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Case Presentation
Chronic Obstructive Pulmonary Disease
Advisor : dr. Riki Tenggara, Sp.PD
By : Budi Darmawan (2011-061-078)Aditya Oetomo (2012-061-078)
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Identity
Name : Mr. J
Age : 56 y o
Job : employee Marital status : married
Religion : moeslem
Admission : July 13rd 2013 Date of examination : july 15th 2013
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History taking
Autoanamnesis :
Chief complaint : shortness of breathing
Additional complaint : cough, malaise, night
sweat, black stools.
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History of present illness
2 days before addmission,patient complain about hisblack stool, without mucus and
fresh blood with solidconsistency. Patient have nocomplaint about GIT problem.
Patient complaint shortness ofbreathing for 18 years beforeadmission, and it worsen 1
day before admission.
Patient had been givenofloksacin, INH and etambutollfor 4 month And patient hadbeen given incomplete therapybefore.
Patient feel shortness of breathing
at rest and worse in activity.
Complaint productive coughsince 1 month with unknownsputum because patient cant
cough up the sputum. Patient also complain night sweating,
and malaise
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History taking
History of past illness :
Smoke since 40 years ago and stop 18 years ago (2
packed a day)
Alcohol
TB 18 years ago
Hipertension 5 weeks ago, uncontrolled
DM (-)
Asthma (-)
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Physical examination
General consciousness : Compos mentis
Vital sign :
Blood pressure : 120/70 mmHg
Pulse : 80 x / minute
Respiration rate : 20x/ minute
Temperature : 36.6 degree celcius
Nutritional state :
BMI : 13 (underweight)
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Physical examination
Head and face Normocephali, no deformity, black hair
Eye Anemic conjunctiva -/-, icteric sclera -/-
Ear
No deformity, no secrete
Nose
Septum in the middle, secret -/-, no deformity
Mouth
Dry mucose lip and oral
Neck Trachea in the middle, lypmh glands not palpable, JVP 5+2 cmH20
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Lungs
I : symetric both in static and dynamic
P: stem fremitus dextra=sinistra
P: Hipersonor in both lung
A: vesicular +/+, rales +/+, wheezing-/-
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Heart:
I : ictus cordis visible on 5th ICS linea
midclavicularis sinistra
P : ictus cordis palpable on 5th ICS linea
midclavicularis sinistra
P :
Top margin : ICS III linea midclavicularis sinistra
Right margin : ICS V linea sternalis dextra
Left margin : ICS V linea midclavicularis sinistra
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Abdomen :
I : flat, striae (-), venectation (-), rash (-)
P: tander, liver is palpable 3cm below costae arch,
with regular edge, firm in consistency, no pain in
palpation, kidney and spleen are impalpable
P: timpani, shifting dullness (-)
A: bowel sound (+) 4-5x/minute
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Back
I : symetric both in static and dynamic
P: stem fremitus dextra=sinistra, CVA pain (-)
P: hipersonor in bith right lung
A: vesicular +/+, rales +/+, wheezing -/-
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Genital was not examined
Anus and rectum werent examined
Extremities : edema -/-, CRT < 2 second
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RESUME
From history taking :
2 days before admission : black stools, mucus (-),fresh blood (-), another GIT problems (-)
1 month before admission : productive cough,malaise, night sweating
18 years before admission : shortness of breath,and 1 day before admission get worsen.
History past illness : TB 18 years ago, hypertension 5 weeks ago, smoke 40
years ago and stop 18 years ago and alcohol.
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From physical examination :
Blood pressure : 120/70 mmHg
Heart rate : 80x/minute
Respiration rate : 20x/minute
Temperature : 36,6 degree celcius
BMI : 13 (underweight)
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General examination
Lungs : vesicular +/+, rales +/+, wheezing -/-
Back : vesicular +/+, rales +/+, wheezing -/-
Abdomen : liver palpable 3cm below arch costae
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Assesment
WD/ suspect acute exacerbation of COPD
Differential Diagnosis : Tuberculosis
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DIAGNOSIS
Clinical manifestation theory Findings
Shortness of breath Progressive
Worsen by activity
Persistent
Effort on breathing
+
+
+
+
Chronic cough Intermittent, maybe non
productive cough
+
Chronic productive cough Productive cough -
History Smoke
Poluttion
Chemical substancedaily
+
-
--
We conclude the diagnosis is suspect acute exacerbation of COPD .
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Work up suggestion
Complete blood count
Blood gas analysis
EKG Alfa-1 antitripsin enzym
Chest x-ray
Spirometry
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Laboratory result
Hematologi
Hb 13,3
Ht 37
Leukosit 8700
Trombosit 233000
LED 15
Hitung jenis : Basofil 0
Eosinofil 0
Batang 1Segment 69
Limfosit 28
Monosit 2
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SGOT 23
SGPT 13
Elektrolit : Na 137
K 2,9
Ca 1,03
Cl 101
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Chest x-ray
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X-ray conclusion : now we found tuberculosis
improvement
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Treatment
IVFD RL 500 cc/24 jam
Soft diet 1800 kcal
Nebulisasi combiven 1cc + NS 2cc 3x1 Omeprazole 2x40mg iv
Ofloksasin 2x400mg p.o
INH 1x300mg p.o Etambutol 1x750mg p.o
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Prognosis
Quo ad vitam : dubia
Quo ad functionam : dubia
Quo ad sanationam : dubia
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THEORITICAL BASIS
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CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
defined as a disease state characterized byairflow limitation that is not fully reversible
emphysema, characterized by destruction andenlargement of the lung alveoli
chronic bronchitis, a clinically defined conditionwith chronic cough and phlegm
small airways disease, a condition in which smallbronchioles are narrowed
COPD is present only if chronic airflowobstruction occurs
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RISK FACTOR
Smoke
Ambient air polution
Respiratory infection Occupational exposures
Passive or second hand, smoke expore
Genetic consideration
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Criteria
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Clinical Presentation
cough sputum production
exertional dyspnea
development of airflow obstruction is agradual process
effort to breathe, heaviness, air hunger, or
gasping
worsening dyspnea
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Patophysiology
Airflow obstruction
Hyperinflation
Gas exchange
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PATHOLOGY
Large airway
Small airways
Lung parechyma
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PATHOGENESIS
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Treatment
Stable COPD
Only three interventionssmoking cessation,
oxygen therapy in chronically hypoxemic patients,
and lung volume reduction surgery in selectedpatients with emphysema
symptomatic
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Pharmacotherapy
Smoking cessation
Bronchodilator
Anticolinergik agents
Beta agonist
Inhaled / oral glukokortikoid
Teophyline
Oxygen
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Non pharmacologic therapies
General medical care
Pulmonary rehabilitation
Lung Volume reduction surgery
Lung transplantation
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EXACERBATIONS OF COPD
Exacerbations are a prominent feature of the
natural history of COPD
Exacerbations are episodes of increased
dyspnea and cough and change in the amount
and character of sputum
They may or may not be accompanied by
other signs of illness, including fever, myalgias,
and sore throat
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Treatment Acute Exacerbation
Bronchodilator
Antibiotics
Glucocorticoid
Oxygen
Respiraon failure mechanical venlatory
support
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Thank You