The patient is a 77-year-old female who presents with shortness of breath, cough, fever, and weakness for 1-2 weeks. Physical exam reveals decreased oxygen saturation and abnormal lung auscultation. Labs show anemia and leukocytosis. Chest X-ray and ECG are performed. Working diagnoses include severe CAP, pulmonary tuberculosis, and metastatic lung cancer. Treatment includes oxygen, IV fluids, antibiotics, and blood transfusion.
The patient is a 77-year-old female who presents with shortness of breath, cough, fever, and weakness for 1-2 weeks. Physical exam reveals decreased oxygen saturation and abnormal lung auscultation. Labs show anemia and leukocytosis. Chest X-ray and ECG are performed. Working diagnoses include severe CAP, pulmonary tuberculosis, and metastatic lung cancer. Treatment includes oxygen, IV fluids, antibiotics, and blood transfusion.
The patient is a 77-year-old female who presents with shortness of breath, cough, fever, and weakness for 1-2 weeks. Physical exam reveals decreased oxygen saturation and abnormal lung auscultation. Labs show anemia and leukocytosis. Chest X-ray and ECG are performed. Working diagnoses include severe CAP, pulmonary tuberculosis, and metastatic lung cancer. Treatment includes oxygen, IV fluids, antibiotics, and blood transfusion.
The patient is a 77-year-old female who presents with shortness of breath, cough, fever, and weakness for 1-2 weeks. Physical exam reveals decreased oxygen saturation and abnormal lung auscultation. Labs show anemia and leukocytosis. Chest X-ray and ECG are performed. Working diagnoses include severe CAP, pulmonary tuberculosis, and metastatic lung cancer. Treatment includes oxygen, IV fluids, antibiotics, and blood transfusion.
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ARMANIAR/ Female /77 yo/FW 13
Chief Complaint: • Shortness of breath that has increased since 1 day ago.
Present Illness History
• Shortness of breath that has increased since 1 day ago.
• Shortness of breath is felt since 1 week ago. Shortness of breath is not influenced by activity, weather and food. • There is a cough, felt since 1 week ago, coughing up phlegm. Phlegm is difficult to expel. • Fever since 1 week ago, fever is not high, fluctuates, sometimes sweats and is not accompanied by chills. • Body feels weak and lethargic since 2 weeks ago • Loss of appetitate since got sick. • Nausea and vomiting are absent. • Pain in the back since 1 year ago. Both legs are difficult to walk • There are no complaints about defecation and urination Past illness history
• History of antituberculosis drugs (-)
• History of trauma (-) • Hypertension (-) • Diabetes Mellitus (-) Physical Examination VII
• General Appearance : Severe
• Consciousness level: Comosmentis
• BP : 145/89mmHg
• HR : 106 x/minute
• RR : 30 x/minute
• T : 38º C
• SpO2 : 95% via NRM 15 lpm
• Eye VII – Conjunctiva anemic (+/+) – Icteric sclera(-/-) • Neck – JVP 5+0 cmH20 • Mouth – Gum bleeding (-) – Tongue : deviation (-) • Lung: – Inspection: statically & dynamically symmetric – Palpation: fremitus right = sinistra – Percussion: flat in RIC V in hemithorax bilateral VII – Auscultation: breath sound: Bronkhovesikuler, Ronkhi +/+, Wh -/+, • Cor: – Inspection: ictus is not seen. – Palpation: ictus is palpated at 1 finger medial LMCS ICS V – Percussion: • Left border: 2 finger lateral LMCS ICS V • Right border: linea sternalis dextra • Upper border: ICS II – Auscultation: BJ I and II regular, murmur (-) • Abdomen: VII – Inspection: enlargement (-) – Palpation: soepel, hepar and lien are not palpable – Percussion: tymphani, Shifting dullness (-), ascites (-) – Auscultation: bowel sound (+) normal
