This is a case of a 74 year old woman who was diagnosed with
Community Acquired Pneumonia.
Pneumonia is an inflammation or infection of the lungs most commonlycaused by a bacteria or virus. Pneumonia can also be caused by inhaling vomitor other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous,and other liquids and cannot function properly. This means oxygen cannot reachthe blood and the cells of the body.Most pneumonias are caused by bacterial infections.The most commoninfectious cause of pneumonia in the United States is the bacteria Streptococcuspneumoniae. Bacterial pneumonia can attack anyone. The most common causeof bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniaeor Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.An increasing number of viruses are being identified as the cause of respiratoryinfection. Half of all pneumonias are believed to be of viral origin. Most viralpneumonias are patchy and the body usually fights them off without help frommedications or other treatments.Pneumococcus can affect more than the lungs. The bacteria can also causeserious infections of the covering of the brain (meningitis), the bloodstream, andother parts of the body.
develops in people with limited or no contactwith medical institutions or settings. The most commonly identified pathogensareStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptomsand signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, andtachycardia. Diagnosis is based on clinical presentation and chest x-ray.Treatment is with empirically chosen antibiotics. Prognosis is excellent for relatively young or healthy patients, but many pneumonias, especially whencaused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.
II. PATIENT PROFILE
I.PATIENT ASSESSMENT DATA BASEA.GENERAL DATA
1.Patient’s Name: K. I.2.Address: Sison, Pangasinan3.Age: 1 y/o & 1 mo.4.Sex: Female5.Birth Date: July 18, 20086.Rank in the Family: 1
child7.Nationality: Filipino8.Civil Status: Single (child)9.Date of Admission: August 30, 200910.Order of Admission:> Please admit order re service of Dr. Callanta> secure consent> I & O every shift & record> Monitor VS q 4° & record> DAT with SAP> Dx with CBC, CXR> IVF D
0.3 NaCl 500cc X 37-38 ugtts/min> Cefuroxime 250mg IVP q 8° ANST (-)> Pediatapp drops 1ml TID> Salbutamol + Ipratopium ½ neb q 6°> Paracetamol drops 100mg/ml 1ml q 4° prn for fever> E-zinc drops 1ml OD> refer accordingly11.Attending Physician: Dr. Callanta, MD
Cough and difficulty of breathing for one week, feverfor three days prior to admission
C.HISTORY OF PRESENT ILLNESS
One week prior to admission, K. O. had positive signsand symptoms of cough and yellowish phlegm followed withfever, three days before admission. Her mother knowing thatthese signs and symptoms were just the usual cough that herdaughter had, she gave her carbocisteine drops for her coughand paracetamol drops for her fever. However, she noticed nochanges so she decided to bring her to Pozorrubio MunicipalHospital. She was diagnosed of Pneumonia and because of theseverity of the condition, she was admitted. She was giveninitial medications and has had her for further observationsand laboratory exams.