West Visayas State University College of Medicine Class of 2021

B13M1L2: History and PE in Pediatric Respiratory

Medicine
Dr. Emiliana G. Carmona | February 27, 2019
Trans Group 12: Pino, Pueblo, Puey | Editor: Postrado | 0929-335-4878

OUTLINE Characteristics
o Quality (e.g. Is cough productive or not productive?)
I. History 1 o Severity (Is it so severe that the child should miss his class
A. General Considerations 1 or just mild that does not affect ADL?)
B. Chief Complaint 1 Associated symptoms
C. History of Present Illness 1 Aggravating and precipitating factors
D. Medical History 2
E. Family History 2
Relieving factors
F. Personal and Social History 3 Current situations
II. Physical Examination 3 o improving or deteriorating
A. Inspection 3 o If medications were given, was there relief?
B. Palpation 4 Effects on activities of daily living
C. Percussion 4 Exercise is a common trigger factor for cough and wheezing
D. Auscultation 4 in many patients with hyperactive airways.
Diurnal variation of symptoms may be apparent, and
LEGEND attention should be paid to changes that occur at night.
Previous diagnosis of similar episodes (Are you having a
Important Lecturer Book Old Trans Trans problem which is recurrent in nature?)
Comm Previous treatment and efficacy
○ From the drugs alone, you will already have an idea on
what the patient is having.
HISTORY B. CHIEF COMPLAINT
The historian should identify the chief complaint and the COUGH
person most concerned about it.  Ask for quality, severity, timing, duration, and precipitating
The illness at presentation should be documented in detail factors.
regarding onset and duration, the environment and If the cough happens after eating, think of aspiration.
circumstances under which it developed, its manifestations Was the patient exposed to fire, perfume, or toxins?
and their treatments, and its impact on the patient and  Explain how it happened.
family.  How did it progress, was it self-limiting or did you do
Symptoms should be defined by qualitative and quantitative something to stop the series of coughs?
characteristics as well as by their timing, location,  Cough and vomiting
aggravating or alleviating factors, and associated If the cough has been there for more than 2 weeks, think of
manifestations. TB.
Common symptoms are fever, cough and sputum production, For severity: Does it awaken you at night?
wheezing or noisy breathing, dyspnea, and chest pain. If the timing is related to food intake, think of GERD.
Relevant past medical and laboratory data should be included If the cough occurs at night and early morning, think of
in the documentation of present illness allergic cough or bronchial asthma.
A. GENERAL CONSIDERATIONS DYSPNEA
ONSET A subjective feeling of difficulty in breathing
The first thing that you ask when you get the history. To know Grunting (At rest? Or after strenuous activity?)
if the problem is acute or chronic.  An audible expiratory sound.
Gradual (e.g., with some interstitial disease)  Posture can help differentiate if cardiac or respiratory in
Sudden (e.g., with foreign body obstruction) origin e.g. squatting in TOF
The historian should ask about initial manifestations and who
TACHYPNEA
noticed them first.
The age at first presentation is important because respiratory An objective finding of an increase in respiratory rate.
disease that manifest soon after birth are more likely to have May not only of respiratory in origin but can also be in cardiac.
been inherited or to be related to congenital malformations. CHEST PAIN
Location Ask for timing, severity, radiation
Radiation HEMOPTYSIS
Duration
May also be non-pulmonary
Frequency, chronology
Ask for amount of blood
CLASSIFICATION Significant to cause you anxiety?
Classification Based on Duration of Illness Frank blood or mixed with sputum?
Acute <3 weeks Associated with leg pain, chest pain, or shortness of breath?
Subacute 3 weeks to 3 months In pulmonary embolism, you may also have hemoptysis or
Chronic >3 months pulmonary congestion.
Recurrent symptoms are clearly discontinuous It is also important to know where the blood came from e.g.
with documented intervals of well-being tonsils (sputum mixed with streaks of blood)

B13M1L2: History and PE in Pediatric Respiratory Medicine DVS – MED 2 1/5

 CYANOSIS SPUTUM PRODUCTION
Primarily cardiac  Productive Cough - When it brings up (produces) mucus or
Central versus peripheral some sort of fluid, including blood.
Associated wheezing? No need to measure the volume of expectorated fluid.
If pediatric patient + difficulty breathing + cyanosis = status  Unproductive Cough - Is one that does not bring up any
asthmaticus mucus or other secretion. Also known as a dry cough, a non-
EXERCISE TOLERANCE productive cough often is caused by some sort of irritation in
Ask if the infant eats slowly, tires during feeding, cyanosis the throat. Many people with describe the irritation as a
with feeding "tickling" or "scratchy" sensation.
Children – inability to keep up with others if the same age Volume might not be that reliable in children as some children
The closest differential diagnoses that you will have which will just swallow the phlegm.
refer to your respiratory system are also problems which refer  Color:
to your cardiovascular system. Viral (whitish)
WHEEZING bacterial (yellow)
allergic (whitish)
Ask for timing
lower resp. tract infection e.g. pneumonia with
FAINTING AND SYNCOPE consolidation (rusty)
Weakness, light headedness, loss of consciousness, relation to Chronic cough with yellow color does not always mean
posture infection it might be neutrophilic.
OTHER ASSOCIATED SIGNS AND SYMPTOMS  Amount
Fever  Consistency
Malaise Mucoid? Purulent? Watery?
Fatigue  Time of the day when sputum production is worse
Anorexia D. MEDICAL HISTORY
Night sweats (e.g. in TB)  Allergies, including seasonal and environmental
Palpitation ○ common respiratory problems in the pediatric age group
Weight loss are allergic cough, bronchial asthma, or allergic rhinitis
GI reflux  Medications used, over-the-counter and prescription meds
Runny nose  Herbal / traditional preparations
Sore throat
 Growth rate – failure to thrive often exhibits slow weight gain
Stridor
relative to height
○ Pathology usually in the upper airway.
 Immunization status
○ High pitched, inspiratory. A serious manifestation that is
○ (before HiB vaccine, Haemophilus influenza type B is
sometimes an emergency.
the most common etiologic agent of cough in children)
○ Differentials: Laryngotracheobronchitis, epiglottitis,
bacterial tracheitis  Medical conditions, admissions, surgeries
○ If patient presents with recurrent stridor since birth or ○ Frequency of colds and respiratory infections, recent
chronic stridor, think of laryngomalacia viral illness, communicable diseases
○ Nasal polyps, chronic sinusitis, asthma, bronchitis,
C. HISTORY OF PRESENT ILLNESS pneumonia, Chronic obstructive pulmonary disease
ONSET (COPD), TB (disease or exposure, mantoux test, CXR),
 Gradual or Sudden Onset. cancer, cystic fibrosis
○ How did it start, when did it start. ○ Diabetes mellitus, thyroid disorder, renal disease
SMOKING ○ Joint pain or swelling, cardiac murmurs, valvular heart
disease
Not only that of the patient but of exposure from family ○ Down’s syndrome
members or from community.
 Exposure to substances while in utero
DIFFICULTY OF BREATHING  Blood transfusion
“Ginalagas ang pagginhawa” Ask the patient what he exactly  Birth and prenatal history if you are dealing with a neonate
means. because you might be dealing with neonatal pneumonia,
How will you ask children? sepsis or congenital malformations.
o You can ask them to draw. They might draw someone  The historian should inquire about the course of pregnancy,
being strangulated indicating that he has difficulty of particularly whether the mother and fetus suffered from
breathing infections, metabolic disorder, or exposure to noxious
OCCUPATIONAL HISTORY agents.
Some parents nowadays bring their children to work.  Duration of pregnancy, possible multiple births and
Whatever work exposure the parents has the children circumstances leading to the onset of labor should be noted.
experiences it too.  Difficult labor and delivery may cause respiratory problems
COUGH WITH POST-TUSSIVE VOMMITING at birth and the physician should ask about birth weight and
Apgar scores.
Occurred by vomiting only, think of gastrointestinal disease
After vomiting ask the appetite of the patient. E. FAMILY HISTORY
o If it is post-tussive (relating to cough) the patient will still  The historian should review at least two generations on
have good appetite. Unlike when it is gastrointestinal in either side. The parents should be asked if they are
origin there will be loss of appetite. related by blood, and information should be obtained
In children, majority of patients presenting with vomiting about any childhood deaths in the family
would turn out to have pneumonia.

B13M1L2: History and PE in Pediatric Respiratory Medicine DVS – MED 2 2/5

 The health of patient’s siblings and of brothers and ○ Degree of comfort or distress
sisters of both parents should be documented. ○ Growth parameters concordant with age
 Particular attention should be paid to histories of ○ Character of cry
asthma, allergies and hay fever, chronic bronchitis, ○ Nutritional, hydration, and mental status
emphysema, tuberculosis, cystic fibrosis, and sudden For newborns and infants, feeding is a substantial physical
unexpected infant death. exercise and may lead to distress in the presence of
 Others at home with similar symptoms respiratory distress. Inquiring how long it takes the patient to
 Allergies, atopy, asthma, TB, cystic fibrosis, bronchitis finish a meal would equate to asking for exercise tolerance.
 Diabetes mellitus CHEST APPEARANCE
 Sudden Infant Death (SIDS)  Observe shape/form:
 Heart disease ○ Skeletal deformities e.g. kyphosis, scoliosis
F. PERSONAL AND SOCIAL HISTORY ○ Barrel chest (associated with pulmonary emphysema)
 Feeding history ○ Pectus excavatum/Funnel chest
○ should include the amount, type, and schedule of ○ Pectus carinatum/Pigeon chest/Chicken Breast
food intake. Historian should ask if the child was fed  Prominent subcutaneous blood vessels of the chest
by breast or bottle ○ Due to mediastinal disease
○ history of cough or choking during feeding should ○ Due to obstruction of the SVC, i.e. vena cava syndrome,
alert the historian to the possibility of pulmonary or azygos vein by a tumor (formation of collateral
aspiration. circulation)
 Smoking history (number of packages/day, number of  Chest circumference
years) ○ Smaller than the head circumference in the first 9-12
 Exposure to second hand cigarette smoke, wood months of life
smoke, pets, ○ Larger than the head at 1 year due to the growth of the
chest muscles
 Crowded living conditions
If HC>CC at 1 year, either there is a problem in the
 Poor personal or environmental cleanliness
head e.g. hydrocephalus or a problem in the growth
 High stress levels of the chest muscle in malnutrition.
 Institutional living  In infancy, AP diameter = Transverse diameter
 Substance use At 2 years, AP diameter < Transverse diameter (wider chest)
○ alcohol, caffeine, street drugs, including injection
and inhaled drugs /solvents RESPIRATION
 Human immunodeficiency virus (HIV)  Both chest and abdomen move during normal respiration.
 Obesity  In infants:
○ Abdominal movements are more visible than thoracic
 Immigration or travel abroad
movements
○ The abdomen bulges during inspiration (by the downward
PHYSICAL EXAMINATION movement of the diaphragm)
 Best accomplished with the patient standing or comfortably ○ The thoracic cage moves upward and outward (chest
seated in an erect position. expansion)
 Disadvantages of PE in the lying position: ○ The abdomen flattens and the thoracic cage returns to
○ Chest may not expand symmetrically resting position upon expiration.
○ Auscultation and percussion sounds may be dampened Observe the abdomen when measuring respiratory rates
since the chest wall is compressed Respiratory rates differ among sleep states and become more
 It is important to use the anatomical reference points of the variable during wakefulness.
chest and back. Points to remember:
○ Normal rate depends on the age of the patient
Midscapular Line ○ Describe the patient’s behavioral state
Suprascapular Area
○ Count over at least one minute
Interscapular Area
Normal Respiratory Rates. From Adeos Notes.
Infrascapular Area
AGE GROUP RR (BREATHS/MINUTE)
0-6 months 30-60
> 6 months-1 year 30-50
Axillary Area > 1-3 years 24-40
Anterior Axillary Area > 3-5 years 22-34
Infraaxillary Area > 5-12 years 14-25
Midaxillary Line > 12 years 12-20
Posterior Axillary Line  Breathing character:
○ Hyperpnea- deep respiration
Midclavicular Line ○ Hypopnea- shallow respiration
Infraclavicular Area ○ Kussmaul breathing- deep, sighing breathing; in
Mammary Area metabolic acidosis
Midsternal Line
 Rate changes:
Inframammary Area
○ Tachypnea
Reference points on the trunk.  Decreased lung compliance
 Metabolic acidosis
A. INSPECTION
 Fever (increase at 5-7 breaths per minute/degree
Observe for the following: above 37˚C)
○ Acutely or chronically ill

B13M1L2: History and PE in Pediatric Respiratory Medicine DVS – MED 2 3/5

 ○ Bradypnea
 Alkalosis
 CNS depression
 Rhythm changes:
○ Periodic breathing- in newborns and preterms
cycles of regular and rapid breathing, may then stop
but regular breathing afterwards
not associated with bradycardia and cyanosis
Apnea if a/w bradycardia and cyanosis.
○ Cheyne-Stokes respiration- cycles of increasing and
decreasing tidal volume separated by apnea
○ Biot breathing- irregular cycles of respiration at variable
tidal volumes interrupted by apnea
 An ominous finding in patients with severe brain
damage.
SIGNS OF INCREASED RESPIRATORY EFFORT
 Dyspnea in older children
 Objective signs of distressed breathing:
○ Chest wall retractions
○ Alar flaring
○ Orthopnea
○ Paradoxical breathing movements
 Paradoxical respiration when the abdomen is flat at
inspiration and prominent at expiration
○ Visible use of accessory muscles
 Scalenes
 Sternocleidomastoids
 Trapezii
 Latissimi dorsi
 Abdominal muscles
Head bobbing can also be seen in respiratory distress.
B. PALPATION
 Symmetry
○ Movement is seen and felt
○ Done with the examiner behind the patient
Test for chest expansion
o Place your thumbs at about the level of the 10th ribs,
with your fingers loosely grasping and parallel to the
lateral rib cage. As you position your hands, slide them
medially just enough to raise a loose fold of skin on each
side between your thumb and the spine.
○ Ask the patient to inhale deeply. Watch the distance
between your thumbs as they move apart during
inspiration, and feel for the range and symmetry of the
rib cage as it expands and contracts. This is sometimes
termed lung excursion.
Asymmetry of respiration if one hand is not moving or has
lesser movement compared to the other.
Lagging if one hand is moving slower than the other;
present in presence of fluid, consolidation, and
atelectasis.
 Pain and tenderness
 Position of the trachea
 Tactile fremitus
○ Employ palm or ulnar surface of the hand
○ Sound vibrations that originate in the larynx pass down
the bronchi and causes the lungs and chest walls to
vibrate.
○ May be diminished or absent in females since the female
voice is of higher frequency than the lungs.
○ High-pitched in children corresponding to small lungs.
○ Increased with lung consolidation as in pneumonia
○ Decreased or may disappear in:
 Effusion or fluid between the lungs and the chest
wall
 Thickening of the pleura
B13M1L2: History and PE in Pediatric Respiratory Medicine
 Atelectasis
 Infiltrating tumor mass between the lungs and the
chest wall
C. PERCUSSION
 Striking the chest wall and perceiving vibrations that are
heard by the ears and felt by the fingers.
 Causes air-filled thorax and its contents to vibrate.
 Fluid and tissues that do not contain air do not vibrate by
ordinary percussion strokes.
Not performed in all pediatric patients
 Character of percussion notes is altered by:
○ Ability of the chest wall to vibrate
○ Vibrating response of the lung
○ Damping effect of solid organs or lesions
Points to remember:
o Lesions 5 cm away from the chest wall or < 2-3 cm in
diameter will not alter percussion note.
o Free fluid in the pleural cavity may not be detected
unless the volume exceeds 200-250 mL, although it can
be detected by PE before it can be seen on X-ray.
 Methods:
○ Direct- percuss directly to the area
○ Mediate- use of plexor and pleximeter
Avoid surface contact by any other part of the hand because
this dampens out vibrations.
 Percussion notes:
○ Resonant- normal chest
○ Dull- solid structures and fluid-filled areas
○ Tympanitic-hollow, air-filled areas
 In pneumothorax and emphysema
 Expected in young infants with thin chest walls
Percussion Notes and Their Characteristics
D. AUSCULTATION
 Goals:
○ Listen to characteristics of breath sounds in different
areas.
○ Compare the sounds on both sides of the same area.
Points to remember:
o Listen directly over the chest wall without intervening
clothes
o In young infants, one must catch whatever is available in
whatever position they are.
 Lying, prone, or supine, but not lying on one side
 Sitting especially when held by a parent.
o Use the bell of the stethoscope in younger infants since
the diaphragm will pick up sounds from too large an area.
o Make sure the chest piece is not too cold.
o Make sure that the child is not shivering.
o Child’s face must be in neutral position.
o Examine the chest in a methodical fashion to include all
parts of the chest.
Clinical points about normal breath sounds:
o Inspiratory phase duration is twice as long as expiration
o There is no pause between inspiration and expiration
o The end of expiratory phase is silent
DVS – MED 2 4/5
 Sounds heard at auscultation:
○ Normal vesicular sounds
REVIEW QUESTIONS
 Common normal sounds heard all over the chest, 1.
particularly over the axilla and infrascapular area
 Transmission of sounds is through the alveoli
 Heard over the entire phase of inspiration
 Expiration immediately follows
○ Bronchial breath sounds 2.
 Heard over the trachea and over the midline
 Elsewhere, it is usually pathologic
○ Bronchovesicular
 Heard more on infants with thin chest wall
Characteristics of Breath Sounds
3.
4.
5.
The following are sign of respiratory distress, EXCEPT
a. Cheyne-Stokes respiration
b. Alar flaring
c. Use of accessory muscles of respiration
d. Chest retractions
Which of the following is a cause of prominent veins in the
chest?
a. Portal hypertension
b. Vena cava syndrome
c. Respiratory distress
d. Congestive heart failure
Which of the following is TRUE in respiratory rate changes?
a. Metabolic acidosis presents with tachypnea
b. Bradypnea is a sign of decreased lung compliance
c. Respiratory rate changes in newborns are always
pathologic
d. Fever has an unpredictable effect on RR
Which of the following is FALSE regarding chest dimensions?
a. An increased HC relative to CC would indicate
hydrocephalus
b. The head is always larger in the first months of life in
normal neonates.
c. A child with an equal HC and CC is a well-developed,
balanced child.
d. In infancy, AP diameter=Transverse diameter
Which of the following pertains to bronchial breath sounds?
a. These are added breath sounds
b. Inspiratory and expiratory sounds are equal in duration
c. These are soft sounds
d. Usually heard over the trachea

A, B, A, C, D

REFERENCES
1. Bickley, L.S. (2013). Chapter 8. Bates’ Guide to Physical
Examination and History Taking.
2. Carmona, E.G. (2019 February). History and PE of the Chest
in Pediatric Patients.
○ Adventitious sounds 3. WVSU-MED 2019 (2017, February). History and PE of the Chest
 Crackles in Pediatric Patients.
 Wheezes
 Rhonchi
Adventitious or Added Breath Sounds

Diminished or absent breath sounds due to absence of air flow

from either total or partial obstruction.
o Due to constriction, consolidations, fluids, or collapse of
the lungs.

B13M1L2: History and PE in Pediatric Respiratory Medicine DVS – MED 2 5/5