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Posted: September 28th, 2022

You are seeing a 14-year-old boy

Copyright © 2018 Wolters Kluwer. All rights reserved. Web page 1
BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 12: Little one and Adolescent Bronchial asthma
This video is designed to Help put together you for goal structured scientific examinations, or
OSCEs.
You are seeing a 14-year-old boy and his mom in an pressing care setting. The boy’s chief
criticism is issue respiratory. As you watch this encounter, you’ll be requested to reply
questions whereas the picture on the display screen freezes. These questions will have interaction you in practising
the talents of targeted historical past taking, bodily examination, and scientific reasoning as you develop
your preliminary differential prognosis, primarily based on the rules designated within the USMLE Step 2
Medical Abilities Examination.
Notice additionally that you’ll be performing the historical past and the bodily examination with the mom
within the room. A few of your historical past can be obtained from the affected person himself, with extra
info obtained from his mom.
You are anticipated to develop three diagnoses with supporting historical past and bodily examination
findings and record the diagnostic workup research you’d order.
You can have time to report your findings and obtain suggestions.
Well being Historical past
Good morning, Devan and Mrs. Williams. Inform me what brings you in right now. Check of scientific abilities.
Additionally, needless to say you’ll do the historical past and bodily examination with the mom.
on the desk. A few of your historical past will come from the affected person himself, and the remaining will come from different sources.
info that he received from his mother.
You need to give you three diagnoses primarily based on the affected person’s historical past and bodily examination.
findings and what exams you’d order to determine what’s incorrect.
You’ll have time to put in writing down what you discover and get suggestions.
Historical past of well being
Good morning, Mrs. Williams and Mr. Inform me why you are right here right now.
I’m having hassle respiratory, and I can’t cease coughing.
You see, Devan has been coughing for three to four days now. However final evening, he couldn’t cease. And I
seen he was having issue catching his breath. I nearly introduced him to the emergency
room, however we had been capable of get him by way of the evening.
I’m sorry to listen to that. And I’m glad you introduced him in now.
What preliminary diagnoses are you contemplating at the moment?
Press pause and record your solutions. Resume whenever you are able to obtain suggestions.
Bronchial asthma.
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Pneumonia.
Viral higher respiratory an infection.
Devan, are you able to or your mother inform me extra about this? Please begin whenever you first received sick.
I believe my mother higher inform you.
[patient coughs]. I can’t bear in mind.
He began about four days in the past. I didn’t suppose something of it….you already know, it was simply a runny nostril
and a gentle cough. However final evening, he was coughing continuous.
Does it really feel like something is arising whenever you cough? Like out of your chest up into your
throat?
Nope. I don’t cough something up.
Inform me about your respiratory.
It seems like I can’t catch my breath. Sort of like once I run an excessive amount of.
Generally he makes a sound when he breathes. He isn’t doing it now, however I heard it final evening.
It was loud.
Might you inform whether or not it was loud when he was inhaling or when he was respiratory out?
I didn’t discover. Perhaps each however I’m undecided. I believed he was wheezing, however I don’t actually know
what wheezing appears like.
That’s okay. Did it seem to be the sound was coming from his nostril or his mouth, or was it from
deep in his chest?
Undoubtedly deep in his chest.
You mentioned Devan was additionally having hassle respiratory, though it’s higher now. Are you able to inform me
extra about what that was like?
He was taking deep breaths, and he seemed anxious. His chest was transferring out and in. I received
scared!
Did he additionally point out chest tightness or shortness of breath?
Sure, he was wanting breath.
That’s proper! My chest felt prefer it was closing in on me.
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What did you each do?
I attempted to offer him some cough medication that I’ve, however he threw up. I turned on the vaporizer,
however I don’t suppose that that helped both. I simply tried to calm him down. It received higher after a
coughing spell. I don’t know if one thing simply loosened up, or what.
Has he had a fever?
Perhaps at first, a few days in the past. However not previously day.
Has this sort of coughing ever occurred earlier than?
Not like this. He coughs a lot at evening although. I don’t know if there’s one thing in his room
making him cough.
Okay. Let me return a bit and ask questions on whether or not this sort of factor has occurred
earlier than. You simply mentioned Devan coughs a lot at evening. Are you able to inform me about how typically he coughs or
has respiratory issues at evening? For instance, throughout a typical 2-week interval, what number of nights
does he cough or have respiratory issues that preserve him from sleeping or that wake him up?
Oh, I don’t suppose a week goes by with out him coughing in his sleep to the purpose the place he wakes
up. His coughing retains me up! I believe this occurs about 2 or three nights in a 2-week interval.
That’s useful. What about total? In a typical week, how a lot would you say Devan’s cough
or respiratory issues limit his normal actions? Would you say: In no way throughout a typical
week? Barely? Reasonably, or a lot?
I’d say barely throughout a typical week. It’s often the cough. However more often than not it isn’t
dangerous, prefer it was final evening.
Okay, so in a typical week, how typically through the day does Devan cough or have respiratory
issues?
It’s largely at evening, however I’d say 2 instances a week, on common.
Thanks. I do know these questions are laborious to reply. Aside from his chilly, is there the rest
which may have triggered or precipitated Devan’s respiratory issues? For instance, is there
something new in your own home? For instance, a new pet or one thing new that you just’re doing?
No, there’s nothing new. We don’t have any pets. I used to be questioning concerning the rug in his
bed room, since it’s previous. However nothing has modified in our residence or in his bed room.
Now I’m going to ask you some particular questions. These questions will Help me perceive
what is going on.
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Does Devan take any medicines recurrently?
No.
Have you ever ever introduced him to the physician or emergency division earlier than for this sort of
factor?
No, by no means. We simply “intestine it out.”
Has a physician or nurse ever mentioned that Devan has bronchial asthma?
No, we’ve by no means heard that.
Does Devan are inclined to have eczema, or dry pores and skin? Or frequent rashes?
He does have very dry pores and skin! I take advantage of lotion on him on a regular basis. And generally he has rashes in
patches.
They usually actually itch!
Does he have allergic reactions?
I believe so. Through the late summer season and fall, he sneezes a lot. I generally give him
antihistamines—and so they have a tendency to Help.
Okay. I requested you about nighttime cough. What about loud night breathing? Does he are inclined to snore?
Sure he does! Not each evening, however generally.
What sort of train do you get, Devan? Do you play any sports activities or train recurrently?
I play soccer. And I bike round a lot.
Does your coughing or respiratory restrict what you are able to do?
Yeah, generally I cough once I play soccer and I get that chest feeling.
Mrs. Williams, do any ailments run in youngsters, both in your loved ones or in your husband’s household?
Something like allergic reactions, pores and skin circumstances, bronchial asthma, or different childhood ailments?
Effectively, everybody has dry pores and skin in my household. It’s a household factor. My nephew had bronchial asthma, however he’s
older and he grew out of it. They don’t stay close by, so I didn’t actually see it. That’s about all.
Okay, thanks. Inform me about Devan’s delivery. Was he full time period, or did he arrive early?
He was full time period. A giant child, in reality.
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Has Devan had any critical sicknesses previously?
No, he’s been wholesome total.
Does anybody smoke in the home, or does anybody smoke round Devan?
Sure, my husband smokes—however he’s right down to half a pack a day. And we open the home or automobile
home windows when he’s smoking, so I believe that helps.
You each have been actually useful in telling me about you, Devan, and what’s taking place. Let
me summarize. You’ve had a chilly for three to four days, and your cough has been fairly dangerous,
particularly final evening whenever you had hassle respiratory. You’ve been wholesome all of your life besides
for eczema or dry pores and skin, and also you do are inclined to cough ceaselessly whenever you train and likewise at
evening. Does that sound correct?
Sure!
Is there something we’ve missed? Anything vital that I ought to find out about?
No, that’s about it.
Let me do a full bodily examination, after which we will speak over what could be occurring,
and our subsequent steps. Okay?
Bodily Examination
With the affected person’s well being historical past in thoughts, and after good hand hygiene, you are prepared for the
bodily examination.
What areas of bodily examination are vital for this affected person?
Press pause and record your solutions. Resume whenever you are able to obtain suggestions.
Very important indicators
Pores and skin
Pharynx (tonsils)
Lungs
Coronary heart
Stomach
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Your weight is 69 Kg, or 153 kilos. That is on the 97th percentile for boys your age. Your
peak is 159 cm or precisely 5 ft three inches tall—about a mean peak to your age. Your
physique mass index is 27, which is concerning the 97th percentile. In different phrases, it’s excessive. Your blood
strain is 120 over 75, which is a bit on the excessive facet however nonetheless okay. And your coronary heart price is 90
beats per minute, which is a bit quick. Your respiratory price, or your pace of respiratory, is about
20 breaths per minute, which can be simply a little quick. Your temperature is regular.
Look at the pores and skin on the arms and torso.
Look at the pharynx.
Open your mouth for me good and vast, stick out your tongue, and say “Ahhh.” Excellent.
Subsequent I’m going to do a cautious examination of your lungs.
Okay.
Lung examination consists of the next steps:
Inspection.
Chest enlargement.
Tactile fremitus.
Percussion.
Auscultation.
Start with inspection.
First, I’m going to look at you breathe. Simply breathe usually.
Mrs. Williams, I do see some retractions right here when he breathes, simply a little bit. Is that this regular
for him?
No, it’s not.
The subsequent step within the lung examination is chest enlargement.
Now, Devan, take a deep breath [Devan coughs]….
Attempt as an alternative to take a breath that’s not fairly so deep. That’s good. I do know that respiratory deeply
is difficult, and it makes you cough.
Palpate to evaluate tactile fremitus.
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Devan, I’m going to ask you say the quantity “99” many instances, as I really feel your again. Maintain saying
99.
99, 99, 99, 99…
This feels regular.
Carry out percussion. In youngsters, generally utilizing the flat of the hand works higher than
percussing with one finger, as is finished in adults.
Now, Devan, I need you simply to breathe quietly together with your mouth open, whereas I faucet in your again
with my hand.
Okay, this all sounds regular.
Carry out auscultation in the identical method as for adults.
Devan I’m going to maneuver my stethoscope backwards and forwards throughout your again as you breathe. I’ll
take heed to your sides and chest. Please preserve your mouth open as you breathe.
I hear some wheezing noises on either side of your chest whenever you breathe out. I additionally hear a
few rhonchi, or moist noises, whenever you breathe in—but simply a few. I don’t hear one thing referred to as
rales, or crackles.
Devan, now please simply breathe usually and sit quietly whereas I take heed to your coronary heart.
I’ll look at your stomach. I need first to take heed to it, after which I’ll gently really feel it.
Diagnostic Concerns
What are your three diagnostic issues, so as of precedence?
Press pause and record your solutions. Resume whenever you are able to obtain suggestions.
This 14-year-old boy most definitely has underlying childhood bronchial asthma.
A latest viral higher respiratory an infection has triggered an exacerbation or flare-up.
His constellation of signs consists of cough; shortness of breath; and intermittent respiratory
issues, significantly final evening.
These signs, collectively along with his historical past of intermittent however frequent coughing at evening, when
exercising, and with colds all counsel typical childhood bronchial asthma.
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The affected person’s private and household historical past of eczema and allergic reactions is also typical amongst youngsters
with bronchial asthma.
Youngsters who are chubby, particularly if overweight, have a larger prevalence of bronchial asthma than
normal-weight youngsters. Youngsters uncovered to tobacco smoke have a larger prevalence of
bronchial asthma.
Devan’s bodily examination confirms childhood bronchial asthma because the most definitely prognosis. He has a
regular respiratory price however a extended inspiration/expiration ratio with expiration longer than
regular. Lung examination reveals good enlargement and no abnormalities or tactile fremitus or
on n percussion. Nonetheless, he displays each bilateral expiratory wheezes and barely elevated
work of respiratory utilizing accent muscle tissue.
This affected person displays a number of different abnormalities on bodily examination suggestive of typical
comorbid circumstances that usually accompany childhood bronchial asthma. These embody the next:
Elevated physique mass index on the 97th percentile, which signifies weight problems.
Higher respiratory indicators of congestion in step with viral an infection, a widespread set off of
bronchial asthma exacerbations in youngsters.
Giant tonsils, which mirror tonsillar hyperplasia that may accompany weight problems.
Devan’s giant tonsils are seemingly a trace for adenoidal hyperplasia, which can be inflicting his
loud night breathing. Patches of eczema, which are inclined to happen in youngsters with allergic reactions and will predispose
them to bronchial asthma through allergy-mediated pathways.
The prognosis of bronchial asthma rests totally on the historical past and bodily examination slightly than on
laboratory exams. The prognosis might be additional supported by demonstration of airflow
obstruction utilizing peak stream meters or spirometry, demonstration that the signs are
reversible (e.g., by utilizing bronchodilator therapy throughout an acute exacerbation), and exclusion
of different seemingly diagnoses. There are dozens of causes of wheezing in childhood, and a even handed,
cautious historical past and bodily examination (with out laboratory exams) will usually rule out most
different causes.
The affected person’s respiratory signs and historical past of fever counsel the opportunity of bacterial
pneumonia, particularly community-acquired pneumonia.
The mixture of fever, cough, and shortness of breath would improve the probability of
pneumonia.
Bacterial pneumonia in youngsters sometimes presents with a triad of indicators and signs:
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Excessive fever.
Cough.
Tachypnea.
Bodily examination typically reveals tachycardia, work of respiratory, and unilateral lung
abnormalities reminiscent of irregular fremitus, dullness, and rales. Aside from a cough, Devan did
not have any of those indicators or signs.
It’s vital to rule out the prognosis of bacterial pneumonia due to the potential for
development and the necessity for fast administration of antibiotics.
Atypical pneumonia, usually from Mycoplasma pneumoniae or a Bordetella pertussis, is extra
indolent, with much less extreme signs and indicators. Lung findings are bilateral and customarily contain
inspiratory rhonchi or crackles, with out expiratory wheezing.
Atypical pneumonia is commonly missed, and plenty of sufferers don’t search medical consideration.
Lack of tachypnea excludes a prognosis of bacterial pneumonia. On bodily examination, lack of
tachypnea and presence of extended inspiration/expiration ratio are very useful to level
towards the prognosis of bronchial asthma.
Viral pneumonia tends to be much less extreme than bacterial pneumonia. Sufferers current with higher
respiratory signs with accompanying cough. Bodily examination might reveal elevated
work of respiratory, tachypnea, and bilateral lung findings.
The widespread chilly, or viral higher respiratory an infection, is the most typical bodily sickness in
childhood. Viral higher respiratory infections are inclined to have a constellation of signs. These
embody:
Nasal congestion and runny nostril.
Cough.
Fever.
Sore throat.
And generally headache.
Sometimes, fever and sore throat happen through the first a number of days of an higher respiratory
an infection. Nasal congestion lasts a number of extra days, and cough might persist for a lot of extra
days.
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Related circumstances embody otitis media and decrease tract infections reminiscent of viral pneumonia or
bronchiolitis. Bronchial asthma in youngsters is commonly triggered by a viral higher respiratory an infection, so that they
typically co-exist. With viral higher respiratory an infection, school-aged youngsters wouldn’t have
respiratory misery or elevated work of respiratory.
Diagnostic Workup
Checklist three subsequent steps in your diagnostic workup.
Press pause and record your solutions. Resume whenever you are able to obtain suggestions.
Pulse oximetry.
A number of diagnostic exams ought to be thought of, though the astute clinician is more likely to carry out
pulse oximetry as the one diagnostic examine.
Bedside pulse oximetry is available to check for oxygen saturation. Usually of gentle
bronchial asthma exacerbations, as on this affected person, oxygen saturation is regular
Chest radiograph.
Seasoned clinicians often is not going to get hold of a chest radiograph in a affected person with gentle bronchial asthma
exacerbations. Excessive fever, tachypnea, and crackles may point out the necessity for a chest
radiograph to determine consolidation that will be suggestive of a bacterial pneumonia.
On this case, the comparatively gentle signs, absence of fever and tachypnea, presence of
bilateral wheezing, and absence of rales all make bacterial pneumonia extremely unlikely.
Though chest radiographs in childhood bronchial asthma typically reveal minor abnormalities reminiscent of
streaking or elevated air trapping, these findings don’t usually help in administration.
Peak stream meter.
Peak expiratory stream price might be obtained within the workplace utilizing hand-held peak stream meters.
A number of readings often are essential to determine a affected person’s baseline measurement and assess
pulmonary operate. Affected person cooperation is required.
Peak stream meters are usually used to watch pulmonary operate for continual bronchial asthma. They
are not for acute bronchial asthma administration. This take a look at is described right here due to its utility in
managing continual bronchial asthma of childhood.
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Abstract
In abstract, this 14-year-old boy presents with respiratory signs triggered by a viral higher
respiratory an infection.
His cough; shortness of breath; intermittent respiratory issues; and frequent coughing at
evening or with train all counsel typical childhood bronchial asthma.
His bodily examination is constructive for extended inspiratory to expiratory ratio in addition to
bilateral expiratory wheezes and barely elevated work of respiratory. His historical past and bodily
examination are in step with continual gentle persistent bronchial asthma and an acute bronchial asthma
exacerbation. Bodily examination can be exceptional for weight problems and eczematous patches.
These comorbid circumstances generally accompany childhood bronchial asthma.
Diagnoses embody bronchial asthma, bacterial pneumonia and viral higher respiratory an infection.
Doable diagnostic research embody:
Pulse oximetry.
Chest radiograph.
Peak stream meter or spirometry testing, as soon as the acute exacerbation has resolved.
Nonetheless, this situation is greatest managed by a cautious historical past and bodily examination, with at
most pulse oximetry for laboratory testing.
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