KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA
UNIT PENDIDIKAN KEDOKTERAN DAN KESEHATAN (UPKK)
Jl. Dr. Moh. Ali Komp.RSMH Palembang 30126, Telp. (0711) 373438, Fax (0711) 37343 Laman http://kedokteran@fk.unsri.ac.id

Skenario A Blok 14 Tahun 2020

Mr. B, a 30 year old scavenger, was admitted to hospital because of massive hemoptoe. He
complained that 3 hours before admission, he had severe cough with bloody sputum about 2 glasses. He
also said that in the previous month he had productive cough with a lot of phlegm, mild fever, and loss of
appetite, loss of body weight and shortness of breath. Since a week ago, he felt his symptoms were
worsening. He also complained about two palpable mass which mobile, painless, with the size of a peanut
in the left side of the neck. He felt the mass since two months before admitted to the hospital.
Physical examination:
General appearance: he looked severely sick and pale. Body height: 170 cm, body weight: 45 kg, BP:
100/70 mmHg, HR: 116x/m, RR: 36 x/m. Temp: 37,6°C. There was multiple lymphadenopathy of the left
neck. Inside chest auscultation, there was an increasing of vesicular sound at the right upper lung with
moderate rales.
Laboratory:
Hb: 8,6 g%, WBC: 5.000/µL, ESR 70 mm/hr, Diff Count: 0/3/2/55/35/5, Acid Fast Bacilli: (+2/+2/+3),
HIV test: Not reactive, Rapid Test Molecular GeneXpert: M. Tb detected high Rif. Resistance not
detected.
Radiology:
Chest radiograph showed infiltration at right upper lung.
FNAC: force granuloma, multinucleated giant cell langhans with Caseoso Necreotic.
For tutors only
Learning objective:
The students will be able to:
1. Explain the anatomy, physiology, histology and patology of the involved sites in this case
2. Explain the patophysiology and symptoms of the disease
3. Explain the immunopathogenecity of the disease
4. Making plan of additional examination
5. Diagnosing of the disease
6. Managing the patient well for massive hemaptoe and tuberculosis
7. Explain the complication if disease untreatable well
Term clarification:
1. Massive hemaptoe
2. Productive cough with a lot of phlegm
3. Mild fever
4. Loss of appetite
5. Loss of body weight
6. Shortness of breath
7. Severely sick
8. Lymphadenopathy of the left neck
9. Granuloma
10. Vesicular sound
11. Moderate rales
Problem identification:
1. Mr. Y has been admitted to hospital for massive hemoptoe starting 3 hours before admission
2. Since a month ago, Mr. Y had productive cough
3. Mr. Y was in sub febrile state  Temp 36,7°C
4. Mr. has anorexia and loss weight
5. Sometimes Mr. Y has dyspnea  RR: 36x/m
6. Since a week ago, Mr. Y felt his condition worsened
7. Body height: 170 cm, Body weight: 45 kg  underweightmalnutrition
8. BP: 100/70 mmHg, HR: 116 x/m, compensation mechanism for blood loss
9. An increasing of vesicular sound at right-upper lung with moderate rales, Hb: 8,6 g%, increased
ESR, X-ray imaging revealed infiltration at right-upper lung, Acid Fast Bacilli: (+2/+2/+3), FNAC:
Four granuloma, multinucleated giant cell langhans with caseosa necrotic
10. HIV: not reactive, Diff Count: 0/3/2/55/35 and multiple lymphadenopathy of the left neck.
Problem analysis:
1. What is the meaning of massive hemoptoe?
2. Why did he has hemoptoe?
3. How hemoptoe occur in this patient?
4. Why was there rapid loss of body weight?
5. Why is infiltration appearance at right upper lung chest X-ray?
6. Is there any relationship between Tb and Lymphadenopathy?
7. What is another laboratory examination that will be done in this case?
8. How to manage this case? (education, diagnosis, therapy, referral system)

Hypothesis:
Mr. B. suffered from pulmonary TB with AFB (+) and lymphadenitis TB

Synthesis:
Pekerjaan pemulung (malnutrisi) dan kerentanan seseorang untuk menderita TB ?