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Community Acquired Pneumonia – Medium Risk

• Case No. 2

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)
– G3: 1994 – NSD (house delivery)
– G4: 1996 – NSD (house delivery)

Review of Systems
• General
o No weight loss, no weight gain, no fever, no chills, no fatigue, no
insomnia, no loss of appetite, no night sweats
• Skin
o No color changes, no sores, no rashes, no itching, no scaling, no
bleeding
• Head
o No headache, no trauma, no stiffness
• Eyes
o No eye pain, no diplopia, no itch, with blurring of vision, no dryness,
no redness
• Ears
o No ear pain, no tinnitus
• Nose
o No colds, no nasal bleeding, no dryness, no nasal discharge, no nasal
pain, no sneezing
• Mouth
o No bleeding gums, no soreness, no ulcers, no hoarseness
• Cardiovascular
o No chest pain, no dyspnea, no PND, no orthopnea, no palpitations
• Gastrointestinal
o No anorexia, no dysphagia, no hematemesis, no nausea, no vomiting,
no hematochezia, no melena, no diarrhea
• Genitourinary
o No dysuria, no hematuria, no nocturia, no retention, no incontinence,
no frequency, no urgency, no discharge
• Musculoskeletal
o No pain, no weakness, no tenderness, no cramps, no trauma, no joint
pain, no backache, no stiffness
• Endocrine
o No polyuria, no polydipsia, no polyphagia, no cold intolerance, no heat
intolerance
• Hematologic
o No pallor, no easy bruising
• Nervous
o No syncope, no seizures, no dizziness, no tremor

Physical Examination
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
o BP: 140/80 mmHg
o PR: 90 bpm
o RR: 20 cpm
o 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 upon palpation.
• 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

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
 (+) shortness of breath
 (+) night sweats
 (-) night fever
 (+) orthopnea
 (+) nonproductive cough
 (-) colds
 (+) easy fatigability
 (-) dysphagia
 Patient verbalized change in voice character

12L ECG results: 04/18/17


• P-Wave: Discernible
• QRS Complexes: Poor R wave progression
• ST Segment: Isoelectric
• T-Wave: Upright
• Interpretation:
o Sinus tachycardia
o 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
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 110/70 mmHg
– PR: 124 bpm
– RR: 30 cpm
– T: 36.3 C
– O2: 96%
• 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
• HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft,
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema

Assessment:
 CAP-MR

Progress Notes: 04/21/17

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
• Increase oral fluid intake
• Therapeutic lifestyle changes
• To come back after 3 days

Progress Notes: 04/24/17

Subjective:
• (+) slight shortness of breath
• (+) loss of appetite
• (+) intermittent cough, non-productive
• (+) easy fatigability
• (-) chest pain
• (-) orthopnea
• (-) fever

Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 130/70 mmHg
– PR: 110 bpm
– RR: 25 cpm
– T: 36.6 C
– O2: 98%
• 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,
• HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema

Assessment:
• CAP-MR: resolving
• Hypertension St. II

Progress Notes: 04/24/17

Plan
• Continue
– Co-Amoxiclav 625mg/tab, 1 tab TID for 4 more days
– Erdosteine 300mg/cap, 1 cap BID for 2 more days
– Multivitamins tab, 1 tab OD
– Vitamin B complex tab, 1 tab OD
• Shift
– Amlodipine 5mg/tab, 1 tab OD to metoprolol 50mg/tab, 1 tab OD
• Daily BP measuring
• Increase oral fluid intake
• Therapeutic lifestyle changes
• To come back after 3 days (April 27, 2017)

Progress Notes: 04/27/17

Subjective:
• (+) shortness of breath (improved)
• (+) appetite improvement
• (+) cough, non-productive
• (-) chest pain
• (-) orthopnea
• (-) fever
• (+) PND – 2 nights

Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 120/70 mmHg
– PR: 112 bpm
– RR: 23 cpm
– T: 36.8 C
– O2: 97%
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, slightly pale palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right posterior lung field, no retraction, no lagging,
• HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no 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 creatinine, RBS, SQPT, SGOT, Sodium, potassium, lipid profile
• Continue:
– Metoprolol 50mg/tab, 1 tab OD
– Vitamin B complex tab, 1 tab OD
– Multivitamins tab, 1 tab OD
• Start:
– Celecoxib 200mg/tab 1 tab BID for pain
• Increase oral fluid intake
• Daily blood pressure monitoring
• Therapeutic lifestyle changes
• Follow up after 5 days (05/02/17) with results

Progress Notes: 05/04/17

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 (437.22mg/D ) 3.89 – 5.83
Creatinine 0.95 mg/dl Women: 0.6 – 1.1
Total Cholesterol 4.12 mmol/L (156.56mg/D) 3.04 – 5.20
Triglycerides 1.01 mmol/L (88.88mg/D) 0.0 – 2.26
HDL 1.726 (65.588mg/D) 0.918 – 2.067
LDL 1.93 mmol/L (73.34mg/D) 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:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 110/80 mmHg
– PR: 89 bpm
– RR: 19 cpm
– T: 36.8 C
– O2: 96%
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, slightly pale palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right posterior lung field, no retraction, no lagging,
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses

Assessment
• Diabetes Mellitus type II, uncontrolled
• Hypertension Stage II, controlled

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:
o DM uncontrolled type II
o Allergic cough
o Hypertension Stage II – controlled
o IM-OPD Referral: 05/04/17
• Plan
o Start
• NaCl tab, 1 tab TID for 6 doses
• Insuman 70/30 “15” u OD before breakfast
• Cetirizine 40mg/tab, 1 tab OD at bedtime for 5 days
o Continue present meds
o For BUN, creatinine, HbA1C, Na, K, CBC, Urinalysis,

Progress Notes: 05/11/17

Subjective:
• (+) Productive cough – whitish
• (+) Chest pain (while coughing)
• (+) 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:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 140/80 mmHg
– PR: 90 bpm
– RR: 20 cpm
– T: 36.6 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, decreased breath sounds
on right lung field, no retraction, no lagging,
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses

Assessment:
• CAP-MR
• DM Type II, uncontrolled
• Hypertension Stage II, controlled

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

Assessment:
• CAP-MR
• PTB clinically diagnosed
• DM Type II, uncontrolled
• Hypertension Stage II, controlled

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
• Increase oral fluid intake
• Respiratory etiquette
• Therapeutic lifestyle changes
• Follow up after 5 days with lab results

Progress Notes: 05/19/17

Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) fever
• (-) back pain

DSSM Sputum Exam Result: 05/16/17


Smeaer Microscopy
Specimen 1 2
Visual appearance Salivary Salivary
Reading 0 0
Lab. Diagnosis Negative

Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 120/80 mmHg
– PR: 88 bpm
– RR: 18 cpm
– T: 36.9 C
• Progress Notes: 05/19/17
• 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, decreased breath sounds
on right lung field, no retraction, no lagging, (+) crackles, right middle to base
of lung
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses

Assessment:
• PTB clinically diagnosed
• DM Type II
• Hypertension St. II controlled

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
• Therapeutic lifestyle changes
• For referral to TB DOTS for evaluation and management
• Follow up after 4 days (05/23/17)

Progress Notes: 05/23/17

Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) abdominal pain
• (-) back pain

Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 130/80 mmHg
– PR: 94 bpm
– RR: 19 cpm
– T: 36.9 C
• 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, decreased breath sounds
on right lung field, no retraction, no lagging,
• Progress Notes: 05/23/17
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses

Assessment:
• PTB clinically diagnosed
• DM Type II, uncontrolled
• Hypertension St. II - controlled

Plan:
• Still for 2D Echo
• Still for repeat FBS, Creatinine
• Continue present meds
• Still for referral to TB DOTS for evaluation and management

Salient Features
• Chief Complaint: Chest pain
• HPI
– Fever (undocumented)
– Shortness of breath/difficulty of breathing
– Headache,
– Weakness,
– Dysphagia
• Progress notes: subjective
– Night sweats
– Orthopnea
– Cough
– Easy fatigability
– PND (5 nights)
• Comorbidities
– Hypertensive (2015) – controlled
– Diabetes mellitus type II
• Family history:
– (+) Asthma (maternal side)
• Physical Examination
– Tachycardic (112bpm)
– Tachypneic (23cpm)
– Decreased breath sounds, right posterior lung field
– (+) crackles, right middle to base of lung