Anamnesis

Patients identity
Name Age Sex Address No. CM Ward Status Date in Date out : Mr. M : 68 years old : Male : Prampelan 1/4 , Sayung, Demak : 1195066 : Baitul Izzah 1 : Jamkesmas : April 30th, 2013 : May 2nd, 2013

Main problem
Cough

History of present illness

A 68 year old male patient had suffered from chronic dry cough for a year. He had been unwell for two months with a cough producing small amounts of purulent sputum, intermittent night sweats, fever and rigors

 He came to our hospital emergency room with grievances coughing up percieved since yesterday evening. There is no blood coming out fresh and mixture of food waste in the sputum. Since last night, patient admitted that he experience many times of coughing up. According to the patient, the coughing up occurs after consuming drugs from clinic

 Currently, the patient feels the cough is very disruptive especially at night. In addition, patient also complained about fever he percieved. His fever is intermittent and not accompanied by chills. The fever will drops to normal body temperature if he taking medication from the clinic. Patient denies that he has common cold, he also admitted that sometimes he percieved night sweats

 Patient also complained of shortness breath since two months ago. Shortness of breath was occured everytime especially if he doing lot of activity. In the last two days patient feel increasingly breathless advancing. Shortness of breath is slightly reduced if patient was resting. Ther is no sound produced by shortness of breath. The shortness of breath is not affected by temperature, weather and dust. Besides, the patient never percieved left chest stabbing pain that radiating into left upper extremity. Chest pain arises particulary if the patient was experiencing coughing and shortness of breath

 Patient complained that his appetite is decreasing in the 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 languid so he can not do his job as a farmer anymore. Patient urinate normally, 3-4 times per day, canary yellow urine, urine stone (-), pain when urinate (-), blood in urine (-). Patient defecate normally 1-2 times per day, yellowish watery consistency, mucus (-), blood (-)

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

Familys illness history

Socioeconomic history

No similiarity complaints among families

Patient using Jamkesmas as payment method

Physical Examination

Vital sign
BP HR RR T = 120/70 mmHg = 84 x/menit

BMI
BB = 50 Kg
TB = 155 cm

= 20 x/menit = 36,5C

BMI

= 20.8 (N)

Thorax - Pulmo
INSPEKTION
STATIC

ANTERIOR

POSTERIOR

DINAMYC

PALPATION PERCUTION
AUSCULTATION

RR: 20 x/min, hyperpigmentation (-), RR: 20 x/min, hiperpigmentasi (-), tumor tumor (-), inflammation (-), spider nevi ((-), inflammation (-), spider nevi (-), ), hemithorax D = S, ICS Normal, hemithorax D = S, ICS Normal, Diameter Diameter AP < LL AP < LL The movement of hemitorax D = S, The movement of hemitorax D = S, abdominothorakal breathing (-), muscle abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS retraction of breathing (-), retraction ICS ((-) ) Palpation pain (-), tumor (-), arcus Palpation pain (-), tumor (-), enlargement costae angle < 900, enlargement of ICS (of ICS (-), sterm fremitus D = S ), stem fremitus D = S Hipersonor in the right lung ronchi (+) wheezing (-) vesikuler (+) Hipersonor in the right lung ronchi (+) wheezing (-) vesikuler (+)

IMPRESSION

Ronchi (+), Hypersonor

Thorax - Cor
INSPECTION Ictus 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 AUSCULTATION Aorta valve Pulmonal valve Trikuspidal valve Mitral valve IMPRESSION : 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 : S1 & S2 standart, additional sound (-), AI<A2 : S1 & S2 standart, additional sound (-), P1<P2 : S1 & S2 standart, additional sound (-), T1>T2 : S1 & S2 standart, additional sound (-), M1>M2 : NORMAL

Abdomen
INSPEKSI Symetric, sycatric (-), striae (-), scuama (-) enlargement of vena (-), hyperpigmentasi (-), spider nevi (-) AUSCULTATION peristaltic (+) Normal (20 x/minutes) PERCUTION side of deaf (-), shifting dullness Hepar : deaf (+), liver span dextra 9 cm, liver span (-), undulation (-) sinistra 5 cm Lien : traube space perkusi dull sound PALPASION Deeper: Superfisial : abdominal pain (-) massa (-) abdominal pain (-) hepar is not palpable, lien is not palpable, kidney is not palpable. IMPRESSION NORMAL

Extremity
Ekstremity Oedem Cold extremities Physiological Reflect Ikteric Impression Superior -/-/+/+ -/NORMAL Inferior -/-/+/+ -/-

ECG

Interpretation
Rhythm Frequency P wave PR Interval QRS Axis QRS complex ST Segment T wave Impression : reguler :1500 : 22 = 68 bpm : 0,08 sec (N) : 0,20 sec (N) : NAD : 0,08 sec (N) : elevation (-); depresion (-) : tall (-); inverted (AVL, V1) : Normo sinus rythm

Laboratory Result - April 30th, 2013

Examination
Hemoglobin Hematocrit Leukocyte Platelet Blood group/ Rh

Result
Hematology 13,7 41.5 6.7 199 B/ positive Chemical

Unit
g/dl % Thousand/uL Thousand/uL

Normal value
11,7-15,5 33-45 3,6-11,0 150-440

GDS
SGOT SGPT Qualitative HBsAg BTA SPS

92
41 32

mg/dl
U/l U/l

75-110
0-50 0-50 Negative Negative

Immunoserology Negative Negative

Chest X - Ray
Taken Aril 30th, 2013
Impression: Reactivated old TB lungs

Summary
2. Fever > 7 days

Physical examination

Laboratory result

History taking

1. Cough

3. Dyspneu
4. Loss of appetite 5. TBC (+)

6. Pulmo percusion hypersonor 7. Pulmo auscultasion dry ronkhi (+)

8. X-Ray lungs TB 9. Sputum BTA

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

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

Regimen kategori I 2RHZE/4R3H3

R/ Rifampisin 450 mg tab S 1ddI R/ Isoniazid 300 mg tab S 1ddI R/ Pirazinamid 500 mg tab S 1ddII R/ Ethambutol 250 mg tab S 1ddIII No.VII No. XIV

No. XIV
No. XXI

R/ Rifampisin 450 mg tab No.VII S 1ddI R/ Isoniazid 300 mg tab No. VII S 1ddI

 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

Prognostic
Ad vitam Ad sanationam Ad functionam : ad bonam : dubia ad malam : dubia ad bonam

Follow Up
Date 30.4.2013 BP 120 70 HR 84 RR 20x T 36,5 oC S Cough O
Compos mentis

A
TBC

P
Sputum BTA S1, ECG, routine blood lab, X-Ray

01.05.2013

110 70 110 70

86

20x

36.4 oC 36.7 oC

Cough

Compos mentis

TBC

Sputum BTA P and S2

02.05.2013

72

20x

Cough

Compos mentis

TBC

1. 2. 3. 4. 5. 6. 7.

Hasil pengobatan TB paru BTA + ? Evaluasi pengobatan pada pasien TB ? Pengobatan TB pada pasien DM ? Kapan pasien TB diberi kortikosteroid ? Regimen obat sisipan dan kapan diberikan ? Komplikasi TB paru ? Gold standard diagnosis TB?

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 ?

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

PR CBD TB PARU

Pasien TB dengan kelainan hati kronik

Bila ada kecurigaan gangguan faal hati, dianjurkan pemeriksaan faal hati sebelum pengobatan TB. Bila SGOT dan SGPT meningkat lebih dari 3 kali OAT tidak diberikan dan bila telah dalam pengobatan, harus dihentikan. Kalau peningkatannya kurang dari 3 kali, pengobatan dapat dilaksanakan atau diteruskan dengan pengawasan ketat. Pasien dengan kelainan hati, Pirasinamid (Z) tidak boleh digunakan. Paduan OAT yang dapat dianjurkan adalah 2RHES/6RH atau 2HES/10HE.

Pasien TB dengan gagal ginjal

Isoniasid (H), Rifampisin (R) dan Pirasinamid (Z) dapat di ekskresi melalui empedu dan dapat dicerna menjadi senyawa-senyawa yang tidak toksik. OAT jenis ini dapat diberikan dengan dosis standar pada pasien-pasien dengan gangguan ginjal. Streptomisin dan Etambutol diekskresi melalui ginjal, oleh karena itu hindari penggunaannya pada pasien dengan gangguan ginjal. Apabila fasilitas pemantauan faal ginjal tersedia, Etambutol dan Streptomisin tetap dapat diberikan dengan dosis yang sesuai faal ginjal. Paduan OAT yang paling aman untuk pasien dengan gagal ginjal adalah 2HRZ/4HR.

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 dalam meminum obat

Efek samping terapi TB mayor dan minor dan penanganannya

PEMANTAUAN BTA PASIEN

SEMBUH? GAGAL? RELAPS?

RONTGEN TB SPESIFIK DAN NON SPESIFIK

Tidak ada gambaran foto rontgen dada yang khas untuk TBC paru Beberapa gambaran yang patut dicurugai sebagai proses spesifik adalah infiltrat, Kavitas, Kalsifikasi dan fibrosis ( pembentukan jaringan ikat pada proses pemulihan atau reaktif) dengan lokasi dilapangan atas paru (apeks) Gambaran non spesifik yang ditemukan pada foto rontgen dada pada seorang penderita yang diduga infeksi paru lain dan tidak menunjukkan perbaikan pada pengobatan dengan antibiotik ada kemungkinan penyebabnya adalah TB