CASE PRESENTATION

◼ 44 JOLAKULA SURESH SADHVI

◼ 31 JABAR ALI ROSHAN SABEEHA
◼ 32 JAKIR USSAIN SHAKIRA
◼ 43 JOHN MARI VIENNI JOHN TENNYSON
◼ 42 JEYAKUMAR PRIYADHARSHINI
◼ 41 JEYAKUMAR DHILEEBAN
◼ 45 KAKULARAPU CHANDRACHARAN REDDY
◼ 48 KAMARAJ ANITHA
◼ 40 JESU ARUL PAUL IGNESH
◼ 35 JAYAKUMAR RUPESH
◼ PATIL AMITH
◼ SATHIYANARAYANAN VIGNESH
 IDENTIFYING
DATA
• Name : W.P
• Age: 1 year 1 month
• Gender : Female
• Address :Buhangin.
• Informant : Mother
• Reliability :90%
CHIEF COMPLAINT

◼ COUGH
 HISTORY OF PRESENT ILLNESS
2 weeks prior to admission
● Mother noticed productive cough and Coryza
● Had consultation at the local health center and prescribed with Cetirizine 1mg/ml ,1 ml
once a day and Procaterol 5 Mcg/ml, 2.8ml every 12 hours and Salbutamol nebule,
nebulize every 12 hours ,which gave no relief, no other associated symptom were
present.
◼ In the interim, persistence of symptoms mother continued the medication

1 week prior to admission

● cough was persistent, productive with greenish phlegm and increasing in
severity, associated with coryza.
● consulted at local hospital, Patient was managed and prescribed with
Clarithromycin125mg/ 5ml,2.5ml every 12 hours for 7 days(13mkD) and
Procaterol 5mcg/ml,2.5 ml every 12 hours
● Chest x ray and CBC were taken as claimed normal.
1 day prior to admission
● After completion of medication no relief as claimed.
● child was unable to sleep at night, as cough increased in intensity and
associated with rhinorrhea. No consultation was done.

On the day of admission

● patient symptoms were persisted so that mother prompted to seek for
consultation at this hospital and advised for admission.
PAST MEDICAL HISTORY

◼ Pneumonia during the 1st week of life, and treated for one week.
◼ No history of surgery.
◼ No known allergies to any food and medications.
◼ No other childhood like chickenpox,measles….
 PRENATAL HISTORY

◼ Born to 37 years old , G4P3( T3P0A0L3).

◼ Her mother had UTI at 9 months during pregnancy ,she was treated
with antibiotics (unrecalled).
◼ She had no medical history of diabetes,hypertension.
◼ No exposure to drugs and radiation.
◼ No smoking and no alcohol .
BIRTH HISTORY

◼ She was born full term at 39 weeks AOG .

◼ Delivered via cesarean section at local hospital .
NEONATAL HISTORY

◼ Her birthweight was 3 kg ,39 AOG .

◼ She had good cry , pinkish and good tone.
◼ No resuscitation was done after delivery.
◼ At 1 week of life she had neonatal pneumonia that was Treated and
discharge after 2 weeks of life.
◼Newborn and Hearing screening test was normal.
NUTRITIONAL HISTORY

◼ She is being breastfed till now.

◼ Supplemental feeding started at 6 months ( porridge) she will eat 3 times a day.
◼ Vitamins- celine and other vitamins( unknown).
◼ Her mother only feeds her child.
IMMUNIZATION

◼ BCG: at birth
◼ DPT: 3 doses
◼ OPV: 3 doses
◼ Hep B: 1 dose
◼ PCV: 3doses
◼ Hib:3 doses
 GROWTH AND DEVELOPMENT
GROSS MOTOR :
◼ Rolled over at 4 months.
◼ Sat alone at 8 months

FINE MOTOR:
◼ Hands not fisted at 3 months.
◼ Linear scribble at 8 months.

SOCIAL DEVELOPMENT
◼ Smile responsibly at 3 months.
◼ Turns to sound at 4 months.

LANGUAGE
◼ Coos at 3 months.
able to speak dada at 9 months.
FAMILY HISTORY

◼ Her Maternal grandfather has diabetes.

◼ No genetically transmitted diseases like cystic fibrosis, asthma
PERSONAL AND SOCIAL HISTORY

◼ She was live with mother, father and 3 elder siblings and 2 helpers.
◼ Primary health giver is one of helper.
◼ Parents are financially stable.
◼ Her mother was a homemaker.
◼ Her father was running a automobile shop.
REVIEW OF SYSTEM

◼ General: weight change(-) weakness(-), fever(-)

◼ Skin: rashes(-), lumps(-), changes in color(-)
◼ Head: headache(-), trauma (-)
◼ Eyes: redness(-), blurring(-)
◼ Ears: ear discharge (-)
◼ Nose and sinus: frequent colds or sneezing(-), nose bleed (-)
◼ Mouth and throat: mouth lesions(-) ulcer(-)
◼ Neck: lump(-), stiffness (-)
◼ Respiratory: dyspnea(-),hemoptysis(-) Cardiovascular: feeding
intolerance(-) syncope(-) Gastrointestinal: diarrhea(-),vomiting(-)
◼ Urinary: dysuria(-) hematuria (-)
◼ Neurologic: Seizures(-), loss of consciousness(-) hyperactivity(-)
PHYSICAL EXAMINATION

VITALS SIGNS:
◼ BP: not taken
◼ HR: 110bpm
◼ RR: 25cpm
◼ TEMP: 36 degree celsius
◼ O2: 99 (@ room air)
 ANTHROPOMETRICS

◼ LENGTH: 76 cm
◼ WEIGHT: 9.4 kg
◼ HEAD CIRCUMFERENCE: 46 cm
◼BMI :16.3kg/m2
25
PHYSICAL EXAMINATION:

◼ GENERAL: patient was awake, Active, not in respiartory distress,

afebrile
◼ Eyes: pupils are black, centrally placed, sclera is white.
◼ Ears: no deformities seen, ears are symmetrically placed.
◼ Nose: symmetrically aligned, nasal septum is at midline, nostrils are
congested, dried mucus.
 CHEST AND LUNGS:
◼ I: equal chest expansion, no scars, no lesions.
◼ P: equal tactile fremitus, no tenderness.
◼ P: not done
◼ A: bronchial breath sounds heard with fine crackles more on left than right
lower lung base.
 CARDIOVASCULAR:
◼ I: adynamic precordium
◼ P: no heaves, no thrills
◼ A: s1s2 distinct, no murmurs
◼ Abdomen:
◼ I: globular, no scars, no lesions
◼ A: bowel sounds with absent bruits.
◼ P: tympanic
◼ P: light and deep palpation abdomen is soft, no tenderness, no rebound
tenderness, gallbladder and spleen are not palpable
◼ EXTREMITIES
◼ full pulses, crt less than 2 sec, warm to touch.
◼ NEUROLOGICAL EXAMINATION :
◼ GCS: 15(E4V5M6)
◼Genital:
◼ Labia majora is larger than minora, no lesions, no scars, no discharge.
 SALIENT FEATURES:

PERTINENT POSITIVE

HISTORY

● 1, YEAR OLD FEMALE

● 2 WEEK HISTORY OF DRY COUGH AND AFEBRILE
● 1 WEEK HISTORY OF COLD

PE

● FINE BILATERAL CRACKLES

31
PERTINENT NEGATIVE

● FEVER
● LETHARGY
● CYANOSIS
● ANXIETY
● NASAL FLARING
● RESPIRATORY DISTRESS
● RETRACTION ( INTERCOSTAL,SUBCOSTAL,SUPRACLAVICULAR)
● TACHYCARDIA
● TACHYPNEA
● GRUNTING
● WHEEZING
● DIMINISHED BREATH SOUNDS
● RONCHI
● ABDOMINAL DISTENTION

32
 DIFFERENTIAL DIAGNOSIS

1. ASTHMA

◼ - It is a chronic inflammatory disorder of the airways,In asthma, the

airways become hypersensitive to various triggers such as allergens,
irritants, viral infections, and exercise, leading to inflammation,
swelling, and constriction of the air passages. This results in reduced
airflow and difficulty breathing, which can be mild or severe and may
require emergency treatment
◼ RULE IN : COUGH ,COLD
◼ RULE OUT : NO WHEEZING, NO HISTORY OF ALLERGIES ,NO DYSPNEA,
 2.GERD:
Gastroesophageal Reflux Disease (GERD) is a common
condition in which stomach contents reflux back into the
esophagus, causing symptoms such as heartburn,
regurgitation, and difficulty swallowing.

◼ RULE IN : COUGH
◼ RULE OUT: NO VOMITING,NO REFUSING TO EAT,NO POOR
WEIGHT GAIN
 3.TUBERCULOSIS:
tuberculosis (TB) is an infectious disease caused by the
bacterium Mycobacterium tuberculosis. TB primarily affects the
lungs but can also affect other parts of the body, such as the
kidneys, spine, and brain

◼ RULE IN : 2 WEEKS HISTORY OF COUGH.

◼ RULE OUT : NO HISTORY OF PRIOR TB , NO HISTORY OF TB
EXPOSURE, NO WEIGHT LOSS,NO FEVER, NO NIGHT SWEATS , NO
HEMOPTYSIS , NO FATIGUE. Need further testing to rule out.
 PNEUMONIA :

◼ RULE IN : 2 WEEKS HISTORY OF COUGH , 1 WEEK HISTORY OF

COLD , ON AUSCULTATION HEARD THE BILATERAL FINE
CRACKLES.
INITIAL IMPRESSION

◼PEDIATRIC COMMUNITY ACQUIRED

PNEUMONIA - LOW RISK
 ADMITTING ORDER

Name: Welborn ,Paulina. Age : 1 yr Sex : female

Medical order
Please admit under the service of Dr. Dechaves (PC)
Secure consent to care.
DAT, NPO for RR > 40 cpm
Monitor VS q4 hrs ; I and O q shift
IVF : D5IMB 500cc at 40 cc/hr(MR)
Labs : CBC
Chest x-ray APL,
RT-PCR -done as OPD pls attach to chart
MEDS
1. Cefuroxime 300 mg IVTT q8 hrs ( 95.7mkd)
2.Montelukast 4mg sachet 1 sachet mix with 10-20 ml
water or milk OD
3.salbutamol + ipratropium Neb 1 neb q 6 hrs
4. Cetirizine drops ,1ml 2x a day(0.26 mkd)
 ROOM NO : 331, Welborn ,Paulina , 1 yr 1 month , female
HOSPITAL DAY 1 of admission, 16 days of illness:

Subjective: Objective:
Vital signs :
(-) Febrile T: 36.5
(-) Dyspnea HR:115
(-) vomiting RR:36
(-) wheezing O2 sat :95%(at room air)
(-) Diarrhea
(-) alar flaring Urine output :
(+) cough Input : 320
(+) Good suck Output :100
(+) Good intake of milk UO for 24 hr = 7.8 cc per hour

PHYSICAL EXAMINATION
General: Awake, alert and not in respiratory distress, Afebrile.
Skin: No rashes, no lesions, no laceration, no discoloration.
Head: Good hair distribution, no trauma.
Eyes- No sunken eyeballs, anicteric sclera, pupils are black, pink
palpebral conjunctiva, no conjunctivitis, no corneal opacities.
Ear- No pitting, no deformity seen, Ears are symmetrical.
Nose- Symmetrical, nasal septum in the midline without deviation, nasal
canal is patent.
Throat: Tonsils and pharynx are noted without exudate.
Mouth- Moist buccal mucosa and lips, no ulcers noted.

39
Chest& Lungs
I- No deformities,No retractions, Equal chest expansion is noted Plan :
P- No tenderness, no masses.
A- Bibasal crackles , no wheezing ● IVF D5IMB 500CC at 40 cc/hr (MR)
CVS: ● Continue medication:
I- Adynamic precordium noted. ● 1. Cefuroxime D1,D2 tom at 2pm
P- No heaves and thrills. ● 2.salbutamol + ipratropium 1 nebul q6
P- No cardiomegaly ● 3. Cetirizine drops BID
A- Regular rate, rhythm, distinct S1 and S2, no murmur noted ● 4.Montelukast OD @HS
Abdomen: ● For PPD TOMORROW
I- Flat, Soft, no visible lesions. ● Continue monitoring
A- Normoactive bowel sounds
P- No masses, bulges and tenderness, Skin turgor <2 secs.
Extremities- Warm, full pulses, CRT <2 sec.

40
 LABORATORY

COMPLETE BLOOD RESULT REFERENCE INTERPRETATION

COUNT VALUE
HEMOGLOBIN 102 102-127

HEMATOCRIT 0.34 0.31-0.38

RED BLOOD CELLS 5.04 3.8-5.0 POLYCYTHEMIA

WHITE BLOOD 8.5 4.9-13.4

CELLS
MCV 68 71-85 MICROCYTIC RBC

MCH 20.20 24.0-29.0 DECREASE HEMOGLOBIN

PER CELL

MCHC 30.0 31.8-34.7 DECREASE HEMOGLOBIN

PER UNIT VOLUME 41
DIFFERENTIAL COUNT

SEGMENTERS 0.32% 0.23-0.52% NORMAL

LYMPHOCYTES 0.60% 0.40-0.69% NORMAL

MONOCYTES 0.06% 0.03-0.12% NORMAL

EOSINOPHILS 0.02% 0.01-0.06% NORMAL

BASOPHILS 0.00% 0.00-0.01% NORMAL

PLATELETS COUNT 499 150-400 THROMBOCYTOSIS

42
CHEST X-RAY 1
 ROOM NO : 331, Welborn ,Paulina , 1 yr 1 month , female
HOSPITAL DAY 2 of admission, 17 days of illness:

Subjective : Objective

Afebrile vital signs

(+)Cough Pulse rate: 128 bpm (no tachycardia)
Good suck, good Intake respiratory rate:30 cpm (no tachypnea)
(-)dyspnea o2 saturation: 99% at room air (no hypoxia)
temperature :35.9 °C (afebrile)

Anthropometric measurements
Height : 76 cm (z score 1)
weight :9.4 kg( z score 1)
BMI: 16.8 (underweight)

44
PHYSICAL EXAMINATIONS ASSESSMENT
Pediatric community acquired pneumonia with low risk
GENERAL : Child is awake, Active , (-)Respiratory distress, (-) Febrile
· EYES : Pupils are black( Centrally placed , sclera is white , status: improving
no coloboma seen
· EARS : no Pitting, no deformity
· NOSE: symmetrically placed , nasal septum is in midline
with no deviation ,(-) Alar flaring, Nasal canal
· CHEST AND LUNGS :
· INSPECTION :CHEST SYMMETRICALLY EXPANDING, NO
CHEST WALL DEFORMITIES, NO RETRACTIONS SEEN
· PALPATION: TACTILE FREMITUS EQUAL ON BOTH
SIDES
· AUSCULTATION: Bilateral crackles heard . R > L
· CARDIOVASCULAR : PLAN
· INSPECTION:ADYNAMIC PRECORDIUM ● cefuroxime 300 mg IV TT q8hr
· PALPATION:NO HEAVES/THRILLS HEARD ● montelukast 4mg 1 sachet mix to 10 -20 ml of water.
· AUSCULTATION :DISTINCT HEART SOUNDS HEARD
po OD
WITH NO MURMURS HEARD
· ABDOMEN : ● cetirizine drops 5 ml po BID
· INSPECTION:GLOBULAR , NO VISIBLE LESIONS ● salbutamol + ipratropium nebulization q8 hrs
· AUSCULTATION:BOWEL SOUND PRESENT WITH ● mupirocin ointment apply bid on previous iv insertion
ABSENT BRUITS site
· PALPATION:NO ABDOMINAL MASS ON LIGHT AND DEEP
PALPATION , ABDOMEN IS SOFT NO TENDERNESS
● D5IMB 500 : 40 cc/ hr
· EXTREMITIES : FULL PULSES ,CRT <2 sec , WARM ● OrderTuberculin skin test
EXTREMITIES ,NO LESIONS,NO EDEMA

LAB
tuberculin skin test is performed and waiting for results 45
 ROOM NO :331 , Welborn ,Paulina , 1 yr 1 month , female
HOSPITAL DAY 3 of admission, 18 days of illness:

Subjective: Objective:
Vital sign :
12 Am:
Afebrile (+) Decreased cough Temperature: 36.0°C
(-) Diarrhea. (+) Good suck Pulse Rate: 133 bpm
(+) Good food intake Respiratory rate: 30 cpm
(+) Bowel movement x 3 O2 saturation: 98% At room air

4 AM
Temperature: 36.5°C
Pulse Rate: 136 bpm
Respiratory Rate: 28 cpm
O2 saturation: 99% at room air
8 AM
Temperature: 36.0 °C
Pulse Rate: 115 bpm
Respiratory Rate: 27 cpm
O2 Saturation: 97% at room air

12 PM
Temperature: 36.3 °C
Pulse Rate: 127 bpm
Respiratory Rate: 29 cpm
46
O2 Saturation: 98% at room air
4 PM
Temperature: 36.8°C Chest& Lungs
Pulse Rate: 138 bpm I- No deformities,No retractions, Equal chest expansion is
Respiratory Rate: 28 cpm noted
O2 Saturation: 96% at room air P- No tenderness, no masses.
A- Decreased fine crackles, no wheezing
8 PM CVS:
Temperature: 36.4 °C I- Adynamic precordium noted.
Pulse Rate: 122 bpm P- No heaves and thrills.
Respiratory Rate: 34 cpm P- No cardiomegaly
O2 Saturation: 98 % at room air A- Regular rate, rhythm, distinct S1 and S2, no murmur noted
Urine output : Abdomen:
Input : 970 I- Soft and globular, no visible lesions.
Output : 840 A- Normoactive bowel sounds
U O for 24 hr = 3.7 cc per hour P- No masses, bulges and tenderness, Skin turgor <2 secs.
Bowel movement Extremities- Warm, full pulses, CRT <2 sec.
General: Awake, alert and not in respiratory distress, Afebrile.
Skin: No rashes, no lesions, no laceration, no discoloration. Tuberculin skin test 24 (0mm
Head: Good hair distribution, no trauma.
Eyes- No sunken eyeballs, anicteric sclera, pupils are black,
no conjunctivitis, no corneal opacities.
Ear- No pitting, no deformity seen, Ears are symmetrical.
Nose- Symmetrical, nasal septum in the midline without
deviation, nasal canal is patent, Nasal congestion is noted.
Throat: Tonsils and pharynx are noted without exudate.
Mouth- Moist buccal mucosa and lips, no ulcers noted.

47
Assessment:

Pediatric community acquired pneumonia with low risk.

PLAN

● cefuroxime 300 mg IV TT q8hr

● montelukast 4mg 1 sachet mix to 10 -20 ml of water. po OD
● cetirizine drops 5 ml po BID
● salbutamol + ipratropium nebulization q8 hrs
● mupirocin ointment apply bid on previous iv insertion site
● D5IMB 500 : 40 cc/ hr
● Repeat Chest X-ray

48
CHEST X-RAY 2

49
 ROOM NO : 331 , Welborn ,Paulina , 1 yr 1 month , female
HOSPITAL DAY 4 of admission, 19 days of illness:

SUBJECTIVE : OBJECTIVE :

· (+) cough – improving · Vital signs

· (-) cold · Heart rate : 138 bpm( no tachycardia)
· (-) dyspnea · Respiratory rate :22 cpm (no bradypnea)
· (-)vomiting · Temperature: 36.4C(afebrile)
· (-)LBM · O2 sat: 99%(not hypoxic)
· (+)good sleep (+) good suck · Anthropometric measurements
Height : 76 cm (z score 1)
weight :9.4 kg( z score 1)
BMI: 16.8 (underweight)

PHYSICAL EXAMINATION FINDINGS:

· GENERAL : Child is awake, Active , (-)Respiratory
distress, (-) Febrile
· EYES : Pupils are black( Centrally placed , sclera is
white , no coloboma seen
· EARS : no Pitting, no deformity
· NOSE: symmetrically placed , nasal septum is in
midline with no deviation ,(-) Alar flaring, Nasal canal is patent
· CHEST AND LUNGS :
· INSPECTION :CHEST SYMMETRICALLY
EXPANDING, NO CHEST WALL DEFORMITIES, NO
RETRACTIONS SEEN
· PALPATION: TACTILE FREMITUS EQUAL ON BOTH
SIDES 50
CARDIOVASCULAR : ASSESSMENT:
· INSPECTION:ADYNAMIC PRECORDIUM · Pediatric community acquired pneumonia
· PALPATION:NO HEAVES/THRILLS HEARD
· AUSCULTATION :DISTINCT HEART SOUNDS HEARD
WITH NO MURMURS HEARD
ABDOMEN :
· INSPECTION:GLOBULAR , NO VISIBLE LESIONS
· AUSCULTATION:BOWEL SOUND PRESENT WITH
ABSENT BRUITS
· PALPATION:NO ABDOMINAL MASS ON LIGHT AND
DEEP PALPATION , ABDOMEN IS SOFT NO TENDERNESS
· EXTREMITIES : Full pulses,CRT <2 sec , warm
extremities ,No Lesions,no Edema PLAN :
· NEUROLOGIC EXAMINATION: · Continue IVF D5 IMB 500 with flow rate of 30cc/hr
· Glascow coma scale 15 · Cefuroxime 300 mg vial #3 (700 mg IVTT 3 times a day)
· Eye – opens spontaneously -4 · Salbutamol + ipratropium nebulization every 8 hrs
· Verbal- say mama -5 · Cetirizine drops 10mg/ml (5ml po 2 times a day)
· Motor – obeys command -6 · Amikacin 95 mg mg IVTT Q24
Tuberculosis skin test · Budesonide 1mg/2ml suspension nebulization (give 2
24hrs : 0 mm 48 hrs: 0 mm times a day for 2 days duration)
Follow up: chest xray progressive infiltrate on both sides of lungs · Montelukast 4 mg ( 1 sachet mix with 10-20ml of water
Impression: mild progression of bronchopneumonia or milk)

51
 ROOM NO : 331 , Welborn ,Paulina , 1 yr 1 month , female
HOSPITAL DAY 5 of admission, 20 days of illness:

Subjective: Objective:

(-) Febrile Vital sign :

(-) Cyanosis T: 36
(-) vomiting HR:109
(-) wheezing RR:30
(-) Diarrhea O2 sat : 99%(@room air)
(-) alar flaring
(+) Occasional cough Urine output :
(+) Good sleep Input :245
(+) Good suck Output : 620
(+) Good intake of milk UO for 24 hr = 4.07 cc per hour

General: Asleep, comfortable and not in respiratory distress.

Skin: No rashes, no lesions, no laceration, no discoloration.
Head: Good hair distribution, no trauma, non bulging, non sunken
fontanelle
Eyes- No sunken eye balls, anicteric sclera, pupils are black, pink
palpebral conjunctiva, no conjunctivitis, no corneal opacities.
Ear- No pitting, no deformity seen, Ears are symmetrical.
Nose- Symmetrical, nasal septum in the midline without deviation, nasal
canal is patent, no alar flaring.
Throat: Tonsils and pharynx are noted without exudate.
Mouth- Moist buccal mucosa and lips, no ulcers noted.
52
Chest& Lungs Plan :
I- No deformities,No retractions, Equal chest expansion is noted
P- No tenderness, no masses. ● IVF D5IMB at 30cc/ hr
A-Fine Bibasal crackles , no wheezing ● Decrease to 20 cc/hr
CVS: ● Please start cefaclor 200/5;2.5ml every 8 hrs(39.89mkd)
I- Adynamic precordium noted. ● Stool exam
P- No heaves and thrills. ● Continue management
P- No cardiomegaly
A- Regular rate, rhythm, distinct S1 and S2, no murmur noted
Abdomen:
I- Flat, Soft, no visible lesions.
A- Normoactive bowel sounds
P- No masses, bulges and tenderness, Skin turgor <2 secs.
Extremities- Warm, full pulses, CRT <2 sec.

53
LABORATORY FINDINGS

FECALYSIS:
PHYSICAL EXAMINATION:
- GREEN COLOR
- LOOSE CONSISTENCY
MICROSCOPIC EXAMINATION:
-NO PARASITES SEEN
-NO PUS CELLS
- NO RBC
CASE DISCUSSION
ETIOLOGY

◼ The most cases of pneumonia are caused by Microorganisms

◼ Noninfectious causes include aspiration (of food or gastric acid, foreign bodies, hydrocarbons, and lipoid
substances).
◼ Hypersensitivity reactions.
◼ Drug- or radiation-induced pneumonitis.
 AGE GROUP FREQUENT PATHOGENS ( IN ORDER OF FREQUENCY)

NEONATES
<3wks

Group B streptococcus, Escherichia coli, other Gram-negative bacilli,

Streptococcus pneumoniae, Haemophilus influenzae (type b,* nontypeable).
3Wks-3mos

Respiratory syncytial virus, other respiratory viruses (rhinoviruses,

parainfluenza viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable); if patient is
afebrile, consider Chlamydia trachomatis
 AGE GROUP FREQUENT PATHOGENS ( IN ORDER OF FREQUENCY)

Respiratory syncytial virus, other respiratory viruses (rhinoviruses,

4 mo-4 yr

parainfluenza viruses, influenza viruses, human metapneumovirus,

adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable),
Mycoplasma pneumoniae, group A streptococcus

M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae

≥5 yr

(type b,* nontypeable), influenza viruses, adenovirus, other respiratory

viruses, Legionella pneumophila
MOST COMMON PATHOGENS BY AGE :

2
1
STREPTOCOCCUS MYCOPLASMA PNEUMONIA
PNEUMONIA CHLAMYDOPHILA PNEUMONIA

3wks - 4 yrs 5yrs and older

PATHOPHYSIOLOGY
VIRAL PNEUMONIA
 Infection spreads along the airways, accompanied by
direct injury of the respiratory epithelium

Leads to inflammation, abnormal secretions and

cellular debris => AIRWAY OBSTRUCTION

Infants susceptible to severe infection

Can predispose to secondary bacterial infection by disturbing normal

host defense mechanism, altering secretions and disruption of the
microbiota
 PATHOPHYSIOLOGY
BACTERIAL PNEUMONIA

Most often occurs when bacteria colonize the lungs and gain
entry to the lungs
• Direct seeding of lung tissue after bacteremia
• Infection establishes in the lung parenchyma .
• S.pneumoniae: produces local edema that aids in proliferation of the
organism and their spread into adjacent areas of the lung (focal lobar
involvement)
• M.pneumonia: attaches to respiratory epithelium, inhibit ciliary action and
cellular destruction
• Group A Streptococcus: diffuse lung involvement with interstitial
pneumonia .
• S. aureus: confluent bronchopneumonia, unilateral, areas of cavitation and
necrosis
 RECURRENT PNEUMONIA
•2 or more episodes in a single year or 3 or more episodes
ever, with radiographic clearing between occurrences.
• An underlying disorder should be considered if a child
experiences recurrent pneumonia
CLINICAL MANIFESTATIONS
• Upper respiratory tract infection.
• Poor feeding.
• Abrupt onset of fever.
• Restlessness
• Apprehension.
• Respiratory distress manifested as grunting;
• Nasal flaring;
• Retractions of the supraclavicular, intercostal, and
subcostal areas;
• Tachypnea;
• Tachycardia;
• Air hunger;
• Cyanosis
CLINICAL MANIFESTATIONS

● VIRAL PNEUMONIA
● Fever is usually present but temperature are lower • BACTERIAL PNEUMONIA:
than bacterial pneumonia. • High fever
● Tachypnea* • Cough
● Intercostal, subcostal and suprasternal retraction. • Chest pain
● Severe: • Others:
1. Cyanosis 1. Drowsiness with intermittent periods of
2. Lethargy restlessness.
• Crackles and wheezing 2. Tachynea*
3. Anxiety
4. Occasional delirium.
• viral vs mycoplasma pneumonia is difficult to
determine.
• BACTERIAL PNEUMONIA continue. ● ATYPICAL PNEUMONIA CAUSED BY
• Diminshed breath sounds, scattered crackles, MYCOPLASMA
rhonchi on affected lung field. ● Tachypnea
• Dullness on percussion. ● Crackles and wheezing
• A lag of expiratory excursion ● Headache
• Abdominal distension becuase of gastric dilation ● Malaise
orbileus. ● Low-grade fever.
• Abdominal pain
• Hepatomegaly
• Vomiting
• Anorexia
• Diarhhea
 MANAGEMENT :
NON SEVERE PCAP, REGARDLESS OF IMMUNIZATION
STATUS AGAINST Streptococcus pneumoniae and /or
Haemophilus influenzae type B (Hib),
start Amoxicillin trihydrate at 40-50mg/kg/day Q8 for 7 days
OR at 80-90mg/kg/day Q12 for 5 to 7days.
start Amoxicillin-clavulanate at 80-90mg/kg/day Q12 (based on
Amoxicillin content using a 14:1 amoxicillin:clavulanate
formulation) for 5 to 7 days OR Cefuroxime at 2030mg/kg/day
Q12 for 7 days in settings with documented high-level
penicillin-resistant pneumococci or beta-lactamase-producing
H. influenzae based on local resistance data or hospital
antibiogram. (Conditional recommendation, low-grade
evidence)
severe PCAP, regardless of immunization status against start Penicillin G at 200,000 units/kg/day Q6 if with complete
Streptococcus pneumoniae, Haemophilus influenzae type b (Hib) vaccination OR Ampicillin
at 200mg/kg/day Q6 if with no or incomplete or unknown
Haemophilus influenzae type b (Hib) vaccination

start Cefuroxime at 100-150mg/kg/day Q8 OR Ceftriaxone at

75-100mg/kg/day Q12 to Q24 OR Ampicillin-sulbactam at
200mg/kg/day Q6 (based on ampicillin content) in settings with
documented high-level penicillin-resistant pneumococci or
betalactamase-producing H. influenzae based on local
resistance data or hospital antibiogram

add Clindamycin at 20-40mg/kg/day Q6 to Q8 when

Staphylococcal pneumonia is highly suspected based on
clinical and chest radiograph features. However, in cases of
severe and life-threatening conditions such as sepsis and
shock, Vancomycin at 40-60 mg/kg/day Q6 to Q8 is preferred.
(Conditional recommendation, low-grade evidence)
Hypersensitivity to penicillin Non-type 1 hypersensitivity to Penicillin, cephalosporins such
as Cefuroxime PO 2030mg/kg/day Q12 or IV 100-
150mg/kg/day Q8 OR Ceftriaxone at 75-100mg/kg/day Q12 to
Q24 is considered.

Type 1 hypersensitivity to Penicillin (immediate, anaphylactic-

type), any of the following is considered:

Azithromycin at 10mg/kg/day PO or IV Q24 for 3 days OR

10mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days 2
to 5

Clarithromycin at 15mg/kg/day Q12 for 7 days

Clindamycin at 10-40mg/kg/day PO or 20-40mg/kg/day IV Q6

to Q8 for 7 days (Conditional recommendation, low-grade
evidence)

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When an atypical pathogen is highly suspected, starting a
macrolide is considered as follows:
Azithromycin at 10mg/kg/day PO or IV Q24 for 5 days,
particularly in infants less than 6 months old whom pertussis is
entertained, OR 10mg/kg/day Q24 for 3-5 days OR
10mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days 2
to 5
Clarithromycin at 15mg/kg/day Q12 for 7 to 14 days
(Conditional recommendation, low-grade evidence)
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 ◼ When a specific pathogen is identified, modifying the empiric treatment based on the antibiotic susceptibility
pattern and/or the drug of choice is recommended. (Strong recommendation, high-grade evidence)
◼ When treating for uncomplicated bacterial PCAP, 7 to 10 days treatment is considered but a longer duration
may be required depending on the patient’s clinical response, virulence of the causative organism and eventual
development of complications.

(Conditional recommendation, low-grade evidence)

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