TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

CLINICAL CASE ANALYSIS

Name of Patient Pio Rodriguez Age: 62yrs old Gender: Male

Address Brgy. San Fernando, Victoria, Tarlac Date Admitted: January 30,
2021
Diagnosis Community Acquired Pneumonia

NURSING HISTORY:

Ten days prior to admission, he had a travel history from Spain.

Four days prior to admission, Mr. Pio experienced muscle aches, head ache, and he had fever with
the temperature of 39 ⁰C.

On the days of his admission, he had a chief complaint of dry cough and shortness of breath. A
while after, he was confused and started to have diarrhea. During the examination, he looks
dehydrated and flushed and central cyanosis was noted. Bilateral crackles and bronchial breathing
in both lower zones posteriorly were audible during auscultation. His abdomen is diffusely tender
but there is no rigidity or guarding and his vital signs are as follow: PR: 120 bpm (Tachecardic),
RR: 32 bpm (Tachypneic), BP 146/72 mmHg, Temperature: 39.5 (febrile).
PATHOPHYSIOLOGY:

Modifiable factor/s: Non modifiable factor/s:

 Travel history  Age

Inhalation/aspiration of microorganism by
environmental transmission

Microorganisms present in the upper airways

(Coughing)

Through micro aspiration of oropharengeal

secretions from thrachea, can enter lower airways.
Altered
conciousness Hematogenous spread
Stomach
tenderness/diarrhea
Enter the alveoli by evading the
respiratory host defenses
Fever,
shortness of
breath Microorganisms spread into the lungs

Audible crackles
Community Acquired Pneumonia and bronchial
breathing
DIAGNOSTIC PROCEDURES:

1. BLOOD TEST

ANALYSIS:
- High WBC
- Decreased sodium
- High BUN
- High Createnine level
- Low calcium level
- Low PCO2
- Low pO2

2. CHEST X – RAY

ANALYSIS
- chest X-ray suggest atypical pneumonia

MEDICAL MANAGEMENT:

Drugs: 
 Cefuroxime 750 mg IV every 8 hours for 5 days 
 Clarithromycin 500 mg IV q 12 hours for 3 days. 
  Paracetamol 100mg IV q 4 hours. 
 
IV Solution: PLRS 1L to run for 6 hours 

Name of Student:
Date Submitted: C.I.’s Signature

Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1