CASE STUDY

BAHAGIAN 1

Nama Pelatih : Mohd Fadzrullah Bin

Razali @ Abdul Aziz

No Matrik : BPP 2006-3014

Tarikh : 11-02-2008

Wad : Medikal 4C

Hospital : Hospital Sultanah Bahiyah

BAHAGIAN 2 : BUTIR-BUTIR PERIBADI PESAKIT

No Pendaftaran : 24139

Nama : Shung Shing Chan

Bangsa : Cina

Pekerjaan : Peniaga

Alamat: 16 Taman Teratai, Jalan

Langgar. Alor Star.

Tarikh Masuk Hospital : 11-02-2008

Waktu : 10.30 a.m

No K/P : 1802011-71-5253

Umur : 90 tahun

Jantina : Lelaki

Agama : Buddha

Tarikh Keluar : 15-02-2008

Waktu : 12.00 p.m

Pengesahan Ketua Unit mengenai kesahihan butir-butir yang terkandung di Bahagian 2

Betul/Tidak betul.

Tandatangan : ……………………………………

Nama : ……………………………………………

Jawatan : …………………………………………

BAHAGIAN 3 : RIWAYAT PESAKIT

C/O :

Fever +Cough + SOB 3/7x and with productive yellowish + greenish sputum.

HOPI/ HISTORY OF PRESENT ILLNESS :

- Orthopnoea. Pesakit mengadu menjadi susah bernafas apabila baring..

- PND/ Paroksimal nocturnal dyspnoea. Pesakit juga tiba-tiba terkejut dari tidur

akibat mengalami SOB secara tiba-tiba

- Mild tachypnoea

- Orthopnoea

- Pallor

- fever

- No chest pain

- No vomit / nausea

PMH/ PAST MEDICAL HISTORY :

- Hx of Renal Impairment , Hx of IHD , Hx of COAD , Hx of Hypertension

PSH/ PAST SURGICAL HISTORY :

- Pesakit tidak pernah menjalani sebarang jenis pembedahan sebelum ini.

DRUG HISTORY :

- Tab ASA 150mg OD

- Tab Atorvastatin 20mg ON

- Tab Tidic 250mg BD

- Tab Amlodipine 5mg

- Tab Neulin 250mg OD

- Tab Bisoprolol

SOCIAL HISTORY :

- Merupakan perokok tetapi telah berhenti 30 tahun lepas

- Merupakan seorang perniaga barang-barang runcit

- Gemar melancong ke dalam Negara dan luar Negara.

- Megambil alcohol dan meminum arak akan tetapi didalam jumlah yang sedikit

sahaja.

- Tidak mengamalkan seks bebas

- Tidak mengambil dadah yang merbahaya ataupun ganja

FAMILY HISTORY :

Bapa pt:(hypertension) ibu pt: (unknown)

pesakit

- Bapa pesakit (meninggal dunia) menghidap hypertensi

- Ibu pesakit (meninggal dunia) sakit tua

♂ ♀

♀

♂

♀

♀

♂ ♀

BAHAGIAN 4 : PHYSICAL EXAMINATION

GENERAL EXAMINATION :

- Alert

- Conscious

- Pallor

- Mild tachypnoea

- Pesakit datang dengan SOB dan Cough productive

- Tanda-tanda vital : B/P : 121/63

PULSE : 91 b/pm

R/R : 24

TEMP : 38.4°c

CARDIOVASCULAR SYSTEM

- Inspection : pallor.

- Auscultation : DRNM, apex beat 90 per minute.

ABDOMEN EXAMINATION

- Inspection : normal

- Palpation : soft, mast, no tenderness

- Percussion : dullness at the both lungs

- Auscultation : bowel sound positive

Soft, no distended

·

RESPIRATORY SYSTEM

- inspection : Gasping for air

- Percussion : dullness at the both side

- Palpation : no tenderness

- auscultation : rhonci, creps

Creps, Rhonci

+ + + + + + + +

+ + + + + + + +

CXR Finding – Hyperinflated lungs, Razzines at lobe 2.

CENTRAL NERVES SYSTEM

- Inspection : pesakit alert (GCS 15/15)

- Sensory nerves : no abnormality detect

- Motor nerves : able to move

BAHAGIAN 7

Different Dianogsis : pneumonia tubercolosis

Diagnosis : Community Acquired Pneumonia

BAHAGIAN 8 : PENYIASATAN

1- CXR = Mengesan keabnormalan paru-paru, kesan keabnormalan jantung

2- BlOOD – FBC - Untuk mengesan sebarang jangkitan mikroorganisma

didalam darah pesakit

C&S - Mengesan jenis mikroorganisma dan jenis antibiotic

yang sesuai digunakan untuk pesakit

BUSE - Mengesan keseimbangan elektrolit didalam badan

pesakit

3- SPUTUM AFB - kesan infeksi

4- PHYSICAL EXAMINATION = Auscultation – Listen to the creps cause

From the pneumonia

Percussion – Dullness at the both side

Because the lungs are full

with the fluid (consolidation)

Palpation -

BAHAGIAN 9: SEBAB-SEBAB DIAGNOSIS

1) CXR shows the both of the lungs were infected and we can see the consolidation

causes from the pneumonia.

2) SPUTUM AFB show the sputum containing the microorganism the make the

infection. Chlamydia pneumonia

3) BLOOD FBC the result is the increase of white cell blood (leukositosis)

BAHAGIAN 10 : RAWATAN DAN JAGAAN KEJURURAWATAN

PUSAT KESIHATAN

HOSPITAL

- RIB pro up position

- Open vein for electrolyte and medication

- Drip N/S 24hrly

- O2 3ml/minutes

- Vital sign B/P, Temperature, R/R, Pulse 4hrly

- Monitor intake and output chart.

- Monitor SPO2 meter untuk memastikan kefungsian paru-paru

- Rawatan ubatan 1) antibiotic – cloxacillin sodium 500 mg Injection

- amoxicillin 500mg tds

- iv augmentin 1.2gm tds

2) Paracetamol 500mg tds

2) anti mucolytic – Bromhexine HCL 80mg tds

4) Nebs Combivent 6hrly akibat terdapat rhonci.

- Peak flow meter test menguji kekuatan paru-paru selepas pemberian nebs.

- Physiotherapy- chest physio

BAHAGIAN 11 : KEMAJUAN PESAKIT DI HOSPITAL

11-02-2008

- Pesakit SOB

- IVD 20N/S 24h

- RIB pro up position

- Nasal pronge O2, 3ml/minutes

- Serial ECG

- Vital sign taking 4hrly

- IV Augmentin 1.2gm TDS

- Cont old medicaton

- fever 38.0°c

- Rhonci, creps

- Orthopnoea

12-02-2008

- Comfortable

- RIB pro-up position

- Cont antibiotic

- Nebulizer combivent 6 hly

- Alert Concious

- SOB

- Mild weak

- CXR- basal opacity pneumonia

- Chest physio

- Cont old medication

- Temp 37.7°c

13-02-2008

- Cough last night (whitish,loose, small amount)

- unable to sleep

- No SOB

- Oksigen off

- alert, conscious

- No fever

- No rhonci

- basal creps

- cont antibiotic

14-02-2008

- Alert, conscious

- look comfortable, dieted well

- No fever 37.2°c

- Cough non productive

- Drip off

- No SOB

15-02-2008

BAHAGIAN 12 : TEORI MENGENAI DIAGNOSIS

COMMUNITY ACQUIRED PNEUMONIA

Community Acquired Pneumonia is a lower reperatory tract infection in nonhospitalized

person that is associated with symptoms of acute infection with or without new infiltrate

on chest radiography.

CAUSES

1- Bacteria -Chlamydia species

-Haemophilus influenzae

-Legionella species

-Moraxella catarrhalis

- Mycoplasma pneumoniae

-Staphylococcus aureus

-Streptococcus pneumoniae

2- virus -adenovirus

-Influenza A and B

-Parainfluenza

- Respiratory syncytial virus

3- fungus - Blastomycosis

-Coccidioidomycosis

-Histoplasmosis

4- parasite

RISK FACTOR

1- Umur yang melebihi 65 tahun

2- HIV

3- Asthma

4- CVA

5- COAD

6- Chronic renal failure

7- Diabetes Mellitus

8- Liver Diseasse

9- Neoplastic Diasesse

SYMPTOM-SYMPTOM

1- Cough with or without sputum

2- Fever greater than 38°c

3- Haemoptysis

4- Pleuritic cest pain

5- Dyspnea

6- Malaise, Fatigue

7- Rales, rhonci, wheezing

8- Dullness to percussion

9- LOA

10- Nausea

11- Arthragia

12- Myalgia

TARIKH PENYERAHAN/PENERIMAAN PENGKAJIAN KES:__________________

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