Dyspnea History-Case 3
Dyspnea History-Case 3
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. DL

 

You are Mr. DL, a 51-year-old single man.  You are currently not working, though you occasionally pick up odd jobs as a carpenter.  You live on your own in downtown Toronto and have no children.  You have been experiencing shortness-of-breath, almost constantly, for the last two days.

 

Over the last two days, you have experienced fever on and off (max. was 38.4 °C orally), as well as shortness-of-breath and a stubborn cough.  Your shortness of breath is present most of the time, though it is made worse with physical exertion.  You have not found a way to make your shortness-of-breath go away.  Your cough is very disruptive and has been getting worse.  The cough often produces teaspoon-like volumes of yellow sputum with very small amounts of blood. You do not notice any wheezing with breathing, nor do you notice any chest pain, chest tightness or palpitations. 

 

About two weeks ago, You were ill with “the flu”:  for three days, you were in bed with a fever, fatigue, nausea and a poor appetite, and vomited on 3 occasions.  Though your illness resolved, you began to feel ill once again two days ago with a different set of symptoms.

 

You are not very physically active.  You drink at least 5 alcoholic drinks a day and are interested in receiving help for alcohol dependence.  You smoke ½ a pack of cigarettes per day (for 35 years).  You are not on any medications and do not have any diagnosed medical conditions or allergies, though you have not visited a doctor for over 8 years. 

 

Community-Acquired Pneumonia (CAP): CAP describes an infection of the lung tissue, most commonly by bacteria (most common =S. pneumonia) or viruses (most common= influenza virus). As the lungs possess natural defences to avoid infection, CAP normally arises in those with impaired immune function (due to previous/concurrent infections or diseases), impaired lung defences (due to poor cough reflex or mucociliary transport), or increased risk of aspiration (due to poor consciousness or neurological conditions).  The gold standard of diagnosis of CAP is the presence of an infiltrate on a plain chest X-ray with supportive clinical and microbiological features.  CAP most commonly presents with the following symptoms: cough, fever, pleuritic chest pain, dyspnea, and sputum production. (see: http://www.respiratoryguidelines.ca/sites/all/files/Community-acquired-Pneumonia-Guidelines-2000.pdf)

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self
       

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
               
Severity of dyspnea
               
Timing of dyspnea
               

Cough

Onset of cough
               
Alleviating factors of cough
               
Exacerbating factors of cough
               
Quality of cough (includes: productivity, quality/quantity of sputum, blood in sputum)
               
Severity of cough
               
Timing of cough
               

General Questions

Associated symptoms

In addition to the symptoms more commonly associated with CAP (such as: productive cough, fever, pleuritic chest pain, and dyspnea), CAP can also present with nausea, vomiting, diarrhea, chest pain, chills, and mental status changes.

               
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
       
Nausea/Vomiting/Diarrhea
               

Respiratory Symptoms

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

Chest tightness
       
Wheezing
       
Pleuritic chest pain

Pleuritic chest pain is often described as a sharp/stabbing pain that is made worse with heavy breathing or coughing. 

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

Those with bacterial pneumonia normally produce more sputum than those with pneumonia caused by other pathogens.  It is not uncommon to find small amounts of blood in the sputum of those with pneumonia. 

               
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 or 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:

Recent history of immunocompromised state (possibly due to: recent illness [flu, cold, etc...], chronic illness [HIV, rheumatic disease], poor self-care
               

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

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

Cigarette smoking may alter a person’s inflammatory response and can damage the mucociliary transport in the airways; both of these changes may predispose a person to developing CAP. 

               
Drugs (includes: types, frequency of use, quantity, methods)
               
Alcohol (includes: quantify)

Alcohol is associated with a higher incidence of pneumonia, likely due to a combination of factors that include poorer general health and immune capacity, increased aspiration risk, and various socioeconomic barriers.  Additionally, those who abuse alcohol are more likely to encounter complications and a slow recovery from CAP.

               
Living arrangement
               
Relationships & Children
               
Hobbies & Interests
               
Occupation
               

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.