CASE

PRESENTATION 3
COMMUNITY ACQUIRED PNEUMONIA
Presented by: Group 3
GROUP MEMBERS
 ESENTATION OUTLIN
PR E

RESPIRATORY
HISTORY TAKING
EXAMINATION
CHIEF COMPLAINT
32 years old male presented to HQE1 with shortness of breath for 4 days
and cough for two weeks
HISTORY
TAKING
 HISTORY OF PRESENT ILLNESS
Patient started to have sudden onset dyspnea 4 days prior to admission. It occurs with
minimal exertion as episodes of dyspnea occur when he does his work as massage therapy
and takes a bath. His dyspnea only gradually relieved after 5 minutes of rest and it is
associated with palpitation, orthopnea, paroxysmal nocturnal dyspnea, and bilateral
ankle swelling. He also described himself to have pursed lip breathing for the past four
days. Patients also never have cardiac problems or disease. He experiences cough for 2
weeks, intermittently lasting for few bouts every episode. Initially, it is dry cough but
become productive cough with yellowish and greenish sputum and associated with sore
throat and pleuritic chest pain. The cough is worse in morning, during cold, and when
lying down and no medication taken to relieve the cough. There is no fever, runny nose,
night sweats, hoarseness, wheezing or noisy breathing, weight loss or appetite loss and
 SYSTEMIC REVIEW
Nervous system: No visual disturbance, no numbness, no paralysis, no change in
behaviour, no delirium, no dizziness

Gastrointestinal system: No loss of appetite, no abdominal pain, no nausea, no

vomiting, no hematemesis and no constipation

Urinary system: No frequency, no urgency, no dysuria, no back pain, no incontinence,

no hematuria, no oliguria, no polyuria,

Genital system: No urinary discharge, no hematuria, no pain

Musculoskeletal system: No myalgia, no arthralgia, no swelling and normal gait

Haematological system: No bruising, no bleeding in gum, no pallor

 PAST MEDICAL HISTORY
Patient diagnosed with hypertension in 2017 but no diabetes mellitus and dyslipidemia.
No other infections except PTB previously, in July 2022. The patient is found to be
asymptomatic but the diagnosis is made after screening was done by all workers in his
workplace. Other than this, he has no other known lung issues and has never been
hospitalised before.

PAST SURGICAL HISTORY

None
 FAMILY HISTORY
Mother passed in 2017 due to lung cancer diagnosed in the same year

Father is alive, previously infected with PTB along with brother and niece

and are receiving treatment from the government hospital

Father has underlying hypertension

Most of the family members are active smokers including his late mother

No family history of heart disease, COPD and bronchial asthma

DRUGS AND ALLERGY
Ongoing anti-tubercular therapy (ATT) day
109
-Rifampicin
-Isoniazid
-Pyridoxine
Patient is compliant to ATT
Side effects: Orange urine, abdominal pain
and nausea. Rare and tolerable
No consumption of herbal medicine,
supplements, vitamins or traditional
medication
No allergies towards food and drugs
SOCIAL HISTORY
Lives in a crowded worker’s quarters where they
sometimes encountered water problems.
Some of his friends are infected with PTB and
some of his housemates experienced similar
symptoms as him.
Married with 3 children but his family lives in the
Philippines.
Works as a massage therapist and not exposed to
dust or chemicals.
Income is around RM 1500 - RM 1700 per month.
Family finance is supported by his wife.
The nearest health care facilities from his place is
about 15 minutes by car.
he has 18 pack years of active smoking since
2005.
he has been drinking two to three tins of beer per
day since ten years ago.
RESPIRATORY
EXAMINATION
 GENERAL INSPECTION
CLINICAL SIGNS CHEST HANDS
Age Symmetry Colour
Cyanosis Scars Tar staining
Chronic or acute
Shortness of breath Deformity Skin changes
Non lung pathology or nah?
Cough Lesion Joint swelling or
Wheeze Intercostal deformity
Pallor Might be dealing with cardiac indrawing Finger clubbing
Edema failure Count respiratory Flapping tremor
Encelopathy
COPD
Cachexia rate Fine tremor

ALWAYS POSITION PATIENT AT 45°

UPRIGT ON THE EXAMINATION COUCH
AND HAVE PROPER EXPOSURE OF THE
CHEST!
General examination is from he ad to toe
1)Tracheal deviation
PALPATION
HEADLINE
Feel for the trachea in the suprasternal notch and decide whether it isHERE
central or deviated to one side.
2) Apex beat
Lorem ipsum dolor sit amet,
Locate the apex beat usually at the normally in the fifth intercostal space in
consectetur adipiscing elit, sed
the mid-clavicular line.
do
3)Chest Expansion
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Place your hands firmly on the patient’s chest wall with your fingers
labore et dolore magna aliqua.
extending around the sides of the chest. Your thumbs should almost meet
in the middle line and should be lifted slightly off the chest.
Tell the patient to take a full breath in.
4) Vocal (tactile) fremitus
Palpate the chest wall with the ulnar aspect of the hand while the patient
repeats ‘one-one’ or ‘ninety-nine’.
 PERCUSSION

Percuss in sequence comparing left and right areas before

moving to the next level
Posteriorly, position the patient sitting forward with their
arms folded in front to move the scapulae laterally
Percuss a few centimetres lateral to the spinal muscles
and compare left and right side
 PERCUSSION
TECHNIQUE
Apply the middle finger of
your non-dominant hand
firmly to an intercostal space
parallel to the rib
Drum the middle phalanx
with the flexed tip of your
dominant index or middle
finger
 AUSCULTATION:
ANTERIOR LUNG
Trachea
Ask patient to take deep breaths, and place bell on the supraclavicular
Findings: Higher pitch bronchial sound is heard

Supraclavicular cleft, 1-6 Intercostal spaces and mid-axillary ICS

Turn diaphragm on (for supraclavicular, use bell), auscultate intercostal spaces
Findings: Normal vesicular breath sound on the right lung but there is bronchial
breath sound on the left lung

Vocal resonance
Auscultate supraclavicular cleft, 1-6 Intercostal spaces and mid-axillary ICS while
the patient repeats ‘one-one’ or ‘ninety-nine’.
Findings: Vocal resonance is reduced in the left lung
AUSCULTATION :
POSTERIOR LUNG
On the posterior thorax, auscultation
begin at the shoulders at the scapular
line, moving from one side to the other
side, then move down, and repeat.

Same as for auscultate vocal fremitus in

which the patient repeats ‘one-one’ or
‘ninety-nine’
 PROVISIONAL
DIAGNOSIS
Community acquired pnemoniae with underlying
PTB

Justification:
Presented with dyspnea, productive cough with
yellowish and greenish sputum, pleuritic chest
pain. These symptoms are acute
 DIFFERENTIAL DIAGNOSIS
1.Pulmonary edema secondary to right heart failure.
Supporting points: Orthopnea, paroxysmal nocturnal dyspnoea, bilateral ankle swelling & palpitation,
underlying uncontrolled hypertension, chronic smoker & recreational drug user
Against points: PE usually produce frothy pink secretion that is not sputum while patient had greenish &
yellowish sputum
2.Chronic Obstructive pulmonary disease
Supporting points: dyspnoea, cough, chronic smokers
Against points: COPD symptoms usually chronic and presented with wheezing and chest tightness that is
absent in this patient

3.Pulmonary edema secondary to chronic renal failure

Supporting points: failure symptoms of this patient suggest fluid build up in the lung & use of recreational
drug may lead to insult to the kidney function
Against points: symptoms of renal disorder like oliguria, hematuria, flank pain , nausea & vomiting is not
present
 DIFFERENTIAL DIAGNOSIS
4. Bronchial asthma
Supporting points: dyspnea, productive cough that worsen in cold and morning.
Against points: no wheezing, no chest tightness.

5. Pulmonary embolism
Supporting points: presented with shortness of breath (SOB), palpitation, cough and
bilateral ankle swelling
Against points: no hemoptysis, no unilateral leg swelling, no other risk factor to
support such as prolonged immobilisation and disease such as SLE

6. Lung cancer
Supporting points: family hostory of lung cancer, chronic smoker and consumed
alcohol everyday.
Against points: no weight loss, no constitutional symptoms such as headache, no
bone pain .
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