Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to life- threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia.

1. Name: Ismaya Tafrijiah Ramli Student No: 1711W035
Medical Record
Name: Xu Ting Department: Department of Respiratory
Sex: Female Address: Sanhe City, Hebei Province
Age: 42 Years Old Date of admission:2021-09-16 (13:35)
Nationality: Han nationality Date of record:2021-09-16 (14:00)
Marital status: Married Medical History Present: The patient himself
Occupation: Free Occupation
Chief complaints: Chest pain and dyspnea for 1 day, hemoptysis for 3 hours.
Present Illness: One day ago, the patient had a sudden chest pain and felt dyspnea after
movement. It became more and more serious, so the patient went to adjacent hospital. After
some treatment, her symptoms were still. 3 hours ago, the patient got hemoptysis. Then, she
came to our hospital. Since its coming on, she never felt headache, nausea, bellyache and her
phlegm was few. Her spirit, sleep and appetite were not good. Stool and urine were normal.
Past History: General health status: normal. Operation history: thyroidectomy. Infection history:
No history of tuberculosis or hepatitis. Allergic history: allergic to sulfanilamide. Traumatic
history: No traumatic history. Deny the history of heart disease, diabetes, cerebrovascular
disease, and mental illness. He denied the history of malaria. History of vaccination is unknown.
Other system reviews are nothing special
Personal History: She was born in Hebei. She never smokes and drinks. Her menstruation was
normal. LMP:13/9,2021. He denied the history of contact with infected water and epidemic areas,
and denied the history of contact with other radioactive materials and poisons. The history of
immunization is unknown.
Family history: Her parents are living and well. No congenital disease in her family.

2. Name: Ismaya Tafrijiah Ramli Student No: 1711W035
Physical Examination
General Status: T: 36.6'C, P: 110/min, R: 32/min, BP: 120/70mmHg.
Normally developed, moderately nourished; active position, alert and
cooperative. His mental status was normal.
Respiratory system: No pharyngalgia; no chronic cough, expectoration, hemoptysis, asthma,
dyspnea or chest pain.
Circulation system: No history of palpitation, hemoptysis, legs edema, short breath after sports,
hypertension, precordium pain or faintness.
Digestive system: No history of low appetite, sour regurgitation, belching, nausea, vomiting,
abdominal distension, abdominal pain, constipation, diarrhea, melena, hematochezia or jaundice.
Urinary system: No history of lumbago, frequency of urination, urgency of urination, odynuria,
dysuria, bloody urine, polyuria or facial edema.
Hematopoietic system: No history of acratia, dizziness, gingival bleeding, nasal bleeding,
subcutaneous bleeding or ostealgia.
Endocrine system: No history of appetite change, sweating, chilly excessive thirst, polyuria,
hands tremor, character alternation, obesity, emaciation, hair change, pigmentation or
amenorrhea.
Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint
deformity, muscle pain or myophagism.
Neural system: No history of dizziness, headache, vertigo, insomnia, disturbance of
consciousness, tremor, convulsion, paralysis or abnormal sensation.
Special Situation
T 36.6℃ , P 110/min, R 32/mi n, BP120/70mmHg. Superficial nodes were not palpable. Mouth
and throat: lips and tongue cyanosis. HR: 110bpm, rhythm is normal. Right lung has moist rales
can be heard. No audible pleural friction. There are rhonchi rales and whoop can be heard in two
lungs. Flat abdomen, Tenderness (-), rebound tenderness (-). Liver and spleen are not palpable.
Shifting dullness (-). Bowl sounds normal.
Auxiliary Examination
ECG: sinus rhythm.
HR:110bpm.
D-Dimer: 1376ug/L

3. Name: Ismaya Tafrijiah Ramli Student No: 1711W035
Primary Diagnosis
Pulmonary Embolism
Progress Note
Xu Ting, 42 years old, Female, She was suffering from “Chest pain and dyspnea for 1 day,
hemoptysis for 3 hours.”, the patient was admitted to our department for futher diagnosis and
treatment.
Case Characteristic:
1. Patient, Middle aged people, acute onset.
2. Medical History: One day ago, the patient had a sudden chest pain and felt dyspnea after
movement. It became more and more serious, so the patient went to adjacent hospital. After
some treatment, her symptoms were still. 3 hours ago, the patient got hemoptysis. Then,
she came to our hospital. Since its coming on, she never felt headache, nausea, bellyache
and her phlegm was few. Her spirit, sleep and appetite were not good. Stool and urine were
normal.
3. Past History: Operation history: thyroidectomy. Allergic history: allergic to
sulfanilamide. Other system reviews are nothing special
4. Physical Examination: T 36.6℃ , P 110/min, R 32/mi n, BP120/70mmHg. Superficial
nodes were not palpable. Mouth and throat: lips and tongue cyanosis. HR: 110bpm, rhythm
is normal. Right lung has moist rales can be heard. No audible pleural friction. There are
rhonchi rales and whoop can be heard in two lungs. Flat abdomen, Tenderness (-), rebound
tenderness (-). Liver and spleen are not palpable. Shifting dullness (-). Bowl sounds normal.
5. Auxiliary Examination: ECG: sinus rhythm. HR:110bpm. D-Dimer: 1376ug/L.
Diagnosis Basis and Differential Diagnosis
Diagnosis Basis
1. Pulmonary Embolism: according to the patient as middle age women, acute onset.
Clinical manifestations were appearance Chest pain and dyspnea, hemoptysis. The patient
had history of thyroidectomy surgery, and allergic to sulfanilamide. On physical
examination were found cyanosis. On Auxiliary examination: ECG: sinus rhythm.
HR:110bpm. D-Dimer: 1376ug/L.. So, the diagnosis is Pulmonary Embolism.

4. Name: Ismaya Tafrijiah Ramli Student No: 1711W035
Differential Diagnosis
As the most typical feature of PE, dyspnea can be most often erroneously considered to be related
to acute left-heart insufficiency; if accompanied by chest pain, acute coronary syndrome with
heart failure may be difficult to differentiate. Dyspnea with chest pain can also be present in other
conditions such as pneumonia, pneumothorax or acute exacerbation of COPD. Initial
discrimination of individual conditions is critical because misdiagnosis can substantially
complicate future therapeutic procedures such as arterial puncture.
Treatment Plan
Treatment of pulmonary embolism is aimed at keeping the blood clot from getting bigger and
preventing new clots from forming. Prompt treatment is essential to prevent serious complications
or death.
Medications
Medications include different types of blood thinners and clot dissolvers.
1. Anticoagulation: This is a drug that causes chemical changes in your blood to stop it
clotting easily. This drug will stop the clot getting larger while your body slowly absorbs
it. It also reduces the risk of further clots developing.
• acute-phase treatment
– administering parenteral anticoagulation over the first 5–10 days
 VKA overlap parenteral heparin
 followed by dabigatran or edoxaban
– oral rivaroxaban or apixaban directely
 increased dose of the oral anticoagulant over the first 3 weeks for
rivaroxaban
 over the first 7 days for apixaban
• Unfractionated heparin (UFH)
– Loading dose：3000－5000IU or 80 IU/kg
– Maintenance dose：18 IU/kg/h
– Dose titration：based value of APTT
– Target ：maintain APTT between 1.5-2.5 normal value
– Adverse effect: Hemorrhage, HIT
2. Thrombolytic: While clots usually dissolve on their own, sometimes thrombolytics
given through the vein can dissolve clots quickly. Because these clot-busting drugs can
cause sudden and severe bleeding, they usually are reserved for life-threatening
situations.

5. Name: Ismaya Tafrijiah Ramli Student No: 1711W035
• Time window: within 14 days
• Indication: high risk PE
3. Duration of Treatment
 For patient with PE secondary to a transient (revesible) risk factor, oral
anticoagulation is recommended for 3 months
 For patient with unprovoked PE, oral anticoagulation is recommended for at least 3
months
 Extended oral anticoagulation should be considered for patients with a first episode of
unprovoked PE and low bleeding risk.
 Anticoagulation treatment of indefinite duration is recommended for patients with a
second of unprovoked PE.
 For patiet with PE and cacer, weight-adjusted subcutaneous LMWH should be
considered for the first 3 to 6 months
 For patients with PE and cancer, extended anticoagulation (beyond the first 3-6
months) should be considered for an indefinite period or until the cancer is cured.