Case Series

Case Series
Community Acquired Pneumonia

CASE 1
CAP-LR
GENERAL DATA
• F.S, is 26 years old female, unemployed, Iglesia
ni Cristo, born on May 21, 1991 in Zamboaga
del sur, currently residing in Novaliches
Quezon City, consulted for the 1st time in our
institutioin
CHIEF COMPLAINT
• Productive cough
HISTORY OF PRESENT ILLNESS
• 11 days prior to consult, patient felt itchiness of the throat
causing nonproductive cough without associated fever,
nausea, vomiting and difficulty of breathing. It was
associated with sore throat and colds. No medication taken.
No consult done.
• 3 days prior to consult, persistence of cough now

productive with yellowish in color prompted patient to self
medicate with Mucofoss Forte 3 times daily.
• 6 hours prior to consult, patient had persistence of

productive cough not relieved by Mucofoss prompted
consult in our institution
PAST MEDICAL HISTORY
• (-) Measles • (-) Dm
• (+) Mumps • (-) Hypertension
• (-) Chicken pox • (-) Ptb
• (-) Surgery • (-) Pneumonia
• (+) Hospitalization – UTI • (-) Goiter
(2007 at Zamboanga • (-) Malignancy
general hospital) • (-) Blood transfussion
• (-) Heart disease • (-) Accident
• (-) Allergies drugs and • (-) Trauma
foods
• (-) Asthma
FAMILY HISTORY
• (+) Hypertension – • (-) Hepatitis
maternal • (-) Pneumonia
• (-) Asthma
• (+) DM – maternal
• (-) Allergy
• (-) Malignancy
• (-) Goiter
• (-) PTB
PERSONAL AND SOCIAL HISTORY
• Oldest of the 7 siblings
• College graduate
• Community facilitator assistant
• Vegetables, meats and rice
• Mineral
• No history of smoking and alcohol intake
OB GYNE HISTORY
• M – 11 years old
• I – 30 days
• D – 3 – 5 days
• A – 4 pads/day
• S - (-)
• LMP: April 20, 2017

REVIEW OF SYSTEM:
• General: (-) Weight loss, (-) weight gain, (-) fever, (-) chills, (-)
fatigue, (-) insomnia, (-) loss of appetite, (-) night sweats
• Skin: (-) Color change, (-) sores, (-) rash, (-) itching, (-) scaling, (-)
bleeding
• Head: (-) Headache, (-) trauma, (-) stiffness
• Eyes: (-) Corrective lenses, (-) pain, (-) diplopia, (-) itch, (-) blurring of
vision, (-) dryness, (-) redness
• Ears: (-) pain, (-) tinnitus
• Nose: (-) Colds/ nasal stuffiness, (-) bleeding, (-) dryness, (-)
discharge, (-) pain, (-) sneezing
• Mouth: (-) Bleeding gums, (-) soreness, (-) ulcers, (-) hoarseness, (-)
pain, (-) dryness
• Respiratory: (-) Cough, (-) chest pain, (-) dyspnea, (-) hemoptysis
• Cardiovascular: (-) Chest pain, (-) dyspnea, (-) PND, (-) orthopnea, (-)
palpitations
• Gastrointestinal: (-) Anorexia, (-) dysphagia, (-) hematemesis, (-)
nausea, (-) vomiting, (-) hematochezia. (-) melena, (-) diarrhea
• Genitourinary: (-) Dysuria, (-) hematuria, (-) nocturia, (-) retention,
(-) incontinence, (-) frequency, (-) urgency, (-) discharge
• Musculoskeletal: (-) Pain, (-) weakness, (-) tenderness, (-) cramps, (-)
trauma, (-) joint - pain, (-) backache, (-) stiffness
• Endocrine: (-) Polyuria, (-) polydipsia, (-) polyphagia, (-) cold
intolerance, (-) heat intolerance
• Hematologic: (-) Pallor, (-) easy bruising
• Nervous: (-) Syncope, (-) seizure, (-) dizziness, (-) tremor
• Psychiatric: (-) Sleep disturbance, (-) depression, (-) hallucination
PHYSICAL EXAMS
• Conscious, coherent not in cardiorespiratory distress
• BP: 110/80
• PR: 106
• RR: 19
• T: 36.5
• O2 Sat: 99%
• Height: 152cm
• Weight: 43kg
• BMI: 18.61
PHYSICAL EXAMS
• SKIN: fair, no lesion, no masses, warm to touch
• HEENT: anicteric sclera, pink palpebral conjunctiva, no
nasoaural discharge, no tonsillopharyngeal congestion, no
cervical lymphadenopathy
• CHEST AND LUNGS: symmetrical chest expansion, no
retraction, no logging, clear breath sound
• HEART: Adynamic precordium, normal rate regular rhythm, no
murmur
• ABDOMEN: Flat abdomen, Normoactive bowel sound, non-
tender
• EXTREMITIES: Grossly normal extremities, no edema, no
pallor
ASSESSMENT
• Community Acquired Pneumonia Low Risk
PLAN
• For Chest X-ray Posteroanterior view
• Start Clarithromycin 500 mg/tab twice a day
for 7 days
• Multivitamins 1 tab once a day
• Increase oral fluid intake
Community Acquired Pneumonia
– Medium Risk
Case No. 2
Michael Jay Linebarger
General Data:
• G.E.
• 53 year old
• Female
• Married
• Employed
• Filipino
• Roman Catholic
• Born on February 11, 1963 at Romblon
• Currently residing at ALL 85 Blk 4 Gk Sitio Pajo, Baesa,
Quezon City
• Consulted for the first time in our institution last April, 18,
2017
Chief Complaint:
• Chest Pain
History of Present Illness
• Two weeks prior to consult, while patient was
sleeping in a side-lying position, her son fell on
her. Patient experienced chest pain with a
pain scale of 8/10, radiating to the back and
right upper quadrant of her abdomen. It was
not associated with fever, difficulty of
breathing, weakness, nausea and vomiting. It
was minimally relieved by rest.
• Four days prior to consult, still with the chest
pain, it was now associated with
undocumented fever, shortness of breath,
headache, and weakness. Patient took
Paracetamol (unknown dose and frequency)
which afforded relief of symptoms.
• One day prior to consult, still with the above
symptoms, patient started experiencing
dysphagia.
• Due to persistence of symptoms, patient
sought consult at our institution.
Past Medical History
• Claims complete childhood vaccines
• Childhood illnesses (unknown ages):
– (+) Measles
– (+) Mumps
– (+) Chickenpox
• No history of hospitalizations, surgeries, accidents,
trauma, or blood transfusions
• No history of allergies to drugs or food
• Diagnosed hypertensive (2015) – controlled
– Amlodipine 5mg OD
• No history of diabetes, asthma, goiter, or PTB
Family History
• (+) Asthma (maternal side)
• No other family history of heredofamilial
diseases such as hypertension, diabetes,
goiter, or malignancies
• No family history of communicable diseases
such as PTB or pneumonia
Personal and Social History
• 6th among 9 siblings
• Elementary graduate
• Worked as a labandera for more than 10 years
• Has 4 children
• Currently lives in a house made of stone, 1 room, with 3
windows and 1 bathroom, manual flush type toilet
• Water supply from NAWASA
• Eats 2 times a day and consumes 2 cups of rice per meal
• Drinks 2-3 cups of coffee a day
• Garage collected twice a week.
• Non-smoker, non-alcoholic drinker, denies any illicit drug
use
OB-Gyne History
• Menarche: 16 years old
• Interval: regular (28-30 days)
• Duration: 3 days
• Amount: 4 pads a day (moderately soaked)
• Symptoms: Dysmenorrhea
• Menopause: 46 years old
Obstetrical Score
• G4P4
– G1: 1990 – NSD (Jose Reyes Hospital)
– G2: 1992 – NSD (house delivery)
Review of Systems
General
• No weight loss, no weight gain, no fever, no chills, no
fatigue, no insomnia, no loss of appetite, no night sweats
Skin
• No color changes, no sores, no rashes, no itching, no
scaling, no bleeding
Head
• No headache, no trauma, no stiffness
Eyes
• No eye pain, no diplopia, no itch, with blurring of vision, no
dryness, no redness
Review of Systems
Ears
• No ear pain, no tinnitus
Nose
• No colds, no nasal bleeding, no dryness, no nasal
discharge, no nasal pain, no sneezing
Mouth
• No bleeding gums, no soreness, no ulcers, no
hoarseness
Cardiovascular
• No chest pain, no dyspnea, no PND, no orthopnea, no
palpitations
Review of Systems
Gastrointestinal
• No anorexia, no dysphagia, no hematemesis, no
nausea, no vomiting, no hematochezia, no melena, no
diarrhea
Genitourinary
• No dysuria, no hematuria, no nocturia, no retention,
no incontinence, no frequency, no urgency, no
discharge
Musculoskeletal
• No pain, no weakness, no tenderness, no cramps, no
trauma, no joint pain, no backache, no stiffness
Review of Systems
Endocrine
• No polyuria, no polydipsia, no polyphagia, no
cold intolerance, no heat intolerance
Hematologic
• No pallor, no easy bruising
Nervous
• No syncope, no seizures, no dizziness, no
tremor
Physical Examination
• Patient is conscious, coherent, ambulatory,
not in cardiorespiratory distress
• Vital signs:
– BP: 140/80 mmHg
– PR: 90 bpm
– RR: 20 cpm
– T: 36.8 C
• SKIN: Brown, no lesions, no masses, soft,
warm to the touch
• HEENT: Anicteric sclera, pink palpebral
conjunctiva, no nasoaural discharge, no
tonsillopharyngeal congestion, no cervical
lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest
expansion, no retraction, no lagging, clear
breath sounds, (+) pain on right side of chest
• HEART: Adynamic precordium, normal rate,
regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel
sounds, soft, (+) tenderness on the right upper
quadrant
• EXTREMITIES: Grossly normal extremities, no
deformities, no cyanosis, no pallor, no edema
Salient Features
• Chief Complaint: Chest pain
– with a pain scale of 8/10, radiating to the back and right
upper quadrant of her abdomen
• Associated symptoms:
– Fever, Shortness of breath, Headache, Weakness,
Dysphagia
• Diagnosed hypertensive (2015) – controlled
• Family history: (+) Asthma (maternal side)
• Physical Examination
– (+) pain on right side of chest
– (+) tenderness on the right upper quadrant
Clinical Impression
• T/C musculoskeletal strain;
• R/O fracture
• R/O IHD
Plan
• For Chest x-ray – PA view
• For 12L ECG
• Start
– Eperisone 50mg, 1 tablet TID for 4 days
– Celecoxib 200mg, 1 tab BID for 4 days then as needed for
pain
– Vitamin B complex, 1 tablet before bedtime
• Avoid lifting heavy objects
• Proper body mechanics
• Avoid pressure manipulation
• Follow-up on 4/21/2017 with results
Progress Notes: 04/21/17
Subjective:
• (+) chest pain • (-) colds
• (+) shortness of breath • (+) easy fatigability
• (+) night sweats • (-) dysphagia
• (-) night fever • Patient verbalized
• (+) orthopnea change in voice
character
• (+) nonproductive
cough
12L ECG results: 04/18/17
• P-Wave: Discernible
• QRS Complexes: Poor R wave progression
• ST Segment: Isoelectric
• T-Wave: Upright
Interpretation:
• Sinus tachycardia
• Poor R wave progression
Chest X-Ray – PA view results: 04/18/17
• Findings
– Hazy densities are seen in right upper and both lower
lobes
– Heart is not enlarged
– Aorta is prominent
– Diaphragm sulci and bony thorax are intact
• Impression
– Pneumonia, right upper and both lower lobes
– Atheromatous aorta
Chest X-Ray – PA
view results:
04/18/17
Objective:
• Vital signs:
– BP: 110/70 mmHg
– PR: 124 bpm
– RR: 30 cpm
– T: 36.3 C
– O2: 96%
Objective:
• SKIN: Brown, no lesions, no masses, soft, warm to the
touch
• HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasoaural discharge, no tonsillopharyngeal congestion,
no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion,
4x4cm Mass above right sternal area, tender,
erythematous, no discharge, non-movable, no
retraction, no lagging, clear breath sounds, equal
tactile fremitus, (-) bronchophony, (-) egophony
Objective:
• HEART: Adynamic precordium, tachycardic,
sounds, soft,
Assessment:
• CAP-MR
Plan:
• Start
– Azithromycin 500mg/tab, 1 tab OD for 3 days
– Co-Amoxiclav 625mg/tab, 1 tab TID for 7 days
– Erdosteine 300mg/cap, 1 cap BID for 5 days
– Multivitamins tab, 1 tab OD
• Continue
– Vitamin B complex tab, 1 tab at bedtime
• Therapeutic lifestyle changes
• To come back after 3 days
Subjective:
• (+) slight shortness of breath
• (+) loss of appetite
• (+) intermittent cough, non-productive
• (+) easy fatigability
• (-) chest pain
• (-) orthopnea
• (-) fever
Objective:
• Vital signs:
– BP: 130/70 mmHg
– PR: 110 bpm
– RR: 25 cpm
– T: 36.6 C
– O2: 98%
Objective:
• SKIN: Brown, no lesions, no masses, soft, warm to the
touch
• HEENT: Anicteric sclera, pale palpebral conjunctiva, no
nasoaural discharge, no tonsillopharyngeal congestion,
no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion,
elevated mass, firm, nontender, erythematous, on the
sternal area above right sternal area, tender,
erythematous, decreased breath sounds on right
posterior lung field no retraction, no lagging,
Objective:
sounds, soft, non-tender
Assessment:
• CAP-MR: resolving
• Hypertension St. II
Plan
• Continue
– Co-Amoxiclav 625mg/tab, 1 tab TID for 4 more days
– Erdosteine 300mg/cap, 1 cap BID for 2 more days
– Vitamin B complex tab, 1 tab OD
• Start
– Amlodipine 5mg/tab, 1 tab OD then shift to metoprolol 50mg/tab, 1
tab OD
• Daily BP measing
• To come back after 3 days (April 27, 2017)
Subjective:
• (+) shortness of breath (improved)
• (+) appetite improvement
• (+) cough, non-productive
• (-) chest pain
• (-) orthopnea
• (-) fever
• (+) PND – 2 nights
Objective:
• Vital signs:
– BP: 120/70 mmHg
– PR: 112 bpm
– RR: 23 cpm
– T: 36.8 C
– O2: 97%
Objective:
• SKIN: Brown, no lesions, no masses, soft, warm
to the touch
• HEENT: Anicteric sclera, slightly pale palpebral
lymphadenopathy
expansion, decreased breath sounds on right
posterior lung field, no retraction, no lagging,
Objective:
deformities, no cyanosis, no pallor, no edema,
full equal pulses
Assessment:
• Hypertension St. II – controlled
• R/O IHD
• CAP-MR – resolving
• STR (soft tissue rheumatism)
Plan
• For 2D-Echo
• For crea, RBS, SQPT, SGOT, Sodium, potassium, lipid profile
• Continue:
– Metoprolol 50mg/tab, 1 tab OD
– Vitamin B complex tab, 1 tab OD
• Start:
– Celecoxib 200mg/tab 1 tab BID for pain
• Daily blood pressure monitoring
• Follow up after 5 days (05/02/17) with results
Subjective:
• (+) difficulty of breathing (improved)
• (+) cough – productive, whitish
• (+) chest pain (when coughing)
• (-) orthopnea
• (-) fever
• (+) PND – 5 nights
• (+) foot pain – right side
Clinical Chemistry Results: 05/02/17
Parameter Results Reference Range
Fasting Blood Sugar 24.29 mmol/L 3.89 – 5.83
Creatinine 0.95 mg/dl Women: 0.6 – 1.1
Total Cholesterol 4.12 mmol/L 3.04 – 5.20
Triglycerides 1.01 mmol/L 0.0 – 2.26
HDL 1.726 0.918 – 2.067
LDL 1.93 mmol/L Les than 3.38
VLDL 0.46 mmol/L 0.0 – 1.4
Sodium 129.2 mmol/L 136 – 148
Potassium 6.01 mmol/L 3.50 – 5.30
SGPT (ALT) 21.0 U/L F: <34
SGOT (AST) 14.0 U/L F: <31
Objective:
• Vital signs:
– BP: 110/80 mmHg
– PR: 89 bpm
– RR: 19 cpm
– T: 36.8 C
– O2: 96%
Objective:
to the touch
• HEENT: Anicteric sclera, slightly pale palpebral
lymphadenopathy
expansion, decreased breath sounds on right
posterior lung field, no retraction, no lagging,
Objective:
full equal pulses
Assessment
• Diabetes Mellitus type II, uncontrolled
Plan
• For referral to IM-OPD for further Evaluation
and management of Diabetes Mellitus type II,
uncontrolled
• Suggest insulin
• Back to FM for final disposition
IM-OPD Referral: 05/04/17
Assessment:
• DM uncontrolled type II
• Allergic cough
• Hypertension Stage II – controlled
IM-OPD Referral: 05/04/17
Plan
• Start
– NaCl tab, 1 tab TID for 6 doses
– Insumma 70/30 “15” u OD before breakfast
– Cetirizine 40mg/tab, 1 tab OD at bedtime for 5
days
• Continue present meds
• For BUN, crea, HbA1C, Na, K, CBC, Urinalysis,
Subjective:
• (+) Productive cough – whitish
• (+) Chest pain (while pain)
• (+) Difficulty of breathing (intermittent &
improved)
• (-) Fever
• (-) Back pain
Clinical Chemistry:
Parameters Results Reference
BUN 3.0 mmol/L 1.7 – 8.3
Creatinine 78 umol/L 53 – 115
HBAIC 11.8% 4.2 – 6.2%
Sodium 130.7 mmol/L 135 – 148
Potassium 4.38 mmol/L 3.50 – 5.30
Objective:
• Vital signs:
– BP: 140/80 mmHg
– PR: 90 bpm
– RR: 20 cpm
– T: 36.6 C
Objective:
to the touch
lymphadenopathy
expansion, decreased breath sounds on right lung
field, no retraction, no lagging,
Objective:
full equal pulses
Assessment:
• CAP-MR
• DM Type II
Plan
• For chest x-ray PA view
• For observation while awaiting lab results
Chest X-Ray PA View: 05/11/17
• Results
– Hazy densities are seen in the right upper and lower lobes
– Reticular densities are seen in the left upper lobes
– The heart is enlarged with left ventricular form
– The aorta is atheromatous
– The right costophrenic sulcus is obscured
– Osseous structures are unremarkable
• Impression:
– PTB vs. Pneumonia, right upper and lower lobes
– PTB, left upper lobe
– Left ventricular cardiomegaly
– Atheromatous aorta
– Minimal pleural effusion vs thickening, right
Chest X-Ray PA View:
05/11/17
Assessment:
• CAP-MR
• PTB presumptive
• DM Type II
Plan
• Still for 2D echo
• For DSSM
• Start
– Sultamicillin 750mg/tab, 1 tab BID for 7 days
– Cefuroxime 500 mg/tab, 1 tab BID for 7 days
• Continue
– Metoprolol 50mg/tab, 1 tab OD
– Insuman 70/30 15 “u” OD before breakfast
• Respiratory etiquette
• Follow up after 5 days with lab results
Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) fever
• (-) back pain
DSSM Sputum Exam Result: 05/16/17
Smear Microscopy
Specimen 1 2
Visual appearance Salivary Salivary
Reading 0 0
Lab. Diagnosis Negative
Objective:
• Vital signs:
– BP: 120/80 mmHg
– PR: 88 bpm
– RR: 18 cpm
– T: 36.9 C
Objective:
to the touch
• HEENT: Anicteric sclera, pale palpebral
lymphadenopathy
field, no retraction, no lagging, (+) crackles, right
middle to base of lung
Objective:
full equal pulses
Assessment:
• PTB clinically diagnosed
• DM Type II
Plan:
• Still for 2D Echo
• For repeat FBS, Creatinine
• Start:
– Clarithromycin 500mg/tab Q12 for 7 days
– Endostein 300mg/cap BID for 5 days
– Multivitamins + minerals 1 tab OD
• Continue
– Insuman 70/30 15 “u” OD before breakfast
• For referral to TB DOTS for evaluation and management
• Follow up after 4 days (05/23/17)
Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) abdominal pain
• (-) back pain
Objective:
• Vital signs:
– BP: 130/80 mmHg
– PR: 94 bpm
– RR: 19 cpm
– T: 36.9 C
Objective:
to the touch
• HEENT: Anicteric sclera, pale palpebral
lymphadenopathy
field, no retraction, no lagging,
Objective:
full equal pulses
Assessment:
• PTB clinically diagnosed
• DM Type II
Plan:
• Still for 2D Echo
• Still for repeat FBS, Creatinine
• Continue present meds
• Still for referral to TB DOTS for evaluation and
management
CASE 3
BORROWED CASE
GENERAL DATA
• This is a case of N.M. 62 year old, male,
single, student, Filipino, Catholic, born on
February 9, 1995 in Makati City, currently
residing at 165 Ilocos Sur St. Bagong
Bantay, Quezon City, consulted for the
first time in QCGH-OPD Family Medicine
on May 3, 2017.
Chief complaints
• No subjective complaints
• For Medical Certificate
History of present illness
• Patient came in apparently well requesting for
medical certificate for school requirement.
Past medical history
• Patient claimed to have complete childhood
immunization. He had chickenpox last 2016
and measles when he was 2 years old. No
other childhood illnesses noted. No history of
hypertension, diabetes, asthma, previous
hospitalization, previous surgery and blood
transfusion. No known allergy to food or
medications.
Family medical history
• The patient father is deceased with history of
diabetes. The patient mother is 69 y/o with
history of hypertension. No history of other
heredofamilial diseases as to goiter, asthma
and malignancies.
Personal and social history
• Patient is a highschool graduate. Patient lives in a two
storey concrete house with his 6 siblings and his
parents. Patients house has 4 bedrooms, 6 windows,
and 1 bathroom. Their water source is Maynilad.
• Patient eats two times per day and prefers to eat rice,
meat and vegetables. He usually drinks 5 glasses of
water per day and 5 cups of coffee per day.
• The patient usually dances ad a form of exercise.
• He is an occasional smoker, non-alcoholic beverage
drinker and denies illicit drug use.
REVIEW OF SYSTEMS
General: (-)chills (-)weight gain/loss (-)fever (-) fatigue
Skin: (-) color change (-) rash (-) itching (-) sores
(-)bleeding (-)scaling
Head: (-) Stiffness (-) headache
Eyes: (-) Blurring of vision (-) Pain(-) Itch (-) Dryness
(-)Redness
Ears: (-) Pain (-) Tinnitus
Nose: (-) Nasal stuffiness (-) bleeding(-) discharge (-) pain
Mouth: (-) bleeding gums (-)soreness (-) ulcer(-)
hoarseness
REVIEW OF SYSTEMS
Cardiovascular:( -) Chest pain (-) Orthopnea (-) PND
(-) Palpitation
GIT:(-) nausea/ vomiting (-) Diarrhea (-)Constipation
(-) Melena (-)diarrhea (-) constipation
Hematologic: (-) Easy bruisability (-) epistaxis
Endocrine: (-) Polyphagia (-) Polydipsia (-) Polyuria
(-) heat/ cold intolerance (-) Exophthalmos
Neurologic: (-) Tingling sensation(-) Numbness
(-) tremors
Musculoskeletal: (-) Joint pain (-) weakness (-) stiffness
Psychiatric: (-)depression (-) sleep disturbance
(-) hallucination
Physical examination
• GENERAL: Patient is conscious, coherent, not in
cardio respiratory distress
• VITAL SIGNS:
– BP:130/90mmHg
– HR: 94 bpm
– RR: 18 cpm
– Temp:37.1 C
• ANTHROPOMETRIC MEASUREMENTS:
– Wt: 61 kg
– Ht: 160 cm
– BMI:23.8 (Normal)
• SKIN: Skin is fair in color, warm to touch, with
good skin turgor. The nails are trimmed, with
capillary refill time of <2secs. No lesions, no
scaling or thickenings noted.
lymphadenopathy
• Chest&Lungs: Symmetrical chest expansion, no
retractions, no lagging, vesicular breath sounds
• HEART: Adynamic precordium, PMI at 5th ICS,
LMCL, normal rate, regular rhythm, no murmur
cyanosis, no edema, no pallor, full equal
peripheral pulses. No limitations in doing the
range of motions.
ASSESSMENT
• T/C Essentially well adult at the time of

examintation
PLAN
• For Chest Xray- PA
• For CBC with PC and Urinalysis
• TCB once with results
• Advised
Second Hospital visit
• May 9, 2017
• S> Patient came in for follow up check up with

lab results of CBC and CXR, awaiting for UA
result. Patient was last seen May 3, 2017 with
the diagnosis of EWA at time of consultation.
No subjective complaints as to cough, fever,
DOB, chest pain and easy fatigability.
• CBC
RBC 4.80 WBC 7.59
HGB 150 NEUTROPHILS 63.1
HCT 0.452 LYMPHOCYTES 30.4
PLATELET 267 MONOCYTES 3.9
EOSINOPHILS 1.8
BASOPHILS 0.8
• CHEST XRAY
–Pneumonia, Right Middle Lobe
• O> Patient is conscious, coherent, not in cardio
respiratory distress
• VITAL SIGNS:
– BP:140/90mmHg HR: 91 bpm RR: 18 cpm Temp:36.8 C
• SKIN: Skin is fair in color, warm to touch, with good
skin turgor. The nails are trimmed, with capillary refill
time of <2secs. No lesions, no scaling or thickenings
noted.
lymphadenopathy
• Chest&Lungs: Symmetrical chest expansion, no
retractions, no lagging, vesicular breath sounds
• HEART: Adynamic precordium, PMI at 5th ICS,
LMCL, normal rate, regular rhythm, no murmur
cyanosis, no edema, no pallor, full equal
peripheral pulses. No limitations in doing the
range of motions.
• A> CAP- LR
Hypertension Suspect
• P> Low Salt Low fat diet

For Na, K, BUN, Crea, ECG, FBS, Lipid Profile,
SGOT, SGPT
Start Co amoxiclav 625mg TIDx 7days
B- Complex tablet OD
For BP Monitoring
TCB on May 17, 2017 with lab results
Advised
Epidemiology, Anatomy and
Physiology
By: DE ASIS, Ariane C.

EPIDEMIOLOGY
• Pneumonia affects 450 million people a year and
occurring in all parts of the world
• CAP results in more that 1.2 million hospitalizations and
more than 55,000 deaths annually
• 80% - treated as outpatient
» < or = 1% mortality rate
• 20% - treated as inpatient
» 12-40% mortality rate
• Major cause of death among all age groups resulting in 4
million deaths
– Children <5 years old
– Adults older than 75 years old
• Pneumonia is the leading cause of death in the
developing country
• RISK FACTORS:
– Alcoholism
– Asthma
– Immunosuppression
– Institutionalization
– Age > or = 70 years old
ANATOMY
PHYSIOLOGY
• Molecules of oxygen and
carbon dioxide are passively
exchanged by diffusion
• CO2 moves into the alveolus
as the concentration is
much lower than in the
blood
• O2 moves out of the
alveolus as the continuous
flow of blood through the
capillaries prevents
saturation of the blood with
O2
Pathophysiology
• Pneumonia results from the proliferation of
microbial pathogens at the alveolar level and the
host’s response to those pathogens
• when the capacity of the alveolar macrophages
to ingest or kill the microorganisms is exceeded
does clinical pneumonia become manifest
• host inflammatory response, rather than the
proliferation of microorganisms, triggers the
clinical syndrome of pneumonia
Respiratory tract defence mechanisms
Factors that render the person
susceptible to infection
1.Alteration of normal oropharyngeal
flora.
2.Depressed Cough and glottis reflexes.
3.Altered consciousness.
4.Impaired mucociliary apparatus
mechanism
5.Alveolar macrophage dysfunction.
6.Immune dysfunction.
release of inflammatory mediators
peripheral leukocytosis increased purulent

secretions, alveolar capillary leak
Decrease compliance
Hypoxemia
Increased respiratory drive
respiratory alkalosis
Decrease lung volume
intrapulmonary shunting of blood
Death
PATTERNS OF PNEUMONIA
1. LOBAR PNEUMONIA (Typical pathological changes seen in

patients w/ pneumonia caused by Strep.Pneumonia)
A. Congestion
• Usually seen in the 1st 24 hours
• Not usually seen by the physician
• Grossly appears red & doughy
• Microscopically: (+) vascular congestion & alveolar
edema + microorganism can spread via pores of Kohn
(within the alveoli)
B. Red Hepatization
• After 24 hours to 2 days
• Inflammatory mediators cause leakiness of the alveolar capilliary causing the
RBC to be able to get through the alveoli including the neutrophils
• Many RBC, neutrophil, desquamated epithelial cells & fibrin
C. Gray Hepatization
• Last 2-3 days
• Lung is dry, friable and gray-brown to yellow as a consequence of a persistent
fibrinopurulent exudates, progressive disintegration of RBC, hemosiderin,
marcophages and neutrophills.
• No RBC but lot of fibrin, start of the rebuilding / reconstitution of the lung
D. Resolution
• Enzymatic digestion of alveolar exudates, resorption and phagocytosis
• Lots of phagocytes, cleans up the debris
• After this, patient recovers from pneumonia
PATTERNS OF PNEUMONIA
2. Bronchopneumonia-margin usually poorly
demarcate neutrophilic infiltrates center in
bronchi, and bronchiole
3. Interstitial pneumonia- inflammation in the

interstitial space alveolar wall and connective
tissue space.
• 4. Miliary Pneumonia
Etiology
Routes of Micro-organism
1. Inhalation of microbes present in the air

TB,SARS, Legionella, Meningococcemia
2. Aspiration of organism from the naso or
oropharynx (most common route)
3. Hematogenous spread
4. Direct spread from a contiguous site of
infection or penetrating injury
Community Acquired Pneumonia Community Acquired Pneumonia
(Typical) (Atypical)
a) Steptococcus pneumoniae (a) Mycoplasma pneumoniae
b) Haemophilus influenza (b) Chlamydia pneumoniae
c) Sterptococcus aureus (c) Chlamydia psittaci
d) Moraxella catarrhalis (d) Chlamydia trachomatis
(e) Coxiella burnetti
e) Klebsiella pneumoniae
(f) Respiratory syncytial virus
f) Legionella pneumophila
(g) Influenza A and B virus
(h) Adenovirus
(i) Parainfluenza virus
Clinical Manifestation
Symptoms
• vary from indolent to fulminant in presentation and from mild
to fatal in severity
• frequently febrile with tachycardia or may have a history of
chills and/or sweats.
• Cough may be either nonproductive or productive of mucoid,
purulent, or blood-tinged sputum.
• Gross hemoptysis is suggestive of CA-MRSA pneumonia. If the
pleura is involved, the patient may experience pleuritic chest
pain
Physical examination
• degree of pulmonary consolidation and the presence or
absence of a significant pleural effusion.
• An increased respiratory rate and use of accessory muscles of
respiration are common.
• Palpation may reveal increased or decreased tactile fremitus,
and the percussion note can vary from dull to flat, reflecting
underlying consolidated lung and pleural fluid, respectively.
• Crackles, bronchial breath sounds, and possibly a pleural
friction rub may be heard on auscultation
Diagnostic Examinations
Can CAP be accurately diagnosed with
history and physical examination?
• The accuracy of predicting CAP by physician‘s
clinical judgement is between 60-76% (Grade
B)
• Clinical prediction rules combining history and
physical examination maybe utilized to
presumptively identify patients with
pneumonia (Grade B)
Chest Radiography
What is the value of the chest
radiograph in the diagnosis of CAP?
• a new parenchymal infiltrate in the chest
radiograph remains the reference
diagnostic standard for pneumonia
• essential in assessing the severity of
disease and the presence of complications
• useful for suggesting the etiologic agent,
prognosis, alternative diagnosis, and
associated conditions
What specific views of chest
radiograph should be requested?
• posteroanterior radiograph minimizes the
magnification of the heart and the
mediastinum on the image, thus
minimizing the amount of lung obscured
by these structures
• In left lateral view, the size of the heart on
the image is minimized
Five essential areas of a film:
• A- Air; lungs, including
central airway and
pulmonary vessels
• B- Bones; ribs, clavicle,
spine, scapula and
shoulder
• C- Cardiac; heart and
mediastinum
• D- Diaphragm and pleural
surfaces
• E-everything else; lines,
tube, upper abdomen,
soft tissue of the chest
wall and neck
Are there characteristic radiographic
features that can predict the likely
etiologic agent from the chest
radiograph?
• There is no likely etiologic agent in
CAP, radiographic presentations in
general are non-specific
• Daunting task in the differentiation
from those produced by bacterial
or viral etiologies due to overriding
clinico-radiologic features
• Findings:
• No focal lung opacities or
consolidation
• Heart and great vessels are
unremarkable
• Diaphragm and sulci are
intact
• The visualized osseous
structures are preserved
• Remarks:
• Essentially normal chest
xray
• Findings:
• Hazy infiltrates seen in the
right upper and both lower
lobes
• Heart is not enlarged
• Aorta is prominent
• Diaphragm, sulci and bony
thorax is intact
• Impression:
• Pneumonia, right upper
and both lower lobes
• Atheromatous aorta
Should a chest radiograph be
repeated routinely?
• a repeat chest x-ray is NOT needed for
patients with low-risk CAP who are
recovering satisfactorily
• if the patient with CAP is not clinically
improving or shows progressive disease
• no need to repeat a chest radiograph prior to
hospital discharge in a patient who is
clinically improving
• repeat radiograph is recommended during a
follow-up office visit
Microbiologic Studies
Low-risk CAP (with or without
comorbid conditions)
• most common etiologic agents are bacterial
(S. pneumoniae, H. influenzae) and atypical
pathogens (M. pneumoniae, C. pneumoniae)
• sputum Gram stain and culture may not be
done, EXCEPT:
– failure of clinical response to previous antibiotics
– clinical conditions in which drug resistance may be
an issue
Moderate and High-risk CAP
• more pathogens to consider (enteric Gram
negatives, P. aeruginosa, S. aureus, L.
pneumophila)
• two sites of blood cultures are recommended
prior to starting any antibiotic treatment
Atypical pathogens (M. pneumoniae,
C. pneumoniae and L. pneumophila)
• most common methods for diagnosis include
serology [a fourfold increase in IgG or IgM
titers or an initially high IgG or IgM titer],
culture, and PCR of respiratory specimens
• L. pneumophila, urine antigen test (UAT) to
detect serotype 1 and direct fluorescent
antibody test (DFA)
TREATMENT
Empirical treatment
STREAMLINING OF ANTIBIOTIC
THERAPY
Indications
Antibiotic dosage of oral agents for
streamlining or switch therapy
Prognosis of Community-Acquired
Pneumonia
Negative prognostic factors in community-acquired
pneumonia (CAP) include preexisting lung disease,
underlying cardiac disease, poor splenic function,
advanced age, multilobar involvement, and delayed
initiation of appropriate antimicrobial therapy.
http://emedicine.medscape.com/article/234240-overview#a5
Recommended hospital discharge
criteria

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Case Series - Cap

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Community Acquired Pneumonia

• 3 days prior to consult, persistence of cough now

• 6 hours prior to consult, patient had persistence of

• LMP: April 20, 2017

• T/C Essentially well adult at the time of

• S> Patient came in for follow up check up with

HGB 150 NEUTROPHILS 63.1

HCT 0.452 LYMPHOCYTES 30.4

PLATELET 267 MONOCYTES 3.9

• P> Low Salt Low fat diet

By: DE ASIS, Ariane C.

peripheral leukocytosis increased purulent

Increased respiratory drive

Decrease lung volume

intrapulmonary shunting of blood

1. LOBAR PNEUMONIA (Typical pathological changes seen in

3. Interstitial pneumonia- inflammation in the

1. Inhalation of microbes present in the air

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