What questions should be asked during the assessment of a child presenting with symptoms such as epistaxis (nosebleed), cough, and vomiting?

Key Assessment Questions for a Child with Epistaxis, Cough, and Vomiting

When assessing a child presenting with epistaxis, cough, and vomiting, clinicians should specifically focus on paroxysmal cough patterns, post-tussive vomiting, and inspiratory whooping sounds, as these are the classical characteristics that strongly suggest pertussis infection. 1, 2

Initial History Questions

Cough Characteristics

• Is the cough paroxysmal (recurrent prolonged coughing episodes with inability to breathe during spells)?
• What is the duration of cough (acute <3 weeks, subacute 3-8 weeks, chronic >8 weeks)?
• Is there an inspiratory whooping sound following coughing episodes?
• Does the cough occur in fits or bursts?
• Is the cough worse at night?
• What triggers or worsens the cough?

Vomiting Assessment

• Does vomiting occur after coughing episodes (post-tussive vomiting)?
• Is vomiting projectile or non-projectile?
• What is the frequency, timing, and content of vomiting?
• Is there any bilious or bloody vomiting (red flag sign)? 3
• Is vomiting associated with feeding or unrelated to meals?

Epistaxis Details

• Is the nosebleed unilateral or bilateral?
• What is the frequency, duration, and quantity of bleeding?
• Is bleeding associated with coughing episodes?
• Is there any history of trauma, foreign body, or nose picking?
• Does the child have other bleeding manifestations?

General Symptoms

• Is there fever present? (Absence of fever with paroxysmal cough suggests pertussis) 1, 2
• Is there any nasal congestion, rhinorrhea, or nasal discharge? 1
• Are there any ocular symptoms (itching, tearing, redness)? 1
• Has the child experienced any apnea episodes? 2
• Is there any difficulty breathing or respiratory distress?
• Has there been any change in activity level, feeding, or sleep patterns?

Exposure and Medical History

Exposure History

• Has the child been exposed to anyone with prolonged cough illness?
• Has the child been exposed to tobacco smoke or other irritants? 1
• Is there any recent travel history?
• Has the child been exposed to anyone with confirmed pertussis? 2
• Are there any known allergic triggers (seasonal, environmental, food)? 1

Medical History

• What is the child's immunization status, particularly for pertussis (DTaP/Tdap)? 2
• Does the child have any history of allergic rhinitis, asthma, or atopic conditions? 1
• Is there any history of bleeding disorders or easy bruising?
• Does the child have any chronic medical conditions?
• Is the child taking any medications (including over-the-counter)? 1

Family History

• Is there a family history of allergic rhinitis, asthma, or atopic dermatitis? 1
• Is there any family history of bleeding disorders?
• Have any family members or close contacts had recent respiratory illnesses?
• Is there any family history of sudden unexplained death? 1

Symptom Timeline and Progression

• When did symptoms first appear and in what order?
• Have symptoms been getting better, worse, or staying the same?
• What treatments have been tried at home and what was their effect?
• Have there been any periods of symptom improvement?
• What is the impact of symptoms on daily activities, sleep, and feeding?

Red Flag Assessment

• Is there altered mental status or lethargy?
• Is there severe dehydration or inability to maintain hydration?
• Is there bilious or bloody vomiting?
• Does the child have a toxic or septic appearance?
• Is there excessive irritability or inconsolable crying? 3
• Is there bent-over posture or signs of severe pain? 3

Diagnostic Considerations

The combination of paroxysmal cough, post-tussive vomiting, and epistaxis should raise suspicion for several conditions:

1. Pertussis infection: Particularly if there is paroxysmal cough (93.2% sensitivity) with post-tussive vomiting (60% sensitivity in children) and absence of fever 1, 2

2. Allergic rhinitis with post-nasal drip: If there are seasonal patterns, nasal congestion, ocular symptoms, and family history of atopy 1

3. Viral respiratory infection: Common in children, but typically resolves within 7-14 days 4, 5

4. Foreign body: Consider especially with unilateral epistaxis and persistent cough 1

Clinical Pearls and Pitfalls

• Pertussis should be considered even in fully immunized children, as 85.9% of children with confirmed pertussis in one study had been fully immunized 6
• The absence of classic "whoop" does not rule out pertussis, especially in partially immunized children or adolescents 2
• Cough from pertussis may persist for weeks to months, with 85% of children with pertussis still coughing at 2 months compared to 48% of children with other causes 6
• Initial viral symptoms may evolve into bacterial complications, so reassessment is important if symptoms persist beyond expected timeframes 5
• In children with persistent cough (>2 weeks), pertussis testing should be considered regardless of immunization status 2, 6

By systematically addressing these assessment questions, clinicians can more accurately diagnose the underlying cause of epistaxis, cough, and vomiting in children and initiate appropriate management strategies.