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History taking and physical       examination      Dr San Thitsa Aung
The first and most important thing• Establish the rapport• Introduce• Smile• Direct attention to both informant /  histori...
History• Patient particulars -Age -Sex -Ethnicity• Source of history• Presenting c/o(obtain a complete chronological seque...
The mindless                Presenting complaints            The logicalfact collector                                    ...
History of present illness COUGH- mode of onset,time of onset- duration(days/weeks/months/years) -dry, moist,productive –...
Dyspnea-abnormally uncomfortable awareness of              breathing- laboured breathing• Mode of onset -acute/chronic• D...
Respiratory Distress ?Normal RR ( /min)                   Tachypnoea• Age less than 1 yr = 30-40   • Neonate(<1 month)= >6...
Noisy breathingWheeze                        Stridor• High pitched musical        • Harsh vibratory sound of  whistling s...
WHEEZE• Age - Infant,Toddler,Preschooltransient infant  wheeze,      viral bronchiolitis            -School age children ...
• Associated factors - cough, rapid laboured  breathing, chest pain, nausea,vomiting,delayed  feeding, coughing with reflu...
Stridor• Age -• Onset* -acute/chronicobstruction,infection/congenital• Persistent/fixed• Preceeding symptoms fever, cory...
Stridor• Difficulty in swallowing,pain                  eg.retropharyngeal abscess• Can’t speak , acutely ill, drolling of...
• System review*Past medical history• H/o of similar episode, completely well between  episodes, hospital  admissions(when...
Past med historyHistory                             Current implicationsEczema                              allergic tende...
Birth History• Antenatal  pregency, maternal intrauterine  infection,GDM,smoking,alcohol,cong anormalies• Natal     gest...
Nutritional H/o• Breast/Bottle/mixed• Breast  frequency,amount, duration,   asso; sweating, dyspnea• Timing of introducti...
Immunisation H/o• Complete according to EPI Schedule  eg. Hib(H.influenza) stridor,pneumonia•       BCG, DTaP,MMR• If fai...
Developmental H/o•   Gross motor•   Fine motor•   Speech/Hearing•   Social•   (Know atleast 4 milestones for different age...
Family History _ consanguinity , overcrowding, parent’s occupation bronchial asthma, atopy, TB, similar illness, congenita...
• 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& perc...
General• Wt ,Ht , nutrition and hydration status• Dysmorphic feature• Well/unwell  alert/toxic looking, fever• Consciousn...
• Respiratory distress• using the accessory m/s, alarnasi flaring, visible  recession(difficult to assess if baby is cryin...
• Hands- clubbing          anaemia          peripheral cyanosis          warm          tremor (fine/flapping)  (pulsus par...
• Throat& Ear- ENT exam; at the end of  examination*• Trachea(perform this on one side)        gently place your index fin...
Observe the chest• Inspection DeformityPectus excurvatum=depressed sternum                (funnel chest)              Pe...
Pectus excurvatum   Pectus carinatum
Hyperinflation-increase AP(antero-posterior)               suggests asthma /emphysemaRachitic rosary-swelling of the cos...
• Approach to infant and older child differ• P&P are not routine parts of the examination of  baby• You should leave out P...
• Palpation Feel quickly for the Apex beat Dextrocardia                                  Scoliosis  Displacement of Trac...
 Assess chest expension  Place the fingertips of the both hands on the  chest wall laterally so that thumbs meet in the m...
Eg. Effusion, Pneumo; collapse,consolidation    fibrosis diminshed expension on that sideTactile vocal framitus - Place ...
• Percussion- only twice at each of the sites            -alternating Lt & Rt            -ant;lly start in supraclavicular...
• Ascultation - ask the child to open his mouth and breath in &   out -show him first and demonstrate how to do   properly...
-Bell is applied tightly to chest wall,it behaveslike a diaphragm-compare the Lt & Rt-listen for one cycle of inspiration ...
Breath sounds Vesicular                    Bronchial• Normal                   • May be heard in normal                   ...
Added sounds1. Conducted upper airway sounds2. Wheeze or rhonchi -high-pitch whistling         more commonly heard in expi...
there are 2 catagories in creptsCoarse and variable pitch due to secretions- eg. Pneumonia,BronchiectasisFine and high-pit...
Physical signs in respiratory diseasesDisease           Chest movt Mediast; shift   Percussion   Vocal       Breath       ...
• To complete the resp; system exam: I’d to per-  form ENT exam and measure PEFR  To palpate the liver and spleen-hyperinf...
References• Macleod’s Clinical Examination, Graham  Douglas, 11th Edition• Illustrated Textbook of Paediatrics 3rd Edition...
Thank You
Resp examination by Dr. San
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Resp examination by Dr. San

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Resp examination by Dr. San

  1. 1. History taking and physical examination Dr San Thitsa Aung
  2. 2. 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
  3. 3. History• Patient particulars -Age -Sex -Ethnicity• Source of history• Presenting c/o(obtain a complete chronological sequence of events)
  4. 4. The mindless Presenting complaints The logicalfact collector strategist Routine history Likely and and physical differential examination diagnoses Important clues Goal orientated missed history and physical examination Diagnosis???? Diagnosis confirm
  5. 5. 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
  6. 6. 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
  7. 7. Respiratory Distress ?Normal RR ( /min) Tachypnoea• Age less than 1 yr = 30-40 • Neonate(<1 month)= >60 • Infant (<1 year )= >50• 1- 2yr =25- 35 • Children (>1 year )= >40• 2-5 = 25-30• 5-12 = 20-25• >12 = 15-20
  8. 8. Noisy breathingWheeze Stridor• High pitched musical • Harsh vibratory sound of whistling sound variable pitch• Expiratory • Inspiratoy phase• Turbulent airflow through • Turbulent airflow through the narrow airways the narrow partial• Intrathoracic trachea and obstruction extrathoracic major bronchi-terminal bronchioles upper airway• Common in infant & young Common in infant &young child child
  9. 9. WHEEZE• Age - Infant,Toddler,Preschooltransient 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
  10. 10. • Associated factors - cough, rapid laboured breathing, chest pain, nausea,vomiting,delayed feeding, coughing with reflux eg.TE fistula, CP• Contact with URTI
  11. 11. Stridor• Age -• Onset* -acute/chronicobstruction,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
  12. 12. 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
  13. 13. • 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
  14. 14. Past med historyHistory Current implicationsEczema allergic tendency relevant to AsthmaHay feverRecurrent childhood viral asso relevant to childhood onset asthmawheeze, childhood asthma (atopy)Whooping cough recognised causes of Bronchiatasis,especiallyMeasle, Pneumonia,Pleurisy complicated by pneumoniaTuberculosis Reactivation if not previously treated effectivelyConnective tissue disorder lung diseases are recognised complicationEg. Rheumatoid arthritis Pulmonary fibrosis,effusion,BronchiatasisAspiration recognised cause of PneumoniaNeuromuscular disease Respiratory failure Aspiration Pneumonia
  15. 15. 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
  16. 16. 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
  17. 17. Immunisation H/o• Complete according to EPI Schedule eg. Hib(H.influenza) stridor,pneumonia• BCG, DTaP,MMR• If failure ask reasons in detail
  18. 18. Developmental H/o• Gross motor• Fine motor• Speech/Hearing• Social• (Know atleast 4 milestones for different ages which parents can easily answer)
  19. 19. Family History _ consanguinity , overcrowding, parent’s occupation bronchial asthma, atopy, TB, similar illness, congenital heart disease , cystic fibrosisSocial History – School performance - frequently absent? – Social interaction , economic status – Housing , indoor pollution-cigarette smokers at home – Environmental allergens : pets, carpets
  20. 20. • Drug and allergies List drugs , frequency and dosage eg. Bronchodilators Allergy to drugs, food, dust
  21. 21. 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
  22. 22. 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, RRUndress the child’s top half to the waist (except for the aldolecent girl) ideally 45 ̊,baby on his back or sit on mum lap
  23. 23. • 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
  24. 24. • 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)
  25. 25. • 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
  26. 26. Observe the chest• Inspection DeformityPectus 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
  27. 27. Pectus excurvatum Pectus carinatum
  28. 28. Hyperinflation-increase AP(antero-posterior) suggests asthma /emphysemaRachitic rosary-swelling of the costochondrial junction in RicketsAbsent clavicle/pectoralis muscleScars- sternotomy,thoracotomy, chest drainsChest wall movement- compare both sidesIntercostal/subcostal recessionScoliosis- Don’t forget to look the back of the chest
  29. 29. • 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••
  30. 30. • Palpation Feel quickly for the Apex beat Dextrocardia Scoliosis Displacement of Trachea+apex to the sameside mediastinal shift Eg. Pleural effusion,Pneumothoraxpush away Collapse,Fibrosis pull towards that side Displacement of Trachea aloneupper lobe pathology Displacement of Apex alonePectus,scoliosis
  31. 31.  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
  32. 32. Eg. Effusion, Pneumo; collapse,consolidation fibrosis diminshed expension on that sideTactile 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
  33. 33. • 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
  34. 34. • 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
  35. 35. -Bell is applied tightly to chest wall,it behaveslike a diaphragm-compare the Lt & Rt-listen for one cycle of inspiration and expirationat each site -2 breathe at each of 6 sites anteriorly and post- eriorly
  36. 36. Breath sounds Vesicular Bronchial• Normal • May be heard in normal child (ant;lly below the Rt clavicle, post;lly over the hila)• Low-pitched • Harsh,high- pitched, • Inspiratory and expiratory• Inspiratory phase is phase are equal longer than expiratory • A pause inbetween• No break inbetween • Abnormal, heard over consolidation,just above effusion
  37. 37. Added sounds1. 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
  38. 38. there are 2 catagories in creptsCoarse and variable pitch due to secretions- eg. Pneumonia,BronchiectasisFine and high-pitched at the base- eg.pulmonary oedema,bronchiolitis,fibrosing alveolitisDescribe the location of the abnormal signs eg. VBS with crepts in Rt middle zone BBS in Lt upper zone
  39. 39. Physical signs in respiratory diseasesDisease Chest movt Mediast; shift Percussion Vocal Breath Resonance soundsConsolidation ↓ none Dull ↑ BBS creptscollapse ↓ to same side Dull ↓ ↓Fibrosis ↓ To same side Dull ↑ BBS creptsEffusion ↓ To opposite Stony dull absent Absent side BBSPneumothorax ↓ To opposite Hyper ↓ ↓ side resonant
  40. 40. • 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
  41. 41. 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
  42. 42. Thank You

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