1. History taking and physical
examination
Dr San Thitsa Aung

2. The first and most important thing
• Establish the rapport
• Introduce
• Smile
• Direct attention to both informant /
historian and the child
• address questions to the child, when
appropriate

4. History
• Patient particulars
-Age
-Sex
-Ethnicity
• Source of history
• Presenting c/o
(obtain a complete chronological sequence of
events)

5. The mindless Presenting complaints The logical
fact collector strategist
Routine history Likely and
and physical differential
examination diagnoses
Important clues Goal orientated
missed history and physical
examination
Diagnosis???? Diagnosis confirm

6. History of present illness
 COUGH
- mode of onset,time of onset
- duration(days/weeks/months/years)
-dry, moist,productive –sputum(rarely),spasmodic-
paroxysmal whooping ,barking
-precipitating/exacerbating factors
- relieving factors
-diurnal-nocturnal/early morning or seasonal variation
-associated symptoms
fever,coryza,running nose,difficult breathing,noisy
breathing(wheeze/stridor),cyanosis ,episode of chocking

7. Dyspnea-abnormally uncomfortable awareness of
breathing- laboured breathing
• Mode of onset -acute/chronic
• Duration -hrs/days/months/years
• Progression
• Pattern -noturnal
• Aggrevating /Releaving factors-triggered by a particular
activity or situation,SOBAR,SOBOE,orthopnoea
• Severity- apnea, pallor,cyanosis,grunting,fast breathing
chest indrawing,use of accessary muscles, nasal flaring
restlessness, drowsy,convulsion, unable to drink/suck
• Associated - CVS , others-Haemato, Renal

8. Respiratory Distress ?
Normal RR ( /min) Tachypnoea
• Age less than 1 yr = 30-40 • Neonate(<1 month)= >60
• Infant (<1 year )= >50
• 1- 2yr =25- 35 • Children (>1 year )= >40
• 2-5 = 25-30
• 5-12 = 20-25
• >12 = 15-20

9. Noisy breathing
Wheeze Stridor
• High pitched musical • Harsh vibratory sound of
whistling sound variable pitch
• Expiratory • Inspiratoy phase
• Turbulent airflow through • Turbulent airflow through
the narrow airways
the narrow partial
• Intrathoracic trachea and obstruction extrathoracic
major bronchi-terminal
bronchioles upper airway
• Common in infant & young Common in infant &young
child child

10. WHEEZE
• Age - Infant,Toddler,Preschooltransient infant
wheeze,
viral bronchiolitis
-School age children  atopy,asthma,infection
• Onset*- acute /recurrent
• Precipitated/trigger – exercise/cold air/URI infection
asthma
• Pattern -day/nocturnal, exercise induced
• Severity -unrelieved by medication, use nebulizer
(Older child) restriction of daily activities,how much
school has been missed,sleep disturbance
(Infant)poor feeding, sweating,regurgitation,
failure to thrive, cyanosis

11. • Associated factors - cough, rapid laboured
breathing, chest pain, nausea,vomiting,delayed
feeding, coughing with reflux eg.TE fistula, CP
• Contact with URTI

12. Stridor
• Age -
• Onset* -acute/chronicobstruction,infection/congenital
• Persistent/fixed
• Preceeding symptoms fever, coryza, sore throat,
barking cough eg.croups
rash,itching,sneezing,facial swelling eg.Angioneurotic
oedema
• Worse at night*
• Episode of choking, gagging, coughing eg.F/B

13. Stridor
• Difficulty in swallowing,pain
eg.retropharyngeal abscess
• Can’t speak , acutely ill, drolling of saliva
eg. epiglottitis
• Hoarseness of voice eg. croups
• Weak cry
• Delayed feeding,coughing with reflux

14. • System review*
Past medical history
• H/o of similar episode, completely well between
episodes, hospital
admissions(when?,frequency, reason)
• H/o any relevant prior medical illness

15. Past med history
History Current implications
Eczema allergic tendency relevant to Asthma
Hay fever
Recurrent childhood viral asso relevant to childhood onset asthma
wheeze, childhood asthma (atopy)
Whooping cough recognised causes of Bronchiatasis,especially
Measle, Pneumonia,Pleurisy complicated by pneumonia
Tuberculosis Reactivation if not previously treated effectively
Connective tissue disorder lung diseases are recognised complication
Eg. Rheumatoid arthritis Pulmonary fibrosis,effusion,Bronchiatasis
Aspiration recognised cause of Pneumonia
Neuromuscular disease Respiratory failure
Aspiration Pneumonia

16. Birth History
• Antenatal  pregency, maternal intrauterine
infection,GDM,smoking,alcohol,cong anormalies
• Natal gestation(prematurity),mode of
delivery,birth trauma, B.wt(LBW/SGA/LGA)
Admitted to SCBU,particularly regarding need for ET
tube intubation
• Post-natal infection

17. Nutritional H/o
• Breast/Bottle/mixed
• Breast  frequency,amount, duration,
asso; sweating, dyspnea
• Timing of introduction of solid /cereals
• Current dietary intake
• Feeding -well/poor
eg.regurgitation and spitting up could be a sign of
GOR

18. Immunisation H/o
• Complete according to EPI Schedule
eg. Hib(H.influenza) stridor,pneumonia
• BCG, DTaP,MMR
• If failure ask reasons in detail

19. Developmental H/o
• Gross motor
• Fine motor
• Speech/Hearing
• Social
• (Know atleast 4 milestones for different ages
which parents can easily answer)

20. Family History
_ consanguinity , overcrowding, parent’s occupation
bronchial asthma, atopy, TB, similar illness, congenital
heart disease , cystic fibrosis
Social History
– School performance - frequently absent?
– Social interaction , economic status
– Housing , indoor pollution-cigarette smokers at home
– Environmental allergens : pets, carpets

21. • Drug and allergies
List drugs , frequency and dosage
eg. Bronchodilators
Allergy to drugs, food, dust

22. Physical exam;
• Differs depending on the age of the child
• Inspection is important in younger child
• Palpation& percussion are difficult
• Ascultation  less informative
• Obsevation provides 90% of information
• Donot undress the young child esp;lly sleeping

23. General
• Wt ,Ht , nutrition and hydration status
• Dysmorphic feature
• Well/unwell  alert/toxic looking, fever
• Consciousness drowsy , confusion
• Receiving additional oxygen , I.V line
• Note the vital signs - BP, PR, RR
Undress the child’s top half to the waist (except for
the aldolecent girl)
ideally 45 ̊,baby on his back or sit on mum lap

24. • Respiratory distress
• using the accessory m/s, alarnasi flaring, visible
recession(difficult to assess if baby is crying)
• Respiratory rate (never guess)-count the rate
exactly by watching chest or abdominal movement
for 1 min
• Cyanosis - centeral
• Audible sounds- wheeze,stridor,grunting,cough

25. • Hands- clubbing
anaemia
peripheral cyanosis
warm
tremor (fine/flapping)
(pulsus paradoxus = >15 mmHg difference)
• Extremeties- eczema, urticaria,oedema
• Face -syndrome-Down’s,Cleft
lip,fever,cyanosis(lips,tongue)
• Nose - alar nasi, nasal discharge, polyps
• Neck- feel for cx LN (at this stage done from front)

26. • Throat& Ear- ENT exam; at the end of
examination*
• Trachea(perform this on one side)
gently place your index finger b/t the
trachea and the sternal head of the
sternocleidomastoid on each side and
seeing if the gap on both side is equal

27. Observe the chest
• Inspection
 DeformityPectus excurvatum=depressed sternum
(funnel chest)
Pectus carinatum=prominent sternum
(pigeon chest)
Harrison’s sulcus = retracted costal cartilages
suggesting chronic condition(either airway obst-
ruction or Lt to Rt cardiac shunt)
Look all round the the chest including under the axilla

28. Pectus excurvatum Pectus carinatum

29. Hyperinflation-increase AP(antero-posterior)
suggests asthma /emphysema
Rachitic rosary-swelling of the costochondrial
junction in Rickets
Absent clavicle/pectoralis muscle
Scars- sternotomy,thoracotomy, chest drains
Chest wall movement- compare both sides
Intercostal/subcostal recession
Scoliosis- Don’t forget to look the back of the
chest

30. • Approach to infant and older child differ
• P&P are not routine parts of the examination of
baby
• You should leave out P&P and go straight to
Ascultation
But in older child –to follow the established sequence
begin with infront of the chest
ask the child to sit up on the bed
lying back against a pillow with arm
by the side
•
•

31. • Palpation
 Feel quickly for the Apex beat Dextrocardia
Scoliosis
Displacement of Trachea+apex to the sameside
mediastinal shift
Eg. Pleural effusion,Pneumothoraxpush away
Collapse,Fibrosis pull towards that side
Displacement of Trachea aloneupper lobe
pathology
Displacement of Apex alonePectus,scoliosis

32.  Assess chest expension
Place the fingertips of the both hands on the
chest wall laterally so that thumbs meet
in the midline, only thumb s/b lifted slightly off
and fingertips must be kept tightly
applied to the chest wall throughout
Ask the child to take deep breath in observe
which thumb move least from the midline

33. Eg. Effusion, Pneumo; collapse,consolidation
fibrosis diminshed expension on that side
Tactile vocal framitus
- Place the palm of the hand on either side of
the chest ant;lly and ask the child to say “99”
-feel for difference between Rt &Lt rather than
increase& decrease

34. • Percussion- only twice at each of the sites
-alternating Lt & Rt
-ant;lly start in supraclavicular fossa,
clavicle,2th to 6th ICS
-don’t forget mid-axillary line on each side-4th
to 7th ICS
-post;lly –apex, below the level of spine of
scapula to 11th ICS
(Avoid percussion near midline)
-to determine where the upper border of liver

35. • Ascultation
- ask the child to open his mouth and breath in &
out
-show him first and demonstrate how to do
properly
-listen upper, middle and lower parts of lung fields
and in mid-axillary line
-diaphragm of stethoscope is better for higher
frequencies

36. -Bell is applied tightly to chest wall,it behaves
like a diaphragm
-compare the Lt & Rt
-listen for one cycle of inspiration and expiration
at each site
-2 breathe at each of 6 sites anteriorly and post-
eriorly

37. Breath sounds
Vesicular Bronchial
• Normal • May be heard in normal
child (ant;lly below the Rt
clavicle, post;lly over the
hila)
• Low-pitched • Harsh,high- pitched,
• Inspiratory and expiratory
• Inspiratory phase is phase are equal
longer than expiratory • A pause inbetween
• No break inbetween • Abnormal, heard over
consolidation,just above
effusion

38. Added sounds
1. Conducted upper airway sounds
2. Wheeze or rhonchi -high-pitch whistling
more commonly heard in expiration
(monophonic-single larger airway obstruction)
(polyphonic-many airway )
3.Crepts/crackles-interrupted bubbling noises
usually in early inspiration

39. there are 2 catagories in crepts
Coarse and variable pitch due to secretions-
eg. Pneumonia,Bronchiectasis
Fine and high-pitched at the base-
eg.pulmonary oedema,bronchiolitis,fibrosing
alveolitis
Describe the location of the abnormal signs
eg. VBS with crepts in Rt middle zone
BBS in Lt upper zone

40. Physical signs in respiratory diseases
Disease Chest movt Mediast; shift Percussion Vocal Breath
Resonance sounds
Consolidation ↓ none Dull ↑ BBS
crepts
collapse ↓ to same side Dull ↓ ↓
Fibrosis ↓ To same side Dull ↑ BBS
crepts
Effusion ↓ To opposite Stony dull absent Absent
side BBS
Pneumothorax ↓ To opposite Hyper ↓ ↓
side resonant

41. • To complete the resp; system exam: I’d to per-
form ENT exam and measure PEFR
To palpate the liver and spleen-hyperinflacted
lung downwards displacement of the liver and
spleen
To find out the s/- of heart failure
Summary
Diagnosis
Differential Diagnosis
Point for Diagnosis

42. References
• Macleod’s Clinical Examination, Graham
Douglas, 11th Edition
• Illustrated Textbook of Paediatrics 3rd Edition
• Nelson Textbook of Pediatrics, 18th Edition
• Clinical examination Systemic guide to physical
diagnosis,6th edition

43. Thank You