DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine
Name: MEEVIE LOVE D. TOLEDO
Batch/SecDon: NMD 3 Date: January 16, 2021

DAY 2 ACTIVITY

InstrucFons:
• Strictly use Harrison’s Principles of Internal Medicine 20th ediFon, Bate’s Guide to Physical ExaminaFon and History Taking, or Clinical PracFce Guidelines as your reference in answering this case. You
may also use the official textbooks used by other departments.
• Indicate the name of the book, chapter and page number in the reference column. Failure to write the reference will incur deducFon from the total grade.
Case:

DB., is 25-year-old male, Roman Catholic, he works as a bank teller from Agdao, Davao City

Chief complaint: cough and fever

Two days prior to consultaDon, the paDent was apparently. Later he developed sudden high grade intermiFent fever associated with chest pain and producDve cough with yellowish sputum, with mild
discomfort in breathing. He self medicated with paracetamol 500mg 1 tablet with temporary relief.

Past medical history • claimed that he has no PTB, no diabetes, no hypertension, no asthma
• no known food and drug allergies
Family history • No Heredofamilial diseases
Personal and social • Non Smoker
history • Consume alcoholic beverage every Saturday since college, such as 2 boFle of 1L Redhorse per session.
Sexual history • Has a girlfriend for 3 years.
• 2 sexual partners
Review of systems • No anorexia, diarrhea, nausea and vomiDng
• Denies orthopnea, PND
• Denies of palpitaDon
• Denies hemoptysis
• Denies of dental problem

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

Physical ExaminaFon Findings

General Survey Vital Signs Skin HEENT Neck
BP 130/90
PR 120 bpm
Neck supple
RR 30 cpm PERRLA, pupil diameter 3mm bilaterally
Awake, cooperaDve, coherent NegaDve for rash or other lesions Trachea midline
T 38.1 C Anicteric sclera
In mild respiratory distress Warm to touch No palpable nodes
02 sat 95% No nasal drainage
Good skin turgor and mobility No vein distenDon
Fundoscopy: Normal findings
No neck mass
Ht 5’4’’
Wt 59 kgs

Lungs Heart Abdomen Genitalia/Rectum ExtremiFes Neuro

Equal chest expansion
No lump nor tenderness
noted, No deformiDes
TacDle fremitus are equally
Adynamic precordium NormoacDve bowel sounds DRE reveals good sphincter ton, no
present all over the lung
Regular rate and rhythm Soc, nontender, masses, no tenderness, empty
field No clubbing, cyanosis, nor edema
PMI at 5th ICS, 5cm from nondistended rectal vault, and no blood on the CNs I-XII intact
VibraDon felt over the palm Pulses 2+ bilateral in all extremiDes
the midsternal line No guarding, no rebound examining finger Muscle strength = 5/5 all extremiDes
more clear at the apex of Intact ROM
No murmur, no heaves and tenderness Normal sized prostate without
lungs.
thrills No bruits, no masses nodules, asymmetry
Crackles and wheezing in
both lung field

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QuesFon/Task
Was your HPI output the same or almost the
same with your instructor? Do you need to
improve on it? Are there any data in the HPI
that you think needs to be clarified in the
HPI? And what were these?
Given the history and physical examinaFon,
what is now your working impression of this
case?
What are the nonmodifiable risk factors of
this paFent?
What are the modifiable risk factors of this
paFent?
DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Answer Reference
(Source, page no.)
My HPI output is almost the same as my instructor’s. I haven’t wriFen it in paragraph form cos I thought there were no clear
informaDon about the onset and duraDon of fever and cough.
There are data in the HPI that need to be clarified further, like if it’s the first Dme of the
paDent to experience these symptoms; clear details of the onset and duraDon prior to consultaDon; history of aspiraDon; if the
paDent noDced any Dnge of blood on his sputum; if in what circumstance that the paDent experienced chest pain; if how long
does the relief of paracetamol provides; and informaDon about last urine volume of the paDent
Harrison’s Principles of
Internal Medicine 20th ed.,
page 910
Philippine Clinical PracDce
Guidelines on the
Moderate-risk Community-Acquired Pneumonia Diagnosis, Empiric
Management, and
PrevenDon of Community-
acquired Pneumonia (CAP)
in Immunocompetent
Adults (2010 Update) page
31.
Harrison’s Principles of
Age of >70 Years Internal Medicine 20th ed.,
chapter 121 page 910
Alcoholism
Harrison’s Principles of
Asthma
Internal Medicine 20th ed.,
Immunosuppression
page 910
InsDtuDonalizaDon
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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Calculate the paFent’s latest BMI? Classify. Bates’ Guide to Physical
Weight (kg) 59
ExaminaDon and History
BMI = —————- = ————— = 22.33 (Normal)
Taking 12th ediDon;
Height (m2) (1.6256)2
Chapter 4, pages 116
and 123
Tools that objecFvely assess the risk
Harrison’s Principles of
outcomes, including severe illness and death. • Pneumonia Severity Index (PSI)
Internal Medicine 20th ed.,
Currently there are 2 sets of criteria. What are • CURB-65
chapter 121 page 912
they
Classic pneumonia evolves through a series of 1. Edema
pathologic changes, what are the following ✓ presence of a proteinaceous exudate—and ocen of bacteria—in the alveoli
and briefly explain. ✓ rarely evident in clinical or autopsy specimens because this phase happens briefly
2. Red HepaDzaDon
✓ presence of erythrocytes in the cellular intra-alveolar exudate
✓ neutrophil influx Harrison’s Principles of
✓ bacteria are occasionally seen Internal Medicine 20th ed.,
3. Gray HepaDzaDon
chapter 121 page 909
✓ no new erythrocytes are extravasaDng, and those already present have been lysed and degraded
✓ neutrophil is the predominant cell, fibrin deposiDon is abundant, and bacteria have disappeared
✓ corresponds with successful containment of the infecDon and improvement in gas exchange
4. ResoluDon
✓ the macrophage reappears as the dominant cell type in the alveolar space
✓ the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response
Please enumerate the atypical organisms of • Mycoplasma pneumoniae
CAP • Chlamydia pneumoniae
• Legionella species Harrison’s Principles of
• Influenza viruses Internal Medicine 20th ed.,
• Adenoviruses chapter 121 page 910
• Human metapneumovirus
• Respiratory syncyDal viruses

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Explain the Cough mechanism
Please differenFate CAP, HAP and VAP
DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Spontaneous cough is triggered by sDmulaDon of sensory nerve endings that are thought to be primarily rapidly adapDng
receptors and C fibers.
Chemical and mechanical sDmuli triggers afferent nerve endings which innervate the pharynx, larynx, and airways to the level of
the terminal bronchioles and extend into the lung parenchyma.
↓
The sensory signals travel via the vagus and superior laryngeal nerves to a region of the brainstem in the nucleus tractus
solitarius — the “cough center.”
Harrison’s Principles of
↓
Internal Medicine 20th ed.,
The vocal cords adduct, leading to transient upper-airway occlusion.
chapter 34 page 230
↓
Expiratory muscles contract, generaDng posiDve intrathoracic pressures as high as 300 mmHg.
↓
With sudden release of the laryngeal contracDon, rapid expiratory flows are generated, exceeding the normal “envelope” of
maximal expiratory flow.
Bronchial smooth muscle contracDon together with dynamic compression of airways narrows airway lumens and maximizes the
velocity of exhalaDon.
A deep breath preceding a cough opDmizes the funcDon of the expiratory muscles;
On the basis of eDology:
CAP: bacteria, fungi, viruses and protozoa; divided based on typical and atypical organisms; acquired through different
epidemiological factors: alcoholism, COPD and/or smoking, structural lung disease, demenDa, stroke, decreased level of Harrison’s Principles of
consciousness, lung abscess, travel to certain countries/states, stay in hotel or cruise, local influenza acDvity, and exposure to Internal Medicine 20th ed.,
animals chapter 121 page 908-918
VAP: divided based on Non-MDR pathogens and MDR pathogens; acquired while on mechanical venDlaDon during hospital stay
HAP: higher frequency of MDR pathogens than VAP; anaerobes are more common; acquired during hospital stay
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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Clinical Features of paFents with CAP Low-risk CAP
according to risk categories: please
enumerate, give the criteria and the site of Presence of:
care for each
Vital signs
Stable
✓RR <30/min Philippine Clinical PracDce
✓PR <125 bpm Guidelines on the
✓Temp 36-40C Diagnosis, Empiric
✓BP >90/160 mmHg Management, and
Features
PrevenDon of Community-
No altered mental status
acquired Pneumonia (CAP)
No suspected aspiraDon
in Immunocompetent
No or stable co-morbids
Adults (2010 Update) page
31.
Chest X-ray
Localized infiltrates
No pleural effusion
No abscess

DisposiDon
OutpaDent

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Moderate-risk CAP

Any of the following:

Vital signs
Stable
✓RR >30/min Philippine Clinical PracDce
✓PR >125 bpm Guidelines on the
✓Temp >40 or <36C Diagnosis, Empiric
✓BP <90/160 mmHg Management, and
Features
PrevenDon of Community-
Altered mental status
acquired Pneumonia (CAP)
Suspected aspiraDon
in Immunocompetent
Decompensated co-morbids
Adults (2010 Update) page
31.
Chest X-ray
MulDlobar infiltrates
Peural effusion
Abscess

DisposiDon
Ward admission
Philippine Clinical PracDce
High-risk CAP
Guidelines on the
Diagnosis, Empiric
Any of the criteria under Modereate-risk CAP, PLUS any of the following:
Management, and
✓ Severe sepsis and sepDc shock, or PrevenDon of Community-
✓Need for mechanical venDlaDon acquired Pneumonia (CAP)
in Immunocompetent
DisposiDon
Adults (2010 Update) page
ICU admission
31.