1. Why the patient feel chest pain and shortness breath ?

INDONESIA

Komponen-komponen asap rokok  merangsang perubahan-perubahan pada

sel-sel penghasil mukus bronkus dan silia  silia yang melapisi bronkus
mengalami kelumpuhan atau disfungsional serta metaplasia  mengganggu
sistem pengeluaran mukus  menyebabkan penumpukan mukus kental 
mengaktifkan reseptor batuk  menghasilkan refleks batuk untuk memebantu
pengeluaran mukus  batuknya kental.
Riyanto BS, Hisyam B. Buku Ajar Ilmu Penyakit Dalam Edisi 4. Obstruksi Saluran
Pernafasan Akut. Jakarta: Pusat Penerbitan Departemen IPD FKUI, 2006. p. 984-
5.

INGGRIS
The components of cigarette smoke  stimulate changes in bronchial mucus-producing cells
and cilia  cilia that line the bronchus with paralysis or dysfunctional as well as metaplasia
 interrupt the mucus discharge system  cause thickening of the thick mucus  activates
the cough receptors  produces a cough reflex to help mucus expenditure  cough thick
Riyanto BS, Hisyam B. Buku Ajar Ilmu Penyakit Dalam Edisi 4. Obstruksi Saluran
Pernafasan Akut. Jakarta: Pusat Penerbitan Departemen IPD FKUI, 2006. p. 984-
5.

INDONESIA
- Pertama, nikotin  menyebabkan konstriksi bronkiolusterminal paru 
meningkatkan resistensi aliran udara ke dalam dan keluar paru.
- Kedua, efek iritasi asap rokok  peningkatan sekresi cairan ke dalam cabang-
cabang bronkus serta pembengkakan lapisan epitel.
- Ketiga, nikotin  melumpuhkan silia  tidak dapat menggerakan kelebihan
cairan dan partikel asing dari saluran pernafasan.
Akibatnya banyak debris berakumulasi dalam jalan napas dan kesukaran bernapas
menjadi semakin bertambah sehingga perokok akan merasakan adanya tahanan dan
nyeri saat bernafas

(Guyton, 2006).
 INGGRIS

- First, nicotine  causes constriction of bronchiolusminal lung  increases airflow

resistance into and out of lung
- Second, the effect of cigarette smoke irritation  increased secretion of fluid into the
bronchial branches as well as the swelling of the epithelial lining
- Third, nicotine  crippling cilia  can not move excess fluid and foreign particles from the
respiratory tract
As a result many debris accumulates in the airway and breathing difficulties become
increasingly so that smokers will feel the presence of prisoners and pain when breathing

(Guyton, 2006).

2. What did the appertite decrease, weight loss and fever?

INDONESIA

 Demam

Demam terjadi karena adanya suatu zat yang dikenal dengan nama pirogen. Pirogen
adalah zat yang dapat menyebabkan demam. Pirogen terbagi dua yaitu pirogen
eksogen (pirogen yang berasal dari luar tubuh pasien) dan pirogen endogen (dari
dalam tubuh pasien).

Pirogen eksogen berasal dari Rokok  inflamasi  stimulasi sel-sel darah putih
(monosit, limfosit, dan neutrofil)  Sel-sel darah putih tersebut akan mengeluarkan
zat kimia yang dikenal dengan pirogen endogen (IL-1, IL-6, TNF-α, dan IFN)
Pirogen eksogen dan pirogen endogen akan merangsang endotelium hipotalamus
untuk membentuk prostaglandin (Dinarello & Gelfand, 2005) terbentuk
Prostaglandin  meningkatkan patokan termostat di pusat termoregulasi hipotalamus.
Hipotalamus akan menganggap suhu sekarang lebih rendah dari suhu patokan yang
baru sehingga ini memicu mekanisme-mekanisme untuk meningkatkan panas antara
lain menggigil, vasokonstriksi kulit dan mekanisme volunter seperti memakai selimut.
Sehingga akan terjadi peningkatan produksi panas dan penurunan pengurangan panas
yang pada akhirnya akan menyebabkan suhu tubuh naik ke patokan yang baru
tersebut (Sherwood, 2001).

INGGRIS

 Fever

Fever occurs because of a substance known as pyrogen. Pyogen is a substance that

can cause fever. The pyrogens are divided into two: exogenous pyrogens
(pyrogens from outside the patient's body) and endogenous pyrogens (from the
patient's body).

Exogenous pyrogens derived from Cigarettes  inflammation  stimulation of

white blood cells (monocytes, lymphocytes, and neutrophils)  These white blood
cells release chemicals known as endogenous pyrogens (IL-1, IL-6, TNF-α , and IFN)
 Exogenous pyrogens and endogenous pyrogens will stimulate hypothalamic
 endothelium to form prostaglandins  Formed Prostaglandins  improve thermostat
benchmarks in hypothalamic thermoregulatory centers
The hypothalamus will assume the temperature is now lower than the new
benchmark temperature so it triggers mechanisms to increase heat such as chills, skin
vasoconstriction and voluntary mechanisms such as wearing a blanket. So there will
be an increase in heat production and reduction of heat reduction which will
eventually cause the body temperature to rise to the new benchmark

(Sherwood, 2001).

INDONESIA

 BB MENURUN

Pirogen eksogen yang berasal dari Rokok  Inflamasi  Sel-sel darah putih
tersebut akan mengeluarkan zat kimia yang dikenal dengan pirogen endogen (IL-
1, IL-6, TNF-α, dan IFN) Pirogen eksogen dan pirogen endogen akan
merangsang endotelium hipotalamus untuk membentuk prostaglandin 
terbentuk Prostaglandin  Cerebral Cortex (respon behavior)  nafsu makan
menurun, leptin meningkat  meningkatkan metabolisme tubuh  BB menurun

INGGRIS

 Weight loss
Exogenous pyrogens derived from Cigarettes  inflammation  stimulation of white blood
cells (monocytes, lymphocytes, and neutrophils)  These white blood cells release chemicals
known as endogenous pyrogens (IL-1, IL-6, TNF-α , and IFN)  Exogenous pyrogens and
endogenous pyrogens will stimulate hypothalamic endothelium to form prostaglandins 
Formed Prostaglandins  Cerebral Cortex (response behavior)  decreased appetite, leptin
increased  increased body metabolism  BB decreased

(Sherwood, 2001).

3. Why in the auscultation sound of lung is losed and dullness detected on percussios?

4. What is the connection between smoking and the symtomps in the case?
 Fever

Exogenous pyrogens derived from Cigarettes  inflammation  stimulation of white

blood cells (monocytes, lymphocytes, and neutrophils)  These white blood cells
release chemicals known as endogenous pyrogens (IL-1, IL-6, TNF-α , and IFN) 
Exogenous pyrogens and endogenous pyrogens will stimulate hypothalamic
endothelium to form prostaglandins  Formed Prostaglandins  improve thermostat
benchmarks in hypothalamic thermoregulatory centers
The hypothalamus will assume the temperature is now lower than the new
benchmark temperature so it triggers mechanisms to increase heat such as chills, skin
vasoconstriction and voluntary mechanisms such as wearing a blanket. So there will
 be an increase in heat production and reduction of heat reduction which will
eventually cause the body temperature to rise to the new benchmark

(Sherwood, 2001).

 Weight loss
Exogenous pyrogens derived from Cigarettes  inflammation  stimulation of white blood
cells (monocytes, lymphocytes, and neutrophils)  These white blood cells release chemicals
known as endogenous pyrogens (IL-1, IL-6, TNF-α , and IFN)  Exogenous pyrogens and
endogenous pyrogens will stimulate hypothalamic endothelium to form prostaglandins 
Formed Prostaglandins  Cerebral Cortex (response behavior)  decreased appetite, leptin
increased  increased body metabolism  BB decreased

(Sherwood, 2001).

 Lung Cancer
Smoking and environmental disturbances  metabolic activation of the mono-thyroidase
enzyme system P-450  Inactivation of tumor suppressor genes  Mutation of TP 53 /
Activation of K-RAS oncogene  respiratory epithelial mutations (field effect effect) 
basal cell hyperplasia and squamous metaplasia  squamous dysplasia and carcinoma in situ
 accumulation of mutated cells  lung carcinoma

Kumar Abbas Aster. Buku Ajara Patologi Robbins Ed 9. 2014. Elseivier Sanders : Singapore
- First, nicotine  causes constriction of bronchiolusminal lung  increases airflow
resistance into and out of lung
- Second, the effect of cigarette smoke irritation  increased secretion of fluid into the
bronchial branches as well as the swelling of the epithelial lining
- Third, nicotine  crippling cilia  can not move excess fluid and foreign particles from the
respiratory tract
As a result many debris accumulates in the airway and breathing difficulties become
increasingly so that smokers will feel the presence of prisoners and pain when breathing

(Guyton, 2006).

5. Why in xray examination perfomed visible right hemithorac was gloom?

6. Why did the doctor do puncture and found flushing out fluids?
Torakosentesis, intended for the treatment of basic diseases and discharge of fluids.
The indications for performing thoracocentesis are: (1) eliminating shortness of breath
caused by fluid accumulation in the pleural cavity, (2) when the specific therapy in
primary disease is ineffective or failing, (3) in case of fluid reaccumulation.

Pleural fluid aspiration (thoracosentesis) is useful as a means for both diagnostic and
therapeutic. Implementation should be done on the patient with a sitting position.
Aspiration is performed at the lower portion of the lung between the posterior ribs of
the posterior axillary line with the needle of Abbocath number 14 or 16. Pleural fluid
removal should not exceed 1,000-1,500 cc at each aspiration. It is better to repeat
aspirations than one-time aspirations that can lead to pleural shock (hypotension) or
pulmonary edema.
Setiati dkk. 2014. Buku Ajar Ilmu Penyakit Dalam. Jakarta: Interna Publishing

7. Why the patien run out of medicine he suffered from shortness breath again?
8. How to diagnose from the case (including anamnesis, physical examination, supportif
examination) and what the diagnosis and DD?
 Physical Examination:
On physical examination of patients with pleural effusions will be found:
1. Inspection: hemithorax inflammation of the sick, ICS widened, respiratory movement
decreased on the pain side, mediastinum pushed toward the contralateral.
2. Palpation: according to the inspection, the fretus femitus decreases.
3. Percussion: percussion of a deaf, Elolis damoisseaux line
4. Auscultation: the sound of the breath decreasing even disappearing.

supportif examination

9. Patogenesis and patofisiologi ?

Patogenesis

10. What are the clasification from the diagnosis?

11. What are the treatment from the diagnosis?

Setiati dkk. 2014. Buku Ajar Ilmu Penyakit Dalam. Jakarta: Interna Publishing

Torakosentesis, intended for the treatment of basic diseases and discharge of fluids. The
indications for performing thoracocentesis are: (1) eliminating shortness of breath caused by
fluid accumulation in the pleural cavity, (2) when the specific therapy in primary disease is
ineffective or failing, (3) in case of fluid reaccumulation.

Pleural fluid aspiration (thoracosentesis) is useful as a means for both diagnostic and
therapeutic. Implementation should be done on the patient with a sitting position. Aspiration
is performed at the lower portion of the lung between the posterior ribs of the posterior
axillary line with the needle of Abbocath number 14 or 16. Pleural fluid removal should not
exceed 1,000-1,500 cc at each aspiration. It is better to repeat aspirations than one-time
aspirations that can lead to pleural shock (hypotension) or pulmonary edema.

Setiati dkk. 2014. Buku Ajar Ilmu Penyakit Dalam. Jakarta: Interna Publishing

12. What are the complication from diagnosis?

13. What Lung malignancy, DD from lung malignancy can cause pleural efusion ?

14. How lung malignancy can cause pleural efusion ?

15. How lung malignancy appear to smoker ?

16. Risk factor of lung malignancy?