TUBERCULOSIS
Definition:
Direct communicable disease caused by
Mycobacterium tuberculosis
Epidemiology
TB in Indonesia
1st killer among the communicable disease 3rd killer among other disease after heart
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Tuberculosis
Risk factor:
Contact with TB patients Young age Had HIV Severe malnutrition
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Pathophysiology
Droplet TB
Restitution ad integrum Cure with a scar such as fibrotic Spread : perkontinuitatum, bronchogenic,
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Pathophysiology
Wallgren
children:
divided 3 type of TB in
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Anamnesis
Physical Examination
Diagnosis
Further Investigation
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Tuberculin Thorax
Eritema Cough
Prolong Body
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weight decreased without any clear cause or didnt get weight gain in 1
3 dari 1o item
Suggested TB
Improved
Deteriorated/ constant
TB
Not TB
Drug resistant TB
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Reconciliate to hospital
Parameter
skor
Contact to TB patients
Tuberculin test
Negative
Nutrition
Fever with unknown cause Cough Limphadenopati coli, axilla, inguinal Swelling on bone, coxae, phalangs Thorax rontgen 7/5/12 Normal
Diagnosis Tuberculosis
Score Score
6 TB
Tuberculin
BCG immunization
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Incubation Anergy
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Score 6
(-) response continued theraphy and searched for the exact cause
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2nd
Isoniazid
Drug Dosage
Name Isoniazid Rifampicin Pyrazinamid Etambuthol Streptomicin Dosage Maximal dosage 5-15 mg/kgBW/ day 300 mg/day 10-20 mg/kgBW/day 600 mg/day 15-30 mg/kgBW/day 2000 mg/day 15-20 mg/kgBW/day 1250 mg/day 15-40 mg/kgBW/day 1000 mg/day
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Follow Up
After
2 months got drugs improve clinical, weight gain, no fever, decrease cough continued theraphy
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Asthma
Definition:
Chronic
reversible
Epidemiology
Prevalence of the world 7,2% (6% for adult
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Risk factor
Gender:
Male: female ratio: 3:2 for 6-11 years old Male female ratio: 8:5 for 12-17 years old
Age
Young age persistent asthma
Pathophysiology
Allergen
inflammation
Bronchoconstriction Hiperventilation Cough
respiratory
tracts
Released
inflammation mediators
additional respiratory
+ muscles contraction
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Imprecise asthma: Start at neonate Failure to thrive Chronic infection Vomit/ choking Pulmonary focal disorder Cardiovascular system disorder
Consider: Thorax and sinus rontgen Pulmonal physiology test Bronchodilator response test Bronchus provocation test Sweat test Cilia motility test Esofagogaster reflux evaluation
Gave bronchodilator
ASTHMA
Grading and seacrhed for precipitate If episodic frequent/ persistent: rontgen thorax
Gave anti asthma drug: Unsuccefully reevaluate diagnosis and loyalty
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NOT ASTHMA
Serangan Ringan (nebulisasi 1x, respons baik bertahan 1-2 jam, boleh pulang gejala timbul lagi serangan sedang
Serangan sedang (nebulisasi 2-3x, repons parsial) berikan O2 nilai ulang sedang Ruang Rawat Sehari pasang infus
Serangan berat (nebulisasi 3x, respons buruk) O2 sejak awal pasang infus nilai ulang berat, Ruang Rawat Inap foto Ro toraks
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Boleh Pulang Bekali -agonis (hirupan / oral) Jika ada obat pengendali, teruskan Inf.virus (+), steroid oral 24-48 jam kontrol proevaluasi
Ruang Rawat Sehari Oksigen teruskan Steroid oral Nebulisasi / 2 jam 8-12 jam klinis stabil boleh pulang 12 jam tetap belum baik rawat inap
Catatan:
Jika menurut penilaian serangannya berat, nebulisasi 1x, langsung -agonis + antikolinergik Bila belum ada alatnya, nebulisasi awal dapat diganti dgn adrenalin sk. 0,01 ml/kgBB/kali, maksimal 0,3 ml/kali. Untuk serangan sedang dan terutama berat, O2 2-4L/mnt diberikan sejak awal, termasuk saat nebulisasi
Ruang Rawat Inap Oksigen teruskan Atasi dehidrasi & asidosis jika ada Steroid IV tiap 6-8 jam Nebulisasi/1-2 jam Aminofilin IV awal, lanjutkan rumatan Nebulisasi 4-6x baik, interval 4-6 j 24 jam stabil boleh pulang Dengan steroid & aminofilin IV tetap tidak baik ICU
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Obat pereda: -agonis atau teofilin (hirupan atau oral) bila perlu > 3x dosis/ minggu 3x dosis/ minggu
(+)
Asma Persisten
Pertimbangkan alternatif penambahan salah satu obat: - -agonis kerja panjang (LABA) - Teofilin lepas lambat - Antileukotrien Atau dosis steroid hirupan ditingkatkan (medium) 6-8 minggu, respons : (-) (+)
Steroid dosis medium ditambahkan salah satu obat: - -agonis kerja panjang - Teofilin lepas lambat - Antileukotrien - Atau dosis steroid hirupan ditingkatkan (tinggi) 6-8 minggu, respons : (-) Obat diganti steroid oral (+)
P E N G H I N D A R A N
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Case
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Patient Identity
Name : Chd. D : 1 year 9 months old : Sudadi/ Rina Javanese : Perawang 24 August 2011
Age
Parent Tribe :
Address Admitted:
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Anamnesis
Chief
complain
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became well
Productive cough happened at the same time
with dispnea
Fever with unknown cause, not too high, and
Patient
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long as dispnea happened, his skin never became blue. weight loss since last 2 months
No
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Anamnesis
Past
Family Parent
Gestation Diet
history growth
Physical Examination
General
Consciousness: Vital
sign
: 122x/minutes : 46x/minutes
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Physical Examination
Nutrition:
92% normal
Upper Head
arm circumference: 15 cm 47 cm
circumference: (normocephali)
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Physical Examination
Skin:
normally
normocephali, anterior fontanel already closed black, not easy to put off
Physical Examination
Ears:
Nose: Lips:
Mucosa
Physical Examination
Thorax
Inspection: simetrical movement of thorax
wall
Palpation: fremitus right and left same Percussion: resonance, head alignment
normally
Auscultation: wheezing
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Physical Examination
Abdomen
Inspection: flat Palpation:
no
tenderness,
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Physical Examination
Genitalia: Extremity:
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Laboratory
Hb Ht :
: 50mm/jam
count:
9,1%
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Working Diagnosis
Asthma
and pulmonary TB
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Treatment
IVFD
Kalmetason
1st
2 months:
Rifampicin 150 mg 1x1 Pyrazinamid 200 mg 1x1 Isoniazid 200 mg 1x1 Vitamin B6 5 mg 1x1
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ad vitam
: bonam
ad fungsionam : bonam
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Tanggal
Subjektif
Objektif
Assestment
Terapi
24/8/11
Asma dan SuspIVFD KAEN1B 20 tpm TB paru Inj kalmetason 1/3 amp Foto thorax AP Asma dan TBIVFD KAEN1B dan paru Inj kalmetason off Foto thorax AP: KP duplex Rawat jalan Rifampisin 150 mg Pirazinamid 200 mg Isoniazid 200 mg Vit B6 5 mg
25/8/11
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Case Analysis
Dispnea
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Case Analysis
Precipitation Happened Fever
factor: activity
since 2 months
pulmonary
Patient No
It
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No
weight loss since last 2 months didnt mean that it wasnt TB family history for asthma
Positive
uncle
Complete
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Parameter
skor 2
Contact to TB patients
Tuberculin test
Negative
Nutrition
Fever with unknown cause Cough Limphadenopati coli, axilla, inguinal Swelling on bone, coxae, phalangs Thorax rontgen 7/5/12 Normal
1 1 0 0 1
Prolong Body
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weight decreased without any clear cause or didnt get weight gain in 1
Analysis
More
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Imprecise asthma: Start at neonate Failure to thrive Chronic infection Vomit/ choking Pulmonary focal disorder Cardiovascular system disorder
Consider: Thorax and sinus rontgen Pulmonal physiology test Bronchodilator response test Bronchus provocation test Sweat test Cilia motility test Esofagogaster reflux evaluation
Gave bronchodilator
ASTHMA
Grading and seacrhed for precipitate If episodic frequent/ persistent: rontgen thorax
Gave anti asthma drug: Unsuccefully reevaluate diagnosis and loyalty
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NOT ASTHMA
dexametason intravena 1/3 amp = 1,3 mg a day bolus mg/kgBW/day. dosage : 0,5-1
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Antituberculosis Agent
Rifampicin
150 mg 1x1, dosage 15 mg/kgBW/day 200 mg 1x1, dosage 20 mg/kgBW/day 200 mg 1x1, dosage 20 mg/kgBW/day B6 5 mg 1x1
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Thank You
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