Emergency round

Pneumonia case report

Personal history:
A 5-year-old female child named Mira Yasser Kamal, was born in Cairo, lives in 5 th
settlement, the 2nd of her siblings and her parents showed negative consanguinity.

Chief complaint: (History is taken from both the mother and Mira)
She came complaining of progressive productive cough of 3 days duration in the
emergency department.
Primary survey:
1st impression:
 Color: negative for cyanosis, pallor and jaundice
A:
 Patent airway as she is saying ‘My name is Mira, I am 5 years old’ in one breath.
B:
1. No oxygen mask
2. RR: 18 breath/min
3. Look:
 Normal shaped chest
 Normal respiratory movements with no paradoxical movements

4. Listen:
 Normal, No Noisy breathing/silent chest.

5. Feel:
 Trachea is centralized
 Mild Diminution of chest expansion on the right side
 No tenderness
 TVF (couldn’t be assessed)
 Localized Dullness note on the lower right lobe (outside midclacivular line) (4th
intercostal space)
 Localized Bronchophony and egophony on the lower right lobe.
 Upper border of the liver is in the 5th intercostal space.
 No hyper-resonant notes

6. Auscultation:
 Normal vesicular breathing
 Diminished air entry on right lower lobe
 Diminished air entry on the right axilla
 No crepitations or rhonchi heard

C:
 BP: 110/70 mmHG
 Pulse: 78 bpm, average volume, equal on both sides, no special character (no
water hummer pulse), blood vessel wall (radial) is not palpable.
 Femoral pulsations are intact, equal on both sides.
 Pulse oximetry: Spo2 94%
D:
 AVPU (alert, conscious, oriented to her mother (date, time, place could not be
assessed) with quiet facial expressions.
 GCS : 15 ( spontaneous eye movements, oriented, obeys commands )
 Bilateral equal, reactive pupils.
 Intact pupillary reflexes.
 Intact bilateral, symmetrical, motor power, tone, sensation.
E:
 No bleeding sites, swellings, dilated veins, abnormal rash, burns, or
hyperpigmentation.

History of present illness:

The condition started 5 days ago, when she developed right upper abdominal pain of
gradual onset, progressive course, exacerbated by food and relieved by fasting
associated with nausea, vomiting and diarrhea of normal color lasting for 3 days with
no dysphagia or hematemesis. The mother denied any history of greasy stool and
thought it was a self-limiting abdominal colic and sought for medical advice in a
pharmacy and was prescribed metronidazole 1 tab 500mg Bid po. However there was
no improvement and Mira didn’t stop crying and was in pain.
Her condition worsened 2 days after the abdominal pain and additional to that, she
also developed productive cough, gradual in onset, progressive in course, present all
day, lasting for 3 days associated with continuous fever (39-400c), cyanotic spells ,
yet no choking after feeding, drooling, arching of back, chest pain, hemoptysis,
stridor, wheezes, hoarseness of voice, rash or jaundice. The mother denied any
history related to drug intake, contact with other ill people, animals or history of
travelling.
She sought medical advice today in the ED in Air Forces hospital, investigated by CBC,
blood culture, sputum analysis and chest x-ray. She was diagnosed as a case of
pneumonia, received IV fluids and was prescribed a course of IV antibiotics
(Ceftriaxone) to be continued for 5 days. Her daughter is currently stable. She is
waiting for repeat chest x-ray.
She had similar condition at the age of 9 months, when the mother noticed that her
daughter started having productive cough, gradual in onset, progressive in course,
with greenish sputum present most of the day, lasting for 1 week associated with
continuous fever (390c), poor breast suckling, cyanotic spells and weight loss, yet no
choking after feeding, drooling, dyspnea on suckling, chest pain, arching of back,
hemoptysis, stridor, wheezes, hoarseness of voice, rash or jaundice. The mother
denied any history related to drug intake, contact with other ill people, animals or
history of travelling.
She sought medical advice in Air Forces hospital where Mira was admitted,
investigated by CBC, blood culture, sputum analysis and chest x-ray. She was
diagnosed as a case of pneumonia, received IV fluids and was prescribed a course of
IV antibiotics for 12 days then was discharged after her symptoms subsided.
The mother also reported that Mira had recurrent attacks of common cold during the
winter season which was more severe compared to her brother and the children of
her age for which she took antiviral drugs.
Systemic review showed no symptoms suggestive of hematuria, hemoptysis,
hematemesis, cyanosis, lower limb edema or any neurological symptoms.
The mother reported that her daughter had no investigation for immunity before.
The mother denied any history suggestive of rheumatic fever (palpitations, arthritis,
arthralgia, skin rash, abnormal limb movements as chorea) or congenital heart
disease.

Past history:
Past history showed no medical abnormality detected.
Perinatal history
 Prenatal history: Normal pregnancy with no diseases or drugs intake.
 Natal history:
1. Normal vaginal delivery
2. Full term baby cried immediately after birth
3. Birth weight: 3.5 kg.
 Postnatal history: no history of NICU admission or any diseases.
Vaccination history:
All Vaccination are up to date.

Allergy history:
She is allergic to mango and bananas (allergy is described as generalized itchy reddish
circular skin rash, however there are no cough, wheezes or anaphylaxis associated).
She has no allergy to drugs, dust, perfumes or smoking.
Drug history:
She is currently receiving IV antibiotics (ceftriaxone) course in Air Forces hospital.
The mother can't remember the medications prescribed before.

Hospitalization history:
She presented 1 time before in Air Forces hospital for pneumonia and is currently
admitted in ED in Air Forces hospital.
Surgical history:
Free
Blood Transfusion history:
Free
Nutritional history:
She received exclusive breast feeding for 6 months.
Weaning started at the age of 6 months by adding rice cereal then small pieces of
yellow and green vegetables.
Social history:
The family lives in a 4-room-apartment on the 4 th floor. The father works as an
engineer with high income. Her mother is a tourist guide.
Family history:
No family history of similar condition.
No family history of other conditions of medical importance in the family.
No history of DM or HTN in the family.
Her parents showed negative consanguinity.

Developmental history:
She had normal development all through her life.

Motor development:
 Head support 3 months (Normal)
 sitting with pelvic support 6 months (Normal)
 Walking to furniture 12 months(Normal)
 Drives bicycle  3 years(Normal)
 Stand on one foot for one second  3 years(Normal)
Vision and fine development:
 Follows moving objects or light 1 month(Normal)
 Palmar grasp  6 months(Normal)
 Transfers objects from one hand to another 7 months(Normal)
  Copies a circle 3 years(Normal)
Social development:
 Social smile  2 months(Normal)
 Prefers the mother 6 months(Normal)
 Respond to sound of name 11 months(Normal)
 Waves bye-bye 12 month(Normal)
 Eat with fork and knife 3 years(Normal)
 Goes to the toilet alone  3 years(Normal)
Language&Hearing development:
 Laughs out loud Vocalization 3 months(Normal)
 Says Mama &Baba 6 months(Normal)
 Says her name, age and sex  3 years(Normal)
 Says 3 colors  3 years(Normal)

Secondary survey
T0c: 38.30c
Decubitus: lies flat in bed
Color: negative for cyanosis, pallor and jaundice
Anthropometric measures:
 Height: 95 cm (normal)
 Weight: 15 kg (normal)
 Head circumference: 49 cm (normal)
Skin: No rash or ulcers all over the skin
Lymph nodes: No abnormality detected (NAD)
Head, eyes, ears, nose and throat (HEENT): No abnormality detected (NAD)

Upper limb:
BCG vaccine scar is present
No leukonychia or koilonychia
No palmar erythema or clubbing of nails.
Capillary refill is normal (2 secs)
No janeway lesions, splinter hemorrhage, or Osler's nodules.

Lower Limb:
No lower limb edema
Peripheral pulsations are intact (dorsalis pedis, posterior tibial artery)

Cardiac examination:
Inspection:
 No precordial bulge
 Apical pulsations are not visible
Palpation:
 Apex is in the 5th intercostal space midclavicular line, regular with no
special character, no thrill
 No pulsations in
1. Suprasternal area
2. Aortic area
3. Pulmonary area
4. Parasternal area
5. Epigastrium
Auscultation:
 Normal s1 s2 heart sounds
 No murmurs or additional sounds heard
 Abdominal examination:
 Inspection:
 No distension.
 Acute subcostal angle
 No dilated veins, hyperpigmentation, rash
 No visible epigastric pulsations

 Superficial Palpation (liver and spleen):

 No superficial tenderness or swelling.

 Deep palpation (liver):

 No hepatomegaly
 No splenomegaly

 Percussion:
 Upper border of the liver is in the 5th intercostal space.
 Traub's area is resonant
 No ascites is found

 Auscultation
 Normal intestinal sounds.

Neurological examination:
 No abnormality detected.
Differential Diagnosis:
1. Pneumonia
2. Pleural effusion
3. Aspiration syndromes (GERD, aspiration pneumonia)
 4. Immune deficient (IgA deficiency)
Diagnosis:
 Recurrent Pneumonia For repeat x-ray, follow up and immunity
investigations.

ISBAR - Disposition
I I am Dr.Hamad Gad, medical student, I went to review a 5-year-old girl named
Mira Yasser Kamal in the ED
S She was admitted today complaining of productive cough and fever. She was
diagnosed as a case of pneumonia.
B She presented 1 time at the age of 9 months before in Air Forces hospital for
pneumonia
A A:
 Patent airway as she is saying ‘My name is Mira, I am 5 years old’ in one
breath.

B:
 No oxygen mask
 RR: 18 breath/min
 Normal shaped chest
 Normal respiratory movements with no paradoxical movements
 Normal, No Noisy breathing/silent chest.
 Trachea is centralized
 Mild Diminution of chest expansion on the right side
 No tenderness
 TVF (couldn’t be assessed)
 Localized Dullness note on the lower right lobe (outside midclacivular line)
(4th intercostal space)
 Localized Bronchophony and egophony on the lower right lobe.
 Upper border of the liver is in the 5th intercostal space.
 No hyper-resonant notes
 Normal vesicular breathing
 Diminished air entry on right lower lobe
 Diminished air entry on the right axilla
 No crepitations or rhonchi heard
C:
  BP: 110/70 mmHG
 Pulse: 78 bpm, average volume, equal on both sides, no special character
(no water hummer pulse), blood vessel wall (radial) is not palpable.
 Femoral pulsations are intact, equal on both sides.
 Pulse oximetry: Spo2 94%
D:
 AVPU (alert, conscious, oriented to her mother (date, time, place could
not be assessed) with quiet facial expressions.
 GCS : 15 ( spontaneous eye movements, oriented, obeys commands )
 Bilateral equal, reactive pupils.
 Intact pupillary reflexes.
 Intact bilateral, symmetrical, motor power, tone, sensation.
E:
 No bleeding sites, swellings, dilated veins, abnormal rash, burns, or
hyperpigmentation.

R I would like you to come and review her

Treatment:

 Empirical antimicrobial therapy should be tailored accordingly.

 Piperacillin-tazobactam is commonly used in severe HAP.

ICU Admission Policy

 Acute respiratory failure requiring ventilatory support (PaO 2<50mmHg,
PCO2>50mmHg, RR>35breaths/min)
 Airway obstruction
 Cyanosis
 Pulmonary embolism with haemodynamic instability
 Status asthmaticus
 Massive haemoptysis
 Flail chest, fracture ribs, haemothorax, pneumothorax