Pneumonia Esmaeli, A.; Francisco U.; Golpeo, K.

A. G. 75 year old Male Single From Sta. Mesa, Manila Unemployed CC: progressive and productive cough, 3 days duration

TEMPORAL PROFILE

Past Medical History PTB (2002) – sputum AFB (+); 6 months quad-tab treatment completed; Chest X-ray after treatment – resolved S/P Cataract surgery (2002) COPD (2011) – Symbicort 2 puffs BID  1 puff BID (2012) Allergy to seafood and chicken (-) HTN, (-) DM Family History (+) HTN (father and younger brother) (+) stroke (father) (+) Lung CA (brother)

Social and Environmental History Smoker (51 pack years); started 14 years old, stopped 2002, 1 pack per day Occasional alcohol drinker ( ); Last drink was 1985, 1 small bottle of pale pilsen per week Denies illicit drug use

Review of Systems (-) anorexia (-) vomiting (-) diarrhea (-) blood in sputum (+) exertional dyspnea (+) sputum production Weight loss

Physical Examination Awake, weak-looking, alert, ambulatory, febrile VS: 110/60 > 72 > 32 > 39 degrees celsius AS, PPC, (-) TPC, (-) CLADS ECE, (+) crackles in L lower lung AP, NRRR, distinct S1 and S2, (-) murmur Flat abdomen, NABS FEP, (-) cyanosis, (-) edema

Primary Impression Community Acquired Pneumonia, Moderate Risk (CAP, MR); Chronic Obstructive Pulmonary Disease (COPD)

Laboratories Ordered CBC UA Blood CS Sputum GS/CS Na, K, Crea, BUN Chest Xray

CBC ReferenceCBC Hemoglobin Mass C g/L144 Hematocrit37-47%43 RBC x10^12/L MCHC32-37% MCH pg MCV80-94 fL RDW11-15% WBC5-10 x10^9/L8.1 Diff count Neutrophil40-75%83 Stabs Lymphocyte2-6%17 Monocytes Eosinophil Platelet N

Chest Xray Impression: 1. Pneumonitis/ Bronchitis Right Lower Lung 2. Pneumonia Left Lower Lung 3. Residual Fibrosis Right Upper Lung

Urinalysis Reference ColorVarying degrees of yellowyellow TurbidityClear ReactionVariable (usually acidic)Acidic Specific GravityVariable but and above, usually no significant kidney damage ProteinaNegative(-) SugarNegative(-) RBC0-1/hpf0-1 WBCMale: 0-2/hpfnone Female: 0-5/hpf Casts None Bacteria Few Epithelial Cells none Yeast Cell noen Mucus threads none Crystals none

Blood Chemistries July 14, 2012 Na134 K3.1 Crea99 BUN5.6 BCR

Cultures Sputum GS – Gram (+) cocci in pairs with neutrophils Sputum CS – Blood CS, 2 sites –

IV FLUID: 1 liter D5NSS to run to 10 hours (100 cc/hr) DIET: 2100 kcal/day TFR

Antibiotic started upon admission Ceftriaxone 2 gm IV Q24 Levofloxacin 750mg/tab, 1 tab Q48 (Azithromycin)

COPD Symbicort 2 puffs BID

Hypokalemia Kalium Durule, 1 durule TID

Pneumonia

Plan