1.

Lung TB
CLINICAL SYMTOMS
Symptoms of pulmonary TB disease can be divided into general symptoms and specific
symptoms that arise according to the organ involved. The clinical picture is not too typical,
especially in new cases, so it is quite difficult to establish a clinical diagnosis.

Systemic / general symptoms:

• Coughing for more than 3 weeks (can be accompanied by blood)
• Fever is not too high which lasts a long time, usually felt at night accompanied by night
sweats. Sometimes a fever attack such as influenza and disappearing arises
• Decreased appetite and weight
• Malaise, weakness

Specific symptoms:
• Depending on which body organ is affected, if there is a partial blockage of the bronchi (the
channel leading to the lungs) due to suppression of enlarged lymph nodes, it will make a
"wheezing" sound, weakened breathing sounds accompanied by tightness.
• If there is fluid in the pleural space (wrapping the lungs), it can be accompanied by
complaints of chest pain.
• When it comes to bones, symptoms will occur such as bone infection which can someday
form a channel and lead to the overlying skin, at this estuary will discharge pus discharge.
• In children it can affect the brain (the lining of the brain) and is called meningitis
(inflammation of the lining of the brain), the symptoms are high fever, decreased
consciousness and convulsions.
In pediatric patients who do not cause symptoms, pulmonary TB can be detected if contact
with adult TB patients is known. About 30-50% of children who come in contact with adult
pulmonary TB sufferers give positive tuberculin test results. In children aged 3 months - 5
years who live at home with adult pulmonary TB sufferers with smear positive, reported 30%
are infected based on serology / blood tests.

STEP DIAGNOSIS
Someone is suspected of suffering from pulmonary TB if there is a cough for more than 2 or
3 weeks with sputum production and weight loss. Clinical symptoms in patients with
pulmonary TB are divided into 2, namely symptoms of respiration and constitution.
Respiratory symptoms include chest pain, hemoptysis and shortness of breath, while
constitutional (systemic) symptoms are fever, night sweats, fatigue, loss of appetite,
secondary amenorrhea. No specific abnormalities were found on physical examination of
pulmonary TB. Common symptoms such as fever, tachycardia, clubbing fingers occur. Chest
examination may show crackles, wheezing, bronchial breath sounds and amforics.
If someone is suspected of contracting TB, then some things that need to be done to
establish the diagnosis are:
• History of the patient and family.
• Physical examination.
• Laboratory tests (blood, sputum, brain fluid).
•Anatomical pathology examination (PA).
• Chest radiograph (chest photo).
• Tuberculin testing.
2. Pneumonia
CLINICAL SYMPTOMS
Typical symptoms of pneumonia are fever, chills, sweating, cough (either non-productive or
productive or produce slimy, purulent sputum, or blood spots), chest pain due to pleurisy and
tightness. Another common symptom is that the patient prefers to lie on the sick with knees
bent due to chest pain. Physical examination found retraction or withdrawal of the lower
chest wall during breathing, tachypnea, increase or decrease in tactile fremitus, dim
percussion until deafness illustrates consolidation or presence of pleural fluid, crackles,
bronchial respiratory sounds, pleural friction rub.

STEP DIAGNOSIS
The diagnosis of community pneumonia is based on a complete history of the disease, a
careful physical examination and investigations. The definitive diagnosis of community
pneumonia is made if the chest radiograph contains new or progressive infiltrate plus 2 or
more of the following symptoms:
a. Coughing up
b. Changes in sputum / purulent characteristics
c. Body temperature> 38C (axillary) / history of fever
d. Physical examination: signs of consolidation, bronchial breath sounds and crackles
e. Leukocytes> 10,000 or <4500.
Assessment of the severity of community pneumonia can be done using a score system
according to the results of the Pneumonia Patient Outcome Research Team (PORT)

Supporting investigation
1. Radiology
Examination using chest radiograph (PA / lateral) is the main supporting examination (gold
standard) to establish the diagnosis of pneumonia. Radiological features can be in the form
of infiltration to consoleudation with water bronchograms, bronchogenic and intertisal
spreads and cavity images.

2. Laboratory
Increased leukocyte counts range from 10,000 - 40,000 / ul, polymorphonuclear leukocytes
in many forms. Although it can also be found leukopenia. The type count shows shift to the
left, and the LED increases.
3. Microbiology
Microbiological examination includes sputum culture and blood culture to determine the
presence of S. pneumonia by examining the coagulation antigen pneumococcal
polysaccharide.
4. Blood Gas Analysis
Moderate or severe hypoxemia found. In some cases, the partial pressure of carbon dioxide
(PCO2) decreases and at an advanced stage shows respiratory acidosis
3. Chronic bronchitis
CLINICAL SYMPTOMS
Signs and Symptoms of Patients with Bronchitis
a. Shortness of breath / dyspnea
Shortness of breath or dyspnea is a feeling of difficulty breathing and is a symptom that is
often encountered in people with bronchitis. Objective signs that can be observed from
shortness of breath are rapid breathing, gasping, breathing with lips drawn into (pursed lip),
hypercapnia (reduced oxygen in the blood), hypercapnia or increased levels of carbon dioxide
in the blood.
b. Breath sounds
The sound of wheezing (weezing) is the sound of breathing caused by the flow of air through
the narrow airways due to excessive mucus excretion or excretion.
c. Cough and sputum
Coughing is the most common symptom in bronchitis sufferers, often in bronchitis sufferers
experience coughing almost every day and expectoration of at least 3 consecutive months in
one year and at least 2 year.
d. Chest pain.
Chest pain often occurs in people with bronchitis because there is inflammation of the
bronchi. In patients with bronchitis, pain in the chest is felt with the severity of the disease.
e. Nasal lobe breath
In toddlers and children with bronchitis sometimes there is nasal lobe breath, but not all
bronchitis sufferers experience it. With the nasal lobe means there is a disruption in the
respiratory system that causes fatigue in breathing.

STEP DIAGNOSIS
The diagnosis can be established first by:

1. History includes major complaints and additional complaints.

• Usually the patient's complaint is coughing or chronic shortness of breath.
• In chronic bronchitis symptoms of cough as a prominent complaint, cough is accompanied
by a lot of phlegm, sometimes thick and if yellowish a sign of super bacterial infection.
• There is a history of smoking or former smokers with or without respiratory symptoms.
• A history of exposure to irritants at work is also common.
• Then there is a family history of the disease and there are predisposing factors in childhood,
such as low birth weight, recurrent respiratory infections and the environment of cigarette
smoke and air pollution.
• Then there is a repeated cough with or without phlegm and tightness with or without
wheezing.

2. Physical examination
On inspection found:
• Pursed - lips breathing or often said to be a half-closed mouth or a mouth-gag.
• Then there is a barrel chest (antero - posterior and transverse diameter are comparable).
• When breathing can be found the use of breathing muscles and hypertrophy of breathing
muscles.
• Rib enlargement and if there has been a right heart failure a jugular venous pulse is seen
• Leg edema and the appearance of pink puffer or blue bloater.
At the time of palpation found:
• Weak stem fremitus and widening of the ribs.
At the time of percussion will be found:
• Hypersonor and heart limits shrink.
• Low diaphragm location.
• The liver is pushed down.

Auscultation is useful for:

Hear whether vesicular breath sounds are normal, or weakened, whether there is crackling
or wheezing during normal breathing or forced expiration, expiration is extended and heart
sounds are heard far away.
Investigations that are routinely carried out to help establish the diagnosis are:
• Pulmonary physiology, using spirometry. If spirometry is not available, the peak expiratory
current (APE) meter, although not quite right, can be used as an alternative by monitoring
daily morning and evening variability. Then another pulmonary physiology test that can be
done is the usual bronchodilator test for stable chronic bronchitis.
• Routine blood tests by looking at leukocytes, hemoglobin and hematocrit.
• Radiological examination, ie, anterior posterior chest (PA) chest X-ray to see whether there
are bronchial restriction features.
Other tests that can be used are pulmonary physiology checks by measuring residual
volume (VR), functional residual capacity (KRF), total lung capacity (KPT), VR / KRF and others.
Then others are cardiopulmonary training test, bronchial provocation test, corticosteroid
trial, blood gas analysis, high-resolution Computerized Tomography (CT Scan),
electrocardiography, echocardiography, bacteriology and alpha-1 antitrypsin levels.

Ref:
• Ermanta N. Keliat, Alwinsyah Abidin, Jamaluddin. Pulmonology and Allergy Immunology
Division - Department of Internal Medicine Faculty of Medicine, University of North Sumatra
RSUP. H. Adam Malik Medan
• Werdhani, Retno Asti. Pathophysiology, Diagnosis, and Tuberculosis Classification.
Department of Community Medicine, Occupation, and Family of FKUI
• Cahyati. Relationship Between Type, Duration and Number of Cigarettes with the Incidence
of Bronchitis. UMP Faculty of Health Sciences, 2016
• Ryusuke, Oyagi. Registrar's Office of Intermediate Clinic / SMF Internal Medicine. Faculty
of Medicine, Udayana University