VMMC GROUP

A. HEALTH HISTORY
I. GENERAL DATA
Mr. E. DC is a 91 years old male patient, married, Filipino, roman catholic, and a former farmer
who is currently residing in brgy. Abanon, San Carlos Pangasinan.
Source of information: Melicio dela Cruz (son), 80% reliability
Date of admission: September 9, 2019
Date of interview: September 12, 2019
II. CHIEF COMPLAINT
- Cough

III. HISTORY OF PRESENT ILLNESS

2 days PTA, patient started having cough which his son described as intermittent, usually
worsens at night, with no precipitating factors, relieved by taking bioflu every after 4 hours, cough is
productive and was characterized as yellowish, slightly foul smelling, thick and expels approximately 30
ml of phlegm daily. Associated symptoms include undocumented fever, chills, fatigue, loss of appetite
and difficulty of breathing.
Few hours prior to admission, patient started vomiting, and simultaneous involuntary urination
and defecation. Blood pressure also increased hence consult.
IV. PAST MEDICAL HISTORY
Medical:
- 2014: admitted at VMMC, diagnosed with hypertension
Surgical: none
Psychiatric: none
Medication: Antihypertensive drug (name and dose unrecalled) taken every morning Immunization:
unrecalled PCV immunization when patient turned 65
V. FAMILY HISTORY
Father: Deceased, reason of death unrecalled
Mother: Deceased, reason of death unrecalled
Wife: Deceased, reason of death unrecalled
3rd daughter: hypertension (60 y/o)
4th daughter: diabetes (51y/o)
 VI. PERSONAL AND SOCIAL HISTORY
Patient is a retired farmer that has 7 children in total. Lives with one of his sons, daughter in law
and grandchildren. No known allergies with animals, diet is composed of rice, vegetables, meat and fish.
No exercise due to weakness and age. Non-smoker and non-alcoholic drinker.
VII. REVIEW OF SYSTEMS
General: recent weight loss, clothing and belt fits more loosely, fatigue, weakness, fever
Skin: no rashes, no lumps, no sores, no itching, no dryness, no changes in color, no changes in hair or
nails.
HEENT:
- Head: no headache, (+) dizziness, no lightheadedness
- Eyes: (+) loss of vision on both eyes, no pain, no redness, no excessive tearing, no double vision, no
spots, no specks, no flashing lights, no glaucoma, no cataract.
- Ears: decrease in hearing, no tinnitus, no vertigo, no earaches, no infection, no discharge.
- Nose and sinuses: (+) colds, no stuffiness, no discharge or itching, no nosebleed
- Throat: no teeth and gum condition, no bleeding gums, no sore tongue, (+) dry mouth, no frequent sore
throat no hoarseness.
Neck: no swollen glands, no goiter, no lumps, no pain, no stiffness in the neck
Breasts: no pain and discomfort
Respiratory: no hemoptysis, no dyspnea, no pleurisy
Cardiovascular: no rheumatic fever, no chest pain or discomfort, no palpitations, (+) orthopnea, no
paroxysmal nocturnal dyspnea
Urinary: (+) urinary incontinence, no increased frequency of urination, no polyuria, no nocturia, no
burning or pain sensation during urination.
Genitalia: not performed
Musculoskeletal: no masses, no lesions, no arthritis, no gout, (+) backache, (+) limitation of motion
Psychiatric: no nervousness, no tension, no depression.
Neurologic: (+) memory loss; no changes in mood, attention or speech; (+) changes in orientation, insight
or judgment; no dizziness, no vertigo, no seizures; no numbness, no tingling or pins and needles, no
tremors or other involuntary movements.
Hematologic: no anemia, no bleeding, no past transfusions
Endocrine: no thyroid trouble, no heat or cold intolerance, no excessive sweating, no excessive thirst, no
hunger, no polyuria
B. PHYSICAL EXAM
I. VITAL SIGNS
BP: 130/70 mmhg
Temperature: 34.9 Celsius
Respiratory rate: 18 bpm
Pulse rate: 78 bpm

II. GENERAL INSPECTION

Mr. DC is a geriatric patient, frail or weak looking. No tension or anxiety seen during interview.
Well groomed, proper hygiene. Has difficulty of communicating.
SKIN
No rash, no scars, no dryness, no lesions, warm, no cyanosis
HEENT
Head: No palpable mass, normal hair distribution, no scars.,
normocephalic
Eyes: white sclera, palpebral conjunctiva appears pale
Ears: no swelling, scars and discharge seen
Nose: No swelling, scars and discharge seen
Throat: tongue, tonsils, soft palate appears pink and symmetric

THORAX AND LUNGS

Thorax is symmetric with good expansion. Lungs are resonant. Breath sounds vesicular, no rales,
wheezes or rhonchi.

CARDIOVASCULAR
Distinct S1 and S2. At the base, S2, is greater than S1. At the apex, S1 is greater than S2 and constant. No
murmurs, no S3 and S4 heard.

ABDOMEN
No scars, umbilicus located in the middle, symmetric, no pain when palpated and normal motility sound
when auscultated.
MUSCULOKELETAL
No wound, no swelling, limited range of motion and decreased strength on all extremities

NERVOUS SYSTEM
Mental status: Alert, relaxed and cooperative. (+) memory loss.
Changes in orientation to person, place and time.

III. SALIENT FEATURES

- Acute productive cough, dyspnea, weight loss, undocumented fever, fatigue, chills, backache, unrecalled
PCV immunization

ADMITTING IMPRESSION:

COMMUNITY ACQUIRED PNEUMONIA - MODERATE RISK (CAPMR)

IV. DIFFERENTIAL DIAGNOSIS

- Tuberculosis

Rule in Rule out

Dyspnea 2 or more weeks of cough

Weight loss Hemoptysis

Fever Night sweat

Fatigue Exposure to patients with TB

Chills

- Chronic obstructive pulmonary disease

Rule in Rule out

Weight loss Chronic productive cough

Fever Wheezing
 Fatigue Mucus accumulation esp when waking up

Cyanosis

Swelling in ankles, feet and legs

- Lung cancer

Rule in Rule out

Weight loss Persistent cough

Fever Hemoptysis

Loss of appetite Hoarseness of voice

Backache Wheezing

V. CLINICAL DIAGNOSIS
- Community Acquired Pneumonia, is a type of pneumonia found in persons that have not been recently
hospitalized or confined in the hospital. It may be caused by bacteria, viruses or fungi but the most
common agent is Streptococcus pneumoniae. Signs and symptoms include cough that is characterized as
yellow colored mucus, fever, chills, dyspnea, loss of appetite and weakness. It commonly affects geriatric
patients, that is why PCV immunization is required in people age 65 and above.

VI. DIAGNOSTICS and ANCILLARY TESTS

A. Chest X-Ray: has been the standard method of diagnosing pneumonia.
Chest radiograph will show lobe infiltration in a patient with pneumonia.
B. Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent your
lungs from moving enough oxygen into the bloodstream.
C. Complete blood cell (CBC) count with differential Leukocytosis is the most common blood
test abnormality (typically between 15,000 and 30,000 per mm3) with a leftward shift.
D. Serum blood urea nitrogen (BUN) and creatinine levels: New elevations in creatinine and
blood urea nitrogen also connote poor prognosis and often indicate need for hospitalization.
E. Sputum Gram stain and/or culture: Tests of your sputum to see if a germ is present there. A
sample of fluid from your lungs (sputum) is taken after a deep cough and analyzed to help
pinpoint the cause of the infection.
F. Pleural fluid culture. A fluid sample is taken by putting a needle between the ribs from the
pleural area and analyzed to help determine the type of infection.

G. Serum sodium level: Hyponatremia is a common complication present at the time of admission
for CAP. Community-acquired pneumonia (CAP) is a frequent cause for hospitalization and may
result in a number of different renal and electrolyte complications.

H. C-reactive protein: As an indicator of the etiology of CAP.

Management for CAP

The initial management of CAP depends on the patient's severity of illness; underlying medical
conditions and risk factors, such as smoking; and ability to adhere to a treatment plan. The need for
hospitalization is the first decision that needs to be made after CAP is diagnosed or suspected.

Because the exact causative organism is not identified in many patients with CAP, treatment is
usually empiric.

A. Antibiotic therapy: for the in patients who are not admitted to the ICU should receive a
respiratory fluoroquinolone or a beta-lactam antibiotic and a macrolide.

 Observational data suggest lower short-term mortality when antibiotic therapy is administered
within four to eight hours of hospital arrival in patients with moderate or severe pneumonia.
Antibiotics are started as soon as possible. Doctors may prescribe antibiotics based on the
severity of the infection and the risk of complications.
 Duration of therapy for patients with CAP has traditionally been 10 to 14 days, but more recent
evidence suggests a shorter course of up to seven days is equally effective.

 To treat influenza pneumonia, the antiviral drugs oseltamivir, zanamivir, or baloxavir can be

given. To treat chickenpox pneumonia, acyclovir is given. If a person with a presumed viral
pneumonia is very sick or does not improve within a few days after beginning treatment,
doctors may prescribe antibiotics in case bacteria have also infected the lung.
 To treat fungal pneumonia, antifungal drugs may be given.

B. You may also need extra support, such as:

 Extra oxygen

 Fluids, if you are dehydrated

 Breathing treatments
  Respiratory support such as with a ventilator, for a severe case

C. Sometimes doctors do follow-up chest x-rays about 6 weeks after treatment to make sure that
any abnormal findings on chest x-ray have resolved. Follow-up may be more important in
people who smoke and in older people to ensure that the abnormal findings seen on chest x-
ray represent pneumonia only rather than an underlying cancer with pneumonia.