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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-overview8/9/2019 Cr Destroyed Lung
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'AN= Q!$ F! Q!$
AENI!N
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