Supervisor:

dr. H. Oscar Djauhari, Sp. THT-KL

Name
Age
Sex
Occupation
Race
Address
Weight
Height

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Mr. Y
55 years old
Male
Retirement
Javanese
Cisaat, Sukabumi
50 kg
170 cm

Chief complaint:
sudden hoarseness and difficulty swallowing
Additional complaint:
Persistent cough, weight loss, blood when
coughing
History of present illness:
Patient came with sudden hoarseness and
difficulty swallowing. He had a persisten cough
for a year and had received medication for about
6 months but never had any improvement. Bad
cough came with productive phlegm that was
green in color. Sometimes there was a stain of
redness in the phlegm. The phlegm got often
swallowed by the patient. The cough was
progressively worsening. Patient also had a
weight loss for around 10 kilos in the last 1 year.
He smoked 3 pack a week for 30 years.

1. General status

General appearance
Consciousness
Blood pressure
Pulse rate
Respiratory rate
Temperature

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Calm
Compos mentis
120/70 mmHg
88 x/min
24 x/min
37,4 C

2. Pulmonal
Inspection

: Chest simetris in static and dynamic

condition
Palpation
: Stem fremitus dextra increased
Percussion : Dull in apex region pulmonal dextra
Auscultation : Ronchi +/+, wheezing -/-

3.

ENT Status

Right ear

Mucuos membrane : hyperemic (-), edema (-), mass (-),

Secretion (-), laceration (-), cerumen (-)
Tymphanic membrane : intact, bulging (-), light reflex
(+)

Left ear :
Mucuos membrane : hyperemic (-), edema (-), mass (-),
secretion (-), laceration (-), cerumen (-)
Tymphanic membrane : intact, bulging (-), light reflex
(+)

Right nose
:
Mucous membrane: hyperemic (-), edema (-),
secretion (-), mass (-), laceration (-), crust (-)
Concha: eutrophy
Septum: no deviation
Air passage: normal

Left nose :
Mucous membrane: hyperemic (-), edema (-),
secretion (-), mass (-), laceration (-), crust (-)
Concha: eutrophy
Septum: no deviation
Air passage: normal

Throat:
Uvula in the middle
Pharynx: normal pharyngeal arch, hyperemic (-)
Tonsils : T1 / T1, detritus (-), enlarged crypt (-)

Neck: Enlargment Lymph nodes

Laboratory finding ( Complete blood count )

Chest radiograph PA position
Mantoux test
Sputum test
Direct laryngoscopy

1.

Laboratory
Haemoglobin : 13.4 g/dL
WBC
: 7300/uL
ESR
: 25/51 mm/hour
Haematocryte
: 39.3%
Platelet
: 289000/uL

2. Chest Radiograph

CXR result : Active Tuberculosis in the right lung

Chronic Laryngitis e.c. suspect lung

tuberculosis

To prevent dehydration :
RL IV line
Emergency proceedings to hypovolemic shock e.c
dehydration:
: head tilt-chin lift maneuver
Airway
Breathing : look, listen, feel
Circulation : chest compression if necessary
To treat tuberculosis :
Rifampisin 450 mg 1x1
INH 300 mg 1x1
Pirazinamid 500 mg 2x1
Ethambutol 500 mg 1x1