Asthma Flashcards
3 year old presented with cough and breatlessness. There is a history
of similar symptoms in the other siblings when they were at the same
age. Take a focused history from the patient
Grip
BIODATA (NASORATI)
Name: what is this child’s name?
Age: now old is ne
Sex: please can you confirm if this is a male or female?
Occupation. what class is This child me
Religion: what religion does his parents practice?
Address. where do the parents caregiver live
Tribe: what tribe are the parents
Informant what is your relationshin to this child?
First C: Presenting Complain
I Can see here that you are complaining about cough and breathlessness in your child is that correct?
which one started first?
second c: course DOCTOR)
cough
Duration: how long has this been going on?
Onset : how did it start? Was it sudden or gradual
course: since it started has it gotten worse or better or remained the same
Character: Is the cough barky? Is it a dry cough or does it produce
sputum..
If it produces sputum; is it whitish or yellowish, does it contain blood, is it foul smelling,
does the cough start or worsen at any time of the day
Other symptoms. any post cough vomiting, any chest pain
Related phenomena: any fever, any reduced appetite
Breathlessness (doctor)
Duration: how long have you noticed this
Onset: how did it start? was it sudden or gradual?
Course: since it started has it worsen, gotten better or remained the same
it is present at all times of the day , or does it worsen at any particular time
Other: do you notice him breathing through his mouth
Do you hear any whistling sound when he breathes?
Related: has he become increasingly tired.
Is he always sleepy
Causes
Family history : was there ween any history of asthma on the father or mother’s side
2 Atopy : has this child had any history of recurrent skin rash and runny
nose or itchy ears
3) Triggers: was this child recently exposed to dust , pollen or feathers
4 Exercise trigger: has he been participating excessively in an exercise
5 Emotional trigger: has your child gone through any emotional stress
6 tuberculosis: in addition to this symptoms have you notice any fever
and drenching nignt sweats
7) Heart failure/disease: are there times when he wakes up suddenly and out of breath, or have you noticed difficulty breathing when he lies down flat
heart failure : together with this cough have you noticed any swelling of the legs
9) Malignancy : has been any weight loss . Loss of appetite and easy
Tatigue
fourth C: Complication
1)Pneumonia: since this symptom appeared, have you noticed sputum becoming more greenish
2)Has there been any loss of consciousness r /o poor oxygen saturation
3) have vou notice that this child is unable to complete his sentences
Has he been too weak to walk
Have you noticed that the medications that were initially effective for
his refleve are longer eftective (exacerbation of asthma)
Care so far
What have vou done so far concerning this situation
Have you visited any prayer house , pharmacy or hospital?
Have you done any investigation? Full blood count, chest ray. sputum analysis
Have you taken any medication?
Pregnancy history prenatal/natal and postnatal
SO what this pregnancy booked for antenatal
Did you have any infections during your pregnancy
was the delivery at term
Was the delivery via vaginal or caesarean section
If vaginal, was it spontaneous or induced
Was there any use of instruments
DId he cry immediately after birth?
How long did the baby stay in the hospital before he was discharged
Nutritional History
DId you give your child breast milk only for the first 6 months
When did you introduce other foods
Frequency how many times does he eat in a day ?
Adequacy- does he finish his and ask for more
Density: does his meal contain all the classes of food in the right
Proportion.
Utility: do you think vour child is growing well?
Immunization History
Has he received all his vaccines for his age
Do you have your vaccination card? can I see it?
Did he have any reaction to the vaccine?
Developmental History
When did he start smiling
when was he able to hold his head on his own
When did he start sitting without support
when did he start crawling walking
How is his performance at school
How does he sociallze with his colleagues
Past medical history
Any history of similar condition in the past
Any history of chronic illnesses like epilepsy, asthma, diabetes, sickle cell diseases
Any previous blood transfusion, surgery or hospitalization in the past.. if yes.. Why?
Family history
How man wives does your husband have
How many children do you have
How many boys and girls
what is his position in the family
Any similar illness in the family
Any history of chronic illnesses like hypertension, epilepsy, asthma
Diabetes , sickle cell disease _ HEADs
Social history
Where do you live
what is your source of water supply
Who prepares the child’s meal
How do you store your food ?
How do you dispose your waste
what kind of toilet do you use
What is the size of the rooms and how many occupants in each room
what do you and your husband do for a living : how much do you earn
what is your highest level of education
Drug history
is your chid on any long term gedication
Is your child on any current medication
Does your cnild nave any drug allergy
is your chid on any long term gedication
Is your child on any current medication
Does your cnild have any drug allergy
Review of system
Ma, just to be sure we covered all the symptoms , I would like you to
Answer yes or no to the following questions
CNS: has your child complained of any headache. has there been any seizure or loss of consciousness
Endo: any excessive sweating., weight loss or weight gain
Respiratory: chest pain, fast breathing
Cardiovascular: couch. palpitations. bluish discoloration of lips
Digestive: constipation, diarrhea, nausea, vomiting
Genitourinary: painful urination, reduced urination
Musculoskeletal: joint pain, joint stiffness, bone pain
