Case 71: Kerrie Griffiths

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history from Kerrie and conduct an appropriate focused clinical examination. Outline your differential diagnosis to the facilitator.

The following information is on her medical record:

• Past medical history

• Asthma

• Medication

• Fluticasone 250 mcg 1 puff bd

• Salbutamol inhaler prn

• Allergies

• Nil

• Immunisations

• Up-to-date, rubella booster pre-pregnancy

• Family history

• Nil significant

• Social history

• Non-smoker.

INSTRUCTIONS FOR THE PATIENT, KERRIE GRIFFITHS

You are 32 years old and your first child was born by caesarean section a week ago. Baby Eloise is doing fine and you were discharged home yesterday. This morning you have noticed a sharp pain on the left side of your chest. This is worse on breathing in and you feel short of breath. You have asked the doctor to see you at home.

This is a new pain. It is preventing you from breathing comfortably. You have had a cough this morning and have coughed up a bit of blood. You do not have a temperature and do not have any pain or symptoms suggestive of a deep vein thrombosis in your legs. You are breastfeeding without difficulty.

The following information is on your medical record:

• Past medical history

• Asthma

• Medication

• Fluticasone 250 mcg 1 puff bd

• Salbutamol inhaler prn

• Allergies

• Nil

• Immunisations

• Up-to-date, rubella booster pre-pregnancy

• Family history

• Nil significant

• Social history

• Non-smoker.

Clinical examination findings

When the doctor examines you, please tell them the following:

• Temperature 37.2°C

• Pulse 106 regular

• BP 112/78 mmHg

• Respiratory rate 20 per minute.

You will experience pain in your left lower lobe on inspiration and be reluctant to take deep breaths

The chest is clear

Legs are normal (the most likely diagnosis is that you have a pulmonary embolus).

SUGGESTED APPROACH TO THE CASE

Establish rapport

Ask after the baby, feeding, sleep etc.

Open questions to explore Kerrie’s ideas, concerns and expectations.

Specific questions

Details about the pain

Check for haemoptysis, dizziness, syncope, shortness of breath

Enquire about asthma control

Exclude infection as likely cause—ask about fever, systemic upset

Leg pain or swelling

Past history of thromboembolism ...