OSCE 12: Child and Adolescent Asthma Bates’ Visual Guide To Physical Examination

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.

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.

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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:

 Child and Adolescent Asthma video transcripts

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.

 Child and Adolescent Asthma video transcripts

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 assist 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.

 Child and Adolescent Asthma video transcripts

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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