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THE CASE OF MP

THE CASE OF MP. Jara -Medrano 22.July.2010. GENERAL DATA. MP 70-year-old male Car technician. HISTORY OF PRESENT ILLNESS. 3 days PTC. PAST MEDICAL HISTORY. Known diabetic since 5 years ago Maintained on Metformin with poor compliance (+) Adverse drug reactions/rashes Amoxicillin

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THE CASE OF MP

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  1. THE CASE OF MP Jara-Medrano 22.July.2010

  2. GENERAL DATA • MP • 70-year-old male • Car technician

  3. HISTORY OF PRESENT ILLNESS • 3 days PTC

  4. PAST MEDICAL HISTORY • Known diabetic since 5 years ago • Maintained on Metformin with poor compliance • (+) Adverse drug reactions/rashes • Amoxicillin • Penicillin • Cefuroxime • (–) Hypertension • (–) Travel history for the past 6 months

  5. PHYSICAL EXAMINATION • Awake, with occasional coughs. • Vital Signs • Pulse rate: 108 beats/min • Respiratory rate: 30 breaths/min • Temperature: 38oC • Blood pressure: 100/60

  6. DIAGNOSTICS • Chest radiograph (CXR) • Right lower lobe consolidation • Minimal pleural effusion • Complete Blood Count (CBC) • Results not yet available

  7. PRIMARY IMPRESSION • Sepsis secondary to moderate-risk community acquired pneumonia (MR-CAP)

  8. DIAGNOSIS of SEPSIS • Sepsis • Systemic inflammatory response syndrome (SIRS) • AND proven or suspected microbial etiology • SIRS (2 or more of the following conditions) • Fever (oral temperature > 38oC) or hypothermia • Tachypnea (RR>24 breaths/min) • Tachycardia (HR>90 beats/min) • Leukocytosis or leukopenia

  9. DIAGNOSIS of MR-CAP • Any of the following (Philippine CPG, 2010): • Unstable vital signs • Tachypnea, tachycardia, fever/hypothermia, SBP < 90 mmHg and DBP ≤ 60mmHg. • Altered mental status of acute onset • Suspected aspiration • Decompensated co-morbid condition • Chest X-ray • Multilobar infiltrates • Pleural effusion or abscess

  10. STEP 1. THE PATIENT’S PROBLEMS • Sepsis secondary to MR-CAP. • Uncontrolled blood sugar due to poorly maintained diabetes.

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