Dyspnea History-Case 1
Dyspnea History-Case 1
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. DI

 

     You are Ms. DI, a 26-year-old accountant who lives in a new condo in downtown Toronto.  You are going to see the doctor today because you have been having episodes of shortness of breath that have been increasing in frequency and severity.

 

     The episodes of shortness of breath last about 30 minutes.  The first episode occurred one month ago while you were at your boyfriend’s house: you woke up with shortness of breath and coughing (no sputum), and were only able to manage the symptoms when you stepped onto the balcony and took deep breaths.   Since then, you have had more similar episodes, and have noticed that you also sometimes experiences shortness of breath and coughing during or after your morning runs.  You have 2-3 episodes per week, and they seem to resolve with rest. 

  

   You are in good health, and exercise regularly.  You drink 5 drinks per week and smoke occasionally, in a social situation (1-2 cigarettes/week for about 3 years). You do not take any medications and have no diagnosed allergies.  You remember that you used to sneeze a lot as a child when visiting your grandmother’s house; your grandmother has smoked a pack of cigarettes per day for as long as you can remember and owns three cats.  You have no pets but just started dating someone who has a pet cat.

 

 

Asthma: Asthma is a chronic obstructive airway disease that is characterized by hyper-responsive bronchial airways and underlying inflammation.  While it sometimes presents with a similar clinical picture to COPD, a pulmonary function test can help differentiate the two diseases as asthma should be completely, or almost completely, reversible with administration of a bronchodilator.  Asthma most commonly presents with the following concerns: dyspnea, cough, and expiratory wheeze.  For more information, see: http://www.respiratoryguidelines.ca/sites/all/files/2012_CTS_Asthma_%20Executive_%20Summary.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

Asthma symptoms may appear after exposure to a certain trigger.  Common triggers include exercise, cold weather, and allergens.

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

 Asthma symptoms often peak at night and in the early morning.

               

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

Asthma symptoms often peak at night and in the early morning.

               

General Questions

Associated symptoms

Asthma is most commonly associated with a cough (non-productive or clear sputum) and an expiratory wheeze.

               
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).

       
Exposures (includes: work exposures, travel exposures, infectious contacts)

Asthma can be triggered by occupation exposure to certain chemicals and dusts.  Additionally, introduction to a novel allergen or pathogen during travel may cause respiratory symptoms.

               
Personal/Family history of asthma, allergies, and eczema

The "allergic triad" consists of three diseases: atopic dermatits (eczema), allergic rhinitis (hay fever), and allergy-induced asthma.  When these conditions appear together, it indicates that the person may be predisposed to developing certain allergic hypersensitivities.

 

               

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, hospitalizations, and immunizations, 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)
               
Alcohol (includes: quantify)
               
Drugs (includes: types, frequency of use, quantity, methods)
               
Living arrangement
               
Relationships & children
               
Hobbies & interests
               
Pets

Asthma can be triggered by exposure to furry animals, such as cats.

       
Occupation

Asthma can be triggered by occupation 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.