Sekenario a Blok 16 Blom Selesai

7/28/2019 Sekenario a Blok 16 Blom Selesai

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SKENARIO A BLOK 16 TAHUN 2013

Mr. X, a 30-year old truck driver, was admitted to hospital with massive hemoptoe. He

complained that 6 hours ago he had a severe bout of coughing with fresh blood of about 3

glasses. He also said that in the previous month he had productive cough with a lot of

phlegm, mild fever, loss of appetite, rapid loss of body weight, and shortness of breath.

Since a week ago, he felt his symptoms were worsening.

.

Physical examination

General appearance : he looked severely sick and pale. Body height : 170 cm, Body

weight: 50 kg, BP : 100/70 mmHg, HR: 100x/minute, temp 37,8 C.There was a tattoo on left arm and enlargement of the right neck lymph node, and

stomatitis

In chest auscultation there was an increase of vesicularsound at the right upper lung with

moderate rales.

Additional Information :

Hb : 8 g%, WBC: 7000/µL, ESR 70 mm/hr, Diff count :-/3/2/75/15/5,

Acid Fast Bacili: (-). HIV test (+), CD4 140/µL

Radiology: Chest radiograph showed infiltrate at right upper lung.

I. KLARIFIKASI ISTILAH

1. Massive hemoptoe : meludah darah /sputum yang mengandung darah.

2. Phlegm : mukus kental yang disekresikan saluran pernafasan dalam jumlah yang

abnormal.

3. Vesicular sound : suara yang terdengar ketika inspirasi lebih panjang dari

ekspirasi.

4. Infiltrate : opacity pada foto rontgen.

5. Productive cought : batuk yang disertai sekresi mucus / dahak.

6. Stomatitis : radang generalisator mukosa mulut.



II. IDENTIFIKASI MASALAH

1. Mr. X, a 30-year old truck driver, was admitted to hospital with massive hemoptoe.

2. Kronologis

a. He also said that in the previous month he had productive cough with a lot of phlegm,

mild fever, loss of appetite, rapid loss of body weight, and shortness of breath

b. Since a week ago, he felt his symptoms were worsening

c. He complained that 6 hours ago he had a severe bout of coughing with fresh blood of

about 3 glasses

d. Mr. X, a 30-year old truck driver, was admitted to hospital with massive hemoptoe.

3. Pemeriksaan fisik

4. Pemeriksaan tambahan

III. ANALISIS MASALAH

Masalah 1

Mr. X, a 30-year old truck driver, was admitted to hospital with massive hemoptoe

1. Apa kriteria dari massive hemoptoe ? ( Erniyati, Ayu Rizki )

2. Apa etiologi dari massive hemoptoe ? ( Dimas, Putri Nilam )

3. Apa hubungan umur, jenis kelamin, pekerjaan dengan massive hemoptoe ?

( Herdwin, Hadley )

4. Bagaimana mekanisme terjadinya massive hemoptoe ? ( Johanes, Fadlia )

Batuk darah jarang merupakan tanda permulaan dari penyakit tuberculosis atau

initial symptom karena batuk darah merupakan tanda telah terjadinya ekskavasi

dan ulserasi dari pembuluh darah pada dinding kavitas. Batuk darah massif terjadi

bila ada robekan dari aneurisma Rasmussen pada dinding kavitas yang kemudian

akan menyebabkan hemoptoe.

Masalah 2

A B DC



He also said that in the previous month he had productive cough with a lot of phlegm,

mild fever, loss of appetite, rapid loss of body weight, and shortness of breath.

Since a week ago, he felt his symptoms were worsening

He complained that 6 hours ago he had a severe bout of coughing with fresh blood of

about 3 glasses

Mr. X, a 30-year old truck driver, was admitted to hospital with massive hemoptoe

1. Apa etiologi dan mekanisme dari tiap tiap gejala :

a. Batuk produktif disertai disertai phlegm. ( Febri, Belinda )

b. Shortness of breath ( Beuty, Rike )

c. Demam ( Beuty, Kardiyus )

d. Kehilangan nafsu makan ( Randina, Erniyanti )

e. Berat badan menurun ( Ayu Rizki, Dimas )

f. Batuk berdarah ( Putri Nilam, Herdwin )

2. Bagaimana pathogenesis pada kasus ini ?

TB in many cases follows a general pattern as described by Wallgren, who

divided the progression and resolution of the disease into four stages (302). In the

first stage, dating from 3 to 8 weeks after M. tuberculosis contained in inhaled

aerosols becomes implanted in alveoli, the bacteria are disseminated by the

lymphatic circulation to regional lymph nodes in the lung, forming the so-called

primary or Ghon complex. At this time, conversion to tuberculin reactivity occurs.

The second stage, lasting about 3 months, is marked by hematogenous circulation

of bacteria to many organs including other parts of the lung; at this time in some

individuals, acute and sometimes fatal disease can occur in the form of

tuberculosis meningitis or miliary (disseminated) tuberculosis. Pleurisy or

inflammation of the pleural surfaces can occur during the third stage, lasting 3 to

7 months and causing severe chest pain, but this stage can be delayed for up to 2

years. It is thought that this condition is caused by either hematogenous

dissemination or the release of bacteria into the pleural space from subpleural

concentrations of bacteria in the lung. The free bacteria or their components are



thought to interact with sensitized CD4 T lymphocytes that are attracted and then

proliferate and release inflammatory cytokines (149). The last stage or resolution

of the primary complex, where the disease does not progress, may take up to 3

years. In this stage, more slowly developing extrapulmonary lesions, e.g, those in

bones and joints, frequently presenting as chronic back pain, can appear in some

individuals

Masalah 3

Pemeriksaan fisik

General appearance : he looked severely sick and pale. Body height : 170 cm, Body

weight: 50 kg, BP : 100/70 mmHg, HR: 100x/minute, temp 37,8 C.

There was a tattoo on left arm and enlargement of the right neck lymph node, and

stomatitis

In chest auscultation there was an increase of vesicularsound at the right upper lung

with moderate rales

1. Interpretasi dan mekanisme abnormal ?

- General appearance : he looked severely sick and pale. Body height : 170 cm,

Body weight: 50 kg, BP : 100/70 mmHg, HR: 100x/minute, temp 37,8 C.

( Hadley, Johanes )

• Pucat:

• IMT: 17,3

• BP: 100/70 (Hipotensi)

• HR: 100 x/minute

• Temperature 37,8 C

Infeksi Mycobacterium tuberkulosa inflamasi peningkatan aktivitas

makrofag IL1 Hipotalamus PGE 2 Peningkatan set point di

hipotalamus demam/suhu meningkat

- There was a tattoo on left arm and enlargement of the right neck lymph node, and

stomatitis. ( Fadlia, Belinda )



- In chest auscultation there was an increase of vesicularsound at the right upper lung

with moderate rales ( Rike, Beuty )

2. Apa hubungan tattoo dengan kasus yang dialami tuan X ? ( Jim, kardiyus )

Masalah 4

Pemeriksaan tambahan :

Hb : 8 g%, WBC: 7000/µL, ESR 70 mm/hr, Diff count :-/3/2/75/15/5,

Acid Fast Bacili: (-). HIV test (+), CD4 140/µL

Radiology: Chest radiograph showed infiltrate at right upper lung.

1. Interpretasi dan mekanisme abnormal ?

a. Hb : 8 g%, WBC: 7000/µL, ESR 70 mm/hr, Diff count :-/3/2/75/15/5 (Febri,

Randina )

b. Fast Bacili: (-). HIV test (+), CD4 140/µL ( Erniyati, Randina )

c. Radiology: Chest radiograph showed infiltrate at right upper lung.

( Mengapa terjadi pada right upper lung ) ( Ayu Rizki, Kardiyus )

Masalah 5

Klinik

1. Bagaimana cara menegakkan diagnosis ? ( Dimas, Jim )

2. Apa working diagnosis dari kasus ini ? ( Putri nilam, beuty )

3. Apa DD dari kasus ini? ( Herdwin, Rike )

4. Apa etiologi dari kasus ini ? ( Hadley, Febri )

• M. tuberculosis hominis, merupakan penyebab sebagian besar kasus

tuberculosis; reservoir infeksi biasanya ditemukan pada manusia dengan

penyakit paru aktif. Penularan biasanya langsung melalui inhalasi

organisme di udara dalam aerosol yang dihasilkan oleh ekspektorasi atau

oleh pajanan ke sekresi pasien yang tercemar.

• M. bovis, jarang ditemukan di Negara berkembang, tetapi masih

ditemukan di Negara yang memiliki sapi perah yang mengidap

tuberculosis dan susu yang tidak dipasteurisasi



• M. avium-intracellulare, jauh kurang virulen dibandingkan dengan M.

tuberculosis serta jarang menyebabkan penyakit pada individu

imunokompeten. Namun, pada pasien dengan AIDS, strain ini sering

ditemukan, mengenai 10% hingga 30% pasien.

5. Apa epidemiologi dari kasus ini ? ( Johanes , Belinda )

6. Bagaimana pathogenesis dari kasus ini ? ( Fadlia, ayu Rizki )

7. Apa faktro resiko dari kasus ini ? ( Dimas, Belinda )

8. Bagaimana penatalaksaan dari kasus ini ? ( Putri nilam, Rike )

9. Bagaimana pencegahan dari kasus ini ? ( Herdwin, beuty )

10. Apa saja komplikasi dari kasus ini ? ( Hadley, Jim )

Penyakit tuberculosis paru bila tidak ditangani dengan benar akan menimbulkan

komplikasi. Komplikasi dibagi atas komplikasi dini dan komplikasi lanjut.

• Komplikasi dini: pleuritis, efusi pleura, empyema, laryngitis, usus,

Poncet’s arthropathy

• Komplikasi lanjut: obstruksi jalan nafas SOPT (Sindrom Obstruksi

Pasca Tuberkulosis), kerusakan parenkim berat fibrosis paru, kor

pulmonal, amyloidosis, karsinoma paru, sindrom gagal nafas dewasa

(ARDS), sering terjadi pada TB milier dan kavitas TB.

11. Bagaimana prognosis dari kasus ini ? ( Johanes, Kardiyus )

12. Apa KDU dari kasus ini ? ( Fadlia, Randina )

13. Apa hubungan TBC dan HIV ? ( Febri, Erniyanti)

14. Bagaimana staging dari HIV ? ( Dimas, Beuty )

IV. LEARNING ISSUE

1. HIV ( Erniyanti, Ayu Rizki, Dimas )

2. TBC ( Putri nilam, herdwin, Hadley )

3. Anatomi Fisiologi Histologi Traktur respiratorius ( Johanes, fadlia, Belinda )

4. Fisiologi pernafasan ( Rike, Beuty, Jim )

5. Imunologi ( Kardiyus, Randina, Febri )

V. HIPOTESIS



Tuan X seorang suspect TB Paru dengan sputum (-) akibat HIV .

NB:

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Sekenario a Blok 16 Blom Selesai

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