PATIENT DETAILS:

NAME: C.K DELA CRUZ

AGE: 4 Years old 9 months
GENDER: Male
BIRTHDAY: June 12, 2013
RELIGION: Jehovah Witnesses
NATIONALITY: Filipino
ADDRESS: San Vicente Sta. Ignacia Tarlac
WEIGHT: 15 Kg

ADMISSION DATE: APRIL 4, 2018

TIME OF ADMISSION: 3:40 PM
ATTENDING PHYSICIAN: Dr. Ma. Rachelle M. Reyes
REFERRAL: Dr. Joseph G. Bautista

CHIEF COMPLAINTS: Cough/ Difficulty of Breathing

HISTORY OF PRESENT ILLNESS:
Started 2 days at cough, non-productive in nature, accompanied by difficulty of breathing. No
fever noted; Patient also experienced slight abdominal pain few days prior to admission. No
vomiting, LBM noted. Ultrasound done on lung and Abdomen-revealed Pleural Effusion with
lungs and ascites.
PAST HISTORY: No previous hospitalization
REVIEW OF SYSTEM: (+) Difficulty of Breathing
FAMILY HISTORY:
(-) Heart Diseases (-) Hypertension (-) Diabetes (-) Asthma
ADMITTING DIAGNOSIS: Pleural Effusion, Ascites

Laboratory Test
1.COMPLETE BLOOD COUNT
2.BLOOD TYPING
3. URINALYSIS
4.WHOLE ABDOMINAL ULTRASOUND
5. CHEST X-RAY AP/L
6. SERUM ELECTROLYTES (SODIUM, POTASSIUM, CHLORIDE)
7. CLOTTING TIME
8. BLEEDING TIME
9. Serum glutamate pyruvate transaminase (SGPT)
10. Serum glutamic oxaloacetic transaminase (SGOT)
11. BLOOD UREA NITROGEN
12. CREATININE
13. KUB ULTRASOUND
14. PERIPHERAL BLOOD SMEAR
15.2D ECHOCARDIOGRAM
16. C-REACTIVE PROTEIN (CRP)
17. ERYTHROCYTE SEDIMENTATION RATE (ESR)

Possible Diagnostic Procedure

Thoracentesis.
A procedure is used to remove fluid from
the space between the lungs and the chest wall called the pleural space. It is done by
inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is
aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up
again and treating the cause of the fluid build-up.
The procedure can also be performed if you have the following conditions:
Asbestos-related pleural effusion
Collagen vascular disease
Drug reactions
Hemothorax
Pancreatitis
Pneumonia
Pulmonary embolism
Pulmonary veno-occlusive disease
Thyroid disease
Collapse of the lung (pneumothorax)

The risks for thoracentesis include excessive loss of blood, fluid re-accumulation,infection,
pulmonary edema, and respiratory distress. So far no serious complications have been
reported.

Introduction of the Client

Juan Dela Cruz (not his real name) is a 4-year-old Filipino man living in Km. 12 Air
Molek, Melaka. He is admitted in General Hospital Malacca on 09 January 2011 at 10:20
AM at male medical ward 3-4. For the past 2 days he was complaining of shortness of breath
upon 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 to
Hospital Malacca. Upon examining, his physician advised him to be admitted to undergo
further investigation.
Encik Ahmad has no chest pain, palpitation, syncope attach, loss of consciousness,
diarrhoea, abdominal pain, nausea, vomiting, headacheand no other upper respiratory and
urinary tract infections. His sputum has no blood stain and tolerating orally well and passing
out urine and bowel are normal.
Clinical Examination
On examination, Encik Ismail sitting blood pressure was 138/92mmHg, his pulse and
respiratory rates were 82 bpm and 16 breaths per min., respectively. His body temperature
was 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 hydration
was good and not tachypneic. His
C
ardio Vascular System showed S
1
S
2
Dual Rhythm No
Murmur, lung has bibasal crept more on right side, no rhenchi, air entry is equal for both
sides. Jugular vein pressure His abdomen was soft System showed normal.