CASE REPORT

A. PATIENT IDENTITY
 Name : Nn. SF
 Age : 15 Years Old
 Address : Semolowaru Surabaya
 Job : Student
 Last education : Elementary School
 Coming to polyclinic : June, 23rd 2016, 10.15

B. SUBJECTIVE
PRIMARY SURVEY
Airway : Corpus alienum (-)
Maksilofacial trauma (-)
Additional breath sounds (-)
Gaps (-)

Breathing : Look: Normochest, symmetric, retraction (-), RR: 20x/minute

Feel: regular breathing
Listen: gargling (-), snoring (-)

Circulatiom : HR : 84x/mnt
Blood pressure : 120/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability : GCS : 456
Round pupil isokor 3mm/3mm
Exposure : (-)

SECONDARY SURVEY
 Main complaint :
Lump in left neck
 HISTORY OF PRESENT ILLNESS :
Patient came to the Surgeon Polyclinic General Hospital of Haji

Surabaya with complaint lump in left neck since 1 month ago and this

is a painless lump. Initially only a small lump as big as soybean and

enlarged until now. She had history 1 month of cough. The cough with

yellow color of mucus and no blood. She had lost weight 6 kgs (from

52 kgs to 46 kgs) in 1 month, sweat in the night, lost of appetite, but

she had no fever and dyspneu. She had no nausea nor vomiting.
 HISTORY OF PAST ILLNESS:

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 History of such illness is denied, history of any operation in abdomen

is denied.
 FAMILY HISTORY :
Herbrother had chronic cough and diagnosed Tuberculosis since 2

month ago, he had been intensive treatment for Tuberculosis.

History of tumor or cancer is denied
 SOCIAL HISTORY :
The patient is a student.The neighborhood and friends had no history

of such illness.
 ALLERGIES HISTORY : Denied

C. GENERAL STATUS :
General state : Good enough, Weight: + 46 kg
Blood pressure :120/80 mmHg
HR : 84 x/minute
RR : 20x/ minute
Tax : 36,5 oC
Head/Neck : A-/I-/C-/D-
Enlarged of lymph node (+)

Thorak s

P I : Normochest, symmetric, retraction (-)

P : Movement of the chestwalls symmetric, crepitation (-),
deviated trachea (-), widened intercostals space (-)
P : sonor/ sonor
A : breath sounds vesicular +/+, Ronchi -/-, Wheezing -/-
C I : Ictus does not seen

P : Ictus no palpable, thrill (-)

P : heart border normal

A : S1S2 single, Gallop (-), Murmur (-)

Abdomen

I : Flat simetris

P : Soepel , tenderness (-), H/L/R no palpable,

P : Meteorismus (-)

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 A : bowel sounds (+) normal

Ekstremity :

o Warm palm

+ +

+ +
o Oedema

- -
- -
o Cyanosis

- -
- -
o CRT < 2 dtk

D. LOCAL STATUS
Regio colli dextra
o I : Mass (+), hiperemi (-), swelling (-)
o P : palpable lump (+) 2,5x1,5x1,5 cm, mass (+) solid, mobile, clear

boundaries, tenderness (-)

o A : no bruit
E. DIAGNOSIS
Limphadenitis ec susp TB
F. PLANNING DIAGNOSIS: -
- FNAB
 Lympadenitis granulomatik sesuai tuberculosa
- Sputum analysis
- Thorax photo PA
G. PLANNING THERAPY
- 2RHZE/4(HR)3
H. PLANNING MONITORING
- General state
- Vital sign.
- Patient complaints.

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Picture of patient: