History taking and physical examination

Dr San Thitsa Aung

Respiratory System

The first and most important thing

• Establish the rapport• Introduce• Smile• Direct attention to both informant /

historian and the child• address questions to the child, when

appropriate

History

• Patient particulars -Age -Sex -Ethnicity• Source of history• Presenting c/o(obtain a complete chronological sequence of

events)

Routine history and physical examination

Important clues missed

Diagnosis????

Likely and differential diagnoses

Goal orientated history and

physical examination

Diagnosis confirm

Presenting complaintsThe mindless fact collector

The logical strategist

History of present illness COUGH- mode of onset,time of onset- duration(days/weeks/months/years) -dry, moist,productive –sputum(rarely),spasmodic-paroxysmal

whooping ,barking -precipitating/exacerbating factors - relieving factors -diurnal-nocturnal/early morning or seasonal variation -associated symptoms fever,coryza,running nose,difficult breathing,noisy

breathing(wheeze/stridor),cyanosis ,episode of chocking

Dyspnea-abnormally uncomfortable awareness of breathing- laboured breathing

• Mode of onset -acute/chronic• Duration -hrs/days/months/years• Progression• Pattern -noturnal• Aggrevating /Releaving factors-triggered by a particular

activity or situation,SOBAR,SOBOE,orthopnoea• Severity- apnea, pallor,cyanosis,grunting,fast breathing chest indrawing,use of accessary muscles, nasal flaring

restlessness, drowsy,convulsion, unable to drink/suck• Associated - CVS , others-Haemato, Renal

Respiratory Distress ?

Normal RR ( /min)• Age less than 1 yr = 30-40

• 1- 2yr =25- 35• 2-5 = 25-30• 5-12 = 20-25• >12 = 15-20

Tachypnoea• Neonate(<1 month)= >60• Infant (<1 year )= >50• Children (>1 year )= >40

Noisy breathing

Wheeze• High pitched musical

whistling sound• Expiratory• Turbulent airflow through

the narrow airways• Intrathoracic trachea and

major bronchi-terminal bronchioles

• Common in infant & young child

Stridor• Harsh vibratory sound of

variable pitch• Inspiratoy phase• Turbulent airflow through

the narrow partial obstruction extrathoracic upper airway

Common in infant &young child

WHEEZE

• Age - Infant,Toddler,Preschooltransient infant wheeze, viral bronchiolitis

-School age children atopy,asthma,infection• Onset*- acute /recurrent • Precipitated/trigger – exercise/cold air/URI infection asthma• Pattern -day/nocturnal, exercise induced• Severity -unrelieved by medication, use nebulizer (Older child) restriction of daily activities,how much school has

been missed,sleep disturbance (Infant)poor feeding, sweating,regurgitation, failure to thrive, cyanosis

• Associated factors - cough, rapid laboured breathing, chest pain, nausea,vomiting,delayed feeding, coughing with reflux eg.TE fistula, CP

• Contact with URTI

Stridor

• Age -• Onset* -acute/chronicobstruction,infection/congenital

• Persistent/fixed• Preceeding symptoms fever, coryza, sore throat, barking cough eg.croups rash,itching,sneezing,facial swelling eg.Angioneurotic oedema • Worse at night*• Episode of choking, gagging, coughing eg.F/B

Stridor

• Difficulty in swallowing,pain eg.retropharyngeal abscess

• Can’t speak , acutely ill, drolling of saliva eg. epiglottitis• Hoarseness of voice eg. croups• Weak cry• Delayed feeding,coughing with reflux

• System review*

Past medical history• H/o of similar episode, completely well between

episodes, hospital admissions(when?,frequency, reason)

• H/o any relevant prior medical illness

Past med historyHistory Current implications

Eczema Hay fever

allergic tendency relevant to Asthma

Recurrent childhood viral asso wheeze, childhood asthma (atopy)

relevant to childhood onset asthma

Whooping coughMeasle, Pneumonia,PleurisyTuberculosis

recognised causes of Bronchiatasis,especially complicated by pneumoniaReactivation if not previously treated effectively

Connective tissue disorderEg. Rheumatoid arthritis

lung diseases are recognised complication Pulmonary fibrosis,effusion,Bronchiatasis

Aspiration recognised cause of Pneumonia

Neuromuscular disease Respiratory failure Aspiration Pneumonia

Birth History

• Antenatal pregency, maternal intrauterine infection,GDM,smoking,alcohol,cong anormalies

• Natal gestation(prematurity),mode of delivery,birth trauma, B.wt(LBW/SGA/LGA)

Admitted to SCBU,particularly regarding need for ET tube intubation

• Post-natal infection

Nutritional H/o

• Breast/Bottle/mixed• Breast frequency,amount, duration, asso; sweating, dyspnea• Timing of introduction of solid /cereals• Current dietary intake• Feeding -well/poor eg.regurgitation and spitting up could be a sign of GOR

Immunisation H/o

• Complete according to EPI Schedule eg. Hib(H.influenza) stridor,pneumonia• BCG, DTaP,MMR• If failure ask reasons in detail

Developmental H/o

• Gross motor• Fine motor• Speech/Hearing• Social • (Know atleast 4 milestones for different ages which parents can easily answer)

Family History _ consanguinity , overcrowding, parent’s occupation

bronchial asthma, atopy, TB, similar illness, congenital heart disease , cystic fibrosis

Social History– School performance - frequently absent?– Social interaction , economic status– Housing , indoor pollution-cigarette smokers at home– Environmental allergens : pets, carpets

• Drug and allergies List drugs , frequency and dosage eg. Bronchodilators Allergy to drugs, food, dust

Physical exam;

• Differs depending on the age of the child• Inspection is important in younger child• Palpation& percussion are difficult• Ascultation less informative• Obsevation provides 90% of information• Donot undress the young child esp;lly sleeping

General • Wt ,Ht , nutrition and hydration status• Dysmorphic feature• Well/unwell alert/toxic looking, fever• Consciousness drowsy , confusion• Receiving additional oxygen , I.V line• Note the vital signs - BP, PR, RR Undress the child’s top half to the waist (except for the

aldolecent girl) ideally 45 ,baby on his back or sit on mum lap (

• Respiratory distress• using the accessory m/s, alarnasi flaring, visible

recession(difficult to assess if baby is crying)• Respiratory rate (never guess)-count the rate exactly by watching chest or abdominal movement for

1 min• Cyanosis - centeral• Audible sounds- wheeze,stridor,grunting,cough

• Hands- clubbing anaemia peripheral cyanosis warm tremor (fine/flapping) (pulsus paradoxus = >15 mmHg difference)• Extremeties- eczema, urticaria,oedema• Face -syndrome-Down’s,Cleft lip,fever,cyanosis(lips,tongue)• Nose - alar nasi, nasal discharge, polyps• Neck- feel for cx LN (at this stage done from front)

• Throat& Ear- ENT exam; at the end of examination*

• Trachea(perform this on one side) gently place your index finger b/t the trachea and the sternal head of the sternocleidomastoid on each side and seeing if the gap on both side is equal

Observe the chest

• Inspection DeformityPectus excurvatum=depressed sternum (funnel chest) Pectus carinatum=prominent sternum (pigeon chest) Harrison’s sulcus = retracted costal cartilages suggesting chronic condition(either airway obst- ruction or Lt to Rt cardiac shunt) Look all round the the chest including under the axilla

Pectus excurvatum Pectus carinatum

Hyperinflation-increase AP(antero-posterior) suggests asthma /emphysemaRachitic rosary-swelling of the costochondrial junction in RicketsAbsent clavicle/pectoralis muscleScars- sternotomy,thoracotomy, chest drainsChest wall movement- compare both sidesIntercostal/subcostal recessionScoliosis- Don’t forget to look the back of the chest

• Approach to infant and older child differ• P&P are not routine parts of the examination of baby• You should leave out P&P and go straight to Ascultation But in older child –to follow the established sequence begin with infront of the chest ask the child to sit up on the bed lying back against a pillow with arm by the side

• •

• Palpation Feel quickly for the Apex beat Dextrocardia Scoliosis Displacement of Trachea+apex to the sameside

mediastinal shift Eg. Pleural effusion,Pneumothoraxpush away Collapse,Fibrosis pull towards that side Displacement of Trachea aloneupper lobe

pathology Displacement of Apex alonePectus,scoliosis

Assess chest expension Place the fingertips of the both hands on the

chest wall laterally so that thumbs meet in the midline, only thumb s/b lifted slightly off

and fingertips must be kept tightly applied to the chest wall throughout Ask the child to take deep breath in observe which thumb move least from the midline

Eg. Effusion, Pneumo; collapse,consolidation fibrosis diminshed expension on that sideTactile vocal framitus - Place the palm of the hand on either side of

the chest ant;lly and ask the child to say “99” -feel for difference between Rt &Lt rather than

increase& decrease

• Percussion- only twice at each of the sites -alternating Lt & Rt -ant;lly start in supraclavicular fossa, clavicle,2th to 6th ICS -don’t forget mid-axillary line on each side-4th to

7th ICS -post;lly –apex, below the level of spine of

scapula to 11th ICS (Avoid percussion near midline) -to determine where the upper border of liver

• Ascultation - ask the child to open his mouth and breath in &

out -show him first and demonstrate how to do

properly -listen upper, middle and lower parts of lung

fields and in mid-axillary line -diaphragm of stethoscope is better for higher frequencies

-Bell is applied tightly to chest wall,it behaves like a diaphragm -compare the Lt & Rt -listen for one cycle of inspiration and expiration

at each site -2 breathe at each of 6 sites anteriorly and post- eriorly

Breath sounds

Vesicular • Normal

• Low-pitched• Inspiratory phase is

longer than expiratory • No break inbetween

Bronchial • May be heard in normal

child (ant;lly below the Rt clavicle, post;lly over the hila)

• Harsh,high- pitched,• Inspiratory and expiratory

phase are equal• A pause inbetween• Abnormal, heard over

consolidation,just above effusion

Added sounds

1. Conducted upper airway sounds2. Wheeze or rhonchi -high-pitch whistling more commonly heard in expiration (monophonic-single larger airway obstruction) (polyphonic-many airway )3.Crepts/crackles-interrupted bubbling noises usually in early inspiration

there are 2 catagories in crepts Coarse and variable pitch due to secretions- eg. Pneumonia,Bronchiectasis Fine and high-pitched at the base- eg.pulmonary oedema,bronchiolitis,fibrosing alveolitis Describe the location of the abnormal signs eg. VBS with crepts in Rt middle zone BBS in Lt upper zone

Physical signs in respiratory diseases

Disease Chest movt Mediast; shift Percussion Vocal Resonance

Breath sounds

Consolidation ↓ none Dull ↑ BBS crepts

collapse ↓ to same side Dull ↓ ↓

Fibrosis ↓ To same side Dull ↑ BBScrepts

Effusion ↓ To opposite side

Stony dull absent AbsentBBS

Pneumothorax ↓ To opposite side

Hyper resonant

↓ ↓

• To complete the resp; system exam: I’d to per- form ENT exam and measure PEFR To palpate the liver and spleen-hyperinflacted lung downwards displacement of the liver and spleen To find out the s/- of heart failure Summary Diagnosis Differential Diagnosis Point for Diagnosis

References

• Macleod’s Clinical Examination, Graham Douglas, 11th Edition

• Illustrated Textbook of Paediatrics 3rd Edition• Nelson Textbook of Pediatrics, 18th Edition• Clinical examination Systemic guide to physical

diagnosis,6th edition

Thank You