FACULTY OF MEDICINE

BLOK RESPIRATION
UNIVERSITAS MUSLIM INDONESIA Makassar, 14 November 2018

MODUL 1
“COUGH”

Tutor :
dr. Nurul Fadilah Ali Polanunu
Created By :
GROUP 14

1. 110 2017 0006 Deddy Kurniawan
2. 110 2017 0026 Nurul Hidayah
3. 110 2017 0033 Riski Amaliah
4. 110 2017 0069 Muhammad Fakhri
5. 110 2017 0071 Miftahul Jannah
6. 110 2017 0086 Aulia Chaeruni
7. 110 2017 0112 Musdalifah
8. 110 2017 0149 Nurul Atmitha Moudya
9. 110 2017 0162 Nurlana Zamaun
10. 110 2017 0174 Nur Khairunnisa

FACULTY OF MEDICINE
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2018
FOREWORD

We thank Allah for the blessings and blessings of His grace so that the results of
this tutorial can be resolved properly. And do not forget to send greetings and prayers
to the Prophet Muhammad SAW that has brought us from a world full of ignorance to
a nature full of intelligence.

We also thank the parties who helped make this report and the tutors who guided
us during the PBL process.

Hopefully this tutorial report can be useful for everyone who has read this report
and especially for the drafting team itself. Hopefully after reading this report can
expand the knowledge of readers

Makassar, 14 November 2018

GROUP 14
A. SCENARIO

A 5 year-old kid come to primary health centre with parents because of the
cough that has been experienced since 2 months ago. This kid loss of appetite and lost
weight. It is known that the child lives with parents in a crowded environment with
poor sanitation. Immunization history: BCG immunization, Hepatitis B, Polio, DPT
and Measles.

B. DIFFICULT WORDS
1. Immunization.
2. BCG immunization.
3. DPT.
4. Measles.
5. Polio.

C. KEYWORDS
1. A 5 year-old kid.
2. Come to primary health centre with parents.
3. Has been experienced cough for 2 months.
4. Loss of appetite and lost weight.
5. lives with parents in a crowded environment with poor sanitation.
6. Immunization history: BCG immunization, Hepatitis B,
Polio, DPT and Measles.
D. QUESTIONS
1. Explain about anatomy of respiratory system!
2. Explain about patofisiology of cough!
3. What is correlation between cough and weight loss?
4. What is correlation between the environment and the disease in the scenario?
 5. Explain the immunization history in scenario!
6. Explain the steps of diagnosis!
7. What the differential diagnosis from the scenario?
8. How is the treatment of the scenario?
9. How is the perspective in islam?

E. ANSWERS
1. Anatomy Of The Respiratory System

Respiratory System
The respiratory system (also referred to as the ventilator system) is a
complex biological system comprised of several organs that facilitate the
inhalation and exhalation of oxygen and carbon dioxide in living organisms (or,
in other words, breathing).
For all air-breathing vertebrates, respiration is handled by the lungs, but
these are far from the only components of the respiratory system. In fact, the
system is composed of the following biological structures: nose and nasal
cavity, mouth, pharynx, larynx, trachea, bronchi and bronchioles, lungs and the
muscles of respiration. (1)
A properly functioning respiratory system is a vital part of our good
health. Respiratory infections can be acute and sometimes life threatening.
They can also be chronic, in which case they place tremendous long term stress
on the immune system, endocrine system, HPA axis, and much more.
Anatomical Components
An image of the respiratory system, showing all the major components,
is shown above.
1. Nose and Nasal Cavity
The nose and nasal cavity constitute the main external opening of
the respiratory system. They represent the entryway to the respiratory tract
– a passage through the body which air uses for travel in order to reach the
lungs. The nose is made out of bone, muscle, cartilage and skin, while the
nasal cavity is, more or less, hollow space. Although the nose is typically
credited as being the main external breathing apparatus, its role is actually
to provide support and protection to the nasal cavity. The cavity is lined
with mucus membranes and little hairs that can filter the air before it goes
into the respiratory tract. They can trap all harmful particles such as dust,
mold and pollen and prevent them from reaching any of the internal
components. At the same time, the cold outside air is warmed up and
moisturized before going through the respiratory tract. During exhalation,
the warm air that is eliminated returns the heat and moisture back to the
nasal cavity, so this forms a continuous process.
2. Oral cavity
The oral cavity, more commonly referred to as the mouth, is the only
other external component that is part of the respiratory system. In truth, it
does not perform any additional functions compared to the nasal cavity, but
it can supplement the air inhaled through the nose or act as an alternative
when breathing through the nasal cavity is not possible or exceedingly
difficult. Normally, breathing through nose is preferable to breathing
through the mouth. Not only does the mouth not possess the ability to warm
and moisturize the air coming in, but it also lacks the hairs and mucus
membranes to filter out unwanted contaminants. On the plus side, the
pathway leading from the mouth is shorter and the diameter is wider, which
means that more air can enter the body at the same speed.

3. Pharynx
The pharynx is the next component of the respiratory tract, even
though most people refer to it simply as the throat. It resembles a funnel
made out of muscles that acts as an intermediary between the nasal cavity
and the larynx and esophagus. It is divided into three separate sections:
nasopharynx, oropharynx and laryngopharynx. The nasopharynx is the
upper region of the structure, which begins at the posterior of the nasal
cavity and simply allows air to travel through it and reach the lower
sections. The oropharynx does something similar, except it is located at the
posterior of the oral cavity. Once the air reaches the laryngopharynx,
something called the epiglottis will divert it to the larynx. The epiglottis is
a flap that performs a vital task, by switching access between the esophagus
and trachea. This ensures that air will travel through the trachea, but that
food which is swallowed and travels through the pharynx is diverted to the
esophagus.
4. Larynx
The larynx is the next component, but represents only a small
section of the respiratory tract that connects the laryngopharynx to the
trachea. It is commonly referred to as the voice box, and it is located near
the anterior section of the neck, just below the hyoid bone. The
aforementioned epiglottis is part of the larynx, as are the thyroid cartilage,
the cricoid cartilage and the vocal folds. Both cartilages offer support and
protection to other components, such as the vocal folds and the larynx itself.
The thyroid cartilage also goes by a more common name – the Adam’s
apple – although, contrary to popular belief, it is present in both men and
women. It is typically more pronounced in adult males. The vocal folds are
mucous membranes that tense up and vibrate in order to create sound, hence
the term voice box. The pitch and volume of these sounds can be controlled
by modifying the tension and speed of the vocal folds.

5. Trachea
The trachea is a longer section of the respiratory tract, shaped like a
tube and approximately 5 inches in length. It has several C-shaped hyaline
cartilage rings which are lined with pseudostratified ciliated columnar
epithelium. (2) Those rings keep the trachea open for air all the time. They
are C-shaped in order to allow the open end to face the esophagus. This
allows the esophagus to expand into the area normally occupied by the
trachea in order to permit larger chunks of food to pass through. The
trachea, more commonly referred to as the windpipe, connects the larynx to
the bronchi and also has the role of filtering the air prior to it entering the
lungs. The epithelium which lines the cartilage rings produces mucus which
traps harmful particles. The cilia then move the mucus upward towards the
pharynx, where it is redirected towards the gastrointestinal tract in order for
it to be digested.
6. Bronchi
The lower end of the trachea splits the respiratory tract into two
branches that are named the primary bronchi. These first run into each of
the lungs before further branching off into smaller bronchi. These secondary
bronchi continue carrying the air to the lobes of the lungs, then further split
into tertiary bronchi. The tertiary bronchi then split into even smaller
sections that are spread out throughout the lungs called bronchioles. Each
one of these bronchioles continues to split into even smaller parts called
terminal bronchioles. At this stage, these tiny bronchioles number in the
millions, are less than a millimeter in length, and work to conduct the air to
the lungs’ alveoli. The larger bronchi contain C-shaped cartilage rings
similar to the ones used in the trachea to keep the airway open. As the
bronchi get smaller, so do the rings that become progressively more widely
spaced. The tiny bronchioles do not have any kind of cartilage and instead
rely on muscles and elastin.
This system creates a tree-like pattern, with smaller branches
growing from the bigger ones. At the same time, it also ensures that air from
the trachea reaches all the regions of the lungs. Besides simply carrying the
air, the bronchi and bronchioles also possess mucus and cilia that further
refine the air and get rid of any leftover environmental contaminants. The
walls of the bronchi and bronchioles are also lined with muscle tissue,
which can control the flow of air going into the lungs. In certain instances,
such as during physical activity, the muscles relax and allow more air to go
into the lungs.

7. Lungs
 The lungs are two organs located inside the thorax on the left and
right sides. They are surrounded by a membrane that provides them with
enough space to expand when they fill up with air. Because the left lung is
located lateral to the heart, the organs are not identical: the left lung is
smaller and has only 2 lobes while the right lung has 3. Inside, the lungs
resemble a sponge made of millions and millions of small sacs that are
named alveoli. These alveoli are found at the ends of terminal bronchioles
and are surrounded by capillaries through which blood passes. Thanks to an
epithelium layer covering the alveoli, the air that goes inside them is free to
exchange gasses with the blood that goes through the capillaries.

8. Muscles of Respiration
The last component of the respiratory system is a muscle structure
known as the muscles of respiration. These muscles surround the lungs and
allow the inhalation and exhalation of air. The main muscle in this system
is known as the diaphragm, a thin sheet of muscle that constitutes the bottom
of the thorax. It pulls in air into the lungs by contracting several inches with
each breath. In addition to the diaphragm, multiple intercostal muscles are
located between the ribs and they also help compress and expand the lungs.

Reference: National Heart, Lung, and Blood Institute, “The Respiratory System

2. COUGH MECHANISM
Basically the mechanism of coughing can be divided into three phases,
namely the inspiration phase, the compression phase and the expiration phase.
Coughing usually starts from an inhalation of some air, then the glottis will
close and the pressure in the lungs will increase which eventually follows the
sudden opening of the glottis and expiration of a certain amount of air at a
certain speed .
The inspiration phase begins with a brief and rapid inspiration from a
large amount of air, at this time the glottis is reflexively open. Inspired air
volumes vary greatly in number, ranging from 200 to 3500 ml above functional
residual capacity. Other studies say the amount of air sucked ranges from 50%
of tidal volume to 50% of vital capacity. There are two main benefits of
consuming a large amount of this volume. First, a large volume will strengthen
the expiration phase later and can produce expiration that is faster and stronger.
The second benefit, a large volume will reduce the closed air cavity so that
secret spending will be easier. After the air is inspired, the compression phase
begins where the glottis will be closed for 0.2 seconds. At this time, the pressure
in the lungs and abdomen will increase to 50- 100 mmHg. Glottic closure is a
characteristic feature of coughing, which distinguishes it from other forced
expiratory maneuvers because it will produce different energies. The pressure
obtained when the glottis is closed is 10 to 100% greater than the other forced
expiration methods. On the other hand, coughing can also occur without glottic
closure. Then, the glottis will open actively and the expiration phase will take
place. The air will come out and vibrate the airway and air tissue that is there,
causing a coughing sound that we know. Maximum expiratory air flow will be
achieved within 30-50 seconds after the glottis opens, which is then followed
by a steady stream. The air velocity produced can reach 16,000 to 24,000 cm
per minute, and in this phase there can be a reduction in trachea diameter to
80%.
 Irritation of the airways (trachea, bronchi, bronchioles)

The signal is captured by the receptor and carried

by the afferent (vagus nerve)

Respiratory Center (medulla oblongata)

Implus efferent through the recurrent laryngeal nerve, phrenic nerve

& intercostal nerve (T1-T12)

Long inspiration followed by epiglottic closure

Contraction of the muscles of expression. Increased pressure

COUGH
Referemce :
1. McCool FD, Leith De, Patophysiology of cough. Clinical Chest medicine
1987 :8: 189- 96
2. Crofton J, Douglas A. Respiratory disease.Oxford: Blackwell Scient Publ
1989: 101-2

3. Nutrition and tuberculosis

An essential dietary nutrient is a substance that a person needs to consume in
order to live, grow and be healthy. Nutrients are required to regulate body
processes and build and repair tissues and thereby promote health and prevent
disease. Macronutrients (protein, carbohydrate and fat) are generally consumed
in large amounts. Carbohydrate and some fat are converted to energy, while
protein and some fat are used to make structural and functional components of
human tissue. Micronutrients (vitamins and minerals) are consumed in small
amounts and are essential for metabolic processes. Macronutrients and
micronutrients work together to contribute to tissue regeneration and cellular
integrity.
Malnutrition is a general term that refers to either overnutrition or
undernutrition or both. Undernutrition refers to a state when the nutritional
status of the person is suboptimal and thereby health and growth may be
limited. Undernutrition may be due to illness that impairs nutrient intake and
metabolism, or result from inadequate intake of macronutrients, micronutrients
or both
Undernutrition is commonly associated with illness and infections such as
gastrointestinal disorders and malabsorption, pneumonia, TB and HIV. Food
insecurity can be a cause of malnutrition, as can alcohol misuse and illicit drug
use, and a number of other conditions. In any case, both the underlying
 condition associated with undernutrition and the malnutrition itself warrant
evaluation and treatment.
The association between TB and undernutrition has long been known. TB
makes undernutrition worse and undernutrition weakens immunity, thereby
increasing the likelihood that latent TB will develop into active disease. Most
individuals with active TB are in a catabolic state and experience weight loss
and some show signs of vitamin and mineral deficiencies at diagnosis. Weight
loss among those with TB can be caused by several factors, including reduced
food intake due to loss of appetite, nausea and abdominal pain; nutrient losses
from vomiting and diarrhoea and metabolic alterations caused by the disease.
Low body mass index (BMI) (lower than 18.5 kg/m2) and lack of adequate
weight gain with TB treatment are associated with an increased risk of death
and TB relapse and can be an indication of severity of TB, poor treatment
response and/or the presence of other comorbid conditions.

Ref : WHO.Guideline:Nutritional care and support for patients with

tuberculosis.Geneva:World Health Organization;2013

4. Pulmonary tuberculosis is a disease, the third leading cause of death after

cardivasculer and respiratory diseases in all age groups and the first cause
of death in infectious diseases.Pulmonary tuberculosis is an infectious
disease caused by Mycobacterium tuberculosis. The bacteria usually enter
the human body through respiration air into the lungs Then the germs can
be spread from the lungs to other parts of the body via the circulatory
system, the lymphatic duct system, through the airways (bronchi) or direct
spread to other body parts.
TB disease is transmitted melaiui airbome spread of droplet
infection with the source of infection is a person with pulmonary TB
disease are coughing. Cough from pulmonary tuberculosis patients can
produce 3000 droplet nuclei. Transmission usually occurs in the room,
where droplet nuclei can stay in the air for a long time. Direct sunlight can
quickly kill bacteria, but they can survive in the darkness.
Pulmonary tuberculosis risk factors such as low income, community
nutrition quality, the quality of the home environment, sanitation and
occupant density. It can be concluded that the bed density, ventilation and
temperature have been associated with pulmonary TB. Therefore, it is
recommended to increase case findings, early treatment and cure of
patients and the need to campaign for the local community environmental
health risks, especially home health. The causative factors of pulmonary
tuberculosis on lower incomes, the poor quality of public nutrition, poor
housing environment (including indoor air quality), sanitation and
occupant density. Residential environmental factors play an important role
in determining the interaction between the host and the causative agent of
the disease process. The physical environment includes residential density
(the ratio of the number of bedrooms and people), ventilation, and the room
temperature.
Residential density is the process of transmission of the disease. The
more dense the transfer of disease, especially communicable diseases by
air will be easier and faster.Usually the most commonly affected are the
lungs but can affect other organs. This disease can be transmitted from
person to person from an infected person.

Reference:
Depkes RI.2013. Pedoman Nasional Prosedur Perawatan TB. Jakarta.
Buku Ilmu Penyakit Dalam. Iternal. Jakarta. Hal 999
5. Immunization is the process of inducing artificial immunity both by
vaccination (active immunization) and by giving antibodies (passive
immunization). Active immunization stimulates the immune system to form
antibodies and cellular immune responses against infectious agents, while
passive immunization provides temporary protection through the
administration of exogenously produced antibodies and transplacental
transmission from mother to fetus.

Types of immunization

1. BCG immunization

Tuberculosis is a disease that has emerged since many years ago. The cause
is Mycobacterium tuberculosis. Giving BCG is an effort to prevent this
disease. Bacille Calmette-Guerin (BCG) is a weakened Mycobacterium
bovis strain vaccine, which results in non-virulent bacilli but still has
immunogenicity. The BCG vaccine was first used in 1921 and is one of the
most widely used vaccines. On average about 80% of infants and children
in countries that promote immunization will get this vaccine. Aside from
being an effort to prevent primary tuberculosis infection, this BCG vaccine
is actually given to reduce the risk of severe tuberculosis such as
tuberculosis meningitis and miliary tuberculosis. BCG vaccine is usually
given at the age of ≤ 2 months. But it can also be given at the age of 0-12
months to get wider immunization coverage. The BCG vaccine should be
given to children with a negative Mantoux test. This vaccine is given to the
right deltoid region so that if there is lymphadenitis (axilla) it is easily
detected. To maintain its quality, this vaccine must be stored at a
temperature of 2-8 degrees Celsius and may not be exposed to the sun. The
protective effect of BCG arises from 8 to 12 weeks after injection with
 various presentation presentations. Repeated BCG is not recommended
because the benefits are doubtful given the effectiveness of protection is
only 40%, 70% of cases of severe TB appear to have scarring BCG, adult
cases with AFB + in Indonesia are quite high even though they have
received childhood. The side effects of injecting BCG intradermally will
result in superficial local ulcers 3 weeks after injection. Ulcers that will
eventually leave a scar with a 4-8mm diameter will heal within 2-3 months.
The size of the ulcer formed depends on the dose given. Complications that
often occur include erythema nodosum, iritis, lupus vulgaris, and
osteomyelitis24. Contraindications to the administration of the BCG
vaccine include: tuberculin test reaction > 5mm, is suffering from HIV
infection or with a high risk of HIV infection, immunocompromise due to
corticostroids, etc., malnutrition, is suffering from a high fever, has
extensive skin infections, has had TB, pregnancy.

2. DPT Immunization

The DTP vaccine contains diphtheria toxoid, tetanus toxoid and pertussis
vaccine. Thus this vaccine provides protection against 3 diseases at once,
namely diphtheria, pertussis, and tetanus. Diphtheria and tetanus are caused
by toxins from bacteria. Therefore, in an effort to prevent it (immunization)
only toxoid is given, which is a modified bacterial toxin that is not toxic but
can stimulate the formation of anti-toxins. While pertussis, although it also
involves toxins in its pathogenesis, has other antigens that play a role in the
emergence of symptoms of the disease, so prevention efforts are given in
the form of vaccines.
 The DTP vaccine is divided into 2, namely DTwP and DtaP based on
differences in the Tetanus vaccine. DTwP (Diphtheria Tetanus whole cell
Pertussis) contains a dead suspension of B. Pertussis, while DTaP
(Diphtheria Tetanus acellular Pertussis) does not contain all the components
of B. Pertussis but only a few components that are useful in pathogenesis
and trigger the formation of antibodies. DTaP vaccine has lighter side
effects than DTwP vaccine.
The DTP vaccine is given when the child is 2, 4 and 6 months, after which
it is followed by giving the vaccine again when the child is 18 months, 5
years and 12 years.

3. Polio Immunization

Polio or poliomyelitis is a disease caused by the polio virus. This disease

attacks the central nervous system and can cause paralysis. The viral
incubation period is usually 8-12 days, but can also range from 5-35 days.
About 90-95% of cases of polio infection do not cause symptoms or
abnormalities.

At present there are 2 types of polio vaccines, namely oral polio vaccine
(OPV) and inactivated polio vaccine (IPV). The polio oral / oral polio
vaccine (OPV) vaccine contains live attenuated type 1, 2 and 3 polio
viruses. This vaccine is a type of polio vaccine that is used routinely. The
virus in the vaccine will enter the digestive tract and then into the blood17.
The virus will trigger the formation of circulating antibodies and local
antibodies in the intestinal epithelium17,18. Inactivated polio vaccine (IPV)
contains type 1, 2 and 3 polio viruses which are inactivated with
formaldehyde. In this vaccine there are also neomycin, streptomycin, and
polymyxin B. The vaccine is given by subcutaneous injection. The vaccine
 will provide long-term immunity (mucosa and humoral) to 3 types of polio
virus, but the mucosal immunity generated is lower than the oral polio
vaccine. In Indonesia, the polio vaccine used is the oral polio vaccine
(OPV). According to IDAI recommendations, the polio vaccine is given 6
times: when the baby is discharged from the hospital or at the first visit
(polio-0), at the age of 2 months, 4 months, 6 months, 18 months, 5 years
and 12 years. Side effects of the vaccine or commonly known as post-
immunization (KIPI) polio events include dizziness, mild diarrhea, and
muscle pain. The most feared side effect is the vaccine associated polio
paralytic (VAPP). VAPP occurs in approximately 1 case per first 1 million
doses of OPV and every 2.5 million doses of complete OPV are given. In
giving OPV, the virus will replicate in the human intestine. At the time of
replication, mutations can occur so that the virus that has been weakened
becomes neurovirulent and can cause acute paralysis. Contraindications to
polio vaccine include children in acute illness, fever (> 38oC), severe
vomiting or diarrhea, while in oral and injectable immunosuppression
treatment including general radiation treatment, having reticuloendothelial-
related malignancies and whose immunological mechanisms are impaired,
HIV infection, and hypersensitivity to antibiotics in vaccines. Children who
have contact with relatives or family members with immunosuppression
should also not be given polio vaccination.

4. Hepatitis B Immunization

Hepatitis is an inflammatory disease of the liver. The causes vary, one of

which is the hepatitis B virus which causes hepatitis
B. Hepatitis B is generally asymptomatic, but often becomes chronic. H
epatitis B infection can also cause cancer and liver cirrhosis. Death from
 hepatitis B infection reaches at least 1 million / year. Until now therapy for
hepatitis B is still unsatisfactory so prevention efforts, especially through
immunization, are very necessary.
The hepatitis B vaccine has been known since 1982. This vaccine contains
30- 40 µg HBs Ag protein (hepatitis B virus antigen). Hepatitis B
immunization for children under five is given 3 times, which is immediately
after birth, age 1 month, and between the ages of 3-6 months. Immunization
is injected in the thigh intramuscularly in. Follow-up events after hepatitis
B immunization are usually in the form of mild local reactions and soon
disappear. You can also have a mild fever for 1-2 days.
The effectiveness of vaccines reaches 90-95% in preventing the onset of
hepatitis B. Defense will last until a minimum of 12 years after
immunization.

5. Measles immunization

Measles is an infectious and acute disease caused by the measles virus. This
disease is transmitted through the air through the respiratory system and
usually the virus will multiply in cells in the back of the esophagus and in
cells in the lungs and cause symptoms such as fever, malaise, redness of the
eye, inflammation of the upper respiratory tract and arising reddish spots
that start from the hairline behind the ear, then gradually spread on the face,
neck, hands and the entire body. The method of transmission of this disease
can be through measles droplets in the early stages containing
paramyxovirus and direct contact with patients and objects contaminated
with paramyxovirus. To prevent measles from contracting, one needs to be
given a measles vaccine, which is actually a strain of the measles virus that
has been weakened. Measles vaccine began to be used in 1963 and was
developed again in 1968. The combination of measles-mumps-rubella
 vaccine (MMR) was started in 1971 and in 2005 a combination of measles-
mumps-rubella-varicella (MMRV) vaccine was developed. Giving the
measles vaccine is recommended twice to reduce the possibility of measles,
the first giving gives 95-98% immunity to measles and is given at 12-15
months. The second giving 99% immunity to measles and can be given at
any time as long as it is more than 4 weeks away from the first
administration, in children usually given when the child is 4-6 years old.
Measles immunization is done using disposable syringes to avoid
transmission of diseases such as HIV / AIDS and Hepatitis B, by being
injected subcutaneously or intramuscularly. Post Immunization Follow-up
Events (KIPI) that can occur after administration of measles vaccines
include fever> 39.5oC, rash, encephalitis, and encephalopathy after
immunization. This KIPI reaction has declined since the use of the
attenuated measles vaccine. Measles vaccine should not be given to people
who are experiencing a high fever, in the treatment of immunosuppression,
are pregnant, have a history of allergies, are on treatment with
immunoglobulins or blood component ingredients.

Reference : Basic Immunization Completion of Toddler Children. Sari

Febriana, FK UI., 2009

6. ANAMNESIS

This history is done in order to be able to communicate with patients and

certainly ask questions related to the patient's illness. The initial question of
the patient's identity and age and place of residence and work of the patient,
then ask the main complaint after the previous history of the disease, history
of treatment and taking medication and family history.1
PHYSICAL EXAMINATION
The first examination of the general condition of the patient may be
found in pain ranging from mild to severe. Patients can look thin or
menururn weight, fever body temperature (subfebris), eye conjunctiva or
pale skin due to anemia, often on physical examination the patient does not
show any abnormality especially in early cases or that has been
asymptomatically infiltrated. Likewise, if a disease nest is located inside, it
will be difficult to find abnormalities on physical examination, because the
vibration / sound delivery depth of lung tissue> 4 cm is difficult to be
assessed by palpation, percussion and auscultation. Even with anamnesis
and physical examination, pulmonary TB is difficult to distinguish from
ordinary pneumonia.
The most suspected place for pulmonary TB lesions is the lung apex
(peak). If there is a suspected broad infiltration, dim percussion and
auscultation of the bronchial breath sounds are obtained. It may also be
found that additional breath sounds such as rough and loud rhonchi. But if
the infiltrates are covered by pleural thickening, the breath sounds become
vesicular weakened. If there is a large cavity, percussion gives a hypersonor
or tympanic sound and auscultation provides an amorphous sound
In advanced pulmonary TB with extensive fibrosis it is often found
atrophy and retraction of intercostal muscles. The diseased part of the lung
becomes shrinking and pulls on the contents of the media or other lung
tissue. The healthy part of the lung becomes more hyperinflation. If the
fibrotic tissue is very extensive, which is half the amount of all lung tissue,
there will be a reduction in the pulmonary blood flow area and then increase
pulmonary artery pressure (pulmonary hypertension) followed by cor-
pulmonary and right heart failure. Here there will be cor-pulmonary signs
or right heart failure such as tachypnea, tachycardia, cyanosis, right
 ventricular lift, right atrial gallop, Graham-Steel murmur, P sounds,
hardening, increased jugular venous pressure, hepatomegaly, ascites and
edema .
If pulmonary tuberculosis of the pleura will form pleural effusion.
A diseased lung looks a little left behind in breathing. Percussion gives a
squeaky sound. Auscultation provides weak breath sounds not heard at all.
In clinical appearance, pulmonary TB often does not show symptoms
(asymptomatic) and new diseases are suspected by obtaining radiological
chest abnormalities on routine examinations or positive tuberculin tests.1

LABORATORY EXAMINATION
Blood
This examination is less attention because the results are sometimes
dubious, the results are insensitive and also not specific. When new TB
starts (active) in the peripheral blood, the amount of leukocytes is slightly
elevated and the count type can be shifted left. The number of lymphocytes
is still normal The sedimentation rate of blood begins to increase. When the
disease begins to heal the number of leukocytes returns to normal and the
lymphocyte count is still high. The sedimentation rate of blood begins to
fall towards normal again. The results of other blood tests are also obtained:
1) Mild anemia with a description of normochrome and normociter. 2)
Gama globulin increases. 3) Decreased blood sodium levels The blood tests
above are also not specific. The serological blood test that was used was
Takahashi's reaction. This examination can show whether the TB process is
still active or not. The positive criteria used in Indonesia are titers 1/128.
This examination also received little attention due to the large number of
false positives and false negatives. This check is no longer used.
Several years ago there was a serological examination of TB
Peroxidase TB (PAP-TB) which some researchers stated had a high
 sensitivity and specificity (85-95%), but other researchers doubted it
because they got the numbers the lower one. This examination has been
abandoned and cannot be used as a single diagnostic tool. False positive
results are often found in rheumatic patients, pregnancies and 3 months of
BCG vaccination. Other serological tests for TB are almost the same way
and the value is the Mycodot test. The serological examination above is also
hardly used anymore. Later it was also found IGRA T-cell inter-gamma
release assay as an immuno-diagnostic examination to detect M.
tuberculosis infection. The basis is to measure the immunocellular response
of T lymphocytes to TB infections that occur. Here further research is
needed to assess the validity of this serological test, although some reports
state that the sensitivity and specificity are quite high and this test is stated
to be better than the tuberculin test. Until now, WHO and IUALTD still
have not recommended this test for TB diagnosis1

Pulasan Sputum (sputum smear)

Sputum pulses to find M. tuberculosis (acid resistant bacilli, AFB
AFB) were carried out using the coloring of Zichl Neelsen. Often it is not
easy to find M. tuberculosis in the presence of suspected sputum. At least
there must be 5000-10,000 bacilli in 1 milliliter of sputum so that you can
find M. tuberculosis immediately in an object glass so that it can classify it
as positive smear sputum. 10-100 basil per milliliter of sputum.2
Tuberculin Test
This examination is still widely used to help diagnose TB, especially
in children (toddlers). The Mantoux test is usually used by injecting 2 TU
(Tuberculin Unit) in 0.1 mL PPD-RT23 (WHO and IUALTD
recommendations) intra-cutaneously. The reading of the results after 3 days
shows a positive reaction if there is induration in the skin of the injection
site with a diameter of 210 mm. For patients who are HIV positive, the
 Mantoux test> 5 mm has been considered positive. Positive positive tests
are certainly an indication of TB diagnosis, but negative tests do not mean
there is no TB. In many countries with other mycobacterial infections that
are often non-pathogenic, they can result in weak positive tuberculin tests.
A positive test can also be caused by previous BCG vaccinations. Always
keep in mind that if there are other directions that lead to a diagnosis of TB,
a negative test does not rule out the possibility of TB. While positive and
even positive tests only show that the patient has been infected with a
previous TB germ. This does not prove that he has active TB.1
It is stated in ISTC that all patients suspected of having extra
pulmonary TB (adults, adolescents & children), must undergo microscopic
specimens obtained from the location of the suspected disorder. If facilities
and resources are available, culture and histopathology tests should be
carried out as well as possible. It is also best to do chest X-ray examination
to find out whether there is pulmonary TB and miliary TB. Sputum
examination in children is also done if possible1

RADIOLOGICAL EXAMINATION
At this time chest radiological examination is a practical way to find
TB lesions. This examination does require more costs than direct phlegm
examination, but in some cases it provides benefits such as in childhood TB
and miliary TB. In both of the above conditions the diagnosis can be
obtained through chest radiological examination, while the sputum
examination is almost always negative.
The location of TB lesions is generally in the area of the pulmonary
apex (apical segment of the upper lobe or apical segment of the lower lobe),
but can also affect the inferior lower lobe or the hilum area resembling a
lung tumor (in endo-bronchial TB). At the beginning of the disease the
lesion is still a nest of pneumonia with a radiological picture in the form of
patches such as clouds and indecisive boundaries. If the lesion is covered
with connective tissue, the shadow will appear in the form of a circle with
a firm boundary. This lesion is known as tuberculoma.
in the cavity of the shadow can be a ring that is initially thin-walled,
a long time the walls are sclerotic and look thickened. If fibrosis occurs, it
can be seen as a striped shadow. The calcification of the shadow appears as
dense patches of high density. Atelectasis is seen as extensive fibrosis
accompanied by shrinkage that can occur in part or 1 lobe or 1 part of the
lung. When miliary TB occurs, it is seen in the form of fine patches which
are generally spread evenly throughout the lung field.
Another radiological picture that often accompanies pulmonary TB
is pleural thickening (pleurisy), intercourse of fluid in the lower lung
(pleural effusion / empyema), radiolucent black shadow in lung edge /
pleura (pneumo-thorax). In one photo of an advanced TB chest often found
a variety of shadows at once such as infiltrates, fibrotic lines, calcification,
cavity (non-sclerotic / sclerotic) or atelectasis and emphysema.
TB often gives a strange picture, especially the radiological picture,
so it says tuberculosis is the great imitator. The description of infiltrates and
tuber culomas is often interpreted as pneumonia, pulmonary mycosis,
bronchial carcinoma or metastatic carcinoma in the lung. Overview of
cavities is often interpreted as lung abscesses. In addition, it is important to
remember also the error factor in reading photos. This error factor can reach
25% Therefore radiological diagnostics are often carried out also lateral,
top lordotic, oblique, tomographic and hard-density photographs. The
presence of lesions (shadows) on the chest photo does not indicate the
presence of disease activity, except for an infiltrate that is truly real. Non-
active disease lesions often persist throughout the patient's life. Lesions that
 are fibrotic, calcified, cavitary and schwarte are common in elderly patients.
A special examination that is sometimes also needed is bronchography to
see bronchial or pulmonary damage caused by TB. Examination of lung
powder. This examination is now rarely done anymore because there is
already a more sophisticated examination and is widely used in referral
hospitals namely Computed Tomography Scanning (CT scan). This
examination is superior to normal chest radiological examination. The
difference in tissue density is more pronounced and the incision can be
made transversely, sagittal, etc. Another more sophisticated examination is
Magnetic Resonance Imaging (MRD). An MRI examination of the
endothorax is not as good as CT scan, but it can evaluate processes near the
lung apex, the chest-abdominal border of the spine and its neural pathways.
Incisions can also be made transversal, sagittal and coronal. 1
Reference:
1. setiati siti . 2017. Buku ajar ilmu penyakit dalam . Jakarta . interna
publishing Hal 869 – 872
2. djojodibroto darmanto. 2014 . respirologi (respiratory medicine) .
Jakarta . EGC . hal 159

7. A.Tuberculosis
tuberculosis (TB) is a chronic infectious disease that attacks almost all organs
of the human body and the most is the lungs. in 1882 Robert Koch discovered
the cause of the bacteria is rod-shaped bacteria and is an acid-resistant bacteria,
namely the bacterium Mycovacterium tuberculosis

clinical symptoms:

a. complaints in general
1. fever
 first fever attack can heal for a while, but then it can reappear. this
condition is strongly influenced by the patient's immune system and the
severity of the infection of the incoming TB bacteria
2. malaise
malaise symptoms are often found in the form of anorexia, no appetite,
headache, fever, muscle aches, night sweats and others. the symptoms of
this malaise are increasingly burdensome and occur irregularly
3. weight loss
in patients with children usually their weight is difficult to rise especially
in the last two to three months or the status of their gaps is less
4. fatigue
this complaint is also felt in most patients

b. respiratory complaints
1. cough/bleeding cough
coughing occurs due to irritation of the bronchi. This cough is needed
to get rid of inflammatory products from the lower respiratory tract. the
nature of the cough starts from a dry (non-productive) cough then after
arising inflammation changes to become productive (produce phlegm).
further conditions can wage coughing up blood because there are small
blood vessels that rupture. and usually lasts long
2. out of breath
mild pulmonary TB disease has not yet felt shortness of breath.
shortness of breath will be found in advanced pulmonary TB disease,
where the infiltration includes half the lung
3. chest pain
these symptoms are rather rare. chest pain arises when the infiltration of
inflammation has reached the pleura causing pleurisy. the second
pleural friction occurs when the patient pulls / releases the breath.
 4. often catch flu
symptoms of a long cough sometimes accompanied by colds often occur
because the patient's immune system is low so it is susceptible to viral
infections

referensi: buku ajar ilmu penyakit dalam jilid 1 edisi vi . Jakarta.

Internapublising. Hal 863

B. Pertussis
pertussis is a highly contagious acute respiratory tract infection characterized by a
syndrome in the form of cough that is spasmodic and paroxysmal accompanied by
an elevated tone because the patient strives to breathe so that at the end of the
cough it is often accompanied by a distinctive sound

the clinical course of pertussis is divided into 3 stages

1. Cataralis stadium (prodromal stadium)
length of one to two weeks. the symptoms are:
a. mild upper respiratory tract infection
b. mild heat
c. malaise
d. discrimination
e. decreased appetite
f. nasal congestion

2. acute paroxysmal stage (splasmodik stadium)

duration of two to four weeks or more. the symptoms are:

a. coughing often five to ten times, as long as the coughing in a child
cannot breathe and in the end during a coughing attack, the patient
 breathes quickly and deeply so that there is a high-pitched sound
(whoop), and ends with vomiting
3. Convaselen stadium
a. marked by stopping whoop and vomiting.
b. coughs usually persist for some time and will disappear for about two
to three weeks
assessment

clinical diagnosis
diagnosis is based on history, physical examination and investigation
criteria
1. detected bordetella pertussis from nasopharyngeal specimens
2. nasopharyngeal swab culture found bordetella pertussis

reference:
Adam G,L Boies L.R Higler. Boies . buku ajar penyakit THT. Ed 6 . Jakarta
EG. 1997

C. Pneumonia

pneumonia is a drug of inflammation or inflammation of the pulmonary

parenchyma, distal from the brongkiolus terminal which covers the respiratory
brongchiolus and alveoli, and causes lung tissue consolidation and disruption
of the local gas exchange pneumonia is caused by microorganisms (bacteria,
viruses, fungi, parasites)

history
clinical picture is usually characterized by:
1. coughing with mucoid or purulent sputum sometimes accompanied by blood
2. shortness of breath
3. high fever
4.chestpain

risk factor
1. age, more range at age above 65 years
2. Untreated airway infections
3. smoking
4. concomitant diseases: diabetes, COPD, neurological disorders,
cardiovascular disorders.
5. display of pollutants or hazardous chemicals
6. Repeat the old bed
7. Imonodeficiency, can be caused by long-term steroid use, malnutrition,
HIV.
the results of a simple physical examination and support
physical patogmonary examination
1. the patient appears to be seriously ill and sometimes accompanied by
cyanosis
2. body temperature increases and pulse is fast
3. respiration increases rapidly and shallow type
4. cyanosis
5. nose lobe breath
6. intercostal refraction with signs and lungs, namely:
- Inspections can show that the affected part lags behind breathing time
- palpation of fremitus can increase
- dim percussion
- auscultation is heard brongkovesikuler to bronchial breath that may be
accompanied by a smooth bass rongki, which then becomes a rough wet ronchi
at the resolution stage.
 supporting investigation
1. chest photo PA visible relationship to the affected area
2. laboratory
a. leukositosis
b. Sputum analysis showed significant leukocyte counts
c. gram of sputum
diagnosis
the diagnosis is based on history and physical examination. for
definitive diagnosis, a checkup is carried out the diagnosis criteria for
pneumonia with trias pneumonia are:
1. cough
2. fever
3. dyspnea

8. MANAGEMENT OF TB IN CHILDREN

Some important things in the management of childhood TB are:

1. TB drugs given in drug guidelines should not be given as monotherapy
2. Adequate nutrition
3. Looking for co-morbidities and if they are managed simultaneously

Medical management of childhood TB consists of therapy (treatment) and

prophylaxis (prevention). TB therapy is given to children who are ill with TB,
while TB prophylaxis is given to children who have TB contact (primary
prophylaxis) or children infected with TB without TB disease (secondary
prophylaxis). (Indonesian Ministry of Health, 2008)
Things that need to be considered in the administration of tuberculosis drugs in
children, namely intensive or advanced drug administration given every day,
the dose of the drug is adjusted to the child's weight, the treatment should not
be interrupted on the road. (Wirawan, 2008)
For tuberculosis therapy consists of two phases, namely the intensive phase
(initial) with 3-5 OAT guidelines for the initial 2 months and the advanced
phase with the guidance of 2 OAT (INH-Rifampicin) for 6-12 months.
Intensive phase (initial) patients get medication every day and need to be
monitored directly to prevent drug resistance, if intensive phase treatment is
given appropriately usually infectious patients become infectious within 2
weeks, most patients with positive smear tuberculosis become negative smear
( conversion) in 2 months while for the advanced phase patients get fewer types
of drugs but for longer periods, this stage is important to kill persister germs so
as to prevent recurrence. (Pusponegoro et all, 2005; (Indonesian Ministry of
Health, 2006)
Anti-Tuberculosis (OAT) drugs commonly used are Isoniazid, Rifampicin,
Piranizamid, Ethambutol and Streptomycin. OAT therapy for pulmonary
tuberculosis is INH, Rifampisis, Pyrazinamide for 2 months intensive phase
followed by INH and Rifampicin for up to 6 months of therapy (2HRZ-4HR).
OAT side effects are rare in children if the dosage and method of administration
are correct. The usual side effect is hepatotoxicity with jaundice symptoms, this
complaint usually appears in the intensive phase (early). (Pusponegoro et all,
2005; (Indonesian Ministry of Health, 2006)
drugs preparation Dose Dosage form Side effects
mg/ kg BB
Isoniazid (INH) Tablet 100 dan 5-15 300mg Enhancement
300 mg; sirup transminase,
10mg/ml hepatitis,
neuritis
peripheral,
 hypersensitivity
Rifampisin (R) Kapsul/tablet 10-15 600mg Urine / secretion
150,300,450,600 yellow,
mg; sirup nauseous vomit,
20mg/ml hepatitis
Piranizamid (Z) Tablet 500 mg 25-35 2g Hepatotoxicity,
hypersensitivity
Etambutol (E) Tablet 500 mg 15-20 2,5 g Optic neuritis
(reversible),
visual
impairment,
color
interference,
channel
interference
digest

Streptomisin Vial 1g 15-30 1g Ototoxicity,

(S) nephrotoxicity

Source: National Guidelines for Child Tuberculosis (Ministry of Health,

Republic of Indonesia, 2006)

How to treat INH is given for 6 months, Rifampicin for 6 months, Piranizamid
for the first 2 months. In severe cases, Ethambutol can be added for the first 2
months. (RI Ministry of Health, 2006)
To reduce the number of drop outs made in the form of FCD (Fixed Dose
Combination) for the first 2 months FDC was used which contained Rifampicin
/ Isoniazid / Piranizamid at a dose of 75 mg / 50 mg / 150 mg while for the next
4 months FDC containing 75 doses of Rifampicin / Isoniazid was used mg /
50mg. (RI Ministry of Health, 2006)

FDC Dosage Table for Tuberculosis in children

weight (kg) 2 months 4 months
RHZ (75/50/150) RH(75/50)

5-9 1 tablet 1 tablet

10-19 2 tablet 2 tablet
20-33 4 tablet 4 tablet
Source: National Guidelines for Child Tuberculosis (Ministry of Health,
Republic of Indonesia, 2006)

Table Dose OAT Combipak in children

Type of medicine weight < 10 kg weight 10-20kg weight 20-32 kg
Isoniazid 50 mg 100 mg 200 mg
Rifampisin 75 mg 150 mg 300 mg
Piranizamid 150 mg 300 mg 600 mg
Source: National Guidelines for Child Tuberculosis (Ministry of Health,
Republic of Indonesia, 2006)

For the category of children (2RHZ / 4RH), the basic principle of tuberculosis
treatment is at least 3 types of medication and given within 6 months. OAT in
children is given every day both in the intensive phase (early) and the advanced
phase, the dose of the drug must be adjusted to the child's weight. (RI Ministry
of Health, 2006)
In the majority of cases 6 months of treatment for children with tuberculosis is
sufficient. After 6 months of drug administration, evaluate both clinical and
investigative. Clinical evaluation of pediatric tuberculosis is the best parameter
to assess treatment success. If you find a real clinical improvement even though
the radiological picture does not show a change that means the OAT is stopped.
(RI Ministry of Health, 2006)
Prophylaxis
About 50-60% of small children living with adult pulmonary TB patients with
positive BTA sputum will be infected with TB as well. Approximately 10% of
this number will experience TB pain. TB infection in young children is at high
risk of severe disseminated TB (eg TB meningitis or miliary TB) so that
chemoprophylaxis is needed to prevent TB disease. (Indonesian Ministry of
Health, 2008)
Primary prophylaxis was given to healthy toddlers who had contact with adult
TB patients with positive BTA sputum, but the evaluation with the scoring
system scored ≤5. The drug given is INH dose of 5-10 mg / kg BB / day for 6
months. If the child has never received a BCG immunization, BCG should be
given after prophylactic treatment with INH completed. (Indonesian Ministry
of Health, 2008)
Reference:
1. Depkes RI. 2006. Pedoman Nasional Penanggulangan Tuberkulosis.
2. Kelompok Kerja TB Anak, 2008. Diagnosis dan Tatalaksana
Tuberculosis Anak. Jakarta: Departemen Kesehatan RI
3. Pusponegoro H.D, Sri Rejeki S.H, Dody F, Bambang T.A, Antonius
H.P, M.Sholeh K, dan K.Rusmil. 2005. Standar pelayanan medis
kesehatan anak. Edisi Ke-1. Jakarta : IDAI (Ikatan Dokter Anak
Indonesia )
 4. Wirawan A dan I Ketut. 2008. Profil penderita tuberculosis anak di
puskesmas Derek tahun 2004-2005. Jurnal cermin dunia kedokteran;
35:127-132

9. Imam Nawawi in kitab al-Majmû’ Syrahul Muhadzdzab (Kairo: Darul Hadits,

2010) said some of the hadiths spoken by the Prophet including:

ََ َ‫ل َوالد ََّوا ََء الدَّا ََء أَ ْنز‬

‫ل تعالى هللا إن‬ َِ ‫بالحرام تداووا وال فتداووا دَ َواءَ دَاءَ ِل ُك‬
ََ َ‫ل َو َجع‬

the meaning: “Indeed, Allah decreases his disease and medicine and makes
every disease a cure. Then take care of you, and do not you seek treatment with
the unclean (HR. Abu Dawud dari Abu Darda)