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Anamnesis

Patients identity

Name : Mr. M

Age : 68 years old

Sex : MaleAddress : Prampelan 1/4 , Sayung, Demak

No. CM : 1195066

Ward : Baitul Izzah 1

Status : Jamkesmas

Date in : April 30th, 2013

Date out : May 2nd, 2013

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Cough

Main problem

A 68 year old male patient had sufferedfrom chronic dry cough for a year. He

had been unwell for two months with acough producing small amounts ofpurulent sputum, intermittent nightsweats, fever and rigors

History of present illness

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He came to our hospital emergency room

with grievances coughing up percieved since

yesterday evening. There is no blood comingout fresh and mixture of food waste in the

sputum. Since last night, patient admitted

that he experience many times of coughingup. According to the patient, the coughing up

occurs after consuming drugs from clinic

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Currently, the patient feels the cough is very

disruptive especially at night. In addition,

patient also complained about fever hepercieved. His fever is intermittent and not

accompanied by chills. The fever will drops to

normal body temperature if he takingmedication from the clinic. Patient denies

that he has common cold, he also admitted

that sometimes he percieved night sweats

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Patient also complained of shortness breath since twomonths ago. Shortness of breath was occuredeverytime especially if he doing lot of activity. In the

last two days patient feel increasingly breathlessadvancing. Shortness of breath is slightly reduced ifpatient was resting. Ther is no sound produced byshortness of breath. The shortness of breath is notaffected by temperature, weather and dust.

Besides, the patient never percieved left cheststabbing pain that radiating into left upper extremity.Chest pain arises particulary if the patient wasexperiencing coughing and shortness of breath

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Patient complained that his appetite is decreasing inthe last two months, he feel that he is getting thinner.He also often feel nauseous. Patient denied on the

heart burn pain. Sometimes he feel dizzy and languidso he can not do his job as a farmer anymore.

Patient urinate normally, 3-4 times per day, canaryyellow urine, urine stone (-), pain when urinate (-),

blood in urine (-). Patient defecate normally 1-2 times per day, yellowish

watery consistency, mucus (-), blood (-)

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History of past illness

Patient had experienced similiar complaints

over 30 years ago

History of hypertension: denied

History of asthma: denied

History of drug allergy: denied

History of gastritis: denied History of cardiovascular disease: denied

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Familysillnesshistory

Socio-

economichistory

No similiaritycomplaintsamongfamilies

Patient usingJamkesmas

as paymentmethod

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Physical Examination

Vital sign

BP = 120/70 mmHg

HR = 84 x/menit

RR = 20 x/menit

T = 36,5C

BMI

BB = 50 Kg

TB = 155 cm

BMI = 20.8 (N)

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Thorax - Pulmo

INSPEKTION ANTERIOR POSTERIOR

STATIC

RR: 20 x/min, hyperpigmentation (-),

tumor (-), inflammation (-), spider nevi (-

), hemithorax D = S, ICS Normal,

Diameter AP < LL

RR: 20 x/min, hiperpigmentasi (-), tumor

(-), inflammation (-), spider nevi (-),

hemithorax D = S, ICS Normal, Diameter

AP < LL

DINAMYC

The movement of hemitorax D = S,abdominothorakal breathing (-), muscle

retraction of breathing (-), retraction ICS

(-)

The movement of hemitorax D = S,abdominothorakal breathing (-), muscle

retraction of breathing (-), retraction ICS (-

)PALPATION

Palpation pain (-), tumor (-), arcus

costae angle < 900, enlargement of ICS (-

), stem fremitus D = SPalpation pain (-), tumor (-), enlargement

of ICS (-), sterm fremitus D = S

PERCUTION Hipersonor in the right lung Hipersonor in the right lungAUSCULTATION ronchi (+) wheezing (-) vesikuler (+) ronchi (+) wheezing (-) vesikuler (+)IMPRESSION Ronchi (+), Hypersonor

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Thorax - Cor

INSPECTIONIctus cordis isnt seen

PALPATION

Ictus cordis is palpable at ICS V, 2 cm medial from linea mid clavicula sinistra, thrill (-),

pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-)

PERCUTION

Dull sound

Upper borderline

Waist

Lower right borderline

Lower left borderline

: ICS II linea sternalis sinistra

: ICS III linea parasternalis sinistra

: ICS V linea sternalis dextra

: ICS V, 2 cm medial from linea mid clavicula sinistra

AUSCULTATION

Aorta valve

Pulmonal valve

Trikuspidal valve

Mitral valve

: S1 & S2 standart, additional sound (-), AIM2

IMPRESSION : NORMAL

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Abdomen

INSPEKSI

Symetric, sycatric (-), striae (-), scuama (-) enlargement of vena (-), hyperpigmentasi (-),

spider nevi (-)

AUSCULTATION

peristaltic (+) Normal (20 x/minutes)

PERCUTION

side of deaf (-), shifting dullness(-), undulation (-)

Hepar : deaf (+), liver span dextra 9 cm, liver span

sinistra 5 cm

Lien : traube space perkusi dull soundPALPASION

Superfisial :

massa (-) abdominal pain (-)

Deeper:abdominal pain (-)

hepar is not palpable, lien is not palpable, kidney isnot palpable.

IMPRESSION NORMAL

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Extremity

Ekstremity Superior Inferior

Oedem -/- -/-

Cold extremities -/- -/-

Physiological Reflect +/+ +/+

Ikteric -/- -/-

Impression NORMAL

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ECG

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Interpretation

Rhythm : reguler

Frequency :1500 : 22 = 68 bpm

P wave : 0,08 sec (N)

PR Interval : 0,20 sec (N)

QRS Axis : NAD

QRS complex : 0,08 sec (N)

ST Segment : elevation (-); depresion (-)

T wave : tall (-); inverted (AVL, V1)

Impression : Normo sinus rythm

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Laboratory Result - April 30th, 2013

Examination Result Unit Normal valueHematology

Hemoglobin 13,7 g/dl 11,7-15,5

Hematocrit 41.5 % 33-45

Leukocyte 6.7 Thousand/uL 3,6-11,0

Platelet 199 Thousand/uL 150-440

Blood group/ Rh B/ positive

Chemical

GDS 92 mg/dl 75-110

SGOT 41 U/l 0-50

SGPT 32 U/l 0-50

Immunoserology

Qualitative HBsAg Negative Negative

BTA SPS Negative Negative

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Chest X - Ray

Taken Aril 30th, 2013

Impression: Re-

activated old TB lungs

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Summary

Hist

orytaking1. Cough

2. Fever > 7 days

3. Dyspneu

4. Loss of appetite

5. TBC (+)

Physicalex

amination

6. Pulmopercusionhypersonor

7. Pulmo

auscultasion

dry ronkhi (+)

Labora

toryresult

8. X-Ray lungs TB

9. Sputum BTA

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Problem Investigating

Lungs TB (1, 2, 3, 4, 5, 6, 7, 8, 9)

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Treatment Planning for Lungs TB

Supporting diagnostic plan

Sputum BTA SPS, X-Ray

Treatment planning

Non pharmacologi: bed rest, high protein, high

calori diet

Pharmacology :

R/ DOTS kategori I S 1 dd III tab

R/ Vitamin B Complex S 2 dd 1

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Regimen kategori I

2RHZE/4R3H3

R/ Rifampisin 450 mg tab No.VII

S 1ddI

R/ Isoniazid 300 mg tab No. XIV

S 1ddIR/ Pirazinamid 500 mg tab No. XIV

S 1ddII

R/ Ethambutol 250 mg tab No. XXI

S 1ddIII

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R/ Rifampisin 450 mg tab No.VII

S 1ddI

R/ Isoniazid 300 mg tab No. VIIS 1ddI

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Education planning

Open the window every morning for house

circulation and sunshine to reduce humidity

High calorie high protein food intake

Bed rest

Taking medication regulary

Dont spit carelessly

Closes mouth by hand when cough or sneezing

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Prognostic

Ad vitam : ad bonam

Ad sanationam : dubia ad malam

Ad functionam : dubia ad bonam

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Follow Up

Date BP HR RR T S O A P

30.4.2013120

7084 20x

36,5

oCCough Compos mentis TBC

Sputum BTA S1,

ECG, routine blood

lab, X-Ray

01.05.2013110

7086 20x

36.4

oCCough Compos mentis TBC

Sputum BTA P and

S2

02.05.2013110

7072 20x

36.7

oCCough Compos mentis TBC -

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1. Hasil pengobatan TB paru BTA + ?

2. Evaluasi pengobatan pada pasien TB ?

3. Pengobatan TB pada pasien DM ?

4. Kapan pasien TB diberi kortikosteroid ?

5. Regimen obat sisipan dan kapan diberikan ?6. Komplikasi TB paru ?

7. Gold standard diagnosis TB?

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8. Seandainya pasien TB di cek SGOT 65 SGPT 60

apa yang akan anda lakukan ?

9. DD TB Paru?

10.Kapan disebut MDR

11.Pengobatan TB paru pada kehamilan ?

12.Biasanya pasien TB Paru resisten pada obat

apa ?

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13.Jelaskan intrepetasi BTA ?

14.Dapatkah anak menularkan TB ke orang

dewasa

15.Pengobatan TB pada pasien kelainan hati

kronik

16.Pengobatan TB pada pasien gagal ginjal

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PR CBD TB PARU

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Pasien TB dengan kelainan hati kronik

Bila ada kecurigaan gangguan faal hati, dianjurkanpemeriksaan faal hati sebelum pengobatan TB.

Bila SGOT dan SGPT meningkat lebih dari 3 kali OATtidak diberikan dan bila telah dalam pengobatan,

harus dihentikan. Kalau peningkatannya kurang dari 3 kali, pengobatan

dapat dilaksanakan atau diteruskan denganpengawasan ketat.

Pasien dengan kelainan hati, Pirasinamid (Z) tidakboleh digunakan.

Paduan OAT yang dapat dianjurkan adalah2RHES/6RH atau 2HES/10HE.

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Pasien TB dengan gagal ginjal

Isoniasid (H), Rifampisin (R) dan Pirasinamid (Z) dapat diekskresi melalui empedu dan dapat dicerna menjadisenyawa-senyawa yang tidak toksik.

OAT jenis ini dapat diberikan dengan dosis standar padapasien-pasien dengan gangguan ginjal.

Streptomisin dan Etambutol diekskresi melalui ginjal, olehkarena itu hindari penggunaannya pada pasien dengangangguan ginjal.

Apabila fasilitas pemantauan faal ginjal tersedia,

Etambutol dan Streptomisin tetap dapat diberikan dengandosis yang sesuai faal ginjal.

Paduan OAT yang paling aman untuk pasien dengan gagalginjal adalah 2HRZ/4HR.

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Kelebihan terapi DOTS dibandingkan

dengan terapi non DOTS?

Menjamin kesembuhan bagi penderita

Mencegah penularan

Mencegah resistensi obat

Mencegah putus berobat dan segera

mengatasi efek samping obat jika timbul

Mempermudah pasien mengingat dalammeminum obat

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Efek samping terapi TB mayor dan

minor dan penanganannya

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PEMANTAUAN BTA PASIEN

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SEMBUH? GAGAL? RELAPS?

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RONTGEN TB SPESIFIK DAN NON SPESIFIK

Tidak ada gambaran foto rontgen dada yang khasuntuk TBC paru

Beberapa gambaran yang patut dicurugai sebagaiproses spesifik adalah infiltrat, Kavitas, Kalsifikasi dan

fibrosis ( pembentukan jaringan ikat pada prosespemulihan atau reaktif) dengan lokasi dilapanganatas paru (apeks)

Gambaran non spesifik yang ditemukan pada fotorontgen dada pada seorang penderita yang diduga

infeksi paru lain dan tidak menunjukkan perbaikanpada pengobatan dengan antibiotik ada kemungkinanpenyebabnya adalah TB