Dyspnea History-Case 2
Dyspnea History-Case 2
Please assess the student as they take the following patient history.
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.

 

Case:  Ms. DP

 

     You are Mr. DP, a 57-year-old engineer.  You live in Mississauga with your wife and have two adult children who live on their own.  You are going to the doctor today because you have noticed that, for the last few months, you feel unusually short of breath during your Saturday morning walks with your wife.  You are concerned because the shortness of breath is getting exceedingly more severe and frequent.

 

     You only notice the shortness of breath during periods of physical exertion.  The episodes normally occur about 10 minutes into your walk, and you can manage your symptoms by sitting down and taking a break or slowing down your walking pace.  You do not wheeze during these episodes, nor do you experience any chest pain, chest tightness, or palpitations during the episodes.  You have not had any episodes of shortness of breath while at rest, or during the night.  You have not had any recent illness, fever, or notable changes in weight or energy level.  You have had a “smoker’s cough” for the last 5-6 years, and note that you occasionally produce clear or yellow sputum with your cough, especially in the morning.  

 

     You were active as a younger man, but you have trouble finding time to be physically active and are now overweight. You drink a glass of wine with dinner on the weekends and smokes 1 pack of cigarettes per day (for 25 years).  You “know you should quit”, but you’re much too busy to find the energy to.  You take ramipril for high blood pressure.  You take no other drugs, have no other diagnosed medical illnesses, and have no diagnosed allergies.

 

    

 

Chronic Obstructive Pulmonary Disease (COPD):  COPD describes chronic obstructive airway disease that includes subtypes emphysema, chronic bronchitis, and chronic obstructive asthma.  COPD is characterized by progressive airflow limitation that is associated with a chronic inflammatory response in the airways.  Changes to the airways are irreversible but preventable and can be treated.   COPD most commonly presents with the following symptoms: dyspnea with activity, wheezing, fatigue, productive cough. (see: http://www.respiratoryguidelines.ca/sites/all/files/CTS_COPD_Guidelines_2007_Update.pdf)

 

 

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self to patient
       

IDENTIFYING DATA- The student should inquire about the following:

Name of patient
       
Age of patient
       

CHIEF CONCERN - The student should inquire about the following:

Nature of concern
       
Duration of concern
       

HISTORY OF PRESENT ILLNESS - The student should inquire about the following:

Dyspnea

Onset of dyspnea
               
Alleviating factors of dyspnea
               
Exacerbating factors of dyspnea
               
Quality of dyspnea
               
Severity of dyspnea
               
Timing of dyspnea

Dyspnea associated with COPD normally begins as exertion-related, but may develop into dyspnea at rest if not treated properly.

               

General Questions

Associated symptoms

Common symptoms associated with a COPD presentation include: expiratory wheeze, productive cough, and fatigue.

               
Previous similar episodes (includes: investigations related to these episodes)
               
Impact on quality of life and work performance
               
Family history of heart disease, COPD, asthma/allergies
               

PERTINENT POSITIVES AND NEGATIVES - The student should inquire about the following:

Constitutional Symptoms

(Differential diagnosis includes: cancer, anemia, pneumonia, and other systemic diseases)

Weight change
       
Fever
       
Fatigue
       
Change in appetite
       

Respiratory Symptoms

(Differential diagnosis includes: obstructive lung disease [COPD, asthma], restrictive lung disease [interstitial lung disease], cancer/mass effect)

Chest tightness
       
Wheezing

Expiratory wheezes are normally generated from problems in the lower airway (below the vocal cords), while inspiratory wheezes are normally generated by problems in the upper airway (above the vocal cords).

       
Cough (includes: productivity, quality/quantity of sputum, blood in sputum)

Individuals with COPD often complain of a productive cough that is worse in the morning.  They normally produce clear sputum, though it can become purulent during an exacerbation.  Individuals with COPD should not produce sputum with a significant amount of blood; this symptom would require a thorough work-up to determine the source of the blood.

               
Exposures (includes: work exposures, travel exposures, infectious contacts)
               
Personal/Family history of asthma, allergies, and eczema
               

Cardiac Symptoms

(Differential diagnosis includes: myocardial infarction, congestive heart failure, other myocardial dysfunction)

Dyspnea at night (paroxysmal nocturnal dyspnea)

Paroxysmal nocturnal dyspnea (PND) can occur in those with poor left-heart function.  After lying down, fluid redistribution due to gravity demands more activity from the left and right sides of the heart.  In those who cannot match left-hear function to right-heart function, pulmonary congestion occurs, leading to the symptom of PND.

       
Dyspnea when lying down (orthopnea)

Orthopnea can occur in those with poor left-heart function when, after lying down, fluid redistributes due to gravity and causes pulmonary congestion.  It should resolve shortly after resuming a more erect body position.

       
Palpitations
       
Chest pain
       
Personal or family history of heart attack, diabetes, heart failure
               

Psychiatric Symptoms

(Differential diagnosis includes: anxiety)

Nervousness/Anxiety
       
Recent major changes in life/major stressors
       
Personal/family history of depression or other mental illness
               

MEDICATIONS AND ALLERGIES- The student should inquire about the following:

Medications (includes: prescription, over-the-counter, and herbal/alternative medicines)
               
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)
               

PAST MEDICAL HISTORY - The student should inquire about the following:

Though it is important to ask about diagnosed medical illnesses, surgeries, and hospitalizations, this is not relevant for this case.

SOCIAL HISTORY AND HABITS - The student should inquire about the following

Smoking (includes: pack years; if they quit, when)

~80% of those with COPD have a history of cigarette smoking.  There is a dose-reponse relationship between cigarette smoking and COPD development.  The single best predictor of COPD development is a history of over 40 pack years of smoking

               
Exposure to second-hand smoke
               
Drugs (includes: types, frequency of use, quantity, methods)
               
Alcohol (includes: quantify)
               
Living arrangement
               
Relationships & Children
               
Hobbies & Interests
               
Occupation

COPD can be triggered by occupational exposure to certain chemicals and dusts.

               

REVIEW OF SYSTEMS-  The student should inquire about the following:

Though it is important to perform a thorough review of systems when seeing patients, this is not relevant for this case.