PNEUMONIA ADMITTING HISTORY - Amarillo College

PNEUMONIA

ADMITTING HISTORY

This 79-year-old man was admitted to the hospital because of cough, fever, and a right lower lobe infiltrate. He

was born in Detroit and worked as a truck driver for a dry cleaning chemicals company for 51 years. He was

always a hard worker and an active member of his local union. As a truck driver, it was not uncommon for him

to be on the road 3 to 4 days at a time.

He never married, and after his sister died when he was 55 years old, he no longer had any living relatives. He

started smoking when he was 14 years old and averaged about two packs a day. When he was not working,

he consumed alcohol on a regular basis. Despite his smoking and drinking habits, he retired in good health at

65 years of age.

The patient was last admitted to the hospital 2 years ago for an acute inferior myocardial infarction. He was

treated with medications and recovered quite well. He stopped smoking at that time but continued to consume

alcohol on a regular basis. He reported that he generally consumed about four to six bottles of beer each night

at a local bar with some of his old retired "buddies." After his myocardial infarction, he continued to manage his

daily affairs without difficulty. He exercised regularly by working in his yard, and he power-walked every other

day at the mall.

Four days before his admission the patient reported that he had "flulike" symptoms. He had chills, a mild fever,

and a hacking, nonproductive cough. Although he was not feeling well, he continued to work and power-walk at

the mall. He also socialized and consumed beer with his friends each night. The evening before this admission

his friends noted that he was progressively getting worse and encouraged him to see a doctor. Thinking he

would get better soon, he stated that if did not feel better in a week or so he would go and see the doctor. The

next day, however, the patient was very short of breath, his cough was more frequent, and he had a

temperature of 38.3¡ã C (101¡ã F). At that point he drove himself to the hospital.

PHYSICAL EXAMINATION

On inspection the patient was a well-nourished man in obvious respiratory distress on 2 L/min O2 by nasal

cannula. He was monitored by pulse oximetry. The patient stated he was very short of breath. He had a

blood pressure of 165/90, heart rate of 120 bpm, respiratory rate of 33/min, and an oral temp of 39.5¡ã C (103¡ã

F). He demonstrated a frequent, strong cough. His cough was "hacky" and productive of small amount of

white and yellow sputum. His skin appeared pale and damp. When the patient repeated the phrase "ninetynine", there was an increased tactile and vocal fermitus over the right lower lung posteriorly. Dull percussion

noted and bronchial breath sounds were noted over the right lower lung regions posteriorly. His SpO2 was 92%

and ABG's were pH 7.54, PaCO2 24 mmHg, HCO3- 22 mEq/L, PaO2 56 mmHg, and B.E. +2.16. His CXR

demonstrated a right lower lobe infiltrate consistent with pneumonia, air bronchograms, and alveolar

consolidation. His WBC was 21,000/mm3.

Complete first assessment using RC ASSESSMENT FLOW CHART

6 HOURS LATTER

The therapist doing the assessment rounds gathered the following clinical information: The patient stated, "My

doctor is too young. I feel worse than when I came in here." He had a blood pressure of 140/70, a heart rate

of 125 bpm, a respiratory rate of 35/min and shallow, and a temperature of 38.9¡ã C (102¡ã F). He demonstrated

a strong, "barking" cough, and during each major coughing episode he produced a small amount of blood

streaked sputum.

His skin was cyanotic. Over his right lower and middle lobes and his left lower lobe, he demonstrated

increased tactile and vocal fremitus, dull percussion notes, bronchial breath sounds, and crackles. His SpO2

was 91%, and ABG's were pH 7.55, PaCO2 26 mmHg, HCO3- 24 mEq/L, PaO2 53 mmHg, and B.E. +4.0.

Complete a second assessment using RC ASSESSMENT FLOW CHART

THE NEXT DAY

The respiratory therapist assigned to evaluate the patient gathered this clinical information: The patient stated

that he slept most of the night and was breathing easier. The patient blood pressure was 135/85; his heart rate

was 90 bpm, his respiratory rate was 19/min; and he had an oral temperature of 37.3¡ã C (99¡ãF). He had a

strong nonproductive cough.

His morning CXR and report indicated a partial resolution of the pneumonic process but persistent consolidation

or atelectasis in the right lower and middle lobes and left lower lobe. In these lung areas the tactile and vocal

fermitus had increased, and dull percussion notes and bronchial breath sounds were heard. His SpO2 was 97%

and his ABG's were pH 7.44, PaCO2 35 mmHg, HCO3- 24 mEq/L, and PaO2 163 mmHg, and B.E. +1.07.

Complete a third assessment using RC ASSESSMENT FLOW CHART

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