University of Perpetual Help Medical Center

Department of Community and Family Medicine

Sto. Nino, Biñan, Laguna

OUTPATIENT DEPARTMENT
CASE PRESENTATION

Submitted by
SALGADO, Israel Jiuliano R..
Post Graduate Intern

December 2023 - January 2024

 ADMITTING NOTES

CLINICAL HISTORY

GENERAL Patient C.A. s a 21 y/o, Female, Filipino, Single, Catholic, born on July 27, 2002 and currently
DATA: residing in Sto. Domingo, Binan, Laguna.

CHIEF Productive Cough

COMPLAINT:

HISTORY OF The patient was apparently well until 2 weeks prior to consultation, the patient noted intermittent
PRESENT greenish productive cough roughly amounting to ¼ cup. The patient denied fever, chest pain,
ILLNESS: shortness of breath, or difficulty in breathing. The patient self-medicated with one dose of Lagundi
capsule which provided temporary relief. No consultation was done.

In the interim, the patient noted persistence of symptoms. No medications nor consultations were
done.

Few hours prior to consultation, the patient noted persistence of productive cough hence consult

PAST MEDICAL Unremarkable

HISTORY:

FAMILY Unremarkable
HISTORY:

PERSONAL/ Non smoker

SOCIAL Non alcohol beverage drinker
HISTORY: Government employee
Non-illicit drug user

REVIEW OF General: (-) weight loss (-) fatigue, (-) body malaise, (-) loss of appetite
SYSTEMS: Integument: (-) petechiae (-) rashes (-) erythema (-) hyperpigmentation
(-) hypopigmentation (-) mass (-) skin lesions (-) pruritus
Head and Neck: (-) dizziness (-) stiffness (-) distention of veins (-) mass (-) swelling (-) neck pain
Eyes: (-) corrective lenses (-) pain (-) itchiness (-) redness (-) discharge (-) flashing light
Ears: (-) otalgia (-) vertigo (-) tinnitus (-) difficulty in hearing (-) discharge (-) hearing aid
Nose & Sinuses: (-) watery discharge/itching (-) epistaxis (-) obstruction
Mouth & Throat: (-) hoarseness (-) dentures (-) toothache (-) tongue fasciculation (-) sore throat (-)
mouth sores (-) tooth decay
Respiratory: (-) colds (-) hemoptysis (-) tachypnea
GUT: (-) hematuria (-) frequency (-) polyuria (-) oliguria (-) nocturia (-) dysuria (-) flank pains (-)
palpable mass
Vascular: (-) varicose veins (-) claudication (-) ulcers
Hematologic: (-) easy bruising (-) easy bleeding
Endocrine: (-) polyuria (-) polydipsia (-) polyphagia (-) diaphoresis (-) heat/cold intolerance
Musculoskeletal: (-) arthralgia (-) limitation of motion (-) fractures (-) edema (-) myalgia
Genitalia: (-) Swelling (-) lesion/ abrasion
Anus: (-) lesions
Nervous: (-) hemiplegia (-) seizures (-) syncope (-) tremors
Autonomic: (-) fecal incontinence (-) urinary incontinence

PHYSICAL EXAMINATION
 GENERAL Patient is awake, alert, well-developed, cooperative, conversant, coherent, oriented to time,
SURVEY: place and person, and not in cardiorespiratory distress.

VITAL SIGNS: BP: 120/80 mmHg

HR: 80 bpm
RR: 23 cpm
Temp: 36.7℃
O2 Sat: 98% at room air

SKIN: No pallor, no jaundice,

HEENT: Anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngitis

CHEST AND Symmetrical Chest Expansion, (+) fine crackles, no wheezes

LUNGS:

HEART: Adynamic precordium, normal rate and regular rhythm, no murmurs

ABDOMEN: Not done

RECTUM/ Not done

GENITALIA

EXTREMITIES: No gross deformities, full and equal peripheral pulses, capillary refill time <2 seconds

NEUROLOGIC Cranial Nerves:

EXAMINATION CN I: Not assessed
CN II: Pupils are 3-4mm in diameter and equally briskly reactive to light
CN III, IV, VI: - Full EOMs
CN V: Equal facial sensation on V1, V2, and V3
CN VII: No facial asymmetry, able to do: smile and frown, forehead wrinkling, eyelid closure, mouth
retraction, and puffing of cheeks
CN VIII: Good gross hearing, Tuning Fork tests not done
CN IX: Good speech, able to swallow
CN XI: Good shoulder shrug, good trapezius and sternocleidomastoid contraction, no muscle atrophy
CN XII: Tongue is midline, no atrophy or fasciculations seen

Muscle Strength:
5/5 on Right Upper Extremities
5/5 on Left Upper Extremities
5/5 on Right Lower Extremities
5/5 on Left Lower Extremities

Somatic Sensory Test:

100% equally felt on Right and Left Upper Extremities
100% equally felt on Right and Left Lower Extremities

PRIMARY WORKING IMPRESSION: Community Acquired Pneumonia, Low Risk

DIFFERENTIAL DIAGNOSIS:

1. Acute Bronchitis

Rule-In Rule-Out

(+) Productive Cough (-) Fever

(-) Tachycardia
(-) Tachypnea
 (-) Wheezing
(-) Chest Congestion

2. Pulmonary Tuberculosis

Rule-In Rule-Out

(+) Productive Cough (-) Fever

(+) cough duration of more thab 2 weeks (-) Weight Loss
(-) Cervical Lymphadenopathy

CASE DISCUSSION:

Community Acquired Pneumonia (CAP) refers to a lower respiratory tract infection contracted within the
community, typically occurring within 24 hours to less than 2 weeks. It typically manifests with symptoms such as an acute
cough, abnormal vital signs like tachypnea, tachycardia, and fever, along with at least one abnormal chest finding like
diminished breath sounds, rhonchi, crackles, or wheezes. The severity of symptoms can range from mild to severe. The
Department of Health notes that pneumonia is a significant cause of mortality in Filipinos, particularly in children under five
and the elderly, ranking as the leading cause of death from an infectious disease and the sixth leading cause of death
overall. Studies indicate a higher susceptibility and mortality risk in males, especially in older age.

The causes of CAP can be bacterial, viral, or fungal. Streptococcus pneumoniae is the most common bacterial
culprit, with other bacteria including Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae,
Legionella pneumophila, and Staphylococcus aureus. Viruses like Influenza, respiratory syncytial virus (RSV), and
adenovirus can also cause CAP. Fungal causes, such as Histoplasma, Coccidioides, and Cryptococcus, are less common
but noteworthy in certain geographic areas.

Diagnosis typically involves clinical assessment, chest X-rays or other imaging studies, and laboratory tests like
blood or sputum cultures. Identifying the specific cause may not always be possible, especially in milder cases. Risk
factors include advanced and very young age, chronic medical conditions (e.g., diabetes, chronic lung diseases), a
weakened immune system, and smoking and excessive alcohol use.

Antibiotics constitute the primary treatment for bacterial pneumonia, with the choice depending on the suspected
causative agent. Antiviral medications may be used for viral pneumonia. Supportive care, including rest, hydration, and
pain relief, is vital for recovery. Vaccines, like the pneumococcal and influenza vaccines, can prevent certain pneumonia
types, while good hygiene practices, including handwashing and avoiding close contact with sick individuals, can lower
infection risk.

Complications may include respiratory failure, sepsis, and lung abscess, emphasizing the importance of prompt
and appropriate treatment to prevent such issues. Most individuals with uncomplicated CAP recover fully with proper
treatment, and prognosis is influenced by factors like age, overall health, and underlying medical conditions.

MANAGEMENT:

Pharmacologic:
1. Amoxicillin 500mg/tab 1 tab TID for 7 days
2. Azithromycin 500mg/tab 1 tab OD for 7 days

Non-pharmacologic:
● Diagnostics
○ Chest X-Ray
● Supportive Treatment
○ Increase oral fluid intake
○ Advised chest physiotherapy during coughing episodes