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  • Coughing Continuously Accompanied by Green Phlegm Patient Sleeps Comfortably With 2 Pillows The Habit of Smoking 3 Packs A Day Has Been 40 Years

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    A 66-year-old male patient presented with shortness of breath for two days that worsened with movement along with cough and green phlegm. He has a history of smoking three packs per day for 40 years. On examination, he had tachypnea, tachycardia and low blood pressure. Chest x-ray and labs showed signs of pneumonia and anemia. He was diagnosed with PPOK exacerbation, asthma, and tuberculosis of the lungs. Treatment included antibiotics, steroids, bronchodilators, and monitoring.

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    A 66-year-old male patient presented with shortness of breath for two days that worsened with movement along with cough and green phlegm. He has a history of smoking three packs per day for 40 years. On examination, he had tachypnea, tachycardia and low blood pressure. Chest x-ray and labs showed signs of pneumonia and anemia. He was diagnosed with PPOK exacerbation, asthma, and tuberculosis of the lungs. Treatment included antibiotics, steroids, bronchodilators, and monitoring.

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    © All Rights Reserved
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    5 просмотров3 страницы

    Coughing Continuously Accompanied by Green Phlegm Patient Sleeps Comfortably With 2 Pillows The Habit of Smoking 3 Packs A Day Has Been 40 Years

    Загружено:

    S WVLOG
    A 66-year-old male patient presented with shortness of breath for two days that worsened with movement along with cough and green phlegm. He has a history of smoking three packs per day for 40 years. On examination, he had tachypnea, tachycardia and low blood pressure. Chest x-ray and labs showed signs of pneumonia and anemia. He was diagnosed with PPOK exacerbation, asthma, and tuberculosis of the lungs. Treatment included antibiotics, steroids, bronchodilators, and monitoring.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 3

    Tn.

    Nardjo, 66 years old

    Jakarta

    Cc : PPOK

    Findings Assesment Therapy Planning


     Shortness of breath  PPOK acute  Levofloxacin  Foto
    continuously 2 days exertion 1x30mg thorax
    before being  Asma  Methylprednisolo  EKG
    hospitalized  Tb paru n 2x6,5mg iv  H2TL
     Shortness of breath  Rantidine 2x1 iv  02kan
    gets heavier when  Acetylsisein ul
    you move 3x200mg po 3lpm
     coughing  Bronsolvan 3x1
    continuously po
    accompanied by  Inhalasi :
    green phlegm Ventoline 3x1
     patient sleeps Pulmicort 2x1
    comfortably with 2 Combivent 3x1
    pillows
     the habit of
    smoking 3 packs a
    day has been 40
    years

     Physical Examination  Lab result :


    : o Hb :
    o GCS : E4 V5 12,1g/d
    M6 l (L)
    o Composment o Ht :
    is 34,6 %
    (L)
    o Ur :
    90mg/
    dL (H)
    o Cr :
    1,94
    mg/dl
    (H)

     BP : 80/60 mmhg
     RR : 36x/min
     PR : 100x/min
     Temp : 36,5
     Head :
    Normochepalii
     Eye :
    o Anemic
    Conjungtiva:
    -/-
    o Lecteric
    Seclera : -/-
     Neck :
    o Lymfoid :
    undetected
    o JVP : Normal
     Thorax :
    o Ins :
    Laterolateral is
    greater than
    anterior posterior
    o Pal :
    symmetrical chest
    wall movements
    o Per :undetected
    o Aus :
    basic breath
    sound broncho
    vesiculer
    Rh : +/+,
    wh +/+
    murmur-/-
    galloop-/-

     Abdomen:
    o Ins :stomach
    looks flat
    o Aus : bowel
    sound (+)
    6x/min
    o Per:
    thympany.
    Percusion
    pain (-)
    o Pal : supple
    pressure pain
    (-)
     Ext : :
    warm acral,
    cappilary reffil <2
    edema -/--/- pitting
    edema

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