case pres reference

7/31/2019 Case Pres Reference

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CHAPTER 2: HEALTH HISTORY

I. PATIENTS PROFILE:Name: Mr. E. T. L.

Sex: Male

Age: 36 years old.

Civil Status: Married

Nationality: Filipino

Birth date: August 26, 1975 12PM

Birth Place: Valenzuela City

Address: Guadalupe, Makati

Religion: Roman Catholic

Educational Attainment: High School Graduate

Occupation: Bag vendor at the Guadalupe market

Date and time of admission: May 6, 2012 8:15 AM

Mode of admission: General ward

Admitting Diagnosis: Spontaneous Pneumothorax

Preoperative Diagnosis: Massive Pneumothorax Left Secondary to Ruptured Bleb vs Idiopathic

Operation Performed: E Chest Tube Thoracostomy, Left

Postoperative Diagnosis: Massive Pneumothorax, Left, Secondary to Ruptured Bleb vs Idiopathic

II. CHIEF COMPLAINT: Dalawang linggo na akong nahihirapang huminga, as verbalizedby Mr. E. T. L.


2/20

III. HISTORY OF PRESENT ILLNESS:2 weeks PTA, the client experienced difficulty of breathing and had a fever of 37.9C.

He was given a tepid sponge bath and took Paracetamol 500mg for his fever. The fever

subsided and his temperature returned to normal ranges. The client took Salbutamol 4mg

during the night and was able to fall asleep. His wife

1 week and 4 days PTA, the difficulty of breathing still persisted. The client used water

steam inhalation and his wife did chest percussion on his back. He still took Salbutamol 4mg,

but only once per day. The symptoms were relieved only for a short time.

There was persistence of symptoms. No improvement or progression was stated.

2 days PTA, the client went to an OPD at Polymedic Clinic for consult and was advised

for admission. The client decided to stay at home against medical advice.

1 day PTA 8Pm, the client was sent to the emergency room at OSMAK with difficulty of

breathing and was diagnosed of impending thyroid storm. Oxygen was administered at 4L/M

via nasal cannula. Intravenous Fluid of D5LR was also administered to the patient. Patient was

then sent home.

After discharge the client experienced chest pain and shortness of breath. Hence, he

went back to the emergency room at 1:27am, the next day, and was scheduled for an

Emergency Chest Tube Thoracostomy on the left lung.


3/20

IV. PAST MEDICAL HISTORY:The client stated that he had received complete immunization during childhood. He was also

never admitted to any hospitals in the past. He has no known allergies. He goes to clinics for a check-up

whenever he is feeling unwell. No recent travel was also made.

.

DATE DIAGNOSIS HOSPITAL INTERVENTION MEDICATIONS

5 yrs old Bronchial Asthma None Self medication Salbutamol

2005 Goiter due to

Hyperthyroidsim

Manila Doctors

Hospital

Unmanaged Was only

compliant with

medications

from yr 2005-

2008.

Unrecalled

V. PERSONAL AND SOCIAL HISTORY:The client and his wife are bag vendors for 3 years with their own stall at the Guadalupe Market.

Their gross income is 20,000/month. He is a high school graduate at Bangkal High School in Makati City.The client lives in his own house, together with his wife and mother. His house is a bungalow

style with two bedrooms. He stated that their environment is clean and has enough space for all of

them. They didnt have any children.

The client gets his exercise by playing tennis every day. He eats 4 times a day.

The client smokes at least half a pack of cigarettes per day and also drinks alcohol occasionally.

CHAPTER 3: PHYSICAL ASSESSMENT

General appearance: (-) chills

(+) Facial grimace

Conscious and coherent


4/20

Has proportionate body built.

Thin body figure

Cooperative and responds appropriately to every question asked at

moderate pace and as long as he can tolerate.

Anthropometric measurements: Height: 172.72 cm

Weight: 120 lbs. BMI *18.2

Vital signs: Temperature: 36.8 C

Respiratory rate: 21 bpm

Pulse rate: 90 bpm

Blood pressure: 120/70 mmHg

ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCE

Head Inspection Normocephalic

(+)ROM

(-) Head injury

(-) Tenderness

(-) Lesions

Normal

Face Inspection Normal facial movements Normal

Skin Inspection

Palpation

*(+) Pallor*Hematomas on

antecubital and radial

surface on both arms

(-) cyanosis

(-) senile skin

Dark complexion

Dry and intact

Good skin turgor

*There is a decrease intissue perfusion

*Hematomas are due to

blood samples taken

Hair Inspection (-) hair parasites

(-) dandruffs

Hair is evenly distributed

Normal

Nails: Inspection

Palpation

(-) Pail

(-) Indentations

Capillary refill less than 3

seconds

Normal


5/20

Eyes Inspection PERRLA:

Pupils are equal and

round, left eye 3 mm

reactive to light and right

eye 3 mm reactive to light,

good accommodation

noted.*slightly protruding eyes * Eye protrusion is one of

the signs of

hyperthyroidism

Ears Inspection

Watch tick test

Palpation

Bilaterally equal in size

(-) lesions

(-) discharge

(-) redness

(-) bleeding

Able to hear sounds on

both ears

Pinna is firm, non tender

and no pain

Normal

Nose: Inspection Symmetric and straight

(-) discharges

(-) nasal flaring

*With O2 administered at

4L/min via nasal cannula

*There is oxygen

assistance

Mouth: Inspection *(+) dental carries

*Absence of teeth on

upper mandible

Uniform and pinkish

tongue with no lesion,

Moist pink buccal mucosa

Abnormal

Neck: Inspection

Palpation

Symmetric and head

centered

(-) Enlarged lymph nodes

(+) Lump on the neck There is thyroid

enlargement

Thorax and lungs: Inspection

Auscultation

Percussion

Palpation

(+) difficulty of breathing

(+) cough

(+)chest wall retraction

(+) use of accessory

muscles

With CTT one-way bottlesystem inserted between

5th

and 6th

ICS, LMA line

Decreased breath sounds

and pleural rub on left

lung

Hyper resonance on left

lung

Tactile fremitus decreased

*Patient is having

problems with

oxygenation

*To eliminateaccumulation of air in the

pleural cavity.

*Air in the pleural space

dampens the transmission

of sounds and vibration.


6/20

PQRST on left lung

Pain on Left chest due to

CTT drainage system on L

lung

P Feels more pain when

ambulating or moving

Q- Stabbing painS- 6/10

R Radiates at the left

shoulder

T After CTT insertion

Heart Inspection

Auscultation

(-) visible pulsation

No heart murmurs

auscultated over aortic,

pulmonic, tricuspid and

mitral area.

Normal heart rate and

regular rhythm

Normal

Abdomen Inspection

Auscultation

Palpation

(-)swelling

(+) bowel sounds

(-) palpable masses and no

tenderness.

Normal

Extremities

Arms

Hands and feet

Inspection

Palpation

Inspection

Arms and legs bilaterally

symmetric, no ulcerations

noted.

*(+) limited ROM

*(+) body malaise

*20.5cm mid-upper arm

circumference

Equal pulses(-) clubbing of fingers

*Due to weakness

*Normal value of MIUC in

adult males is 23cm. This

shows decreased amounts

of fat and muscles in thearms

Genito-urinary Inspection No swelling, no lesions

noted

Normal

Anus/ Rectum Inspection Anal area pink w/ small

amount of hair

(-) hemorrhoids

Normal


7/20

GCS was taken as follows:

Date: 05-07-12 05-08-12

EYE OPENING: 4 4

VERBAL : 5 5

MOTOR: 6 6

GCS SCORE: 15 15

Verbal interpretation: Last GCS shows patient opens eyes spontaneously,

oriented and converses normally, and obeys commands.

Nursing implication: Provide safety to prevent injury. Provide comfort and ROMexercises to maintain muscle and skin integrity. Provide bedside care and personal

hygiene to the patient.

CHAPTER 4: REVIEW OF SYSTEMS

SYSTEM CUES INTERPRETATION SIGNIFICANCE

General Medyo nanghihina pa ako. (+) body malaise Body weakness is attributed to the presentcondition

Skin/Integumentary

System

May konting sakit sa mga

parte na pinagkuhaan ng

dugo

(+) Tenderness Tenderness is due to puncture of skin from

obtaining blood specimen.

EENT

Ears

Eyes

Throat

Pantay ang pandinig ko.

Parehas malinaw ang

paningin ko.

Nahihirapan akong

lumunok,

Is able to hear on

both ears

Is able to see on

both eyes

Difficulty in

swallowing

Normal

Normal

Brought about by thyroid enlargement

Respiratory System Hirap akong huminga. DOB Due to escape of oxygen into the pleural

space.


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Cardiovascular

System

Medyo tumataas BP ko

lately.

BP BP is due to increased force of cardiac

contractility and the bodys attempt to

increase cerebral tissue perfusion and

oxygenation

Gastrointestinal

System

Hindi naman ako nagtatae

Nagsuka ako kanina dahil sa

sama ng pakiramdam ko.

(-) Diarrhea

Vomiting Attributed to present condition

Genitourinary System Regular ang ihi ko, normal

ang kulay at hindi rin ako

nahihirapang umihi

Normal

Musculoskeletal

System

Madali akong mapagod. (+) muscle

weakness

Limited ROM

Weakness is attributed to present condition

and limited ROM

Hematologic Medyo maputla ako Pallor Due to poor oxygenation

Neurologic Maayos naman ang aking

memorya at kaya kong

makipagusap.

Is able to

communicate

Normal

CHAPTER 6: GORDONS FUNCTIONAL HEALTH PATTERN

Before hospitalization During hospitalization

Health perception and

Health Management

pattern

Client seeks medical

consultation every time

he feels that there is

something abnormal with

his health. He normally

takes OTC drugs when heexperiences a cough or

cold.

Client is adherent to the treatment regimen

Nutritional and

metabolic pattern

He is fond of eating salty

and fatty foods.

He eats what the dietary department serves.

On low salt and low fat diet.


9/20

Elimination pattern He defecates at least 2

times a day and urinates

at least 6 times a day.

Client uses a urinal to urinate. He has not

made any bowel movement since

hospitalization.

Activity-exercise

pattern

He plays badminton every

day.

Has difficulty ambulating

Sleep-rest pattern Has lack of sleep. Has more difficulty of sleeping.

Cognitive perpetual

pattern

The client can hear

clearly. PERRLA. Cognitive

and alert.

The client can hear clearly. PERRLA.

Self-perception and self

concept pattern

Confident and he has a

good outlook on the way

things are happening.

The client still has a positive outlook.

Role relationship Is satisfied with family,

work, and

social relationships

He cannot perform his roles as of the

moment.

Vices Drinks alcohol

occasionally and smokes

half a pack of cigarettes

per day.

None

Sexual pattern Is satisfied with sexual

relationship

None

Coping/ Stress

Tolerance

Client manages stress

listening to music

Client handles stress of condition by

practicing a regular breathing pattern.

Value - Belief Client prays often for

good health.

Client often reads the bible.

CHAPTER 5: MEDICAL AND NURSING DIAGNOSIS

Medical diagnosis: Spontaneous Pneumothorax


10/20

CHAPTER 6: LABORATORY EXAMS

Arterial Blood Gas 05-08-12 3:40PM

Component Result Normal Value Interpretation

PH :

pCO2:pO2

HCO3:

B.E

Sat O2

Total CO2:

7.455

30.2 mm/Hg97.5 mm/Hg

22.9 mmol/L

1.9 mmol/L

97.8 %

21.7 mmol/L

7.350-7.450

35.00-45.0080.00-100.00

Normal

DecreasedNormal

Normal

Normal

Hematology 09-16-11

Component Result Normal Value Interpretation Analysis

Hemoglobin

Hematocrit

WBC count

RBC count

Differential count:

Eosinophils

Neutrophils

Segments

16.8

0.52

15.9

5.8

0.01

0.71

14-18 g/L

0.40-0.54

4-11 x10 g/L

5.0-6.4

0.02-0.04

0.50-0.70

Normal

Normal

Increased

Normal

Decreased

Increased

WBC is due to presence of

infection

Neutrophil is bodys primary

defense against bacterial

infection and physiolic stress


11/20

Lymphocytes

Monocytes

Platelet count

PT

% activity

INR

Activated PTT

0.16

0.12

202

16.3 secs

57.0%

1.52

48.0 secs

0.20-0.40

0.02-0.05

150-450 x10 g/L

10.4-14.05

73-127%

0.88-1.21

30.4-41.2

Decreased

Increased

Normal

Slow

Decreased

Increased

Slow

neutrophils indicates

presence of infection

lymphocytes make the host

susceptible for viral infection

Monocytes act as phagocytes in

some inflammatory diseasesmonocytes act as defense

against infection

Nursing implications: Assess for fatigue, dietary deficiencies and V/S. Assess fluid balance and

respiratory status.

Clinical chemistry 05-07-12 2:50PM


Sodium

Potassium

Chloride

Calcium, Ionized

Calcium, Total

Magnesium

Phosphorus

134 mmol/L

4.3 mmol/L

97 mmol/L

1.08 mmol/L

1.88 mmol/L

0.63 mmol/L

1.68 mmol/L

135 148 mmol/L

3.5 4.5 mmol/L

98 107 mmol/L

1.12-1.32 mmol/L

2.15-2.55 mmol/L

0.66-0.99 mmol/L

0.81-1.58 mmol/L

Decreased

Normal

Decreased

Decreased

Decreased

Decreased

Increased

Clinical chemistry 05-07-12 7:14AM


Glucose (fasting)

Cholesterol

Triglycerides

8.84 mmol/L

2.73 mmol/L

0.83 mmol/L

4.1 - 5.5 mmol/L

0.0 5.2 mmol/L0.0 2.3 mmol/L

Increased

Normal

Normal


12/20

HDL -cholesterol

LDL - cholesterol

0.51 mmol/L

1.66 mmol/L

0.9 1.45 mmol/L

0.0 2.59 mmol/L

Decreased

Normal

Blood chemistry 05-07-12

Component Result Normal Value Interpretation Analysis

Blood Urea Nitrogen

Serum creatinine

3.9 mmol/L

60 mmol/L

2.1-7.1 mmol/

45-104 mmol/L

Normal

Normal

BUN is affected by

hydration, hepatic

metabolism of protein and

reduced GFR

BUN indicates kidney

damage, GFR

serum Crea indicates

nephron damage, GFR

Nursing implications: Assess kidney function and check Input and Output.

* Mr. E. T. L. as indicated in her blood chemistry is having a normal renal function

LIVER ENZYMES 05-07-12 11:06 PM

Component S.I. Result Normal Value Interpretation Analysis

AST (SGOT)

ALT (SGPT)

41u/L

37u/L

15-37 u/L

30-65 u/L

Increased

Normal


13/20

STOOL EXAM 05-06-12

Macroscopic

Examination:

Color:Consistency:

Gross Evidence of:

>WBC

>RBC

Remarks:

Light Brown

Soft

0-3/HPF

0-2/HPF

No intestinal

Parasites seen

URINALYSIS 05-06-12

Component Result Interpretation

MACROSCOPIC EXAM:

Color

Transparency

Sugar

Protein

pH

S.G.

MICROSCOPIC EXAM:

WBC

RBC

Epithelial Cells

Crystals

Bacteria

Dark Yellow

Slightly Hazy

N (-)

+2

6.0

1.025

0-2/ HPF

1-3/ HPF

FEW

Amorphous Urates /

Phosphates: Occasional

FEW


14/20

CHEST X-RAY 05-06-12

TYPE: In-patient

Examination:

Remarks:

Department of Medicine

General Ward

Chest

-Follow up chest x-ray aftera few hours shows complete

re-expansion of the left lung

with no evidence of

pneumothorax

-Left sided CTT seen in

place.

Electrocardiogram Test (ECG) MAY 6, 2012

ABNORMAL FINDINGS INTERPRETATION

Poor R progression ST-T abnormality (Ant, Lat) Negative T (Inf) Right axis deviation QT prolongation Clockwise rotation Atrial Fibrillation

- Noise or baseline drift is present (V1, V6)

Nursing Implications: Explain the purpose of the test and explain that there will be no pain from the test. Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy,

undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations.

Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to thetest.

Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening tothe patient. Reassure the patient that he will not get a shock from the machine, especially if this is the

first time this patient will have this test. Patients have other misconceptions and fears about the test.

Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) mayaffect the results of the test. Report if the patient is unusually anxious or upset before the test.

The patient will be carefully observed during the test. Ask the patient to relax and lay still during the test. Usually, normal activity may resume after the test.


15/20

CHAPTER 7: COURSE IN THE WARD

May 07, 2012

6am-2pm shift

Time Data Action Response

6:00 am -received pt. lying on

bed, conscious and

coherent

- with O2 support via

nasal cannula at 4LPM

- With IV contraption onR metacarpal infusing

PNSS 1L x 40cc/min

-with CTT to thoraco

bottle on L lower lateral

chest wall at 400water

peak level. Initial H2O in

CTT: 200

7:00 am -v/s taken and recorded -Temp : 36.8c

RR: 21 bpm


16/20

-chest tube tubings,

dressing and patency

was checked

-medication given:

methimazole 20mg

-meds given:

Aspirin 80mg

Enalapril 5mg

PR: 90 bpm

BP: 120/70 mmHg

-chest tube are patent,

tubings are hang in

straight line from

mattress to the

drainage bottle

7:14am -clinical chemistry done

-chest tube tubings,

dressing and patency

was checked

-medication given:

methemazole 20mg

-chest tube are patent,

tubings are hang in

straight line from

mattress to the

drainage bottle

8:00 am -meds given:

Aspirin 80mg

Enalapril 5mg

-O2 Saturation and CBG -O2 sat. 97%


17/20

taken - CBG: 109 mg/ dL

9:00 am -Masakit ang balikat

ko, parang tinutusok

tusok. As verbalized by

the patient.

--assessed pt.

-v/s taken & recorded

-medication given:

Tramadol 50mg TIV

9:30am - Pain relieved as

verbalized by the pt.

10:00am -bed side care done

-health teaching on

chest tube drainage

system provided

-pt. verbalized

understanding on chest

tube system precaution

12:00 nn - v/s taken and

recorded

-input & output

measured

-meds given:

PTU 50mg

Furosemide 20mg

Ceftriaxone 2g TIV

- Temp: 36.9c

RR: 20 bpm

PR: 80 bpm

BP: 130/70 mmHg

- Input Oral: 500 cc

IV: 80cc

Total: 580 cc

- urine output: 300 cc

-chest tube drainage

output: 250cc


18/20

Total: 550cc

-BM: 0

May 08, 2012

6am-2pm shift

Time Data Action Response

6:00 am -received pt. sitting on

bed, conscious andresponsive

-spontaneous with O2

support via nasal

cannula at 4LPM

- With IV contraption

on R metacarpal

infusing PNSS 1L x

2gtts/min

-with CTT to thoraco

bottle on L lower

lateral chest wall at

400water peak level.

Initial H2O in CTT: 200


19/20

7:00 am -v/s taken and

recorded

- medication given:

methimazole 20mg

-Temp : 36.9 c

RR: 20 bpm

PR: 88 bpm

BP: 110/70 mmHg

8:00 am - meds given:

Aspirin 80mg

Enalapril 5mg

9:00 am -O2 Saturation and

CBG taken

-O2 sat. 98%

-CBG: 116 mg/ dL

10:00am -health teaching on

deep breathing

exercises provided

-pt demonstrate deep

breathing exercises

12:00 nn - v/s taken and

recorded

-input & output

measured

-meds given:

- Temp: 36.9c

RR: 19 bpm

PR: 89 bpm

BP: 110/70 mmHg

- Input Oral: 300 cc

IV: 320cc

Total: 620 cc

- urine output: 400 cc


20/20

PTU 50mg

Furosemide 20mg

Ceftriaxone 2g TIV

CTT output: 140cc

Total:540cc

-BM: 0

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