1. Chapter 4 Cough or difficult breathing Case I

2. Case study: Faizullo
Faizullo is a 3-year old boy presented in the hospital with a 3 day history of cough and cold. 24 hours before coming he became tired and began to breathe rapidly, and complained of left-sided chest pain.

3. What are the stages in the management of Faizullo?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. Have you noticed any emergency or priority signs?
Temperature: C, pulse: 120/min, RR: 60/min with moderate chest indrawing, warm hands and feet, tired but looking around

6. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable,
lethargic
Referral
Malnutrition
Oedema of both feet
Burns

7. History
Faizullo is a previously well 3-year old boy who presented with a 3 day history of moist cough.
1 day before coming to hospital he became tired and began to cough and breathe rapidly, and complained of left-sided chest pain.
He was still able to drink but took less than half of his normal intake.

8. Examination
Faizullo had fast breathing and moderate chest indrawing. He was not cyanosed.
Vital signs: temperature: C, pulse: 120/min, RR: 60/min
SpO2: 92% on room air
Weight: 15 kg
Mouth: dry mucus membranes, red pharynx, no cyanosis
Ears: red tympanic membranes
Chest: some nasal flaring; dullness to percussion and decreased breath sounds over left lower chest at the back
Cardiovascular: two heart sounds were heard with
no added sounds
Neurology: tired but alert; no neck stiffness

9. Differential diagnoses
List possible causes of the illness, in order they are likely, use clinical features to say which are most and least likely (Ref. p )

10. Differential diagnoses
What clinical features make these diagnoses most or less likely?
Pneumonia
Severe anaemia
Cardiac failure
Congenital heart disease
Tuberculosis
Pertussis
Foreign body
Effusion/empyema
Pneumothorax
Pneumocystis pneumonia
(Ref. p )

11. What investigations would you like to do to make your diagnosis ?

12. Investigations
Pulse oximetry (SpO2 : 92%)
Chest x-ray:
(Ref. p. 77)

13. Diagnosis Summary of findings:
Examination: chest indrawing, nasal flaring, decreased breath sounds left
Fast breathing: 60 / min
for age 1-5 years ≥40/min (Ref. p. 80)
Chest x-ray shows left lower lobe opacity
SpO2 : 92% on room air
Severe Pneumonia (Ref. p. 80)

14. Treatment
Benzylpenicillin 50,000 units/kg IV 6 hourly for at least 3 days
When he improves, switch to oral amoxicillin (25mg/kg 3 times a day). The total course of treatment is 7 days.
(Ref. p. 82)

15. Supportive Care Paracetamol (pain)
Remove by gentle suction any thick secretions in the throat, which the child cannot clear spontaneously
Ensure that the child receives daily maintenance fluids appropriate for the child's age
Give fluids preferably by mouth and encourage the child to eat as soon as food can be taken
If wheeze is present, give rapid-acting bronchodilator
(Ref. p. 83)

16. Monitoring
The child should be checked by nurses frequently (at least every 3 hours) and by doctors at least twice a day Observations of:
Respiratory rate
Pulse
Temperature
Oxygen saturation if pulse oximeter is available
Use a Monitoring chart (Ref. p. 320, 413)
Daily medical check
Assess fluid intake, daily weight
Within two days there should be improvement (if not look for complications or other diagnoses) (Ref. p. 83)

17. Discharge planning and Follow-up
After 2 days Faizullo's fever had resolved and he was walking around and eating well. He was discharged on day 3 with oral amoxicillin and an appointment for review in the further 5 days.
His mother was told to return sooner if Faizullo's breathing became worse or other symptoms developed.

18. Summary
Faizullo is a 3 year old boy who presented with a typical history of pneumonia.
He responded well to intravenous antibiotics and oxygen therapy.
He only required 3 days in hospital, but needed to be followed-up 5 days after discharge to ensure he had completed his oral antibiotics and had remained well.