CSL Paed RS Exam
Tues 27-08-02
Dr Allan Lau
OBJECTIVES
- Detect and define physical abnormalities
- Assess degree of resp distress (amt of work on work of breathing)
GENERAL CONDITIONS
- General status of health
- Colour
- Appearance: Eg. Wasted: undernutrition, disease?
- Nutrition
- Activities
- Interactions with caregiver and examiner
SKIN & MUCOUS MEMBRANE
- Mucous membrane for central and peripheral cyanosis
- Presence of scars on chest: clues to past resp problems
- Clubbing of fingers
URT
- ENT examination
- Cervical LN
- Position child with hands of parent
- Sitting on mother's lap, mother holding baby's head, hold into mother's chest
NECK - 4 regions
- Submental: lower jaw, gum, mandible area
- Submandibular
- Anterior cervical: in front of SCM, drains anterior pharynx
- Posterior cervical: ME, mastoid
- Supraclavicular: lung, gastric ca, lymphoma, sometimes TB (as well as hilar LN) (note: resp infection in children does not give supraclavicular enlargement)
- Tracheal
- Pre- and postauricular: skull; usually only seen in skull folliculitis or African hair-braiding; measles affect postauricular
- Axillary: drains inside of chest cavity
Revise lymphatic drainage: direction, subgroups, location
Describe LN: size, shape, mobility, adherence, warmth, number, location, tenderness, consistency, discharge
Infants: infection not confined to one area
- Trachea position: central between 2 insertions of SCM muscles
CHEST EXAMINATION
DEFORMITIES & SURGICAL SCARS
-
AP Æ : chronic lung disease
- Pectus carinatum (Pigeon chest)
® spondyloepiphyseal dysplasia, Noonan ® fixed deformity assoc. with increased AP diameter of disease - always indicates chronic resp problems
- Pectus excavatum (Funnel chest)
® Marfan, Noonan, normal
- Harrison's Groove - horizontal depression from lower sternum to mid-axillary
® congenital, Rickets
RESPIRATORY EXAM
Movt of chest - paradoxical movt (retraction of lower sternum with inspiration - commonly seen in infants ® reflects degree of compliance of thoracic cage rather than disease (as in adults)
Work of breathing
- Rate/minute
- Counted best when Pt at rest or asleep
-
SA for wt - mechanical disadvantage \ RR cf. older children and adults
- Best indicator of resp disease
Rhythm: regular or irregular
- Periodic breathing (< 6mo), apnoea (premies)
- Periodic breathing most striking in premies, may be assoc. with hypoxia/hypoxaemia and bradycardia
- Metabolic, IVH
Breath Sounds
- URT: hoarseness, stridor
- Epiglottic swelling, subglottic oedema, retropharyngeal
- Stridor: usually inspiratory stridor, 'e' sound
- LRT: wheezing, crackles/rales
- Bronchiolar narrowing, oedema, reactive constriction, fluid
- Usually prolonged expiratory phase
- Abnormal breath sounds
- Quality
- Symmetry: in R and L lung
- Timing: inspiratory or expiratory phase
- Lung anatomy: where are the abnormal sounds coming from (remember: upper lobes extend a long way down at the front; lower lobes extend a long way up at the back)
Signs of Respiratory Distress
- Inspection: head nodding, nasal flaring (<6mo only), tracheal rugs, subcostal and intercostal retractions
- Palpation: chest expansion (thumbs meet in midline) - upper, middle, lower back, abnormal masses/bones, infants: measure chest expansion by inspection alone (excursion)
- Percussion: be gentle (erroneous impression of hyperresonance in small children), small size of chest, don't percuss each IC space, always compare L and R sides (asymmetry?)
- Auscultation: use diaphragm (filters out low-pitched sounds), place firmly against skin, avoid exam through clothing, transmissible sounds due to small chest and ¯ lung tissue, no need for big breaths
PEARLS
- PQRST in Hx taking
- P - provokes / palliates
- Q - quality
- R - region, radiation
- S - severity
- T - timing
- Always think about differential Dx
- Perform the P/E with analytical mind
- Use your common sense to interpret the findings
ADDITIONAL POINTS
- Mother to undress baby
- Know systems from head to toe: practically, be selective - keep invasive and uncomfortable procedures for last (eg. Throat and ear exams ® eg. Tongue depressor)
- Epiglottitis: resp distress, drooling, dyspnoea, dysphagia, baby throwing itself fwd, dog-like appearance ® if Pt lies down, epiglottis covers aw -> asphyxia, tracheotomy needed