CASE REPORT

Chronic Obstructive Pulmonary Disorder (COPD)

Created By :
Putri Rahmawati Evi Emilia Res&y 'anti (atubara Rahma Erlina 0 !"0!!0# 0$!"0!!0!% 0"!"0!!0% 0"!"0!!0%$

Perceptor: Dr) DED' *A+R,S- S.)P

C/+0+CA/ 1OR2 O3 +0TER0A/ 4ED+C+0E- S43) P,/4O0O/O5'

0O6E4(ER 70!% A(D,/ 4OE/OE2 8OSP+TA/ (A0DAR /A4P,05

CASE REPORT
The history taking and physical examination were done on October 19th 201 in P!lmonary "ard #$elati% &r' (i' )bd!l $oeloek *eneral (ospital+ Bandar ,amp!ng' +) )ge *ender )ddress Pro1esion 2d!cation $arriage stat!s 3eligion )dmission date ++) 8istory : )!toanamnesa : .hortness o1 breath one week +denti9ication o9 Patient : $r' . : /1 : $ale : 0otab!mi : 2ntreprene!r : .enior (igh .chool : $ariage : $oslem : October 4th 201

-ame

Anamnesis Chie9 Com.laint

Secondary Com.laint : chest pain+ co!gh

8istory o9 Present +llness : Os came with complaints o1 le1t chest pain thro!gh to the back and abdomen+ accompanied by shortness+ and prod!cti5e co!gh' Chest pain 1elt since 2 months be1ore entering the hospital b!t patients do not care and contin!ed to work' Os 1eel chest pain se5ere increasingly since 2 days' Os 1eel na!seo!s and he 5omit

since 2 days be1ore entering the hospital' Os complained o1 shortness' Tightness is 1elt i1 he in acti5ity' (e can not work as !s!al' Tightness has been 1elt since 2 days be1ore entering the hospital' Tightness is red!ced when at rest b!t he was still di11ic!lt to breathe' Os also complained o1 prod!cti5e co!gh+ co!gh has been 1elt since 1irst week be1ore entering the hospital' Co!gh is persistent with sp!t!m and the colo!r is yellowish+ now he is not co!gh anymore' (e did not notice any whee6ing or weird breath so!nds' (e also said that he ne5er been sweaty night+ low appetite+ and weight loss' (im weight is same with he has illness' Os came to the clinic and recommended to get x7rays examination ' 87rays examination res!lts ill!strated there was 1l!id in the l!ngs' Os has a history o1 intermittent 1e5er and the 1e5er still common when taking the stall medicine' Os did not has a long co!gh history' Os did not has a history o1 )T& #)nti T!berc!losis &r!g%' Os did not has a history o1 dibetes melit!s' Os did not has a history o1 hypertension' Penderita datang dengan kel!han sesak na1as yang telah diderita se9ak 1 mingg! sebel!m mas!k r!mah sakit+ sesak na1as dirasa memberat ter!tama setelah berakti5itas+ akan sedikit berk!rang bila pasien beristirahat' dan pasien sering terbang!n pada malam hari karena sesak' Pasien tid!r lebih nyaman dengan bantal' .esak na1as diik!ti dengan kel!han bat!k dengan dahak yang makin lama bertambah banyak+ dan 9ika kel!ar dahak berwarna k!ning+ demam naik t!r!n+ menggigil+ pen!r!nan berat badan drastis+ na1s! makan men!r!n+ keringat malam #:%+ nyeri dada #:% saat bat!k' B)0 dan B)B tidak ada kelainan' &alam 1 b!lan ini+ sesak dirasakan oleh pasien s!dah x kamb!h' -am!n+ sekarang sesak na1as penderita m!lai berk!rang+ penderita s!dah bisa bicara perkalimat+ tidak seperti pada awal mas!k+ yang terengahengah ketika berbicara' Bat!k 9!ga s!dah berk!rang' .ebel!mnya+ pasien ra9in kontrol di p!skesmas' .at! b!lan ini pasien diberi obat kaps!l dan di!ap bila sesak' Pasien perokok se9ak rema9a+ sehari 2 b!ngk!s+ pasien tidak pernah min!m obat paket'

The patient came in with the complaint that has been s!11ered shortness o1 breath since 1 week be1ore entering the hospital+ shortness o1 breath is 1elt memberat especially a1ter acti5ity+ will be slightly red!ced when the patient is at rest' and patients o1ten wake !p at night beca!se o1 tightness' Patients sleep more com1ortably with pillows' .hortness o1 breath accompanied by a co!gh with

phlegm complaints that the longer abo!nded+ and i1 it comes o!t yellow sp!t!m+ 1e5er+ chills !p and down+ drastic weight loss+ decreased appetite+ night sweats+ chest pain when co!ghing #%' B)0 and chapter no abnormalities' ;n 1 month+ tightness 1elt by patients already x relapse' (owe5er+ now that shortness o1

breath s!11erer begins to diminish+ the patient can already talk perkalimat+ !nlike at the beginning o1 admission+ which terengahengah when speaking' Co!gh has diminished' Pre5io!sly+ the patient diligent controls in the clinic' This patient was gi5en a one7month dr!g caps!les and di!ap when the seams' Patient a smoker since his teens+ smoker patients a day 2 wrap+ patients ne5er take medication packages'

Riwayat Penya&it Dahulu 3iwayat &$ : disangkal 3iwayat hipertensi : disangkal 3iwayat sakit 9ant!ng : disangkal 3iwayat min!m O)T : disangkal

Riwayat Penya&it 2eluar;a 3iwayat penyakit ser!pa : disangkal

3iwayat (ipertensi : disangkal 3iwayat &$ : disangkal 3iwayat <ant!ng : disangkal

2eadaan Sosial E&onomi Penderita adalah s!ami dari 1 istri dan ayah dari anak+ beker9a sebagai b!r!h

bang!nan dan men9adi t!lang p!ngg!ng kel!arga' Pasien berobat dengan mengg!nakan <amkesmas'

Riwayat 2ebiasaan dan 5i<i Pasien makan kali sehari+ sebanyak = porsi+ dengan nasi+ la!k pa!k #tah!+

tempe+ tel!r+ikan% dan say!r' Pasien 9arang makan b!ah dan min!m s!s!' Pasien min!m air p!tih sebanyak /7> gelas belimbing pehari' 3iwayat olah raga : disangkal 3iwayat min!m alkohol : disangkal 3iwayat merokok : 2 b!ngk!s perhari

8istory o9 Past +llness Os has a history o1 intermittent 1e5er and the 1e5er still common when taking the stall medicine' Patient has not diabetes $elit!s' (e ne5er had asthma or se5ere breathlessness be1ore+ and ne5er had tra!matic in chest' 8istory o9 3amily +llness There was no 1amily member who diagnosed as COP& /i9estyle and Activity

The patient was not an acti5e smoker' The patient is a entrepren!er+ and still able to do his work be1ore the worsening o1 his breathlessness' +++) Physical E=amination *eneral appearance Conscio!sness "eight )5erage weight #kg% : // kg (eight #cm% Present weight #kg% B$; Blood Press!re P!lse Temperat!re 3espiration 3ate 8ead Eye 0ose 4outh Throat 0ec& : 1@0 cm : // kg : 21+4 : 140AB0 mm(g : B2 bpm + reg!lar : @'>0 C : 29 xAmin!te : -ormocephali+ atra!matic+ normal hair distrib!tion+ hair not easily re5oked : isochor p!pils+ anemic con9!cti5a :A:+ icteric sclera 7A7 5is!al 1ield intact+ : .ymmetrical+ sept!m de5iation #7%+ discharge #7%+ concha oedem #7% : caries + stomatitis #7% : tonsil T17T1 calm+ hyperemis pharing #7% : thyroid gland normal si6e+ lymph nodes not palable+ de5iation o1 trachea #7% Thora= /un; ;nspection : asymmetrical shape+ asymetrical chest mo5ement+ decreased le1t hemithorax mo5ement+ accessory m!scle !se #7%+ : $oderate ill : Compos mentis+ 24?/$@

Palpation Perc!ssion )!sc!ltation

: absent 5ocal 1remit!s on the le1t hemithorax+ no tenderness' : sonor on le1t hemithorax : absent breathe so!nds o1 the le1t hemithorax+ 5esic!lar breath so!nd on the right hemithorax' "hee6ing #7%+ Crackles #:%'

Cor ;nspection Palpation : ict!s cordis is 5isible : ict!s cordis is palpable in the 4th ;C. o1 le1t $id cla5ic!la' Perc!ssion ,e1t bo!ndary Cpper limit )!sc!ltation Abdomen ;nspection Palpation Perc!ssion )!sc!ltation E=temity : abdomen 1lat+ no tension+ no dilated 5eins : no perc!ssion pain+ no de1ense m!sc!lar+ no enlarged li5er : timpanic+ perc!ssion pain #7%+ shi1ting d!llness #7% : bowel mo5ement #:%+ normal : warm + oedem regio dors!m pedis dextra et sinistra #7%+ oedem regio antebrachii dextra #7%+ cyanosis #7% +6) /aboratory and +ma;in; : : ;C. ? linea parasternal dextra : ;C. ? linea midcla5ic!la sinistra : ;C. ;;; linea parasternal sinistra : .1A.2 heart so!nds+ reg!lar + m!rm!r #7%+ gallop#7%

3ight bo!ndary

(RSA4 >uly 7%rd 70!% (b 1 '1 gAdl #- : 1 +/71B grD %

2.3 ,e!cocyte &i11 co!nt Trombocyte

B1 mmA9am 1 '@00Aml 0A0A0A92A2A@ 11'000 A!l

#- : 0710 mmA9am% #- : 4/00710'>00% #- : 071A 17 A27@A/07>0A20740A27B% #- : 1/0'0007400'000A!l%

Chemical (lood OTAPT Cre!m Creatinin *&. 19A24 !l 9/ !Al 1+1 !Al 1 / mgAdl #- : @7 0A@74/ !l% #- : 10740 !Al% #- : 0+>71+ !Al% #- : >07200 mgAdl%

Postero?anterior chest Roent;en ( October ! ;nterpretation :

th

70!%)

7 7 7 7 7

Bones and 9oints #cla5ic!la+ scap!la+ costae+ 5ertebrae% are intact Trachea de5iasi #7% )5asc!lar and hyperl!scent area in le1t l!ng 1ield Bl!nting o1 right costophrenic angle #air 1l!id le5el 1orm% ;n5isible in1iltrat in le1t l!ng 1ield

.i6e o1 cor is normal

Concl!sion : (idropne!mothoraks dextra with colaps in right l!ng 1ield

6)

RES,4E

Os came with complaints o1 le1t chest pain thro!gh to the back and abdomen+ accompanied by shortness+ and prod!cti5e co!gh' Chest pain 1elt since 2 months be1ore entering the hospital b!t patients do not care and contin!ed to work' Os 1eel chest pain se5ere increasingly since 2 days' Os 1eel na!seo!s and he 5omit since 2 days be1ore entering the hospital' Os complained o1 shortness' Tightness is 1elt i1 he in acti5ity' (e can not work as !s!al' Tightness has been 1elt since 2 days be1ore entering the hospital' Tightness is red!ced when at rest b!t he was still di11ic!lt to breathe' Os also complained o1 prod!cti5e co!gh+ co!gh has been 1elt since 1irst week be1ore entering the hospital' Co!gh is persistent with sp!t!m and the colo!r is yellowish+ now he is not co!gh anymore' (e did not notice any whee6ing or weird breath so!nds' (e also said that he ne5er been sweaty night+ low appetite+ and weight loss' (im weight is same with he has illness' Os came to the clinic and recommended to get x7rays examination ' 87rays examination res!lts ill!strated there was 1l!id in the l!ngs' Os has a history o1 intermittent 1e5er and the 1e5er still common when taking the stall medicine' Os did not has a long co!gh history' Os did not has a history o1 )T& #)nti T!berc!losis &r!g%' Os did not has a history o1 dibetes melit!s' Os did not has a history o1 hypertension' Physical examination re5ealed the patient looks ill b!t not in ac!te distress+ compos mentis+ P!lse >4 bpm+ reg!lar+ Temperat!re B'>0 C+ 3espiration 3ate @ xAmin!te+ B$; 22+49 kgAm2+ )nanemic con9!ncti5a :A:' Chest examination re5ealed ".& t!be inserted into 1i1th intercostal space+ le1t axillary line' &ecreased le1t side thoracic expansion and absent breath so!nd on the le1t side' ,aboratory 1indings re5ealed mild anemia #(b 14 gAdl%+ total le!cocyte co!nt o1

2@'000' The posteroanterior chest x ray re5ealed a le1t pne!mothorax with le1t l!ng in1iltrat' Erom ".& 1l!id we 1o!nd secret like p!s+ and the res!lt o1 bactery c!lt!re 1o!nd gram7negati5e rods bacteria #Alkaligenes Sp% 6+) Dia;nosis

Piopne!mothoraks 6++) Treatment 1' O2 2 ,itresAmin!te 2' ;?E& 3, gtt 8Amin!te ' Ce1triaxone 1 gA 12 ho!rs #;?% 4' $etronida6ol A 12 ho!rs #;?% /' )mbroxol sir!p x1C @' Obser5e the de5elopment o1 ".& till the !nd!lations and B!bble negati5e >' Chest 873ay i1 the l!g re7expands+ then o11 ".&

6+++) Pro;nosis F!o ad 5itam F!o ad 1!nctionam F!o ad sanationam : d!bia : d!bia : d!bia ad bonam

+@) Recommended E=amination 7 ,ipid pro1ile+ !ric acid ser!m 7 2C* 7 )cid7resistant bacteria 7 .itology bacteria