Respiratory history taking and examination in pediatrics

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The common respiratory cases that could be asked are

1. Pleural effusion
2. Community-acquired pneumonia
3. Pulmonary tuberculosis (non-infective)
4. Bronchiectasis
5. Cystic fibrosis

Introduction / Opening the consultation

1. Wash hands, wear PPE if needed
2. Introduce yourself
3. Confirm the patient by name and DOB
4. State the purpose of the consultation and obtain consent

You can start presenting the case as

" I am presenting the history and physical examination of Sumit, a 12 yr old boy, 1st born child of non consanguineously married parents, xxx by religion. He is a student of class 6 who resides at Howrah city but originally hailing from Bihar. He is accompanied by his mother today who is also a source of history and seems reliable. "

Chief complaints

Sumit has presented with chief complaints of

1. On and off cough for last 4 years
2. Frequent episodes of respiratory exacerbations and worsening respiratory distress over the last 4 years.

History of presenting illness

Sumit was apparently well till 8 years of age. He was performing all age-appropriate activities and growing well when compared with his peers. The illness began as repeated bouts of a cough that gradually progressed in severity. He often had breathing difficulty requiring frequent hospitalization.

1. Let us describe the cough

1. The cough was subacute in onset, gradual in the progression.
2. It initially started as a dry cough and later turned productive. The sputum is thick, grayish-yellow in color but not mixed with blood and has a foul smell.
3. It is associated with breathing difficulty.
4. and is more prominent after waking up in the morning. Aggravated by lying down and exercise, relieved after nebulization. Sumit prefers the sitting position since it relieves his symptoms.

Identifying various types of cough

2. Describing breathing difficulty

Use the same format as above including onset of breathing difficulty, how long it is persisting, how is the progression, aggravating and relieving factors including the position of choice. Wheather associated with other symptoms like cyanosis.

Course in hospital or treatment part - He was treated with nebulization, oxygen, intravenous injections, and fluids and discharged home after 20 days with few oral medications nature of which is not known. For the past 4 years, he is suffering from chronic cough and intermittent respiratory distress, and multiple hospital admissions. During this period he is on oral medication (mention names), nebulization, and chest Physiotherapy.

Describe the impact of symptoms on daily life activities.

Exercise tolerance is a very important symptom in respiratory and cardiac disorders. In pulmonary cases, it gives an idea about the respiratory reserve and the severity of illness.

Sumit is not able to participate well in outdoor games and drops school many times. He is poor in academics. Additionally, he also has anorexia and not gaining weight properly.

Negative history/History on the leading question

Leading question for etiology

While presenting the case you can mention 'on the leading question regarding etiology there is or there isn't a history of

1. No H/O Allergy in family, night cough, aggravation following exposure to an allergen (Asthma)
2. No H/o of recurrent fevers for repeated respiratory infections, Also recurrent infections are suggestive of immunodeficiency. Recurrent middle ear infections are suggestive of ciliary dyskinesia or immunodeficiency.
3. Wheezing which might point toward allergic bronchopulmonary aspergillosis
4. No H/O Tuberculosis contact in past, in long term even if is patient is non-infectiotious might result in bronchiectasis.
5. No H/O of Dyspnea on exertion or rest, bluish discoloration of the skin, palpitation, pedal edema, oliguria - to rule out primary cardiac etiology
6. No h/o Choking spell or foreign body in past
7. No h/o Abdominal distension, jaundice in the newborn period, offensive smelling bulky oily stool, chronic diarrhea (CF)
8. No h/o Recurrent skin rash, joint pain, recent infection (autoimmune, PID)
9. Pointers to History of congenital or acquired immunodeficiency like recurrent infections, ill-health in siblings, parents

Leading question for Complication

Ask about the history of

1. Hemoptysis and pneumothorax ( even if it might have happened in past and you feel it is a part of past history, it is important to mention here to project you have taken history about complications to complete HOPI)
2. ICU admission
3. Ventilation Invasive or non-invasive
4. Surgical intervention (In respiratory case of CAMS)

Past history

In this particular case, this will include

1. Past admission
2. Significant investigations etc
3. Other medical and surgical illnesses

Sometimes it is very confusing since the history-taking information overlaps, however, remember it doesn't harm. But at the same time, don't be annoyingly repetitive. Menton that before the onset of current illness there is no significant medical or surgical history as such. What is important is you are covering all the possible points to reach a conclusion or differential. Try to do this in a sequential manner.

Antenatal, natal, and postnatal history

Mention only relevant points. In a case of developmental delay or cerebral palsy, this is really important and you should begin the history from the antenatal then natal, and postnatal period. This is logical since it connects the dots in a sequence,

Here is an example of this - Presenting a case of global developmental delay.

In respiratory cases, history of respiratory distress syndrome, use of surfactant, etc is important.

Developmental history

Mention all 4 domains - Gross motor, fine motor, language, and social skills.

If you are interested, here are two posts on how to approach a child with short stature?

Immunization history

Mention vaccines that prevent respiratory infections like flu, covid-19, measles, pertussis, pneumococcal vaccine

Drug history

Mention the name of the drugs, how long he/she has been on this and whether or not they have modified the course of illness. Ask about allergies to any drugs etc.

Nutritional history

The important thing here is to obtain sufficient data to differentiate the growth failure etiology. Whether it is secondary to chronic respiratory illness or purely nutritional or of mixed origin. This will also give an idea about how severe the primary disease is impacting your case.

In respiratory cases, it is important to identify predisposing factors through Personal, family, and socioeconomic history.

Predisposing factors could be

• Pre-existing respiratory diseases like asthma, and airway diseases.
• Family history of respiratory diseases like cystic fibrosis, and alpha-1 antitrypsin deficiency.
• Smoking habits of other house members
• Occupational exposure (Home near mines, )

Personal history

In respiratory cases, it is usual to have sleep disturbances due to breathing difficulty, disturbed nighttime sleep impacts the daytime behavior of the child, and can cause irritability and daytime somnolence. Ask "What task he/she is able to do independently?"

Family history

Obtain a history of familial respiratory diseases such as interstitial lung disease, cystic fibrosis, primary ciliary dyskinesia, or Infertility.

Obtain a history of familial risk factors that may predispose the child to respiratory illness such as allergies or exposure to particulate matter, smoke, etc.

Remember you might have already mentioned some of these things in negative history/ history on the leading question. In such cases, you can skip it from here. If the examiner stops and asks you, you can mention "I have already mentioned the history of/no history of Tuberculosis, familial or acquired immune deficiencies". Remember nobody has a 100% attention span.

Socio-economic history

Enquire about housing conditions, economic sources, approx daily/monthly expenditure, and how the disease has or has not added to the expenses. Enquire about funding support from Govt or non-governmental organizations.

Use the Kuppuswamy scale, to compare family income vs cost of the treatment.

It is not unusual to forget the psychological angles related to chronic diseases and how the family is coping with them. Ask about any counseling sessions, or issues that the child or family is facing?

Enquire about schooling and what kind of support the child is getting if he/she is of school-going age.

Signposting

Read more detail on signposting below

Signposting is simply an answer to the examiner's question - "So what do you think you are dealing with based on history so far?"

Most of us get stuck here, despite knowing more about the case. Summarizing these details is a skill that can be obtained only by practicing.

The other thing which helps in summarizing to the point is to keep your differentials ready while obtaining the history itself including the sequence of the likelihood of diagnosis.

Let us try summarising this case

Sumit is a 12 yr old boy suffering from an acquired, chronic lung disease with gradual deterioration with primary symptoms of recurrent cough and breathing difficulty. This has significantly impacted his growth and development and is requiring prolonged supportive management without a definitive cure. Based on history alone, this can be a case of bronchiectasis or cystic fibrosis and I would like to examine further for more definitive diagnosis.

Moving on to the examination part in our case.

General Physical examination

A pediatric physical examination can be divided into 3 parts

1. Opening remarks
2. General examination
3. Systemic examination

Opening remarks/General condition

The opening remarks have to be presented spontaneously. Speak about your first impression of the child at the time of examination. This may include posture/decubitus of the patient and the most prominent and obvious clinical features such as irritability or lethargy. Psychological things like apathy, irritability, etc could be easily noticed.

Say for example in this case

Sumit is a thin built boy, sitting slightly bent backwards and taking interest in surrounding, having visible respiratory distress at the moment.

Vital parameters

Start with usual vital parameters, temperature, heart rate/Pulse, respiratory rate, Visible distress, Blood pressure, etc.

In older cases, head to toe examination can be replaced by following

PICCLE

Pneumonic PICCLE in general physical examination stands for

1. Pallor
2. Icterus,
3. Cyanosis,
4. Clubbing,
5. Lymphadenopathy, and
6. Edema

If you add K for Koilonychia it can be PICKLE too!

In this particular case, clubbing needs a special mention as chronic hypoxia is likely to cause clubbing.

JVP

Even though JVP is precisely a part of the cardiac examination. It is worth mentioning when following respiratory differentials are possible.

• Tension pneumothorax
• Severe acute asthma

Other things to notice in the General examination

1. Mention if you see nearby instruments like oxygen masks or nasal prongs.
2. Flapping tremor, CO2 narcosis tremor
3. Irritability and or anxious behavior due to hypoxia or increased WOB.

Growth and development

1. Anthropometry

1. Weight - Plot on the growth chart if provided
2. Height - Plot on the growth chart if provided
3. Head circumference - Plot on the growth chart if provided
4. Classify the grade of malnutrition based on your findings

Want to know which growth charts to be used?

2. Pubertal status

Use Tanner staging for pubertal status, Chronic respiratory illness might result in delayed puberty.

Systemic Examination

Respiratory system

The respiratory examination is given excellently in Hutchinson's clinical methods. Want to know which clinical pediatric books you must read?

Inspection

1. Start with obvious findings like accessory muscles of respiration, scalene, and sternocleidomastoid.
2. The pattern of breathing increased WOB, retractions etc
3. Chest movement -symmetrical or asymmetrical
4. Mention if any chest deformity like
   1. Kyphosis - anterior-posterior curvature of the spine
   2. Scoliosis - lateral curvature of the spine
   3. Barrel chest - chest wall with increased anterior-posterior. This is normal in children to some extent but typical of hyperinflation.
   4. Pectus excavatum
   5. Pectus carinatum

What is a barrel chest?

Palpation

1. Tracheal position and Upper airway noise wherever applicable, like a case with upper airway compression.
2. Measure AP diameter to see if chest is hyperinflated
3. Feel apex beat for displacement in the mediastinal shift, inability to palpate in large effusions, and dextrocardia.
4. Chest expansion - check whether the chest is expanding equal on both the sides.
5. Location of apex beat - check if there has been deviation of heart

Tactile vocal fremitus

Place hand at various levels over the chest and back (all lobes of lungs covered), each time asking the patient to say "one-two-three or ninety-nine". Note the sound transmitted to the hand.

Tactile vocal fremitus is decreased or absent over areas of effusion or collapse and increased over areas of consolidation,

Percussion

Percus for signs of Hyperinflation /consolidation.

Do not forget to compare the same points on both sides of the chest.

1. Dullness indicates consolidation, effusion, collapse
2. Hyper-resonance suggests a pneumothorax, air trapping..

Auscultation

Start in a sequential manner, this way you will not skip the format.

1. Equality of breath sounds on both sides
2. Type of breathing, Bronchial vs Vesicular
3. The ratio of inspiration to expiration time, you can mention " Prolong expiration can be heard on auscultation"
4. Other sounds - Rales, wheezes, rhonchi
5. Inspiratory crackles can be heard in congestive heart failure
   1. Expiratory wheezes can be heard in asthma, emphysema
   2. Stridor and other upper airway sounds
6. Egophony, Whisper pectoriloquy just to complete the list.

Coarse crepitations can be heard over the affected region in cystic fibrosis, they usually start in the upper lobes in cystic fibrosis.

Look for Gallop rhythm in cor pulmonale, Dextrocardia in Kartagener syndrome.

Cardiovascular system

This is the second most important system in a pure respiratory case.

Cardiac findings mainly reflect the effect of chronic respiratory pathology on the CVS. Like long-standing respiratory insufficiency leading to secondary pulmonary hypertension.

Examination of the rest of the systems

You may not be required to mention all the points but do not skip any system unless asked by the examiner and when not relevant.

Want to know how to perform an abdominal examination?

Summarising/Sign posting

Sumit is a very cooperative 12 yr old young boy who has acquired chronic respiratory illness with gradual deterioration, impacting his growth and development requiring frequent hospitalization and supportive care including repeated antibiotic courses (in CF and bronchiectasis. There is no family history. of similar illness. On examination, he has Grade IV/ severe malnutrition, delayed puberty, Grade 3 clubbing, hyperinflated chest, and diffuse crepitation on the right He is on prolonged supportive treatment without any complication at present.

Differential diagnosis

Based on this the likely differential diagnosis could be Bronchiectasis followed by cystic fibrosis.

1. Bronchiectasis
2. Infectious- TB,HIV, aspergillosis
3. Cystic fibrosis is unlikely as the child was symptom-free till 8 yrs of age but still has to be excluded.
4. A long-standing foreign body is still possible but usually presents as an acute onset disease.
5. Acquired Immune deficiency

Some of the viva questions can be

1. What are the categories of lung disease?
2. What are the causes of tachypnoea and bradypnoea?
3. What are possible nail findings in lung disease?
4. What are the causes of tracheal deviation?
5. What are the types of percussion notes?
6. What is the significance of different sputum types?
7. What is the significance of different cough types?
8. What are the types of abnormal breath sounds?

Want to know more about bronchiectasis in children for viva questions?

You can get answer to some viva question here - History taking in RS (pdf)

Useful resources

1. Respiratory examination - wikidoc
2. Pulmonary Examination Technique
3. Respiratory system examination - oxford medical education
4. Respiratory history taking

Audio attributions

1. Respiratory sounds. Wikipedia
2. Dr Shashikiran Umakanth.  Respiratory auscultation with audio examples. Mediscuss

Author

Mandira Roy | DNB(Pediatrics), fellowship in Devlopemental Pediatrics

Mandira has completed her pediatric residency at the Institute of Child health Kolkata and currently working as a Pediatrician with special focus on developmental medicine

Author

Ajay Agade | DNB(Pediatrics), FNB(Pediatric Intensive Care), Fellowship in Pediatric pulmonology and LTV

Ajay is a Paediatric Intensivist, currently working in Pediatric Pulmonology & LTV at Great Ormond Street Hospital NHS, London