CHAPTER IV

RESULTS, ANALYSIS AND JUSTIFICATION

A. Course in the Ward

On October 22, 2019, Patient X was admitted to Metro Davao Medical And
Research Center due to fever and cough. Four days before admission, there is an
onset of fever and cough.

On the day of admission patient was noted to be breathing faster and not drinking. The
patient’s past medical history revealed admission last 5 months with the same
compliant no history of diarhea, abdominal pain, or other symptoms, nor any significant
travel history or exposure to sick contact. There was family history of sever cough due
to smoking.

On exam, she was he was tachypneic and in mild respiratory distress.On arrival to the
admitting hospital, the vital signs were: temperature 100.6°F, heart rate of 196 beats per
minute and respiratory rate of 82 breaths per minute. Her oxygen saturations were 96%
to 98% on room air. Overall, she was alert and interactive and easily consoled by her
mother. She did appear to be in mild respiratory distress as evidenced by her
tachypnea, in addition to mild intercostal retractions, intermittent grunting and nasal
flaring. There was good air movement heard throughout the right lung fields and left
upper fields. Decreased breath sounds and scattered crackles were heard in the left

base. A chest X-ray and computerized tomography (CT) scan of the chest revealed

possible of pneumonia.

She received Disudrin and Biaxin orally. She remained in the hospital and still under
treatment.