Tan Lok/86years/chinese/male

non smoker/non alcoholic

lives in nursing home since 5years ago.

DNR issued in ED 6/5/2020

U/L

-hpertension

-hypothyrodism (T.levothyroxine 50mg ON under KK Segamat f/up)

-Prostate ca (T. Avodart 0.5mg ON and T. Terazosin 5mg ON)

-internal haemorrhoid (banding done under surgical)

-Bronchial asthma (MDI salbutamol 2puff PRN and Budesonide 2puff BD)

Admitted in 5/6-14/6/2019 : CAP TRO pulmonary TB (sputum AFB no growth)

CT thorax 27/3/19

-known case of prostate CA, current finding shows multiple lungs nodules and pleural effusion with
adjuvant right lower lobe collaps consolidation is suggedtive of infective changes

History taken from caretaker in charge at home

C/o

1)SOB since 8am this morning after eating 1 spoon of oats

2)Cough x 3/7 with whitish sputum

O/w

no GI losses, no fever, no vomiting, no chest pain, no hisotry of recent travelling, no recent contact with
sick patient/covid patient, no h/o attending mass gathering

patient lives in nursing home(mercy) sice wife passed away 5years ago. Has 3 children.

At Nursing home, sleeps in a room with 6people, others are well.

no sick patient at nursing home. No visitor are allowed since MCO.

At ED E4V4M5 pupil 3/3 reactive, mild pallor, CRT <2sec

lungs reduce A/E Left Lower zone with crepitation at left mid zone

CVS DRNM

PA soft, non tender

pedal edema until below knee

BP 100/60

PR 88

T 35.6

RR26

Spo2 88% under HFM

reflo 6.3

CXR multiple scattered nodules with fibrotic changes

Given IV augmentin 1.2g

Treat as

1)otostatic peumonia with U/L advance prostate CA with possible lunngs metastatis

2)SARI syndrome COVID

In ward

E4V1M6, CRT <2sec, good PV

lungs transmitted sound

abdomen soft, non tender, no hepatosplenomegaly

no pedal edema

BP 93/54
PR80

RR24

Spo2 100HM

T37

was given IV rocephine 2g stat & OD

IV pantoprazole 40mg OD

IVD 3pint NSD5%/24h

T. Levothyroxine 50mcg OM

T.avodart 0.5mg OD

reduce to FM5L/min with maintain spo2 >95%

Patient then transferred from ward 7C to 3A (8/5/20)

FBC TWC 3.6 to 8.8/ Hb 4.5 to 8.5 after transfuse 2packcell/ PLT 162 to 148

RP 8.0/130/3.8/106

CRP 112.4

patient saturated under RA

Offed Npo2 and IVD

on CBD since 7/5/20

afebrile

tolerating orally

O/e alert,concious, not tachypneic, E4V1M6

Bp 118/59

HR 75

Spo2 98RA

T37
lungs clear

Allow discharge

Medication

IV rocephine 2g STAT and OD x 4/7

IV pantoprazole 40mg OD

T. Avodart 0.5mg ON

T. Levothryroxine 50mcg OM

T. Hematinic 1/1 OD

Ix

6/5/20

Hb 4.5/ TWC 3.6/PLT 162

8/5/20

Hb 8.5/ TWC 8.8/ PL145

3/6/19

T4 14.9

TSH 2.79