General data: Name: Neu Monia Age: 32 Gender: Male Address: 66 Walanghinga St.

, Tondo Manila Occupation: Garbage collector Marital status: Single Citizenship: Filipino Name of Father: Emphy Sema Monia Name of mother: Taberka Lassisa Monia Informant: Mother Percent of Reliability: 88% C/C: The patient entered the ER and said, “Nahirapan ako huminga at masakit dibdib ko.” History of Present Illness: 2 weeks PTA, the patient said he was collecting garbage early in the morning when he started coughing. At first the cough was dry but after a day or 2, the cough became productive, the mother stated. She said that her son’s sputum was green in color, and saw his son expectorated 8-10ml of phlegm on his 3 rd day of coughing. The mother advised him not to work and just rest on that day. She also went to buy medicine for his son on that same day; she said she gave him Ambroxol Hydrochloride (Mucosolvan) 75 mg prolonged action capsule. She made her son drink the medicine for once for 4 days every after they eat dinner. But her son’s cough did not improve and caused her son not to work anymore so they decided to go to the Barangay health center for consultation. 1 week PTA, the patient’s mother accompanied him for a check-up. The Barangay health center nurse gave him a 7-day supply of Erythromycin (E-Mycin) 250 mg every 6 hours. On his 3rd night of medication, he felt cold then had chills and became febrile with a temperature of 39.10C. His mother was not able to give him any medication at that time because according to her they did not have any paracetamol and there was no store open. After that night, her mother said that his son was still febrile with a temperature of 38.40C, so she went out to buy Paracetamol (Biogesic) Analgesic-Antipyretic 500mg tablet. She said that she gave her son Biogesic 4 times a day for 2 days. According to the mother, when his son became febrile, he also started complaining that his chest was painful most especially during inhalation. And also, his mother noticed that the patient was breathing fast. A few hours PTA, the mother accompanied the patient to the ER. The patient was presented with grade 3 dyspnea and was complaining of chest pains. His chest pain was rated 7 as 10 as most severe and was characterized as pinching like pain and he can feel it most especially when he inhales. His temperature was 38.30C and looks fatigued. Past Medical History: The patient did not complete his immunization according to the mother. His mother cannot remember the vaccines given to her son. When his son was 22 years old he was hospitalized and diagnosed for asthma. The patient was not confined,

(-) leg cramps MSS: (-) joint pains. (+) dyspnea – grade 3. (-) lumps Breast: (-) pain. and is apparently healthy. (+) dizziness. he was medicated with Albuterol (Ventolin) inhaler 1. Skin: Patient is pale in color. His older sister died of epilepsy when she was 18 years old. (-) heart murmurs GIT: (-) nausea. (-) light headedness Eyes: (-) pain. (-) infection. (-) lumps Respiratory: (+) cough. (+) sputum – greenish. When he was 18. Patient did not lose weight since his symptoms started. His mother is 64 years old. (-) head injury. Patient’s body built is .25 mg. (+)asthma. He is the 2nd of 3 siblings. The mother said that the patient goes home drunk most of the time. according to mother. (+) chest pain – rated 7. Review of Systems: General: patient is awake but with grade 3 dyspnea. 2 puffs every 6 hours. (-) hesitancy Genital: (-) hernias. (-) itching. Patient does not eat fish and frequently eats vegetables and fruits. (-) vomiting GUT: (-) nocturia. (-) redness. (-) nosebleed Neck: (-) pain. (-) goiter. He worked as a porter in a bus company for 2 years. hypertensive and asthmatic. HEENT: Head: (+) headache. (-) gout. He has no surgical history. Patient did not lose weight since his symptoms started. (-) testicular masses Peripheral vascular: (-) varicose veins. and drinks coffee 2-3 times a day. 8-10 ml/expectoration. 10 as most severe Cardiovascular: (-) high blood pressure. There are no attachments on the body like IV line and Oxygen line. his mother remembered. Personal/Social/Occupational/Environmental History: The patient lives with his mother in a 2 bedroom wooden house. (-) discharge Nose: (+) alae nasi dilatation. he worked as a barker for jeepneys going Tondo until he reached 22 years old. according to mother. (-) back ache PHYSICAL EXAMINATION: General survey: Patient is awake but with grade 3 dyspnea. (-) hemoptysis. Patient’s body built is moderate. The patient finished high school level in Tondo Elementary School. He also started smoking and drinking at 18 years old. lumps or lesions present. Family History: The patient’s father was 65 years old when he died of emphysema. (-) blurred vision Ears: (-) earaches. Smoking is 14 pack years and drinks anything with alcohol every night.however. works as a bus conductor. No rashes. (-) diarrhea. And his younger brother is 30 years old.

Grooming and personal hygiene is poor. Nose is positive for nares dilatation. P-Capillary refill is 3 seconds. Back: Patient does not have scoliosis or kyphosis. P-Dull to flat on lower lobes of both lungs. There are no attachments on the body like IV line and Oxygen line. no nail clubbing. Chest and Lungs: I-Patient muscle movement on anterior chest is obvious. No rashes. Decrease tactile fremitus. A-Diminished breath sounds Extremities: I-No lesions P. Skin color of patient is pale. P-No tenderness on frontal sinuses. P-No nodules. no deviation in trachea.moderate. no lymphnodes and tracheal sounds heard during auscultation. Eyes are aligned. Ears don’t have discharges. Increase vocal fremitus.No edema .30C BP: 130/100 mm Hg Skin: I-Patient is pale in color. pupils dilate in reaction to light. Vital Signs: Height: 5’8’’ Weight: 70kg RR: 28 bpm PR: 99 beats/min Temperature: 38. HEENT: I-No lesions on any part of the head. Percussion on chest is from dull to flat-both lungs. lumps or lesions present. Neck: No lymphnodes during inspection and palpation. there are no lesions present on the chest.

SAM MAINGGANG. RINALIZA P.PNEUMONIA SUBMITTED TO: MRS. CEASARINA . BOGUSLEN SUBMITTED BY: KOTAILA.

SALAZAR. ROBINETTE EDNA VIRGINIA SIM. MAE SIA. RHEALYN .

Skin color of patient is pale.percussion secretions on both in draining lungs procedure. Percussion on chest is from dull to flat-both lungs. Increase vocal fremitus.30C BP: 130/100 mm Hg I-Patient muscle movement on anterior chest is obvious.SUBJECTIVE Name: Neu Monia Age: 32 Gender: Male Address: 66 Walanghinga St. Inflammation of Aerosol therapy the parenchyma Couging technique Breathing exercise – segmental breathing Modified Plan: Pleuritic chest pain – expectorants to clear lungs.” The patient said. Inflammation of the parenchyma PLAN Rest. Hyperventilation. Vital Signs: Height: 5’8’’ Weight: 70kg RR: 28 bpm PR: 99 beats/min Temp: 38. Tondo Manila Occupation: Garbage collector Marital status: Single Citizenship: Filipino Name of Father: Emphy Sema Monia Name of mother: Taberka Lassisa Monia C/C: “Nahirapan ako huminga at masakit dibdib ko.. high blood pressure. OBJECTIVE Patient is awake but with grade 3 dyspnea. Fiber optic bronchospy – if pneumonia becomes recurrent . A-Diminished breath sounds ASSESSMENT Pleuritic chest pain Fatigue due to dyspnea. there are no lesions present on the chest. P-Dull to flat on lower lobes of both lungs. febrile. and low oxygenation Tachypneic. and analgesic drugs should be given Oxygen therapy Breathing technique: segmental breathing Lobar consolidation and presence of CPT. Decrease tactile fremitus. P-No nodules.tachyc ardia.

normal/increase in FEV1/FVC .Laboratory findings: Chest X-ray: P-A view: hyperdensity CBC: increase in WBC: increase in leukocytes and neutrophils Sputum exam: (+) alveolar macrophages. decrease FEV1. <25 squamous epithelial cells ABG: moderate hypoxia and moderate hypocarbia PFT: DLCO – decrease Spirometric measurements: decrease FVC.