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

What is significant about the physical exam?

What lab do you want to order and why?

Answer 1

The significance of the physical examination are

• It reveals the patient has fever because of infection
• The breathing pattern due to secretion
• Increased secretion and infection in it has lead to the expulsion process by cough and generating nasal purulent discharge
• Fremetus is because of the decreased function of the lungs
• Serous fluid in ear is a sign of infection
• Rales occurs because of secretion on the lungs

The following lab orders are needed to be assessed

• Complete blood count:increased level of white blood cells can be observed due to infection
• Sputum culture to identify the growth of any microorganisms
• CRP levels can increase in case of severe infection
• Blood culture to rule out the presence of any bacteria in the blood stream