PneumoniaEsmaeli, A.; Francisco U.; Golpeo, K.

A. G.

75 year old

Male

Single

From Sta. Mesa, Manila

Unemployed

CC: progressive and productive cough, 3 days duration

3 days PTA

2 days PTA

1 day PTA

ADM0

1

2

3

4

5

6

7

coughsputum productionfeverchillsSymbicortParacetamol

TEMPORAL PROFILE

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)

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

Review of Systems

(-) anorexia

(-) vomiting

(-) diarrhea

(-) blood in sputum

(+) exertional dyspnea

(+) sputum

production

Weight loss

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

Primary Impression

Community Acquired Pneumonia, Moderate Risk (CAP, MR); Chronic Obstructive Pulmonary Disease

(COPD)

Laboratories Ordered

CBC

UA

Blood CS

Sputum GS/CS

Na, K, Crea, BUN

Chest Xray

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

Chest Xray

Impression:

1. Pneumonitis/ Bronchitis Right Lower Lung

2. Pneumonia Left Lower Lung

3. Residual Fibrosis Right Upper Lung

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

Blood ChemistriesJuly 14, 2012

Na 134

K 3.1

Crea 99

BUN 5.6

BCR 13.97

ECC @ 60 13.37

Cultures

Sputum GS – Gram (+) cocci in pairs with neutrophils

Sputum CS –

Blood CS, 2 sites –

IV FLUID: 1 liter D5NSS to run to 10 hours (100 cc/hr)

DIET: 2100 kcal/day

TFR

Antibiotic started upon admission

Ceftriaxone 2 gm IV Q24

Levofloxacin 750mg/tab, 1 tab Q48 (Azithromycin)

COPD

Symbicort 2 puffs BID

Hypokalemia

Kalium Durule, 1 durule TID

Pneumonia

Plan