Lopez, Lovelle

NMD- CLERK

General Data

This is a case of Patient’s RM, 70 years old, female, who came in due to difficulty of breathing.
She came from bislig, surigao. Her religion is Church of God.

History of Present Illness

3 weeks prior to admission, patient had onset of non-productive cough with mild
exertional dyspnea aggravated by activities such as walking, climbing stairs (10 steps) and lifting
heavy objects approximately 5-10 kilos, body malaise and undocumented fever and there was no
orthopnea, paroxysmal nocturnal dyspnea, chest tightness or bipedal edema reported. Patient
only took fluticasone/salmeterol puff as needed and noticed to have slight relief.

1 week prior to admission, recurrence of shortness of breath associated with productive

cough with purulent sputum amounting to 2.5 ml was noted. However, there was no hemoptysis,
night sweats or weight loss reported. Again, patient took fluticasone plus salmeterol puff which
offers temporary relief and did not seek consult.

In the interim, patient tolerated the condition until on the day of admission, with
increasing severity of difficulty of breathing and non-productive cough prompted patient to
sought consult in this institution, hence this admission.

Past Medical History

She is known asthmatic for 54 years and uses fluticasone/salmeterol (seretide) inhaler as
a needed medication prescribed by her physician. There was no attack for the last 2 years as
claimed by the patient. She is known hypertensive for ten years with maintenance medication of
Losartan with poor compliance. In the year 2017, She had cataract removal on both eyes. Patient
also have Osteoarthritis since midyear of 2018, with medications of celecoxib 200 mg once a
day, vitamin D and calcium with poor compliance. Patient does not have any history of exposure
to pulmonary tuberculosis patients. There is no known food and drug allergy. For the obstetrical
and gynecologic history: Gravida 5 Para 5 (3003). Patient is menopause for 16 years.

Family History
Asthma and hypertension were both present maternal and paternal side. There is no
known diabetes mellitus or cancer.

Social History
She is married and has five children. She is a housewife and her daily activity is doing the
house chores such as washing the dishes and clothes and cleaning the house. She walks to the
market once a week for about a kilometer. She does not exercise on a regular basis.

She is a non-smoker, non-alcoholic beverage drinker. There is no known food and drug
allergy. Her diet mainly composed of chicken, pork, rice and some vegetables. She drinks water
1-2 liters per day.

Review of systems
In general, patient noticed weight gain, an evidence of one size larger from her usual
clothes. Patient also noted body malaise. However, she did not notice any insomnia and anorexia.
She did not feel any heat-cold intolerance or palpitation. There is no visual dysfunction,
lacrimation or eye itching. For her ears, there is no tinnitus or discharges. As well as, there is no
epistaxis or nasal obstruction. She did not experience any sore throat, bleeding gums or neck
stiffness. There is no chest pain noted. For the gastrointestinal, she did not have any nausea,
vomiting, melena, hematochezia or change of bowel movements. The patient noted swelling on
the knees.

Physical examination
Patient was received at the emergency room, lying on bed awake, conscious, responsive and
coherent
Vital signs
Blood pressure 147/80 mmhg
Temperature 36.5 degree Celsius
Pulse rate 81 beats per minute
Respiratory rate 21
Oxygen saturation 90%

Anthropometric measurement
Height: 5 feet and 4 inches or 362 centimeters
Weight: 176 pounds
BMI: 30.5, obese

The skin is brown in complexion. There is no visible lesions, jaundice or pallor. It is warm to
touch.

The head is normocephalic and hair is black with some white strands and evenly distributed.

The eyes are brown, with anicteric sclera and pinkish palpebral conjunctiva. Pupils are round and
equally reactive to light. There are no discharges or periorbital edema noted.

The ears are symmetrical in size and shape. There are no lesions or masses noted on both ears.
There is no palpable post auricular lymph node or swelling noted.

There is no nasal flaring or discharges noted. Both nares are patent. Absence of tenderness of the
sinuses upon palpation.

There are slightly dry lips with no lesions. The tongue is at midline and tonsils are not swollen.

Upon inspection, there is no neck vein engorgement, scars or lesions noted. Neck is supple with
normal range and motion. There are no cervical lymphadenopathies noted.
There is symmetrical chest expansion. There is no masses or crepitation noted. Both lung fields
were resonant upon percussion. Crackles noted on both right and left basal lung field.

Point of maximal impulse is displaced 6th intercostal space and lateral to the midclavicular line
with an adynamic precordium. There was no heaves or thrills noted on palpation. Normal cardiac
rate and rhythm with no murmur noted.

Upon inspection of the abdomen, it is globular in contour, non-tender and soft. There is
normoactive bowel sounds at 10 per minute. Upon percussion, tympanic in all quadrants.

For the genitourinary, patient refused to be examined. But upon palpation of the bladder, there
was no tenderness or masses noted.

There are full and equal pulses on both upper and lower extremities. Upon palpation, there is
bilateral knee swelling, non-erythematous. There is limited range of motion due to pain and had
difficulty on ambulation. Capillary refill time is less than two seconds.

The sense of smell is intact. Both pupils constrict when light is shone. The extraocular muscles
are intact. The muscles of mastication are intact. The face is symmetric and patient was able to
smile and frown the patient able to hear whispered voice at a distance of 2 feet. She was able to
shrug and raise shoulders. She was able to stick out tongue and move it sideways. The motor was
5/5 on both upper and lower extremities. There is an intact and pain sensations. The reflexes are
2+ on all extremities. There is no Babinski sign.

Salient features:

The following are the pertinent positive; Chief complaint difficulty of breathing, Uncontrolled
hypertension, Oxygen saturation 90%, Productive cough with minimal yellowish-greenish
sputum, Body malaise, History of undocumented fever, Exertional dyspnea, Weight gain,
Crackles on both right and left basal lung field, Shortness of breath
The following are the pertinent negative; Hemoptysis, Bipedal Edema, Wheeze, Previous
exposure to patient with pulmonary tuberculosis, weight loss, night sweats, chest pain,
palpitation, bipedal edema

Impression: Community Acquired Pneumonia-Moderate Risk, Osteoarthritis

Differential Diagnosis

Community Acquired Pneumonia, included it in since patient’s had signs of infection,

undocumented fever, history of productive cough with purulent sputum, shortness of breath,
oxygen saturation of 90%, crackles on both right and left basal lung field. However, it cannot be
excluded.

Asthma in Acute Exacerbation, included since patient had history of asthma, difficulty of
breathing, oxygen saturation of 90 % however excluded it since patient had history of productive
cough, history of undocumented fever, crackles on both right and left basal lung field.

Pulmonary Congestion, included since patient’s chief complaint difficulty of breathing,

exertional dyspnea, crackles on both right and left basal lung field, oxygen saturation of 90%
however excluded since patient has signs of infection such as history of undocumented fever and
cough with purulent sputum. There is no bipedal edema, chest tightness and palpitation.

Pulmonary Tuberculosis, included it in since patient had cough for almost 3 weeks, oxygen
saturation of 90%, crackles on both right and left basal lung field, shortness of breath and history
of undocumented fever. However, excluded, since patient doesn’t have hemoptysis, night sweats
and weight loss.

Course in the ward

Hospital day 1
Patient had subjective complain of dyspnea. Patient is awake, conscious, and coherent.
Temperature of 36.5 Celsius, Respiratory rate of 21 cycles per minute, pulse rate is 81 beats per
minute, blood pressure of 147/80 mmhg with oxygen saturation of 90%. Upon physical
examination, patient noted to have bilateral crackles on both lung fields and non-productive
cough noted. Laboratories noted to have neutrophilia of 98. Patient’s assessment is Community
Acquired Pneumonia, Osteoarthritis. Patient is to maintain on low salt and low fat diet.
Laboratories requested were complete blood count, blood culture and sensitivity, sputum culture
and sensitivity, 12 Lead electrocardiogram and chest x-ray. Chest x-ray shows infiltrates are
noted in the lingular segment of left upper and both lower lobe, suggestive of inflammatory lung
disease compatible with pneumonia, atherosclerosis of aorta, degenerative bone joint disease,
cardiomegaly. Patient was hooked to oxygen 2 liters per minute. Medications were given
ampicillin sulbactam 1.5 g IV every 6 hours, Azithromycin 500 mg/tab, Salbutamol Ipratropium
1 nebulization every 6 hours.

Hospital day 2
Patient had no subjective complain of dyspnea but unable to stand due to bilateral knee pain.
Patient is awake, conscious, and coherent. Vital signs were the following; Temperature of 36
Celsius, Respiratory rate of 20 cycles per minute, pulse rate is 96 beats per minute, blood
pressure of 140/80 mmhg with oxygen saturation of 98%. Upon physical examination, crackles
noted on both lower lung field, non-productive cough noted and bilateral knee swelling, non-
erythematous with leg muscle spasm. Patient’s assessment Community Acquired Pneumonia-
Moderate Risk, Osteoarthritis. Patient’s added medication were Losartan 5 mg, 1 tab od,
Eterocoxib mg/tab, 1 tab bid, Pregabalin 75 mg/cap 1 cap bid and potassium chloride tab 1 tab
TID for 3 days. Patient was referred and seen by rheumatologist and possible for Arthrocentesis.
Laboratories revealed creatinine of 66.50 umol/L, serum potassium 3.4 mmol/ L, complete blood
count revealed of neutrophilia of 98. Patient’s oxygen was reduced to as needed. Patient’s intake
of 1,600 ml and output of 1,700 ml.

Hospital day 3
Patient had no subjective complain of dyspnea but still unable to stand due bilateral knee pain.
Patient is awake, conscious, and coherent. Vital signs were the following; Temperature of 35.2
Celsius, Respiratory rate of 20 cycles per minute, pulse rate is 85 beats per minute, blood
pressure of 130/80 mmhg with oxygen saturation of 90%. Upon physical examination, crackles
noted on both lower lung field, minimal non-productive cough noted and bilateral knee swelling,
non-erythematous. Intake of 1130 ml and output of 1170 ml, for repeat chext x-ray and complete
blood count, arthrocentesis was done. Present medications were continued.

Hospital Day 4
Patient had no subjective complains. Vital signs were the following; Temperature of 36.2
Celsius, Respiratory rate of 18 cycles per minute, pulse rate is 81 beats per minute, blood
pressure 130/70 mmhg with oxygen saturation at 97%. Upon physical examination, decrease
crackles on both lower lung field, minimal non-productive cough noted and reduced swelling of
the knee. Patient’s Input of 1470 ml and Output of 1500 ml. Blood culture was done, results
revealed Streptoccocus hominis on left arm while negative on the right arm. Complete blood
count revealed neutrophilia of 86 and Chest x-ray revealed minimal progression of the infiltrates
in the lingular segment of the left upper and both lower lobes. Continued present medication and
monitoring.

Hospital Day 5
Patient does not have any subjective compalins. Patient is awake, conscious, and coherent. Vital
signs were the following; Temperature of 36.2 Celsius, Respiratory rate of 18 cycles per minute,
pulse rate is 81 beats per minute, blood pressure of 130/80 mmhg with oxygen saturation of 98%.
Patient is clinically stable and able to stand with assistance. Plan for the patient is to may go
home.

Medications:

Ampicillin sulbactam 1.5 g IV every 6 hours is a makeup group of penicillin that is highly active
against sensitive strains of gram positive cocci and whose antimicrobial activity is extended to
include such as gram-negative microorganisms as Haemophilus influenza, Escherichia coli and
Proteus mirabilis. It was taken by the patient as a first line treatment for community acquired
pneumonia moderate risk category.
Azithromycin 500 mg/tab is a macrolide that works by binding to a specific subunit of ribosomes
(sites of protein synthesis) in susceptible bacteria, thereby inhibiting the formation of bacterial
proteins. It was given to the patient to cover for the atypical pneumonia causing bacteria such as
Moraxella catarrhalis, Chlamydophila pneumoniae and Legionella pneumohila.

Salbutamol Ipratropium 1 nebulization every 6 hours Ipratropium is a nonselective competitive

antimuscarinic agent. It causes bronchodilation by blocking the action of acetylcholine-induced
stimulation of guanyl cyclase while Salbutamol activates the enzyme adenyl cyclase that
Increases cAMP leads to activation of protein kinase A, which inhibits phosphorylation of
myosin and lowers intracellular ionic Ca concentrations, resulting in smooth muscle relaxation.
Since the patient had difficulty of breathing and to relieve bronchospasm, this medication was
given.

Losartan 5 mg, 1 tab od is an angiotensinogen II receptor antagonists it keeps blood from the
blood vessels from narrowing, lowers blood pressure and improves blood flow. This medication
is given to the patient since she is having high blood pressure of 140-160/80-90 mmhg.

Eterocoxib mg/tab, 1 tab bid eases pain and swelling (inflammation) in conditions like
osteoarthritis, rheumatoid arthritis and ankylosing spondylitis, and it may also be used for short
periods of time in gout. It was given to the patient since she is having bilateral knee pain.

Pregabalin 75 mg/cap 1 cap bid, it has an active substance is a gamma-aminobutyric acid

analogue ((S)-3-(aminomethyl)-5-methylhexanoic acid). It binds to an auxiliary subunit (α-δ
protein) of voltage-gated calcium channels in the central nervous system. Patient had complained
of muscles pain especially on the calf.

Potassium chloride tab 1 tab three times a day, acts as an electrolyte replenisher of K ions. It is
essential for maintenance of acid-base and fluid and electrolyte balance of the cell. It also plays a
vital role in the conduction of nerve impulses, contraction of cardiac, smooth and skeletal
muscles, gastric secretion, normal renal function and carbohydrate metabolism. It was given to
the patient to correct hypokalemia of 3.4 mmol/L.
Diagnostics:

12 Lead electrocardiogram is a representation of the heart's electrical activity recorded from

electrodes on the body surface. For the Patient’s 12 lead electrocardiogram revealed a sinus
rhythm.

Chest radiography is necessary to differentiate community acquired pneumonia from other

conditions. Radiographic findings may include risk factors for increased severity example
cavitation or multilobar. Patient’s chest x-ray revealed infiltrates in the lingular segment of left
upper and both lower lobe, suggestive of inflammatory lung disease compatible with pneumonia,
atherosclerosis of aorta, degenerative bone joint disease, cardiomegaly. After day 3 of ampicillin
sulbactam and azithromycin, patient’s repeat chext x-ray showed minimal progression of the
infiltrates in the lingular segment of the left upper and both lower lobes. It is indicative that the
patient’s improved due to medication intake.

Gram stain and Culture of Sputum is to identify certain pathogen by their characteristic
appearance. An adequate sputum sample have greater than 25 neutrophils and less than
squamous neutrophils per low power field. The sensitivity and specificity of the sputum gram’s
stain and culture are highly variable. In elderly individual may not be able to expectorate to
produce an appropriate expectorated sample. Others may have started a course of antibiotics that
can interfere with the results. Hence, this patient wasn’t able to do this since had difficulty
expectorating.

For the Blood Culture, there is a small chance that it will be positive according to Harrison’s,
only 5-14%. Since it has low-yield and the lack of clinical outcome, it is not considered in all
hospitalized CAP patients. The patient blood culture results revealed Streptoccocus hominis on
left arm in less than 24 hours incubation while negative on the right arm. It is indicated that the
left arm culutre was contaminated.
Complete blood count, a blood used to evaluate your overall health and detect a wide range of
disorders such as infection. In pneumonia, increase in neutrophils due to host inflammatory
response against microorganisms. In relation to the patient, revealed neutrophilia of 98 and after
3 days of antibiotic regimen, repeat complete blood count showed decrease neutrophilia of 86.

Final Diagnosis: Community Acquired Pneumonia-Moderate Risk, Osteoarthritis, Bronchial

Asthma not in AE

Discussion:

The patient presented with a productive cough and unstable vital signs such as the history
of undocumented fever with radiologic finding of infiltrates noted in the lingular segment of left
upper and both lower lobe which is compatible with pneumonia. The presence of unstable vital
signs on admission and unstable comorbidities such as poorly controlled hypertension prior to
admission, has fit the classification of the patient’s pneumonia into Moderate Risk, according to
the Philippine CAP clinical practice guidelines of 2016.

Lower respiratory tract infection acquired in the community within 24 hours to less than
2 weeks. It results from the proliferation of microbial pathogens at the alveolar level and the
host’s response to those pathogens. The most common form of access is through aspiration from
the oropharynx, it can be inhaled as contaminated droplets, or rarely via hematogenous spread or
contiguous expansion from an infected pleural of mediastinal space.

Anatomically there are barriers that is critically important for the host defense against
invading microorganisms such as the nasal hair, branching architecture of the tracheobronchial
tree, mucociliary clearance of the airway lining, the gag reflex and coughing mechanism. Once
these barriers are overcome or the organisms are small enough to be inhaled at the alveolar level,
resident macrophages and proteins secreted by the alveolar cells clear out these pathogens. Only
when the capacity of these cells to ingest these foreign pathogens is exceeded does clinical
pneumonia become manifest and initiates an inflammatory response that triggers the disease,
causing alveolar capillary leak and increase in purulent secretions, resulting to radiographic
infiltrates and rales, hypoxemia from alveolar filling, and increased respiratory drive leading to
alkalosis. These may eventually cause an intrapulmonary shunting of blood due to the leak,
decrease in compliance of the lungs causing dyspnea, reductions in lung volume and eventually
respiratory failure and death.

At the initial phase is one of edema, with the presence of proteinacious exudate, and often
of bacteria, in the alveoli. The next is the red hepatization phase, mainly characterized by the
presence of erythrocytes in the cellular intraalveolar exudates, but neutrophil influx is more
important with regard to host defense. Bacteria may be occasionally seen in this phase. The third
phase is gray hepatization, no new erythrocytes are extravasating and those already present have
been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is abundant
and bacteria have disappeared. This corresponds to a successful containment of infection and
improvement of gas exchange. In the final, resolution phase, the macrophage is the dominant cell
type and the debris and inflammatory response has abated. This pattern is best described for
lobar pneumonia, usually caused by bacteria, as opposed to bronchopneumonia, from nosocomial
infections.

Treatment:

For Moderate risk

Intravenous non-antipseudomonal B-lactam (BLIC,cephalosphorin) + Extended macrolides or
respiratory fluoroquinolones per orem. An example of Intravenous non-antispeudomonal B-
Lactam are Ampicillin – Sulbatam 1.5 mg every 6 hours, Cefuroxime 1.5 gram every 8 hours
and Ceftriaxone 2 grams once a day. For macrolide or respiratory fluoroquinolones are
Azithromycin 500 mg once a day, Clarithromycin 500 mg twice a day, Levofloxacin 500 mg
once a day, Moxifloxacin 400 mg once a day.

Recommended hospital discharged criteria

During 24 hours before discharge, the patient should have the following characteristics;
Temperature of 36-37C, Pulse of <100/min, Respiratory rate between 16-24 cycles per minute,
Systolic BP of >90mmHg, Blood oxygen saturation of >90%, Functioning GI tract.