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7/27/2019 COPD Casepresentation
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TITTLE CASE : COPDGroup Puskesmas (Puskesmas Mergangsan)
Participant’s :
dr. Yulaika Kusuma Wardanidr.Tri Wahyuliati, SpS,M.Kes.
dr.Siti Kusdinariyalun H.
dr. Pramudi Darmawan W., M.Kes
dr. Sandra Kartika
Consultant :
dr. Sumardi, SpPD-KP
I. CASE
A. Patient’s Identity
Name : Mr. SS
Sex : Male
Age : 81 years old
Height : 159 cm
Weight : 42 kg
Marital status : widower
Occupation : toys vendor (in the past)
Address : Dalem, Rt 42 Rw 10 Purbayan KotagedeExamination date : 9 July 2010
B. Anamnesis
1. Chief complaint : Dyspnoe
2. Current History : Patient came to primary health care with
dyspnoe complaint along with cough for 3
days. Dyspnoe often recurrent if he gets cool
weather, exhausted, and inhales smoke.
Cough with white yellowish sputum occurred,
often slimy purulent. Patient complaints if hecan’t relieved in breathing.
3. Past History :Since 1964 patient has often experienced
dyspnoe and diagnosed as suffered from
asthma. In 2006, patient ever had outpatient
treatment in “BP Paru” with persistent dyspnoe
and cough (more than 3 months). At that time,
pulmonary x-ray result showed Chronical
Bronchitis. The patient smoked at the age of
16-56 years old. He usually smoked 2 packed /
day. After that, the patient decided to give upsmoking until this time, because of his
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condition that often suffered from dyspnoe and
cough.
4. Family Illness History : Mother had asthma (passed away)
Sister also had asthma (passed away)
5. Family Tree :
Mother had asthma (death: 55 years old)
Sister also had asthma (death: 71 years old)
Patient
6. System :
a. Cerebrospinal : Within normal limits
b. Cardiovascular : Within normal limits
c. Respiratory : Barrel Chest Shape, Pulmonary ronchi +/+
wheezing +/+, pulmonary vesicular is weaken
d. Gastrointestinal : Acute abdomen signs (-), within normal
limits
e. Urogenital : Within normal limits
f. Musculoskeletal : Within normal limits
g. Integument : Within normal limits
h. Lymph nodes : Enlargement of lymph nodes (-)
i. Eye : Cyanosis -/- Icteric sclera -/-
j. ENT : Inflammation / Infection signs (-)
C. Bio-Psycho-Social Background: The patient lives with children andgrandchildren, the wife was death, had 4
children and 4 grandchildren.
D. Socio-economic Background: Economical condition is middle and lower
class.
E. Environmental Background: Live in dense neighborhood.
F. Other Notes: -
G. Physical Examination
On July 9, 2010
1. General Appearance : compos mentis
2. Vital Signs : BP 110/80 mmHg RR 28/min
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HR 84/min Temperature 36,7 0C
3. Nutritional status :
Weight/Age : 159 cm
Height/Age : 42 kg
Head : Cyanosis -/- Icteric sclera -/-
Neck : JVP normal, enlargement of lymph nodes
(-)
Thorax : Barrel chest shape
Cardiac : Cardiac murmur -/-
Pulmonary : Pulmonary ronchi +/+ wheezing +/+, pulmonary
vesicular is weaken
Abdomen : within normal limits
Extremity : Oedema (-)
H. Adjunct Examinations
1. Blood testHb : -
WBC : -
L/M/N/B/E : 36/1/59/0/2
RBC : -
Platelet : -
Na : -
K : -
Cl : -
AST/SGOT : -
ALT/SGPT : -2. Urinalysis : -
3. Stool examination : -
4. X-ray : COPD pulmonary impression, cor is not large
5. Other examination : -
I. Diagnosis
Working Diagnosis : Chronic Obstructive Pulmonary Disease (COPD)
Differential Diagnosis : Chronic Bronchitis
Chronic Asthma
Emphysema
II. Therapy
1. Medication : at Primary Health Care
a. Pharmacology : Aminofilin 1 tab (if necessary)
Methylprednisolon 0-0-1
GG 3x1 tab
b. Non-pharmacology : suggestion for physiotherapy
2. Diet : High calories and proteins
III. Education
Avoid smocking and airpolution, prevent respiratory tract infection.
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IV. Monitoring
Pulmonary function test
Blood gas examination
V. Prognosis
Dubia ad bonam
VI. DISCUSSION
A. Self Raising Questions & Answers
1. Definitions of Chronic Obstructive Pulmonary Disease (COPD)?
COPD is a general term which covers many previously used clinical labels which
are now recognized as being different aspects of the same problem Diagnostic
labels encompassed by COPD include:
_ chronic bronchitis
_ emphysema
_ chronic obstructive airways disease
_ chronic airflow limitation
_ some cases of chronic asthma
COPD is a chronic, slowly progressive disorder characterized by airways
obstruction (FEV1 <80% predicted and FEV1/FVC ratio <70%) which does not
change markedly over several months The impairment of lung function is largely
fixed but is partially reversible by bronchodilator (or other) therapy. Most cases are
caused by tobacco smoking. COPD causes significantly more mortality and
morbidity than do other causes of airflow limitation in adults.
2. Diagnosis of COPD?The diagnosis is usually suggested by symptoms but can only established by
objective measurement, preferably using spirometry (see chart overleaf). Unlike
asthma, airflow limitation in COPD as measured by the FEV1 can never be
returned to normal values. However, treatment can improve both symptoms and
measured airflow limitation. The symptoms & signs vary with the severity of the
disease
3. Factors for consideration by the GP?
In managing COPD, the GP needs to consider
_ smoking cessation
_ screening in Well-person clinics for smokers, aged 40+ _ access to spirometry
_ hospital referral/follow-up
4. Indications for specialist referral
A specialist opinion may be helpful at any stage of disease. The principal reasons are
summarized in the table below:
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5. Scheme of Diagnosis and Management of COPD?
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B. Group Raising Questions
1. Q :
A :
Ref :
2. Q :
A :
Ref :
3. Q :
A :
Ref :
4. Q :
A :Ref :
5. Q :
A :
Ref :
C. Feedbacks and answers from clinical consultant
Consultant 1
1.
Ref:
Consultant 2
1.
Ref:
VII. REFLECTION and REVISIONLESSON LEARNT:
Primary Prevention:
1. Health Promotion
- Avoid the modifiable risk factors below
a. Smoking: The primary risk factor for COPD is chronic tobacco smoking. In the
United States, 80 to 90% of cases of COPD are due to smoking. Exposure to cigarette
smoke is measured in pack-years, the average number of packages of cigarettes
smoked daily multiplied by the number of years of smoking. The likelihood of
developing COPD increases with age and cumulative smoke exposure, and almost all
life-long smokers will develop COPD, provided that smoking-related, extrapulmonary
diseases (cardiovascular, diabetes, cancer) do not claim their lives beforehand
b. Occupational exposures
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Intense and prolonged exposure to workplace dusts found in coal mining, gold
mining, and the cotton textile industry and chemicals such as cadmium, isocyanates,
and fumes from welding have been implicated in the development of airflow
obstruction, even in nonsmokers. Workers who smoke and are exposed to these
particles and gases are even more likely to develop COPD. Intense silica dust
exposure causes silicosis, a restrictive lung disease distinct from COPD; however, lessintense silica dust exposures have been linked to a COPD-like condition. The effect of
occupational pollutants on the lungs appears to be substantially less important than the
effect of cigarette smoking.
c. Air pollution
Studies in many countries have found that people who live in large cities have a
higher rate of COPD compared to people who live in rural areas. Urban air pollution
may be a contributing factor for COPD as it is thought to slow the normal growth of
the lungs although the long-term research needed to confirm the link has not been
done. In many developing countries indoor air pollution from cooking fire smoke(often using biomass fuels such as wood and animal dung) is a common cause of
COPD, especially in women.
- Non Modifiable risk factor : Genetics
Some factor in addition to heavy smoke exposure is required for a person to develop
COPD. This factor is probably a genetic susceptibility. COPD is more common
among relatives of COPD patients who smoke than unrelated smokers. The genetic
differences that make some peoples' lungs susceptible to the effects of tobacco smoke
are mostly unknown. Alpha 1-antitrypsin deficiency is a genetic condition that is
responsible for about 2% of cases of COPD. In this condition, the body does not make
enough of a protein, alpha 1-antitrypsin. Alpha 1-antitrypsin protects the lungs from
damage caused by protease enzymes, such as elastase and trypsin, that can be released
as a result of an inflammatory response to tobacco smoke.
- Other risk factors
A tendency to sudden airway constriction in response to inhaled irritants, bronchial
hyperresponsiveness, is a characteristic of asthma. Many people with COPD also have
this tendency. In COPD, the presence of bronchial hyperresponsiveness predicts a
worse course of the disease. It is not known if bronchial hyperresponsiveness is acause or a consequence of COPD. Other risk factors such as repeated lung infection
and possibly a diet high in cured meats may be related to the development of COPD.
- Autoimmune disease
There is mounting evidence that there may be an autoimmune component to COPD.
Many individuals with COPD who have stopped smoking have active inflammation in
the lungs. The disease may continue to get worse for many years after stopping
smoking due to this ongoing inflammation. This sustained inflammation is thought to
be mediated by autoantibodies and autoreactive T cells.
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2. Specific Protection
- Smoking cessation
- Stop Occupational exposures : avoid the Intense and prolonged exposure to
workplace dusts found in coal mining, gold mining, and the cotton textile
industry and chemicals such as cadmium, isocyanates, and fumes fromwelding have been implicated in the development of airflow obstruction, even
in nonsmokers. Intense silica dust exposure causes silicosis, a restrictive lung
disease distinct from COPD; however, less intense silica dust exposures have
been linked to a COPD-like condition. The effect of occupational pollutants on
the lungs appears to be substantially less important than the effect of smoking.
- Stop Air pollution : In many developing countries indoor air pollution from
cooking fire smoke (often using biomass fuels such as wood and animal dung)
is a common cause of COPD, especially in women.
Secondary Prevention:1. Early Diagnosis & Prompt Treatment
Make Diagnosis: spirometry
In general, spirometry is preferred to peak expiratory flow recordings. If the latter are
used, serial recordings over one week are needed to confirm the absence of
variability. Many COPD patients show some degree of response to bronchodilators. A
chest x-ray excludes other pathologies but cannot positively diagnose COPD.
2. Disability Limitation
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- Pulmonary rehabilitation including out-patient based programmes have been
shown to improve exercise performance and reduce breathlessness.
- Depression should be identified and treated
- Non pharmacological : Exercise should be encouraged, Obesity or poor
nutrition both require treatment, Influenza vaccination is recommended
Tertiary Prevention: Rehabilitation
- Assess social circumstances
- Long term O2 therapy referral to respiratory specialist for measurement of
arterial blood gases. Prescribe only if PaO2 <7.3kPa