jom belajar sama2..

CASE WRITE UP..

should be kena tulis by handwriting... but, disebabkan tulisan cantik sangat... anin nak kena taip lah dulu... later anin tulis ek... =P


Thank you for seeing this patient..(ayat yg anin selalu jmp time praktikal kt IPR dulu...)

This patient 16 y/o Malay student with no know medical illness previously. she came to emergency department accompany by her parents due to chief complain of cough for 2 week associated with yellowish sputum. There is no Hx of pleuritic pain and no haemoptysis. She present of Hx of exertional dyspnea and palpitation. She also has fever for 1 week duration, on & off with chills and rigors. She does not have night sweat, loss of weight or loss of appetite. She has a hx of contact with her uncle with pulmonary tuberculosis but the contact was not prolonged and her uncle already completed his TB medication of 6 month. she does not have altered bowel habits and no family hx of malignancy.

on clinical examination, she was no tachypnea, BP 123/56 mmHg, Pulse rate 108 beat/min,regular,good volume, afebrile SpO2 97% under room air. Respiratory system revealed trachea deviated to left, stony dullness on percussion and reduce air entery on left lower zone. On auscultation, normal S2 and S2 heard without any murmur. Her abdomen was soft and non tender.

A pleural biopsy and pleural tap under aseptic technique was performed on day 2 of admission. Aspirate was around 100ml pus, foul smelling and not blood stained. Chest tube was inserted on left on day 6 of admission. Howerever, the was no drainage. The chest tube was subsequently removed.

She was treated as left lung empyema for further investigation. She was started on Augmentin 1.2g TDS for 5 day and complete T.Azithromycin  500mg OD for 3 days. She is currently on IV Rocephine 2g OD (5 days)and IV Flagy 500 mg TDS (5 day)

Radiology investigation
Chest radiography
left sided homogenous opacity

Ultrasound of left hemithorax
revealed marked elevates left hemidiaphragm with remarked displacement of spleen and left kidney suggestion of left lung collapse. No significant pleural effusion identified on ultrasound.

CT Thorax
was performed on day of admission and the CT scan showed reduced left volume with trachea and mediastinal shift to the left. Cystic bronchiectasis change of whole left lung. Thick wall collection in the anterior segment  of upper hemithorax, measuring 4.5 (AP) X2.2 (W) X 4.9 (CC) cm with air fluid leve;. No calcification noted in the left hemithorax. The chest tube tip is in th epleural space at left middle thoracic region. the left superior mediastinal nodes are enlarged and matted. the largest measuring 2.0 X 2.3 with central necrosis. Nodes also seen in the carinal region. Subcentimeter nodes in both axillary region. No enlarged nodes in lower cervical and superclavicular region. Minimal left pleural effusion.

compensatory hyperinflation of upper and lower right lung. Cystic bronchiectasis of the right middle lobe, no right pleural effusion. The visualized upper abdominal angle appear normal. No upper abdominal lymphadenopathy.Vesicual bones are normal.

Impression:
 the lung empyema with matted left superior mediastinal lymphadenopathy in the background of cystic bronchiectasis. Reactivation of PTB need to consider.
TRO Bronchigenic carcinoma associated obstructive pneumonia.

Biochemical Investigation:

FBC (19/10/2012) Hb : 11
                              WBC : 14.26 (on admission) , currently 8.12 (19/10/2012)
                              Hematocrit : 34.4
                              Platelet : 550

Renal profile : Urea: 4.8
   (19/10)               Sodium : 137
                     Potassium : 5.3
                     Chloride : 103
                     Creatinine : 55
Liver function test :
Total protein  : 55
Albumin : 30
Globulin : 58
ALP : 103
ALT : 20
Total Bilirubin: 3.3

CRP                      96.1
ESR                     114
Ca125                  55.6 (0-35)
Ca 19-9               11.1 (0-27)
CEA                      1.2
Blood C&S          No organic isolated
Mantoux               negative
Sputum AFBX 3   negative


Pleural Fluid Investigation

Plaural fluid gram stain - Aspirate appeared pussy & no organism isolated
Pleural FEME              >1000 cells/mm3, predominantly ,neutrophils
Pleural fluid for AFB        negative
Plaural Biopsy               no granuloma or malignancy

this patient is referred to seek your expert clinical evaluation and subsequently needful management.

on 23/10/20012

patient are alert, conscious, cooperative, to time,places and people.
B/P : 118/71
PR : 72 (rate/rhythm/volume)
T  : 37'C
SpO2 : 100 % under room air

Plan :
1) continue respiratory plan
2) to ask patient to bring letter from Serdang Hospital (kept by mom)

24/10/2012

B/P: 109/91
PR : 71
T: 37'C
SpO2 : 100 % under room air

plan :
1) continue abx X 2/52
2) continue medication
3)SpO2 monitor
4)confirm empyema
5) Hypoplastic left lung secondary congenital

continue:
Azitromycin/ Augmentin
reduce IV Rocephine 2g OD
Hagly 500mg TDS
TROMAL 50mg 3OD




p/s: this is only a STORY about how doctor make the decision during ward round... and what they plan for the real patient... please don't make anything conclusion before you can really understand what the patient being going thru... kasihanlah pada mereka.. jika, kita berada dalam kedudukan mereka.. barulah kita benar2 faham apa erti nikmat kesihatan.. saat berserah diri pada Allah.. Allah uji lagi kita dengan perkara yang tak kita jangka... percayalah... Allah sangat-sangat-SANGAT menyayangi KAMU......

insya-allah...

cerita tentang kisah adik ini belum berakhir lagi.....

my CASE WRITE UP tak siap lagi.... hehhehehe...

handwritinglah kena check betul2.......................... bkn boleh edit... so, bila dah tenang nnati anin tulis balik ek... kat kertas... sekarang masanya untk makan daging korban....

Bismillahirammanirrahim.................................