Bronchial Asthma: Long Case

CONTENTS

1. History
2. Examination
3. Summary
4. List of problems
5. Management plan
6. Possible questions that could be ask during the discussion 

Bronchial asthma is one of the commonest long case topics. It is more commonly given in Paediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management.  First, a proper history should be taken.

HISTORY

• Introduction of the patient
• Name
• Sex
• Age
• From
• Occupation
• History is taken from .................... who is educated up to .................. and the history is reliable
• Presenting Complain

Patients often presents with difficulty in breathing with wheezing and cough. In pediatrics, the mother knows the diagnosis of asthma, so you can straightly start by saying that the child is a diagnosed patient with asthma, but still you will have to analyze the presenting symptoms to exclude other differential diagnosis.

History of Presenting Complaint

In a pediatric history with a chronic disease like bronchial asthma, it is better to start from the beginning of the illness and tell the story up to now. So, start by describing the initial attack of bronchial asthma, how it was diagnosed and what was done briefly. Then information should be gathered to identify the severity and control of asthma before this episode. The control and severity of asthma is summarized in the following table.

	Day time symptoms	Night time symptoms	PEF	PEF Variability	FEV1
Intermittent	<1 week	<=2/ month	>=80%	<=20%	>=80%
Mild	>1 week	>2 /month	>=80%	20-30%	>=80%
Moderate	Daily	>1/week	60-79%	>30%	60-79%
Severe	Daily	Frequently	<60%	>30%	<60%

According to the table, you should ask about the day time and night time symptoms with their frequency.    Describe about the sleep at night. Some may only have nocturnal cough. When assessing the severity, the frequency of hospital admissions, ICU care and life threatening attacks should be mentioned.

Then the exercise tolerance of the child should be inquired. Quantify the exercise tolerance by the type of physical activity which the child is involved in. If his illness has limited his participation in a certain kind of activity, it should be mentioned. If he is engaged in any kind of vigorous exercise, it should be mentioned whether it provokes any symptoms.

Drug compliance should be inquired. Then the response to treatment and their complications should be described. Children on steroids will have side effects of steroids such as,

• slowed growth
• Weight gain 
• Thin skin
• Hyperactivity
• Gastritis

After describing the illness up to now, describe the present attack,. Patients with bronchial asthma could present with,

• Exacerbation of bronchial asthma
• Infective exacerbation of bronchial asthma

The severity of asthma attack could be

• mild
• moderate 
• severe

The history should be targeted to find out the etiology of exacerbation and the severity of exacerbation. If the child is having an infective exacerbation, he will have fever, rhinorrhea, productive cough with yellowish sputum etc. Exposure to cold air could also aggravate the symptoms. Sometimes, the exacerbation may have resulted from an exposure to some substance such as dust, house dust mites, cockroaches, mosquito coils, and out door allergens (pollen, fungal mould, chemical irritants, fumes).  Sometimes, asthma can be induced by exercise (exercise induced asthma). Allergic foods such as brinjal, prawn, crabs and cow milk and drugs such as beta blockers, NSAIDs (Non Steroidal Anti-inflammatory Drugs) and aspirin are also responsible agents. 

Other differential diagnosis should be excluded before confirming this attack as an exacerbation of bronchial asthma. They are,

• Bronchiactasis - Presence of copious amounts of productive cough
• Bronchiolitis - very young age (less than 1 year)
• Topical pulmonary eosinophilia
• Gastro-esophageal reflux disease - Past history of regurgitation, burning sensation of upper abdomen
• H type tracheo-bronchial fistula - Respiratory illness since birth
• Foreign body - History of ingestion of a foreign body
• Cystic fibrosis
• Mediastinal mass

Also mention about the ward management done so far according to the mother.

Birth History

Immunization History

Past Medical History

• past history of eczema, urticaria,  hay fever, allergic rhinitis, allergic conjunctivitis

Past Surgical History

Allergies

Drug History

Mention if the child is on any other drugs.

Family History

Many children with bronchial asthma often have a family history of atopy (asthma, eczema, allergies etc.)

Social and Environmental History

Social and environmental history is one of the most important parts of the history. A detailed social and environmental history should be taken. 

• The child lives with ............
• His parents are educated up to...............
• Description of the house (number of rooms, ventilation, dusty area or not, cleanliness, moping or sweeping, presence of furry objects, cushions, leaking roof, kitchen etc)
• Usage of mosquito coils
• Passive smoking
• Smoking coming from the kitchen
• Bed room, bed linen
• Pets
• Distance to hospital
• Availability of transportation - important in case of an emergency
• Income of the caretakers
• Other children 
• Difficulties in taking care of the child
• Care taker's understanding regarding the illness

EXAMINATION

General Examination

General examination of a patient with bronchial asthma may not reveal many signs, but look carefully for the following features.

• Height and weight of the child - height and weight gives an idea about the growth of the child. Children on steroids are at a risk of growth retardation. You will have to plot the height and weight on a growth chart and comment on the adequacy. 
• General appearance
• Cyanosis
• Dyspnoec
• Presence wheezing sounds
• Other routine general examination findings such as pallor
• BCG vaccination scar - this is one of the most important signs that you should look for
• Lymphadenopathy
• Signs of skin rash or eczema
• Clubbing - Cystic fibrosis

Respiratory System Examination

This the most important part of the examination. Do a thorough examination to find out the signs.

On inspection,

• Dyspnoec
• Respiratory rate - tachypnoec
• Subcostal and intercostal recession
• Usage of accessory respiratory muscles
• Chest deformities

On palpation,

• Position of the trachea
• Position of the apex beat
• Chest expansion

On percussion,

• Resonant or hyper-resonant
• Liver and cardiac dullness

On auscultation,

• Vesicular breathing or bronchial breathing
• Presence of rhonchi - In bronchial asthma, the child will have bilateral end expiratory polyphonic rhonchi, also mention about the zones of the lungs in which the abnormal sounds were herd.
• Crepitations - Important in infective exacerbation

Complete the rest of the examination quickly and be prepared to present a summary.

SUMMARY

The summary should include the most important parts of the history and examination. Important positive and negative findings should be included in the summary. Usually a summary should not be longer than 4 to 5 sentenses.

PROBLEM LIST

The aim of taking a history and examination is to formulate a comprehensive list of problems. Identify your patient's problems and categorize them as follows. Formulation of a comprehensive list of problems is the key to successful management of your patient.

• Medical Problems 
• Acute problems
• Chronic problems
• Psychological Problems
• Social Problems

MANAGEMENT

Address each and every problem in your problem list, through your management plan.

DISCUSSION

Possible questions during discussion are,

1. How do you manage this patient?
2. If the patient presents to you in an acute attack, how do you manage this patient? To answer this question, you should be thorough with your knowledge, especially when it comes to management of emergencies. You should know the exact doses and how to give them. Through the discussion, the examiners will test whether you have seen the management of an emergency. Some of them might even ask to how to prepare the nebulizer, how to give theophiline, what the container of theophilin look like, is it a liquid or a powder etc. Be calm, think carefully and answer. If you are calm and know your way around, even you don't know the correct answer, you can get through the exam easily. If you panic, they will think that you will do the same during an actual situation.
3. What is the severity of asthma of this child? Why do you say so?
4. What is the control of asthma of the child? Why do you say so?
5. What are the advises you are going to give to the child and the mother?