1. soft stool and has yellowish urine.

1. Introduction

Ms. Siu Sum Yi, a 67 years old woman, was admitted to hospital A because of chest discomfort. Her blood pressure was 121/66 mmHg, respiration rate was 24 breathes per minute, heart rate was 120 beat per minute and the SaO2 was 94% on 2L nasal O2.  She has productive cough of yellow sputum with streaks of blood and shortness of breath for 3 days presented with feverish, chills, rigors, dizziness, fatigue, general weakness, anxious and had vomited once of clear fluid. She has dyspnea with compressing chest discomfort in the retrosternal region, accompany with sweating.  Her appetite has decreased for 2 months. Her bowel movement is 3 times per week with brownish soft stool and has yellowish urine. Her face was pale and has malar flush, she has edema on sacrum and both lower limbs, palmer erythema, tendon xanthomata and hand tremor.  Besides, she has corneal arcus, lid lag and retraction. She also has nasal obstruction and she has sweating with postnasal drip and goitre. Chest expansion has decreased and has stony dull percussion on right lung base with diminished vesicular breath sound, coarse crackles was auscultated. She has irregularly irregular heartbeats. Holosystolic murmur was auscultated on the mitral and tricuspid area which indicate regurgitation. She has bilateral ankle edema and bilateral metatarsophalangeal joint swelling with pain therefore she couldn’t walk. She always worries about prognosis of her multiple chronic illness and has expressed the concern about the current health issue, she doesn’t want to become a burden to her husband. She is an non-drinker and ex-smoker with 30 packs per year and had quit smoking in 2000. She has lack of exercise and likes fatty and salty food. She had hypertension, diabetes mellitus, rheumatic heart disease and chronic obstructive pulmonary disease. Her family history includes ischemic heart disease, colon cancer and rheumatoid arthritis.

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2. Five Medical Problems of Ms. Siu

2.1 Pneumonia
Pneumonia is an infection that can be caused by bacteria, viruses, or fungi. It causes inflammation in alveoli. The alveoli are filled with fluid or pus, that leads to difficult in breathing (Normandin, B., 2017). Ms. Siu has decreased chest expansion with stony dull percussion on right lung base with diminished vesicular breath sound and crackles were auscultated. In addition, she has productive coughing of yellow sputum with streaks of blood, shortness of breath, fever, sweating, chills, chest pain, respiratory rate above 20 breaths per minute, oxygen saturation below 95 %, oxygen therapy initiated and dyspnoea which are the signs and symptoms of pneumonia (Normandin, B., 2017). Pneumonia may cause dyspneic with compressing chest discomfort in the retrosternal region (Garikiparithi, 2017). In addition, Ms. Siu has heart disease, diabetes and chronic obstructive pulmonary disease which are the risk factors of developing pneumonia (Stöppler, M. C.,2017).

2.2 Rheumatoid Arthritis
Rheumatoid arthritis is a chronic inflammatory and autoimmune disorder that affects different body systems occurs when the immune system attacks own body tissues (Mayo Clinic Staff, 2017). Ms. Siu has joint pain, loss of joint function which she can’t walk due to joint pain, fever, fatigue, general weakness and decreased appetite which are the symptoms of  rheumatoid arthritis. In addition, rheumatoid arthritis may leads to heart problem and lung diseases causing chest pain with shortness of breath or coughing (Shiel, 2017). The risk factors include family history , age between 40-60 and cigarette smoking (Mayo Clinic Staff, 2017).

2.3 Hyperthyroidism
Hyperthyroidism is caused by over production of hormone thyroxine by thyroid gland which accelerate body’s metabolism significantly causing sudden rapid or irregular heartbeat, sweating and nervousness (Mayo Clinic Staff, 2015). Ms. Siu has irregular heartbeat (arrhythmia) and rapid heartbeat of 120 bpm (tachycardia), anxiety, hand tremor, goiter, lid lag, eyelid retraction, sweating, general weakness and fatigue which are the symptoms of hyperthyroidism (Mayo Clinic Staff, 2015).

2.4 Coronary Artery Disease
Coronary artery disease occurs when the arteries that supply blood to heart muscle become damaged and narrowed  due to the buildup of plaque on their inner walls (Mayo Clinic Staff , 2017). Ms. Siu has shortness of breath, chest pain, dizziness, sweating, and tachycardia which are the signs and symptoms of coronary artery disease (Beckerman, 2016). The risk factors include smoking, high cholesterol and diabetes. 

2.5 Heart failure 
Heart failure is the inability of the heart to supply oxygen and nutrients to organs and tissues. This decrease in cardiac output is not enough to circulate the blood returning to the heart from the body and lungs, causing fluid to leak from capillary blood vessels (Kulick, D. L., & Wedro, B., 2017).
Ms. Siu has presented with shortness of breath, fatigue, general weakness, loss of appetite, coughing, pounding or racing heart, problems thinking, swelling in the ankles, chest pain which are the signs and symptoms of heart failure (Oberg, E., & Guarneri, M., 2016). Furthermore, Ms. Siu has tricuspid regurgitation and mitral regurgitation as holosystolic murmurs were auscultated at the tricuspid area and mitral area, and she has lack of exercise which increase the chance of heart failure (Oberg, E., & Guarneri, M., 2016).

3. Investigations for Ms. Siu’s Medical Problems 

3.1 Investigations for pneumonia
Blood test, chest X-ray and CT scan are suggested for investigations for pneumonia. Blood test  such as a complete blood count can help confirm an infection and may identify the cause of infection (Mayo Clinic Staff, 2017). Chest X-ray helps diagnose pneumonia and determine the extent and location of the infection (Mayo Clinic Staff, 2017) . A chest CT scan provides a clearer and more detailed image of the lungs that helps diagnose pneumonia by observing excessive fluids around the lungs  (Normandin, B., 2017).

3.2 Investigations for rheumatoid arthritis
Blood test, x-ray or ultrasound images are suggested for investigations for rheumatoid arthritis. Blood tests are run to look for antibodies and the levels of inflammation. X-rays can help detecting rheumatoid arthritis. Ultrasound scanning can be done to help confirm and judge the severity of rheumatoid arthritis (Murphy, J., 2017).

3.3 Investigations for hyperthyroidism
Thyroid function blood test, ultrasounds and thyroid scan and uptake are suggested. Thyroid function blood test to test for the thyroid stimulating hormone level which controls the production of thyroid hormones can help diagnose hyperthyroidism (Marcin, J., 2016). Ultrasounds can help measure the size of the entire thyroid gland and the masses within it. Ultrasounds can also determine whether a mass is solid or cystic (Marcin, J., 2016). Thyroid scan and uptake can reveal the area of the gland that cause the overactivity (Giorgi, A., & Cherney, K., 2017).

3.4 Investigations for coronary artery disease
Coronary artery disease can by diagnosed by echocardiogram, cardiac catheterization and angiogram and CT scan. Echocardiogram uses sound waves to produce images of the heart which helps determine whether all parts of the heart wall are contributing normally to the heart’s pumping activity (Mayo Clinic Staff, 2017). Cardiac catheterization and angiogram can be done to view the blood flow through the heart, a special dye is injected into coronary arteries. The dye outlines narrow spots and blockages on the X-ray images, a balloon can be pushed through the catheter and inflated to improve the blood flow in the coronary arteries if there is blockage that requires treatment (Mayo Clinic Staff, 2017). CT scan shows the substance in the arteries that can narrow the arteries which help diagnose and determine the cause of coronary artery disease (Mayo Clinic Staff, 2017).

3.5 Investigations for heart failure
Heart failure can be diagnosed by electrocardiogram, blood tests and echocardiography.
Electrocardiogram help assess heart rate, rhythm, and indirectly, the size of the ventricles and blood flow to the heart muscle (Kulick, D. L., & Wedro, B., 2017). Blood tests such as B-type natriuretic peptide (BNP) test helps decide whether patient has shortness of breath from congestive heart failure or from other causes (Kulick, D. L., & Wedro, B., 2017). Echocardiography assess the anatomy and function of the heart which helps evaluate the heart valves and muscle. It allows to look at  the blood flow within the heart and measure the ejection fraction of the heart (Kulick, D. L., & Wedro, B., 2017).

4. Abnormal Findings in Investigations

4.1 Abnormal findings in pneumonia
The elevated of white blood cell count in the complete blood count blood test indicates an infection. Appearance of white spots in the lungs in the chest X-ray indicates an infection (Teague, S., 2017) If there are atoll signs in chest CT scan, the peripheral consolidation represents the organizing pneumonia in the alveolar ducts (Raju, S., Ghosh, S., & Mehta, A. C., 2017).

4.2 Abnormal findings in rheumatoid arthritis
Abnormal blood tests in rheumatoid arthritis include elevated erythrocyte sedimentation rate which confirms the amount of inflammation in the joints (Murphy, J., 2017).

4.3 Abnormal findings in hyperthyroid
For the thyroid function blood test, an abnormally low thyroid stimulating hormone indicates hyperthyroidism (Marcin, J., 2016). An enlarged thyroid may be seen in the ultrasound (Marcin, J., 2016). For the thyroid scan, red spots on the image indicate abnormal growths in the thyroid (Giorgi, A., & Cherney, K., 2017).

4.4 Abnormal findings in coronary artery disease
If the echocardiogram shows parts that move weakly that may be damaged or receiving too little oxygen may indicate coronary artery disease (Mayo Clinic Staff, 2017). The cardiac catheterization and angiogram test can find plaque that are narrow the coronary arteries which indicate coronary artery disease (Pai, R. K., & Philippides, G., 2015). if If a substantial amount of calcium is discovered in the CT scan, it may indicate coronary artery disease (Mayo Clinic Staff, 2017).

4.5 Abnormal findings in heart failure
Pressence of B-type natriuretic peptide in blood test indicates heart muscles are overloaded (Kulick, D. L., & Wedro, B., 2017). For the echocardiogram, the percentage of blood ejected with each beat below 50% indicate heart failure (Kulick, D. L., & Wedro, B., 2017).