Record the essential details
Informant (If informant is not mother, mention who is providing the history and whether the history is reliable or not. You are likely to get a reliable information only if the child is under the care of the informant).
APPROACH TO HISTORY TAKING
- Involve older children in interview. They may be able to provide greater information regarding their illness, e.g. history of exercise induced asthma (Parents may be unaware of its existence).
- The general scheme would be to list out the complaints in chronological order. Then each of the complaints is dealt in detail. Here the description follows the sequence — Onset, duration, progression, aggravating and relieving factors and any associated conditions. This is applicable to any symptoms. Elaborate the complaints in parents own words, and avoid leading questions.
- Duration of the illness: This helps us to classify the child's condition. For example, whether the condition is acute (less than 3 weeks duration), chronic (more than 3 months duration) or recurrent (where there is symptom free period of 2 weeks in between the attacks) So, the history will begin as:
Arun, 6 years old male child from Pariyaram, presented with complaints of fever for one week, cough for 5 days and breathing difficulty of one day duration. Informant is mother and history is reliable.
NB: Do not cook up history. This can land you in trouble. The aim is to take a reasonable history in order to come to the most probable diagnosis.
DETAILS IN HISTORY
- Cough: Type, duration, productive or nonproductive, dry or wet (in young children who are unable to bring out sputum, comment whether cough is dry or wet), hemoptysis, any precipitating factors or diurnal variation. If child can bring out sputum, mention the character, quantity of sputum produced and presence of any postural variation. Sputum may be mucoid, purulent, frothy, blood stained or rusty (altered blood).
- Dyspnea: On exertion or at rest. Any diurnal variation/postural variation/orthopnea/paroxysmal nocturnal dyspnea.
- Presence of wheezing. Enquire whether it is more during morning or evening hours.
- Lower chest indrawing, suprasternal recession (suggests upper respiratory tract obstruction), intercostal retractions (suggests alveolar involvement) and subcostal retractions.
- Chest pain: Localize the chest pain, whether increased on deep inspiration (indicates pleural involvement), and whether child prefers to lie on any particular side. Also differentiate, chest pain from other causes with an appropriate history.
- Mention regarding history suggestive of upper respiratory tract involvement like nasal discharge, nasal blockade, earache and ear discharge.
- Noisy breathing/grunt: What parents comment as noisy breathing could actually be any of the following—wheeze, stridor, snoring, grunting or sound produced by upper airway blockade due to secretions. Hence, a thorough history should be taken to differentiate these entities.
- Hemoptysis: Presence of frank blood/altered blood (rusty sputum in pneumonia). Also comment on the amount of blood. More than 100 ml is referred to as bronchorrhea.
- History of significant weight loss: Suggests chronic disease process (e.g. bronchiectasis).
- Past history of recurrent wheeze or cough, recurrent pneumonia, bleeding manifestations (in case of hemoptysis), any hospitalizations with special mention to intensive care admission and any history of nebulisations. Past history of any cardiac disease should be ruled out.
- Family history of wheeze or other allergic disorders; tuberculosis (ask if anybody is on antituberculous drugs or has chronic cough), any history of contact with Tuberculosis (e.g. a neighbour taking ATT or has chronic cough and the child frequently visits their home).
- Consanguinity is important in autosomal recessive conditions like cystic fibrosis.
- Any pets in family (Fur of pets may precipitate wheezing).
- Any smokers in family, type of fuel for cooking or any other precipitants of asthma.
- Any drug intake—Sometimes the history of ATT may not be forthcoming. In these cases, ask whether the child is on any medication that turns urine red. ACE inhibitors may be associated with dry cough, beta blockers and NSAIDS may precipitate wheeze and hence intake of these drugs should be enquired into.
At the end of history, we should be able to arrive at a list of possible diagnosis. For this, a summary of the history would be helpful, listing only the positive points from the history.
An acceptable summary is like:
6 years old male child, normal until one week back presented with acute onset fever, cough and breathing difficulty. He also gives history of pleuritic type of chest pain on the right side. There is no other relevant history (This summary will easily bring you to the diagnosis of right sided pneumonia with a probable pleural involvement. The rest of the effort will go towards confirming your clinical impression by means of a thorough physical examination).
Comment on the general appearance of the child, like child is tachypnoeic with lower chest indrawing. Comment on the most obvious finding that leads to the diagnosis. Also mention on the built and nourishment of the child if you feel that it is significant (Chronic cough in a wasted and malnourished child would point towards the possibility of Tuberculosis).
Respiratory rate: Cut off for tachypnea, according to ARI control programme is:
- Newborns – 60/minute
- Infants – 50/minute
- Children up to 5 years – 40/minute.
Counting for 30 seconds is found to be as good as counting for one minute, except in newborns where one should count for one full minute in view of periodic breathing due to respiratory immaturity.
Abdominothoracic type of respiration is seen in children. Comment as—Respiratory rate is 56/minute and is abdominothoracic. Child is tachypnoeic.
If respiratory rate is borderline, repeat the count once again.
Pulse rate: It is usually 4 times the respiratory rate.
Temperature: Comment whether child is febrile or not. Normal temperature is 36.6 to 37.2°C. Rectal temperature is 0.5° more than oral which is 0.5° more than axillary temperature.
Blood pressure: Comment as _____mm of Hg in right arm in supine position. Look for postural variation as well, in indicated cases.
HEAD TO FOOT EXAMINATION (With Relevance to Pulmonology)
Comment on pallor, cyanosis, clubbing, significant lymph node enlargement or pedal edema, before embarking on detailed head to foot examination.
Hair: Sparse, thin, depigmented in malnutrition.
Eyes-Phlycten in Tuberculosis, polycythemia in chronic lung diseases, conjunctivitis as a pointer to chlamydial infection and follicles in eyes as a marker of atopy.
Nose: Dennie line, allergic salute (transverse creases over bridge of nose) and nasal polyps are pointers to allergy. Alae nasi flaring is seen in very severe pneumonia.
Mouth: Cyanosis, angular cheilitis (B complex deficiency), oral candidiasis as evidence of immunodeficiency, enlarged or absent tonsils (absent tonsils may suggest B cell immunodeficiency).
Skin: Any stigmata of malnutrition/skin rashes/pyoderma. Presence of active pyoderma lesions in a sick child with features of pneumonia suggests a staphylococcal etiology.
- Harrison sulcus: A prominent sulcus just above the costal margin. This may be seen in rickets, congenital cyanotic heart disease, premature infants and sometimes even as a normal variant.
- Funnel shaped chest may be seen as a congenital anomaly and rarely in adenoid hypertrophy.
- Short wide chest may be seen in short children or in cases like Morquio disease.
- Pigeon chest characterised by protuberant sternum may be seen in rickets and osteopetrosis.
- Xiphoid process may appear prominent or even broken due to loose attachment to the sternum. This is often a normal variant.
- Edema of chest wall may be seen in superior vena cava obstruction or mediastinal compression syndrome.
- Normal angle between sternum and rib margin is approximately 45°. Larger angle may be seen in lung diseases while smaller angle may be seen in malnutrition.
- Excessive thoracic activity in the form of intercostal and subcostal retractions can result from lung disease or due to peritonitis (due to limitation of abdominal movements).
One general examination, if there is one congenital anomaly, always look for other internal and external anomalies as well.
Though we calculate and assess anthropometry, comment as growth assessment (Anthropometry is a mechanical work while growth assessment is an intellectual exercise).
PROTEIN ENERGY MALNUTRITION (IAP classification)
Present weight/expected weight for age × 100
Parameter (wt for age)
More than 80%
Grade 1 PEM
Grade 2 PEM
Grade 3 PEM
Less than 50%
Grade 4 PEM
Add K to grading in case of presence of kwashiorkor.
STUNTING (Waterlow Classification)
Present height/expected height for age × 100
Parameter (height for age)
More than 95%
Grade 1 stunting
Grade 2 stunting
Less than 85%
Grade 3 stunting
WASTING (Waterlow Classification)
Present weight/weight required for the present height x 100
More than 110
Less than 70
Wasting—Index of acute malnutrition and suggests an acute illness.
Stunting suggests chronic malnutrition and indicates chronic respiratory illness.
Significant weight loss in a stunted child suggests acute on chronic malnutrition.
Chest circumference: Normally chest circumference is less than head circumference during the first year of life. Beyond this period, chest circumference exceeds the head circumference. In some cases of well-built children, the chest circumference may be more than head circumference during the first year as well.
In infancy, transverse diameter is equal to anteroposterior diameter. As child grows, there is an increase in transverse diameter. Round and emphysematous chest beyond 6 years of age suggests chronic lung disease like Bronchial asthma.
A sample comment on growth assessment would be:
Child is wasted and stunted. Child has acute on chronic malnutrition.
EXAMINATION OF RESPIRATORY SYSTEM
Upper respiratory tract: Comment on nasal discharge, ear discharge, nasal septal deviation, furunculosis or nasal polyp. Also comment on alae nasi flaring.
Pharynx: Congestion/cobblestoning of posterior pharyngeal wall suggest lymphoid hyperplasia secondary to chronic irritation by postnasal drip. Look for tonsillar enlargement or absent tonsils.
Trail sign: Sternomastoid prominence on the side of tracheal shift.
Comment on respiratory rate. Mention whether child is tachypnoeic or not. Also comment whether there is lower chest indrawing and intercostal retractions.
Apex beat: Whether normal in position, or shifted to left or right. Shift of trachea and apex to right indicates mediastinal shift to right and vice versa.
Shape of chest: Pectus carinatum or pectus excavatum, emphysematous chest, etc. (The comment would already have been discussed under head to foot examination. However, it is prudent to repeat the same, due to its relevance to respiratory system).
Chest symmetry: Comment if there is any asymmetry like chest wall flattening, drooping of shoulders or excessive hollowing of supraclavicular fossa. If there is no asymmetry, comment as “chest is symmetrical” (avoid using the term “bilaterally symmetrical”).
Intercostal fullness: Can occur in case of empyema.
Chest movements: Comment if there is decrease in movements on any side, e.g. chest movement is decreased on right side.
Movement may be decreased on the affected side in case of:
- Pleural effusion
- Obstructive foreign body
Scoliosis: Comment as “child has scoliosis with concavity to right” (as in a case of right sided pleurisy causing the child to splint on the same side).
Engorged veins or prominent pulsations over chest: Engorged veins may be seen in case of superior vena cava compression due to mediastinal mass.
Sinus tenderness: Comment on this should be age appropriate ex. A 2-year-old child is not expected to have frontal sinusitis.
Position of trachea: Comment whether it is deviated to right or left. Place 2nd and 4th finger on medial end of each clavicle and then try inserting the middle finger on either sides of trachea. Finger insertion is difficult on the side of tracheal deviation and is easy on the other side.
Apex beat: Locate the apex beat in the lying down position. Place the entire palm over the precordium and then localize the site of maximum impulse. Comment as –“apex beat is in the left fifth intercostal space in the midclavicular line”. If the apex beat cannot be localized in the lying down position, try localizing in the sitting position (the common practice of palpating in the left lateral position is to be avoided as the impulse shifts about 2 cm outwards in this position thereby making it impossible to comment on mediastinal shift).
Local tenderness: Palpate for tenderness in the intercostal spaces. Comment as–“tenderness is present in right mammary and infra-axillary areas suggesting empyema on the same side”.
Chest expansion: Encircle the chest with both hands, with the thumbs approximating in midline. Ask the child to take a deep inspiration. Look for the movements of the thumb away from the midline on both sides. The movement of the thumb, from the midline, is restricted on the side of pathology (as in pneumonia, pleural effusion or pneumothorax). Comment as “chest expansion is reduced on right mammary and inframammary areas”. Often it is difficult to comment areawise and often the comment would be—chest expansion is reduced on right side (only a significant lesion is going to produce a restriction of chest on the side of pathology). The apical portion of the lungs is examined from the back by placing both hand on the shoulders and asking the patient to take deep inspiration. Look for differential movement on either sides, with the clinician standing behind the patient and looking from above downwards.
Measure with a tape to make an objective assessment of the difference. Look for hemithorax expansion. Measure from the spine to the midline anteriorly on both sides. Comment as ‘chest expansion is 0.5 cm on left side and 2 cm on right side’ (indicating a pathology on left side). The normal chest expansion is 4 to 5 cm in teenagers. Lesser expansion could suggest intathoracic pulmonary disease.
Tactile vocal fremitus: Place the ulnar aspect of the hand sequentially on the corresponding areas of chest wall on either sides and ask the patient to say ‘one-one-one’. Comment as “tactile vocal fremitus is increased in right mammary, inframammary, infra-axillary and lower interscapular areas suggestive of lower lobe pneumonia”.
Percussion: Percuss with middle finger of right hand (plexor) over the middle phalanx of the middle finger of left hand (Pleximeter). The pleximeter should be placed firmly over the chest, so that no air intervenes in between. Cardinal laws to be observed in percussion are:
- Percuss from resonant area to dull area.
- The movement should be from the wrist and not from the elbow.
- Percuss corresponding areas on the chest, like right mammary and then left mammary, and compare.
Comment as “percussion note is stony dull in inframammary, infra-axillary and infrascapular areas implying pleural effusion”.
Auscultate the corresponding areas of the chest. Look for vocal resonance bilaterally and comment as vocal resonance normal, increased or decreased, e.g. vocal resonance increased in right, infra-axillary and interscapular areas could imply a pneumonia of right lower lobe. Remember that comment on vocal resonance and tactile vocal fremitus should be the same (If they differ, it can land you in trouble in the examination). If the vocal resonance is increased and if you are sure of the character, describe it (It is better to limit yourself only to a comment on increased vocal resonance, if you are doubtful regarding its character): Increased vocal resonance may be described as:
- Whispering pectroloquy
Comment on type of breath sounds (vesicular or bronchial) as:
- Normal vesicular breath sounds bilaterally with decreased intensity on left side (implying some pathology on left side).
- Bronchial breathsounds heard in right lower interscapular and infra-axillary areas (implying consolidation right lower lobe).
- Vesicular breathsounds with prolonged expiration (can occur in bronchial asthma).
Comment on any added sounds like:
- Pleural rub
- Wheeze (localized or bilateral/inspiratory or expiratory).
Describe the site of presence of the added sounds which helps to localize the site of pathology.
Try to make an anatomical, functional and an etiological diagnosis in all cases. Remember to include comorbidities like malnutrition in the final diagnosis. If you do not have a definite diagnosis and wish to consider a few differential diagnosis, comment that, in view of such and such symptoms and findings, you would like to consider the diagnosis of_____. However, I would also like to consider the differential diagnosis of so and so due to the following positive features. This type of comment is surely going to make a good impression on the examiner. Some sample diagnosis formats include:
- Right sided pneumonia with effusion.
- Collapse right lower lobe.
- Pleural effusion, right side, most probably Tuberculous.
- Pneumothorax, right side, in respiratory failure.