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PEDIATRIC PNEUMONIA (Part 1) Clinical Case Presentation — Transcript

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0:00Ma'am thank you ma'am I'm presenting a
0:02case of a child named master XY Z he is
0:053 years 2 months old born out of
0:07non-consanguinous marriage is from
0:10hailing from hulkotic gad is Hindu by
0:12religion informment is his mother ABC
0:16her age is 26 years and education 10th
0:19standard date of examination 3rd of
0:21March 2020 and date of examination was
0:244th March 2020 coming to the chief
0:28complaints cuffs in sixth days, fever
0:30since 5 days, difficulty in breathing
0:32since 3 days.
0:35History of presenting illness. The child
0:37was apparently well 6 days back. Then he
0:40developed the cuff which was sudden in
0:42onset. There were no aggravating
0:44factors. Cuff has relieved after taking
0:47medications. There is no uh there is no
0:50dal variations. There is also history of
0:53rapid respiration, noisy breathing and
0:56fullness of chest. There is also history
0:58of fever since 5 days which is sudden in
1:01onset present throughout the day.
1:03High-grade fever associated with chills
1:06not associated with rashes relieved
1:08after medications.
1:11There is also history of difficulty in
1:13breathing since 3 days. It is of
1:16incidious in onset, progressive in
1:18nature, aggravates during feeding,
1:20relieved on medication. There is also
1:22history of chest retractions and
1:24grunting. There is history of
1:26irritability, excessive crying,
1:29increased food intake since a week.
1:31There is no history of running nose, ear
1:33pain or ear discharge. There is no
1:36history of mouth breathing, snoring,
1:38difficulty in swallowing, horarsseness
1:40of voice. There is no history of bluish
1:42discoloration of the lips or
1:44extremities. There is no history of
1:46vomiting, diarrhea, worms in stool,
1:48joint pains, headache or malise.
1:52There is no history of hemoptasis,
1:54evening rise of temperature, no history
1:56of postal preferences, just pain. No
1:59history of whis. There is also no
2:01history of daytime sleepiness, altered
2:03sensorium or convulsions. There is no
2:06history of bleeding from nose or trauma
2:08to the chest. There is no history of cry
2:10during maturation. There is no history
2:13of progressive palo, pica, bot spots or
2:16bleeding gums.
2:18[Music]
2:20Okay. Okay. Uh
2:23uh yeah uh you have completed till hopi.
2:27Uh basically few comments about your uh
2:31initial presentation regarding the
2:34informment is uh uh better to tell the
2:37reliability also. Since it is a mother
2:39we understand it is uh the uh
2:43information is reliable but it is better
2:45to mention about that specifically. Uh
2:49one comment and uh other than that uh go
2:53to the sing history page chief
2:56complaints. Yeah.
2:58Uh yeah just tell me about your thought
3:02process about cough,
3:06fever and difficulty in breathing.
3:07Whatever the chief complaints, what
3:09thoughts come to your mind and uh which
3:11system may be involved and what may be
3:14the disease? What are your uh thought
3:16process after the chief complaints?
3:19Sir, uh I would I think about
3:21respiratory tract uh is involved sir.
3:24Okay.
3:26Um it may be upper respiratory tract or
3:28lower respiratory tract sir. Uh since
3:30there is difficulty in breathing maybe
3:32lower respirate tract may be involved
3:34sir.
3:35Okay. And uh other thing about the chief
3:38complaint since the child is a
3:40three-year-old uh uh uh
3:44uh this child specifically can't
3:48complain about difficulty in breathing.
3:51The breathlessness is basically a
3:53complaint in an adolescent or in an
3:55adult. Either it is better to mention it
3:58as a fast breathing or a slow chest
4:01retraction or a refusal to feed
4:03something like that than a difficulty in
4:05breathing as the child three-year-old
4:08child may not complain about difficulty
4:11in breathing by herself. So better to
4:14mention in that
4:16okay sir.
4:16Yeah.
4:17Okay. Uh
4:19shanti.
4:22Hello.
4:26Hello.
4:37Hello.
4:40Yeah. One second. One second. Yes sir.
4:44Son,
4:44are you there? SRI
4:49are you there?
4:50Yeah. Yeah, I can hear now.
4:52Yeah. Yeah. Can you please continue?
4:54Yeah. Yeah. Sure. So, uh we were talking
4:56about difficulty in breathing, right?
4:59Yes.
5:00Yes. So, we cannot in a uh this small
5:04child we cannot comment on the
5:06difficulty in breathing. So, what mother
5:09observes is hurried breathing. Just that
5:12means you can say fast breathing in the
5:14form of some chest retractions or
5:16grunting that as you mentioned in your
5:18next slide right
5:20yes ma'am
5:21hello can you hear me
5:23yes ma'am I'm here
5:24yes
5:25hello
5:26hello
5:27yeah you are audible audible please
5:30okay fine so what is your thought
5:32process cough fever and difficulty in
5:34breathing is it an acute onset or is it
5:36there since so many days what is your
5:38thought process
5:40it is a acute onset ma'am.
5:42So what it could be acute onset fever,
5:46cough and difficulty in breathing in a
5:482-year-old child. What it could be
5:51ma'am? Respiratory tract infection.
5:54Okay. Respiratory tract infection that
5:56is acute in onset right?
5:58Yes ma'am. Yes ma'am.
6:00Fine. So go to your next slide.
6:03[Music]
6:05Okay fine. Uh you complained about the
6:09cough right? cough. Uh you said it is
6:12sudden onset and there is no aggravating
6:15factors. In a 2-year-old child, it is
6:17very difficult to comment much about the
6:20dial variation, postural position, all
6:22that. It is very difficult. So what we
6:25can say is cough whether it is wet
6:28sounding or not wet sounding. So when
6:31the child coughs the child cannot
6:33expectate 2 year old child until 5 years
6:36of age the child cannot expect it.
6:39swallows and it vomits out. So that is
6:42called postersive vomiting that happens
6:45after the 5 years of age.
6:47Okay ma'am. So the expectation we can
6:50comment only after 5 years of age. Till
6:525 years of age the child whatever is the
6:55sputum it swallows and it post vomits
6:58out that is called postal vomiting. So
7:01here in your cough you can say cough it
7:04was sudden onset.
7:08So a sudden in onset here in pediatrics
7:11is very scary. Why? What are the reason
7:15for your sudden onset cough in a
7:17pediatric 2 year 2 year old child?
7:20Right.
7:21Yes ma'am.
7:22So what it could be the reason for the
7:24sudden onset cough.
7:27Yes. Many are typing it is foreign body.
7:29Exactly. The child might be eating uh
7:32some uh ground nut or whatever that
7:36causes sudden obstruction and it causes
7:38sudden onset cough in a child.
7:41Yes ma'am.
7:42Okay. So usually the cough it will be
7:45insidious onset in pediatric. Sudden
7:47onset cough it goes in terms of uh this
7:51thing foreign body aspiration. Okay. And
7:55you can say whether it is wet type of
7:57cough or dry cough type of cough. So the
8:00basically mother feels whether it is dry
8:03cough or wet kind of cough. Okay. So you
8:07can hear say insidious in onset dry type
8:11no postive vomiting.
8:14Okay ma'am.
8:15Okay. So in uh some other uh situation
8:18if a uh older child has a dal variation
8:21of cough uh so what dation dional
8:24variation of c uh you think of in a
8:27pediatric age group
8:29ma'am uh generally in bronchalma there
8:31will be noal cuff ma'am.
8:33Yes. Yes. So there will be a noxal cuff.
8:37Okay. Uh and as shriy said there is no
8:40postal variation. Usually the postial
8:42variation what we talk about is in case
8:45of a cough in a bronchasis but
8:47bronchiais the disease itself is very
8:50rare in case of pediatric population. So
8:52you generally no need to mention that
8:54there is no portional variation because
8:56if you mention it and all the whole uh
8:59discussion will go into uh that part.
9:02Okay. So whatever you mention whether it
9:05is relevant to the case then only
9:07mention otherwise no need to mention.
9:09Okay.
9:09Okay. And there is a history of rapid
9:12respiration you told now. So in this
9:14child what are the possibilities? I mean
9:17what are the causes of rapid respiration
9:19or fast breathing? What all you can
9:21think of?
9:22Other than the lower respirator
9:24infection what other causes can
9:26not only in this child in this scenario
9:28in a pediatric what are the causes of
9:31fast eating? What is she asking about?
9:35Um if there is any metabolic acidosis
9:38kind of thing. Yes, correct. Metabolic
9:40oasis
9:42um if there is any brain stimulation.
9:46Okay.
9:47Okay. ICT you mean? Okay. Generalizely
9:51all the conditions which cause
9:54intraanial tension. Yeah. Okay.
9:56Yes.
9:58Okay. So uh think from the simple uh
10:01part. So nasal block in a pediatric age
10:04nasal block can cause fast breathing.
10:07Okay. in an active happy child otherwise
10:09okay child nasal block is a most common
10:11cause and fever when there is a high
10:13temperature that the breathing
10:15respirator rate increases that can also
10:17cause a uh fast breathing that and
10:21acidosis as you told already and uh in
10:24this child obviously there is a lower
10:26respiratory tract infection that can
10:27also cause fast breathing. So one very
10:30important cause of fast breathing in
10:32pediatric is cardiac condition. Okay. So
10:36the cardiac conditions like cardiac
10:38failure in a pediatric case presents
10:41also as a fast breathing that is one of
10:43the most differential diagnosis you have
10:45to keep it in your mind. Okay.
10:47Okay ma'am.
10:47And uh there is noisy breathing you
10:50told. Okay. Then you tell me what are
10:52the causes of noisy breathing and what
10:54are the different types.
10:56Um ma'am uh
10:59strider ves.
11:01Yes. So uh can you uh tell me in the
11:03anatomical region also when there is a
11:06uh when you say it's strider where is
11:08the pathology
11:09ma'am uh if there is strider we suspect
11:12there is a lesion in laryingot tracheal
11:15region.
11:15Yes. Yes. Upper respirator tract
11:17upper respirator tract.
11:19Then v is generally seen in the lower
11:21respir in alva or the bron bronchios or
11:24the bronus is involved. So V is
11:26basically
11:27basically the strider is mainly due to
11:30the involvement of it is the lower
11:32respiratory tract can be a lower
11:34respiratory track. The lesion can be
11:36below the glauus also but it is
11:39extrahypatic trachea or bronchi or a
11:42larynx and we will hear the V when the
11:46lesion is within the intrahypatic region
11:50and sorry intra thoracic region and the
11:53bronchi or a bronchial.
11:56Okay. And what are the other noisy
11:58breathing we you anticipate in the
12:00respirator? Yes.
12:03Uh sir rattling
12:06crepitations.
12:07Okay that is more of a oscultative
12:09finding. Uh
12:11other than this you can tell as
12:13grunting. Yes.
12:15What is what does the grunting specify?
12:19Uh sir there is a increased effort of
12:22breathing is present. We can say
12:24grunting is mainly uh is the post
12:28expiration against the closed glottus.
12:30It is actually granting suggest it is
12:33the alvolar lesions. Okay. When the
12:36alvar alvoli are about to collapse, it
12:39is the protective reflex to keep the
12:41alvoli open.
12:43Okay.
12:44You got it.
12:45Yes sir.
12:46Okay. So what do you mean by fullness of
12:50ma'am? I'm not sure about this like why
12:52I mentioned is like as the child
12:55swallows all the spumm so there will be
12:58secretions will be within the bron
13:00bronus so I mentioned it as fullness of
13:03chest ma'am
13:04okay so
13:05fullness probably I don't think it will
13:08be very intelligent to present at
13:11present fullness we will think more of a
13:14whether it is a localized plural eusion
13:16whether it is fullness is generalized or
13:19a localized condition
13:21or any chest wall deformity which is
13:23presenting as fullness. So otherwise to
13:26notice uh by the mother that the
13:29fullness of the chest it is unlikely to
13:32uh caused by the uh uh the events what
13:35you explained. So better not to mention
13:37it. Okay. Unless there is a br chest
13:40wall deformity which is visible grossly
13:43otherwise no need to mention it as
13:44fullness of chest
13:46or fullness of the chest will be seen in
13:48either localized will be seen in a
13:50plural generalized fullness can be seen
13:53in an emphyma or a bronchulitis with the
13:57hyperinflated lung then only uh the
14:01fullness of the chest will be seen.
14:03Okay sir. Okay. Okay.
14:06Then
14:06about the fever,
14:07fever you have mentioned uh almost uh
14:10everything. Okay. High grade fever in a
14:13uh three year old again it is little
14:16difficult to say whether associated with
14:18chills or not. Okay. Uh maybe uh it is
14:21associated and if fever is associated
14:24with rash and there is cough and fast
14:27breathing what disease you think of?
14:32Fever.
14:33Yeah. Exanthamatus fevers like measles.
14:37So
14:37yes, very good. Measles is a one disase
14:41which we generally call it as three C's.
14:44Cough, conjunctivitis and corisa. Okay.
14:47And rashes obviously. So when there is a
14:51rash not only measles other viral exam
14:53things also can cause a uh cough uh uh
14:57pneumonia like uh picture and when there
15:00is a uh rash and uh lower respir the
15:03symptoms suggest of lower respiratory
15:05tract infection we usually think of
15:07viral pneumonia than the bacterial uh
15:10pneumonas.
15:11Okay ma'am.
15:12Okay. So go ahead.
15:13There can be other viral exantimatus
15:15fever also rarely bacterial infections
15:18like stafalopile pneumonia can have
15:20associated rashes. Other things are also
15:23you can think of. And one more thing
15:25what I felt important is
15:28the activity of the child during
15:31interbral period. Whether the child is
15:33well in in the interbral period or not.
15:37It is better to mention if the child
15:39remains toxic and sick during the
15:41interprial period also we probably think
15:44of the bacterial infections and if the
15:47child becomes well in between the fever
15:50we think more of a viral or a parasitic
15:54infections not in this case parasite are
15:57less likely to cause a respon
16:01okay
16:01okay so go to next slide yes ma'am
16:10Okay. So, difficulty in breathing in
16:13serious onset progressive in nature
16:15aggravates during feeding. So, what what
16:18do you think of when the difficulty in
16:19breathing aggravates during feeding? Dr.
16:23Sajan has already mentioned now
16:26cardiac conditions right. So there is a
16:30suck if there is a uh
16:34breathing difficulty happens during
16:36feeding especially breastfeeding we call
16:39it as sress c suck rest suck cycle okay
16:43and uh there will be sweating of
16:45forehead also right so so when you're
16:49presenting all other complaints or all
16:52your complaints are going towards one
16:53direction that is your lower respiratory
16:55tract direction and you're attributing
16:57this difficulty in breathing also to the
16:59respiratory condition. If you write as
17:02there is a difficulty in breathing
17:04aggravates during uh feeding so there
17:06will be a confusion like what you are
17:09telling that the child has a
17:11cardiovascular system illness or a child
17:14has a pure respiratory tract illness. So
17:16you should be very careful with your
17:17words while you're writing. Okay.
17:20And what what is the what do you think
17:24when when the difficulty breathing
17:26relieved on medication? So what is your
17:28interfer uh inference on that like what
17:30do you think which difficulty in
17:32breathing relieves on medication?
17:34We have talked about fast breathing and
17:36nosy breathing before. No. So what do
17:38you think which which what are the
17:40conditions which relation?
17:43What she meant was fast breathing what
17:45all the condition it can relation.
17:49Example as
17:51yeah asma. So in this asthma with the
17:54nebilization or MDI a child can have a
17:58relief.
17:58Any other possib
18:02if it is due to a fever or a pain with
18:05the dose of paracetamol it can child can
18:08become abr or painfree and the fast can
18:12and simple nasal block will clear with
18:14salon nasal drops or any decongestence.
18:17Okay. So be careful with your words. If
18:20you tell if if the inference is going
18:22opposite of what you are presenting,
18:24better not to mention. Okay? Even the
18:26mother tells you need not uh mention
18:29everything what uh as the mother uh
18:31tells you have to interpret it and then
18:33present it. That will be an intelligent
18:35thing. Okay.
18:36Yeah.
18:38If if the scenario is like fever for
18:43about two to three weeks, cough for two
18:45to three weeks and a fast breathing of
18:48about 3 to 5 days, what will be your
18:50thought process?
18:53Just a change in scenarios.
18:55Yes sir. Uh it may be persistent
18:58pneumonia or TB infection.
19:01Okay. Yeah. Very good.
19:05Uh
19:07yeah.
19:07Okay. If there is a TB infection then
19:10what all history additional history you
19:12want to ask?
19:14Ma'am there will be loss of like the
19:16baby will be not gaining the weight and
19:18uh appetite will be decreased.
19:22Okay. Yeah.
19:24Loss of weight or failure to gain weight
19:27and fever and cough of more than two
19:29weeks. Yeah. And other than that what
19:32important history you will ask in a
19:33pediatric particularis?
19:35Any contact history sir in a family if
19:38there are any TB patient?
19:40Okay. What is the what is called as a
19:43significant contact and how do you
19:45elicit that history?
19:47Yes sir. A significant contact can be
19:49defined as a person the child will be in
19:52a household where a patient is on AT or
19:56he has taken the AT in the past two
19:58years.
19:59Okay. So
20:01whether it should be a sputum positive
20:04tuberculosis or it can be any
20:06tuberculosis.
20:08Yes, sputum should be positive.
20:11That was the old concept at present
20:14according to the R&TCP guidelines even
20:17extra pulmonary tuberculosis in the past
20:20contact with the extra pulmonary
20:22tuberculosis patient in the past two
20:24years is also taken as a significant
20:27contact nowadays. Okay. Previously they
20:30used to tell only the sputum positive.
20:33What differs from the adult tuberculosis
20:35and pediatric tuberculosis is the three
20:37symptom uh concept what we tell fever
20:40for more than two weeks and cough for
20:41more than two weeks. In adult it is
20:44significant face loss more than 5% in
20:46last uh 3 months. In pediatrics along
20:49with weight loss there is if there is a
20:52fail failure to gain weight in last 3
20:54months that's also considered as a
20:56symptom. Okay. And uh when it comes to
21:00contact uh we'll have a question know
21:02when we hear the definition of contact
21:04if pulinary or extra pulinary in last
21:07two years why only two years why not
21:09five years
21:11any idea anybody why only two years why
21:14not five years why not 10 years why not
21:15one year
21:19the chance of reactivation of the baseli
21:23yeah you're almost close uh the concept
21:25is when there is a Exposure to
21:28tuberculosis lifetime lifetime risk of
21:31getting tuberculosis is almost 10% in
21:33general population. Okay. Once the
21:35person is exposed his lifetime risk of
21:37getting tuberculosis as a disease is
21:4010%. In that 50% of the chance is in
21:43first two years first two years of
21:45exposure. So that's why the two years
21:47becomes a uh becomes important and uh
21:51the logically uh if adult TB patients
21:55are uh multibasillary and pediatric TV
21:58gets are posible.
22:00Yeah. So the infectivity rate is more if
22:03the adult is infected.
22:05And uh when you get ask for the history
22:08of contact while asking the parent you
22:10will not just ask that any patient uh
22:13any uh TB patients are there in the
22:15family. So uh everybody may not come up
22:18with the answer and everybody may not
22:20know. So you you have to ask
22:22intelligently asking any chronic cough
22:25which is not treated or anybody uh any
22:27death in the family died due to
22:30unexplained cough not treated or anybody
22:33in the neighbor or in the street where
22:35the child goes for play or anything or
22:37especially in schools. This data or this
22:40history is missing in most of the case
22:41presentations. any child with chronic
22:44cough or chronic lung conditions which
22:46is chronic absent uh from the school or
22:49any teacher who is only long live
22:51because of some uh respiratory
22:53conditions. So all this history becomes
22:55important. So that's why you have to ask
22:57complete history. Okay. Okay. And okay
23:00uh uh some point is like uh the
23:03tuberculosis if there is a contact then
23:05we should ask that whether is it
23:07completely treated or not because if it
23:11is uh the if tuberculosis is not treated
23:14then we'll give prophylaxis to the uh
23:16child and if it if the adult patient is
23:19a MDR tuberculosis then the whole
23:21management changes so we will offer MDR
23:25treatment to the child not the
23:27prophylaxis so the uh uh complete
23:31treatment history of the contact also
23:33important in your history. Okay. When
23:35you take history if there is a uh case
23:39okay
23:40where did this child belong to? What
23:42address?
23:44Who court is g?
23:46Okay. What is the importance at this
23:48scenario
23:49in a current pandemic situation? What is
23:51the importance of address? We are
23:53referring to 19 situations.
23:57Spardon sir I didn't get your question.
24:00Yeah. Uh this child belongs to a uh what
24:03place you told? Gadak.
24:06Gadak sir. Yes sir.
24:07Yeah. Uh so what is the importance of
24:11address where the patient belong to at
24:14this scenario at this pandemic
24:16situation?
24:16Pandemic situation this corona virus
24:18pandemic situation.
24:19A child is presented with pure cough and
24:22past greeting. You're thinking of a
24:24lower
24:25like red zone, green zone belongs, which
24:27zone the child belongs to.
24:29Yes. Yes.
24:30If the child belongs to a containment
24:33zone or a hot spot, then better
24:36probably you you are thinking of a
24:38corona virus infection and you should
24:41isolate the patient and immediately send
24:44the throat swab until the throat swab
24:47results are uh are available. till that
24:52it is proved to be negative you should
24:54be isolating the patient.
24:55Yeah.
24:56Okay.
24:56Okay. Uh so just a general knowledge
24:58questions uh can you uh tell me uh like
25:02what is the criteria for swabbing at
25:04this stage corona swabing because your
25:07exam going batch and by the time you
25:09present a case in your exam some of the
25:11other questions will be on corona virus.
25:13So uh so at present scenario what is the
25:17criteria for swabing?
25:21uh
25:21what all patient you should send the
25:23throat swap that is what she is asking
25:27there is any past history of traveling
25:29travel history in the last two weeks or
25:32uh there is any contact with
25:34travel history to the places where
25:37community transmission of the corona
25:39virus is proved okay yeah then next
25:43and any contact with the corona vir
25:46positive patient or health care
25:49healthare worker who has been treating
25:51the corona virus positive patient.
25:53Okay.
25:55Health care patient. Okay. Yeah.
25:58Healthare person.
25:59Yes sir.
26:00All the healthare person or specifically
26:03only
26:04symptomatic develop. Yeah.
26:06Symptomatic
26:07healthare person we are sorry. And one
26:10more important is severe acute
26:12respiratory illness that is sari. uh the
26:15history history of fever, cough and or
26:18or breathlessness
26:21with hypoxia saturation less than 94 and
26:24fast breathing according to age related
26:26cutff. So irrespective of the travel
26:29history irrespective of the uh
26:31epological link to a covid patients we
26:33are going to swap that patient. Okay,
26:35these guidelines are uh uh very dynamic
26:39at this stage. This is the criteria for
26:41swabbing. will uh uh it will keep
26:44changing but as a medical students you
26:47should keep a track of what is the
26:50current guidelines because in your
26:51family your friends only may be asking
26:54okay so keep a track of current
26:56guidelines
26:57and in the exams also questions about
27:00the corona virus situation and what are
27:03the present guidelines are very much
27:05expected at this point
27:07okay sir
27:08okay so we'll go to the negative history
27:11okay So
27:12any other thoughts Dr. Shi about the
27:16till now?
27:17No tuberculosis one cardiac case she has
27:21to keep in mind that she has already
27:23yeah yeah shall we move on to a negative
27:26history then? Yeah. Yeah.
27:28Yeah.
27:32Uh okay. Uh
27:33can you please uh Yeah. Uh tell point by
27:37point why have you asked all these
27:40negative historyries? Just in short.
27:42Yes.
27:42Just keep elaborating.
27:45Yes sir. Uh history of running nose, ear
27:47pain, ear discharge. I want to rule out
27:49upper respect symptoms. Sir then mouth
27:53breathing, snoring, difficulty in
27:54swallowing, horarsseness of voice. uh
27:57this is to rule out adinoids or
27:59tonsillitis kind of things and bluish
28:02discoloration. It is to rule out sinosis
28:05which indicates the severity like
28:07hypoxia in the child. Uh history of vom,
28:10diarrhea, worms in stool joint pain.
28:12These are the generalized symptoms to
28:14rule out
28:16other like
28:19example forypical pneumonia which is
28:20caused by uh other organisms. So to rule
28:24out there there is only pulmonary or
28:26systemic symptoms sir.
28:28Okay the vomiting diarrhea uh yeah come
28:32to the previous set. Yeah I could
28:34understand vomiting diarrhea in a case
28:36of a pneumonia you can think of a
28:38multi-ymic involvement a case of either
28:42a viral pneumonia or a septicmia causing
28:45a generalized multi-ymic involvement can
28:47be thought of worms in stools probably
28:50may not be needed at this scenario.
28:53Fever, pop cold,
28:55fast breathing as joint pains. Yeah,
28:57good some
29:01pneumonia causing a lot.
29:04That's a 2year-old child cannot complain
29:07of joint pains and even a mother cannot
29:10assist the joint pain. So joint pain,
29:12headache, malise is irrelevant in this
29:152year-old child.
29:17So any case the negative history uh
29:20should suggest what what is your thought
29:23process. Okay. Any case there is a
29:25pattern to take a negative history. So
29:27when you elaborate the uh with the chief
29:30complaint we have some differential
29:31diagnosis in mind and we have elaborated
29:34the chief complaints. Now now we have to
29:37rule out the uh uh rule out uh one by
29:41one the whatever the differential
29:42diagnosis we have made. Okay. in that uh
29:45direction your differential diagnosis
29:47code. So uh in motors headings you can
29:51tell first you can uh
29:55uh rule out the other system uh uh other
30:00system involvement. Uh for example in
30:02this case you can uh rule out the
30:04cardiovascular involvement by asking uh
30:08any sinosis or uh any uh breathlessness.
30:12Okay. Okay. And three-year-old is very
30:13young to tell a palpitation. But in
30:15older child, yes. So that way you can
30:17ask. Next the concept will be you have
30:20to rule out the when once you rule out
30:22other system examination and you are
30:24sure of that is a respiratory
30:26involvement or lower respiratory act
30:28involvment with the explanation what you
30:30have got from your HOBI. You are going
30:32to look for the complications of lower
30:34respirator involvement. Okay. So in that
30:37direction you have to ask the history.
30:38So what are the complications? what we
30:40expect in lower respiratory tract
30:42infection. Some things have already
30:44mentioned but better to be in a proper
30:47direction. So examiner one is uh sinosis
30:51you have mentioned. Yes.
30:52Hello.
30:54Yes ma'am. Yes ma'am.
30:55Sinosis you have mentioned and history
30:57of repeated vomitics history of refusal
31:00to feed history of seizures history of
31:03lethargy or history of unconsciousness.
31:06These are all symptoms of severe
31:08pneumonia. what you're going to ask in
31:09this condition.
31:11It will it will help you uh uh help you
31:14to recognize whether this child needs a
31:17hospital admission or you are going to
31:19send uh uh send the child home at this
31:22point. This is your uh impression. Okay.
31:26And the next thing will be once you uh
31:30once you know about the complications
31:32then next will be a ideological what is
31:34the ideology of the uh present
31:36condition. So you know this is the
31:38respiratory tract you know whether there
31:40is a complications or not then you're
31:43going to think that what is the ideology
31:46right
31:46whether it is bacterial
31:47whether it is bacterial or uh viral. So
31:51uh when you think of bacteria we have
31:53already mentioned and we would have
31:55asked in the previous uh negative
31:57history also whether the child is
31:59lethargic or feeding well or not all
32:02those things will come or any history of
32:04similar complaints in the uh family
32:07member. So it will more of suggestive of
32:10a viral. So in this means so if there is
32:14a tubicular contact then you are going
32:16to ask this tubicular contact history
32:18and other history related to
32:20tuberculosis in that part. Okay. So
32:22negative history you should have one
32:24direction. So when the examiner listens
32:27to your negative history you should come
32:29to the conclusion like this is a
32:31respiratory yes lower respiratory
32:33infection with complications or without
32:35complication ideology likely is
32:37bacterial or viral or tubl. Okay. So any
32:41case this is a pattern in this
32:43respiratory case it should uh mention
32:45like this
32:46and while writing the history in a less
32:49than 5 year old you should avoid
32:53presenting the all the subjective
32:54symptoms as such like pain or
32:59chills in fever you can't mention you
33:02had mentioned chills in fever you can't
33:03mention in a child with less than five
33:06years of age you can tell only rigers in
33:10a fever. fever or a joint pain, you
33:12can't mention, headache, you can't
33:14mention, breathlessness, you can't
33:16mention. You should make it all the
33:18objective symptoms than a subjective
33:21symptoms in a less than five year rates.
33:23So, daytime sleepiness, altered
33:25sensorium, all those things. Uh uh yeah.
33:29Uh why you have asked that?
33:31Yeah. Continue with the negativity.
33:33So, you got the point now how you should
33:35be presenting. So can you rearrange your
33:37uh negative history and tell us?
33:40Uh yes ma'am.
33:43No history of uh running nose, ear pain
33:45or ear discharge.
33:46Yes, correct. This a part of the
33:48respiratory tract.
33:49Finish up all the upper respiratory
33:51tract symptoms first. Yeah. Okay. Good.
33:53Yes.
33:54And no history of bluish discoloration
33:57of the lips or extremities?
33:59Yes.
33:59Okay.
34:00No history of
34:02daytime sleepiness, altered sensorium or
34:05conversions ma'am to for hypox.
34:09Yeah.
34:10Okay. Daytime sleepiness may not be that
34:12specific in the pediatric age group. All
34:14the kids sleep during the daytime there
34:18decreased activity. You can tell.
34:20Yeah. Decreased activity sensorium.
34:23Okay. Yeah. Convulsions.
34:26Yeah. Then
34:28sir actually in for rolling out the
34:31fever for other causes no issue of cry
34:33during maturation sir.
34:36So this is like when you have the one
34:38system involvement. Okay. So uh in every
34:41case you will not ask other system
34:44involvement for uh fever. So when you
34:46have only fever as a complaint and no
34:48other uh complaints which is specifying
34:51any any system will not ask all uh
34:54symptoms uh to rule out uh fever rule
34:58out the causes for fever. So history of
35:00pride during will not be relevant uh uh
35:04during uh this case. So while presenting
35:07a case you should give a impression to
35:09the examiner that you have taken the
35:11history and you have made an impression
35:12and you are telling the examiner that is
35:14how it should be.
35:16Yeah. What she's meaning is negative
35:18history should be specific to every
35:20case. You should be like you should be
35:23completing or any format or anything.
35:26Okay. So whatever specifically you are
35:30thinking after the HOPI to rule out
35:32specific things only you be asking about
35:34the negative. Yeah.
35:37In a negative first you have ruled out
35:39all the other upper respiratory uh
35:42involvement. Next you have passed all
35:45the complications or a general danger
35:47signs you have mentioned
35:49vomiting decreased feeding cley
35:52unconsciousness
35:53convulsions. This child had a granting
35:56or other things earlier.
35:58You have mentioned it already. So that
36:00should be a sufficient. And instead of
36:02similar complaint in a sibling or a
36:04family member, one line you can mention
36:06just to in this case just to uh
36:13make out what ideological
36:16it could be. Okay. If the multiple
36:19members in the family are involved with
36:21the fever pop infection, we think more
36:24of a viral ideology than a bacterial
36:28ideology. All the parents or a sibling
36:31involved and kid also had got the
36:34similar infection. So heising type of
36:38temperature, bleeding from nose, trauma
36:40to the chest at this point are not
36:43relevant. If you get any uh uh
36:46examination finding like some scar signs
36:49over the chest or uh uh or in a past
36:52history you get the history of uh some
36:54treatment outside or treatment long-term
36:57uh medication taken something like that
36:59then you can come back and add to your
37:02uh negative history. Okay. Otherwise uh
37:05any other thought was there about asking
37:08this negative
37:13likeis evening temperature
37:18okay
37:20to rule out pediatric TB than history of
37:24hemoptis and evening rise of temperature
37:27history of contact should come first
37:29okay sir
37:30okay or weight loss or a failure to gain
37:33weight are the most important complaint
37:35than a hemotis or a evening rice of
37:38temp.
37:38So you need not ask all this history in
37:41every case. If history is longer
37:43duration
37:44then only you ask otherwise no need to
37:46ask. Okay. So uh imagine that this child
37:49has one episode of convulsions. So what
37:52are the causes of convulsions? What
37:54would be the cause of convulsions in
37:56this child?
37:57U febil convulsions.
37:59Yes. Good. File convergence.
38:03uh due to severe uh respiratory distress
38:07uh there may be hypoperusion.
38:10Yeah. Hypoxmia
38:12specific. Yeah. Very good. Yeah.
38:17Okay.
38:17Other than that any infection CN
38:21infections can you think of pneumonia
38:24with menitis?
38:27Yes sir.
38:28Okay.
38:30[Music]
38:32Okay.
38:32Yeah. Very good. These are the most more
38:36commoner causes of the conventions.
38:38Yeah.
38:40So, okay. Uh uh next next history. So,
38:44uh right now we have a history uh sist
38:47of lower respiratory tract involvement.
38:50So, according to your complaints, there
38:51is no complications as of now. And uh
38:54regarding radiology, we are not very
38:55sure of what it is. So we'll see in the
38:57examination and uh uh uh and decide. Dr.
39:02is there any thoughts? Any other thing
39:04to be asked?
39:05No. Carry on.
39:07Okay. Next.
39:09Okay.
39:10Birth. Birth history. Antiatal history.
39:13It is a book case. Birth space of 2
39:15years. Weight gain in pregnancy 8 kgs.
39:18Anamealy scan was done. Iron and folic
39:20acid tablets were taken. Two injection
39:23injections of titanus oxide were taken.
39:25No history of fever in pregnancy. No
39:28history of diabetes malitus,
39:30hypertension or other chronic illnesses.
39:33Natal history fullterm normal vaginal
39:36delivery. Birth weight of 3 kg. Cried
39:39immediately after birth. No history of
39:41NICU admissions. No history of any
39:44congenital anomalies. Breastfeeding
39:46started after half an hour of delivery.
39:49No pre-actal feeds were given. Postnatal
39:52history. Child was exclusively breastfed
39:54for 6 months and beaning was after 6
39:57months. There is no history of
39:58hospitalization.
40:01Developmental history, gross motor
40:04development, rides tricycle, alternate
40:06feet going upstairs, fine motor, copies
40:09circle, builds a tower of six nine
40:11blocks. Personal and social development
40:13knows his full name and gender. Language
40:16ask questions. Tells its name.
40:18Developmental milestones are achieved
40:20appropriately and it corresponds to the
40:22chronological age.
40:26Immunization history. The child is fully
40:28immunized up to date.
40:31Nutritional history. Total
40:33what
40:36immunizations you you will be
40:38specifically interested in a case of
40:41pneumonia.
40:43Sir BCG vaccines are important. Uh BCG
40:47sneakal.
40:50Okay.
40:52Uh influenza.
40:54Okay.
40:56Measles MMR.
40:58Yeah. Yeah. Very good. Uh in a case of
41:02influenza, you should be specifically
41:04asked whether the child has taken the
41:08vaccine in this season for this train
41:10specifically. It's not like influenza
41:13vaccine was taken at six months and
41:15child has present at three years then it
41:17may not be giving a protective case
41:20because influenza schedule is every year
41:23and the strains are the vaccine strains
41:26are modified every year.
41:28Okay ma'am. Uh so so you should be
41:30asking uh specifically
41:32regarding the antiatal history.
41:35If you think it is the acquired
41:38condition not a canatal condition you
41:40need not elaborate so much about the
41:43antiatal history.
41:45Okay you can
41:47directly come to a birth history full
41:50delivery whatever it is can directly
41:52mean
41:52because in your exam you'll not be able
41:54to uh you'll not have this much time to
41:56elaborate your history. So if it is
41:58relevant to your case then only you ask
42:01otherwise the import
42:04conditions if you ask it
42:06uh that is sufficient. Okay. So
42:09regarding immunization can you tell
42:11about Indra what are disases it covers
42:14Indra.
42:16Yes, ma'am.
42:24One of the
42:27members.
42:30Okay.
42:34Then
42:37seven vaccine
42:39Yes ma'am. Hepatitis B and uh TB ma'am.
42:44TB, polio, hepatitis B, deria,
42:49certis, tetanus,
42:51measles
42:52and measles. Whatever the
42:55things we are give giving vaccin we are
42:58giving within the one year of age mostly
43:00it covers except the hemopilus influenc.
43:04So when you tell
43:11immunization status is up to date. So be
43:13careful because uh in a less than one
43:15year old you can't tell that child has
43:17received all vaccinations
43:20which are uh these are the seven
43:23vaccinations which are which complete
43:25the first dose of vaccination schedule
43:27in the
43:29baby. Okay.
43:30So one point here in this is uh so at 6
43:3310 and 14 weeks the child
43:42S your voice is breaking
43:44now the recent guidelines have which I'm
43:47aware of now can you hear me now? Yeah.
43:49Yeah.
43:50Okay. Uh, regarding polio vaccination,
43:53Shraanti, are you aware of the schedule
43:55that is overlapping now? Oral polio
43:57vaccin and the interv
44:01IPV ma'am?
44:02Yes. Yes. What is the schedule you are
44:04aware of?
44:05Uh ma'am IPV is given at 14 weeks ma'am.
44:10Okay. It is a single uh dose. You are
44:13aware of national schedule and IB
44:15schedule. Ma'am I am aware of national
44:18imun immunization schedule ma'am.
44:20Okay. So what is the national
44:22immunization schedule for IPV?
44:24Ma'am IPV is given at 14 weeks ma'am.
44:27One dose of 0.5 ml to be given
44:31intramuscularly ma'am.
44:33So no uh it is uh national is different
44:36and is different. National recommends
44:38two intermal dose because national
44:42because there is a scarcity of uh IPV
44:46all over the world. So that's why we
44:48have given they have nationally 6 and
44:5214p two doses of intraermal.1
44:55ml is national but recommends
44:59intramuscular 10 14 and a booster dose
45:03okay that is overlapping with the
45:08So regarding developmental history so uh
45:10there are two ways uh usually uh one is
45:14if you are mentioning every milestone so
45:18in every do domain you have to mention
45:20every milestone neck holding at this
45:22stage with support is this this stage
45:25all these things but this elaborated
45:27developmental history is not required in
45:29all cases okay so whatever you have
45:32taken is correct so for the present age
45:35the latest developmental milestone
45:36achieved you have to mention in all four
45:38domains and you have to tell development
45:40is appropriate for age or not. Okay. So
45:44for more than five years of age you can
45:46tell child is uh attending school and
45:49good school school performance or
45:50average school performance. So in a more
45:53than five year old you have to mention
45:54about the scholastic performance and you
45:57need not mention it in all four domains.
45:59Okay. So but you should not mix up you
46:01are telling Ross motel all milestones
46:03according to the age and fine motors the
46:06latest milestones achieved. So one
46:08pattern you should follow better to
46:10follow this pattern unless it is a
46:11neurological case or a developmental
46:13delay case. In all other cases better to
46:15follow the latest milestones achieved.
46:18Okay. Okay. Next.
46:25Yes ma'am.
46:26Shall I continue?
46:28Yeah. Yeah. Nutritional history. Total
46:31calories to be taken at this age is
46:33over,35
46:35kilo calories and 13 grams of protein.
46:38But the child is deficient of 265 kilo
46:42calories and 2.4 g. So it corresponds to
46:46a percentage of 19% of calories and 15
46:5058% of proteins are deficient.
46:54Okay. So this is what method?
46:57U ma'am 24 hours recall method.
46:59So uh when you ask a diet history uh uh
47:03you asked in last 5 days what the child
47:06has taken the previous day like that you
47:08have asked or what is the specific?
47:10No ma'am before like before the illness
47:13uh when the child preorbid diet you
47:16should be asking in specific. Okay.
47:19And uh uh you have taken a very good
47:21diet history. But uh uh in in a to
47:25complete this diet history, you should
47:26be asking because he is a three-year-old
47:28and he's on a family pot diet. How much
47:31uh the green leafy vegetables he
47:33consumes or how much how many times he
47:35consumes a non-vegetarian diet in a
47:38bean. So it will give give us a gross
47:40idea what is its iron intake and maybe
47:44this 15% protein uh deficit in a 24-hour
47:48uh recall method may be fulfilled if he
47:52takes non-vegetarian diet or a protein
47:53richch diet uh in alternate days or once
47:56or twice a week. So it is better to
47:59mention that he consumes this many green
48:01leafy vegetables and non-vegetarian diet
48:04in as in addition to these. Okay. Just
48:07to mention this micronutrient uh
48:10fulfillment. Okay.
48:12Okay. Ma'am.
48:13Okay. Next.
48:15Past history. There is similar history
48:17in the similar history in the past when
48:19the child was 2 years old. The child was
48:21admitted to hospital for a week with
48:24complaints of cuff, fever, difficulty in
48:26breathing and was cured completely.
48:28There is no history of bronchasma in the
48:30past or other any illnesses.
48:33Okay. Specifically you would have
48:35mentioned for how many days child was
48:38admitted, whether child was given IV
48:39antibiotic, whether child was evaluated
48:42with the chest X. So those details if
48:44you have you can mention that probably
48:47in the
48:49and other than that
48:51the past history has to come only after
48:53your HOPI not so late.
48:56Yeah, exactly. I was looking for the
48:59past history after the hop also and
49:03other than that I think you can't
49:06mention directly there is no history of
49:08bronchial asma in a kid in a
49:10three-year-old mostly we don't coin a
49:12child as asatic unless it is a very
49:15frequent or a very uh severe one okay
49:19probably the suggestive histories you
49:21can ask history of previous nebilization
49:24history of
49:26repeated cough more in the night which
49:28is disturbing child sleep or history of
49:32any other allergies
49:34like a skin rash those things you can
49:37ask probably that would be more
49:39appropriate in a three-year-old kid
49:42okay past if you mentioned the child had
49:44a similar complaint so even though the
49:47treatment history is not available now
49:50uh available here and the duration of
49:52disease was is not available with the
49:54history if we assume it has a the last
49:57episode was also pneumonia. Then this
50:00child uh is is is he fitting into the
50:03definition of recurrent pneumonia?
50:06Uh
50:07what is the definition of recurrent
50:08pneumonia?
50:09Uh recurrent pneumonia there should be
50:12three episodes in a year.
50:15No can you revise it a bit?
50:21So okay uh the more than two episodes in
50:23last 6 months or more than three
50:25episodes of pneumonia in a lifetime we
50:28classify it as secret pneumonia. So we
50:30should be careful in asking the history
50:32because uh the every uh the cough and
50:36fever episode if the if it is treated
50:38with antibiotic need not be a pneumonia
50:41episode. Okay. So you should be very
50:43careful. the child hospitalized uh
50:46hospitalized for longer days received IV
50:49antibiotics or child was sick enough
50:51then only or the any uh chest
50:54radiography is available then only we
50:57take it as a pneumonia episode if there
51:00is a recurrent pneumonia then the then
51:02you have to ask a history regarding the
51:06ideology so uh any simple uh ideologist
51:11you can think of for recurrent pneumonia
51:14um neoccoal staff.
51:18Okay, these are all ideologies. Any
51:19other things?
51:20What are the
51:22thought process comes to your mind when
51:25the child develops recurrent multiple
51:27episodes of pneumonia
51:32like asinotic congenital heart disease?
51:35Ah so congenital heart disd
51:38PDA.
51:39Yes. Yes. Correct. Any other things do
51:42you think of
51:43in cystic fibrosis?
51:45Yes, correct.
51:46Okay. Any other things?
51:49So, it's like
51:51deformities. So, very good.
51:54Cleft pallet, cleft lip.
51:56Yes. Yes.
51:57Causing recurrent aspirations. Yeah.
51:59Very good.
52:00Any other things you think of?
52:02Uh any chest deformities like
52:04kyphosoliosis.
52:06Okay.
52:07can cause hypoatic pneumonia and other
52:09things. Yeah. Any other things?
52:11So foreign body can also class or GD or
52:15any uh neurologically impaired child
52:17like in cerebral palsy child or in the
52:21child affected with stroke when feeding
52:24and swallowing deformities there then
52:27that child can have recurrent pneumonia.
52:30Okay. So uh you should be careful and
52:33you if the child is admitted and if it
52:35is relevant you can elaborate on the uh
52:38history
52:38and other imuno deficient deficiencies
52:41can also cause recurren.
52:43So in past history if you have a medical
52:46record you can definitely mention it
52:48because you can see the records and
52:50definitely mention what treatment has
52:52received and explain what uh how it was
52:55interpreted. Okay. So you you need not
52:58mention whatever the mother says. You
53:00have a document you can see the document
53:02and mention it in past history.
53:05Okay. Okay.
53:06And one more thing important in
53:08recurrent pneumonia is child should be
53:10symptom free in between the episodes
53:12that we should be making sure of not
53:15like it should be a child had symptoms
53:18in between and if you have a x-ray
53:22showing clearance of patch it should be
53:25very much.
53:27Okay sir.
53:29Okay. So next
53:32treatment stream. Uh the child had has
53:35been on given IV fluids, paracetamol,
53:38cotramoxisol are being given. Now the
53:41child is improving.
53:42Okay. Oral or IV? Kotamoxisol probably
53:46oral.
53:48Uh yes sir.
53:50Yeah. This treatment history can come
53:53just after the HOPI that will look
53:56better. the HOPI the after the negative
54:01history treatment history after that as
54:04Dr. Shuki have mentioned past history
54:06come after that antiatal birth history,
54:09immunization history, feeding history,
54:12developmental history. Yeah. Next.
54:15So when you mention now the child has
54:17improved uh you should mention properly
54:20what in what way you are telling child
54:22has improved? Uh for example, if you're
54:25mentioning that child has been prep for
54:27last 24 hours, child is feeding well
54:30which the child was not taking well
54:32before. Now the child is feeding well
54:34and the cough has decreased or the fast
54:37breathing has decreased or whatever it
54:39is you have to elaborate properly. Okay.
54:42So you have to present like examiner is
54:45seeing the child and you are telling
54:47what it is. Okay.
54:49Yes ma'am.
54:49You have to mention your impression.
54:52Yeah ma'am.
54:53Okay. Next.
54:55Family history. Uh no history of genetic
54:58or chromosomeal disorders in the family.
55:00No history of bronal ama in the family.
55:03Type of family is joint family of 10
55:05members. Uh no contact with the TB
55:08patient. Married life of six years. It
55:10is a non-consinous marriage. The patient
55:13is having another sibling brother of 5
55:16years old who is completely normal.
55:19Yeah, we have almost covered everything
55:21in the family history. Only thing is uh
55:23epipit is not related to place. You need
55:26not mention genetic or chromosomal
55:28disorders in the family. and history of
55:31bronchial estma there's a specific point
55:33okay so if if this child would have
55:36presented with breathing and pictures
55:39like asthma then you have to ask history
55:41of bronchial asthma in a parent because
55:44if the parents are as any any of the any
55:46one of the parents are asthmatic and it
55:48then it doubles the risk of getting
55:50asthma in a child if parent and the
55:52sibling is asthmatic then it is triples
55:54the risk of getting asthma in a child
55:56but it is unlikely if the grandmother
55:58has asthma or a grandparent or uncle or
56:02whatever the secondary relatives if they
56:04have a asthma then it is not very much
56:06related to a baby's present condition.
56:09If you get a history of asthma then you
56:11should be asking uh allergies to uh
56:15other things okay like allergic rhinitis
56:18or attopic all those things you should
56:20be asking but you should not ask it
56:21regularly if you get a history like asma
56:23then only you should ask just for
56:25completion of the format you need not
56:27ask okay
56:29okay ma'am
56:29okay so economic
56:32uh father is a farmer he has studied

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