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SMF PENYAKIT DALAM

Name : NIM :

RSUD Dr. H. ABDUL MOELOEK


.

BANDARLAMPUNG

PATIENT STATUS
PATIENT IDENTITY Full Name Sex Place / Date of Birth /Age Nationality Marital status Religion Occupation Educational background Address ANAMNESIS Taken From : Autoanamnesis Date 6th March 2009 Time 11.30 WIB : Mrs S : Female : Tanjung Karang, 22th Nop 1959 : Lampung : Married : Islam : Farmer : SD : Tanjung Karang

The main complained : Sputum cough The History of the Illness : The patient came to hospital with complaint of sputum cough. The complaint held since 3 months before came to the hospital. She also complained about chest pain, blood cough, 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 the shymptom wasnt getting better, later the patient gone to the hospital and she must to stay in the hospital for treatment. And she had no treatment with Packet Drug of OAT History of DM: denied History of Hypertension: denied

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

History of Family : Connection Grandfather Grandmother Father Mother Brother-sister Children Age (th) 75 60 70 63 Sex Male Female Male Female Healthy Death Death Death Death Health Health Causa of Death

An any relation who suffer : Illness Alergyc Asthma Tuberkulosa Artritis Rematisme Hipertensi Cor Kidney Gaster Yes No Connection

ANAMNESIS SISTEM Note Complain Positif beside the title Skin ( ) Boil ( ) Nail

( ) ( )

Hair Yellow / Ikterus

() ( ) ( )

Night swet Sianotic Others

Head ( ) Trauma ( ) Sinkop Eye ( ) Pain ( ) Secret ( ) yellow / Ikterus Ear ( ) Pain ( ) Secret

( ) ( )

Headache Pain of the sinus

( ) ( ) ( )

Inflammation of night sweat Eye disorder Sharpness to see

( ) ( ) ( )

Tinitus Ear disorder Deaf

Nose ( ) Trauma ( ) Pain ( ) Sekret ( ) Epistaksis Mouth ( ) Lip ( ) Gums ( ) Membrane Throat ( ) Throats pain Neck ( ) Protruding Cor / Lung () Chest pain (Left) ( ) Pulse ( ) Ortopnoe

( ) ( ) ( )

Clogging Nose disorder Have a cold

( ) ( ) ( )

Tongue Mouth disorder Stomatitis

( )

Voice (change)

( )

Necks pain

() () ()

Dyspneu Hemoptoe Cough

Abdomen (Gaster / intestine) ( ) Puffing ( ) Nausea ( ) Emesis ( ) Hematemesis ( ) Disfagi ( ) Kholik

( ( ( ( ( ( (

) ) ) ) ) ) )

Acites Hemoroid Diarrhea Melena Pale colour of feses Black colour of feses Nodul

Urogenital ( ) Disuria ( ) Stranguri ( ) Poliuria ( ) Polakisuria ( ) Hematuria ( ) Kidney stone ( ) Wet the bed Katamenis ( Leukore ) ( Others ) Haid ( ) Last menarche ( ) ( ) frequently / no Menarche disorder

( ( ( ( ( ( (

) ) ) ) ) ) )

Pyuria Kolik Oliguria Anuria Urine retention Drip urine Prostat

( ) ( )

Bleeding

( ) ( ) ( )

Quantity and ( ) duration Pain ( ) Post menopause

Menarche Klimakterium symptom

Muscle and neuro ( ) Anestesi ( ) Parestesi ( ) Weak muscle ( ) Convultion ( ) Afasia ( ) Amnesis ( ) Others

( ( ( ( ( ( (

) ) ) ) ) ) )

Bite less Ataksia Hipo/hiper-estesi Syncope Tick Vertigo Disartri

Ekstremitas ( ) Edema ( ) Hinge pain

( ) ( )

Deformitas Sianotic

Weight Average weight (kg) Max weight (kg) Present weight (kg)

: 50 kg : 60 kg : 45 kg

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

THE HISTORY OF LIFE


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Birth place Helped by

: ( ) in home : ( ) Doctor ( ) Others

( ) matrinity ( ) nurse

( ) Matrinity hospital ()Traditional matrinity

Imunitation History ( ) Hepatitis ( ) BCG ( ) Tetanus Food History Frekuensi/day Amount /day Variation /day Appetite

( ) Campak

( ) DPT

( ) Polio

: 3x/day : 2 plate/eat (health), plate/eat (illness) : Rice, vegetables, egg, fish : Enough

Educational ( ) SD Problem Financial Works Family Others

( ) SLTP

( ) SLTA

( ) SMK ( ) Course

( ) Academy ( ) Unschool

: Low : Farmer : Good relation :-

Body Check Up General Check up Height Weight Blood Pressure Pulse Temp Breath (frequence&type) Nutrition condition Consciousness Cianotic General edema Habity The way of walk Mobility (active/pasive) The age prediction based on check up Mentality Aspects

: 150cm : 45 kg : 110/70 mmhg : 100 x/minute : 36,8 oC : Regular : Underweight : Compos mentis :::: Normal : Active : 50

Behavior Nature of feeling The thinking process Skin Color Efloresensi Keloid Pigmentasi Hair Growth Arteries Touch temperature Humid/dry Sweat Turgor Icterus Fat layers Edema Others Lymphatic Gland Submandibula Neck Supraklavikula Armpit Head Face expression Face symmetric Hair Temporal artery Eye Exopthalmus Enopthalmus Palpebra Lens Conjungtiva Visus Sklera Eye movement Vision scope Eye ball pressure Deviatio konjungae

: Normal : Normal : Normal

: : : : : : : : : : : : : :

Brown Normal feel Afebris Humid Normal Normal Anicteric -

: Untouched enlargement : Untouched enlargement : Untouched enlargement : Untouched enlargement

: Normal : Symmetric : Black and uprooted : Normal

::: edeme : Clear : Ananemis : 4/6 : Anicteric : Good in every side : Normal : Normal Perpalpation : 7

Nystagmus Ear Deaf Membrane tymphani Foramen Obstruction Serumen Bleeding Liquid Mouth lips Tonsil Palatal Halibsts Teeth Trismus Farings Liquid layer Tongue Neck JVP Tiroid gland Limfe gland Chest Shape Artery Breast Lung Inspeksi Palpasi Perkusi Auskultasi

: -

:::::::-

::: Normal : No : Caries :: Unhiperemis : Saliva : Not dirty

: Normal : Untouched enlargement : Untouched enlargement

: Simetric : Normal : Normal

Left Right Left Right Left Right Left Right

: simetric : simetric : tactil fremitus = dextra : tactil fremitus = Sinistra : Dullness : Dullness : Vesiculer , wet Ronchi : Vesiculer , wet Ronchi

Cor
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Inspection Palpation Percution Auskultation

: IC unseen : IC feel in linea midclavicula sinistra ICS V : decrease of heart sound : heart voice I and II normal, murmur (-), gallop (-)

Artery Artery temporalis Artery karotis Artery brakhialis Artery radialis Artery femoralis Artery poplitea Artery tibilias posterior Stomach Inspection Palpation Stomach wall Heart Limfe Kidney Percution Auscultation Refleks stomach wall Genital (based on indication) Female : no indication OUE : no indication Flour albus : no indication Movement joint Arm Muscle Tonus Massa Joint Movement Strength Others

: No distinct : No distinct : No distinct : No distinct : No distinct : No distinct : No distinct

: normal in 4 region : pressure pain (-) : not feel : not feel : ballotemen (-) : shifting dullness (-) : intestine sounds (+)

Right normal normal normal normal normal weakness

Left normal normal normal normal normal weakness

Heel and leg


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Wond/injury Varices Muscle (tonus & mass) Joint Movement Strength/power Edema Others Reflexs Tendon reflex Bisep Trisep Patela Achiles Cremaster Skin reflex Patologic reflex

: not found : (-) : normal : normal : normal : weaken (+) : (-) : (-)

Right normal normal normal normal normal normal normal not found

Left normal normal normal normal normal normal normal not found

LABORATORY (6th march 2009) Blood Hb : 11,8 gr/dl Ht : 34% Leukosit : 6400/l Variety count Basofil :0% Eusinofil :3% Batang :0% Segmen : 80% Limfosit : 18% Monosit :2% LED Trombosit SGOT SGPT BTA Complete feses : 30 mm/jam : 216.000 /l : 18 U/L : 8 U/L : (+) (+) (+) : Not do it

(13,5 18,0 gr/dl) (4.500 10.700/ l) (0 1 %) (1 3 %) (2 6 %) (50 70 %) (20 40 %) (2 8 %) (0 10 mm/hour) (6 30 U/L) (6 45 U/L)

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RADIOLOGI (5th march 2009)

1. Lung: Active tuberculocis:shown infiltrate > 2/3 ICS, and radioopaque 2. Cor: normal

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Follow Up Date Hard Breathing Chest pain Night sweat Sputum cough Appetite Weakness Weight decreasing 6/03/2009 (+) (+) (+) (+) (+) (+) (+) 7/ 03/2009 () (+) (+) (+) (+) (+) (+) Intermediet ill appearance Compos mentis 10/03/2009 () (-) (+) (+) (+) (+) (+)

General present Awakeness Vital sign - BP - Temperature - RR - HR Status generalis - Eyes - Anemis - Thoraks - Inspection - Palpation - Percusion - Auscultation Additional Analyze - Thorax Photo PA

110/70 mmHg 36,20 C 28 x / menit 100 x / menit

110/70 36,40 C 27x/ menit 100x/ menit

110/70 36,40 C 27x menit 92x/ menit

(-) Symmetric L : Fremitus L : Dullness L : Vesiculer Wet Rhonchi +/+

(-) Symmetric L : Fremitus L : Dulness L : Vesiculer Wet Rhonchi +/+

(-) Symmetric L : Fremitus L : Dullness (basal) L : Vesiculer Wet Rhonchi +/+

Inflitrat (+/+) >2/3 ICS, radioopaque, bilateral

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Treatment - IVFD RL XX gtt/mnt - O2 3L/mnt - DMP Syr 3x1C - KalneX 500mg/8jam - Cefotaksim 1 gr/12 jam - Rifampisin 1x450mg - INH 1x300 mg - Pirazinamid 1x2(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 of sputum 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 Blood Pressure Pulse Touch temperature Lung Inspeksi Left Right Palpasi Left Right Perkusi Left Right Auskultasi Left Right Movement joint Strength

: 45 kg : 110/70 mmhg : 100 x/minute : Afebris

: simetric : simetric : tactil fremitus = dextra : tactil fremitus = Sinistra : Dullness : Dullness : Vesiculer , wet Ronchi : Vesiculer , wet Ronchi Right weakness Left weakness

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LABORATORY Blood Hb Ht Leukosit Variety count Basofil Eusinofil Batang Segmen Limfosit Monosit LED Trombosit SGOT SGPT BTA

: 11,8 gr/dl : 34% : 6400/l :0% :3% :0% : 80% : 18% :2% : 30 mm/hour : 216.000 /l : 18 U/L : 8 U/L : (+) (+) (+)

(13,5 18,0 gr/dl) (4.500 10.700/ l) (0 1 %) (1 3 %) (2 6 %) (50 70 %) (20 40 %) (2 8 %) (0 10 mm/hour) (6 30 U/L) (6 45 U/L)

Working diagnose and basic diagnose 1. Working diagnose Lung Tuberculosis BTA (+), maXimal lesion, new case. 2. Basic Diagnose Anamnesis : sputum cough, blood cough, chest pain, hard breathing, night sweat, weakness and weight decreasing. Clinical checkup : I : Weakness, underweight P: Tactil Fremitus right = left P: Dullness A: Vesiculer , Ronkhi + Support checkup : Result SPS (+)(+)(+) Blood LED : 30 mm/hour Segmen : 80%

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Differencial diagnose 1. Differencial diagnose Pneumonia 2. Differencial basic diagnose chest pain, Rontgen thorak, LED high Plan treatment DOTS (directly observation treatment shortcut) Bed rest Pollution denied Suplement Nutrition Prognose Quo ad vitam Quo ad functionam Quo ad sanationam

: dubia ad bonam : dubia ad bonam : dubia ad bonam

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DISCUSSION

This Patient had been diagnosed as Lung Tuberculosis New case/BTA (+), MaXimal Lesion based on history taking, physical examination, and support examination. 1. Taking from anamnesis, the patient complained sputum cough happening repeatedly everyday, chest pain, breathless, night sweat, weakness and weight decreasing History of 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 or decreased resonance to percussion, diminished or inaudible breath sounds at left and right 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 case included 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 B 6 50 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 as primary 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 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-ray photo 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 Sputum mixed with blood Haemoptoe Dyspnea and chest pain Weakness Night sweat Decrease weight Feverish fever more than 1 month

If three sputum specimen are negative, give an extensive spectrum antibiotic during 1-2 weeks. 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 death 3. 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 TBC

Intensive 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 by sequel 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 1st category or patient BTA 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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