ACUTE RESPIRATORY INFECTION

NAME:
AGE:
GENDER:
ADDRESS:
OCCUPATION:
INFORMANT:
CHIEF COMPLAINTS: Patient presented with chief complaints of
Fever
Cough and Cold
Breathlessness
HISTORY OF PRESENTING ILLNESS: The patient was apparently
normal, complaint started as,
a) History of fever:
Onset (sudden/progressive)
Duration
Grade (low/high)
Type of fever (continuous/intermittent)
Diurnal variation – evening rise of temperature
Associated with chills and rigors

b) History of Cough and Cold:

Onset
Duration
Severity
Associated with running nose/not
 With expectorant (productive/non-productive)
Type of expectorant (serous/mucous/muco-purulent)
Sputum – Colour
Amount
Consistency
Diurnal variation
History of cough syncope – if present

c) History of breathlessness:
Onset
Duration
Severity
Diurnal variation
Positional variation
Associated factors
Relieving factors

d) History of lethargy

e) History of irritability

f) History of convulsions

g) History of refusal of feeds

h) History of increased crying

i) History of loose stools

j) History of vomiting

k) History of decreased urine output

 l) History of ear discharge

PAST HISTORY:
History of similar episode
History of exanthematous fevers
History of previous surgeries
History of congenital conditions or any acquired diseases
CONTACT HISTORY:
No History of similar episodes in the neighbourhood
BIRTH HISTORY:
ANTENATAL HISTORY:
Mother booked and immunized
Consumption of iron and folic acid tablets regularly
No history of diabetes and hypertension during pregnancy
No history of pre-eclampsia and eclampsia
NATAL HISTORY:
Mother delivered a baby through normal delivery/ at hospital
without any complications.
Baby cried immediately after birth
Birth weight
Breast feeding initiated within 1 hour of birth
POSTNATAL HISTORY:
No postnatal complications
No NICU admission
 Baby was exclusively breastfed for the 1st 6 months
Weaning started by the 7th month with soft mashed
vegetables, cerelac powder
Whether still breastfeeding the baby/ Not
IMMUNISATION HISTORY:
National Immunization Schedule (NIS) for Infants, Children and
Pregnant Women.
Vaccine When to give Dose Route Site
For Pregnant Women
TT-1 Early in pregnancy 0.5 ml Intra-muscular Upper Arm
TT-2 4 weeks after TT-1* 0.5 ml Intra-muscular Upper Arm
TT- Booster If received 2 TT doses in a pregnancy 0.5 ml Intra-muscular Upper Arm
within the last 3 yrs*
For Infants
BCG At birth or as early as possible till one 0.1ml Intra-dermal Left Upper Arm
year of age (0.05ml until
1 month
age)
Hepatitis B - Birth At birth or as early as possible within 0.5 ml Intra-muscular Antero-lateral
dose 24 hours side of mid-thigh
OPV-0 At birth or as early as possible within 2 drops Oral Oral
the first 15 days
OPV 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks 2 drops Oral Oral
(OPV can be given till 5 years of age)
Pentavalent At 6 weeks, 10 weeks & 14 weeks 0.5 ml Intra-muscular Antero-lateral
1, 2 & 3 (can be given till one year of age) side of mid-thigh
Rotavirus# At 6 weeks, 10 weeks & 14 weeks 5 drops Oral Oral
(can be given till one year of age)
IPV Two fractional dose at 6 and 14 0.1 ml Intra dermal two Intra-dermal:
weeks of age fractional dose Right upper arm
Measles /MR 1st 9 completed months-12 months. 0.5 ml Sub-cutaneous Right upper Arm
Dose$ (can be given till 5 years of age)
JE - 1** 9 completed months-12 months. 0.5 ml Sub-cutaneous Left upper Arm

Vitamin A At 9 completed months with measles- 1 ml Oral Oral

(1st dose) Rubella ( 1 lakh IU)
For Children
DPT booster-1 16-24 months 0.5 ml Intra-muscular Antero-lateral
side of mid-thigh
Measles/ MR 2nd 16-24 months 0.5 ml Sub-cutaneous Right upper Arm
dose $
OPV Booster 16-24 months 2 drops Oral Oral
JE-2 16-24 months 0.5 ml Sub-cutaneous Left Upper Arm
Vitamin A*** 16-18 months. Then one dose every 6 2 ml Oral Oral
(2nd to 9th dose) months up to the age of 5 years. (2 lakh IU)
DPT Booster-2 5-6 years 0.5 ml. Intra-muscular Upper Arm
TT 10 years & 16 years 0.5 ml Intra-muscular Upper Arm
 *Give TT-2 or Booster doses before 36 weeks of pregnancy. However, give these even if more
 than 36 weeks have passed. Give TT to a woman in labour, if she has not previously received TT.
 **JE Vaccine is introduced in select endemic districts after the campaign.
 *** The 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during
biannual rounds, in collaboration with ICDS.
 #Phased introduction, at present in Andhra Pradesh, Haryana, Himachal Pradesh and Orissa from
2016 & expanded in Madhya Pradesh, Assam, Rajasthan, and Tripura in February 2017 and
planned in Tamil Nadu & Uttar Pradesh in 2017.
 $ Phased introduction, at present in five states namely Karnataka, Tamil Nadu, Goa,
Lakshadweep and Puducherry. (As of Feb’ 2017)

Immunisation status: Partial/ completely immunized

DEVELOPMENTAL HISTORY:
Child’s growth is normal
Normal milestone
Last attained milestones are
Motor –
Language –
Adaptive development –
Socio- personal development –
Milestones of development
The 'milestones' given here are approximations and to assess any individual
child, all types of growth development and behaviour must be taken into
account.
Age Motor Language Adaptive Socio-personal
development development development development
6-8 weeks - - - Looks at mother
and smiles
3 months Holds head erect - - -
4-5 months - Listening Begins to reach Recognizes
out for objects mother
6-8months Sits without Experimenting Transfers objects Enjoys hide and
support with noises hand to hand seek
9-10 months Crawling Increasing range Releases objects Suspicious of
of sounds strangers
10-11 months Stands with First words - -
support
12-14 months Walks wide base - Builds -
18-21 months Walks narrow Joining words Beginning to -
base beginning to explore
run
24 months Runs Short sentences - Dry by day

DIET HISTORY:
According to 24 hours recall method
S.No. Item Time Calorie Protein
(kcal) level (g)

Total intake: ___________ __________

Total calorie intake –
Required calorie intake –
Calorie deficit –
Protein intake –
Protein required –
FAMILY HISTORY:
Type of family – 3 generation family/ joint family/ nuclear
family
S.No. Name Age Status in Education Occupation Income
househol
d

Family income: _______

Education –
Occupation –
Income –
Total score –
 According to Modified kuppuswamy’s scale, this family
comes under upper/ middle/ lower scale.
Modified Kuppuswamy’s Socioeconomic Status Scale

Kuppuswamy’s Socioeconomic Status Scale1

(A) Education Score

1. Profession or Honours 7
2. Graduate or post graduate 6
3. Intermediate or post high school diploma 5
4. High school certificate 4
5. Middle school certificate 3
6. Primary school certificate 2
7. Illiterate 1

(B) Occupation Score

1. Profession 10
2. Semi-Profession 6
3. Clerical, Shop-owner, Farmer 5
4. Skilled worker 4
5. Semi-skilled worker 3
6. Unskilled worker 2
7. Unemployed 1

(C) Family income per Score Modified

month(in Rs)- original for January 2019 (CPI[IW]-307)

1. >47348 12
2.23674 - 47347 10
3. 17756 - 23673 6
4. 11837 – 17755 4
5. 7102 – 11836 3
6. 2391- 7101 2
7. <2390 1
Total Score Socioeconomic class
26-29 Upper (I)
16-25 Upper Middle (II)
11-15 Middle Lower middle (III)
5-10 Lower Upper lower (IV)
<5 Lower (V)

ENVIRONMENTAL HISTORY:
Rural/ Urban area
Type of house
Number of rooms and windows
Overcrowding
Adequate lighting and Ventilation
Separate kitchen
Separate sanitary latrine
Source of drinking water
Source of water for household use
Garbage disposal
Specific vector breeding sites around house
Pet animals
GENERAL EXAMINATION:
Child is active/ not active
Alert/ not alert
Hydrated/ not hydrated
Built and nourishment
 Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal oedema
HEAD TO FOOT EXAMINATION:
Anterior frontellar closed/ not yet closed
Dysmorphic facies
No congenital anomalies
BCG scar/ seen
Neck – Engorged veins
Hydration - Fair
VITAL SIGNS:
Temperature
Pulse rate
Respiratory rate
Blood pressure
ANTHROPOMETRIC MEASUREMENTS:

Observed Expected
Length
Weight
Head circumference
Chest circumference
Midarm circumference
EXAMINATION OF RESPIRATORY SYSTEM:
Number of breaths per minute –
Chest indrawing –
Wheeze –
Stridor –
ASSESSMENT OF ARI AS PER IMNCI:
Signs Chest indrawing (if No chest indrawing No chest indrawing
also recurrent and fast breathing (50 and No fast breathing
wheezing, go directly per minute or more if (Less than 50 per
to treat wheezing) child 2 months upto minute if child 2
12 months; 40 per months up to 12
minute or more if months; Less than 40
child 12 months upto per minute if child is
5 years}. 12 months up to 5
years).
Classify as SEVERE PNEUMONIA PNEUMONIA NO PNEUMONIA:
COUGH OR COLD
Treatment Refer URGENTLY to Advise mother to give If coughing more than
hospital Give first home care. Give an 30 days, refer for
dose of an antibiotic. antibiotic. assessment.

Treat fever, if present, Treat fever, if present. Assess and treat ear
Treat wheezing, if Treat wheezing, if problem or sore
present (if referral is present. Advise throat, if present.
not feasible, treat mother to return with Assess and treat other
with an antibiotic and child in 2 days for problems. Advise
follow closely) reassessment, or mother to give home
earlier if the child is care. Treat fever, if
getting worse. present. Treat
wheezing, if present.

Re-assess in 2 days a child who is taking an antibiotic for pneumonia,

Signs WORSE THE SAME IMPROVING

Not able to drink Breathing slower
Has chest indrawing Less fever
Has other danger signs Eating better
Treatment Refer URGENTLY to Change antibiotic or Finish 5 days of
hospital Refer antibiotic.
LOCAL EXAMINATION:
INSPECTION:
Chest wall deformities
Moves symmetrically with respiration
Trachea appears to be in midline
Spine – Normal
No kyphosis/ scoliosis
No scars/ sinuses
No surgical scars
No suprasternal retractions
No visible pulsations
Apical impulse seen at left 4th intercostal space lateral to
midclavicular line
PALPATION:
Not warm/ tender
No crepitus
Trachea in midline
Apical impulse in the left 4th intercostal space lateral to
midclavicular line
Measurements
Findings of inspection should be confined by palpation
PERCUSSION:
Resonant/ Dull
Region Right Left
Supraclavicular
Clavicle
Infraclavicular
Mammary
Axillary
Inframaxillary
Suprascapular
Interscapular
Infrascapular

AUSCULTATION:
Breath sounds:
Normal vesicular
Bronchial – Tubular
Cavernous
Amphoric
Added sounds:
Crepitations
Ronchi
Pleural sub

Region Right Left

Supraclavicular
Clavicle
Infraclavicular
Mammary
Axillary
Inframaxillary
Suprascapular
Interscapular
Infrascapular

OTHER SYSTEM EXAMINATION:

CVS – S1, S2 heard
No murmers
CNS – No focal neurological deficit
Abdomen – Soft, non-tender, No organomegaly
DIAGNOSIS:
A male/ female child belonging to upper/ middle/ lower
class suffers from acute respiratory infection with/ without
pneumonia.
INVESTIGATION:
Chest X-Ray
TREATEMENT:

Signs Chest indrawing (if No chest indrawing No chest indrawing

also recurrent and fast breathing (50 and No fast breathing
wheezing, go directly per minute or more if (Less than 50 per
to treat wheezing) child 2 months upto minute if child 2
12 months; 40 per months up to 12
minute or more if months; Less than 40
child 12 months upto per minute if child is
5 years}. 12 months up to 5
years).
Classify as SEVERE PNEUMONIA PNEUMONIA NO PNEUMONIA:
COUGH OR COLD
Treatment Refer URGENTLY to Advise mother to give If coughing more than
hospital Give first home care. Give an 30 days, refer for
dose of an antibiotic. antibiotic. assessment.

Treat fever, if present, Treat fever, if present. Assess and treat ear
Treat wheezing, if Treat wheezing, if problem or sore
present (if referral is present. Advise throat, if present.
not feasible, treat mother to return with Assess and treat other
with an antibiotic and child in 2 days for problems. Advise
follow closely) reassessment, or mother to give home
 earlier if the child is care. Treat fever, if
getting worse. present. Treat
wheezing, if present.

Re-assess in 2 days a child who is taking an antibiotic for pneumonia,

Signs WORSE THE SAME IMPROVING

Not able to drink Breathing slower
Has chest indrawing Less fever
Has other danger signs Eating better
Treatment Refer URGENTLY to Change antibiotic or Finish 5 days of
hospital Refer antibiotic.

ADVICE TO MOTHER:
 Additional 1 cup of milk, ½ cup of mashed vegetables, 1
egg to make up for calorie deficit.
 To increase the feeding and keep the child warm.
 To completely immunise the child according to
immunisation schedule.
 Continue breast feeding upto 2 years of age.
 Keep the child away from pet animals.
 Improve hygiene in the household.
RELATIVE PROGRAMES:
 Reproductive and child healthcare (RCH-II).
 Integrated management of newborn and childhood illness
(IMNCI).
 Global action plan for the prevention of control of
pneumonia and diarrhoea (GAAPD).

Epidemiological Determinants of Acute Respiratory

Infections .
The determinants of ARI can be classified into 3 main components :
1.)AGENTS
 2.)HOST FACTORS
3.)ENVIRONMENT

1.)Agents.
There are numerous microbial agents that cause acute
respiratory infections .
They could be classified as Bacteria , Virus and other agents.

○ Bacterial Agents.
 Bordetella pertussis
 Cornybacterium diphtheriae
 Haemophilus influenzae
 Klebsiella pneumoniae
 Staphylococcus pyogenes
 Legionella pneumophilia
 Streptococcus pneumoniae
 Streptococcus pyogenes
○ VIRUS
 Influenza (A,B,C)
 MEASLES
 PARAINFLUENZA
 Respiratory Syncytial Virus
 Corona Virus
 Rhino Virus

2.)Host factors.

 Small children succumb to the disease within a matter of

days
 Case fatality rates are higher in young infants and
malnourished children
  Adults are also affected and the symptoms tends to be
more among females
 The infection is common in preschool children attending
day care centers
 Low socioeconomic status children tend to have more
episodes of ARI.
 Maternal smoking has been linked to increased
occurrenxe of respiratory infections during the first year
of life.

3.)Environment

 Climatic conditions and housing are noted as major

environmental risk factors
 Overcrowding, poor nutrition.
 Intense indoor smoke pollution underline the high rates
 Infections are more common in Urban communities than
in rural communities
 Passive smoking, house make and size are other factors to
be noted.

Classification and management of ARI for children aged 2 months- 5

yrs:
1. Very severe disease
2. Severe pneumonia
3. Pneumonia(not severe)
4. No pneumonia: cough or cold

1. Very severe disease:

Signs:
  Unable to drink
 Convulsions
 Abnormally sleepy
 Stridor
 Severe malnutrition

Treatment:
 Refer urgently to hospital
 Give first dose of an antibiotic
 Treat fever
 Treat wheezing

2. Severe pneumonia:
Signs:
 Chest indrawing
 Nasal flaring
 Cyanosis

Treatment:
 Refer urgently to hospital
 Treat wheezing
 Give first dose of antibiotics

3. Pneumonia:

Signs:
 No chest indrawing
 Fast breathing
Treatment:
  Advice mother to give home care
 Give antibiotics
 Treat fever and wheezing
 Advice mother to return with child in 2 days for
reassessment

4. No pneumonia:

Signs:
 No fast breathing
 No chest indrawing

Treatment:
 Assess and treat ear problem and sore throat if present
 Advice mother to give home care
 Treat fever and wheezing if present

Classification and management of ARI for children less than 2

months:

1. Very severe disease

2. Severe pneumonia
3. No pneumonia

1. Very severe disease:

Signs:
 Stopped feeding well
 Convulsions
 Stridor
  Wheezing
 Abnormally sleepy
Treatment:
 Refer urgently to hospital
 Keep infant warm
 Give first dose of antibiotics

2. Severe pneumonia:
Signs:
 Severe chest indrawing
 Fast breathing
Treatment:
 Refer urgently to hospital
 Keep infant warm
 Give first dose of antibiotics

3. No pneumonia:
Signs:
 No fast breathing
 No severe chest indrawing
Treatment:
 Advice mother to give following home care

i. Keep infant warm

ii. Breast feed frequently
iii. Clear nose
  Return quickly if,

1. Breathing becomes difficult

2. Breathing becomes fast
3. Feeding becomes a problem
4. Younger infant become sick

Prevention of Acute Respiratory Infections:

In developing countries, improved living conditions, better
nutrition and reduction of smoke pollution indoors will reduce the
burden of mortality and morbidity associated with ARI.
Immunisation is an important measure to reduce cases of
pneumonia which occurs as a complication of vaccine preventable
disease, especially measles.
Immunisation:
Three vaccines have potential of reducing deaths from
pneumonia.

 Measles vaccine:
Pneumonia is a serious complication of measles and
most common cause of death associated with measles. A safe
and effective vaccine against measles is available for past 40
years. Only live attenuated vaccines are recommended for
use; that are both safe and effective, and may be used
interchangeably within immunisation programmes.
Before use, the lyophilized vaccine is reconstituted with
sterile diluent.
Each dose of 0.5 ml contains >1000 viral infective units of
vaccine strain. The reconstituted vaccine is generally
injected subcutaneously, it is also effective when
administered intramuscularly.
 HIB vaccine:
Haemophilia influenza type B(Hib), is an important cause of
pneumonia and meningitis among children on developing
countries. The vaccine is often given as combined
preparation with DPT and poliomyelitis vaccine. Three or
four doses are given depending on the manufacturers and
type of vaccines used, and is given intramuscularly. The
vaccine schedule is at 6,10, and 14 weeks of age. For children
more than 12 months of age, who have not received their
primary immunisation series a single dose is sufficient for
protection. The vaccines is not generally offered to children
aged more than 24 months.

 PNEUMOCOCCAL PNEUMONIA VACCINE:

 PPV23:
It is recommended for selected groups, e.g., those who
have undergone splenectomy or have sickle cell disease,
chronic disease of heart, liver or kidney; diabetes
mellitus ,alcoholism, generalized malignancies., organ
transplants etc.
For primary immunisation, PPV23 is administered as
a single intra muscular dose preferably in the deltoid
muscle or as subcutaneous dose. The vaccine should
not be mixed in the same syringe with other vaccines
for eg, with influenza vaccine, but may be administered
at the same time by separate injection in the other arm.

 PCV:
Two conjugate vaccines are available since 2009 Pcv10
and pcv13.Both vaccines are preservative free and
their storage temperature is 2-8°c.
For PCV administration to infants, WHO
recommends 3 primary doses (the 3p +0 schedule) or,
as an alternative, 2 primary doses plus one booster (the
2p +1 schedule). In 3p+0 schedule, vaccination can be
initiated as early as 6 weeks of age with an interval
between doses of 4-8 weeks, with doses given at 6,10
and 14 weeks or 2,4 and 6 months, depending on
programme convenience.
If 2p+1 schedule is selected,2 primary doses are
given during infancy as early as 6 weeks at an interval
of 8 weeks or more for young infant, and 4-8 weeks or
more between primary doses for infants>=7 months of
age.one booster dose should be given between 9-
15months of age.
 PROJECT DONE BY.,
ROLL No. NAME WORK’s DONE
61 NIVETHA U Preliminary details, History of presenting
illness.
62 PARVEEN BANU H Past history, Contact history, Birth history.
63 POOJA VERMA Immunisation history.
64 PRAHLADA N Developmental history and Milestones.
65 PRATHIK S Family history, Modified Kuppuswamy’s
scale.
66 PRAVEEN K Environmental history, General examination,
Head to foot examination.
67 PRAVEEN KUMAR M Vital signs, Anthropometric measurements,
 Examination of Respiratory system, Diet
history.
68 PREETHI T Local examination upto percussion.
69 RAGAVI R Auscultation, Investigation,
Diagnosis, Other system examination.
70 G RAHUL PRASANTH Treatment, Advice to mother, Related
programmes.