CHAPTER II CASE REPORT

I. IDENTIFICATION Name Age Sex Address Status Occupation "ducation : Mrs.DS : 28 years old : female : bukit kecil palembang : married : ouse!ife

: elementary sc ool

#ospitali$ed : 2% agustus 2&&8

II. ANAMNESIS ' ief of complain Difficult of breat become se(ere since ) ours before admitted to t e ospital. #istory Of *llness + , 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. blood /01. breat ing difficulty /01. c est pain /01. 'oug reco(ered by itself. no take medications.-re2uently coug about 3 !eek after. 4atient also complained sometimes fe(er at nig t. c ill /01. nig t s!eat /51. no problem !it er appetite. urination and defecation. +) mont s before admittion. patient complained coug more often !it a bit of ! ite pleg m. blood /01. dyspnea /51 no depend on acti(ity and position. ! ee$ing /01. c est pain /01. fe(er at nig t. c ill /01. nig t s!eat /51. loss of appetite. loss of !eig t. nausea /01. (omiting /01. fatigue /51. s e !asn6t take any drug. S e ad no problem in urination and defecation

+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 ad no 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 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 8 ere are no patient6s family ! o a(e t e same complain

III. PHISYCAL EXAMINATION 9eneral condition 9eneral condition Sicness condition 'onciousness Nutrient De ydration 7lood preassure 4ulse rate <espiration rate 8emperature 7ody !eig t 7ody leng t : sick : moderate sickness : compos mentis : unade2uat : /01 : 32&:8& : ;8x:minute : )&x:minute : )8.8&' : ), kg : 3,& cm

Spesific condition Skin 8 e skin is black bro!n. "fllourecention and scar /01. abnormal pigmentation /01. icteric /01. >ymp 9lands 8 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 /A021 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 e2ual 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 extremity 4aint 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 >"D Diff 'ount: 7asofil "osinofil 7atang Segmen >imfosit Monosit

: %3&&:mm) : ;& : &E /&03E1 : 3E /30)E1 : 3E /20,E1

/A&&&03&.&&&:mm)1 /D3&mm:?am. D3A1

: 8,E /A&0%&E1 : 3&E /2&0=&E1 : 2E /208E1

'linical ' emistry 7SS : 3)2 mg:dl /D2&& mg:dl1 /FAA mg:dl1 /D3)& mg dl1 /D3A& mg:dl1 /).A0%.3:2.,0,.& mg:dl1 /3A0); mg:dl1 /&.;03.) mg:dl1 /3)A03A& mmol:>1 /).A0A mmol:>1 8otal c olesterol : 2&) mg:dl #D>0c olesterol : 3% mg:dl >D>0c olesterol : 332 mg:dl 8riglyceride Cric acid Creum 'reatinin Natrium Galium <ontgen 4A t orax 0 0 0 0 0 symetric of t orax !ell0maerked of trac ea good condition of bone !idening intercostal space infiltrat in all area of lung : ),; mg:dl : =.; mg:dl : )A mg:dl : &.% mg:dl : 3)A mmol:> : ).; mmol:>

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.-re2uently 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. 8 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 oarseness. fe(er /51. c ills /51. S e er breat become se(ere. *t6s not influence by temperature. emotion. 'oug !it green0 yello! pleg m. 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 )Ax:menit. ?ugular (ein preasure /A021 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:

)A mg:dl. 'reatinin: &.% mg:dl. sputum A-7 /51 )x. <ontgen t orax s o!s infiltrat in all area of lung.

DIAGNOSIS >ung 8uberculosis in !ide lession for ne! case DIFFERENTIAL DIAGNOSIS /01 TREATMENT 0 0 0 0 0 0 0 0 8aking a rest *H-D <> gtt II:minute O7# syr )x3 <ifamficin 3x =A& *N# 3x)&& 4yra$inamide )xA&& "t ambutol 3x%A& 737,732 )x3

EXAMINATION PLANNING 0 culture and resistance sputum mycroorganism

PROGNOSIS 0 0 Juo ad (itam Juo ad functionam : dubia ad bonam : dubia ad malam