case laringitis tb dr oscar

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Tuberculous Laryngitis

-A Case Presentation-Supervised by :

Dr H.Oscar Djauhari, Sp. THT-KL

Presented by :Florencia (2012 061 046)

Clinical RotationOtolaryngology, Head and Neck Surgery Department

Medical Faculty of Unika Atma JayaSyamsudin, S.H. Regional General Hospital, Sukabumi

December 1st, 2014 – January 3rd, 2015

Patient’s Identity

Name : Mr. Y Age : 55 years old Sex : Male Race : Javanese Address : Babakan Bandung, Sukabumi Weight : 50 kg Height : 170 cm

History of Illness

Chief complaint : Sudden hoarseness and difficulty swallowing

Additional complaints : Persistent with bloody cough, neck mass, and weight

loss

History of present illness

Patient came with sudden hoarseness and difficulty in swallowing. He had a persistent cough for about a year, he had received a medication for his cough but never had any improvement. Bad cough came with productive phlegm that was green in color, sometime with a stain of redness in it. The phlegm got often swallowed by the patient. The cough was progressively worsening. Patient also had a weight loss for around 15 kilos in the last 1 year. He smoked 1 pack a day for 25 years

History of past illness

There’s history of diabetes mellitus No history of hypertension No history of cerebrovascular disease No history of trauma Family’s History No history of malignancy in his

family

Physical Examination

General appearance : calm Consciousness : compos mentis Blood pressure : 120/70 mmHg Pulse rate : 80 x/min Respiratory rate : 24 x/min Body temperature : 37,4 C

Physical Examination

Pulmonal Inspection: breathing looks symmetric on both side

of the lung in static and dynamic condition Palpasion : stem fremitus in right lung increased Percussion: dull sound in apex region of the right

lung Ausculttation : Ronchi +/+ , wheezing -/-

ENT Examination Right Ear

Auriculae : normal CAE : mucous membrane hyperemic (-), edema (-), mass (-),

secretion (-), laceration (-), cerumen (-) Tymphanic Membrane : intact, bulging (-), Light reflex (+) Rinne test (+), weber test no lateralization, normal Schwabach test

Left Ear Auriculae : normal CAE : mucous membrane hyperemic (-), edema (-), mass (-),

secretion (-), laceration (-), cerumen (-) Tymphanic Membrane : intact, bulging (-), Light reflex (+) Rinne test (+), weber test no lateralization, normal Schwabach test

ENT Examination

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

ENT Examination

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

Neck : Lymphadenopathy at right upper clavicle lymph

node

Planning

Laboratory finding ( complete blood count ) Chest radiograph PA position Mantoux test Sputum test Direct laryngoscopy

Workup

Laboratory

Workup

Plain chest x-ray PA position

CXR result : active Tuberculosis on the right lung

Working Diagnosis

Chronic Laryngitis ec suspect lung tuberculosis

Therapy

To treat tuberculosis : Rifampisin 450 mg ( 1 time a day ) INH 300 mg ( 1 time a day ) Pirazinamid 500 mg ( 2 times a day ) Ethambuthol 500 mg ( 1 time a day )

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