History taking & Physical Exam of
the Respiratory System in a child
Dr Jacquie Oliwa
Dept of Paediatrics & Child Health
University of Nairobi
2016
History Taking
Respiratory symptoms
• Cough
• Breathlessness
• Difficulty in breathing
• Noisy breathing – wheeze, stridor, snoring
(stertor)
• Chest pain, sore throat, ear ache
• Irregular breathing
2
History of presenting illness: Cough
• Onset - sudden (choking), gradual
• Duration – acute vs persistent (> 2wks), chronic
• Pattern, course
– getting worse/better, persistent vs recurrent
– Paroxysmal, nocturnal, after meals
• Dry or productive
• Triggers / precipitants
– Inhalation of irritants/allergens, exercise, lying flat,
during meals
• Relieving factors
• Timing of day
3
History of presenting illness ctd..
• Breathlessness, difficulty in breathing
• Noisy breathing
– Arising from chest? Wheeze vs rattles
– Arise from upper airway? Stridor vs Snoring
– Variation in intensity? With time of day or
agitation, when sleeping?
– Intermittent/persistent/chronic/seasonal
– Triggers/exacerbating/relieving factors?
4
History of presenting illness ctd..
• Chest pain
– Acute or chronic
– Continuous vs intermittent
– Exacerbating factors (cough, deep breath palpation)
– Site of pain
chest wall (pleura, musculoskeletal),
retro-sternal (bronchi, distal trachea)
• Sore throat, sinus pain
• Associated FEVER?
5
Past Medical History
• Asthma
• Recurrent infections / immuno-suppression
• Chronic disease from other systems that
interact with RS
• Congenital conditions
• Perinatal respiratory insults, prematurity
6
History – Systemic Enquiry
Current Symptoms from other systems that
interact with respiratory system
• Cardiovascular
• Gastrointestinal
• CNS
• Immune system (including allergy)
• Haematologic
7
History – Perinatal, Family
• Antenatal/Perinatal History
• Family & Social History
• Environment –smoking, biomasss fuel,
overcrowding, mould/damp homes
• Atopy
• Genetic diseases – SCD, Chromosomal
(Trisomy)
8
History – other areas
• Growth & Development
– Abnormal from birth implies congenital, genetic
cause, or pre- or perinatal insult.
– Initially normal, then delay later implies acquired
problem
• Immunization
• Nutrition
9
Examination of Respiratory System
• General exam
– Normal quiet respiration vs obvious respiratory distress
– Mouth breathing
– Pallor, cyanosis, clubbing
– Allergic salute
– Any scars/dysmorphic features
• Vital signs – RR, HR, Temp, SPO₂
• Anthropometry
• Specific exam of the respiratory system
10
Clubbing
11
Respiratory Rate
Age Normal Range • Evaluate when child
(breaths/ calm or asleep
min)
• Count for a full minute
Neonate 40 - 60 • Tachypnoea defining
6wk-6mth 35 + / - 10 ALRI (review ETAT
thresholds)
6mth-1yr 30 +/- 5 • Pattern
-regular vs irregular
1 – 5yr 25 +/- 5 periodic,
6 – 10yr 20 +/- 5 -apnoea,
-Kussmauls,
11 + yr 16 +/- 4
-prolongation of expiration
12
Respiratory system examination
• Shape of chest – any abnormality?
– Increased antero-post diameter (obstructive dx)
– Pectus exacavatum vs carinatum
– Harrison’s sulcus
– Kypho-scoliosis
• Any obvious lesions – surgical scars, trauma, bleeding
• Overall movement of chest
– Normal?
– Increased ?
– Reduced?
– Symmetric vs assymetric?
13
Respiratory system examination
Evaluate activities of specific muscles of respiration
• Diaphragm – abdominal wall movement
• Intercostals - chest movement
• Use of accessory muscles, increased work of breathing
– Flaring of alae nasi
– Suprasternal, supra-clavicular indrawing (SCM, trapezius)
– Head nodding (SCM)
– Intercostal indrawing
– Subcostal indrawing (++diaphragmatic force)
– During expiration – abdominal muscles
14
RS exam - Listen
• Normal quiet breathing
• Abnormal sounds
– Stridor
– Wheeze
– Grunting
– Snoring
15
Respiratory system exam - palpation
• Trachea position
• Tenderness
• Chest excursion
• Tactile fremitus (increased vs decreased)
• (Surgical emphysema)
• Cervical and axillary lymph nodes
16
Respiratory exam - Percussion
• Technique
• Anterior, posterior
• Avoid bony surfaces (scapula, sternum)
• Normal areas of dullness – cardiac, liver
• Abnormal
– Dull vs stony dull (causes?)
– Hyper-resonant (causes?) – check upper border
liver
17
RS exam - Auscultation
• Use diaphragm of stethoscope
• Normal vesicular breath sounds
• Abnormal sounds
– During inspiration or expiration?
– Arising from upper airways (transmitted down) or
lower airways?
– Crackles (crepitations) – mainly inspiratory
– Wheeze (rhonchi) – mainly expiratory
– Vocal fremitus / whispering pectoriloquy)
18
Other relevant systems
• ENT – rhinorrhoea, nasal turbinate enlargment
tonsils, pharynx, tympanic membrane
• CVS – tachycardia, odema, abnormal CVS signs
• Atopy – eczema, eyes, nose, sinuses
• Immune deficiency – (HIV signs)
• Etc….
19
Finally..Integrate your findings
• Main symptoms
• Abnormal physical signs
Decide if pathology is:
• Upper versus lower resp tract, or both
• Infective vs not
• Lung parenchyma (pneumonia)
• Airway obstruction – upper or lower
• Pleura
• Other systems involved
20
Diagnosis, differentials and complications
Finally make your:
• Primary diagnosis
– Classify/define severity
• Differential diagnosis (RS and/or or other
system)
• Note any complications present
21
In today’s world of technological wonders,
there is no substitute for a proper history and
physical examination!
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