General

Case Study -Tuesday 06092016

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6 Sep 2016 - General
 

A young lady, with background of asthma, was attending to casualty department due to 3 days history of productive cough, increasing shortness of breath and wheeze. On arrival to emergency department, pateint is able to complete a sentence. On examination, her respiratory rate was 20, with oxygen saturation of 93% on room air, blood pressure of 145/85, pulse of 75 beats/minute, and apyrexia. Chest examiation showed generalized widespread wheeze, and some crackles in right lung base. Other physical eaminatoion is unremarkable. Chest x ray done showed consolidation right lower lobe. Her white cell count, neutrophil count, and CRP were slighlty elevated. What is your working diagnosis ?? What is the management plan??

Thanks Kathleen Peralta Yes, the diagnosis will be pneumonia (community acquired pneumonia, with chest x ray finding and elevated white cell count, neutrophil count and CRP), causing the infective exacerbation of asthma. With regards to her community acquired pneumonia, antibiotics are required to treat it, usually by co-amoxiclav, and clarithromycin. In addition, we need to treat her exacerbation of asthma as w...
 (Total 108 words)
I am not a doctor and I already forgot about nursing diagnosis as I'm not using it at work but I would still like to have a go, and see if what i'm thinking is correct. Diagnosis is Pneumonia basing on the Xray result, physical observations and elevated results in the blood tests which are white cell count, neutrophil and CRP. I'm not sure about the management either, but antibiotics would normally be prescribed for this patient, Paracetamol PRN and oxygen? This would be a good inter...
 (Total 113 words)