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OBSTRUCTION SYNDROME POST-TUBERCULOSIS

Created by

Andre Prasetyo Mahesya 11!111"

Per#e$tor%dr& Dedy 'a(r)s* S$&P

CLINICAL +OR, O INTERNAL MEDICINESM PULMONOLO.Y

PERIOD DECEMBER /10 TO MARC /12ABDUL MOELOE, OSPITAL

BANDAR LAMPUN.

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ANAMNESISa&en ,rom: Autoanamnesis

-ate : -e"emer* /0st* 1024ime : 22.00

3ie, 3om#lain : !ut o, reat sin"e a ee& ago

Additional 3om#laint : 3oug it #legm* sin"e 2 ee&s ago*

nausea5 Emesis5 loss o, eigt.

(story o3 The Present I44ness %!ne ee&s ago* #atients ,elt "oug it #legm eavely in det* ande"ome a sortness o, reat 6 mount later* te sym#tom isintermitten. e #legm as trans#arant* ti"&* and as no lood

a##earan"e (7). Se as a##roximately 20 times entered te os#ital tesame "om#laints sin"e last 6 mounts. Anoter sy#mtoms are loss o,a#etite and loss o, eigt (,rom 40 &g to /4 &g). 8atiens also o,tennausea* vomiting* and ,re9uent el"ing. omiting is not mu"* just li&e alittle ;uid out o, te stoma"* te sym#toms is ,elt a,er te #atient eats.Se "ould ave ad tuer"ulosis treatment ,or < monts and de"leared y

do"tors "om#leted in 4 years ago. 8atient deny ave #revious ig loodreassure diaetes melitus and astma. %ut te 8atient as ever

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(7)

Small #ox (7) Malaria (7) =idney stone

(7) 3i"&en #ox (7) -isentri

(7)

'ernia

(7) -i,tery (7) 'e#atitis

(7)

8rostat

(7) 8ertusis (7) i,usAdomina

lis

(7)

Melena

(7) Measles (7) S&iro,ula (7) -iaeti"(7) In,luen>a (7) Si#ilis

(7)

Alergy

(7) onsilitis (7) ?onore

(7)

u m o r

(7)

=olera (7) 'i#ertension. (7) as&ular

-isease

8neumonia (7) -uodeni $l"er (+) Tuberculosis

he (story o3 I44ness %

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a5(4y6s d(seases (story % Fater still alive* 'i#ertension.

Moter still alive* uer"ulosis.

Seven silings still alive* ealty.

3ildren are still alive* ealty.

Is there any 3a5(4y 7ho s)8er %

'er moter suer it te same sym#toms orad een diagnose it tuer"ulosis.

'er ,ater ad een diganose it i#ertensian.

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(@)

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99

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TE ISTORY O LIEB(rth $4a#e

(7) in ome (7) matrinity (@) matrinity

os#ital

e4$ed by%

(7) raditional matrinity(@) -o"tor (7) Nurse (7)

!ters

I5)n(tat(on (story ;Un

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Body Che#< U$

.enera4 Che#< U$

'eigt : 2

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Menta4(ty As$e#ts

%eavior: Normal

Nature o, Feeling : Sad

e tin&ing o, #ro"ess : Normal

S

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Ly5$hat(# .4and

Sumandiula : no enlargement

Ne"& : no enlargement

Su#ra"lavi"ula : no enlargement

Arm#it: no enlargement

ead

Fa"e Ex#ression : Sad

Fa"e Symmetri" : Symmetri"

'air : %la"&

em#oral artery : Normal

Eye

Exo#talmus : (7)

Eno#talmus : (7) 8al#era: edema (7)C(7)

+ens : 3learC3lear

3onjun"tiva : Anemis 7C7

isus : Normal

S&lera : I"teri" 7C7

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Ear

-ea,nes : (7)

Foramen : (7)

Memrane tym#ani : inta"t

!stru"tion : (7)

Serumen : (7)

%leeding : (7)

+i9uid : (7)

Mo)th

+i# : (7)

onsil : (7)

8alatal : Normal

'alists : No

eet : (7)

rismus : (7)

Farings : $ni#eremis

+i9uid +ayers: (7)on ue : Normal

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L)n:

Ins#e"tion : +e,t : good reat* no lession

igt: reat le,t eind* no lession

8al#ation : +e,t : vo&al ,remitus normal* #ain (7)

igt: vo&al ,remitus de"rease* #ain (7)

8er"ussion : +e,t : resonan"e

igt: dim

Aus"ultation : +e,t : ron&ial* ee>ing (@)* ron&i (@) igt: ron&ial* ee>ing (@)* ron&i (@)* de"reased reat

sounds

Cor

Ins#e"tion : I"tus "ordis not visile

8al#ation : I"tus 3ordis no #al#ale 8er"ussion : to#: di"ult to determinate

igt: di"ult to determinate

+e,t: di"ult to determinate

Aus"ultation : 'eart Sound 2 1 egular* murmur (7)* gallo# (7).e "or is on te rigt.

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Artery

em#orali" artery : No aerration

3ariti" artery : No aerration

%ra"ial artery : No aerration

adial artery : No aerration

Femoral artery : No aerration

8o#litea artery : No aerration

8osterior tiialis artery : No aerration

Sto5a#h

Ins#e"tion : ;at 8al#ation : Stoma" Ball : undulation (7)* #ain (7)

'eart : 'e#atomegali (7)

+im,e : S#lenomegali (7)

=idney : %allotement (7)

8er"ussion : Si,ting -ullness (7)

Aus"ultation : Intestine Sounds (@)

?enital (ased on indi"ation)

Male : no indi"ation

8enis : no indi"ation

estis : no indi"ation

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Re@es

igt +e,t

endon e;ex Normal Normal

%ise# Normal Normalrise# Normal Normal

8attela Normal Normal

A"iles Normal Normal

3remaster Normal Normal

S&in e;ex Normal Normal

8atologi" e;ex Not Found Not Found

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Laboratory

e5ato4o:y ;/0-1/-/10=Nor5a4

'aemogloin : 21.1 grCdl2172< grCdl

+eu"o"yte : 20.

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Rad(o4o:y 17G71024 A8 "est radiogra#: destroyed lung

dextra* atele&tasis* deviasi tra"ea to te dextra*"or #used to te dextra @ #ost %

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Rad(o4o:y 1472171024 A8 "est radiogra#: destroyed lung

dextra* atele&tasis* deviasi tra"ea to te dextra*"or #used to te dextra @ #ost %

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esume

8atient Ms. E (44t)* !ne ee&s ago* #atients ,elt "oug it#legm eavely in det* and e"ome a sortness o, reat6 mount later* te sym#tom is intermitten. e #legmas trans#arant* ti"&* and as no lood a##earan"e (7).Se as a##roximately 20 times entered te os#ital tesame "om#laints sin"e last 6 mounts. Anoter sy#mtomsare loss o, a#etite and loss o, eigt (,rom 40 &g to /4 &g).8atiens also o,ten nausea* vomiting* and ,re9uent el"ing.omiting is not mu"* just li&e a little ;uid out o, testoma"* te sym#toms is ,elt a,er ter #atient eats. Se

"ould ave ad tuer"ulosis treatment ,or < monts andde"leared y do"tors "om#leted in 4 years ago. 8atientdeny ave #revious ig lood #reassure* diaetes melitus*and astma. %ut te 8atient as ever smo&er e,ore illness.

-i

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-iagnose+or

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S)$$ort Che#< U$S#irometri

(2) ?eneral reatment

%ed est* al, sitting.

Nutrition (ig "alory* ig #rotein)

(1) S#e"ial reatment

IF- + gtt 10KCminute

!1 / liter

Amino#iline 14 mgC21 ours

3omivent *GmlCours neuli>er Amroxol syr /x2 "t

Sul"ar,at syr /x2 "t

!me#ra>ole ta 1x2

Amino;uid &ol,Cday

3i#ro;oxa"in 1x2 am#

Treat5ent P4an

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8!?N!SE

Luo ad itam : -uia ad malam

Luo ad Fun"tonam : -uia admalam

Luo ad Sanationam : -uia admalam

LITERATURE REIE+

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LITERATURE REIE+

3om#li"ations o,8ulmonary

uer"ulosi

s

Parenchymallesions

Thin &alled ca#it% (pen negati#e s%ndrome)

Aspergilloma

'nd stage lung destruction$car carcinoma

Airway Lesions

Tuberculous ar%ngitis

ronchiectasis

Tracheobronchial stenosis

Anthracofibrosisroncholithiasis

Vascular Lesions

*asmussen aneur%sm

Pleural Lesions

!r% pleuris%

Pleural effusion'mp%ema ronchopleural fistula

Pneumothora,

General Complications

"or-pulmonale

$econdar% am%loidosis

"hronic respirator% failure

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Destroyed L)n:

$nilateral destru"tion o, te lung dueto tuer"ulosis as een are"ogni>ed entity.

Analy>ed #atients it unilaterallung destru"tion and ,ound#ulmonary tuer"ulosis as te "ause

in /./J o, #atients. It may o""ur a,ter #rimary disease or

rein,e"tion.

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"hest -ra% PA and H*"T Thora, sho&ing destro%ed lung on left side &ith compensator%

h%perinflation on the right side.

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8ulmonary arterial ;o is redu"ed orasent en tere is ron"ialostru"tion* stasis o, se"retions* or

#aren"ymal in,e"tion. +igation o, te#ulmonary artery o, #atients andex#erimental animals it #ulmonarytuer"ulosis is re#orted to exa"erate te

disease* as does anastomosis o, a majorsystemi" vessel to te #ulmonary artery.

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In our #atients angiogra#y soed#ulmonary arterial ;o to e asent*ron"ial arteries ere #rominent* and

tere as radiologi"al eviden"e o,systemi" ;o into te #ulmonary arterialtree.

It seems li&ely tat tese ,a"tors led to

lym# stasis and a raised oxygen tension*,avouring #rogression o, te disease andeventual lung destru"tion.

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.ASTROESOA.EAL RELU,SDISEASE

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Eso$ha:ea4 de3ense 5e#han(s5s

Eso#ageal "learan"e must e ale to neutrali>e tea"id re;uxed troug te loer eso#ageal s#in"ter

Anormal #eristalsis "an "ause ine"ient and

delayed a"id "learan"e.

Dys3)n#t(on o3 the 4o7er eso$ha:ea4 s$h(n#ter

transient relaxation o, te +ES (most "ommon

me"anism)* #ermanent +ES relaxation* andtransient in"rease o, intra7adominal #ressure tatover"omes te +ES #ressure.

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De4ayed :astr(# e5$ty(n:

in"reased intragastri" #ressure and* ultimately* in"reased#ressure against te loer eso#ageal s#in"ter.

(ata4 hern(a e loer eso#ageal s#in"ter may migrate #roximally into

te "est and lose its adominal ig7#ressure >one ('8)* orte lengt o, te '8 may de"rease.

Obes(ty as #ontr(b)t(n: 3a#tor In"reased intragastri" #ressure and gastroeso#ageal

#ressure gradient* in"om#eten"e o, te loer eso#ageals#in"ter (+ES)* and in"reased ,re9uen"y o, transient +ESrelaxations may all #lay a role in te #ato#ysiology o, ?E-in #atients o are moridly oese.

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S(:n and sy5to5

y#i"al eso#ageal sym#toms in"lude te ,olloing:

'earturn

egurgitation

-ys#agia

Anormal re;ux "an "ause aty#i"al (extraeso#ageal)

sym#toms* su" as te ,olloing:

3ouging andCor ee>ing

'oarseness* sore troat !titis media

Non"ardia" "est #ain

Enamel erosion or oter dental mani,estations

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D(a:nose

Testing

e ,olloing studies are used to evaluate #atients it sus#e"tedgastroeso#ageal re;ux disease:

$##er gastrointestinal endos"o#yCeso#agogastroduodenos"o#y:Mandatory

Eso#ageal manometry: Mandatory Amulatory 147our #' monitoring: 3riterion standard in estalising

a diagnosis o, gastroeso#ageal re;ux disease

Imaging studies

3est images may also demonstrate a large iatal ernia* ut smallernias "an e easily missed.

3urrently* no role exists ,or "om#uted tomogra#y s"anning*magneti" resonan"e imaging* or ultrasonogra#y in te routineevaluation o, #atients it re;ux disease.

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Mana:e5ent

Nonpharmacotherapy

+i,estyle modiD"ations used in te management o,gastroeso#ageal re;ux disease in"lude te ,olloing:

+osing eigt (i, overeigt)

Avoiding al"ool* "o"olate* "itrus jui"e* and tomato7ased#rodu"ts

Avoiding #e##ermint* "oee* and #ossily te onion ,amily

Eating small* ,re9uent meals rater tan large meals

Baiting / ours a,ter a meal to lie don

e,raining ,rom ingesting ,ood (ex"e#t li9uids) itin / ourso, edtime

Elevating te ead o, te ed in"es

Avoiding ending or stoo#ing #ositions

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Pharmacotherapy

e ,olloing medi"ations are used in temanagement o, gastroeso#ageal re;ux disease:

'1 re"e#tor antagonists (eg* ranitidine*"imetidine* ,amotidine* ni>atidine)

8roton #um# iniitors (eg* ome#ra>ole*lanso#ra>ole* rae#ra>ole* esome#ra>ole*#anto#ra>ole)

8ro&ineti" agents (eg* aluminum ydroxide)

Anta"ids (eg* aluminum ydroxide* magnesiumydroxide)

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Surgical option

ranstora"i" and transadominal,undo#li"ations are #er,ormed ,orgastroeso#ageal re;ux disease*in"luding #artial (anterior or#osterior) and "ir"um,erential ra#s.

!#en and la#aros"o#i" te"ni9uesmay e used

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REERENCES

?ayatri -. 3om#li"ations !, 8ulmonaryuer"ulosis. -e#artement o, es#iratoryMedi"ine M.S. amaia Medi"al 3ollage.

India. tt#:CCemedi"ine.meds"a#e."omCarti"leC2

6o H. 1021. 'arrisonPs8rin"i#les o, Internal Medi"ine 2t Edition.$nited States : M"?ra7'ill e%oo&s.

http://emedicine.medscape.com/article/176595-overviewhttp://emedicine.medscape.com/article/176595-overviewhttp://emedicine.medscape.com/article/176595-overviewhttp://emedicine.medscape.com/article/176595-overview

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'AN= Q!$ F! Q!$

AENI!N