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CASE ILUSTRATIONPATIENT IDENTIFICATIONName: Mrs. ErnawatiDate birth/Age: December 26 2015/44yrMarriage Status: MarriedOccupation: EnterpreneurAdress: KotabumiSex: FemaleRace: LampungReligion: Moslem

ANAMNESISTaken from autoanamnesis In June 22, 2015 at 14.30 WIB

Main plaint:Breathing shortness since 22 days agoAdditional plaint : Cough with plegm, heavy right chest

History of diseasePatient came with breathing shortness since 22 days ago. Complaints had felt before and treated in hospital one month ago. Intermittent breathing shortness. Breathing Shortness is not time affected. Tightness aggravated by activity. Patients had a history of TB treatment completion in 2005. The history of smoking 10 cigarettes for a year around 10 years ago. Tightness is felt increasingly heavy with wheezing sound. No history of heart disease. No history of kidney disease.

Tightness accompanied by coughing up phlegm and heaviness in the right chest. Yellowish sputum without blood. Fever is not perceived by patient. Weight loss slightly occur. Appetite slightly occur.

History of past diseasePulmonary TB

Family history No such complaints were appeared

Systemic AnamnesisSkinNo disorder

HeadNo disorder

EyeNo disorder

Ear No disorder

NoseNo disorder

MouthNo disorder

ThroatNo disorderNeckNo disorder

ChestDyspneu , Heavy Chest, Cough

AbdomenNo disorder

Urinary TractNo disorder

HaidNo disorder

Nerve and muscleNo disorder

Extremity No disorder

Body WeightHighest body weight: 45 kgHeight: 158 cmCurrent body weight: decreaseLIFE HISTORYBorn place: at homeHelper: midwifeImmunisation history: polioFood historyFrequency: 3x/dayAmount : 3 plate/dayVariation: fish, chicken, vegetableAppetite : decreaseEducation: High SchoolDifficultyFinance : none Occupation : noneFamily: none

PHYSICAL EXAMINATIONBlood pressure: 130/80 mmHgRespiration: 36 x/minutePulse: 88 x/minuteTemp.: 36,50C axilaHeight: 158 cmWeight: 43 kgNutritional status: BMI = 17,2 lack of nutritionAwareness: compos mentisSianosis: -General edem: -Habitus: astenikusMobility: activeAge based on appraisal : around 40 yrs

PHSYCHOLOGICAL ASPECTBehavior: normalSentiment: normalThinking process: normal

GENERAL STATUSSkin: normalLymph Gland: normalHead: normalEye: normalEar: normalMouth: normalNeckLymph gland: normalTiroid gland: normalJVP: 5+1 cmH2O

Chest (thorax)Shape: NormochestBlood vessel: Normal

LungHeartInspectionNormochest, right chest movement left by right chest, ictus cordis not visiblePalpationRight vocal Fremitus> left vocal fremitusictus cordis not palpable

PercusionSonor at left, dull at righthardly assessedAuscultationBonchial breathing sound, Wheezing +/+ Coarse crackles +/+heart sound I-II regularBlood VesselA. Temporale: normalA. Carotid: normalA. Brachialis: normalA. Radialis: normalA. Femorale: normal A. Poplitea: normalA. Tibialis posterior: normal

AbdomenInspection: flatPalpation: hepar-spleen normal, painful regio epigasterPercussion: TimpaniAuscultation: intestine noise(+) normal

EkstremitySuperior: tonus, mass, joint, movement, strenght normal, no edemInferior: tonus, mass, joint, movement, strenght normal, no edemReflexes Biseps: normalTriceps: normalPatella: normalAchilles: normalPatological reflexes: -

ADDITIONAL EXAMINATIONBlood routine 22/06/2015Hb: 13,2 gr/dlHt: 39 %LED: 10 mm/jamLeukosit: 27.000 /ulDiff. CountBasophil: 0 %Eosinophil: 0 %Batang: 0 %Segmen: 92 %Limposit: 4 %Monosit: 4 %

Trombosit: 385.000 /ulSGOT: 12 U/LSGPT: 9 U/LUreum: 31 mg/dlCreatinin: 0,5 mg/dlGDS: 90 mg/dl

Rontgen Thoraks

trakea deviated to the left, infiltrate and cavity at the right lung, heart shift to the left, fibrotic line at left lungResumePatient came with breathing shortness since 22 days ago. Complaints had felt before and treated in hospital one month ago. Intermittent breathing shortness. Breathing Shortness is not time affected. Tightness aggravated by activity. Patients had a history of TB treatment completion in 2005. The history of smoking 10 cigarettes for a year around 10 years ago. Tightness is felt increasingly heavy with wheezing sound. No history of heart disease. No history of kidney disease.

Tightness accompanied by coughing up phlegm and heaviness in the right chest. Yellowish sputum without blood. Fever is not perceived by patient. Weight loss slightly occur. Appetite slightly occur.

Resume (add.)ChestInspection :Normochest, right chest movement left by right chest, Palpation:right vocal Fremitus> left vocal fremitus, Percussion: Sonor at left, dull at rightAuscultation: bonchial breathing sound, Wheezing +/+ Coarse crackles +/+

Leukosit: 27.000 /ulSegmen: 92 %Ro Thorax: trakea deviated to the left, infiltrate and cavity at the right lung, heart shift to the left

Working diagnosisPost Tubercular Obstructive Syndrome + Destroyed Lung Dextra

Reason:History of TBRepeated complaintsShortness breath esp. By activityPainful chestCough up plegmAnorektiaWeight loss

Asymetric movement of chestRight Fremitus > left fremitusDullness at right chestCrackles and wheezing +, bronchial breathing soundLeukositosisSegment 90%Rontgen: cavity and massive infiltrate, fibrotic lineDifferential diagnosis: PPOK on acute exacerbation

Reason of differential diagnosisRepeated complaintsShortness breath esp. By activityCough up plegmCrackles and wheezing +, bronchial breathing soundLeukositosisSegment 90%Examination suggestionBTASpirometri (RV, VC, TLC, FEV1)Arterial Blood GasCulture sputum ManagementO24-5 L/minuteAminofilin drip 0,5-1 mg/kgBB/HourNebulisasi Salbutamol 1 amp Ambroxol syr 3x1 cCeftriaxon vial 1gr/12 Hour

PrognoseQuo ad Vitam: Dubia ad malamQuo ad Fungtionam: Malam Quo ad Sanationam: Malam

Reference:S.K. Verma, S. Kumar, Kiran Vishnu Narayan, R. Sodhi. 2009. Post Tubercular Obstructive Airway Impairment. Indian J Allergy Asthma Immunol 2009; 23(2) : 95-99Inam Muhammad Baig, Waseem Saeed and Kanwal Fatima Khalil. 2010. Post-Tuberculous Chronic Obstructive Pulmonary Disease. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 542-544Chih-Hsin Lee, Ming-Chia Lee. 2012. Pulmonary Tuberculosis and Delay in Anti-TuberculousTreatment Are Important Risk Factors for ChronicObstructive Pulmonary Disease. May 2012 | Volume 7 | Issue 5Alimuddin Zumla, M.D., Ph.D., Mario Raviglione, M.D., Richard Hafner, M.D.,and C. Fordham von Reyn, M.D. 2015. current conceptsTuberculosis. N Engl J Med 2013;368:745-55.