COPD and Key Indicators For Considering Diagnosis
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The document details a medical case of a 74-year-old male patient experiencing worsening shortness of breath and cough, diagnosed with Chronic Obstructive Pulmonary Disease (COPD). It includes patient history, physical examination findings, laboratory results, and treatment protocol. Key indicators for diagnosing COPD are also referenced, alongside prognosis and recommendations for management.
COPD and Key Indicators For Considering Diagnosis
- 1. 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
- 2. 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
- 3. 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
- 4. ANAMNESIS Alloanamnesis on April 26 2017 CHIEF COMPLAINT Shortness of breath since 5 hours before entering hospital
- 5. 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
- 6. 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.
- 7. PAST ILLNESS HISTORY Hypertension(-), diabetes (-) COPD (+) since 2015 Heart disease since 2012 with bypass and stents at 2014
- 8. 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
- 9. FAMILY ILLNESS HISTORY No family member with the same symtpom Hypertension(-), diabetes (-), heart disease(-)
- 10. 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
- 11. 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
- 12. 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
- 13. 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,
- 14. 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
- 15. 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%
- 16. Emfisematous lung Aorta calcification Cardiac: normal
- 18. 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.
- 19. 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
- 20. List of Problems Dypsena ec COPD
- 21. 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)
- 22. Prognosis Quo ad Vitam : Dubia ad bonam Quo ad Functionam : Dubia ad bonam Quo ad Sanationam : Dubia ad bonam
- 26. The Refined ABC Assesment Tool Global Initiative fot COPD 2017
- 27. Key Indicators for Considering Diagnosis of COPD Global Initiative fot COPD 2017
- 28. Etiologi, Pathobiologi & Pathologi COPD Global Initiative fot COPD 2017
- 29. Differential diagnosis of COPD Global Initiative fot COPD 2017
- 30. Classification of COPD by Impairment of Lung Function Global Initiative fot COPD 2017
- 31. Modified Medical Research Council (mMRC) Dyspnea Scale Global Initiative fot COPD 2017
- 32. COPD Assessment Test (CAT) Global Initiative fot COPD 2017
- 33. EBMedicine.net
- 34. EBMedicine.net
- 35. EBMedicine.net
- 36. EBMedicine.net
- 38. Thank You..