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    Case Study

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    Mr. Armah, a 32-year-old man, presented with a 4-day history of cough, fever, chills, and malaise. He had a chronic smoker's cough for 10-15 years and smoked 2 packs of cigarettes per day for 50 years. On examination, he appeared tired and underweight, with diminished breath sounds bilaterally and dullness over the right lung fields. Chest x-ray revealed acute pneumonia in the right middle lobe. After treatment, a follow up x-ray showed a right hilar mass and sputum cytology demonstrated atypical cells.

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    Case Study

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    profarmah6150
    78 views7 pages
    Mr. Armah, a 32-year-old man, presented with a 4-day history of cough, fever, chills, and malaise. He had a chronic smoker's cough for 10-15 years and smoked 2 packs of cigarettes per day for 50 years. On examination, he appeared tired and underweight, with diminished breath sounds bilaterally and dullness over the right lung fields. Chest x-ray revealed acute pneumonia in the right middle lobe. After treatment, a follow up x-ray showed a right hilar mass and sputum cytology demonstrated atypical cells.

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    Mr. Armah, a 32-year-old man, presented with a 4-day history of cough, fever, chills, and malaise. He had a chronic smoker's cough for 10-15 years and smoked 2 packs of cigarettes per day for 50 years. On examination, he appeared tired and underweight, with diminished breath sounds bilaterally and dullness over the right lung fields. Chest x-ray revealed acute pneumonia in the right middle lobe. After treatment, a follow up x-ray showed a right hilar mass and sputum cytology demonstrated atypical cells.

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    78 views7 pages

    Case Study

    Uploaded by

    profarmah6150
    Mr. Armah, a 32-year-old man, presented with a 4-day history of cough, fever, chills, and malaise. He had a chronic smoker's cough for 10-15 years and smoked 2 packs of cigarettes per day for 50 years. On examination, he appeared tired and underweight, with diminished breath sounds bilaterally and dullness over the right lung fields. Chest x-ray revealed acute pneumonia in the right middle lobe. After treatment, a follow up x-ray showed a right hilar mass and sputum cytology demonstrated atypical cells.

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    You are on page 1of 7

    CASE STUDY

    By
    Dr. Armah

    CHIEF COMPLAINT: COUGH AND FEVER FOR FOUR DAYS


    HISTORY: Mr. Armah is a 32 year old man who developed
    a harsh, productive cough four days prior to being seen by
    a physician.
    The sputum is thick and yellow with streaks of blood. He
    developed a fever, shaking, chills and malaise along with
    the cough.
    One day ago he developed pain in his right chest that
    intensifies with inspiration. The patient lost 15 lbs.
    over the past few months but claims he did not lose his
    appetite. "I just thought I had the flu."

    Past history reveals that he had a chronic smoker's


    cough for "10 or 15 years" which he describes as
    being mild, non-productive and occurring most often
    in the early morning.
    He smoked 2 packs of cigarettes per day for the past
    50 years.
    The patient is a retired truck driver who has been
    treated for mild hypertension, bronchitis, appendicitis
    (as a young adult), hemorrhoids and a fractured
    femur and splenic injury. (motorcycle accident).

    PHYSICAL EXAMINATION
    The patient is an elderly man who appears tired haggard and
    underweight. His complexion is sallow.
    He coughs continuously. Sitting in a chair, he leans to his right
    side, holding his right chest with his left arm.
    Vital signs are as follows: blood pressure 152/90, heart rate
    112/minute and regular, respiratory rate 24/minute and
    somewhat labored, temperature 102.6F.
    Examination of the neck reveals a large, non-tender hard lymph
    node in the right supraclavicular fossa.

    Both lungs are resonant by percussion with one exception:


    the right mid-anterior and right mid-lateral lung fields are
    dull.
    Auscultation reveals bilateral diminished breath sounds.
    The remainder of the lung fields is clear.
    Percussion and auscultation of the heart reveals no
    significant abnormality. Examination of the fingers shows
    clubbing.

    COURSE OF ILLNESS:
    Following a chest x-ray revealed an acute pneumonia in
    the right middle lobe, the patient was treated with
    antibiotics as an outpatient.
    During the 10 days of treatment the patient's fever
    abated and he felt somewhat better.
    A post-treatment (follow up) chest x-ray reveals a right
    hilar mass.
    Sputum cytology demonstrates atypical cells.

    1.Identify the problems from the history.


    2. Identify and explain the significance of physical findings.
    3. Review the lab findings. What is your diagnosis?
    4. What do you understand by the terms "hospital acquired" and
    "community acquired " pneumonia.? Which type of pneumonia
    does our patient have?

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