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SCOFYL
o Hypothesis
1. Patient has tuberculosis as evidenced by acid fast result and symptoms.
2. Patient has a resistant strain of Mycobacterium tuberculosis due to improper medication.
3. Pleural effusion from capillary permeability, that leads to VQ mismatch.
o Learning Issues
1. Airway and its mechanism
Respiratory tract
o Upper Respiratory Tract
Nose, vestibule, nasal cavity, nasopharynx, Larynx
o Lower Respiratory Tract
Trachea, primary bronchus, tertiary bronchus, bronchioles, terminal bronchioles, respiratory
bronchioles, alveolar ducts to sacs, alveoli
Blood air barrier components:
o Cytoplasm of Type 1 pneumocytes
o Single basement membrane
o Pulmonary capillary endothelium
Nasopharynx for Filtration and Humidification
Type 2 Pneumocytes
o Surfactant production
Parietal: (sensitive to pain) costal, mediastinal, diaphragmatic
Visceral: Autonomic Nervous Supply
Tracheobronchial tree
o Larynx, trachea (C6 to T4-5), bifurcates to two primary bronchi.
o Three secondary bronchi on Right, two secondary bronchi on Left
o Right lung has 3 lobes, left lung has 2 lobes.
2. Pathogenesis/Pathophysiology of TB
Droplet nuclei of bacteria is inhaled. Travelled thru alveoli and multiply. Small number of the tubercle will enter
systemic circulation. Macrophages surround tubercle creating a granuloma. Bacilli multiply rapidly.
Initially the tubercle bacilli will lodge in middle lobe (Gon Focus).
Lower alveoli in the middle lobe or inferior lobe, upper alveoli.
Gon Complex: Gon focus and enlarged lymph node which drained the complex
Macrophage: rapidly multiplies in response to the tubercle.
o Tubercle feeds on the macrophage (phagolysosomes), inhibiting it and rendering macrophage inactive
therefore leading to multiplication of tubercle.
Cough - Two to 12 weeks in average of 3 weeks. Other systems will come into play.
Macrophage is innate immunity. Cellular immunity T cells (helper t-cells) is activating epitheloid histocytes.
o T-helper cells activate B cells
o B cells humoral immunity
3. Development of cavitary lesion
Accumulation of the tubercle
Asymmetrical expansion of lungs
4. Shape of bacteria (AFB and gram staining)
Cell wall component of proteoglycan and mycolic acid causes the acid fast positive reaction
Carbolfuchsin: stain used
Counterstain: methylene blue
Acid alcohol for decolorizing non-acid fast bacilli
5. VQ mismatch
Mismatch between ventilation and perfusion
High VQ: higher ventilation
Low VQ: higher perfusion than ventilation
Ventilation is lower than the perfusion
6. Chloride effect
Exchange of bicarbonate for chloride. To regulate levels of bicarbonate.
Also known as Hamburger effect
7. Oxygen dissociation curve
Bohr: Increase in Carbon Dioxide facilitate Oxygen unloading
In the case of the patient, there is Reverse BOHR: Decrease CO2, Increase O2 loading.
o Evidenced by respiratory alkalosis of the patient
Anemic patient: low oxygen tension
o Compensate by tachypnea to increase oxygen tension for the purpose of peripheral perfusion
Oxygen and carbon dioxide transport: Protoporphyrin ring capable of binding to 4 oxygen molecules.
Sigmoidal in shape.
o Shift in right: increase in temperature, increase in pH, increase in 2,3-DPG, increase in CO2
Increase in oxygen demand: decrease O2 affinity, hence, oxygen is efficiently delivered in tissues
Shift in the left is reverse of the factors
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Adequate oxygenation, oxygen is less efficiently delivered to tissues
8. Pulse oximetry
SPo2 principles
o Hemoglobin and oxyhemoglobin differs in absorption of red light.
Oxyhemoglobin absorbs light more such as in arterial blood.
o Volume of arterial blood
Normal: 90-100%. 95% above is desirable
9. Treatment for tuberculosis
Isoniazid and Vitamin B6: can be used alone in treatment of active tuberculosis.
o Antibiotic: Inhibits synthesis of mycolic acid but depletes Vitamin b6.
o Side effect is peripheral neuropathy.
Common dose: 300 mg PO, once daily for 6-9 months
Pyridoxine: 25 mg/day
DOTS program: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Streptomycin
Class 1: two months intensive phase and four months maintenance phase
10. Mechanism of cefuroxime
Family of cephalosporin
2nd generation
For gram positive and some gram negative
Inhibits bacterial cell wall synthesis
11. Hemoptysis mechanism: Rupture of superficial vessels, splitting of blood from lungs and bronchial tubes as a result
of bronchial hemorrhage
12. Infection leads to engorgement of vessels.
Granuloma erode on nearby vessels. Secretions include the blood and secretions from the cavitary
lesions
More infectious
13. Mechanism of pleural effusion:
Caused by hypersensitivity response by imbalance of oncotic and hydrostatic pressure
Mechanism:
o Transudate: yellowish, thin fluid. Partial and complete blockage of drainage of lymph.
Decrease in lung compliance exhibited in X-ray and the result of tactile fremitus
14. Prognosis
Resistant to isoniazid.
Multidrug resistant.
Test for culture and sensitivity for proper medication regimen.
15. Preventive measure for TB
BCG vaccine in newborns. 0.05ml ID deltoid
N95 mask - airborne transmission
Isolate patient for 2-3 weeks
DOTS program/medication adherence
Negative pressure room
Boil 30 minutes the clothes used by the patients before laundry
Well ventilated room, well lighted (sunlight)
Increase immunity and resistance
16. Thoracentesis
Surgical perforation of the chest wall and pleural space with a needle to aspirate fluid for diagnostic or
therapeutic purposes or to remove a specimen for biopsy
Superiorly posteriorly the rib to avoid the VAN at the 7th to 9th ICS.
Sitting leaning forward