ARI (PNEUMONIA)

CLINICOSOCIAL CASE
PRESENTATION
SWATHI KANNAN
7 TH TERM
BMCRI
DEMOGRAPHIC DETAILS

Name : Master ABC

Age : 3 years 1 month

Sex: Male

Religion : Hindu

Address-Bangarapet, Deshalli, KGF main road, Kolar

Informant: mother(Reliable ): Age-25years Education – 4th std

DOA- 31/1/20

DOE-31/1/20
FAMILY STRUCTURE Education 2
Number of Family members : 4, Type of family :
Nuclear Monthly income 2

Head of family- Father of ABC- XYZ Occupation 3

Score 7
Total family income: 10000 per month
Upper Lower
Percapita income : 2500 per month class
Socioeconomic status : Upper lower class

Modified Kuppuswami Classification

Relation to Education Occupation
S.No Name Gender Age Marital Income Health
head of Remark
Family
status
1 XYZ M 30 --- Married 5th std Labourer 5000 SMOKER
(10years)
2 GHI F 25 Wife Married 4th std Labourer 5000 CHEWS
PAAN
3 JKL F 5 Daughter --- --- ---- --- ----

4 ABC M 3 years 1 Son --- --- ---- --- ----

month
CC-
1)Nasal stuffiness since 7 days
2) Cough and fever since 5 days
3) Fast breathing since 4 days

Patient was apparently normal 7 days ago when she developed nasal stuffiness and runny
nose. It relieved with medications .

The child developed wet cough 5 days ago which was insidious in onset, not associated
with post-tussive vomiting. The cough is gradually progressive in nature . It has now begun to
interfere with the child’s sleep .There was no diurnal variation of cough.

Patient developed fever 5 days ago. It was high grade in nature associated with rigors. It was
not associated with rashes. The fever was intermittent in nature relieved with medications.
Child was well during the inter febrile period. Older sibling had fever 10 days ago.
There is history of fast breathing since 4 days. It was insidious in onset. It was associated with
difficulty in breathing and noisy breathing.

No H/O ear tugging , ear discharge

No H/O mouth breathing, voice change, snoring
No H/O wheeze

No H/O convulsions or vomiting

No H/O unconsciousness
No H/O diarrhoea
No H/O bluish discolouration of lips or extremities
No H/O refusal to feed

No H/O repeated hospitalizations or nebulisations

No H/O chronic cough in the family or in neighbours.
FAMILY HISTORY
No H/O genetic or chromosomal disorders in the family
No H/O Bronchial asthma in the family
Non consanguineous family

PAST HISTORY
The child had h/o diarrhoea 6 months back.
There is no h/o suck rest suck cycle. No h/o sweating of forehead after
feeds.

PREVIOUS PREGNANACY
First child (female)- 5years
Normal vaginal delivery
No contraceptives used after birth of the child.
Inter-pregnancy interval – 1 year 11months
BIRTH HISTORY
ANTENATAL HISTORY

Booked Pregnancy
Iron and Folic acid tablets were taken.
In first month dT booster was taken
No H/O fever or rashes during the pregnancy.
No H/O increased blood sugar levels and no H/O increased BP during pregnancy.
All 3 scans were done

NATAL HISTORY
Term delivery normal vaginal delivery at hospital.
Birth weight- 2.4 kg, cried immediately after birth
Breastfeeding was started within 30 min of delivery.
POSTNATAL HISTORY

Child was exclusively breastfed up to 6 months of age.

Ragi-sori was started as complementary feeds during weaning.
After 1 year of age child began sharing the family pot .
No H/O Hospital admissions
Mother underwent IUCD placement within 1 day of delivery.
IMMUNIZATION HISTORY

AGE SCHEDULE
At birth BCG , OPV-0 , HepB-0

6weeks Penta-1 , Rota-1 , fIPV-1 , OPV-1

10weeks Penta-2, Rota -2, OPV-2

14weeks Penta-3 , Rota-3 , fIPV-2 , OPV-3

9months Measles and Rubella , Vitamin A

18 months DPT booster, OPV booster, Measles and Rubella-

2nd dose
Immunisation is complete according to NIS.
DEVELOPMENTAL HISTORY
GROSS RIDES TRICYCLE, ALTERNATE FEET GOING UPSATIRS

FINE TOWER OF 9 BLOCKS , COPIES CIRCLE

SOCIAL Shares toys, knows full name and gender

AND
ADAPTIVE
LANGUAGE Asks questions , knows full name and gender

For the present age of 3 years 1 month the latest developmental milestones are
achieved in all 4 domains. So development is appropriate for age.
PERSONAL HYGIENE STATUS- Mother
S.No Component Condition Remarks
1 Hair, Nails clean long nails,
2 Teeth Poor Chews paan
3 Bath regular
4 Washing hands
1)before and after Done
feeding child
2)After ablution
with soap and water Only water
5 Clothes clean
6 Footwear good slippers
DIET HISTORY
MEALS FOOD STUFF CALORIES PROTEIN
Diet is mixed predominant
CONSUMED
Staple food : Rice
BREAKFAST LEMON RICE(1cup) 110 2.2
Total calories required-1060kcal
11a.m Milk (1/2 glass) 83kcal 4
Total proteins required- 12.9 g
LUNCH Kitchri(1cup) 355kcal 3

5p.m Biscuit(2 parle-G) 37kcal 0.33g

Calories consumed = 706kcal
DINNER Bread -2slices 121 2
Calories deficit=354kcal

Calorie Deficit percentage=33%

Protein consumed=11.53g

Protein deficit =1.37g

Protein deficit percentage

=10.6%
ENVIRONMENTAL HISTORY
Pucca house.
Separate
4 members , enough space
Floor - Cement
Roof – Cement
Walls- Plastered
Rented house with 1 room , 1 hall
1 door in home only
one window in hall cum attached kitchen – window size 1/6th floor area
one window in room – window size 1/4th of floor area.

over crowding present

Lighting is inadequate – both natural and artificial

ventilation is inadequate
 Attached kitchen, with cooking platform. Firewood is used.

Food grains are stored in air tight containers.

Cooked food is eaten on the same day it is prepared.

Drinking water- tap water boiled. Water for drinking is stored in pots .

A cup is used to retrieve the water.

One bathroom outside home with

continuous water supply. Proper Drainage system is seen
Surroundings- Dirty

Waste disposal : regularly collected(once a week) Occasionally waste is disposed to nearby

vacant site.

No sites of stagnant water around the house .

Domestic Pets- Cat

Distance of nearest health facility : 5km

SUMMARY
Here is a 3 years 1 month old male child , who came to the hospital after mother noticed nasal
stuffiness for 7 days, cough and high fever for 5 days , fast breathing for 4 days with flaring of
ala-nasi, intercostal and subcostal retractions and grunting . It was associated with difficulty in
breathing and noisy breathing . There is no past history of suck-rest-suck cycle , sweating of
forehead after feeding or prolonged feeding . The child belongs to a upper lower class family
according modified Kuppuswamy classification. He was born out of a non consanguineous
marriage. His immunization history is up to date according NIS. His diet is deficient in calories,
protein ,fruits and green leafy vegetables.
GENERAL PHYSICAL EXAMINATION
The child is alert but quiet.
He was examined in supine position.

VITALS-
Temp- 38 degress Celsius , measured in axilla(Normal values= 36.5 to 37.5 degrees celsius)

Pulse- 120bpm (Normal H.R= 100bpm) , normal in rhythm and volume.

Respiratory Rate- 50 breaths per minute,(NORMAL VALUES- 30 cycles per min)

abdomino-thoracic type (flaring of ala nasi and usage of accessory muscles of respiration was seen)

BP-100/60mmHg measured over right brachial artery in sitting position (Normal value= 76 to
96mmhg of systolic)
O2 saturation- 96%
NO STRIDOR IN CALM CHILD
HEAD TO TOE EXAMINATION
Skull shape- Normal, fontanels closed .
Eyes- not Sunken, no pallor, no Bitot’s spots
Nose- Flaring of ala nasi, congested nasal mucosa
No deviated nasal septum
Lips- no cleft lip
no cyanosis
Tongue- appears moist
Oropharynx- Normal Tonsils
Posterior pharyngeal wall- inflamed
Palate- no cleft palate, no high arched palate
Teeth- normal dentition
Nails- no clubbing
Skin- normal, BCG scar over left arm
Spine and back – normal
No edema
No lymphadenopathy
ANTHROPOMETRY
OBSERVED EXPECTED INTERPRETATION

WEIGHT 12.9 14.5 -1SD

HEIGHT 93cm 96.7cm -1SD

WEIGHT FOR 0SD 0SD

HEIGHT
MAC 14cm 15cm

HC 50cm 50cm
RESPIRATORY SYSTEM EXAMINATION
INSPECTION
Shape of chest- Elliptical in shape
Spine- Normal
Trachea- appears central
Apex beat- not visible
Movements with respiration decreased on both sides.
Subcostal and intercostal retractions are seen. There is use of accessory muscles of respiration.

PALPATION
Inspectory findings were confirmed on palpation.
No tenderness, no local rise in temperature
Position of trachea central
Apical impulse felt- in left 4th intercostal space medial to midclavicular line
PERCUSSION
Decreased resonance on percussing both lungs

AUSCULTATION
Diffuse crepitation were heard in both the lungs.
SYSTEMIC EXAMINATION
Cardiovascular examination
S1 and S2 heard. No murmurs

Abdominal examination
No mass per abdomen , No Organomegaly

CNS examination
No neurological deficits present
Remarks and Clinical Diagnosis
Here is a 3 years 1 month old male child , who came to the hospital after mother noticed nasal
stuffiness for 7 days, cough and high grade fever for 5 days , fast breathing for 4 days with
difficulty in breathing and noisy breathing .
Examination revealed decreased chest movements both sides and use of accessory muscles of
respiration . Auscultation revealed diffuse crepitation on both sides.
diagnosis- A case of viral bronchopneumonia, belonging to PINK ( SEVERE PNEUMONIA) according
to IMNCI.

KNOWLEDGE ATTITUDE PRACTICE

KAP about disease
1)Causative factors- Careless Poor practice
Ignorant about risk factors like
overcrowding, smoking,
firewood fuel. Lack of
awareness about good
nutrition
TREAMENT
According IMNCI, child should be treated with antibiotics intramuscular (Benzyl Penicillin/
Ampicillin/Chloramphenicol) for first 48 hours, given 6 hourly .If condition improves, switch to
oral ampicillin, chloramphenicol or procaine penicillin. If condition does not improve CHANGE
antibiotics.
Antibiotic therapy should be given for minimum of 5 days and continued for at least 3 days after
the child gets well.

Monitor food and fluid intake

Advice mother on home management on discharge.