PBL

RHM2020
Case writer:
Vien Vinh Phu, MD, MSc
Administration
• Patient’s full name: Tran Thị T., female, 68-year-old
• Occupation: housewife
• Reason of admission: chest pain
History of present illness
• The patient has had high fever accompanied with cough 3 days ago.
• In the morning of hospitalization, patient was very tired and had
difficulty breathing with chest pain. She went to the hospital for
medical examination and admitted.
History of present illness
• 3 days hospitalization, patients had high fever accompanied with cough
yellow sputum. The patient just took antipyretic medication (one tablet
of Paracetamol 500mg ). The fever relieved and went back after about
5 hours. In addition, the patient felt anorexia and tired.
• In the morning of hospitalization, patient was more tired and had
difficulty breathing with chest pain. Patients who had difficulty
breathing in inspiration and expiration. She must lie still for easy
breathing. Chest pain increased with a lot of coughing, it did not radiate
and decreased when the cough was gone.
• Patient coughed about 1ml of solid yellow sputum. She does not sweat
and does not take any more medicine. She went to the hospital for
medical examination and was admitted.
Past history
• Individual: Patient has diagnosed hypertension at Thongnhat Hospital
5 years ago (the highest BP 180 mmHg, normally BP 130 - 140
mmHg). She take the medicine monthly and follow-up the
examination.
• Family: no disease-related records
Clinical examination
• Conscious, fatigue
• Vital signs are as follows: blood pressure 120/80 mmHg, apical heart
rate 84/minute and regular, respiratory rate 24/minute, temperature
390C, SpO2 94%.
• Both lung are resonant by percussion, auscultation reveals crackles
and bubble in both sides of lower lung fields.
• No abnormalities in other organs
Investigations
• Blood counting
• Na+, K+, Cl- , AST, ALT, uremia, Creatinin
• LDL, HDL, Cholesterol, Triglyceride
• Troponin T, CK-MB, NT-proBNP
• ECG, chest X-ray, echocardiography
• Urine test
• Sputum Gram stain and culture
Blood counting
RBC 4.89 M/uL
HGB 14.1 g/d
HCT 42.3 %
MCV 86.4 fL
MCH 28.9 pg
MCHC 33.4 g/dL
WBC 20.00 K/uL
%NEU 81.2 %
%LYM12.4 %
%MONO3.9 %
%EOS2.1 %
%BASO 0.4 %
PLT 200 K/uL
• Na: 140 mmol/l • Uremia: 4.6 mmol/L
K: 3.5 mmol/l Creatinin: 87µmol/L
Cl: 100 mmol/l eGFR: 83.06 ml/min

• AST 36 UI/L • Cholesterol: 4.6 mmol/L

ALT 40 UI/L Triglyceride: 1.3 mmol/L
HDL-C: 1.4mmol/L
• Glycemia: 6 mmol/l. LDL-C: 2.61 mmol/L