PART 1: PATIENTs 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 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
2.1
GENERAL

Patient was in pain. Alert

Not tachypnoeic not in respiratory distress.
No pallor and central cyanosis noted.
Good hydration.
Vital signs on arrival are:
o GCS
: 15/15
o Blood Pressure
: 140/90 mmHg
o Respiration Rate
: 20 / minute
o Pulse
: 80 / minute
o SpO2
: 98% (room temperature)
o Temperature
: 38 degree centigrade

2.2 PHYSICAL

2.2.1

2.2.2

2.2.3

HEAD
Inspection
o No swelling or bleeding noted.
Palpation
o No swelling.
EYES
Inspection
o No swelling.
o No hematoma.
o No blurring of vision.
o Both pupils equal and react to light (BPEARL).
Palpation
o No periorbital tenderness.
EARS
Inspection
o No bleeding.
o No discharged at both ears.
o Tympanic membrane intact.
Palpation
o No tenderness and mass.
No hearing impairment.

2.2.4

NOSE
Inspection
o Normal in shape
o No bleeding / discharged
Palpation
o No tenderness.

2.2.5

THROAT
Inspection
o Not inflamed
o Tonsil not enlarged / injected
o No foreign body seen

2.2.6

MOUTH
Inspection
o Normal in shape
o No bleeding from gum
o Not wearing dentures
o Lips dry with central cyanosis

2.2.7

NECK
Inspection
o No abnormality in shape
o No swelling
o No neck stiffness.
o Trachea not deviated
o Able to swallowed

2.2.8

Palpation
o No tenderness
o No mass palpable
o No lymph node swelling
o Carotid pulse palpable

RESPIRATORY SYSTEM

Inspection
o No hematoma / bruises on chest.
o Equal chest movement on inspiration and expiration.
Palpation
o Trachea not deviated.
o No displacement of mediastinum.
o No vocal fremitus.
o No tenderness on the chest.
Percussion

2.2.9

o Normal resonance at both lungs.

Auscultation
o Crepitation sound heard on left lung.
o No ronchi.

CARDIOVASCULAR SYSTEM
Inspection
o No surgical wound.
o No abnormalities seen.

Palpation
o Apex beat at 5th intercostals space midclavicular line.
o Pulse (Radial):
80 beat per minute.
Regular beat.
Strong.
Percussion
o Normal cardiac dullness.
Auscultation
o Heart rate was 80 beat per minute, regular and strong.
o Dual rhythm no murmur
2.2.10 ABDOMEN
Inspection

o Scaphoid in shape.
o No surgical scar seen.
o Not distended.
o No dilated vein seen.
o No wound.
Palpation
o Non tender.
o Abdomen soft
o No hepatospleenomegaly felt.

Percussion
o Normal resonance.
o No fluid thrill.
Auscultation
o Bowel sound present: 6 times per minute
o No bruit sound heard.

2.2.11 GENITALIA
o No abnormal noted.
2.2.12 RECTUM
o Physical examination not done.
4

2.2.13 PELVIC
Inspection
o Nothing abnormality noted.
Palpation
o Nothing abnormality noted.

2.2.14 UPPER EXTREMITIES (RIGHT AND LEFT)

o No deformity / abnormality seen.
o Able to move both hands without restrictions.
Upper Extremity

Right

Left

Muscle Tone
Normatania
Normatania
Muscle Power*
a. Shoulder
5/5
5/5
b. Elbow
c. Wrise
Refleks**
a. Biseps
2+
2+
b. Triseps
2+
2+
c. Brachioradialis
2+
2+
Sensation Test
Intact
Intact
Table 2.1 Result Of Patients Muscle And Tendon Reflexes For Upper Extremities

2.2.15 LOWER EXTREMITIES (RIGHT AND LEFT)

o 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 Extremity
Muscle Tone
Muscle Power*
a. Hips
Refleks**
b. Quadriceps
c. Angkle Jirk
d. Plantar Refleks
Sensation Test

Right
Normatania

Left
Normatania

5/5

5/5

++
++
++
Intact

++
++
++
Intact
5

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

SCORE
5
4
3

DESCRIPTION
Normal power or muscle strenght in extremities
Weak extremities, but patient can overcome resistance applied by examiner
Patient can overcome gravity (can lift extremities) but cannot overcome
resistance applied by examiner
2
Weak muscle contraction, but not enough to overcome gravity (movement, but
cannot lift extremities)
1
Palpable or visible muscle flicker or twitch, but no movement
0
No response to stimulus, complete paralysis
Table 2.3 Muscle Strength Scale*

SCORE
DESCRIPTION
0
Absent
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: DIAGNOSIS
Diagnosis :

Pneumonia

Differential Diagnosis:

Pulmonary Tuberculosis

Pulmonary Infection

Congestive Heart Failure

Pleurisis

Bronchiolitis

PART 5: BLOOD INVESTIGATION AND X-RAY FINDING

5.1

BLOOD UREA SERUM ELECTROLITE (BUSE)

7

Blood Urea Nitrogen (BUN)

o To measure how well the kidneys are working. Urea is a nitrogencontaining 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)

o Typically, tests for electrolytes measure levels of sodium, potassium,
chloride, and bicarbonate in the body.
o 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.
o 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.
o 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.
o 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.
o Creatinine (CREAT) levels in the blood that are too high can
indicate that the kidneys aren't working properly. The kidneys filter
8

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 :
14.4.2014
Test
NA
K
CHLO
UREA|
CREAT

5.2

BUSE
Result
unit
138
mmol/L
3.3
mmol/L
99
mmol/L
4.1
mmol/L
75
umol/L
Table 5.1 Patients BUSE Result

Normal Range
135 -145
3.3 5.1
98 107
1.7 8.3
40 - 90

Interpretation:
o All results are within normal range.
FULL 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)
o 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)

o To determine infection.

Platlet (PLT)
o To evaluate the anti-coagulation factor in the blood.

Date :
14/4/2014
Test
WBC
RBC
HGB
PLT

FULL BLOOD COUNT RESULT

Result
Unit
Normal Range
3
9.57
10 / ul
4.0 10
5.05
106 / ul
4.04 6.13
15.4
g/dl
12.2 18.1
255
103 / ul
142 - 424
Table 5.2 Patients Full Blood Count Result

Interpretation:
o 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.

10

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 signs
Vital Signs

Result

Blood pressure

130/80 mmHg

Pulse

84/ minute

Temperature
Respiration

37o C
20 / minute

SpO2

Table 7.1 Patients Vital Signs.

98%

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
o Full blood count
o BUSE
5. MEDICATIONS
11

IV Cefuroxime given.
Tab Doxycyline 250mg TDS given.

6. MONITORING
Vital signs
Vital Signs

Result

Blood pressure

140/90 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 @ 15.04.2014
1. 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 done
4. MEDICATIONS
Tab Doxycyline 250mg TDS PO
IVD Normal Saline for hydration
5. MONITORING
Vital signs 4 hourly
Vital Signs

Result

Blood pressure

130/80 mmHg

Pulse

86/ minute

Temperature

37o C

Respiration

18 / minute

SpO2

99%

Table 8.4 Patients Vital Signs.

DAY THREE @ 16.04.2014

12

1. GENERAL CONDITION
Patient stable and comfortable.
2. PHYSICAL EXAMINATION:
Lungs :
Crepitation less noted.
CVS : DRNM
Abdomen:
Soft.
Non tender.
3. MEDICATIONS
o Tab Doxycyline 250mg TDS PO
o IVD Normal Saline for hydration
4. MONITORING
Vital signs 4 hourly
Vital Signs

Result

Blood pressure

100/70 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 COAD
PART 9: Health Education Given To The Patient
-

Maintain the healthy life style.

Avoid/stop smoking and consuming alcohol.

Doing simple exercise regularly.

13

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

x
14

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 DETAILS

Nombor Pendaftaran:

Nombor K/P:

8293

-TIDAK PERLU-

Nama:
-TIDAK PERLU DIISI -

15

Jantina: Lelaki/
Perempuan* :
MALE

Bangsa:
SULUK

Pekerjaan:
FARMER

Umur:
29 THN

Alamat:

No. Tel:

-TIDAK PERLU-

-TIDAK PERLU-

Hospital/Klinik:

Tarikh:

HOSPITAL TAWAU

MASUK WAD:
14-04-2014 @
10.00 AM
KELUAR WAD:

16