Patients Profile

Name Blente, Cecilia

Age 73 years old

Sex Female

Marital Status Widowed

Address Brgy. Utap, Tacloban City

Date of Admission September 22, 2008

Time of Admission 4:35 PM

Chief Complaint Chest Pain

Attending Physician Dr. Avito Salinas

Diagnosis Moderate Risk for CAP, rule out MI

General Data

A case of Blente, Cecilia, female, 73 years old, widowed, residing at

Brgy. Utap, Tacloban City was admitted at this center with chief complaint of
chest pain.

History of Present Illness

Condition started a few hours prior to admission when patient

experienced sudden chest pain, associated with difficulty in breathing, which
prompted patient to seek medical consult. Hence, subsequently admitted.

Patient has had cough for a long time, with yellowish sputum, and had
undergone PTB treatment at the City Health Office for 6 months, but
condition did not lessen.

Past Medical History

Patient has never been hospitalized nor admitted before; she had
regular check up but as OPD only.

Family History

Patient has no known heredofamilial disease on both her mothers and

fathers side. Patients husband had tuberculosis.

Psychosocial History

Patient lives in a house made of concrete, fully equipped with water,

electricity and toilet, with her daughter, two sons, and three grandsons.

Patients usual activities include gardening, washing the dishes and

cleaning their house. She considers these chores as her forms of exercise.
Patients usual source of stress is keeping watch at her grandsons, and going
up and down the stairs. Patient relieves stress by resting.
 Patients sleeping pattern is often disturbed due to her constant
coughing.

Physical Examination

General Survey

Patient is conscious, coherent and oriented to time, place and person.

Weight: 46 kg, BP: 180/100, PR: 84 bpm, RR: 21 cpm, T: 36.8oC

Skin

I: (-) edema, (-) lesions.

P: Good skin turgor.

Head

I: Normocephalic.

P: (-) nodules, (-) masses.

Eyes

I: Pink palpebral conjunctiva.

Ears

P: Pinna recoils, (-) discharges.

Throat

I: Dry lips, pale gums.

Neck

P: Palpable lymph nodes.

Cardiovascular

A: (-) murmurs.

Respiratory

I: Shallow breathing, (+) dyspnea.

A: (+) crackles.

Sensory

I: Sensitive to light, touch and temperature.

Mental Status

I: Normal

Extremities

I: (-) lesions, (-) edema.

Introduction

Pneumonia is an inflammatory illness of the lung. Frequently, it is described

as lung parenchyma/alveolar inflammation and abnormal alveolar filling with
fluid. The alveoli are microscopic air-filled sacs in the lungs responsible for
absorbing oxygen. Pneumonia can result from a variety of causes, including
infection with bacteria, viruses, fungi, or parasites, and chemical or physical
injury to the lungs. Its cause may also be officially described as idiopathic
that is, unknownwhen infectious causes have been excluded.

Typical symptoms associated with pneumonia include cough, chest pain,

fever, and difficulty in breathing. Diagnostic tools include x-rays and
examination of the sputum. Treatment depends on the cause of pneumonia;
bacterial pneumonia is treated with antibiotics.

Pneumonia is a common illness which occurs in all age groups, and is a

leading cause of death among the elderly and people who are chronically
and terminally ill. Vaccines to prevent certain types of pneumonia are
available. The prognosis depends on the type of pneumonia, the appropriate
treatment, any complications, and the person's underlying health.

Epidemiology

Pneumonia is a common illness in all parts of the world. It is a major cause of

death among all age groups. In children, the majority of deaths occur in the
newborn period, with over two million deaths a year worldwide. The World
Health Organization estimates that one in three newborn infant deaths are
due to pneumonia and WHO also estimates that up to 1 million of these
(vaccine preventable) deaths are caused by the bacteria Streptococcus
pneumoniae, and 90% of these deaths take place in developing countries.
Mortality from pneumonia generally decreases with age until late adulthood.
Elderly individuals, however, are at particular risk for pneumonia and
associated mortality.

In the United States, about 3 million cases of pneumonia are reported each
year. Of these, about one-third of cases occur in people over age 65.
Approximately 4 out of every 100 children in the United States develop
pneumonia each year and about 60,000 people die as a result of the
condition.

In the United Kingdom, the annual incidence of pneumonia is approximately

6 cases for every 1000 people for the 1839 age groups. For those over 75
years of age, this rises to 75 cases for every 1000 people. Roughly 2040%
of individuals who contract pneumonia require hospital admission of which
between 510% is admitted to a critical care unit. Similarly, the mortality
rate in the UK is around 510%.

More cases of pneumonia occur during the winter months than during other
times of the year. Pneumonia occurs more commonly in males than females,
and more often in Blacks than Caucasians. Individuals with underlying
illnesses such as Alzheimer's disease, cystic fibrosis, emphysema, tobacco
smoking, alcoholism, or immune system problems are at increased risk for
pneumonia. These individuals are also more likely to have repeated episodes
of pneumonia. People who are hospitalized for any reason are also at high
risk for pneumonia.

Laboratory Exams

Urinalysis 9-22-08
Type Result Normal Values Significance
Color Light Straw to dark Normal
yellow yellow
Transparency Clear Clear Normal
pH 6.5 4.5-8 Normal
Specific 1.005 1.005-1.035 Normal
Gravity
Proteins (-) (-) Normal
Sugar (-) (-) Normal
Pus Cells 0-1/hpf 0-2/hpf Normal
Red Cells 0-1/hpf 0-2/hpf Normal
Epithelial Cells Rare Few to none Normal
Mucus Threads Rare Few Normal
Amorphous Rare Few Normal
Urates
Bacteria Few None Contamination of genitalia;
infection.

Clinical Chemistry 9-22-08

Type Result Normal Significance
Values
Creatini 53.17 71-115 Seen in the elderly; occurs in muscle
ne umol/L atrophy.
Sodium 121.6 135-148 Inadequate sodium intake or excessive
mmol/L sodium loss.
Potassiu 3.12 3.5-5.3 Occurs with loss of body fluids.
m mmol/L

Hematology 9-22-08
Type Result Normal Values Significance
Hemoglobin 116 140-175 g/L Occurs with anemia or fluid
retention.
Hematocrit 0.33 0.42-0.50 Occurs with anemia,
hemodilution.
WBC 4.4 4.5-11.54x109/L Normal
Neutrophils 0.66 0.45-0.65 Normal
Lymphocyte 0.28 0.20-0.35 Normal
s
Monocytes 0.06 0.02-0.06 Normal
Clinical Chemistry 9-23-08
Type Result Normal Values Significance
FBS 5.70 3.9-6.4 mmol/L Normal
Cholesterol 3.75 3.87-6.7 Normal
HDL 1.03 >1.42 Decreased
LDL 2.0 <3.9 Normal
Triglycerides 0.60 0.46-1.88 Normal
mmol/L

Anatomy and Physiology of the Respiratory System

The Lungs

The lungs are located in the chest on either side of the heart. They are
surrounded and protected by the ribcage. The left lung is a little smaller than
the right lung because it shares space in the left side of the chest with the
heart. Each lung is divided into sections (lobes).

The right lung has three sections or lobes, including the:

Right upper lobe, which takes up the top third of the right lung

Right middle lobe, which is the smallest of the three lobes and shaped
like a triangle

Right lower lobe, which is the largest of the three

The major fissure separates the right lower lobe from the right middle and
upper lobes.

The left lung is shaped slightly differently than the right. It has only two lobes
- the left upper lobe and the left lower lobe.

The Respiratory System

Our lungs are the main organs of the respiratory system. The lungs are
located inside the upper part of our chest on either side of the heart, and
they are protected by the ribcage. The breastbone (sternum) is at the center
front of the chest, and the spine is at the center of the back of the chest.

The inside of the chest cavity and the outside of the lungs are covered by the
pleura, a slippery membrane that allows the lungs to move smoothly as they
fill up with and empty out air when we inhale and exhale. Normally, there is a
small amount of lubricating fluid between the two layers of the pleura. This
helps the lungs glide inside the chest as they change size and shape during
breathing.

With each breath, our lungs are filled with air that comes into our body
through the nose or mouth. It flows down the throat (pharynx) and through
the voice box (larynx). A small flap of tissue (epiglottis) covers the entrance
to the larynx, and it automatically closes when we swallow to prevent food or
liquids from getting into our airways.

Our largest airway is the windpipe (trachea), which is between three-and-a-

half and six inches long and a little over half an inch in diameter. It brings air
to the chest, where it branches into two smaller airways: the left and right
bronchi, which lead to the left and right lungs.

The bronchi themselves divide many times into smaller and smaller airways
(bronchioles). Because the pattern of these increasingly smaller passages
looks like an upside-down tree, this part of the system is sometimes called
the bronchial tree. The airways are held open by flexible, fibrous connective
tissue called cartilage. Circular airway muscles can make the airways wider
or narrower. The smallest bronchiole is only half a millimeter across.

At the end of each bronchiole are clusters of air sacs called alveoli. Each air
sac is surrounded by a dense network of tiny blood vessels (capillaries). The
extremely thin barrier between the air and the blood allows the blood to pick
up oxygen and release carbon dioxide into the alveoli.

How We Breathe

The body's ability to breathe involves the nose, mouth, chest muscles and
diaphragm. Breathing is usually automatic and controlled by the respiratory
center at the base of the brain. We breathe during sleep and usually even
during unconsciousness. Small sensors in the brain and aorta and carotid
arteries monitor the blood. If there is too little oxygen in the blood these
sensors trigger faster or deeper breathing. (In quiet breathing, the average
adult inhales and exhales about 15 times a minute.)

The work of breathing is done by the diaphragm and the muscles between
the ribs, in the neck and in the abdomen. The diaphragm, a bell-shaped
sheet of muscle that separates the lungs from the abdomen, is the most
important muscle used for breathing. The diaphragm is attached to the base
of the breastbone, the lower parts of the ribcage and the spine.

Inhaling

A breath starts when the ribs and the chest wall expand and the diaphragm
tightens and flattens, which causes the lungs to fill with air. All the muscles
used in breathing contract only if the nerves connecting them to the brain
are healthy. In some neck and back injuries, the spinal cord can be severed,
in which case, a person will die unless he or she has a machine to help with
breathing.
As the air enters our mouth and nose, the mucus membranes lining the
mouth and nose make the air moist and warm, and they trap any particles.
The air then passes down the throat into the trachea (or windpipe), the
bronchi, the bronchioles and then the alveoli.

When the air rushes into the lungs, it fills the alveoli like balloons. Each
alveolus is surrounded by tiny blood vessels. The oxygen that moves across
the walls of the air sacs is picked up by the blood and carried to the rest of
the body. The carbon dioxide and waste gases that the blood carried to the
lungs pass into the air sacs and are exhaled.

Exhaling

Once the blood has picked up fresh oxygen and released carbon dioxide into
the alveoli, the diaphragm and chest muscles relax. This relaxation pushes
the air out of the alveoli, through the bronchioles and the bronchi, up
through the windpipe and out through the nose or mouth.

When we are at rest, the process of breathing out requires no effort from the
respiratory muscles. During vigorous exercise, however, many muscles assist
in exhalation. The abdominal muscles are the most important of these.
Abdominal muscles contract, raise abdominal pressure and push a relaxed
diaphragm against the lungs, causing air to be expelled.

The Gas Exchange

The purpose of breathing is to provide a way for the body to receive fresh
oxygen in exchange for the carbon dioxide and other waste gases that the
cells of the body have produced. During this exchange of gases, between six
and 10 liters of fresh air per minute is brought into the lungs.

Inhaled air fills the alveoli, which are only one-cell thick and are surrounded
by capillaries that are also one-cell thick. Oxygen passes through the air-
blood barrier quickly and into the blood in the capillaries. About 0.3 of a liter
of oxygen are transferred from the alveoli to the blood each minute. In much
the same way, the carbon dioxide passes from the blood into the alveoli and
is then exhaled. About 0.3 of a liter of carbon dioxide flows across the walls
of the capillaries and the alveoli to be exhaled each minute.

Blood loaded with fresh oxygen flows out of the lungs through the pulmonary
veins and into the left side of the heart, which pumps the blood to the rest of
the body. Oxygen-depleted, carbon dioxide-rich blood returns to the right
side of the heart through two large veins, the superior vena cava and the
inferior vena cava. Then the blood is pumped through the pulmonary artery
to the lungs, where it picks up oxygen and releases carbon dioxide.

During exercise, we can breathe in as much as 100 liters of air per minute.
The rate at which oxygen enters the body is one way to measure how much
energy the body is using.

How the Lungs Protect Themselves

Because the lungs are continuously pulling in air (as well as germs, particles
and dirt), a system to protect the lungs in needed.
The mucus membranes that line the nose, mouth, throat and airways of the
lungs are the first line of defense. The mucus traps dirt and foreign matter
that we may breathe in. Tiny hairs (cilia) beat back and forth more than
1,000 times a minute in the airways to move the mucus and dirt up to where
it can be coughed out of the body or swallowed.

Because of the requirements of gas exchange, alveoli are not protected by

mucus and cilia. Mucus is too thick and would impair movement of oxygen
and carbon dioxide.

Macrophages (special cells in the airways that consume toxins) are the next
line of defense. Mobile cells on the alveolar surface (called phagocytes) seek
out deposited particles, bind to them, ingest them, kill any that are living and
digest them. Phagocytes in the lungs are called alveolar macrophages.

When the lung is exposed to serious threats, white blood cells in the
circulation can help. For example, when the person inhales a great deal of
dust or is fighting a respiratory infection, more macrophages are produced
and white blood cells are recruited.

Pathophysiology

Decreased immune system/resistance.

Environmental pollutants.Age: above 64 years old.

Inflammatory pulmonary response to the

offending organism/agent.
 Defense mechanisms of lungs
lose effectiveness.

Organisms penetrate the sterile

lower respiratory tract.

Inflammation and
production of exudates.

Inflamed and fluid-filled alveolar sacs cannot exchange

oxygen and carbon dioxide effectively.

Alveolar exudates tend to consolidate, so it is

increasingly difficult to expectorate.

PNEUMONIA.

SSx: (+) crackles, cough,

increased sputum production,
dyspnea.

Prognosis

Prognosis varies according to the type of organism causing the infection.

Recovery following pneumonia with Mycoplasma pneumoniae is nearly
100%. Staphylococcus pneumoniae has a death rate of 3040%. Similarly,
infections with a number of gram negative bacteria (such as those in the
gastrointestinal tract which can cause infection following aspiration) have a
death rate of 2550%. Streptococcus pneumoniae, the most common
organism causing pneumonia, produces a death rate of about 5%. More
complications occur in the very young or very old individuals who have
multiple areas of the lung infected simultaneously. Individuals with other
chronic illnesses, including cirrhosis of the liver, congestive heart failure,
individuals without a functioning spleen, and individuals who have other
diseases that result in a weakened immune system, experience
complications. Patients with immune disorders, various types of cancer,
transplant patients, and AIDS patients also experience complications.