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

No K/P : 1802011-71-5253

Pekerjaan : Peniaga

Umur : 90 tahun

Alamat: 16 Taman Teratai, Jalan

Jantina : Lelaki

Langgar. Alor Star.

Agama : Buddha

Tarikh Masuk Hospital : 11-02-2008

Tarikh Keluar : 15-02-2008

Waktu : 10.30 a.m

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 : 38.4c

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 38.0c

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

37.7c

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 37.2c

- 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 38c
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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