The document details a medical case of a 74-year-old male patient experiencing worsening shortness of breath and cough, diagnosed with Chronic Obstructive Pulmonary Disease (COPD). It includes patient history, physical examination findings, laboratory results, and treatment protocol. Key indicators for diagnosing COPD are also referenced, alongside prognosis and recommendations for management.

1. COPD : IT’S AND
PROBLEM KEY INDICATORS FOR
CONSIDERING DIAGNOSIS
SUPERVISOR: Dr .dr. Soroy Lardo, Sp.PD FINASIM
DOCTOR’S ON DUTY: dr. Ike & dr. Nita
COASS ON DUTY: Maharani Falerisya Nabilla & Isni Ayu Lestari
DEPARTEMENT OF INTERNAL MEDICINE INDONESIA ARMY
CENTRAL HOSPITAL GATOT SUBROTO

2. PATIENT RECAPITULATION
 Mr. Said / 74y.o/ dypsnea ec copd
 Mr. Haryo/ 51y.o/ Hypertention Urgency
 Mr. Kamal/ 48y.o/ Vertigo + ACS
 Mr. Haryanto/ ACS dd/GERD
 Mr. Arry Julianto/ malaria
 Mrs. Titi/ 72y.o/ CKD on HD

3. PATIENT’S IDENTITIY
 NAME : Mr. Said
 SEX : Male
 AGE : 74 years old
 Religion : Moslem
 OCCUPATION: Purnawirawan
 ADDRESS : Kodamar Jakarta Utara
 DATE OF ADMISSION: Wednesday 26 April
2017

4. ANAMNESIS
 Alloanamnesis on April 26 2017
 CHIEF COMPLAINT
Shortness of breath since 5 hours before
entering hospital

5. HISTORY OF PRESENT ILLNESS
 Patients complain of shortness of breathing, 5
hours before entering hospital. has been felt
since 1 week and getting worse. Shortness is
felt throughout the day, getting heavier during
exercise, coughing, and not decreasing with
rest.
5 hours before entering
hospital

6.  Patient sleeps with 2 pillows. Patients also
complained of cough with phlegm since 1 week
ago. Cough with yellow phlegm, no blood, have
OBH (cough medicine), but cough is not
reduced. Right chest pain especially when
coughing, no spreading pain, no fever, nausea,
no vomiting, can’t defecate since 5 days, the
colonoscopy is normal. Patients are smokers
for> 30 years of 1 pack per day but have been
stopped since 10 years ago.

7. PAST ILLNESS HISTORY
 Hypertension(-), diabetes (-)
 COPD (+) since 2015
 Heart disease since 2012 with bypass and
stents at 2014

8. Treatment History
 Simvastatin 20mg 1x1
 V bloc 6,25mg 1x1 (carvedilol)
 Furosemide 40mg 1x1
 Spiriva 18mg
 Salbutamol 2mg 3x1½ tab
 Retaphyl SR 300mg 2 ½ tab (theophylline)
 Symbicort
 Ventolin inhaler

9. FAMILY ILLNESS HISTORY
 No family member with the same symtpom
 Hypertension(-), diabetes (-), heart disease(-)

10. PHYSICAL EXAMINATION
General Examination
 General condition: weak
 State of Consciousness: compos mentis
 GCS : E 4, M 5, V 6
 Vital sign
- Blood pressure: 115/72 mmHg
- Heart rate: 91 x/mnt
- Respiratory: 24 x/mnt (SaO2 92%)
- Temperature: 36,5’C
 Body weight: 50 kg
 Body height: 162 cm
 Body mass index: 19,08 normal

11.  Head : Normocephal
 Eye : anemis conjungtiva (-/-), icteric sclera (-/-)
 Ears : normotia, discharge (-)
 Nose : septum deviation (-), discharge (-)
 Mouth : pursed lips breathing (+). dry lips (-),
normal tongue, hyperemic phariynx (-), T1-
T1
 Neck : lypm nodes enlargement (-) JVP 5+2cm

12.  Thorax
• Pulmonary examination
- Inspection: symmetrical lung movement, scar (-), intercostal
retrraction (-),
use of accessory muscles with breathng (+)
- Palpation: symmetrical chest expansion and vocal fremitus,
mass (-), tenderness (-)
- Percussion: hipersonor or at both lung field
- Auscultation: vesicular breath sound, crackles (-), wheezing (+/+)
• Cardiac examination
- Inspection: ictus cordis not visible
- Palpation: ictus cordis palpable at ICS V left midclavicula line
- Percussion: right cardiac border at ICS IV right parasternal line,
left cardiac border at ICS V left midclavicular line,
upper border at ICS III left parasternal line
- Auscultation: normal S1/S2 regular, no murmur, no gallop

13.  Abdomen
- Inspection: distended, no skin lession/scar,
ascites (-)
- Auscultation: bowel sound (+)
- Percussion: tympani on four abdominal
quadrant, shifting dullness (-)
- Palpation: Supple, skin turgor (+), tenderness on
epigastrium (-), liver and spleen not palpable
 Extremities: CRT <2 seconds, warm distal
extremities,

14. Laboratory Findings
Complete blood
tests
Result Normal value
Hemoglobin 13,0 g/dl 13,0 - 18,0
Hematocrit 40 % 40,0 - 52,0
Erythrocyte 4,3 juta 4,30 – 6,0 juta
MCV 86 fL 80,0 – 96,0
MCH 29 g 27,0 – 32,0
MCHC 34 g/dl 32,0 – 36,0
Thrombocyte 277.000 150.000- 400.000
Leukocyte 18.570 ↑ 4800 – 10.800

15. Blood metabolic
Ureum 51 mg/dl ↑ 20 – 50 mg/dl
Creatinin 1,7 mg/dl ↑ 0.5 – 1.5 mg/dl
Glucosse 155 mg/dl ↑ <140 mg/dl
Electrolyte
Natrium (Na) 138 135 – 147
Calium 3,1 ↓ 3.50 – 5.00
Chloride 99 95.0 – 105.0
Blood Gas Analysis
pH 7,380 7,37 – 7,45
pCO2 33,5 33 – 44 mmHg
pO2 175,4 ↑ 71 – 104 mmHg
HCO3 20 ↓ 22 – 29 mmol/L
BE -3,8 (-2)-3 mmol/L
Sat O2 98,3 94 – 98%

16.  Emfisematous
lung
 Aorta
calcification
 Cardiac:
normal

18. Resume
 Patients complain of shortness of breathing, has
been felt since 1 week and getting worse. Shortness
is felt throughout the day, getting heavier during
exercise, coughing, and not decreasing with rest.
 Patient sleeps with 2 pillows. Patients also
complained of cough with phlegm since 1 week ago.
Cough with yellow phlegm, have OBH but cough is
not reduced.
 Right chest pain especially when coughing, nausea,
can’t defecate since 5 days,. Patients are smokers
for> 30 years of 1 pack per day but have been
stopped since 10 years ago.

19. Resume
 Phsycial examination shows Respiratory: 24
x/mnt, pursed lips breathing (+). use of
accessory muscles with breathing, wheezing
(+/+)
 Laboratory found increase leukosit, Increase
glucosse, decrease calium, increase pO2 and
decrease HCO3

20. List of Problems
 Dypsena ec COPD

21. Problem Solving
 Dypsnea ec COPD
Anamnesis:
shortness of breathing,, cough with phlegm since 1 week agoRight
chest pain especially when coughing, smokers for> 30 years of 1
pack per day but have been stopped since 10 years ago..
Physical examination:
Respiratory: 24 x/mnt, pursed lips breathing (+). use of accessory
muscles with breathing, wheezing (+/+)
Lab examination: increase leukosit (18.570)
Assesment: Rontgen Thorax, ECG, Spirometry test
Teraphy: O2 4-5 lpm, Head up 30’, Nebulization combivent +
Flixotide, metylprednisolon inj 125mg, IVFD NaCL 0,9% 20tpm.
Monitoring :
vital sign, clinical symptoms, ABG (arterial blood gas)

22. Prognosis
 Quo ad Vitam : Dubia ad bonam
 Quo ad Functionam : Dubia ad bonam
 Quo ad Sanationam : Dubia ad bonam

26. The Refined ABC Assesment Tool
Global Initiative fot COPD
2017

27. Key Indicators for Considering Diagnosis of
COPD
Global Initiative fot COPD
2017

28. Etiologi, Pathobiologi & Pathologi COPD
Global Initiative fot COPD
2017

29. Differential diagnosis of COPD
Global Initiative fot COPD
2017

30. Classification of COPD by
Impairment of Lung Function
Global Initiative fot COPD
2017

31. Modified Medical Research Council
(mMRC) Dyspnea Scale
Global Initiative fot COPD
2017

32. COPD Assessment Test (CAT)
Global Initiative fot COPD
2017

33. EBMedicine.net

34. EBMedicine.net

35. EBMedicine.net

36. EBMedicine.net

38.  Thank You..