Pneumonia

-“The forgotten killer”

Harleen Kaur Dehal

070101108
Name: Padmakshi

Age: 1 year and 2 months

D.O.B. : June 6, 2009

Sex: Female

Place: Parkala

Informant: Mother

Reliability: Good
Chief Complaints:

• Cough with expectoration x 2 days

• Hurried Breathing x 2 days

• Fever x 1 day
HOPI:
The child is a known case of Down's Syndrome with
associated cardiac anomalies.

Cough:
• Was apparently normal 2 days back when she suddenly
developed cough. The cough has been progressively
increasing and is worse at night. Relieved on taking
medication.
• Associated with expectoration. But the child cannot
spit out the sputum.
• No h/o post tussive vomiting.
 Hurried Breathing:

✔Started 2 days back.

✔No H/o wheeze or noisy breathing.

Danger signs :
 Convulsions
 Difficulty to wake
 Stridor
 Not able to drink water
 Fever:

•Duration : 1 day

•Acute in onset and intermittent.

• H/0 sweating when the fever comes down.

• Increased sleep and irritability.

• No chills and rigor.

• No rash.

•No history of evening rise of temperature.

•Also there is no history of discharge from the nose or ear.

• No history of excessive crying while passing urine.

• Jaundice or itching.

•No seizures or LOC.

Past History:

The child is a known case of Down's Syndrome. She

was admitted in February with complaints of difficulty
in feeding, hurried breathing, persistent cough and
wheeze and was diagnosed to have congestive cardiac
failure. She was started on medical therapy for the
same.
Treatment History
• Inj Augmentin
• Inj Amikacin
• Tab Envas
• Syrup Fusoped
• Syrup Digoxin
• Syrup calcimax
• Tab Soldenafil
• Inj Hydrocortisone
Birth History:
Pre natal History:
Pregnancy was detected at one and a half month of amenorrhea
and was confirmed by ultrasound.
I Trimester: Mother had no complaints of excessive vomiting, fever
with rash, burning micturition, bleeding per vagina, abdominal
pain or radiation exposure. She took regular folic acid tablets.
II Trimester: Quickening was felt at around 17 weeks. Fe prophylaxis
was also started. Her USG was done which showed no anomalies.
GCT was nornal. She had no complaints of headache. Blurring of
vision, epigastric discomfort or pedal edema.
III Trimester: Fetal well being scan was done where she was
diagnosed to have oligohydramnios.
Peri Natal History:
The baby was delivered by LSCS, indication being oligohydramnios.
Post Natal History:
Post natal period was unremarkable. Mother had no complications.
Birth Weight: 3.12kgs
The child cried immediately after birth.
Passed meconium in 24 hours and urine in 48 hours.
Breast feeding was started within 6 hours of delivery.
The baby was diagnosed to have Down's Syndrome following which
an echocardiogram was done which revealed the child to have
various cardiac anomalies (ASD, VSD, PDA).
Developmental History:
(a) Gross motor: The child has partial head control
which started at around 6½ month.
Sits momentarily with support.- 7½months.
(b) Fine Motor: Transfer of objects
(c)Personal-Social: Claps her hands and waves
(d)Language: Can speak bisyllables.
Inference: Developmental delay
Developmental age: 9 months
Chronological age: 14 months
Diet History:

The child is breast fed 6-8 times a day.

Morning: ½ cup milk + 1 teaspoon sugar, 3 rusk

Afternoon: ½ bowl of ganji, ½ glass milk
Evening: Biscuits, 3 rusk and milk(1/2 glass) and
vegetables.
Night: ½ bowl of ganji
Calorie and protein Intake:

Calories Proteins

Expected 1100 Cal 15 gm

Actual 545.5 Cal 15.2 gm

Deficit 554.5 Cal Normal

Immunization History:

OPV and BCG given at birth.

DPT, OPV at 2-4-6 months.
Measles vaccine, Vitamin A at 9 months.
Optional vaccines: Hepatitis B and HiB.
Family History:

• No history of consanguinity.
• No history of contact with people suffering from TB,
Hepatitis etc.
• No one in the family has similar complaints.
GENERAL EXAMINATION:
The child looks sick and irritable.

Anthropometry:

Expected Actual % of Inference

expected

Length 76 cm 67.5 cm 88.8% Normal

Grade III
Weight 10.3 kg 5.84 kg 56.6% Malnutrition
(I.A.P.)
Head
Circumferen 40.75-45.75 cm 40.5 cm - Normal
ce
* Pallor +ve

* Icterus –ve

* Cyanosis -ve

* Clubbing –ve

* Lymphadenopathy –ve
Head to Toe Examination:
• Anterior Fontanelle open.
• Flat frontal profile
• Epicanthal folds present
• Nystagmus +
• Depressed nasal Bridge
• Low set ears
• Mouth open with protruding tongue
 Vitals:

Pulse: 136 beats/min

BP= 90/56mm of Hg
Respiratory Rate: 68 breaths/minute
(Normal:40)
Temperature: Afebrile
Systemic Examination:
Respiratory System:
(A) Inspection:
No DNS
Trachea central
Movements bilaterally equal with respiration.
Suprasternal and sub costal retractions present.
Type of breathing: Abdomino-throacic.
(B)Palpation:

Trachea central.

Movements bilaterally symmetrical.

Apex beat palpable in the left 4th intercostal space in the

MCL.

Vocal fremitus increased in infra mammary, infra axillary,

infra and inter scapular areas.
(C)Percussion:

Dull note on percussion in infra mammary, infra axillary ,

infra and inter scapular areas.

(D)Auscultation:

Normal vesicular breath sounds heard.

Bilateral basal crepititions heard.
Increased vocal resonance.
Abdomen:

(A)Inspection:
No distention, visible masses or engorged veins.
No scars present.

(B)Palpation:
Soft on palpation.
Liver was palpable 5.5cm below the costal margin in
the mid clavicular line.
Spleen not palpable.
(C)Percussion:
No shifting dullness.

Liver span = 8 cm

(D)Auscultation:
Normal bowel sounds heard.
Cardiovascular System:
S1, S2 heard.
S2 normal split.
No murmurs.

Nervous System:
No abnormality detected.
 Diagnosis

Severe Pneumonia….

# Chest indrawing present

# Fast breathing.
Investigations:
Chest X Ray:
Lab Investigations:

Normal Range

Hb% 9.8gm% 11-14gm%

Total WBC 16,300 6,000-16,000

Platelet 2,71,000 2,00,000 -5,50,000

ESR 20mm/hr
 Peripheral Smear:

RBCs: Normocytic Normochromic,

Anisopoikilocytosis +,
nucleated RBCs +

WBCs: Increased.
Neutrophils raised, left shift present.
Karyotyping:
Trisomy 21 found.
USG Abdomen:

Normal study.

Echocardigram and Doppler:

Revealed ASD, VSD, PDA.

Neurosonogram:

Normal Study.
 Family Particulars:
Type of family: Nuclear
Name Age Sex Relation Literacy Occupation Income Present
to head state of
health

Ramesh 37 yrs M Head X Std Taxi Driver Rs. Healthy,

5000/- Smokes

Geeta 36 yrs F Wife VII Std Housewife - Healthy

Kartick 6 yrs M Son I Std - - Healthy

Padmakshi 14 F Daughter - - - Affected

mnts child
Housing and Environment :
• Type of house: Pucca

• Source of water supply: Well

• Fuel: LPG

• Method of waste disposal: Community waste disposal.

• Personal Hygiene: Good. (Take bath everyday, wash

hands before and after meals, clean nails)
Actions to be taken:
At Individual level:
• Adequate nutrition must be provided to the child.
• Breast feeding should be continued.
• As the child is suffering from severe pneumonia, treatment must
be started according to the protocol:
1)IM injections of Benzyl Penicillin / Ampicillin /
Chloramphenicol.
2) Review after 48 hours.
Antiobiotic therapy must be given for a minimum of 5 days and
continued for atleast 3 days after the child gets well.
At family level:

• Father must be advised to not smoke in the house

to prevent indoor air pollution.
• Adequate hand washing must be promoted.
• Strengthen family’s capacity to recognize danger
signs.
• Promote prompt care seeking.
At community level:
• Promote exclusive breast feeding for the first six
months.
• Prevent low birth weight.
• Vaccination against measles, pertussis, Spn and Hib.
• Prevention of HIV in children.
• Promote care seeking.
• Increasing access to appropriate care through
community based case management.
Thank you…