PART 1: PATIENT’s HISTORY CHIEF COMPLAIN
•
Patient claimed having piercing chest pain and radiating to shoulder and arm for x 3/7
HISTORY OF PRESENT ILLNESS •
Patient claimed that he was having piercing chest pain which radiating to his lower back, shoulder and upper arm for x 3/7
•
According to patiend, he was having shortness of breath and getting worst when he cough for x 3/7
•
Patient claimed that whenever he coughed, he was having thick cough and his sputum contain blood stain for x 3/7
•
Patient claimed that he was having vomiting and dizziness for x 3/7
•
Patient claimed that he was dehydrated and having feverish symptom for x 3/7
PAST MEDICAL / SURGICAL HISTORY •
•
Patient was diagnosed with Pulmonary uberculosis on !""# and claimed that he managed to finish his treatment and $A% &o history of any allergies on medication%
FAMILY HISTORY HIST ORY
•
Patient was the fifth child from eight siblings%
•
Patient claimed that his elder brother was on 'ypertension medication and currently received treatment from the nearest government clinic%
•
(oth parents still alive%
•
Patient was married and having four children, all of his children reasonably healthy%
•
$urrent residential is at )ampung )elabakan%
SOCIAL HISTORY
#
•
*ork as a farmer
•
*orking at his own farm at village%
•
Patient was a heavy smoker and claimed that usually he manage to finish a box of cigarettes per day%
PHYSICAL EXAMINATION 2.1 GENERAL • • • • •
Patient was in pain% Alert &ot tachypnoeic not in respiratory distress% &o pallor and central cyanosis noted% +ood hydration% ital signs on arrival areo +$. - #/# o (lood Pressure - #0"/1" mm'g o 2espiration 2ate - !" / minute Pulse - " / minute o .p4! - 15 6room temperature o o emperature - 3 degree centigrade
PHYSICAL !%!%# HEAD 8nspection o &o swelling or bleeding noted% Palpation o &o swelling% !%!%! EYES 8nspection o &o swelling% o &o hematoma% o &o blurring of vision% (oth pupils e9ual and react to light 6(P:A2;% o Palpation o &o periorbital tenderness% 2.2
!%!%3
EARS
8nspection o &o bleeding% o &o discharged at both ears% o ympanic membrane intact% Palpation o &o tenderness and mass% &o hearing impairment%
!
!%!%0
NOSE 8nspection o &ormal in shape o &o bleeding / discharged Palpation o &o tenderness%
!%!%
THROAT 8nspection o &ot inflamed o onsil not enlarged / in
!%!%=
MOUTH 8nspection o &ormal in shape o &o bleeding from gum o &ot wearing dentures o ;ips dry with central cyanosis
!%!%7
NECK 8nspection o &o abnormality in shape o &o swelling o &o neck stiffness% o rachea not deviated Able to swallowed o
!%!%
Palpation o &o tenderness o &o mass palpable o &o lymph node swelling o $arotid pulse palpable
RESPIRATORY SYSTEM
8nspection &o hematoma / bruises on chest% o :9ual chest movement on inspiration and expiration% Palpation rachea not deviated% o o &o displacement of mediastinum% o &o vocal fremitus% o &o tenderness on the chest% Percussion o
3
&ormal resonance at both lungs% Auscultation $repitation sound heard on left lung% o o &o ronchi% o
!%!%1
CARDIOVASCULAR SYSTEM 8nspection o &o surgical wound% o &o abnormalities seen%
Palpation o Apex beat at th intercostals space midclavicular line% o Pulse 62adial " beat per minute% 2egular beat% .trong% Percussion o &ormal cardiac dullness% Auscultation 'eart rate was " beat per minute, regular and strong% o o >ual rhythm no murmur !%!%#" ABDOMEN 8nspection .caphoid in shape% o &o surgical scar seen% o &ot distended% o &o dilated vein seen% o &o wound% Palpation o &on tender% o Abdomen soft o &o hepatospleenomegaly felt% o
Percussion o &ormal resonance% o &o fluid thrill% Auscultation o (owel sound present- = times per minute o &o bruit sound heard%
!%!%## GENITALIA &o abnormal noted% o !%!%#! RECTUM o
Physical examination not done%
0
!%!%#3 PELVIC 8nspection o &othing abnormality noted% Palpation o &othing abnormality noted%
!%!%#0 UPPER EXTREMITIES (RIGHT AND LEFT o &o deformity / abnormality seen% Able to move both hands without restrictions% o U!!"# E$%#"&'%
R')*%
L"+%
?uscle one &ormatania &ormatania ?uscle Power@ a% .houlder / / b% :lbow c% *rise 2efleks@@ a% (iseps ! ! b% riseps ! ! c% (rachioradialis ! ! .ensation est 8ntact 8ntact able !%# Result Of Patient’s Muscle And Tendon Reflexes For Upper Extremities
!%!%# LO,ER EXTREMITIES (RIGHT AND LEFT 2ight ;eg B ;eft ;eg o &o deformity / abnormality detected% &o loss of sensation% &o pitting oedema% Able to move right leg without restriction% $apillary refill ! seconds% Posterior tibia artery and dorsalis pedis artery are palpable%
L-"# E$%#"&'% ?uscle one ?uscle Power@ a% 'ips 2efleks@@ b% Cuadriceps c% Angkle Dirk d% Plantar 2efleks .ensation est
R')*% &ormatania
L"+% &ormatania
/
/
8ntact
8ntact
able !%! Result Of Patient’s Muscle And Tendon Reflexes For Lower Extremitie
SCORE 0 3
DESCRIPTION &ormal power or muscle strenght in extremities *eak extremities, but patient can overcome resistance applied by examiner Patient can overcome gravity 6can lift extremities but cannot overcome resistance applied by examiner ! *eak muscle contraction, but not enough to overcome gravity 6movement, but cannot lift extremities # Palpable or visible muscle flicker or twitch, but no movement " &o response to stimulus, complete paralysis able !%3 Muscle Strengt Scale!
SCORE DESCRIPTION " Absent # >isminished ! &ormal 3 8ncreased, more brisk than average 0 'yperactive, clonus able !%0 Scale for deep tendon reflexes!!
PART : SUMMARIES AND RELEVAN IMPORTANT FINDING
=
PART 0: DIAGNOSIS
>iagnosis •
Pneumonia
>ifferential >iagnosis•
Pulmonary uberculosis
•
Pulmonary 8nfection
•
$ongestive 'eart Eailure
•
Pleurisis
•
(ronchiolitis
PART : BLOOD INVESTIGATION AND XRAY FINDING .1
BLOOD UREA SERUM ELECTROLITE (BUSE
7
B3--4 U#"5 N'%#-)"6 (BUN o o measure how well the kidneys are working% Frea is a nitrogenG
containing waste product thatHs created when the body breaks down protein% 8f the kidneys are not working properly, the levels of (F& will build up in the blood% >ehydration and excessive bleeding can also elevate the (F& levels in the blood%
S"#7& E3"8%#-3%"s (SE ypically, tests for electrolytes measure levels of sodium, potassium, o
chloride, and bicarbonate in the body% o
S-4'7& (NA plays a ma
the body% Also, the passage of sodium in and out of cells is necessary for many body functions, like transmitting electrical signals in the brain and in the muscles% he sodium levels are measured to detect whether thereHs the right balance of sodium and li9uid in the blood to carry out those functions%
o
8f a child becomes dehydrated because of vomiting, diarrhoea, or inade9uate fluid intake, the sodium levels can be abnormally high or low, which can cause a child to feel confused, weak, and lethargic, and even to have seizures%
o
P-%5ss'7& (K is essential to regulate how the heart beats% Potassium
levels that are too high or too low can increase the risk of an abnormal heartbeat% ;ow potassium levels are also associated with muscle weakness%
o
C*3-#'4" (CHLO, like sodium, helps maintain a balance of fluids in
the body% 8f thereHs a large loss of chloride, the blood may become more acidic and prevent certain chemical reactions from occurring in the body that are necessary it to keep working properly% o
C#"5%'6'6" (CREAT levels in the blood that are too high can
indicate that the kidneys arenHt working properly% he kidneys filter
and excrete creatinineI if theyHre not functioning properly, creatinine can build up in the bloodstream% (oth dehydration and muscle damage also can raise creatinine levels%
>ate #0%0%!"#0 T"s% &A ) $';4 F2:AK $2:A
•
.2
R"s73%
BUSE 76'%
N-#&53 R56)"
#3 mmol/; 3%3 mmol/; 11 mmol/; 0%# mmol/; 7 umol/; able %# Patient’s "USE Result
#3 G#0 3%3 J %# 1 J #"7 #%7 J %3 0" G 1"
8nterpretationAll results are within normal range% o
FULL BLOOD COUNT (FBC
A +733 93--4 8-76% (FBC is a very common clinical procedure and often the Lstarting pointM for most medical investigations% An E($ not only tests for disorders and 596-#&53'%'"s -+ %*" 93--4 but, as blood travels throughout the whole body, it can give an indication of disease present in other organs%
H"5&-)3-9'6 (H9 o o determine any changes in patientNs heamoglobin such as low 'b so
called aneamia that indicates blood loss 6internal or external and Polycythaemia which is associated with an abnormally high haemoglobin concentration in the blood, and is an indication that red blood cell numbers are also too high% his could be due to respiratory or circulatory disorders or, in some cases, to a tumour% .ometimes a high red blood cell count is due to dehydration%
T-%53 ,*'%" C"33s (,BC o o determine infection%
P35%3"% (PLT o o evaluate the antiGcoagulation factor in the blood%
1
>ate #0/0/!"#0 T"s%
FULL BLOOD COUNT RESULT R"s73% U6'% N-#&53 R56)"
1%7 #"3 / ul %" #"= / ul #%0 g/dl ! #"3 / ul able %! Patient’s Full "lood #ount Result
*($ 2($ '+( P; •
0%" J #" 0%"0 J =%#3 #!%! J #%# #0! G 0!0
8nterpretationAll results are within normal range% o
%
.: CHEST XRAY
$hest radiographs are used to diagnose many conditions involving the chest wall, including its bones, and also structures contained within the thoracic cavity including the lungs, heart, and great vessels% Pneumonia and congestive heart failure are very commonly diagnosed by chest radiograph% $hest radiographs are used to screen for
such as mining where workers are exposed to dust% .0 SPUTUM FOR CS A sputum culture is a test to detect and identify bacteria or fungi that infect the lungs or breathing passages% .putum is a thick fluid produced in the lungs and in the ad
PART ;: TREATMENT PRIMARY EMERGENCY CARE 1. TRIAGING.
riaging was done and patient was sent to yellow zone% 2. AIR,AY. Airway not blocked% Patient can talk% . BREATHING. Patient can breathe poorly and suffering shortness of breath% 2espiration- !/minute% 0. CIRCULATION. 2adial pulse present% 0 / minute% (lood pressure- #3"/"mm'g% &o obvious bleeding from the in
#"
. DISABILITY. &o neurological deficit noted% ;. EXPOSURE &o abnormalities noted% <. INVESTIGATIONS. (lood and OGray investigation was not done in :mergency and rauma
>epartment%
=. MONITORING ital signs V'%53 S')6s
R"s73%
B3--4 !#"ss7#"
#3"/" mm'g
P73s"
0/ minute
T"&!"#5%7#" R"s!'#5%'-6
37o $ !" / minute
able 7%# Patient’s $ital Signs%
15
S!O2
>. PLANNING. Admission to ?ale ?edical for further investigation and treatment plan%
PART <: ,AD MANAGEMENT AND PATIENT PROGRESSIONS
DAY ONE ? [email protected]@10 1. GENERAL CONDITION Patient well and alert% • aking orally well% • Ambulating well% • 2. PHYSICAL EXAMINATION;ungs • $repitation present on left lung% $.- >2&? • Abdomen• .oft% &on tender% . PROCEDURE &o procedure done% • 0. INVESTIGATION (lood • Eull blood count o (F.: o . MEDICATIONS
##
8 $efuroxime given% ab >oxycyline !"mg >. given%
• •
;. MONITORING • V'%53 s')6s V'%53 S')6s
R"s73%
B3--4 !#"ss7#"
#0"/1" mm'g "/ minute
P73s"
able %3 Patient’s $ital Signs%
37o $
T"&!"#5%7#"
!" / minute
R"s!'#5%'-6
#""5
S!O2
<. PLANNING :ncourage orally% • o discuss with •
specialist for further planning%
DAY T,O ? 1[email protected]@10 1. GENERAL CONDITION Patient stable and comfortable% • aking orally well% • 2. PHYSICAL EXAMINATION;ungs • $repitation noted $.- >2&? • Abdomen• .oft% &on tender% . INVESTIGATION (lood- &ot done • 0. MEDICATIONS ab >oxycyline !"mg >. P4 • 8> &ormal .aline for hydration • . MONITORING • V'%53 s')6s 0 *-7#3 V'%53 S')6s
R"s73%
B3--4 !#"ss7#"
#3"/" mm'g
P73s" T"&!"#5%7#" R"s!'#5%'-6 S!O2
=/ minute 37o $
able %0 Patient’s $ital Signs%
DAY THREE ? 1;[email protected]@10
# / minute 115
#!
1. GENERAL CONDITION Patient stable and comfortable% • 2. PHYSICAL EXAMINATION;ungs • $repitation less noted% $. - >2&? • Abdomen• .oft% &on tender% . MEDICATIONS
ab >oxycyline !"mg >. P4 8> &ormal .aline for hydration
o o
0. MONITORING • V'%53 s')6s 0 *-7#3 V'%53 S')6s
R"s73%
B3--4 !#"ss7#"
#""/7" mm'g "/ minute
P73s" T"&!"#5%7#" R"s!'#5%'-6
37o $ # / minute 115
S!O2
able % Patient’s $ital Signs%
. PLANNING Allow orally% • o be seen by specialist for further treatment% •
PART =: FINAL DIAGNOSIS PNEUMONIA ,ITH COAD
PART >: H"53%* E4785%'-6 G'"6 T- T*" P5%'"6%
G
?aintain the healthy life style%
G
Avoid/stop smoking and consuming alcohol%
G
>oing simple exercise regularly%
#3
G
aking all the medication given by the doctor within the time ordered%
G
Attend the appointment $A ordered by the doctor
G
8mmediately come to hospital if there is complaint of severe pain along the healing progress%
G
aking high fibre of meal and drink a lot water to prevent constipation%
LAPORAN REFLEKTIF:
LAPORAN REFLEKTIF:
6(erikan komen mengenai pembela
Pengurusan kes-
(aik
x
#0
?emuaskan
;emah
2efleksi pembela
(ased on this case, 8 have learnt on various information regarding Pneumonia with $4A>% 8 learnt on what is the clinical manifestation of Pneumonia, and all the investigation that has been made to confirmed the diagnosis% (esides that, from this case clerking, 8 managed to know on the treatment and management plan of the disease, including the drugs and medication given to the patient% 8 also managed to know on how to differentiate Pneumonia and other $4A> related disease% 4ther than that, during my ?edical *ard posting, 8 have learnt many procedure which related to my field of study% (esides, 8 have been exposed on various of medical and surgical situation which is very useful for my futher study and work%
PATIENT’S PERSONAL DETAILS
Nombor Pendaftaran:
Nombor K/P:
8293
-TIDAK PERLU-
Nama: -TIDAK PERLU DIISI -
#
Jantna: Le!a"/ Perem#$an% : &ALE
'an()a: SULUK
Pe"er*aan: +AR&ER
Um$r: 29 T,N
A!amat:
No Te!:
-TIDAK PERLU-
-TIDAK PERLU-
,o)#ta!/K!n":
Tar"0:
,.SPITAL TAAU
&ASUK AD: 1--21 4 1 A& KELUAR AD:
#=
