Case Dr. Hamid tB Kiki

7/28/2019 Case Dr. Hamid tB Kiki

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SMF PENYAKIT DALAM Name :.

RSUD Dr. H. ABDUL MOELOEK N I M :.

BANDARLAMPUNG

PATIENT STATUS

PATIENT IDENTITY

Full Name : Mrs SSex : FemalePlace / Date of Birth /Age : Tanjung Karang, 22th Nop 1959

Nationality : LampungMarital status : MarriedReligion : IslamOccupation : Farmer Educational background : SDAddress : Tanjung Karang

ANAMNESIS

Taken From : Autoanamnesis Date 6th March 2009 Time 11.30 WIB

The main complained : Sputum coughThe History of the Illness :

The patient came to hospital with complaint ofsputum cough. The complaint heldsince 3 months before came to the hospital. She also complained about chest pain, bloodcough, hard breathing, night sweat, weakness, less passion eat, and weight decreasing.

She confessed that she had ever bought a drug which is bought in midwife. But theshymptom wasnt getting better, later the patient gone to the hospital and she must to stayin the hospital for treatment. And she had no treatment with Packet Drug of OAT

History of DM: deniedHistory of Hypertension: denied

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The History of Illness :

( ) Small pox ( ) Malaria ( ) Kidney stone( ) Chicken pox ( ) Disentri ( ) Burut (Hernia)( ) Difthery ( ) Hepatitis ( ) Prostat( ) Pertusis ( ) Tifus Abdominalis ( ) Melena( ) Measles ( ) Skirofula ( ) Diabetic() Influenza ( ) Sifilis ( ) Alergyc( ) Tonsilitis ( ) Gonore ( ) T u m o r ( ) Kholera ( ) Hipertensi ( ) Vaskular Disease( ) Demam Rematik Akut ( ) Ulkus Ventrikuli( ) Pneumonia ( ) Ulkus Duodeni( ) Pleuritis () Gastritis( ) Tuberkulosis ( ) Stone Gall others : ( ) Operation

( ) Accident

History of Family :

ConnectionAge(th)

Sex Healthy Causa of Death

Grandfather 75 Male DeathGrandmother 60 Female DeathFather 70 Male Death

Mother 63 Female DeathBrother-sister HealthChildren Health

An any relation who suffer :

Illness Yes No ConnectionAlergyc Asthma Tuberkulosa

Artritis Rematisme Hipertensi Cor Kidney Gaster

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ANAMNESIS SISTEM

Note Complain Positif beside the title

Skin

( ) Boil ( ) Hair () Night swet( ) Nail ( ) Yellow / Ikterus ( ) Sianotic( ) Others

Head( ) Trauma ( ) Headache( ) Sinkop ( ) Pain of the sinus

Eye( ) Pain ( ) Inflammation of night sweat

( ) Secret ( ) Eye disorder ( ) yellow / Ikterus ( ) Sharpness to see

Ear( ) Pain ( ) Tinitus( ) Secret ( ) Ear disorder

( ) Deaf

Nose( ) Trauma ( ) Clogging

( ) Pain ( ) Nose disorder ( ) Sekret ( ) Have a cold( ) Epistaksis

Mouth( ) Lip ( ) Tongue( ) Gums ( ) Mouth disorder ( ) Membrane ( ) Stomatitis

Throat

( ) Throats pain ( ) Voice (change)

Neck( ) Protruding ( ) Necks pain

Cor / Lung() Chest pain (Left) () Dyspneu( ) Pulse () Hemoptoe( ) Ortopnoe () Cough

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WeightAverage weight (kg) : 50 kgMax weight (kg) : 60 kgPresent weight (kg) : 45 kg

(if the patient doesnt know certainly)Steady ( )Down ()Up ( )

THE HISTORY OF LIFE

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Birth place : ( ) in home ( ) matrinity ( ) Matrinity hospitalHelped by : ( ) Doctor ( ) nurse ()Traditional matrinity

( ) Others

Imunitation History

( ) Hepatitis ( ) BCG ( ) Campak ( ) DPT ( ) Polio( ) Tetanus

Food History

Frekuensi/day : 3x/dayAmount /day : 2 plate/eat (health), plate/eat (illness)Variation /day : Rice, vegetables, egg, fishAppetite : Enough

Educational

( ) SD ( ) SLTP ( ) SLTA ( ) SMK ( ) Academy( ) Course ( ) Unschool

Problem

Financial : LowWorks : Farmer Family : Good relation

Others : -

Body Check Up

General Check upHeight : 150cmWeight : 45 kgBlood Pressure : 110/70 mmhgPulse : 100 x/minute

Temp : 36,8o

CBreath (frequence&type) : Regular Nutrition condition : UnderweightConsciousness : Compos mentisCianotic : -General edema : -Habity : -The way of walk : NormalMobility (active/pasive) : ActiveThe age prediction based on check up : 50Mentality Aspects

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Behavior : NormalNature of feeling : NormalThe thinking process : Normal

SkinColor : BrownEfloresensi : -Keloid : -Pigmentasi : -Hair Growth : NormalArteries : feelTouch temperature : AfebrisHumid/dry : HumidSweat : Normal

Turgor : NormalIcterus : AnictericFat layers : -Edema : -Others : -

Lymphatic Gland

Submandibula : Untouched enlargementNeck : Untouched enlargementSupraklavikula : Untouched enlargement

Armpit : Untouched enlargement

Head

Face expression : NormalFace symmetric : SymmetricHair : Black and uprootedTemporal artery : Normal

Eye

Exopthalmus : -Enopthalmus : -Palpebra : edeme -Lens : Clear Conjungtiva : AnanemisVisus : 4/6Sklera : AnictericEye movement : Good in every sideVision scope : NormalEye ball pressure : Normal Perpalpation

Deviatio konjungae : -

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Nystagmus : -

Ear

Deaf : -

Membrane tymphani : -Foramen : -Obstruction : -Serumen : -Bleeding : -Liquid : -

Mouth

lips : -Tonsil : -

Palatal : NormalHalibsts : NoTeeth : CariesTrismus : -Farings : UnhiperemisLiquid layer : SalivaTongue : Not dirty

Neck

JVP : NormalTiroid gland : Untouched enlargementLimfe gland : Untouched enlargement

Chest

Shape : SimetricArtery : NormalBreast : Normal

Lung

Inspeksi Left : simetricRight : simetric

Palpasi Left : tactil fremitus = dextraRight : tactil fremitus = Sinistra

Perkusi Left : DullnessRight : Dullness

Auskultasi Left : Vesiculer , wet RonchiRight : Vesiculer , wet Ronchi

Cor

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Inspection : IC unseenPalpation : IC feel in linea midclavicula sinistra ICS VPercution : decrease of heart soundAuskultation : heart voice I and II normal, murmur (-), gallop (-)

Artery

Artery temporalis : No distinctArtery karotis : No distinctArtery brakhialis : No distinctArtery radialis : No distinctArtery femoralis : No distinctArtery poplitea : No distinctArtery tibilias posterior : No distinct

Stomach

Inspection : normal in 4 regionPalpation

Stomach wall : pressure pain (-)Heart : not feelLimfe : not feelKidney : ballotemen (-)

Percution : shifting dullness (-)Auscultation : intestine sounds (+)

Refleks stomach wall

Genital (based on indication)Female : no indicationOUE : no indicationFlour albus : no indication

Movement joint

Arm Right LeftMuscle normal normalTonus normal normalMassa normal normalJoint normal normalMovement normal normalStrength weakness weaknessOthers

Heel and leg

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Wond/injury : not foundVarices : (-)Muscle (tonus & mass) : normalJoint : normal

Movement : normalStrength/power : weaken (+)Edema : (-)Others : (-)

Reflexs

Right LeftTendon reflex normal normalBisep normal normalTrisep normal normal

Patela normal normalAchiles normal normalCremaster normal normalSkin reflex normal normalPatologic reflex not found not found

LABORATORY (6th march 2009)

Blood

Hb : 11,8 gr/dl (13,5 18,0 gr/dl)Ht : 34%Leukosit : 6400/l (4.500 10.700/ l)Variety count

Basofil : 0 % (0 1 %)Eusinofil : 3 % (1 3 %)Batang : 0 % (2 6 %)Segmen : 80% (50 70 %)Limfosit : 18% (20 40 %)

Monosit : 2 % (2 8 %)

LED : 30 mm/jam (0 10 mm/hour)Trombosit : 216.000 /lSGOT : 18 U/L (6 30 U/L)SGPT : 8 U/L (6 45 U/L)

BTA : (+) (+) (+)

Complete feses : Not do it

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Follow Up

Date 6/03/2009 7/ 03/2009 10/03/2009

- Hard Breathing

- Chest pain

- Night sweat

- Sputum cough

- Appetite

- Weakness

- Weight decreasing

(+)(+)(+)(+)(+)(+)(+)

()(+)(+)(+)(+)(+)(+)

()(-)(+)(+)(+)(+)(+)

General present Intermediet ill appearance

Awakeness Compos mentis

Vital sign

- BP

- Temperature

- RR

- HR

110/70 mmHg36,20 C

28 x / menit100 x / menit

110/7036,40 C

27x/ menit100x/ menit

110/7036,40 C

27x menit92x/ menit

Status generalis

- Eyes

- Anemis- Thoraks

- Inspection

- Palpation

- Percusion

- Auscultation

(-)

SymmetricL : Fremitus L : Dullness

L : Vesiculer Wet Rhonchi +/+

(-)

SymmetricL : Fremitus L : Dulness

L : Vesiculer Wet Rhonchi +/+

(-)

SymmetricL : Fremitus L : Dullness

(basal)L : Vesiculer

Wet Rhonchi +/+Additional Analyze

- Thorax Photo PA Inflitrat (+/+) >2/3

ICS, radioopaque,bilateral

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Treatment

- IVFD RL XXgtt/mnt

- O2 3L/mnt

- DMP Syr 3x1C- KalneX 500mg/8jam- Cefotaksim 1 gr/12

jam

- Rifampisin 1x450mg

- INH 1x300 mg

- Pirazinamid1x2(500mg)

- Etambutol 2x500mg

- Vit B Complex 3x1

(+)

(+)

(+)(+)(+)

(-)(-)(-)

(-)(-)

(+)

(-)

(+)(+)(+)

(+)(+)(+)

(+)(+)

(+)

(-)

(+)(-)(+)

(+)(+)(+)

(+)(+)

Result Hasnt been changed

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RESUME

Patient, Mrs. S 50 years old came to hospital with complaint ofsputum cough, chest pain,blood cough, hard breathing, night sweat, weakness, less passion eat, and weight

decreasing. And she had no treatment with Packet Drug of OAT

Height : 150 cm

Weight : 45 kg

Blood Pressure : 110/70 mmhg

Pulse : 100 x/minute

Touch temperature : Afebris

Lung

InspeksiLeft : simetricRight : simetric

PalpasiLeft : tactil fremitus = dextraRight : tactil fremitus = Sinistra

Perkusi

Left : DullnessRight : Dullness

AuskultasiLeft : Vesiculer , wet RonchiRight : Vesiculer , wet Ronchi

Movement joint Right Left

Strength weakness weakness

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LABORATORY

BloodHb : 11,8 gr/dl (13,5 18,0 gr/dl)Ht : 34%

Leukosit : 6400/l (4.500 10.700/ l)Variety countBasofil : 0 % (0 1 %)Eusinofil : 3 % (1 3 %)Batang : 0 % (2 6 %)Segmen : 80% (50 70 %)

Limfosit : 18% (20 40 %)Monosit : 2 % (2 8 %)

LED : 30 mm/hour (0 10 mm/hour)

Trombosit : 216.000 /lSGOT : 18 U/L (6 30 U/L)SGPT : 8 U/L (6 45 U/L)

BTA : (+) (+) (+)

Working diagnose and basic diagnose1. Working diagnose

Lung Tuberculosis BTA (+), maXimal lesion, new case.

2. Basic DiagnoseAnamnesis : sputum cough, blood cough, chest pain, hard breathing, night sweat,weakness and weight decreasing.Clinical checkup :

I : Weakness, underweightP: Tactil Fremitus right = leftP: DullnessA: Vesiculer , Ronkhi +

Support checkup :Result SPS (+)(+)(+)Blood

LED : 30 mm/hour Segmen : 80%

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Differencial diagnose

1. Differencial diagnosePneumonia

2. Differencial basic diagnose

chest pain, Rontgen thorak, LED high

Plan treatment

DOTS (directly observation treatment shortcut)

Bed rest

Pollution denied

Suplement

Nutrition

PrognoseQuo ad vitam : dubia ad bonamQuo ad functionam : dubia ad bonamQuo ad sanationam : dubia ad bonam

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DISCUSSION

This Patient had been diagnosed as Lung Tuberculosis New case/BTA (+),

MaX

imal Lesion based on history taking, physical examination, and support examination.

1. Taking from anamnesis, the patient complained sputum cough happening repeatedlyeveryday, chest pain, breathless, night sweat, weakness and weight decreasing Historyof cough 3 months years ago and had no treatment with Packet Drug of OAT

2. Taking from physical examination were found decreased tactile fremitus, dullness ordecreased resonance to percussion, diminished or inaudible breath sounds at left andright hemithorax.

3. Taking from Support examination, laboratorium segmen 80 %, LED 30 mm/hour,BTA (+) (+) (+).

4. Thorax Photo PA appearance shown infiltrat > 2/3 ics, radioopaque, bilateral.

5. Treatment based on DOTS (Directly Observed Treatment Shortcourse). This caseincluded to 1st Category. OAT drug are 2RHZE/4RH

6. Simptomatic treatment for sputum cough was given mucolitic group, for example

DMP syrup 15mg/5ml 3 times/day.

7. To Anticipate the side effect of INH (nausea), the patient should be given Vitamin B650 mg 3 times/day.

8. The Differencial diagnose Pneumonia

TUBERCULOSIS

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TB is a infection disease that caused of mycobacterium tuberculosis. The spots of

TB infection germ are respiratory tracts, absorption tracts and opened injury in skin. Most

of TB infection occur pass through air , by means of droplet inhalation that consist of

basil which come from person who infected. The spreading capacity from a sufferer is

depended on the number of germ that issued from the lung.someone might be infected by

TB from the droplet concentration in the air, and how long they breath that air.

TB is a disease that controlled by imunity response insequenced cell. Efector cells

are macrofag and limfosit ( usually T cell ). They are imunoresponsive cells. This type

usually local, involving macrofag which actived in infection spot by limfosit and its

limfokin. The response is called as hypersensitivity cellular reaction ( slow reaction )

CLASSIFICATION OF TBC BASE ON THE HISTORY

1. Primary TBC

its happen when someone attack primarly by TBC germ. The infection started

when the TBC germ replicated successfully in the lung. Thats cause the inflammation.

Limfe tractus will carry TBC germ into limfe gland around lung hilus and it.s called asprimary complexs.

Time between infection happens until primary complexs form are around 4 6 weeks.

The infection cold be proven by by the occur of tuberculin reaction that changes from

negative into positive. The incubation period is time needed from infected till become

sick, approximated for about 6 month.

2. After Primary TBC

Usually happen after several month or year. After primary infection, for example

because of the descent body defense in consequence infected by HIV or malnutrient

status. The main characteristic for after primary TBC is the broadening lung damage in

occurring cavity or pleural effusion.

PATOGENENCY

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The risk factor are :

1. must have infection sorce

2. the number of bacillus as an infection cause must be sufficient

3. the high virulence of TBC bacillus

4. The descent of body defense make the bacillus reproduce

Clinic illustration :

1. The main symptom

Continous cough with/without sputum during 3 weeks or more

2. Additional symptom

- Sputum mixed with blood

- Haemoptoe

- Dyspnea and chest pain

- Weakness

- Night sweat

- Decrease weight

- Feverish fever more than 1 month

DIAGNOSIS

Lung TBC diagnosis can be stood at by BTA finding in sputum inspection microscopicly.

The inspection result tangibled positive if at least 2 from 3 SPS specimen must be positive.

If only 1 specimen which positive, so its needed a further check up, that is chest x-rayphoto or SPS sputum check up repeated.

a. If the x-ray result supports TBC, so the patient is diagnosed as TBC BTA sufferer

positive

b. If the x-ray result unsupports TBC, so the sputum check up repeated

If three sputum specimen are negative, give an extensive spectrum antibiotic during 1-2weeks. If the condition still bad, do SPS sputum check up repeated.

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a. If the SPS result are positive, diagnosed as infection TBC BTA infected

b. If the SPS result are still negative, do thr chest X-ray check up.

If the X-ray result supports TBC, diagnosed as negative BTA patient but

the X-ray positive If the X-ray result not supports TBC, the patient is not TBC.

MEDICAL TREATMENT

Purpose :

1. Cure the patient

2. Prevent death3. Prevent relapse

4. Decreasing the level of spreading

Category 1 (2HRZE/4H3R3) :

New patient lung TBC positive BTA

Patient lung TBC negative BTA, X-ray positive who got serious illness

Patient heavy extra lung TBCIntensive stage consist of Isoniasid(H), Rifampicin(R), Pirazinamid(Z), dan Etambutol(E).

Those medicine are given everyday during two (2) month (2HRZE). Then continued by

next stage, that consists of Isoniasid(H), and Rifampicin(R). Given three times a week

during four month (4H3R3).

Category 2 (2HRZES/HRZE/5H3R3E3):

Relaps patient Failure patient

After default patient

Intensive stage are given for three month consists of HRZES during 2 month given

everyday (2HRZES), continued by HRZE during 1 month given every day (HRZE). Then

continued by next stage that consists of HRE during 5 month given 3 times a week.

Category 3 (2HRZES/4H3R3) :

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New patient BTA negative and X-ray positive, light ill.

Patient extra light lung, it is TBC limfadenitis, pleuritis eksudativa unilateral, skin

TBC, bone TBC (except backbone), joint TBC and adrenal gland.

Intensive stage consist of HRZ, given everyday during 2 month(2HRZ), continued bysequel stage that consist of HR during 4 month given 3 times a week(4H3R3). One packet

of Combipac 3rd category contents of 114 daily blister that consist of 60 blister HRZ for

the intensive stage and 54 blister HR for the sequel stage each packed in a small doss and

bounded in a big doss.

Implied OAT (HRZE)

If the end of intensive treatment of new patient BTA positive in 1

st

category or patientBTA positive retreatment by category 2nd, sputum check up result still BTA positive

(positive BTA), given medical implied (HRZE) everyday during 1 month.

BIBBLIOGRAPHY

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1. W, Aru. Sudoyo, et all. 2006. Ilmu Peyakit Dalam Ed IV Jilid I. Departemen Ilmu

Penyakit Dalam FKUI, Jakarta.

2. Yoga, Tjandra Aditama. 2006. TUBERKULOSIS PEDOMAN DAN

PENATALAKSANAAN DI INDONESIA. Perhimpunan Dokter Paru Indonesia, Jakarta.

3. Arun Gopi, Sethu M. Madhavan, Surendra K. Sharma and Steven A.Sahn. 2007.

Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006. American College

of Chest Physicians.

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Case Dr. Hamid tB Kiki

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