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Mr. Raja - (Shortness of Breath and Cough) : History of Present Illness

Mr. Raja presented with a 4 week history of intermittent shortness of breath and cough. He reported low grade fever, night sweats, and weight loss. He works as a construction worker and smokes 10 cigarettes per day. On examination, he was coughing and wearing a mask. His medical history revealed a penicillin allergy but no history of tuberculosis, pneumonia, or other illnesses. The doctor's objective is to demonstrate proper history taking for respiratory diseases and determine if Mr. Raja has tuberculosis or another chest infection.

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34 views3 pages

Mr. Raja - (Shortness of Breath and Cough) : History of Present Illness

Mr. Raja presented with a 4 week history of intermittent shortness of breath and cough. He reported low grade fever, night sweats, and weight loss. He works as a construction worker and smokes 10 cigarettes per day. On examination, he was coughing and wearing a mask. His medical history revealed a penicillin allergy but no history of tuberculosis, pneumonia, or other illnesses. The doctor's objective is to demonstrate proper history taking for respiratory diseases and determine if Mr. Raja has tuberculosis or another chest infection.

Uploaded by

hafizahhoshni
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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MR.

RAJA (SHORTNESS OF BREATH AND COUGH)


Age -- 39

Presenting complaint shortness of breath off and on x 4 weeks

-- cough off and on x 4 weeks

Scenario -- your chief complaint is shortness of breath and cough one month associated
with low grade fever , night sweating and weight loss.

Your profile -- construction worker, married, four children

Weight = 55 kg, height= 5 8

Your behaviour -- cough during interview, wearing mask

HISTORY OF PRESENT ILLNESS:

Onset- When did it all start?one month ago


Acute or Gradual - Did it come on suddenly?gradually , off and on
Intermittent or continuous? intermittent
Duration - is this an acute or chronic health problem? Chronic
Progression of symptoms has it gotten worse/better or remained the same?remain the same
Does it interfere with your work? - workeasily tired on exertion
Sputum amount, colour, smell, consistency, blood (haemoptysis)(small, colourless or
sometime yellowish, no smell, no blood)

Associated symptoms:
- Cough productive/non-productive?both
-Fever -- felt febrile at times, but has not measured your temperature.
-- evening rise pattern, night sweat, loss of appetite
- Wheeze ?no
- Haemoptysis ?no
- Weight loss --?yes. your clothes are loose on you
- Chest pain --?during cough
- Orthopnea ?no
- PND ?no

PAST MEDICAL HISTORY

Any similar symptoms in the past? no


Any hospital admissions? no
Any known history of TB or pneumonia, HIV, STD, DM, liver disease
PAST SURGICAL HISTORY

Any operations? - Chest drains-no


Any surgical operations?-no

IMMUNIZATION HISTORY
BCG immunization? yes

DRUG HISTORY
Any drug allergy?- yes. Penicillin allergy
Steroids(dexamethasone, prednisone)---no
Intravenous drug use--no
Traditional medicines? No

FAMILY HISTORY
Family history of tuberculosis, DM, COPD? no
Anyone currently ill in home? - pneumonia, TBno
Housing live with spouse and 4 children

SOCIAL HISTORY
Construction worker-
Smoking yes, since young(18 yrs), approx 10cigaretts/day
Alcohol yes, one bottle/day

TRAVEL HISTORY
Any travelling history? No
recent travel to places where TB is common?no

Questions to ask;

What do you think I have?

Do you think I am suffering from TB or other chest infection?

Is this serious or curable?

Objectives

To demonstrate good history taking in respiratory system diseases.

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