Tbl 4 case discussion
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Transcript of Tbl 4 case discussion
TBL 4
Case for Discussion
• Puan Rojia a 42 years old administration assistant in a local school presents with dyspnea that occurs suddenly on her way back to Kota Kinabalu in KLCC.
• Been admitted in PJH since 27th Dec 2011.• Presents with productive cough, with
greenish-yellow sputum.• Does not wheeze.
Chief Complain
Past Medical History
• Have history of asthma for more than 25 years.
• Frequent asthma attacks usually during stress or exertion.
• Severe allergy to cat furs and dusts.
Systemic Review
• No HPT.• No DM.• Have symptoms of anemia.
Current Medication• Breathing using the oxygen supply. To supply
adequate O2.• Inhaler is given every 2 hours. • Budesonide. Antiallergy agent.• Salbutamol. β2 adrenergic receptor agonist,
bronchodilator.• Afuroxime. 2nd gen cephalosporin, URTI
Current Medication
• Hydrocort. Anti-inflammatory• Prednisolone. Anti-inflammatory• Ferrous fumarate. Supplement to treat
anemia• T. folate. Supplement to treat anemia• Vit B complex. Supplement to treat anemia• Vit C. Supplement to treat anemia
Drug Allergies
• Have no known drug allergies
Family History
• No family history of asthma.• Uneventful family history.
Social History
• Lives in Lahad Datu with her family.• Complains that her working environment is
full with people who smokes.• Patient does not smoke or consume any
alcohol.
Examination
• On examination the patient is sitting on her bed, breathing with the oxygen supply.
• RR of 20/min. (12-18 at rest)• BP of 120/81. • T of 37°C.
Hands Examination
• No signs of clubbing.• No peripheral cyanosis.• Hands are pale.• No palmar erythema.• Nails are pale.
Arms Examination
• PR of 96 beats/min. (60-100)• Volume is normal and pulse is regular.
Face and Neck Examination
• No jaundice.• No pallor.• No central cyanosis.• Lymphadenopathy?• Raised JVP?• Trachea centrally located?
Investigations
• Arterial Blood Gas. To check for her pO2 and pCO2 levels
• Electrolytes. To detect for any metabolic disorders• FBC. To check for infections• Blood smear. To check for the morphology of the RBC• ECG. To exclude any cardiac diseases• Urine FEME. To detect for any metabolic complications• Sputum C&S. To check for the causative agent of her
URTI
• pH 7.44 (7-7.7)• pCO2 25mmHg (15-125)• pO2 141mmHg (14-410)
Arterial Blood Gas
Electrolytes
• cNa+ 43mmol/L (120-180)• cK+ 2.4mmol/L (2.0-8.0)• cCa+ 1.02mmol/L (0.50-2.50)• cCl- 101mmol/L (85-140)• cGlu 11.6mmol/L (2.0-15.0)
Investigation – what we would do
• Spirometry. To detect any obstruction/restriction
• Chest X-ray. To detect any mass/consolidation/pneumothorax/pulmonary edema