Case Scenario PLEURAL EFFUSION Phase I.pdf - PLEURAL...

PLEURAL EFFUSION
Phase I
Case Scenario:
A.B., a 40-year-old man, is admitted to your medical floor with a diagnosis of pleural effusion. He
complains of shortness of breath; pain in his chest; weakness; and a dry, irritating cough. His vital
signs are 142/82, 118, respirations are 38 and labored and shallow, 38.9° C. His chest x-ray shows a
large right pleural effusion as well as pneumonic infiltrates in the middle third and lower lobe of the
left lung consistent with pneumonitis.
Activity:
1. Kardexing
2. Carrying out orders
3. Medication Card
4. Therapeutic Sheet
November 22, 2021 at 8am
Doctor’s Order (Kevin Jake Quilala MD)
Impression: Right Pleural Effusion to consider Pneumonia
Please admit patient to ROC under the service of Dr. Glenn Agleo Battad
Secure consent for admission and management
V/S q4 and record
I&O q shift and record
NPO Temporarily
Stat IVF of PNSS 1L x KVO
Give Paracetamol 300 mg IV q4h PRN for Fever
Hook to O2 at 2-3LPM/NC
For:
CBC, Platelet Count
CXR-AP
RAT
Refer accordingly
***For the Laboratory and Diagnostic Test Result please click the link in your HIS.

Patient’s Profile
Name : Antonio De Leon Barreras
Age : 40
Gender : Male
Civil Status : Married
Address: Flora, Sto. Domingo, Ilocos Sur
Room Number : 315
Hospital Number : 2021-10500
Class : Private
Blood Type : O+
Case Progress
November 22, 2021 at 9:00 am
Doctor’s Order (Dr. G. Battad)
For Ultrasound Guided Thoracentesis today at 12nn.
Please Secure Consent
Refer
Case Progress
The physician performs a thoracentesis and drains 1500 mL of fluid. A specimen for culture and
sensitivity (C&S) is sent to the laboratory, and A.B. is started on cefuroxime (Ceftin) 1 g IV piggyback
q8h.
November 22, 2021 at 1pm
Doctor’s Order (Dr. G. Battad)
S/P Ultrasound-Guided Thoracentesis
Specimen for Culture and Sensitivity
Start: cefuroxime (Ceftin) 1 g IV piggyback q8h (infuse 1 g in 100 mL 0.9% NaCl over 30 minutes)
Give tramadol 50mg IV q6h PRN for pain
For repeat CXR tomorrow at 8am.
Refer