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PneumoniaEsmaeli, A.; Francisco U.; Golpeo, K.
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A. G.
75 year old
Male
Single
From Sta. Mesa, Manila
Unemployed
CC: progressive and productive cough, 3 days duration
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3 days PTA
2 days PTA
1 day PTA
ADM0
1
2
3
4
5
6
7
coughsputum productionfeverchillsSymbicortParacetamol
TEMPORAL PROFILE
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Past Medical HistoryPTB (2002) – sputum AFB (+); 6 months quad-tab treatment completed; Chest X-ray after treatment – resolved
S/P Cataract surgery (2002)
COPD (2011) – Symbicort 2 puffs BID 1 puff BID (2012)
Allergy to seafood and chicken
(-) HTN, (-) DM
Family History(+) HTN (father and younger brother)
(+) stroke (father)
(+) Lung CA (brother)
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Social and Environmental HistorySmoker (51 pack years); started 14 years old, stopped 2002, 1 pack per day
Occasional alcohol drinker (1960 -1970); Last drink was 1985, 1 small bottle of pale pilsen per week
Denies illicit drug use
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Review of Systems
(-) anorexia
(-) vomiting
(-) diarrhea
(-) blood in sputum
(+) exertional dyspnea
(+) sputum
production
Weight loss
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Physical Examination
Awake, weak-looking, alert, ambulatory, febrile
VS: 110/60 > 72 > 32 > 39 degrees celsius
AS, PPC, (-) TPC, (-) CLADS
ECE, (+) crackles in L lower lung
AP, NRRR, distinct S1 and S2, (-) murmur
Flat abdomen, NABS
FEP, (-) cyanosis, (-) edema
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Primary Impression
Community Acquired Pneumonia, Moderate Risk (CAP, MR); Chronic Obstructive Pulmonary Disease
(COPD)
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Laboratories Ordered
CBC
UA
Blood CS
Sputum GS/CS
Na, K, Crea, BUN
Chest Xray
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CBCCBC Reference CBC
Hemoglobin Mass C 120-140 g/L 144
Hematocrit 37-47% 43
RBC 4.0-4.5 x10^12/L
MCHC 32-37%
MCH 27.5-33.2 pg
MCV 80-94 fL
RDW 11-15%
WBC 5-10 x10^9/L 8.1
Diff count
Neutrophil 40-75% 83
Stabs
Lymphocyte 2-6% 17
Monocytes
Eosinophil
Platelet N
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Chest Xray
Impression:
1. Pneumonitis/ Bronchitis Right Lower Lung
2. Pneumonia Left Lower Lung
3. Residual Fibrosis Right Upper Lung
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Urinalysis Reference 07.14.12Color Varying degrees of yellow yellow
Turbidity Clear Clear
Reaction Variable (usually acidic) Acidic
Specific Gravity Variable but 1.023 and above, usually no significant kidney damage
1.030
Proteina Negative (-)
Sugar Negative (-)
RBC 0-1/hpf 0-1
WBC Male: 0-2/hpf none
Female: 0-5/hpf
Casts None
Bacteria Few
Epithelial Cells none
Yeast Cell noen
Mucus threads none
Crystals none
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Blood ChemistriesJuly 14, 2012
Na 134
K 3.1
Crea 99
BUN 5.6
BCR 13.97
ECC @ 60 13.37
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Cultures
Sputum GS – Gram (+) cocci in pairs with neutrophils
Sputum CS –
Blood CS, 2 sites –
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IV FLUID: 1 liter D5NSS to run to 10 hours (100 cc/hr)
DIET: 2100 kcal/day
TFR
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Antibiotic started upon admission
Ceftriaxone 2 gm IV Q24
Levofloxacin 750mg/tab, 1 tab Q48 (Azithromycin)
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COPD
Symbicort 2 puffs BID
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Hypokalemia
Kalium Durule, 1 durule TID
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Pneumonia
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Plan