asthma possible.docx

7/27/2019 Asthma Possible.docx

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STATION #

PLEASE CONDUCT FOCUSED HISTORY AND COUNSEL AS YOU WOULD IN

PRACTICE.

INSTRUCTIONS

1 - YOU HAVE 8 MINUTES TO COMPLETE THE STATION

2 - WARNING WILL NOT BE GIVEN3 - THERE WILL BE POST ENCOUNTER QUESTIONS

J.D.


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MY ACTUAL 2 MINUTES NOTES:

ACTUAL ENCOUNTER:

Patient cues:

POST ENCOUNTER QUESTIONS:

FEEDBACK COMMENTS:

POSSIBLE APPROACH:

Possible Differentials I should think about while waiting for 2 minutes:Vascular:

Infectious:

Trauma:

Autoimmune:

Metabolic:

Idiopathic/Iatrogenic:

Neoplastic:

Substance abuse and psychiatric:

Congenital:

INTRODUCTION:

Hello. (First Name) (Last Name)?

I am Dr.

First of all, (how may I call you?) (may I call you (First Name)?

I would like to begin by asking you some questions (and later on do a physical exam) so I could

determine what needs to be done.

CHIEF COMPLAINT:

So, (First Name), what brings you in today? DOB(ASTHMA)

HISTORY OF PRESENT ILLNESS:

Focus on Chief Complaint

Character Do you feel shortness of breath?

Can you describe the nature of your breathing difficulty?


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Can you describe the wheeze?

What time of the day is the wheeze at its worst?

Location - Where was the patient when it started? What were you doing?

Onset - How did the wheeze start? Was it sudden? How did the SOB start?

Radiation -

Intensity - How severe is the wheeze right now on a scale of 1 to 10, with 10 being the most

severe? How severe is the SOB right now? Is it affecting your daily activity?

Duration - How long has the wheeze been going on? Is it getting worse? How long have you been

SOB?

Events associatednocturnal cough, decreased exercise tolerance, atopy/ ASA, NSAID sensitivity, nasal

polyps

Frequency - Has this happened before? When? How often?

Palliative factorsIs there anything that makes it better?

Provocative factorsIs there anything that makes it worse?

Previous investigations

Past medical/surgical historyAsthma? Atopy? Any previous hospitalization/surgery?

Medications What medications are you giving him?

Allergies Any known allergy?

Social history Usual diet? Smokers in the home, pets, carpets, dust?

Family historyAsthma, allergies, eczema, rhinitis,?

STANDARD Qs: (Now, I would like to ask questions that I usually ask all my other patients/parents)

(Determine if age/case appropriate)

PRENATAL:

Did you have prenatal care?

Any difficulties during the pregnancy?

Any complications during it?

High blood pressure, Anemia, diabetes, infection?

Explore: What? How was it treated?

Did you use alcohol or recreational drugs during the pregnancy?

Did you smoke during the pregnancy?

Was it a single pregnancy or multiple?

NATAL:

When was your delivery?

Was it a term pregnancy?

What was the method of delivery?

(If, induced) Why?

How long did it take?

Any complications during labor like prolonged labor, ruptured water bag, fever?


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NEONATAL:

How was he/she at birth?(APGAR SCORE)

How much was his/her weight?

Any abnormalities or complications like being yellow or blue, feverish, or didnt cry

immediately? Explore:What/ When/ How long?

(Empathy for healthy/ unhealthy pregnancy.)

Any problems as a baby? Any hospital admissions?

IMMUNIZATION HX:

What needles has been done so far?

Does he/she have? (age appropriate immunization)

NUTRITION/ OUTPUT:

Tell me about his/her feeding/eating habits?

Is he/she on breast or bottle feeding?

How much do you give him/her each time? How many times in a day?

Any solids, vitamins, iron, supplements? What? When did you start?

Is it balanced diet? Any junk food?

Any difficulty sucking/ swallowing?

Is he/she a picky eater?

Tell me about the feeding setting & facilitation?

OUTPUT (BLADDER/ BOWEL MOTIONS):

How many times a day dose he/she pass water?

How much each time? (Or How many wet diapers day?)

Smelly urine? Red urine?

How many times a day does he/she have a bowel motion?

How much each time? Is it formed or loose? Smelling stool? Blood? Mucus? What color is it?

Green/ yellow/ white cheesy?

Explore. Does he/she control his/her bladder & bowel? (for >4 years old)

DEVELOPMENT:

Any delay in speech, language, or motor development?

Physical: What is his/her height and weight now?

Milestones Is he/she able to.. ? (Gross motor, Fine motor, Speech, Social)Age appropriate

now only, no need for previous.

Social/ School performance: How is his temper? Is he irritable, crying frequently? What about

sleep? Does he/she attend school? What grade? Any problems at school? Any failures or

suspensions? What is his/her daily routine?

ENVIRONMENT:

Are there similar problems with relatives, at daycare, at school?


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Who is usually taking care of him/her?

How are the family relationships?

How has this been affecting the family?

Do you feel your mood low?

Any lost workdays?

How are you managing with the expenses?

COUNSEL:

(First Name) or Mr./Ms (Last Name), let me give you some information about the .(Subject).

Then EDUCATE the patient about: SRS AI OEM

1- Subject: In small chunks asking him in between:

Am I making sense? or Is that clear?

2- Risk factors/ Seriousness: of not acting on the subject. (e.g Keep smoking)

As you may realize, ..(Subject) causes

3- Side effects and complications of acting on the subject, emotionally and physically, and how to avoid

them. There is a chance to have . as a side effect. If that happens, you can ./ call me/ go to

emergency.

4- Alternatives: of acting on the subject.

To deal with this, there are other options. ..

5- Investigations: Im going to send youfor some (blood work and X-Ray/Ultrasound), which will help us

to rule out any contraindications.

6- Outcome/ Prognosis: Clearly & truly: If treatable/successful - Assure.

If severe/ chronic/ bad - Discuss family and community support.

7- Effect on patient: Now, how do you feel about that?

8- Mode of Usage: Pills, puffs, patches, injections, instruments, ..etc

WRAP UP:

1- Okay (First Name) or Mr/Ms (Last Name) is there anything else youd like to tell me or ask me?

2- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT.

Clarify his/her and your responsibilities:

Okay, so Ill send you for the investigations, you will take the medication/change your life style and

report progress .

3- Follow up: I wantto see you next week / in a month.

4- Last word in the interview is for the patient: Is there anything else youd like to tell me or ask me?

5- It was nice to meet you, have a nice day.

DIFFERENTIAL DIAGNOSIS:

Asthma

Bronchiolitis

Pneumonia

INVESTIGATIONS:


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CBC

PEFR/PFT > 6y/o

CXR

MANAGEMENT:

0to keep 0saturation >92%

Fluids if dehydrated

Beta 2 agonists: Salbutamol 0.03 cc/kg in 3 cc NS q20 minutes by mask until improvement, then

masks hourly if necessary

Ipratropium bromide if severe: 1 cc added to each of first 3 salbutamol masks

Steroids: prednisone (2 mg/kg in ER, then 1 mg/kg daily x 4 days) or dexamethasone

(0.3 mg/kg/day)

asthma possible.docx

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