LBM 3 : BATUK BERDAHAK KENTL DISERTAI PANAS BADAN

STEP 1
Pneumonia severity index : is validated risk statification
instrumen which can help indetifying CAP patient who can
safely be trated with patient antibiotic
Determine the or carculate of probability about morbility
and also mortality in patient with pneumonia
Infiltrat : something that from other tissue spread into another
tissue and trap in the tissue
Example : pus , bacteria , eksudat
Dim : the sound that you made almost likely hepar sound or
lien sound
The sound that make by percution in lung because there are
sputum fibrin in pleura that sound became a dim because
the contain

STEP 2
1) Why the man feel dyspneu and cough with green
sputum and fever ?
2) Why in the lung examination the doctor get dim and
wet ronchi in the bronchial basis ?
3) How to score the penumonia severity index ?
4) Why in rontgen photo is found infiltrat in both og the
lung ?
5) Why the doctor ask the patient to do gram staining and
sputum culturing ?
6) What is diagnosis and different diagnosis ?

7) What are the etiologies from the scenario ?

8) Why in routine blood examination get leukositosis ?
9) What causes his RR increased until 32/minutes and HR
110/minutes?
10) What are risks factor possible causes pneumonia ?
11) What are treatments ?
12) What are additional examination ?

STEP 3
1) Why the man feel dyspneu and cough with green
sputum and fever ?
Included because of inflamation , inflamation in this boddies
in the sinus tissue or bronchial tissue and etc
Trap the mucus , mucus became the nest of the agent , agen
reproducing multiply white blood cell infiltrate mukus , the
pigmen of the white blood cell is green that why the colour
green
Fever : the body has inflamation , and the bodies
temperature get higher and the brain soldier white blood
cell to attack that place because its full of agent
Fever caused by released inflamatory mediator like IL1 and
TNF
2) Why in the lung examination the doctor get dim and
wet ronchi in the bronchial basis ?

 Wet ronchi can be heard in the tissue because exsudat and

fibrin in the alveolus , this sound can be heard to in the
surface of pleura
3) What causes his RR increased until 32/minutes and HR
110/minutes?
- Because of dyspnea , the compentation is increas
the RR to fullfill the need of oxygen
- Dyspneu Hipoksemia increas HR . because the
blood bring more O2 to all of our body
4) Why in rontgen photo is found infiltrat in both og the
lung ?
Because of there are exudat and fibrin in alveolus
5) Why the doctor ask the patient to do gram staining and
sputum culturing ?
The main purpose of gram staining to identify certain
patogen to determine adekuat treatment
6) Why in routine blood examination get leukositosis ?
Because of had a inflamation progres
Chemokines such as IL8 and granulocyte colony
stimulating factor .

- If the caused by bacterial infection usually the

leukocyte is increase if caused by virus infection
usually leukocyte increase or normal
7) How to score the penumonia severity index ?
- Risk class 1 : out patient treatment and give oral
antibiotic
- Risk class 2 & 3 : out patient treatment and
intravena antibiotic or treated and monitored for 24
hours in hospital
- Risk class 4 & 5 : should be hospitalized treatment
8) What is diagnosis and different diagnosis ?
Diagnosis : Pneumonia
DD : bronchitis acute , bronchopneumonia ,
9) What are the etiologies from the scenario ?
- Bacteria : streptococcus pneumonia , streptococcus
pyogenes , staphylococcus aureus
- Fungi : coccidioidies immitis , aspergilus ,
phycomycetes
- Virus : influenza virus , adenovirus
10) What are clasification of pneumonia ?
-

Pneumonia bacterial : caused by bacteria

Pneumonia non bacterial
Pneumonia pneumosistis
Pneumonia atipik

11) What are risks factor possible causes pneumonia ?

-

Age > 65thn

Alcoholism
Malnutrisi
Smokker
Abdominal and thoracs surgery
Long time bedrest
Cancer
HIV
Asthma
Immunosipresion
COPD

12) What are additional examination ?

-

CBC bloodtest white blood cell

Culture sputum
Pleural fluid culture
Bronchoscopy
Pulse oxymetri

13) What are treatments ?

- Antibiotik penisilin , selafosforin , amoxylin ,
amoxycilin
- Cough drugs : antitusif , mukolitik , espektoran

STEP 3
1. Why the man feel dyspneu and cough with green sputum and
fever ?

Most of the time, your nose and airways filter germs out of the air you breathe. This
keeps your lungs from becoming infected. But germs sometimes find a way to enter the lungs
and cause infections. This is more likely to occur when:

Your immune system is weak.

A germ is very strong or present in large amounts.
Your body fails to filter germs out of the air you breathe.

When the germs that cause pneumonia reach your lungs, the lungs' air sacs (alveoli) become
inflamed and fill up with fluid. This causes the symptoms of pneumonia, such as a cough,
fever, chills, and trouble breathing.
When you have pneumonia, oxygen may have trouble reaching your blood. If there is too
little oxygen in your blood, your body cells can't work properly. Because of this and the
infection spreading through the body, pneumonia can cause death.

http://www.lung.org/lung-disease/pneumonia/understandingpneumonia.html
Mikroorganisme (MO) yang masuk ke dalam tubuh umumnya memiliki suatu zat
toksin/racun tertentu yang dikenal sebagai pirogen eksogen. Dengan masuknya MO
tersebut, tubuh akan berusaha melawan dan mencegahnya yakni dengan memerintahkan
pertahanan tubuh antara lain berupa leukosit, makrofag, dan limfosit untuk memakannya
(fagositosit). Dengan adanya proses fagositosit ini, tubuh itu akan mengelurkan zat kimia
yang dikenal sebagai pirogen endogen (khususnya interleukin 1/ IL-1) yang berfungsi
sebagai anti infeksi. Pirogen endogen yang keluar, selanjutnya akan merangsang sel-sel
endotel hipotalamus untuk mengeluarkan suatu substansi yakni asam arakhidonat. Asam
arakhidonat bisa keluar dengan adanya bantuan enzim fosfolipase A2.
Proses selanjutnya adalah, asam arakhidonat yang dikeluarkan oleh hipotalamus akan
pemacu pengeluaran prostaglandin (PGE2). Pengeluaran prostaglandin pun berkat
bantuan dan campur tangan dari enzim siklooksigenase (COX). Pengeluaran prostaglandin
ternyata akan mempengaruhi kerja dari termostat hipotalamus. Sebagai kompensasinya,
hipotalamus selanjutnya akan meningkatkan titik patokan suhu tubuh (di atas suhu
normal). Adanya peningkatan titik patakan ini dikarenakan mesin tersebut merasa bahwa
suhu tubuh sekarang dibawah batas normal. Akibatnya terjadilah respon dingin/ menggigil.
Adanya proses mengigil ini ditujukan utuk menghasilkan panas tubuh yang lebih banyak.
Sehingga terjadilah demam(suhu tubuh meningkat pada seseorang).
Guyton Hall Fisiologi Kedokteran

2. Why in the lung examination the doctor get dim and wet ronchi
in the bronchial basis ?
Wet ronchi can be heard in the tissue because exsudat and
fibrin in the alveolus , this sound can be heard to in the
surface of pleura
Patofisiology sylvia
Pneumonia affects your lungs in two ways. It may be in only one part, or lobe, of
your lung, which is called lobar pneumonia. Or, it may be widespread with
patches throughout both lungs, which is called bronchial pneumonia (or
bronchopneumonia).

http://www.lung.org/lungdisease/pneumonia/understanding-pneumonia.html

3. What causes his RR increased until 32/minutes and HR

110/minutes?
- Because of dyspnea , the compentation is increas
the RR to fullfill the need of oxygen
- Dyspneu Hipoksemia increas HR . because the
blood bring more O2 to all of our body
4. Why in rontgen photo is found infiltrat in both og the lung ?
Pemeriksaan radiologis. Pola radiologis dapat berupa pneumonia alveolar dengan
gambaran airbronkhogram ( airspace disease) misalnya oleh Streptococcus pneumoniae,
bronkopneumonia (segmental disease) oleh antara lair. staphylococcus, virus atau
mikoplasma; dan pneumonia interstisial (interstitial disease) oleh virus dan ikoplasma.
Distribusi infiltratpada segmen apikal lobus bawah atau inferior lobus atas sugestif untuk
kuman aspirasi. Tetapi pada pasien yang tidak sadar, lokasi ini bisa di mana saja. Infiltrat di

lobus atas sering ditimbulkan Klebsiella spp, tuberkulosis atau amiloidosis. Pada lobus
bawah dapat terj adi infiltrat at'rbat St ap hy lo c o c cus atau bakteriemia.

Buku ajar ilmu penyakit dalam

5. Why the doctor ask the patient to do gram staining and sputum
culturing ?
Pemeriksaan dahak. l).Pewamaan gram dan pemeriksaan basil tahan asam (BTA)
adalah suatu tindakan rutin;2). Kultur mikobakteri dan jamur. Pemeriksaan ini
dilakukan pada pasien yang didapatkan adanya kelainan foto toraks berupa infilfrat
di apeks atau kavitas atau pada pasien imunokompromis; 3). Pemeriksaan sitologi
dilakukan pada pasien batuk yang dicurigai juga menderita kanker paru; 4).
Pewarnaan silver pada dahak untuk mencari Pneumocystis carinii pada pasien
imunokompromis.
Buku ajar ilmu penyakit dalam

6. Why in routine blood examination get leukositosis ?

Leukositosis urnumnya menandai adanya infeksi bakteri; leukosit norma/ rendah
dapat disebabkan oleh infeksi virus/mikoplasma atau pada infeksi yang berat
sehingga tidak terjadi respons leukosit, orang tua atau lemah. Leukopenia
menunjukkan depresi imunitas, misalnya neutropenia pada infeksi kuman Gram
negatif atau S. aureus pada pasien dengan keganasan dan gangguan kekebalan.
Faal hati mungkin terganggu.

Buku ajar ilmu penyakit dalam

7. How to score the penumonia severity index ?

Demographic factors
Age (in years)
Men
Women
Nursing home resident
Coexisting illnesses
Neoplastic disease
Liver disease
Congestive heart failure
Cerebrovascular disease
Renal disease
Findings on physical examination
Altered mental status

-10
+10
+30
+20
+10
+10
+10
+20

Respiratory rate >= 30/min

+20
Systolic blood pressure <90 mm Hg
+20
Temperature <35C or >= 40C
+15
Pulse >= 125 beats/min
+10
Laboratory and radiographic findings
Arterial pH <7.35
+30
Blood urea mitrogen >= 30/mg/dl (11
+20
mmol/liter)
Sodium < 130 mmol/liter
+20
Glucose >= 250 mg/dl (14 mmol/liter)
+10
Hematocrit <30%
+10
Partial pressure of arterial oxygen < 60 mm
+10
Hg or oxygen saturation < 90%
Pleural effusion
+10
Stratification of Risk Score
Risk
Risk Class
Score
Mortality
Low
I
Based on algorithm 0.1%
Outpatient
Low
II
<= 70
0.6%
treatment
Low
III
71-90
0.9%
Moderate
IV
91-130
9.3% Hospital
High
V
>130
27.0% admission

http://internalmedicine.osu.edu/pulmonary/cap/10675.cfm
8. What is diagnosis and different diagnosis ?
Diagnosis : Pneumonia
DD : bronchitis acute , bronchopneumonia ,
9. What are the etiologies from the scenario ?

Many different germs can cause pneumonia. There are five main causes of pneumonia:

Bacteria
Viruses
Mycoplasmas
Other infectious agents, such as fungiincluding pneumocystis
Various chemicals

If you have viral pneumonia, you also are at risk of getting bacterial pneumonia.

http://www.lung.org/lung-disease/pneumonia/understandingpneumonia.html
10.

What are clasification of pneumonia ?

Bacterial Pneumonia
Bacterial pneumonia can attack anyone, at any age.
Bacterial pneumonia can occur on its own or develop after you've had a cold or the flu.
People at greatest risk for bacterial pneumonia include people recovering from surgery,
people with respiratory diseases or viral infections and people who have weakened immune
systems.
If your body's defenses are weakenedby illness, old age, malnutrition, or impaired
immunitythe pneumonia bacteria, which can live in healthy throats, can multiply and work
their way into the lungs. The infection can quickly spread through the bloodstream and
invade the entire body.
Dozens of different types of bacteria can cause pneumonia.

The most common cause of bacterial pneumonia in adults is Streptococcus

pneumoniae (pneumococcus), but there is a vaccine available for this form of
pneumonia.
Atypical pneumonia is caused by bacteria such as Legionella pneumophila,
Mycoplasma pneumoniae, and Chlamydophila pneumoniae.
Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system
is impaired (due to AIDS or certain medications that suppress the immune system).
Other bacteria that can cause pneumonia include Staphylococcus aureus, Moraxella
catarrhalis, Streptococcus pyogenes, Neisseria meningitidis, Klebsiella pneumoniae,
and Haemophilus influenzae.

Viral Pneumonia
Most respiratory viruses attack the upper respiratory tract, but some cause pneumonia,
especially in children. Most of these pneumonias are not serious and last a short time but
others can be severe.
Viral pneumonia caused by the influenza virus may be severe and sometimes fatal. The virus
invades the lungs and multiplies; however, there are almost no physical signs of lung tissue
becoming filled with fluid. This pneumonia is most serious in people who have pre-existing
heart or lung disease and pregnant women.
In extreme cases, the patient has a desperate need for air and extreme breathlessness. Viral
pneumonias may be complicated by an invasion of bacteria, with all the typical symptoms of
bacterial pneumonia.
Mycoplasma Pneumonia
Mycoplasms are the smallest free-living agents of disease in humankind. They are not
classified as to whether they are bacteria or viruses, but they have traits of both.

Mycoplasms usually cause a mild form of pneumonia, but may be severe. They affect all age
groups, but occur most often in older children and young adults.
Other Types of Pneumonia
Tuberculosis can cause pneumonia (tuberculosis pneumonia). It is a very serious lung
infection and extremely dangerous unless treated early.
Pneumocystis carinii pneumonia (PCP) is caused by an organism believed to be a fungus.
PCP may be the first sign of illness in many persons with AIDS.
PCP can be successfully treated in many cases. It may recur a few months later, but treatment
can help to prevent or delay recurrence.
Other less common pneumonias may be quite serious and occur more often. Various special
pneumonias are caused by the inhalation of food, liquid, gases or dust, and by fungi.
Rickettsia (also considered an organism somewhere between viruses and bacteria) cause
Rocky Mountain spotted fever, Q fever, typhus and psittacosis, diseases that may have mild
or severe effects on the lungs.

http://www.lung.org/lung-disease/pneumonia/understandingpneumonia.html
11.

What are risks factor possible causes pneumonia ?

Risk factors (that increase your chances of getting pneumonia) include:

Cigarette smoking
Recent viral respiratory infectiona cold, laryngitis, influenza,etc.
Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other
neurological conditions)
Chronic lung disease such as COPD, bronchiectasis, or cystic fibrosis
Cerebral palsy
Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes
Living in a nursing facility
Impaired consciousness (loss of brain function due to dementia, stroke, or other
neurologic conditions)
Recent surgery or trauma
Having a weakened immune system due to illness, certain medications, and
autoimmune disorders

http://www.lung.org/lung-disease/pneumonia/understanding-pneumonia.html

12.

What are additional examination ?

Physical exam: Your doctor will listen to your lungs with a stethoscope. If you have
pneumonia, your lungs may make crackling, bubbling, and rumbling sounds when
you inhale. You also may be wheezing, and it may be hard to hear sounds of breathing
in some areas of your chest.
Chest x-ray (if your doctor suspects pneumonia)
Some patients may need other tests, including:
o CBC blood test to check white blood cell count
o Arterial blood gases to see if enough oxygen is getting into your blood from
the lungs
o CT (or CAT) scan of the chest to see how the lungs are functioning
o Sputum tests to look for the organism (that can detected by studying your spit)
causing your symptoms
o Pleural fluid culture if there is fluid in the space surrounding the lungs
o Pulse oximetry to measure how much oxygen is moving through your
bloodstream, done by simply attaching a small clip to your finger for a brief
time
o Bronchoscopy, a procedure used to look into the lungs' airways, which would
be performed if you are hospitalized and antibiotics are not working well

http://www.lung.org/lung-disease/pneumonia/symptoms-diagnosisand.html
13.

What are treatments ?