PNEUMONIA CASE PRESENTATION

By MBBS GANG
A] PATIENT’S PARTICULARS:
Name-
Age-
Sex-
Religion-
Residence-
Informant- Mother (reliable)
Date of admission-
Date of examination-
Bed no-
Mobile no of guardian-
B] CHIEF COMPLAINTS: Cough since 6days
Fever since 5days
Hurried breathing since 3days
C] HISTORY OF PRESENTING ILLNESS:
The child was apparently well 6days back then developed cough.
Cough
1. Onset- Insidious. [If sudden onset→ Foreign body aspiration]
2. Progression- gradual
3. Type- dry cough
4. Associated with rapid respiration [D/D→ Acidosis, cardiac failure] & noisy breathing
[stridor, wheeze, grunting → know their location]
5. No episodes of vomiting after bout of cough.
6. Aggravating factor-
7. Relieving factor- medication
There is also history of fever for 5 days.
Fever
1. Onset- sudden
2. Present throughout the day
3. High grade, associated with chills (only >5 yr age)
4. Not associated with rash. [If rash present → Exanthematous fever, viral pneumonia]
5. Relieving factor- medication
There is also history of hurried breathing since 3days.
Hurried breathing
1. Onset- insidious
2. Progression- gradual
3. A/W chest retractions, grunting
There is history of irritability, excessive crying, decreased food intake since a week.
 Chest Indrawing

Negative history:
No h/o running nose, ear pain or ear discharge. [R/O URTI]
No h/o mouth breathing, snoring, difficulty in swallowing, hoarseness of voice. [R/O
adenoids, tonsillitis, epiglottitis, croup]
No h/o bluish discoloration of lips or extremities. [R/O Cyanosis, hypoxia]
No h/o vomiting. [R/O Multisystemic involvement, GERD]
No h/o decreased activity, altered sensorium, convulsions. [R/O Complication of pneumonia,
meningoencephalitis, febrile seizure]
No h/o contact with TB patient, evening rise of temperature, loss of appetite. [R/O
Tubercular pneumonia]
D] HISTORY OF PAST ILLNESS:
There is similar history in the past when he was 2 yrs. The child was admitted to
hospital for a week with complaints of cough, fever, difficulty in breathing. and was cured
completely. There is no h/o bronchial asthma, or other illnesses, previous nebulization. [>2
episodes of pneumonia in last 6 months (or) >3 episodes of pneumonia in lifetime →
Recurrent pneumonia; Causes → cystic fibrosis, URT/LRT congenital defects, cyanotic heart
diseases, cerebral palsy a/w repeated food aspiration]
E] TREATMENT HISTORY: IV fluids, paracetamol, cotrimoxazole are been given. Now the child
has improved.
F] ANTENATAL HISTORY:
The mother is a registered case and history is as follows:
1st trimester No h/o of fever, rash.
Dating scan was done
Folic acid was taken
No other drug intake or radiation exposure.
No alcohol/tobacco/substance abuse.
2nd Trimester Quickening felt at 18 weeks.
2 doses of Tetanus toxoid taken 1 month apart.
Iron, folic acid & calcium taken.
Anomaly scan done and no abnormality noted.
No h/o Headache, swelling of feet, blurring of vision, pedal oedema,
documented hypertension.
No h/o of Polyuria, Polydipsia & OGTT was done and was normal.
3rd Trimester Appreciated fetal movements well.
 No h/o maternal fever, diarrhoea, UTI.
No bleeding per vaginum, leaking per vaginum, foul smelling liquor,
premature rupture of membranes.

G] BIRTH HISTORY:
Place:
Mode: Normal Vaginal Delivery
Period of gestation: 39 weeks of gestation
Baby cried immediately after birth.
Birth weight: 2.9kg.
Full term
H] NEONATAL HISTORY:
Breastfeeding started 30 mins after delivery.
Breast feeding was done adequately on demand at day and night, no feeding
problems was noticed.
No respiratory difficulty, jaundice, cyanosis or seizures. No H/O admission to NICU.
I] DEVELOPMENTAL HISTORY: All developmental domains achieved till date.
J] IMMUNIZATION HISTORY: Immunised up to date according to National Immunization
schedule, BCG Scar is present. [BCG, PCV, MR, Influenza]
K] DIET HISTORY: The child was exclusively breastfed till 6 months of age. Complimentary
feed was started at 6 months of age with _______. Breastfeeding stopped by _______ Years.
24 hour recall method:
Time Food item Amount Calorie (Kcal) Protein (gm)
Morning
Afternoon
Evening
Night
Calories:
Consumed: ____ kcal
Required: ____kcal
Deficit: ____ kcal (__%)
Protein:
Consumed: ___ gm
Required: ____ gm
Deficit: ___ gm (__%)
L] FAMILY HISTORY:
Type: Nuclear/ joint family
Members:
Sibling:
Non consanguineous marriage
No abortion or stillbirths.
 No history of tuberculosis contact, similar complaints, early death due to congenital
disorders.
No h/o genetic or chromosomal disorders in the family.
No h/o bronchial asthma in the family.
M] SOCIO-ECONOMIC STATUS: Calculate according to modified kuppuswamy scale.
N] GENERAL EXAMINATION:
Child was alert, conscious, irritable.
Facies: Normal
Decubitus: Of choice.
Examined in sitting position.
Pallor: absent.
Icterus: absent
Cyanosis: absent
Clubbing: absent
Edema: absent
Lymphadenopathy: absent
Vitals:
Temperature: 100.4 degree Fahrenheit (axilla)
PR: 120bpm, regular rhythm, good volume, no delay, all peripheral pulses felt.
RR: 60/min, regular, abdominothoracic type. Flaring of ala nasi, use of accessory
muscles seen. [Know limits of fast breathing]
BP: 100/80 mmHg, in right brachial artery, sitting position.
SpO2:
CFT<3 seconds
HEAD TO TOE EXAMINATION
Skull shape: normal, fontanelles closed
Hair: black, no colour changes
Eyes: no kf rings, bitot's spot, dryness
Ears: no discharge seen
Nose: flaring of ala nasai seen, no nasal deviations
Lips: no cleft lip, no cyanosis
Mouth: no cheliosis or stomatitis, bleeding gums
Tongue: appears to be normal
Palate: no high arched palate or cleft palate
Teeth: normal dentition present
Neck: normal
Nails: normal
Skin: no skin lesions seen, no Mantoux test marking is present
Abdomen and genitalia: normal
Spine and back: normal
Lower limbs: normal
ANTHROPOMETRY:
Observed Expected Inference
Weight(wet) for
age
Length for age
HC
MUAC
Weight for Length

O] SYSTEMIC EXAMINATION:
Respiratory system examination
UPPER RESPIRATORY TRACT:
Nose: flaring of nasal ala seen, nasal septum is normal
Air sinuses: no tenderness of frontal or maxillary sinuses felt
Oropharynx: appears to be normal, there is no enlargement of tonsils
Pharynx: posterior wall appears to be congested
LOWER RESPIRATORY TRACT
Inspection:
Shape of chest: elliptical in shape
Movements with respiration: decreased on right side
Trachea appears to be in centre. [know the causes of deviation]
Both nipples are at same level
Apical beat is not seen
Subcoastal and intercoastal retractions seen and there is use of accessory muscles.
No scars, sinuses, dilated veins seen
No dropping of shoulder, crowding of ribs

Palpation:
All inspectory findings confirmed
No tenderness
No rise in local temperature
Position of trachea- central
Apical impulse- felt at fifth intercoastal space in midclavicular line
Chest expansion- decreased on right side
Vocal fremitus: could not be elicited

Percussion:
AREA RIGHT LEFT
Supraclavicular Resonant
Infraclavicular Resonant
Mammary Dullness
Axillary Resonant Resonant
Infra-axillary Dullness
Suprascapular Resonant
 Interscapular Resonant Resonant
Infra-scapular Dullness

Auscultation:
Breath sounds (below). Vocal resonance: could not be elicited.
No added sounds heard.
AREA RIGHT LEFT
Supraclavicular Vesicular
Infraclavicular Vesicular
Mammary Bronchial (consolidation)
Axillary Vesicular Vesicular
Infra-axillary Bronchial
Suprascapular Vesicular
Interscapular Bronchial
Infra-scapular Vesicular

Other systems:
• CVS: No raised jvp, S1 S2 heard

• PER ABDOMEN: No hepatomegaly [Pushed down liver] or splenomegaly

• CNS: Higher mental functions are normal, no sensory or motor deficit

P] PROVISIONAL DIAGNOSIS: It is a case of lower respiratory tract infection most probably

Very Severe Pneumonia of right lower lobe, mostly bacterial etiology.
Q] SUMMARY: Here is a 3years 2 months old male child born out of nonconsanguineous
marriage. Presented with complaints of cough since 6days, fever since 5days, difficulty in
breathing since 3days. O/E there was fever, no pallor, cyanosis, clubbing. O/E of respiratory
system, chest expansion decreased on right side, chest retractions are seen, trachea is
central, dullness felt on percussion in right mammary, infra-axillary and infra-scapular areas
and also on auscultation bronchial breath sounds heard on right mammary, infra-axillary,
infra-scapular areas. The patient has provisionally diagnosed as lower respiratory tract
infection most probably Very Severe Pneumonia.
VIVA POINTS
1. Integrated Management of Neonatal and Childhood Illness (IMNCI) 2017 Guidelines:
• "PINK" indicates urgent hospital referral or admission.
• "YELLOW" indicates initiation of specific outpatient treatment.
• "GREEN" indicates supportive home care.
If 2 months - 5 years age child with Wheezing with Fast breathing / Chest indrawing -
• Rapidly acting Inhaled bronchodilator trial up to 3 times 15-20 minutes apart
• Count the breath and look for chest indrawing again • Now classify

Type of ARI Signs/ Symptoms Management

At Home:
Inhaled bronchodilator* x 5 days
Soothe the throat and relieve the cough with
a safe remedy.
Green: No signs of severe
COUGH OR pneumonia or very severe If cough > 14 days, refer for TB assessment
COLD pneumonia If recurrent wheeze, refer for Asthma
assessment
Advise mother when to return
immediately.
Follow-up in 5 days if not improving.
AT PHC:
Oral Cotrimoxazole / Amoxycillin x 5 days
Inhaled bronchodilator* x 5 days
• Chest indrawing.
Yellow: Soothe throat with safe remedy
PNEUMONIA • Fast breathing: If cough > 14 days, refer for TB assessment
If recurrent wheeze, refer for Asthma
(Not Severe) RR > 50 (in 2 to 12 months) assessment
RR > 40 (in 12 months to 5
years) Advise mother when to return immediately
Follow-up in 3 days
If Chest indrawing in HIV exposed/ infected:
Give 1st dose of Amoxycillin and Refer
• Stridor in calm child or REFER TO CHC/HOSPITAL
Pink: • Any general danger sign:
SEVERE 1. Inability to breastfeed / First dose of referral antibiotic (IM)
PNEUMONIA drink
Diazepam if Convulsing now
OR VERY 2. Vomit out everything
SEVERE 3. Prior H/o convulsions Treat to prevent Low sugar
DISEASE 4. Convulsing now
5. Lethargy/ unconscious Keep the child warm
* - If wheezing disappeared after administering rapidly acting bronchodilator
If 0-2 months old Young Infant -
• Count the breaths (Recount if > 60/min)
• Look for Severe chest indrawing
Any of the following signs: REFER TO CHC/HOSPITAL
1. Not feeding well
2. Convulsions First dose of referral
Pink: 3. Fast breathing (>60/ min) antibiotic (IM)
SEVERE OR VERY 4. Severe chest indrawing
SEVERE 5. Fever > 37.5° C Diazepam if Convulsing now
DISEASE 6. Body temperature < 35.5° C
7. No movement or Treat to prevent Low sugar
Movement only on
stimulation Keep the child warm

Daily dose schedule of Cotrimoxazole in Pneumonia

(not to be given in case of premature baby / neonatal jaundice)

Paediatric Tablet: Paediatric syrup:

Sulpha-methoxazole 100 mg Each spoon (5 ml):
AGE / WEIGHT
+ Trimethoprim 20 mg Sulpha-methoxazole 200 mg +
Trimethoprim 40 mg
< 2 months 1 tablet BD ½ spoon (2.5 ml) BD
(Wt. 3-5 kg)
2- 12 months 2 tablets BD 1 spoon (5 ml) BD
(Wt. 6- 9 kg)
1- 5 years 3 tablets BD 1 ½ spoon (7.5 ml) BD
(Wt. 10- 19 kg)
The condition of the child should be assessed after 48 hours. Cotrimoxazole should be
continued for another 3 days in children who show improvement in clinical condition.
If there is no significant change in condition (neither improvement nor worsening),
cotrimoxazole should be continued for another 48 hours and condition reassessed. If
at 48 hours or earlier the condition worsens, the child should be hospitalized
immediately.

2. Respiratory vaccines: MR, DPT, HiB, PCV, COVID19 vaccine.

3. Causes:
Bacterial Streptococcus pneumoniae, H influenzae, Staphylococcus.
Viral RSV, measles, influenza, parainfluenza.
In neonate → Herpes simplex, CMV
In neonates Gr B streptococci, E Coli
In children with HIV Pneumocystis jirovecii
Adolsecsents Atypical- Mycoplasma
4. Complications:
1. Parapneumonic effusion.
2. Empyema.
3. Pneumatocele (staphylococcus).
4. Pneumothorax.
5. ARDS.
6. Septic shock.
7. Pulmonary hemorrhage.
5. Investigations:

Blood examination TLC increased

DLC- Increased polymorphonuclear leucocytes in bacterial cause.
Increased lymphocytes in viral pneumonia.
Chest Xray

Isolation of causative Lung aspirate

agent Pleural fluid
Tracheo-bronchial washing
USG Detect parapneumonic effusion.

6. Guidelines for Diagnosis of pulmonary tuberculosis in children →