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) 1.Triage 2.Emergency treatment 3.History and examination 4.Laboratory investigations, if required 5.Main diagnosis and other diagnoses 6.Treatment 7.Supportive care 8.Monitoring 9.Discharge planning 10.Follow-up

5. Have you noticed any emergency (danger) or priority (important) signs? Temperature: 39.5 0 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 was a previously well 3-year old boy who presented with a 3 day history of upper respiratory tract symptoms. 24 hours 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 only took about one third of his normal intake.

8. Faizullo had fast breathing and moderate chest indrawing. He had no signs of cyanosis. Vital signs: temperature: 39.5 0 C, pulse: 120/min, RR: 60/min SpO 2 : 92% on room air Weight: 15 kg Mouth: dry mucus membranes, red pharynx, no cyanosis Ears: reddened 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 Examination

9. List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 77-79) Differential diagnoses

10. Differential diagnoses (continued) Pneumonia Malaria Severe anaemia Cardiac failure Congenital heart disease Tuberculosis Pertussis Foreign body Effusion/empyema Pneumothorax Pneumocystis pneumonia (Ref. p. 77-79)

11. Additional questions on history Cough - duration in days - paroxysms with whoops or vomiting or central cyanosis Exposure to someone with tuberculosis History of choking or sudden onset of symptoms Known HIV infection Personal or family history of asthma (Ref. p. 76-77)

12. Further examination based on differential diagnoses Look for General: - grunting, wheeze, stridor, head nodding, raised jugular venous pressure, severe palmar pallor Chest: - apex beat displaced/trachea shifted from midline, auscultation: coarse crackles or bronchial breath sounds, gallop rhythm of heart; percussion signs of effusion Abdomen: - abdominal masses, enlarged liver and spleen (Ref. p. 76-77)

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

14. Investigations Pulse oximetry (SpO 2 : 92%) Chest x-ray: (Ref. p. 77)

15. Diagnosis Summary of findings: Examination: chest indrawing, nasal flaring, decreased breath sounds left -fast breathing: -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)

16. How would you treat Faizullo?

17. Treatment (Ref. p. 82) Benzylpenicillin 50,000 units/kg IM or IV 6 hourly for at least 3 days When he improves, switch to oral amoxicillin (25mg/kg 2 times a day). The total course of treatment is 5 days.

18. What supportive care and monitoring are required?

19. 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)

20. 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)

21. 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.

22. 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.