LAPORAN KASUS

Identitas Pasien
Nama : Tn. Endi
Ruang Perawatan : Arben
Usia : 56 Tahun

Anamnesis
Dilakukan tanggal 20 Mei 2021, secara autoanamnesis dengan pasien.
a. Keluhan Utama
Pasien datang dengan keluhan sesak 1 bulan SMRS
b. Riwayat Penyakit Sekarang
 8 tahun SMRS pasien bekerja sebagai petani jamur tiram, setiap hari
pasien terpapar asap kayu bakar untuk membuat uap sebagai media
jamur tiram, pasien terpapar asap dari jam 6 sore sampai jam 4 pagi
(sekitar 10 jam/hari) serta tidak pernah memakai masker.
 7 tahun SMRS pasien seering mengeluhkan batuk berdahak, namun
tidak pernah berobat.
 5 tahun SMRS pasien mengeluhkan batuk berdahak, dahak sulit
dikeluarkan, sesak nafas, sesak biasanya setelah beraktivitas,
berkurang setelah istirahat, dan terdapat keringat malam, berobat ke
dokter spesialis paru dan manjalani pengobatan TB selama 6 bulan.
Karena merasa gejala perbaikan, pasien tidak pernah kontrol kembali.
 4 tahun SMRS pasien berhenti bekerja sebagai petani jamur, karena
sering mengalami sesak nafas dan batuk.
 2 tahun SMRS pasien mengeluhkan sesak, batuk berdahak dan dirawat
4 hari di RSUD Sayang cianjur, setelah dirawat diberikan obat sesak
nafas namun menurut pasien tidak ada perbaikan pada gejala sesak
nafasnya.
 1 bulan SMRS pasien mengeluhkan keluhan yang sama berupa sesak
setelah aktivitas, berkurang setelah istirahat, sesak kadang disertai
dengan suara mengi, pasien tidur lebih nyaman menggunakan 2-3

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 bantal, tidak pernah terbangun karena sesak, batuk berdahak, tidak
disertai darah namun disertai keringat malam. Pasien juga
mengeluhkan adanya lesi kulit pada kedua betis kaki dan terasa gatal.
Keluhan mual, muntah, dan demam disangkal.
 1 hari SMRS , pasien merasa sesak yang sangat berat disertai batuk-
batuk yang tidak kunjung berhenti, ia merasa sesak yang dirasanya
lebih berat dari hari ke hari membuat pasien tidak bisa beraktivitas,
batuk berdahak, kadang dahak sulit dikeluarkan. Akhirnya pasien
dibawa oleh keluarganya ke IGD RSUD Sayang Cianjur.

c. Riwayat Penyakit Dahulu

 Riwayat pengobatan TB paru selama 6 bulan
 Riwayat Hipertensi (-), DM (-), asma (-) dan penyakit lain (-)
d. Riwayat Penyakit Keluarga
 5 tahun yang lalu terdapat keluarga yang mengalami TB paru
e. Riwayat Pengobatan
 Selama ini sering mengkonsumsi obat sesak
f. Riwayat Alergi
 Riwayat alergi disangkal.
g. Riwayat Psikososial
 Pasien merupakan kepala keluarga yang bekerja sebagai petani jamur
tiram, sering terpapar asap kayu bakar setiap hari selama 4 tahun,
namun sudah tidak bekerja sejak 4 tahun yang lalu.
 Riwayat merokok sejak kelas 2 SD, sekitar 1 bungkus/hari. (indeks
brickman??)
 Riwayat konsumsi alkohol dan NAPZA disangkal oleh pasien.
Pemeriksaan Fisik
a. Keadaan Umum : Pasien Tampak sakit sedang, tampak sesak serta
menggunakan nasal kanul
b. Kesadaran : Compos mentis, GCS E4M6V5
c. Tanda-Tanda Vital (TTV)
 Tekanan darah :

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  Nadi :
 Pernapasan :
 Suhu :
d. Status Generalis
 Kepala : normocephal, rambut tidak rontok
 Mata : pupil isokor, RCL/RCTL (+)/(+) kongjungtiva
anemis (-)/(-), sklera ikterik (-)/(-)
 Telinga : simetris, deformitas (-)/(-), sekret/darah (-)/(-),
membran timpani intak
 Hidung : deviasi septum (-)/(-), sekret (-)/(-), darah (-)/(-),
nafas cuping hidung (-)
 Mulut : sianosis (-), mukosa bibir kering, faring
hiperemis-
 Leher : pembesaran KGB (-), pembesaran tiroid (-), JVP
tidak meningkat
Pemeriksaan thorax
 Inspeksi : Barrel Chest (cari diameter antara anterior dan
posterior), pergerakan dinding dada simetris,
retraksi sela iga (-)/(-)
 Palpasi : vocal fremitus kanan dan kiri teraba simetris,
sela iga melebar?
 Perkusi : sonor di kedua lapang paru, batas paru hepar pada
ICS V dextra
 Auskultasi : vesikuler (+)/(+), rales (+)/(+), Ronki (+)/(+)
wheezing (-)/(-) dengerin lagi
Pemeriksaan jantung
 Inspeksi : ictus cordis tidak terlihat
 Palpasi : ictus cordis teraba di ICS V linea midclavicula
sinistra
 Auskultasi : BJ I-II reguler, murmur (-),gallop (-)
Pemeriksaan abdomen

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  Inspeksi : datar (+), supel, tidak ada bekas luka atau jahitan
 Auskultasi : bising usus (+) normal, berapa kali??
 Palpasi : Nyeri tekan epigastrium (-), hepatomegali (-)
spleenomegali (-)
 Perkusi : timpani (+) pada semua lapang abdomen

Ekstremitas
Ekstremitas Atas Bawah
Sianosis (-) (-)
Akral hangat hangat
CRT <2 detik (+) (+)
Edema (-) (-)
Status Dermatologis
Lokasi : kedua betis kaki
Efloresensi : makula hiperpigmentosa dengan ekskoriasi,
skuama dan likenifikasi.
Pemeriksaan Penunjang
a. Pemeriksaan hematologi lengkap
07/04/2021
Pemeriksaan Hasil Nilai Rujukan Satuan
Hemoglobin 12.6 12-16 g/dL
Hematokrit 39.7 37-47 %
Leukosit 8.2 4,8-10,8 10^3/L
Eritrosit 5.09 4,2-5,4 10^6/L
Trombosit 502 150-450 10^3/L
MCV 77.9 80-94 fl
MCH 24.7 27-31 pg
MCHC 31.7 33-37 %
KIMIA KLINIK
Glukosa Rapid 105 <180 mg/dL
Sewaktu
ELEKTROLIT
Natrium (Na) 136.4 135-148 mEq/L
Kalium (K) 3.71 3,5-5,3 mEq/L
Calcium (Ca) 1,17 1,15-1,29 mmol/L
08/04/2021
FUNGSI GINJAL
Ureum 11.3 10-50 mg%

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Kreatinin 0,7 0,5-1,0 mg%

b. Pemeriksaan Ro Thorax
Sinuses dan difragma berselubung
Pulmo:
Hilli normal
Corakan bronkovaskular normal
Tampak infiltrat disertai fibrosis di apeks sampai lapang tengah paru
bilateral
Tampak infiltrat di lapang bawah paru kiri
Skleletal dan soft tissue:
Dalam batas normal
Kesan:
- Bronkopneumona kiri
- Susp. Tb paru lama aktif
- Efusi pleura bilateral DD/penebalan pleura
Daftar Masalah
1. PPOK eksaserbasi akut derajat apa mang? dd/TB relaps, CHF
2. Dermatitis
Saran Pemeriksaan
 Spirometri
 Ro Thoraks
 EKG
 Gene Expert

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 ANALISIS KASUS
1. PPOK eksaserbasi akut derajat…… (SUMBER GUIDELINE GOLD)
a. Dasar diagnosis
Chronic Obstrucive Pulmonary Diasease is a common, preventable
and treatable disease that characterized by persistent respiratory
symptomp and airflow limitation that is due to airway and/ or alveolar
abnormalities usually caused by a significant exposure to noxious
particle or gases.

COPD should be considered in any patient who has dyspnea, chronic

cough or sputum production, and/or a history of exposure to risk factors
for the disease.

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 Spirometry is required to make the diagnosis in this clinical context;
the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the
presence of persistent airflow limitation and thus of COPD in patients with
appropriate symptoms and significant exposures to noxious stimuli.
Spirometry is the most reproducible and objective measurement of
airflow limitation. It is a noninvasive and readily available test. Despite its
good sensitivity, peak expiratory flow measurement alone cannot be
reliably used as the only diagnostic test because of its weak specificity

b. Diagnosis Banding

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c. Klasifikasi
The classification of airflow limitation severity in COPD uses
specific spirometric cut- points for purposes of simplicity. Spirometry
should be performed after the administration of an adequate dose of at
least one short-acting inhaled bronchodilator in order to minimize
variability.
It should be noted that there is only a weak correlation between
FEV1, symptoms and impairment of a patient’s health status. For this
reason, formal symptomatic assessment is required.

d. E
t
i
o
l
ogi
The most commmonly encountered risk factor for COPD is tobacco
smoking. The risk of developing COPD is related to the following factors:
 Tobacco smoke – cigarette smokers have a higher prevalence of
respiratory symptoms and lung function abnormalities, a greater
annual rate of decline in FEV1, and a greater COPD mortality rate than
non-smokers. Other types of tobacco (e.g., pipe, cigar, water pipe) and
marijuana are also risk factors for COPD, as well as environmental
tobacco smoke (ETS).
 Indoor air pollution – resulting from the burning of wood and other
biomass fuels used for cooking and heating in poorly vented
dwellings, is a risk factor that particularly affects women in
developing countries.
 Occupational exposures – including organic and inorganic dusts,
chemical agents and fumes, are under-appreciated risk factors for
COPD.

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  Outdoor air pollution – also contributes to the lungs’ total burden
of inhaled particles, although it appears to have a relatively small
effect in causing COPD.
 Genetic factors – such as severe hereditary deficiency of alpha-1
antitrypsin (AATD) ; the gene encoding matrix metalloproteinase 12
(MMP-12) and glutathione S-transferase have also been related to a
decline in lung function or risk of COPD.
 Age and sex – aging and female sex increase COPD risk.

 Lung growth and development – any factor that affects lung growth
during gestation and childhood (low birth weight, respiratory
infections, etc.) has the potential to increase an individual’s risk of
developing COPD.
 Socioeconomic status – Poverty is consistently associated with
airflow obstruction and lower socioeconomic status is associated with
an increased risk of developing COPD. It is not clear, however,
whether this pattern reflects exposures to indoor and outdoor air
pollutants, crowding, poor nutrition, infections, or other factors
related to low socioeconomic status.
 Asthma and airway hyper-reactivity – asthma may be a risk factor
for the development of airflow limitation and COPD.
 Chronic bronchitis – may increase the frequency of total and
severe exacerbations.
 Infections – a history of severe childhood respiratory infection has
been associated with reduced lung function and increased
respiratory symptoms in adulthood.

e. Target

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 The goals of COPD assessment are to determine the level of
airflow llimitation, its impact on the patient’s health status and the risk
of future events ( such exacerbation, hospital admissions or death), in
order to, eventually guide therapy. Tho achieve these goals, COPD
assessment must consider the following aspects of the disease
separately :
 The presence and severity of the spirometric abnormality
 Current nature and magnitude of the patients symptoms
 History of moderate and severe exacerbations
 Presence of comorbidities
An understanding of the impact of COPD on an individual patient
combines the symptomatic assessment with the patient’s spirometric
classification and/or risk of exacerbations. In the revised assessment
scheme, patients should undergo spirometry to determine the severity of
airflow limitation (i.e., spirometric grade). They should also undergo
assessment of either dyspnea using mMRC or symptoms using CAT.
Finally, their history of moderate and severe exacerbations (including
prior hospitalizations) should be recorded.

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 The number provides information regarding severity of airflow
limitation (spirometric grade 1 to 4) while the letter (groups A to D)
provides information regarding symptom burden and risk of
exacerbation which can be used to guide therapy.

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2. CHF

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