RESPONSI

Chronic Obstructive Pulmonary Disease (COPD) +

Pulmonary tuberculosis (TB) New Case
By :
Nor fatimatuzzahra, S.Ked
NIM. 1730912320100

Consulent: dr. Paul A. Dwiyanu, Sp.P(K) - FISR

BAGIAN/SMF ILMU PENYAKIT DALAM BAGIAN PARU

FAKULTAS KEDOKTERAN ULM/ RSUD ULIN
BANJARMASIN
1 November , 2018
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 Patient’s Identity

Name : Tn. MD
Age : 69 years old
Religion : Islam
Race : Javanese
Status : Widower
Ocuppation : Pensionary
Address : Jl. Kelayan A, Banjarmasin
Hospitalized on : 22/10/2018

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 Anamnesis
Mr. MD/ Male/ 69 years old.
Main complaint : Shortness of breath
Description :
The patient comes to the ED of RSUD Ulin with a shortness of breath complaint. It
was felt since 1 week ago before hospitalized and getting worse since 1 day before
hospitalized. Shortness appears slowly and felt continuously. Shortness will appear if the
patient is inhaled volcanic dust from the Mount Kelud because the patient lives at the
foothills of Mount Kelud. Shortness does not decrease with position change and use of
an inhaler. Shortness was not specifically at night or in the morning and not dependent
on the weather. Shortness sometimes accompanied by 'ngik' sound when its burden, the
patient's activity is disturbed. Patients burden until unable to walk. Shortness felt heavier
when coughing complaints burden. Creeping chest pain, chest palpitations and legs
swelling denied by the patient. Shortness usually occurs with a complaint of coughing. 3
 Anamnesis

Cough is felt approximately 2 months before hospitalized. Cough is accompanied by

yellow phlegm sputum with thick consistency. Blood on phlegm is denied by the patient.
Cough felt continuously and increasingly heavier. Fever denied by the patient. One month
before hospitalized, the patient has decreased of appetite, that the patient's weight
decreased by 4 kg in the period of 1 month. The patient also complained about the
frequent night sweats that appeared without activity. The patient admitted that he had
never had Anti TB treatment for the previous 6 months. Contact with other people who
experience a long cough or treated with Anti TB treatment were denied by the patient.
Complaints of vomiting, nausea and abdominal pain were denied by the patient.
Defecating and urinating were normal, no complaints.

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• Past medical history : History of 5 times hospitalized with complaints of shortness of
breath within a period of approximately 7 months. Patients claimed to have a history of
asthma from the age of 30 years and routinely controlled to a pulmonary specialist and
prescribed inhaler drugs by 2 x 1.

• History of family : Diabetes mellitus (-), hypertension (-), asthma (-), atopy (-), tb
pulmonary (-) heart disease(-)

• Smoking history : Patient had been smoke from the age of 23 to 30 years and stopped
after marriage until now. 2 packs per day.

• Alcohol history : No alcohol consumption history.

• Social environmental history : Patient lived in the foothills of Mount Kelud in Java and
sometimes the mountain released dust. The patient stayed for 7 months in Java and he
did not work only stay at home doing light activities. Neighbors and families of patients
did not have anti TB treatment. 5
 PHYSICAL EXAMINATION
BP: 110/60 mmHg HR= 110 beats per RR: 24 times per minute Tax= 36,7◦C
minute Sp O2: 97% without O2
Regular , palpated
strong enough

General circumstance : Moderate sickness, the patient GCS : E4V5M6

have difficulty to breath.
Weight: 53 kg, Height: 171 cm, BMI: 18,13 kg/m2 (underweight)
Head and skin Normocephaly Rash (-)
Pale conjungtivity (-) Pale (-)
Sclera icteric (-) Icteric (-)
Neck meningeal sign(-), JVP: 5 + 2 cmH2O , swollen lymph nodes (-)
Thorax Inspection: Ictus cordis is not seen
Cor: Palpation: Ictus cordis is palpable on ICS V linea midclavicula sinistra, thrill (-)
Percusion:
Dextra: linea midclavicula dextra ICS V
Sinistra: linea midclavicula sinistra ICS VI
Auscultation: S1, S2 single, Murmur (-) gallop (-) 6
Pulmo Inspection : Simetric (+/+) both in inspiration
and expiration, regular rhythm, breathing use of
accessory respiratory muscle, barrel chest (+)
Palpation : Simetric (+/+) both in inspiration
and expiration, fremitus focal dextra/sinistra (+/+).
Percussion : S S
Resonance: S S
S S

Auscultation :Vs Vs
Breath sound: Vs Vs
Vs Vs

+ +
Rhonky: - -
- -
+ +
Wheezing:
- -
- - 7
Abdomen Inspection: Striae (-), scar (-), sikatric (-), venectasi
(-)
Auscultation: bowel sound : 5x/min
Percussion: tymphany on all abdominal regio
Palpation: hepatomegaly (-) splenomegaly (-)
Pain: - - -
- - -
- - -
Ekstremitas Pitting edem on lower extremity (-/-), deformity (-)

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 Laboratory
Hasil
Pemeriksaan Nilai Rujukan Satuan
14/10/18 18/10/18 22/10/18
HEMATOLOGI
Hemoglobin 14.6 12.8 12.3 14.0 – 18.0 g/dl
Lekosit 19.7 15.1 10.4 4.0 – 10.5 rb/μl
Eritrosit 5.47 4.81 4.65 4.10 – 6.0 juta/μl
Hematokrit 45.6 40.2 39.1 42– 52 vol%
Trombosit 430 462 535 150 – 450 ribu/μl
RDW-CV 16.1 15.6 15.4 12.1 – 14.0 %
MCV.MCH.MCHC
MCV 83.4 83.6 84.1 75.0 – 96.0 Fl
MCH 26.7 26.6 26.5 28.0 – 32.0 Pg
MCHC 32.0 31.8 31.5 33.0 – 37.0 %
HITUNG JENIS
eosinofil % 0.3 0.9 2.0 1.0-3.0 %
Gran% 89.1 85.7 80.8 50.0-81.0 %
Limfosit % 4.5 5.0 9.2 20.0-40.0 %
Gran# 17.57 12.89 8.38 2.50-7.00 ribu/ul
Limfosit# 0.88 0.76 0.96 1.25-4.00 ribu/ul 9
monosit # 1.19 1.25 0.81 0.30-1.00 ribu/ul
 Pemeriksaan Hasil Nilai Rujukan Satuan
HATI DAN PANKREAS
SGOT 12 5-24 U/L
SGPT 21 0-55 U/L
GINJAL
Ureum 28 0-50 U/L
Creatinine 0.77 0.72-1.25 U/L
ELEKTROLIT
Natrium 135 136-145 Meq/L
Kalium 3.7 3.5-5.1 Meq/L
Chlorida 100 98-107 Meq/L
HEMATOLOGI
LED/ESR 61 0-10 mm/jam
MIKROSKOPIS
Sputum pagi negatif -
Sputum sewaktu negatif -
HBsAg (Elisa) 0.22 <1.00 s/co
KUALITAS SPUTUM
Leukosit >25/LPB 10
Epitel <10/LPB
11
Sinus Tachycardia,
HR: 110 beat per
minute, regular.
Normo axis

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 CUE AND CLUE Problem List PDx
POMR PTx Pmo PEdu

Ax: Chronic Spirometry Bed rest General Explain to patients and

Sortness of breath since a
day ago
Productive cough with
yellowish sputum since 2
months ago and thick
consistency without blood
History of active smoker
History of inhaled volcanic
dust
History of hospitalized 5
times in period 7 months
with SoB complaint
Px Phy:
Tachypnea
Use of accessory
respiratory muscles
Ronkhi and wheezing on
apex pulmo
Obstructive Circumstamces their families about the
Pulmonary Disease Bronchodilator (Nebuli Vital Sign diagnosis of the
(COPD) Group D salbutamol/Ipratropium SpO2 disease, treatment
Bromide) per 8 hour BGA plan, prognosis, and
Combination Long-acting Nutritions complications
beta2 -agonist (LABA) + Avoid exposure to air
Long acting muscarinic pollution and cigarette
agonist (LAMA) smoke
Combination LABA +
ICS
methylprednisolon 30-40
mg/days
Respiratory and chest
Physiotherapy

CXR:
Increased
bronchovascular
Emphysema toast lung
Flattening of the
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diaphragm
 CUE AND CLUE Problem List PDx
POMR PTx Pmo PEdu

Ax: Community Sputum culture Respiratory General Explain to patients and

Sortness of breath(+) Acquired Sputum Gram stain fluoroquinolones (Inj. Circumstamces their families about the
Productive cough(+) Pneumonia Levofloxacin 1x750 mg) Vital Sign diagnosis of the
(CAP) NAC 3x1 tab check DR post disease, treatment
Px Phy: Antibiotics/3 days plan, prognosis, and
Ronkhi on apex pulmo Nutritions complications

Lab :
Leukositosis (14.600/μl)
Granulositosis (89,1 %)

CXR :
Infiltrat (+)

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 CUE AND CLUE Problem List PDx
POMR PTx Pmo PEdu

Ax: Pulmonary Gene expert Isolate patients with General Explain to patients and
Chronic cough (since 2 tuberculosis (TB) possible TB in a private Circumstamces their families about the
months ago) New Case room Vital Sign diagnosis of the
weight loss (+) Anti tuberculosis Obs. Cough disease, treatment
decressed of apetite (+) drugs, category 1 Nutritions plan, prognosis, and
night sweats (+) Initial empiric complications.
has history of taking pharmacologic therapy Wear a surgical mask.
antidrug TB (-) consists of the Do not spit carelessly.
following 4-drug Side effects of anti
Px Phy: regimens (2 months) : tuberculosis drugs.
BW : 53 kg Isoniazid 300 mg Regular consumption
RR : 24 times/m Rifampin 450 mg of drugs.
Pyrazinamide 1250 mg
CXR: Ethambutol 1000 m
Fibroinfiltrat (+)
infiltrate (+) high-calorie high-
protein diet

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Thank You

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