Jason Aranzado
SOM - 3
IM Case
Chief Complaint: “One-month cough”
History of Present Illness:
Patient CL, a 71-year-old female from New Cortes, New Corella, Davao del Norte, was admitted
to Davao Regional Medical Center on March 12, 2025, due to a persistent cough lasting one
month. The cough had a sudden onset, hard, difficult to expectorate, and with yellow
phlegm. The cough was present throughout the day but worsened at night. The patient
suspected that it might be allergy-related, as it was exacerbated by certain foods and anxiety.
Then she attempted to alleviate her symptoms by taking a herbal “gabon” plant concoction.
Over time, additional symptoms emerged. Three days prior to admission, she became unable to
walk. She also experienced a loss of appetite, difficulty swallowing solid food, intermittent
headaches, fever, fatigue, and episodes of confusion. Additionally, she noted elevated blood
pressure.
Past Medical History:
The patient has a history of hypertension and has been taking Losartan (50 mg) and
Amlodipine (5 mg). Her childhood vaccination status is unknown, and she has never
received the COVID-19 vaccine. She had chickenpox and mumps during childhood and was
diagnosed with cataracts in both eyes in an unspecified year. She has no known food or drug
allergies.
During her current admission, she was tested for COVID-19, which was negative. A CT scan
showed no abnormalities, while the result of her chest X-ray is still pending.
Menstrual and Obstetric History:
The patient had menarche at 13 years old and menopause at 52. She has a gravidity and parity
score of G9P9 (9005), having given birth to nine children through normal spontaneous vaginal
delivery (NSVD). Among her children, five are alive, while four passed away—three during
childhood due to tetanus, an undiagnosed neck swelling, and an unspecified illness, while the
eldest child died of breast cancer at 42.
Family History:
Her father died of an unknown illness, while her mother, who had hypertension, was a victim of
homicide. There are no other known hereditary conditions in the family.
Personal and Social History:
Patient CL is a member of the Mansaka tribe and has lived in New Cortes, New Corella, for 62
years with her husband and three of her children. She reached grade 6 in education and worked
as a farmer, exposing her to occupational hazards such as chemicals, parasitic infections, and
physical injuries.
She was a long-term tobacco smoker, consuming 10 tobaccos per day for 50 years, but
quit in 2025 due to her current illness. She does not consume alcohol. Her diet consists mainly
of rice and vegetables, and she drinks less than a liter of water daily. She does not take any
supplements. Walking was her primary form of exercise.
Jason Aranzado
SOM - 3
Review of Systems:
General: Reports unquantified weight loss, fatigue, and weakness. No chills or fever.
Skin: No rashes, scars, lumps, or discoloration.
Head: Reports headaches and dizziness, likely due to cataracts.
Eyes: Blurry vision, lacrimation, cataracts in both eyes, and arcus senilis. No redness
or pain.
Ears: No hearing problems, earaches, or discharge.
Nose: No colds or allergic symptoms.
Throat/Mouth: No dental issues, mouth sores, or swallowing difficulty.
Neck: Reports stiffness, but no lumps or pain.
Breast: No lumps or pain.
Respiratory: Productive cough with yellow phlegm and dyspnea. No wheezing or
hemoptysis.
Cardiovascular: Hypertension but no chest pain, palpitations, or edema.
Gastrointestinal: No nausea, vomiting, abdominal pain, diarrhea, or constipation.
Urinary: No issues with urination.
Genital: No pain, discharge, or swelling.
Peripheral Vascular: No leg cramps or varicose veins.
Musculoskeletal: Reports back pain but no joint swelling or muscle weakness.
Psychiatric: Denies anxiety, depression, or hallucinations.
Neurologic: Reports extremity weakness and numbness. Positive hemiplegia.
Hematologic: No signs of easy bruising or bleeding.
Endocrine: No symptoms of diabetes or thyroid dysfunction.
Jason Aranzado
SOM - 3
Physical Examination:
General Appearance & Mental Status: The patient, lying supine in bed, appeared
weak, lethargic, and unkempt. She was initially cooperative but became fatigued towards
the end of the interview. Her speech was mostly coherent but occasionally confused.
GCS: 13 (E3V4M6).
Vital Signs: BP 170/90 mmHg, RR 31 cpm, SpO₂ 95%, HR 90 bpm, Temp 36.5°C.
HEENT:
Head: Normocephalic, no asymmetry.
Eyes: Cataracts OU, arcus senilis OU, pupils 4mm constricting to 3mm, reactive to
light. No hemorrhages or exudates.
Ears: Good hearing, no tenderness.
Nose: Septum midline, no sinus tenderness.
Throat/Mouth: Pale oral mucosa, no exudates.
Neck:
Symmetrical, no masses, trachea midline, no carotid bruits.
Lymph Nodes:
No palpable lymphadenopathy.
Thorax & Lungs:
Symmetrical chest expansion, coarse crackles in all lung fields.
Cardiovascular:
No murmurs, PMI at the 5th ICS.
Abdomen:
Non-distended, non-tender, normal bowel sounds, no visible abnormalities.
Peripheral Vascular:
Warm extremities, no edema or varicose veins.
Musculoskeletal:
Weak hand grip, no joint swelling or deformity.
Neurologic:
Mental Status: Poor judgment and insight.
Cranial Nerves: Facial symmetry intact, gross hearing weak, tongue midline. Some
tests not performed due to weakness.
Motor: Weak hand grip.
Sensory: Intact pain sensation in upper extremities, absent in lower extremities.
Reflexes: Intact deep tendon reflexes, negative Babinski and Hoffman reflexes.
Jason Aranzado
SOM - 3
Primary Impression: “Community-acquired Pneumonia, to consider exacerbation by TB
or COPD”
Community-Acquired Pneumonia (CAP) is a lung infection that develops outside of a hospital
or healthcare setting. It causes inflammation and consolidation of the lung tissue due to infection
by bacteria, viruses, or fungi.
CAP is acquired through inhalation or aspiration of infectious agents that colonize the
respiratory tract or are present in the environment. The main routes of infection include:
1. Inhalation of Respiratory Droplets (Most Common Route)
2. Aspiration of Microorganisms from the Upper Airway
3. Hematogenous Spread (Less Common)
4. Direct Inoculation (Rare)
Some individuals are at a higher risk of developing CAP due to weakened immunity or lung
function. These include:
Elderly patients (≥65 years old) – Weakened immune response.
Smokers – Damaged lung defenses
Patients with chronic diseases – COPD, diabetes, heart disease, or kidney disease.
Immunocompromised individuals – HIV, cancer, long-term steroid use.
Malnourished individuals – Poor immune function.
Patients with difficulty swallowing or aspiration risk – Stroke, dementia, alcohol use
disorder.
Key Findings Supporting the Diagnosis of Pneumonia
Clinical Symptoms Consistent with Pneumonia:
• Cough with yellow phlegm (productive cough, suggestive of bacterial infection).
• Dyspnea (shortness of breath, a common symptom in pneumonia).
• Fever and fatigue (systemic inflammatory response to infection).
• Coarse crackles on lung auscultation.
Risk Factors Predisposing to Pneumonia:
• Elderly patient (71 years old) → Increased susceptibility to infections.
• History of smoking (50 years, 10 sticks/day) → Chronic lung damage (risk for COPD,
impaired mucociliary clearance).
• Poor nutritional status (weight loss, reduced food intake) → Weakened immune
defense.
• Uncontrolled hypertension (BP 170/90 mmHg) → May indicate underlying
cardiovascular stress contributing to respiratory symptoms.
Jason Aranzado
SOM - 3
Complications
1. Respiratory Failure
• Cause: Fluid-filled alveoli impair oxygen exchange → Hypoxemia (low O₂),
hypercapnia (high CO₂).
• Signs: Dyspnea, SpO₂ <90%, cyanosis, confusion.
• Management: Oxygen therapy, nebulization, BiPAP/intubation if severe.
2. Septic Shock
• Cause: Bacteria enter the bloodstream → Massive vasodilation → Low BP → Organ
hypoperfusion.
• Signs: Hypotension (SBP <90), tachycardia, fever, cold extremities, low urine output.
• Management: IV fluids, broad-spectrum antibiotics, vasopressors (Norepinephrine).
3. Multi-Organ Failure (MOF)
• Cause: Prolonged hypoxia & hypotension → Organ ischemia (lungs, kidneys, liver,
brain).
• Signs: ARDS (respiratory distress), AKI (low urine), liver failure (jaundice), confusion,
DIC (bleeding).
• Management: ICU care, ventilation, dialysis, hemodynamic support.
Jason Aranzado
SOM - 3
Differential Diagnosis
1. Pulmonary Tuberculosis (TB)
Rule In
Chronic cough (≥1 month)
Weight loss, fatigue, and intermittent fever
Worsening of symptoms at night
Elderly and history of smoking
Rule Out
No hemoptysis
Diagnostic test needed to rule out: AFB or GENEXPERT
2. Chronic Obstructive Pulmonary Disease (COPD)
Rule In
Long-term smoking history (50 years, 10 sticks/day) - Major risk factor for COPD
Chronic productive cough
Dyspnea - key symptom of COPD.
Coarse crackles in lung fields
Rule Out
Acute systemic symptoms (fever, weakness, confusion)
No prior COPD diagnosis or history of exacerbations
No reported wheezing or prolonged expiratory phase
Diagnostic test needed: Pulmonary Function Test (PFTs) or spirometry to confirm airflow
obstruction.
3. Lung Cancer
Rule In
Chronic cough
Weight loss and fatigue
History of heavy smoking
History of cancer in the family
Dyspnea and progressive weakness
Rule Out
No hemoptysis
Diagnostic test needed: Chest CT scan, sputum cytology, or biopsy if cancer is still
suspected.
4. Acute Bronchitis
Rule In
Recent onset of productive cough
Worsening at night
History of smoking
Rule Out
Jason Aranzado
SOM - 3
Cough lasting ≥1 month
Presence of fever and systemic symptoms – More indicative of pneumonia than
bronchitis.
Jason Aranzado
SOM - 3
Laboratory Tests to Request
Hematology:
CBC (Check for WBC level)
Chemistry:
Serum Electrolytes (Na, K, Ca, Mg, Cl) - for electrolyte imbalances
Blood Urea Nitrogen (BUN) & Creatinine - Assess renal function
ABG – assess hypoxemia
Liver Function Tests (ALT)
Lipid Profile - Stroke risk assessment
Bacteriology:
Gram-stain – presence of bacteria
AFB – presence of mycobacterium
GeneXpert
Culture and Antibiotic Sensitivity Testing
Imaging Tests:
Chest X-ray – evaluate presence of consolidation, caviations, or masses
CT-scan – for malignancy
Jason Aranzado
SOM - 3
Principles of Management
1. Antibiotic therapy for pneumonia.
Empiric Antibiotic Therapy
o First-line Antibiotic Regimen for Severe CAP (Non-ICU)
Beta-lactam + Macrolide
Ceftriaxone 1-2g IV once daily OR Ampicillin-Sulbactam 1.5-3g IV
q6h
PLUS Azithromycin 500 mg IV once daily
o Alternative
Respiratory Fluoroquinolone (if beta-lactam allergy)
Levofloxacin 750 mg IV once daily
2. Supportive care to address symptoms
Symptom Management
o Antipyretics (Paracetamol 500-1000 mg PO q6h PRN) – For fever.
o Cough Suppressants (Guaifenesin or Ambroxol) – If excessive mucus
Oxygen Therapy (If Needed)
o Target SpO₂ ≥ 92%
o Nasal cannula 2-4 L/min if mild hypoxia.
o High-flow oxygen or noninvasive ventilation (BiPAP) if respiratory distress
develops.
Fluids & Electrolyte Management
o IV fluids (e.g., Normal Saline or Lactated Ringer’s) for dehydration.
o Monitor for electrolyte imbalances (e.g., sodium, potassium) due to poor
oral intake.
Nutritional Support
o Encourage high-protein, high-calorie diet (soft foods due to dysphagia).
o Consider nasogastric feeding if oral intake is inadequate.
3. Monitoring and prevention of complications (e.g., respiratory failure, sepsis).
Daily Clinical Monitoring
o Respiratory status (RR, SpO₂, lung sounds, ABG if worsening).
o Vital signs (BP, HR, temperature, urine output) to detect sepsis.
o Neurologic status (monitor for worsening confusion).
o Nutritional intake and hydration.
Watch for Complications
o Sepsis/Shock → If worsening BP and mental status, consider IV fluids +
Vasopressors (Norepinephrine if needed).
o Respiratory Failure → If RR >30 or worsening hypoxia, consider ICU
admission and possible intubation.
o Parapneumonic Effusion/Empyema → If worsening, consider Chest
Ultrasound + Thoracentesis.
4. Investigation and management of underlying conditions
Rule Out Tuberculosis (TB)
Assess for COPD & Chronic Bronchitis
Screen for Lung Cancer
Jason Aranzado
SOM - 3
5. Vaccination and Long-Term Prevention
Pneumococcal Vaccine (PPSV23 or PCV13) – Reduces risk of pneumonia in elderly
patients.
Annual Influenza Vaccine – Reduces viral infections that predispose to bacterial
pneumonia.
COVID-19 Vaccination – Recommended for protection.
Concept Map
Prognosis
The prognosis depends on the patient’s age, comorbidities, and site of treatment (inpatient or
outpatient). Older patients and those with comorbid conditions may take several weeks longer to
recover fully. For patients requiring hospitalization, overall mortality ranges from 12% to
40%, depending on the category of patient and the processes of care, particularly the timely
administration of appropriate antibiotics.
