Comprehensive Bacterial Pneumonia Case Study

Patient Chart

Patient Name: Thomas Allen Spencer
Date of Birth: 04/03/1959
Age: 65
Gender: Male
Medical Record Number: 20250310
Date of Admission: 03/10/2025
Primary Care Provider: Dr. Linda Green

Chief Complaint (CC)

"I’ve been having a cough, fever, and trouble breathing for the past three days. I feel really tired and weak."

History of Present Illness (HPI)

Thomas Spencer is a 65-year-old male presenting with a 3-day history of worsening cough, fever, chills, and shortness of breath. The patient describes the cough as productive, with yellow-green sputum, and has become more frequent and painful. He also reports feeling fatigued, weak, and unable to perform daily activities. He has had a low-grade fever that has worsened over the last 24 hours, with chills accompanying the fever. The patient denies any hemoptysis (blood in the sputum).

He has a past medical history of chronic obstructive pulmonary disease (COPD), hypertension, and smoking. He recently had a cold that did not resolve as expected, and he believes his symptoms have become worse since then.

Past Medical History (PMH)

  • Chronic Obstructive Pulmonary Disease (COPD) – diagnosed 10 years ago, managed with inhalers
  • Hypertension – diagnosed 15 years ago, controlled with Lisinopril
  • Coronary Artery Disease – diagnosed 5 years ago, status post stent placement
  • Smoking – 40 pack-years, quit 5 years ago
  • Hyperlipidemia – diagnosed 8 years ago, controlled with atorvastatin

Surgeries & Procedures

  • Coronary Artery Bypass Graft (CABG) 5 years ago
  • Percutaneous Coronary Intervention (PCI) (stent placement) 5 years ago

Allergies

  • Penicillin – Rash

Medications

  • Lisinopril 10 mg daily
  • Atorvastatin 20 mg nightly
  • Albuterol inhaler 2 puffs as needed
  • Tiotropium inhaler 1 puff daily
  • Nitroglycerin as needed for chest pain

Family History (FH)

  • Father: Deceased, 75, with a history of lung cancer
  • Mother: Deceased, 72, with a history of hypertension and diabetes
  • Sister: Alive, 68, with COPD

Social History (SH)

  • Smoking: 40 pack-years, quit 5 years ago
  • Alcohol: Occasional drinker (1-2 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: Retired construction worker
  • Living Situation: Lives with wife in a single-story home

Review of Systems (ROS)

  • General: Fatigue, malaise, fever, and chills
  • Cardiovascular: History of chest pain, no current complaints
  • Respiratory: Productive cough, shortness of breath, fever
  • Gastrointestinal: No nausea, vomiting, or diarrhea
  • Neurological: No headache, dizziness, or confusion

Physical Assessment Findings

Vital Signs:

  • Temperature: 101.4°F (38.6°C)
  • Heart Rate: 98 bpm, regular
  • Respiratory Rate: 22 breaths/min, labored
  • Blood Pressure: 140/85 mmHg
  • Oxygen Saturation: 88% on room air, improves with oxygen
  • Height: 5'10"
  • Weight: 166 lbs.

General Appearance: Patient appears fatigued, in mild distress, slightly cyanotic around lips
Cardiovascular: Regular heart rate, no murmurs, no jugular venous distention
Respiratory: Decreased breath sounds in lower lobes bilaterally, crackles on auscultation, wheezing, accessory muscle use
Abdomen: Soft, non-tender, no organomegaly
Neurological: Alert and oriented, no confusion

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 138 mEq/L 135-145 mEq/L
Potassium (K) 4.0 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 101 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 23 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 18 mg/dL 7-20 mg/dL
Creatinine (Cr) 1.0 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 92 mg/dL 70-99 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 15.8 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 14.5 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 43% 36-46%
Platelets (Plt) 310 x10³/µL 150-450 x10³/µL

Liver Function Tests (LFTs)

Test Result Reference Range
Alanine Aminotransferase (ALT) 35 U/L 10-40 U/L
Aspartate Aminotransferase (AST) 45 U/L 10-40 U/L
Alkaline Phosphatase (ALP) 120 U/L 45-115 U/L
Bilirubin, Total 0.8 mg/dL 0.1-1.2 mg/dL

Arterial Blood Gas (ABG)

Test Result Reference Range
pH 7.35 7.35-7.45
PaO₂ 65 mmHg 75-100 mmHg
PaCO₂ 48 mmHg 35-45 mmHg
HCO₃ 24 mEq/L 22-28 mEq/L
Oxygen Saturation (SaO₂) 90% 95-100%

Sputum Culture & Sensitivity

Result:

  • Streptococcus pneumoniae (gram-positive cocci) – Susceptible to Penicillin, Ceftriaxone, and Levofloxacin

Chest X-Ray

Findings:

  • Consolidation noted in the right lower lobe, consistent with bacterial pneumonia. No pleural effusion observed.