. Patient is case of bronchiolitis and anaemia and now Sam patient name is Aryan and father is Akshay Make history and examination format
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Here is the complete History & Examination format for Aryan, a pediatric case of Bronchiolitis with Anaemia:
HISTORY AND PHYSICAL EXAMINATION
PATIENT DETAILS
| Patient Name | Aryan |
| Father's Name | Akshay |
| Age | ___ months / years |
| Sex | Male |
| Date of Admission | ___ |
| IP Number | ___ |
| Ward / Bed | ___ |
| Informant | Father (Akshay) - reliability: Good |
PRESENTING COMPLAINTS
(Duration in days/weeks - fill as appropriate)
- Rapid / noisy breathing - since ___ days
- Cough - since ___ days
- Fever - since ___ days
- Wheeze / whistling sound from chest - since ___ days
- Pallor / generalised weakness - since ___ weeks / months
- Poor feeding / lethargy - since ___ days
HISTORY OF PRESENT ILLNESS
Aryan, a ___-month/year-old male child, is brought by his father Akshay with complaints of rapid and noisy breathing since ___ days. The breathlessness was gradual in onset, progressive in nature, associated with audible wheeze.
Cough: Present / Absent - ___ days duration; dry / productive; paroxysmal / continuous; nocturnal worsening: Yes / No.
Fever: Present / Absent - ___ days duration; low grade / high grade; continuous / intermittent; chills: Yes / No; response to antipyretics: Yes / No.
Rhinorrhoea / nasal discharge: Yes / No - colour ___, onset ___ days prior to respiratory symptoms.
Feeding difficulty: Yes / No - unable to feed due to breathlessness: Yes / No.
Cyanosis: Yes / No.
Apnoea episodes: Yes / No.
Pallor / anaemia-related complaints:
- Generalised weakness / fatigue: Yes / No
- Easy fatigability: Yes / No
- Palpitations: Yes / No
- Yellowish discoloration of eyes (jaundice): Yes / No
- Blood in stools / black tarry stools: Yes / No
- Bleeding from any site: Yes / No
- Swelling of body / pedal oedema: Yes / No
PAST HISTORY
| Similar episodes in past | Yes / No - how many times: ___ |
| Hospitalisation | Yes / No - details: ___ |
| Recurrent URTI / chest infections | Yes / No |
| Known asthma / allergies | Yes / No |
| Tuberculosis contact | Yes / No |
| Past blood transfusions | Yes / No - when: ___ |
| Surgical history | Yes / No |
| Drug history / medications | Yes / No - details: ___ |
BIRTH HISTORY
| Place of delivery | Hospital / Home |
| Mode of delivery | Normal vaginal / LSCS / Assisted |
| Gestation | Term / Preterm (___ weeks) |
| Birth weight | ___ kg |
| Cry at birth | Immediate / Delayed |
| NICU stay | Yes / No - duration: ___ |
| Complications at birth | Yes / No |
FEEDING HISTORY
| Breastfeeding | Yes / No - exclusive till ___ months |
| Formula feeds | Yes / No - started at ___ months |
| Complementary feeds | Started at ___ months - type: ___ |
| Current diet | ___ |
| Iron-rich food intake | Adequate / Inadequate |
IMMUNISATION HISTORY
| Vaccine | Given | Age given | Remarks |
|---|---|---|---|
| BCG | Yes / No | ||
| OPV (0, 1, 2, 3) | Yes / No | ||
| Hepatitis B | Yes / No | ||
| DPT / Pentavalent | Yes / No | ||
| IPV | Yes / No | ||
| Measles / MMR | Yes / No | ||
| PCV | Yes / No |
Immunisation status: Up to date / Partial / Not immunised
DEVELOPMENTAL HISTORY
| Milestone | Expected Age | Achieved | Age Achieved |
|---|---|---|---|
| Social smile | 6 weeks | Yes / No | |
| Neck holding | 3-4 months | Yes / No | |
| Sitting without support | 6-9 months | Yes / No | |
| Standing with support | 9 months | Yes / No | |
| Walking | 12-15 months | Yes / No | |
| First words | 9-12 months | Yes / No | |
| 2-word sentences | 18-24 months | Yes / No |
Global developmental delay: Yes / No
FAMILY HISTORY
| Similar illness in siblings / family | Yes / No |
| Asthma / atopy in family | Yes / No |
| Haemoglobinopathy (sickle cell / thalassaemia) | Yes / No |
| G6PD deficiency | Yes / No |
| Consanguinity of parents | Yes / No |
| Siblings | Number: ___, alive / deceased |
SOCIOECONOMIC AND ENVIRONMENTAL HISTORY
| Type of residence | Kuccha / Pucca |
| Crowding | Yes / No |
| Indoor air pollution (biomass fuel, smoking) | Yes / No |
| Passive smoke exposure | Yes / No |
| Clean water source | Yes / No |
| Sanitation | Adequate / Inadequate |
| Socioeconomic status (Kuppuswamy / BG Prasad scale) | ___ |
GENERAL PHYSICAL EXAMINATION
Date & Time: ___ Examined by: ___
General appearance: Conscious / Irritable / Lethargic / Toxic-looking
| Parameter | Findings |
|---|---|
| Weight | ___ kg (___ centile) |
| Height / Length | ___ cm (___ centile) |
| Head circumference | ___ cm (___ centile) |
| Temperature | ___ °F / °C - Febrile / Afebrile |
| Heart Rate (PR) | ___ /min - regular / irregular |
| Respiratory Rate | ___ /min |
| SpO2 | ___ % on room air / ___L O2 |
| Blood Pressure | ___ / ___ mmHg |
| Capillary Refill Time | ___ seconds |
Pallor
| Grading | Present / Absent |
|---|---|
| Conjunctival pallor | Yes / No |
| Palmar pallor | Yes / No - grade: mild / moderate / severe |
| Nail bed pallor | Yes / No |
Other Signs
| Sign | Present / Absent | Details |
|---|---|---|
| Icterus | Yes / No | Scleral / dermal |
| Cyanosis | Yes / No | Central / peripheral |
| Clubbing | Yes / No | Grade: ___ |
| Lymphadenopathy | Yes / No | Site: ___, size: ___, tender: ___ |
| Oedema | Yes / No | Pitting / Non-pitting, site: ___ |
| Rash | Yes / No | Description: ___ |
| Fontanelle (if infant) | Open / Closed, bulging / sunken / normal |
Signs of Respiratory Distress (BRONCHIOLITIS)
| Sign | Present / Absent | Grade |
|---|---|---|
| Nasal flaring | Yes / No | |
| Subcostal recession | Yes / No | Mild / Moderate / Severe |
| Intercostal recession | Yes / No | |
| Suprasternal recession | Yes / No | |
| Head bobbing | Yes / No | |
| Grunting | Yes / No | |
| Tracheal tug | Yes / No |
Respiratory Distress Score (Modified Tal / RDAI): ___ /17
SYSTEMIC EXAMINATION
1. RESPIRATORY SYSTEM
Inspection:
- Shape of chest: Normal / Barrel-shaped (hyperinflation) / Asymmetrical
- Movement: Bilateral equal / Reduced on ___ side
- Intercostal / subcostal retractions: Present / Absent
Palpation:
- Trachea: Central / Deviated
- Tracheal tug: Present / Absent
- Vocal fremitus: Normal / Increased / Decreased bilaterally
Percussion:
- Bilateral: Resonant / Hyperresonant / Dull
- Liver dullness: ___ cm (pushed down due to hyperinflation?)
Auscultation:
- Air entry: Equal bilaterally / Reduced on ___ side
- Breath sounds: Vesicular / Bronchial
- Added sounds:
- Wheeze (expiratory): Present / Absent - bilateral / unilateral
- Crackles: Present / Absent - fine / coarse, inspiratory / expiratory, site: ___
- Prolonged expiration: Yes / No
2. CARDIOVASCULAR SYSTEM
- Precordium: Normal / Bulging / Depressed
- Apex beat: Located at ___ ICS, ___ to MCL
- Heart sounds: S1 S2 heard, normal / tachycardic
- Murmur: Present / Absent - if present: grade ___, type: ___, area: ___
- Signs of cardiac failure (in severe anaemia): Gallop rhythm: Yes / No; Hepatomegaly: Yes / No; Oedema: Yes / No
3. ABDOMEN
- Distension: Present / Absent
- Liver: Palpable / Not palpable - ___ cm below costal margin, tender / non-tender, edge: sharp / round, surface: smooth / nodular, consistency: soft / firm / hard
- Spleen: Palpable / Not palpable - ___ cm below costal margin (splenomegaly suggests haemolytic anaemia / thalassaemia)
- Bowel sounds: Normal / Abnormal
- Ascites: Present / Absent
4. CENTRAL NERVOUS SYSTEM
- Consciousness: Alert / Irritable / Lethargic / AVPU scale: ___
- Fontanelle (if infant): ___
- Neck rigidity: Present / Absent
- Tone: Normal / Hypotonic / Hypertonic
- Reflexes: Normal / Abnormal
- Seizures: Present / Absent
5. ENT / OROPHARYNX
- Tonsils: Normal / Enlarged - grade: ___
- Throat: Normal / Congested
- Nasal discharge: Clear / Purulent
- Ears: Normal / Discharge present
PROVISIONAL DIAGNOSIS
- Bronchiolitis - likely viral aetiology (RSV most common in infants)
- Anaemia - type to be determined:
- Nutritional (Iron deficiency / B12 / Folate)
- Haemolytic
- Anaemia of chronic disease
- Thalassaemia / haemoglobinopathy
INVESTIGATIONS PLANNED
For Bronchiolitis:
- SpO2 monitoring (continuous)
- Chest X-ray PA view
- Nasopharyngeal swab for RSV rapid antigen / PCR (if available)
- ABG (if severe distress)
- NPA for viral panel
For Anaemia:
- Complete Blood Count (CBC) with peripheral smear
- Reticulocyte count
- Serum iron, TIBC, serum ferritin
- Serum B12 and folate
- Peripheral blood smear morphology
- Haemoglobin electrophoresis (if thalassaemia suspected)
- G6PD assay
- LFT (bilirubin - for haemolysis)
- Stool for occult blood
SEVERITY ASSESSMENT
Bronchiolitis Severity (Modified Tal Score or RDAI):
| Parameter | Mild (0-4) | Moderate (5-8) | Severe (9-12) |
|---|---|---|---|
| Wheeze | End expiratory only | Whole expiration | Inspiratory + expiratory |
| Recession | None / Mild | Moderate | Severe |
| RR | <40 | 41-60 | >60 |
| SpO2 | >95% | 90-95% | <90% |
Current Score: ___ / severity: Mild / Moderate / Severe
Anaemia Severity (WHO):
| Hb level | Grade |
|---|---|
| 10-10.9 g/dL | Mild |
| 7-9.9 g/dL | Moderate |
| <7 g/dL | Severe |
Aryan's Hb: ___ g/dL - Severity: ___
Signature of Examiner: ______________ Date: __________
This is a complete pediatric history and examination format tailored for Aryan (father: Akshay) covering both bronchiolitis and anaemia. Fill in the blanks during the actual clinical encounter. The format follows standard pediatric clinical case documentation.
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