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Pnemonia Case Discussion | Pediatrics | Dr Balaji Chinnasami M.D., | Medusane — Transcript

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0:00foreign
0:09students
0:12today we are going to do on a pediatric
0:15pneumonia followed by uh asthma
0:20so it's a very good uh topic from uh
0:23respiratory case point of view I'll try
0:25to be as concise as possible and
0:28followed by the important questions that
0:30might come okay
0:34so to start with the
0:36Manju one year old one month old female
0:40child resident of uh sadar Bazar Delhi
0:44so the first will be your demographics
0:46of which age is important I will come to
0:49the later on depending upon the age the
0:51type of organism will vary so this is
0:54the age group where viral infections are
0:56very common up to five years okay six
0:58months to six years you have more viral
1:00infections common
1:03informant make sure the mother is giving
1:05a reliable make sure mother is giving
1:07the history so it's going to be reliable
1:10and try to use the patient's own words
1:13okay press and presenting with
1:14complaints of fever and cough since six
1:17days
1:18and uh fast breathing since four days
1:22reduced oral intake since one day and
1:25increase the irritability since one day
1:27so use patient words don't use technical
1:29words like tachypnea similarly the words
1:32like dyspnea which is a patient's own
1:35awareness for a one-year-old child it's
1:37not possible so patients own awareness
1:39all you don't try to use okay
1:42and coming to the history of presenting
1:45illness
1:46child was apparently well six days ago
1:48when she developed a fever the
1:50temperature was recorded what not two to
1:53one or three fever Fahrenheit fever not
1:56was not associated with chills and
1:57Rikers there was no rash no diurnal
2:01variation and somewhat relieved with
2:03medications like antipyretics and child
2:06well in between episodes okay
2:09I'll keep reading the presenting
2:10complaints fully
2:12cough was wet as there were some sounds
2:15noticed by the parents non peroxisible
2:18non spasmodic no diurnal variations no
2:21aggravating factors and not associated
2:23with any post acid vomiting cough was
2:27still persisting in spite of medicines
2:29taking medications child has fast
2:31breathing for the past four days and
2:34increasing but no chest retractions
2:37according to the mother and not relieved
2:39promptly by medicines
2:41no history of worsening with the feeding
2:44the fast breathing no suck wrist suck
2:46cycle no foreheads sweating
2:49history of noisy breathing present but
2:51not able to characterize mother is not
2:53able to characterize their noisy
2:54breathing residues to oral acceptance
2:56and increased irritability since one day
3:00so here uh chills chills is something
3:03which is subjective don't try to use
3:05that in this uh presenting complaints so
3:07chills will not come rigas may be
3:10present and the presence of fever
3:12suggests that there is probably some
3:15infection or at least some inflammation
3:17is going on
3:18and if there is any rash it could be a
3:21viral uh fever because viral infections
3:24are common so try to elicit history of a
3:26viral rash and try to characterize if it
3:29is not measles you have the macro
3:32popular rash coming from the head to
3:34foot with conjunctivitis make sure it's
3:37not a measles rash because the pneumonia
3:39staff pneumonia is very common with
3:41measles
3:43and it usually it cannot be an asthma
3:47because usually asthma will be a fibril
3:49and coming to cough the gurgling sound
3:53wet cough or dry cough you can
3:55differentiate and remember children uh
3:58up to five years do not expect to rate
4:00they swallow the sputum followed by
4:03vomiting so the post-tustive vomiting or
4:06the post cough vomiting is an equivalent
4:08to productive cough so if the child
4:10keeps on vomiting often with cough and
4:13whatever vomit is new called it is an
4:15equivalent to expectoration
4:17diagonal variation very often uh we talk
4:21about diagonal variation if it is
4:22nocturnal probably it is asthma where
4:24you have diagonal variation
4:26and
4:28paroxysmal event here it is non-proximal
4:31paroxysmal means sudden sudden even in a
4:34child they try to ask you because they
4:37want that it could be a foreign body
4:39they want you to tell that it could be a
4:41foreign body and regarding fast
4:43breathing remember the moment there is
4:45fast breathing instead of the you URI it
4:49has gone to the lower airway involvement
4:51okay so there can be running nose which
4:53is probably upper away but once you have
4:55fever running nose cough and fast
4:58breathing fast breathing then the lower
5:00Air wave especially the parenchyma is
5:02involved and also you should remember
5:04that always not always fast breathing is
5:07equivalent to respiratory tract they
5:08will ask you the differential diagnosis
5:10it could be a respiratory it could be a
5:12cardiac it could be metabolic acidosis
5:14it could be raised ICT resulting in
5:17hyperventilation and sometimes a very
5:19trivial causes like fever can cause
5:22tachypnea or fast breathing even in
5:24nasal block children breathe through
5:26their nose small all babies breathe
5:28through the nose so nasal block itself
5:30causes respiratory distress and
5:32regarding noisy breathing they might
5:34attempt to ask you sometimes you can
5:37have Audible noises it could be a
5:39Strider they might ask you what is it
5:42it's a inspiratory sound Strider due to
5:45laryngeal involvement Strider okay these
5:48it's a an expiratory noise Audible for
5:52by the parents okay it's an expiratory
5:54phenomenon these and sometimes grunting
5:56where the baby breathes against a closed
5:59glottis to prevent collapse of the
6:01alveoli they expect you to tell these
6:03birds what is grunting grunting is a
6:05noise produced by the baby breathes out
6:08against a closed glottis to prevent the
6:11alveoli from collapsing so that is
6:13grunting which is suggestive of
6:14parenchymal lesion okay and the reduced
6:17overall acceptance we have asked because
6:19we need to understand whether it is
6:22severe enough needing hospitalization or
6:24not okay and after the presenting
6:27illness you should be able to say that
6:29it is an acute onset infection it is an
6:33infection because fever is there acute
6:35onset less than a weak duration and
6:37probably because of the fast breathing
6:39the lower respiratory tract is involved
6:42okay and it's does it deserve
6:45hospitalization yes the there is uh
6:47severity is high reduce oral acceptance
6:50is there and the irritable child is also
6:52irritable okay
6:54and coming to the negative history
6:56no history of running nose ear pain and
7:00ear discharge no history of loose tools
7:02vomiting abdominal pain and rash here
7:04why we are asking because we want to
7:06differentiate a viral infection from the
7:08bacterial infection viral infection
7:10usually is multi-systemic so it involves
7:13the upper respiratory tract infection
7:15which includes running nose it can even
7:17involve the ear discharge ear pain and
7:20also it will it can involve the ga
7:22system so loose tools vomiting abdominal
7:25pain so it can involve the
7:26multi-systemic okay and viral often can
7:30present with some sort of rash
7:32especially remember the measles rash
7:35because the pneumonia which is going to
7:37be serious type if it's going to be
7:39measles rash okay the staph pneumonia is
7:41going to be very serious enough
7:43no history of failure to gain weight or
7:46uh there is any weight loss so not only
7:48weight loss failure to gain weight is
7:50also important no evening rise in
7:52temperature because uh if there is a
7:55fever history of more than two weeks so
7:57here it's only six days more than two
7:59weeks along with respiratory symptoms
8:01along with maybe an history of not
8:04gaining weight we should suspect
8:07tuberculosis here they will always in
8:09the respiratory case they will always
8:11come back to tuberculosis so when will
8:13you suspect to go closer so it's going
8:15to be a longer duration of fever plus
8:18respiratory symptoms plus this not only
8:21weight loss five percent weight loss
8:23even failure to gain weight is also
8:25important okay
8:27okay and no history of cyanosis and
8:31sodium convulsions vomiting letter okay
8:33so here these are all symptoms
8:35suggestive of complication okay so the
8:38pneumonia is severe enough to cause
8:39cyanosis the there is lot of hypoxemia
8:42and carbon dioxide so resulting in
8:45lethargy altered and sodium and
8:47convulsions or the infection has passed
8:50on to cause meningitis and septicemia
8:52okay so you have to ask questions
8:54related to come
8:59applications in that negative history
9:01coming to history of here no history of
9:04any previous nebulization or
9:05hospitalization in the past
9:08no history of earlier treatment no
9:11history of any form of allergies in the
9:13past it could be skin allergies or food
9:15allergies okay why this recurrent
9:17episodes are asked because uh very
9:20important is the asthma it is
9:22characterized by recurrent episodes of
9:24respiratory symptoms as well as cough
9:27requiring nebulization which Madam will
9:29be explaining later on in the other case
9:31also recurrent episodes of cough with
9:34fast breathing needing hospitalization
9:36suggestive of real pneumonitis recurrent
9:39pneumonias always think in terms of
9:41cystic fibrosis immunodeficiency or
9:44sometimes congenital heart disease like
9:46vsds or if the child is a CP or any uh
9:50or atomical malformation like turquoise
9:53visual fistula is there so aspiration is
9:55common causing recurrent lra so whenever
9:58a child has two episodes in six months
10:00or more than three episodes for the
10:02whole lifetime we call that as recurrent
10:05episodes okay and space are history try
10:08to ask in the past history regarding the
10:10treatment also in treatment history
10:11whether spacer works used whether any
10:13preventive treatment was used or not
10:15then comes history of contact with the
10:17TB there is no history of contact with
10:20any person with tuberculosis very
10:23important and respiratory case and you
10:26need to understand that in the recent
10:29two years they ask about contact history
10:31in the recent two years anybody had any
10:34TB they don't come up with straight away
10:37so they had TB you have to ask whether
10:39any family member with chronic cough
10:41whether anyone died due to respiratory
10:44symptoms and it doesn't stop with
10:45household contacts close contacts so
10:48even here the child is one year so even
10:51if a child goes to school so even in the
10:53school also close contacts is important
10:55with TB definition in the last two years
10:58okay
10:59and treatment history prior to admission
11:01oral medications were given after
11:03admission IV fluids and some medications
11:06probably antibiotics have been given so
11:08here the history is important because to
11:10choose the antibiotics if recently
11:12overall medication given a child is not
11:14responding maybe we have to step up the
11:16antibiotics okay and coming to antenatal
11:19history it has been uh it's uh not much
11:22important so just say uneven full and it
11:25was a book case and immunized mother was
11:28immunized make sure that proper care was
11:31given entry in Italy and it was uneven
11:33fully and finally in the natal history
11:35it's going to be a full uh full term
11:38normal vaginal delivery three kilogram
11:40immediately cried after birth and make
11:43sure that everything went normal so no
11:46Nico admission and breastfeeding was
11:48started within half an hour that says
11:50that everything was fine okay and
11:52postnatal history was also uneven full
11:54if any jaundice was there for any
11:56photography was given anything you'd
11:58have to mention that otherwise no need
12:00to elaborate as in cerebral palsy where
12:03we elaborate in first semester second
12:04trimester third trimester okay
12:08okay coming to the nutrition history so
12:12any Pediatrics try to take your
12:16nutrition history development to see
12:18immunization history in detail okay
12:19child was breastfed till one year
12:22exclusively breastfed for uh
12:25uh here eight months okay then semi
12:28solids were introduced and child was
12:30breastfed till one year after that they
12:31have stopped breastfeeding and at
12:34present the child consumes about 650
12:36calories and around 15 grams of protein
12:39as against the expected 1000 calories
12:42and 20 grams requirement so you can even
12:45give a deficit how much is the deficit
12:48so that would be nice okay so the
12:50nutritional history is important suppose
12:53breastfeeding is also going you just say
12:55in addition to 65 650 calories and 15
12:58grams of protein child is also taking
13:00breastfeeding okay and immunization
13:03history make sure the major vaccines
13:06have been given or not so child has
13:07received a DPT Hepatitis B polio drops
13:11and measles vaccine at appropriate age
13:13the mother might not come up with this
13:15but as per National immunization
13:17schedule you can even say like that as
13:18per National immunization schedule the
13:20child has been given vaccination and the
13:22last vaccination was given at 9 moments
13:25of age so it is understood that they
13:27have given all these vaccines and
13:29nowadays in National immunization
13:31schedule it's of the rotavirus is also
13:33given and in some places pneumococcal is
13:36also given and recently nemococcal has
13:37been made mandatory for all over India
13:39it's going to come very soon okay and uh
13:42what they might ask you about questions
13:44about related to pneumonia so one is BCG
13:47vaccine definitely they will ask you
13:49about BCG vaccination and the most
13:52important question they will ask is if
13:53the child has been BCG vaccinated so
13:55will the child not give TB so the answer
13:58is no they will get TB because BCG
14:00protects doesn't protect from all forms
14:03of TB only mainly the severe forms of TB
14:05it protects so the the mild pulmonary
14:09tuberculosis all it may not protect it
14:12protects mainly against the milie
14:13reforms meningeal forms of tuberculosis
14:16then they will ask you about the
14:18importance of pneumococcal vaccine the
14:20schedule hash influenza vaccine measles
14:23vaccine and sometimes they might even
14:25ask about the influenza vaccine so keep
14:27that with the schedule and Route Etc
14:30then developmental assessment child is
14:33able to stand without support and trying
14:35to walk able to speak three words wave
14:37bye bye please
14:39so whatever at this age child is doing
14:42you just tell those milestones and say
14:44that the child's development is
14:46appropriate for each okay
14:52in family history the child is born out
14:55of non-consumuous marriage no history of
14:57similar complaints and siblings or
14:59parents no history of asthma allergy or
15:02tuberculosis in their family make sure
15:04that there is no family history make
15:06sure that everything is fine or if they
15:08are suffering from anything you just
15:09mentioned especially the allergies run
15:11in families okay socioeconomic history
15:13very important so here lives in a Paka
15:17house and belongs to lower middle
15:18socioeconomic status according to the
15:21modified kupusami scale main important
15:24is consider about overcrowding is there
15:26overcrowding present suppose you have
15:29more than three persons family persons
15:31for two room it's considered
15:33overcrowding more than five for a three
15:36room then it is overcrowding okay and
15:39here overcluding is present and father
15:41smokes at home he's a smoker so children
15:43are exposed to passive smoking that is
15:45also a risk factor and mother is a
15:47housewife and father Works in a shopper
15:49salesman mother's literature is fifth
15:51grade and Father tell so the education
15:53status is very important so they might
15:55not be so aware and you have to give lot
15:57of education and counseling to follow
15:59the complaints with treatment okay so
16:02the summary of the history is uh
16:06here is a one year and one month old
16:09female child resident of sadar Bazaar
16:12Delhi presented with a short one week
16:13history of fever of fast breathing
16:15without curessa and reduced to oral
16:18acceptance and increase the irritability
16:20okay there is no history of similar
16:22complaints in the past no history of
16:24nebulization and no history of recurrent
16:26infections in the past analysis is a
16:29child presented so this they might ask
16:31you what do you infer from it so I infer
16:34that it is probably a respiratory tract
16:36infection it is an infection and
16:39probably it is a lower respiratory tract
16:41infection in view of the faster
16:42breathing and it's a short acute uh
16:46history so infection is the etiology and
16:49since there is no viral program there is
16:51no such as choriza or rash or diarrhea
16:55Etc the a viral disease is unlikely it
16:57looks it doesn't look like a viral
16:59disease okay so the my professional
17:01diagnosis is a lower respiratory tract
17:03infection okay and probably it could be
17:06pneumonia Broncho pneumonia pneumonia or
17:08Bronco pneumonia either of it and
17:10sometimes complications like pleural
17:12efficient also could be there so I would
17:14like to even exclude complications and I
17:16would like to examine the respiratory
17:18system so that will be your provisional
17:20diagnosis I'm coming to the examination
17:22child is a conscious irritable and not
17:26comfortable very important whether the
17:28child is comfortable or not okay where
17:31the child is irritable irritable is a
17:33sign of hypoxemia so make sure that the
17:35child is comfortable not having any
17:38distress okay the other ways you mention
17:40it then comes the vitals so respiratory
17:43weight is 68 per minute and it is
17:45abdominal thoracic and there are
17:47subcostal retractions present but no
17:49flaring of Allen they say no accessory
17:51muscles in the neck are involved and
17:53there is no head bobbing very important
17:55to know how severe is the respiratory
17:58problem so you here they will ask you
18:00about the ium and say criteria for fast
18:02breathing okay so less than two months
18:04so more than 60 is tachypnea two months
18:07to one year more than 50 per minute is
18:10tachypnea and more than one year more
18:12than 40 is considered as tachypnea so
18:15any techie
18:20yeah that's foreign
18:31is there then the pneumonia is very uh
18:33serious sort of infection might need
18:35immediate Ico admission okay and the
18:38pulse rate is 110 per minute pulses
18:40regular rhythmic good volume no radio
18:42radial or radio femoral delay and click
18:45CRT very important it's less than three
18:48seconds so the child is not in shock and
18:51remember all these uh parameters may
18:53vary because of the fever itself so here
18:55fever is uh one or two so for every one
18:58degree raise in temperature they will
19:00ask you four RR will increase and 10
19:02pulse rate will increase so you have to
19:04subtract for that so here three fours
19:07are twelve so even if we subtract 12
19:09from this still it will fit with the
19:11tachypnea criteria okay and coming to
19:13the anthropometry very important for
19:16less than five years we are going to use
19:17the who growth charts more than that IAP
19:19growth charts you have to give your
19:21interpretation so here weight is 8 kg so
19:24it is just above the third Central for a
19:27one year we want at least 9 kg place so
19:30it is just greater than third Center so
19:32it is just above the criteria for under
19:34nutrition or else we would call the
19:36child as under nutrition then height is
19:3976 centimeters so it is around the 50th
19:41Century so it is normal otherwise we
19:43would put under stunting less than third
19:45sentence stunting and head circumference
19:47it is in the third to 50th sentence so
19:50it is normal and wait for height very
19:52important very for height it is between
19:55the first and the third Center so it is
19:57uh below the third Center so it falls
20:00under the moderate acute malnutrition if
20:03less than one Center then it is severe
20:05acute malnutrition so here it is
20:07moderate acute malnutrition so which
20:10means recently there has been some
20:12problem with the feeding issues so in
20:15addition to the all the treatment at the
20:17end while discharge you have to also
20:19address the nutrition issues also okay
20:23foreign
20:27to 12.5 centimeter so about 12.5 is uh
20:31above 13.5 is fine so here 11 to 12.5 so
20:35it also suggests that it is moderate
20:37acute malnutrition less than 11 is going
20:39to be severe acute malnutrition okay so
20:41use the who grow charts to tell your
20:44interpretation then head to foot
20:46examination so itrespeller cyanosis so
20:48here mild trailer is there no cyanosis
20:51which means uh because of the
20:53respiratory distress the cyanosis has
20:55not developed otherwise it's going to be
20:56a serious issue requiring intensive care
20:59no interest no lymphadenopathy
21:02especially for tuberculosis
21:03lymphadenopathy is important no clubbing
21:05no edema clubbing suggests that there is
21:09a long-standing severe disease
21:11especially suppose you have a bronchic
21:14cases you get clubbing and cyanosis if
21:17the disease is going to be severe you
21:19are going to get cyanosis and in
21:20addition to this from head to foot all
21:22the vitamin deficiencies you try to tell
21:25about that no signs of vitamin
21:26deficiency and related to the
21:28respiratory system the ears are
21:30important no discharge from the ears
21:32mouth is important how is the throat and
21:34tonsils and is there any cleft lip or
21:37cleft palate because that can cause
21:38aspiration dentitions are fine make sure
21:41that you talk about the BCG Mark the BCG
21:44Mark is present
21:45and uh
21:48and the BCG Mark gives protection from
21:51severe forms which we have already told
21:53sometimes man to Mark might be there in
21:56the arm where you have to look into the
21:58induration not the erythema more than 10
22:01millimeter is considered a significant
22:03it only suggests that the child has been
22:05exposed to prior to TBC life okay
22:10okay coming to the respiratory system
22:13examination very important part here
22:17so you start with nose do not straight
22:20away go with the inspection start with
22:22the upper Airway nose is normal no
22:25flaring of the Allen ACI then go to the
22:27oral cavity oral cavity and throw
22:29tonsils are normal
22:31inspection start with the turkey and
22:34turkey is in the midline the apical
22:36impulse you have to talk about and the
22:38chest shape is a circular or normal in
22:41shape there is no use of accessory
22:43muscles but some subcostal recessions
22:47are present no nasal flaring is present
22:50and no scars sinuses or veins over the
22:53chest scene apical impulse I am not able
22:55to make out in the inspection okay
22:58then finally you look into the movements
23:00movements appear decreased on the right
23:03side okay so this will be your
23:04inspection you can also comment in the
23:07spine also from the looking at the back
23:09how is the back any type of scoliosis is
23:11there or not then comes to the palpation
23:13where you are going to confirm about the
23:16tracheal and the apical impulse okay we
23:19need to assure there is no mediastinal
23:21shift okay so apical impulse is in the
23:24fourth intercostal space along the Met
23:25clavicular line usually for children
23:27it's going to be in the fourth
23:28interpersonal space then Takia is in the
23:31midline okay and chest expansion is
23:34decreased on the right side so you are
23:36going to confirm by the palpatory method
23:39that the chest expansion is decreased on
23:41the right side and you look into the
23:43vocal parameters so you cannot ask the
23:45child so it may not be done and any of
23:48an auscultation you are going to confirm
23:50with ocal resonance so okal remittance
23:52could not be done you can see no issues
23:54then on percussion the note is impact
23:58third or dull over the right memory
24:01right infra axillary and right infras
24:03capular areas okay so there is a
24:06dullness impaired dullness it's not
24:08store needle it's impaired dullness over
24:10the right memory right infra axillary
24:12and the right infrascapular areas and
24:15the cardiac Apex is normally placed okay
24:18cardiac Apex is normally placed in the
24:21fourth intercostal space along the mid
24:22clavicular line on auscultation I am
24:25able to make out first you talk about
24:27the bronchial breath sounds if any on
24:29the right memory right axillary and the
24:31right interscapular areas occasional
24:33gravitations are also present no other
24:36added sounds and local resonance is
24:39increased in the those areas vocal
24:42resonance is increased so bronchial
24:43breath zones are heard some crepitations
24:45are made out no other added zones are
24:48there and vocal resonance is also
24:50increased in the same areas so coming to
24:54uh one by one so apical impulse and
24:57tracheal position is very important as I
24:59already said it says that the medials
25:01there is no mediastinal shift if there
25:04is going to be a pneumothorax or pleural
25:07effusion the epical impulse and turkey
25:09position is automatically going to shift
25:11to the opposite side okay and trails
25:14sign suggests it's nothing but what is
25:16Trail sign so the stenocular mastoid
25:19looks prominent on the side where the
25:21trachea moves so that is tracing so it's
25:23inspector finding okay and this uh
25:28severe pneumonia and very severe
25:30pneumonia on inspection you try to make
25:33sure the accessory muscles the nasal
25:36flaring the head bobbing is there or not
25:38so these things suggest that it's not
25:41just a pneumonia pneumonia means only
25:43the fast breathing once the other things
25:45like this retractions are this subcostal
25:47retractions nasal flaring head bobbing
25:50which are this way severe pneumonia okay
25:52and the child needs immediate Intensive
25:54Care Management and decrease the
25:57movement on the right side whenever
25:59movement is decreased on one side the
26:01pathology is on that side so you
26:03remember that whenever you talk about
26:04movements decreased on one side it means
26:06that the pathology is on that side
26:08always okay and the chest expansion is
26:12uh decreased here
26:14and with regards to consolidation
26:17remember this is a all the findings
26:19which you have told is suggestive of
26:21consolidation or pneumonia where which
26:23will have a dull note on percussion it's
26:26going to be dull note and your vocal
26:28resonance and vocal parameters is going
26:30to be increased and you are going to get
26:32bronchial breath sounds in the uh
26:34consolidation
26:36but with regards to plural effusion
26:38where it's going to be Stony Delon
26:40percussion it's going to be Stony Bell
26:42on percussion remember it's like a
26:44curtain it's like a curtain plural
26:46efficient or nemothorax it's like a
26:48curtain in the pleura and nothing is
26:49going to be heard so your breath sounds
26:51are going to be diminished the local
26:53resonance local parameters is going to
26:55be decreased in plural effusion and
26:58pneumothorax but on percussion in plural
27:01effusion it's going to be Stony dull and
27:03in pneumothorax it's going to be hyper
27:05resonant okay so remember this
27:07differences and in bronchopneumonia it's
27:11like a diffuse bilateral involvement so
27:13you will be hearing in addition to the
27:15repetitions visas also will be in
27:18involved because the bronchus is
27:20involved and it is going to be a diffuse
27:22so both the lungs you will have findings
27:24it will not be localized to one side so
27:26bronchi will be there so these are the
27:28important findings in addition to the
27:31abdominal examination is normal as
27:33abdomen is soft with no tenderness no
27:35ergonomically sometimes liver can be
27:37palpable especially where you have a
27:39hyper inflated chest so you can have
27:42some amount of liver being palpable
27:44cardiovascular system examination is
27:47normal as S1 S2 is heard normal and no
27:49murmurs are there in central nervous
27:52system revealed that except for the
27:54irritability otherwise everything is
27:55fine and make sure that there are no
27:57meningeal signs because sometimes the
27:58pneumonia can spread causing meningitis
28:00okay
28:01so the summary of the findings are
28:05here is Manju one year old female child
28:08presented with fever cough and fast
28:10breathing for the past four to six days
28:12with no contact history for tuberculosis
28:15on physical examination there is fever
28:17tachypnea with subcostal retractions
28:20decreased movements on the right side
28:21along with dullness on percussion on the
28:23right lower chest region infra axillary
28:26and infrascapular areas and bronchial
28:28breathing on the right side and
28:30occasional reputations are seen
28:33so my provisional diagnosis it's a lower
28:36respiratory tract infection probably
28:38severe right lower severe right lower
28:41pneumonia etiology probably being
28:44streptococcus pneumonia with moderate
28:46acute malnutrition okay sometimes maybe
28:49you may not uh say exact etiology they
28:52might be offended you can just stop with
28:54lower respiratory tract infection
28:56probably it is a right lower pneumonia
29:00with moderate acute malnutrition and as
29:03per a human say criteria you can say
29:05that it is
29:07severe pneumonia okay
29:10so investigations what investigations
29:12you are going to do CBC peripherals me a
29:15CRP and blood culture but blood culture
29:17you may not get so much yield and CBC
29:19you will have a neutrophilic predominant
29:22leukocytosis okay and uh peripheral
29:25smear might show the toxic granules
29:27suggest your bacterial infection CRP may
29:29be elevated but blood culture yield is
29:31low and the chest x-ray chest x-ray will
29:34show the air bronchogram and if a plural
29:37effusion is there obliteration of the
29:39cost of running angles can be seen
29:41mantle test is one important test to
29:43rule out the prior exposure to the TB
29:46Baseline so remember the induration is
29:48important not the erythema and the
29:50horizontally you have to check whether
29:52it is more than 10 millimeter and if
29:54possible if sputum is there if when you
29:57can do the gram staining in the culture
30:00most important investigation coming to
30:03the important discussion points very
30:05important in desperately they will ask
30:07you this imnc flowchart remember this
30:09imancya flowchart
30:10uh understand the general danger signs
30:13is the child able to drink or breastfeed
30:16does the child vomit everything out and
30:19does the child have convulsions and is
30:21the child lethargic or unconscious if
30:23anything is there any danger sign is
30:25there automatically it's going to become
30:27a very severe disease pink category and
30:31immediate referral okay so these are the
30:33dangerous signs pink category
30:35immediately refer originally to the
30:37hospital
30:38then you count the breads for one minute
30:42and look for any chest in drawing see
30:44whether any Strider is there and as per
30:47the imancy criteria I said for two
30:49months to 12 months it's going to be 50
30:50breaths per minute and for 12 months up
30:53to five years it's going to be 40
30:55breaths per minute for the tachypnea so
30:57if any fast breathing is there it's
30:59going to be pneumonia give amoxicillin
31:01for five days if there is going to be
31:03fast breathing press chest in drawing or
31:06Strider then it's going to be severe
31:08pneumonia if there is going to be
31:10General danger sign also then it's going
31:12to be very severe disease so give an
31:14injectable and immediately refer
31:16urgently to the hospital okay and some
31:19questions about community acquired
31:21pneumonia
31:23hospitalization so remember uh if just
31:27fast breathing is not enough there need
31:29to be a lot of retractions and accessory
31:31muscle involvement uh head bobbing Alan
31:35SI flaring grunting and lethargy and
31:38shock these are all suggests the
31:39indication for hospitalization or very
31:42poor intake then spo2 saturation pulse
31:45ox if you available spo2 if the
31:47saturation is less than 92 percentage of
31:49improvement then it is also indication
31:51for hospitalization important
31:54etiological agents remember bacteria is
31:56going to be streptococcus pneumoniae
31:57staph aureus and H influenza H
32:00influencer has become rare because of
32:02the vaccination pneumococcal vaccination
32:04if you have taken the pneumonia is also
32:06going to be a bit less incident
32:08staff or yes yes it's always there in
32:11the especially when there is
32:15then it is tap or yes and viruses very
32:19common etiology especially in the six
32:22months to six years RSV influence and
32:24para influenza and more than five years
32:26school going children atypical organisms
32:28like mycoplasma and chlamydia remember
32:30that staff warriors specialty is
32:33remember employment remember staff
32:35warriors nematocells remember staph
32:37aureus and as a complication for measles
32:39you get staphys influence are very
32:42common for less than three years and
32:44that also because of the immunization it
32:45has come down and atypical organism
32:48specialty is they have few physical
32:50signs it's called Walking Pneumonia they
32:53will be comfortable but once you take
32:54the chest x-ray you realize that there
32:56is a huge bronchopneumonia so atypical
32:59organisms few physical signs on loan
33:01will be there treatment oxygen IV fluids
33:04and nebulization if whis is there go for
33:06immobilization or antibiotics
33:08antibiotics do not say any Hi-Fi
33:11antibiotics it's going to be amoxicillin
33:13or cotrimoxazole for five days and if
33:15you suspect staff then you can add
33:17amoxiclav or amoxicillin plus
33:19cloxacillin if the child needs admission
33:23still it's going to be IV ampicillin or
33:26IV
33:27amoxicillin if staff you suspect it's
33:29going to be amoxiclav or oxacillin still
33:32not responding then only go for the
33:34third generation cephalosporine don't go
33:36straight away for chapter action coming
33:38to tuberculosis discussion points
33:41now it's not rntcp it is now called ntep
33:45National TB elimination program okay
33:48previously it was only smear microscopy
33:51for AFB so sputum you do microscopy for
33:54acid fast Baseline but now we have moved
33:56on to molecular methods so you have to
33:59tell all this rapid nucleic acid
34:01amplification test net so rapid nna CC
34:05so two hours you are going to get the
34:07report so it can be true net or Gene
34:09expert it's a higher sensitivity than
34:12your just mere microscopy and one
34:14advantage is refumbing resistance will
34:16also be said in that itself okay and
34:19nowadays we also do if refumbent
34:21resistance is seen or if the patient
34:24comes after
34:26discontinuing defaulter then you can
34:30also do the line Pro buses to test for
34:33reform facing inh and other second line
34:35drug resistance so now here is a
34:38possibility where you get the values for
34:40resistance very easily so there is no
34:43need to have a separate category for
34:45defaulter so now as for NDP there is
34:48only one category okay that I will tell
34:51so so the now the mandatory is nucleic
34:55acid amplification test that is Gene
34:57expert or tree nut for every patient
35:00where a biological specimen can be
35:02produced so if there is a biological
35:04specimen you have to submit for net
35:07so Universal drug sensitivity testing so
35:10once Nat is applied since reform pin
35:13resistance is automatically part of nat
35:15so Universal drug sensitivity testing is
35:18also being done
35:19and daily drugs previously it was
35:21alternate day drugs now it's daily drugs
35:24with fixer dose combination for children
35:26so it's going to be a fixer dose there
35:28is no weight per kg basis kg per day
35:31basis it's going to be a fixed drug dose
35:34and you have six weight bands If the
35:36child Falls in that big band that fix up
35:38those combination is going to be given
35:40and the dosage remember hrzd okay for
35:44two months followed by hre for four
35:46months previously when you we used to
35:48read there was no Ethan but all so now
35:50for maintenance hre is also being given
35:53for four months plus they suggest to add
35:55a pyroduction because of the inh
35:57neurotoxicity so 10 mg per day paradoxin
36:00can be given and for preventive
36:03treatment Suppose there is a family
36:04member who has household contact has TB
36:07on treatment you have to give for a
36:10child less than five years uh first find
36:13out that there is no TB in the child and
36:15give ins 10 energy per kg per day for
36:18six months so that is relative therapy
36:21so this flowchart not need not remember
36:24fully so you need to know when will you
36:27suspect tuberculosis so persistent fever
36:29for more than two weeks very important
36:31so the fever should be more than two
36:33weeks if the cough may not may or may
36:37not be present for two weeks weight loss
36:39of five percent may or may not be
36:41present or failure to gain weight for
36:43the past three months these are all
36:44extra but most important will be fever
36:47should be present for more than two
36:48weeks to suspect TB along with maybe
36:51cough may be present for two weeks
36:53weight loss may be present of five
36:55percent or the child is not gaining
36:56weight for the past three months despite
36:58adequate nutrition and with or without
37:01contact still contact may or may not be
37:03present and the first step is do a chest
37:05x-ray if chest x-ray is suggest you of
37:08TB then go for the net go for the true
37:11net or Gene expert if Nat is positive
37:13straight away start the treatment if
37:16there is non-specific Shadows not
37:17suggestive of TB then give a course of
37:20antibiotics then again check the chest
37:22exercise till it persists then again you
37:24submit for Nat if not come positive then
37:27give the ATT so this is the protocol for
37:30TB
37:31and if you remember since you are in the
37:34covered era they will definitely ask
37:35some questions about covid-19 in
37:38children so covid-19 is the disease
37:41caused by the virus SARS
37:44coronavirus 2
37:46it doesn't affect much the children it's
37:49going to be mild infection most often it
37:53might affect the immunosuppressed kids
37:54presentation will be just like any other
37:57viral infection the person with cough
37:58fever gastrointestinal symptoms running
38:00no sore throat nasal congestion rash
38:03conjunctivist loss of smell it's just
38:05like any other viral infection viral URI
38:08and uh in during the time of pandemic
38:11you have to suspect that's all and do
38:13the RT PCR by mesopharyngeal Swap and
38:16oropharyngeal swap which is a viral
38:18nucleic acid where we detect the RNA
38:21and some laboratory parameters
38:22suggesting of code is lymphopenia and
38:25increased inflammatory markers like CRP
38:27ESR procalcitonic increased CPK and sgot
38:32is GPT LDH and d diamond so some
38:34inflammatory markers and the CPK and
38:36sgot sgpt LDH and D dimer may be
38:39increased Imaging chest exercise
38:41remember to talk about bilateral ground
38:43glass opacities supportive care not much
38:46available just oxygen if too much
38:48distress only approved drug available
38:50and presentation
38:52vaccination is also not approved for
38:55children so far and it's at present only
38:58for the 18 years of above only possible
39:00so vaccination also not possible and
39:03they might ask you maybe just one point
39:04if you are good enough you are talking
39:06lot of good so multi-system inflammatory
39:08syndrome for covid which is similar to
39:11Kawasaki disease where you have fever
39:13with inflammation with multi-system
39:15involvement so fever will be there
39:17inflammatory markers will be there crb
39:19ESR and ferritin will be created okay
39:22and multi-system involvement so you can
39:24have rash you can have conjunctivities
39:25you can have diarrhea okay but most
39:28important will be a history of SARS
39:31covered infection
39:33recently within the four weeks at
39:36present the uh the rtpc will be negative
39:39but recently there will be a history of
39:41infection it could be either the child
39:44would have suffered with a covet or it
39:46could be a contact with a strongly
39:48contact with a covered household contact
39:50or at present the antibody may be
39:53positive so this is about covert 19. I
39:55think I will stop with the presentation
39:58so mainly in RS they will concentrate
40:00especially the imnci so remember to read
40:04about the MNC criteria they will ask you
40:07lot of clinical findings so okay so they
40:09will ask you how will you say it as
40:10consolidation how will you say it as
40:12plural efficient Nemo correct so the
40:14clinical interpretation they might ask
40:15you lot of questions and the imsa
40:19criteria again okay thank you foreign
40:30[Music]

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