MANILA THEOLOGICAL COLLEGE
COLLEGE OF MEDICINE
CASE STUDY ON GROSS ANATOMY:
PULMONARY SYSTEM
GROUP 3
BATCH 2023
LAVIÑA, OSWALD
MAMENTA, JARED
MARQUEZ, JAY ANTHONY
MATEO, MARIA ANGELIKA ISABEL
MEDINA, ELMIRA EMERY
MEMBRIDO, JUSTINE MAE
MILANES, CLARENCE
MIRANDA, ASELA
PARK, JONG CHAN
PELAYO, JOANA MARIE
SUBMITTED TO:
DR. FERNANDO PERALDO, M.D., M.P.H
CASE: Fever, Chills and Fishballs
Gary, a 45-year-old fish ball vendor, presents with sudden onset of shaking chills, fever,
and productive cough. He was in his usual state of good health until 1 week ago, when
he developed mild nasal congestion and achiness. He otherwise felt well until last night,
when he became fatigued and feverish, and developed a cough associated with
right-sided pleuritic chest pain.
Gary’s medical history is remarkable only for his 15-pack per year smoking habit.
In your office, Gary’s vital signs are normal except for a temperature of 38.9°C. His
oxygen saturation on room air is 100%. He is comfortable, except when he coughs.
His physical examination is unremarkable except for bronchial breath sounds and
end-inspiratory crackles in the right lower lung field.
Gary thinks that his fishball vending for a long time has taken a toll on his health.
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ASSESSMENT: PATIENT HISTORY
Patient is remarkable for his 15-pack per year smoking habit.
Patient developed a mild nasal congestion and achiness a week ago.
ASSESSMENT: PHYSICAL EXAMINATION
Age: 45 years old (male)
Occupation: Fishball vendor
SSX: sudden onset of shaking chills, fever, and productive cough
Temperature: 38.9°C
Oxygen level: 100%
Breath Sounds: Bronchial breath sounds and end-inspiratory crackles in the right
lower lung field.
INITIAL DIAGNOSIS
COMMUNITY ACQUIRED PNEUMONIA
The salient features that reassure the initial diagnosis are:
● Productive cough
● Pleuritic chest pain
● Fever
DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
ACUTE BRONCHITIS Fever Wheezing
Chest pain 100% oxygen saturation
Productive cough
Cigarette Smoking as a
cause
EXACERBATION OF Fever Chest and belly Pain
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE Productive Cough Wheezing
(COPD)
Cigarette Smoking as a Irregular Breathing
cause
The symptoms are usual
but are worsen
100% oxygen saturation
PNEUMONIA
It is an infection of the lung parenchyma, which may be caused by bacteria,
viruses, fungi, or rarely protozoa.
It influences the air sacs in one or both lungs. The air sacs may fill with fluid or pus
(purulent material), causing cough with phlegm or pus, fever, chills, and difficulty
breathing.
TYPICAL PNEUMONIA
Sudden onset of fever, cough with productive rust-colored sputum,
pleuritic chest pain, pneumococcal pneumonia.
ATYPICAL PNEUMONIA
More insidious onset, dry cough, extrapulmonary symptoms, caused by
Mycoplasma pneumoniae.
COMMUNITY ACQUIRED PNEUMONIA
It is the most common type of pneumonia. It occurs outside of hospitals or
other health care facilities which affects individuals of all ages. It is an
infection of the alveoli, distal airways, and interstitium of the lungs.
HEALTH CARE ASSOCIATED PNEUMONIA (HCAP)
It occurs in a non-hospitalized patient who had significant experience with
the healthcare system
● IV Therapy
● Wound care
● Residence in nursing homes
● Hospitalization or 2 or more days
● Attendance at a hospital or hemodialysis clinic.
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GUIDE QUESTIONS:
1. What is your diagnosis?
Community Acquired Pneumonia due to smoking and from possible unsanitary
work environment.
Positive for productive cough, pleuritic chest pain , and a high grade fever.
Further workup for confirmation of infective agent.
Furthermore, pneumonia is the third top leading cause of death in the
Philippines
2. What is your next step?
● Make a comprehensive history checking on the patient - aside from the given
details that the patient smokes 15 packs of cigarettes a year, we can also add
other questions to further our investigation with the patient’s illness. We can ask
the patient to describe his work environment, his daily lifestyle, habits, how he
takes care of himself, etc. Since the patient is also coughing along with pain in
the right side of his chest correlated by crackling sounds during end-respiration,
we can infer that there is presence of infiltrates (phlegm, blood or pus) in his
lungs. If the patient has phlegm present, we can also ask him to describe the
color, texture, and odor of it to help us give an idea on the type of infection he is
having.
● Request for:
○ Chest X-ray - Presence of consolidation, which is the replacement of air in
the alveoli by transudate, pus, blood, cells or other substances,
represented by white elements filling the black spaces (for air) can give
you a good confirmation that the patient has pneumonia.
○ Sputum Gram Stain - A request for gram stain would be necessary to
narrow down the different causative agents that can cause the patient’s
illness(whether it is Gram-positive or Gram-negative). This can also help
you confirm the initial diagnosis and cross-out your differential diagnoses
along with giving aid on your management to follow when treating your
patient.
○ Bacterial Culture and Sensitivity Testing - Since gram staining is still a broad
test for bacterial identification, a bacterial culture can be requested to
finally confirm the true causative agent of the patient’s disease. Bacterial
culture is done by planting a part of a specimen (in this case the patient’s
sputum) on a culture medium and allowing it to grow in an environment
where it can exhibit it’s differentiating features which can give you an
idea of the type of bacteria present in the specimen. Sensitivity testing is
done to identify antibiotics that can be used to treat the bacterial
infection by measuring it’s susceptibility or resistance.
● While waiting for the laboratory results, the physician can:
○ Manage the manifesting symptoms on the patient through:
■ Cigarette smoking management
■ Oral antibiotic therapy
■ Pain relievers
■ Antipyretics
■ Cough suppressants
■ Follow-up (in 1-2 weeks)
3. What are the causative organisms and the appropriate therapeutic regimens.
ATYPICAL PNEUMONIA TYPICAL PNEUMONIA
CAUSATIVE Mycoplasma pneumoniae, Streptococcus pneumoniae,
ORGANISM Legionella pneumophilia, Haemophilus influenzae,
Chlamydophila pneumoniae, Klabsiella pneumoniae,
viruses, protozoa and fungi mixed aerobic and
anaerobic oral flora
THERAPEUTIC Antibiotics to kill causative Antibiotics to kill causative
REGIMENS bacteria bacteria
NSAIDs to help reduce NSAIDS to help reduce
symptoms symptoms
No OTC cough medicine to Cough Suppressants to
prevent harder expelling of reduce cough
mucus and septum
Drinking non-caffeinated fluids to loosen phlegm and mucus
Rest to prevent immune system to weaken
INTERVENTION
DRUGS (ANTIBIOTICS)
First-line antibiotics
- Macrolide Antibiotics to inhibit bacterial growth (e.g.)
Azithromycin,Clarithromycin, tetracycline.
Other appropriate antibiotics
- (Combi-drug) Fluoroquinolone, beta-lactam / Augmentin (penicillin
derivatives) + Macrolides
OXYGEN THERAPY
- use of high flow/non-rebreather mask to keep oxygen saturation >
93%
IV FLUIDS
- to address any sign of dehydration and hypotension for patient to
easily expectorate secretions
NUTRITION
- (a) diet as tolerated, but expect the patient to experience nausea,
thus has poor appetite; (b) increased protein and caloric
requirements due to the presence of infection
4. What are the clinical criteria indicating inpatient versus outpatient therapy.
Inpatient therapy means you are admitted to the hospital on a doctor’s order.
You are classified as an inpatient as soon as you are formally admitted.
Outpatient therapy is defined as hospital or medical facility care that you receive
without being admitted or for a stay of less than 24 hours.
CRITERIAS
CURB-65 Score - most commonly used tool to identify patients who are
sick or have the potential to become very unwell, possibly requiring
admission to ICU
C New mental confusion
U Urea > 7mmol/l
R Respiratory Rate > 30bpm
B BP (systolic <90 mmHg, diastolic <60 mmHg)
65 Age of > 65
SCORE INDICATIONS:
≤ 2 ~ hospital admission not necessary but will depend on other
pre-existing condition
> 2 ~ hospital admission is a must for further assessment &
management, higher score = more severe
Modified Early Warning Score (MEWS) - cumulative score based on blood
pressure, respiratory rate, consciousness level, temperature and pulse.
Systolic BP Heart Rate
Respiratory Rate AVPU Score
Temperature
SCORE INDICATIONS:
≥ 5 ~ hospital admission is a must to prevent progression and death,
higher score = more severe condition.
5. Discuss the role of radiologic and laboratory evaluation in the diagnosis.
Chest Radiography helps in diagnosing pneumonia and determine the extent and
location of the infection. White spots (called infiltrates) that identify an infection can
be seen in the lungs. This exam will also help determine if you have any
complications related to pneumonia such as abscesses or pleural effusions (fluid
surrounding the lungs).
Ultrasound may be used if fluid surrounding the lungs is suspected. An ultrasound
exam will help determine how much fluid is present and can aid in determining the
cause of the fluid.
Blood tests. Blood tests are used to confirm an infection and to try to identify the
type of organism causing the infection.
Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can
prevent your lungs from moving enough oxygen into your bloodstream.
Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough
and analyzed to help pinpoint the cause of the infection.
CONCLUSION
With the given signs and symptoms shown by the patient and based on the lab results,
most likely diagnosis is Community Acquired Pneumonia (CAP) caused by
Streptococcus pneumoniae germ which can be treated by oral antibiotic therapy with
close follow up check up. Give health teachings to the patient on how to avoid the
recurrence of CAP and proper lifestyle changes to improve his health and boost his
immune system.
Health Teachings for the patient:
Get plenty of rest. Getting enough sleep will give your body the strength it needs to
fight the illness.
* Take deep breaths and cough several times each hour to loosen up mucus and get it
out of your lungs.
* Wash your hands with soap and water or use an alcohol-based hand rub after
blowing your nose or using the bathroom, and before eating.
* Cough or sneeze into a tissue or into your elbow or sleeve.
* If you smoke, stop. Ask your healthcare provider about support groups, medicines,
and other ways to help you quit smoking.
* Drink several glasses of water a day. Fluids help thin and loosen up the mucus in your
lungs and throat.
* Eat a balanced diet so your body can work its best and heal quickly.
