S

HPI
R/Female/30
CC: Fever
5 days PTC, intermittent dry cough with throat itching and colds.
3 days PTC The patient cough with whitish to yellowish phlegm. No medication, The
patient only increased my fluid intake.
2 days PTC, the patient fever temp of 38.5 C to 39 C. She took Paracetamol 500 mg 1
tab every 4 hours if I have fever which lowered my temperature to 37 -37. 5 C.
Took. 2 -3 tabs a day only
A Day PTC , The patient had trouble sleeping because of my cough and fever. The
symptoms persisted until morning thus reason for consultation.

Past Medical History

Unrecalled immunization. No history of using medication. No allergies. No surgical hx.

Social History
She had history of smoking, 2-3 sticks per day. No recent travel. No hazardous
occupation. Use cocaine few times. Occasional Drinking. Eat health foods as well as
sweets.
Past Family History
Mother – Hypertensive

ROS
General: the patient is awake, alert, febrile, not in respiratory distress
Skin: No cyanosis, redness
Head: No headache
Nose : With nasal congestion but resolved
Mouth: No dryness
Cardio: No chest pain
Respiratory: Every day, worst at night, No asthma, bronchitis, wheezing
Whitish to yellowish phlegm, but small quantity. No orthopnea
No weight change

PE
Ht: 5’9”
Wt: 56.7kg
BMI: 18.5 underweight
PR: 80 Normal
Heart Rate 85 normal
Temperature 37.9° C Febrile
BP:110/80mmhg Non hypertensive
RR:22breaths/min Normal
O2 sat 97%
Normal

Head: Eyes are symmetric in size, shape, color and position. Conjunctiva is moist 
Mouth: Gums are pale red
Nose:

Respiratory:

Inspection: symmetrically. No use of accessory muscles is noted. The expansion of the

chest and abdomen is synchronized.

Pa: No area of tenderness is noted; no masses or deformities are found: palpated

respiratory excursion is symmetric. Vocal fremitus is moderate and symmetric.
Percussion : Resonant in all lung fields. There is no tenderness over the spinous processes or
the paravertebral or trapezius muscles.

Auscultation: Crackles on Left Lower Back

CBC
WBC- 11,700/mm3 high
RBC- 4.0 m/mm3 low
Hgb: 10g/dl Low
Ht: 31% Low
Plt: 285,00 Normal
Neutrophils: 69% High
Lymphocytes: 13% Low

Gram Staining: No Specimen

Chest Xray:
PA view, Adequate Exposure, Lobar consolidation on the left lower lobe, trachea is in midline, the heart
is not enlarged, reticulonodular on the left lower lobe. costophrenic angle is not sharp, Cardiophrenic
angle is not sharp.

Sputum Test: Negative for bacterial growth. No acid-fast bacilli culture. No cytopathic
effect (CPE) is expected on cell culture.
Pneumonia is usually caused by a pathogenic infection of the lungs. The most consistent presenting
symptom of bacterial pneumonia is cough productive of sputum. There would be breakdown in your
body's natural defenses allows germs to invade and multiply within your lungs. To destroy the attacking
organisms, white blood cells rapidly accumulate.

Intermittent productive cough associated with yellowish sputum, with fever, difficulty in sleeping,
presence of lobar consolidation of left lower lobe upon chest xray, increase tactile fremitus LLB, as well
in high in neutrophils suggest inflammation.