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Pneumonia Case Summary

Autor:   •  March 29, 2011  •  Essay  •  537 Words (3 Pages)  •  2,241 Views

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Pneumonia

I. Salient Features from history

This is a case of a 7 y.o. male coming in with the chief complaint of fever with cough and colds. Patient presented with a 5-day history of persistent fever (tmax 41) with productive cough. Patient also had headache, generalized body weakness, malaise, nosebleeding, and decreased appetite. Few hours PTA, the patient had difficulty of breathing. Patient had negative NS1 and normal CBC.

Patient had is a known asthmatic and had unrecalled immunization for H. influenza B and Pneumococcal vaccine.

II. Salient Features from PE

Patient was febrile and tachypneic. Patient was in respiratory distress and was weak-looking. Subcostal retractions were observed. Patient had occasional wheezing and rales on both lung fields.

III. Differential Diagnosis

Differentials Rule In Rule Out

Systemic Viral Illness - Fever

- Cough

- Constitutional Symptoms such as generalized body weakness, decreased appetite and headache - Patient was tachypneic

- Respiratory Distress

- Presence of rales suggest a more severe disease

Upper Respiratory Tract Infection - Cough and colds

- Constitutional symptoms - High grade fever

- Rales suggest involvement of Lower respiratory tract

- Respiratory distress and tachypnea

Bronchial Asthma in Acute Exacerbation - Difficulty of breathing

- Wheezing - High grade fever

- Rales

- Constitutional symptoms

Dengue Fever - Fever for 5 days

- Bleeding

- Headache

- Constitutional symptoms - NS1 negative

- Normal CBC trend (Ht, WBC, platelet)

- No abdominal pain

IV. Final Diagnosis

Community Acquired Pneumonia (PCAP C)

V. Etiology of Final Diagnosis

The etiology of pneumonia differs in each age group. For ages 5-18 (patient is 7 years old), the most common pathogens include M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae

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