Community-acquired pneumonia — branching viva

Opening

Examiner: A 3-year-old arrives with three days of fever and cough, now breathing fast at 44 per minute with focal right basal crackles, mild recession, feeding three-quarters of normal and saturating 96 percent. How do you approach her? ^[1]

Candidate: I would make a clinical diagnosis of community-acquired pneumonia — a febrile child with fast breathing for age and focal chest signs — and grade its severity by observation before disturbing her. She has a raised respiratory rate but is alert, feeding adequately and saturating well with only mild recession, which places her in the non-severe band. My plan is oral amoxicillin at home with antipyresis and safety-net advice, and I would deliberately not order routine imaging or bloods. ^{[1] [2]}

Branch 1 — investigation and first-line therapy

Examiner: Would you get a chest X-ray to confirm it? ^[3]

Candidate: No, not in non-severe pneumonia. A chest radiograph does not change management in a well child treated as an outpatient, and a randomised trial in ambulatory children with acute lower respiratory infection showed imaging did not improve clinical outcome. It also cannot reliably separate bacterial from viral pneumonia. I reserve a film for severe, complicated, uncertain, recurrent or non-responding cases or a suspected effusion. ^{[3] [2]}

Examiner (probe): What antibiotic, route and duration would you choose, and why? ^[4]

Candidate: I would give oral amoxicillin as first-line, because it covers the pneumococcus, which is the main treatable cause, and oral therapy is as effective as intravenous therapy for a child well enough to absorb it. I would use a short course, because the SAFER trial showed about five days is non-inferior to a longer course for non-severe pneumonia, which reduces antibiotic exposure without harming outcomes. ^{[4] [1]}