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Klarifikasi istilah
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
hemoptoe
a severe bout of coughing
fresh blood
phlegm
productive cough
mild fever
lymphadenopathy
stomatitis
shortness of breath
vesicular sound
severely sick
pale
moderate rales
hours ago he had a severe bout of coughing with fresh blood of about 2 glasses
2. Riwayat perjalanan penyakit
a. He also said that in the previous month he had had:
i. productive cough with a lot of phlegm,
ii. mild fever,
iii. loss of appetite,
iv. rapid loss of body weight (previous weight: 70 kg), and
v. shortness of breath.
b. Since a week ago, he felt his symptoms were worsening
3. Pemeriksaan fisik
a. General appearance: he looked severely sick and pale. Body height: 175 cm, body
weight: 55 kg, BP: 100/70 mmHg, HR: 112x/minute, RR: 36x/minute, temp 37,6
C
b. There was a tattoo on the chest and lymphadenopathy of the right neck, and
stomatitis
c. In chest auscultation there was an increase of vesicular sound at the right upper
lung with moderate rales
4. Pemeriksaan tambahan
a. Laboratory
i. Hb: 8,5 g%, WBC: 6000 L, ESR 65 mm/hr, Diff count: 0/3/2/75/15/5,
Acid fast bacilli: (-), HIV test (+), CD4 120/L
b. Radiology:
i. Chest radiograph showed infiltrate at right lower lung
NB:
Times New Roman, Uk 12, Spasi 1.5, Justify
Margin: top 2, left 3, bottom 2, right 2
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