COPD and Key Indicators For Considering Diagnosis

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

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Key Indicators for Considering Diagnosis of

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Etiologi, Pathobiologi & Pathologi COPD

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Differential diagnosis of COPD

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Classification of COPD by

Impairment of Lung Function

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Modified Medical Research Council

(mMRC) Dyspnea Scale

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COPD Assessment Test (CAT)

Global Initiative fot COPD

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Thank You..