CASE REPORT

January 24th 2019

Resident on duty:
dr. Ghamal, dr. Indri
Co-ass:
Darry, Faiz, Muthia, Setia
Doctor in Charge :
Dr. dr. Noni N Soeroso, M.Ked (Paru) Sp.P (K)

Working Diagnosis:
Severe exacerbation of Chronic Obstructive Pulmonary Disease without
Respiratory Failure + Community Acquired Pneumonia
 PATIENT’S IDENTITY

Name : Mr. MS
Age : 51 years old
Sex : Male
Occupation : Teacher
Ethnic : Bataknese
Main complaint : Shortness of breath
Differential Diagnosis

1. Respiratory disease
2. Cardiovascular disease
3. Hematological disease
History Taking
 Male, 51 years old, smoker (IB: Severe) came to USU General Hospital with
shortness of breath as the chief complaint since 2 months ago and worsened
since a week ago. Shortness of breath is affected by activity but not by weather.
Shortness of breath occur when patient go to bathroom. Orthopnea (+), DOE
(+), Trepopnea (-), Platypnea (-), Paroxysmal nocturnal dyspnea (-). History of
shortness of breath (+), Wheezing (+), history of wheezing (+). Shortness of
breath is not associated with position changes. mMRC: 4
 Cough (+) with the white yellowish-colored sputum since this 2 years ago.
Volume of sputum is one teaspoon per cough, with mucoid consistency. No
smell of sputum.
 Bloody cough (-). History of bloody cough (-)
 Chest pain (+) VAS 3. History of chest of pain(-)
 Lost of appetite (+). Weight loss (-) .
 Intermitten fever (-). History of fever (-) . Night sweating (-) . Headache (-).
History of seizure (-), weakness on extremities (-).
 Hoarseness (-). Swallowing dificulty (-). Ankle swelling (-), history of ankle
swelling (-).
 History Taking
 Patient is a smoker until nowadays, with a history of smoking 2 packs
a day for 40 years (IB: Severe).
 History of ATT (Anti Tuberculosis Treatment) (+) only consumed
around 2 months a year ago.
 History of DM (-).
 History of hypertension (-) hypertension in family (-).
 History of biomass exposure (-) , history of firewood exposure(-),
 History of alcohol (-).
 History of Inhaler (-). history of asthma (-). History of allergy (-) history
of nebulizer (-).
 History of cancer in the family (-).History of Pulmonary TB in family(-)
 History of hospitalization on January 20th 2019 in Tebing Tinggi
general hospital with chief complaint shortness of breath for 3 days.
 DIFFERENTIAL DIAGNOSIS BASED ON
HISTORY TAKING
1. Severe exacerbation of Chronic Obstructive Pulmonary Disease

2. Asthma Excacerbation Severe

3. Asthma COPD Overlap

4. Community Acquired Pneumonia

5. Pulmonary Tuberculosis

6. Lung Tumor
VITAL SIGN IN ER
 Level of Consciousness : Compos mentis
 BP : 120/70 mmHg
 Pulse : 112x/i regular,t/v enough, paradoxus
pulse (-)
 RR : 30x/i, regular
(-) Cheyne-Stokes (-) , Kussmaul (-)
 Temp : 36,7 ºC axilla
 SpO2 : 90% with oxygen 3 liters per minute
via nasal canule
• Pain : (-)
Physical Examination
General Inspection
1. Head
Deformity :-
Face : Moon face (-)
Eyes : Pale conjunctiva 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 accessory muscle in breathing (+)
3. Thorax :
Cor : S1(+) S2(+) S3(-) S4(-) activity: enough, regularity: regular
Murmur : (-)
Heart borders :
Upper : 2nd ICS LMCS
Right : 3rd ICS LPSD
Left : 5th ICS ± 1 cm medial LMCS
Lower : Diaphragm
 Chest Examination
Anterior Findings
Inspection Static: Symmetrical, no deformity, collateral vein (-), venectatio
n (-)
Dynamic: Symmetrical (no delayed movement)
Barrel Chest (-).
Palpation - Trachea : medial
- Tactile fremitus right > left hemithorax,
- Symmetrical chest expansion
- Subcutaneous emphysema (-)
Percussion Lung Resonance: Hypersonor in both hemithorax
Liver border: ICS VI

Auscultation - Breath sound: prolonged expiration

- Additional sounds: crackles (-/-) Wheezing (+/+) generalized,
polyphonic, low-pitched sound.
- Vocal Resonance Egophony (-) Bronchophony (-) Whispered
pectoriloquiy (-)
4. Abdomen :
Liver/spleen/kidney : unpalpable
Ascites (-)
5. Hands : clubbing fingers (-), palmar eritema (-), edema
(-), nicotine staining (-), resting tremor (-),
weakness of the hand (-), cyanosis (-)
6. Limbs : Pretibial oedema (-)
DIFFERENTIAL DIAGNOSIS
BASED ON PHYSICAL FINDINGS

1. Severe exacerbation of Chronic Obstructive

Pulmonary Disease
2. Asthma Excacerbation Severe
3. Asthma COPD Overlap
4. Community Acquired Pneumonia
5. Pulmonary Tuberculosis
6. Lung Tumor
 Clinical Pathologic Laboratory (January 24th 2019)
USU General Hospital
24/01/2019 Normal
HGB 12.6 g/dL 13-16 g/dL
WBC 27.3 x 103/mm³ 3.6-11 x 103/mm³
RBC 4.31 x 106/mm³ 3.8-5.2 x 106/mm³
Hematokrit 37.8% 38-44 %
Thrombosit 410x 10³/mm³ 150-440 x 10³/mm³
Neutrofil absolut 22.51x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 2.48x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 2.32x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0.00x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0.02x 103 /µL 0-0,1 x 10³/µL

Na/K/Cl 135/4.4/100mEq/L 135-147/3,5-5,0

Kesan Mild Anemia + Leukocytosis
Blood Gas Analysis (January 24th 2019)
USU General Hospital
24/01/2019 Normal
pH 7,49 7,37 – 7,45
pCO2 31.0 mmHg 33 – 44
pO2 107.00 mmHg 71 – 104
Bikarbonat(HCO3) 23.6 mmol/L 22 – 29

BE 0.3 mmol/L (-2) – (+3)

Saturasi O2 99,0% 94 – 98
TCO2 24,6 mmol/L 23-29
Respiratory alkalosis without compensation + Hyperoxemia
 Position PA Erect
Chest X-Ray on January
Exposure of radiatio Normal
8th 2018 in Tebing Tinggi n
Hospital Trachea Deviated to the right
Clavicle Assymmetric, no fracture
Scapula No superposition on both hemithor
ax
Bone Symmetric, no fracture
Lung Right lung : Inhomogen consodilatio
n in medial lobe, infiltrate in inferi
or lobe

Left lung: hyperlucent

Cor CTR<50%

Costhophrenic angle Left : sharp

Right : sharp

Cardialphrenic angle Left : sharp

right : sharp
Diaphragma Right : tenting
Left : dome shaped
 Position PA Erect
Chest X-Ray on January
Exposure of radiatio Normal
24th 2019 in USU Hospital n
Trachea Deviated to the right
Clavicle Symmetric, no fracture
Scapula No superposition on both hemithor
ax
Bone Symmetric, no fracture
Lung Right lung : Inhomogen consodilatio
n in medial lobe, infiltrate in inferi
or lobe

Left lung: hyperlucent

Cor CTR<50%

Costhophrenic angle Left : sharp

Right : sharp

Cardialphrenic angle Left : sharp

right : sharp
Diaphragma Right : tenting
Left : dome shaped
Chest X-Ray on January
24th 2019 in USU Hospital
Position Lateral Dextra

Exposure of radiation Normal

 DIFFERENTIAL DIAGNOSE :
Primary Diagnosis :
Severe Exacerbation of COPD without Respiratory Failure
DD/ 1. Asthma Excacerbation Severe
2. Asthma COPD Overlap
Secondary Diagnosis :
Community Acquired Pneumonia
DD/. 1. Hospital Acquired Pneumonia
2. Pulmonary Tuberculosis
Working diagnosis

Severe Exacerbation of COPD without

Respiratory Failure + CAP
MANAGEMENT in ER
 Oxygen therapy : 3 liters per minute via nasal canule
 IVFD NaCl 0,9% 20 drops per minute(macro)
 Nebule Ventolin 2.5 mg
 Nebule Fulmicort 0,5 mg
 Injection of Methylprednisolone 5 mg
 Injection intravenous of Ranitidine 50 mg
MANAGEMENT in ROOM
 Oxygen therapy : 3 liters per minute via nasal canule
 IVFD NaCl 0,9% 20 drops per minute(macro)
 Injection of Levofloxacine 750 mg/24 h
 Injection of Methylprednisolone 125mg / 8 h
 Injection intravenous of Ranitidine 50 mg / 8 h
 Ambroxol syr 3 x C I
 Nebule Ventolin 2.5 mg / 8 h
 Nebule Pulmicort 0,5 mg / 8 h
Investigations
Gen Xpert sputum
Sputum Microbiology, Gram Staining, Acid Fast B
acilli, sputum culture and sensitivity test
Sputum citology
Spirometry
Thorax CT Scan with Contrast IV Injection
HIV Test
THANK YOU