Clinic illustration : 1. The main symptom Continous cough with/without sputum during 3 weeks or more

25

2. Additional symptom Sputum mixed with blood Haemoptoe Dyspnea and chest pain Weakness Night sweat Decrease weight Feverish fever more than 1 month

DIAGNOSIS

Lung TBC diagnosis can be stood at by BTA finding in sputum inspection microscopicly. The inspection result tangibled positive if at least 2 from 3 SPS specimen must be positive. If only 1 specimen which positive, so it’s needed a further check up, that is chest x-ray photo or SPS sputum check up repeated. a. If the x-ray result supports TBC, so the patient is diagnosed as TBC BTA sufferer positive b. If the x-ray result unsupports TBC, so the sputum check up repeated

If three sputum specimen are negative, give an extensive spectrum antibiotic during 1-2 weeks. If the condition still bad, do SPS sputum check up repeated. a. If the SPS result are positive, diagnosed as infection TBC BTA infected b. If the SPS result are still negative, do thr chest X-ray check up.   If the X-ray result supports TBC, diagnosed as negative BTA patient but the X-ray positive If the X-ray result not supports TBC, the patient is not TBC.

MEDICAL TREATMENT

Purpose : 1. Cure the patient

26

2. Prevent death 3. Prevent relapse 4. Decreasing the level of spreading

Category 1 (2HRZE/4H3R3) :    New patient lung TBC positive BTA Patient lung TBC negative BTA, X-ray positive who got serious illness Patient heavy extra lung TBC

Intensive stage consist of Isoniasid(H), Rifampicin(R), Pirazinamid(Z), dan Etambutol(E). Those medicine are given everyday during two (2) month (2HRZE). Then continued by next stage, that consists of Isoniasid(H), and Rifampicin(R). Given three times a week during four month (4H3R3).

Category 2 (2HRZES/HRZE/5H3R3E3) :    Relaps patient Failure patient After default patient

Intensive stage are given for three month consists of HRZES during 2 month given everyday (2HRZES), continued by HRZE during 1 month given every day (HRZE). Then continued by next stage that consists of HRE during 5 month given 3 times a week.

Category 3 (2HRZES/4H3R3) :   New patient BTA negative and X-ray positive, light ill. Patient extra light lung, it is TBC limfadenitis, pleuritis eksudativa unilateral, skin TBC, bone TBC (except backbone), joint TBC and adrenal gland. Intensive stage consist of HRZ, given everyday during 2 month(2HRZ), continued by sequel stage that consist of HR during 4 month given 3 times a week(4H3R3). One packet of Combipac 3rd category contents of 114 daily blister that consist of 60 blister HRZ for the intensive stage and 54 blister HR for the sequel stage each packed in a small doss and bounded in a big doss.

Implied OAT (HRZE)

27

If the end of intensive treatment of new patient BTA positive in 1st category or patient BTA positive retreatment by category 2nd, sputum check up result still BTA positive (positive BTA), given medical implied (HRZE) everyday during 1 month.

COMPLICATION OF TUBERCULOSIS Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your lungs, but it can spread to other parts of the body through your bloodstream. Examples include:


Bones. Spinal pain and joint destruction may result from TB that infects your bones. In many cases, the ribs are affected. Brain. Tuberculosis in your brain can cause meningitis, a sometimes fatal swelling of the membranes that cover your brain and spinal cord. Liver or kidneys. Your liver and kidneys help filter waste and impurities from your bloodstream. These functions become impaired if the liver or kidneys are affected by tuberculosis. Heart. Tuberculosis can infect the tissues that surround your heart, causing inflammation and fluid collections that may interfere with your heart's ability to pump effectively. This condition, called cardiac tamponade, can be fatal.







PLEURAL EFFUSION IS CAUSED BY TUBERCULOSIS

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DEFINITION A pleural effusion is a collection of fluid in the space between the two linings (pleura) of the lung. Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluidfilled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation. When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and the diaphragm moves down. For the lung to expand, its lining has to slide along with the chest wall movement. For this to happen, both the lungs and the ribs are covered with a slippery lining called the pleura. A small amount of fluid acts as a lubricant for these two surfaces to slide easily against each other. Too much fluid impairs the ability of the lung to expand and move. Pleural fluid is secreted by the parietal layer of the pleura and reabsorbed by the visceral layer of the pleura.

Types of fluids Four types of fluids can accumulate in the pleural space:
   

Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyema)

ETIOLOGI A pleural effusion is not normal. It is not a disease but rather a complication of an underlying illness. Extra fluid (effusion) can occur for a variety of reasons. Common classification systems divide pleural effusions based on the chemistry composition of the fluid and what causes the effusion to be formed. Two classifications are 1) transudate pleural effusions; and 2) exudate pleural effusions. Sometimes the pleural effusion can have characteristics of both a transudate and an exudate. 1. Transudate pleural effusions are formed when fluid leaks from blood vessels into the pleural space. Chemically, transudate pleural effusions contain less protein and LDH (lactate dehydrogenase) than exudate pleural effusions. If both the pleural fluid–to–serum total protein ratio is less than or equal to 0.50 and the pleural fluid–to–serum LDH ratios

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are less than or equal to 0.67, the fluid is usually considered to be a transudate while exudates ratios are above 0.50 and above 0.67. Examples of transudate pleural effusions include:
   

congestive heart failure, liver failure or cirrhosis, kidney failure or nephritic syndrome, and peritoneal dialysis.

2. Exudate pleural effusions are caused by inflammation of the pleura itself and are often due to disease of the lung. Examples of exudate causes include:
           

lung or breast cancer, lymphoma, pneumonia, tuberculosis, post pericardotomy syndrome, systemic lupus erythematosus, uremia or kidney failure, Meigs syndrome, pancreatic pseudocyst, ascites, intra abdominal abscess, and asbestosis and mesothelioma.

Most pleural effusions are caused by congestive heart failure, pneumonia, pulmonary embolism and malignancy.


Transudate Increased hydrostatic Main causes pressure, Decreased colloid osmotic pressure Appearance Specific gravity Clear[5] < 1.012

Exudate

Inflammation

Cloudy[5] > 1.020
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Protein content fluid protein

< 25 g/L < 0.5

> 35 g/L[6] > 0.5[7]

serum protein Difference of albumin content with blood albumin fluid LDH upper limit for serum Cholesterol content See also: Rivalta test

> 1.2 g/dL

< 1.2 g/dL[8]

< 0.6 or < ⅔ < 45 mg/dL

> 0.6[6] or > ⅔[7] > 45 mg/dL[6]

SIGN AND SYMPTOM Shortness of breath is the most common symptom of a pleural effusion. As the effusion grows larger with more fluid, the harder it is for the lung to expand and the more difficult it is for the patient to breathe. Chest pain occurs because the pleural lining of the lung is irritated. The pain is usually described as pleuritic, defined as a sharp pain, worsening with a deep breath. While the pain may be localized to the chest, if the effusion causes inflammation of the diaphragm (the muscle that divides the chest from the abdominal cavity) the pain may be referred to the shoulder or the upper abdomen. As the pleural effusion increases in size, the pain may increase. Other associated symptoms are due to the underlying disease. For example, individuals with:


congestive heart failure may complain of swelling of their feet and shortness of breath when laying flat, (orthopnea) or wakening them in the middle of the night (paroxysmal nocturnal dyspnea);



tuberculosis may be have night sweats, cough up blood (hemoptysis), and loose weight;

 

hemoptysis may have associated infection and lung cancer; pneumonia may complain of fever, shaking chills, cough producing colored sputum and pleuritic pain.

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Many patients with pleural effusions are asymptomatic. However, when symptoms arise, they do so because of pleural inflammation or the effusion's effects on mechanics. The most common symptoms of pleural effusion are dyspnea, nonproductive cough, and pleuritic chest pain. The mechanisms by which dyspnea occurs are not well understood, but they do not appear to correlate with blood oxygen levels or the size of the pleural effusion. Dyspnea is probably related to increased thoracic cage size, which affects respiratory muscle function. Nonproductive cough may occur secondary to lung compression and resultant bronchial irritation. Pleuritic chest pain is associated with inflammation of the parietal pleura. Pain is occasionally referred to the abdomen. If the central portion of diaphragmatic pleura is involved, patients experience pain in the lower chest and ipsilateral shoulder simultaneously. Historical features, including underlying disease processes, drug use, and radiation therapy, can alert you to the possibility of pleural effusion in a patient with less common symptoms. Several physical findings suggest the presence of pleural effusion. Tactile fremitus is lost over the area of effusion because voice-induced vibrations are attenuated by the fluid adjacent to aerated lung. This finding is more sensitive than the use of percussion for detecting pleural fluid collections. Absent or diminished breath sounds over the area of effusion are characteristic. Pleural friction rubs are occasionally noted in the initial stages or as the effusion resolves and are caused by roughened pleural surfaces moving across one another.

DIAGNOSTIC AND TEST Pleural effusion is usually diagnosed on the basis of medical history and physical exam, and confirmed by chest x-ray. Once accumulated fluid is more than 300 ml, there are usually detectable clinical signs in the patient, such as decreased movement of the chest on the affected side, stony dullness to percussion over the fluid, diminished breath sounds on the affected side, decreased vocal resonance and fremitus (though this is an inconsistent and unreliable sign), and pleural friction rub. Above the effusion, where the lung is compressed, there may be bronchial breathing and egophony. In large effusion there may be tracheal deviation away from the effusion. A systematic review (2009) published as part of the Rational Clinical Examination Series in the Journal of the American Medical Association (JAMA) showed that dullness to conventional percussion was most accurate
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for diagnosing pleural effusion (summary positive likelihood ratio, 8.7; 95% confidence interval, 2.2–33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.12–0.37).[2] Pleural effusions are often discovered by doctors attempting to determine the source of a patient's symptoms. For example, a doctor examining a patient with a stethoscope may notice soft breathing or a dull sound when tapping the patient's chest. If a doctor suspects the existence of a pleural effusion, he or she may order X-rays to confirm the diagnosis and determine how much fluid is present in the pleural space. If congestive heart failure has been ruled out, the doctor may then perform a procedure called thoracentesis to extract a small sample of the pleural fluid for analysis. Also known as pleural fluid aspiration, this relatively painless procedure is done by inserting a needle between the ribs to access the pleural space. The fluid is then extracted and examined under a microscope to look for cancerous cells, bacteria and a protein called mesothelin. New research suggests that high levels of mesothelin may indicate mesothelioma. Ultrasound and/or a thoracic CT scan (CT scan of the chest) may also be ordered to diagnose pleural effusions.

MECHANISME PLEURAL EFFUSION IN TUBERCULOSIS The pleural space is 10 to 20 µm in width and normally contains about 0.1 mL/kg of fluid. A volume greater than 7 to 14 mL is abnormal. Many mechanisms can result in abnormal amounts of pleural fluid, including:
    

Increased hydrostatic pressures in the microvascular circulation. Decreased oncotic pressures in the microvascular circulation. Decreased pleural space pressure (resulting from lung collapse). Increased permeability of the microvascular circulation. Obstruction of lymphatic drainage Generally, transudative effusions are formed in response to increased hydrostatic pressure, while exudative effusions form when pleural inflammation or disrupted lymphatic drainage results in increased protein leak or decreased protein removal from the pleural space. In CHF, pleural effusions are secondary to pulmonary venous hypertension. Neoplasms can cause pleural effusions by direct involvement of the pleura, by lymphatic obstruction, or in association with a post-obstructive pneumonia. Pleural effusions associated with pulmonary embolism are secondary to increased capillary permeability, pleuropulmonary hemorrhage, and increased hydrostatic pressure.
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Many different things can cause pleural effusion. Heart failure or other heart and lung problems may cause pleural effusion. Infections (in-FECK-shuns) such as pneumonia (noo-MOH-nyah) or tuberculosis (TB) may cause pleural effusion. Inflammation of the pleura, called pleurisy (PLOOR-i-see), may cause pleural effusion. Other causes may include cancer, injury, or problems with other organs in your chest or abdomen (belly). Pleural effusion is a secondary disease being related to tuberculosis or other lung disease such as TB, pneumonia etc. because there is irritation on the lining of pleural cavity, thus altering the permeability of the membrane and decreasing the oncotic pressure needed to drain the excess fluid in the pleural space. normally there is a small amount of pleural fluid in the pleural space that lubricates the parietal and visceral pleura during expiring and inspiring. Primary pulmonary tuberculosis is often asymptomatic, so that the results of diagnostic tests are the only evidence of the disease. Although primary disease essentially exists subclinically, some self-limiting findings might be noticed in an assessment. Associated paratracheal lymphadenopathy may occur because the bacilli spread from the lungs through the lymphatic system. If the primary lesion enlarges, pleural effusion is a distinguishing finding. This effusion develops because the bacilli infiltrate the pleural space from an adjacent area. The effusion may remain small and resolve spontaneously, or it may become large enough to induce symptoms such as fever, pleuritic chest pain, and dyspnea. Dyspnea is due to poor gas exchange in the areas of affected lung tissue. Dullness to percussion and a lack of breath sounds are physical findings indicative of a pleural effusion because excess fluid has entered the pleural space.

COMPLICATION Complications of pleural effusions include collapse of the lung; pneumothorax, or air in the chest cavity, which is a common side effect of the thoracentesis procedure; and empyemas (abscesses) caused by infection of the pleural fluid, which require drainage of the fluid. Pleural effusion can place patients with asbestosis or mesothelioma at even more risk than other patients — if it leads to difficulty breathing. This is because patients with these conditions so often suffer from pleural scarring, which itself makes it extremely difficult to breathe. Pleural effusion can exacerbate this problem, and ultimately the inability to breathe properly can contribute significantly to the patient's downward spiral.
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Risks: A pleural effusion may cause or worsen a lung infection, such as pneumonia. The extra fluid may get infected and form a pocket of pus, which is called empyema (em-peye-EEma). You may have other problems, such as a collapsed lung. The problems you may have depend on what is causing your pleural effusion. Talk to your caregiver about any concerns you may have about your illness or treatment.

TREATMENT In some cases, no treatment is required for pleural effusions. However, when doctors link the fluid build-up to a patient's discomfort or pain — or to other, more serious side effects — they often take measures to address the cause and/or effects of the effusion. As previously mentioned, a patient suffering from asbestosis or mesothelioma may experience more than one condition that makes it difficult to breathe. To address this, doctors do whatever they can to treat the root causes. For patients with pleural-effusion-related breathing problems, this may include the following: Thoracentesis. Further extraction of pleural fluid can alleviate pressure in the chest, making it easier to breathe. Once a pleural effusion is diagnosed, the cause must be determined. Pleural fluid is drawn out of the pleural space in a process called thoracentesis. A needle is inserted through the back of the chest wall in the sixth, seventh, or eighth intercostal space on the midaxillary line, into the pleural space. The fluid may then be evaluated for the following: 1. Chemical composition including protein, lactate

dehydrogenase (LDH), albumin, amylase, pH, and glucose 2. Gram stain and culture to identify possible bacterial infections 3. Cell count and differential 4. Cytopathology to identify cancer cells, but may also identify some infective organisms 5. Other tests as suggested by the clinical situation – lipids, fungal culture, viral culture, specific immunoglobulins

Chemical pleurodesis. This procedure involves the insertion of agents such as talc or bleomycin to eliminate the pleural space altogether, so that fluid can no longer build up.

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Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, later, when the space scars down. Repeated effusions may require chemical

(talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either mechanically abrading the pleura or inserting the chemicals to induce a scar. This requires the chest tube to stay in until the fluid drainage stops. This can take days to weeks and can require prolonged hospitalizations. If the chest tube becomes clogged, fluid will be left behind and the pleurodesis will fail. Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or Aspira Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or care givers connect it to a simple vacuum tube and remove from 600 cc to 1000 cc of fluid. This can be repeated daily. When not in use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant pleural effusions, it allows them to continue chemotherapy, if indicated. Generally the tube is in for about 30 days and then it is removed when the space undergoes a spontaneous pleurodesis.

Pleural decortication. Also called pleurectomy, this surgery removes the pleura; like chemical pleurodesis, pleural decortication eliminates the pleural space, thereby preventing pleural fluid from building up. Mesothelioma Lawyers For more information on mesothelioma symptoms and other issues related to asbestos exposure, asbestosis and malignant mesothelioma, please refer to other articles on our site. If you or a family member has been diagnosed with an asbestos-related disease, contact a mesothelioma attorney as soon as possible.

The treatment you receive may depend on what is causing your pleural effusion and how bad your symptoms are. You may need medicines such as antibiotics (an-ti-bi-AH-tiks) to
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prevent or treat a bacterial (bak-TEE-ree-al) infection. Steroids and other kinds of medicines may be given to decrease inflammation. You may need medicines for pain. Diuretic (deye-yoo-RET-ik) medicine may help you lose extra fluid caused by heart failure or other problems. You may need to have the extra pleural fluid removed by having a thoracentesis (thohr-ah-sen-TEE-sis) or a chest tube. During a thoracentesis, a needle is used to remove the extra pleural fluid from around a lung. This fluid may be sent to the lab for tests. A thoracentesis may help you breathe easier, and help your caregiver find the best way to treat you. A chest tube is a tube that stays in your chest for days or weeks. This lets the extra fluid around your lung drain out over time. You may need medicines put directly into your chest if the fluid does not drain out easily. Some people have pleural effusions that come back over and over. For example, a tumor (growth) may cause extra fluid to keep collecting around a lung. If your pleural effusion keeps coming back or if it increases your risk for other problems, you may need surgery or other treatments. Ask your caregiver for more information about other treatments that you may need.

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BIBLIOGRAPHY

Arun Gopi, Sethu M. Madhavan, Surendra K. Sharma and Steven A.Sahn. 2007. Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006. American College of Chest Physicians.

http://ccn.aacnjournals.org/content/29/2/34.full

http://www.allaboutmalignantmesothelioma.com/pleural-effusion.htm

http://www.consultantlive.com/display/article/10162/36884

http://www.medicinenet.com/pleural_effusion/page2.htm#risk

W, Aru. Sudoyo, et all. 2006. Ilmu Peyakit Dalam Ed IV Jilid I. Departemen Ilmu Penyakit Dalam FKUI, Jakarta.

Yoga, Tjandra Aditama. 2006. TUBERKULOSIS PEDOMAN DAN PENATALAKSANAAN DI INDONESIA. Perhimpunan Dokter Paru Indonesia, Jakarta.

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