Question

Pneumonia Case Study

• 63 yof bank manager presents to clinic in Nov
• 1 wk hx of upper respiratory symptoms, 2 day hx of fever, malaise, nausea
• cough productive yellow sputum
• right-sided pleuritic chest pain

Additional hx:

• no rash, no headache or vomiting, no hemoptysis, friends recently ill
• nonsmoker
• negative past medical hx
• no allergies
• had flu shot last year

Physical exam:

• alert, flushed, oriented using accessory muscles
• T-39.2 orally, P 100 and regular, RR 32 BP 110/80
• skin warm and moist
• ears slight serous fluid
• purulent nasal drainage
• decreased expansion over right chest
• increased fremitus
• inspiratory rales-right middle, clear RUL,RLL, LLL, LUL
• no cyanosis, no clubbing, no edema
• ABG ph 7.56 CO2 26 O2 90 on RA
• WBC 15, 000--5% bands, 83% segs, 10% lymphs, 3%monos, 1% eoso
• Sputum +muliple gram diplococci

Describe your plan of treatment in detail (from this point to discharge)

Answer 1

Welcome sir, firstly we confirmed our diagnosis, than we h have to consult with physician about diagnosis

Take proper information about this conditions, take proper rest, fever treated by antibiotics therapy for this, incresed fluid intakes at least 3 liter per day, oxygen therapy, analgesic use and antipyretic medicines.

You should take a light food with good calories, you have to do some physical exercise like use of incentive spirometer use(take a breath and hold it and exahle). Coughing exercises, nebulizing yourself which promote your health.

Proper and regular follow up with your doctors and be positive, sure positivness brings your recovery fastly.