Case Study of a Patient with Acute Pneumonia

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A CASE STUDY REPORT OF A PATIENT WITH ACUTE PNEUMONIA
Introduction of the patient and the use of framework of practice thinking
This is a case study of a female patient aged 52 years old by the name Jenny who felt unwell
since two weeks ago with presentations of productive cough which was intermittent and
sometimes productive of green sputum. She has also been feeling the hotness of the body and
general body malaise for the last few days. On examination by the general practitioner, she
looked lethargic but oriented. On auscultations, she had coarse crackles on the right lower lobe
of the lungs. Specimen of green sputum was taken and for culturing which confirmed the
presence of infiltration of infections throughout her lungs and specifically the right lower lobe.
She has a past medical history of high blood pressure, obesity and hypercholesterolemia and she
is on the medication as; PO Atorvastatin drug that reduces cholesterol levels in the body, PO
Tenormin the antihypertensive drug, Tiotropium bromide inhaler, Ventolin inhaler as required.
Her vital signs were; BP- 135/85mmHg, PR- 104 beats/minute, RR-28 breaths/minute,
temperature-38.9^0c and SPO2 of 90% with no supplemental oxygen. In her social history, she
reports that she does smoke cigarettes about a pack per day. She has been doing so for the past
30 years. She stays with her husband and she does a part-time shift work as a cashier at a local
club. She has a well formed social network of friends centering close to her in the place of work.
From the clinical signs and symptoms, it is clear that she is ailing from bacterial pneumonia
which has affected the lower part of the respiratory tract. When the patient was done chest X-ray,
there were the areas of congestions within the bases and the patchy compaction at the right lung
base with the deprivation of coastal phrenic angle at the right side. The principal diagnosis,
therefore, was confirmed to be acute pneumonia.
Altered physiology and associated symptoms related to principal diagnosis
Pneumonia is an infection that causes inflammation of the air sacs in either one or both
lungs. The air sacs are filled with fluid or pus causing cough with phlegm or pus accompanied
with the feeling of chills and difficulty in breathing (Weinberger, Cockrill, & Mandel, 2017).
The extent of the effect of pneumonia infections vary in seriousness from mild to life-threatening
depending on the individual age and immunological status and also the type of agent causing the
disease. It is more serious in young children of less than five years of age and individuals of age

65 years and above. The common causes of pneumonia are bacteria that we inhale together with
the air we breathe and virus that is a presence in the lungs as normal flora and causes infections
when conditions are favorable like cold seasons in young children (Wojsyk-Banaszak, &
Bręborowicz, 2013). and when the immune system goes down. General Signs and symptoms of
pneumonia include; productive cough, chills, sweating, fever, general body malaise, shortness of
breath, decreased air entry, difficulty in breathing, wheezing, decreased oxygen saturation to less
than 90% and chest pains (Winland-Brown, & Klause, 2017).
Pneumonia can be classified in two ways, by the cause and as per the place it was acquired.
Classification by the place of acquisition includes; Community-acquired pneumonia. This is the
type of pneumonia acquired outside hospital settings (José, Periselneris, & Brown, 2015).
Another type according to acquisition is Hospital-acquired pneumonia where especially the
admitted patients in the hospitals acquire (Barbier, Andremont, Wolff, & Bouadma, 2013). This
one can be very much more serious than any other type since the bacteria involved may be more
resistant to several common antibiotics. Classification by the cause includes; bacterial
pneumonia and the common bacterium involved areas; streptococcus pneumonia. Other bacteria
that can cause pneumonia are Legionella pneumophila and Chlamydophila pneumonia
(Huijskens, et.al, 2013). Viral pneumonia; this one is not usually serious and last for a very short
period, unlike bacteria. It commonly affects young children, old people, and immune-suppressed
individuals. Mycoplasma pneumonia; mycoplasma is an organism that are neither bacteria nor
viral but has traits that are common to both. These organisms cause mild pneumonia, especially
on old age adults. Fungal pneumonia; fungi are mostly acquired through inhalation from the
environment, which they are a presence in animals and bird droppings and cause infections when
inhaled in large quantities and also when the immune system becomes weak. The common
fungus that causes pneumonia is Pneumocystis cariini pneumonia.
Bacterial pneumonia alters the physiology of the human body. The streptococcal pneumonia
bacterium leads to high fevers; this is due to the fact that the body adjusts in such a way that it
raises its temperature as a defense mechanism of the body aim at destroying the bacteria by high
temperatures (Fairbrother, & Taylor, 2014). The inflammation causes the production of phlegm
or mucus, which are secreted by the goblet cells in the respiratory tract when they are inflamed
just as a defense mechanism by these goblet cells. The body becomes generally weak due to the