SCHOOL OF MEDICAL SCIENCE

UNIVERSITY OF SCIENCE MALAYSIA CAMPUS OF HEALTH KUBANG KERIAN KELANTAN

PHASE 2 RESPIRATORY BLOCK

CLINICAL REPORT

NAME: MATRIC NUMBER: YEAR/COURSE: GROUP: CLINICAL TUTOR:

YVONNE NG YEE THENG 108466 DENTAL 2 DENTAL PBL GROUP 2 DR. WONG MUNG SEONG

History

Patient information: Name: Mohd Hakim Ismail Age: 15 years old Address: Lot 1271, Kampung PauhBadang, Jalan PCB, 15350, Kota Bharu, Kelantan Gender: Male Race: Malay Religion: Islam Occupation: Student (Form3) School: SM Penambang Marriage status: Not married Date of Admission: 11/10/2011 Date of clerking: 11/10/2011 Chief Complaint: Fever History of presenting illness: Patient is suffering from fever one week ago prior the date of admission. Patient claimed that he started to have fever in the morning when he woke up from sleep. The fever is persistent for one week but not severe such that it can affect his daily activity. However patient complained that fever causes the headache. It is low grade fever with no chill and rigor. One of the associated symptoms is headache. Patient was having pain on postorbital area with no radiation to other part of the body. The pain started gradually and it was persistent. Patient was given score from 0 to 10 in which 0 is painless whereas 10 is most painful. Patient claimed that his score of pain is 7. Patient felt most painful when he was coughing. Nature of pain is needle pricking and sharp. Another associated symptom is cough. The cough is continuous but not so frequent. The sputum is whitish and greenish in colour. Patient also experienced throat pain when cough. He had no hemoptysis in his sputum produced. The cough is relieved when patient drank cough syrup. However the cough came back when after patient stopped taking the medication. Moreover, patient also suffered from vomiting since Monday. He had vomited more than 10 times and came to hospital but was not admitted. Patient also claimed that his vomiting was due to headache. Patient experienced dizziness but no blackout. Patient had lost of appetite because patient feels like vomiting. Systemic Review: Gastrointestinal system:

Loss of appetite Vomiting Nausea No Diarrhea Musculoskeletal: No joint pain No swelling No deformity No stiffness Central nervous system: No loss of consciousness Dizziness No tremor No weakness No numbness Cardiovascular system: No hypertension No palpitation No chest pain No shortness of breath No cyanosis No effortness Renal system: No dysuria No hesistency Eyes: No blurry vision Head: Headache Nose: No nasal block No sinusitis

Social History:

Patient is currently resides in cement house in town area of Kelantan. He is living with his parents and brother. He shares room with his brother and his room is equipped with fan but not air-condition. Patient is a nonsmoker and does not drink alcohol. His father is retired for 3 to 4 years and previously worked in ladang. His mother is a housewife. Family members and friends surrounding him do not smoke as well. Family history: My patient is the youngest in the family with 3 sisters and 4 brothers. His family background does don have asthma or any other chronic disease. Diet history: My patient is having normal diet with home cooked food. Past medical history: Patient has never admitted to hospital. He visited hospital on Monday due to vomiting but was not admitted. Patient is taking drug syrup from pharmacy one week ago and does not seek for any medical help when he is fever. Drug history: Currently, patient is given Nacl 0.9% IV drip, T. Azithromycin and Analgestic to reduce headache. Allergy: Patient claimed that he is not allergic to any food or drug. However patient will feel irritation when there is dust surrounding. Travel history: Patient does not travel to anywhere within this year. Summary: My patient, Mohd Ismail Hakim is a Malay gentleman from Kota Bharu, Kelantan who is a form 3 student studying in SM penambang. His chief complaint is fever in which it persists for one week with other associated symptoms like headache, cough but no hemoptysis and vomiting. He is a nonsmoker and nonalcoholic. He has no other chronic disease. He has lost his appetite to eat.

Physical Examination General inspection:

My patient is lying down comfortably in supine position on the bed supported by one pillow, with the bed propped-up 45 degree. Patient is conscious with time, place and person oriented. There were no gross deformities and movement seen. There was an intravenous cannula attached to dorsum of patients left hand. The colour of the face is normal. There was no sign of respiratory distress. The nutritional and hydration level is adequate. Vital sign: Blood pressure: 118/68 mmHg Pulse rate: 98 beat/min with adequate volume and regular rhythm Respiratory rate: 24/min with regular rhythm Temperature: 37.6C Hands: The palm is moist, pinkish and warm. There was no peripheral cyanosis, no splitter hemorrhage and no tar stain. Patient had good capillary bed refill which is within 2 seconds. There was no clubbing and no weakness in finger abduction. Patient did not experienced flapping tremor and no bony tenderness. Eyes: There was no discolouration on sclera. The conjuctiva was pinkish and no pallor Ears: There was no discharge in both ears Nose: There was no discharged in nose and no polyps are seen Neck: There was submental, cervical and preauricular lymph nodes enlargement. The JVP was not elevated Mouth: The oral hygiene is adequate. There was no coated tongue indicating adequate hadration status and there was no central cyanosis.

Trachea: Trachea is centred and there was no deviation. There was negative trachea tug Specific examination: Inspection: My patients chest moved symmetrically with each respiration. There was no gross deformity or scar on chest wall. There was also no skin discolouration or hyperpigmentation. No pulsation was detected on the chest wall and no dilated veins. The patient had no radiotherapy markings and skin changes.

Palpation During the chest expansion test, the lungs expanded symmetrically for upper, middle and lower parts. On palpation, the apex beat was located at the 5 th intercostals space, 1 cm from the midclavicular line. During vocal fremitus test, upper, middle and lower part of the lungs are of adequate volume and symmetrical on both sides of the lungs. Percussion Left and right clavicle: dullness Upper lobes: resonant bilaterally Middle lobes: resonant on right side, dullness on left side due to presence heart Lower lobes: dullness on right side due to presence of liver, resonant on left side Auscultation: Breath sound: vesicular breath sound is heard with normal intensity and no gap in between. Added sound: no other added sound is heard Vocal resonance is equal on both sides of lung with adequate volume.

Discussion: Problem list Symptoms: Fever Productive cough with whitish and greenish sputum Headache Vomiting

Sign:

Respiratory rate increases Pulse rate slightly increases

Provisional Diagnosis: Community acquired pneumonia Differential diagnosis:Tuberculosis Acute bronchitis-Chronic obstructive pulmonary disease (COPD) Chronic Gastritis Pneumonia Pneumonia is lung inflammation presenting with cough, purulent sputum and fever together with radiological and physical sign compatible with lung consolidation. Pneumonia is caused by varieties of infectious agent such as bacteria, viruses, fungi, mycoplasma and etc. Positive findings: fever Cough Breathes rapidly Negative findings: No pleuritic pain No pleural rub No sign of consolidation No rigors and chill

Tuberculosis TB is infection caused by Mycobacterium Tuberculosis. Positive findings: fever Productive Cough

Negative findings: No night sweat No significant weight loss No haemoptysis

Acute bronchitis Acute bronchitis is previously healthy subjects is often viral. Bacterial infection with organisms such as Strep. Pnuemoniae and H. Influenza is a common sequel to viral infection, and is more likely to occur in individuals who are cigarette smokers and those in chronic obstructive pulmonary disease (COPD)

Positive findings: Mild fever Productive Cough

Negative findings: No tightness of chest No wheezing No shortness of breath

Chronis Gastritis It consists of an infiltration of the lamina propria with lymphocytes and plasma cells. This can lead to the development of atrophic changes in the mucosa, including loss of parietal and chief cells, and sebsequent intestinal metaplasia. Positive findings: vomiting Negative findings: No epigastric discomfort and pain No anorexia

Pathophysiology Fever with chill and rigor

Infection by bacteria PNEUMONIA Productive cough Acute pulmonary congestion Rusty sputum Cough reflex Fibrous blood Neutrophil exudate

In alveoli In alveoli

In pleural

Lung consolidation Increase vocal fremitus & resonance Dullness on percussion Auscultation while breathing Bronchial breath sound over Consolidation site

Tags of fibrin on the pleural and lung surface

Pleural effusion Rough pleural surfaces rub together as lung expand and contract

Getting severe

Deviation of trachea to opposite site of lung

pleural rub Crackles while Pleuritic chest pain due to rub between the parietal and visceral pleural

Fever

Infection, toxins and other inducer of pyrogen

Monocytes, macrophages, B lymphocytes and other cell

Endogenous pyrogenic cytokines IL 1, IL 2, IL 6, TNF and IFN

Hypothalamic regulatory center antipyretics Prostaglandin E2

Elevated set point to Febrile level

Heat production and heat conservation

Cough and sputum Pneumonia

Infection of bacteria

Normal alveolar defense have been overcome

Complement activation

Acute inflammation

Active dilation of alveolar capillaries (increase permeability)

Plasma protein, blood, neutrophil leak out into interstitial space and then into alveolar

Exudation into alveolar

Cough reflex

Sputum production consist of bacteria, exudates, blood & neutrophils Consolidation Organism

Attachment to respiratory epithelium

Inflammatory response

Vasodilation of pulmonary vascular

Increase blood flow

Increase intravascular hydrostatic pressure

Filtration of fluid in interstitium

Vascular permeability still increase

Flow of protein rich fluid

Decrease in vascular osmotic pressure Increase in interstitial fluid osmotic pressure

Outflow of water & ions to extravascular tissues

Oedema

Lung consolidation

Vomiting Stimuli (Over distended, irritated or over excitable)

Go to the vomiting center at medulla via sympathetic and parasympathetic afferent nerve fiber

Deep inspiration

Closure of the glottis and elevation of the soft palate

Breathing is held at mid inspiration

Contraction of the abdominal muscle

Increase abdominal pressure and upper small intestine

Relaxation of the lower esophageal sphincter

Food enter the esophagus

Upper esophageal sphincter relaxed

The vomitus is propelled outward

Relevant Investigations and Rationale 1. Peak Flow Chart a. Measurement of PEFR on walking, on middle of the day and before bed. b. Demonstrating the variable airflow limitation. c. Assessment of severity and respond to treatment. 2. Spirometry a. spirometric assessment also differentiates between obstructive and restrictive lung disease b. Spirometry before and after administration of bronchodilator also differentiates asthma from COPDs ( if FEV1 increase more then 50% after administration of bronchodilator, asthma is confirmed). 3. Chest X-ray a. To confirm cause of dypsnea and cardiac failure.
b. To exclude pneumothorax. c. To exclude bronchopneunia. d. Look for signs of hyperinflated lungs, such as low and flat diaphragm.

4. Whole blood count a. patients with asthma may have an increase in the number of eosinophils in peripheral blood.

5. Blood and Sputum Test a. There may be large number of eosinophils in clumps of sputum and higher differential count of eosenophils in blood, indicating allergic reation. b. Helpful in differentiating the diagnosis of asthma from COPD.

c. To confirm present of bacteria in the sputum which is indicated

bronchopneumonia or chronic bronchitis. 6. Echocardiogram a. To assess cardiac function.

Principles of Management Aims of Management: 1. 2. 3. 4. Recognize pneumonia and determine its severity. Relieve or alleviate symptoms associated with pneumonia. Restore normal functions of lungs. Reduce morbidity and prevent mortality.

Approach to Management: 1. Determine the type and severity of pneumonia acquired by my patient. i. This is important to determine whether hospitalization is required. ii. My patient is suffering from fever, and also vomiting, which makes him dehydrated and required intravenous drip. iii. Thus my patient is hospitalized. 2. Treatment by removal of causative agents i. This case is a typical community-acquired pneumonia caused by bacterial agents. ii. Antibiotics is given to kill bacteria and eliminate bacterial infections. iii. Choice of antibiotics depends on the patients age, health status, presence of underlying conditions, symptoms present and also the severity of the symptoms. iv. First line antibiotics given are usually broad-spectrum antibiotics capable of killing many types of bacteria, examples include macroglides such as azithromycin. 1. Providing appropriate supportive care

i. ii. iii.

The aim is to relieve or minimize symptoms of pneumonia and maintain the patients general well- being. Fever is usually relieved by prescription of ibuprofen or paracetamol. Since my patient is suffering from vomiting, an intravenous drip of sodium chloride is given to maintain good hydration status by replacing water and electrolytes lost from vomiting.

1. Preventive care i. Maintenance of good personal hygiene, this includes cough etiquette, hand washing and disinfection of contaminated surfaces. ii. Prevent spreading of disease by advising patient not to go to crowded places or wear a face mask if he really needs to do so.