Yesti Angelia Setyani Rapri

Asyira Nurhidayu binti Ashri

Residen Pembimbing: Hanna Amiera binti Abdul Razak Burke
Nurul Safiah Hamizah binti Suhaimi
dr. Ahmad Mustang Muhammad Farid bin Roslan
Omar Nafiis bin Hairuddin
Amir Farid bin Aminuddin
Nama : Tn. S
Jenis kelamin : Laki-laki
Umur : 25 tahun
No. rekam medis : 784695
Masuk RS tanggal : 2 Januari 2017
Chief complaint: Coughing up blood
History of present illness:
Mr. S is a 25-year-old Hispanic man who presents with a 5-year
history of a cough, which was accompanied by the presence of
white sputum and blood in the sputum. The cough has been
gradually worsening over the past 2 days. The patient did not take
any medication to minimize the complaint. Along with the cough,
the patient also complains of subjective fevers and an
unintentional weight loss over the past few months. There is no
night sweats, dyspnea, and chest pain.
He also reports that he has abdominal pain.
• There is a history of myoclonic seizures since childhood. The patient
had been treated in RSUD Daya 5 years before with a left arm
fracture due to fall while seizures and unconsciousness. According
to the patient's family, after that, the patient began to cough up
blood.
• There is also a history of bloody stools with some bowel
movements 1 year before. The blood is black in color. And, the
patient was treated in RS Pelamonia with suspected pulmonary
tuberculosis because of the cough and received tuberculosis
treatments for 3 days, but because of the negative smear
examination, the diagnosis was changed to gastrointestinal
bleeding.
Medications: None.
Allergies: No Known Drug Allergies, no food or insect allergies

Family history: Medical history of family is not known.

No known family history of tuberculosis.

Social history: The patient is developmentally delayed and did not

go to school. He is live with his parents. The parents said that he did
not have any past or present tobacco, illicit drug use, alcohol use and
denies any contact of tuberculosis in the neighbourhood. The patient
is covered by BPJS.
General condition : Moderate illness/ overweight /Compos Mentis
(GCS 15 E4M6V5)
• Weight : 555kg
• Height : 1.65 m
• BMI : 20.2kg/m2

Vital Signs
 Blood pressure : 120/80 mmHg
 Heart rate : 86x/mnt regularly
 Respiratory rate : 20x/mnt
 Body Temperature : 37.0°C
Eye :
• Exoptalmus/Enoptalmus : (-)
• Palpebra : Edema (-)
• Conjunctiva : Anemis (+)
• Sclera : Icterus (-)
• Cornea : clear
Ear, Nose and Throat :
• Ottorhea (-), Epistaxis (-), Rhinorrhea (-), Dry lips (-),
Cyanotic lips (-),
Neck :
• Lymph node : swelling (-)
• Thyroid Gland :Swelling (-)
• Stiffness neck : (-)
• Lung
Inspection : left and right symetrically
Palpation : Vocal fremitus normal
Percussion : Left lung : sonor
Right lung : sonor
Lung-Hepar borderline : ICS VI dekstra
Right back lung borderline : CV Th. X dekstra
Left back lung borderline : CV Th. XI sinistra

Auscultation : Breathing sound : Bronchial

Additional sound : Ronchi (+), Wheezing (-)
 Heart
Inspection : Ictus cordis not visible
Palpation : Ictus cordis not palpated,
Percussion :
• Heart borderline : ICS II sinistra
• Right heart borderline : ICS IV linea parasternalis dextra
• Left heart borderline : ICS V linea axillaris anterior sinistra
Auscultation : Heart sound I/II regularly normal,
murmur(-)
 Abdomen
Inspection : Flat, follow the breathing rythm
Auscultation : Peristaltic (+) normal
Palpation : Hepar and spleen not palpated
Percussion : Tympany, shifting dullness (-)
 Extremity
Muscle wasting (-), Muscle tone normal, Pretibial oedema (-)
 Complete blood count (2/1/2017)

• WBC : 7.9 x 103 /uL

• RBC : 4.69 x 106/uL
• HGB : 6.8 g/dL
• HCT : 25.9 %
• MCV : 55 fL
• MCH : 14.5 pg
• PLT : 339.000 /uL
• Neutrophil : 61.4 L
• Lymphocyte : 27.6L

ANEMIA MICROCYTIC HYPOCHROMIC

 BLOOD GAS ANALYSIS (2/1/2017)
• PH : 7.611
• pCO2 : 40.6
• SO2 : 96.2
• PO2 : 76.8
• HCO3 : 41.3

METABOLIC ALKALOSIS
• Hemoptisis kronis et causa suspek
Tuberkulosis
• Suspek Tuberkulosis paru klinis kasus baru
• Anemia mikrositik hipokrom

• Pemeriksaan mikrobiologi sputum BTA 3x

• Kultur sputum dan sensitivitas antibiotik
• Infus Natrium klorida 0.9% 20 tetes/menit
• N-Ace 200mg/8jam/oral
• Asam traneksamat 500mg/8jam/intravena
• Vit K 1 amp/8jam/intravena
• Vit C 1 amp/8jam/intravena
• Transfusi PRC 2 kantong
Tuberkulosis (TB):
Penyakit yang disebabkan oleh infeksi Mycobacterium tuberculosis complex.
Dapat mengenai berbagai organ, tetapi paling sering mengenai organ paru.
Jumlah seluruh pasien TB yang ditemukan dan tercatat di antara 100.000 penduduk
di tingkat nasional.
• Diperkirakan terdapat 8,6 juta kasus TB pada tahun 2012
dimana 1,1 juta orang (13%_ diantaranya adalah pasien TB dengan
HIV positif.
• Pada tahun 2012, diperkirakan terdapat 450.000 orang menderita TBMDR dan
170.000 orang diantaranya meninggal dunia.
• Penyakit ini bisa dicegah dan disembuhkan. Peningkatan angka insidensi TB secara
global berhasil dihentikan dan menunjukkan penurunan, angka kematian juga
berhasil diturunkan 45% dibandingkan tahun 1990.
• 75% pasien TB adalah kelompok usia yang paling produktif secara ekonomis (15-
30 tahun).
Mycobacterium tuberculosis
Faktor utama meningkatnya kasus TB:
• Kemiskinan, terkhusus pada negara berkembang
• Kondisi sanitasi, papan, sandang, dan pangan yang buruk
• Angka pengangguran yang tinggi, tingkat pendidikan yang rendah
• Kegagalan program TB
• Besarnya masalah kesehatan lain yang bisa mempengaruhi tetap tingginya beban TB, seperti gizi
buruk dan merokok
• Pandemik HIV
• Kekebalan kuman TB terhadap obat anti TB (multidrug resistance = MDR)
Primary infection Entry of microorganism through droplet
nuclei

Bacteria is transmitted to alveoli through

airways

Deposition and multiplication of bacteria in

alveoli

Bacili are also transported to others parts of the

body through blood stream and phagocytosis by
macrophage and neutrophils

Accmulation of excudate in alveoli

Bronchopneumonia
 A small number of tubercle bacilli enter
the bloodstream and spread throughout
body. The tubercle bacilli may reach any
part of body sych as brain, lymph node,
lung, spine, bone or kidney

Within 2 to 8 weeks, special immune cells

called macrophage ingest and surround
the tubercle bacilli. The cells form a
barrier shell called granuloma that keeps
the bacilli contained and under controlled

If the immune system cannot keep yhe

tubercle bacilli under control, the bacilli
begin to multiply rapidly
TB DISEASE
CLINICAL MANIFESTATION
• Persistent cough of more than 2 weeks
• Associated with green, yellow or bloody sputum

• Breathlessness
• Subfebris fever

• Chest pain
• Fatigue

• Loss of weight
• Lack of appetite
• Swollen or tender lymph nodes in neck or others areas
• Pleural effusion
• Unusual breath sound (crackles)
• Auscultation : wheezing or rhonchi
A)Klasifikasi berdasarkan organ
tubuh yang terkena:
• Tuberkulosis paru
• Tuberkulosis ekstra paru
Klasifikasi berdasarkan hasil
pemeriksaan dahak mikroskopis,
yaitu pada TB Paru:
• Tuberkulosis paru BTA positif
• Tuberkulosis paru BTA negatif
C) Klasifikasi berdasarkan riwayat
pengobatan sebelumnya:
• Kasus baru
• Kasus kambuh (Relaps)
• Kasus setelah putus berobat
(Default )
• Kasus setelah gagal (Failure)
• Kasus Pindahan (Transfer In)
• Demam
• Batuk/batuk darah
• Sesak napas
• Nyeri dada
• Malaise
• Kehilangan berat badan
Gambaran radiologi yang dicurigai sebagai lesi TB aktif adalah:
• Bayangan berawan/nodular di segmen apikal dan posterior lobus atas paru dan segmen
superior lobus bawah
• Kavitas, terutama lebih dari satu, dikelilingi oleh bayangan opak berawan atau nodular
• Bayangan bercak milier
• Efusi pleura unilateral (umumnya) atau bilateral (jarang)

Gambaran radiologi yang dicurigai sebagai lesi TB inaktif:

• Fibrotik
• Kalsifikasi
• Schwarte atau penebalan paru
PEMERIKSAAN SPUTUM

Pemeriksaan dahak berfungsi untuk menegakkan diagnosis, menilai keberhasilan

pengobatan dan menentukan potensi penularan. Pemeriksaan dahak untuk penegakan
diagnosis dilakukan dengan mengumpulkan 3 spesimen dahak yang dikumpulkan dalam dua
hari kunjungan yang berurutan berupa Sewaktu-Pagi-Sewaktu (SPS),
• S (sewaktu): dahak dikumpulkan pada saat suspek TB datang berkunjung pertama kali. Pada saat
pulang, suspek membawa sebuah pot dahak untuk mengumpulkan dahak pagi pada hari kedua.
• P (Pagi): dahak dikumpulkan di rumah pada pagi hari kedua, segera setelah bangun tidur. Pot dibawa
dan diserahkan sendiri kepada petugas di UPK.
• S (sewaktu): dahak dikumpulkan di UPK pada hari kedua, saat menyerahkan dahak pagi.