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
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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.
- 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
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.