IMCI training video: Case study Ben

Summary

In this case study, a 7-month-old baby named Ben presents with a worsening cough that has lasted for two weeks. After assessing his general condition and breathing, it’s found that he is not experiencing any danger signs such as lethargy or vomiting. However, his breathing is fast at 55 breaths per minute, and he shows chest in drawing. No stridor is present. Based on these findings, Ben is classified as having severe pneumonia or very severe disease, emphasizing the importance of thorough clinical assessment in diagnosing respiratory conditions in young children.

Takeaways

• 😀 Ben is a 7-month-old infant brought to the clinic by his mother due to a persistent cough lasting 2 weeks.
• 😀 Ben's general danger signs were checked: he can drink, isn't vomiting, hasn't had convulsions, and is not lethargic or unconscious.
• 😀 No general danger signs were identified in Ben during the initial assessment.
• 😀 The primary symptom being assessed is Ben's cough and difficulty breathing, as his cough has worsened over the last 2 weeks.
• 😀 Ben's breathing rate was counted, revealing 55 breaths per minute, indicating fast breathing for his age (7 months).
• 😀 Chest indrawing was present in Ben, indicating a more serious respiratory condition.
• 😀 No stridor (harsh sound) was heard during Ben's breathing assessment.
• 😀 Based on the clinical signs, Ben's condition was classified under the category of severe pneumonia or very severe disease.
• 😀 The classification of severe pneumonia was determined by the presence of chest indrawing and fast breathing.
• 😀 The clinical classification table for cough or difficulty breathing guided the diagnosis of severe pneumonia for Ben.
• 😀 Ben’s mother provided important details about his symptoms, which helped in accurately assessing and classifying his condition.

Q & A

What is the age of the child in the case study?

The child, Ben, is 7 months old.

What symptoms prompted the mother to bring Ben to the clinic?

Ben has been coughing for two weeks, and his mother noticed that the cough is getting worse.

What general danger signs were assessed for Ben?

Ben was assessed for lethargy, unconsciousness, vomiting, and the ability to drink. He did not show any general danger signs.

How long has Ben been coughing?

Ben has been coughing for two weeks.

What is the significance of counting the number of breaths per minute?

Counting the breaths per minute helps assess whether the child is experiencing fast breathing, which is a key symptom in classifying respiratory illnesses.

What did the breath count reveal for Ben?

Ben had 55 breaths in one minute, which indicates fast breathing given his age.

What does chest in-drawing signify in a child with a cough?

Chest in-drawing indicates that the child is having difficulty breathing, as the chest muscles are drawing inward during breathing.

What does the absence of stridor suggest about Ben's condition?

The absence of stridor suggests that Ben's condition does not involve a harsh, high-pitched sound during inhalation, which typically points to severe respiratory distress.

How is Ben's illness classified based on the signs observed?

Ben's illness is classified as severe pneumonia, or very severe disease, due to the presence of chest in-drawing and fast breathing.

Why is it important to assess for general danger signs in a child with a cough?

Assessing for general danger signs is critical to determine if the child is at risk of more severe complications and needs urgent medical attention.