Impression: LRTI probably CAP, Hypertension stage 1, Diabetes mellitus type 2

Differential Diagnoses:

Patients Profile

Occupational
asthma (allergic)
- caused by
sensitisation
or becoming
allergic to a
specific

COPD
- as a disease
state
characterized
by the
presence of
airflow

Bronchiectasis
- congenital
or acquired
disorder of
the large
bronchi
characteriz

CAP
-

PTB
-

chemical
agent in the
workplace
over a period
of time
Latency
periods are
variable and
can be as
short as
several
weeks or as
long as 30
years. If
exposure is
consistent,
the period of
greatest risk
is the first
two years of
exposure but
the risk does
not go away
after that but
may reduce
somewhat.

obstruction
due to chronic
bronchitis or
emphysema;
the airflow
obstruction is
generally
progressive,
may be
accompanied
by airway
hyperreactivity
, and may be
partially
reversible.

ed by
permanent,
abnormal
dilation and
destruction
of bronchial
walls

General data
present in the fifth
or sixth decade of life
complaining of
excessive cough,
sputum production,
and shortness of
breath.

73 y/o
male

CC: dyspnea
HPI:
1 month: on and
off cough
Productive
Non-blood

Risk factors for the

development of CAP
include advanced age;
alcoholism; tobacco use;
comorbid
medical conditions,
especially asthma or
COPD; and
immunosuppression.

coughing, ,

Symptoms
have often been
present for 10 years or
more.

chronic cough with

production of
copious amounts
of purulent
sputum,

acute or subacute
onset of fever, cough
with or without sputum
production,
and dyspnea.

with slowly
progressive
constitutional
symptoms of
malaise,

streaked
Yellowishgreenis
h
Fever (39 C37.
9-38 :low grade)
Body malaise
Dyspnea
Occasionalpleur
itic chest pain
NO abdominal
pain,diarrhea,vom
iting
NO WEIGHT LOSS
ROS:
Negative orthopnea,chest
pain, palpitations
Occasional back pain and
stiffness
Polyuria, polydipsia
PE:
In mild cardiopulmonary
distress
BP: 140/80 (stage 1)
PR:99 RR: 25 (tachypneic)
Temp: 38 deg C
SpO2: 91 (LOW)
No neck vein engorgement
Adynamic precordium
(normal), normal rate,
regular rhythm, no heaves,
no murmur, no gallop..PMI
at 5th LICS MCL
DECREASED BREATH
SOUNDS in RIGHT lower
hemithorax
DIFFUSE bilateral coarse
crackles
POSITIVE occasional

shortness of
breath and
breathing
difficulty
chest tightness

Eye irritation,
nasal
congestion,
and/or runny
nose may also
be present.

including increased
dyspnea, an increased
frequency or
severity of cough,
increased sputum
volume or change in
sputum character.
These exacerbations
are commonly
precipitated
by infection (more
often viral than
bacterial) or
environmental factors. can explain the
FEVER

hemoptysis, and
pleuritic chest
pain.
Dyspnea and
wheezing occur in
75% of patients.
Weight loss,
anemia,
and other systemic
manifestations are
common. Physical
findings are
nonspecific, but
persistent crackles
at the lung
bases are
common. Clubbing
is infrequent in
mild cases
but is common in
severe disease

Other common
symptoms include
sweats,
chills, rigors, chest
discomfort, pleurisy,
hemoptysis,
fatigue, myalgias,
anorexia, headache, and
abdominal pain.
Common physical
findings include fever or
hypothermia,
tachypnea, tachycardia,
and arterial oxygen
desaturation.
Many patients appear
acutely ill. Chest
examination
often reveals inspiratory
crackles and bronchial
breath
sounds. Dullness to
percussion may be
observed if lobar
consolidation or a
parapneumonic pleural
effusion is present.
The clinical evaluation
is 50% sensitive
compared
to chest imaging for
the diagnosis of CAP

anorexia, weight
loss, fever, and
night sweats.
Chronic
cough is the
most common
pulmonary
symptom. It
may be
dry at first but
typically
becomes
productive of
purulent
sputum as the
disease
progresses.
Blood-streaked
sputum
is common, but
significant
hemoptysis is
rarely a
presenting
symptom; lifethreatening
hemoptysis may
occur in
advanced
disease.
Dyspnea is
unusual unless
there is
extensive
disease. Rarely,
the patient is
asymptomatic.
On physical
examination,
the patient
appears
chronically ill
and
malnourished.
On chest
examination,
there are no
physical

wheeze
NO cyanosis, no clubbing
CN intact, normal motor &
sensory

Meds:
Self-medicated
paracetamol 500 mg q 4
Self-medicated
salbutamolno relief
Self medicated unrecalled
antibiotics q 8 10
dayswith relief
Prescribed CO-AMOXICLAV
625 mg BID 7 days
PMI:
Dx: HPN (20 yrs prior): no
maintenance
DM type 2 (10 yrs prior):
Metformin 500 mg OD at
night
POSITIVE hx of trauma,
MVA (10 yrs ago), minimal
wound on right leg,
sutured, negative fractures
Family hx:
M: HPN, died MI (80 y/o)
P: HPN, DM type 2, died
CVD hemorrhage (80)
NEGATIVE: cancer, PTB
Social & Environmental
Living with 6 other
members: wife,
son,daughter, 1 daughter
in-law, 2 grandchildren
3 bedroom, 1 toilet
(apartment)
Middle of congested
neighborhood

findings specific
for tuberculosis
infection. The
examination
may be normal
or may reveal
classic findings
such as
posttussive
apical rales.

 Occupation: foreman local

construction company (30
yrs)
Previous smoker (30 pack
years)10 yrs ago
Occasional alcoholbeverage drinker

Patients Profile
General data
73 y/o
male
CC: dyspnea
HPI:
1 month: on and
off cough
Productive
Non-blood
streaked
Yellowishgreenis
h
Fever (39 C37.
9-38 :low grade)
Body malaise
Dyspnea
Occasionalpleur
itic chest pain
NO abdominal
pain,diarrhea,vom
iting
NO WEIGHT LOSS
ROS:
Negative orthopnea,chest
pain, palpitations

asbestosis

Patients with
asbestosis usually
first
seek medical
attention at least 15
years after exposure
with
the following
symptoms and
signs: progressive
dyspnea,
inspiratory crackles,
and in some cases,
clubbing and
cyanosis.

Occasional back pain and

stiffness
Polyuria, polydipsia

PE:

In mild cardiopulmonary
distress
BP: 140/80 (stage 1)
PR:99 RR: 25 (tachypneic)
Temp: 38 deg C
SpO2: 91 (LOW)
No neck vein engorgement
Adynamic precordium
(normal), normal rate,
regular rhythm, no heaves,
no murmur, no gallop..PMI
at 5th LICS MCL
DECREASED BREATH
SOUNDS in RIGHT lower
hemithorax
DIFFUSE bilateral coarse
crackles
POSITIVE occasional
wheeze
NO cyanosis, no clubbing
CN intact, normal motor &
sensory

Meds:
Self-medicated
paracetamol 500 mg q 4
Self-medicated
salbutamolno relief
Self medicated unrecalled
antibiotics q 8 10
dayswith relief
Prescribed CO-AMOXICLAV
625 mg BID 7 days
PMI:

 Dx: HPN (20 yrs prior): no

maintenance
DM type 2 (10 yrs prior):
Metformin 500 mg OD at
night
POSITIVE hx of trauma,
MVA (10 yrs ago), minimal
wound on right leg,
sutured, negative fractures
Family hx:
M: HPN, died MI (80 y/o)
P: HPN, DM type 2, died
CVD hemorrhage (80)
NEGATIVE: cancer, PTB
Social & Environmental
Living with 6 other
members: wife,
son,daughter, 1 daughter
in-law, 2 grandchildren
3 bedroom, 1 toilet
(apartment)
Middle of congested
neighborhood
Occupation: foreman local
construction company (30
yrs)
Previous smoker (30 pack
years)10 yrs ago
Occasional alcoholbeverage drinker
r/o