Presentation Case

Tuberculosis

Milda Dwi Risnandar

111170046
 Patient’s identity
 Name : An. S
 Age : 11 year-old
 Sex : Female
 Religion : Islam
 Father’s name : Tn. J
 Age : 51 year-old
 Education : Primary school
 Occupation : Trader
 Mother's name : Ny. O
 Age : 45 year-old
 Education : Primary school
 Occupation : Trader
 History taking
a. Main complaint:
Haemaptoe
b. History of present illness:
The patient came to the emergency room escorted parents
Waled Hospital on 5 november 2015 at 20:20 pm with a main
complaint of cough blood 1 day before entering the hospital.
Blood red colored fresh by volume ± 1/4 cup aqua. Cough
(without the blood) experienced since 3 weeks, with yellow
mucus, cough with shortness, patients also complain of fever
and frequent night sweats, appetite decreased, while chapters
and tub normal. There is a history of tuberculosis contacts
which is from the biological mother of the patient.
c. Past medical history:
Patient had never suffered from such diseases
d. Family history of disease :
Mother of patient suffer tuberculosis
e. Treatment history:
Patient had never been to the doctor or taking
medication
e. History of growth

AGE Growth and Development

4 Month Prone

8 Month Sit

11 Month Crawling and walking

12 Month Say mother and father

f. Immunization history

Immunization Early Advanced

Hepatitis B 0 Month 1 and 6 Month

BCG 1 Month

Polio 0 Month 2, 4, 6 Month

DPT 2 Month 4, 6 Month

Campak 9 Month
g. Labor history
 Prenatal
During pregnancy, mother regularly
followed antenatal assessement every
month, get TT immunization, and do not
suffer from illnesses.
 Perinatal and post-natal
Spontaneous birth assisted by midwives
clinic, with a birth weight of 3500 gram.
h. A history of eating and drinking

AGE Eat And Drink

0 – 6 Month ASI

6 – 12 Month PASI, Grain

12-24 Month Porridge

3-11 Month Rice and side dishes

i. Social and economic history
Patients living with his father, mother and
siblings in the house which consists of 2
bedrooms, bathroom and toilet are located
inside the house, the house is less ventilation
and good lighting, there are three pieces of the
window.
 Physical examination
a. Status Present
General conditions : Looked ill
Consciousness : Compos Mentis
b. Vital sign
Blood pressure : 100/60 mmHg
Pulsepressure : 120x/m
Respiration rate : 28x/m
Temperature : 36,6°C
c. Anthropometric Status:
Weight : 24kg
Height : 138cm
d. Nutritional status
Bw/Age :24
Bh/Age :38
Bw/Bh :24/138
BMI/Age :Bw(kg) : Bh(m)²
= 24 : (1,38)²
= 12,63 Kg/m²
e. Physical examination
 Head: normocephal shaped, long-black hair, not
easily removed
 Eyes: not anemic conjunctiva, sclera no jaundice,
light reflex normal, clear lens, pupil isokor with a
diameter of 3mm / 3mm
 Ears: easy on the ear leaf folding, back quickly,
not found secretions
 Nose: Not found deviation of the septum, nostril
breathing was not there and did not reveal any
secretions
 Mouth: lips cyanosis, clean membranes, tonsils T1-T1
calm no hyperemia, faring no hyperemia
 Neck: there are enlarged lymph nodes
thoracic
Inspection: Symmetrical right and left, no breath
lagging
Palpation: no tenderness, expansion
respiratory symmetric
Percussion: resonant both lung fields
Auscultation: breathing sounds bronkovasikuler,
there were no sound ronkhi / wheezing
 COR
Inspection: Ictus cordis does not appear
Palpation: Ictus palpable
Percussion: ICS 2 linea parasternal the left, ICS 3
heart waist, ICS 5 apex of the heart
Auscultation: heart rate 108x / m, regular, BJ1 / BJ2
normal, no audible murmurs or gallops
 Abdomen:
Inspection: The shape is flat, there is no retraction
epigastric
Auscultation: bowel (+)
Percussion: Timpani entire field abdomen
Palpation: no tenderness, liver and
lien is not palpated
 Genitalia: Female, labium major and labium
minor bilateral, no abnormalities.
 Extremities: Warm extremities, CRT <2 second,
normal muscle strength, physiological reflexes
normal, pathological reflexes no abnormalities,
found no edema.
 Differential diagnostic
• Tuberculosis
• Bronkiektasis
• Pneumonia
• Cancer pulmonar
 Support Examination
Routine blood Elektrolit Rontgen Serologi
Haemoglobine : 9,1 Koch Pulmonum
Erythrocyte : 3,99 Aktif Sinistra
Leukocytes : 7800
Hematocrit : 27,7
Platelet : 302
 Scoring Symptoms and Examination
Support Tuberculosis Children
Variable 0 1 2 3 Score
Household Unknown Contact with smear Contact with 3
contact negative TB patient smear positive
or unknown sputum TB patient
smear result

Tuberculin Negative Positive(≥ 3

test 10mm, or in
immunocompo
mised children
≥ 5 mm)
Nutritional BW/age < Severe malnutrition 1
state 80% (BW/age < 60%)
Fever of ≥ 2 weeks 1
unknown origin
≥ 2 weeks

Cough ≥ 3 weeks 1
Lymph node Multiple, non- 0
(cervical, tender, diameter ≥
axillary, 1 cm
inguinal)
enlargement
Joint swelling Swelling 0
(knee,
phalanges)

Chest X ray Normal SuggestiveTB 1

or
unknown

Score total 10
 Management
a. IUFD NaCl 0,45 in D5 = 34-35cc/hour (11-
12gtt/m)
b. Plan OAT :
 INH 10mg/KgBW = 240mg
 Rimfampisin 15mg/kgBW = 360mg
 Pirazinamid 35mg/kgBW = 840mg
 Prognosis
• Quo ad vitam : ad bonam
• Quo ad functionam : ad bonam
• Quo ad Sanationam : ad bonam
 Follow up
Present 6 -11-2015 7-11-2015 8-11-2015
S Cough (+), blood (-), Cough (+), blood (-), Reduced cough, blood
sputum (-), Fever (+) sputum (-), Fever (+) (-), sputum (-), fever (-)
O GC : TSS GC : TSS GC : TSS
Consciousness: CM Consciousness: CM Consciousness : CM
Vital sign: Vital sign: Vital sign:
• Blood pressure : •Blood Pressure : •Blood pressure :
100/60x/m 100/70x/m 100/70x/m
• Pulse pressure : •Pulse pressure : 100x/m •Pulse pressure :
108x/m •Respiration rate : 108x/m
• Respiration rate : 28x/m •Respiration rate:
28x/m •Temperature : 37,5 24x/m
• Temperature :36,8 Mantoux test result: •Temperature: 36,5
positif (undurasi 25 mm)
A Tuberculosis Tuberculosis Tuberculosis
Present 6-11-2015 7-11-2015 8-11-2015

P IUFD NaCl 0,45 in D5 = IUFD NaCl 0,45 in IUFD NaCl 0,45

34-35cc/hour (11-12gtt/m) D5 = 34-35cc/hour in D5 = 34-
Plan OAT : (11-12gtt/m) 35cc/hour (11-
INH, 10mg/Kg = 240mg OAT : 12gtt/m)
Rimfampisin 15mg/kgBw = INH, 10mg/KgBw = OAT :
360mg 240mg INH, 10mg/KgBw
Pirazinamid, 35mg/kgBw = Rimfampisin = 240mg
840mg 15mg/kgBw = 360mg Rimfampisin
Pirazinamid, 15mg/kgBw =
35mg/kgBW = 840mg 360mg
Pirazinamid,
35mg/kgBw =
840mg
 Final Diagnostic
Tuberculosis
Thank you