The University of Adelaide, Adelaide Medical School Yr 1 Clinical Practice

Year 1 Case History Maria Koufilakis

Case 13, Week 8, S1 2017

Maria Koufalakis
Female, 59
DOB: 27/01/1957
Address: 59 Jacob St Marion

Chronic Bronchitis

Overview

Most of your life you have been a moderately well person

Over the last 2-3 years you have become more and more unwell
Every winter for the last 4-5 years you get a severe cough, which always comes with green
sputum that you cough up regularly
This year you feel like you have had this condition all year and are worried that it isn’t going to
go away

Setting
GP clinic

As the story goes…

Opening line: “I’m getting really sick of this cough”

 You are coughing on and off all day most days.

 The cough is usually accompanied by thick green phlegm that can be very
embarrassing if you are out socializing. It tastes terrible.
 You are also very tired especially with the coughing
 You get a wheeze while you are walking or exert yourself at all
 Currently, you are only able to walk approx 50 –60 metres on flat ground before you
feel uncomfortably breathless
 You have never noticed any blood in the phlegm that you cough up
 You have not had a fever recently but you do have them from time to time.
 You have not experienced any chest pain
 Another doctor started you on some ‘puffers’ a while ago but you don’t feel like they do
any good at all. You have stopped taking them
 You are quite worried that you are never going to feel well again

Past History
 You had asthma as a child. The asthma went away by the time you were around 12
years old
 You had a cancer scare 10 years ago when you found a lump in your right breast. This
was surgically removed. You have regular annual check ups and have not had any
further lumps

Clinical Practice 2017 Originally written by Dr Andrew Linn

Adapted from a case by Amy Williams
The University of Adelaide, Adelaide Medical School Yr 1 Clinical Practice
Year 1 Case History Maria Koufilakis

Drug History
 Medications: No regular medications
 Allergies: Penicillin gives you a rash
 You smoke approx 10 cigarettes per day, after cutting down about 5 years ago from
20/day. You have smoked since you began work when you were 16.
 You drink 1 or 2 glasses of alcohol at functions, approximately once a fortnight.

Social history
 Your parents migrated from Greece just before you were born.
 You work as a junior primary teacher and love your work.
 You live with your husband Roberto, who you have been married to for the last 25
years
 You have 3 adult children, 1 who has moved back home recently after a recent
relationship break up.
 You love to cook and try to make healthy food for you and your husband. You love a
little treat after dinner too though!
 You have never really been into exercise and now can hardly get to the letter box
because of this cough.

Family History
 Your father passed away 15 years ago, aged 65, after a long struggle with bowel
cancer. He was a smoker
 Your mother is still living, aged 81 and is now a resident of a hostel. You visit her twice
a week. She has diabetes and high blood pressure

Systems Review
All questions answer in the negative

Diagnosis (for Tutor)

Chronic bronchitis on a background of a long smoking history

Discussion points (for tutor if time permits)

A structured approach to asking about coughs

Clinical Practice 2017 Originally written by Dr Andrew Linn

Adapted from a case by Amy Williams