Praise be to Allah, The cherisher and sustainer of the worlds; God who has been giving His blessing

and mercy to the writer to complete the paper entitled "The Great Immitator This paper is submitted to fulfill one of the requirements in SMF Paru. In finishing this thesis, the writer really gives his regards and thanks for people who has given guidance and help; he is Prof. Dr. Tamsil Syarifuddin, Sp. P (K), the first supervisor, who has given his best guidance to write a quality content of the thesis. Finally, the writer realizes there are unintended errors in writing this thesis. He really allows all readers to give their suggestion to improve its content in order to be made as one of the good examples for the next paper. Medan, April, 2013

The Writter

Pulmonary tuberculosis

The Great Imitator

Pulmonary tuberculosis is an infectious disease caused by the bacillus tuberculosis mikrobakterium humanus type, similar to the rod-shaped bacteria that 14/mm length and thickness 0.3-0.6 / mm. Most of germ consisting of fatty acids (lipids). Lipids that make germs more resistant to acids and is more resistant to

chemical and physical disorders. These germs survive in dry air or in the cold (can withstand many years in the refrigerator). This happens because the bacteria are in a dormant properties. Of the nature of these dormant bacteria can bounce back and make active tuberculosis again. Another trait is the aerobic bacteria.

A. ENZYME-ENZYME BREATH

1. Enzymes estalase A proteolytic enzyme, an enzyme which are dialveolus enzymes that can damage elastin network.Diparu important enzyme is an enzyme-lung neutrophil elastase, which is released by azurofilik neutrophil granules. Alveolar macrophages and monocytes can also secrete the enzyme elastase. 2. Antietalase enzymes (A-1-AT) Neutralizing enzyme elastase to lung elastin tissue damage can be prevented. Located on the lower respiratory tract. This enzyme is made hearts that can diffuse through the alveoli of the lower respiratory tract. 3. Mucus Broncus inhibitor Is an enzyme contained antielastase lower respiratory canals. 4. Methioninsulfoside reductase enzyme An enzyme that functions to alter enzyme oxide 1_AT A-to A-1-AT, which would later serve as the neutralizing action of the enzyme re storefront. 5. The enzyme carbonic anhidrasi

B. ORGAN STRUCTURE OF ADULT respiration

Humans need oxygen supplied continuously to the process of cell respiration, and remove excess carbon dioxide as a toxic waste product of the process. Pertukatan between oxygen with carbon dioxide gas is done in order to continue the process of cellular respiration. Oxygen needed for cellular respiration process is derived from the atmosphere, which provides oxygen gas content as much as 21% of all existing gas. Oxygen to enter the body through the mediation of a respirator that is outside. In humans, the alveoli are contained in the lung serves as a surface for gas exchange places.

C. BREATHING PROCESS

Respiratory process includes two processes, namely breath and exhale or inspiration or expiration.When you inhale, the diaphragm muscle to contract, from the curved position upwards into the straight. At the same time, the rib muscles were contracting. As a result of these two types of muscle berkontraksinya the chest cavity is deployment so that the pressure in the chest cavity decreases and the air intake. When you exhale, the diaphragm muscle and rib muscles limp. As a result, the chest cavity decreases and the air pressure inside the lungs up so that air out. So, things you need to remember, that the air flows from place to place great pressure pressurized smaller.

D. GAS EXCHANGE Air exchange takes place in the avelous and surrounding blood

vessels. Oxygen and carbon dioxide gas will diffuse through the cells that make up the walls and capillary blood avelous. Aveolus air containing higher oxygen and carbon dioxide gas is lower than in the blood capillaries. Therefore the molecules tend to move from a higher concentration to low, then aveolus oxygen diffuses from the air into the blood, and carbon dioxide diffuses from the blood vessels into avelous. Transport of CO by blood can be implemented through 3 ways: (1) Carbon dioxide dissolved in the plasma and to form carbonic acid anhydrase enzyme. (2) Carbon dioxide bound to hemoglobin in the form of hemoglobin karbomino (3) Carbon dioxide in the cluster bound bicarbonate ion (HCO ) through the process of exchange of chloride chain.

E. BREATHING PATTERN

Examination of the respiratory pattern needs to be done to assess oxygen uptake during inspiration and expiration at the disposal of carbon dioxide. normal pattern (eupnea): Regular and frequency of 12-20 x / min.

The purpose of this inspection was to assess:

 respiratory rate rhythm pernafasanan into inspiration type / pattern of breathing . Pathophysiology PULMONARY TB and pleural effusion

Pulmonary tuberculosis is an infectious disease caused by the bacillus tuberculosis mikrobakterium humanus type, similar to the rod-shaped bacteria that 1-4/mm length and thickness 0.3-0.6 / mm. Most of germ consisting of fatty acids (lipids). Lipids that make germs more resistant to acids and is more resistant to chemical and physical disorders. These germs survive in dry air or in the cold (can withstand many years in the refrigerator). This happens because the bacteria are in a dormant properties. Of the nature of these dormant bacteria can bounce back and make active tuberculosis again. Another trait is the aerobic bacteria. These properties indicate that the more germs network enjoys a high oxygen content. In this case the pressure of the apical portion of the lung is higher than in other parts, so this is where the apical part predilection of tuberculosis.

Clinical Manifestations

Tuberculosis is often called "the great imitator" is a disease that has many similarities with other diseases are also common symptoms such as weakness and fever. In some patients the symptoms are not clear so overlooked sometimes even asymptomatic. Clinical picture of pulmonary tuberculosis can be divided into 2 groups, respiratory symptoms and systemic symptoms:

1. Respiratory symptoms, including: a. Cough Most cough symptoms arise early and is a disorder that most often complained. At

first non productive then bloody phlegm even when there is tissue damage. b. Coughing up blood Blood in the sputum varied issued, may appear in the form of lines or splotches darak, or blood clots in the amount of fresh blood very much. Darak cough occurs due to rupture of blood vessels. Severity of coughing up blood depends on the size of a ruptured blood vessel. c. Shortness of breath These symptoms are found when the damage is extensive lung parenchyma or because there are things that accompany such as pleural effusion,

pneumothorax,anemia and others. d. Chest pain Chest pain in pulmonary TB include pleuritic pain is mild. These symptoms occur when the neural systems in the pleural exposed. 2. Systemic symptoms include: a. Fever Is a common symptom that usually occur in the afternoon and evening influenza like fever, and intermittent attacks grew longer being free period shorter attack. b. Other systemic symptoms Other systemic symptoms are night sweats, anorexia, weight loss and malaise. Gradual onset of symptoms is usually within a few weeks and months, but with the appearance of acute cough, heat, shortness of breath although rare can also arise resemble symptoms of pneumonia. Clinical symptoms Haemoptoe: We must make sure that the bleeding from the nasopharynx by way of distinguishing characteristics as follows: 1. Coughing up blood a. Coughed blood with a burning sensation in the throat b. Frothy blood mixed with air c. Pink fresh blood d. Blood is alkaline e. Anemia sometimes occurs f. Benzidine test negative 2. Vomiting blood a. Blood spewed by nausea

b. Blood mixed with leftovers c. Black blood mixed with stomach acid due d. Acidic blood e. Anemia occurs as cheerfully as f. Benzidine test positive 3. Epistaxis a. Blood dripped from his nose b. Coughing quietly sometimes out c. Fresh red blood d. Blood is alkaline e. Anemia is rare

Pleural effusion Under normal circumstances, there are always fluid filtration into the pleural cavity through the capillaries in the parietal pleura, but the liquid is immediately reabsorbed by lymph channels, resulting in a balance between production and reabsorption, daily fluid produced approximately 16.8 ml (in people with severe weight 70 kg). Ability to reabsorpsinya be increased up to 20 times. If the products and reabsorpsinya not balanced (production increases or decreases reabsorpsinya) will arise pleural effusion. It is known that the liquid gets into the cavity through the parietal pleura and then out again in the same amount through the membrane of the parietal pleura via lymphatic and vascular systems.Movement of fluid from the pleura to the parietal pleura visceralis may occur because of differences in hydrostatic pressure and colloid osmotic pressure. Liquid mostly absorbed by the lymphatic system and only a small portion is absorbed by the pulmonary capillary system. Things that facilitate the absorption of fluid in the pleural visceralis is the presence of many microvilli around mesothelial cells. Pleural fluid accumulation can occur when: 1. Increased intravascular pressure increases the formation of pleural pleural fluid through the influence of the law Starling.Keadaan ni can occur in right heart failure, heart failure and left superior vena cava syndrome. 2. Intra-pleural pressure is very low as there is in atelectasis, either because of bronchial obstruction or pleural thickening visceralis

3. Increased levels of protein in pleural fluid may draw more fluid into the pleural cavity 4. Hipoproteinemia such as the liver and kidney disease can cause pleural transudation of fluid from the capillaries toward the pleural cavity

5. Obstruction of lymph channels in the parietal pleum. Lymph channels boils down to a systemic vein.Improvement of systemic venous pressure will inhibit emptying lymph fluid.

Pathophysiology
Port de 'entry microbaterium tuberculosis germs are respiratory tract, gastrointestinal tract, and open sores on the skin, most tuberculosis infections occur through the air (water borne), ie through inhalation droppet containing tubercle bacillus germs from an infected person. Tubercle bacillus is usually inhaled reaches alveoli surface consists of one to three bacilli larger clumps tend to be confined in the nasal passages and the large bronchi branch and does not cause disease. Once in the alveolar space is usually at the bottom of the lobe or lung, or at the top of the lower lobe. The tubercle bacillus evoke an inflammatory reaction. Polymorphonuclear leukocytes appear on the site and phagocytosing bacteria but does not kill the organism. After the first few days then replaced leukocytes by macrophages. Alveoli are attacked will consolidate and symptoms of acute pneumonia. This mobile Pneumonia can heal by itself so there is no residue left, or the process can also walk on, and constantly difagosit or bacteria multiply inside the cell. Basil also spread through the lymph toward the regional lymph nodes. Macrophage infiltration mcajadi hold longer and partly united to form tubercles epiteloit cells, surrounded by fosit. This reaction usually takes 10 to 20 days.

PHARMACOLOGY OF PULMONARY TB AND PLEURAL EFFUSION

1. Pulmonary TB Types of drugs used 1. Primarydrug A. Isoniazid B.Rifampisin

C. Pyrazinamide D. Streptomycin E. Ethambutol 2. Secondary drug A. Ethionamide B. Protionamid C. Sikloserin D. Kanamycin

2. Pleural effusion Treatment Causal- TB pleurisy was given anti-TB treatment. With this treatment pleural fluid can be reabsorbed quickly done to eliminate thoraxosentesis. Pleurisy due to pyogenic bacteria were given chemotherapy before bacterial culture and sensitivity obtained, 4 x 1 gram of ampicillin and metronidazole 3 x 500 mg. Another therapy that is more important is removing the infected pleural fluid out of the pleural cavity with effectively. Thoraxosentesis, indications:

Eliminate spasms caused fluid- When specific therapy is not effective in primary disease or fail In case of liquid reakumulasi. The disadvantage: loss of protein, infection, pneumothoraxs. Water Sealed Drainage, Management by using WSD frequently in malignant effusion and empyema. Indications WSD on empyema: very viscous and difficult Pus aspirated, Pus continued to form after 2 weeks. Terjadinva piopneumothoraxs Pleurodesis. Pleural melengketkan action visceralis with parietal pleura using chemical substances (tetracycline, bleomycin, thiotepa, Corynebacterium, perfumes, talc) or with surgery. Action performed when fluid accumulates so much and always come back.

J. MEDICAL MANAGEMENT OF PULMONARY TB AND PLEURAL EFFUSION RADIOLOGICAL EXAMINATION

At this time chest radiographs is a practical way to find tuberculosis lesions. These checks do require cost more than sputum examination, but can provide the advantage that the examination of tuberculosis in children and miliary

tuberculosis. In both cases the diagnosis can be obtained through the chest radiological examination for sputum examination is almost always negative.

Location lesions of pulmonary tuberculosis generally areas apex (apical segment of the upper lobe or apical segment of the lower lobe). But can also be the lower lobe (inferior part) or hilar endobronkhial). Picture of miliary tuberculosis subtle form of patches that are scattered uniformly throughout the lung field. Due to hematogenous spread of pulmonary tuberculosis will appear as small nests of 1-2 mm, or as big as the head of a needle (milium), spread evenly on both sides of the lungs. On chest radiograph, it can resemble tuberculosis miliaris picture "fog storm" (snow storm appearance).Penayakit spread pulmonary tuberculosis can also occur to the kidneys, bones, joints, brain membranes (meninges), and so on. On radiological examinations, miliary tuberculosis picture in the form of small images that look very firm boundary, as if each of the spots can be removed with tweezers. Different magnitude in each case, but in one case the same is usually large. The shadows are actually caused by the superposition of many tubercles, and this may lead to a not at all before the shadow is quite a lot or a large enough magnitude to cause a shadow due to superposition. Therefore radiograph may initially normal form, but it would appear the images in approximately 2 weeks. While in treatment, shadow-bayangn lost long before the tubercle-tubercle pathologically completely disappeared, so the treatment should be continued even if the patient had been feeling unwell and therefore radiological picture has become region resembles lung tumor (eg in tuberculosis

normal. Maybe there are other signs of pulmonary tuberculosis as a cavity, or hilar glands may swell Radiological picture of tuberculosis miliaris is a shadow sightings subtle nodules scattered throughout the lung field.