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,
however, he was medicated with Albuterol (Ventolin) inhaler 1.25 mg, 2 puffs every
6 hours, his mother remembered. He has no surgical history.

Family History:
The patient’s father was 65 years old when he died of emphysema. His
mother is 64 years old, hypertensive and asthmatic. He is the 2nd of 3 siblings. His
older sister died of epilepsy when she was 18 years old. And his younger brother is
30 years old, works as a bus conductor, and is apparently healthy.

Personal/Social/Occupational/Environmental History:
The patient lives with his mother in a 2 bedroom wooden house. The patient
finished high school level in Tondo Elementary School. He worked as a porter in a
bus company for 2 years. When he was 18, he worked as a barker for jeepneys
going Tondo until he reached 22 years old. He also started smoking and drinking at
18 years old. Smoking is 14 pack years and drinks anything with alcohol every
night. The mother said that the patient goes home drunk most of the time. Patient
does not eat fish and frequently eats vegetables and fruits, and drinks coffee 2-3
times a day.

Review of Systems:
General: patient is awake but with grade 3 dyspnea. Patient did not lose
weight since his symptoms started, according to mother. Patient’s body built is
moderate. There are no attachments on the body like IV line and Oxygen line.
Skin: Patient is pale in color. No rashes, lumps or lesions present.
HEENT:
Head: (+) headache, (+) dizziness, (-) head injury, (-) light headedness
Eyes: (-) pain, (-) redness, (-) blurred vision
Ears: (-) earaches, (-) infection, (-) discharge
Nose: (+) alae nasi dilatation, (-) itching, (-) nosebleed
Neck: (-) pain, (-) goiter, (-) lumps
Breast: (-) pain, (-) lumps
Respiratory: (+) cough, (+) sputum – greenish, 8-10 ml/expectoration, (+)
dyspnea – grade 3, (+)asthma, (-) hemoptysis, (+) chest pain – rated 7, 10 as
most severe
Cardiovascular: (-) high blood pressure, (-) heart murmurs
GIT: (-) nausea, (-) diarrhea, (-) vomiting
GUT: (-) nocturia, (-) hesitancy
Genital: (-) hernias, (-) testicular masses
Peripheral vascular: (-) varicose veins, (-) leg cramps
MSS: (-) joint pains, (-) gout, (-) back ache

PHYSICAL EXAMINATION:
General survey:
Patient is awake but with grade 3 dyspnea. Patient did not lose weight
since his symptoms started, according to mother. Patient’s body built is
moderate. There are no attachments on the body like IV line and Oxygen line.
Skin color of patient is pale. Grooming and personal hygiene is poor.
Vital Signs:
Height: 5’8’’
Weight: 70kg
RR: 28 bpm
PR: 99 beats/min
Temperature: 38.30C
BP: 130/100 mm Hg
Skin: I-Patient is pale in color. No rashes, lumps or lesions present.
P-Capillary refill is 3 seconds, no nail clubbing.
HEENT: I-No lesions on any part of the head. Eyes are aligned, pupils dilate in
reaction to light. Ears don’t have discharges. Nose is positive for nares
dilatation,
P-No tenderness on frontal sinuses.
Neck: No lymphnodes during inspection and palpation, no deviation in
trachea, no lymphnodes and tracheal sounds heard during auscultation.
Back: Patient does not have scoliosis or kyphosis.
Chest and Lungs: I-Patient muscle movement on anterior chest is obvious,
there are no lesions present on the chest.
P-No nodules. Decrease tactile fremitus. Percussion on chest is
from dull to flat-both lungs. Increase vocal fremitus.
P-Dull to flat on lower lobes of both lungs.
A-Diminished breath sounds
Extremities: I-No lesions
P- No edema
 PNEUMONIA

SUBMITTED TO:

MRS. RINALIZA P. BOGUSLEN

SUBMITTED BY:

KOTAILA, SAM

MAINGGANG, CEASARINA
SALAZAR, MAE

SIA, ROBINETTE EDNA VIRGINIA

SIM, RHEALYN
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

Name: Neu Patient is awake but Pleuritic chest pain Rest, and
Monia with grade 3 dyspnea. analgesic drugs
Age: 32 should be given
Gender: Male Skin color of patient is Fatigue due to
Address: 66 pale. dyspnea, and low Oxygen therapy
Walanghinga St., oxygenation
Tondo Manila Vital Signs:
Occupation: Height: 5’8’’ Tachypneic,tachyc Breathing
Garbage Weight: 70kg ardia, febrile, high technique:
collector RR: 28 bpm blood pressure. segmental
Marital status: PR: 99 beats/min Hyperventilation. breathing
Single Temp: 38.30C Inflammation of
Citizenship: BP: 130/100 mm the parenchyma
Filipino Hg
Name of Father:
Emphy Sema Lobar
Monia I-Patient muscle consolidation and
Name of mother: movement on anterior presence of CPT- percussion
Taberka Lassisa chest is obvious, there secretions on both in draining
Monia are no lesions present lungs procedure.
on the chest.
P-No nodules. Inflammation of Aerosol therapy
C/C: “Nahirapan Decrease tactile the parenchyma
ako huminga at fremitus. Percussion on Couging
masakit dibdib chest is from dull to technique
ko.” The patient flat-both lungs. Breathing
said. Increase vocal exercise –
fremitus. segmental
P-Dull to flat on lower breathing
lobes of both lungs.
A-Diminished breath
sounds

Modified Plan:
Pleuritic chest pain – expectorants to clear lungs.
Fiber optic bronchospy – if pneumonia becomes recurrent
Laboratory findings:

Chest X-ray: P-A view: hyperdensity

CBC: increase in WBC: increase in leukocytes and neutrophils

Sputum exam: (+) alveolar macrophages; <25 squamous epithelial cells

ABG: moderate hypoxia and moderate hypocarbia

PFT: DLCO – decrease

Spirometric measurements: decrease FVC, decrease FEV1, normal/increase in

FEV1/FVC