THE HISTORY AND PHYSICAL EXAMINATION Arnold Nicholas T. Lim, MD, DPPS, DPAPPTHE HISTORY * Should be ina clear and chronological narration. * Chief complaint * History of present illness * Onset and duration * Environment and circumstances under which it developed * Its manifestations and their treatments * Define symptoms by their qualitative and quantitative characteristics, timing, location, aggravating or alleviating factors, and associated manifestations * Past medical history and laboratory data > ‘Scanned with CamSeannerTHE HISTORY * Onset of disease — sudden or gradual * Age at first presentation * Duration of symptoms * Acute — lasting less than 3 weeks * Chronic — vary from 4-8 weeks * Recurrent — symptoms are discontinuous w/ interval of well-being Children have on average of 5 to 8 respiratory infections a year ‘Scanned with CamSeannerTHE HISTORY * Search for environmental factors to uncover possible allergic causes. * Birth history * Feeding history * Family history * Immunization * Childhood illnesses and previous hospitalization * Current medications ‘Scanned with CamSeannerINSPECTION Pattern of breathing * Respiratory rate 2 World Health Organization Age Normal Respiratory Rate Newborn to imo. < 60 breaths per minute 2mos to 11mos <50 breaths per minute 1yo—5yo < 40 breaths per minute >Syo < 30 breaths per minute ‘Scanned with CamSeannerINSPECTION Pattern of breathing * Respiratory rate * Tachypnea * Abnormally high breathing frequencies * Seen in patients with decreased lung compliance and in those with metabolic acidosis. * Other causes: Fever (~5—7 breaths/min increase per degree above 37°C) Anemia Exertion Intoxication (salicylates) Anxiety Psychogenic hyperventilation ‘Scanned with CamSeannerINSPECTION Pattern of breathing * Respiratory rate * Bradypnea * Abnormal slow RR * Occur in patients with metabolic alkalosis or central nervous system depression. * Hyperpnea * Deep respirations * Hypopnea © Shallow respirations ‘Scanned with CamSeannerINSPECTION Pattern of breathing * Rhythm of breathing * Periodic breathing * Groups of respiratory pauses <6 secs separated by <20 seconds of respiration. * Preterm: occurs after first days of life; may persist until 44 wks PCA. * Term: occurs b/w 1 week to 2 mos. old; disappears by 6 mos. old. A ’ tow om 3} N Term Crescendo- Decrescendo tow = 3 Preterm ‘Scanned with CamSeannerINSPECTION Pattern of breathing * Rhythm of breathing * Apnea * Cessation of airflow lasting >15 seconds accompanied by bradycardia and/or iy cyanosis. * Cheyne-Stokes breathing * Cycles of increasing and decreasing tidal volumes separated by apnea * Occurs in: CHF, increase ICP, central opioid depression ‘Scanned with CamSeannerINSPECTION LCR eh 4 * Rhythm of breathing * Biot’s breathing + Fixed tidal volume of breathing separated by apnea. * Ominous finding in patients with severe brain damage. * Kussmaul’s breathing * Deep, regular breaths that may be rapid, slow, or normal in rate. ‘Scanned with CamSeannerINSPECTION Pattern of breathing ° Effort of breathing * Chest wall retractions * Use of accessory muscles * Alar flaring * Paradoxical breathing * “Seesaw Breathing” * Inward motion of the chest wall during inspiration * In children w/ neuromuscular disease. * Impending respiratory failure ‘Scanned with CamSeannerPALPATION * To detect swellings and deformities. * To identify areas of tenderness or lymph node enlargement. * To document the position of the trachea. * To assess symmetry of chest expansion. * To detect changes in the transmission of voice sounds through the chest (Tactile fremitus). "Scanned with CamSeannesPALPATION * Tracheal position * Deviation toward the ipsilateral site of lung involvement * Atelectasis * Deviation to contralateral side * Pneumothorax, pleural effusion, mass + Posterior displacement * Anterior mediastinal tumors or barrel chest deformities * Anteriorly displaced * Mediastinitis ‘Scanned with CamSeannerPALPATION * Tactile Fremitus * Decreased * Pneumothorax * Pleural effusion + Atelectasis * Mass * Normal or present * Consolidation with open airways ‘Scanned with CamSeannerPERCUSSION * Tympanic or resonant * Normal * Flat or Dull * Pleural effusion * Consolidation * Atelectasis * Mass * Hyperresonant * Hyperinflated lungs * Pneumothorax ‘Scanned with CamSeannerAUSCULTATION * Most important part of chest examination. “Normal” Breath Sounds * Normal lung or vesicular breath sound * Soft, low pitch, and rustling in quality. * Inspiratory phase is longer than the expiratory phase (L:E ratio — 3:1). * Intensity of inspiration is greater than that of expiration. + No pause between inspiration and expiration. * Best heard in most areas of the lung but are most prominent at the lung bases and periphery. ‘Scanned with CamSeannerAUSCULTATION * Bronchial breath sound * Loud, high pitch, and hollow/tubular quality. * Expiratory phase is longer than inspiratory phase (I:E ratio = 1:2). * There is distinct pause between inspiration and expiration. * Normal if auscultated over the trachea. * Abnormal if heard in the lungs (consolidation, fibrosis, and of atelectasis w/ patent airways) ‘Scanned with CamSeannerAUSCULTATION * Bronchovesicular breath sound * Intermediate between bronchial and vesicular. * It has mid-range pitch and intensity. * Same duration of inspiratory and expiratory phase (I:E ratio — 1:1). * Can be heard throughout the lung fields but commonly heard anteriorly over the 1% and 2"4 intercostal spaces and between scapulae posteriorly. b ‘Scanned with CamSeannerAUSCULTATION us Breath Sounds * Wheeze * High-pitched, musical and continuous sound * Originate from oscillations in narrowed airways. \ _ * Polyphonic * Widespread narrowing of airways e a * Various pitches * Heard in patients with asthma 5 * Monophonic * Fixed obstruction in large airway * Single pitch * In patients w/ FB aspiration did: ‘Scanned with CamSeannerAUSCULTATION Adventitious Breath Sounds * Rhonchi * Low-pitched, continuous sound * From copious secretions in the large airways. * Heard in patients with: * Bronchitis * Pneumonia * Bronchiectasis > = ‘Scanned with CamSeannerAUSCULTATION PNEUMONIA Adventitious Breath Sounds -% * Crackles 6 * Nonmusical and discontinuous es * Result from the following: * Air movement through secretions or by sudden equalization of gas a pressure. * Release of tissue tension during oe « sudden opening and closing of \ airways. — * Coarse — low pitch * Fine — high pitch aq: 4 ‘Scanned with CamSeannerAUSCULTATION Adventitious Breath Sede. * Pleural rub * Nonmusical * Grating, rubbing, LD or leathery in character * Occurs due to inflamed pleural surfaces * Heard in patients w/ pulmonary infection, pulmonary embolism, and connective tissue disease. ‘ ‘Scanned with CamScannerAUSCULTATION Adventitious Breath Sounds Pleural friction rub Is biphasic Usually localized to a small area No change after coughing Often palpable Pressure of stethoscope intensify the sounds Associated with pleuritic chest pain or local tenderness Crackles Either inspiratory or expiratory or both Widespread May clear after coughing Usually nonpalpable No effect No pain or tenderness ‘Scanned with CamSeannerAUSCULTATION * Stridor * Loud, high-pitched, musical sound * Due to oscillations of narrowed extra- thoracic airways. * Heard in patients w/ UAO croup io eanaren _ Inside the Trachos Stridor Wheeze sven Louder overthe Louder over the | K neck chest wall Mainly Mainly expiratory veuy een inspiratory ™" ‘Scanned with CamSeannerAUSCULTATION PONT elem sige yel Lely * Grunting * Low-pitched, expiratory sound * Occurs when a child exhales against a partially closed glottis. * Mechanism to generate PEEP to keep the alveoli open * Mostly heard in premature infants. 4 ‘Scanned with CamSeannerAUSCULTATION Adventitious Breath Sounds * Stertor * Low-pitched, non-musical sound * Caused by obstruction in the nose, nasopharynx, or oropharynx. * Snoring * Similar to stertor * Heard during sleep ‘Scanned with CamSeannerAUSCULTATION COMMON CAUSES OF STERTOR © @6@ Nasal congestion Choanal atresia Tonsillar hypertrophy 0c 8 Micrognathia Retrognathia Macroglossia ‘Scanned with CamSeannerAUSCULTATION * Bronchophony * Increased transmission of voice sound. * Ask patient to say “ninety-nine” ina NORMAL VOICE while auscultating. * Increase in voice transmission or clearly audible voice suggests consolidation. * Pectoriloquy * WHISPERED VOICE * Egophony * Recommended term for both findiings. ‘Scanned with CamSeannerPhysical Findings in Selected Chest Disorders cern Percussion srscheg | Breath Adventitious | Ba nai 4 Note sounds | Sounds | (remus ant Consolidation | Alveolifilled w/fluidor Dull. | Midline Bronchial | Crackles over | Increased blood cells, as seen in over the the involved over the pneumonia, pulmonary involved area involved edema, or hemorrhage. area area, w/ |__egophony Atelectasis | Lung tissue collapse as Dull Maybe | Usually None Usually a result of airway shifted absent | absent obstruction from mucus toward or foreign object. involved side Pleural Effusion — Dull Shifted | Decreased | None Decreased Fluid accumulation in toward to absent except to absent the pleural space. opposite posible bide in large pleural rub effusion ‘Scanned with CamSeannesPhysical Findings in Selected Chest Disorders Tactile itl Condition Percussion | trachea | Breath | Adventitious | -. oitus and Note sounds Sounds Vocal Sounds Pneumothorax When air leaks intothe Hyperreson Shifted | Decreased | None Decreased to pleural space. ant or toward to absent absent tympanic opposite over the over the overthe side if pleural air pleural air pleural air massive Bronchitis | Inflammation of the Resonant Midline Vesicular None, or Normal bronchus with wet (Normal) | crackles or cough. rhonchi anos dnarrowing ot RESonantto | Midline Often Wheezes, | Decreased the airways. During, aifusely obscured by| possibly ator ufistioreee ea wheezes | crackles ant further, and lungs hypeinflate ‘Scanned with CamSeannerREFERENCES * Kendig's Disorders of the Respiratory Tract in Children, 9th Edition. * Sarkar, M., Madabhavi, |., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory system. Annals of thoracic medicine, 10(3), 158-168. Retrieved from https://doi.org/10.4103/1817-1737.160831 DISORDERS Tsoi a1 V0) adel ere t Acsatatn othe respi system c ‘Scanned with CamSeannerried with CamSeanner