A clinical meeting on Lobar Pneumonia. The patient was admitted & treated in Pulmonology Department of BSMMU

1. Welcome to
Clinical Meeting
Presenters:
DR. RENESHA ISLAM &
DR. SHARMIN JAHAN NIPA
Residents, Phase A (Year 1)
Paediatric Hematology & 0ncology.

2. Particulars Of The Patient :
 Name : Zunurain
 Age : 7 years
 Sex : Male
 Address : Narayanganj
 Informant : Mother
 Date of admission : 03/12/18
 Date of Examination : 03/12/18

3. Chief Complaints
1. Fever for 15 days.
2. Cough for same duration.
3. Breathing difficulty for 2 days.

4. History Of Present Illness
According to the statement of the informant
mother, Her child was reasonably well 15 days
back. Then he developed fever which initially
was low grade then became high grade,
continued in nature, not associated with chills
& rigor, highest recorded temperature was
103F & usually subsided after taking
antipyretic. Zunurain also developed cough for
same duration which was productive, mucoid
in nature, had no diurnal variation.

5. On query, Mother gave history of breathing
difficulty for last 2 days.
There was no history of runny nose, conjunctivitis,
atopy, no history of contact with TB patient or
significant weight loss. For these complaints, He
took oral antipyretics & antitussive for 7 days
prescribed by a registered physician. But his
condition did not improve. So, he got admitted in
BSMMU for further evaluation & better
management.

6. History Of Past Illness :
Nothing significant.

7. Antenatal: Mother was on regular antenatal
check up.
Natal: Delivered by LUCS at term with
average birth weight, without any
complication.
Postnatal: Uneventful.
Birth History

8. Developmental history :
Developmentally he is age appropriate. He
reads in class two with average school
performance.
Immunization history :
He is immunized as per EPI schedule.

9. Feeding history:
Exclusively breastfed upto 6 months of age.
Then complementary feeding started. Now
he is on normal family diet.
Family History :
He is the 4th issue of his non-consanguineous
parents. Other family members are in good
health & there is no history of asthma or
similar type of illness.

10. Socio economic history :
He belongs to middle socio economic
condition. His father is a school teacher
and his average monthly income is about
20,000 taka. Mother is a homemaker.
They live in pacca house . Drink tubewell
water & use sanitary latrine.
Drug History:
He took Syrup paracetamol &
Syrup Ambroxol for 7 days.

11. Physical Examination

12. General Physical Examination
• Appearance : Ill looking.
• Pallor
• Jaundice
• Cyanosis
• Clubbing
• Koilonychia Absent
• Leukonychia
• Oedema
• Dehydratiton

13. cont’d..
• Lymph node : Not palpable.
• Skin survey : BCG mark present.
• Back and Spine : Normal.
• SPO2 : 97% in room air

14. cont’d..
• Bony tenderness : Absent
• Signs of meningeal irritation : Absent.
• Bed side urine for Albumin : Nil
• Examination of Eye : Normal
• Examination of Ear, Nose and Throat: Normal

15. cont’d..
Vital signs:
Temperature : 103°F
Heart rate : 100 beats /min
Respiratory rate : 42 breaths/min
BP : 100/60 mm of Hg
(SBP & DBP lies between
50th-90thcentile)

16. Weight: 30 kg (lies
between 90th to 95th
centile)
Height: 130 cm (90th to
95th centile)
BSA: 1.05 m²
Anthropometry

17. Systemic Examination

18. Respiratory system
Inspection :
Respiratory rate : 42 breaths/min
Shape of the chest : Normal
Chest movement : Restricted on right
side. subcostal recession present.

19. Respiratory system
Palpation :
Trachea : Centrally placed
Chest expansibility : Reduced on right side
Apex beat : Left 5th ICS, just medial
to mid clavicular line.
Vocal fremitus : Increased on right
side from 2nd ICS to 5th ICS.

20. Percussion :
Dull on right side from 2nd ICS to 5th ICS.
Auscultation :
Breath sound : Bronchial breath sound
on right side from 2nd ICS to 5th ICS.
Added sound : Coarse crepitation present
In right lung field
Vocal Resonance : Increased on right side
from 2nd ICS to 5th ICS.

21. Cardiovascular System
Inspection:
No visible pulsation.
Palpation:
Apex beat : In the left 5th ICS, just medial to mid
clavicular line.
Thrill : Absent
Palpable P2 : Absent
Lt. parasternal heave : Absent
Auscultation:
1st & 2nd heart sounds audible in all 4 areas.
No murmur.

22. Alimentary System
Oral cavity : Healthy
ABDOMEN PROPER:
Inspection –
•Shape : Normal
•Umbilicus: centrally placed, inverted
•No visible vein or scar mark

23. Palpation-
• Abdomen is soft, non tender
• No organomegaly
• Fluid thrill : Absent
Percussion:
• Shifting dullness : Absent
Auscultation :
Bowel sound: present.

24. Genitourinary system examination
Inspection: Abdomen not distended, flanks not
full. Umbilicus central in position, transverse slit
present. Genitalia male type. Hernial orifice
intact.
Palpation: Kidneys not ballotable
Urinary bladder not palpable
Renal angle not tender
Percussion: Shifting dullness absent
Auscultation: renal bruit absent

25. Nervous system
Higher Psychic Function : Normal.
Motor Function :
Bulk of muscle : Normal on both side
Tone of muscle : Normal
Power of muscle : Normal.
Reflex : Normal
Plantar : Flexor.
Gait : Normal
Cranial Nerves : Intact .
Sensory function : Intact.

26. Locomotor system examination
Look: No deformity or muscle wasting, position of
the limb is normal.
Feel: non tender. No local rise of temperature or
swelling.
Move: movement not restricted.

27. Salient Feature:
Zunurain, 7 years old boy, immunized, 4th issue of his
non consanguineous parents got admitted with the
complaints of fever for 15 days which initially was low
grade then became high grade, continued, highest
recorded temperature 103F, not associated with chills
& rigor & subsided after taking antipyretic. He had
productive cough for same duration, having no diurnal
variation. Zunurain also developed respiratory distress
for last 2 days. He had no H/O contact with TB patient,
significant weight loss or atopy.
On examination, he was ill looking, febrile; temp 103F,
tachypnic; respiratory rate 42b/min, having BCG mark
present on skin survey.

28. Anthropometrically he is well thriving. Respiratory
system examination revealed chest movement
and expansibility reduced on right side. Signs of
respiratory distress present evidenced by
subcostal recession, Vocal fremitus increased,
Percussion note dull, vocal resonance increased
on right side from 2nd to 5th ICS. Breath sound
bronchial. Other systemic examination revealed
normal findings.

29. Provisional diagnosis

30. Provisional Diagnosis
Right Sided Consolidation Due
To Pneumonia.

31. Differential Diagnosis
Consolidation Due To Pulmonary
Tuberculosis

32. Consolidation Due To Pneumonia
Points in favour
 Fever for 15 days
Cough for same duration
Respiratory distress for 2days
O/E- Features of right sided consolidation

33. Consolidation Due to Pulmonary
Tuberculosis
Points in favour
Fever for 15 days.
Cough for same
duration.
Points against
No evening rise of
temperature.
No H/O contact with
known TB patient
Anthropometrically
Well thriving, no h/o
weight loss.

34. INVESTIGATIONS

35. Plan Of Investigation
• CBC with ESR
• Chest X Ray (P/A view)
• CRP
• Sputum for AFB
• TST (Mantoux test)
• Multiplex PCR (Sputum)

36. Investigations (02.12.18):
Complete blood count –
Hb - 12.2 gm/dl.
ESR - 116 mm in 1st hour.
WBC count -23,270/cu mm.
N - 91%
L - 4%
M - 2%
E - 3%
Platelet count – 2,44,000/cu mm.

37. Investigations:
 CRP : 24 mg/dL
TST ( Mantoux test) : 02 mm ( negative)
Sputum for AFB : No AFB found
Multiplex PCR (Sputum): Report pending.

38. Chest Xray
(02.12.18)
Comment:
Dense
homogenous
opacity is noted
in right upper &
part of middle
zone.

39. Management
 Counseling
 Supportive care
 Diet –normal.
 Antipyretic (Paracetamol)-15mg/kg/dose
 Specific treatment :
 Antibiotics therapy
inj ceftriaxone-100mg/kg/day
inj clarithromycin-15mg/kg/day

40. Final Diagnosis
LOBAR PNEUMONIA.

41. SUBJECTIVE OBJECTIVE ASSESMENT PLAN
cough
Fever
Well alert
Temp- 100° F
Pulse 92b/min
R/R: 36b/m
Blood pressure 100/60
both SBP and DBP=50th-90th
centile
Heart-s1+s2+0
Respiratory system
examination: movement
restricted on right side
Breath sound bronchial from
2nd to 5th ics
Crepitation present
static Continue the
treatment
Follow up on4.12.18 [hospital stay D2]

42. SUBJECTIVE OBJECTIVE ASSESMENT PLAN
cough (↓) Well alert
Temp- 98.4° F
Pulse 90b/min
R/R: 28b/m
Blood pressure :100/60mmhg
[both SBP and DBP=50th-90th
centile
Heart-s1+s2+0
Respiratory system
examination:Breath sound
vesicular with
few crepitation present
improving Continue the
treatment
Follow up on7.12.18 [hospital stay D5]