Pneumonia
IDENTIFYING DATA
NAME: GUARDANOSA SENEN BERTULFO
AGE: 58 YEARS
GENDER: MALE
DOB: APRIL 26, 1965
PLACE: DAVAO CITY
CIVIL STATUS: WIDOW
RELIGION: CATHOLIC
INFORMANT: PATIENT’S SON
RELIABILITY: 80%
DATE OF ADMISSION: 24th NOV, 2023
CHIEF COMPLAINT
FEVER
HISTORY OF PRESENT ILLNESS
• 3 weeks PTA, the started having intermittent fever. No meds were taken. No consultation was
done. No history of travel. The temperature was documented to be 38 – 39’c.
• 3 weeks PTA, the patient also had on and off non-productive cough especially aggravated in in the
evening. So the patient took SOLMUX (carbocisteine) with no relief. No consult was done.
• In the interim, symptoms was on and off but still persisted. No consult was done.
• On the day of admission, due to worsening of the symptoms the patient in for consultation and
admission
PERTINENT POSITIVES PERTINENT NEGATIVES
• FEVER • DYSPNEA
• DRY COUGH • CHEST PAIN
• BODY MALAISE • SWEATING AND CHILLS
•LOSS OF APPETITE
• NO SIGNS OF HYPOXIA
• CONFUSION
PAST MEDICAL HISTORY
• (+) hypertension (July 2023), no maintenance meds
• No diabetes
• No asthma
• No previous hospitalization or surgeries
• Had 2 primary COVID vaccines.
Family history
unremarkable
PERSONAL AND SOCIAL HISTORY
• (+) smokes 5-7 sticks per day for 39 years.
• Pack years of 9.75 (chronic smoker)
• Occasional alcohol drinker
• Lives alone
REVIEW OF SYSYTEMS
• (+) dizziness
• (+) body malaise
VITAL SIGNS
• AWAKE, ALERT, CONSCIOUS AND NIRD
• BP: 120/70 mmHg
• TEMP: 39’c (febrile)
• PR: 109bpm (tachycardia)
• RR: 23cpm (tachypnea)
PE OF THE LUNGS
I : no retractions and equal chest expansions
P : increased tactile fermites
P : dullness of the left lung
A : (+) bilateral rales
DDX – PULMONARY TUBERCULOSIS
RULE IN RULE OUT
• (+) COUGH • (-) DYSPNEA
• (+) FEVER • (-) NIGHT SWEATS
• (+) BODY MALAISE • CXR TO RULE OUT?
DDX – BRONCHITIS
RULE IN RULE OUT
• (+) FEVER • (-) PRODUCTIVE COUGH
• (+) DRY COUGH • (-) CHEST DISCOMFORT
• (+) BODY MALASIE • (-) SORE THROAT
• (-) CXR TO RULE OUT?
Dx – COMMUNITY ACQUIRED PNEUMONIA
ETIOLOGY
The list of potential etiologic agents of CAP includes bacteria, fungi, viruses, and protozoa.
Separation of potential agents into “typical” bacterial pathogens and “atypical” organisms may be
helpful.
CRITERIA
PREVENTION
• The main prevention is vaccination.
• PPSV23
• PCV13 are available in US.
