CASE REPORT

Date : 13 May 2019

Resident on duty : dr Felly, dr Gwanita
Co-ass : Anita Rahmawati, F. Audri Dhania Wulina
Supervisor : Dr. dr. Noni Soeroso, M.Ked (Paru), Sp.P (K)

Working Diagnosis
severe exacerbation COPD without respiratory failure
 PATIENT’S IDENTITY

Name : Mr. SD
Age : 73 years old
Sex : Female
Occupation : Teacher
Ethnic : Batak
Chief complain : Shortness of breath
Differential Diagnosis
(Based on Chief Complain)

1. COPD
2. Asthma
3. Pneumonia
4. Lung Tumor
5. CHF
 History Taking
 Female, 73 years old, came to USU General Hospital with:
Chief complain : shortness of breath
Additional complain: cough, chest pain

 Shortness of breath (SOB) was experienced since 2 years ago and it get worse
since 1 week ago. SOB getting worsened by activity (+) but by weather (-). Paroxysmal
nocturnal dyspnea (-), Platypnea (-), Trepopnea (-), Ortopnoe (-). mMRC grade 1.
Cough (+) since 2 months ago with green-ish sputum, consistency mucoid. Volume
of sputum 1/4 teaspoon each cough. History of cough with sputum (+) since 3 years
ago.
 Bloody cough (-). History of bloody cough (+) since 5 month ago,with of fresh red
bloody cough with the volume 1/4 teaspoon each cough.
 Chest pain (+) for the past 1 month ago and spreaded to the back. It felt like having
a heavy burden on chest, and sometimes happen while coughing. VAS 2. History of
chest pain (-) .
 Fever (+) for the 1 week ago , with not too high temperature and without shivering, and
not taking antipyretic medication, Night sweating (-)
 Hoarseness (-). Swallowing dificulty (-).
 Loss of appetite with loss of body weight (+) 1 kg/ month.
 History Taking
 History of smoking: (-), passive smoker, for about 30 years.
 History of biomass exposure (+), mosquito coils, for about 20 years.
 History of prior ilness:
COPD (+) Asthma (-), tuberculosis (+), cancer (-) HIV (-) Diabetes Mellitus (-),
Hypertension (-).
 History of medication:
- Anti Tuberculosis Treatment 1st category, given by general practisioner in
Tebing Tinggi Hospital based on clinical findings, radiology, microbiology
consumed for 5 months untill now.
-Inhaler: (+)
 Family history
Cancer (-), asthma (-)
 History of alcohol (-)
 History of narcotics user (-)
 History of being hospitalized (+) about 1 month ago with the same complain.
Conclusion

 Shortness of breath
 Chest pain
 Cough with sputum
 History of fever
 Passive smoker
 History of TB
 History of having ATT till now
 VITAL SIGN IN ER
 Consciousness : Alert
 BP : 130/90 mmHg
 Pulse : 95 x/i regular
 RR : 20x/i (Cheyne-Stokes (-) , Kussmaul (-)
 Temp : 36.2 ºC axilla
 Pain : VAS 2
 SpO2 : 95% with O2 2 L/i via nc
 General condition : Mild
 Disease condition : moderate
 Nutritional status : normoweight
 Physical Examination
General Inspection
1. Head
Deformity :-
Face : Moon face (-) Plethoric face (-)
Eyes : Pale conjungtiva palpebra inferior (-/-), sclera icteric
(-/-), ptosis (-), enophtalmus (-), miosis (-)
Nose : Septum deviation (-), nose lid (-), redness (-)
Mouth : Cyanosis (-) , pursed lip breathing (-)
Tongue : Oral candidiasis (-), cyanosis (-).
2. Neck : JVP R+2 cmH2O, nuchal rigidity (-), lymph node
enlargement (-), used accesory muscle in breathing (-)
3. Thorax :
Cor : S1(+) S2(+) S3(-) S4(-) activity: enough, regularity: regular
Murmur : (-)
Heart borders :
Upper : 2nd ICS LMCS
Right : 4th ICS LPSD
Left : 5th ICS ± 1 cm lateral LMCS
Lower : Diaphragm
4. Abdomen :
Liver/spleen/kidney : not palpated
Ascites (-)

5. Hands : clubbing fingers (-), palmar eritema (-), edema (-),

nicotine staining (-), flapping tremor (-),weakness of the hand (-),
cyanosis (-)

6. Limbs : Pretibial oedema (-), clubbing fingers (-), cyanosis(-)

 Chest Examination
Anterior Findings
Inspection Static: symmetric, no deformity, collateral vein (-), venectation (-)
Dynamic:symmetric
Chest expansion: symmetric

Palpation - Tactile fremitus right = left

- Subcutaneous emphysema (-/-)
Percussion Resonance of sound: sonor on the both of lung

Auscultation - Breath sound: prolonged expiration

- Additional sounds: crackles (-/-), wheezing (+/+) low pitch
localized
- Egophoni ( - ) Bronchophoni ( -)
- Whispered pictoriloquiy ( - )
- Pleural Friction Rub ( - )
Differential Diagnosis
(Based on History Taking and Physical Findings)

1. COPD
2. Asthma
3. Lung Tumor
4. Pleural effusion
5. Pneumonia
6. Lung TB
7. CHF
 Clinical Pathologic Laboratory
(9th May 2019) USU Hospital
9/05/2019 Normal
HGB 13,9 g/dL 12-16 g/dL
WBC 14,23 x 103/mm³ 3,8-10,6 x 103/mm³
RBC 4,46 x 106/mm³ 4,4-5,90 x 106/mm³
Hematokrit 40,9 % 43-49 %
Thrombosit 255x 10³/mm³ 150-440 x 10³/mm³
Neutrofil absolut 11,42 x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 1,89 x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 0,71 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0,18 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,03 x 103 /µL 0-0,1 x 10³/µL
KGD Sewaktu 199 mg/dl < 200 mg/dL
Ureum 39,6 mg/dL <50 mg/dL
Kreatinin 0,88 mg/dL 0,6 – 1,3 mg/dL
Na/K 140 /3,30 mEq/L 135-147/3,5-5,0
Kesan Leukocytosis, hipocalemia
 Blood Gas Analysis
((9th May 2019) USU Hospital
9/05/2018 Normal
pH 7,42 7,37 – 7,45
pCO2 43 mmHg 33 – 44
pO2 98 mmHg 71 – 104
Bikarbonat(HCO3) 27,9 mmol/L 22 – 29

BE 3,4 mmol/L (-2) – (+3)

Saturasi O2 96% 94 – 98
normal
 Chest X-Ray
on 11th May 2019 in USU hospital
Position PA Erect

Exposure of Enough
radiation
Trachea deviation to the left
Clavicle Symmetric, no fracture
Scapula No superposition on both
hemithorax
Bone Symmetric, no fracture
Lung inhomogenous consolidation of
lower right lung.
Hyperinflation of the lung.
Widened intercostalis
Cor CTR > 50 %, aorta dilatation

Costhophrenic Left costhophrenic angle is

angle sharp
Right costhophrenic angle is
sharp
Bronchodilator test

APE pre nebule 90

APE post nebule 110

Bronchodilator test
= APE post nebule - APE pre nebule x 100%
APE pre nebule
= 110-90 x 100%
90
=22,2%
 Diagnosis & Differential Diagnosis

DIFFERENTIAL DIAGNOSIS:
1. COPD
2. Asthma
3. Pneumonia
4. Pleural effusion
5. Lung Tumor
6. Lung TB

DIAGNOSIS:
Primary Diagnosis : severe exacerbation COPD without respiratory
failure
Secondary Diagnosis :
Tertiary Diagnosis :
 MANAGEMENT in ER
• Non pharmacology:
Bed rest

• Pharmacology
O2 2L/i via nc
IVFD NaCl 0,9% 20 gtt/i
Inj. Methylprednisolone 62,5 mg/8hours
Inj. Ceftriaxone 1gr/12 hours
Inj. of Ranitidine 50 mg/8hours
Nebule Combivent 2,5mg/8hours
Nebule Fluxotide 1 mg/12 hours
Retaphyl SR 2 x 1/2 tab
Fartolin expectorant 3 x cth II
Plan

 Sputum microbiologic, gram staining, BTA direct smear, culture and

sensitivity test.
CT Scan thorax with IV Contrast
Spirometry if patient is stable
THANK YOU