I.

PERSONAL DATA

Name: Benedicto Tamayo Paysan

Age: 54 years old

Birthdate: May 06, 1954

Birthplace: Aparri, Cagayan

Address: Block 2 Lot 12 Kalayaan Village, Pasay City

Date of admission: Dr. Sta. Maria/ Dr. Delos Reyes

Diagnosis: Community- acquired pneumonia high-risk ARDS 2nd Septic

Shock

II. HISTORY OF PAST ILLNESS

Last month, June 2010, the patient had bipedal edema, and encountered
depression because of learning that he was diagnosed Diabetes Mellitus
thinking that it will be add up to his wife’s extra expense because she is
having a weekly dialysis since last January. After being diagnosed with
DM, he had a maintenance medicine which is Metformin 500mg/tab.

Three weeks before admission, patient had a loss of appetite and became
incoherent and responsive.

III. HISTORY OF PRESENT ILLNESS

 Because of sudden depression he had, the patient had anxiety and
became fatigue, he even had a loss of appetite wherein, he used to eat
only twice a day skipping dinner time.

IV. PSYCHOSOCIAL HISTORY

Patient, BTP, is a smoker since 14 years old, but decided to stop when he
was 31 years old. He was a non-alcoholic drinker since then.

V. PATHOPHYSIOLOGY

COMMUNITY-
ACQUIREDVI.
PNEUMONIA
VII.

PRECIPITATING FACTORS:
-inhalation of streptococcal
pneumonia from the air
-

Reached the upper respiratory tract

which is being inhaled into the
alveoli.

Bacteria and fungi travels into the

space between cells and adjacent
alveoli through connecting pores

Fever
Enabling the immune system to Chills
send WBC’s(neutrophils) to attack Fatigue
Neutrophils,
Bacteria
Releases
bacteria
travels
theand
from
cytokines
fluid
lungswhich
to the
the microorganisms.
SEPTIC SHOCK
leaked travels
body
activates
leading
to blood
thetoIMMUNE
vessels
serious SYSTEM
illness Impaired oxygen transport
VIII. ANATOMY AND PHYSIOLOGY
IX. LABORATORY EXAMS
X. DRUG STUDY
XI. NCP