Cough or difficult breathing Case I

Chapter 4

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.

What are the stages in the management of Faizullo?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

Have you noticed any emergency (danger) or priority (important) signs?

Temperature: 39.5 0C, pulse: 120/min, RR: 60/min with moderate chest indrawing, warm hands and feet, tired but looking around

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

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.

Examination
Faizullo had fast breathing and moderate chest indrawing. He had no signs of cyanosis. Vital signs: temperature: 39.5 0C, pulse: 120/min, RR: 60/min SpO2: 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

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

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)

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)

Further examination based on differential diagnoses

Look for
General:
- grunting, wheeze, stridor, head nodding, raised jugular venous pressure, severe palmar pallor

(Ref. p. 76-77)

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

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

Investigations
Pulse oximetry (SpO2 : 92%) Chest x-ray:

(Ref. p. 77)

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)

How would you treat Faizullo?

Treatment
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.

(Ref. p. 82)

What supportive care and monitoring are required?

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)

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)

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.

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.