Posted: March 30th, 2022

You are seeing a 14-year-old boy

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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 12: Child and Adolescent Asthma
This video is designed to help prepare you for objective structured clinical examinations, or
OSCEs.
You are seeing a 14-year-old boy and his mother in an urgent care setting. The boy’s chief
complaint is difficulty breathing. As you watch this encounter, you will be asked to answer
questions while the image on the screen freezes. These questions will engage you in practicing
the skills of focused history taking, physical examination, and clinical reasoning as you develop
your preliminary differential diagnosis, based on the guidelines designated in the USMLE Step 2
Clinical Skills Examination.
Note also that you will be performing the history and the physical examination with the mother
in the room. Some of your history will be obtained from the patient himself, with additional
information obtained from his mother.
You are expected to develop three diagnoses with supporting history and physical exam
findings and list the diagnostic workup studies you would order.
You will have time to record your findings and receive feedback.
Health History
Good morning, Devan and Mrs. Williams. Tell me what brings you in today. Test of clinical skills.
Also, keep in mind that you will do the history and physical exam with the mother.
on the table. Some of your history will come from the patient himself, and the rest will come from other sources.
information that he got from his mom.
You have to come up with three diagnoses based on the patient’s history and physical exam.
findings and what tests you would order to figure out what’s wrong.
You’ll have time to write down what you find and get feedback.
History of health
Good morning, Mrs. Williams and Mr. Tell me why you’re here today.
I’m having trouble breathing, and I can’t stop coughing.
You see, Devan has been coughing for 3 to 4 days now. But last night, he couldn’t stop. And I
noticed he was having difficulty catching his breath. I almost brought him to the emergency
room, but we were able to get him through the night.
I am sorry to hear that. And I’m glad you brought him in now.
What preliminary diagnoses are you considering at this time?
Press pause and list your answers. Resume when you are ready to receive feedback.
Asthma.
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Pneumonia.
Viral upper respiratory infection.
Devan, can you or your mom tell me more about this? Please start when you first got sick.
I think my mom better tell you.
[patient coughs]. I can’t remember.
He started about 4 days ago. I didn’t think anything of it….you know, it was just a runny nose
and a mild cough. But last night, he was coughing non-stop.
Does it feel like anything is coming up when you cough? Like from your chest up into your
throat?
Nope. I don’t cough anything up.
Tell me about your breathing.
It feels like I can’t catch my breath. Kind of like when I run too much.
Sometimes he makes a sound when he breathes. He isn’t doing it now, but I heard it last night.
It was loud.
Could you tell whether it was loud when he was breathing in or when he was breathing out?
I didn’t notice. Maybe both but I’m not sure. I thought he was wheezing, but I don’t really know
what wheezing sounds like.
That’s okay. Did it seem like the sound was coming from his nose or his mouth, or was it from
deep in his chest?
Definitely deep in his chest.
You said Devan was also having trouble breathing, although it is better now. Can you tell me
more about what that was like?
He was taking deep breaths, and he looked anxious. His chest was moving in and out. I got
scared!
Did he also mention chest tightness or shortness of breath?
Yes, he was short of breath.
That’s right! My chest felt like it was closing in on me.
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What did you both do?
I tried to give him some cough medicine that I have, but he threw up. I turned on the vaporizer,
but I don’t think that that helped either. I just tried to calm him down. It got better after a
coughing spell. I don’t know if something just loosened up, or what.
Has he had a fever?
Maybe at first, a few days ago. But not in the past day.
Has this type of coughing ever happened before?
Not like this. He coughs a lot at night though. I don’t know if there’s something in his room
making him cough.
Okay. Let me go back a bit and ask questions about whether this type of thing has happened
before. You just said Devan coughs a lot at night. Can you tell me about how often he coughs or
has breathing problems at night? For example, during a typical 2-week period, how many nights
does he cough or have breathing problems that keep him from sleeping or that wake him up?
Oh, I don’t think a week goes by without him coughing in his sleep to the point where he wakes
up. His coughing keeps me up! I think this happens about 2 or 3 nights in a 2-week period.
That is helpful. What about overall? In a typical week, how much would you say Devan’s cough
or breathing problems restrict his usual activities? Would you say: Not at all during a typical
week? Slightly? Moderately, or a lot?
I would say slightly during a typical week. It is usually the cough. But most of the time it isn’t
bad, like it was last night.
Okay, so in a typical week, how often during the day does Devan cough or have breathing
problems?
It is mostly at night, but I would say 2 times a week, on average.
Thanks. I know these questions are hard to answer. Other than his cold, is there anything else
that might have triggered or caused Devan’s breathing problems? For example, is there
anything new in your house? For example, a new pet or something new that you’re doing?
No, there’s nothing new. We don’t have any pets. I was wondering about the rug in his
bedroom, since it is old. But nothing has changed in our home or in his bedroom.
Now I’m going to ask you some specific questions. These questions will help me understand
what is happening.
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Does Devan take any medicines regularly?
No.
Have you ever brought him to the doctor or emergency department before for this type of
thing?
No, never. We just “gut it out.”
Has a doctor or nurse ever said that Devan has asthma?
No, we’ve never heard that.
Does Devan tend to have eczema, or dry skin? Or frequent rashes?
He does have very dry skin! I use lotion on him all the time. And sometimes he has rashes in
patches.
And they really itch!
Does he have allergies?
I think so. During the late summer and fall, he sneezes a lot. I sometimes give him
antihistamines—and they tend to help.
Okay. I asked you about nighttime cough. What about snoring? Does he tend to snore?
Yes he does! Not every night, but sometimes.
What kind of exercise do you get, Devan? Do you play any sports or exercise regularly?
I play soccer. And I bike around a lot.
Does your coughing or breathing limit what you can do?
Yeah, sometimes I cough when I play soccer and I get that chest feeling.
Mrs. Williams, do any diseases run in children, either in your family or in your husband’s family?
Anything like allergies, skin conditions, asthma, or other childhood diseases?
Well, everyone has dry skin in my family. It’s a family thing. My nephew had asthma, but he is
older and he grew out of it. They don’t live nearby, so I didn’t really see it. That’s about all.
Okay, thank you. Tell me about Devan’s birth. Was he full term, or did he arrive early?
He was full term. A big baby, in fact.
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Has Devan had any serious illnesses in the past?
No, he’s been healthy overall.
Does anyone smoke in the house, or does anyone smoke around Devan?
Yes, my husband smokes—but he is down to half a pack a day. And we open the house or car
windows when he is smoking, so I think that helps.
You both have been really helpful in telling me about you, Devan, and what is happening. Let
me summarize. You’ve had a cold for 3 to 4 days, and your cough has been pretty bad,
especially last night when you had trouble breathing. You’ve been healthy all your life except
for eczema or dry skin, and you do tend to cough frequently when you exercise and also at
night. Does that sound right?
Yes!
Is there anything we’ve missed? Anything else important that I should know about?
No, that’s about it.
Let me do a complete physical examination, and then we can talk over what might be going on,
and our next steps. Okay?
Physical Examination
With the patient’s health history in mind, and after good hand hygiene, you are ready for the
physical examination.
What areas of physical examination are important for this patient?
Press pause and list your answers. Resume when you are ready to receive feedback.
Vital signs
Skin
Pharynx (tonsils)
Lungs
Heart
Abdomen
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Your weight is 69 Kg, or 153 pounds. This is at the 97th percentile for boys your age. Your
height is 159 cm or exactly 5 feet 3 inches tall—about an average height for your age. Your
body mass index is 27, which is about the 97th percentile. In other words, it’s high. Your blood
pressure is 120 over 75, which is a bit on the high side but still okay. And your heart rate is 90
beats per minute, which is a bit fast. Your respiratory rate, or your speed of breathing, is about
20 breaths per minute, which is also just a little fast. Your temperature is normal.
Examine the skin on the arms and torso.
Examine the pharynx.
Open your mouth for me nice and wide, stick out your tongue, and say “Ahhh.” Very good.
Next I’m going to do a careful examination of your lungs.
Okay.
Lung examination consists of the following steps:
Inspection.
Chest expansion.
Tactile fremitus.
Percussion.
Auscultation.
Begin with inspection.
First, I am going to watch you breathe. Just breathe normally.
Mrs. Williams, I do see some retractions here when he breathes, just a little bit. Is this normal
for him?
No, it’s not.
The next step in the lung examination is chest expansion.
Now, Devan, take a deep breath [Devan coughs]….
Try instead to take a breath that’s not quite so deep. That’s good. I know that breathing deeply
is hard, and it makes you cough.
Palpate to assess tactile fremitus.
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Devan, I’m going to ask you say the number “99” many times, as I feel your back. Keep saying
99.
99, 99, 99, 99…
This feels normal.
Perform percussion. In children, sometimes using the flat of the hand works better than
percussing with one finger, as is done in adults.
Now, Devan, I want you just to breathe quietly with your mouth open, while I tap on your back
with my hand.
Okay, this all sounds normal.
Perform auscultation in the same manner as for adults.
Devan I’m going to move my stethoscope back and forth across your back as you breathe. I’ll
listen to your sides and chest. Please keep your mouth open as you breathe.
I hear some wheezing noises on both sides of your chest when you breathe out. I also hear a
few rhonchi, or wet noises, when you breathe in—but just a few. I don’t hear something called
rales, or crackles.
Devan, now please just breathe normally and sit quietly while I listen to your heart.
I’ll examine your abdomen. I want first to listen to it, and then I will gently feel it.
Diagnostic Considerations
What are your three diagnostic considerations, in order of priority?
Press pause and list your answers. Resume when you are ready to receive feedback.
This 14-year-old boy most likely has underlying childhood asthma.
A recent viral upper respiratory infection has triggered an exacerbation or flare-up.
His constellation of symptoms includes cough; shortness of breath; and intermittent breathing
problems, particularly last night.
These symptoms, together with his history of intermittent but frequent coughing at night, when
exercising, and with colds all suggest typical childhood asthma.
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The patient’s personal and family history of eczema and allergies also is typical among children
with asthma.
Children who are overweight, especially if obese, have a higher prevalence of asthma than
normal-weight children. Children exposed to tobacco smoke have a higher prevalence of
asthma.
Devan’s physical examination confirms childhood asthma as the most likely diagnosis. He has a
normal respiratory rate but a prolonged inspiration/expiration ratio with expiration longer than
normal. Lung examination reveals good expansion and no abnormalities or tactile fremitus or
on n percussion. However, he exhibits both bilateral expiratory wheezes and slightly increased
work of breathing using accessory muscles.
This patient exhibits several other abnormalities on physical examination suggestive of typical
comorbid conditions that often accompany childhood asthma. These include the following:
Elevated body mass index at the 97th percentile, which signifies obesity.
Upper respiratory signs of congestion consistent with viral infection, a common trigger of
asthma exacerbations in children.
Large tonsils, which reflect tonsillar hyperplasia that can accompany obesity.
Devan’s large tonsils are likely a hint for adenoidal hyperplasia, which may be causing his
snoring. Patches of eczema, which tend to occur in children with allergies and may predispose
them to asthma via allergy-mediated pathways.
The diagnosis of asthma rests primarily on the history and physical examination rather than on
laboratory tests. The diagnosis can be further supported by demonstration of airflow
obstruction using peak flow meters or spirometry, demonstration that the symptoms are
reversible (e.g., by using bronchodilator treatment during an acute exacerbation), and exclusion
of other likely diagnoses. There are dozens of causes of wheezing in childhood, and a judicious,
careful history and physical examination (without laboratory tests) will generally rule out most
other causes.
The patient’s respiratory symptoms and history of fever suggest the possibility of bacterial
pneumonia, specifically community-acquired pneumonia.
The combination of fever, cough, and shortness of breath would increase the likelihood of
pneumonia.
Bacterial pneumonia in children typically presents with a triad of signs and symptoms:
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High fever.
Cough.
Tachypnea.
Physical examination often reveals tachycardia, work of breathing, and unilateral lung
abnormalities such as abnormal fremitus, dullness, and rales. Other than a cough, Devan did
not have any of these signs or symptoms.
It is critical to rule out the diagnosis of bacterial pneumonia because of the potential for
progression and the need for rapid administration of antibiotics.
Atypical pneumonia, generally from Mycoplasma pneumoniae or a Bordetella pertussis, is more
indolent, with less severe symptoms and signs. Lung findings are bilateral and generally involve
inspiratory rhonchi or crackles, without expiratory wheezing.
Atypical pneumonia is often missed, and many patients do not seek medical attention.
Lack of tachypnea excludes a diagnosis of bacterial pneumonia. On physical examination, lack of
tachypnea and presence of prolonged inspiration/expiration ratio are very helpful to point
toward the diagnosis of asthma.
Viral pneumonia tends to be less severe than bacterial pneumonia. Patients present with upper
respiratory symptoms with accompanying cough. Physical examination may reveal increased
work of breathing, tachypnea, and bilateral lung findings.
The common cold, or viral upper respiratory infection, is the most common physical illness in
childhood. Viral upper respiratory infections tend to have a constellation of symptoms. These
include:
Nasal congestion and runny nose.
Cough.
Fever.
Sore throat.
And sometimes headache.
Typically, fever and sore throat occur during the first several days of an upper respiratory
infection. Nasal congestion lasts several more days, and cough may persist for many additional
days.
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Associated conditions include otitis media and lower tract infections such as viral pneumonia or
bronchiolitis. Asthma in children is often triggered by a viral upper respiratory infection, so they
often co-exist. With viral upper respiratory infection, school-aged children do not have
respiratory distress or increased work of breathing.
Diagnostic Workup
List three next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
Pulse oximetry.
Several diagnostic tests should be considered, although the astute clinician is likely to perform
pulse oximetry as the only diagnostic study.
Bedside pulse oximetry is readily available to test for oxygen saturation. In most cases of mild
asthma exacerbations, as in this patient, oxygen saturation is normal
Chest radiograph.
Seasoned clinicians usually will not obtain a chest radiograph in a patient with mild asthma
exacerbations. High fever, tachypnea, and crackles might indicate the need for a chest
radiograph to identify consolidation that would be suggestive of a bacterial pneumonia.
In this case, the relatively mild symptoms, absence of fever and tachypnea, presence of
bilateral wheezing, and absence of rales all make bacterial pneumonia highly unlikely.
Although chest radiographs in childhood asthma often reveal minor abnormalities such as
streaking or increased air trapping, these findings do not generally Help in management.
Peak flow meter.
Peak expiratory flow rate can be obtained in the office using hand-held peak flow meters.
Multiple readings usually are necessary to identify a patient’s baseline measurement and assess
pulmonary function. Patient cooperation is required.
Peak flow meters are generally used to monitor pulmonary function for chronic asthma. They
are not for acute asthma management. This test is described here because of its utility in
managing chronic asthma of childhood.
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Summary
In summary, this 14-year-old boy presents with respiratory symptoms triggered by a viral upper
respiratory infection.
His cough; shortness of breath; intermittent breathing problems; and frequent coughing at
night or with exercise all suggest typical childhood asthma.
His physical examination is positive for prolonged inspiratory to expiratory ratio as well as
bilateral expiratory wheezes and slightly increased work of breathing. His history and physical
examination are consistent with chronic mild persistent asthma and an acute asthma
exacerbation. Physical examination is also remarkable for obesity and eczematous patches.
These comorbid conditions commonly accompany childhood asthma.
Diagnoses include asthma, bacterial pneumonia and viral upper respiratory infection.
Possible diagnostic studies include:
Pulse oximetry.
Chest radiograph.
Peak flow meter or spirometry testing, once the acute exacerbation has resolved.
However, this condition is best managed by a careful history and physical examination, with at
most pulse oximetry for laboratory testing.
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