Ifugao State University

College of Health Sciences

Nayon, Lamut, Ifugao
A Case Study of
Community Acquired Pneumonia
Prepared by:
GROUP 3

December 7, 2009
 I-PATIENT’S PROFILE
 Name : Ja Ko
 Hospital No. : 14-26-47
 Address : Liwang,Banaue,
Ifugao
 Gender : Male
 Birthdate : September 27, 1935
 Birth Place : Banaue, Ifugao
 Age : 72
 Nationality : Filipino
 Civil Status : Married
 Religion : Roman Catholic
 Chief complaints : Continuous

productive cough, on
and off fever, DOB
 Date of Admission : November 27,
2009
 Time of Admission : 8:20 A.M
 Admitting Diagnosis : Community
Acquired
Pneumonia
 Attending Physician : Dr. Jessie

Guimbatan
 Number of hospitalization: 5 days

 Date of discharge : December

2, 2009
 II- HISTORY OF PAST ILLNESS
 A. Family History
Mr. Ko is the eldest among 3 children. He was
born on September 27, 1935 in an NSD at home
assisted by a trained hilot. Mr. Ko graduated from
elementary level but did not continue to pursue to a
higher education instead he choose to earn money
through wood carving that he was able to hand
small amount of money to his parents and two
siblings after selling his wood carved products.
 According to Mr. Ko since childhood, his
parents was already farmers, they would spend their
time working in the field from morning to afternoon.
Their whole family lived at Bangaan, Banaue,
Ifugao
Mr. Ko got married at age 22 y/o and decided to
stay with his wife in a separate house from his
parents but within the same Barangay.
Both of Mr. Ko’s parents passed away at an old
age, and both of his siblings got married at age 23
y/o and live with their respective wife and children.
 B. Socio – Cultural History

At the age 15 y/o Mr. Ko was able to earned

money through carving. He had friends of his age
and are out for school and are working as wood
carvers. Most of the time they would gather together
and proceed to the forest to look for trees with sizes
appropriate to their design products to carve. Mr. ko
then enjoyed chewing beetle nuts with his friends
during their rest periods.
 Presently, during his stay in the hospital Mr. Ko
spend his time talking with his wife, children and
visitors and asking question to the health care
provider about his present condition.
 C. Past History of Illness
Mr.Ko has no remarkable illness like
hypertension and diabetes mellitus. He
claimed that he was not hospitalized/ admitted
in any hospital for treatment. At times when he
suffers from headache and body pain he would
take in 1 tablet of Mefenamic or Alaxan as
usually given to him in their RHU. and when
caught by the rain and caused him to get cough
and colds he usually increase water intake and
have rest periods to recover.
 III- HISTORY OF PRESENT
ILLNESS
Two weeks before admission Mr. Ko
suffered from continuous productive cough
as he expectorate with on and off fever. Mr.
Ko taught that it could be relieved by drinking
of warm water and staying home for rest but
his condition worsened that he experience
DOB so his son brought him to the hospital at
8:20 in the morning and was admitted with an
admitting diagnosis of CAP.
 IV- BRIEF DESCRIPTION OF THE
DISEASE
Pneumonia is a serious infection or inflammation
of the lungs. The air sacs in the lungs are filled with
pus and other liquid. Oxygen has trouble reaching
the blood. If there is too little oxygen in the blood,
the body cells can’t work properly. Because of this
and spreading infection through the body,
pneumonia can cause death.
 Pneumonia affects the lungs in two ways. Lobar
pneumonia affects a section (lobe) of a lung.
Bronchial pneumonia (or bronchopneumonia)
affects patches throughout both lungs.
  CAUSES OF PNEUMONIA

 Causative agent for CAP that requires

hospitalization:

 >S.pneumoniae
 >H. influenzae
 >Pseudomonas aeruginosa
 Pneumonia is most likely to occur when normal
defense mechanisms are weakened or overcome by
the virulence, quality or number of organisms.
The common feature of all types of pneumonia is
an inflammatory response to the offending organism
or agent. Infectious agents are usually introduced
by inhalation. The defense mechanisms of the lungs
lose effectiveness and allow organisms to penetrate
the lower airways, in which inflammation develops.
 Diagnostic Assessment

 A doctor or other health care provider diagnoses

pneumonia based on:

 Symptoms
 Physical examination
 Laboratory tests
 Chest x-ray
VI- PATHOPHYSIOLOGY
 VII- PHYSICAL ASSESSMENT
FINDINGS SIGNIFICANCE
Significant others:

P
Wife and his
children
Coping mechanism:
Verbalization
>To relieve stress and
feelings to significant
anxiety
others and health
Psychosocial workers.
Praying

>for spiritual growth

Religion: Roman
Catholic
Primary dialect:
Tuwali
Primary source of
>Nearest health
health care:
unit in their
Barangay
Barangay
Health clinic,
Banaue RHU
Financial Sources >It helps to lessen
related to illness: their hospital bill
Philhealth and
Financial support from
his children

Educational
Attainment:
Elementary graduate
General
appearance:

The patient >due to his present

looks , weak, pale condition
and not well >lack of grooming
groomed and proper hygiene
Affect:
In respiratory
distress, irritable, >appropriate
and easily get
tired

Speech:
The patient can
>normal
speak well
Memory: >he was asked what was
the day he was admitted in
the hospital
Short term
memory: intact
>able to respond and
Long term answer questions related to
his past and the patient can
memory: remember important dates
intact in his life. (eg. His
Birthday, Birthdays of his
children)
 Stool:

E
Elimination
Pattern: O.D, during
morning

Consistency: Semi
solid

Color: Brownish
Urine:
Pattern: 2-3 times a day
Transparency: Clear
Color: Amber
Quantity: approximately
150-300ml /voiding
Abdomen:
Contour: Flat
Bowel sounds: Gurgling
sounds
Toileting Ability:

Able to walk going

to the comfort room
 Current Activity

R
level

Sitting on bed
while talking to his
wife and significant
others.
REST
ADL’s

Able to perform >The patient

some ADL’s with performs light
minimal assistance activities with
like when he is minimal assistance
eating, sitting, because he feels weak
drinking and when and easily gets tired
going the comfort
room.
Sleep Pattern: >Due to physiological
symptoms and
approximately 7-8 environmental factors
hours with like administering
interruptions medications and taking of
vital signs.
>Due to present
Body frame: condition
Ectomorph

Posture: Kyphotic >Due to old age

Coordination: Not >Due to pain when
well coordination coughing

Motor Function:

Fine: can grasp

small objects and
can open a bottle
of minerals
Gross: can stand and
able to move on bed
without assistance

Range of motion:

Arms: can slowly lift

and flex.
>due to weakness

Legs: can slowly lift

and flex
>due to weakness
 Allergies
Food: None - as
claimed by pt.

S
Medication: None

Pupils: PERRLA –
Normal

Safety Hearing:
Structure:
Symmetric in shape,
no hearing aid.
Hearing Acuity:

Patient has
moderate hearing > due to aging
loss, cannot hear
soft spoken words
and cannot hear
clearly from an
approximated
distance of 2 feet.
Skin Integrity:
-Lesions/scars:
With minor scar at
left upper extremity
and no surgical
incision.

Mucous membrane:
Moist and intact
Temperature:
37.8 0C/axilla
 Airway Clearance:
-Nose > presence of mucus
Clogged nose, at the nasal passage

O
symmetric in shape

-Mouth
Clear, with presence >poor oral hygiene
of dental carries and
Oxygenation stained teeth
Respiration:
Rate:29 cpm >to promote lung
Rhythm: rapid expansion
Depth: shallow
Position assumed:
semi-fowlers
Color:
Skin: fair
complexion
Nails: light pink
Lips: reddish
Capillary refill: 1
sec.
Peripheral pulse:

Location: radial
Rate:98 bpm
Rhythm: rapid
Blood pressure:
130/90
O2 therapy: with O2
regulated at 2-3
LPM
 Hospital diet:
DAT
Fluid intake:

N
Approximately 5-6
glasses a day
IVF:D5LRS
Insertion Site: Right
arm
Nutrition Solution: D5 LRS 1
L x 80
Tissue Turgor:
Good skin turgor
Height: 5’6”

Hospital
diet:DATFluid
intake:Approximatel
y 5-6 glasses aday

IVF:D5LRSInsertion
Site: Right
armSolution: D5
LRS 1 L x 80Tissue
Turgor: Good skin
turgor
Height: 5’6”
Weight:53Kgs.
BMI:
Able to:Chew:
yesSwallow: yesAble
to feed self with
assistance.
-With intact gag
reflex
 VII- LABORATORY
November 27,2009

Test Result Normal Valus Interpretation

Hgb 109 g/L 110-160 g/L

Hct 33 vol % 35 – 50 vol %
Leucocyte no. 4.9 x 10 g/L 5-10 x 10 g/L
conc.
Neutrophils .44
Lymphocytes .56

•Significance: Decreased values indicates possible anemia

 RADIOLOGIC REPORT

 CXR-APL
 there is haziness in both perihilar and
paracardiac areas
 suggestive nodulari test are seen in the hilar

region
 heart is normal in size

 lenidiaphragms, costophrenic sulci and the

visualized bones are intact

Thank you so much for listening!!!!!!!

God Bless and Have a nice day!!!

MERRY CHRISTMAS AND HAPPY

NEW YEAR