Pneumonia

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍coughfeverdifficulty breathing

Symptoms include:

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍sputum, ‍clearwhiteyellowgreen

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍shortness of breath

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍fatigue

‍loss of appetite

‍confusion



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍recent hospitalization

‍immobility

‍malnutrition

no history of: ‍immunodeficiency, ‍pneumonia, ‍chronic obstructive pulmonary disease, ‍asthma, ‍heart disease





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍Pneumonia ‍likelysuspectedpossible

DDx: pneumonia, aspiration pneumonia, URI, Acute bronchitis, bronchiolitis, COPD exacerbation, pulmonary embolism, pleural effusion, lung cancer, interstitial lung disease, heart failure, pneumothorax, asthma exacerbation, COVID-19, influenza, tuberculosis, ARDS, eosinophilic pneumonia, hypersensitivity pneumonitis





PLAN:

Investigations:

- Chest X-ray

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine, ‍blood cultures

- Sputum culture

- CT scan of the chest

Treatments:

- Oxygen therapy if SpO2 < 92%

- ‍Oral antibiotics

- ‍Acetaminophen

- ‍Ibuprofen

- Hydration and rest

- Smoking cessation counseling

- Vaccination for ‍pneumococcus, ‍influenza, ‍covid

Further care:

- Repeat chest X-ray in 6 weeks

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Referral to ER if severe chest pain, severe shortness of breath, or high fever occurs