CASE ILUSTRATION

PATIENT IDENTIFICATION
Name

: Mrs. Ernawati
Date birth/Age : December 26 2015/44yr
Marriage Status : Married
Occupation
: Enterpreneur
Adress
: Kotabumi
Sex
: Female
Race
: Lampung
Religion
: Moslem

ANAMNESIS
Taken from autoanamnesis
In June 22, 2015 at 14.30 WIB
Main plaint

:
Breathing shortness since 22 days ago

Additional plaint
:
Cough with plegm, heavy right chest

History of disease

Patient came with breathing shortness since 22 days

ago. Complaints had felt before and treated in hospital
one month ago. Intermittent breathing shortness.
Breathing Shortness is not time affected. Tightness
aggravated by activity. Patients had a history of TB
treatment completion in 2005. The history of smoking
10 cigarettes for a year around 10 years ago.
Tightness is felt increasingly heavy with wheezing
sound. No history of heart disease. No history of
kidney disease.
Tightness accompanied by coughing up phlegm and
heaviness in the right chest. Yellowish sputum without
blood. Fever is not perceived by patient. Weight loss
slightly occur. Appetite slightly occur.

History of past disease

Pulmonary TB
Family history

No such complaints were appeared

Systemic Anamnesis
Skin

No disorder
Head

No disorder
Eye

No disorder
Ear

No disorder
Nose

No disorder
Mouth

No disorder
Throat

No disorder

Neck
No disorder
Chest
Dyspneu , Heavy Chest, Cough
Abdomen
No disorder
Urinary Tract
No disorder
Haid
No disorder
Nerve and muscle
No disorder
Extremity
No disorder

Body Weight
Highest body weight
Height

: 45 kg

: 158 cm
Current body weight : decrease

LIFE HISTORY
Born place : at home
Helper : midwife
Immunisation history
Food history

: polio

Frequency : 3x/day
Amount : 3 plate/day
Variation: fish, chicken, vegetable
Appetite
: decrease

Education : High School

Difficulty
Finance : none
Occupation
: none
Family : none

PHYSICAL EXAMINATION
Blood pressure : 130/80 mmHg
Respiration

: 36 x/minute
Pulse : 88 x/minute
Temp. : 36,50C axila
Height : 158 cm
Weight : 43 kg
Nutritional status : BMI = 17,2 lack of nutrition
Awareness : compos mentis
Sianosis: General edem : Habitus : astenikus
Mobility : active
Age based on appraisal : around 40 yrs

PHSYCHOLOGICAL ASPECT
Behavior

: normal
Sentiment
: normal
Thinking process : normal

GENERAL STATUS
Skin : normal
Lymph Gland : normal
Head : normal
Eye

: normal
Ear : normal
Mouth : normal
Neck
Lymph gland : normal
Tiroid gland: normal
JVP

: 5+1 cmH2O

Chest (thorax)
Shape

: Normochest
Blood vessel : Normal
Lung
Inspectio Normochest, right chest
n
movement left by right
chest,
Palpation Right vocal Fremitus> left
vocal fremitus

Heart
ictus cordis not
visible
ictus cordis not
palpable

Percusio Sonor at left, dull at right hardly assessed

n
Auscultat Bonchial breathing sound, heart sound I-II
ion
Wheezing +/+ Coarse
regular

Blood Vessel
A. Temporale
A. Carotid
A.
A.
A.
A.
A.

: normal
: normal
Brachialis
: normal
Radialis
: normal
Femorale
: normal
Poplitea
: normal
Tibialis posterior : normal

Abdomen
Inspection
Palpation

: flat
: hepar-spleen normal, painful

regio
epigaster
Percussion
: Timpani
Auscultation : intestine noise(+) normal

Ekstremity
Superior : tonus, mass, joint, movement, strenght

normal, no edem
Inferior : tonus, mass, joint, movement, strenght
normal, no edem

Reflexes
Biseps

: normal
Triceps : normal
Patella : normal
Achilles : normal
Patological reflexes : -

ADDITIONAL EXAMINATION

Blood

routine 22/06/2015
Hb: 13,2 gr/dl
Ht : 39 %
LED : 10 mm/jam
Leukosit: 27.000 /ul
Diff. Count

Basophil : 0 %

Eosinophil: 0 %

Batang : 0 %

Segmen : 92 %

Limposit : 4 %

Monosit : 4 %

Trombosit

: 385.000 /ul
SGOT : 12 U/L
SGPT : 9 U/L
Ureum : 31 mg/dl
Creatinin : 0,5 mg/dl
GDS : 90 mg/dl

Rontgen Thoraks
trakea
deviated to
the left,
infiltrate and
cavity at the
right lung,
heart shift to
the left,
fibrotic line at
left lung

Resume
Patient came with breathing shortness since 22 days

ago. Complaints had felt before and treated in hospital

one month ago. Intermittent breathing shortness.
Breathing Shortness is not time affected. Tightness
aggravated by activity. Patients had a history of TB
treatment completion in 2005. The history of smoking
10 cigarettes for a year around 10 years ago. Tightness
is felt increasingly heavy with wheezing sound. No
history of heart disease. No history of kidney disease.
Tightness accompanied by coughing up phlegm and

heaviness in the right chest. Yellowish sputum without

blood. Fever is not perceived by patient. Weight loss
slightly occur. Appetite slightly occur.

Resume (add.)
Chest
Inspection :Normochest, right chest movement left by

right chest,
Palpation
:right vocal Fremitus> left vocal fremitus,
Percussion : Sonor at left, dull at right
Auscultation : bonchial breathing sound, Wheezing +/+
Coarse crackles +/+
Leukosit : 27.000 /ul
Segmen : 92 %
Ro Thorax : trakea deviated to the left, infiltrate and cavity
at
the right lung, heart shift to the left

Working diagnosis
Post Tubercular

Obstructive Syndrome +
Destroyed Lung Dextra
Reason

History of TB
Repeated complaints
Shortness breath esp.

By activity
Painful chest
Cough up plegm
Anorektia
Weight loss

Asymetric movement of
chest
Right Fremitus > left
fremitus
Dullness at right chest
Crackles and wheezing
+, bronchial breathing
sound
Leukositosis
Segment 90%
Rontgen: cavity and

Differential diagnosis:
PPOK on acute exacerbation

Reason of differential diagnosis

Repeated complaints
Shortness breath esp. By activity
Cough up plegm
Crackles and wheezing +, bronchial breathing sound
Leukositosis
Segment 90%

Examination suggestion
BTA
Spirometri (RV, VC, TLC, FEV1)
Arterial Blood Gas
Culture sputum

Management
O24-5 L/minute
Aminofilin drip 0,5-1 mg/kgBB/Hour
Nebulisasi Salbutamol 1 amp
Ambroxol syr 3x1 c
Ceftriaxon vial 1gr/12 Hour

Prognose
Quo ad Vitam: Dubia ad malam
Quo ad Fungtionam
Quo ad Sanationam

: Malam
: Malam

Reference:
S.K. Verma, S. Kumar, Kiran Vishnu Narayan, R. Sodhi. 2009.

Post Tubercular Obstructive Airway Impairment. Indian J

Allergy Asthma Immunol 2009; 23(2) : 95-99
Inam Muhammad Baig, Waseem Saeed and Kanwal Fatima
Khalil. 2010. Post-Tuberculous Chronic Obstructive Pulmonary
Disease. Journal of the College of Physicians and Surgeons
Pakistan 2010, Vol. 20 (8): 542-544
Chih-Hsin Lee, Ming-Chia Lee. 2012. Pulmonary Tuberculosis
and Delay in Anti-TuberculousTreatment Are Important Risk
Factors for ChronicObstructive Pulmonary Disease. May 2012 |
Volume 7 | Issue 5

Alimuddin Zumla, M.D., Ph.D., Mario Raviglione, M.D., Richard

Hafner, M.D.,and C. Fordham von Reyn, M.D. 2015. current
conceptsTuberculosis. N Engl J Med 2013;368:745-55.