Case Presentation Chronic Obstructive Pulmonary Disease

Advisor : dr. Riki Tenggara, Sp.PD By : Budi Darmawan (2011-061-078) Aditya Oetomo (2012-061-078)

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

History taking
Autoanamnesis :
Chief complaint : shortness of breathing Additional complaint : cough, malaise, night sweat, black stools.

History of present illness

2 days before addmission, patient complain about his black stool, without mucus and fresh blood with solid consistency. Patient have no complaint about GIT problem. Complaint productive cough since 1 month with unknown sputum because patient cant cough up the sputum.
Patient also complain night sweating, and malaise

Patient complaint shortness of breathing for 18 years before admission, and it worsen 1 day before admission. Patient had been given ofloksacin, INH and etambutoll for 4 month And patient had been given incomplete therapy before.
Patient feel shortness of breathing at rest and worse in activity.

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 (-)

Physical examination
General consciousness : Compos mentis Vital sign :
Blood pressure Pulse Respiration rate Temperature Nutritional state : : 120/70 mmHg : 80 x / minute : 20x/ minute : 36.6 degree celcius

BMI : 13 (underweight)

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

 Lungs
I : symetric both in static and dynamic P: stem fremitus dextra=sinistra P: Hipersonor in both lung A: vesicular +/+, rales +/+, wheezing-/-

 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

 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

 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 -/-

 Genital was not examined Anus and rectum werent examined Extremities : edema -/-, CRT < 2 second

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.

 From physical examination :

Blood pressure Heart rate Respiration rate Temperature BMI : 120/70 mmHg : 80x/minute : 20x/minute : 36,6 degree celcius : 13 (underweight)

 General examination
Lungs : vesicular +/+, rales +/+, wheezing -/ Back : vesicular +/+, rales +/+, wheezing -/ Abdomen : liver palpable 3cm below arch costae

Assesment
WD/ suspect acute exacerbation of COPD Differential Diagnosis :
Tuberculosis

DIAGNOSIS
Clinical manifestation Shortness of breath theory Progressive Worsen by activity Persistent Effort on breathing Intermittent, maybe non productive cough Productive cough Smoke Poluttion Chemical substance daily Findings + + + + + + -

Chronic cough Chronic productive cough History

We conclude the diagnosis is suspect acute exacerbation of COPD .

Work up suggestion
Complete blood count Blood gas analysis EKG Alfa-1 antitripsin enzym Chest x-ray Spirometry

Laboratory result
Hematologi Hb Ht Leukosit Trombosit LED Hitung jenis : Basofil Eosinofil Batang Segment Limfosit Monosit 13,3 37 8700 233000 15 0 0 1 69 28 2

SGOT SGPT

23 13

Elektrolit : Na K Ca
Cl

137 2,9 1,03

101

Chest x-ray

 X-ray conclusion : now we found tuberculosis improvement

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

Prognosis
Quo ad vitam Quo ad functionam Quo ad sanationam : dubia : dubia : dubia

THEORITICAL BASIS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

defined as a disease state characterized by airflow limitation that is not fully reversible emphysema, characterized by destruction and enlargement of the lung alveoli chronic bronchitis, a clinically defined condition with chronic cough and phlegm small airways disease, a condition in which small bronchioles are narrowed COPD is present only if chronic airflow obstruction occurs

RISK FACTOR
Smoke Ambient air polution Respiratory infection Occupational exposures Passive or second hand, smoke expore Genetic consideration

Criteria

Clinical Presentation
cough sputum production exertional dyspnea development of airflow obstruction is a gradual process effort to breathe, heaviness, air hunger, or gasping worsening dyspnea

Patophysiology
Airflow obstruction Hyperinflation Gas exchange

PATHOLOGY
Large airway Small airways Lung parechyma

PATHOGENESIS

Treatment
Stable COPD
Only three interventionssmoking cessation, oxygen therapy in chronically hypoxemic patients, and lung volume reduction surgery in selected patients with emphysema symptomatic

Pharmacotherapy
Smoking cessation Bronchodilator Anticolinergik agents Beta agonist Inhaled / oral glukokortikoid Teophyline Oxygen

Non pharmacologic therapies

General medical care Pulmonary rehabilitation Lung Volume reduction surgery Lung transplantation

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

Treatment Acute Exacerbation

Bronchodilator Antibiotics Glucocorticoid Oxygen Respiration failure mechanical ventilatory support

Thank You