Long Case Templates
1. While greeting and introduction: eyeball patient (and parent) and decide if child looks normal
2. Presenting complaint: A seizure! ;
3. History of presenting complaint: sta. 1 question: Is this the first time this happened? If yes, then can’t say its epilepsy
b. Who witnessed it?
c. Describe the seizure:
i. Prodrome : Any aura? Change in behaviour?
ii. Seizure :
？ Tonic clonic? (tensing, then shaking, LOC)
？ Atonic? (Drop attack)
？ Absence? (Just staring, not respoinding when called, + blinking)
？ Partial? Child may be fully conscious, only ? limbs
？ If temporal lobe – Automations, strange behaviour, sltered conscious
？ How many?
？ How long did it last? (>20mins ， status epilepticus)
？ Any loss of consciousness? Any tongue biting?
？ What did you do for the child? (Appropriate vs. Inappropriate first aid
iii. Post ictal : Drowsy? Sleeping? Vomiting? Temporary paralysis (Todd’s
d. Did the child have a fever?
i. Do seizures occur only when child has fever?
？ Tmax of fever
？ Associated symptoms (e.g. cough, sorethroat etc)
？ Exclude meningitis, encephalitis as a cause. e. Any head injury just before the seizure?
; Is it a febrile fit?
o OR epilepsy? sto OR 1 time seizure with no defined cause?
o OR seizure, probable cause _______?
？ e.g poisoning, hypoglycaemia
o OR is it a pseudoseizure
？ Rigors, breath holding attack?
4. Past history
i. Frequency of seizures
ii. Time, occurrence of seizures
iii. Date of last seizure
b. Epilepsy: sti. Age at 1 seizure, describe seizure, a/w fever?
ii. h/o febrile seizures when young?
iii. When and how diagnosed. Any event preceding seizure?
？ Anticonvulsant medications
； How many?
； Any ?/?/? in drug dosage & types?
； Compliance, how often is a dose missed & what to do if it is
； For how long; any attempt to stop medications?
； Sde effects of medications?
？ Outpatient review
； Test done @ f/u
； Other Inxs e.g EEG to date
； How many? Reasons?
v. Any identifiable triggers for seizures, e.g. fever, emotion, lack of sleep, bright
vi. Any identified medical problem/cause associated with seizures? Diagnosis
？ Neurocutaneous syndromes (NF-1, TS, S-W)
？ Cerebral palsy
？ Neurodegenerative syndromes (Rett’s, Lennox-Gastaut)
？ Past h/o brain tumour, head trauma, meningitis/encephalitis/brain
To exclude /note on ？ Inborn errors of metabolism
physical examination How are these problems managed?
vii. Any other past medical history?
viii. FAMILY HISTORY?
5. Developmental history
a. Antenatal history
b. Development in infancy – milestones
Assess on physical c. Interaction with friends, children his age, family
examination d. If schooling: keeping pace with classmates? e. Any regression e.g. loss of walking/talking ability
6. Social history
a. Impact on child:
ii. Athletic participation
iii. Self esteem, peer relationships
iv. Does teacher know of condition?
b. On family : Financial burden
c. CONTINGENCY PLAN : What to do in the event of a seizure?
a. Type of seizure ， Classify
b. Associated problems/possible cause
c. Treatment and complications
CP is a non progressive motor disorder of movement and posture, due to a defect or lesion in the
Types : Spastic (70%) – Hemiplegic/Diplegic/Quadriplegic
: Dyskinetic (15%)
: Ataxic (5%)
: Mixed (10%)
Consider various associated problems
Look for possible cause of CP
1. Presenting Complaint
a. May be complications of CP, e.g. swallowing problem, aspiration pneumonia, seizures
b. May be for elective surgery, e.g. tenotomy (correction of contractures), tendon transfer
(correct deformity from muscle imbalance)
2. History of presenting complaint – Onset, duration, progression… (according to complaint)
3. Current symptoms/Functioning
a. Intellectual ability/Present developmental status
b. Current placement (education/domestic e.g. home)
c. Behaviour, affect
d. Vision. E.g. strabismus/myopia/blindness
Hearing, speech, communication problems
e. ADL – dependent/independent?
i. Sucking/swallowing ability
ii. Tube feeds/gastrostomy
g. Seizures : Type, duration, frequency, last episode
h. Mobility – Able to walk? If so, gait pattern? Abnormal posturing?
i. Others, e.g. constipation, chest infection, urinary incontinence, pressure sores…
4. Birth history
a. Prenatal : PIH, GDM, drug history, findings on ultrasound, IUI, fetal movements
b. Delivery : Gestational age, BW, mode of delivery, any complications, APGAR score,
any resuscitation needed?
c. Postnatal : Respiratory distress, Feeding difficulties, Seizures, Hydrocephalus, Jaundice
requiring phototherapy/exchange transfusion, IVH/PVL, any NAI in infancy, e.g. head
5. Developmental history
a. Milestones achieved: Ascertain quality of attainment! i. Gross and fine motor e.g.bottom shuffling, development of early hand ii. Social preference, splaying of fingers when attempting grasp iii. Language
6. Past medical history
a. Any illnesses in infancy e.g.meningitis/encephalitis, severe jaundice, severe sepsis
b. Any HI/NAI/neurosurgery
7. Family history of CP
8. Management so far:
a. Recent management in hospital
b. Usual treatment at home
c. Usual doctors seen
d. Compliant with follow up?
e. Frequency of therapy (PT/OT/ST) 9. Social history
a. Disruption to family routine
b. Financial considerations
c. Social support, including self help groups
d. Special school/sheltered workshop?
; Classify type of CP
； Spastic hemiplegic/diplegic/quadriplegic
; List associated problems, e.g.
； Poor swallowing, chest infection, urinary incontinence, behaviour problems, contractures
； Functional status: Mobility/Wheelchair bound? ; Postulate underlying cause if confident
; Differential diagnoses
; Management: MULTIDISCIPLINARY
; Know social support avenues, e.g. Spastic Children’s Association.
; MRI/CT scan of the brain
; TORCH screen
; Urinary metabolite screen
PHYSICAL EXAMINATION (As part of the long case as well as short case)
1. Greet, introduce yourself to the parents and patient
2. GENERAL INSPECTION
a. Dysmorphic features (e.g. chromosomal abnormalities)
b. Growth parameters
i. OFC (usually obvious microcephaly in quadriplegics)
ii. Height (usually decreased)
iii. Weight ( often there is FTT)
i. Increased extensor tone
ii. ATNR (persisting beyond 6 months)
iii. Fisting (thumbs buried in fists)
i. Involuntary : Dystonic, choreoathetoid
ii. Voluntary : Hemi/diplegic gait, immature gait pattern (tiptoeing, wide base)
f. Behaviour – lack of interaction with the environment, crying g. Eyes – squint, not fixating, cortical blindness (roving eye movements)
h. Bulbar signs – dysarthria, drooling
i. Interventions – NG tube, gastrostomy tube, scars from previous interventions,
j. Clothing – Nappies in child > 4 years old ， abnormal
k. Peripheral aids – Wheelchair, orthoses, walking aids
3. DEMONSTRATE SIGNS OF CP
a. Older, mobile child – Standard gait examination (hemiplegia, ataxia shows up)
b. Child who can crawl – Asymmetry (hemiplegia), buttock crawling (di/quadriplegia)
c. Gross motor assessment (180? maneouvre)
SUPINE ， PTS ， SIT ， STAND ， VS ， PRONE
i. Supine – Extensor posturing
ii. Sit – Poor trunk control
iii. Tilt sideways – Assess head righting
iv. Stand – Scissoring
v. Parachute reflex – Detect asymmetry
d. Inspect for tension release scars
e. Palpate muscle bulk in each muscle group
i. Early CP – Hypotonia, often with increased reflexes
ii. Later CP – Hypertonia ， Spasticity (clasp knife rigidity) g. DEEP TENDON REFLEXES
i. Increased reflexes (3+)
ii. Sustained clonus
i. Assess voluntary movement
ii. Functional power e.g. grasp of toys
i. Test for persistence of primitive reflexes.
4. COMPLICATIONS OF CP
a. Measure OFC (microcephaly)
b. Vision, extraocular movements (squint, blindness,…)
c. Hearing (sensorineural deafness)
d. Ears (Chronic serous OM)
e. Teeth (Dental caries)
f. Back (Kyphoscoliosis)
g. Chest (Signs of consolidation – Chest infection)
h. Abdomen (Constipation)
i. Hips (Dislocation)
j. Screen nutritional status
k. Functional assessment for ADL (more in diplegic/hemiplegic/ataxic)
l. Assess other areas of development (social, language).
1. PRESENTING COMPLAINT
a. Reason for current admission
2. HISTORY OF PRESENTING COMPLAINT
a. Ask in detail!
b. Usually those of acute exacerbation c. Ask whether attempted treatment at home d. Anything that suggest another problem, e.g. pneumonia, pneumothorax
3. ASTHMA : SYMPTOMS & PATTERN (CURRENT STATUS) a. Symptoms:
iv. Chest pain/tightness
v. Decreased exercise tolerance
i. Frequency – Day/Night (GINA Classification)
； Number of attacks per year (or month)
； Need for bronchodilators/oral steroids
； Admitted to hospital? ICU? A&E?
； Dust (faeces of house dust mites!)
； Cigarette smoke
； Pet fur/ dander
； Temperature changes
； Exercise (in EIA)
4. DESCRIBE a typical acute exacerbation a. Initial symptoms
b. Precipitant(s), if identified
c. Tempo of progression
d. Rate of recovery
e. How child handles illness
i. Still able to talk?
ii. Breathing fast?
f. Usual outcome
g. Treatment used
5. PAST HISTORY (may be asked at the same time as ；)
a. Age of onset of symptoms
b. Age of diagnosis
c. As a baby : Any respiratory complications in perinatal period? Recurrent bronchiolitis?
d. Number of A&E visits/hospitalization/IV therapy/ventilation
e. Previous investigations e.g. spirometry, skin prick test
f. Change in clinical course - ?/? frequency of symptoms
g. Past history of, or concurrent allergic rhinitis, eczema, food/drug allergies.
6. FAMILY HISTORY of asthma or any atopic conditions.
a. Present treatment in hospital
b. Usual treatment at home
iii. Mode of delivery
iv. Before exercise?
v. Any changes in medicines before?
vi. Any ADRs?
vii. Allergy avoidance (ask about HOME ENVIRONMENT)
viii. Crisis plan?
ix. COMPLIANCE WITH TREATMENT?
8. SOCIAL HISTORY
a. Home environment
i. Carpets, rugs
iii. Types of pillows
iv. How frequently is the house cleaned, and how is it cleaned?
v. Any construction/upgrading going on nearby?
vi. Any smokers at home?
b. Impact on child
i. Amount of school missed
ii. Impact on exam grades
iii. Limitation of ADL/physical activity?
iv. Effect on development/behaviour?
v. Peer interaction
vi. Developmental milestones
c. Impact on family
i. Financial considerations – Can afford medications, hospital fees?
ii. Disruption of family routine
iii. Support groups?
d. Teens – ASK ABOUT SMOKING! If positive :
i. For how long?
ii. Number of cigarettes per day
iii. Where/how they get their cigarettes (and the moolah for it! :p)
iv. Why they smoke
v. Do their parents know?
vi. Who they usually hang out with?
vii. Tried to quit?
viii. Aware of adverse affects of smoking?
ix. Do they think it makes their asthma worse?
9. Check inhaler technique
1. General Inspection
； Atopic facies
； Cushingoid features
； Tachypnoeic? Any other signs of respiratory distress?
； Skin : Eczema (elbows, knees, neck) 2. Vital signs
； Pulse (rate, bounding?)
； Respiratory rate (??)
； Blood pressure – SE of steroids?
； Temperature – Precipitation of URTI
； Hands : Tremors (from β-agonists)
Will have NO clubbing
； Eyes : Allergic conjunctivitis
Swollen discoloured lids
； Nose : Pale, swollen mucosa
Visible inferior turbinates
； (Ears : Serous OM)
； Throat : Redness, exudates
； Cervical lymphadenopathy
； Inspection :
？ Increased AP diameter (barrel chest)
？ Harrison’s sulcus
； Palpation :
？ Chest expansion
？ Apex beat
？ Trachea central?
； Percussion should be resonant, unless:
？ Chest infection – Dull
？ Pneumothorax – Resonant
； Auscultation :
？ Decreased breath sounds?
Test inhaler technique
PEFR – difficult in exams
1. Clinical history and physical examination (especially in infants and toddlers, who can’t follow
instructions for usual spirometry test) 2. Investigations (helpful in confirming diagnosis in children > 5 years old)
; Peak expiratory flow rate
； Reflects large airway patency
； Effort dependent, only in older kids!
； Better to have series of measurements, e.g. for diurnal variation >20% (exaggerated
compared to normal people), or before/after bronchodilator treatment
; Spirometry – Time-volume curve, Flow-volume loop
； FEV/FVC ， Obstructive pathology 1
； Cutoffs : FEV < 75%, FEV/FVC < 75% 11
； Response to bronchodilator treatment > 15%
； Provocation inhalation challenge (Methacholine) ; Allergy testing:
； Skin prick test
？ Discontinue antihistamines for > 3 days
？ Wheal of 3mm diameter, (+) erythema = positive test
？ Histamine as positive control
； RAST for specific IgE
？ Useful if taken antihistamines/extensive skin disease/anaphylaxis.
； Food challenge/avoidance
？ More for eczema, GI allergies
; Chest X-Ray - Asthma DOES NOT have CXR findings. Purpose is to exclude:
； Inhaled FB
； Chest infection
3. Establish severity (by STEP classification)
; Step 1 : Intermittent
； Day : < 1 time a week, asymptomatic in between attacks
； Night : < 2 times a month
; Step 2 : Mild persistent
； Day : > 1 time a week BUT < 1 time daily
； Night : > 2 times a month
; Step 3 : Moderate persistent
； Day : DAILY symptoms, affects daily activities, β-agonists daily
； Night : > 1 time a week
; Step 4 : Severe persistent
； Day : Continuous limited physical activity
； Night : Frequent symptoms
4. Decide if TREATMENT is ADEQUATE
; On bronchodilators only?
; If on preventer medications:
； Dosage adequate?
； What’s used? E.g. inhaled steroids, LABA, theophylline, anti-leukotrienes. ; Have the symptoms decreased with medications? Have the symptoms increased with need
to revise medications?
; Any asthma action plan (written, divided into green, yellow and red zones)
; Who follows up on the patient, and is this follow up regular? ; Teens who smoke – Counselling?