Case Study:

G.P., 48-year-old woman, married, residing in Talomo, Davao City, was brought to emergency department complaining of cough and fever. She has been
complaining of cough with yellowish phlegm for the past 2 weeks. Four days prior to this consult, she developed fever associated with on and off shortness of
breath. She took Paracetamol and Lagundi which afforded no relief. Her past medical history was unremarkable. Vital signs: BP 140/90 mmHg, HR 120 beats per
minute, RR 24 cycles per minute, T 38.3°C, weight 72 kg and height 5’1”. Her physical examination revealed tachycardia with regular rhythm and coarse crackles on
both lung fields.

Instructions:
Use Harrison’s Principles of Internal Medicine 20th edition, MIMS, or Clinical Practice Guidelines as your reference. Indicate the reference you used and page
number in the column provided. Answers taken from other sources will not be honored.

IMPRESSION:
ENUMERATE THE SALIENT FEATURES REFERENCES
General Data Name: G.P. Age: 48 years old Sex: Female CASE STUDY
Address: Talomo, Davao City; Occupation: Not Stated; Religion: Not Stated PROVIDED
Chief Complaint Cough
History of Present Illness Two weeks prior to consultation, the patient had an onset of productive cough with yellowish phlegm. Four days
PTC, the productive cough persisted and was associated with fever and shortness of breath. Paracetamol and
Lagundi (missing data) was taken, but afforded no relief.
Past Medical History ● Unremarkable
Family History ● None mentioned

Personal and Social History ● None mentioned

Physical Examination
● General Survey: None mentioned
● Vital Signs: BP: 140/90 mmHg, HR: 120 beats per minute, Temperature: 38.3 degrees C, RR: 24
cycles per minute, O2 Saturation: Not mentioned
● Anthropometrics: Height: 5’1” (154.94 cm), Weight: 158.4 lbs (72kg), BMI: 29.9 = Overweight
● Skin:
● HEENT:
● Neck:
● Posterior Thorax and Lungs:
o RR: 24 cycles per minute
o Coarse crackles were heard at both lung fields.
● Breast, Axillae and Epitrochlear Nodes:
● Anterior Thorax and Lungs:
● Cardiovascular System:
o Tachycardic with regular rhythm
● Abdomen:
● Peripheral Vascular System:

TASK/ QUESTION
What is your primary impression?
Justify your answer why you
considered such primary
impression. ANSWER IN
SENTENCE FORM.
Enumerate other specific/ focused
questions you need to ask from the
patient (bullet format)
Enumerate other physical
examination procedures you plan
to do to help you in your diagnosis.
(bullet format)
● Musculoskeletal System:
● Genitalia:
ANSWER REFERENCE (source, page no.)
COMMUNITY ACQUIRED PNEUMONIA- MODERATE RISK
The patient presented with fever and acute (less than 3 weeks), productive cough. There were also Harrison’s Principles of Internal
bouts of on and off shortness of breath. Upon Physical Examination, it was noted that the patient Medicine 20th edition, p911
had crackles in both lung fields. Fever is brought about by recruitment of mediators such as IL-1 and
TNF.
● History of Present Illness:
○ Two weeks PTC, were there any precipitating, alleviating or aggravating factors?
○ 4 days PTC, were there any precipitating, or aggravating factors?
○ Was the fever documented? If yes, range, what is the highest?
○ Did the blood have any red streaks/ was blood tinged?
○ What was the dose of Paracetamol and Lagundi taken? How frequent was the intake
of medication?
○ Is the patient feeling anxious, tired? Or did she perform any physical activity?
○ Was there a history of travel? (e.g. places with community transmission of COVID-19)
● Past Medical History:
○ Allergies, Co-morbidities
○ Does the patient drink any other medication? If so, is it prescribed? What is the dose?
○ Gynecologic, Hospitalization, Medical and Surgical History? Duration of admission if
any
○ Childhood and Adult Vaccinations? (i.e. Influenza, Pneumococcal)
● Family History
● Personal and Social History
○ Occupation
○ Smoking history: Pack years
○ Alcoholic beverage intake
○ Use of illicit drugs
● Inspection of the skin and mucous membranes Harrison’s Principles of Internal
● Inspection of the Eyes, Ears, Nose and Throat Medicine 20th edition, p910- 911
● Assessment of sense of smell
● Assessment of sense of taste
● Inspection of the Neck
● Palpation of lymph nodes in the neck
● Palpation of the Tactile Fremitus at the posterior thorax
● Percussion of the thorax

Will you manage this patient in an
outpatient setting or admit the
patient? Justify your answer
● Auscultation of the lungs in all lung fields
● Egophony, Bronchophony, Whispered Pectoriloquy
● Determine Inspiration/ Expiration Ratio and Symmetry of Chest Expansion
● Inspection of the APL Ratio
● Inspection and Palpation of the Precordial Area
● Auscultation of Heart Sounds
● Palpation and Grading of Peripheral Pulses
● Eliciting capillary refill time
● inspection of the back for postural abnormalities
● Inspection of musculoskeletal system
According to the Pneumonia Severity Index, the following scores warrant either outpatient or Harrison’s Principles of Internal
inpatient care. In the case of the patient who is 48 years old, female, with no known comorbidities Medicine 20th edition, p912
and only slightly elevated vital signs, pending laboratory data, she may be at RISK CLASS I and
would warrant OUTPATIENT CARE SETTING.

But due to the nature of the medication for CAP MR, wherein they will be administered via the
intravenous route, HOSPITALIZATION may be warranted.
Laboratory and Diagnostic Tests to ● Chest Radiograph (PA and Lateral views) Harrison’s Principles of Internal
be requested: ● Direct Sputum Smear Microscopy Medicine 20th edition, p911
● Sputum GS/CS
● Arterial Blood Gas Analysis
● Complete Blood Count with differentials
TREATMENT ● A combination if an IV non-antipseudomonal Beta lactam with either an extended macrolide CPG on Community Acquired
or a respiratory fluoroquinolone is recommended as initial antimicrobial treatment ASAP Pneumonia 2016 Update (p. 3)

DIFFERENTIAL DIAGNOSES
● Give five (5) pertinent differential diagnoses and justify you answer including a brief discussion of each disease entity. REFERENCE
Explain why it was considered and how you ruled out in terms of etiology, epidemiology, risk factors, pathophysiology,
history & PE, diagnostic tests, treatment, and prognosis. If you cannot rule out a certain disease entity, discuss ancillary
 test/s need/s to be done to help you.

COVID-19 SUSPECT
Rule-in: Rule-out:
According to the Interim Guidance of the WHO on COVID-19, A Per physical examination of the patient, it was noted that there WHO Interim Guidance (PH
suspect is defined as patient who meets the clinical and epidemiological were COARSE crackles. In patients with pulmonary fibrosis Surveillance) dated 7 August
criteria. The patient, having presented with cough AND fever, is also (which may occur in patients with COVID-19), end-inspiratory 2020 p.2
residing in an area with community transmission (Davao City) fine crackles are noted at the lung bases. Harrison’s Principles of Internal
Medicine 20th edition, p 2001
Etiology ● The novel coronavirus, SARS CoV2 (enveloped, ssRNA) was first isolated in Wuhan City, Hubei PSMID, PCCP, PCP, PRA,
Province, China in December 2019. PCHTM Interim Guidance on
Epidemiology ● As of June 30, 2020, there were more than 10,000,000 COVID-19 cases worldwide, with more than Clinical Management of Adult
500,000 reported deaths. In the Philippines, there are more than 60,000 reported cases with more than Patients with Suspected or
1,000 deaths. The predominant mode of transmission is person to person spread via respiratory Confirmed COVID Infection ver
droplets. The peak of infectiousness is just before or within 5 days of symptom of onset. 3.1 July 20, 2020 pp-4-5
Risk Factors ● Elderly
● Those with co-morbidities
● Those with pneumonia
Pathophysiology ● SARS CoV 2 targets cells, such as nasal and bronchial epithelial cells, pneumocytes, through the viral
structural spike (S) protein that binds to ACE2 receptor. TMPRSS2 promotes viral uptake by cleaving ACE2
and activating SARS CoV2 S protein which mediates coronavirus entry into host cells.
History and PE ● The clinical presentation of COVID-19 ranges from a mild common cold-like illness, to a severe viral
Findings pneumonia leading to acute respiratory distress syndrome that is potentially fatal.
Diagnostic tests and ● Real time reverse transcription- polymerase chain reaction (RT-PCR) assay- Current recommended PSMID, PCCP, PCP, PRA,
results test PCHTM Interim Guidance on
● Rapid tests based on Antigen production Clinical Management of Adult
● Detection of antibodies to Sars CoV-2 Patients with Suspected or
● Ancillary tests: CBC, Metabolic panel, Inflammatory markers, PT and D-Dimer, ABG, GS/CS, Chest Confirmed COVID Infection ver
xray, High resolution chest CT scan plain, ECG 3.1 July 20, 2020 p.7-11
Treatment ● Treatment is largely supportive: Antipyretics for fever, oral fluid for hydration, isolation at home or in
temporary treatment and monitoring faciltiies.
● Drugs such as Remdesivir (for hospitalized adult patients; 200mg IV loading dose followed by 100 mg
IV once a day for 5-10 days), Chloroquine, Hydroxychloroquine, Lopinavir-ritonavir, and Tocilizumab
shows promise
Prognosis ● The incidence of ARDS was 14.8%. The case fatality rate of patients with COVID-19 infection was PSMID, PCCP, PCP, PRA,
4.3% PCHTM Interim Guidance on
● The elderly and individuals with underlying diseases have higher fatality rate compared to younger and Clinical Management of Adult
healthier patients. Patients with Suspected or
Confirmed COVID Infection ver
3.1 July 20, 2020 pp-17

TUBERCULOSIS
Rule-in: Rule-out:
 According to PSMID 2016 CPG, for patients 15 years old and ● With no SPUTUM AFB data, and the duration of cough is not Harrison’s Principles of Internal
avoce, a presumptive TB has any of the following: Cough of at longer than 2 weeks. Medicine 20th edition, p 1968
least 2 weeks duration, … [cont] table 921
PSMID CPG for Tuberculosis in
Adult Filipinos 2016
Etiology ● Mycobacteria belong to the family Mycobacteriaceae and the order Actinomycetales. Of the pathogenic Harrison’s Principles of Internal
species belonging to the M. tuberculosis complex, which comprises eight distinct subgroups, the most Medicine 20th edition, p 1968
common and important agent of human disease by far is M. tuberculosis (sensu stricto). table 1236
Epidemiology ● The WHO estimated that 10.4 million (range, 8.8–12.2 million) new (incident) cases of TB occurred Harrison’s Principles of Internal
worldwide in 2016, 95% of them in developing countries ofAsia (6.5 million), Africa (2.6 million), the Medicine 20th edition, p 1968
Middle East (0.77 million), and Latin America (0.26 million). table 1236-1237
● Seven countries accounted for 64% of all new cases: India, Indonesia, China, the Philippines, Pakistan,
Nigeria, and South Africa.
● Two-thirds of cases typically occur in male patients, and 1.04 million children are affected every year.
● It is further estimated that 1.7 million (range, 1.5–1.8 million) deaths from TB, including 0.37 million among
people with HIV infection, occurred in 2016; 96% of these deaths were in developing countries.
Risk Factors ● Recent infection (<1 year) Harrison’s Principles of Internal
● Fibrotic lesions (spontaneously healed) Medicine 20th edition, p 1968
● Comorbidities and iatrogenic causes table 1239
● HIV infection
● Silicosis
● Chronic renal failure/hemodialysis
● Diabetes
● IV drug use
● Excessive alcohol use
 ● Immunosuppressive treatment
● Tumor necrosis factor α inhibitors
● Gastrectomy
● Jejunoileal bypass
● Post-transplantation period (renal, cardiac)
● Tobacco smoking
● Malnutrition and severe underweight
Pathophysiology ● The outcome of infection in a previously unexposed, immunocompetent person depends on the
development of anti-mycobacterial T-cell–mediated immunity. These T cells control the host response
to the bacteria and also result in development of pathologic lesions, such as caseating granulomas and
cavitation.
● Infection by M. tuberculosis proceeds in steps, from initial infection of macrophages to a subsequent TH1
response that both contains the bacteria and causes tissue damage
History and PE ● It may be asymptomatic or may present with fever and occasionally pleuritic chest pain. In areas of Harrison’s Principles of Internal
Findings high TB transmission, this form of disease is often seen in children Medicine 20th edition, p 1968
● Erythema nodosum on the legs table 1240
● Phlyctenular conjunctivitis
● Pleural effusion
● Diurnal fever and night sweats due to defervescence, weight loss, anorexia, general malaise, and
weakness.
● 90% of cases, cough eventually develops—often initially nonproductive and limited to the morning and
subsequently accompanied by the production of purulent sputum, sometimes with blood streaking.
Diagnostic tests and ● WHO approved rapid diagnostic tests specifically Xpert MTB/Rif Harrison’s Principles of Internal
results ● Direct sputum smear microscopy Medicine 20th edition, p 1968
● Radiographic procedures (CXR: Presence of Ghon focus) table 1248
● Nucleic acid amplification tests PSMID CPG for Tuberculosis in
● Bacterial culture Adult Filipinos 2016 p. 18
Treatment ● First-line agents for the treatment of TB: Harrison’s Principles of Internal
o Isoniazid Medicine 20th edition, p 1968
o Rifampin table 1249
o Pyrazinamide, and PSMID CPG for Tuberculosis in
o Ethambutol Adult Filipinos 2016 p. 23
Prognosis ● TB is a severe and often deadly disease without treatment. After 5 years without treatment, the
outcome of smear-positive pulmonary TB (PTB) in HIV-negative patients is as follows:
o 50-60% die (case fatality ratio for untreated TB);
o 20-25% are cured (spontaneous cure);
o 20-25% develop chronic smear-positive TB.
● With adequate treatment, the case fatality ratio (CFR) often falls to less than 2 to 3% under optimal
conditions.
● Similar CFRs are seen with untreated EPTB and smear-negative PTB, with an equivalent fall in CFR
 with adequate treatment.
● Untreated TB in HIV-infected patients (not on antiretrovirals) is almost always fatal.
● Even on antiretrovirals, the CFR is higher than in non-HIV infected patients

VIRAL UPPER RESPIRATORY TRACT INFECTION

Rule-in: Rule-out:
● Acute cough (<3 weeks duration) brought this differential diagnosis ● Crackles were heard at both lung fiends fields. This breath
in question. sound indicates alveolar disease, which is common in
pneumonia.
Etiology Most common: Rhinovirus Harrison’s Principles of Internal
● Most common serious: Influenza viruses, RSV, and human metapneumovirus (HMPV: Medicine 20th edition, chapter
194, page 1375-1382
Epidemiology ●Most primary infections occur during the first few years of life AND in the elderly (due to immune Harrison’s Principles of Internal
senescence and general medical decline) Medicine 20th edition, chapter
● Common during the winter 194, page 1375-1382
Risk Factors ● Most profound: COPD Harrison’s Principles of Internal
● Underlying heart and lung disease Medicine 20th edition, chapter
● Smoking (or exposure to wood smoke) 194, page 1375-1382
● Low socioeconomic status
● Male gender
Pathophysiology ● Predilection for replication in differing cells or regions of the respiratory tract. Virus infections in the upper Harrison’s Principles of Internal
respiratory tract are rhinitis or the common cold, sinusitis, otitis media, conjunctivitis, pharyngitis, tonsillitis, Medicine 20th edition, chapter
and laryngitis. In reality, some upper respiratory tract infections affect more than one upper respiratory tract 194, page 1375-1382
anatomic site during a single infection.
History and PE PE: Harrison’s Principles of Internal
Findings ● Nasal congestion Medicine 20th edition, chapter
● Sneezing / Rhinorrhea 194, page 1375-1382
● Cough
● Sore throat
Diagnostic tests and Gold standard: VIRUS ISOLATION Harrison’s Principles of Internal
results ● Most sensitive: RT-PCR molecular diagnostic tests Medicine 20th edition, chapter
194, page 1375-1382
Treatment Hydration Harrison’s Principles of Internal
Temperature management Medicine 20th edition, chapter
● Supportive care 194, page 1375-1382
Prognosis ● Easily recovers
 ACUTE BRONCHITIS
Rule-in: Rule-out:
Acute bronchitis is characterized by a dry or productive cough of <3 There was crackles auscultated on both lung fields. There was
weeks duration. also no noted hemoptysis.
Etiology Adenovirus Harrison’s Principles of Internal
Rhinovirus Medicine 20th edition, chapter
194, page 1375-1382
Epidemiology Harrison’s Principles of Internal
This is the most common cause of the common cold Medicine 20th edition, chapter
194, page 1375-1382
Risk Factors Immunocompromised patients are highly susceptible to severe disease during infection with respiratory Harrison’s Principles of Internal
adenoviruses Medicine 20th edition, chapter
194, page 1375-1382
Pathophysiology Replication in differing cells or regions of the respiratory tract, not clear whether rhinovirus is restricted to the Harrison’s Principles of Internal
upper respiratory tract and only indirectly induces inflammatory responses that affect the lower respiratory tract Medicine 20th edition, chapter
or whether the viruses spread to the lower respiratory tract. 194, page 1375-1382
History and PE Dry or productive cough of < three weeks’ duration (most prevalent in winter) in the absence of signs and Harrison’s Principles of Internal
Findings symptoms of pneumonia and of evidence of pneumonia on chest radiography and is primarily caused by Medicine 20th edition, chapter
viruses 194, page 1375-1382
Diagnostic tests and Gold standard: VIRUS ISOLATION Harrison’s Principles of Internal
results Medicine 20th edition, chapter
194, page 1375-1382
Treatment Most sensitive: RT-PCR molecular diagnostic tests Harrison’s Principles of Internal
Medicine 20th edition, chapter
194, page 1375-1382
Prognosis Hydration

BRONCHIAL ASTHMA
Rule-in: Rule-out:
On physical exam, it was noted that there was crackles on both lung The patient showed no atopy no allergy. PE findings showed no
fields. wheezing.
Etiology ● The airways in asthmatic persons makes them more responsive and inflames more easily than non- Harrison’s Principles of Internal
asthmatics to a wide range of triggers, leading to excessive narrowing with consequent reduced airflow Medicine 20th edition, p 1957
and symptomatic wheezing and dyspnea.
● Narrowing of the airways is usually reversible, but in some patients with chronic asthma there may be
an element of irreversible airflow obstruction.
Epidemiology ● Affects 300 million people worldwide Harrison’s Principles of Internal
● 250,000 deaths annually Medicine 20th edition, p 1597-
 ● 10-12% of adults are asthmatic and 15% of children are affected by it. 1598
● Cases are rising in affluent countries
● Peaks at three years of age
● In children males are 2x more prone than females, in adults they equalized.
Risk Factors ● Atopy Harrison’s Principles of Internal
● Genetic predisposition Indoor allergens Medicine 20th edition, p 1968
● Atopy Outdoor allergens table 281-1
● Airway hyperresponsiveness Occupational sensitizers
● Gender Passive smoking
● Ethnicity
● Obesity
● Early viral infections
● Respiratory infections
● Air pollution (diesel particulates,
● nitrogen oxides)
● Diet
● Dampness and mold exposure
● Acetaminophen (paracetamol)
Pathophysiology ● Caused by a TH2 and IgE response to environmental allergens in genetically predisposed individuals.
● This results to airway inflammation with eosinophils and T lymphocytes and Mast cells.
History and PE PE: Harrison’s Principles of Internal
Findings ● Wheezing Medicine 20th edition, p 1968
● Dyspnea table
● Coughing
● Symptoms are worse at night
● Tenacious mucous production that is hard to expectorate
● Prodromal symptoms may precede an attack, with itching under the chin, discomfort between the
scapulae, or inexplicable fear (impending doom)
● Rhonchi and hyperinflation of the chest
Diagnostic tests and ● Pulmonary function tests : reduced FEV1, FEV1/FVC ratio, and PEF Harrison’s Principles of Internal
results ● Airway responsiveness Medicine 20th edition, p 1968
● Radioallergosorbent test [RAST] table 1963-1964
● Skin prick tests to common inhalant allergens
● Fractional exhaled nitric oxide (FENO) is now being used as a noninvasive test to measure eosinophilic
airway inflammation.
Treatment ● β2-Agonists: bronchodilator, relax airway smooth-muscle cells of all airways, where they act as Harrison’s Principles of Internal
functional antagonists, reversing and preventing contraction of airway smooth-muscle cells by all Medicine 20th edition, p 1968
known bronchoconstrictors. table 1964-1966
● Anticholinergics: prevent cholinergic nerve-induced bronchoconstriction and mucus secretion.
● Theophylline: inhibition of PDE in airway
smooth-muscle cells, which increases cyclic AMP, but doses required for bronchodilatation commonly
 cause side effects that are mediated mainly by phosphodiesterase inhibition
● Inhaled corticosteroids: most effective anti-inflammatory agents used in asthma therapy, reducing
inflammatory cell numbers and their activation in the airways. ICS reduce eosinophils in the airways
and sputum, and numbers of activated T lymphocytes and surface mast cells in the airway mucosa.
● Antileukotrienes: block cys-LT1-receptors and provide modest clinical benefit in asthma.
Prognosis ● Complete remission is possible
● Lifetime maintenance is necessary

DIAGNOSTICS:
Test Patient Result Normal Value Interpret Is this test important? Why? Discuss pathophysiology. Reference
Hgb 11.6 mg/dL 12.0 -16.0 g/dL Low Yes. oxygenation and perfusion due to presence of exudates in lung Harrison’s Principles of
Hct 0.35 0.38 – 0.47 Low parenchyma IM 20th edition, p 386
Yes. Peripheral leukocytosis and Increased purulent secretions results Harrison’s Principles of
WBC 14.6 x 103 mm3 4.5-11x103/mm3 Elevated from IL-8 and GCSF (chemokines). Internal Medicine 20th
Radiographic Infiltrate, Rales on auscultation, Hypoxemia occur due to edition (p. 909)
Neutro 0.75 0.50-0.70 Elevated Alveolar capillary leak (as in ARDS) from inflammatory mediators
released by macrophages & recruited neutrophils leading to filling. 
Lympho 0.22 0.20-0.50 Normal Yes. WBC differentials with the complete blood count provide clues to Harrison’s Principles of
Mono 0.02 0.02-0.09 Normal the probable causes of infection. It allows the clinician to increase Internal Medicine 20th
Eosino 0.01 0.00-0.06 Normal diagnostic yield edition (p. 916)
150-450x
Plt 264 x 103 mm3 Normal
103/mm3
pH 7.41 7.35-7.45 Respiratory alkalosis, if found, may cause increased respiratory drive  Harrison’s Principles of
PCO2 39 35-45 If the patients present with severe hypoxemia: Bacterial pathogens Internal Medicine 20th
PaO2 95 80-100 interfering with hypoxemic vasoconstriction edition (p. 909)
ABG HCO3 22 22-28 Normal
tCO2 23 23-29
BE 0.2 -2 to 2
O2sat 97% 92-100%
FBS 5.5 mmol/L <5.6 mmol/L Normal These measurements, as part of the metabolic panel, determines the Harrison’s Principles of
Chole 233 mg/dL <150-199 mg/dL Elevated likelihood of other possible medical conditions. The patient is Internal Medicine 20th
LDL 121 mg/dL <130 mg/dL Normal overweight and is thus at higher risk of developing co-morbidities. edition (p. 909)
Approach and response to management differs among these
HDL 46 mg/dL >45 mg/dL Normal
individuals. These also aid in the management of patients using the
Trigly 184 mg/dL <250 mg/dL Normal Pulmonary Severity Index
Crea 70 mmol/L 46-92 mmol/L Normal
Sputum Gm (-) bacilli None Positive The main purpose of sputum Gram’s stain is to ensure that the Harrison’s Principles of
 GS sample is suitable for culture, and to help identify certain Internal Medicine 20th
Sputum Moderate growth No pathogenic Isolated pathogens by their characteristic appearance. The greatest edition (p. 911)
CS Kleb. pneumoniae organism Pathogenic benefit is in alerting physicians of unsuspected/ resistant
organism pathogens and to permit appropriate modification of therapy.
Sputum Mucopurulent 0 Negative This aids in the presumptive diagnosis of PTB is still commonly Harrison’s Principles of
AFBx2 #1 AFB 0 based on the finding of AFB on microscopic examination. In this Internal Medicine 20th
#2 AFB 0 case, we can rule out PTB infection. edition (p. 1247

Describe the chest x-ray.

What view was this taken? This view is taken in the postero-anterior (PA) view. The clavicles are seen
Explain. over the lung fields. The inner border of the scapula is facing away from the
lung fields. Posterior ribs are visible.
Describe the images (ABCD Airway: trachea is centrally located; angle of carina is not too wide/narrow.
or inner-outer) Breathing: (+) coarse reticular opacities throughout the lung field, both
lung fields pleura not thickened, evidence of pleural effusion in left lung
Cardiac: no apparent cardiomegaly (heart is not greater than 50% of the
thoracic width), cardiac borders visible (right side less distinct)
Diaphragm: blunt left costophrenic angle, right diaphragm slightly higher
than left (normal)
Everything else: No fracture seen on the ribs, vertebra seen along with
discs and spinous processes. No lines/ tubes.
Final Reading Diffuse areas of consolidation. Heart size within normal limits. Pleural
effusion on left lung. No evidence of pneumothorax.

Is this necessary? Why? Yes. Visualization of the lung parenchyma enable us to arrive at a more
accurate diagnosis.
 Interpret the ECG
Rate 93 beats per minute

Rhythm Regular
PR 0.12
QRS 0.08

Axis Normal Axis

QT 0.28
Normal Sinus Rhythm

Readin
g

TREATMENT:
What medicine will you give specific for this case? Rationalize include brief drug study
Drug Mechanism of Action Dosing/ Contraindication Side Effects What to monitor Reference
Frequency/
Duration
Ampicillin Binds to penicillin-binding 1.5g IV every 6 hypersensitivity diarrhea, liver function CPG on Community
Sulbactam proteins to inhibit cell wall hours for 7 history of cholestatic IV site pain, thrombophlebitis, IV site Acquired Pneumonia
synthesis. Causing days jaundice rashes, abdominal distention, WBC differentials 2016 Update (p. 11)
disruption of cell wall and hepatic dysfunction candidiasis, chest pain,
leads to death. dysuria, edema, epistaxis,
erythema, fatigue
The addition of sulbactam
increases the bioavailability
of oral ampicillin when the
two drugs are administered.
Moxifloxacin Inhibits DNA gyrase, a type 400mg PO allergies, taking N/V, diarrhea, light ECG, vision and CPG on Community
II topoisomerase, and once daily for other quinolones, headedness, headache, urinary changes Acquired Pneumonia
topoisomerase IV, inhibiting 7 days heart problems, DM, weakness, bruising/bleeding, 2016 Update (p. 10)
cell replication kidney disease, liver infection(i.e. fever, sore WOF: Tendinitis,
 diseases, throat), urine changes(kidney tendon rupture,
neuropathic function), liver QT prolongation,
conditions changer(tiredness, abdominal peripheral
pain, jaundice), CV neuropathy
effects(arrythmia, aneurysm)

Question Answer Reference

If you decided to admit this  Planning for discharge occurs as soon as the start of admission. CPG on
case, when can you start  In the absence of any unstable coexisting illness or other life threatening complication, the patient Community
planning for discharge? may be discharged once clinically stable and oral therapy is initiated. Acquired
If you decided to manage this The following are the recommended discharge criteria: Pneumonia 2016
case as outpatient, how do you During the 24 hours before discharge, the patient should have the following characteristics (unless this Update (p. 20-21)
follow up? represents the baseline status): 
 Temperature of 36 to 27 C
 Pulse < 100/min
 RR between 16 to 24 /min
 SBP > 90 mmHg
 Blood oxygen saturation >90%
 Functioning GI tract
Follow up assessment:
Explain to the patients with CAP that after starting treatment, their symptoms are expected to steadily
improve, although the rate of the improvement will vary with the severity of the pneumonia. Most people
can expect that by: 
 1 week: fever should have resolved
 4 weeks: chest pain and sputum production should have substantially reduced
 6 weeks: cough and breathlessness should have substantially reduced
 3 months: most symptoms should have resolved but fatigue may still be present
 6 months: most people will feel back to normal
Repeat CXR is recommended approximately 4 to 6 weeks after discharge to establish a new radiographic
baseline
What is the prognosis of this Given the new laboratory data, we can compute the patient’s Risk Class using the Pneumonia Severity Harrison’s
patient? Index (PSI), we can classify the patient at Risk Class II with 0.6-0.9% mortality. Thus, the patient’s Principles of
prognosis is good. Internal Medicine
20th edition, p912
Can this disease be  Hand hygiene and respiratory hygiene is necessary to prevent the disease. CPG on Community
 prevented? How? What will  Vaccination against pneumococcal disease may be one to prevent disease. Acquired Pneumonia
you advise your patient?  Tertiary prevention, such as empiric antibiotic therapy must also be initiated as soon as possible to 2016 Update (p. 1-2)
prevent complications.

CONCEPT MAP

Provide a diagram or a concept map on the pathophysiology of the patient’s case correlating the history, signs and symptoms, and diagnostic test results. The diagram should be
able to explain the sequence of events resulting to the diagnosis and manifestations of the patients. Include the medicines that you will use in this case demonstrating where
these medicines will have its effect in the pathophysiology. You may save it as PDF file to maintain the organization of your figures and arrows OR write it in a clean white sheet
of paper(s) and take a picture of it, then copy and paste it here in the document, OR upload the picture directly to the assignment section. You may also make a screen shot of
the pathophysiology then paste and crop it in the word document.