BACHELOR OF MEDICINE & BACHELOR OF

SURGERY

Emergency Department Case-

writeup
YEAR 4

FACULTY OF MEDICINE
SESSION : 2022-2023
Patient: Putri Safira
Age: 14 years old
Registration number: 091211101378
Sex: Female
Occupation: Student
Date and Time of Admission: 1 Feb 2023, 12.30am
Date and Time of Clerking: 1 Feb 2023, 8.30pm
Source of Data: Patient
Zone: Yellow Zone

CHIEF COMPLAINT
Patient was admitted to the emergency department at 12.30am with shortness
of breath and productive cough.

HISTORY OF PRESENTING ILLNESS

Patient was relatively well 3 days ago. She developed productive cough with
yellowish sputum and runny nose for 2 days and had fever for 1 day. Patient
had sudden onset of shortness of breath on 31st January while playing with her
friends. She then had to sit down to relieve her shortness of breath. After she
came back home and slept at night, she woke up again with shortness of
breath and chest tightness and was brought to the ED by her parents at
12.30am. On the way, in the car, she was conscious and alert without any chest
pain, palpitations and seizures.

PAST SURGICAL HISTORY

Patient had no surgical history.

PAST MEDICAL HISTORY

Patient does not have Diabetes Mellitus, Hypertension & dyslipidemia.

PAST MEDICATION HISTORY

Patient does not have significant past medication history and is not on vitamin
supplements or herbal medications.
PAST FAMILY HISTORY

No family history of asthma and eczema

SOCIAL HISTORY

Putri lives with her family and 3 younger siblings. Patient is non- smoker and
non- alcoholic.

ALLERGY HISTORY

No significant allergic history

REVIEW OF SYSTEMS
General Fever, Headache, no seizure, no
weight loss

Cardiovascular No chest pain, no palpation

Respiratory Productive cough with yellowish

sputum, shortness of breath

Urinary No polyuria, no dysuria

Gastrointestinal Tract No Abdominal pain, no loss of

appetite

No polyphagia, no constipation, no
diarrhoea,
Musculoskeletal No backache, no joint pain, no
weakness

Central Nervous No blurred vision, no numbness

PHYSICAL EXAMINATION
GENERAL
Alert, conscious, sitting comfortably on bed playing with her phone.
Patient is able to talk in complete sentences GCS 15/15
Hemodynamically stable, Peripheries are warm, good pulse volume and
rhythm, and CRT < 2 seconds.

inspection of eye: Neither pallor nor yellow discoloration of sclera

inspection of oral cavity: Patient was well hydrated. Oral hygiene was good.
Patient had no central cyanosis & angular stomatitis.

inspection of the neck: No swelling of cervical lymph nodes

inspection of the hands: No clubbing, no cyanosis, no pallor, capillary refilling

time was less than 2 seconds, no palmar erythema.

inspection of legs: No pitting edema, no swelling, both dorsalis pedis and

posterior tibialis pulses were palpable.

VITAL SIGNS
Temperature : 38°C
Pulse rate : 111 beats per minute
Respiratory
: 22 breaths per minute
rate
Blood pressure : 107/64 mm Hg
SpO2 : 95%
Airway was patent and the patient was breathing room air. She is mildly
tachypneic with respiratory rate 22 BPM.

LOCALIZED EXAMINATION

Cardiovascula
: Dual rhythm present, no murmur
r
: Equal vesicular breath sounds with prolonged expiratory
Respiratory phase with bilateral expiratory rhonchi. Crepitations in the right
mid chest.
Abdominal : Soft, No abdominal distension, no abdominal tenderness and
 no palpable mass

Provisional Diagnosis-

Patient has a case of community acquired pneumonia.

DIFFERENTIAL DIAGNOSIS
DDX POINTS FOR POINTS AGAINST
ASTHMA Shortness of breath Productive cough with
Prolonged expiration yellow sputum
Reduced air entry. No wheezing

Tuberculosis Shortness of breath No history of weight

Intermittent fever loss
No history of exposure
to infectious
tuberculosis
No dullness to
percussion
No anorexia and night
sweats
Bronchitis Shortness of breath No signs of wheezing
Fever, No barking cough
Productive cough

SUGGESTED INVESTIGATIONS

1.Full blood count- Elevated white cell count is suggestive of infective process.
Neutrophil predominance, especially if immature neutrophils, is suggestive of
bacterial infection. FBC is also done to check the hematocrit, platelet count and
monitor the disease progression or any coagulation abnormalities.

2.Chest X ray- Posteroanterior and latero-lateral projections increase the

likelihood of diagnosis of pneumonia and are useful in establishing the severity
of the illness. It will demonstrate consolidation, classically a lobar pattern.
3.Serum electrolytes/ blood urea nitrogen- Baseline blood should be taken.
Provides information about renal function. Sodium and blood urea nitrogen
are used in severity scoring. (Chronic renal failure is a significant risk factor for
mortality in patients with CAP)

4.Liver function test- monitor the level of aspartate aminotransferase (AST) and
alanine transaminase (ALT). Pneumonia is common in hospitalized patients
with cirrhosis, and chronic liver disease is a risk factor for pulmonary
complication in patients hospitalized due to pneumococcal pneumonia.

5.Arterial blood gas (ABG) or Venous blood gas (VBG) -To check the blood pH,
concentration of bicarbonate ion, PaCO2, PaO2 hence evaluate the patient’s
respiratory and metabolic status.

6.RTK COVID-19 antigen test. For any COVID-19 infection and put the patient in
the isolation ward to avoid spreading of COVID-19 to other patients.

7. serum C reactive protein- A sensitive marker of progress in pneumonia;

should be measured regularly in severely ill patients. High levels at initial
presentation represent a risk factor for inadequate response to
treatment, whereas low levels are protective.

PLANNED EMERGENCY MANAGEMENT

 Assess the status of airway, breathing and circulation status of the

patient.

 -  Assess hydration status and hemodynamic status.

 -  Vital signs monitoring including pulse rate, respiratory rate, oxygen

saturation, temperature and blood pressure.

 -  Start nebulizer salbutamol and set up IV access for serial blood

sampling and IV fluid.

 -  Take blood sample for full blood count, renal profile and serum
electrolyte, liver function test, coagulation profile, arterial blood gas

 -  Start IV fluid therapy by giving 0.9% normal saline for fluid and
electrolyte replenishment.

 -  Encourage intake orally.

  -  Strict monitoring of ongoing fluid losses and hourly fluid input and
output

 -  Admission into the ward for observation and monitoring of the

patient.

ACTUAL RESULTS

1.Full blood count (FBC)

FBC Value Normal Range

WBC
14.7 4.00 - 11.00
[*10L]
Hb [g/dL] 14.5 12.0-15.0
Plt [*10L] 76.1 110-450
HCT [%] 43.5 37-47

She has increased white blood cell counts which illustrate leukocytosis. This
shows that she has bacterial pneumonia. Her platelet is also lower than the
normal level.

2.Renal profile and serum electrolyte

Value Normal Range

Urea [mmol/L] 2.6 2.5-6.7
Sodium [mmol/L] 141 135-146
Potassium [mmol/L] 3.5 3.5-5.0
Chloride [mmol/L] 105 98-107
Creatinine [μmol/L] 42 50-98

Creatinine is slightly lower than the lower range. All the electrolytes are within
the normal range.

3. Arterial blood gas (ABG)

Valu
Normal Range
e
pH 7.43 7.32-7.45
pCO2 [mmHg] 35 41-51
Lactate [mmol/L] 0.9 0.5-1.3
HCO3- [mmol/L] 23.2 22.0-29.0
P02 {mmHg} 78 75-100

Compensated respiratory alkalosis.

4. Chest x ray

Consolidation seen on left upper lobe of the lung.

5. RTK COVID-19 antigen test Negative test for COVID-19.

TREATMENT DONE IN ED

1. Nebulizer salbutamol stat and 2h hourly

2. Iv cefuroxime 750mg

3. Bromhexine 8mg tablet

4. IV Drip 0.9% normal saline.

5. Strict monitoring of fluid input/output chart.

6. Encourage oral intake.

DISPOSITION OF PATIENT

1ST Feb 2023, 12.30am

Patient arrived at the Emergency Department and was triaged to Yellow Zone.
Vital signs are taken.

Patient was admitted to the emergency department at 12.30am with shortness

of breath and productive cough.

1ST Feb 2023, 1.00am

Nebulizer salbutamol was given. Intravenous access was established and blood
samples were taken from the patient and covid 19 test was done.

2nd Feb 2023, 8.00am

Patient was kept under observation and was planned for discharge.

DISCUSSION

Severe community-acquired pneumonia is a subtype of pneumonia for which

critical care provided supportive management is needed, incurring markedly
elevated mortality. Community-acquired pneumonia has an estimated annual
incidence of 1.6 to 10.6 per 1000 adults in Europe. The incidence of CAP
correlates with increasing age

Community-acquired pneumonia most typically presents with productive

cough, shortness of breathless, pleuritic pain and pyrexia. It is important to
remember that these symptoms, whilst classical, can be subdued/absent,
especially in the immunocompromised and elderly. Often accompanying the
symptoms, are clinical signs, including tachypnoea and tachycardia. The
development of pneumonia follows the inhalation/aspiration of a pathogen
which overwhelms the natural defences of the lungs. Streptococcus
pneumoniae,Staphylococcus aureus, meticillin-resistant Staphylococcus
aureus (MRSA) are the common pathogens. For children treated as
outpatients, treatments are dictated by age:
 < 5 years: Amoxicillin or amoxicillin/clavulanate is usually the drug
of choice. If epidemiology suggests an atypical pathogen as the
cause and clinical findings are compatible, a macrolide
(eg, azithromycin, clarithromycin) can be used instead. Some
experts suggest not using antibiotics if clinical features strongly
suggest viral pneumonia.
  ≥ 5 years: Amoxicillin or (particularly if an atypical pathogen
cannot be excluded) amoxicillin plus a
macrolide. Amoxicillin/clavulanate is an alternative. If the cause
appears to be an atypical pathogen, a macrolide alone can be
used.
For children treated as inpatients, antibiotic therapy tends to be more broad-
spectrum and depends on the child's previous vaccinations:
 Fully immunized (against S. pneumoniae and H. influenzae  type
b): Ampicillin or penicillin G (alternatives are ceftriaxone or
cefotaxime). If MRSA is suspected, vancomycin or clindamycin is
added. If an atypical pathogen cannot be excluded, a macrolide is
added. 
 Not fully immunized: Ceftriaxone or cefotaxime (alternative
is levofloxacin). If MRSA is suspected, vancomycin or clindamycinis
added. If an atypical pathogen cannot be excluded, a macrolide is
added.

REFERENCES

1. https://radiopaedia.org/articles/community-acquired-
pneumonia
2. https://bestpractice.bmj.com/topics/en-us/17/investigations
3. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-
1581ST
4. https://onlinelibrary.wiley.com/doi/full/10.1111/crj.12674
5. https://link.springer.com/article/10.2165/00003495-
200060060-00004
6. https://www.msdmanuals.com/professional/pulmonary-
disorders/pneumonia/community-acquired-pneumonia
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812437/