SUBMITTED TO:

SUBMITTED BY:
REPRESENTATIVE CASE
IDENTIFYING DATA:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL HISTORY:
FAMILY HISTORY:
PERSONAL AND SOCIAL HISTORY:
REVIEW OF SYSTEMS
General Survey:
HEENT:
Chest and Lungs:
Cardiovascular:
Gastrointestinal:
Musculoskeletal:
Genitourinary:
CNS:

SILLIMAN UNIVERSITY MEDICAL SCHOOL

DATE:

PHYSICAL EXAMINATION
General Survey:
Vital Signs:
BP:
RR:
Skin:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Abdomen:
Genitourinary:
Extremities:
CNS:

HR:
Temp:

II. PRIMARY IMPRESSION

DIAGNOSIS

RULE IN

RULE OUT

III. DIFFERENTIAL DIAGNOSIS

DIAGNOSES

RULE IN

RULE OUT

IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS

LABORATORY WORKUPS

CBC Count
Pulse Oximetry
(Oxygen
Saturation)
Creatinine

Sputum Gram
stain and culture

Sputum AFB
Smear for 3
consecutive days

Chest radiograph
PATHOPHYSIOLOGY

INTERPRETATION/NECESSITY

This is used to determine the hematologic profile of the patient, to detect if there is
anemia, infection, and other possible blood disorders. Leukocytosis with a left shift may be
observed in any bacterial infection. Leukopenia (usually defined as a WBC count < 5000
cells/L) may be an ominous clinical sign of impending sepsis.
A pulse oximetry finding of < 90-92% indicates significant hypoxia. It is performed to
assess the adequacy of oxygen levels (or oxygen saturation) in the blood and could help in
the management of the patient.
Some patients presenting with pneumonia have elevated creatine kinase (CK) levels. In
patients with severe respiratory failure and profound hypoxemia, cellular death can occur
with the release of CK into the circulation. Destruction of alveolar epithelial cells by both
bacteria and bacterial toxins can result in CK release into the circulation.
Sputum Gram stain and culture should be performed before initiating antibiotic therapy (if
a good-quality, contaminant-sparse specimen containing < 10 squamous epithelial cells
per low-power field can be obtained). The white blood cell (WBC) count should be more
than 25 per low-power field in non-immunosuppressed patients. A single predominant
microbe should be noted at Gram staining. Mixed flora may be observed with anaerobic
infections.
AFB testing may be used to detect several different types of acid-fast bacilli, but it is most
commonly used to identify an active tuberculosis (TB) infection caused by the most
medically important AFB, Mycobacterium tuberculosis. Sputum AFB Smear helps in rulingout Pulmonary Tuberculosis for suspected cases.
Chest radiography is considered the standard method for diagnosing the presence of
pneumonia, that is, the presence of an infiltrate is required for the diagnosis. pleural
effusions can be identified by chest radiographs. The presence of a parapneumonic pleural
fluid can have inportant therapeutic implications. In H influenzae pneumonia, pleural
effusion is present in approximately half of infected individuals.

V. THERAPEUTIC MANAGEMENT (DE LOS SANTOS, GARSUTA, GOROY)

LIST OF PROBLEMS
THERAPEUTIC OBJECTIVES
1.
ADVICE AND INFORMATION
NON-PHARMACOLOGIC MANAGEMENT
1.
PHARMACOLOGIC MANAGEMENT
DRUG NAME

P-DRUGS
DRUG NAME

EFFICACY

EFFICACY

VI. MONITORING AND FOLLOW-UP

1.

SAFETY

SAFETY

SUITABILITY

SUITABILITY

COST