Bronchopneumonia

Patient’s Profile
 Patient D
 64 years old/Male/Saudi
 3rd among 6 siblings
 Married and with 4 children

Patient’s Past and Present Medical History

 Admitted in Procare Riaya Hospital on 17/09/19 at 1500H under the service of Dr. Z with
complaints of cough, fever difficulty of breathing and body weakness
 Discharged on 19/09/19 at 1200H
 Diagnosed of COPD 8 years ago in SAAD Hospital
 Known with mild hypertension on maintenance of Concor tablet
 Allergic to banana and beans
 No known surgical history
 Mother has known case of diabetes type 2 with oral maintenance
 Father died of lung cancer 13 years back

Socio-economic Profile
 Works as chemical engineer in a refinery company in Dammam
 Lives in 2-storey house in main road along Khobar
 Has 2-pack-per day smoking habit
 Every end of the month, he goes out with his friends and hang around
 Fond of eating spicy foods
 Drinks coffee twice a day
 No regular exercise
 Drinks approximately 4 to 6 glasses of water daily

Clinical Manifestations of Patient

 Fever
 Non-productive cough
 Body weakness
 Difficulty of breathing
 Fatigue

Diagnostic Exams
1. Urinalyis done 17/09/19

Test Result Normal Range Interpretation

PH 5
Nitrite Negative
Crystals Nil
 Protein Trace
Glucose Neg
Ketones Trace
Urobilinogen Normal
Bilirubin Negative
WBC 0.20
P-AMO Negative
U-AMO Negative
Specific Gravity 1.035
Color Yellow
Mucus ++
Turbidity Light Turbid
RBC 0.40
Bacteria Negative
Squamous Negative
Epithelial Cells

2. CBC done 17/09/19

Test Result Normal Range Interpretation

RBC 4.41million/cu 3.75.3million/cu Normal
Platelet Count 346 K/ul 150-550 K/uL Normal
Hemoglobin 12.2 g/dl 10.5-13.5 g/dl Normal
Hematocrit 35% 33-39% Normal
MCV 79.3 fl. 70 – 86 fl. Normal
MCH 27.7pg 23 – 31pg Normal
MCHC 34.9 g/dl 30 – 36 g/dl Normal
WBC 28.4 K/ul 6 – 17.5 K/ul Infection
Neutrophils 60.2 % 1 –49 % Acute bacterial
infection
Lymphocytes 32.1 % 67 – 77 % Bacterial infection
Monocytes 6.52 % 4 – 11 % Normal
Eosinophil 0.11 % 0–8% Normal
Basophil 0.986 % 0 -3 % Normal

3. 17/09/19

Test Result Normal Range Interpretation

CRP- 15 mg/dl 0.5-13 mg/dl Infection
Quantitative
C & S (Sputum) Klebsiella No growth Indication of
Pneumoniae Pneumonia/Bronchopneumonia
Potassium 5.2mol/L 3-6mmol/L Normal
(Serum)
 Sodium 141mmol/L 139-146mmol/L Normal
Chloride 100mmol/L 98-107mmol/L Normal
(Serum)
BUN (UREA) 11 mg/dl 5-17 mg/dl Normal
Creatinine 0.5 mg/dl 0.2-0.4 mg/dl Normal
Glucose (Serum) 190mg/dl 60-160 mg/dl Hyperglycemia
RBS

4. Chest X-Ray done on 17/09/19

- bilateral increased lung vascular markings with peribronchial thickening.
- dilated unfolded aorta .
- normal heart size and configuration.
- no pleural effusion.

5. 18/09/19

Test Result Normal Range Interpretation

Total Cholesterol 155 mg/dl < 200 mg/dl Normal
C & S (Sputum) Klebsiella No growth Indication of
Pneumoniae Pneumonia
Triglycerides 102 mg/dl < 150 Normal
LDL (Low Density 119 <100 Near / Above Optimal
Lipoprotein)

Inpatient Medications
1. Ceftriaxone (Samixon) 1 gram BID IV
2. Paracetamol (Perfalgan) 1 gram PRN for temperature equal or above 38C q6H IV
3. Prednisolone Sodium Phosphate (Prednisolone) 5mg TID PO
4. Ipratropium Bromide (Atrovent) 500mcg/2ml TID per neb
5. Budesonide (Pulmicort) 0.5mg2/ml TID per neb
6. Bisoprolol Fumerate (Concor) 10mg OD PO

Home Medications
1. Levofloxacin (Tavanic) 500mg OD PO for 10 days
2. Paracetamol (Fevadol Plus) 1 gram PRN for temperature equal or above 38C q6H PO
3. Bisoprolol Fumerate (Concor) 10mg OD PO

Discharge Instructions
 Follow up checkup in pulmonology clinic after 1 week
 Continuous BP monitoring
 Take all prescribed medications according to doctor’s order
 Do exercise of deep breathing for lung expansion and clearing for progressive normal
breathing pattern
 Have adequate rest period
 Health teachings regarding the importance of lifestyle changes to prevent recurrence,
maintain proper hygiene to prevent further infection