Pediatric community acquired pneumonia

1. CASE PRESENTATION
PCAP
COMMUNITY MEDICINE | 2025

2. OVERVIEW
o History & PE
o Clinical impression
o Differential diagnosis
o Final diagnosis
o Case Discussion

3. GENERAL DATA
Name: C.N.A
Age/Sex: 3 years old, Male
Nationality: Filipino
Religion: Roman Catholic
Address: Dao, Tagbilaran City, Bohol

4. CHIEF COMPLAINTS
▪Cough

5. HISTROY OF PRESENT ILLNESS
2 days prior to consult:
▪- Nonproductive cough and rhinorrhea (white discharge).
1 day prior to consult:
▪- Nonproductive Cough and rhinorrhea persisted.
▪- Received Salbutamol nebulization twice a day (morning and evening)
Day of consult:
▪- Persistent cough and Received salbutamol syrup once in the morning and
prompted RHU visit.

6. PRENATAL HISTORY
▪Mother was 30 years old G2P1(1001)had her complete
prenatal checkups at LHC
▪mother took folic acid, ferrous sulfate.
▪Mother doesn't have hypertension and diabetes.
▪No food allergies.

7. NATAL HISTORY
▪Pt was delivered full term(40 weeks)via NSD
attented by OB-GYN at GCGMMC hospital.
▪Good cry, good activity,no complications
▪Took Antibiotics

8. POSTNATAL HISTORY
▪Pts birth weight , birth length, APGAR score and Ballard score
was unrecalled.
▪New born care was given
▪breast feeding was initiated and good suck noted.

9. FEEDING HISTORY
▪ The baby was exclusively breastfed until the age of 6
months.
▪ after which they transitioned to a regular diet consisting
of nutritious foods such as rice, chicken, vegetables, and
other wholesome meals.

10. IMMUNIZATION HISTORY
▪Patients received following vaccines at the barangay health centre
❖BCG at 1 week (6/9/2021)
❖Hep B at birth (6/3/2021)
❖DPT (6 wks, 10 wks, 14 wks) 21st July, 18th August, 15th September 2021
❖OPV (6 wks, 10 wks, 14 wks) 21st July, 18th August, 15th September 2021
❖MMR (10 months) 7/13/22
❖Pneumococcal PCV (7 wks, 11 wks, 15 wks) 21st July, 18th August, 27th
October 2021

11. DEVELOPMENTAL HISTORY

12. PAST MEDICAL HISTORY
▪Non asthmatic
▪- Allergies: Shrimp, dust.
▪- No recent travel history.

13. FAMILY HISTORY
▪The patient’s father and mother does not have
hypertension, diabetes, asthma, or any other chronic
illness.
▪The patient’s grand father has history of
hypertension(Telmisartan), asthma.

14. PERSONAL AND SOCIAL HISTORY
▪Patient is the 1st child in the family.
▪Patient’s father is 32 year-old, he done his education upto college
graduate & he is sea man (oiler)
▪Patient’s mother is 30-year-old, she done her education upto college
graduate & she is housewife
▪1st child is boy 3 year old and student (nursery)
▪The Patient’s family is financially stable.

15. ENVIRONMENTAL HISTORY
▪Patient lives in a fully concrete house. The Source of
drinking water is from refilling station. Garbage is
collected every 3 day.

16. REVIEW OF SYSTEM
▪Skin: no pallor, (-) jaundice, no rashes , warm to touch and good turgor
▪HEENT: (+)Nasal discharge, (+) dry cough
▪Neck: (-) lymphadenopathy
▪C/L: (+) cough
▪CVS: (-) chest pain
▪Abd: : (-) abdominal pain, (-) diarrhea, (-) Vomiting
▪Ext: (-) edema

17. Vital Signs
BP: 100/70 mmHg,
HR: 167 bpm,
RR: 42 cpm,
T: 36.4°C,
O2 Sat: 96% RA.
Weight: 22 kg,
Length: 103 cm.

18. PHYSICAL EXAMINATION
▪ General survey - Awake, alert uncomfortable or irritable
▪ Skin: No pallor, warm to touch, Good turgor
▪ HEENT: Anicteric sclera, pink palpebral conjunctiva,(+) nasal discharge, dry
lips, moist mucosa
▪ Neck- No lymphadenopathy
▪ C/L: : symmetrical chest,equal chest expansion, No tenderness, no masses,
▪ Rales left lower lung field
▪ CVS: Adynamic perecordium, Distinct heart sound, (-) murmur
▪ Abd: : Flat, round and symmetrical, Normo active bowel sounds, Soft and non
tender,
▪ Ext: Strong peripheral pulse, Capillary refill time <2sec, erthyma on lower leg
▪ GUT- Grossly male

19. PHYSICAL EXAMINATION
Neurologic: alert, oriented to place, irritable
▪CN I - Not assessed
▪CN II- Pupils are equally reactive to light and accommodation
▪CN III, IV, VI- not assessed
▪CN V- not assessed
▪CN VII- No facial asymmetry
▪CN VIII- not assessed
▪CN IX, X- not assessed
▪CN XI- able to shrung the shoulders and turn head from side to side
▪CN XII- able to move tounge without any difficulty
▪Muscle strength- 5/5 on both the upper and lower extremities

20. SALIENT FEATURES
▪NONPRODUCTIVE COUGH
▪RHINORRHEA
▪RALES

21. PCAP with LOW Risk
ADMITTING DIAGNOSIS

22. DIFFERENTIAL DIAGNOSIS
Viral URTI
RULE IN
▪ Rhinorrhea with white discharge.
▪ Nonproductive cough without associated
systemic symptoms.
▪ No signs of bacterial infection, such as high
fever or purulent sputum.
RULE OUT
▪ Rales are typically absent in URTI unless
progressing to lower respiratory tract
infection.

23. DIFFERENTIAL DIAGNOSIS
Bronchial Asthma
RULE IN
▪ Family history of asthma.
▪ Recurrent respiratory issues (e.g., history of
hospitalization for pneumonia).
▪ Nonproductive cough is a common
symptom during an exacerbation.
RULE OUT
▪ No wheezing or expiratory phase
prolongation.
▪ Absence of shortness of breath or chest
tightness, which are hallmark symptoms of
asthma exacerbation.

24. DIFFERENTIAL DIAGNOSIS
Acute Bronchitis
RULE IN
▪ Nonproductive cough persisting for days.
▪ Rhinorrhea and recent history of respiratory
symptoms.
▪ Family History of asthma (predisposing
factor).
RULE OUT
▪ No fever, chills, or systemic symptoms typical
of bronchitis.
▪ Absence of wheezing or crackles (though rales
could overlap).

25. CASE DISCUSSION

26. PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA
▪ It is an acute infection of the lung parenchyma occurring in children who have
not recently been hospitalized or exposed to healthcare settings.
▪ It is a significant cause of morbidity and mortality in children worldwide,
particularly in those under 5 years of age.
▪ The condition is typically caused by a variety of pathogens, including viruses,
bacteria, and atypical organisms, with the predominant cause varying by age
and region.

27. ETIOLOGY
The causative agents of pediatric community-acquired pneumonia (PCAP) ;
•Pneumonia is caused by a number of infectiou agents, including viruses, bacteria and fungi. Th most
common are:
•Streptococcus pneumoniae - the most common cause of bacterial pneumonia in children;
•Haemophilus influenzae type b (Hib) - the second most common cause of bacterial pneumonia;
• Respiratory syncytial virus is the most commor viral cause of pneumonia;
•In infants infected with HIV, Pneumocystis jiroveci is one of the most common causes of
pneumonia, responsible for at least one quarter all pneumonia deaths in HIV-infected infants.

28. PATHOPHYSIOLOGY
The pathophysiology of pediatric community-acquired pneumonia (PCAP) begins
with the entry of pathogens into the lower respiratory tract, often through
inhalation of droplets, aspiration of oropharyngeal secretions, or less commonly,
hematogenous spread. These pathogens, which include bacteria (e.g., Streptococcus
pneumoniae) and viruses (e.g., RSV, influenza), evade the upper airway defenses
like mucociliary clearance and secretory IgA. Once in the alveoli, they colonize and
replicate, damaging the epithelium and triggering an inflammatory response.
This response involves the release of cytokines and chemokines that recruit
neutrophils, macrophages, and other immune cells to the site of infection. The
inflammatory process causes the alveoli to fill with fluid, exudates, and immune
cells, leading to impaired oxygen exchange. This results in ventilation-perfusion
mismatch and hypoxemia, causing respiratory symptoms such as tachypnea, cough,
and in severe cases, respiratory distress. The severity depends on factors like the
virulence of the pathogen, the child's immune competence, and the extent of lung
involvement.

29. CLINICAL MANIFESTATIONS

30. CLASSIFICATION OF SEVERITY
This chart categorizes the severity of respiratory distress in children into four levels: PCAP A (Minimal Risk), PCAP B (Low Risk), PCAP C (Moderate
Risk), and PCAP D (High Risk).
The classification is based on respiratory rate (varies by age group) and the presence of signs of respiratory failure, such as retractions, head
bobbing, cyanosis, and grunting.
Minimal and low risk (PCAP A and B) show increased respiratory rates without signs of failure. Moderate risk (PCAP C) involves intercostal or
subcostal retractions, while high risk (PCAP D) includes severe retractions (supraclavicular involvement) and other critical signs.

31. DIAGNOSTICS
1. Chest X-ray:
Purpose: Confirms pneumonia by visualizing lung infiltrates, pleural effusions, or abscesses. It also helps in
assessing the extent of infection and identifying complications.
2. CBC (Complete Blood Count):
Purpose: Measures white blood cells (WBCs) to evaluate infection or inflammation
3.Acute-phase reactants such as the erythrocyte sedimentation rate and C-reactive protein can support a
clinical assessment for managing the development strategy and in a response to therapy evaluation,
particularly for complicated CAP.

32. DIAGNOSTICS
If patient is still not improving with given treatment.These diagnostic tests
would guide to determine the antibiotic therapy
1.Sputum Gram Stain and Smear:
Purpose: Detects the bacterial or fungal cause of pneumonia.
2.Gram Stain, Culture, and Sensitivity of Pleural Fluid:
Purpose: Identifies organisms causing empyema (infected pleural fluid) and
determines antibiotic susceptibility.
3.Arterial Blood Gas (ABG):
Purpose: Evaluates oxygenation, carbon dioxide levels, and blood pH.

33. TREATMENT

34. TREATMENT

35. RESPONSE TO TREATMENT

36. PREVENTION
•Immunization against Hib, pneumococcus, measles anu whooping cough (pertussis) is the
most effective way to prevent pneumonia.
•Adequate nutrition is key to improving children's natural defences, starting with exclusive
breastfeeding for the first 6 months of life. In addition to being effective in preventing
pneumonia, it also helps to reduce the length of the illness if a child does become ill.
•Addressing environmental factors such as indoor air pollution (by providing affordable
clean indoor stoves, for example) and encouraging good hygiene in crowded homes also
reduces the number of children who fall ill with pneumonia.
• In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the
risk of contracting pneumonia.