Paediatric-History taking & Physical examination to a patient with respiratory disease

Paediatric-History taking & Physical examination to a patient with respiratory diseaseCreated OnApril 23, 2020Last Updated OnApril 23, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination to a patient with respiratory disease < All Topics Table of Contents History taking: Ask about patient’s identification Name Age Gender Race *if relevant Ask about chief complaint The major concern that bring the patient to visit doctor List down the complaint along with duration in chronological order Ask about history of presenting illness Examples of common symptoms in paediatric Cough Timing Cough on lying down in evening -> gastro-oesophageal reflux Cough disrupting sleep -> asthma Cough on rising in the morning -> rhinosinusitis/ postnasal drip Quality Productive/ non-productive cough Colour of phlegm Amount of phlegm Associated symptoms Shortness of breath Post-tussive vomiting Wheeze Precipitating factors (e.g. exercise, exposure to allergen, occupation) Wheeze on exercise -> asthma Sputum Colour Clear: chronic bronchitis with no active infection Yellow: acute lower respiratory tract infection & asthma Green: chronic infection (e.g. bronchiectasis) Rusty red: pneumococcal pneumonia Amount Large volume of purulent sputum -> bronchiectasis Taste/smell Foul-tasting/ smelling sputum -> anaerobic bacterial infection Solid material ‘Worm-like’ structures (mucus plug)-> asthma Haemoptysis Amount Location Blood coughed up from respiratory tract/ vomited/ appeared in mouth without coughing Duration & frequency Intermittent haemoptysis-> bronchiectasis Breathlessness Onset, duration & progression Breathlessness that wakes patient up from sleep -> asthma Aggravating & relieving factors Common allergens: house dust mite, animals, grass pollens, tree pollens Severity Chest pain SOCRATES Site Onset Character Radiation Associated symptoms Timing Exacerbating factors/ relieving factors Severity (grade the pain from 0-10) Ask about systemic review General Recent weight changes, fever, activity level, sleep disturbance Cardiovascular system Chest pain, breathlessness, palpitation, oedema Respiratory system Breathlessness, cough, wheeze, hoarseness, haemoptysis, chest pain Gastrointestinal system Vomiting, change in bowel habit, jaundice Urinary system Frequency, urgency, haematuria, dysuria Neurological system Numbness, weakness, seizures, visual or hearing disturbances Musculoskeletal system Deformity, joint pain, joint swelling Ask about past medical & surgical histories Previous admission to hospital Date of previous admission Reason for hospital admission Any investigation/ treatment done How long is the duration staying in hospital Follow up – frequency/compliance Ask about birth history Baby born at term Type of delivery Birth weight Ask about drug history Type of inhaler, dosage & frequency Drug allergy Previous & current drug used Ask about immunization history Types of vaccines the child received Any missed vaccine? Ask about developmental history Developmental milestones Feeding history Ask about family history Family history of asthma, eczema/ tuberculosis Ask about social history Any smokers in close contact with the child? Pets (hair & fur of pets may aggravate asthma) Carpet Ask about travel history – tuberculosis Physical examination: General examination Surrounding Oxygen, nebulizers Inhalers Sputum pot Peak flow General inspection Activity level: sedate, alert, active, restless General well-being: well/ill looking/lethargic Size & appearance of child: well-nourished/under-nourished, tall/short, built (** also comment that you would like to plot the height & weight of patient on the growth chart) Pink/ cyanosed Hands & nails Pallor, peripheral cyanosis, clubbing (cystic fibrosis & bronchiectasis), single palmar crease (trisomy 21) Eczema/atopic dermatitis Capillary refill time Pulse Brachial: infant & toddler / radial: older children Rhythm Volume Character Rate Count the number of pulses in 15s, and multiply by 4 (however, you should inform the examiner that ideally you would like to count for 1 minute) Causes of increased heart rate Physiological: anxiety/ exercise Pathological: fever/ disease of lung & heart/ metabolic conditions (e.g. hyperthyroid) Normal ranges of heart rate Age Heart rate (beats per minute) Birth – 1 month 120-170 3 months 115-160 6-12 months 110-160 18 months 100-155 2 years 100-150 3 years 90-140 4-5 years 80-135 6-7 years 80-130 8-11 years 70-120 12 years 65-115 14 years 60-100 Forearm Blood pressure Face Normal/ dysmorphic features Pallor of conjunctiva, scleral jaundice Oral hygiene, central cyanosis Cervical & axillary lymph nodes Legs Pitting oedema Respiratory examination Inspection Chest exposure Inspect from the end of the bed, top of the patient, from the sides and also at the level of the patient Surgical scars, old branula insertion scars, central venous line Midline sternotomy scar Pacemaker scar Posterolateral thoracotomy Anterolateral thoracotomy Axillary thoracotomy Chest shape Normal Symmetrical & cylindrical in children (anteroposterior & lateral diameter almost equal) Abnormal Pectus carinatum (pigeon chest) Protrusion of sternum & adjacent costal cartilages May be associated with scoliosis or Marfan syndrome Pectus excavatum (funnel chest) Depression of lower end or whole length of sternum Pectus carinatum is always accompanied by Harrison sulcus Harrison sulcus Symmetrical horizontal grove above costal margin caused by indrawing of the ribs Seen in severe & poorly controlled childhood asthma, osteomalacia & rickets patient Symmetry of the chest If chest is asymmetrical during chest expansion -> pathological site: the site with reduced chest expansion Causes: spinal deformity/ flattening of chest wall Chest movement Observe the depth & symmetry of chest movement Accessory muscle for breathing Sternocleidomastoid, pectoralis major & minor, serratus anterior, latissimus dorsi & serratus posterior superior Respiratory rate Normal ranges of respiratory rate Age Respiratory rate at rest (breaths per minute) Birth – 1 month 25-50 3 months 25-45 6-12 months 20-40 18 months 20-35 2-7 years 20-30 8-11 years 15-25 12-14 years 12-24 Palpation Position of trachea Warn the patient that this examination may be uncomfortable Place the tip of index & ring fingers on the medial end of the clavicle Then put the middle finger on the trachea Compare the distance between both sides, and determine whether the trachea is centralized or deviated Deviation of trachea If trachea deviated toward the side of lung lesion -> lobar collapse & pneumonectomy If trachea deviated away from the side of lung lesion -> pneumothorax & large pleural effusions Trachea tug Place the middle finger on the trachea If tracheal tug -> finger moves inferiorly with each inspiration Indicates respiratory distress Apex beat Normal: located at 5th intercostal space & mid-clavicular line Chest expansion Place both of the hands firmly on each side of the chest Both thumbs should almost meet in the midline & free floating Ask the patient to inhale deeply Observe the movement of the thumb during chest expansion, they should move symmetrically apart Observe the chest expansion on the back of the patient Reduced chest expansion -> lung collapse/ pneumothorax/pleural effusion Tactile fremitus Ask the patient to say 99 Place the ulnar aspect of the hand on the patient’s chest to sense any changes in sound conduction Increased ->...

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