Laporan Kasus

Ilmu Penyakit Dalam

Rumah Sakit Umum Siloam
Pembimbing: dr. Titis Dewi Wahyuni, Sp.P
Disusun oleh: Vincent (01073170032)
01 Laporan Kasus
Informasi mengenai pasien, hasil pemeriksaan dan
pemeriksaan penunjang

02 Follow Up

03 Tinjauan Pustaka

04 Pembahasan Kasus
Argumentasi diagnosis, tatalaksana, dan respons terhadap
terapi
Laporan Kasus
Identitas Pasien
Nama : Ny. M
Jenis Kelamin : Perempuan
Tanggal lahir : 2 – Juni – 1972
Umur : 46 tahun 10 bulan
Alamat : Kp. Nangerang RT 005/ RW 003,
Cilaku, Tenjo
Pekerjaan : Tidak bekerja
No. Rekam medis : 83-74-xx
Hari/Tanggal kunjungan: Jumat, 12 April 2019
Tanggal anamnesis dan pemeriksaan fisik: Sabtu, 13
April 2019
Anamnesis: autoanamnesis dan alloanamnesis
(melalui rekam medis dan pendamping pasien)
Keluhan dan Riwayat Penyakit Sekarang

Onset
Awalnya pasien sedang tertidur, di mana tiba-
KELUHAN UTAMA tiba pasien memiliki dorongan yang kuat untuk
batuk

Karakteristik
Batuk sangat hebat hingga akhirnya keluar
gumpalan-gumpalan darah berwarna merah
kegelapan dengan volume sekitar 3-4
sendok teh

Batuk
berdarah Keluhan lain
sejak 6 jam Tidak disertai dengan muntah, dan tidak
SMRS ada episode di mana pasien mengalami
penurunan kesadaran (pingsan),
ataupun riwayat buang air besar
berdarah atau kotoran berwarna
kehitaman
Progresivitas

Sesampainya di IGD RSUS, pasien mengeluhkan masih

batuk-batuk hebat dan masih mengeluarkan darah jika batuk
 Keluhan dan Riwayat Penyakit Sekarang

Onset
Sudah dirasakan pasien sejak beberapa bulan
KELUHAN TAMBAHAN terakhir

Karakteristik
• Tidak memiliki pola yang jelas, namun lebih
dirasakan pada malam hari di mana disertai
dengan keringat malam dan menggigil
• Demam yang dirasakan cukup tinggi hingga
mengganggu tidur pasien

Demam Durasi
Demam biasanya berlangsung selama
beberapa hari, dan akan perlahan-lahan
menurun dengan sendirinya

Riwayat kontak
Pasien tidak memiliki riwayat bepergian ke daerah Indonesia
bagian Timur ataupun memiliki kontak dengan hewan liar
 Keluhan dan Riwayat Penyakit Sekarang

Onset
Pasien juga merasakan sesak sejak beberapa
KELUHAN TAMBAHAN bulan terakhir

Karakteristik
Awal mulanya sesak  pasien
menjelaskan sensasinya seperti seolah-
olah sulit untuk menarik nafas dan dada
pasien terasa tertekan

Sesak
Timing
Sesak dirasakan sepanjang hari,
dan tidak memburuk di malam hari

Aggravating factor / relieving factor

Sesak napas tidak dipengaruhi oleh aktivitas, dan tidak

disertai dengan nyeri dada. Pasien memiliki keterbatasan
dalam beraktivitas, di mana pasien tidak mampu untuk
berjalan jauh oleh karena sesak yang dialaminya.
 Keluhan dan Riwayat Penyakit Sekarang

Onset
KELUHAN TAMBAHAN Pasien mengeluhkan penurunan nafsu makan sejak
beberapa bulan terakhir yang disertai dengan penurunan
berat badan yang drastis

Karakteristik
• Tidak disertai dengan mual dan
muntah, dan pasien mengaku bahwa
dirinya memiliki ketertarikan yang
kurang untuk mengkonsumsi
Penurunan makanan
nafsu makan • Semakin kendornya pakaian yang
dan berat biasa digunakan oleh pasien
badan
Faktor pencetus
Tidak disertai dengan program diet
khusus ataupun peningkatan aktivitas,
dan sudah terjadi sekitar kurang lebih
awal munculnya demam dan batuk-batuk
yang dialami pasien.
Keluhan dan Riwayat Penyakit Sekarang

Onset
Pasien memiliki riwayat diagnosis menderita penyakit
Riwayat diagnosis tuberkulosis paru sejak awal tahun ini

Compliance berobat
• Pasien tidak mengkonsumsi obat-
obatan secara rutin oleh karena
Tuberkulosis kendala berobat
• Pasien telah menjalani pengobatan
paru selama sekitar 2 bulan

Keluhan sebelumnya
Sebelum terdiagnosis tuberkulosis paru
pada awal tahun ini, pasien juga
mengeluhkan adanya batuk produktif
selama lebih dari satu bulan yang
disertai dengan penurunan berat badan
dan adanya periode demam
 Riwayat Penyakit Dahulu dan
Perawatan di Rumah Sakit

Pasien tidak pernah

Riwayat Penyakit Perawatan di menjalani perawatan di
Dahulu Rumah Sakit rumah sakit
Pasien tidak memiliki riwayat
penyakit yang signifikan ataupun
A B
riwayat dirawat di rumah sakit
sebelum penyakit ini..
 Riwayat Penyakit Keluarga
Riwayat Menstruasi
Riwayat Penggunaan Obat

Pasien tidak memiliki hubungan
yang dekat dengan orangtua
ataupun saudara kandungnya.
Tidak ada penyakit yang dapat
diwariskan
Pasien tidak mengingat usia
ketika menarche, namun siklus
reguler tanpa adanya
abnormalitas dalam durasi
menstruasi ataupun volume darah
Riwayat pengobatan TB paru
selama 2 bulan namun tidak rutin
Riwayat pengobatan
pengendalian hipertensi dan DM
namun tidak rutin mengkonsumsi
obat
 Riwayat
Sosioekonomi

Suami bekerja Pasien tinggal di sebuah

Tinggal bersama rumah yang berukuran
sebagai petani
suaminya dengan penghasilan relatif kecil dengan
ventilasi udara yang cukup
yang tidak menentu baik. Rumah pasien tidak
memiliki pencahayaan
yang cukup, dan udara di
rumah pasien lembab
 Pemeriksaan Fisik

Tekanan Darah: Keadaan umum: tampak sakit

125mmHg (Sistol) / 70 mmHg sedang
(Diastol) Kesadaran: Compos Mentis /
Denyut Jantung: GCS E4V5M6
98 bpm reguler, kuat angkat

Laju napas: 24 bpm Suhu tubuh: 36.9oC

SpO2: 95%
 Pemeriksaan Sistem
Kulit  Pigmentasi kulit seragam (sawo matang)
keseluruhan  Tidak ada sianosis/kebiruan
 Tidak ada ikteris/jaundice/kekuningan
 Tidak ada kemerahan
 Tidak terdapat edema periorbital
 Elastisitas dan turgor normal

Kepala dan Rambut  Rambut tersebar secara merata

wajah  Rambut berwarna hitam, kuat, tidak
mudah rontok
Kulit kepala  Tidak ada ruam
 Tidak terdapat bekas luka
 Tidak ada masa
 Tidak ada deformitas
 Tidak ada sianosis/kebiruan
 Tidak ada ikteris/jaundice/kekuningan
 Tidak ada kemerahan

Fungsi  Pergerakan kepala normal

 Tidak ada keterbatasan gerak (range of
motion)
Mata  Mata normal
 Konjungtiva pucat
 Tidak ada sklera ikteris
 Tidak ada ptosis (drooping eyelids)
 Tidak ada bekas luka
 Jarak antar mata simetris

Mulut  Bibir normal, simetris, kemerahan, lembab, tidak ada

sianosis/kebiruan
 Mukosa mulut normal, lembab, tidak ada ulkus/luka, tidak ada
nodul/masa
 Lidah normal, merah muda, bersih, gerakan normal, indra perasa
normal, tidak ada deviasi maupun atrofi
 Palatum normal, celah langit-langit tidak terlihat.
 Faring normal.
 Uvula intak di tengah
 Tonsil normal.
Leher  Penampakan leher normal
 Tidak terdapat abnormalitas pigmentasi warna kulit
 Tidak ada bekas luka
 Tidak ada ruam
 Trakea intak di tengah, tidak ada deviasi
 Tidak ada pembesaran tiroid
 Tidak ada pembesaran kelenjar parotis
Jantung Inspeksi  Iktus kordis tidak
terlihat
Palpasi  Iktus kordis teraba di ICS
V linea anterior aksila
sinistra
Perkusi  Tidak ditemukan adanya
perbesaran ukuran
jantung
Auskultasi  Suara jantung normal:
- S1 normal
- S2 normal
- Tidak ada murmur
- Tidak ada gallop
Paru-paru Inspeksi  Tidak terdapat abnormalitas pigmentasi kulit
 Kembang paru asimetris, bagian kiri dada
pasien sedikit tertinggal
 Tidak ada barrel chest
 Tidak ada pectus excavatum maupun pectus
carinatum
 Tidak ada masa
 Tidak ada lesi
 Tidak ada ruam
 Tidak ada bekas luka
 Tidak ada retraksi intercostal
 Tidak ada retraksi supraclavicular

Palpasi  Tidak terdapat nyeri tekan ataupun massa pada

dinding dada pasien
 Taktil vremitus asimetris, hipo-resonan untuk
paru kiri
 Pengembangan dada asimetris, bagian kiri dada
lebih tertinggal
Perkusi  Perkusi paru kanan normal, sonor
 Perkusi paru kiri dull pada seluruh lapangan paru
 Batas paru hepar normal (ICS 6 linea
midklavikula kanan)

Auskultasi  Terdengar penurunan suara napas vesikuler pada

lapangan paru kiri
 Terdapat rhonchi basah halus pada lapangan paru
kiri yang terdengar di seluruh lapangan paru
Abdomen Inspeksi  Tidak terdapat abnormalitas
pigmentasi kulit
 Tidak ada distensi abdomen
 Tidak ada ruam
 Tidak ada bekas luka
 Tidak ada striae
 Tidak ada caput medusa
 Tidak ada spider naevi
 Tidak ada masa
Auskultasi  Bising usus normal terdengar
 Tidak ada bruit aorta abdominalis
maupun bruit arteri renalis
 Tidak ada clicking sound maupun
metallic sound
Perkusi  Perkusi normal, timpani di seluruh
bagian abdomen
Palpasi  Palpasi normal
 Tidak terdapat nyeri tekan
 Tidak ada hepatomegali
 Tidak ada splenomegali
 Ballotement test (-/-)
 Pemeriksaan nyeri ketok CVA
negatif pada kedua sisi (-/-)
Ekstremitas Look  Tidak terdapat abnormalitas
atas dan pigmentasi kulit
bawah  Ekstremitas simetris secara
orientasi anatomis dalam
posisi istirahat
 Jari-jari tidak ada tanda
deformitas
 Tidak ada pucat
 Tidak sianosis/kebiruan
 Tidak
ikteris/jaundice/kekuningan
 Kuku normal, tidak ada
clubbing finger
Feel  Ekstremitas hangat
 Capillary Refill Time normal (+-2
detik)
 Tidak terdapat krepitasi ataupun
nyeri tekan
 Diagnosis dan Diagnosis Banding

Diagnosis banding
Diagnosis 1. Hemoptysis et causa
1. Hemoptysis et causa pneumonia
tuberkulosis paru status BTA 2. Hemoptysis et causa
belum dapat dipastikan, keganasan paru unspecified
suspek lesi luas, kasus putus 3. Hemoptysis et causa
berobat bronchiectasis
2. Diabetes mellitus
3. Hipertensi Diagnosis Diagnosis
banding
Pemeriksaan Penunjang
12 April 2019

11.70-
Hb 11.70 15.50 g/dL
35.00-
Hematokrit
33.10 47.00 %
RBC 4.59 3.80-5.20 rb/ul
WBC 18.23 3.60-11.00 rb/ul
Basofil - 0-1,0 %
Eosinofil - 1.0-3.0 %
Neutrofil Batang 2 2.0-6.0 %
Neutrofil Segmen 75 50-70 %
Limfosit 15 25-40 % SGPT 6 0-33 U/L
Monosit 8 2,0-8,0 % Ureum 21.0 <50.00 mg/dL
Platelet 448.00 150-440 rb/ul Creatinine 0.40 0.5-1.1 mg/dL
ESR 80 0-20 mm/jam mL/m/1.73
MCV 72.10 80-100 fL eGFR
124.9 m2
26.00- Na 131 137-145 mmol/L
MCH
25.50 34.00 pg K 2.4 3.6-5.0 mmol/L
32.00- Cl 83 98-107 mmol/L
MCHC
35.30 36.00 g/dL Random Blood
SGOT 10 0-32 U/L Glucose 340.0 <200 mg/dL
Blood Ketones 0.4 <0.6 mmol/L
 X-ray thorax 1. Paru: perselubungan
inhomogen dengan kavitas
pada lapang atas dan
#1 tengah paru kiri. Infiltrat
pada lapang atas paru
Admisi pertama kanan
(awal tahun 2. Hilus: suram
3. Impression: TB paru aktif,
2019) aorta elongasi dan
kalsifikasi

4. Paru: perselubungan
inhomogen dengan kavitas
pada lapang atas dan

X-ray thorax tengah paru kiri. Infiltrat

pada lapang atas dan
bawah paru kanan,
#2 lapangan tengah dan
bawah paru kiri
Admisi kedua 5. Hilus: suram
6. Impression: TB paru aktif
relatif bertambah, aorta
elongasi dan kalsifikasi
 You can
A. simply
Ritme: impress
Sinus your audience and
takikardia
add a unique zing and appeal to your
B. Laju:Easy
Presentations. kurang lebih
to change 100bpm
colors,
C.and
photos Aksis: Normoaksis
Text. Get a modern
PowerPoint
D. Gelombang: thattidak
Presentation is ditemukan
beautifully designed. You can simply
adanya
impress your audience and abnormalitas
add a unique yang
bermakna
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to your Presentations.
Easy to change
seluruh colors, photos
lead and Text. ataupun
prekordial
Get a modern PowerPoint Presentation
tungkai.
that is beautifully Ditemukan Q patologis
designed.
pada lead V1 tanpa adanya
abnormalitas kompleks QRS
pada lead lainnya yang
bermakna. Terdapat inversi
gelombang T pada lead V1-V3,
disertai dengan depresi segmen
ST pada lead V1-V3 namun
tidak bermakna.
E. Hipertrofi: tidak ditemukan
adanya tanda-tanda hipertrofi
ruang jantung
F. Kesimpulan: sugestif OMI
ELEKTROKARDIOGRAFI anteroseptal
 Mikrobiologi Sputum

14 April 2019
Dilakukan pemeriksaan GenExpert dan mikrobiologi sputum dengan hasil
sebagai berikut:

GenExpert MDR TB Mikrobiologi sputum

Polymerase chain reaction Good quality sputum,

M. tuberculosis: detected leukosit 100/lpf,
epitel <10/lpf,
MDR Rifampicin: not detected acid fast bacillus +2
R E S U M E
Batuk berdarah Demam sejak Batuk
sejak 6 jam beberapa produktif lama
SMRS bulan terakhir

Mikrositosis,
leukositosis, imbalans
Sesak elektrolit, peningkatan
LED, GDS 304mg/dL

Chest x-ray Pemeriksaan BTA

menandakan
EKG: OMI
dan GenExpert:
perluasan lesi anteroseptal BTA (+), sensitif R
TB
 Diagnosis Akhir

Diagnosis lain
1. Pneumonia dengan susp.
Diagnosis
atelectasis
Hemoptysis et causa
2. Anemia mikrositik
tuberkulosis paru BTA positif,
lesi luas, kasus putus hipokromik
berobat, HIV negatif 3. Imbalans elektrolit
4. Diabetes Mellitus
Diagnosis Diagnosis 5. Hipertensi
banding
Tatalaksana
1. IVRL 500cc/8jam
2. Ceftazidime IV 1gram TDS
3. Rifampicin PO 450mg PO
4. Isoniazid PO 300mg OD
5. Pyrazinamid PO 1000mg OD
6. Ethambutol PO 1000mg OD
7. Ambroxol PO 30mg TDS
8. Ranitidine IV 50mg BD
9. Domperidone PO 10mg TDS
10. KSR PO 1 tab TDS
11. Novorapid SC (ac) prn
Follow Up
 FOLLOW UP HARI KEDUA
O
TTV:
110/75, 81bpm reguler, 20bpm, 96% (room air), 36.9C
Konjungtiva: pucat
Kembang paru asimetris, bagian kiri dada pasien sedikit
S tertinggal
Taktil vremitus asimetris, hipo-resonan untuk paru kiri
Sesak, batuk berdarah Pengembangan dada asimetris, bagian kiri dada lebih

O
iv
masih ada (14mL). Sulit

bj
tertinggal

t
ec

ec
Perkusi paru kiri dull pada seluruh lapangan paru
tidur di malam hari

bj

tiv
Terdengar penurunan suara napas vesikuler pada lapangan

Su

e
paru kiri
Terdapat rhonchi basah halus pada lapangan paru kiri yang
terdengar di seluruh lapangan paru

14 Apr
A P
t
en

Pl
1. Hemoptysis et causa tuberkulosis IVRL 500cc/8jam

sm

a nn
paru BTA positif, kasus putus Ceftazidime IV 1gram TDS

es

i ng
berobat Rifampicin PO 450mg PO

s s
2. Pneumonia dengan susp. atelectasis Isoniazid PO 300mg OD

A
3. Anemia mikrositik hipokromik Pyrazinamid PO 1000mg OD
4. Imbalans elektrolit Ethambutol PO 1000mg OD
5. Diabetes Mellitus Ambroxol PO 30mg TDS
6. Hipertensi Ranitidine IV 50mg BD
Domperidone PO 10mg TDS
KSR PO 1 tab TDS
Novorapid SC (ac) prn
 FOLLOW UP HARI KETIGA
O
TTV:
100/70, 79bpm reguler, 21bpm, 97% (room air), 36.8C
Konjungtiva: pucat
Kembang paru asimetris, bagian kiri dada pasien sedikit
S tertinggal
Taktil vremitus asimetris, hipo-resonan untuk paru kiri
Sesak dan batuk masih Pengembangan dada asimetris, bagian kiri dada lebih

O
iv
ada. Batuk berdarah

bj
tertinggal

t
ec

ec
Perkusi paru kiri dull pada seluruh lapangan paru
(sekitar 12mL). Sudah bisa

bj

tiv
Terdengar penurunan suara napas vesikuler pada lapangan

Su

e
tidur paru kiri
Terdapat rhonchi basah halus pada lapangan paru kiri yang
terdengar di seluruh lapangan paru

15 Apr
A P
t
en

Pl
1. Hemoptysis et causa tuberkulosis IVRL 500cc/8jam

sm

a nn
paru BTA positif, kasus putus Ceftazidime IV 1gram TDS

es

i ng
berobat Rifampicin PO 450mg PO

s s
2. Pneumonia dengan susp. atelectasis Isoniazid PO 300mg OD

A
3. Anemia mikrositik hipokromik Pyrazinamid PO 1000mg OD
4. Imbalans elektrolit Ethambutol PO 1000mg OD
5. Diabetes Mellitus Ambroxol PO 30mg TDS
6. Hipertensi Ranitidine IV 50mg BD
Domperidone PO 10mg TDS
KSR PO 1 tab TDS
Novorapid SC (ac) prn
 FOLLOW UP HARI KEEMPAT
O
TTV:
110/80, 79bpm reguler, 19bpm, 98% (room air), 36.9C
Konjungtiva: pucat
Kembang paru asimetris, bagian kiri dada pasien sedikit
S tertinggal
Taktil vremitus asimetris, hipo-resonan untuk paru kiri
Sesak sudah membaik, Pengembangan dada asimetris, bagian kiri dada lebih

O
iv
batuk berdarah masih ada

bj
tertinggal

t
ec

ec
Perkusi paru kiri dull pada seluruh lapangan paru
(10mL)

bj

tiv
Terdengar penurunan suara napas vesikuler pada lapangan

Su

e
paru kiri
Terdapat rhonchi basah halus pada lapangan paru kiri yang
terdengar di seluruh lapangan paru

16 Apr
A P
t
en

Pl
1. Hemoptysis et causa tuberkulosis IVRL 500cc/8jam

sm

a nn
paru BTA positif, kasus putus Ceftazidime IV 1gram TDS

es

i ng
berobat Rifampicin PO 450mg PO

s s
2. Pneumonia dengan susp. atelectasis Isoniazid PO 300mg OD

A
3. Anemia mikrositik hipokromik Pyrazinamid PO 1000mg OD
4. Imbalans elektrolit Ethambutol PO 1000mg OD
5. Diabetes Mellitus Ambroxol PO 30mg TDS
6. Hipertensi Ranitidine IV 50mg BD
Domperidone PO 10mg TDS
KSR PO 1 tab TDS
Novorapid SC (ac) prn
 FOLLOW UP HARI KELIMA
O
TTV:
110/75, 82bpm reguler, 20bpm, 96% (room air), 36.9C
Konjungtiva: pucat
Kembang paru asimetris, bagian kiri dada pasien sedikit
S tertinggal
Taktil vremitus asimetris, hipo-resonan untuk paru kiri
Sesak sudah membaik, Pengembangan dada asimetris, bagian kiri dada lebih

O
iv
batuk masih ada. Batuk

bj
tertinggal

t
ec

ec
Perkusi paru kiri dull pada seluruh lapangan paru
berdarah (sekitar 6mL)

bj

tiv
Terdengar penurunan suara napas vesikuler pada lapangan

Su

e
paru kiri
Terdapat rhonchi basah halus pada lapangan paru kiri yang
terdengar di seluruh lapangan paru

17 Apr
A P
t
en

Pl
1. Hemoptysis et causa tuberkulosis IVRL 500cc/8jam

sm

a nn
paru BTA positif, kasus putus Ceftazidime IV 1gram TDS

es

i ng
berobat Rifampicin PO 450mg PO

s s
2. Pneumonia dengan susp. atelectasis Isoniazid PO 300mg OD

A
3. Anemia mikrositik hipokromik Pyrazinamid PO 1000mg OD
4. Imbalans elektrolit Ethambutol PO 1000mg OD
5. Diabetes Mellitus Ambroxol PO 30mg TDS
6. Hipertensi Ranitidine IV 50mg BD
Domperidone PO 10mg TDS
KSR PO 1 tab TDS
Novorapid SC (ac) prn
 FOLLOW UP HARI KEENAM
O
TTV:
105/70, 80bpm reguler, 18bpm, 98% (room air), 36.7C
Konjungtiva: pucat
Kembang paru asimetris, bagian kiri dada pasien sedikit
S tertinggal
Taktil vremitus asimetris, hipo-resonan untuk paru kiri
Sesak ringan, batuk sudah Pengembangan dada asimetris, bagian kiri dada lebih

O
iv
tidak ada darah namun

bj
tertinggal

t
ec

ec
Perkusi paru kiri dull pada seluruh lapangan paru
masih berdahak dan

bj

tiv
Terdengar penurunan suara napas vesikuler pada lapangan

Su

e
banyak paru kiri
Terdapat rhonchi basah halus pada lapangan paru kiri yang
terdengar di seluruh lapangan paru

18 Apr
A P
t
en

Pl
1. Hemoptysis et causa tuberkulosis IVRL 500cc/8jam

sm

a nn
paru BTA positif, kasus putus Ceftazidime IV 1gram TDS

es

i ng
berobat Rifampicin PO 450mg PO

s s
2. Pneumonia dengan susp. atelectasis Isoniazid PO 300mg OD

A
3. Anemia mikrositik hipokromik Pyrazinamid PO 1000mg OD
4. Imbalans elektrolit Ethambutol PO 1000mg OD
5. Diabetes Mellitus Ambroxol PO 30mg TDS
6. Hipertensi Ranitidine IV 50mg BD
Domperidone PO 10mg TDS
KSR PO 1 tab TDS
Novorapid SC (ac) prn
TABEL HEMOPTYSIS
Tanggal/Jam 14 15 16 17 18
0 - - - - -
1 - - - - -
2 - - - - -
3 - - 5 - -
4 - - - - -
5 5 - - - -
6 - - - - -
7 - 5 - 6 -
8 - - - - -
9 - - - - -
10 - - - - -
11 - - - - -
12 5 - - - -
13 - - - - -
14 - - - - -
15 - - - - -
16 - - 5 - -
17 - 7 - - -
18 - - - - -
19 4 - - - -
20 - - - - -
21 - - - - -
22 - - - - -
23 - - - - -
Prognosis
Ad Sanationam
Ad Vitam
Dubia ad bonam
Bonam

Ad functionam

Bonam
TINJAUAN
PU STAKA
Your Picture Here

Tuberkulosis
Penyakit infeksi yang disebabkan oleh bakteri Mycobacterium
tuberculosis yang biasanya menginfeksi paru-paru. Berdasarkan data
yang diberikan oleh World Health Organization pada tahun 2017
menunjukkan bahwa setiap tahunnya terjadi penurunan incidence rate
dari penyakit ini sebanyak 1.5%. Tuberkulosis masih merupakan
penyebab sakit dan kematian yang signifikan di negara-negara
berkembang, terutama Indonesia.
 PATO
FISIOLOGI
MANI FES
TASI
KLINIS
MANIFESTASI KLINIS

Batuk bersputum, hemoptisis, sesak napas,

penurunan berat badan, anoreksia, demam,
lemas, atrofi otot, dan penampilan kakeksia;
yang semuanya dapat muncul dalam
kombinasi manapun. Meskipun demikian,
tidak ada satu dari gejala yang baru
dituliskan merupakan fitur khusus dari
tuberkulosis.
ALUR DIAGNOSIS
Prinsip utama
Diagnosis TB merupakan sebuah tantangan klinis oleh karena presentasi klinis
dari pasien yang berbeda-beda, maka dari itu diperlukan sebuah algoritma
diagnosis untuk dapat memaksimalkan deteksi dan pencegahan penyebaran dari
kuman tersebut

Uji tuberkulin
Metode screening untuk melihat infeksi yang sedang berlangsung
atau riwayat infeksi. Sering digunakan pada anak, tidak dapat
dijadikan penunjang diagnostik pada orang dewasa.

Interferon-Gamma Release Assay:

Mendeteksi interferon gamma yang dilepaskan pada infeksi TBC.
Menggunakan metode enzyme-linked immunosorbent assay
(ELISA) atau enzyme-linked immunospot assay (ELISpot).

Gene-Xpert dan GenoType MTBDRplus:

Pemeriksaan GeneXpert MTB/RIF dan GenoType MTBDRplus
telah dijadikan sebagai salah satu modalitas yang dapat digunakan
untuk diagnosis TB oleh WHO pada tahun 2011.
Mengamplifikasi gen rpoB yang spesifik pada bakteri M.
tuberculosis (MTB) dan mendeteksi adanya resistensi terhadap
rifampicin (RIF)
 K LAS I F I KAS I
PAS I E N
Klasifikasi berdasarkan organ tubuh

A
1. Tuberkulosis paru: tidak termasuk pleura dan kelenjar
getah bening parahiler
2. Tuberkulosis extra paru: pleura, meninges,
pericardium, kelenjar parahiler, tulang

Klasifikasi berdasarkan pemeriksaan sputum

B 1. Tuberkulosis paru BTA positif

2. Tuberkulosis paru BTA negatif

Klasifikasi berdasarkan keparahan penyakit

C 1. TB paru BTA negatif foto toraks positif: berat dan

ringan
2. TB ekstra-paru: ringan dan berat

D
Klasifikasi berdasarkan riwayat pengobatan
1. Kasus baru 4. Kasus gagal
2. Kasus kambuh 5. Kasus pindahan
3. Kasus putus berobat 6. Kasus lain

E
Klasifikasi berdasarkan status HIV
1. Kasus TB dengan HIV positif
2. Kasus TB dengan HIV negatif
3. Kasus TB dengan HIV tidak diketahui
P R I N S I P TATALAK SANA
1. OAT harus diberikan dalam kombinasi (multidrug therapy)
2. Untuk memastikan kepatuhan berobat dibutuhkan PMO (pengawas minum obat) dengan DOT
(directly observed treatment)
3. Terapi dibagi menjadi fase intensif dan fase lanjutan

TATALAKSANA
PASIEN
T BC
 1. Pasien baru TB paru BTA
PAN D UAN OAT positif
KATEGORI 1 2. Pasien TB paru BTA
negatif foto toraks positif
3. Pasien TB ekstra paru

KATEGORI
PENGOBATAN
LINI 1

1. Pasien kambuh PAN D UAN OAT

2. Pasien gagal
3. Pasien dengan KATEGORI 2
pengobatan setelah putus
berobat
TINDAK LAN J U T

Prinsip utama pemantauan

Pemantauan kemajuan hasil pengobatan pada orang dewasa dapat dilakukan
melalui pemeriksaan ulang sputum secara mikroskopis. Pemeriksaan sputum
secara mikroskopis lebih baik dibandingkan dengan pemeriksaan chest x-ray
dalam memantau perjalanan penyakit.

Pemeriksaan laboratorium
Pemeriksaan laboratorium dengan Laju Endap Darah (LED) tidak
digunakan untuk memantau kemajuan pengobatan karena tidak
spesifik untuk TB

Pemeriksaan BTA
Untuk memantau kemajuan pengobatan dilakukan pemeriksaan
spesimen sebanyak dua kali (sewaktu dan pagi). Hasil
pemeriksaan dinyatakan negatif bila ke 2 spesimen tersebut
negatif. Bila salah satu spesimen positif atau keduanya positif,
hasil pemeriksaan ulang sputum tersebut dinyatakan positif.
PEMBAHASAN
KASUS
Topik yang akan
dibahas
01 Penegakkan Diagnosis

02 Tatalaksana: inisial,
follow up

03 Respons terhadap terapi

 DIAGNOSIS
ANAMNESIS
Keluhan
Utama
Jan Pengobatan TBC paru
HEMOPTISIS

Penghentian konsumsi obat

Feb
Keluhan Keluhan
Tambahan Tambahan

Demam Sesak
Demam, batuk, penurunan BB

Keluhan Keluhan
Tambahan Tambahan Apr Perburukan batuk, batuk berdarah
Penurunan nafsu Penurunan berat
makan badan
x Admisi kedua
 Infeksi (bronkitis,
pneumonia) (50%)
Karsinoma bronkial (17.4%)
Penyakit paru Bronkiektasis (6.8%)
Edema paru (4.2)
Tuberkulosis (2.7%)
Aspergiloma (1.1%)
Tumor bronkial (0.2%)
Vaskulitis (0.2%)

Pulmonary artery embolism

(2.6%)
Keluhan
Utama Malformasi vaskular (0.2%)
Penyakit Idiopathic pulmonary
HEMOPTISIS kardiovaskular hemosiderosis (0.1%)
Septic embolism
Pulmonary hypertension

Iatrogenic (3.5%)
Trauma (0.7%)
Benda asing (0.1%)
Penyakit lainnya Koagulopati
Trombositopenia
Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Deutsches
Aerzteblatt Online [Internet]. 2017 [cited 25 April 2019];114(21):371-381. Available from:
https://www.ncbi.nlm.nih.gov/
 Keluhan Keluhan
Tambahan Tambahan
Penyebab
hemoptisis Demam Sesak
Tuberkulosis

Keluhan Keluhan
Tambahan Tambahan

Penurunan nafsu Penurunan berat

makan badan

G E JALA K O N S T I T U S I O NAL
Riwayat pengobatan Indonesia merupakan
TBC putus berobat negara endemis
 Keluhan Keluhan
Tambahan Tambahan
Tuberkulosis
Demam Sesak

Keluhan

Proses kronis Epidemiologi

Batuk lama

Airway remodelling
FAKTOR PENDUKUNG

Predisposisi

Diagnosis
tambahan dan
diagnosis
banding Hemoptisis
Pneumonia
 Meningkatkan resiko

Keganasan

Perokok pasif
Dipikirkan atas dasar

Batuk berdarah Penurunan berat

badan secara drastis Tinggal dengan
seorang perokok

FAKTOR PENDUKUNG
Tidak ada perubahan
aktivitas fisik
 Meningkatkan resiko

Bronkiektasis

Dipikirkan atas dasar

Prevalensi
Batuk produktif sejak Sesak Demam Compliance
pneumonia dan
lama infeksi saluran berobat yang
pernapasan buruk
lainnya

FAKTOR PENDUKUNG
 DIAGNOSIS
Sistem pulmo
Pemeriksaan fisik

Konjungtiva
Pucat
Signifikan
untuk
hemithorax kiri

Tanda-tanda anemia

Pengembangan Tactile Suara dull Suara

dada asimetris vremitus hipo- pada perkusi rhonchi
resonan basah halus
Kemungkinan

Anemia Anemia
penyakit defisiensi
kronis besi
Bagian kiri Atelectasis
sediit tertinggal sinistra
dibandingkan (?)
yang kanan
 DIAGNOSIS
Pemeriksaan Penunjang
Hasil
Pemeriksaan
Darah Rutin

Diabetes
Peningkatan GDS mellitus tidak
terkendali

Hb: batas bawah Imbalans elektrolit

WBC: meningkat signifikan
dengan peningkatan
neutrofil segmen Peningkatan resiko?
Mikrositosis dan
hipokromia Penurunan nafsu makan

Pemeriksaan
panel besi Hubungan kausal?
Interpretasi
Suspek infeksi kronis
dan akut
superimposed
 DIAGNOSIS
Pemeriksaan Penunjang

Hasil
Hasil pemeriksaan Keluhan batuk,
Leukositosis
Pemeriksaan sputum dan sesak,
yang signifikan
Chest x-ray GenExpert hemoptisis

Status diabetes Perubahan

mellitus tidak struktur
terkendali  jaringan paru
Proses spesifik, kavitasi, M.Tb positif resiko infeksi
perselubungan Sensitif terhadap
inhomogen, lesi meluas rifampicin

FAKTOR PENDUKUNG

TB paru Pneumonia

Atelectasis (?)
Pada pasien ini, skor PORT-PSI adalah 46 (usia
pasien dan status gula darah). Hasil ini
menandakan bahwa pasien berada pada klasifikasi
risk class II, di mana sebenarnya pada pasien ini
tidak terdapat indikasi rawat inap karena pneumonia
dan peluang terjadinya mortalitas adalah 0.6-0.9%.
 Hemoptisis Hemoptisis Hemoptisis Hemoptisis masif
ringan sedang berat
Volume Volume Volume 1. Volume
<100mL<24jam 100-300mL/24 300-600mL/24 >600mL/24ja
jam jam m dan batuk
tidak berhenti

2. Volume 250-
600mL/24 jam
dengan kadar
hemoglobin
<10g/dL dan
batuk
berdarah
masih
berlangsung

3. Volume 250-
600mL/24 jam
dengan kadar
hemoglobin
>10g/dL dan
batuk
berdarah
masih
berlangsung
meskipun
Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and dalam terapi
konservatif
Treatment of Hemoptysis. Deutsches Aerzteblatt Online selama 48
[Internet]. 2017 [cited 25 April 2019];114(21):371-381. jam
Available from: https://www.ncbi.nlm.nih.gov/
 TATALAKSANA
TATALAKSANA INISIAL
Tuberkulosis
paru

Antibiotik golongan beta

laktam dan dapat
Pneumonia
ditambah makrolida (jika
Pengobatan perlu)
antituberkulosis dengan
lini 1 kategori 1

Cephalosporin generasi 3
M.Tb pada WHO 2017:
pasien masih pertambahan S
sensitif sebagai
terhadap monoterapi
Rifampicin tambahan tidak
dianjurkan
Watkins RR, Lemonovich TL. Diagnosis and Management of Community-Acquired
Pneumonia in Adults. American Family Physicians 2011; 83(11): 1299-1306.
http://www.ahaphysicianforum.org/ (accessed 25 April 2018).

World Health Organization. Guidelines for treatment of drug-

susceptible tuberculosis and patient care. Switzerland: World
Health Organization; 2017. https://apps.who.int/ (accessed 25
April 2019).
 TATALAKSANA
FOLLOW UP
Terapi bernapas
Pengobatan untuk atelectasis
Pemeriksaan
GenExpert dan pneumonia Sesak berkurang,
batuk berkurang,
x-ray yang
hemoptisis
mendukung berkurang
Pemberian antibiotik
sefalosporin generasi 3

Evaluasi respon
terapi
Pengobatan Mencakup bakteri
Profilaksis
dengan anti- gram positif dan
terhadap infeksi
tuberkulosis lini 1 negatif seperti
nosokomial (HAP)
kategori 1 pseudomonas

Ekspektasi Ekspektasi

Perbaikan Perbaikan Perbaikan

 RESPON TERHADAP TERAPI

Pemberian Perbaikan
antituberkulosis Sesuai guideline,
sesuai dengan agen gejala hari per
dan antibiotik harinya
kausatif

Resolusi dari
hemoptisis

Tidak sesak
napas
Kriteria
DISCHARGE pemulangan
Tidak pasien
membutuhkan
suplementasi O2

Kadar Hb >10g/dL
tanpa perdarahan
aktif
REFERENSI
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• Moussa H, Bayoumi F, Ali A. Evaluation of GeneXpert MTB/RIF assay for direct diagnosis of pulmonary
tuberculosis. Saudi Medical Journal [Internet]. 2016 [cited 19 April 2019];37(10):1076-1081. Available from:
https://www.ncbi.nlm.nih.gov/
• Ravimohan S, Kornfeld H, Weissman D, Bisson G. Tuberculosis and lung damage: from epidemiology to
pathophysiology. European Respiratory Review [Internet]. 2018 [cited 21 April 2019];27(147):170077. Available
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2019];121(5):1827-1833. Available from: https://www.ncbi.nlm.nih.gov/
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AMPK-Dependent Matrix Destruction in Human Pulmonary Tuberculosis. PLOS Pathogens [Internet]. 2015 [cited
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Deutsches Aerzteblatt Online [Internet]. 2017 [cited 25 April 2019];114(21):371-381.
Available from: https://www.ncbi.nlm.nih.gov/
• World Health Organization. Guidelines for treatment of drug-susceptible tuberculosis and
patient care. Switzerland: World Health Organization; 2017. https://apps.who.int/
(accessed 25 April 2019).
• Watkins RR, Lemonovich TL. Diagnosis and Management of Community-Acquired
Pneumonia in Adults. American Family Physicians 2011; 83(11): 1299-1306.
http://www.ahaphysicianforum.org/ (accessed 25 April 2018).
• Buising K. A prospective comparison of severity scores for identifying patients with severe
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Thank You
 Keluhan dan Riwayat Penyakit Sekarang

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Thank You
Fully Editable Shapes
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You can Resize without

losing quality
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Color &
Line Color

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You can Resize without

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You can Change Fill
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 Fully Editable Icon Sets: C

You can Resize without

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