Clinical Vignettes
Patient Info
You are a medical student on placement at a general practice. Your next
patient is Mr Jones a 75 year old gentleman who has come to discuss his
shortness of breath.
Please take a history from this patient.
Role play info
Patient 1
Name: Mr Ricky Jones
Age: 75
PMH



Asthma when a child
Hypertensive
Hyperlipidemia
Operations
PC

Short of breath







None
Social History
HPC


Progressively worse SOB over
the last month
Dry cough has become worse
over last 6 months
Small wheeze noticed in the
mornings
No sputum brought up
o Reveal haemoptysis
ONLY if directly asked
Feels a tightening of chest wall
as well
Exercise tolerance reduced
from 100m walking to 15m
walking in 1 year
Has had problems sleeping,
and feels tired all the time
Has not noticed weight loss
(but if prompted he has
dropped a belt size)



Smoked 15 a day for 50 years
Does not drink
Lives with wife who has carers
2x a day
DHx




Anti-hypertensives
Statins
Paracetamol for the chest
pain
Allergies – hay fever
Concerns

Finding it increasingly difficult
to look after his wife with his
SOB. Does not want to let her
down.
DDx
Investigations

Lung cancer

FBC

TB

Sputum Gram stain, culture &

Lung abscess

COPD

CXR

Vasculitis (Wegner’s)

CT-chest

ILD

Bronchoscopy

CHF
Cytology
Patient 2
volunteer this info unless
Name: Mr Benjamin Walker
Age: 76
directly asked)

Has a cough that won’t go
away, especially at night
PC





No haemoptysis

Swelling of his ankles
First noticed it 3 weeks ago

No leg pain
when walking to the local

Feeling very tired and weak
shop to get a newspaper

Otherwise well
It has been getting

Normally leads an active life
progressively worse

Eats a take away 2-3 times a
Now unable to walk until the
end of drive way because of
SOB

Cannot sleep flat has
week

Does not enjoy fruit and veg
PMH
increased number of pillows

Hypertensive
up to 3 from 1 (Do not

Hyperlipideamia
volunteer this info unless

MI 8 years ago
directly asked)

over last 2 weeks
Short of breath
HPC

Producing pink frothy sputum
Has woken up gasping with air
in the middle of the night a
number of times (Do not
Social History

Lives alone in a 2 – story house
(cannot get up the stairs
without being short of breath),
has to pause for breath.

Booked a holiday to Australia
Normally capable and able to
in 3 months’ time to see
look after himself
brother. Worried he won’t be

Ex-pilot now retired
able to make the trip.

Smokes 12 a day for the last 60
years

Alcohol socially 1-2 pints a
week
DHx

Antihypertensives, and statins

NKDA (no known drug
allergies)

No allergies
FHx
DDx

Heart failure (LVF)

CCF

Cardiac Valvular disease

Pulmonary fibrosis

COPD
Investigations

FBC

CXR

Father died of an MI ages 62

ECG

Mother died of old age

Echo

Brother who is well

BNP

No children
Concerns
Mini cases
Give you a flavor for common PC’s and the common DDx and Dx.
30 yo M presents with shortness of breath, cough, and wheezing that worsen in
cold air. He has had several such episodes in the past 4 months.
Differential

Asthma

GORD

Bronchitis

Pneumonitis

Foreign body
56 yo F presents with shortness of breath and productive cough that lasts for at
least 3 months each year in the past 2 years. She is a heavy smoker.
Differential

COPD—chronic bronchitis

Bronchiectasis

Lung cancer

Tuberculosis
58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with
purulent yellow sputum. He is a heavy smoker with COPD.
Differential

Pneumonia

COPD exacerbation (bronchitis)

Lung abscess

Lung cancer

Tuberculosis

Pericarditis
25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she
had a sore throat and runny nose.
Differential

Atypical pneumonia

Reactive airway disease

URI-associated cough (“postinfectious”)

Postnasal drip

GORD
65 yo M presents with worsening cough for the past 6 months accompanied by
hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
Differential

Lung cancer

Tuberculosis

Lung abscess

COPD

Vasculitis (ie, Wegener)

Interstitial lung disease

CHF
55 yo M presents with increased dyspnea and sputum production for the past 3
days. He has COPD and stopped using his inhalers last week. He stopped
smoking 2 days ago.
Differential

COPD exacerbation (bronchitis)

Lung cancer

Pneumonia

URI

CHF
34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied
by weight loss, fatigue, night sweats, and fever. She has a history of contact with
tuberculosis patients at work.
Differential

Tuberculosis

Pneumonia

Lung abscess

Vasculitis

Lymphoma

Metastatic cancer

HIV/AIDS

Sarcoidosis
35 yo M presents with shortness of breath and cough. He has had unprotected
sex with multiple sexual partners and was recently exposed to a patient with
active tuberculosis.
Differential

Tuberculosis

Pneumonia (including Pneumocystis jiroveci)

Bronchitis

CHF (cardiomyopathy)

Asthma

Acute HIV infection
50 yo M presents with a cough that is exacerbated by lying down at night and
improved by propping up on 3 pillows. He also reports exertional dyspnea.
Differential

CHF

Cardiac valvular disease

GORD

Pulmonary fibrosis

COPD

Postnasal drip