Case histories exercises from the

Clinical Skills Education Centre in

Queen´s University, Belfast

Case histories
Medicine 2018-2019

Brian Crilly/ Patricia Elhazaz Walsh

 1

1. Cardiovascular histories
1.1 Cardiovascular checklist
 2

1.2 Example 1: Mr Johnson, 63 year old male

1. What do you think the diagnosis is?

2. What lifestyle advice would you give this patient?

 3

1.3 Example 2: Heart failure history, Mrs Jones, Age 64

 4

Questions

1. What is causing the shortness of breath?

2. What other information would you need?

3. What should you do for this lady?

Answers

1. Most likely heart failure. She is describing paroxysmal nocturnal dyspneoa.

2. You will need to get the details of what medication she is taking – doses and frequency

3. She will need further investigation – blood tests, ECG, CXR, echocardiogram. You will

also need to consider her social needs. Can she stay at home? Is there any extra help you can

offer her? Would a commode downstairs help?

 5

1.4 Exercise 1. Write the questions in the following cardiovascular history:

PC What brought you to the doctor today? I’ve been having this fluttering in
my chest

HPC T Tell me more about this? It comes and goes

My heart feels like it is fluttering

It’s really uncomfortable

2 or 3 times per day

10‐ 15 minutes
No, there is no pattern to it.

No – I’ve even got it lying down

resting

I normally just rest but I don’t

know if that helps

Actually I do get a bit short of

breath

I had a heart attack about 3

months ago

Not apart from the heart

Yes I have high blood pressure

which is controlled on medication
and I’m on
cholesterol medication

FH Not that I can think of

No I’m the first

No

No
 6

I work in the supermarket. Usually

on the tills

I’m living with my daughter since

I had the heart attack.

I’m quite frightened about it. I

don’t really like being on my own.

D(drug/medical)H The doctor has given me BP

medications and statins for my
cholesterol. I also take
aspirin

Occasionally paracetamol

1.5 Exercise 2: Role play with another student taking a medical history from the
following patients:

Name Mr Bobby Brown

Age 53

P/C:

• Attends surgery with 3 week history of mild, intermittent central chest pain
going to the jaw.
• Character: He says it is like a heavy weight.
• It is associated with sweating and breathlessness
• It generally comes on when climbing hills or rushing but is never there at rest.
• It is eased after a few minutes by resting.
• It is getting more frequent – occurs at least once a day now, and slightly more
severe.
• It has caused him to give up taking any exercise.

PMH: High blood pressure

Recently told cholesterol borderline.

SH: Married, lorry driver, smokes 30/day, drinks 20 pints a week. Diet – eats in
 7

transport cafes- fish & chips

FH: Father had heart attack at 46; brother had bypass last year, mother with
diabetes.

Medication: Tablet for blood pressure- doesn’t take it often as it makes him pass
more urine.

Questions:

• What is the likely cause of the pain? Why? What lifestyle changes would
you suggest?
• What tests do you think he needs?

Name Mrs Mary Black

Age 34

P/C

• Attends surgery with constant severe pain left chest pain going to left
shoulder.
• Started suddenly after lifting baby daughter this morning.
• Sharp stabbing pain.
• Worse with movement, lifting and touching chest wall.
• Only eased by sitting still.
• Feels very anxious. Aware of her heart beat. Thinks she may be having a
heart attack.
PMH: Nil

SH: Teacher, married, non smoker, 2 glasses wine per week.

Medication : contraceptive pill

FH: Father died suddenly of a heart attack aged 42- he had been a smoker.

• What is the likely cause for the pain?

• Does she require investigations?
• What treatment would you advise?
 8

2. Respiratory histories
2.1 Respiratory checklist
 9

2.2 Respiratory histories

Respiratory histories
Kindly produced by Dr Heather Carlisle
March 2007

Name: Peter Brown

Age: 21 yr old
Occupation: Student

Presenting complaint:
SOB and wheeze over the last 2 months

History of presenting complaint:

SOB and wheeze on playing football for past 2 months, getting worse. Bit breathless on
climbing stairs, no problems at rest. Occasionally wakes up wheezy at night. Chest
tightness on exertion 2 months, central chest dull ache, not severe, no radiation, relieved
by rest. Dry cough on exercise and at night. No sputum, no haemoptysis. Normal energy,
no weight loss

Past medical history:

No asthma, no TB, heart problems, chest surgery, has mild hay fever.

Drug history:
Nasal spray for hay fever. Tried sister’s blue inhaler once and it helped wheeze, no
allergies to medication

Social history: smokes 5/day for past 3 years, art student, never worked with asbestos
but uses paint at college. 5 pints beer on Fridays and Saturday nights, no
pets/birds/pigeons. Effect - has had to stop playing football for team.

Family History: Sister asthmatic, brother eczema, no TB.

Questions
• What is likely diagnosis?
• What test could you do to help make the diagnosis?
 10

Name: Emily Green

Age: 64
Occupation: Retired factory worker

• SOB and wheeze for past 5 years, getting worse, now difficulty walking 100yards
on flat to the shops and doing housework. No breathlessness at night or probs
lying flat
• Central chest tightness on exertion, no radiation, not severe, eased with rest.
• Cough- chronic “smoker’s” cough for years, getting worse. Brought on by exercise,
productive of small amounts of greyish sputum, no blood. Frequent chest
infections “colds always go to my chest”, when sputum is thick and green and
increases in volume.
• Lost half a stone in past year, feels tired.
• Effect- has stopped going to shops
• PMH- told by GP has bronchitis No heart probs, chest surgery, TB
• Drugs- blue inhaler for 5 yrs- doesn’t really help, gets courses of antibiotics and
steroids for chest infections, no allergies
• FHX- father had TB
• SH- Smoker 10/day for past 5 years but before that smoked 20/day since mid 20s,
worked in factory- very dusty, never kept pets or birds

What is likely diagnosis?

What is likely underlying cause(s)?

 11

2.3 Exercise 1: Write the RESPIRATORY HISTORY QUESTIONS for Emily Green

1. How can I help you? What brings you in to see me today?

SOB and wheeze, difficulty walking

2. How long have you had this problem?/ When did this problem start?

Past 5 years

3.

No breathlessness at night

4.

No probs lying flat.

5.

Central chest tightness

6.

On exertion

7.

No radiation

8.

Eased with rest.

9.

cough for years

10.

Productive

11.

Brought on by exercise

12.

Small amounts of sputum.

13.
 12

greyish

14.

No blood.

15.

Frequent chest infections

16.

Lost half a stone

17.

Had stopped going to shops

18.

PMH- told by the GP has bronchitis, no heart probs, chest surgery, TB

19.

Drugs. Blue inhaler for 5 years

20.

Doesn´t really help

21.

No allergies

22.

Father had TB

23.

Smoker 10 day for past 5 years but before that smoked 20/day since mid 20s

24.

Worked in a factory

25.

Never kept pets or birds

 13

2.4 Respiratory history role play: Patient

Karen Campbell, 76 year old female
 14

Respiratory history role play: Doctor

Karen Campbell, 76 year old female
 15

3. Gastrointestinal histories
3.1 Gastrointestinal checklist 1
 16

3.2 Gastrointestinal checklist 2

 17

3.3 Gastrointestinal history. Example 1

 18

3.4 Gastrointestinal history. Example 2

 19

3.5 Gastrointestinal role play: Doctor

NAME Tom Smith

AGE 19
OCCUPATION Student

PRESENTING COMPLAINT
1. What brought you to the doctors today?
2. How long has it been present for?
3. Any inquiry? onset/pattern

HISTORY OF PRESENTING COMPLAINT

4. How did the pain start?
5. Where is the pain?
6. Does the pain move anywhere?

7. Can you describe the pain?

8. Does anything make it worse?

9. Does anything make it better?
10. Have you noticed anything else different since
this pain started?
11. Have you vomited?
12. Have you noticed any change in your bowel
habit?
13. Is this a change for you?
14. Do you have any pain passing motions?
15. Have you noticed any change in your appetite?
16. Have you had a high temperature?
17. Have you notice any blood in the motions?
18. Any change to colour of stools? Black?
19. Any mucus?
20. Ever feel you want to pass but nothing
happens?
21. Any weight loss?; Dysphagia?;
Indigestion?Lethargy?

PAST MEDICAL HISTORY

22. operations in the past?
23. FAMILY HISTORY (General & targeted)

24. SOCIAL HISTORY

25. DRUG HISTORY
Summary
 20

3.4 Gastrointestinal role play: Patient

NAME Tom Smith

AGE 19
OCCUPATION Student
PRESENTING COMPLAINT

1. “I have pain in my tummy doctor”

2. “It just started this morning”
3. “I felt well yesterday”

4. “It woke me from my sleep at 6am”

5. “Its low down on the right side”
6. “Initially it was around the centre of my tummy but now it’s just on
the right side”
7. “Initially it was just cramps but now its constant and very severe”

8. “If I move that definitely makes it even worse”

9. “No not really”
10. “Yes, I have been feeling sick this afternoon
11. “No”
12. “Only today - my bowels have moved twice and were loose”
13. “I am normally quite regular –every day or two”
14. “Not really but my tummy pain is really constant now”
15. “Yes, I haven’t felt like eating anything at all today”
16. “Yes, I have started to feel feverish this afternoon”
17. “No”
18. “No”
19. “No”
20. “No”
21. Nil

22. Fit & well – never go to my GP. No have never had any pain
like this in the past.
23. “Not that I am aware of” My parents are still alive.
24. “Teetotal; Non smoker; Studying law” “Unable to go to lectures
today”
25. Nil“ NKDA
 21

4. Headache histories
4.1 Headache checklist
SKILL DETAIL CHECK

INTRODUCTION Introduce yourself & identify the patient’s details.

CONSENT Gain informed consent from the patient

PRESENTING COMPLAINT Reason for patient seeking medical advice; Onset of symptoms?

HISTORY OF PRESENTING
Further exploration of the presenting complaint.
COMPLAINT
• Site (unilateral / bilateral / neck / around eye?)
-pain history • Prodromal symptoms?
• Character (Sharp / dull / ”tight band” / throbbing?)
• Duration (Seconds/minutes/hours/days/weeks?)
• Frequency (One off / intermittent or episodic / progressive / constant?)
• Onset (Acute/gradual?)
• Severity (e.g. Score between 0-10; 10 = “worst headache ever”)
• Radiation (to other parts of the head / eye / neck)
• Aggravating factors (Leaning forward /bright lights / sound / lying flat?)
• Relieving factors (standing / sitting / lying still?)
• Special times (Morning / menses / when overtired / stress)
• Associated (Vomiting / drowsiness / temp / rash etc)

• Cognitive / higher function changes?

• Mood / mental state alteration?
• Visual disturbances?
• Speech alteration?
• Episodes of loss of consciousness?
• Seizures?
• Sensory symptoms (numbness; pins & needles?)
• Motor symptoms (involuntary movements; reduction of power?)

PAST MEDICAL HISTORY General enquiry; also specific enquiry

DRUG HISTORY Any prescribed medication? Over the counter medication? Allergies?

FAMILY HISTORY General enquiry; Also targeted enquiry?

SOCIAL HISTORY Occupation / alcohol / smoking history Effect of symptoms on lifestyle / work

SYSTEMATIC QUESTIONING
Allows patient to confirm that you have the right story
SUMMARIZE TO PATIENT
 22

4.2 Headache role play 1: Doctor

NAME: Mrs Norma Smith

AGE: 42
OCCUPATION: Shop assistant

PRESENTING COMPLAINT:

1. D: Mrs Smith, What`s the problem that has brought you to the Dr?

HISTORY OF PRESENTING COMPLAINT:

2. D: When did you start to get the headaches?

3. D: Is the pain constant or does it come and go?

4. D: How often would they be occurring now?

5. D: Is the pain now, similar to those headaches you have had in the past?

6. D: How long would the headaches last?

7. D: Where is the pain?

8. D: Can you describe the pain?

9. D: Does it go anywhere else?

10. D: How severe is the headache…?

11. D: Have you noticed anything else?

12. D: Have you noticed any problems occurring before the headache starts?

13. D: Any other change in your eye-sight ? Any double vision ?

14. D: Does anything bring the pain on? Or does anything make it worse?

15. D: Does it stop you working?

16. D: Anything make it better?

 23

17. D: Is the pain better or worse at any time of the day or night?

18. D: Does the pain disrupt your sleep?

19. D: Have you taken anything for the pain?

20. D: Is there anything in particular you are worried about?

21 D: Do you have any weakness or numbness in your arms or legs? Do you suffer from any
pins & needles? Do you have a tremor? Have you ever suffered from any fits, faints or
blackouts? Have you noticed or has anyone else noticed a change in your behaviour?

22 D: How has your mood been? -

PAST MEDICAL HISTORY

23 General enquiry

24. D: Have you ever had a head injury or recent lumbar puncture? Have you ever been
diagnosed with…migraine headaches? High BP? Shingles? Any cancer?

25 FAMILY HISTORY

26 SOCIAL HISTORY

27 DRUG HISTORY

Headache role play 2: Patient

NAME: Mrs Norma Smith

AGE: 42
OCCUPATION: Shop assistant

PRESENTING COMPLAINT:

1. P: I have been getting a lot of headaches over the past few months”

HISTORY OF PRESENTING COMPLAINT:

 24

2. P: “I have had occasional headaches in the past…..but they were never bad enough to see
the GP. ….but over the past 6 months my headaches have got much worse.”

3. “It comes and goes.”

4. “They have been coming more often over the 6 months and over the past month or so, I
have had a headache most weeks now”

5. “It would be, but I have never had headaches which are as bad and they would only come
a couple of times a year in the past – I have missed a few days off work over the past few
months”

6. “1-2 days, then goes away”

7. “It is over the right side of my face and goes behind my eye”

8. It just throbs!”

9. “No”

10. “8/10 at its worst”

11. “Yes, I sometimes feel sick”

12“Yes, I have seen some zigzag lines on a number of occasions…..then they just disappeared
after ½ hour and the headache came”

13. “No”

14 “Initially I thought it was caused by the bright lights at work….they do make it worse. But
now for whatever reason, it tends to happen when I get a few days off work”

15. “Yes, some days I have had to leave work”

16. “I find resting in a dark quiet room helps”

17. “No”

18. “No”

19. “I have some ease with ibuprofen”

 25

20. “Well yes, I do worry about my father…he had a stroke last year, lives on his own and
refuses to have any outside help at home…”

21 NIL

22. My mood has been ok

PAST MEDICAL HISTORY

General enquiry
23 You do not suffer from any illnesses, you have never been hospital and never had any
operations.
Specific enquiry
24 NIL
FAMILY HISTORY
25Your father had a stroke – “clot”- age 75. Nil else and no FH cancer. Only if asked. Your
older sister suffered migraines in her teens which settled.

SOCIAL HISTORY
26 “Teetotal. Smoke 20 cigs/day for 25 years. Married with 2 teenage children” “The pain
really stops me from doing anything for a day or two –I am even missing work recently”

DRUG HISTORY
27 If asked. I am not on any regular medicines.
I buy the ibuprofen just from the chemist. No allergies
I am not on contraception as my husband has had a vasectomy.
 26

4.3 Headache case history 2

NAME: Mrs Georgina Black

AGE: 30
This patient attends the GP Surgery:
PRESENTING COMPLAINT:
Mrs Smith, What`s the problem that has brought you to the Dr?
“I have a really bad headache”

HISTORY OF PRESENTING COMPLAINT:

When did the headache start? “About 3 weeks ago”
Did it come on suddenly or gradually? “It came on gradually over a day or so”
What were you doing when the pain started? “Nothing special, it was just there
one morning”
Has the headache changed over the past 3 weeks? “Yes, it wasn’t too bad at the
start but it has gradually been getting much worse”
Does it come and go? Or is it constant? “It has just been constant”
Have you ever suffered from headaches in the past? “No – none I ever thought
about!”
Where is the pain? “It just feels like it is all over my head”
Can you describe the pain? “It’s a constant dull ache”
Does it go anywhere else? “No”
How severe is the headache? “It would now be 9/10”
Have you noticed anything else? “Yes, I had been feeling a bit sick with the pain
but this week I have been sick a few times when the pain was really bad”

Anything else?
Have you been had any recent ear infections or sinusitis? Temperature?
Rash? “No”
Does anything make it better? “No… I`ve taken paracetamol and
ibuprofen but they are not helping at all now”

Does anything bring the pain on? “It is really just constant now”

Does anything make it worse? “Yes, it seems to be worse when I lie down, laugh,
sneeze or cough and even when I go to the toilet”
Is the pain better or worse at any time of the day or night? “Yes, recently it
seems to be worst first thing in morning and then gets a bit easier through the
day”
 27

Has the pain woken you from your sleep?

“Yes, over the past week, I have been woken with pain and felt very sick”

Have you noticed any other problems? “I sometimes find it hard to find words but
I think that’s because I am exhausted with not sleeping. I would not normally be
forgetful”

Any change in your eyesight? “No”

Any changes in your periods? “No …but I am on the pill”

Answer “No” if asked;

Do you have any weakness or numbness in your arms or legs?
Do you suffer from any pins & needles?
Do you have a tremor?
Have you ever suffered from any fits, faints or blackouts?

How has your mood been? -“OK, I am just a bit worried about the pains. I
have barely missed a day off work “

PAST MEDICAL HISTORY

General enquiry You do not suffer from any illnesses. You have never been in
hospital and never had any operations.
Specific enquiry No history of head injury. No cancer. Not aware of any stress.

FAMILY HISTORY
General enquiry No serious illnesses run in the family.
Specific enquiry No FH headaches, glaucoma, cerebral haemorrhage or cancer

SOCIAL HISTORY “Teacher. Avge 10 glasses of wine a week. Never smoked. I

just got married last year” “The pain has really stopped me from doing
anything this week and I have even had to be off work”

DRUG HISTORY I don’t take any regular medicines.

28