CASE REPORT

PULMONARY TUBERCULOSIS

By

Muhammad Iqbal 04043100054

Vini Ilyani HAM 04043100055

Advisor: Prof.dr.H.Eddy Mart Salim

CASE REPORT

IDENTIFICATION• Name : Mr.D• Age : 60 years old• Sex : Male• Address : Talang kemang palembang• Status : married• Occupation :• Religion : moslem• Hospitalized : 28 Oktober 2008

ANAMNESISChief of complainShortness of breath since 3 days before admitted

History Of Illness± 1 months before addmition patient complained

having a cough. Cough without phlegm, blood (-). Breathing difficulty (+), without depend on weather and emotion, mengi(-), depend on position, patient will be more comfortable when sit. Patient also complained sometimes fever at night, chill (-), night sweat (+),loss of apetite, weight loss. Urination and defecation normal. Patient didn’t take any medication.

History of illness cont-1

±2 weeks before admittion, patient complained having a cough. Cough with phlegm, colour in yellow + ½ tea spoon, blood (-). Breathing difficulty (+), without depend on weather and emotion, mengi(-), depend on position, patient will be more comfortable when sit. Patient also complained sometimes fever at night, chill (-), night sweat (+),loss of apetite, weight loss. Urination and defecation normal. Patient take medication, and no changes in complain.

±3 days before addmition, patient complained cough more often with yellow phlegm, + 1 tea spoon , blood (-), Breathing difficulty (+), without depend on weather and emotion, mengi(-), depend on position, patient will be more comfortable when sit. Patient also complained sometimes fever at night, chill (-), night sweat (+),loss of apetite, weight loss. Urination and defecation normal. Patient admitted to RSMH

History of past illness History of Diabetes Melitus uncontrolledNo history of pulmonary diseaseNo history of consuming anti tuberculoid

drugs No history of consuming alcohol or smoking

History of family’s diseasesThere are no patient’s family who have

the same complain

HabitualHistory of smoking since 25 years old 1pack/day

PHISYCAL EXAMINATION

General condition• General condition: sick• Sicness condition : moderate sickness• Conciousness : compos mentis• Nutrient : normoweight• Dehydration : (-)• Blood pressure : 130/80• Pulse rate : 102x/minute• Respiration rate : 34x/minute• Temperature : 36,70C• Body weight : 50 kg• Body lenght : 160 cm

Spesific condition• Skin

The skin is black brown. Efllourecention and scar (-), abnormal pigmentation (-), icteric (-).

• Lymph GlandsThere are no enlargment of the lymph node on submandibular, neck, axilaries, and inguinal

• HeadOval, symmetrical, puffy face (-), deformity (-), malar rash (-)

• NoseEpistaxis (-), normal nasal septum, normal mucous layer.

• EyesExopthalmus (-/-), edematous palpebra superior (-/-), pale of conjungtiva palpebra (-/-), icteric sclera (-/-). Good light response on both of eyes, symmetrical eyes movement.Anophtalmia (+)

• EarNormal both of meatus accusticus externus

• NeckJugularvein preassure (5-2) cmH2O, lymph nodes enlargment (-), tyroid gland enlargment (-), hypertrophy sternocleidomastoideus (-), siffness (-)

• LungI : Symetrical of static and dynamic right and left are equal, hoarsenessP : stemfremitus right<leftP : sonor in all area of lungA : vesikuler decreased in right lung, moderate wet rales in upper of both lung, wheezing (-)

• CorI : ictus cordis is not seenP : ictus cordis is not palpableP : Upper boundary of cor is ICS II, left boundary of cor is LMC sinistra and right boundary of cor is LS dextra. A : HR=102x/minute, murmur (-), gallop (-)

• AbdomenI : flatP : soft, liver and spleen are not palpable, preasure pain (-).P : tympaniA : bowel sound (+) normal

• GenitalNot examinated

• Upper extremityPaint on joint (-), pale on finger (-), erythema of palmar (-), pitting edema (-)

• Lower extremityPain on joint (-), varices (-), pale on foot (-), pitting edema (-)

Laboratory finding (October 28th 2008)• Hematology

Hemoglobin : 13,5 g/dlHematocrite : 41 g/dlLeucocyte : 12100/mm3LED : 93 Trombocyt : 230000Hitung JenisBasofil : 0% (0-1%)Eosinofil : 5% (1-3%)Batang : 2% (2-6%)Segmen : 84% (50-70%)Limfosit : 6% (20-40%)Monosit : 3% (2-8%)

• Clinical ChemistryBSS : 455 mg/dlTotal protein : 6,4mg/dlAlbumin : 2,0 mg/dlGlobulin : 4,4 mg/dlSGOT : 40 mg/dlUric acid : 4,9 mg/dlUreum : 26 mg/dlCreatinin : 0,9 mg/dlNatrium : 131 mmol/LKalium : 2,6 mmol/LSGOT :40 uLSGPT : 30uL

• UrinalisaGlukosa +4Keton (-)

RESUME

Resume con’t 1

RESUME CON’t 2

WORKING DIAGNOSIS• Suspect new case pulmonary tuberculosis

wide lession + hipokalemia + hipoalbuminemia + Diabetes Mellitus type II normoweight uncontrolled

DIFFERENTIAL DIAGNOSIS• Pneumonia atypical + DM type II

normoweight uncontrolled + hipokalemia + hipoalbuminemia

TREATMENT

• Non-pharmachologyO2 2LBedrestDiet DM 1900kkal

• PharmachologyIVFD RL gtt XX/mReguler insulin 3x8 iu scKCl drip 2flesh in RL gtt XX/mOBH syrup 3x1 ccNeurodex 2x1 tabletHuman Albumin 1 kolf

PLANNING

• BTA Sputum

• Rontgen thorax PA

• BSN/BSPP

PROGNOSIS

• Quo ad vitam : bonam

• Quo ad fungtionam : bonam

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