Template of history taking presentation for asthmatic patient

Template of history taking presentation for asthmatic patientCreated OnMay 27, 2020Last Updated OnMay 27, 2020byadmin You are here: Main Clinical Examination Template of history taking presentation for asthmatic patient < All Topics Table of Contents Chief compliant: Name, is a age, race, occupation, gender, with underlying chronic diseases or active illness under hospital____ follow up since when was brought to/presented to hospital______ with a chief complaint of main presenting symptoms with duration (eg. SOB for 3 hours) associated with one or two main symptoms (eg. persistent cough or wheezing or 1/2 episodes of hemoptypsis) prior to admission or was electively admitted for evaluation of presenting problem or follow up for previously diagnosed disease with onset of disease History of presenting illness: Acute Asthma He/she was previously well until duration prior to admission (eg. 1 day prior to admission) when he/she developed acute/gradual onset of main presenting symptoms. The presenting symptoms was precipitated by cause/precipitating factors/activities patient was doing at that moment. This is the first episode, patient never experience anything similar before/ patient had suffered from the same condition before. It lasted for duration before being sent to the emergency department It was aggravated by aggravating factors and relieved by relieving factors/medication. Along with SOB, patient also complaint of cough. Patient states that the cough worse at night and he/she was unable to sleep. There was no relieving factors. **please read the common symptoms and ask the relevant questions from respective symptoms using OLD CART/SOCRATES.** Aggravating factors (DIPLOMAT) Drugs: aspirin, NSAIDs, beta blockers, etc Infections: URTI, LRTI, sick contact Pollutants: at home, at work, constructions nearby Laughter: emotions ( sad or happy) Oesophagus reflux: nocturnal asthma Mites Activity and exercises Temperature: cold, early morning/night Relieving factors Inhaler? Nebulization Grade the severity of difficulty in breathing with MRC breathlessness scale Eg. Patient claimed that he/she was unable to walk at the moment of attack. Progression of symptoms (Used inhaler, any improvement? Still able to work, sleep? Affect daily activities? Require nebulizer? Rescue steroid? Worsening symptoms leading to admission? Treatment in ED.) Chronic asthma He/she was previously diagnosed with asthma when he/she was at what age at which hospital by who. He/she presented with presenting symptoms at the onset of diagnosis. He/she states that he/she has (cough worse at night/early morning, recurrent wheeze, recurrent SOB, recurrent chest tightness). He/she was investigated/what was done for the diagnosis. He/she was prescribed with treatment given (require controller medication or reliever only?) and follow ups where and when (eg. Monthly). Currently he/she is on treatment given. The last follow up was on date. He/she was compliant/not compliant to treatment. He/she did not suffer/suffered from any complications of disease or treatment given (eg. cushings). The asthma was well/poorly controlled as patient has no daytime symptoms more than 2 weeks, there was no night time symptoms, no activity limitation and doesn’t require reliever, PEFR was improving. **Ask for symptoms and precipitating factors of each exacerbation, any admission to ICU, require intubation/nebulization, duration of stay.** Rule out differential diagnosis: Acute dyspnea...

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