What are the key components of a complete history and physical examination for a pediatric patient with community-acquired pneumonia (CAP), considering demographic information, past medical history, and symptoms?

Complete History and Physical Examination for Pediatric Community-Acquired Pneumonia

History Taking

Demographic and Age-Specific Considerations

Age is the single most important predictor of likely pathogens and should guide your entire clinical approach. 1

• Document exact age in months for children <5 years - viruses predominate in younger children, while bacterial causes (particularly Chlamydia and Mycoplasma pneumoniae) increase with age 1
• Record sex - males under 5 years have significantly higher incidence, particularly for Streptococcus pneumoniae (11.2/1000 in boys vs 5.7/1000 in girls) 1

Critical Past Medical History Elements

Specific risk factors dramatically alter your assessment and management approach. 1

For children <5 years, specifically ask about: 1

• Recurrent respiratory infections in the previous year
• History of wheezing episodes
• History of acute otitis media requiring tympanocentesis before age 2 years

For children 5-15 years, specifically ask about: 1

• Recurrent respiratory infections in the previous year
• History of wheezing episodes

Immunization Status

• Document pneumococcal conjugate vaccine (PCV) status - this fundamentally changes your empiric antibiotic selection 2
• Document Haemophilus influenzae type b vaccine status 3
• Document pertussis and influenza vaccination status 3

Symptom Assessment

Key presenting symptoms to document: 3

• Fever - specifically document if >38.5°C 1
• Cough - duration and character 3
• Tachypnea - parent-reported difficulty breathing 3
• Anorexia or decreased feeding 3
• Duration of illness - particularly important if >48-72 hours without improvement 2, 3

Physical Examination

Vital Signs Assessment

These are your most critical objective measures for severity assessment. 1

For infants, document: 1

• Respiratory rate - admission threshold is >70 breaths/min 1
• Oxygen saturation - admission threshold is <92% 1
• Presence of apnea or grunting 1

For children aged up to 3 years: 1

• Temperature - bacterial pneumonia more likely if >38.5°C 1
• Respiratory rate - bacterial pneumonia more likely if >50/min 1
• Presence of chest recession 1

For older children: 1

• History of difficulty breathing is more helpful than specific clinical signs 1

Respiratory Examination

Critical findings to document: 3

• Grunting - strongly associated with radiographic infiltrate 3
• Retractions (subcostal, intercostal, suprasternal) - strongly associated with radiographic infiltrate 3
• Crackles on auscultation - strongly associated with radiographic infiltrate 3
• Wheeze - if present in preschool children, primary bacterial pneumonia is unlikely 1

General Assessment

• Cyanosis - indicates need for immediate hospitalization 1
• Ability to feed - inability indicates need for hospitalization 1
• Overall clinical impression - strongly associated with radiographic infiltrate 3

Clinical Decision Points

Indicators for Hospitalization

These are absolute criteria requiring admission: 1

For infants: 1

• Oxygen saturation <92% or cyanosis
• Respiratory rate >70 breaths/min
• Difficulty breathing
• Intermittent apnea or grunting
• Not feeding
• Family unable to provide adequate care

For all children: 2

• Failure to demonstrate clinical improvement after 48-72 hours of outpatient treatment
• Progressive symptoms despite appropriate therapy
• Hypoxemia or significant respiratory distress 3

Age-Specific Pathogen Likelihood

This guides empiric therapy selection: 1

Children <5 years: 1

• S. pneumoniae: 8.6/1000/year incidence
• Mycoplasma pneumoniae: 1.7/1000/year
• Chlamydia species: 1.7/1000/year
• Respiratory syncytial virus most common viral cause 3

Children 5-15 years: 1

• Mycoplasma pneumoniae: 6.6/1000/year (most common bacterial cause in this age group)
• S. pneumoniae: 5.4/1000/year
• Chlamydia species: 3.9/1000/year

Common Pitfalls to Avoid

• Do not rely on wheeze to rule out all pneumonia - it specifically rules out primary bacterial pneumonia in preschool children but viral pneumonia remains possible 1
• Do not assume single pathogen - 8-40% of CAP cases represent mixed infections 1
• Do not order routine chest radiography for mild cases - reserve for uncertain diagnosis, hypoxemia, significant respiratory distress, or failure to improve within 48-72 hours 1, 3
• Clinical signs alone cannot distinguish bacterial from viral etiology - age and epidemiological context are more reliable 4, 5