This is a case of a 62 year old, female, with a chief complaint of difficulty of

breathing, and a working diagnosis of Community Acquired Pneumonia Moderate Risk.

Upon arrival at the Emergency Department, the patient was conscious, coherent, in
cardiorespiratory distress with the following vital signs: BP: 200/120 mmHg, CR: 138 bpm,
RR: 28 cpm, Temp: 37.2 C, O2Sat: 94%. She was hooked to Oxygen via nasal cannula at 2
lpm. The following laboratories were requested: 12LECG, CBC, and Chest Xray PA-L (intial:
Bilateral pneumonia, atheromatous aorta, pleuodiaphragmatic adhesion, Right, PTB both
upper lobes). She was nebulized with combivent 3 doses, 15 minutes apart. The patient was
reassessed and was advised admission.
Upon admission, the patient was placed on low salt, low fat diet with strict aspiration
precaution. She was venoclyzed with PNSS x 30cc/hr. The following additional laboratories
were requested: Na, K, Creatinine, ABG, Sputum GC/CS and AFB. The following medications
were started: Ceftriaxone 2g IV OD ( ) ANST, Azithromycin 500mg/tab 1 tab OD, Nacetylcysteine 600mg/tab dissolve in glass of water, Combivent neb Q4, Losartan
50mg/tab 1 tab OD in AM, Amlodipine 10mg/tab 1 tab OD, Paracetamol 500mg/tab 1 tab
every 4 hours for temperature >/= 37.8 C and Pantoprazole 40mg/tab 1 tab OD 30 minutes
before breakfast. She was then hooked to Oxygen via nasal cannula at 3 lpm. Vital signs
were monitored Q1. IVF was shifted to D5W to run at same rate.
On the 2nd hospital day, patient was seen and examined with the following vital signs:
BP: 110/60 CR:71 RR:21 Temp: 36.3 O2 Sat: 98%. The patient had subjective complaints
such as productive cough with occasional yellowish phlegm and occasional difficulty of
breathing. Upon physical examination, patient still has bilateral wheezes and crackles.
Furosemide was increased to 40 mg TIV Q12, NAC was shifted to BID, K Citrate was given
TID x 6 doses. For repeat serum K post correction
On the 3rd hospital day, patient was seen and examined with the following vital signs:
BP: 100/60 CR: 82 RR: 21 Temp: 36.6 O2 Sat: 97%. The patient still has subjective complaint
of productive cough described as with occasional yellowish phlegm and difficulty of
breathing. Upon physical examination, the patient has bilateral crackles. Increased
combivent nebulization to Q2. Increased Hydrocortisone to 100mg Q4. Increased Furosemide
to Q8 with BP precaution. Refer to MROD if BP < 90/60mmHg. Hold Losartan; Amlodipine
temporarily. Patient was referred with a BP of 90/70mmHg. Stat ABG analysis was taken.
Chest X-ray was done. And Vital signs were monitored Q15 and recorded. Aminophylline drip
at 0.3 mg/kg/hr. Previous ECG reviewed. For 12 Lead ECG.

Pantoprazole 40mg TIV given now. For repeat Na, K, Ca, and Mg. Zykast 1 tab OD started.
Day 3 of Ceftriaxone. Day 3 of Azithromycin to complete for 5 days. Follow up Sputum GS.
Continue Aminophylline Drip. Cardiac rate monitored full minute. Modified nebulization to
alternating combivent and Salbutamol nebulization to Q2. Continue Antibiotics and
Hydrocortisone. Referred accordingly.
On the 4th hospital day, patient was seen and examined with the following vital signs:
BP 120/80 CR: 85 RR: 23 Temp:36.7C. The patient still has subjective complaints of
productive cough described as whitish and is associated with occasional chest pain
described as sharp and non-radiating and difficulty of breathing. Upon physical examination,
the patient still has bilateral crackles and wheezes. No other associated symptoms such as
nausea, vomiting, abdominal pain, and hemoptysis. Discontinuation of Oxygen
supplementation was advised and Combivent nebulization was decreased to Q4. Chest
physiotherapy was done after each nebulization. Giving of antibiotics was continued (Day 4
of Ceftriaxone and Azithromycin) and KCl tablet 1 tablet TID was started. Repeat CBC, Na, K,
and Creatinine were facilitated to be done the next day.
On the 5th hospital day, patient was seen and examined with the following vital signs:
BP: 140/80 CR: 73 RR: 20 T: 36. Still with productive cough, with whitish phlegm. No other
subjective complaints such as fever, nausea and vomiting. Still on low salt, low fat diet with
SAP, venoclyzed with D5W x 10 cc/hr. Medications were Ceftriaxone on day 4, Azithromycin
on day 3,Combivent neb q4, HAA 100mg TIV q6, Budesonide neb q12, Zykast 1 tab OD,
Furosemide 40 mg TIV q8, pantoprazole 40 mg/tab, KCL tab TID, Mupirocin ointment TID.
Chet physiotherapy was done after each nebulization.
On the 6th hospital day, patient was seen and examined with the following vital signs:
BP: 150/90 CR: 79 RR:20 T:36.8 O2: 96%. Still with productive cough, with whitish phlegm.
No other subjective complaints such as fever, nausea and vomiting. Increased oral fluid
intake. Shifted IVF to PNSS 1L x 60cc/ hr. Monitored intake and output accurately. Modify
alternating combivent and salbutamol neb to combivent nebulization Q4 only. Shift
ceftriaxone to Piperacilin-tazobactam 4.5gms IV now then 2.25 gms IV Q8. Azithromycin to

complete 5 days. Modified Piperacillin-tazobactam to 4.5gms IV now then 2.25gms IV Q6.

Started ciprofloxacin 750mg/tab OD
On the 7th hospital day, patient was seen and examined with the following vital signs:
BP: 160/100 CR: 79 RR:20 T:36.8 O2: 96%. Still with productive cough, with whitish phlegm.
No other subjective complaints such as fever, nausea and vomiting. Decreased HAA to Q12.
Decreased combivent nebulization to Q6. Shift Ciprofloxacin

750 to Ciprofloxacin 500mg/tab BID.

On the 8th hospital day, patient was seen and examined with the following vital
signs: BP: 170/100 CR: 79