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Laporan Kasus PPOK
Laporan Kasus PPOK
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
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
Cor CTR<50%
Cor CTR<50%