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CASE REPORT

COPD AND BRONCHIECTASIS

Resident:
dr. Hasan Nyambe

Presenter:
Vivi Utami Mulia
Wan Hani Nadiah Binti Wan Jusof
Ummi Asyiqin Binti Kamil
Zaidatul Hidayah Binti Mohd Idris
Nur Illani Binti Ibrahim
Nur Izzati binti Adli

Department of Pulmonology
Medical faculty
Hasanuddin University
PATIENT`s IDENTITY
Name Mr B

Age 75 years old

Address Tanete Bone

Occupation Retired

Marrital Status Married

Admitted 16 November 2016

Medical Record 069737

Hospital Universitas Hasanuddin


Hospital
ANAMNESIS
Chief complaint : shortness of breath
Present illness history :
Shortness of breath since 3 days ago and worsen since one hour before admitted to Universitas Hasanuddin
hospital. Patient has been experiencing shortness of breath and periodic coughing for the past 5 years.
Dyspneu is continuously felt by patient, not affected by activity and weather. Patients SOB isnt relieved by resting.
Patient had cough with thick white mucus since a week ago, with no blood
There is no chest pain
Patient had fever about two days ago but he didnt take any medication. He also had a history of frequent fever.
He rountinely went to the doctor and was given theofilin (300mg 2x1), Symbicort (if SOB), Combivent (if SOB),
comtusi syrup
He has not been sweating at night
No nausea and no vomitting.
Patient has a good appetite
No weight loss
Defecation and urination is normal.
HISTORY OF PREVIOUS ILLNESS
He underwent an operation on his prostate 2 years ago.
History of allergy and asthma (-)
History of TB (-)
History of anti tuberculosis regiment consumption (-)
History of hypertension, diabetes mellitus and heart
disease (-)
FAMILY HISTORY
His father died because of lung disease.
There is no history of anti tuberculosis
regiment consumption in the family.
There is no history of DM, hypertension
and heart disease in the family.
PERSONAL HISTORY
Job : Retired
Allergy : No
Food habits : Nothing specific
Exercise : Nothing special
Hist. of alcohol : No
Hist. of drugs addiction : No
Hist. of smoking : He smoked for almost 40 years. 12 cigarettes per
day.
PHYSICAL EXAMINATION
Present condition : moderate illness
Nutritional status: normal
Conciousness : composmentis, GCS E4V5M6
Height : 160 cm
Weight : 55 kg
BMI : 21.5 kg/m2
Vital Signs
- Blood pressure : 130/ 80 mmHg
- Pulse rate : 98 x/m, regular
- Respiratory rate : 28 x/m (sat: 98% with O2 nasal canule)
- Body temperature : 37.0 oC
Physical Examination
Head : Normocephaly
Eyes : No anemic conjunctiva , no icteric sclera, no oedema of
palpebra, no exophthalmus.
Ears : No secretion
Nose : No secretion
Oral and throat : Normal
Neck : JVP R+2 cmH2O, no lymph nodes enlargement
Thorax

Inspection : Hyperinflated barrel chest. Symmetrical on both side.


Palpation : No mass , No pain, Vocal fremitus decreased on both side.
Percussion : Resonant on both side
Auscultation : Breath sound vesicular, decreased on both side.
wheezing (-/-), crackles (+/+).
HEART EXAMINATION

Inspection : Ictus cordis invisible


Palpation : Ictus cordis

Percussion :

right heart border right parasternal line ICS IV

left heart border left midclavicula sinistra ICS V

upper heart border left midclavicula sinistra ICS II

lower heart border left midclavicula sinistra ICS V

Auscultation : heart sound I/II regular, murmur (-)


Abdominal examination

Inspection : Flat and follows breath movement


Auscultation : Peristaltic normal
Palpation : No abdominal pain , liver and spleen normal
Percussion : Tympanic, no ascites

Extremity examination
Inferior extremity oedema (-)
LABORATORY FINDINGS (16-11-
16)
BLOOD ROUTINE VALUE BLOOD TEST VALUE
WBC 10.03 x 103/uL
SGOT 38 u/L
RBC 5.00 x 10 /uL
6

HGB 14.6 g/dL SGPT 52 u/L

HCT 42.4 % Ureum 28 mg/dL


MCV 84.8 fL
Kreatinin 0.9 mg/dL
MCH 29.2 pg
MCHC 34.4 g/dL
PLT 262 x 103/uL
Neutrophil 61.7%
Lymphocyte 25.6%
Monocyte 10.7%
Eosinophil 1.9 %
Basophil 0.1 %
THORAX X-RAY (16-11-16)
THORAX X-RAY INTERPRETATION
Homogen consolidation on lower left hemithorax on front left costae IV, covering
sinus, diaphragm and left cor
An increase in bronchovascular markings on both lungs
Bronchi seen end on may appear as ring shadows at the base of both lungs.
Flattening of the diaphragm
Widening between the ribs
Intact bones
No soft tissue swelling

Conclusion :
Bronchiectasis bilateral
WORKING DIAGNOSIS
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Infected Bronchiectasis
INITIAL MANAGEMENT
IVFD NaCI 0,9% 20 drops/min
Oxygen 2 Litre per minute via nasal canule
Combivent/8h/inhalation
N-Ace 1 respul/8 h/nebu
Flixotide / 8h/inhalalation
Azitromisin 500mg/24h/oral
Curcuma 1 tab/ 8 hours /oral
INITIAL ASSESSMENT
No Subjective Objective Assesment Planning

1 Shortness of breath since 3 days Vital sign : respiratory rate : COPD -Therapy :
ago and worsen since one hour 28x/minutes
-O2 2 LPM via nasal canule
before admitted. Inspection : Barrel chest. Symetris
Dyspneu is continuously felt by on both side. Retraction at ICS. -IVFD NaCI 0,9% 20 drops/min
patient, not worsen by activity and Palpation : No tumour mass , No -Combivent/8h/inhalasi
weather. pain, Vocal fremitus decreased on
both side. -N-Ace 1 respul/8 h/nebu
Patient had cough with thick white Percussion : Sonor on both side -Flixotide / 8h/inhalasi
mucus since a weeks ago, with no Auscultation : breathing sound
blood . vesicular, decreased on both side. -Comtusi syrup/12h/oral
Since the last 5 years, patients wheezing (-/-), crackles (+/+).
-Retaphyl syrup/12jam/oral
often complain of shortness of Thorax AP:
breath and coughing intermittent. Flattening of the diaphragm -curcuma
He used to smoke for almost 40 Widening between the ribs
years. 1 pack per day. No soft tissue swelling
Planning:

Spirometry
Conclusion :
Acute exacerbations of COPD
No Subjective Objective Assesment Planning

2 Shortness of breath since 3 days Vital sign : respiratory rate : Infected Theraphy
ago and worsen since one hour 28x/minutes
bronchiectasis Azitromisin
before admitted. Inspection : Barrel chest. Symetris
Dyspneu is continuously felt by on both side. Retraction at ICS. 500mg/24h/oral
patient, not worsen by activity and Palpation : No tumour mass , No
weather. pain, Vocal fremitus decreased on
both side.
Patient had cough with thick white Percussion : Sonor on both side Planning
mucus since a weeks ago, with no Auscultation : breathing sound High resolution
blood vesicular, decreased on both side.
Patient had fever about two days computed
wheezing (-/-), crackles (+/+).
ago but he didnt take any drugs. Thorax AP: tomography (HRCT)
Since the last 5 years, patients An increase in bronchovascular markings
often complain of shortness of on both lungs
breath and coughing intermittent. Bronchi seen end on may appear as ring
shadows at the base of both lungs.
Conclusion :
Bronchiectasis bilateral
FOLLOW UP

1st Day 2nd Day 3rd Day 4th Day


16-11-16 17-11-16 18-11-16 19-11-16
DATE DAY OF TREATMENT THERAPY
16/11/2016 First Day IVFD NaCI 0,9% 20 drops/min
17 : 00 WITA S: Shortness of breath since 3 days ago and worsen since one
hour before admitted to Universitas Hasanuddin hospital.
-O2 2 LPM via nasal canule
BP: Dyspneu is continuously felt by patient, not worsen by activity Combivent/8h/inhalasi
130/80mmHg and weather.
PR: 98 x/m, Patient had cough with thick white mucus since a weeks ago, -N-Ace 1 respul/8 h/nebu
regular with no blood
RR: 28 x/m (sat: There is no chest pain
98% with nasal Patient had fever about two days ago but he didnt take any -Flixotide / 8h/inhalasi
canule) drugs.
Temp: 36.7 oC Since the last 5 years, patients often complain of shortness of -Azitromisin 500mg/24h/oral
breath and coughing intermittent. He rountinely went to the
doctor and was given theofilin (300mg 2x1), Symbicort (if
SOB), Combivent (if SOB), comtusi syrup -Comtusi syrup/12h/oral
No sweating at night
No nausea and no vomitting. -Retaphyl syrup/12jam/oral
Good appetite
No decreased body weight
Defecation and urination is normal. -Azitromysin 500mg/24h/oral

O : Vital sign : respiratory rate :28x/minutes -curcuma


Inspection : Barrel chest. Symetris on both side. Retraction at ICS.
Palpation : No tumour mass , No pain, Vocal fremitus decreased on PLANNING:
both side.
Spirometry
Percussion : Sonor on both side
Auscultation : breathing sound vesicular, decreased on both side.
HRCT Scan
wheezing (-/-), crackles (+/+).
Thorax AP:
An increase in bronchovascular markings on both lungs
Bronchi seen end on may appear as ring shadows at the base of both
DATE DAY OF TREATMENT THERAPY

17/11/2016 Second Day IVFD NaCI 0,9% 20 drops/min


17 : 00 S: SOB (+), cough with mucous (+) -O2 2 LPM via nasal canule
WITA
O : Ronchi (-), wheezing (+), bilateral --Combivent/8h/inhalasi
BP: -N-Ace 1 respul/8 h/nebu
120/80mmHg A:
PR: 98 x/m, Acute exacerbations of COPD -Flixotide / 8h/inhalation
regular Infected bronciectasis -Comtusi syrup/12h/oral
RR: 26 x/m
(sat: 98% -Retaphyl syrup/12jam/oral
with nasal
canule) -Ceftazidime 2gr/24h/intravena
Temp: 38 oC
-curcuma 1 tab/8h/oral

-sistenol 1g/8h/iv

PLANNING:
AFB sputum 3 times, gram
staining, bacterial culture,
sensitivity test,
Antibiotic sensitivity test
DATE DAY OF TREATMENT THERAPY
18/11/2016 Third Day IVFD NaCI 0,9% 20 drops/min
Time 06.00 S : SOB (+), cough (+) O2 2 litre per minute
BP: 130/ 70 N-Ace 1 respul/8 h/nebu
mmHg O : ronchi (-), wheezing (+)
PR: 88x/m, -Flixotide / 8h/inhalasi
regular A : Acute exacerbations of COPD -Comtusi syrup/12h/oral
RR: 28 x/m (sat: Infected bronciectasis
98% via -Retaphyl syrup/12jam/oral
monitor)
Temp: 37.5oC -metylprednisolon 125mg/24h/iv

-cetazidime 2g/24h/iv

Curcuma 1 tab/8h/oral

PLANNING:
Follow up AFB sputum
DATE DAY OF TREATMENT THERAPY
19/11/2016 Forth Day IVFD NaCI 0,9% 20 drops/min
Time 06.00 S : SOB decreased, cough (+) O2 2 litre per minute
BP: 130/ 70 N-Ace 1 respul/8 h/nebu
mmHg O : ronchi (-), wheezing (+)
PR: 94 x/m, -Flixotide / 8h/inhalation
regular A : Acute exacerbations of COPD (improved) -Comtusi syrup/12h/oral
RR: 24 x/m Infected bronciectasis
(sat: 97% via -Retaphyl syrup/12jam/oral
monitor)
Temp: 37.2 oC -metylprednisolon 125mg/24h/iv

-ceftazidime 2g/24h/iv

-curcuma 1 tab/8h/oral

PLANNING:
Follow up AFB sputum
DATE DAY OF TREATMENT THERAPY
20/11/2016 Fifth Day IVFD NaCI 0,9% 20 drops/min
Time 06.00 S : SOB decreased, cough (+) O2 2 litre per minute
BP: 130/ 70 N-Ace 1 respul/8 h/nebu
mmHg O : ronchi (-), wheezing (+)
PR: 94 x/m, -Flixotide / 8h/inhalation
regular A :Acute exacerbations of COPD (improved) -Comtusi syrup/12h/oral
RR: 24 x/m Infected bronciectasis
(sat: 97% via -Retaphyl syrup/12jam/oral
monitor)
Temp: 37.2 oC -metylprednisolon 125mg/24h/iv

-ceftazidime 2g/24h/iv

-curcuma 1 tab/8h/oral

PLANNING:
Follow up AFB sputum