Pneumonia Case Study Essay

1657 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 pneumonia in adults is a bacteria called
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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

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