Archive for the ‘ 3-Medical ’ Category

Medical Department (17 Ogos – 28 Ogos)

List of Cases

1) Acute Pulmonary Edema (APO) 2ry to Anemia , acute on Chronic Renal Failure (CRF) 2ry to traditional medication

2) Decompensated 2ry to non-compliance of fluid restriction

3) Lt Parietal Hemorrhage transformation of an infarct w/ Rt sided Hemiplegia

4) Decompensated Congestive Cardiac Failure (CCF) w/ fast Atrial Fibrillation (AF) precipitated by anemia , possible underlying IHD , myelofibrosis , unlikely autoimmune hepatitis probably due liver congestion

5) meningitis

6) Dengue w/out warning sign

7) Unstable angina (USA) , Atrial Fibrillation(AF) -rate controlled , ischaemic stroke

8 ) Anterocutaneous fistula at previous appendicectomy wound , prolapse & retracted loop ileostomy , treated as IBD by surgery , malnutrition , dermatitis over scrotal gluteal cleft

9) Spontaneous Pneumothorax

10) Myeloblastic Anemia

11) Neuroglycopenis sepsis

12) Acute Coronary Syndrom (ACS)

13) Chronic Kidney Disease (CKD) , Pneumonia , AGE , DM , HPT , normochromic normocystic anemia 2ry to CKD

14) Pseudomonas Sepsis , acute on Chronic Renal Failure (CRF) , Hx Upper GastroIntestinal Bleeding (UGIB) 2ry to ? bleed Peptic Ulcer Disease (PUD) , Myeloproliferative Disorder , IHD , HPT , DM , Hyperlipidemia , Gout

15) Lt sided HPT bleed , aspiration pneumonia

16) Lt ischemic Stroke

17) Acute Pulmonary Oedema (APO) 2ry to Hypotensive Emergency , Fluid Overload 2ry ESRF , DM , HPT

18) Congestive Cardiac Failure (CCF) w/ Community-acquired Pneumonia (CAP)

19) Community-Acquired Pneumonia TRO of Pulmonary Tuberculosis (PTB)

20) Dengue w/ warning sign + hepatitis

Dokumentation in Medical Ward

HISTORY

1) Chief C/O :

-63 malay man

-KCO COPD on Hospital Jerantut follow up

-defaulted follow up and medication

2) Hx of Presenting Illness

-chronic smoker >40 years (1pack / day)

-C/O shortness of breathing (SOB) , progressively worsened over 1/52

-worsened today

-has been having chronic cough over 1 year duration

-sputum whitish

-x hemoptysis

-fever on & off 1 year

-got lost of weight (+LOW)

-no lost of appetite (-LOA)

-no sore throat / RN / abd pain / diarrhea / vomit

-was never investigated for Pulmonary Tuberculosis (PTB)

3) Medication Hx

-not on any medication

4) Allergies Hx

-Bactrium / sulphur-base medication

5) Social Hx

-ex english teacher

-chronic smoker

-non alcohol

Physical Exam

1) General Exam

-tachypneic

-CRT < 2 sec

-GCS full

-speaking in phrases

-BP =102/74

-PR = 113

-Temp = 36.5

-dxt = 8.0 mmol/L

-SPO2 on nasal prong

=82 on admittance (pneumothorax unfixed)

=96-97 post chest tube (pneumothorax fixed)

2) Head & Neck

-no virchow’s LN

3) CVS

-Dual Rhythm No Murmur (DRNM)

4) Respiratory

-reduced A/E on lf side (crept / ronchi) = airway block

-no A/E on rt side =airway o.k

-percussion hyperresonant on rt side = got air

5) Abdomen

-soft / non tender

-no hepatosplenomegaly

Diagnosis

-rt pneumothorax ? 2ry to Pulmonary Tuberculosis (PTB) / Malignancy

Management

-put in chest tube

-maintainance – IVD 3 pints N/S over 24 hours

-put on nasal prong

-nebs combivent hounty

-IV hydrocort 0.5 mg stat was given at ED

-IV Rocephin 2 g stat then 1 g OD

-T-Azithromycin 500 mg OD x 3/7

-stat IV Aminophylline 500 mg in 1 pint HS over 1 day

-T. Nuelin SR 250 mg BD CM

-IV Pethidine 50 mg stat + IV Maxalon 10 mg stat given in ED prior to chest tube

-stat on suction in ward 10-20 cmH2O in ward

-HO on call to review , inform MO if patient unwell

-FBC

-RP

-LFT

-ABG post chest tube on nasal prong

-Alpha-fetoprotein

-LDH

-CA 19.9

-CA 125

-ESR

-Sputum AFB x 3

-Mantoux test

Advertisements