ILIGAN MEDICAL CENTER

COLLEGE
COLLEGE OF NURSING AND MIDWIFERY
San Miguel Village, Iligan City 9200
Telephone No. (063) 221-4661 Local
1120
Fax No. (063) 221-6584
Website: www.imcc.edu.ph

Case Study
Submitted to
Ma. Brenda C.Mutya
College of Nursing and Midwifery
Iligan Medical Center College
Iligan City

In Partial Fulfillment of the

Requirements in MID 103 and
PHC 2

Fernandez, Julie Carl C.

December 2023
 Table of Contents

 Introduction I

 Personal Data II

 Social Background III

 Past Medical History IV

 Present Medical History V

 Internal Organ Anatomy and Physiology VI

 Laboratory Result VII

 Pathophysiology VIII

 Midwifery Care Plan IX

 Drug Study X

 Health Teaching XI

 Prognosis XII
 I. Introduction

Pneumonia is a common and potentially serious respiratory infection that affects the
lungs. It occurs when the air sacs in the lungs, known as alveoli, become inflamed and filled
with fluid or pus. This can make breathing difficult and lead to symptoms such as cough, chest
pain, fever, and difficulty breathing.

Pneumonia can be caused by various factors, including bacteria, viruses, fungi, or other
microorganisms. The most common cause of pneumonia is bacterial infection, with
Streptococcus pneumoniae being the most common bacterial culprit. Viral pneumonia, caused
by viruses such as influenza or respiratory syncytial virus (RSV), is also quite prevalent.

The infection can affect people of all ages, but certain groups are more vulnerable,
including young children, older adults, individuals with weakened immune systems, and those
with underlying health conditions like chronic lung disease or heart disease.

Pneumonia can range from mild to severe, and the severity of symptoms can vary
depending on the cause, age, and overall health of the affected individual. Mild cases can often
be treated at home with rest, fluids, and over-the-counter medications to manage symptoms.
However, severe cases may require hospitalization and more intensive treatment, such as
intravenous antibiotics or antiviral medications.

Prevention of pneumonia involves practicing good hygiene, such as washing hands

regularly, avoiding close contact with sick individuals, and getting vaccinated against common
bacterial and viral causes of pneumonia, such as the pneumococcal and influenza vaccines.

If you suspect you or someone else may have pneumonia, it is important to seek medical
attention for proper diagnosis and treatment. Pneumonia can be a serious condition, especially
in vulnerable populations, so early detection and appropriate management are crucial.

The signs and symptoms of pneumonia can vary depending on the cause, age, and overall
health of the affected individual. Here are some common signs and symptoms:

1. Cough: A persistent cough is a common symptom of pneumonia. It may produce

phlegm or mucus, which can be yellow, green, or bloody.

2. Fever: A high fever, often above 100.4°F (38°C), is a typical symptom of pneumonia.
However, in some cases, especially in older adults, the fever may be mild or absent.

3. Chest pain: Chest pain can occur, particularly when coughing or taking deep breaths. It
may be sharp or a dull ache.

4. Shortness of breath: Difficulty breathing or shortness of breath is a common symptom,

especially during physical activity or exertion.

5. Rapid breathing: Increased respiratory rate, characterized by rapid and shallow

breathing, is often observed in pneumonia.

6. Fatigue: Feeling tired or fatigued is a common symptom, as the body works harder to
fight off the infection.

7. Sweating and chills: Experiencing sweating and chills, especially during fever episodes,
is common in pneumonia.

8. Loss of appetite: A decreased desire to eat or loss of appetite can occur due to the
illness.

9. Confusion (in older adults): Older adults with pneumonia may experience confusion or
changes in mental awareness.

It's important to note that these symptoms can also be associated with other respiratory
conditions, so a proper medical evaluation is necessary for an accurate diagnosis. If you or
someone you know is experiencing these symptoms, it is advisable to seek medical attention
for proper evaluation and treatment.
 II. Personal Data

Case number: 2300000121

Patient’s Name: Chu, Josh Nigel P.

Age: 26 years old

Gender: Male

Birthday: May 3, 1997

Birthplace: Iligan City

Citizenship: Filipino

Religion: Roman Catholic

Chief Complaint: Fever and Vomiting

Final Diagnosis: Community Acquired Pneumonia-Moderate Risk Electrolyte

Imbalance
and Typhoid Fever

Date Admitted: February 6, 2023 / 7:30pm

Admitting Institution: Iligan Medical Center Hospital

 III. Social Background

Josh Nigel, a 26 years old male residing in Rosario, Iligan City, is the eldest
member of his family. He is a breadwinner of his family so in the very young age he
already faced how difficult life is. Because of his hard work he graduated in college with
a degree of BEED major in Early Childhood. He is now a license teacher and currently
working at private school here in Iligan City.

Unfortunately, Josh Nigel has recently been diagnosed with Community Acquired
Pneumonia-Moderate Risk Electrolyte Imbalance and Typhoid Fever, a concerning
illness caused by various factors including bacteria, viruses, fungi, or other
microorganisms. This has undoubtedly brought worry and concern to his family, who
are doing everything they can to address his condition and provide him with the
necessary medical care and attention.

The community in Rosario actively promotes prevention of pneumonia involves

practicing good hygiene, such as washing hands regularly, avoiding close contact with
sick individuals, and getting vaccinated against common bacterial and viral causes of
pneumonia, such as the pneumococcal and influenza vaccines.

Despite the difficulties faced by Josh Nigel and his family, they draw strength from
their faith and the support of their community. They remain resilient and unwavering in
their commitment to Josh Nigel well-being, while also contributing to the collective effort
of fostering a healthier environment for everyone.
IV. Past Medical History

According to the mother of the patient, the patient did not yet experience having
serious health problems other than fever and vomiting. He has received BCG, Hepatitis
B, Diphtheria, and OPV first dose vaccines, and he is currently ongoing of receiving
additional immunizations.

V. Present Medical History

Three days prior to admission the patient has fever and loss of appetite. According
to the mother of the patient, they went to consult a physician during the first day of his
fever. The physician prescribed Paracetamol for the patient. On the third day, the
patient still had the said symptoms. He went back for a check-up. He had CBC and was
determined that he has dengue. The patient then was admitted immediately on March
03, 2023.
 VI. Internal Organ Anatomy and Physiology

Pneumonia primarily affects the lungs, which are vital organs responsible for the
exchange of oxygen and carbon dioxide in the body. Let's explore the internal organ anatomy
and physiology related to pneumonia:

1. Lungs: The lungs are a pair of spongy, cone-shaped organs located in the chest
cavity. They are divided into lobes (right lung has three lobes, left lung has two lobes)
and are surrounded by a protective membrane called the pleura. The lungs contain
bronchial tubes that branch into smaller airways called bronchioles, which eventually
lead to tiny air sacs called alveoli.

2. Alveoli: The alveoli are the functional units of the lungs where the exchange of oxygen
and carbon dioxide takes place. They are surrounded by a network of tiny blood
vessels called capillaries. Oxygen from the inhaled air enters the bloodstream through
the thin walls of the alveoli, while carbon dioxide, a waste product, is expelled from the
bloodstream into the alveoli to be exhaled.

3. Respiratory System: The respiratory system includes the lungs, airways, and
associated structures. It is responsible for the intake of oxygen and the elimination of
carbon dioxide. The process begins with inhalation, where air enters the body through
the nose or mouth, passes through the throat (pharynx) and voice box (larynx), and
then travels down the windpipe (trachea) into the bronchial tubes and bronchioles,
finally reaching the alveoli.

4. Immune System: The immune system plays a crucial role in defending the body
against infections, including pneumonia. It consists of various components, such as
white blood cells, antibodies, and lymphoid tissues. When bacteria, viruses, or other
pathogens enter the lungs, the immune system responds by activating immune cells to
fight off the infection and clear the pathogens.

In the case of pneumonia, the infection causes inflammation and damage to the lung
tissue, particularly the alveoli. This leads to an accumulation of fluid, pus, and inflammatory
cells within the air sacs, impairing their ability to exchange oxygen and carbon dioxide
effectively. As a result, the affected individual may experience symptoms such as cough, chest
pain, difficulty breathing, and fever.

Understanding the anatomy and physiology of the lungs and respiratory system helps in
comprehending how pneumonia affects these organs and disrupts their normal functioning.
Treatment for pneumonia aims to eliminate the infection, reduce inflammation, and support the
healing process of the lungs.
VII. Laboratory Results

HEMATOLOGY REPORT
Date: March 3, 2023

PARAMETER NORMAL ACTUAL ANALYSIS

FINDINGS FINDINGS
White Blood Cells 5-10 x 10^g/L 3.9 x 10^g/L Decreased due to
inadequate
inflammatory
defenses to
suppress infection
and humoral
immunity
takes place
Hemoglobin M: 13.0-18.0 g/dL 10.2 g/dL Decreased due to
poor oxygen
supply
Hematocrit 39-54 % 31 % Decreased due to
poor
oxygen supply
Segmenters 0.60-0.70 0.73 Increased;
indicate high
glucose level in
the blood
Lymphocytes 0.20-0.30 0.27 normal
Platelet Count 150-450 x 10^g/L 163 x 10^g/dL Normal

ABO/ Rh Type: O Rh positive

FECALYSIS REPORT
Date: March 3, 2023

PARAMETER NORMAL ACTUAL ANALYSIS

FINDINGS FINDINGS
Physical
Properties Yellow Brown Due to the presence
Color of bacteria
Consistency Semi-formed Loose Due to presence of
bacteria

Bacteria:Occasional Occult
Blood: Negative
Remarks: No ova/intestinal parasite seen

URINALYSIS REPORT
Date: March 3, 2023

PARAMETER NORMAL ACTUAL ANALYSIS

FINDINGS FINDINGS
Color Yellow Amber Yellow normal
Transparency Clear to slightly clear normal
turbid
Reaction 4.5-8 6.5 normal
Specific Gravity 1.005-1.030 1.020 normal
Sugar Negative Negative normal
Protein Negative Negative normal
Squamous Few Occasional normal
 Epithelial
Cells
Red Blood Cells Few 0-2 normal
Pus Cells Few 0-2 normal
Amorp. Few Occasional normal
Urates/
Phosphates

Complete Blood
Count Date: March
3, 2023

Test Result Result Result Result Referen Unit

3-3-23 3-4-23 3-5-23 3-6-23 ce

WBC 14 13.5 12.4 10.7 4.8 – 10^9/L

10.8
Hgb 122 125 125 128 120 – g/L
160
Hct 0.57 0.54 0.50 0.47 0.37 – L/L
0.47
MCV 85 86 84 84 81 – 99 Fl
MCH 28 28 28 28 27 – 31 Pg
RBC 4.3 4.4 4.5 4.5 4.2 – 5.4 10^12/ L

MCHC 332 335 342 330 330 – g/L

370
RDW 13 13.2 13.4 12.7 11.0 – %
16.0
MPV 7.5 7.4 7.4 7.9 7.2 – Fl
11.1
Platelet 101 120 135 151 150 – 10^9/L
count 400
Neutrophil 55 53 56 550 40 – 74 %
Lymphocy
42 40 41 40 19 – 47 %
te
Monocyte 3 4 3 3 3–9 %
Eosinophil 2 1 1 0 0–7 %

Complete Blood Count is a set value of the cellular (formed elements) of

blood. These measurements are generally determined by specially designed
machines that analyze the different components of blood in less than a minute.

Table 2 shows the different complete blood count results from March 03 to
March 06, 2023. As revealed in the table, there is a markedly increased in the
WBC and a decreased in the platelet count in the first three results. This
noticeable changes could predispose bleeding and infection.

The Hematocrit was above the normal range for the three consecutive
results that could mean dehydration. The low levels of WBC indicate the
client’s predisposition to infections. The combined thrombocytopenia and high
hematocrit count poses a great risk for massive bleeding. There is delayed clotting
and due to hemoconcentration, there is altered tissue perfusion.
 The result for the last test displayed return to normal levels of all blood
components. The evident progression in the results could imply an improvement of
the patient’s condition.
 VIII. Pathophysiology

The pathophysiology of pneumonia involves the progression of the infection and the
resulting inflammatory response in the lungs. Here is a general overview of the pathophysiology
of pneumonia:

1. Entry of Pathogens: Pneumonia can be caused by various pathogens, including

bacteria, viruses, fungi, or other microorganisms. These pathogens can enter the
lungs through inhalation of contaminated air droplets or aspiration of infected fluids
from the upper respiratory tract or stomach.

2. Infection and Colonization: Once the pathogens reach the lungs, they can invade the
respiratory epithelium, leading to infection and colonization. Bacterial pathogens, such
as Streptococcus pneumoniae, can multiply and release toxins, damaging the lung
tissue. Viral pathogens, like influenza or respiratory syncytial virus (RSV), can infect
the respiratory cells and cause cell death.

3. Inflammatory Response: The presence of pathogens triggers an immune response in

the lungs. The immune system releases various inflammatory mediators, such as
cytokines and chemokines, to recruit immune cells to the site of infection. This
inflammatory response aims to eliminate the pathogens and repair the damaged
tissue.

4. Alveolar Inflammation and Consolidation: In pneumonia, the infection and

inflammation primarily affect the alveoli, leading to alveolar inflammation and
consolidation. The alveoli become filled with fluid, pus, and inflammatory cells,
impairing their ability to exchange oxygen and carbon dioxide effectively. This can
result in decreased oxygen levels in the bloodstream and reduced lung function.

5. Impaired Gas Exchange: The accumulation of fluid and inflammatory cells in the
alveoli interferes with the diffusion of oxygen from the inhaled air into the bloodstream
and the removal of carbon dioxide
IX. Midwifery Care Plan

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIO

N
Diagnostics:
Subjective: Short term  Note  Evaporation
 Tulo na Objectives: presence or is
ka adlaw After 8 absence of decreased Goal met.
ang hours of sweating as by Patient’s
hilanat midwifery body environment temperature
sa akong intervention attempts to al factors of subsided from
anak, as the client will increase high 39.1°C to
verbalize be able to: heat loss by humidity 37 °C.
d by the evaporation, and high
mother Decrease conduction, ambient
of patient temperature and diffusion. temperature.
from 39.1° C
Objective: to 37 ° C
 Flushe  Monitor  Oliguria
d skin Skin will and record and/or
 Weak in back to all sources renal failure
appearan normal of fluid loss may occur
ce such as due to
 Teary eyes Long term urine. hypotension
 Increase Objectives: ,
d in vital After 24 dehydration
signs hours of , shock,
PR: 96 midwifery and tissue
bpm T: intervention  Monitor necrosis.
39.1 ° C the client will vital signs
RR: 45 be able to: especially  To evaluate
temperatu effects or
Display r e. degree of
hemodynami Therapeutics: hyperthermi
c stability Dependent: a
AEB vital  Administer .
sign within medications
normal range as indicated
for client and or ordered
adequate by the  To
urinary physician. treat
output underly
i ng
Display
laboratory  Administer cause.
results for replaceme
clotting nt of fluids
times and and
factors electrolytes  To
within . support
normal circulatin
range. Independent: g volume
and
 Perform tissue
tepid perfusion.
sponge
bath.  Heat
loss
by
evap
o
ration
and
cond
u
 Promote ction.
surface  To assist
cooling with
measures
to
by means of reduce body
undressing/re temperature/
d ucing restore
clothes and normal
removing body/organ
excess function.
blankets.

 To reduce
 Maintain metabolic
Bed rest. demands
and oxygen
consumptio
n
.
 X. Drug Study

Generic name: Ceftriaxone Sodium

Brand name: Rocephin
Drug Classification: Antibiotic, Cephalosporin (third
generation) Indications: Urinary Tract Infection

MECHANIS SIDE EFFECT CONTRA- ADVER MIDWIFERY

M OF INDICATIO SE RESPONSIBILITI
ACTION NS REACTI ES
ON
Bactericidal:  Nausea,  Contrain CNS:  Teaching
Inhibits vomiting, di cated headache, points:
synthesis of diarrhea, with  You may
dizziness,
cell wall allergy to experienc
anorexia, lethargy,
causing cell cephalos e these
death abdomin paresthesia
p orins or side
al pain, penicillins s
flatulence effects:
. Use
 Ranging cautiousl GI: Nausea, stomach
from y with vomiting, upset or
renal diarrhea, diarrhea
rash to failure. anorexia,  Report
fever abdominal severe
 Pain, pain, diarrhea,
phlebiti flatulence, difficulty
s
pseudomem breathing
Super
br anous , unusual
colitis, liver tiredness
toxicity or
fatigue,
GU: pain at
nephrotoxicity
injection
Hematologic: site.
Bone marrow
Discontinue if
depression
hypersensitivit
– decreased y reaction
WBC, occurs.
decreased
platelets,
decreased
Hct.

Hypersensit
i vity:
Ranging
from rash
to fever to
anaphylaxi
s; serum
sickness
reaction
Generic Name: Paracetamol
Brand Name: Flugard
Drug Classification: Antipyretic, analgesic (non
opioid) Indications: For Fever

MECHANISM SIDE CONTRA- ADVER MIDWIFERY

OF EFFECT INDICATIO SE RESPONSIBILIT
ACTION NS REACTI IES
ON
Antipyretic:  none Contraindica CNS: headache Assessment:
reduces fever ted with
by acting allergy to CV: chest History:
directly on the acetaminop pain, dyspnea, allergy to
hypothalamic hen. myocardial acetaminoph
damage when e n, impaired
heat-
doses of 5-8 hepatic
regulating Use cautiously
g/day are function.
center to with impaired
cause hepatic ingested daily
function, for several Physical: skin
vasodilation
chronic weeks or when color, lesions,
and sweating,
alcoholism, doses of 4 T; liver
which helps
pregnancy, g/day are evaluation;
dissipate
lactation. ingested for 1 CBC, LFT’s,
heat.
year. renal function
tests.
Analgesic: site
and mechanism GI: Hepatic
action unclear. toxicity and
failure,
jaundice

GU: acute
renal failure,
renal tubular
necrosis.

Hematologic:
methemoglobi
nemia –
cyanosis;
hemolytic
anemia –
hematuria;
anuria;
neutropenia,
leukopenia,thro
mbocytopenia,
hypoglycemia

Hypersensitivit
y: rash, fever
XI. Health Teaching

When it comes to a 5-month-old child with dengue fever, it is important for

the mother to be proactive in providing proper care and ensuring the child's well-being.
Here are some key health teaching points for the mother:

1. Monitor for symptoms: The mother should be vigilant in observing any signs of
dengue fever in her child. These may include high fever, rash, body aches,
headache, vomiting, and a decrease in appetite. Promptly notify the healthcare
provider if any symptoms are noticed.
2. Maintain hydration: Encourage the mother to ensure that her child stays well-
hydrated. Offer frequent breastfeeding or formula feeding to provide fluids. If the
child is showing signs of dehydration, such as decreased urine output, lethargy,
or dry mouth, seek immediate medical attention.
3. Protect from mosquito bites: Dengue fever is transmitted through mosquito bites.
Educate the mother on the importance of protecting her child from mosquito
bites. Methods include dressing the child in long-sleeved clothes, using mosquito
nets, and applying appropriate mosquito repellents recommended by a
healthcare professional.
4. Fever management: Fever is a common symptom of dengue fever. Teach the
mother how to manage her child's fever. Use age-appropriate fever-reducing
medication, such as acetaminophen, following the recommended dosage for
infants. Avoid giving aspirin to children due to the risk of a serious condition
called Reye's syndrome.
5. Monitor for warning signs: Inform the mother about the warning signs of severe
dengue fever that require immediate medical attention. These signs may include
severe abdominal pain, persistent vomiting, bleeding gums or nosebleeds, rapid
breathing, and lethargy. Urgently seek medical help if any of these symptoms
occur.
6. Follow-up appointments: Emphasize the importance of attending all scheduled
follow- up appointments with the healthcare provider. This ensures proper
monitoring and continued management of the child's condition.

It is essential to involve a healthcare professional in the care of a child with

dengue fever. This information is purely educational and should not replace professional
medical advice.
XII. Prognosis

The prognosis for patients with dengue fever can vary depending on several
factors, including age, overall health, and promptness of medical intervention. In the
case of a 5-month- old child with dengue fever, it is important to closely monitor their
condition and seek appropriate medical care.

For infants with dengue fever, the prognosis is generally favorable, especially
when diagnosed and managed early. Most cases of dengue fever in infants resolve
without complications, and the child recovers fully with appropriate medical care and
supportive treatment.

However, infants, especially those under six months old, are considered a high-
risk group for severe dengue fever. They may be at greater risk of developing
complications such as dengue hemorrhagic fever (DHF) or dengue shock syndrome
(DSS). These severe forms of dengue fever can be life-threatening and require
immediate medical attention.

Prognosis can be influenced by the presence of certain risk factors, such as

secondary infection with a different serotype of the dengue virus. If an infant has
previously been infected with one serotype and then contracts a different serotype, the
risk of severe dengue increases. Pre-existing medical conditions, immunodeficiency, or
malnutrition may also affect the prognosis.

Early detection and prompt medical management play a crucial role in

improving the prognosis for a 5-month-old child with dengue fever. If the child exhibits
warning signs of severe dengue fever, such as persistent vomiting, severe abdominal
pain, bleeding, or lethargy, immediate medical attention is essential. Early intervention
can help prevent complications and ensure appropriate treatment.

It is important to note that dengue fever can have a wide range of outcomes,
and the prognosis can differ from case to case. Ultimately, the child's prognosis
depends on factors such as timely medical intervention, access to healthcare, and the
overall health status of the infant. It is important for the child to receive proper medical
care and monitoring throughout their recovery process.