Case presentation proforma for a respiratory case

History taking and Clinical case presentation in chronic lung diseases in children.

INTRODUCTION

XYZ, a 12 yr old boy, 1^st born male child of a non consanguineous parents, hindu by religion, XYZ by community, student of class 6 resident of Howrah, originally hailing from Bihar came for a check up today with mother, informant being mother who seems to be very reliable.

(INTRODUCTION SHOULD BE CLEAR AND NON STOP)

CHIEF COMPLAINTS

XYZ presented with chief complaints of :

1. Cough for last 4 years

2. Frequent episodes of respiratory distress for same duration

(Now add any other associated symptoms if important as per case. Chief complaints should indicate the system affected)

HOPI:

MOST IMPORTANT PART OF HISTORY. STORY OF A CHILD FROM MOTHER WITH MEDICAL INTERPRETATION.

XYZ was apparently well till 8 years of age, performing all age appropriate activities, growing well. Then he started having cough that gradually progressed to respiratory distress requiring hospital admission. (ONSET)

1. DESCRIBE COUGH

· Cough was subacute in onset, gradual in progression

· Cough was initially dry that gradually became productive

· Lead to respiratory distress over 15 days

· Without any noisy breathing, more prominent during morning just after waking up

· A/w- heavy, grayish yellowish sputum, not blood tinged, foul smelling

· Aggravated by lying down and exercise, relieved after nebulisation. He preferred sitting position

2. DESCRIBE DISTRESS

( Same way onset, duration, progression, decubitus of choice, aggravating relieving factor, a/w cyanosis or not )

He was treated with nebulisation, oxygen, intravenous injections, fluids and discharged home after 20 days with few oral medication nature of which is not known. Since past 4 years he is suffering from chronic cough and intermittent respiratory distress and multiple hospital admissions.

3. DESCRIBE HIS DAILY LIFE ACTIVITIES

XYZ has anorexia, constipation, not gaining proper weight he is not able to participate well in outdoor games and drops school many times and is poor in academics.

It looks like a chronic disease, involving respiratory system or multisystem, so we have to formulate DDs, then stand by 1 or 2 and exclude others. That takes us to positive and negative history. First positive then negative, Same way first etiology then complication to be described

DDs of Chronic Cough (? bronchiectasis): Take most important 5-6 DDs as per case

· Asthma

· Brochiectasis

· Infectious- TB,HIV, aspergillous

· Can be a cardiac cause

· Cystic fibrosis(unlikely as child was ok till 8 yrs still have to exclude)

· Long standing foreign body (but that will have sudden onset distress )

· Immune deficiency(acquired/as congenital unlikely)

· You can think many more if u get time….

POSITIVE HISTORY

H/o poor weight gain, multiple exacerbation, delayed puberty, halitosis

Add some other pointers of chronic disease if they are present, For examples in HIV there will be h/o parents dying of HIV

NEGATIVE HISTORY

A. ETIOLOGY

B. COMPLICATION OF DISEASE AND TREATMENT

COURSE IN HOSPITAL AND TREATMENT TO BE INCLUDED IN HOPI

Since last 4 yrs he is on some oral medication, nebulization and chest Physio and others if there

PAST HISTORY: Past admission, any test, follow ups, improvements and deterioration

ANTENATAL, BIRTH, POSTNATAL- Only relevant points

DEVELOPMENT HISTORY: Mention 4 domains and say normal/ delayed

IMMUNIZATION HISTORY: Measles, pertusis, influenza, pneumo

NUTRITION HISTORY: Observed vs ideal. Match according to anthropometry

FAMILY HISTORY: TB, HIV, ILD, CF, primary ciliary dyskinesia, Infertility

SOCIO ECONOMIC HISTORY: Kuppuswamy scale, family income vs cost of the treatment? Any fund from Govt?

PERSONAL HISTORY: Any drug allergy

SUMMARISING THE HISTORY

Ans to : So what do you think you are dealing with from history only?

12 yr old boy suffering from a chronic acquired lung disease with gradual deterioration, growth arrest without any significant past or family history requiring prolonged supportive treatment. Can be a case of bronchiectasis. I would like to examine the child to come to provisional diagnosis.

EXAMINATION:

OPENING REMARKS:

The opening remarks has to be presented on spot. Posture/decubitus of the patient, most prominent and obvious clinical features. Say for example in this case

Thin built child, sitting slightly bent backwards and taking interest in surrounding, having visible respiratory distress

GENERAL EXAMINATION

· Pubertal status (Tanner staging) – MUST in patients where applicable. A delay in puberty may be  seen.

· Nutritional status

· ANTHROPOMETRY: VV IMP Weight, height, percentiles, BMI. As per latest WHO, IAP chrts

· VITALS: Pulse, RR, BP,

· PICCLE: grade of clubbing

AFFECTED SYSTEM

RESPIRATORY SYSTEM

Upper respiratory tract: ENT, nasal polyp, sinus

Lower respiratory tract: Follow Scotts given well (List of practical book here)

Inspection- Note the increase in AP diameter, chest movement, any skeletal changes, back

Cough-Moist/productive/ foul smelling

Palpation- look for dextrocardia, Measure the AP diameter (hyperinflation), Tracheal position, position of apex, palpable pulmonary valve closure

Percussion- Hyperinflation /consolidation

Auscultation- Coarse leathery crepts over the affected region (First heard in the upper lobes in cystic fibrosis),  Wheeze++

OTHER SYSTEM :

GI, CARDIAC- Loud second heart sound in pulmonary hypertension, mention just important points

SUMMARY:

12 yr old boy suffering from a chronic acquired lung disease with gradual deterioration, growth arrest without any significant past or family history. On examination having Grade IV/ severe malnutrition, delayed puberty, Grade 3 clubbing, increased chest diameter, diffuse crepitation's and wheeze. He is on prolonged supportive treatment without any complication at present.

DIAGNOSIS:

A case of acquired chronic lung disease (bronchiectasis involving multiple lobes) with growth failure, delayed puberty. Probable etiology being chronic infection(HIV)

More on Bronchiectasis in children in CRACKING THE CODE OF THEORY SERIES Here