Case Study on Pleural Effusion
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.
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
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
ardio Vascular System showed S
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.
After a series of investigation, Encik Ismail was diagnosed with cardiomegaly,fluid overload in
F secondary to non-compliance to fluid restriction and
right andleft pleural effusion
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