Community-acquired pneumonia — formative SAQs

SAQ 1 (10 marks)

A 3-year-old girl is brought to the emergency department with three days of fever and cough and one day of fast breathing. She is alert but flushed, her respiratory rate is 42 per minute with mild subcostal recession, there are focal crackles and reduced air entry at the right base, and her oxygen saturation is 96 percent on air. She is drinking about three-quarters of normal. ^{[1] [2]}

1. State your assessment of severity and how you graded it. (3) ^[2]
2. Outline your investigation and initial treatment. (4) ^{[1] [5]}
3. Describe how you would decide on disposition and what advice you would give. (3) ^[2]

Model answer — SAQ 1

(1) Severity (3). This is non-severe community-acquired pneumonia: a febrile child with focal chest signs and fast breathing for age, but who is alert, feeding at around three-quarters of normal and saturating at 96 percent on air with only mild recession. I grade severity by integrating the respiratory rate against the age threshold, the degree of chest indrawing, oxygenation and feeding rather than a single number, and I would reassess her after antipyresis to read the trajectory. ^[2]

(2) Investigation and treatment (4). She does not need routine investigation. In non-severe pneumonia a chest radiograph, bloods and microbiology do not change management, and a randomised trial showed imaging in ambulatory children did not improve outcome, so I would treat clinically. I would start first-line oral amoxicillin at an appropriate weight-based dose, give antipyresis and encourage fluids, and I would not use the intravenous route because she can absorb oral therapy. I would keep the course short, as short standard-dose regimens are non-inferior for non-severe disease. ^{[1] [5]}

(3) Disposition and advice (3). She can be managed at home because she is non-severe, feeding adequately, saturating well and has a family able to give oral antibiotics and return if needed. I would give concrete safety-net advice: return urgently if her breathing becomes harder or faster, if she will not drink or has far fewer wet nappies, if she becomes drowsy or blue, or if the fever persists beyond about forty-eight hours. I would arrange review at around forty-eight hours to confirm improvement. ^{[2] [1]}