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Pneumonia Case Study

1647 words - 7 pages

I. Introduction
This is a case of a 74 year old woman who was diagnosed with Community Acquired Pneumonia.

Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body.
Most pneumonias are caused by bacterial infections.The most common infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial ...view middle of the document...

pneumoniae or influenza virus, are fatal in older, sicker patients.

II. Patient Profile

Name: E. Costales

Age: 74 years old

Sex: Female

Religion: Roman Catholic

Date Admitted: September 17, 2009 at exactly 11:15 AM

Admission diagnosis: COPD not in exacerbation

Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk

III. Patient History

Chief Complaint: Difficulty of Breathing

General Data:

This is a case of a 74 year old female Filipino, presently residing in Adelina 3 Binan, Laguna who was admitted in Perpetual Help Hospital on September 17, 2009.

History of Present Illness:

5 days prior to admission, patient had positive signs and symptoms of cough, yellowish pleghm, persistent fever and back pain. Knowing that these signs and symptoms were just forms of little discomforts, she self medicated with paracetamol. However, she noticed no changes and experienced difficulty of breathing so she sought medical consultation.


Date Assesed: September 17, 2009

Time Assessed:

Vital Signs:

Blood Pressure: 110/60

Temperature: 35.7 C

Pulse rate: 78bpm

Respiratory rate: 26 breaths/min

General appearance:

The patient is awake, lying on bed, conscious and coherent with an IVF of PNSS and side drip of D5W with incorporation of aminophylline on the right arm.


The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in...

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