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    FOLOW UP Dan Terapi Yang Diberikan

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    farizrr
    The patient was admitted to the hospital with complaints of shortness of breath, cough, and fever. Examinations revealed left pleural effusion suspected of tuberculosis. The patient received oxygen therapy, intravenous fluids, antibiotics, antituberculosis drugs, and other medications. Over the course of treatment, the patient's symptoms improved but shortness of breath, cough and fever persisted. Further tests including CT-guided FNAB were planned to diagnose the cause of ongoing pleural effusion, which was suspected to be tuberculosis or a mediastinal tumor.

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    FOLOW UP Dan Terapi Yang Diberikan

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    farizrr
    14 views11 pages
    The patient was admitted to the hospital with complaints of shortness of breath, cough, and fever. Examinations revealed left pleural effusion suspected of tuberculosis. The patient received oxygen therapy, intravenous fluids, antibiotics, antituberculosis drugs, and other medications. Over the course of treatment, the patient's symptoms improved but shortness of breath, cough and fever persisted. Further tests including CT-guided FNAB were planned to diagnose the cause of ongoing pleural effusion, which was suspected to be tuberculosis or a mediastinal tumor.

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    The patient was admitted to the hospital with complaints of shortness of breath, cough, and fever. Examinations revealed left pleural effusion suspected of tuberculosis. The patient received oxygen therapy, intravenous fluids, antibiotics, antituberculosis drugs, and other medications. Over the course of treatment, the patient's symptoms improved but shortness of breath, cough and fever persisted. Further tests including CT-guided FNAB were planned to diagnose the cause of ongoing pleural effusion, which was suspected to be tuberculosis or a mediastinal tumor.

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    14 views11 pages

    FOLOW UP Dan Terapi Yang Diberikan

    Uploaded by

    farizrr
    The patient was admitted to the hospital with complaints of shortness of breath, cough, and fever. Examinations revealed left pleural effusion suspected of tuberculosis. The patient received oxygen therapy, intravenous fluids, antibiotics, antituberculosis drugs, and other medications. Over the course of treatment, the patient's symptoms improved but shortness of breath, cough and fever persisted. Further tests including CT-guided FNAB were planned to diagnose the cause of ongoing pleural effusion, which was suspected to be tuberculosis or a mediastinal tumor.

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    of 11

    FOLOW UP dan Terapi yang Diberikan

    Tanggal
    22-08-2011

    S
    Sesak (+)
    Batuk (+)

    O
    TD ;110/70 mmHg
    N : 135 x/menit
    R : 45 x/menit
    T= 36oC
    BB = 25 kg

    A
    Efusi pleura sinistra e.c
    susp.TB

    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    23-08-2011

    Demam (-)
    Sesak (<)
    Batuk (+)
    BAB/BAK (+/+)

    TV : TD = 110/70 mmHg
    N =120 x/menit
    R = 40 x/menit
    T= 36,7oC

    Efusi pleura sinistra e.c


    susp.TB

    P
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.Metamizol 3x1 amp
    drip
    Po: Ambroxol 3x1cth
    Aspirin 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Diet bebas
    Pro: Analisa Cairan pleura
    Kultur cairan pleura
    Cek albumin
    Sitologi cairan pleura
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg

    BB = 25 kg

    Inj.antrain 3x1 amp drip


    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)

    Hidung: Pch (+)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).
    24-08-2011

    Demam (-)
    Sesak (<)
    Batuk (+)
    BAB/BAK (+/+)

    TV : TD = 110/70 mmHg
    N =118 x/menit
    R = 38 x/menit
    T= 36,5oC
    BB = 25 kg

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg

    Hidung: Pch (+)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).
    25-08-2011

    Demam (-)
    Sesak (<)
    Batuk (<)
    BAB/BAK (+/+)

    TV : TD = 100/80 mmHg
    N = 114 x/menit
    R = 30 x/menit
    T= 36,4oC

    Nyeri kepala (+)


    Nyeri punggung (+)
    Nyeri dada (+)

    26-08-2011

    27-08-2011

    Demam (-)
    Sesak (<)
    Batuk (<)
    BAB/BAK (+/+)
    Nyeri kepala (+)
    Nyeri punggung (+)
    Nyeri dada (+)

    Demam (-)
    Sesak (<)

    BB = 25 kg

    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).
    Hasil Mantoux test =
    negative
    TV : TD = 100/80 mmHg
    N = 130 x/menit
    R = 30 x/menit
    T= 35,8oC
    BB = 25 kg

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).
    TV : TD = 100/70 mmHg
    N = 110 x/menit

    28-08-2011

    Batuk (<)
    BAB/BAK (+/+)
    Nyeri kepala (<)
    Nyeri punggung (<)
    Nyeri dada (<)

    R = 28 x/menit
    T= 36oC
    BB = 25 kg

    Demam (-)
    Sesak (<)
    Batuk (<)
    BAB/BAK (+/+)
    Nyeri kepala (<)
    Nyeri punggung (<)
    Nyeri dada (<)

    TV : TD = 100/70 mmHg
    N = 110 x/menit
    R = 28 x/menit
    T= 36oC
    BB = 25 kg

    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4
    Pro : Konsul Paru
    CT-scan

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4

    29-08-2011

    30-08-2011

    Demam (-)
    Sesak (<)
    Batuk (<)
    BAB/BAK (+/+)
    Nyeri kepala (<)
    Nyeri punggung (<)
    Nyeri dada (<)
    Makan/Minum (+/+)

    TV : TD = 110/70 mmHg
    N = 110 x/menit
    R = 28 x/menit
    T= 36oC
    BB = 25 kg

    Sesak (<)
    batuk (<)
    febris (-)
    sakit kepala (<)
    nyeri punggung (<)
    BAB (+)
    BAK (+)

    TV : TD = 100/70mmHg
    N = 128 x/menit
    R = 32 x/menit
    T=36,5o C
    BB = 25 kg

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (+) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Efusi pleura sinistra e.c


    susp.TB

    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4
    Pro: Rencana FNAB CT
    guiding
    efusi
    pleura O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    sinistra e.c susp
    Inj.Ampisilin 4x500 mg
    TB + susp. Tumor Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    mediastinum
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4

    31-08-2011

    September
    2011

    Sesak (-), batuk (<),


    febris
    (-),
    sakit kepala
    (-),
    nyeri
    punggung (-)
    BAB
    (+),
    BAK (+)

    TV : HR = 120 x/menit
    RR = 30 x/menit
    T = 36,0o C
    TD= 100/80mmHg
    BB = 25 kg

    Sesak (-), batuk (<),


    febris
    (-),
    sakit kepala
    (-),
    nyeri
    punggung (-)
    BAB
    (+),
    BAK (+)

    HR = 120 x/menit, RR
    = 31 x/menit, T = 36,6o
    C, TD= 100/80mmHg

    efusi pleura sinistra


    e.c susp TB + susp.
    Tumor mediastinum

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (-) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (-) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    efusi pleura sinistra


    e.c susp TB + susp.
    Tumor mediastinum

    Pro: Rencana FNAB CT


    guiding
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin 2
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4 full dose
    tapering off 2 minggu
    Pro: Rencana FNAB CT
    guiding
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin 2

    September
    2011

    September
    2011

    Sesak (-), batuk (<),


    febris
    (-),
    sakit kepala
    (+),
    nyeri
    punggung (-)
    BAB
    (+),
    BAK (+)

    HR = 120 x/menit, RR
    = 30x/menit, T = 36,0o
    C, TD= 100/80mmHg

    Sesak (-), batuk (-),


    febris
    (-),
    sakit kepala
    (+),
    nyeri
    punggung (-)
    BAB
    (+),

    HR = 106 x/menit, RR
    = 24 x/menit, T = 36,6o
    C, TD= 100/80mmHg

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (-) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (-) subcostal

    efusi pleura sinistra


    e.c susp TB + susp.
    Tumor mediastinum

    efusi pleura sinistra


    e.c susp TB + susp.
    Tumor mediastinum

    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4 full dose
    tapering off 2 minggu
    Pro: Rencana FNAB CT
    guiding
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin 2
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4 full dose
    tapering off 2 minggu
    Pro: Rencana FNAB CT
    guiding
    O2 2 Lpm
    IVFD D51/2 NS 14 tpm
    Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg

    BAK (+)

    September
    2011

    Sesak (-), batuk (-),


    febris
    (-),
    sakit kepala
    (+),
    nyeri
    punggung (-)
    BAB
    (-),
    BAK (+)

    substernal, Fremitus vokal


    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    HR = 110 x/menit, RR
    = 24 x/menit, T = 36,3o
    C, TD= 100/80mmHg

    Hidung: Pch (-)


    Thorax = Asimetris,
    retraksi (-) subcostal
    substernal, Fremitus vokal
    mnurun sblh kiri, perkusi
    paru kiri redup, Rh (-/-),
    wh (-/-).

    Po: Ambroxol 3x1cth


    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin 2
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4 full dose
    tapering off 2 minggu
    Pro: Rencana FNAB CT
    guiding
    efusi pleura sinistra O2 2 Lpm
    e.c susp TB + susp. IVFD D51/2 NS 14 tpm
    Tumor mediastinum Inj.Ampisilin 4x500 mg
    Inj.Gentamsin 1x160 mg
    Inj.antrain 3x250 mg
    Inj.Ranitidin 3x25 mg
    Po: Ambroxol 3x1cth
    Aspilet 80 mg 3x1 tab
    OAT (INH 200
    mg,Rimfapisin 2
    300mg,pirazinamid 800
    mg)
    Prednison 3-3-4 full dose
    tapering off 2 minggu
    Pro: Rencana FNAB CT
    guiding

    Pemeriksaan Penunjang selama di rawat di RSUD Ulin

    Hasil laboratorium
    Hb
    Leukosit
    Eritrosit
    Hematokrit
    Trombosit
    MCV
    MCH
    MCHC
    AGD

    22-08-2011
    14,9 g/dl
    10,3 ribu/uL
    6,05 juta/uL
    47 vol%
    1018 ribu/uL
    76,9 fl
    24,7 pg
    32,1%

    24-08-2011
    11,9 g/dl
    7,2 ribu/uL
    4,69 juta/uL
    29 vol%
    698 ribu/uL
    62,6 fl
    25,4 pg
    40,6%

    25-08-2011

    26-08-2011
    12,4 g/dl
    6,2 ribu/uL
    4,84 juta/uL
    31 vol%
    715 ribu/uL
    63,7 fl
    25,6 pg
    40,3%

    27-08-2011

    Suhu
    pH
    PCO2
    PO2
    HCO3
    O2 Saturasi
    BE
    K+
    Na+
    Albumin
    Hasil PT
    APTT
    SGOT
    SGPT
    Ureum
    Creatinin
    LDH
    Natrium
    Kalium
    Klorida
    Analisa cairan pleura
    Makroskopis
    Warna
    Kejernihan
    Mikroskopis
    Leukosit
    Pewarnaan MB
    PMN

    35,9oC
    7,460
    32 mmHg
    92 mmHg
    22,4 meq/l
    97%
    -1 mmol/L
    3,9 mmol/L
    139 mmol/L
    5,3 g/dL
    13,5 detik
    36,2 detik
    27 U/l
    24 U/l
    26 mg./dl
    0,6 mg/dl

    3,8 g/dL

    4,0 g/dL

    432 U/L
    141 mmol/L
    3,3 mmol/L
    109 mmol/L

    135 mmol/L
    3,2 mmol/L
    102 mmol/L

    Merah
    Keruh
    10-30/LPB
    10%

    MN
    Perwarnaan gram
    Perwarnaan ZN
    Kimiawi
    Glokosa

    90%
    Tidak ditemukan
    kuman gram negatif
    dan positif
    BTA negatif
    17 mg/dL

    PEMERIKSAAN
    PENUNJANG
    PA

    Thorax Foto

    CT Scan

    Sitologi cairan
    pleura proses radang
    TBC/spesifik
    Suspect massa
    mediastinum efusi
    pleura sinistra
    Primary (benign)
    mediastinal (inferoanterior, medius
    posterior) yang
    mengesankan
    atelektasis left lung
    tissue dengan left
    pleura efusion yang
    mengalami
    organisasi.

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