CLERKSHIP –II

(PCP 4154)

AT
HTAR
PATIENT BACKGROUND/DEMOGRAPHICS

• Name : Mr K
• Age: 22
• Gender: Male
• Ethnicity: Indian
• Date of admission: 16/5/18
Chief Complaint & History of Present Illness

• Fever 3/7 (relieved by PCM), cough, sore throat,

yellowish sputum
• No abdominal pain
• No nausea & diarrhea
 PAST MEDICAL HISTORY NIL

PAST MEDICATION HISTORY

• PCM
 FAMILY HISTORY -

SOCIAL HISTORY
• Living in dengue prone area.
• Works as a storekeeper, claimed lot of mouse at the workplace.
• Smoker for 3 years. 1 pack/2 days.
• A drinker.

DRUG ALLERGY - NKDA

LAB INVESTIGATIONS
ANY OTHER FINDINGS SPECIFIC to
THE CASE
• Sputum CTS, Blood CTS • CXR: Patchy consolidation
• Leptospirosis serology: • ECG: No acute ischemic
Inconclusive change
• BFMP: No malaria parasite • UFEME: Normal
• Viral screening • Dengue combo: Normal
• FBP : Response to infection
• Serum mycoplasma: Pending
• AFB: No AFB
VITAL SIGNS/REVIEW OF
PROVISIONAL AND FINAL DIAGNOSIS

• CAP (Community Acquired Pneumonia)

• Thrombocytopenia ( likely secondary infection)
• Pharyngitis
CURRENT/WARD MEDICATIONS-
PATHOPHYSIOLOGY OF DISEASE
• Microorganisms gain access to the lower respiratory tract by three
routes: inhaled as aerosolized particles, enter the lung via the
bloodstream from an extrapulmonary site of infection, or aspiration
of oropharyngeal contents may occur.
• Lung infections with viruses suppress the bacterial clearing activity
of the lung by impairing alveolar macrophage function and
mucociliary clearance, thus setting the stage for secondary bacterial
pneumonia.
• CAP- Pneumonia developing in patients with no contact to a
medical facility.
TREATMENT STRATEGIES
Pharmaceutical Care Issues
DISCHARGE MEDICATIONS

• T. Azithromycin 500mg OD for 5 days

 REFERENCES

Dipiro, J. T. (2012). Pharmacotherapy Handbook: Ninth

Edition (9th Editio). McGraw Hill Professional.
Pharmaceutical Services Division. (2014). National Antibiotic
Guideline 2014. Ministry of Health Malaysia, 1689–1699.
https://doi.org/10.1017/CBO9781107415324.004
Society, B. T. (2009). Guidelines for the Management of
Community Acquired Pneumonia in Adults Update 2009 A
Quick Reference Guide. British Thoracic Society,
64(November).