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COPD : IT’S AND
PROBLEM KEY INDICATORS FOR
CONSIDERING DIAGNOSIS
SUPERVISOR: Dr .dr. Soroy Lardo, Sp.PD FINASIM
DOCTOR’S ON DUTY: dr. Ike & dr. Nita
COASS ON DUTY: Maharani Falerisya Nabilla & Isni Ayu Lestari
DEPARTEMENT OF INTERNAL MEDICINE INDONESIA ARMY
CENTRAL HOSPITAL GATOT SUBROTO
PATIENT RECAPITULATION
Mr. Said / 74y.o/ dypsnea ec copd
Mr. Haryo/ 51y.o/ Hypertention Urgency
Mr. Kamal/ 48y.o/ Vertigo + ACS
Mr. Haryanto/ ACS dd/GERD
Mr. Arry Julianto/ malaria
Mrs. Titi/ 72y.o/ CKD on HD
PATIENT’S IDENTITIY
NAME : Mr. Said
SEX : Male
AGE : 74 years old
Religion : Moslem
OCCUPATION: Purnawirawan
ADDRESS : Kodamar Jakarta Utara
DATE OF ADMISSION: Wednesday 26 April
2017
ANAMNESIS
Alloanamnesis on April 26 2017
CHIEF COMPLAINT
Shortness of breath since 5 hours before
entering hospital
HISTORY OF PRESENT ILLNESS
Patients complain of shortness of breathing, 5
hours before entering hospital. has been felt
since 1 week and getting worse. Shortness is
felt throughout the day, getting heavier during
exercise, coughing, and not decreasing with
rest.
5 hours before entering
hospital
Patient sleeps with 2 pillows. Patients also complained of cough with phlegm since 1 week ago. Cough with yellow phlegm, no blood, have OBH (cough medicine), but cough is not reduced. Right chest pain especially when coughing, no spreading pain, no fever, nausea, no vomiting, can’t defecate since 5 days, the colonoscopy is normal. Patients are smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago.
PAST ILLNESS HISTORY
Hypertension(-), diabetes (-)
COPD (+) since 2015
Heart disease since 2012 with bypass and
stents at 2014
Treatment History
Simvastatin 20mg 1x1
V bloc 6,25mg 1x1 (carvedilol)
Furosemide 40mg 1x1
Spiriva 18mg
Salbutamol 2mg 3x1½ tab
Retaphyl SR 300mg 2 ½ tab (theophylline)
Symbicort
Ventolin inhaler
FAMILY ILLNESS HISTORY
No family member with the same symtpom
Hypertension(-), diabetes (-), heart disease(-)
PHYSICAL EXAMINATION
General Examination
General condition: weak
State of Consciousness: compos mentis
GCS : E 4, M 5, V 6
Vital sign
- Blood pressure: 115/72 mmHg
- Heart rate: 91 x/mnt
- Respiratory: 24 x/mnt (SaO2 92%)
- Temperature: 36,5’C
Body weight: 50 kg
Body height: 162 cm
Body mass index: 19,08 normal
Head : Normocephal
Eye : anemis conjungtiva (-/-), icteric sclera (-/-)
Ears : normotia, discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : pursed lips breathing (+). dry lips (-),
normal tongue, hyperemic phariynx (-), T1-
T1
Neck : lypm nodes enlargement (-) JVP 5+2cm
Thorax
• Pulmonary examination
- Inspection: symmetrical lung movement, scar (-), intercostal retrraction (-),
use of accessory muscles with breathng (+)
- Palpation: symmetrical chest expansion and vocal fremitus, mass (-), tenderness (-)
- Percussion: hipersonor or at both lung field
- Auscultation: vesicular breath sound, crackles (-), wheezing (+/+)
• Cardiac examination
- Inspection: ictus cordis not visible
- Palpation: ictus cordis palpable at ICS V left midclavicula line
- Percussion: right cardiac border at ICS IV right parasternal line, left cardiac border at ICS V left midclavicular line, upper border at ICS III left parasternal line
- Auscultation: normal S1/S2 regular, no murmur, no gallop
Abdomen
- Inspection: distended, no skin lession/scar, ascites (-)
- Auscultation: bowel sound (+)
- Percussion: tympani on four abdominal
quadrant, shifting dullness (-)
- Palpation: Supple, skin turgor (+), tenderness on epigastrium (-), liver and spleen not palpable
Extremities: CRT <2 seconds, warm distal extremities,
Laboratory Findings
Complete blood
tests
Result Normal value
Hemoglobin 13,0 g/dl 13,0 - 18,0
Hematocrit 40 % 40,0 - 52,0
Erythrocyte 4,3 juta 4,30 – 6,0 juta
MCV 86 fL 80,0 – 96,0
MCH 29 g 27,0 – 32,0
MCHC 34 g/dl 32,0 – 36,0
Thrombocyte 277.000 150.000- 400.000
Leukocyte 18.570 ↑ 4800 – 10.800
Blood metabolic
Ureum 51 mg/dl ↑ 20 – 50 mg/dl
Creatinin 1,7 mg/dl ↑ 0.5 – 1.5 mg/dl
Glucosse 155 mg/dl ↑ <140 mg/dl
Electrolyte
Natrium (Na) 138 135 – 147
Calium 3,1 ↓ 3.50 – 5.00
Chloride 99 95.0 – 105.0
Blood Gas Analysis
pH 7,380 7,37 – 7,45
pCO2 33,5 33 – 44 mmHg
pO2 175,4 ↑ 71 – 104 mmHg
HCO3 20 ↓ 22 – 29 mmol/L
BE -3,8 (-2)-3 mmol/L
Sat O2 98,3 94 – 98%
Emfisematous
lung
Aorta
calcification
Cardiac:
normal
Resume
Patients complain of shortness of breathing, has been felt since 1 week and getting worse. Shortness is felt throughout the day, getting heavier during exercise, coughing, and not decreasing with rest.
Patient sleeps with 2 pillows. Patients also complained of cough with phlegm since 1 week ago. Cough with yellow phlegm, have OBH but cough is not reduced.
Right chest pain especially when coughing, nausea, can’t defecate since 5 days,. Patients are smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago.
Resume
Phsycial examination shows Respiratory: 24
x/mnt, pursed lips breathing (+). use of
accessory muscles with breathing, wheezing
(+/+)
Laboratory found increase leukosit, Increase
glucosse, decrease calium, increase pO2 and
decrease HCO3
List of Problems
Dypsena ec COPD
Problem Solving
Dypsnea ec COPD
Anamnesis: shortness of breathing,, cough with phlegm since 1 week agoRight chest pain especially when coughing, smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago..
Physical examination:Respiratory: 24 x/mnt, pursed lips breathing (+). use of accessory muscles with breathing, wheezing (+/+)
Lab examination: increase leukosit (18.570)
Assesment: Rontgen Thorax, ECG, Spirometry test
Teraphy: O2 4-5 lpm, Head up 30’, Nebulization combivent + Flixotide, metylprednisolon inj 125mg, IVFD NaCL 0,9% 20tpm.
Monitoring : vital sign, clinical symptoms, ABG (arterial blood gas)
Prognosis
Quo ad Vitam : Dubia ad bonam
Quo ad Functionam : Dubia ad bonam
Quo ad Sanationam : Dubia ad bonam
The Refined ABC Assesment Tool
Global Initiative fot COPD
2017
Key Indicators for Considering Diagnosis of
COPD
Global Initiative fot COPD
2017
Etiologi, Pathobiologi & Pathologi COPD
Global Initiative fot COPD
2017
Differential diagnosis of COPD
Global Initiative fot COPD
2017
Classification of COPD by
Impairment of Lung Function
Global Initiative fot COPD
2017
Modified Medical Research Council
(mMRC) Dyspnea Scale
Global Initiative fot COPD
2017
COPD Assessment Test (CAT)
Global Initiative fot COPD
2017
EBMedicine.net
EBMedicine.net
EBMedicine.net
EBMedicine.net
Thank You..