Respiratory Cases Flashcards
You are a 79y.o. lady who lives at home alone independently. Your daughter lives with her family up the central coast. You are a widow of 20 years.
You’re seeing the doctor today because you have a cough for the last 3-4 weeks. It is productive of sputum. It is white-yellow in colour, no blood. It is disrupting your sleep despite trying to sleep upright in an armchair.
You feel quite tired. You’ve lost your appetite. You haven’t noticed any fevers.
You’ve had 1 course of antibiotics already and you don’t think it did any good.
You’re an ex-smoker of 15 years but you have a past history smoking from age 17.
Your background medical history – high blood pressure, high cholesterol, chronic obstructive pulmonary disorder
You take medications for your blood pressure, cholesterol and puffers for your COPD. You haven’t experienced any significant weight loss.
Once the doctor has finished the history, they will summarise what they have found back to you. You can provide feedback about what important information they have missed. Together discuss what physical examination could be performed, the possible diagnosis, investigations that would support/refute those diagnoses and management goals for the patient.
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Jane is a 26 year old woman presenting with chest pain.
She works in retail, is a non-smoker, does not drink more than 2 standard drinks on one occasion, no recreational drugs and leads a healthy lifestyle with her diet and exercise. She lives with her parents and younger siblings.
There is no significant family history.
Presenting complaint
“I’ve got a weird pain in my chest and just wanted to check it wasn’t anything serious.” Case information
Your name is Jane. You are 26 years old.
History of presenting complaint
Site: You have left sided chest pain, under the arm pit.
Onset: It started 5 days ago.
If asked what happened 5 days ago, you can tell them you had just landed in Sydney after flying home from England. You may also tell them this information if they ask about any recent long haul travel.
If asked, no history of trauma.
Character: It is a pleuritic chest pain, and is sharp in nature.
Associated symptoms: If the student asks if there are any associated symptoms, please ask them “Like what?”
You may volunteer that you feel a bit nauseous from the pain.
They should ask specifically for shortness of breath or cough. You have a dry cough. You are slightly breathless especially with the stairs at home.
If asked about runny nose, sore throat you can tell them that yes, a few days before you got on the plane home from England you had runny nose, sore throat, wet cough and fatigue (so you slept much of the flight home).
If asked, you have also noticed right calf pain and a bit of swelling.
Time: The pain is there all the time.
Exacerbating and relieving factors: It is worse after a coughing fit, laughter, exercise and with a deep breath. Nothing makes it better.
If asked if you have tried anything, you can tell them that you tried Panadol but it had minimal effect. Ventolin doesn’t help and it doesn’t feel like an asthma attack.
Severity: The pain is not too bad.
The student should ask you about severity. You would rate it 6 out of 10 and that it is strong enough to be a constant bother you.
If asked: You’ve never had this pain before.
If asked about your thoughts: You hope it’s just a muscle pain from coughing so much from your recent cold, but you’re also a bit worried that it doesn’t seem like a simple muscle pain.
Past medical history
Polycystic ovarian syndrome
Asthma on preventer puffers and as needed ventolin
Medications
Preventer puffer for asthma As needed ventolin
The contraceptive pill
Social history (given to student)
You work in retail, are a non-smoker, do not drink more than 2 standard drinks on one occasion, no recreational drugs and lead a healthy lifestyle with your diet and exercise. You live with your parents and younger siblings.
Family history (given to student)
There is no significant family history.
Questions
1) Think about what physical examination would be performed.
These were the examination findings:
Heart rate 120bpm
Blood pressure 90/60 mmHg Temperature 37.5°C Respiratory rate 30 bpm
Talking in short sentences. Symmetrical chest wall expansion. Resonant to percussion. Vesicular breath sounds.
Right calf swelling and pitting oedema, warmth and tenderness.
2) Based on history and examination, what differential diagnoses are you thinking of?
3) What would you tell the patient about their symptoms, signs, diagnosis and severity of illness? What would you advise this patient in regards to medical assessment?
Some things to think about about
- Can you explain the calf pain (if not elicited on history, you can tell the student)?
- What factors contributed to this presentation/illness?
- Can you explain the pleuritic left sided chest pain?
- What do you think about the vital signs?
- Do they need to see someone medical today?
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