CASE REPORT

PATIENTS STATUS
 Name : Mr A. Pawelai
Age : 51 year
Sex : Male
Occupation : Civil Worker
Address : Jl Kamboja
Religion : Islam
Medical Record No. : 777975
Date of treatment : 05.11.2016
Room : Infection Centre

Patients Identity
 Chief Complaint: Malaise
Structural Anamnesis:
Male patient, age 51 years old, was admitted to Wahidin Hospital, with
chief complaint of malaise. The complaint was felt since 2 days ago.
Patient had also presented abdominal pain since a week ago. Pain is felt
on the upper right quadrant. Pain is not triggered by any daily activities,
only felt when palpated.
Patient rarely cough and forget the onset. Cough with yellowish
secretion, not affected by the weather, no history of medication. Patient
do not has night sweating, no nausea and vomit, no shortness of breath,
no fever.
Defecation : yellow, no blood.
Urination : normal, yellow, no blood.

Present Illness
 Patient has Diabetes Mellitus newly diagnosed. There is
no other family members and neighbours with the same
complaints. Patient do not has history of cardiovascular
disease and hypertension. History of smoking since 10
years ago, about 24 cigarettes per day. Patient worked as
civil worker.
PHYSICAL EXAMINATION
 General state:
moderate illness, underweight, Compos Mentis (E4 M6 V5)
Height : 158 cm
Weight : 39 kg
BMI :15.5 kg/m2 (Underweight)

Vital signs:
Blood Pressure : 110/70 mmHg
Heart Rate : 80 x/minute
Respiratory Rate : 24 x/minute
Temperature : 36.0 C (axilla)

PHYSICAL EXAMINATION
 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 : (-)

PHYSICAL EXAMINATION
 THORAX
Inspection
Shape : Simetrical
JVP : DVS R+1 cm H2O
Intercostal : normal range
Palpation
Pain : (-)
Tumor : (-)

Percussion
lung : Sonor/Sonor

Auscultation
Breathing sound : Bronchovesicular
Additional sound : Ronchi (+/+) Wheezing (-/-)

PHYSICAL EXAMINATION
 HEART
Inspection : Ictus cordis not visible
Palpation : Thrill (-)
Percussion : Dull
Border line:
Upper right : unidentified
Upper left : ICS II linea parasternalis sinistra
Lower right : unidentified
Lower left : ICS V linea midclavicularis
Auscultation : heart sound I/II normal, additional sound (-)

PHYSICAL EXAMINATION
 ABDOMEN
Inspection : Flat, follow respiratory rhythm, tumor mass (-)
Palpation :
Pain (-), Tumor (-)
Enlargement of hepar 3cm below costal arch
No spleen enlargement

Percussion :
Tympany
Auscultation : Peristaltic (+), normal

PHYSICAL EXAMINATION
EXTREMITIES
Muscle wasting (-), Muscle tone normal, Pretibial oedema
(-)

PHYSICAL EXAMINATION
 Subjective Objective Assesment Planning

Male patient admitted to 1.Pulmo: Clinical Planning: Bta

Rumah Sakit Wahidin with Auscultation
chief complain of malaise Breathing sound :
diagnosed sputum test, culture,
since 2 days ago. Patient has Bronkovesikuler tuberculosis gene xpert
abdominal pain since a week Additional sound :
ago. Patient rarely cough and
Ronchi (+/+) Wheezing (-)
forget the onset. Cough with
yellowish secret, not 2.Lab(17-10-16):RBC=4.39
affected by the weather, no HGB=10.2g/dl
history of medication. HCT=35.1%
Patient do not has night MCV=80
sweating, no nausea and MCH=23.2
vomit, no shortness of
MCHC=29.1
breath, no fever.. History of
smoking since 10 years ago, RDW=20.3
about 24 cigarettes per day. PLT=114
Patient worked as civil MPV=9.1
worker.. PCT=0.103%
WBC=7.6
3.Radiology Thorax(03-11-16):
1. Infitrate apearrance at the
apex of both lung
4.BTA sputum test: negatif
 Subjective Objective Assesment Planning

malase, Phisical examination: Choronic liver Treatments:

eye: Anemic (-), icteric failure - Curcuma 1
(+) tab/8jam/oral
Abdomen: Peristaltic - Consul divisi
normal, no distention, Gastroenterohepatol
ascites(-), pain(-) ogi
Enlargement of hepar
3cm below arcus costa,
elastic, straight margin
Extrimitas: Edema
pedis at both leg.
Laboratory finding:
Bilirubin total=2.68
Bilirubin direct=1.03
SGOT=72
SGPT=61
Albumin=3.3
 Subjective Objective Assesment Planning

malaise,patient has Laboratorium finding Diabetis - Novorapid 6 unit

Diabetes Mellitus GDS=756 mellitus type 2 sebelum makan pagi
newly diagnosed. dan malam
- Consul divisi
Endochrine
Subjective Objective Assesment Planning

Laboratorium finding: hiperkalemia - Kalitake 1

NATRIUM/KALIUM/ Sachet/12jam/oral
KLORIDA=123/6.1/89
FOLLOW UP
DATE DAY OF TREATMENT THERAPY
05/11/2016 S : Male patient reffered from Rumah Sakit Barru with chief Planning
complain of malaise and abdominal pain since a week ago. - Infus Nacl 0.9% 20 tpm
23.00 No nausea and vomit, no shortness of breath, rarely cough,
rarely fever. History of smoking since 10 years ago, about a Chronic Liver Disease:
box per day. Patient has history of Diabetes Mellitus. Patient - Curcuma 1 tab/8jam/oral
do not has history of cardiovascular disease. - Konsul divisi Gastroenterohepatologi
O : moderate illness/composmentis E4V5M6
Anemic (-), icteric (+) Diabetes Melitus Type 2
JVP R+2 cm - Novorapid 6 unit sebelum makan pagi
Sonor at right and left hemithorax Vesikuler, ronkhi +/+, dan malam
Wheezing - /- - Konsul divisi Endochrine
Peristaltic normal, no distention, ascites(-), pain(-)
Enlargement of hepar 3cm below arcus costa, elastic, Hyperkalemia
straight margin - Kalitab 1 sachet/12 jam/oral
A : Chronic Liver Disease
Diabetes Melitus Type 2 Tuberculosis Paru Klinis
Hyperkalemia Planning
Clinial DiagnosedTuberculosis - Sputum AFB 3 kali
- Kultur M tuberculosis

Follow up
DATE DAY OF TREATMENT THERAPY

06/11/2016 S : Shortness of breath (-) Planinng

06.00 cough (+) - Infus NaCl 0.9% 20 tetes
Abdominal pain (+) /menit
O : Vesikuler - N-ace 200mg/8jam/oral
Ronkhi on both lung - Curcuma 1
Wheezing (-) tab/8jam/oral
CXR : Tuberculosis Paru Lama Aktif - Novorapid 6 unit
A : Clinically Diagnosed Tuberculosis sebelum makan pagi dan
New Case malam
Diabetes Mellitus Tipe 2
Increase of Transaminase Enzyme Waiting for sputum result

Follow up
DATE DAY OF TREATMENT THERAPY

07/11/2016 S : Shortness of Breath (-) Planinng

06.00 cough (+) - Infus NaCl 0.9% 20
Abdominal pain (+) tetes /menit
O : Vesikuler - N-ace 200mg/8jam/oral
Ronkhi on both lung - Waiting for sputum
Wheezing (-) result
CXR : Tuberculosis Paru Lama Aktif
A : Clinically Diagnosed Tuberculosis
New Case
Diabetes Mellitus Tipe 2
Increase of Transaminase Enzyme

Follow Up
DATE DAY OF TREATMENT THERAPY

08/11/2016 S : Shortness of Breath (-) Planinng

cough (+)
Abdominal pain (+)
O : Vesikuler
Ronkhi on both lung
Wheezing (-)
CXR : Tuberculosis Paru Lama Aktif
A : Clinically Diagnosed Tuberculosis
New Case
Diabetes Mellitus Tipe 2
Increase of Transaminase Enzyme
- Infus NaCl 0.9% 20 tetes
/menit
- N-ace 200mg/8jam/oral
- O2 3 liter/menit
- Waiting for sputum
result

Follow up
DATE DAY OF TREATMENT THERAPY

09/11/2016 S : Shortness of Breath (-) Planinng

06.00 cough (+) - Infus NaCl 0.9% 20 tetes
Abdominal pain (+) /menit
O : Vesikuler N-ace 200mg/8jam/oral
Ronkhi on both lung O2 3 liter/menit
Wheezing (-)
CXR : Tuberculosis
Paru Lama Aktif - Sputum 3X negative
A : Clinically Diagnosed - Multi slice computed
Tuberculosis New Case tomography without
Diabetes Mellitus Tipe contrast
2 - Gene expert
Increase of
Transaminase Enzyme

Follow up
LABORATORY FINDINGS
HGB :10.2g/dl
HCT :35.1% PCT :0.103%
WBC: 7.6
MCV :80
NEU :48.8
MCH :23.2 LYM :42.4
MCHC :29.1 MON :6.7
RDW :20.3 EOS :1.3
PLT :114 BAS :0.8
MPV :9.1

COMPLETE BLOOD COUNT

03/11/2016
COLOUR : YELLOW
pH :5.5
PRO :NEGATIVE
SG :1.010
GLUCOSE :4+
BIL :NEGATIVE
UBG :NORMAL
KETON :1+
NIT :NEGATIVE
BLD :1+
LEU :NEGATIVE
VC :NEGATIVE
Results :GLUCOSURIA, KETOURIA, MICROSCOPIC HEMATURIA

URINALYSIS
04/11/2016
pH :7.456
pCO2 :54.8
SO2 :91.5
PO2 :61.6
HCO3 :38.9
ctO2 :17.4
ctCO2 :40.5
BE :14.7

BLOOD CHEMICALS WORKUP

04/11/2016
COAGULATION LIVER FUNCTION
PT:15.4 TOTAL BILIRUBIN:2.68
INR:1.37
DIRECT BILIRUBIN:1.03
APTT:33.1
SGOT/ALT:72
BLOOD CHEMICALS
SGPT/AST:61
GLUCOSE
GDS:756 ALBUMIN:3.3
RENAL FUNCTION IMMUNOSEROLOGY
UREUM:42 HBsAG:negative
CREATININE:0.89 ANTI HCV:negative
ELECTROLYTE
NATRIUM/POTASSIUM/CHLORIDE:

Hematology 123/6.1/89

04/11/2016
BLOOD CHEMICAL
GLUCOSE
GDS:212
HBA1C:8.6
LIVER FUNCTION
ALKALINE PHOSFATASE:61
PROTEIN TOTAL:6.2
ALBUMIN:2.6
-GT:21
IMMUNOSEROLOGY
HBsAG:NON REACTIVE
ANTI HCV:NON REACTIVE

HEMATOLOGY
08/11/2016
TYPE OF SPECIMEN:SPUTUM
AFB1 :NEGATIVE
AFB2 :NEGATIVE
AFB3 :NEGATIVE
CULTURE :CHECK RESULT ON (26.01.2017)

MICROBIOLOGY EXAMINATION
08/11/2016
RADIOLOGY FINDINGS
USG WHOLE
ABDOMEN
 Jenis Pemeriksaan: USG Abdomen Atas + Bawah(Whole Abdomen) (03.11.2016)
Telah dilakukan pemeiksaan USG abdomen dengan hasil sebagai berikut:
1. Hepar- ukuran dalam batas normal, echo parenkim dalam batas normal, permukaan
reguler tip tajam, tidak tampak dilatasi ductus biliaris dan vaskuler, tidak tampak SOL.
2. GB- dinding tidak menebal, mukosa reguler, tidak tampak echo batu/mass.
3. Pankreas- ukuran dan echo parenkrim dalam batas normal, tidak tampak dilatasi ductus
pancreaticus, tidak tampak echo mass.
4. Lien- ukuran dan echo parenkrim dalam batas normal, tidak tampak echo mass.
5. Ginjal kanan- ukuran dan echo corticomedullary dalam batas normal, PCS tidak dilatasi,
tidak tampak echo batu/echo mass/cyst
6. Ginjal kiri- ukuran dan echo corticomedullary dalam batas normal, PCS tidak dilatasi,
tidak tampak echo batu/echo mass/cyst
7. VU- dinding tidak menebal, mukosa reguler, tidak tampak echo batu mass
Kesan: -hepar dalam batas normal
-pelvocalyectasis sinistra

USG WHOLE ABDOMEN

03/11/2016
Telah dilakukan pemeriksaan foto toraks posisi AP dengan
hasil sebagai berikut:
1. Tampak bercak berawan pada kedua lapangan paru
disertai garis fibrosis yang meretraksi hilus kedua paru.
2. Cor kesan normal, aorta normal.
3. Kedua sinus dan diafragma baik.
4. Tulang-tulang intak
kesan: TB paru lama aktif

AP CHEST XRAY
03/11/2016
DISCUSSION
 TB is an infectious disease caused by the bacillus
Mycobacterium tuberculosis. It typically affects the lungs
(pulmonary TB) but can affect other sites as well
(extrapulmonary TB).
The disease is spread in the air when people who are sick
with pulmonary TB expel bacteria, for example by
coughing.
The most common method for diagnosing TB worldwide
remains sputum smear microscopy (developed more than
100 years ago),

INTRODUCTION
 Tuberculosis (TB) is one of the top 10 causes of death worldwide.
In 2015, 10.4 million people fell ill with TB and 1.8 million died from the disease
(including 0.4 million among people with HIV). Over 95% of TB deaths occur in
low- and middle-income countries.
Six countries account for 60% of the total, with India leading the count, followed by
Indonesia, China, Nigeria, Pakistan and South Africa.
TB is a leading killer of HIV-positive people: in 2015, 35% of HIV deaths were due
to TB.
Globally in 2015, an estimated 480 000 people developed multidrug-resistantt TB
(MDR-TB).
TB incidence has fallen by an average of 1.5% per year since 2000. This needs to
accelerate to a 45% annual decline to reach the 2020 milestones of the "End TB
Strategy".
An estimated 49 million lives were saved through TB diagnosis and treatment
between 2000 and 2015.
Ending the TB epidemic by 2030 is among the health targets of the newly adopted
Sustainable Development Goals.

EPIDEMIOLOGY
 TB is an infectious disease
caused by the bacillus
Mycobacterium tuberculosis
Acid fast bacilli
Obaligat aerob
Non-spora
Non-capsule

ETIOLOGY
PATHOGENESIS
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS
 A. Based on bacteriological examination:
A patient diagnosed as TB based on the confirmation of a few
tests which includes biology test with direct microscopic
examination, bacteriology culture or rapid diagnostic tests
recommended by the Health Ministry of Indonesia .
TB patient with positive AFB smear
TB Patient with positive M. Tb Culture
TB patient with positive M. Tb rapid diagnostic test
Extra pulmonary TB patients, confirmed by AFB examination
or bacteriological culture of infected sites.

Definition of Tuberculosis
Other than the categorisation of patients based on the
definition of the diagnose, other classiffication include:
a. Anatomical location of the disease
b. Previous treatment history
c. Drugs sensitivity test
d. HIV status

Classification of TB
Pulmonary tuberculosis:
Occurs on the lung parenchyme
Miliary tuberculosis is considered
pulmonary TB due to its lesion on
the lung
Anatomical Location
Extra pulmonary tuberculosis:
Is tuberculosis that occurs
elsewhere except the lung.
Such as pleura, lymph nodes,
abdomen, genitourinary tract,
joints, bone etc
It is diagnosed by beacteriology
examination or clinically
evaluation.
The diagnose for extrapulmonary
TB with multiple organs affected is
based on the organ with the most
severe implication.
 New patients have never been treated for TB or have taken anti-TB drugs for less
than 1 month (<28 dosage).
Previously treated patients have received 1 month or more (>28 dosage) of anti-
TB drugs in the past. They are further classified by the outcome of their most
recent course of as follows:
Relapse patients have previously been treated for TB, were declared cured or treatment
completed at the end of their most recent course of treatment, and are now diagnosed
with a recurrent episode of TB (either a true relapse or a new episode of TB caused by
reinfection).
Treatment after failure patients are those who have previously been treated for TB and
whose treatment failed at the end of their most recent course of treatment.
Treatment after loss to follow-up patients have previously been treated for TB and
were declared lost to follow-up at the end of their most recent course of treatment.
(These were previously known as treatment after default patients.)
Other previously treated patients are those who have previously been treated for TB but
whose outcome after their most recent course of treatment is unknown or
undocumented. Patients with unknown previous TB treatment history do not fit into any
of the categories listed above. New and relapse cases of TB are incident TB cases.

Previous Treatment
History
 Mono-resistance (MR): resistance to one first-line anti-TB drug
only
Poly-resistance (PR): resistance to more than one first-line anti-TB
drug, other than both isoniazid (H) and rifampicin (R)
Multidrug resistance (MDR): resistance to at least both isoniazid
(H) and rifampicin (R)
Extensive drug resistance (XDR): resistance to any
fluoroquinolone, and at least one of three second-line injectable drugs
(capreomycin, kanamycin and amikacin), in addition to multidrug
resistance
Rifampicin resistance (RR): resistance to rifampicin detected using
phenotypic or genotypic methods, with or without resistance to other
anti-TB drugs. It includes any resistance to rifampicin, in the form of
mono-resistance, poly-resistance, MDR or XDR.

Drugs Sensitivity Tests

 HIV-positive TB patient refers to any bacteriologically confirmed or
clinically diagnosed case of TB who has a positive result from HIV
testing conducted at the time of TB diagnosis or other documented
evidence of enrolment in HIV care, such as enrolment in the pre-ART
register or in the ART register once ART has been started.
HIV-negative TB patient refers to any bacteriologically confirmed
or clinically diagnosed case of TB who has a negative result from
HIV testing conducted at the time of TB diagnosis. Any HIV-
negative TB patient subsequently found to be HIV-positive should be
reclassified accordingly.
HIV status unknown TB patient refers to any bacteriologically
confirmed or clinically diagnosed case of TB who has no result of
HIV testing and no other documented evidence of enrolment in HIV
care. If the patients HIV status is subsequently determined, he or she
should be reclassified accordingly.

HIV status
A. CLINICAL EVALUATION
Divided into 2: localised and systemic symptoms
Respiratory Systemic Extrapulmonary Symptoms:
Symptoms: Symptoms: Lymphadenitis Tuberculosis :
Cough 2 Fever slow, painless swelling lymph
weeks Malaise nodes
Bloody cough Nocturnal Meningitis tuberculosis:
Dyspneu hyperhidrosis meningitis signs
Chest pain Anorexia Pleural tuberculosis: Dyspneu,
Weight loss pain on the chest side with the
pleural effusion
Genitourinary tuberculosis:flank
pain, haematuria, dysuria and
frequency of micturition

Diagnosis
C. BACTERIOLOGICAL EXAMINATION
Sputum collection (S-P-S)
Microscopic examination
Ziehl-Nielssen
Auramin-Rhodamin (fluorescent staining)
Bacteriology culture
Egg based media : Lowenstein-Jensen, Ogawa, Kudoh
Agar based media: Middle Brook

Diagnosis
D. RADIOLOGY EXAMINATION
The radiographic appearance may be divided into two broad categories:
Primary tuberculosis
In primary tuberculosis, the predominant radiographic feature is the
presence of hilar and/or mediastinal adenopathy in the appropriate
lymph drainage pathways. The primary focus of tuberculous pneumonia
may or may not be visible.
Reactivation (postprimary) tuberculosis
The apical/posterior segments of the upper lobes and the superior
segments of the lower lobes are most often involved. The possible
radiographic findings are elaborated in the following section.

Diagnosis
D. RADIOLOGY EXAMINATION
ACTIVE INACTIVE
Consolidation Discrete fibrotic scar or linear
Cavitary lesions opacity
Nodule with poorly defined Discrete fibrotic scar with
margins volume loss or retraction
Hilar ormediastinal
lymphadenopathy
Pleural effusion
Milliary tuberculosis

DIAGNOSIS
E. OTHER SPESIFIC EXAMINATIONS
BACTEC
PCR
Serological Examination:
ELISA
ICT
Mycodot

DIAGNOSIS
 Tuberculosis Pneumonia
Clinical Cough > 2 weeks within (+/-) Cough within (+/-) sputum
Manifestation sputum Shortness of breath
Shortness of breath Chest pain (+/-)
Chest pain (+/-) Hemoptysis (rarely)
Hemoptysis High fever + shiver
Fever subfebril Malaise
Malaise
Night sweats
Loss weight and appetite
Physical Retraction Retraction
Examination Fremitus vocal increase or Expansion of the chest left behind
decrease during breathing
Respiratory sound : Fremitus vocal increase
Dim during percussion
Respiratory sound : Bronchial +
Rhonchi

DIFFERENTIAL DIAGNOSIS
 Tuberculosis Pneumonia
Radiology Cloudy appearance + cavity Inhomogen consolidation both
Manifestation both of hemothorax of hemothorax
Cloudy appearance + cavity + Pleura effusion
calcification + fibrosis line
both of hemothorax
Calcification + fibrosis line
both of hemothorax
Granulation spot both of
hemothorax
Pleura effusion
TB and Pneumonia
 2RHZ (E-S)/4RH with good regulation or controlled
blood sugar
Ptn with uncontrolled blood sugar : continuation phase
for 7 months (2RHZ [E-S]/7RH)
Control the blood sugar

TREATMENT
 Hemoptysis
Pneumothorax
Heart failure
Respiratory failure

COMPLICATIONS