RESPIRATORY SYSTEM
• A 3 ½ YEAR OLD FEMALE CHILD HARINI SHREE FROM
MADURAI WHOSE INFORMANT BEING MOTHER GIVING
GOOD RELIABLE HISTORY CAME TO GRH WITH
COMPLAINTS OF
• COUGH X 1 WEEK
• FEVER X 3 DAYS
HISTORY OF PRESENT ILLNESS:
AN APPARENTLY NORMAL CHILD 1 WEEK BACK DEVELOPED
•COUGH FOR PAST ONE WEEK
GRADUAL IN ONSET ,WET COUGH
NO DIURNAL OR POSTURNAL VARIATION
NO AGGREVATING OR RELIEVING FACTORS
•FEVER FOR PAST 3 DAYS
HIGH GRADE , INTERMITTENT
NOT ASSOCIATED WITH CHILLS AND RIGORS
NO DIURNAL VARIATION
RELIEVED BY MEDICATION
H/O RUNNING NOSE FOR PAST 1 WEEK
INITIALLY WATERY IN NATURE NOW TURNED MUCOID
H/O FAST BREATHING
H/O CHEST INDRAWING
NO H/O FOREIGN BODY ASPIRATION
NO H/O EAR DISCHARGE
NO H/O SNORING OR MOUTH BREATHING OR HALITOSIS
NO H/O LOSS OF WEIGHT OR EVENING RISE IN TEMPERATURE.
NO H/O INCREASED PRECARDIAL ACTIVITY OR DECREASED
URINE OUTPUT
NO H/O DIARRHOEA AND VOMITING
NO H/O REFUSAL OF FOODS OR LETHARGY OR CONVULSIONS.
PAST
HISTORY
• NO H/O SIMILAR ILLNESS IN THE PAST REQUIRING HOSPITALISATION
• NO H/O RECURRENT LOWER RESPIRATORY TRACT INFECTION
• NO H/O ANY EXANTHEMATOUS FEVER, TUBERCULOSIS, WHOOPING
COUGH, DIPHTHERIA
• NO H/O DENTAL EXTRACTION OR NEAR DROWNING
• NO H/O PREVIOUS SURGERY UNDER GA
ANTENATAL HISTORY
• MOTHER BOOKED AND IMMUNIZED
• REGULAR ANTE-NATAL CHECKUP DONE
• IRON ,FOLIC ACID ,CALCIUM TABLETS TAKEN
• NO H/O EXANTHEMATOUS FEVER OR RADIATION EXPOSURE
• ALL THREE TRIMESTERS ARE UNEVENTFUL
NATAL HISTORY:
• FULL TERM
• NORMAL VAGINAL DELIVERY CONDUCTED AT GRH MADURAI
• BIRTH WEIGHT-2.7 KG
POSTNATAL HISTORY:
• CHILD CRIED IMMEDIATELY AFTER BIRTH
• BREAST FED WITHIN 1 HOUR
• NO H/O NICU ADMISSION
IMMUNISTION HISTORY:
• IMMUNISED UPTO AGE
• LAST IMMUNIZATION AT 1 ½ YEARS
DEVELOPMENTAL HISTORY:
• DEVELOPMENTAL MILESTONES ACHIEVED UPTO AGE
DIET HISTORY:
• BY 24 HOURS RECALL METHOD
calories protein
morning 1 cup milk + 2 166+40 8
teaspoon of sugar
2 biscuit 18
noon Rice-1 cup 175 4
CURD-1/2cup 77 4
Vegetable ½ 93 2
cup(potato)
night Rice -1 CUP 175 4
DHAL -1/2 CUP 150 2
1 cup milk 166 8
• TOTAL CALORIE REQUIREMENT=1060 KCAL
• CALORIE DEFICIT=NO
• PROTEIN REQUIREMENT=16.7 G/DL
• PROTEIN DEFICIT=NO
FAMILY HISTORY:
• NON CONSANGUINEOUS MARRIAGE
• NO H/O SIMILAR ILLNESS IN THE FAMILY
CONTACT HISTORY:
• NOT IN CONTACT WITH OPEN CASE OF TB
SOCIO ECONOMIC HISTORY:
• LOWER MIDDLE CLASS ACCORDING TO MODIFIED KUPPUSAMY SCALE
• RURAL AREA
• OWN HOUSE
• SEMIPUCCA HOUSE
• 2 ROOMS
• NO SEPARATE KITCHEN
• OVERCROWDING PRESENT( 4 PERSONS IN A ROOM)
• NO ADEQUATE VENTILATION
• SEPARATE TOILET PRESENT
• DRINKING CORPORATION WATER –BOILED BEFORE DRINKING
• GARBAGE-DAILY DISPOSAL
• NO PETS
• NO VECTOR BREEDING SITES
SUMMARY:
A 3 ½ YRS OLD FEMALE CHILD PRESENTED WITH COUGH FOR PAST 1
WEEK ASSOCIATED WITH HIGH GRADE , INTERMITTENT FEVER FOR PAST
3 DAYS ,RUNNING NOSE , FAST BREATHING AND CHEST INDRAWING
NOTICED BY THE MOTHER WITH NO HISTORY SUGGESTIVE OF
ASPIRATION AND NO HISTORY OF INCREASED PRECARDIAL ACTIVITY OR
DECREASED URINE OUTPUT IS A CASE OF RESPIRATORY SYSTEM
PATHOLOGY.
GENERAL EXAMINATION:
• CHILD WAS ALERT
• TACHYPNOEIC AT REST
• AFEBRILE
• NO PALLOR
• NO ICTERUS
• NO CYANOSIS
• NO CLUBBING
• NO PEDAL EDEMA
• NO GENERALIZED LYMPHADENOPATHY
HEAD TO FOOT EXAMINATION:
•HAIR -NORMAL
•FACE -NORMAL
•EYES -NORMAL
•EAR -NO DISCHARGE
•NOSE -RHINNORHEA PRESENT
•ORAL CAVITY -NO DENTAL CARIES / ULCERS
•THROAT - NO TONSILLAR ENLARGEMENT
•CHEST WALL –SUBCOSTAL AND INTERCOSTAL
INDRAWINGS PRESENT
• ABDOMEN -NOT DISTENDED
• SKIN -NORMAL
• EXTREMITIES -NOT COLD
• EXTERNAL GENITALIA –NORMAL
• SPINE –NO KYPHOSIS/SCOLIOSIS
ANTHROPOMETRY:
• WEIGHT-11KG AGAINST 15 KG
GRADE I PEM ACCORDING TO IAP CLASSIFICATION
• HEIGHT-96 CM AGAINST 98 CM
NO STUNTING ACCORDING TO WATERLOW CLASSIFICATION
• MIDARM CIRCUMFERENCE -14CM(NORMAL)
• HEAD CIRCUMFERENCE-47CM
VITALS:
• RR-52/MIN
ABDOMINOTHORACIC
TACHYPNOEIC
• PR-88/ MIN
NORMAL IN RATE ,RHYTHM , VOLUME
CONDITION OF VESSEL WALL NORMAL
NO SPECIAL CHARACTER
NO RADIORADIAL OR RADIO FEMORAL DELAY
FELT IN ALL FEASIBLE PERIPHERAL ARTERY
• BP-100/60MMHG IN SITTING POSITION IN LEFT UPPER LIMB
EXAMINATION OF RESPIRATORY SYSTEM:
UPPER RESPIRATORY TRACT:
• NOSE-NO DEVIATED NASAL SEPTUM
NO POLP
• ORAL CAVITY-NO DENTAL CARIES
• PHARYNX- NO TONSILLAR ENLARGEMENT
INSPECTION:
• SHAPE OF CHEST- ELLIPTICAL
• BILATERALLY SYMMETRICAL
• MOVES EQUALLY WITH RESPIRATION
• INTERCOSTAL AND SUBCOSTAL INDRAWINGS PRESENT
• ACCESORY MUSCLES OF RESPIRATION ARE ACTING
• TRACHEA SEEMS TO BE IN MIDLINE
• APICAL IMPULSE SEEN IN LEFT 5TH INTERCOSTAL SPACE LATERAL TO MID
CLAVICULAR LINE
• NO DILATED VEINS ,SCARS , SINUSES
• NO VISIBLE PULSATION
PALPATION:
• NOT WARMTH ,NON TENDER
• TRACHEAL POSITION CONFIRMED BY THREE FINGER TEST
• APICAL IMPULSE IN LEFT 5 INTERCOSTAL SPACE LATERAL TO
TH
MID CLAVICULAR LINE IS CONFIRMED
• CHEST-AP DIAMETER-10CM
TRANSVERSE DIAMETER- 14CM
RATIO-5:7
• CHEST EXPANSION 54-52CM=2CM
• VOCAL FREMITUS INCREASED OVER RIGHT MAMMARY ,INFRAAXILLARY ,
INFRASCAPULAR AND INTERSCAPULAR AREAS
• NO TACTILE OR FRICTION FREMITUS
PERCUSSION:
• IMPAIRED RESONANCE OVER RIGHT MAMMARY ,INFRAAXILLARY ,
INFRASCAPULAR AND INTERSCAPULAR AREAS
• TIDAL PERCUSSION :DULLNESS OVER UPPER BORDER OF LIVER AT
RIGHT 5TH INTERCOSTAL SPACE.
• TRAUBE’S SPACE :NOT OBLITERATED
AUSCULTATION:
• NORMAL VESICULAR BREATH SOUNDS HEARD
• AIR ENTRY DIMINISHED OVER RIGHT MAMMMARY ,INFRAAXILLARY ,
INFRASCAPULAR AND INTERSCAPULAR AREAS
• NO ADDED SOUNDS
• VOCAL RESONANCE INCREASED OVER RIGHT MAMMARY ,
INFRAAXILLARY ,INFRASCAPULAR AND INTERSCAPULAR AREAS
OTHER SYSTEM EXAMINATION:
CVS -S1,S2 HEARD ,NO ADDED SOUNDS
ABDOMEN -SOFT ,NONTENDER
NO ORGANOMEGALY
CNS - NO FOCAL NEUROLOGICAL DEFICIT
SUMMARY:
A 3 ½ YEARS OLD FEMALE CHILD PRESENTED WITH COUGH FOR 1 WEEK
ASSOCIATED WITH HIGH GRADE INTERMITTENT FEVER FOR 3 DAYS, RUNNING NOSE ,
FAST BREATHING ,CHEST INDRAWINGS NOTICED BY MOTHER FOR PAST 1 WEEK AND
ON EXAMINATION THE CHILD IS TACHYPNOEIC AT REST ,INTERCOSTAL AND
SUBCOSTAL INDRAWINGS PRESENT ,ACCESSORY MUSCLES OF RESPIRATION ARE
ACTING ,INCREASED VOCAL FREMITES AND VOCAL RESONANCE ,IMPAIRED RESONANCE
AND DIMINISHED AIR ENTRY OVER RIGHT MAMMARY, INFRAAXILLARY, INFRASCAPULAR ,
INTERSCAPULAR AREAS PROBABLY A CASE OF LOWER RESPIRATORY TRACT INFECTION.
DIAGNOSIS:
• A CASE OF LOWER RESPIRATORY TRACT INFECTION MOST PROBABLY
SEVERE PNEUMONIA ACCORDING TO IMNCI ,WITHOUT ANY
COMPLICATIONS
INVESTIGATIONS:
• COMPLETE BLOOD HAEMOGRAM – HAEMOGLOBIN , TOTAL COUNT , DIFFERRENTIAL
COUNT , ESR ,PCV ,C-REACTIVE PROTEIN
• SPUTUM –CULTURE AND SENSITIVITY (BY GASTRIC LAVAGE)
MICROSCOPIC EXAMINATION: AFP AND GRAM STAINING
• THROAT SWAB
• BLOOD CULTURE
• CHEST X RAY
• MANTOUX TEST
MANAGEMENT:
• ASSESS THE CHILD
• CLASSIFY THE ILLNESS
• IDENTIFY TREATMENT
• TREAT THE CHILD
• COUNSEL THE MOTHER
• FOLLOWUP CARE
• HOSPITALISATION
• FIRST 48 HRS – BENZYL PENICILLIN :50,000IU PER KG/DOSE - 6TH HOURLY (IM)
IF CONDITION IMPROVES – FOR NEXT THREE DAYS
PROCAINE PENICILLIN :50,000IU /KG - ONCE (IM)
IF NO IMPROVEMENT FOR THE NEXT 48 HRS – CHANGE THE ANTIBIOTICS
• SYMPTOMATIC TREATMENT OF FEVER BY
PARACETAMOL 15 MG/KG EVERY 4 HRS
• MONITOR FLUID AND FOOD INTAKE
• ADVISE MOTHER ON HOME MANAGEMENT ON DISCHARGE
