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Chief Complaints
ASTHMA IN CHILD
Role-play – 15 minute
Charles, 7-year-old child, coming with his grandfather (George). The grandfather is
complaining that Charles had coughs and sneezes for the past 2 days. Charles and his
family are from Aboriginal background; moreover, he has been suffering from
bronchial asthma since age of three. He is presenting for you today with his
grandfather after administering the Ventolin puffer with little benefit.
· Charles’ development is normal, and his nutrition is optimal.
· His immunization is up-to-date including influenza vaccine.
· He lives with his grandfather most of the time.
· He has no family history of asthma or same condition.
Please answer the following questions:
1. How are you going to approach this case?
2. What is the examination required for Charles?
3. What are the investigations required for this child?
4. What is your differential diagnosis?
5. What is your management plan?

DDx
· Asthma (non-acute)
- Infrequent intermittent (attacks >6 weeks apart),
- Frequent intermittent (attacks <6 weeks apart),
- Persistent.
· Anaphylaxis,
· Foreign body aspiration,
· Croup,
· Epiglottitis.
· Pneumonia,
· Bronchitis,
· Viral infection,
· Respiratory tract infection,
· Post viral cough.

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History Taking
· First, check the patient according to paediatric assessment triangle in order
to exclude emergency:
- Appearance,
- Breathing pattern,
- Circulation.
· Hello George, hi Charles…
· Language barrier (aboriginal).
· Confidentiality.
· Reason parents are not present.
· What do you think is causing this?
· Open-ended Qs: Tell me more about the cough.
· Cough questions (SOCRATES)
o Onset & 1ˢᵗ episode
§ When did it start?
§ Is this the first time?
§ Sudden/ gradual? Constant/ on & off?
§ Has he been diagnosed with asthma before?
§ Any asthma medication?
· When the diagnosis was made the first time?
· Do you know what the diagnosis was?
· Prescriber/ frequency of use/ last use/ action plan?
· Compliance & the technique. Show how you use it.
o Character
§ Can you describe it for me?
§ Is it barking or whooping? Does he turn blue and vomit?
§ Dry or wet? any phlegm
o Associated symptoms:
§ Any chest tightness or shortness of breath?
§ Any fever or rash?
§ Any noisy sound in his breathing?
§ Any runny nose?
§ Weight loss/ lumps & bumps,
o Timing:
§ How many times in a year do you have similar symptoms?
§ When was the last time he had similar symptoms?
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 o Exacerbating/relieving factors:
§ Cold, dust, smoking
§ Does anyone smoke at home?
§ Any recent flu infection?
§ Anyone in family or school has similar symptoms?
§ Any pets, new carpets, or soft toys?
o Severity
§ Does it occur at day or night mostly or both?
§ Does it affect his sleep or wake him up at night?
§ Has he been hospitalized before due to any lung problem?
· BINDS
o Birth
o Immunization (Flu shot)
o Feeding
o Development
o Siblings/ social
§ Stress at home, why parents not available?
§ Can separation have caused stress?
· PMHx: Previous medications.
· FHx: Any family history of asthma, hay fever, eczema.

Physical examination
· Wash hands,
· Explain examination & obtain consent.
· General appearance:
o alert, irritable, restless, drowsy,
o pallor, cyanosis,
o dehydration (sunken eyes),
· respiratory distress signs:
o nasal flaring,
o accessory muscle use,
o subcostal or intercostal recessions,
o If the patient can speak in whole sentences?
· Vital signs: Especially RR, T + SpO₂.
· Growth chart.
· Complete head & neck exam (including ENT & cervical lymphadenopathy).

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 · Heart & chest examination:
o Inspection:
§ Deformity,
§ chest movement.
o Palpation
§ chest expansion,
§ tracheal position.
o Percussion
§ Dullness.
o Auscultation
§ air entry,
§ breathing sounds,
§ Wheeze or crackles (bilateral expiratory wheezes),
§ Heart sounds.
· Abdomen examination
· Office tests
o Spirometry depend on age and severity:
§ No Ventolin (puffer) use for the past 6 hours.
§ Explain about spirometry: It is an easy test to measure lung
function & the practice nurse will coach you about the test.
§ I will ask my practice nurse to perform the spirometry.
§ NOT used in the assessment of acute asthma in children.
§ Confirm patient’s name & date
§ Check FEV₁/FVC & FVC.
§ If FEV₁/FVC<LLN & FVC>LLN Þ obstructive.
§ Post bronchodilatory response:
· ↑FEV₁ (or ↑FVC) ≥12% or ≥200ml Þ asthma.
§ FEV₁: forced expiratory volume in one second.
§ FVC: forced vital capacity.
§ LLN lower limit normal.

Investigations
N/A

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Management
· Thank you for your cooperation answering my questions and helping me to
do the examination.
· Based on my examination and spirometry he most likely has infrequent
intermittent asthma (does not need preventer).
· Educate:
o About asthma - what do you know about asthma?
o Explain about asthma. May draw on paper for easier explanation.
o Avoid triggers (pet, cigarette smoke, vacuum clean carpets).
o Try to talk to his father about not smoking around him.
o Or his father can come and see me to tell him.
· Flu shot.
· Fluid and paracetamol.
· Pharmacotherapy:
o His asthma is infrequent intermittent Þ Ventolin would be enough.
o But I need to show you the best way to use the puffer.
1. patient shows,
2. doctor demonstrate,
3. patient shows again.
o Puffer should always be upright, and shake well.
o Always wash the spacer with water only and air-dry only.
· Asthma action plan,
· If you like, I can put you on CTG program,
· Reading material:
- video,
- asthma educator,
· Review,
· Red flags.

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