A 9-year-old female child presented with a 15-day history of chest pain, fever, cough, and hurried breathing. Clinical examination suggested left-sided pleural effusion likely secondary to a bacterial infection, with significant respiratory distress and severe thinness. Investigations confirmed the presence of pleural effusion and moderate anemia, leading to a final diagnosis of left-sided parapneumonic pleural effusion.

2. CASE PRESENTATION
Dr Chinmayi Y S
Moderators- Dr Nagabhushan, Dr Balasubramaniam, Dr Shilpa K L

3. ● Name- ABC
● Age- 9years
● Sex- Female
● Address- D J Halli, Bangalore
● Informant- Mother, reliable

4. Presenting complaints
● H/o chest pain for 15 days
● H/o fever for 5 days
● H/o cough for 4 days
● H/o hurried breathing for 1 day

5. History of presenting illness
Apparently well prior to onset of symptoms
● Chest pain- left lower chest, 15 days duration, occasional, dull aching, mainly felt on
deep inspiration, no aggravating or relieving factors, no diurinal or postural variation.
It has come down since past 6 days. Associated with easy fatiguability since 15 days
● Fever- 5 days duration, acute in onset, intermittent type, low grade, relived with
medication. No diurinal variation, not associated with chills or rigors

6. History of presenting illness
● Cough- 4 days duration, acute in onset, productive, no h/o diurinal variation, No
postural variation
● Sputum- whitish,non blood stained non foull smelling, scanty in amount
● Hurried breathing and chest indrawing for1 day
● Child was able to speak in sentences
● No h/o weight loss or loss of appetite
● No h/o breathlessness, cyanosis .

7. Negative history
No h/o
● running nose
● sneezing
● sorethroat
● ear ache/discharge
● headache
● dysphagia/ change in voice

8. Treatment details
● Received treatment in a hospital for above complaints
● Received oxygen by mask and IV antibiotics
● Evaluated and shifted to tertiary centre for further management

9. Course in hospital
● Child after admission to our hospital received respiratory support for 3
days. A tube was inserted to chest and fluid was drained
● Distress decreased and fever spikes reduced
● Child improved over 7 days

10. Past History
No h/o
● previous similar complaints
● previous hospital admission
● nebulization
● Tuberculosis

11. Family history
● 3rd born
● non consanginously married couple
● Other family members-healthy
● No h/o current similar complaints
● No h/o Asthma/ TB in family members

12. Antenatal, birth and postnatal history
● Antenatal history - She had regular ANC visits in government hospital,
no comorbidities
● Birth history - Full term vaginal delivery in a hospital. Birth weight -
3kg
● Postnatal history - uneventful

13. Diet History
Observed Expected Deficit
Calories 1100kcal 1800kcal 38%
Proteins 23g 36g 36%

14. Immunization history
● Immunized upto date (as per UIP)
● BCG scar present

15. Development history
● Studying in 2nd standard
● Good scholastic performance
● Development milestones-appropriate for age

16. Socioeconomic history
● Family of 5 members
● Father is an auto driver, not literate
● Mother is a homemaker, has studied till 5th std
● Live in a house with1 room, hall , kitchen
● There is over crowding present
● Exposure to Indoor smoking present
● No dust exposure or pets
● Belong to Class 4 SES ( modified Kuppuswamy Classification)

17. 9yrs girl child
● no significant past and family history
● immunized upto date
● attained age appropriate milestones
● significant calorie and protein deficit
● apparently well till 15 days back
● presented with chest pain, fever, productive cough, hurried breathing, chest
indrawing and and easy fatiguability over past 15 days
Case Summary

18. ●System -Respiratory system
●Lower respiratory tract
●Probably acute in onset
●Probably unilateral-(Left side involvement)
●Probably parenchymal and pleural involvement
●Due to an infective etiology- probably bacterial
Case history Analysis

19. Differential Diagnosis
●Pneumonia
●Pneumonia with pleural effusion
●Empyema
Case history Analysis

20. Examination
Done in supine position on bed
● Sick looking
● Respiratory distress

21. Vital parameters
● Temperature - 100.7 F
● Pulse- 120 beats per minute, good volume, regular rhythm, no radioradial or
radiofemoral delay.
● Respiratory Rate- 52 cycles per minute
● Blood pressure - 94/56 mm Hg
● SPo2- 92% under room air

22. Anthropometry
PRESENT EXPECTED INTERPRETAT
ION
WEIGHT 20kg
HEIGHT 128cm 132cm 0 TO -1SD
BMI 12.2 kg/m2 16.1kg/m2 -3SD
( SEVERE
THINNESS)

23. Head to toe examination
● SMR 3
● Ears- normal, no ear discharge
● Nose- Septum mild deviation to right, no nasal discharge, polyp
● Oral cavity - no tonsillar hypertrophy or pharyngeal congestion
● No sinus tenderness
● Dental caries present. No halitosis
● Mild pallor noted in palms, nail beds
● No cyanosis/ lymphadenopathy/clubbing

24. Systemic examination (Respiratory System)
INSPECTION - ( child examined in Sitting and supine position)
● Nose- septum slightly deviated to right, inferior turbinate normal.
● Throat- No tonsillar hypertrophy or pharyngeal congestion
● Ears- No ear discharge
● Trachea appears to be in midline
● Shape of chest- appears normal
● Symmetry of chest – b/l symmetrical
● Apical impulse- could not be visualised
● Movement of chest- appears to be equal on both sides
● Mild intercostal retractions noted on bilateral lower chest region
● No supraclavicular, suprasternal or subcoastal retractions noted
● No scars or sinuses

25. Systemic examination (Respiratory System)
Palpation
● Trachea is in midline
● Apex beat felt in 5th ICS, 0.5 cm lateral to midclavicular line
● Chest movement -decreased on left lower chest
● No tenderness
● Measurements: AP diameter - 22cm, Transverse diameter - 13cm
● Chest circumference, Inspiration - 56 cm, Expiration - 55 cm
● Hemithorax – Right Inspiration - 27.5cm, Expiration - 27cm
Left Inspiration - 28.5cm, Expiration - 28 cm

26. RIGHT LEFT
SUPRACLAVICULAR Normal Decreased
INFRACLAVI UR Normal Decreased
MAMMARY Normal Decreased
INFRAMAMMARY Normal Decreased
AXILLARY Normal Decreased
INFRA AXILLARY Normal Decreased
SUPRASCAPULAR Normal Decreased
INTERSCAPULAR Normal Decreased
INFRASCAPULAR Normal Decreased
VOCAL FREMITUS

27. Percussion
RIGHT LEFT
CLAVICLE Resonant Dull
SUPRACLAVICULAR Resonant Dull
INFRACLAVI UR Resonant Dull
MAMMARY Resonant Stony Dull
INFRAMAMMARY Resonant Stony Dull
AXILLARY Resonant Stony Dull
INFRA AXILLARY Resonant Stony Dull
SUPRASCAPULAR Resonant Dull
INTERSCAPULAR Resonant Stony Dull
INFRASCAPULAR Resonant Stony Dull

28. Tidal percussion- Dullness noted ( no change on inspiration)
Tympanic percussion- ( Traubes space) - tympanic note
Auscultation
● Normal vesicular breath sounds heard
● No added sounds

29. BREATH SOUNDS
RIGHT LEFT
SUPRACLAVICULAR Normal Decreased
INFRACLAVI UR Normal Decreased
MAMMARY Normal Decreased
INFRAMAMMARY Normal Decreased
AXILLARY Normal Decreased
INFRA AXILLARY Normal Decreased
SUPRASCAPULAR Normal Decreased
INTERSCAPULAR Normal Decreased
INFRASCAPULAR Normal Decreased

30. RIGHT LEFT
SUPRACLAVICULAR Normal Decreased
INFRACLAVI UR Normal Decreased
MAMMARY Normal Decreased
INFRAMAMMARY Normal Decreased
AXILLARY Normal Decreased
INFRA AXILLARY Normal Decreased
SUPRASCAPULAR Normal Decreased
INTERSCAPULAR Normal Decreased
INFRASCAPULAR Normal Decreased
VOCAL RESONANCE

31. CVS- S1 S2 heard, no murmur
P/A- Soft, non tender, no organomegaly
CNS- Higher mental function - normal
No cranial nerve abnormalities
Tone, power and reflexes -normal

32. ● Sick look
● Severe thinness
● Febrile
● Pallor
● Tachycardia
● Respiratory distress (tachypnea, chest indrawing)
● Hypoxemia (SPO2-92%)
● Dental caries
● Decreased chest wall movement, vocal fremitus,Vocal resonance with dull note
all over left lung fields
Positive examination findings

33. ● Respiratory system
● Lower airway
● Unilateral
● Left side- parenchyma/pleural involvement
Inference From Clinical Examination

34. Diagnosis
● Left sided pleural effusion probably secondary to infective
etiology most likely bacterial
● To r/o Tuberculosis
● Mild anaemia
● Severe thinness
●

35. Investigations
Hb- 10.8gdl
HCT- 31.5 fl
TLC- 8070 cells
DLC- 47.3%/38.6%
Platelet - 2.34 lakhs
ESR- 74 mm/hr

38. Pleural fluid analysis
● Appearance- yellow ( straw) color
● Cell count - 8000 cells
● 80% neutrophils, 20% lymphocytes
● Glucose- 15mg/dl
● Protein- 2.9g/dl
● Gram stain- gram positive cocci seen in singles and pairs
● Culture- sterile

39. ● Sputum for CBNAAT- NEGATIVE
● Pleural fluid cbnaat - NEGATIVE
● USG thorax- left moderate pleural effusion.
Final Diagnosis
Left sided parapneumonic pleural effusion with mild Anaemia with
severe thinness

40. THANK YOU