PATIENT’S IDENTITY

Name : Mr. MS
Age : 73 years old
Sex : Male
Occupation :
Ethnic : Bataknese
Chief complaint : Shortness of breath
1. Respiratory disease
2. Cardiovascular disease
3. Metabolic disease
 Male, 73 years old, ex smoker, came to ED of USU
General Hospital with chief complaint shortness of
breath since 10 years ago and worsened since 3 months
ago. Shortness of breath persists the whole day.
Shortness of breath is not affected by weather.
Shortness of breath is affected by activity. Shortness of
breath is not associated with position changes. mMRC :
3.
 Orthopnea (-), DOE (-), Trepopnea (-), Platypnea (-),
Paroxysmal nocturnal dyspnea (-), history of shortness of
breath (+), wheezing (+), history of wheezing (+),
history of inhaler using (+).
 Cough (+), since 2 months ago sometimes with yellowish
sputum, volume 1 teaspoon, consistency mucoid, no
smell of sputum, the sputum can be removed
occasionally, history of cough (+), bloody cough (-),
history of bloody cough (-)
 Chest pain (+) 2 months ago
 Hoarseness (-), Swallowing difficulty (-), ankle
swelling (-), history of ankle swelling (-)
 Fever (-), history of fever (-), night sweating (+)
 Lost of apetite (+), weight loss (+)
 History of ATT (+)
 History of Diabetes Mellitus (-), hypertension
(-)
 History of Stroke (-)
 History of smoking (+)
 History of biomass exposure (-), history of
firewood exposure (-)
 History of inhaler (+) with ventolin,
symbicort turbuhaler, and spiriva hardihaler,
history of asthma (-), history of allergic (-)
 History of alcohol (-)
 History of cancer in the family (-)
 DIFFERENTIAL DIAGNOSIS BASED ON
HISTORY TAKING
1. Severe exacerbation COPD without Respiratory
failure
2. Asthma Attack
3. Pneumonia
4. Pulmonary TB
5. CHF
 Level of Consciousness : Alert
 BP : 140/90 mmHg
 Pulse : 126 x/I, regular, p/v enough, paradoxus
pulse (-)
 RR : 30 x/i, regular, used accessory muscles
(+), Cheyne-Stokes (-) , Kussmaul (-)
 Temp : 37,2 ºC axilla
 SpO2 : 99% room air without oxygen
 Pain :-
General Inspection
1. Head
Deformity :-
Face : Moon face (-), jaundice (-)
Eyes : Pale conjungtiva 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 accesory 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 ± 2 cm lateral LMCS
Lower : Diaphragm
Anterior Findings
Inspection Static: jaundice (-), barrel chest (-), no deformity, collatera
l vein (-),venectation (-)
Dynamic: Symmetric (No delayed movement)
Palpation - Trachea : medial
- Vocal fremitus right = left
- symmetrical chest expansion
- Subcatenoues emphysema (-)
Percussion Lung Resonance: sonor in both hemithorax
Liver border: absolute ICS VI

Auscultation - Breath sound: prolonged expiration

Additional sounds: late inspiratory coarse crackles (+/+),
wheezing (+/+) generalized, high pitch, monophonic
Vocal Resonance Egophony (-) Bronchophony (-) Whispered
pectoriloquiy (-)
4. Abdomen :
Liver/spleen/kidney : unpalpable
Ascites (-)
5. Hands : tofus (-), clubbing fingers (-), palmar eritema
(-), edema (-), nicotine staining (-), resting tremor (-), weakn
ess of the hand (-), cyanosis (-)
6. Limbs : tofus (-), pretibial oedema (-)
1. Severe Exacerbation COPD
2. Asthma Attack
3. Pneumonia
4. Pulmonary TB
5. Chronic Bronchitis
 Result Reference Range
Hb 12.0 g/dL 14-17 g/dL
WBC 13.48 x 103/µL 3.8-10.6 x 103/µL
RBC 4.49 x 106/µL 4.4-5.9 x 106/µL
Hematocrit 35.70 % 43-49 %
Thrombocyte 512 x 10³ /µL 150-440 x 10³/µL
Neutrophils absolut 16.77 x 103 /µL 2.7-6.5 x 10³/µL
Lymphocytes absolut 0.59 x 103 /µL 1.5-3.7 x 10³/µL
Monocytes absolut 1.60 x 103 /µL 0.2-0.4 x 10³/µL
Eosinophils absolut 0.20 x 103 /µL 0-0.10 x 10³/µL
Basophils absolut 0.35 x 103 /µL 0-0.1 x 10³/µL
B. Glucose 204 mg/dL < 200 mg/dL
Ureum/ creatinine 14.70 / 0.5 mg/dL <71 / 0.6-1.3 mg/dL
Na/K 131 / 4.21 mEq/L 135-155/3.5-5.0 mEq/L
Conclusion :
 Result Reference Range
pH 7.34 7.37 – 7.45
pCO2 37.0 mmHg 33 – 44 mmHg
pO2 100 mmHg 71 – 104 mmHg
Bicarbonat(HCO3) 20.9 mmol/L 22 – 29 mmol/L

BE -5.8 mmol/L (-2) – (+3) mmol/L

Saturasi O2 97 % 94 – 98
Conclusion
Position PA

Exposure of radiat Enough

ion
Trachea Medial
Clavicle symmetric, no fracture
Scapula No superposition on both hemith
orax
Bone Symmetric, no fracture, widene
d ICS
Lung - Cavity in the lower right hemit
horax
-Hyperinflation
-Flattened diaphragm
-Infiltrate at right paracardial

Cor CTR <50%

Costhophrenic Left : sharp

angle Right : sharp

Cardialphrenic Left : sharp

angle right : sharp
Diaphragma Lowered position
Right : dome shaped
Left : dome shaped
Position Lateral

Exposure of radiat Enough

ion
Trachea Medial
Clavicle symmetric, no fracture
Scapula No superposition on both hemith
orax
Bone Symmetric, no fracture, widene
d ICS
Lung - Cavity in the lower right hemit
horax
-Hyperinflation
-Flattened diaphragm
-Infiltrate at right paracardial

Cor CTR <50%

Costhophrenic Left : sharp

angle Right : sharp

Cardialphrenic Left : sharp

angle right : sharp
Diaphragma Lowered position
Right : dome shaped
Left : dome shaped
Position PA

Exposure of radiat Enough

ion
Trachea Medial
Clavicle symmetric, no fracture
Scapula No superposition on both
hemithorax
Bone Symmetric, no fracture
Lung - Cavity in the lower right hemit
horax
-Hyperinflation
-Flattened diaphragm
-Infiltrate at right paracardial

Cor CTR <50%

Costhophrenic Left : sharp

angle Right : sharp

Cardialphrenic Left : sharp

angle right : sharp
Diaphragma Lowered position
Right : dome shaped
Left : dome shaped
Position PA

Exposure of radiat Enough

ion
Trachea Medial
Clavicle symmetric, no fracture
Scapula No superposition on both
hemithorax
Bone Symmetric, no fracture
Lung - Cavity in the lower right hemit
horax
-Hyperinflation
-Flattened diaphragm
-Infiltrate at right paracardial

Cor CTR <50%

Costhophrenic Left : sharp

angle Right : sharp

Cardialphrenic Left : sharp

angle right : sharp
Diaphragma Lowered position
Right : dome shaped
Left : dome shaped
Position Lateral

Exposure of radiat Enough

ion
Trachea Medial
Clavicle symmetric, no fracture
Scapula No superposition on both hemith
orax
Bone Symmetric, no fracture
Lung - Cavity in the lower right hemit
horax
-Hyperinflation
-Flattened diaphragm
-Infiltrate at right paracardial

Cor CTR <50%

Costhophrenic Left : sharp

angle Right : sharp

Cardialphrenic Left : sharp

angle right : sharp
Diaphragma Lowered position
Right : dome shaped
Left : dome shaped
 Pre Bronchodilator : 200 ml

 Post Bronchodilator : 230 ml

 Reversibility:
 (Post Bronchodilator – Pre Bronchodilator)/
Pre Bronchodilator
 (230 ml – 200 ml)/200
 15 %
 AGE : 73 -10 : 63
 History of CVD :
 Total :
DIFFERENTIAL DIAGNOSE :
Severe Exacerbation COPD without Respiratory Failure
+ Pulmonary Tuberculosis in Treatment Category 1 +
Community Acquired Pneumonia
 Oxygen therapy : 2 liters per minute via nasal
canule
 IVFD NaCl 0,9% 20 drops per minute
 Nebulizer Combivat 2.5 / 20 minutes in 1 hour
 Inj Methylprednisolone 62,5 mg/ 8 hours
 Inj Ranitidine 50 mg/ 12 hours
 Oxygen therapy : 2 liters per minute via nasal
canule
 IVFD NaCl 0,9% 20 drops per minute
 Nebulizer Combivat 2.5 / 20 minutes in 1 hour
 Inj Methylprednisolone 62,5 mg/ 8 hours
 Inj Ranitidine 50 mg/ 12 hours
 Azithromycin tab1x500 mg PO
 N-Acetylsisteine caps 3x200mg PO
Spirometry
Sputum microbiologic, gram staining, culture and sensi
tivity test, Molecular rapid test
THANK YOU