DISCUSSION

1. What are the problems of the patient ? The problem of the patient that we found including : a. Hydropneumothorax ec pulmonary tuberculosis b. Subcutaneous emphysema c. Type II diabetes melitus The patient was admitted to the hospital because of worsening of shortness of breathe for the past few days. He already felt mild shortness of breathe for 3 months, until it suddenly got worse and made him dyspneic even in resting state. There was some possible cause of sudden onset severe breathlessness. But with deeper history taking, it might be possible to distunguish the likely cause of severe breathlessness. This patients symptomp including productive cough for 6 months along with night sweat, prolonged mild fever, and decreased body weight make pulmonary tuberculosis is likely. Besides, the absence of weird breath sounds (like wheezing) and no history of asthma attack make asthma is unlikely. The absence of high fever makes pneumonia is unlikely too. The patient was a moderate smoker ( Brinkman index 200-600), then the very severe of COPD exacerbation or pulmonary carcinomas should be kept in mind.. Another cause that come from outside the respiratory organs (i.e. cardiovascular, neurological, metabolism) must be evaluated. Then, it could be confirmed by physical examination. The absence of breath sound in one side of the chest along with decreased expansion movement , decreased vocal fremitus, and hyperresonance percussion could lead to the pneumothorax diagnosis. Beside, there was absence heart dullness that supposed to be found in chest percussion on the left side of the chest. That might be because of shift of mediastinal structure due to enforcement of the trapped air. The trachea couldve been deviated too. If the patient is stable, we could use chest x ray to confirm. But in emergency setting, confirming chest x ray is not mandated. Pneumothorax itself is one of the complication of pulmonary tuberculosis. Seaton et al recorded that 1.4% of people with pulmonary tuberculosis can have pneumothorax, and with the cavity can increase the risk up to 90%. Pneumothorax that caused by TB can be classified as secondary spontaneous pneumothorax. We also found subcutaneous crepitation, that might be due to subcutaneous emphysema. Subcutaneus emphysema is the accumulation of air in the soft tissue. Most

cases of subcutaneous emphysema are benign. The patient also diagnosed as diabetes for a year and have taken oral medicine to control the blood glucose. Further evaluation of patients blood glucose profile (fasting blood glucose, glucose tolerance test) should be performed.

2. Is the management of the patient ? a. O2 2 Litres/minute b. IVFD RL gtt X/minute c. OBH 3x1C d. Rifampicin 1x450 mg e. Isoniazid 1x300 mg f. Ethambutol 1x750 mg g. Pyrazinamide 1x 750 mg h. Ceftriaxone 1 gram/12 hours i. WSD Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone. There is no need for the patient to receive intravenous fluid deliveries. The antituberculosis regimen given is 1st category, dosage for weight between 40 to 60 kgs. The patient given 1st category because he has never taken any antituberculosis regiment (new case) and his sputum evaluation show positive result for acid fast bacilli. He weighs 40 kg. So in this patient, whom given 450 mg of rifampicin; 300 mg of isoniazid; 750 mg of pyrazinamide; and 750 mg of ethambutol, the antituberculosis drug is adequate. The antituberculosis given to the patients for 2 months. This called intensive phase. This patients laboratory result showed 2-fold increase of SGOT/SGPT. This patient still can receive the antituberculosis therapy but with strict supervision. The ceftriaxone used as the empiric therapy because of invasive procedure done and possibility concordance of bacterial infection that causing hydropneumothorax. The dosage of ceftriaxone is 50-100 mg/kg/day, divided into 2 doses. This patient weighs 40 kg so the dosage was 2 grams, divided into 2 dose. WSD in pneumothorax is indicated if pneumothorax >25%. In this patient, the pneumothorax is more than 25%. There are currently two methods described in adults:

If lateral edge of lung is > 2cms. from thoracic cage at the level of the hilum, then this or implies pneumothorax is at least 50%, and hence large in size.

Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).

To express the pneumothorax size as a percentage, multiply the fractional size by 100.

Regarding the patients condition of having type II diabetes melitus, the diet of the patient shouldve been changed to the DM diet, for kcal. If the patient given sulfonyl urea, the

dosage should be given more because of its interaction with the antituberculosis drugs. Rifampicin could decrease effectivity of sulfonyl urea. The use of ethambutol can increase the risk of visual impairment caused by diabetic retinopathy.