Ifugao State UniversityIfugao State UniversityCollege of Health SciencesCollege of Health Sciences

Nayon, Lamut, IfugaoNayon, Lamut, Ifugao

A Case Study of A Case Study of Community Acquired Community Acquired

Pneumonia Pneumonia Prepared by:Prepared by:

GROUP 3GROUP 3

December 7, 2009December 7, 2009

I-PATIENT’S PROFILEI-PATIENT’S PROFILE

NameName : Ja Ko: Ja Ko Hospital No.Hospital No. : 14-26-47 : 14-26-47 AddressAddress : Liwang,Banaue, : Liwang,Banaue,

Ifugao Ifugao Gender Gender : Male: Male Birthdate Birthdate : September 27, 1935: September 27, 1935 Birth Place Birth Place : Banaue, Ifugao : Banaue, Ifugao

AgeAge : 72: 72 Nationality Nationality : Filipino: Filipino Civil Status : MarriedCivil Status : Married Religion Religion : Roman Catholic: Roman Catholic Chief complaints : Continuous Chief complaints : Continuous

productive cough, on productive cough, on and off fever, DOBand off fever, DOB

Date of Admission Date of Admission : November 27, : November 27, 2009 2009

Time of Admission Time of Admission : 8:20 A.M: 8:20 A.M

Admitting DiagnosisAdmitting Diagnosis : Community : Community Acquired Acquired

PneumoniaPneumonia Attending PhysicianAttending Physician : Dr. Jessie : Dr. Jessie

GuimbatanGuimbatan Number of hospitalization: 5 daysNumber of hospitalization: 5 days Date of dischargeDate of discharge : December : December

2, 20092, 2009

II- HISTORY OF PAST ILLNESSII- HISTORY OF PAST ILLNESS A. Family HistoryA. Family History

Mr. Ko is the eldest among 3 children. He was Mr. Ko is the eldest among 3 children. He was born on September 27, 1935 in an NSD at home born on September 27, 1935 in an NSD at home assisted by a trained hilot. Mr. Ko graduated from assisted by a trained hilot. Mr. Ko graduated from elementary level but did not continue to pursue to a elementary level but did not continue to pursue to a higher education instead he choose to earn money higher education instead he choose to earn money through wood carving that he was able to hand through wood carving that he was able to hand small amount of money to his parents and two small amount of money to his parents and two siblings after selling his wood carved products.siblings after selling his wood carved products.

According to Mr. Ko since childhood, his According to Mr. Ko since childhood, his parents was already farmers, they would spend their parents was already farmers, they would spend their time working in the field from morning to afternoon. time working in the field from morning to afternoon. Their whole family lived at Bangaan, Banaue, Their whole family lived at Bangaan, Banaue, IfugaoIfugao

Mr. Ko got married at age 22 y/o and decided Mr. Ko got married at age 22 y/o and decided to stay with his wife in a separate house from his to stay with his wife in a separate house from his parents but within the same Barangay.parents but within the same Barangay.

Both of Mr. Ko’s parents passed away at an Both of Mr. Ko’s parents passed away at an old age, and both of his siblings got married at age old age, and both of his siblings got married at age 23 y/o and live with their respective wife and 23 y/o and live with their respective wife and children.children.

B. Socio – Cultural HistoryB. Socio – Cultural History

At the age 15 y/o Mr. Ko was able to earned At the age 15 y/o Mr. Ko was able to earned money through carving. He had friends of his age money through carving. He had friends of his age and are out for school and are working as wood and are out for school and are working as wood carvers. Most of the time they would gather together carvers. Most of the time they would gather together and proceed to the forest to look for trees with sizes and proceed to the forest to look for trees with sizes appropriate to their design products to carve. Mr. ko appropriate to their design products to carve. Mr. ko then enjoyed chewing beetle nuts with his friends then enjoyed chewing beetle nuts with his friends during their rest periods.during their rest periods.

Presently, during his stay in the hospital Mr. Presently, during his stay in the hospital Mr. Ko spend his time talking with his wife, children Ko spend his time talking with his wife, children and visitors and asking question to the health care and visitors and asking question to the health care provider about his present condition.provider about his present condition.

C. Past History of Illness C. Past History of Illness

Mr.Ko has no remarkable illness like Mr.Ko has no remarkable illness like hypertension and diabetes mellitus. He hypertension and diabetes mellitus. He claimed that he was not hospitalized/ admitted claimed that he was not hospitalized/ admitted in any hospital for treatment. At times when he in any hospital for treatment. At times when he suffers from headache and body pain he would suffers from headache and body pain he would take in 1 tablet of Mefenamic or Alaxan as take in 1 tablet of Mefenamic or Alaxan as usually given to him in their RHU. and when usually given to him in their RHU. and when caught by the rain and caused him to get cough caught by the rain and caused him to get cough and colds he usually increase water intake and and colds he usually increase water intake and have rest periods to recover.have rest periods to recover.

III- HISTORY OF PRESENT III- HISTORY OF PRESENT ILLNESSILLNESS

Two weeks before admission Mr. Ko Two weeks before admission Mr. Ko suffered from continuous productive cough suffered from continuous productive cough as he expectorate with on and off fever. Mr. as he expectorate with on and off fever. Mr. Ko taught that it could be relieved by drinking Ko taught that it could be relieved by drinking of warm water and staying home for rest but of warm water and staying home for rest but his condition worsened that he experience his condition worsened that he experience DOB so his son brought him to the hospital at DOB so his son brought him to the hospital at 8:20 in the morning and was admitted with an 8:20 in the morning and was admitted with an admitting diagnosis of CAP. admitting diagnosis of CAP.

IV- BRIEF DESCRIPTION OF THE IV- BRIEF DESCRIPTION OF THE DISEASEDISEASE

Pneumonia is a serious infection or Pneumonia is a serious infection or inflammation of the lungs. The air sacs in the lungs inflammation of the lungs. The air sacs in the lungs are filled with pus and other liquid. Oxygen has are filled with pus and other liquid. Oxygen has trouble reaching the blood. If there is too little trouble reaching the blood. If there is too little oxygen in the blood, the body cells can’t work oxygen in the blood, the body cells can’t work properly. Because of this and spreading infection properly. Because of this and spreading infection through the body, pneumonia can cause death. through the body, pneumonia can cause death.

Pneumonia affects the lungs in two ways. Pneumonia affects the lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. affects patches throughout both lungs.

CAUSES OF PNEUMONIA CAUSES OF PNEUMONIA

Causative agent for CAP that requires Causative agent for CAP that requires hospitalization:hospitalization:

>S.pneumoniae>S.pneumoniae >H. influenzae>H. influenzae >Pseudomonas aeruginosa>Pseudomonas aeruginosa

Pneumonia is most likely to occur when Pneumonia is most likely to occur when normal defense mechanisms are weakened or normal defense mechanisms are weakened or overcome by the virulence, quality or number of overcome by the virulence, quality or number of organisms.organisms.

The common feature of all types of pneumonia The common feature of all types of pneumonia is an inflammatory response to the offending is an inflammatory response to the offending organism or agent. Infectious agents are usually organism or agent. Infectious agents are usually introduced by inhalation. The defense mechanisms introduced by inhalation. The defense mechanisms of the lungs lose effectiveness and allow organisms of the lungs lose effectiveness and allow organisms to penetrate the lower airways, in which to penetrate the lower airways, in which inflammation develops. inflammation develops.

Diagnostic AssessmentDiagnostic Assessment

A doctor or other health care provider diagnoses A doctor or other health care provider diagnoses pneumonia based on:pneumonia based on:

SymptomsSymptoms Physical examination Physical examination Laboratory testsLaboratory tests Chest x-ray Chest x-ray

VI- PATHOPHYSIOLOGYVI- PATHOPHYSIOLOGY

VII- PHYSICAL ASSESSMENTVII- PHYSICAL ASSESSMENTFINDINGSFINDINGS SIGNIFICANCESIGNIFICANCE

PPPsychosocialPsychosocial

Significant others: Significant others: Wife and his Wife and his childrenchildren

Coping mechanism: Coping mechanism: Verbalization Verbalization feelings to significant feelings to significant others and health others and health workers.workers.PrayingPraying

>>To relieve stress and To relieve stress and anxietyanxiety

>for spiritual growth>for spiritual growth

Religion: Roman Religion: Roman

CatholicCatholic

Primary dialect: Primary dialect:

TuwaliTuwali

Primary source of Primary source of health care:health care:

Barangay Barangay Health clinic, Health clinic, Banaue RHUBanaue RHU

>Nearest health >Nearest health unit in their unit in their

BarangayBarangay

Financial Sources Financial Sources related to illness:related to illness:

Philhealth and Philhealth and Financial support from Financial support from his childrenhis children

Educational Educational Attainment:Attainment:

Elementary graduateElementary graduate

>It helps to lessen >It helps to lessen their hospital billtheir hospital bill

General General appearance:appearance:

The patient The patient looks , weak, pale looks , weak, pale and not well and not well groomed groomed

>due to his present >due to his present conditioncondition

>lack of grooming >lack of grooming and proper hygieneand proper hygiene

Affect:Affect:

In respiratory In respiratory distress, irritable, distress, irritable, and easily get and easily get tiredtired

Speech:Speech:

The patient can The patient can speak wellspeak well

>appropriate>appropriate

>normal>normal

Memory:Memory:

Short term Short term memory: intactmemory: intact

Long term Long term memory:memory:

intactintact

>he was asked what was >he was asked what was the day he was admitted in the day he was admitted in the hospitalthe hospital

>able to respond and >able to respond and answer questions related to answer questions related to his past and the patient can his past and the patient can remember important dates remember important dates in his life. (eg. His in his life. (eg. His Birthday, Birthdays of his Birthday, Birthdays of his children)children)

EEEliminationElimination

StoolStool::

Pattern: O.D, during Pattern: O.D, during morningmorning

Consistency: Semi Consistency: Semi solidsolid

Color: BrownishColor: Brownish

UrineUrine::

Pattern: 2-3 times a day Pattern: 2-3 times a day

Transparency: ClearTransparency: Clear

Color: AmberColor: Amber

Quantity: approximately Quantity: approximately 150-300ml /voiding150-300ml /voiding

Abdomen:Abdomen:

Contour: FlatContour: Flat

Bowel sounds: Gurgling Bowel sounds: Gurgling soundssounds

Toileting Ability: Toileting Ability:

Able to walk going Able to walk going to the comfort room to the comfort room

RRRESTREST

Current Activity Current Activity levellevel

Sitting on bed Sitting on bed while talking to his while talking to his wife and significant wife and significant others.others.

ADL’sADL’s

Able to perform Able to perform some ADL’s with some ADL’s with minimal assistance minimal assistance like when he is like when he is eating, sitting, eating, sitting, drinking and when drinking and when going the comfort going the comfort room.room.

>The patient >The patient performs light performs light activities with activities with minimal assistance minimal assistance because he feels weak because he feels weak and easily gets tiredand easily gets tired

Sleep Pattern:Sleep Pattern:

approximately 7-8 approximately 7-8 hours with hours with interruptions interruptions

Body frame: Body frame: EctomorphEctomorph

Posture: KyphoticPosture: Kyphotic

>>Due to physiological Due to physiological symptoms and symptoms and environmental factors environmental factors like administering like administering medications and taking of medications and taking of vital signs.vital signs.

>>Due to present Due to present conditioncondition

>Due to old age>Due to old age

Coordination: Not Coordination: Not well coordinationwell coordination

Motor Function:Motor Function:

Fine: can grasp Fine: can grasp small objects and small objects and can open a bottle can open a bottle of mineralsof minerals

>Due to pain when >Due to pain when coughingcoughing

Gross: can stand and Gross: can stand and able to move on bed able to move on bed without assistancewithout assistance

Range of motion:Range of motion:

Arms: can slowly lift Arms: can slowly lift and flex.and flex.

Legs: can slowly lift Legs: can slowly lift and flexand flex

>due to weakness >due to weakness

>due to weakness>due to weakness

SSSafetySafety

AllergiesAllergies

Food: None - as Food: None - as claimed by pt.claimed by pt.

Medication: NoneMedication: None

Pupils: PERRLA – Pupils: PERRLA – NormalNormal

Hearing:Hearing:

Structure:Structure:

Symmetric in shape, Symmetric in shape, no hearing aid.no hearing aid.

Hearing Acuity:Hearing Acuity:

Patient has Patient has moderate hearing moderate hearing loss, cannot hear loss, cannot hear soft spoken words soft spoken words and cannot hear and cannot hear clearly from an clearly from an approximated approximated distance of 2 feet.distance of 2 feet.

> due to aging> due to aging

Skin Integrity:Skin Integrity:

-Lesions/scars:-Lesions/scars:

With minor scar at With minor scar at left upper extremity left upper extremity and no surgical and no surgical incision.incision.

Mucous membrane:Mucous membrane:

Moist and intactMoist and intact

Temperature:Temperature:

37.8 0C/axilla 37.8 0C/axilla

OOOxygenationOxygenation

Airway Clearance:Airway Clearance:

-Nose-Nose

Clogged nose, Clogged nose, symmetric in shapesymmetric in shape

-Mouth-Mouth

Clear, with presence Clear, with presence of dental carries and of dental carries and stained teethstained teeth

> presence of mucus > presence of mucus at the nasal passageat the nasal passage

>poor oral hygiene>poor oral hygiene

Respiration:Respiration:

Rate:29 cpmRate:29 cpm

Rhythm: rapidRhythm: rapid

Depth: shallowDepth: shallow

Position assumed: Position assumed: semi-fowlerssemi-fowlers

Color:Color:

Skin: fair Skin: fair complexioncomplexion

Nails: light pinkNails: light pink

Lips: reddishLips: reddish

Capillary refill: 1 Capillary refill: 1 sec.sec.

>to promote lung >to promote lung expansionexpansion

Peripheral pulse: Peripheral pulse:

Location: radialLocation: radial

Rate:98 bpmRate:98 bpm

Rhythm: rapidRhythm: rapid

Blood pressure: Blood pressure: 130/90130/90

O2 therapy: with O2 O2 therapy: with O2 regulated at 2-3 regulated at 2-3 LPM LPM

NNNutritionNutrition

Hospital diet:Hospital diet:

DATDAT

Fluid intake:Fluid intake:

Approximately 5-6 Approximately 5-6 glasses a dayglasses a day

IVF:D5LRSIVF:D5LRS

Insertion Site: Right Insertion Site: Right armarm

Solution: D5 LRS 1 Solution: D5 LRS 1 L x 80L x 80

Tissue Turgor: Tissue Turgor:

Good skin turgorGood skin turgor

Height: 5’6”Height: 5’6”

Hospital Hospital diet:DATFluid diet:DATFluid intake:Approximatelintake:Approximately 5-6 glasses adayy 5-6 glasses aday

IVF:D5LRSInsertion IVF:D5LRSInsertion Site: Right Site: Right armSolution: D5 armSolution: D5 LRS 1 L x 80TissueLRS 1 L x 80Tissue

Turgor: Good skin Turgor: Good skin turgorturgor

Height: 5’6”Height: 5’6”

Weight:53Kgs.Weight:53Kgs.

BMI:BMI:

Able to:Chew: Able to:Chew: yesSwallow: yesAble yesSwallow: yesAble to feed self with to feed self with assistance. assistance.

-With intact gag -With intact gag reflexreflex

VII- LABORATORYVII- LABORATORYNovember 27,2009November 27,2009

TestTest ResultResult Normal ValusNormal Valus InterpretationInterpretation

HgbHgb 109 g/L 109 g/L 110-160 g/L110-160 g/L

HctHct 33 vol %33 vol % 35 – 50 vol % 35 – 50 vol %

Leucocyte no. Leucocyte no. conc. conc.

4.9 x 10 g/L 4.9 x 10 g/L 5-10 x 10 g/L 5-10 x 10 g/L

Neutrophils Neutrophils .44 .44

Lymphocytes Lymphocytes .56 .56

•Significance: Decreased values indicates possible anemia

RADIOLOGIC REPORT RADIOLOGIC REPORT

CXR-APL CXR-APL there is haziness in both perihilar and there is haziness in both perihilar and

paracardiac areas paracardiac areas suggestive nodulari test are seen in the hilar suggestive nodulari test are seen in the hilar

region region heart is normal in sizeheart is normal in size lenidiaphragms, costophrenic sulci and the lenidiaphragms, costophrenic sulci and the

visualized bones are intactvisualized bones are intact

Thank you so much for listening!!!!!!!Thank you so much for listening!!!!!!!

God Bless and Have a nice day!!!God Bless and Have a nice day!!!

MERRY CHRISTMAS AND HAPPY MERRY CHRISTMAS AND HAPPY NEW YEARNEW YEAR