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    Case Report: Severe Exacerbation COPD Without Respiratory Failure

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    Asdar Raya Rangkuti
    This case report summarizes the medical history, examination findings, diagnoses, and treatment plan for a 73-year-old female patient presenting with shortness of breath. Key findings included a history of COPD and tuberculosis, wheezing on lung auscultation, chest X-ray showing right lung consolidation and hyperinflation, and a diagnosis of severe COPD exacerbation without respiratory failure. The patient was admitted and started on oxygen, IV fluids, steroids, antibiotics, bronchodilators, and expectorants. Further tests including sputum analysis and CT scan were planned.

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    Case Report: Severe Exacerbation COPD Without Respiratory Failure

    Uploaded by

    Asdar Raya Rangkuti
    71 views20 pages
    This case report summarizes the medical history, examination findings, diagnoses, and treatment plan for a 73-year-old female patient presenting with shortness of breath. Key findings included a history of COPD and tuberculosis, wheezing on lung auscultation, chest X-ray showing right lung consolidation and hyperinflation, and a diagnosis of severe COPD exacerbation without respiratory failure. The patient was admitted and started on oxygen, IV fluids, steroids, antibiotics, bronchodilators, and expectorants. Further tests including sputum analysis and CT scan were planned.

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    This case report summarizes the medical history, examination findings, diagnoses, and treatment plan for a 73-year-old female patient presenting with shortness of breath. Key findings included a history of COPD and tuberculosis, wheezing on lung auscultation, chest X-ray showing right lung consolidation and hyperinflation, and a diagnosis of severe COPD exacerbation without respiratory failure. The patient was admitted and started on oxygen, IV fluids, steroids, antibiotics, bronchodilators, and expectorants. Further tests including sputum analysis and CT scan were planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    71 views20 pages

    Case Report: Severe Exacerbation COPD Without Respiratory Failure

    Uploaded by

    Asdar Raya Rangkuti
    This case report summarizes the medical history, examination findings, diagnoses, and treatment plan for a 73-year-old female patient presenting with shortness of breath. Key findings included a history of COPD and tuberculosis, wheezing on lung auscultation, chest X-ray showing right lung consolidation and hyperinflation, and a diagnosis of severe COPD exacerbation without respiratory failure. The patient was admitted and started on oxygen, IV fluids, steroids, antibiotics, bronchodilators, and expectorants. Further tests including sputum analysis and CT scan were planned.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 20

    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

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