Community-acquired

pneumonia (CAP)
Presented by:
Nureen Humairah
Nur Batrisya
 HISTORY TAKING

Name: Nik Raimah bt Derahim

Registration number: A908058
Age: 58 years old
Gender: Female
PATIENT’S IDENTIFICATION Race: Malay
Occupation: Housewife
Address: Limbat, Pasir tumboh,Kelantan
Date of Admission: 18/5/2022
Date of clerking: 22/5/2022
 My patient was presented to ED with complaint of chills and rigor one day before admission
CHIEF COMPLAINT

One day before admission, my patient started to experience chills and her whole body was
shivering. It was sudden in onset and it occurred while the patient was at rest in a normal
room temperature surrounding area. Before the onset, patient claimed that she did not do
any heavy works or take any medications. The chills and rigors lasted for about 2-3 hours
per episode and was associated with nausea and vomiting. She claimed to vomit water
content twice that day after the chills and rigors episodes began. No exacerbating factors
and no relieving factors was mentioned by the patient. This was not her first episode as
similar complaint had occurred once for the past 3 years. However, the chills and rigors only
lasted for about 5-10 minutes only. It was also associated with nausea and vomiting where
she vomited food content once on the same day. Otherwise, there was no pain, no
HISTORY OF PRESENTING shortness of breath, no cough, no sore throat, no sweating, no diarrhea, no swelling, no
ILLNESS (HOPI) malaise, no dizziness or blurring of vision.

On the same night, her son brought her to Klinik Premiere for a check up. She claimed that
her oxygen level was dropped to 91% at the clinic. Chest x-ray was done and the patient
was told that her lung was infected. A referral letter was then written for her admission to
HUSM.
 She was treated with antibiotics in the ward. One day after her admission, she started to
experience fever and loss of appetite for two days. It was also associated with chills and
rigor. The fever was relieved by antipyretic medications. Her chills and rigor were improved.
It happened intermittently and lasting for about less than 1 hour per episode.

HISTORY OF PRESENTING As for raya occasion recently, my patient mentioned that she held an open house. Patient
ILLNESS (HOPI) noticed the symptoms started to appear 10 days after the open house event. Other than
that, my patient has underlying hypertension and diabetes mellitus.
 1. Cardiovascular System
- No palpitation
- No chest pain
2. Respiratory system
- No shortness of breath
- No productive cough
3. Gastrointestinal System
- Nausea and vomiting
- Normal bowel habit
4. Genitourinary System
- Polyuria
SYSTEMIC REVIEW - No hematuria
- No dysuria
5. Hematological System
- No bruising
- No pallor
6. Endocrine System
- Polydipsia
- No enlarged lymph nodes
- No neck swelling
7. Musculoskeletal System
- No muscle weakness
8. Neurological System
- No seizure episode
- No neck stiffness
 My patient had underlying hypertension and diabetes mellitus. The hypertension was
diagnosed about 10 years ago during a routine checkup after she had giving birth. She was
currently on medication and claimed to be compliance to the medications. She denied
having blurry of vision and severe headache. Her diabetes mellitus was diagnosed a year
PAST MEDICAL HISTORY ago during the follow up for her hypertension at the clinic. She was also on medication for
her diabetes however was given insulin injection throughout her current admission to
HUSM. She denied ever experiencing hypoglycemic episodes. She also had no blurring of
vision and no numbness at her hands or legs.

She was the third child out of 5 siblings. Her mother died because of stroke while for her
father, she could not recall the reason for her father’s death. Both of her parents had no
FAMILY HISTORY know chronic illnesses. 2 of her siblings had also died. One of them died to the heart attack.
Her other siblings also had no known medical illnesses.

She was married and blessed with 9 children. Her oldest child was 39 years old while the
youngest is 20 years old. Her husband had already retired and used to work as a
government officer. She and her husband is not a smoker. She lived with her husband and
SOCIAL HISTORY his 2 children in a village house equipped with good water and electrical supply from the
government. Her household monthly income was about RM1100.
 For her hypertension, she was on tablet Amlodipine 10 mg and Atenolol 100 mg which need
to be taken once a day. For her diabetes mellitus, she was on tablet gliclazide 30 mg which
DRUG HISTORY need to be taken once a day at morning. She was given insulin injection throughout her
current admission to HUSM. Currently, she is treated with antibiotics. Otherwise, she did not
take any traditional medicine or over the counter drugs. She had no known drug allergy.

My patient practed a normal adult diet where she ate 3 meals a day. She usually will eat
DIET HISTORY rice for breakfast, lunch and dinner. She was not on a strict diabetic diet. She drank sweet
drinks sometimes. Otherwise, she had no known food allergy.
 Summary History Taking
My patient, Nik Raimah, 58 years old malay lady came to Emergency Department HUSM due to the
complain of chills and rigor one day before admission. It was associated with nausea and vomiting of
water content. Otherwise, there was no pain, no shortness of breath, no cough, no sore throat, no
sweating, no diarrhea, no swelling, no malaise, no dizziness or blurring of vision. Patient was suspected
with lung infection based on x-ray findings.
 Physical Examination
GENERAL EXAMINATION
On inspection, the patient was lying comfortably at 45 degrees supported by one pillow. She was alert,
conscious and well-oriented to time, place and person. She was not in pain and showed no sign of
respiratory distress. The hydrational and nutritional status seems adequate. There was no skin
discoloration such as cyanosis or jaundice over the body and face. There were no gross deformities and
a green IV cannula was attached at the dorsum of her left hand.

VITAL SIGNS
Blood pressure: 147/80 mmHg
Pulse rate: 84 beats per min
Temperature : 37 ℃
Respiratory rate: 16 breaths per min
SpO2: 97% under room air
PERIPHERAL EXAMINATION
i) Upper limbs
Both patient’s palms were pink, moist and warm. Capillary refill time was less than 2 seconds. There were no
leukonychia and koilonychia. No sign of finger clubbing and no peripheral signs of cyanosis. No palmar erythema,
dupuytren contracture and no tar staining, no thenar and hypothenar muscle wasting can be seen. Fine and
flapping tremors were also absent. No radio-radial delay, collapsing pulse and any swellings.

ii) Head and Neck

There was no facial puffiness and any dysmorphic features. Conjunctiva was pink but there was mild yellowish
discoloration of sclera. Otherwise, there was no diplopia and no xanthelasma. There was no conjunctival
suffusion, no abnormal discharge as well as polyps from the ear and nose. There were also no glossitis, angular
stomatitis and fetor hepaticus. No coated tongue, central cyanosis, ulcerations and enlarged tonsils can be seen.
Oral hygiene was good. No spider naevi at the neck and no loss of axillary hair. No neck swelling, no
lymphadenopathy and no raised Jugular Venous Pressure (JVP). The carotid pulse was palpable and the trachea
was centrally located, not deviated.

iii) Lower limbs

There was no pitting edema and calf tenderness. Posterior tibial and dorsalis pedis were palpable. Capillary refill
time was less than 2 seconds.
RESPIRATORY EXAMINATION
On inspection of the chest, the patient's chest moved symmetrically with each respiration. There was no chest
deformity seen such as pectus excavatum, pectus carinatum and barrel chest. Otherwise, there was no skin
discolouration, no scars, no attachments to the chest wall and no prominent dilated veins seen.

On palpation, the trachea was centrally located and was not deviated. The apex beat was palpable at the left 5th
intercostal space around the midclavicular line. The chest expanded bilaterally symmetrical with each respiration at
all lobes of the lungs. Tactile fremitus was normal and equal on both sides of the lungs.

On percussion, dull sound can be heard at the base of her right lung. Otherwise, resonance sound was heard at
the other zones of the lungs.

On auscultation, fine crepitation can be heard at the base of the right and left lung. Decreased vocal resonance can
be heard at the lower right side of the lungs.
CARDIOVASCULAR EXAMINATION
Upon inspection, the chest wall moves symmetrically with respiration. There was no gross deformity such as
pectus excavatum and pectus carinatum seen. There was also no skin discolouration, no scars, no precordial
bulge, no dilated veins, no attachment to the chest wall and no visible pulsation over the chest.

On palpation, the apex beat was felt at the left 5th intercostal space, around the midclavicular line.. Otherwise,
there were no palpable thrills and no parasternal heave felt. No radio radial delay and radio femoral delay and no
collapsing pulse. Patient’s chest was non tender and had no fracture.

Upon auscultation, normal s1 and s2 heart sounds were heard at the aortic, pulmonary, tricuspid and mitral areas.
No additional sounds and murmurs were heard.
ABDOMINAL EXAMINATION
On inspection, the abdomen was not distended, and it moved symmetrically with each respiration. The
umbilicus was inverted and centrally located. There was no scar, no scratch marks, no bruises, and no spider
naevi on the abdomen. There was no dilated vein.

On superficial palpation, the abdomen was soft and non tender. On deep palpation, there was no mass felt and
no guarding. There was no rebound tenderness. Liver and spleen were not palpable. Kidneys were not
ballotable.

On percussion, the liver span was normal with a measurement of 9 cm. There was no shifting dullness and no
rebound tenderness. Percussion of the spleen and Traube’s space was resonant which showed no
splenomegaly.

On auscultation, normal bowel sounds with regular intervals were heard over the 4 quadrants of the abdomen.
There was no renal bruit.
 Summary physical examination
On the physical examination, the patient was lying comfortably at 45 degrees supported by one
pillow. He was alert, conscious, not in pain, not in respiratory distress and well oriented to the time,
place and person. On general examination, mild yellowish discoloration of the sclera was noted. On
respiratory examination, dull sound can be heard at the base of her right lung during percussion.
On auscultation, bilateral fine crepitation can be heard at the base of the lungs. Decreased vocal
resonance was heard at the lower right side of the lungs. There were no positive findings in specific
examinations for other systems.
 Diagnosis
Provisional diagnosis:Community-acquired pneumonia (CAP)

Positive points Negative points

- Fever with chills - No shortness of breath

- History of open house event - No cough
- Chest x-ray showed infected lung - No chest pain
- Low oxygen level - No malaise
- Crepitation sound on lungs auscultation - No loss of appetite
Differentials:

Positive points Negative points

Tuberculosis - Fever with chills - No shortness of breath

- History of open house event - No cough
- Chest x ray showed infected lung - No chest pain
- Crepitation on lung auscultation - No night sweat
- Low oxygen level - No malaise
- No weight loss
- Not immunodeficiency patient

pneumothorax - Fever - No shortness of breath

- hypoxia - no chest pain
- no cough
- no fatigue

Chronic obstructive pulmonary disease - Fever - No shortness of breath

- No chest tightness
- No wheezing on auscultation
- No cough
- Not exposed to tobacco smoke
 Investigation
1. Full blood count (18/05/2022)
Rationale: To look evidence of infection.

Parameters Results Reference value Interpretation

WBC (x10^9/L) 7.76 3.40 – 10.1 Normal
RBC (x10^12/L) 4.12 3.52 – 5.16 Normal
HGB (g/dl) 12.4 11.6 – 15.1 Normal
HCT (%) 35.4 31.8 – 42.4 Normal
MCV (fl) 85.9 77.5 – 94.5 Normal
MCH (pg) 30.1 24.8 – 31.2 Normal
MCHC (g/dl) 35.0 29.4 - 34.4 Normal
PLT (x10^9/l) 196 158 – 410 Normal

Impression : All parameters are within normal range

 Investigation
2. C-Reactive protein (24/05/2022)

Rationale: To look evidence of inflammation and infection

Parameters Results Reference value Interpretation

CRP(mg/L) 133 <10 Increased

Impression: C-reactive protein elevated, this indicates there was ongoing inflammation due to infection
 Investigation
3. Chest X-Ray (17/05/2022)

Rationale: To look for any changes and pathology of respiratory system and cardiovascular system

Impression :
- Cardiomegaly
- Haziness at left lung field
 Investigation
4. Blood Culture & Sensitivity (19/05/2022)

Rationale: To assess any infection in the bloodstream

Results No growth Detected

Impression: There is no hematological spread

 Investigation
5. Renal function test (18/05/2022)

Rationale: To assess renal function, which is to measure levels of electrolytes in blood.

Parameters Results Reference value Interpretation

Na (mmol/L) 131 135-145 Low

K (mmol/L) 4.8 3.5-5.0 Normal

Urea (mmol/L) 7.8 1.7-8.3 Normal

Creatinine
(μmol/L) 121 70 – 130 Normal

Cl (mmol/L) 104 98 – 107 Normal

Calcium
(mmol/L) 2.09 2.15 -2.55 Low

TB (μmol/L) 33 3.4-17.1 High

Impression: Sodium and Calcium level are slightly low while Total Bilirubin level is high.
 Investigation
6. Liver function test (18/05/2022)

Rationale: To assess liver function and detect liver impairment.

Parameters Results Reference value Interpretation

Total Protein (g/L) 75 65 – 83 Normal

Albumin (g/L) 39 38 – 44 Normal

Globulin (g/L) 36 23 - 35 High

A/G ratio 1.08 1.10 – 2.10 Normal

AST (U/L) 87 5 – 34 High

ALP (U/L) 120 42 – 98 High

ALT (U/L) 70 <34 High

Impression: Globulin and the three liver enzymes which are AST, ALP and ALT are high.
The chills was not happening continuously. It happened intermittently every 2
hours apart and every episode of chills lasted long around 2-3 hours. No
exacerbating factors and no relieving factors mentioned by the patient such as
taking medications, controlling room temeprature or doing extra house chores.
The severity of the chills mentioned by the patient was around 8/10 to compared
to the first occasion of chills happening in less than 3 years before as previously
it only happened once and lasted long around 5-10 minutes only. Otherwise, no
pain, no shortness of breath, no cough, no sore throat, no sweating, no diarrhea,
no swelling, no malaise, no dizziness or blurring of vision.
At night, patient went to Klinik swasta. Her oxygen level was drop to 91. Other
than that, ultrasound was done and patient was told that her lung was infected,
so referral letter was written for her admission to HUSM.
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