Respairatory Examination
1- WIPPPER:
- wash hands
- Introduce yourself
- take permission
- position
- ensure privacy
- Exposure (neck to waist)
- Rt side of the patient
2- ABCDE:
[A]- Appearance+ Alertness: ill or well, is the child engaged and alert or quiet.
[B]- Body built: underweight, overweight, average
[C]- colour and consciousness: pale, jaundice, cyanosed , comatose,conscious, sleeping normally or drowsy
Turner syndrome [D]- Decubitus>> setting or laying or on mother’s lap
- Deformity>> scoliosis, kyphosis, and kyphoscoliosis
- Distress>> tachypnea, flaring of ala nasi, intercostal+ subcostal+ suprasternal recession, cyanosis,
grunting (noisy expiratory breathing against partial closed epiglottis), head nodding, audiable
[Link]
Down syndrome wheeze or stridor
- Dysmorphic feature>> look for syndromic features
- Hydration status>> well or dehydrated (dry tongue, sunken eyes, thirst, dry mucous membrane)
[E]- Environment: connections to patient (neublizer, oxygen, IV line, inhaler or spacer, sputum
÷
pot, chest tube)
3- Vital signs:
HR, BP (appropriate cuff size cover 2/3 of length of upper arm+ should not be
tight), O2 sat (accepted is 92% and higher), temp( every 1 degree rise will
increase HR 10 cycles and RR 5 cycles), RR
4- Growth parameters:
you should ask for weight, height, head circumference (in respiratory
usually weight is affected)
5- General examination:
[1]- Hands:
- Clubbing
- Tremor ( B2 agonist, CO2 retention)
- palmar creases pallor or erythema
- muscle wasting
- peripheral cyanosis
- eczema
- pulses>>
* (brachial pulse in infant and radial pulse in older children)
* assess the rate if it’s regular in 30 sec and multiply it by 2 but ideally you should count it in a full minute (bradycardia
suggest severe asthma)
*character ( bounding pulse in CO2 retention )
[2]- arm for BP to measure pulsus paradoxus and BCG scar
[3]- LN:
Cervical and axillary lymph node examination
[4]- Face:
* Eyes>> conguctiva for pallor, ptosis (Horner syndrome), dark shiners (allergic rhinitis)
*Nose>> nostril patency, nasal polyps (CF), nasal discharge, enlarged turbinate, allergic
salute (allergic rhinitis)
* Mouth and tongue>> central or peripheral cyanosis,high arched palate, cleft lip or palate,
tonsils (present, absent, or inflamed)
*Ears>> wax, tympanic membrane (bulge, hyperaemic, effusion, or perforated)
[5]- LL edema
6- local examination:
[1]- Inspection:
* Respiratory rate>> 30 sec
* Type of breathing>> thoraco abdominal or abdomino thoracic
- Abdominal in infants
- Thoracic after 4-5 yr
- flat abdomen with decrease movements indicates diaphragmatic hernia
- paradoxical chest movements (abnormal)
* Pattern of breathing>> (normal, tachypenic, heavy)
* Deformities>> pectus excavatum(funnel chest), pectus craniatum (pigeon chest), barrel chest ( increase AP diameter), shield chest
(Turner syndrome), flattening of hemi chest (Poland anomaly)
* Chest wall asymmetry and unequal movement>> (from the end of bed and eyes should be at the same level of chest wall)
* Scars>> (midline sternotomy, Rt or Lt thoracotomy, axilla, lobectomy) non surgical like cautery marks
* Apex pulse
[2] palpation:
*Tracheal position>> (it’s a gap between sternal head of SCM muscle and tracheal margin by ur index
finger, normally in young children it’s deviated slightly to the right)
* Apex beat>> cardiac impulse in lower most outer most position (usually located in 4th intercostal space
midclavicular line) in case of dextrocardia think about kartagener syndrome a type of 1ry ciliary dyskinesia
* Tenderness
* Chest expansion>> in older children in 3 zones
→
* Tactile vocal fremitus >> in older children who can speak but not perform nowadays ask the ptn to say ٤٤ or 99
by placing ur ulnar surface of hand
[3]- Percussion:
* Direct percussion on the clavicle (apex of lung)
* percuss the chest into lines from up to down (mid clavicular and mid axillary) by comparing Rt to Lt
* note the liver and heart dullnes
* comment on the character normally it’s resonance or abnormal sounds like (hyper resonance,
dullness, stony dullness)
*Liver span normally 5-8 cm in younger children and 8-12 cm in older children
[Link] [4]- Auscultation:
*Air entry>> normally bilateral equal air entry
*Don’t forget to compare Rt and Lt and use diaphragm of stethoscope
* Character of breathing>> normally it’s vesicular, character of inspiration and expiration if one of them prolonged than the other one
*Other added sounds>> inspiratory or expiratory
1- wheeze: continuous, uninterrupted, musical whistling sound (usually expiratory as in asthma)
2- stridor: harsh high pitched musical sound caused by turbulent air flow in the upper airway (inspiratory)
3- Crepitation: discontinuous explosive and non musical sound like popping of bubbles normally heard in inspiration
Either fine rales(find in alveoli ) or course rales ( in main bronchus)
4- pleural rub: in case of pleurisy
*Vocal resonance>> in older children put ur stethoscope and ask the ptn to say ٤٤ or 99 (increased indicates consolidation or fibrosis,
if decrease indicates pleural effusion or pneumothorax)
* transmitted sounds>> by egophony test (e sounds like a)
7- Back examination:
If possible ask the ptn to seat and place his hands on head
[1]- Inspection: scoliosis, kyphosis, scars, and abnormal scapular shape
[2]- Palpation: chest expansion, tactile vocal fremitus, and tenderness
[3]- Percussion: percuss medial to the scapula (paravertebral) and compare
[4]- Auscultation: same as the front of the chest don’t forget the base of lungs and vocal resonance
[Link]
[Link]
[Link]
examination-osce-guide/
Taif Alsaadi
* q
