STUDENT NAME : NIK MUHD.

FARIS
D.O.C : 28/12/18

PATIENT’S DETAILS
 Ichan ak Garai
 66 y.o male
 ward 15
 addmited 2 days ago on 26/12/18 wednesday morning.

HISTORY
 chief complain:
◦ increasing shortness of breath for the past 2 days (severe)

PHYSICAL EXAMINATION

 General inspection
◦ patient is lying comfortably at 45 degrees
◦ with an iv canulation on right dorsal hand (normal saline)
◦ there is a usage of accessory muscle
◦ normal speech and thin build
◦ there is metered dose inhalers and nebulisers beside the patient bed.

 Hand
◦ the is fine tremors (usage of beta 2 agonist from inhaler)
◦ slight peripheral cyanosis
◦ pallor
◦ cappilary refills time less than 2s
◦ warm and moist
◦ no clubbing

 Pulse and Respiratory rate

◦ 78 beats per minute
◦ regular rhythm
◦ normal volume
◦ 18 breath per minute

 Head and neck

◦ eyes : conjunctival is pallor but no jaundice
◦ mouth: good oral hygine with dental carries but no central cynosis
◦ neck: JVP is normal

 Chest
◦ Frontal
▪ Inspection
 collar hyperpigmentaion,
 slight barrel chest
 no scars, no trauma , no tattoos
 chest wall movement – right side is a bit lagging (asymmetrical)
  hyperexpanded chest

▪ palpation
 asymetry chest movement (right side is lagging)
 no heave and no palpable P2
 tactile vocal fremitus is the same on both side
 apex beat is not palpable

▪ percussion
 dull on right side (apex and mid lobes)

▪ auscultation
 wheezing ? On the right side of the lung (or it can be ronchi sound?)
 vocal fremitus is normal on both side

◦ Back
▪ Inspection
 hypopigmentation
 no scars or trauma
 kyphosis
 chest wall movement – right side is a bit lagging (asymmetrical)
▪ palpation
 asymetry chest movement (right side is lagging)
 tactile vocal fremitus is increased on right side

▪ percussion
 dull on right side (apex and mid lobes)

▪ auscultation
 wheezing ? On both lungs this time (or it can be ronchi sound?)
 vocal fremitus is increased on both side

 cervical lymph node is not palpable

 no paedal oedema

I would like to comple my exam with :
 Peak flow / lungs funtion test
 FBC
 ABG
 chest x-ray