CASE CLERKING

PART 1: PATIENTs HISTORYCHIEF COMPLAIN Patient claimed having piercing chest pain and radiating to shoulder and arm for x 3/7HISTORY 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 3/7PAST MEDICAL / SURGICAL HISTORY Patient was diagnosed with Pulmonary Tuberculosis on 2001 and claimed that he managed to finish his treatment and TCA. No history of any allergies on medication.FAMILY HISTORY Patient was the fifth child from eight siblings. Patient claimed that his elder brother was on Hypertension medication and currently received treatment from the nearest government clinic. Both parents still alive. Patient was married and having four children, all of his children reasonably healthy. Current residential is at Kampung Kelabakan.SOCIAL HISTORY Work as a farmer Working 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

2.1GENERAL

Patient was in pain. Alert

Not tachypnoeic not in respiratory distress.

No pallor and central cyanosis noted.

Good hydration.

Vital signs on arrival are:

GCS

: 15/15

Blood Pressure : 140/90 mmHg

Respiration Rate: 20 / minute

Pulse

: 80 / minute

SpO2

: 98% (room temperature)

Temperature

: 38 degree centigrade

2.2 PHYSICAL

2.2.1 HEAD Inspection

No swelling or bleeding noted.

Palpation

No swelling.

2.2.2 EYES

Inspection

No swelling.

No hematoma.

No blurring of vision.

Both pupils equal and react to light (BPEARL).

Palpation

No periorbital tenderness.

2.2.3 EARS

Inspection

No bleeding.

No discharged at both ears.

Tympanic membrane intact. Palpation

No tenderness and mass.

No hearing impairment.

2.2.4 NOSE

Inspection

Normal in shape

No bleeding / discharged

Palpation

No tenderness.

2.2.5 THROAT

Inspection

Not inflamed

Tonsil not enlarged / injected

No foreign body seen

2.2.6 MOUTH

Inspection

Normal in shape

No bleeding from gum

Not wearing dentures

Lips dry with central cyanosis

2.2.7 NECK

Inspection

No abnormality in shape

No swelling

No neck stiffness.

Trachea not deviated

Able to swallowed

Palpation

No tenderness

No mass palpable

No lymph node swelling

Carotid pulse palpable

2.2.8 RESPIRATORY SYSTEM

Inspection

No hematoma / bruises on chest.

Equal chest movement on inspiration and expiration.

Palpation

Trachea not deviated.

No displacement of mediastinum.

No vocal fremitus.

No tenderness on the chest.

Percussion

Normal resonance at both lungs.

Auscultation

Crepitation sound heard on left lung.

No ronchi.

2.2.9 CARDIOVASCULAR SYSTEM

Inspection

No surgical wound.

No abnormalities seen.

Palpation

Apex beat at 5th intercostals space midclavicular line.

Pulse (Radial):

80 beat per minute.

Regular beat.

Strong.

Percussion

Normal cardiac dullness.

Auscultation

Heart rate was 80 beat per minute, regular and strong.

Dual rhythm no murmur

2.2.10 ABDOMEN

Inspection

Scaphoid in shape.

No surgical scar seen.

Not distended.

No dilated vein seen.

No wound.

Palpation Non tender.

Abdomen soft

No hepatospleenomegaly felt.

Percussion

Normal resonance.

No fluid thrill.

Auscultation

Bowel sound present: 6 times per minute

No bruit sound heard.

2.2.11 GENITALIA

No abnormal noted.2.2.12 RECTUM

Physical examination not done.

2.2.13 PELVIC Inspection

Nothing abnormality noted.

Palpation

Nothing abnormality noted.2.2.14 UPPER EXTREMITIES (RIGHT AND LEFT) No deformity / abnormality seen.

Able to move both hands without restrictions.

Upper ExtremityRightLeft

Muscle ToneNormataniaNormatania

Muscle Power*

a. Shoulder

b. Elbow

c. Wrise5/55/5

Refleks**

a. Biseps

b. Triseps

c. Brachioradialis2+

2+

2+2+

2+

2+

Sensation TestIntactIntact

Table 2.1 Result Of Patients Muscle And Tendon Reflexes For Upper Extremities

2.2.15 LOWER EXTREMITIES (RIGHT AND LEFT) Right Leg & Left Leg

No deformity / abnormality detected.

No loss of sensation.

No pitting oedema.

Able to move right leg without restriction.

Capillary refill 2 seconds.

Posterior tibia artery and dorsalis pedis artery are palpable.Lower ExtremityRightLeft

Muscle ToneNormataniaNormatania

Muscle Power*

a. Hips5/55/5

Refleks**

b. Quadriceps

c. Angkle Jirk

d. Plantar Refleks++

++

++++

++

++

Sensation Test

IntactIntact

Table 2.2 Result Of Patients Muscle And Tendon Reflexes For Lower Extremitie

SCOREDESCRIPTION

5Normal power or muscle strenght in extremities

4Weak extremities, but patient can overcome resistance applied by examiner

3Patient can overcome gravity (can lift extremities) but cannot overcome resistance applied by examiner

2Weak muscle contraction, but not enough to overcome gravity (movement, but cannot lift extremities)

1Palpable or visible muscle flicker or twitch, but no movement

0No response to stimulus, complete paralysis

Table 2.3 Muscle Strength Scale*

SCOREDESCRIPTION

0Absent

1+Disminished

2+Normal

3+Increased, more brisk than average

4+Hyperactive, clonus

Table 2.4 Scale for deep tendon reflexes**

PART 3: SUMMARIES AND RELEVAN IMPORTANT FINDING

PART 4: DIAGNOSISDiagnosis : PneumoniaDifferential Diagnosis: Pulmonary Tuberculosis

Pulmonary Infection Congestive Heart Failure Pleurisis

BronchiolitisPART 5: BLOOD INVESTIGATION AND X-RAY FINDING

5.1BLOOD UREA SERUM ELECTROLITE (BUSE)

Blood Urea Nitrogen (BUN) To measure how well the kidneys are working. Urea is a nitrogen-containing waste product that's created when the body breaks down protein. If the kidneys are not working properly, the levels of BUN will build up in the blood. Dehydration and excessive bleeding can also elevate the BUN levels in the blood. Serum Electrolytes (SE)

Typically, tests for electrolytes measure levels of sodium, potassium, chloride, and bicarbonate in the body.

Sodium (NA) plays a major role in regulating the amount of water in 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. The sodium levels are measured to detect whether there's the right balance of sodium and liquid in the blood to carry out those functions.

If a child becomes dehydrated because of vomiting, diarrhoea, or inadequate 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.

Potassium (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. Low potassium levels are also associated with muscle weakness.

Chloride (CHLO), like sodium, helps maintain a balance of fluids in the body. If there's 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.

Creatinine (CREAT) levels in the blood that are too high can indicate that the kidneys aren't working properly. The kidneys filter and excrete creatinine; if they're not functioning properly, creatinine can build up in the bloodstream. Both dehydration and muscle damage also can raise creatinine levels.

Date :

14.4.2014BUSE

Test ResultunitNormal Range

NA138mmol/L135 -145

K3.3mmol/L3.3 5.1

CHLO99mmol/L98 107

UREA|4.1mmol/L1.7 8.3

CREAT75umol/L40 - 90

Table 5.1 Patients BUSE Result

Interpretation:

All results are within normal range.

5.2FULL BLOOD COUNT (FBC) A full blood count (FBC) is a very common clinical procedure and often the starting point for most medical investigations. An FBC not only tests for disorders and abnormalities of the blood but, as blood travels throughout the whole body, it can give an indication of disease present in other organs. Heamoglobin (Hb)

To determine any changes in patients heamoglobin such as low Hb so called aneamia that indicates blood loss (internal 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. This could be due to respiratory or circulatory disorders or, in some cases, to a tumour. Sometimes a high red blood cell count is due to dehydration.

Total White Cells (WBC)

To determine infection. Platlet (PLT)

To evaluate the anti-coagulation factor in the blood.

Date :

14/4/2014FULL BLOOD COUNT RESULT

Test ResultUnit Normal Range

WBC9.57103 / ul4.0 10

RBC5.05106 / ul4.04 6.13

HGB15.4g/dl12.2 18.1

PLT255103 / ul142 - 424

Table 5.2 Patients Full Blood Count Result Interpretation:

All results are within normal range.

.5.3: CHEST X-RAY

Chest 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. Chest radiographs are used to screen for job-related lung disease in industries such as mining where workers are exposed to dust.

5.4 SPUTUM FOR C&S

A sputum culture is a test to detect and identify bacteria or fungi that infect the lungs or breathing passages. Sputum is a thick fluid produced in the lungs and in the adjacent airways. A sample of sputum is placed in a sterile container and sent to the laboratory for testing.

PART 6: TREATMENT & PRIMARY EMERGENCY CARE

1. TRIAGING.

Triaging was done and patient was sent to yellow zone.

2. AIRWAY.

Airway not blocked. Patient can talk.3. BREATHING.

Patient can breathe poorly and suffering shortness of breath. Respiration: 25/minute.4. CIRCULATION.

Radial pulse present. 84 / minute.

Blood pressure: 130/80mmHg.

No obvious bleeding from the injury site or any part of the body.

5. DISABILITY.

No neurological deficit noted.6. EXPOSURE

No abnormalities noted.7. INVESTIGATIONS.

Blood and X-ray investigation was not done in Emergency and Trauma Department.8. MONITORING

Vital SignsResult

Blood pressure130/80 mmHg

Pulse 84/ minute

Temperature 37o C

Respiration 20 / minute

SpO2 98%

Vital signs

Table 7.1 Patients Vital Signs.

9. PLANNING.

Admission to Male Medical for further investigation and treatment plan.PART 7: WAD MANAGEMENT AND PATIENT PROGRESSIONS

DAY ONE @ 14.04.2014

1. GENERAL CONDITION

Patient well and alert.

Taking orally well.

Ambulating well.

2. PHYSICAL EXAMINATION:

Lungs :

Crepitation present on left lung.

CVS: DRNM

Abdomen:

Soft.

Non tender.

3. PROCEDURE

No procedure done.4. INVESTIGATION

Blood Full blood count

BUSE 5. MEDICATIONS

IV Cefuroxime given.

Tab Doxycyline 250mg TDS given.

6. MONITORING

Vital signs

Vital SignsResult

Blood pressure140/90 mmHg

Pulse 80/ minute

Temperature 37o C

Respiration 20 / minute

SpO2 100%

Table 8.3 Patients Vital Signs.7. PLANNING

Encourage orally.

To discuss with specialist for further planning.

DAY TWO @ 15.04.20141. GENERAL CONDITION

Patient stable and comfortable.

Taking orally well.

2. PHYSICAL EXAMINATION:

Lungs :

Crepitation noted CVS: DRNM

Abdomen:

Soft.

Non tender.

3. INVESTIGATION

Blood: Not done4. MEDICATIONS

Tab Doxycyline 250mg TDS PO IVD Normal Saline for hydration

5. MONITORING

Vital signs 4 hourlyVital SignsResult

Blood pressure130/80 mmHg

Pulse 86/ minute

Temperature 37o C

Respiration 18 / minute

SpO2 99%

Table 8.4 Patients Vital Signs.

DAY THREE @ 16.04.20141. GENERAL CONDITION

Patient stable and comfortable.

2. PHYSICAL EXAMINATION:

Lungs :

Crepitation less noted. CVS : DRNM

Abdomen:

Soft.

Non tender.

3. MEDICATIONS

Tab Doxycyline 250mg TDS PO IVD Normal Saline for hydration

4. MONITORING

Vital signs 4 hourlyVital SignsResult

Blood pressure100/70 mmHg

Pulse 80/ minute

Temperature 37o C

Respiration 18 / minute

SpO2 99%

Table 8.5 Patients Vital Signs.5. PLANNING

Allow orally.

To be seen by specialist for further treatment.PART 8: FINAL DIAGNOSIS

PNEUMONIA WITH COADPART 9: Health Education Given To The Patient

Maintain the healthy life style.

Avoid/stop smoking and consuming alcohol.

Doing simple exercise regularly.

Taking all the medication given by the doctor within the time ordered.

Attend the appointment TCA ordered by the doctor

Immediately come to hospital if there is complaint of severe pain along the healing progress.

Taking high fibre of meal and drink a lot water to prevent constipation.

LAPORAN REFLEKTIF:LAPORAN REFLEKTIF:(Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah diperolehi daripada pengkajian kes ini)

Pengurusan kes:Baik

Memuaskan

Lemah

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini:

Based on this case, I have learnt on various information regarding Pneumonia with COAD. I learnt on what is the clinical manifestation of Pneumonia, and all the investigation that has been made to confirmed the diagnosis. Besides that, from this case clerking, I managed to know on the treatment and management plan of the disease, including the drugs and medication given to the patient. I also managed to know on how to differentiate Pneumonia and other COAD related disease.

Other than that, during my Medical Ward posting, I have learnt many procedure which related to my field of study. Besides, I have been exposed on various of medical and surgical situation which is very useful for my futher study and work.

PATIENTS PERSONAL DETAILSNombor Pendaftaran:

8293

Nombor K/P:

-TIDAK PERLU-

Nama:

-TIDAK PERLU DIISI -

Jantina: Lelaki/ Perempuan* :

MALE

Bangsa:

SULUKPekerjaan:

FARMERUmur:

29 THN

Alamat:

-TIDAK PERLU-

No. Tel:

-TIDAK PERLU-

Hospital/Klinik:

HOSPITAL TAWAU

Tarikh:

MASUK WAD:

14-04-2014 @

10.00 AM

KELUAR WAD:

x

PAGE 18