Respiratory Common Cases

Respiratory Common Cases

 1. Asthma

Asthma is a common chronic inflammatory disease of the airways and is characterised by reversible airflow obstruction and bronchospasm.

Signs to look out for:

- Inhalers and/or peak flow meter around the child.

- On general inspection, patient may have signs of chronic lung condition including pectus carinatum or Harrison sulcus. Patient may also be using accessory muscles to breathe.

- On auscultation, patient may have bilateral expiratory wheeze. However, do bear in mind that the child may be asymptomatic when you see them and thus his/her chest may be clear on auscultation.

How to score the marks:

Respiratory examination may take a long time so be mindful of your time. Practise well to make sure that you are able to complete your examination before the first ring of the bell so that you have time to present as well as for the examiner to ask you questions.

In order to score as much points as you go along, comment about the things around the child (e.g. inhalers), and whether the child is in respiratory distress. Appear confident when you perform the examination.

Once you complete the examination, present your findings, and give your differential diagnosis. In a younger child, the child may just be having a viral induced wheeze so you may also list that as your differential diagnosis.

Read British Thoracic Society (BTS) guidelines on management of asthma as you may be questioned on it.

Exam Vignette

I examined John, a 10-year-old boy who looks well-grown for his age and I would like to plot his height and weight on a growth chart. He is pink and not in respiratory distress. There is a salbutamol inhaler and clenil modulate inhaler next to his bedside. There are no dysmorphic features or finger clubbing. There are no scars on his chest. He has mild bilateral expiratory wheeze on auscultation. My differential diagnosis includes asthma.

I would like to complete my examination by testing John’s peak flow and measuring his oxygen saturations.

 

 2. Cystic Fibrosis

 Cystic fibrosis is an autosomal recessive disorder that is caused by mutations in the gene for the protein cystic fibrosis transmembrane conductance regulator, which is involved in the production of sweat, digestive fluid and mucous. It affects the lungs, pancreas, liver, kidneys and intestine. It is diagnosed by a sweat test and genetic testing. In some areas of the world, newborns are screened for CF by measuring for raised blood concentration of immunoreactive trypsinogen. Infants with abnormal newborn screen will need a sweat test to confirm the diagnosis of cystic fibrosis.

Signs to look out for:

-Creon, sputum pot, oxygen masks, antibiotic nebulisers nutritional drinks around the bed.

- On general inspection, patient may look thin. They may have a Portacath (for antibiotic administration) and/or percutaneous gastrostomy (for nutrition) in situ.

- Clubbing, cyanosis, use of accessory muscles may be present.

- On auscultations, there may be bilateral crepitations and/or crepitations.

How to score the marks:

Comment on the things (creon, sputum pot) around the patient during general inspection.

Once you complete the examination, present your findings.

Exam Vignette

I examined Mary, a 13-year-old girl who looks thin for her age and I would like to plot her height and weight on a growth chart. She appears cyanotic and has some increase work of breathing including use of accessory muscles and mild intercostal recession. There is a bottle of creon next to her bedside. She has finger clubbing. She also has Portacath and percutaneous gastrostomy in situ. She has bilateral expiratory crepitations and wheeze on auscultation. My differential diagnosis include cystic fibrosis.

I would like to complete my examination by measuring Mary’s oxygen saturations and examining her sputum pot.

 

3. Chronic Lung Disease

Also known as bronchopulmonary dysplasia, chronic lung disease affects primarily ex-preterm babies. These babies required mechanical ventilation during the neonatal period and needed oxygen supplementation or CPAP at 36 weeks postmenstrual age or 56 days of postnatal days.

Signs to look out for:

-Nasal cannula oxygen with a portable oxygen tank

-Patient may be on a wheelchair if he/she also has cerebral palsy

-Chest may be clear, or the patient may have wheeze / crepitations if he has concurrent respiratory infections

 How to score the marks:

Comment on the things (nasal cannulae, oxygen tank) around the patient during general inspection. Comment on the obvious, e.g. wheelchair, percutaneous gastrostomy button.

Once you complete the examination, present your findings.

Exam Vignette

I examined Tom, a 1-year-old boy who looks well-grown for his age and I would like to plot his height and weight on a growth chart. He is sitting in a wheelchair and is on nasal cannulae oxygen with his oxygen tank in his wheelchair. He appears pink and has mild intercostal recession. Tom has some drooling and has increased tone both upper and lower limbs. He has percutaneous gastrostomy in situ. He has bilateral expiratory wheeze on auscultation. My differential diagnosis includes chronic lung disease in an ex-preterm baby with quadriplegic cerebral palsy.

 I would like to complete my examination by measuring Tom’s oxygen saturations.

 

4. Thoracotomy Scar

You may be presented with a child with thoracotomy scar and no other signs. The approach should be the same – systematic respiratory examination, present your findings and come up with differential diagnosis.

The reasons for thoracotomy include:

-Empyema

-Bronchiectasis

-Congenital cystic adenomatoid malformation of the lungs

-Cardiovascular causes

-Operation on the sympathetic trunk

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