case b.ing

8/13/2019 case b.ing

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+3 !eek before addmition patient complained coug more often !it

green0 yello! blood /01 oarsenees c est pain /01. S e also complained

breat ing difficulty no depend on acti(ity !eat er and not accompanied by

soriumound. 7eside t at fe(er at nigt nig t s!eat /51 loss of appetite and

decreassed of er !eig t. S e ad no problem in urination and defecation.

+) ours before admittion patient complained dificulty of er breat

become se(er. *t6s not influence by temperature or emotion. 'oug !it green0

yello! pleg m oarseness c est pain /01 fe(er /51 c ills /51. S e ad no

problem !it urination and defecation.

#istory of past illness

Diabetic melitus is dinied

No istory of consuming anti tuberculoid drugs

No istory of consuming alco ol or smoking

#istory of family6s diseases

ere are no patient6s family ! o a(e t e same complain

III. PHISYCAL EXAMINATION

9eneral condition

9eneral condition : s ick

Sicness condition : moderate sickness

'onciousness : compos mentis

Nutrient : unade uatDe ydration : /01

7lood preassure : 32& 8&

4ulse rate : ;8x minute

<espiration rate : )&x minute

emperature : )8 8 &'

7ody !eig t : ), kg

7ody leng t : 3,& cm

=



Spesific condition

Skin

e skin is black bro!n. "fllourecention and scar /01 abnormal pigmentation /01

icteric /01.

>ymp 9lands

ere are no enlargment of t e lymp node on submandibular neck axilaries and

inguinal.

#ead

O(al symmetrical puffy face /01 deformity /01 malar ras /01.

Nose

"pistaxis /01 normal nasal septum normal mucous layer.

"yes"xopt almus /5 51 edematous palpebra superior /0 01 pale of con?ungti(a

palpebra /0 01 icteric sclera /0 01. 9ood lig t response on bot of eyes

symmetrical eyes mo(ement.

"ar

Normal bot of meatus accusticus externus.

Neck

@ugular(ein preassure / 021 cm# 2O lymp nodes enlargment /01 tyroid gland

enlargment /01 ypertrop y sternocleidomastoideus /01 siffness /01.

>ung /Anterior and 4osterior1

* : symetrical of static and dynamic rig t and left are e ual

4 : stemfremitus immeasurable



4 : stony0dull in all area of lung

A : (esikuler increassed rales moist /51 all lung area ! ee$ing /01

'or

* : ictus cordis is not seen

4 : ictus cordis is not palpable

4 : immeasureable

A : #<B;8x minute murmur /01 gallop /01

Abdomen

*: flat

4: soft li(er and spleen are not palpable preasure pain /01.

4: tympani

A: bo!el sound /51 normal

9enital

Not examinated.

Cpper extremity4aint on ?oint /01 pale on finger /01 eryt ema of palm /01 pitting edema /01.

>o!er extremity

4ain on ?oint /01 (arices /01 pale on foot /01 pitting edema /01.

IV. LABORATORY FINDING

Sputum

A-7 * /5)1

A-7 ** /5)1

A-7 *** /521

#ematology

#emoglobin : 3& = g dl /3=038 3203, g dl1

,



>eucocyte : %3&& mm) / &&&03&.&&& mm) 1

>"D : ;& / 3&mm ?am 3 1

Diff 'ount:

• 7asofil : &E /&03E1

• "osinofil : 3E /30)E1

• 7atang : 3E /20,E1

• Segmen : 8,E / &0%&E1

• >imfosit : 3&E /2&0=&E1

• Monosit : 2E /208E1

'linical ' emistry

7SS : 3)2 mg dl

otal c olesterol : 2&) mg dl / 2&& mg dl1

#D>0c olesterol : 3% mg dl /F mg dl1

>D>0c olesterol : 332 mg dl / 3)& mg dl1

riglyceride : ),; mg dl / 3 & mg dl1

Cric acid : = ; mg dl /) 0% 3 2 ,0, & mg dl1Creum : ) mg dl /3 0); mg dl1

'reatinin : & % mg dl /& ;03 ) mg dl1

Natrium : 3) mmol > /3) 03 & mmol >1

Galium : ) ; mmol > /) 0 mmol >1

<ontgen 4A t orax

0 symetric of t orax

0 !ell0maerked of trac ea

0 good condition of bone

0 !idening intercostal space

0 infiltrat in all area of lung

9ambar

%



RESUME

A 28 years old !omen ospitali$ed since 2% agust 2&&8 !it difficult of

breat since ) ours before ospitali$ed.

+ , mont s before addmition patient complained a(ing a coug . -irst

coug !it out p legm a fe! days later coug accompanied by a bit ! ite

pleg m. 'oug reco(ered by itself no take medications.-re uently coug about 3

!eek after. 4atient also complained sometimes fe(er at nig t nig t s!eat /51.

+) mont s admittion patient complained coug more often !it a bit of

! ite pleg m dyspnoe /51 no depend on acti(ity and position fe(er at nig t

nig t s!eat /51 loss of appetite loss of !eig t fatigue /51. s e !asn6t take any

drug.

+3 !eek before addmition patient complained coug more often !it

green0 yello! p legm. ere6s also oarsenees. 7eside t at fe(er at nigt nig t

s!eat /51 loos of appetite and decreassed of er !eig t.+) ours before admittion patient complained dificulty of er breat

become se(ere. *t6s not influence by temperature emotion. 'oug !it green0

yello! pleg m oarseness fe(er /51 c ills /51. S e ad no problem !it

urination and defecation.

No istory of comsumpting antituberculosis drugs.

-rom t e p isical examination patient in moderate sickness condition and

compos mentis conciousness. 7lood preasure 32& 8& pulse rate ) x menit ?ugular (ein preasure / 021 cm# 2&. *n lung examination increasing of (esikuler

stony0dull in all area of lung moderate moist rales /51 in all area of lung. *n eart

examination #<B ;8x menit.

>aboratory findings s o! us #b: 3& = g dl >eucocyte: %3&& mm ) >"D:

;& 7SS: 3)2 mg dl total c olesterol: 2&) mg dl #D>0c olesterol: 3% mg dl

>D>0c olesterol: 332 mg dl triglyceride: ),; mg dl Cric acid:= ; mg dl. Creum:

8



) mg dl 'reatinin: & % mg dl sputum A-7 /51 )x. <ontgen t orax s o!s

infiltrat in all area of lung.

DIAGNOSIS

>ung uberculosis in !ide lession for ne! case

DIFFERENTIAL DIAGNOSIS

/01

TREATMENT

0 aking a rest

0 *H-D <> gtt II minute

0 O7# syr )x3

0 <ifamficin 3x = &

0 *N# 3x)&&

0 4yra$inamide )x &&

0 "t ambutol 3x% &0 737,732 )x3

EXAMINATION PLANNING

0 culture and resistance sputum mycroorganism

PROGNOSIS

0 Juo ad (itam : dubia ad bonam0 Juo ad functionam : dubia ad malam

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