Pertanyaan
Seorang pasien laki-laki berusia 45 tahun datang ke UGD dengan keluhan demam tinggi (39^circ mathrm(C)) selama 3 hari, batuk berdahak kuning kehijauan, sesak napas, dan nyeri dada yang terasa tajam saat bernapas dalam. Pasien juga mengeluh lemas dan menggigil. Riwayat penyakit menunjukkan merokok berat selama 20 tahun. Hasil pemeriksaan klinis dan laboratorium adalah sebagai berikut: Pemeriksaan Lab & Nilai Normal & Hasil Pemeriksaan Suhu tubuh & 36,5-37,5^circ mathrm(C) & 39^circ mathrm(C) Tekanan Darah & <130 / 85 mathrm(mmHg) & 100 / 60 mathrm(mmHg) Laju Jantung & 60-100 mathrm(kali) / mathrm(menit) & 110 mathrm(kali) / mathrm(menit) Laju Pernapasan & 12-20 mathrm(kali) / mathrm(menit) & 28 mathrm(kali) / mathrm(menit) Saturasi Oksigen (mathrm(SpO)_(2)) & >95 % & 90 % Leukosit & 4.000-10.000 / mu mathrm(L) & 18.000 / mu mathrm(L) C-Reactive Protein (CRP) & <10 mathrm(mg) / mathrm(L) & 120 mathrm(mg) / mathrm(L) Laktat Serum & <2 mathrm(mmol) / mathrm(L) & 3,0 mathrm(mmol) / mathrm(L) Rontgen Dada & & Infiltrat pada lobus kanan bawah paru-paru Kultur Dahak & & Streptococcus pneumoniae, sensitif terhadap levofloxacin Buat analisis SOAP dari kasus tersebut dan jawab pertanyaan berikut: 1. Identifikasi data klinis yang tidak wajar. 2. Jelaskan apa kemungkinan diagnosis yang dapat diberikan. 3. Rekomendasikan strategi farmakologis dan non-farmakologis untuk memperbaiki kondisi pasien.
Jawaban
2. Kemungkinan diagnosis adalah pneumonia komunitas yang disebabkan oleh Streptococcus pneumoniae.
3. Strategi farmakologis termasuk pemberian antibiotik levofloxacin dan antipiretik. Strategi non-farmakologis mencakup hidrasi, istirahat, berhenti merokok, dan latihan pernapasan.
Penjelasan
Step 1:
Identify Abnormal Clinical DataThe examination results show several abnormalities compared to normal values:
- Body Temperature: 39°C (high fever, normal is 36.5–37.5°C)
- Heart Rate: 110 beats per minute (tachycardia, normal is 60–100 bpm)
- Respiratory Rate: 28 breaths per minute (tachypnea, normal is 12–20 bpm)
- Oxygen Saturation (SpO2): 90% (hypoxemia, normal is >95%)
- Leukocytes: 18,000/μL (leukocytosis, normal is 4,000–12,000/μL)
- C-Reactive Protein (CRP): 120 mg/L (elevated, normal is <10 mg/L)
- Serum Lactate: 3.5 mmol/L (elevated, normal is <2 mmol/L)
- Chest X-ray: Infiltrate in the right pulmonary lobe (suggestive of pneumonia)
- Sputum Culture: Streptococcus pneumoniae sensitive to levofloxacin
Step 2:
Possible Diagnosis Based on the clinical data and symptoms (fever, productive cough with yellow-green sputum, shortness of breath, chest pain, weakness, chills), the likely diagnosis is community-acquired pneumonia, possibly caused by Streptococcus pneumoniae.
Step 3:
Recommend Pharmacological and Non-Pharmacological Strategies Pharmacological Strategies:
- Antibiotics: Levofloxacin, as the sputum culture indicates sensitivity.
- Antipyretics: To manage fever, such as acetaminophen or ibuprofen.
- Bronchodilators: If wheezing or bronchospasm is present.
Non-Pharmacological Strategies:
- Hydration: Encourage fluid intake to help thin mucus and prevent dehydration.
- Rest: Adequate rest to support recovery.
- Smoking Cessation: Strongly advise quitting smoking to improve lung health.
- Breathing Exercises: To improve lung function and oxygenation.
Pertanyaan Panas
lebih
a patient with Addison's disease asks the nurse what causes the disease. which is the best response by the nurse? A. "addison's disease is the result
Blood pressure dynamic during exercise
Volumetric Infusion Pump
Treatment - Osteomalacia
in order to determine if Ms. Phillips is a good candidate for the medication, Depo-Provera, the nurse asked Ms. Phillips if she:
what is an efficacious treatment for ASR?
A nurse on a rehabilitation unit is creating a plan of care for a newly admitted client who has difficulty swallowing following a stroke. Which of the
how can estheticians and dermatologists work collaboratively?
A buildup of plaque in the arteries leads to _______.
Some horses are subclinical carriers of this disease(s)?
Synthetic sources of drugs
Dr. Castillo attributes the recovery of Kevin Everette from his spinal cord injury to "the way the quick response team _____________. They __________
Angiographic embolization
A 20-year-old female has a mid shaft humeral fracture. Assessment reveals the presence of wrist drop. What should you suspect?
Patho: Inadequate cardiac output despite sufficient vascular volume