LAPORAN KASUS SULIT

Nama : Tn. I
Jenis Kelamin : Laki Laki
Umur : 22 thn
Masuk RS : 31 Maret 2018

Diagnosis :
 SIRS ec Pneumonia
 TB paru kasus putus obat
 Susp. CHF
 Hiponatremia
 Tn. I /22 Th
Riwayat Perjalanan Penyakit
Keluhan Utama : Sesak Nafas
RPS

28 Maret 2018 31 Maret 2018

Pasien dirawat di RSUD selama 4  Pasien datang ke IGD dengan keluhan sesak
hari kemudian dirujuk untuk napas sejak lebih kurang 1 minggu dan
diagnostik dan tatalaksana memberat dalam beberapa hari yang lalu.
lanjutan yang timbul dengan aktifitas ringan, tidak
dipengaruhi oleh cuaca, debu, dan posisi,
serta tidak disertai oleh suara mengi. Pasien
juga mengeluh kan batuk berdahak sejak 5
bulan yang lalu. Dengan dahak berwarna
putih kekuningan. Batuk berdarah dan riw.
Batuk darah disangkal. Nyeri dada di sangkal.
Pasien juga mengeluhkan demam naik turun
sejak 1 bulan. Berkeringat malam disangkal.
Selera makan menurun (+). Penurunan berat
badan (+) tetapi tidak di ketahui berapa kg.
BAB dan BAK tidak ada keluhan.
 RIWAYAT PERJALANAN PENYAKIT
 RPD : DM (-), HT (-), Tb Paru (+) 1 tahun yang lalu
 RPO : Obat DM (-) Obat Ht (-), OAT (+) 1 tahun yang lalu hanya di
 minum selama 1,5 bulan.
 RKS : Pasien seorang pekerja swasta (penjual ikan) dengan riwayat
 merokok 1 bks /hari. IB ringan
 Tn. I /22 Th

Pemeriksaan Fisis 31/3/2018

KU : Tampak Sakit Berat Kepala : Normocephalic Abdomen :
SENS : CM Mata : Konjungtiva Anemis I : Distensi (-) , Ikterik (-)
TD : 120/60 mmHg (-/-), Sklera Ikterik (-/-) P : Hepar teraba (-) , lien
HR : 127 x/menit Mulut : Higienitas cukup, teraba (-), Nyeri tekan
RR : 36 x/menit Faring hiperemis (-), Pursed epigastric (-) defans (-)
Suhu : 36,0 oC Lips (-) P : Tympani
Leher : TVJ 5-2 cmH2O A: Peristaltik (+)
SpO2 : 95% dengan O2 Pembesaran KGB : Leher (-), Ekstremitas : Akral hangat,
5 lpm NK Axilla (-) Supraclavicula (-) Pretibial , edema (-/-),
BB : 40 kg Jantung : clubing Finger(-)
TB : 155 cm I : Thrill (-)
IMT : 16,6 ( moderate P : Ictus Cordis (+) normal
thinnes) A : BJ I-II reguler,
murmur (-) gallop (-)
 Pemeriksaan Fisik Paru
Inspeksi :
Asimetris kiri tertinggal , Penggunaan otot bantu pernafasan (-), Venektasi (-), Pelebaran sela
iga (-), retraksi iga (-).

Palpasi Kanan Kiri

Lap. Paru Atas SF Ka < SF Ki
Lap. Paru Tengah SF Ka< SF Ki
Lap. Paru bawah SF Ka SF Ki
Krepitasi (-) (-)
Nyeri Tekan (-) (-)
Perkusi Kanan Kiri
Lap. Paru Atas Sonor ↓ Sonor ↓
Lap. Paru Tengah Sonor ↓ Sonor ↓
Lap. Paru Bawah Sonor sonor
 Pemeriksaan Fisik Paru
Auskultasi Kanan Kiri
Lap. Paru Atas bronkovesikuler bronkovesikuler

Lap. Paru Tengah bronkovesikuler bronkovesikuler

Lap. Paru Bawah vesikuler Vesikuler
Rhonki Kanan Kiri
Lap. Paru Atas + +
Lap. Paru Tengah + +
Lap. Paru Bawah - -
wheezing Kanan Kiri
Lap. Paru Atas - -
Lap. Paru Tengah - -
Lap. Paru Bawah - -
Foto Thorax Tgl 27/3/2018
• Kesan:
Deviasi Trakea, Fibro
Infiltrat dan kardiomegali
 Foto Thorax Tgl 31/3/2018

Kesan : Deviasi trakea, Fibrio Infiltrat dan kardiomegali

 Pemeriksaan Laboratorium

31/03/2017 Rujukan
Hb 13 12,0 – 15,0 g/dl
Ht 38 45 - 56%
Erit 5.1 4,2- 5.403/mm3
Leuko 13.4 4,5 – 10,5. 103/mm3
Trom 277 150 – 45.103/ mm3
MCV 74 80 – 100 fL
MCH 25 27 -31 pg
MCHC 35 32 – 36%
RDW 16.6 11,5 – 14,5 %
Hit jenis
E/B/NB/NS/L/M 0/0/1/91/5/3 0-6/0-2/2-6/50-70/20-40/2-7 %
Na / K/ Cl 124/3.5/89 135-145/3,7-5,4/98-106
Ur/Cr 54/0.61 13-14/0,51-0,95
KGDS 100 <200
 AGDA

Kesan : Alkalosis Respiratorik Tidak Terkompensasi

 EKG

Kesan : Sinus Takikardi : HR 140 x/I, RAD, RBBB, RVH,

OMI septal
 DIAGNOSIS & TATALAKSANA
Planing Diagnostik Planing Evaluasi :

 Sputum Mo gram K/R  Evaluasi gejala klinis (sesak

 Gen Expert napas, batuk kering ,nyeri

 EKG (+) dada)

kesan : sinus takikardi, RVH,  Evaluasi darah rutin 3 hari

infark miokard septal pasca AB

 Konsul kardiologi  Cek DR ulang 3 hari pasca AB

 Echocardiografi  Cek elektrolit pasca koreksi

 CT Angiografi  Foto thorax ulang 5 Hari Pasca

 CT Scan Thorak AB.

 DIAGNOSIS & TATALAKSANA
Diagnosis Kerja : Planing terapi :
1. SIRS ec severe pneumonia  O2 5 LPM NK

2. Tb paru kasus putus obat  IVFD Nacl 3 % 10 gtt/i

 Inj. Methylprednisolon 62.5 mg /12 jam
3. Hiponatremia ec dd/
 AB golongan Quinolon (Inj. Levofloxacin
1. low intake
750 mg/ 24 jam)
2. Peny kronik  Drip dobutamin 3 meq dalam Nacl 0.9 %
4. susp. CHF 50 cc  1.8 cc/jam dosis titrasi

6. Susp pulmonary hipertensi  N asetyl sistein 3 x 1

 Rencana pemberian OAT
Terapi kardiologi
 Inj. Furosemid 2 cc/jam (Tunda)
 Sildenafil 2x 6.25 mg
 DIAGNOSIS & TATALAKSANA
Planing Edukasi : Prognosis :
- Menjelaskan tentang penyakit - Dubia
dan tatalaksana penyakit
- Menjelaskan etika batuk
 FOLLOW UP

TGL S O A P

Sesak nafas Vital Sign • SIRS ec severe  O2 5 LPM NK - Gene expert

Batuk berdahak Sens :  IVFD Nacl 0,9 % 15 - Kultur
TD : 90/60 mmhg Pneumonia gtt/I sputum Mo
HR : 125x/i • Tb paru kasus putus  Inj. gram K/R
RR : 39 x/i Methylprednisolon - SGOT/SGPT
T : 36,9 0C obat 62.5 mg /12j
SPO2 : 95% dengan • Susp. CHF NYHA III-IV  Inj. Levofloxacin
O2 5 lpm NK 750 mg/ 24 jam
• Susp. Pulmonary  Drip dobutamin 3
PF Paru: Hypertensi meq dalam Nacl 0.9
1/3/2018

% 50 cc 1.8
• Hiponatremia ec dd/
H1

Insp : Asimetris statis, cc/jam

Kiri tertinggal dinamis a. Low intake  N. Asetil Sistein 3 x
Palp : SF kanan < SF 1
kiri b. Penyakit kronis  Sildenafil 2x 6.25mg
Perk : Sonor↓ / sonor
Ausk : Vesikuler (̀+/+) ,
Rh (+/+),
Wh (-/-)
 FOLLOW UP

TGL S O A P

Sesak nafas Vital Sign • SIRS ec severe  O2 5 LPM NK  Gene expert

Batuk berdahak Sens :  Kultur
TD : 90/60 mmhg Pneumonia  IVFD Nacl 0.9 % 15 sputum Mo
HR : 125x/i • Tb paru kasus putus gtt/I gram K/R
RR : 30 x/i
T : 36,9 0C obat  Inj.
SPO2 : 95% dengan • Susp. CHF NYHA III-IV Methylprednisolon Echo :
O2 5 lpm NK RA, RV dan LV
• Susp. Pulmonary 62.5 mg /12 jam dilatasi. Fungsi
PF Paru: Hypertensi  Inj. Levofloxacin sistolik LV
menurun
2/3/2018

Insp : Asimetris statis, • Hiponatremia ec dd/ 750 mg/ 24 jam dengan global
H2

Kiri tertinggal dinamis a. Low intake  Drip dobutamin 3 hipo kinetik, Rv

Palp : SF kanan < SF fungsi menurun,
kiri b. Penyakit kronis meq dalam Nacl 0.9 TR dan PR
Perk : Sonor↓ / sonor % 50 cc 1.8 moderated
Ausk : Vesikuler (̀+/+) , dengan PH mild,
Rh (+/+), cc/jam Susp
Wh (-/-)  Flumucyil 3 x 1 Cardiomyopaty

 Sildenafil 2x 6.25
mg
 TERIMA KASIH
MOHON SARAN & BIMBINGAN
 Background
• Tuberculosis (TB) rarely involves the heart but when it
does most usually manifests as isolated pericarditis
leading to a pericardial effusion or myopericarditis.
Isolated TB myocarditis is extremely rare but can present
(like any other cause of myocarditis) with sudden cardiac
death, tachy and brady arrhythmias, ventricular
fibrillation, long QT syndrome, congestive heart failure,
dilated cardiomyopathy and even sudden cardiac arrest.
• TB myocarditis can mimic other cardiac infiltrative
diseases and is usually diagnosed late and only following
biopsy of either cardiac or surrounding lymphatic tissue
 CASE PRESENTATION
• 33 year old male of Pakistani complaining of chest pain and shortness
of breath, anorexia, nonproductive cough and night sweats.
• On presentation, the patient had a marked hypoxia (arterial oxygen
saturations of 88% on high flow oxygen) and tachypnoea with a
respiratory rate of 32 bpm.
• Examination was only remarkable for fine crepitations at Past medical
history acute myocarditis of uncertain aetiology.

• Investigations : positive TB Quantiferon gold test (IGRA TEST),

negative human deficiency virus (HIV), Computerised tomography
(CT) imaging of the chest demonstrated asymmetrical hilar
lymphadenopathy
ECG
CHEST X RAY AP
ECHO
CT SCAN
 Treatment and outcome
• The patient received aggressive diuresis with
intravenous furosemide. The patient slowly
improved over the following few days
• The patient received intravenous antibiotics to
cover any potential infection
• Given the uncertainty about diagnosis, high dose
steroids and anti tuberculosis medication
 PLANNING
• Endobronchial ultrasound guided biopsy and
further high resolution CT chest imaging
 POST MORTEM
• There was almost complete replacement of the
right ventricular myocardium with scar tissue and
patchy fibrosis of the left ventricle. Other positive
findings included hilar lymphadenopathy as seen on
the CT thorax.
• Ziehl-Neelsen stain for mycobacterium of the lymph
nodes was positive and there was evidence of giant
cells invading cardiac myocytes. Biopsy of the lung
tissue showed mycobacterium tuberculosis after
four week incubation.
 Discussion
• Difficulty in diagnosis Cardiac involvement with TB
infection occurs in approximately 1% of affected
individuals and most commonly affects the
Pericardium. Myocardial involvement is very rare
and estimated to be responsible for <0.1% of TB-
related deaths and usually present with acute
fulminant myocarditis, sudden cardiac death or
brady or tachy arrhythmias
 Discussion
• Biopsy of the myocardium can be a useful
diagnostic tool in cases of congestive cardiac failure
with unknown aetiology, but only carries a weak
recommendation for use in European guidelines
 Discussion
• Tuberculous myocarditis seems to only affect
the mitral and tricuspid valves causing valvular
incompetence.