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Pleural Effusion - Case Study

Pleural Effusion - Case Study

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Published by Lilian Linogao
case study on pleural effusion
case study on pleural effusion

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Published by: Lilian Linogao on Feb 21, 2011
Copyright:Attribution Non-commercial

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07/31/2013

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Case Study on Pleural Effusion
1 |Page 
Introduction of the Client
Encik Ahmad (not his real name) is a 56-year-old Malay man living in Km. 12 Air Molek, Melaka. He is admitted in General Hospital Malacca on 09 January 2011 at 10:20AM at male medical ward 3-4. For the past 2 days he was complaining of shortness of breathupon exertion, orthopneic, sore throat and is havinga productive coughwith whitish sputum.The wife was worried of these symptoms because his medical history, decided to go toHospital Malacca. Upon examining, his physician advised him to be admitted to undergofurther investigation.Encik Ahmad has no chest pain, palpitation, syncope attach, loss of consciousness,diarrhoea, abdominal pain, nausea, vomiting, headacheand no other upper respiratory andurinary tract infections. His sputum has no blood stain and tolerating orally well and passingout urine and bowel are normal.
Clinical Examination
On examination, Encik Ismail sitting blood pressure was 138/92mmHg, his pulse andrespiratory rates were 82 bpm and 16 breaths per min., respectively. His body temperaturewas 37.1
°
C;
sPO2 was 96% on 3L/min nasal prong oxygen and blood glucose level of 17.6mmol/L.Encik Ismail was alert, conscious, can speak in full sentences, pink, and his hydrationwas good and not tachypneic. His
C
ardio Vascular System showed S
1
S
2
Dual Rhythm NoMurmur, lung has bibasal crept more on right side, no rhenchi, air entry is equal for bothsides. Jugular vein pressure His abdomen was soft System showed normal.
D
iagnosis
 
After a series of investigation, Encik Ismail was diagnosed with cardiomegaly,fluid overload in
CC
F secondary to non-compliance to fluid restriction and
right andleft pleural effusion
secondary tohypertension
.
Medical History
Encik Ismail is a patient withcomplicated diseases. He is havinghypertension for 1 year, an insulin dependentfor 10 years, right side hemiparesis, and hasischemic heart failure with triple vesseldisease. He has done angiogram clone in IJNand on follow up since November 2010.He is on the following medication for the above diseases and claimed compliance to it but daughter said he is not complying with fluid restriction:
Chest x-ray showing bilateral  pleural effusion
 
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1.
 
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02
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i
mvas
t
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40 mg ON3
.
 
T.
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15
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.
 
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Isord
il
 
1
0 mg
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5.
 
T.
Vas
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are
l
20 mg
T
D
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 6
.
 
T.
C
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dogre
l
7
5
mg OD7
.
 
T.
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sopro
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o
l
 
1.
2
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mg OD8
.
 
T.
D
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gox
i
0
.
062
5
mg OD9
.
 
C
.
Gem
t
obroz
il
300 mg ON
1
0
.
 
T.
Frusem
i
de 40 mg BDHe a
l
so had a mu
lti
 p
l
e adm
i
ss
i
on due
t
o ches
t
pa
i
n a
t
same hosp
it
a
l
and h
i
s
l
as
t
 adm
i
ss
i
on was December 20
1
0 of wh
i
ch he was
t
rea
t
ed w
it
h s
t
ab
l
e ang
i
na
.
 
Surg
ili
ry
 
Enc
i
Ahmad a
l
so has a b
il
a
t
era
l
basa
l
knee ampu
t
a
ti
on
.
H
i
s r 
i
gh
t
 
l
eg was ampu
t
a
t
ed
1
0 years ago wh
il
e h
i
s
l
ef 
t
 
l
eg was ampu
t
a
t
ed 4 years ago
.
 
Fam
il
y H
i
ry
Bo
t
h paren
t
s of Enc
i
k Ahmad have a med
i
ca
l
h
i
s
t
ory of d
i
abe
t
es me
llit
us andhyper 
t
ens
i
on and hear 
t
prob
l
em
.
H
i
s bro
t
hers and s
i
s
t
ers
i
nher 
it
ed
t
he same
.
H
i
s w
i
fe
i
shav
i
ng hyper 
t
ens
i
on and c
l
a
i
med
t
ha
t
h
i
s ch
il
dren are a
ll
hea
lt
hy
.
 
Soc
i
a
l
H
i
ory
Enc
i
k Isma
il
was prev
i
ous
l
y work 
i
ng as Chef 
t
o
S
e
l
angor 
oya
l
Fam
il
y
.
He has 7ch
il
dren and curren
tl
y s
t
ay
i
ng w
it
h h
i
s w
i
fe and 2 ch
il
dren
.
O
t
her ch
il
dren are marr 
i
ed,work 
i
ng and s
t
ay
i
ng on
t
he
i
r own
.
He
i
s non-smoker, non-a
l
coho
l
dr 
i
nker and never use any proh
i
 b
it
ed drugs before
.
Due
t
o h
i
s cond
iti
on (r 
i
gh
t
s
i
de hem
i
 pares
i
s and ampu
t
a
t
ed
l
egs) he
i
s sem
i
dependen
t
 
i
n do
i
ng h
i
s ac
ti
v
iti
es of da
il
y
li
v
i
ng
.
He a
l
so has f 
i
nanc
i
a
l
suppor 
t
from
t
he soc
i
a
l
we
l
fare of 
RM
15
0
.
00
/
mon
t
h
.
 
Food and rug A
ll
rg
i
 
Enc
i
k Isma
il
has noknown a
ll
erg
i
es
.
 
 
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a
¨©  
t
  
dy
   
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©  
ral
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¨ 
i
  
3
 
|
 Pag
e
 
ASS
E
SSM
ENT
OF AC
TVTE
S OF AILY LI
V
I
NG
(AL)
Pa
ti
en
t'
s Name
:
Enc
i
k Ahmad
eg
i
s
t
ra
ti
on No
.
:
6790
1
0
A
TE
 AC
T
I
V
I
T
I
E
S OF AILY LI
V
I
NG
PA
T
I
ENT'
S PROBL
E
MWhat pate
i
nt can or cannot perform byherse
l
f/h
i
mse
l
f AC
TU
AL/PO
TENT
IAL
09
.1.11
 
Ma
i
nta
i
n
i
ng a safe env
i
ronment
t
o
1
4
.1.11
 Bed and bed s
i
de ra
il
are a
l
ways
l
ocked and upaf 
t
er each procedure
/
s
.
 
Ri
sk for 
i
njury re
l
a
t
ed
t
o
i
gh
t
hemepares
i
s and
l
ossof ex
t
rem
iti
es
.
 
Commun
i
cat
i
on
Pa
ti
en
t
 
i
s ab
l
e
t
o
t
a
l
k c
l
ear and
i
n fu
ll
 sen
t
ences
.
 
Breath
i
ng
Pa
ti
en
t
 
i
s hav
i
ng shor 
t
of brea
t
h espec
i
a
ll
ydur 
i
ng exer 
ti
on
.
 Brea
t
h
i
ng pa
tt
ern
i
mpa
i
rmen
t
re
l
a
t
ed
t
o p
l
eura
l
l
u
i
d bu
il
d-up
.
 
E
at
i
ng and r
i
nk 
i
ng
Ri
sk for body nu
t
iti
onexcess re
l
a
t
ed
t
o h
i
ghg
l
ucose
l
eve
l
.
 Pa
ti
en
t
can ea
t
and dr 
i
nk by h
i
mse
l
f and
i
s
t
o
l
era
ti
ng ora
ll
y we
ll
.
 
Eli
m
i
nat
i
ng
Pa
ti
en
t
 
i
s on bed pan and ur 
i
na
l
 
S
e
l
f care def 
i
c
it:
e
li
m
i
na
ti
onre
l
a
t
ed
t
o
li
m
it
ed mob
ilit
yas ev
i
dence by pa
ti
en
t
 
i
shav
i
ng r 
i
gh
t
hemepares
i
sand be
l
ow kneesampu
t
a
ti
on
.
 
Persona
l
c
l
ean
i
ng and dress
i
ng
Pa
ti
en
t
needs he
l
 p
i
n ba
t
h
i
ng, wash
i
ng anddress
i
ng h
i
mse
l
f due
t
o r 
i
gh
t
s
i
de hemepares
i
s
.
 Ba
t
h
i
ng
/
hyg
i
ene def 
i
c
it
 re
l
a
t
ed
t
o
l
oss of ab
ilit
y
t
ouse
t
he r 
i
gh
t
arm and handas ev
i
dence by pa
ti
en
t
 
i
shav
i
ng r 
i
gh
t
hemepares
i
s
.
 

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